PATIENT CARE PLAN (PSYCHOLOGICAL) STUDENT PATIENT INITIALS A.A.

ADMITTING DX FRANCISCO J ORTIZ DN AGE 69 PSYCHOSIS ADMISSION DATE OTHER MEDICAL DX 08/25/2011 SEIZURES, LOWER BACK PAIN, ELEVATED CHOLESTEROL, ANEURYSM REPAIR

SEX (F)

NURSING DIAGNOSIS (In priority order) NDDISTURBED SENSORY PERCEPTION RELATED TO PSYCHOLOGICAL STRESS AS EVIDENCE BY ALTERED COMMUNICATION PATTERN AS EVIDENCE BY PT STATING TO ME S: HEY I KNOW YOU ARE MY CONTACT PERSON S: HEY WHEN AM I LEAVING THIS JOINT? S: HEY I AM TIRED OF THIS PLACE THIS PEOPLE ARE CRAZY O: PATIENT VIGORUSLY LOOKING FOR ME AT ALL TIMES AND BEING NEEDY TO SEE IF I HAD ANY INFORMATION IN HER WHEREABOUTS IN LEAVING FACILITY O:PT GAVE ME A PAPER TO GIVE TO NURSE TO THAT SAID I AM LEAVING TODAY NO MATTER WHAT! O:CHART SHOWS PT HAS BEEN THERE FOR 7 DAYS AND NO DISCHARGE IS SCHEDULED

PATIENT-CENTERED GOALS Short term goal: PT WILL acknowledge whom her real contact person in group therapy within 1 day. Long Term goal: PT WILL ACKNOWLEDGE CHANGES IN ABILITY & PRESENCE OF RESIDUAL INVOLVEMENT WITHIN 1 WEEK OF STATING THE GOAL OF THE DAY.

NURSING INTERVENTION SHORT TERM: 1.Speak in calm quiet voice, using short sentences (Independent) (pg 230 DOUGNES) 2. ASCERTAIN & VALIDATE CLIENT PERCEPTION REORIENT CLIENT FREQUENTLY TO ENVIRONMENT STAFF & PROCEDURES (Independent) (pg 232 DOUGNES) 3 ELIMINIATE EXTRANEOUS NOISE & STIMULI AS NECESSAY (Independent) (pg 230 DOUGNES) LONG TERM: 1.Teach client to validate perception reorient client frequently to environment (Independent) (pg 230 DOUGNES)

RATIONALE

EVALUATION

1. Client may have limited attention span or problems with comprehension 2.ASSISTS CLIENT TO IDENTIFY INCONSISTENCIES IN RECEPTION & INTEGRATION OF STIMULI & MAY REDUCE PERCEPTUAL DISORTITATION OF REALITY 3.REDUCES ANXIETY & EXAGGERATED EMOTIONAL RESPONSES & CONFUSION ASSOCIATED WITH SENSORY OVERLOAD 1.Assists client to identify inconsistencies in perception & integration of stimuli

SHORT TERM: PATIENT UNDERTOOD WHERE SHE WAS AND FOUND OUT THAT THE NURSE IS HER CONTACT PERSON BY END OF FIRST GROUP MEETING

2. Presence of visual disorders can negatively affect clients ability to perceive 2. Assess sensory awareness (Independent) environment (pg 231 DOUGNES) 3. HELPS DETERMINE PATIENT PSYCHOLOGICAL STATE 3. ASSESS PATIENT READINESS TO LEARN (Independent) (pg 232 DOUGNES)

LONG TERM: GoaL NOT MET BECAUSE I WAS NOT THERE LONG ENOUGH TO SEE CLIENT BE DISCHARGED FROM UNIT

REFERENCE: NURSING CARE PLANS: GUIDELINES FOR INDIVIDUALIZING CLIENT CARE ACROSS THE LIFE SPAN 8TH EDITION BY DOUGENS, MOORHOUSE 2011 PAGES 230-232