ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Disturbed though After 8 hours of 1. Ensure safety of the 1. Safetyness of the
“mulupad baya ko ako process related to nursing interventions client. client is priority.
baya si superman possibility of the client will be able 2. Assess and observe 2. Intervene before
ayaw lang banha sa hereditary factor. to Patient will sustain clients regularly for client loses control.
uban kay maulaw ko” attention and signs of increasing 3. Suspicious clients
as verbalized. Scientific basis: concentration to anxiety and hostility. will automatically
The most common complete task or 3. Be aware of client’s think that they are the
OBJECTIVE DATA: early warning signs of activities. tendency to have ideas target of the
-talking to the wall schizophrenia are of reference; do not do interaction and
-suspicious eyes usually detected until things in front of client interpret it in a
-delusions adolescence. These that can be negative manner.
-inaccurate include depression, misinterpreted such as 4. Recognizing the
interpretation of social withdrawal, laughing or client’s perception can
environment unable to concentrate, whispering. help you understand
-memory deficit hostility or 4. Recognizes the the feelings he or she
-disorganized thought suspiciousness, poor client’s delusions as is experiencing.
-Inappropriate non- expressions of the client’s perception 5. When people
reality-based thinking emotions, insomnia, of the environment. believe that they are
lack of personal 5. Identify feelings understood, anxiety
hygiene, or odd related to delusions might lessen.
beliefs. Schizophrenia like if client believes 6. When thinking is
refers to a group of someone is going to focused on reality-
severe, disabling harm him/her, client is based activities, the
psychiatric disorders experiencing fear. client is free of
marked by withdrawal 6. Interact with delusional thinking
from reality, illogical clients on the basis during that time.
thinking, possible Helps focus attention
of things in the
delusions and externally.
hallucinations, and environment. Try to 7. Suspicious clients
emotional, behavioral, distract client from might misinterpret
or intellectual their delusions by touch as either
disturbance. engaging in reality- aggressive or sexual in
based activities nature and might
interpret it as
(e.g., card games, threatening gesture.
simple arts and 8. Arguing will only
crafts projects etc). increase client’s
7. Do not touch the defensive position,
client; use gestures thereby reinforcing
carefully. false beliefs.
8. Initially do not argue 9. This help to keep
the client in remission.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUA
SUBJECTIVE DATA: Anxiety related to actual After 5 hours of nursing  Maintain calm and,  Client develops
“mahadlok ko mugawasa or perceived threat to intervention the client will non threatening feeling of security in
ug balay kay basin niya biologic integrity. be able to reduce own manner while working presence of calm staff
naay taw mupasakit nako” anxiety level as with the client . person.
as verbalized. Scientific basis: manifested by:  Establish and  Therapeutic skills
Neural circuitry involving -appears calm and relax maintain a trusting need to be directed
OBJECTIVE DATA: the amygdala and -no signs of discomfort relationship by toward putting the
-pacing back and forth hippocampus is thought to -stop pacing back and listening to the client; client at ease, because
-restlessness underlie anxiety. When forth displaying warmth, the nurse who is a
-decreased attention span confronted with answering questions stranger may pose a
-appears discomfort unpleasant and potentially directly, being threat to the highly
-poor impulse control harmful stimuli such as available and anxious client.
foul odors or tastes, PET- respecting the client’s  The client’s safety is
scans show increased use of personal space. utmost priority. A
bloodflow in the  Remain with the client highly anxious client
amygdala. In these at all times when should not be left
studies, the participants levels of anxiety are alone as his anxiety
also reported moderate high (severe or panic); will escalate.
anxiety. reassure client of his  Anxious behavior
or her safety and escalates by external
security. stimuli.
 Move the client to a  The client will feel
quiet area with more secure if you
minimal stimuli such are calm and inf the
as a small room or client feels you are in
 seclusion area (dim control of the
lighting, few people, situation.
and so on.)  Pharmacological
 Maintain calmness in therapy is an effective
your approach to the treatment for anxiety
client. disorders.
 Educate the patient  During a panic attack,
and/or SO that anxiety the patient needs
disorders are treatable. reassurance that he is
 Stay with the patient not dying and the
during panic attacks. symptoms will
Use short, simple resolve
directions. spontaneously.
 Avoid asking or  The client may not
forcing the client to make sound and
make choices. appropriate decisions
 Encourage the client’s or may unable to
participation in make decisions at all.
relaxation exercises  Relaxation exercises
such as deep are effective non-
breathing, progressive chemical ways to
muscle relaxation, reduce anxiety.
guided imagery,  So the client can start
meditation and so using relaxation
forth. techniques; gives the
 Teach signs and client confidence in
symptoms of having control over
escalating anxiety, his anxiety.
and ways to interrupt
its progression (e.g.,
relaxation techniques,
deep- breathing
exercises, physical
exercises, brisk walks,
jogging, meditation).