CUES NURSING PSYCHOPATHOPHYSIOLOGY SPECIFIC NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES
SCHIZOPHRENIA
SUBJECTIVE: >High risk -Verbalize INDEPENDENT: -Patient
“Kadali sa akon for self and 1. Premorbid personality: individuals use understanding of •Observe or listen for early cues of distress/increasing =may indicate possibility of loss control. verbalizes that he
the compensatory mechanisms of the anxiety
mangakig, other- why behavior easily gets mad
withdrawn pattern of behavior. •Ask directly if the person is thinking of acting on =to determine violent intent
ginsumbag ko directed occurs thus such
2. Severe emotional problems: although thoughts/feelings
manghod ko kag Violence unrecognized begin early in life. •Develop therapeutic nurse-client relationship. =Promotes sense of trust, allowing client to behavior occurs
ginlampos ko related to 3. Chronic insecurity and an almost total Provide consistent caregiver when possible. discuss feelings openly
amon dvd inability to failure in interpersonal relationships. •Maintain straightforward communication =to avoid reinforcing manipulative behavior
player.” discharge 4. Etiology is still unknown; however, -Remains free •Discuss motivation for change =crisis situation can provide impetus for change, -Patient stated
emotions some interesting findings in genetics, from injury from but requires timely therapeutic intervention to that he can
verbally biochemistry, psychology, family therapy, self and others sustain efforts control himself
HISTORY OF: and sociology present hope for a •Confront client’s tendency to minimize situation or =in domestic violence situations, individual may now and try not
1) Violence breakthrough. behavior be remorseful after incident and will apologize to happen it
5. Regardless of the ultimate etiology, a and say that it won’t happen again
against self and again
disturbed relationship with the •Acknowledge reality of suicide/homicide as an option =provides an opportunity for client to look at
others environment and the family is an almost -Verbalizations or reality of choices and potential outcomes -Patient is calm
>hitting his universal characteristic. body language •Accept client’s anger without reacting on emotional =Promotes acceptance and sense of safety when being
younger brother demonstrates a basis interacted but
>arguing with Symptoms reduction in •Help client identify more appropriate =to lessen sense of anxiety and associated keeps on moving
younger brother Delusions anxiety solutions/behaviors physical manifestations his feet and
>jumping over Hallucinations •Give client as much control as possible =enhances self-esteem, promotes confidence in scratching his
the bridge Bizarre behavior ability to change behavior head
2) Indirect Disorganized thinking and speech •Be truthful in giving information and dealing with =builds trust, enhancing therapeutic relationship
Social withdrawal client and prevents manipulative behavior
violence -Continues taking -Patient said that
Others symptoms •Identify current/ past successes and strengths =they can be use as basis for change
>destructiveness -difficulties with memory, attention span, prescribed •Give positive reinforcement for client’s efforts =encourages continuation of desired behaviors he is given an IV
-broke things at abstract thinking, and planning ahead medication •Maintain calm, matter-of-fact, nonjudgmental =decreases defensive response medication which
home, door and -problems with anxiety, depression, and attitude is Fluphenazine
facilities in jail suicidal thoughts •Provide client with a sense that caregiver is in control =to provide feeling of safety decanoate
where he has of the situation monthly.
been safe kept. Nursing Diagnosis
-kicking the High risk for self and other-directed COLLABORATIVE: ->goal partially
dining table •Identify support systems =in addition to client, those around him need to met
Violence related to inability to
learn how to be positive role models and display
discharge emotions verbally
a broader array of skills for resolving problems
Reference: MOSBY’S COMPREHENSIVE REVIEW •Refer to formal resources, as indicated
OF NURSING Phil. Edition, p372

Patient initials: A.C. Date of admission: March 28, 2011

Age: 40y/o Diagnosis: Schizophrenia, chronic
GENERAL OBJECTIVES: Maintain good hygiene and promote safety.