Cues / Clues

Psychiatric Nursing Diagnosis Disturbed Thought Processes related to disruption in cognitive operations and activities as evidenced by confused facial expression

Psychodynam ics (RATIONALE)

PLANNING

Therapeutic Approach

RATIONALE (with Theories)

EVALUATION

Subjective Cue: Nung nasa Taiwan ako napossess ako. Dinala ako dito ng tatay ko sa Pilipinas tapos nasaktan ko yung nanay ko nung may kausap siya sa phone , as verbalized by the patient Objective: GA: Poor personal grooming Confused facial expression Unkempt/disheveled appearance Sensory & Cognition: Conscious, oriented to time, person & place Impaired memory on personal information Poor concentration regarding specific topics

Short term outcome:

INDEPENDENT: 1. Providing general After 8 hours of nursing leads intervention, the pt will a. Approach the be able to : client in slow, calm, matter-af Demonstrate fact manner reality based b. Maintain facial thinking in expression and verbal and non behaviors that are verbal behavior consistent with Demonstrated verbal statements reduction of frequency of delusions Participate in social activities and group therapies

1. A calm approach Outcome helps to avoid Achieved: distorting the clients sensory The perceptual field patient which helps could demonstr promote disturbed ated thoughts and reality perceptions based Peplau defined thinking in Psychodynamic verbal nursing as being and non able to understand verbal ones own behavior. behavior to help The others identify felt patient difficulties and to demonstr apply principles of ated a human relations to reduction the problems that of arise at all levels frequency of experience. of delusions. The 2. Delusions cannot patient

2. Providing specific questions Avoid challenging the clients delusional system or arguing with the client.

be changed thru logic and challenging the belief of the patient, no matter how irrational. As the client may be forced to cling to it and defend it. Rogers described a variation of self as the inherent potentialities of the actualizing tendencies that can suffer the distorted expression when maladjustment occurs resulting in behavior destructive to oneself and others.

participate d in social activities such as group therapies.

3. Presenting Reality Distract the client from the delusion by engaging him in a less threatening or a

3. Dwelling to the delusional content may increase the clients anxiety, aggression and

more comforting topic or activity at the first sign of anxiety and discomfort.

4. Offering praise Offer recognition as soon as the client begins to differentiate between reality based and non reality based thoughts and behaviors.

other dysfunctional behavior. Rogers revised his previous thinking concerning this incongruence. He stated the perversions of the unitary actualizing tendency. We do not come into the world estranged from ourselves, socialization is behind this alienation. 4. Positive reinforcement increases self esteem and encourage the client to identify and continue reality based thoughts and behavior. 5. Clear direct

5. Giving information Offer the client clear, simple explanations of environmental events, activities and

the behaviors of other clients as necessary,

explanations of environment events help to lessen the clients suspiciousness and fear or mistrust of the surroundings and other. This can prevent aggressive behavior.

COLLABORATIVE: 1. Continue to administer and monitor the effects of the prescribed medication CHLORPROMAZINE (Thorazine) Haloperidol Fluprenazine

CHLORPROMAZINE is classified as a low potency antipsychotic and in the past was used for the treatment of both acute and chronic psychosis, including Schizophrenia. It is still well recommended for short term management of severe anxiety and aggressive episodes.