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Name of Patient:

Nursing Diagnosis: Disturbed

NURSING CARE PLAN


Medical Diagnosis:
Schizophrenia

Students Name:
Area:

Date:
Section/Group:

Sensory Perception related to


Auditory Hallucinations

Assessment
(1 mark)
Subjective:
Patient verbalized
I can hear
someone calling
me.
Objective:

Looks fearfull
Irritability noted
Talkativeness
Hyperactivity
Agitation
Hostile behavior
Threatened
toward self
Restlessness
Hears voices

Nursing
Diagnosis
(1 mark)
Disturbed
Sensory
Perception
related to
Auditory
Hallucinations

Scientific
Explanation
(0.5 mark)
Schizophrenia is
composed of a broad
collection of
symptoms from all
domains of mental
function. The
term schizophrenia lit
erally means split
mind it is often
confused with a split
or multiple
personality.
Individuals affected
with such syndrome
may show a wide
range of disruptions
in their ability to see,
hear and otherwise
process information
from the world
around them. They
may also experience
disruption in their
normal thought
processes, as well as
their emotions and
behaviors.

Planning
(0.5 mark)
Short Term:
After 4 Hours of
nursing
intervention,
The Nurse will
be able to
present reality
to the patient.
Long Term:
After 3 days of
nursing
intervention,
patient will be
able to
verbalize
understanding
that the voices
are result of his
illness and
demonstrate
ways to
interrupt
hallucinations.

Interventions
(0.5 mark)

Rationale
(1 mark)

1.Encourage
1. To promote
same staff to
development
work
with
of
trusting
client as much
relationship.
as possible
2. Suspicious
2.Avoid physical
clients may
contact.
perceive
touch as a
threatening
3.Be honest and
gesture.
keep
all 3. This Honesty
promises.
and
dependability
promote
a
4. Mouth
checks trusting
may
be relationship.
necessary after 4. To verify that
medication
client is
administration.
swallowing the
tablets or
5.Encourage
capsules.
client
to Suspicious
verbalize true
clients may
feelings. The
nurse should believe they are
being poisoned
avoid
with their
becoming
defensive
medication and
when
angry attempt to
feelings
are

Evaluation
(0.5 mark)
Short Term:
Patient was able
to recognize

that
hallucinations
occur at times
of extreme
anxiety.

Long Term:
Patient was able
to recognize
signs of
increasing
anxiety and
employ
techniques to
interrupt the
response.

directed
him or her.

at discard the pills.

6.An assertive,
matter-of-fact,
yet
genuine
approach
is
the
least
threatening to
the suspicious
person.
7.Encourage
client
to
verbalize true
feelings. The
nurse should
avoid
becoming
defensive
when
angry
feelings
are
directed
at
him or her.

5. Verbalization
of feelings in a
nonthreatening
environment
may help client
come to terms
with longunresolved
issues.
6.
The
suspicious client
does not have
the capacity to
relate
to
an
overly friendly,
overly cheerful
attitude.
7. Verbalization
of feelings in a
nonthreatening
environment
may help client
come to terms
with
longunresolved
issues.

Name of Patient:
Nursing Diagnosis: Disturbed

NURSING CARE PLAN


Medical Diagnosis:
Schizophrenia

Students Name:
Area:

Date:
Section/Group:

Thought Process related to inability


to trust as evidenced by
suspiciousness

Assessment
(1 mark)
Subjective:
Patient verbalized
that somebody will
hurt him
Objective:

Talkativeness
Hallucinations

Hyperactive
Agitation
Hostile behavior
Restlessness

Nursing
Diagnosis
(1 mark)
Disturbed
Thought Process
related to
inability to trust
as evidenced by
suspiciousness,

distractibility.

Scientific
Explanation
(0.5 mark)
Schizophrenia is
composed of a broad
collection of
symptoms from all
domains of mental
function. The
term schizophrenia lit
erally means split
mind it is often
confused with a split
or multiple
personality.
Individuals affected
with such syndrome
may show a wide
range of disruptions
in their ability to see,
hear and otherwise
process information
from the world
around them. They
may also experience

Planning
(0.5 mark)

Interventions
(0.5 mark)

Rationale
(1 mark)

Evaluation
(0.5 mark)

Short Term:
After 4 Hours of
nursing
intervention,
patient will
develop trust in
at least one
staff member

1. Encourage
same staff to
work
with
client
as
much
as
possible.
2. Avoid
physical
contact.
3. Avoid
laughing,
whispering,
or
talking
quietly
where client
can see but
not
hear
what
is
being said.
4. Be
honest
and keep all
promises.

1. To
promote
development
of
trusting
relationship.
2. Suspicious
clients may
perceive
touch as a
threatening
gesture.
3. Suspicious
clients often
believe
others
are
discussing
them,
and secretive
behaviors
reinforce the
paranoid
feelings.
4. Honesty and

Short Term:
Patient was able
to ate foods
from tray and
took
medications
without
evidence of
mistrust and
was
appropriately
interacts with
staff.

Long Term:
After 3 days of
nursing
intervention,
patient will
demonstrate
use of more
adaptive coping
skills, as
evidenced by
appropriatenes
s of interactions

Long Term:
Patient able to
appraise
situations
realistically and
to refrain from
projecting own

disruption in their
normal thought
processes, as well as
their emotions and
behaviors.

and willingness
to participate in
the therapeutic
community.

5. A
creative
approach
may have to
be used to
encourage
food intake
(e.g., canned
food
and
clients own
can opener
or
familystyle meals).
6. Mouth
checks may
be
necessary
after
medication
administrati
on.
7. Activities
should never
include
anything
competitive.
Activities
that
encourage a
one- to-one
relationship
with
the
nurse
or
therapist are
best.
8. Encourage
client
to
verbalize
true feelings.
The
nurse
should avoid
becoming
defensive

5.

6.

7.

8.

dependability
promote
a
trusting
relationship.
Suspicious
clients may
believe they
are
being
poisoned and
refuse to eat
food from the
individually
prepared
tray.
To verify that
client
is
swallowing
the tablets or
capsules.
Suspicious
clients may
believe they
are
being
poisoned
with
their
medication
and attempt
to
discard
the pills.
Competitive
activities are
very
threatening
to suspicious
clients.
Verbalization
of feelings in
a
nonthreateni
ng
environment
may
help

feelings onto
the
environment,
recognized and
clarify possible
misinterpretatio
ns of the
behaviors and
verbalizations
of others, and
cooperates with
staff and peers
in therapeutic
community
setting.

when angry
client come
feelings are
to terms with
directed
at
longhim or her.
unresolved
9. An assertive,
issues.
matter-of9. The
fact,
yet
suspicious
genuine
client
does
approach is
not have the
the
least
capacity
to
threatening
relate to an
to
the
overly
suspicious
friendly,
person.
overly
cheerful
attitude.