Subjective Objective Assessment Planning Nursing Intervention Rationale Evaluation

> Lonely Social At the end of - Identify with the -Increased

> Blunted affect Isolation/Impaire our two weeks client symptoms he anxiety can
> Appears upset d Social exposure, our experiences when he identify
> anxious Interaction client will be begins to feel anxious agitation,
> Inappropriate Related to able to: around others aggressiveness
emotional Impaired thought -participate in and
response processes group activity suspiciousness
> wants to be -improve social
alone skills, -Keep client in an -Client might
> poor eye interactions environment as free of respond to
contact -shows interest stimuli (loud noises, noises and
to start coping crowding) as possible crowding with
skills training agitation,
anxiety and
increased
inability to
concentrate on
outside events

-Ensure that the goal -avoid pressure

set are realistic, on the client and
whether sense of failure
In the hospital or in the on part of the
community nurse/family,
this sense of
failure can lead
to mutual
withdrawal

-Structure activities that -Client can lose

work at the client’s interest in
pace and activity. activities that
are too
ambitious,
which can
increase sense of
failure.

-Structure time each -Helps client to

day to include planned develop a sense
times for brief of safety in a
interactions and nonthreatening
activities with the client environment
on a one-on-one basis

-If client is -Even simple

delusional/hallucinating activities help
or having trouble draw client
concentrating at this away from
time, provide very delusional
simple concrete thinking into
activities with the client reality in the
(looking at a picture or environment
doing painting)

-Teach client to remove -teach client

himself briefly when skills on dealing
feeling agitated and with anxiety and
work on some anxiety increasing a
relief exercise sense of control
(medications, rhythmic
exercise, deep
breathing exercise)
 -Eventually engage
other clients and - Client
significant others in continues to feel
social interactions and safe and
activities with the client competent in a
(chess game, sing-a- graduate
song, group sharing hierarchy of
activities) at client’s interactions
level

Subjective Objective Assessment Planning Nursing Rationale Evaluation

Intervention

>Altered Disturbed At the end of our - Accept the fact - Validating that
communication Sensory two weeks that the voices his reality does
pattern Perception: exposure, our are real to the not include voices
> Auditory Auditory/Visual client will be client, but can help client
disorientation to related to able to: explain that you cast “doubt” on
person, place, psychologic -learn ways to do not hear the validity of his
time stress refrain from voices. Refer to or her voice
> hallucinations responding to the voices as
> frequent hallucinations “voices that you
blinking of the -identify its own hear”
eyes level of anxiety
> mumbling to -demonstrate -explore how the - Exploring the
oneself, talking techniques that hallucinations are hallucinations and
or laughing to help distract him experienced by sharing the
oneself from the voices the client experience can
help give the
person a sense of
 power that he
might be able to
manage the
hallucinatory
voices

-If voices are - People often

telling the client obey hallucinatory
to harm himself Early assessment
or others take and intervention
necessary might save lives.
environmental
precautions.
* Notify others
and police,
physician, an
administration
according to unit
protocol
* If in the
hospital, use unit
protocols for
suicidal or
threats of
violence if client
plans to act on
command
* If in the
community,
evaluate the need
for
hospitalization
- Decrease - Decrease the
environmental potential for
stimuli when anxiety that might
possible (low trigger
noise, minimal hallucinations.
activity) Help calm the
client

- Keep to simple, - Client’s thinking

basic, reality- might be confused
based topics of and disorganized,
conversation. this intervention
Help the client helps the client
focus on one idea focus and
at a time comprehend
reality-based
issues.

- Engage client in - Redirecting the

reality-based client’s energies
activities such as to acceptable
a card playing, activities can
writing, drawing, decrease the
doing simple arts possibility of
and crafts or acting on
listens to music hallucinations and
help distract from
voices.
Subjective Objective Assessment Planning Nursing Rationale Evaluation
Intervention

> Delusions Disturbed At the end of our - Recognizes the -Recognizing the
> Inaccurate Thought Process two weeks client’s delusions client’s
interpretation of related to panic exposure, our as the client’s perception can
environment level of anxiety client will be perception of the help understand
> Inaccurate non- able to: environment the feeling he’s
reality-based -verbalize experiencing
thinking recognition of
> memory delusional -Identify feelings - When people
problems thoughts if it related to believe that they
persists delusions. For are understood,
-demonstrate example: anxiety might
satisfying * If client lessen.
relationships believes someone
with real people is going to harm
- demonstrate him, client is
decreased experiencing
anxiety level fear.
Refrain from * If client
acting on believes someone
delusional or something is
thinking controlling his
thoughts, client is
experiencing
helplessness

-interact with - When thinking

clients on the is focused on
basis of things in reality-based
the environment. activities, the
Try to distract client is free of
client from their delusional
delusions by thinking during
engaging in that time. Help
reality-based focus attention
activities (card externally.
games, simple
arts and crafts)