NCP and FDAR

KIW-IS KRISTIAN KARL B.

DATA GOALS/                  ACTION/ NURSING RATIONALE RESPONSE &

Expected INTERVENTIONS
EVALUATION
outcomes

Subjective STG: within Accept the fact that the Validating that your Goal Fully Met
findings:” may ___8___hour/s of voices are real to the reality does not include
STG: within
naririnig akong NI the patient will client, but explain that voices can help client
___8___hour/s
boses babaeng be able to you do not hear the cast “doubt” on the
of NI the
nagsasalita’’ voices. Refer to the voices validity of his or her
Demonstrate patient was
as “your voices” or voices.
Objective techniques that able to
“voices that you hear”.
findings:  help distract him
Demonstrate
from the voices.
Seen laughing techniques
by him only, as Be alert for signs of that help
Might herald
becoming manifested/evide increasing fear, anxiety or distract him
hallucinatory activity,
aggressive and nced by: agitation. from the
which can be very
always shouting. voices.
Absence of panic frightening to client, and
Poor appetite, attacks client might act upon as
unable to sleep command hallucinations manifested/evi
LTG: after
and hearing a (harm self or others). denced by:
_3__days of NI
female voice in
the patient will be Absence of
his ear.
able to: panic attacks
Explore how the Exploring the
Depressed and
Maintain role hallucinations are hallucinations and Goal Partially
at the same
performance. experienced by the client. sharing the experience Met
time became
can help give the person
anxious and as manifested by: LTG: after
a sense of power that
experienced _3__days of NI
Absence of he or she might be able
panic attacks the patient
auditory to manage the
was able to:
Suspicious and hallucinations hallucinatory voices.
verbally Help the client to identify Maintain role
assaultive the needs that might performance.
underlie the Hallucinations might
Overly paranoid as manifested
hallucination. What other reflect needs for anger,
by:
Focus/ Nursing ways can these needs be power, self-esteem, and
Dx: (PE/S) met? sexuality. Absence of
auditory
Disturbed
hallucinations
Sensory
Perception Help client to identify
Related to times that the Helps both nurse and
Altered sensory hallucinations are most client identify situations
perception as prevalent and frightening. and times that might be
manifested by most anxiety-producing
suspicious and and threatening to the
verbally client.
assaultive
If voices are telling the
secondary to
client to harm self or
Paranoid
others, take necessary
Schizophrenia
environmental
precautions.

 Notify others and

police, physician,
 and administration
according to unit
protocol.
 If in the hospital, People often obey
use unit protocols hallucinatory commands
for suicidal or to kill self or others. Early
threats of violence assessment and
if client plans to act intervention might save
on commands. lives.
Clearly, document what the
client says and if he/she is a
threat to others, document
who was contacted and
notified (use agency
protocol as a guide).

Stay with clients when they

are starting to hallucinate,
and direct them to tell the
“voices they hear” to go
away. Repeat often in a
matter-of-fact manner.

The client can sometimes

learn to push voices aside
Decrease environmental when given repeated
stimuli when possible (low instructions, especially
noise, minimal activity). within the framework of a
trusting relationship.

Intervene with one-on-one,

seclusion, or PRN Decrease the potential for
medication (As ordered) anxiety that might trigger
when appropriate. hallucinations. Helps calm
client.

Intervene before anxiety

Keep to simple, basic, begins to escalate. If the
reality-based topics of client is already out of
conversation. Help the control, use chemical or
client focus on one idea at a physical restraints
time. following unit protocols.

Client’ thinking might be

confused and
disorganized; this
intervention helps the
Work with the client to find client focus and
which activities help reduce comprehend reality-based
anxiety and distract the issues.
client from a hallucinatory
material. Practice new skills
with the client.
If clients’ stress triggers
 hallucinatory activity, they
might be more motivated
to find ways to remove
Engage client in reality- themselves from a
based activities such as card stressful environment or
playing, writing, drawing, try distraction techniques.
doing simple arts and crafts
or listening to music.

F> Disturbed Sensory Perception Related to Altered sensory perception as manifested by suspicious and verbally
assaultive secondary to Paranoid Schizophrenia

D> Received sitting on bed awake and alert. Seen laughing by him only, becoming aggressive and always
shouting. Poor appetite, unable to sleep and hearing a female voice in his ear. Depressed and at the same time
became anxious and experienced panic attacks. Suspicious and verbally assaultive, overly paranoid. V/S: BP:
110/80, PR: 78, T: 36.4, SPO2:97%, RR: 15

A> Accepted the fact that the voices are real to the client, but explain that you do not hear the voices. Noted
and alert for signs of increasing fear, anxiety or agitation. Explored how the hallucinations are experienced by
the client. Helped the client to identify the needs that might underlie the hallucination. Helped client to identify
times that the hallucinations are most prevalent and frightening. Documented what the client says and if he is a
threat to others, document who was contacted and notified (use agency protocol as a guide). Stayed with clients
when they are starting to hallucinate, and direct them to tell the “voices they hear” to go away. Decreased
environmental stimuli when possible (low noise, minimal activity). Intervened with one-on-one, seclusion, or
PRN medication (As ordered) when appropriate. Kept to simple, basic, reality-based topics of conversation.
Helped the client focus on one idea at a time.

R> Patient was able to identify to personal interventions that decrease or lower the intensity or frequency of
hallucinations (e.g, listening to music, wearing headphones, reading out loud, jogging, socializing).