XI.

NURSING CARE PLANS

ASSESSMENT
Actual Abnormal Cues: Kung minsan hindi ko na kaya nagpapatali na lang ako, I can hear voices, as verbalized by the client. Attention deficits Inability to make decisions Risk Related Factors: History of drug and alcohol abuse Strength: Compliance to medication Good family support Positive attitudes towards his situation

NURSING DIAGNOSIS
Disturbed sensory perception: auditory related to biochemical imbalances for sensory distortion as evidenced by hearing unusual voices Definition: Change in the mount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. Source: (Doenges, 2006)

RATIONALE
PREDISPOSING/ PRECIPITATING FACTOR: Substance abuse Passed on the blood brain barrier Prolonged vasoconstriction of blood vessels in the brain Decrease blood circulation in the brain Poor oxygenation in the brain Neurodegeneration of the brain Dysfunction in the pre-frontal cortex Release of excessive dopamine Excites psychosis Signs and Symptoms: Auditory disturbances such as auditory hallucinations, attention deficits and inability to make decisions Disturbed sensory perception: auditory

Nursing Care Plan #1 DESIRED NURSING OUTCOME INTERVENTION

After 4 days of nurseclient interaction, the client will be able to: Independent: Try to decrease stimuli or move the client to another area.

JUSTIFICATION

EVALUATION
After 4 days of nurseclient interaction, the client will be able to:

To decrease the chances of misperception.

Demonstrate decreased hallucinations.

Interact appropriately with others and with the environment. Verbalize plans to deal with hallucinations, if they occur.

Engage the client in conversation or concrete activity.

To distract client from responding to hallucinations.

GOAL MET client was able to verbalize that he does hallucinate sometime but not frequent. GOAL MET client was participating during the activity and has friends in the institution.

Encourage client to tell staff members and student nurse about hallucinations.

To help client to cope with problems about hallucinations.

Collaborative: Refer to experts in the field of psychiatry for advice.

To assess causative/contributi ng factors and degree of impairment.

GOAL MET client said that in order to deal with hallucination, he tell others to tie him to avoid him from hurting his self and others.

Source: (Videbeck, 2004) (Stuart, 2005) (Old notes in Psychiatric

Source: (Fortinash, 2007)

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Nursing)

ASSESSMENT
Actual Abnormal Cues: I dont want to go out in this institution baka may masamang mangyari sa family ko dahil sakin. As verbalized by the client. Expressed concerns due to change in life events Risk Related Factors: History of drug and alcohol abuse Strength: Compliance to medication Good family support Positive attitudes towards his situation

NURSING DIAGNOSIS
Anxiety related to threat of danger as evidenced by expressing concerns due to changes in life events, unusual thoughts about possible danger he may bring to his family

RATIONALE
PREDISPOSING/ PRECIPITATING FACTOR:

Nursing Care Plan #2 DESIRED NURSING OUTCOME INTERVENTION

After 4 days of nurseclient interaction, the client will be: Independent: Provide positive reinforcement when patient is able to continue ADLs and other activities despite of anxiety. Encourage patient verbalize thoughts and feelings

JUSTIFICATION

EVALUATION
After 4 days of nurseclient interaction, the client will be able to:

Negative life experiences low self-esteem and emotionally unstable Emotional Conflict Signs and Symptoms: unusual thoughts and feelings of danger Anxiety

Able to continue necessary activities even though anxiety persists. Able to verbalize needs and negative feelings appropriately

To divert patients attention to something interesting.

GOAL MET patient was able to participate activities prepared for them

Definition: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

To decrease the burden felt by the patient. GOAL MET patient was able to verbalize feelings of danger when he will be out of the institution to the student nurse GOAL MET patient does not harm anybody and know what to do when aggressive behavior occurs.

Able to avoid demonstration of aggressive behavior. Reduces excessive stimulation by providing quiet environment and limit of caffeine and other stimulants.

To prevent unnecessary things to occur that may harm him or others.

Source: (Doenges, 2006)

Source: (Videbeck, 2004) (Stuart, 2005) (Old notes in Psychiatric Nursing)

To reduce anxiety. Collaborative: Administer medication as prescribed. Source: (Fortinash, 2007)

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ASSESSMENT
Risk Cues: I can hear voices telling me, ikaw may sala nga napatay siya and then nagiging restless na ako, I try to cut my arms, as verbalized by the client. Related Factors: History of suicide attempt History of drug and alcohol abuse.

NURSING DIAGNOSIS
Risk for self directed violence related to auditory disturbances

RATIONALE
PREDISPOSING/ PRECIPITATING FACTOR: Substance abuse Passed on the blood brain barrier Prolonged vasoconstriction of blood vessels in the brain Decrease blood circulation in the brain Poor oxygenation in the brain Neurodegeneration of the brain Dysfunction in the pre-frontal cortex Release of excessive dopamine Excites psychosis Signs and Symptoms: Auditory disturbances such as auditory hallucinations Risk for self directed violence

Nursing Care Plan #3 DESIRED NURSING OUTCOME INTERVENTION

After 4 days of nurseclient interaction, client will be able to: Name of the things he was doing to prevent him from hurting himself. Independent: Develop therapeutic nurse-client relationship.

JUSTIFICATION

EVALUATION
After 4 days of nurseclient interaction, client will be able to:

Definition: At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to self.

Participate in care and meet own needs in an assertive manner.

Assist client to learn assertive rather than manipulative, nonassertive or aggressive behavior. Give client as much control as possible within constraints of individual situation.

Strength: Good family support Compliance to medication Positive outlook towards recovery.

Express realistic self-evaluation and increase sense of self-esteem.

To promote sense of trust allowing client to discuss feelings GOAL MET client openly. verbalized I asked them to tie me up to prevent me from To promote behavior hurting myself. that help client to engage in positive social activities with GOAL MET client others. was attentive during discussions and activities such To enhance selfas OT and exercises esteem, promotes confidence and ability to change GOAL MET client behavior. was able to accept his condition.

Collaborative: Refer psychologist psychiatrist counseling. to or for

To evaluate further the patients condition.

Source: (Doenges, 2006)

Source: (Videbeck, 2004) (Stuart, 2005) (Old notes in Psychiatric Nursing)

Source: (Fortinash, 2007)

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