NURSING CARE PLAN 1

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Disturbed At the end of 1. Identified factors 1. Identifying factors present is
mayo 31 Thought 2 weeks of present important to know the GOAL MET:
diay ta Processes r/t nursing 2. Determined causative/contributing factors.
karon as mental intervention alcohol/other drug use. 2.Drugs can have direct effects Patient
verbalized disorder as the client is 3. Assisted with treatment on the brain recognized and
by the Evidenced expected to: for underlying 3. Cognition/thinking often clarified possible
patient by: problems improves with misinterpretation
when Confusion/dis Patient 4. Reoriented to treatment/correction of s as evidenced
oriented to orientation maintains time/place/person, as medical/psychiatric problems. by patient stating
date reality needed. 4. Inability to maintain orientation the right date
Rationale: orientation 5. Have patient write is a sign of deterioration. and place
Objective: Disruption in and name periodically 5. These are important measures Patient
Patient is such mental communicate 6. Schedule structured to prevent further deterioration maintained
disoriented activities as clearly with activity and rest and maximize level of function. reality orientation
to date and conscious others periods. 6. This provides stimulation while and
place thought, Patient 7. Maintained a pleasant reducing fatigue. communicate
Patient is reality expresses and quiet environment 7. Patient may respond with clearly with
confused orientation, delusional and approach patient anxious or aggressive behaviors others
Anhedonia problem- material less in a slow and calm if startled or over stimulated. Patient
noted solving, frequently. manner. 8.Delusional patients are recognized
Avolition judgment, Patient will 8. Presented reality extremely sensitive about others changes in
noted and be oriented to concisely and briefly and can recognize insincerity thinking/behavior
Alogia comprehensi time, place, and do not challenge 9. Clear, consistent limits provide .
noted on related to and people illogical thinking a secure structure for the patient.
coping, 9. Be consistent in setting 10. This is to avoid triggering
personality, expectations, enforcing fight/flight responses.
and/or mental rules, and so forth.
disorder. 10. Reduce provocative
stimuli, negative
Psychiatric criticism, arguments,
 mental health and confrontations.
nursing book
6th edition by
Videbeck

NURSING CARE PLAN 2

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired At the end 1. In a respectful, neutral 1. From the beginning, clients GOAL MET
Dili ko social of 2 weeks manner, explain expected need to have explicit
ganahan mag interaction of nursing client behaviors, limits, and guidelines and boundaries Client
dula Patient r/t interventio responsibilities during for expected behaviors on expressed
responds Biochemic n the client sessions with nurse their part, as well as what thoughts and
when asked al is expected clinician. client can expect from the feelings and
to participate alterations to: 2. Assessed need for and nurse. spend time with
in the in the brain encourage skills training 2. Skills training workshops one or two other
activities of certain Patient workshop. offer the client a chance to people.
neurotrans will spend 3. Problem solved and role increase social skills Patient
Objective: mitters. time with play with client acceptable through role play and participated in
Patient one or two social skills that will help interactions with others who activities and
doesnt like Rationale: other obtain needs effectively and are learning similar skills. games
to participate Emotional people in appropriately. 3. Over time, alternative ways
in activities withdrawal/ structured 4. Eventually involved the of experiencing
Patient flatness is activity client in group activities interpersonal relationships
barely one of the neutral (e.g., group discussions, art might emerge.
initiates negative topics therapy, dance therapy). 4. Socialization minimizes
communicati symptoms Patient 5. Eventually maximized the feelings of isolation.
on of will clients contacts with others Genuine regard for others
schizophre participate (first one other, then two can increase feelings of
-nia in the others, etc.). self-worth
activities 6. Ensured that the goals set 5. Contact with others distracts
Psychiatric and are realistic; whether in the the client from self-
mental games. hospital or community
health 7. Use simple, concrete, and
nursing literal explanations.
book 6th 8. Structure activities that work
edition by at the clients pace and
Videbeck activity
9. Structure times each day to
include planned times for
brief interactions and
activities with the client on
one-on-one basis
10. Try to incorporate the
strengths and interests the
client had when not as
impaired into the activities
planned
preoccupation
6. Avoids pressure on the
client and sense of failure
on part of nurse/family. This
sense of failure can lead to
mutual withdrawal
7. Minimizes
misunderstanding and/or
incorporating those
misunderstandings into
delusional systems.
8. Client can lose interest in
activities that are too
ambitious, which can
increase a sense of failure.
9. Helps client to develop a
sense of safety in a non-
threatening environment
10. Increase likelihood of
clients participation and
enjoyment.
 NURSING CARE PLAN 3

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Impaired At the end of 1. Clarified patients 1. Feedback promotes effective GOAL MET:
the verbal 2 weeks of understanding of the communication.
patients communicati nursing patients 2. To keep patient focused, Patient
responds to on r/t intervention communication with decrease stimuli going to the expressed
questions Biochemical the client is the patient or an brain for interpretation, and thoughts and
with a nod alterations in expected to: interpreter. enhance the nurses ability to feelings in a
only or by the brain of 2. Keep distractions such listen. coherent, logical,
raising certain Patient as television and radio 3. Excluding the patient from an goal-directed
eyebrows neurotransmit expresses at a minimum when interaction increases the manner.
patient ters as thoughts and talking to patient. patients sense of frustration Patient used a
replies to evidenced feelings in a 3. Avoided talking with and feeling of helplessness. form of
questions in by: Alogia coherent, others in front of the 4. Loud talking does not improve communication
short logical, goal- patient as though he or the patients ability to to get needs met
sentences Rationale: directed she comprehends understand if the barriers are and to relate
patient Schizophreni manner. nothing. primary language, aphasia, or effectively with
barely a patients Patient uses 4. Do not speak loudly a sensory deficit. people and his or
initiates often have a form of unless patient is 5. Patients may have defect in her environment.
communicat trouble with communicatio hearing-impaired. field of vision or they may Patient spent
ion common n to get 5. Maintained eye contact need to see the nurses face time with one or
(+) social cues needs met with patient when or lips to enhance their two other people
looseness that most and to relate speaking. Stand close, understanding of what is in structured
association people do effectively within patients line of being communicated. activity neutral
and with people vision (generally 6. Individuals with expressive topics.
recognize and his or her midline). aphasia may talk more easily
without environment. 6. Given the patient when they are rested and
thinking, Patient ample time to respond. relaxed and when they are
body spends time 7. Use clear or simple talking to one person at a
language, with one or words, and keep time.
eye-contact, two other directions simple as 7. Client might have difficulty
 gesturing, people in well. processing even simple
varying the structured 8. When you do not sentences.
tone of the activity understand a client, let 8. Pretending to understand
voice. neutral topics. him/her know you are limits your credibility in the
having difficulty eyes of your client and
Psychiatric understanding. lessens the potential for trust.
mental health 9. When client is ready, 9. Helping client to use tactics to
nursing book introduce strategies lower anxiety can help
6th edition by that can minimize enhance functional speech
Videbeck anxiety and lower 10. Even if the words are hard to
voices and worrying understand, try getting to the
thoughts feelings behind them.
10. Use therapeutic
techniques (clarifying
feelings when speech
and thoughts are
disorganized) to try to
understand clients
concerns.

NURSING CARE PLAN 4

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for At the end of 1. Frequently assessed 1. Early detection and GOAL MET:
nag wild Violence: 2 weeks of clients behavior for intervention will prevent the
ko others nursing signs of increased possibility of harm to self or Patient
gilabay directed r/t intervention agitation and others, and decrease the responded to
nako ang Rage the client is hyperactivity. need for seclusions. external control
pagkaon sa reaction as expected to: 2. Used a calm and firm 2. Provides structure and control and did not
akong evidenced Patient will approach. for a client who is out of display violent
gisugo, by: history of respond to 3. Remained neutral as control. behavior towards
gibira nako aggressive external possible; Do not argue 3. Client can use others. Patient
iyahang behavior controls with the client; inconsistencies and value did not exhibit
buhok as Patient will 4. Maintained a judgments as justification for signs and
verbalized Rationale: display consistent approach, arguing symptoms of
by the People who nonviolent employ consistent 4. Clear and consistent limits aggressive
patient have behavior expectations, and and expectations minimize behaviors such
when asked schizophreni toward others provide a structured potential for clients as mood swings,
about cause a have an Patient will environment. manipulation of staff. agitation, social
of altered reality not exhibit 5. Redirected agitation 5. Can help to relieve pent-up withdrawal
admission perception. signs and and potentially violent hostility and relieve muscle
They may symptoms of behaviors with physical tension.
Objective: able to hear Aggressive outlets in an area of 6. Helps decrease escalation of
history of and see behaviors low stimulation anxiety
Aggressive things that do such as mood 6. Decreased 7. quiet environment and firm
behavior not exist, swings, environmental stimuli limit setting
and Alcohol speak in agitation, 7. Alert staff if a potential 8. Have a guideline for what
abuse weird or social for seclusion appears might work best for the
unclear ways, withdrawal imminent. individual client.
and believe 8. Took note the
that someone behaviors;
is trying to interventions; what
hurt them, or seemed to escalate
even feel like agitation; what helped
someone is to calm agitation; when
constantly as-needed (PRN)
watching medications were
them given and their effect;
and what proved most
Psychiatric helpful.
mental health
nursing book
6th edition by
Videbeck
 NURSING CARE PLAN 5

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for At the end of 1. Assessed for the 1. Behavioral and physiological GOAL MET:
Patient Ineffective 2 weeks of presence of defining responses to stress can be
wrote in a individual nursing characteristics. varied and provide clues to Patient
letter Dr. coping r/t intervention 2. Set a working the level of coping difficulty. communicated
Maam and Inadequate the client is relationship with the 2. An ongoing relationship needs, identifies
my family support expected to: patient through establishes trust, reduces the personal
kamusta na system as continuity of care. feeling of isolation, and may strengths and
kayo dyan evidenced Patient will 3. Assisted patient set facilitate coping. accepts support
sa atin? My by: inability to communicate realistic goals and 3. Involving patients in decision through the
birthday contact family needs identify personal skills making helps they move nursing
wish is to members Patient will and knowledge. toward independence. relationship.
see you my identify 4. Provided chances to 4. Verbalization of actual or Patient
family in my Rationale: personal express concerns, perceived threats can help verbalized
birthday. support strengths and fears, feeling, and reduce anxiety feelings related
system accepts expectations. 5. Acknowledging and to emotional
Objective: increases support 5. Used empathetic empathizing creates a state.
Past levels of well- through the communication. supportive environment Patient stated
history of being and nursing 6. Conveyed feelings of 6. An honest relationship positives views
Alcohol helps relationship. acceptance and facilitates problem-solving about self
Past patients with Patient will understanding. Avoid and successful coping
history of schizophreni verbalize false reassurances. 7. Participation gives a feeling of
aggressive a as well as feelings 7. Encourage patient to control and increases self-
behavior patients related to make choices and esteem.
Inability to recovering emotional participate in planning 8. During crises, patients may
contact from alcohol state. of care and scheduled not be able to recognize their
family and drug Patient will activities. strengths
members abuse to state positive 8. Encourage the patient 9. Interventions that improve
have a better views about to recognize his or her body awareness such as
prognosis. self own strengths and exercise.
abilities. 10. It can be helpful for the
Psychiatric 9. Consider mental and patient to recognize that he or
mental health physical activities she has the skills and
nursing book within the patients reserves of strength to
6th edition by ability effectively manage the
Videbeck 10. Assist patients with situation
accurately evaluating
the situation and their
own accomplishments.