Professional Documents
Culture Documents
Nursing Care Plans Schizophrenia
Nursing Care Plans Schizophrenia
(Following are care plans supplemental to those found in the 4th edition of
Goals/Objectives
Short-Term Goal
With assistance from caregiver, client will maintain orientation to time, place, person, and
circumstances for specified period of time.
Long-Term Goal
1. Decrease the amount of stimuli in the client's environment (e.g., low noise level,
few people, simple decor). This decreases the possibility of forming inaccurate
sensory perceptions.
2. Do not reinforce the hallucination. Let client know that you do not share the
perception. Maintain reality through reorientation and focus on real situations and
people. Reality orientation decreases false sensory perceptions and enhances
client's sense of self-worth and personal dignity.
Outcome Criteria
1. With assistance from caregiver, client is able to recognize when perceptions within
the environment are inaccurate.
Goals/Objectives
Short-Term Goal
Client will voluntarily spend time with staff and peers in dayroom activities within 1 week.
Long-Term Goal
2. Devise methods for assisting client with memory deficit. Examples follow:
e. Large calendar, indicating 1 day at a time, with month, day, and year
identified in bold print.
f. Printed, structured daily schedule, with one copy for client and one posted
on unit wall.
g. "News board" on unit wall where current national and local events may be
posted.
These aids may assist client to function more independently, thereby increasing
self-esteem.
Outcome Criteria
1. Client initiates own self-care according to written schedule and willingly accepts
assistance as needed.
2. Client interacts with others in group activities, maintaining anxiety at minimal level
in response to difficulties with verbal communication.
Goals/Objectives
Short-Term Goal
Long-Term Goal
Caregivers will demonstrate effective problem-solving skills and develop adaptive coping
mechanisms to regain equilibrium.
1. Assess caregivers' ability to anticipate and fulfill client's unmet needs. Provide
information to assist caregivers with this responsibility. Caregivers may be
unaware of what client will realistically be able to accomplish. They may be
unaware of the progressive nature of the illness.
2. Ensure that caregivers are aware of available community support systems from
which they can seek assistance when required. Examples include adult day-care
centers, housekeeping and homemaker services, respite care services, or perhaps a
local chapter of the Alzheimer's Disease and Related Disorders Association
(ADRDA). This organization sponsors a nationwide 24-hour hotline (1-800-272-
3900) to provide information and to link families who need assistance with nearby
chapters and affiliates. Caregivers require relief from the pressures and strain of
providing 24-hour care for their loved one. Studies have shown that elder abuse
arises out of caregiving situations that place overwhelming stress on the
caregivers.
Outcome Criteria
1. Caregivers are able to problem solve effectively regarding care of elderly client.
SUBSTANCE-RELATED DISORDERS
Goals/Objectives
Short-Term Goal
Long-Term Goal
3. Obtain urine sample for laboratory analysis of substance content. Subjective history
is often not accurate. Knowledge regarding substance ingestion is important for
accurate assessment of client condition.
4. Place client in quiet, private room. Excessive stimuli increase client agitation.
c. Pad headboard and side rails of bed with thick towels to protect client in
case of seizure.
d. Use mechanical restraints as necessary to protect client if excessive
hyperactivity accompanies the disorientation.
6. Ensure that smoking materials and other potentially harmful objects are stored
outside client's access. Client may harm self or others in disoriented, confused
state.
8. Monitor vital signs every 15 minutes initially and less frequently as acute symptoms
subside. Vital signs provide the most reliable information regarding client
condition and need for medication during acute detoxification period.
Outcome Criteria
Goals/Objectives
Short-Term Goal
Client will be able to verbalize effects of [substance used] on the body after implementation
of teaching plan.
Long-Term Goal
Client will verbalize the importance of abstaining from use of [substance] in order to
maintain optimal wellness.
2. Assess client's level of anxiety and readiness to learn. Learning does not take place
beyond moderate level of anxiety.
3. Determine method of learning that is most appropriate for client (e.g., discussion,
question and answer, use of audio or visual aids, oral or written method). Level of
education and development are important to consider in the selection of
methodology.
4. Develop teaching plan, including measurable objectives for the learner. Measurable
objectives provide criteria for evaluation of the teaching experience.
5. Include significant others, if possible. Lifestyle changes often affect all family
members.
6. Implement teaching plan at a time that facilitates, and in a place that is conducive to,
optimal learning (e.g., in the evening when family members visit, in an empty, quiet
classroom or group therapy room). Learning is enhanced in an environment with
few distractions.
7. Begin with simple concepts and progress to more complex ones. Retention is
increased if introductory material is easy to understand.
9. Provide activities for client and significant others to actively participate in during
the learning exercise. Active participation increases retention.
10. Ask client and significant others to demonstrate knowledge gained by verbalizing
information presented. Verbalization of knowledge gained is a measurable method
of evaluating the teaching experience.
11. Provide positive feedback for participation, as well as for accurate demonstration of
knowledge gained. Positive feedback enhances self-esteem and encourages
repetition of acceptable behaviors.
12. Evaluate teaching plan. Identify strengths and weaknesses and any changes that may
enhance the effectiveness of the plan.
Outcome Criteria
Hypervigilance
Distractibility
Inappropriate non--reality-based thinking
Inaccurate interpretation of environment
Goals/Objectives
Short-Term Goal
Client will develop trust in at least one staff member within 1 week.
Long-Term Goal
Client will demonstrate use of more adaptive coping skills, as evidenced by appropriateness
of interactions and willingness to participate in the therapeutic community.
1. Encourage same staff to work with client as much as possible in order to promote
development of trusting relationship.
3. Avoid laughing, whispering, or talking quietly where client can see but not hear
what is being said. Suspicious clients often believe others are discussing them, and
secretive behaviors reinforce the paranoid feelings.
4. Be honest and keep all promises. Honesty and dependability promote a trusting
relationship.
5. A creative approach may have to be used to encourage food intake (e.g., canned
food and clients own can opener or family-style meals). Suspicious clients may
believe they are being poisoned and refuse to eat food from the individually
prepared tray.
6. Mouth checks may be necessary after medication administration 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.
8. Encourage client to verbalize true feelings. The nurse should avoid becoming
defensive when angry feelings are directed at him or her. Verbalization of feelings
in a nonthreatening environment may help client come to terms with long-
unresolved issues.
Outcome Criteria
1. Client is able to appraise situations realistically and to refrain from projecting own
feelings onto the environment.
3. Client eats food from tray and takes medications without evidence of mistrust.
4. Client appropriately interacts and cooperates with staff and peers in therapeutic
community setting.
DEPRESSIVE DISORDERS
Definition: Social isolation is the condition of aloneness experienced by the individual and
perceived as imposed by others and as a negative or threatened state; impaired social
interaction is the state in which an individual participates in an insufficient or excessive
quantity or ineffective quality of social exchange.
Goals/Objectives
Short-Term Goal
Client will develop trusting relationship with nurse or counselor within reasonable period of
time.
Long-Term Goals
1. Client will voluntarily spend time with other clients and nurse or therapist in group
activities by discharge from treatment.
2. Client will refrain from using egocentric behaviors that offend others and
discourage relationships by discharge from treatment.
1. Spend time with client. This may mean just sitting in silence for a while. Your
presence may help improve client's perception of self as a worthwhile person.
4. Verbally acknowledge client's absence from any group activities. Knowledge that
his or her absence was noticed may reinforce the client's feelings of self-worth.
7. The depressed client must have a lot of structure in his or her life because of
impairment in decision-making and problem-solving ability. Devise a plan of
therapeutic activities and provide client with a written time schedule. Remember:
The client who is moderately depressed feels best early in the day, whereas the
severely depressed individual feels better later in the day; choose these times for the
client to participate in activities.
Outcome Criteria
Goals/Objectives
Short-Term Goal
Long-Term Goal
Client will exhibit no signs or symptoms of malnutrition by discharge from treatment (e.g.,
electrolytes and blood counts will be within normal limits, a steady weight gain will be
demonstrated, constipation will be corrected, client will exhibit increased energy in
participation of activities).
2. To prevent constipation, ensure that diet includes foods high in fiber. Encourage
client to increase fluid consumption and physical exercise to promote normal bowel
functioning. Depressed clients are particularly vulnerable to constipation because
of psychomotor retardation. Constipation is also a common side effect of many
antidepressant medications.
3. Keep strict documentation of intake, output, and calorie count. This information is
necessary to make an accurate nutritional assessment and to maintain client
safety.
5. Determine client's likes and dislikes and collaborate with dietitian to provide
favorite foods. Client is more likely to eat foods that he or she particularly enjoys.
6. Ensure that client receives small, frequent feedings, including a bedtime snack,
rather than three larger meals. Large amounts of food may be objectionable, or
even intolerable, to the client.
7. Administer vitamin and mineral supplements and stool softeners or bulk extenders,
as ordered by physician.
9. Stay with client during meals to assist as needed and to offer support and
encouragement.
10. Monitor laboratory values, and report significant changes to physician. Laboratory
values provide objective data regarding nutritional status.
11. Explain the importance of adequate nutrition and fluid intake. Client may have
inadequate or inaccurate knowledge regarding the contribution of good nutrition
to overall wellness.
Outcome Criteria
2. Vital signs, blood pressure, and laboratory serum studies are within normal limits.
Goals/Objectives
Short-Term Goal
Within 1 week, client will be able to recognize and verbalize when thinking is non--reality
based.
Long-Term Goal
1. Convey your acceptance of client's need for the false belief, while letting him or her
know that you do not share the delusion. A positive response would convey to the
client that you accept the delusion as reality.
2. Do not argue or deny the belief. Use reasonable doubt as a therapeutic technique: "I
find that hard to believe."' Arguing with the client or denying the belief serves no
useful purpose, because delusional ideas are not eliminated by this approach, and
the development of a trusting relationship may be impeded.
4. Reinforce and focus on reality. Talk about real events and real people. Use real
situations and events to divert client from long, tedious, repetitive verbalizations of
false ideas.
Outcome Criteria
2. Client is able to recognize thoughts that are not based in reality and to intervene to
stop their progression.
ADJUSTMENT DISORDER
Short-Term Goals
1. Client will seek out staff member when hostile or suicidal feelings occur.
2. Client will verbalize adaptive coping strategies to use when hostile or suicidal
feelings occur.
Long-Term Goals
1. Client will demonstrate adaptive coping strategies to use when hostile or suicidal
feelings occur.
2. Observe for suicidal behaviors: verbal statements, such as "I'm going to kill myself'"
and "Very soon my mother won't have to worry herself about me any longer," and
nonverbal behaviors, such as mood swings and giving away cherished items.
Clients who are contemplating suicide often give clues regarding their potential
behavior. The clues may be very subtle and require keen assessment skills on the
part of the nurse.
3. Determine suicidal intent and available means. Ask direct questions, such as "Do
you plan to kill yourself?" and "How do you plan to do it?" The risk of suicide is
greatly increased if the client has developed a plan and particularly if the client
has means to execute the plan.
4. Obtain verbal or written contract from client agreeing not to harm self and to seek
out staff if suicidal ideation occurs. Discussion of suicidal feelings with a trusted
individual provides a degree of relief to the client. A contract gets the subject out
in the open and places some of the responsibility for his or her safety with the
client. An attitude of acceptance of the client as a worthwhile individual is
conveyed.
5. Assist client to recognize when anger occurs and to accept those feelings as his or
her own. Have client keep an "anger notebook," in which feelings of anger
experienced during a 24-hour period are recorded. Information regarding source of
anger, behavioral response, and client's perception of the situation should also be
noted. Discuss entries with client and suggest alternative behavioral responses for
responses identified as maladaptive.
6. Act as a role model for appropriate expression of angry feelings and give positive
reinforcement to client for attempting to conform. It is vital that the client express
angry feelings because suicide and other self-destructive behaviors are often
viewed as the result of anger turned inward onthe self.
7. Remove all dangerous objects from client's environment (e.g., sharp items, belts,
ties, straps, breakable items, smoking materials). Client safety is a nursing priority.
8. Try to redirect violent behavior with physical outlets for the client's anxiety (e.g.,
punching bag, jogging). Physical exercise is a safe and effective way of relieving
pent-up tension.
9. Be available to stay with client as anxiety level and tensions begin to rise. The
presence of a trusted individual provides a feeling of security and may help
prevent rapid escalation of anxiety.
10. Staff should maintain and convey a calm attitude to client. Anxiety is contagious
and can be transmitted from staff members to client.
11. Have sufficient staff available to indicate a show of strength to client if necessary.
This conveys to the client evidence of control over the situation and provides some
physical security for staff.
13. Use of mechanical restraints or isolation room may be required if less restrictive
interventions are unsuccessful. Follow policy and procedure prescribed by the
institution in executing this intervention. The Joint Commission on Accreditation of
Healthcare Organizations requires that the physician issue a new order for restraints
every 4 hours for adults and every 1 to 2 hours for children and adolescents. If the
client has previously refused medication, administer it after restraints have been
applied. Most states consider this intervention appropriate in emergency situations
or in situations in which a client would likely harm self or others.
14. Observe the client in restraints every 15 minutes (or according to institutional
policy). Ensure that circulation to extremities is not compromised (check
temperature, color, pulses). Assist client with needs related to nutrition, hydration,
and elimination. Position client so that comfort is facilitated and aspiration can be
prevented. Client safety is a nursing priority.
15. As agitation decreases, assess client's readiness for restraint removal or reduction.
Remove one restraint at a time, while assessing client's response. This minimizes
risk of injury to client and staff.
Outcome Criteria
Goals/Objectives
Short-Term Goal
Long-Term Goal
By discharge from treatment, client will be able to recognize events that precipitate anxiety
and intervene to prevent disabling behaviors.
1. Be available to stay with client. Remain calm and provide reassurance of safety.
Client safety and security are nursing priorities.
2. Help client identify situation that precipitated onset of anxiety symptoms. Client
may be unaware that emotional issues are related to symptoms of anxiety.
Recognition may be the first step in eliminating this maladaptive response.
3. Review client's methods of coping with similar situations in the past. Discuss ways
in which client may assume control over these situations. In seeking to create
change, it would be helpful for client to identify past responses and to determine
whether they were successful and whether they could be employed again. A sense
of control reduces feelings of powerlessness in a situation, ultimately decreasing
anxiety. Client strengths should be identified and used to his or her advantage.
4. Provide quiet environment. Reduce stimuli: low lighting, few people. Anxiety level
may be decreased in a calm atmosphere with few stimuli.
6. Discuss with client signs of increasing anxiety and ways of intervening to maintain
the anxiety at a manageable level (e.g., exercise, walking, jogging, relaxation
techniques). Anxiety and tension can be reduced safely and with benefit to the
client through physical activities.
Outcome Criteria
2. Client is able to verbalize ways in which he or she may gain more control of the
environment and thereby reduce feelings of powerlessness.
INEFFECTIVE COPING
Goals/Objectives
Short-Term Goal
By the end of 1 week, client will comply with rules of therapy and refrain from
manipulating others to fulfill own desires.
Long-Term Goal
By discharge from treatment, client will identify, develop, and use socially acceptable
coping skills.
1. Discuss with client the rules of therapy and the consequences of noncompliance.
Carry out the consequences matter of factly if rules are broken. Negative
consequences may decrease manipulative behaviors.
2. Do not debate, argue, rationalize, or bargain with the client regarding limit setting
on manipulative behaviors. Ignoring these attempts may decrease manipulative
behaviors. Consistency among all staff members is vital if this intervention is to
be successful.
3. Encourage discussion of angry feelings. Help client identify the true object of the
hostility. Provide physical outlets for healthy release of the hostile feelings (e.g.,
punching bags, pounding boards). Verbalizing feelings with a trusted individual
may help client work through unresolved issues. Physical exercise provides a safe
and effective means of releasing pent-up tension.
5. Help client recognize some aspects of his or her life over which a measure of
control is maintained. Recognition of personal control, however minimal,
diminishes the feeling of powerlessness and decreases the need for manipulation
of others.
6. Identify the stressor that precipitated the maladaptive coping. If a major life change
has occurred, encourage client to express fears and feelings associated with the
change. Assist client through the problem-solving process:
Outcome Criteria
2. Client is able to solve problems and independently fulfill activities of daily living.
Definition: Patterns of behavior and self-expression that do not match the environmental
context, norms, and expectations.
Goals/Objectives
Short-Term Goal
Client will verbalize understanding that physical symptoms interfere with role performance
in order to fill an unmet need.
Long-Term Goal
1. Determine client's usual role within the family system. Identify roles of other family
members. An accurate database is required in order to formulate appropriate plan
of care for the client.
3. Encourage client to discuss conflicts evident within the family system. Identify how
client and other family members have responded to this conflict. It is necessary to
identify specific stressors, as well as adaptive and maladaptive responses within
the system, before assistance can be provided in an effort to create change.
4. Help client identify the feelings associated with family conflict, the subsequent
exacerbation of physical symptoms, and the accompanying disabilities. Client may
be unaware of the relationship between physical symptoms and emotional
problems. An awareness of the correlation is the first step toward creating
change.
5. Help client identify changes he or she would like to see within the family system.
7. Allow all family members input into the plan for change: knowledge of benefits
and consequences for each alternative, selection of appropriate alternatives, methods
for implementation of alternatives, formation of alternate plan in the event initial
change is unsuccessful. Family may require assistance with this problem-solving
process.
8. Ensure that client has accurate perception of role expectations within the family
system. Use role playing to practice areas associated with clients role that he or she
perceives as painful. Repetition through practice may help desensitize client to the
anticipated distress.
Outcome Criteria
3. Client and family are able to verbalize plan for attempt at resolving conflict.
Goals/Objectives
Short-Term Goal
Client will describe characteristics that make him or her a unique individual.
Long-Term Goal
Client will be able to distinguish own thoughts, feelings, behaviors, and image from those
of others as the initial step in the development of a healthy personal identity.
1. Help client recognize the reality of his or her separateness. Do not try to translate
client's thoughts and feelings into words. Because of blurred ego boundaries, client
may believe you can read his or her mind. For this reason, caution should be taken
in the use of empathetic understanding. For example, avoid statements such as "I
know how you must feel about that."
2. Help client recognize separateness from nurse by clarifying which behaviors and
feelings belong to whom. If deemed appropriate, allow client to touch your hand or
arm. Touch and physical presence provide reality for the client and strengthen
weak ego boundaries.
3. Encourage client to discuss thoughts and feelings. Help client recognize ownership
of these feelings rather than projecting them onto others in the environment.
Verbalization of feelings in a nonthreatening environment may help client come
to terms with unresolved issues.
4. Confront statements that project client's feelings onto others. Ask client to validate
that others possess those feelings. The expression of reasonable doubt as a
therapeutic technique may be helpful ("I find that hard to believe").
5. If the problem is with gender identity, ask client to describe his or her perception of
appropriate male and female behaviors. Provide information about role behaviors
and sex education, if necessary. Client may require clarification of distorted ideas or
misinformation. Convey acceptance of the person regardless of preferred identity.
An attitude of acceptance reinforces client's feelings of self-worth.
7. Help client understand that there are more adaptive ways of validating his or her
existence than self-mutilation. Contract with the client to seek out staff member
when these feelings occur. A contract gets the subject out in the open and places
some of the responsibility for the clients safety with him or her. Client safety is a
nursing priority.
8. Work with client to clarify values. Discuss beliefs, attitudes, and feelings underlying
his or her behaviors. Help client identify those values that have been (or are
intended to be) incorporated as his or her own. Care must be taken by the nurse to
avoid imposing his or her own value system on the client. Because of
underdeveloped ego and fixation in early developmental level, client may not have
established own value system. In order to accomplish this, ownership of beliefs
and attitudes must be identified and clarified.
9. Use of photographs of the client may help establish or clarify ego boundaries.
Photographs may help increase client's awareness of self as separate from others.
10. Alleviate anxiety by providing assurance to client that he or she will not be left
alone. Early childhood traumas may predispose borderline clients to extreme
fears of abandonment.
Outcome Criteria
1. Client is able to distinguish own thoughts and feelings from those of others.
2. Client claims ownership of those thoughts and feelings and does not use projection
in relationships with others.
Goals/Objectives
Short-Term Goal
Client will verbalize an understanding that derogatory and critical remarks against others
reflects feelings of self-contempt.
Long-Term Goal
1. Ensure that goals are realistic. It is important for client to achieve something, so
plan for activities in which success is likely. Success increases self-esteem.
4. Encourage client to talk about his or her behavior, the limits, and the consequences
for violation of those limits. Discussion of feelings regarding these circumstances
may assist the client in achieving a degree of insight into his or her situation.
8. Assist client in identifying positive aspects of the self and in developing ways to
change the characteristics that are socially unacceptable. Individuals with low self-
esteem often have difficulty recognizing their positive attributes. They may also
lack problem-solving ability and require assistance to formulate a plan for
implementing the desired changes.
11. Help client increase level of self-awareness through critical examination of feelings,
attitudes, and behaviors. Help client understand that it is perfectly acceptable for
attitudes and behaviors to differ from those of others, as long as they do not become
intrusive. As client becomes more aware and accepting of himself or herself, the
need for judging the behavior of others will diminish.
12. Teach client assertiveness techniques, especially the ability to recognize the
differences between passive, assertive, and aggressive behaviors and the importance
of respecting the human rights of others while protecting one's own basic human
rights. These techniques increase self-esteem while enhancing the ability to form
satisfactory interpersonal relationships.
Outcome Criteria