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Nursing Diagnosis


Nursing Intervention

Rationale Accurate baseline data are important in planning care to assist client with this problem


Subjective: Sleep hindi talaga ako Disturbance makatulog sa gabi. to agitation As verbalized by the client


Pattern Short term: 1. 1. Keep strict records related With the aid of of sleeping patterns Antipsychotic medication, within 2 home visits, client will be able to exhibit a well-rested feeling 2. 2. Discourage sleep during the day Long term: At the end of 5 home 3. 3. Administer visits client will antidepressant verbalize continuous medication at sleep of at least 6- bedtime 8hrs 4. 4. Perform relaxation techniques to soft music

At the end of 5 home visits objectives were not met but client was sleeping during the final visit so we cannot determine if To promote more interventions were restful sleep at night effective So client may not become drowsy during the day

Maybe helpful prior to sleep

5. 5. Assist clients with To help client get to measures that may sleep promote sleep, such as warm, nonstimulating drinks, light snacks, warm bath, back rubs 6. 6. Limit intake of caffeinated drinks, such as tea, coffee, and colas Caffeine is a CNS stimulant that may interfere with the clients achievement of rest and sleep


Nursing Diagnosis

Objective Short term: 7. At the end of 3 home visits client will be able to verbalize understanding reality against delusion Long term: 8. At the end 6 days client will be able to define and test reality, eliminating the occurrence of 9. sensory misperception

Nursing Intervention 1. Observe client for signs of hallucinations (listening pose, laughing or talking to self, stopping in midsentence) 2. Avoid touching the client before warning her that you are about to do so 3. An attitude of acceptance will encourage the client to share content of the hallucination with you



Subjective: Sensory perceptual ayokong mag lakad alteration related to mag isa kasi sleep deprivation sumusunod sa akin si God, pinaparemind niya ako sa mga kasalanan ko. As verbalized by the client Objective:

Early intervention At the end of may prevent aggressive responses to command hallucinations

Client may perceive touch as threatening and respond in an aggressive manner This is important in order to prevent possible injury to the client or others from command hallucination

10. 11. 4. Do not reinforce Words like they the hallucination. Use may validate that the words as the voices voices are real instead of they when reffering to the hallucinations 12. 5. Try to connect the times of misperception to times of increased anxiety. Help client to If client can learn to interrupt the escalating anxiety, reality orientation may be maintained

understand connection


13. 6. Try to distract the Involvement in client away from the interpersonal misperception activities explanation of actual situation bring the client to reality

the and the may back

Cues Subjective:

Nursing Diagnosis Dysfunctional grieving related to feelings of guilt generated by ambivalent relationship with lost concept

Objective Short term: 14. At the end of 3 home visits client will express anger toward lost concept Long term: At the end of 5 visits 15. client will be able to verbalize behaviors associated with the normal stages of grief

Nursing Intervention 1. Determine stage of grief in which client is fixed. Identify behaviors associated with this stage

Rationale Accurate baseline assessment data are necessary to effectively plan care for the grieving client

Evaluation At the end of 5 visits objectives were not met because client was unable to resolve ambivalent feelings towards mother.


2. Develop trusting Trust is the basis for relationship with the therapeutic client. Show empathy communication and be caring. Be honest and keep promises An accepting attitude conveys to the client that you believe she is a worthwhile person. Trust is enhanced Verbalization of feeling is nonthreatening environment may help client come to terms with unresolved issues

16. 3. Convey an accepting attitude, and enable the client to express feelings, openly

17. 4. Encourage client to express anger. Do not become defensive if initial expression of anger is displaced on nurse or therapist. Assist client to explore angry feelings so that they may be directed toward the intended object or

person 18. 19. 5. Assist client to discharge pent-up anger through participation in large motor activities (e.g., brisk walks, jogging, physical exercise, volleyball, punching bag, exercise bike) 20. 6. Teach normal stages of grief and behaviors associated with each stage. Help client to understand that feeling such as guilt and anger toward the lost entity are appropriate and acceptable during the grief process Physical exercise provide a safe and effective method for discharging pent-up tension

Knowledge of acceptability of the feelings associated with the normal grieving may help to relieve some of the guilt that these responses generate