In partial fulfillment of the requirements for the subject NCM 117

NURSING CARE PLAN

Submitted by:
Ingrid Valerie R. Balendez
3 BS Nursing – Block E

Submitted to:
Mrs. Gemma V. Panal RN N LPT

March 22, 2021

ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

 INTERVENTIONS

Attempt to Important clues to

“Ako ang hari Disturbed At the end of 8 understand the underlying fears and Goal Met
sa mga thought hours of nursing significance of these issues can be found
engkanto” As process r/t intervention, the beliefs to the client at in the client’s After 2 weeks of
verbalized by overwheling patient will be able the time of their seemingly illogical nursing
the patient. stresful life to: presentation. fantasies. intervention, the
events as patient was able
evidenced by  Verbalize Recognizes the to:
hallucination recognition of client’s delusions Recognizing the
s delusional as the client’s client’s perception  Verbalize
thoughts if perception of the can help you recognition of
they persist. environment. understand the delusional
feelings he or she is thoughts when
 Perceive the Explain the they persist.
experiencing.
environment procedures and try
correctly.  perceive the
to be sure the client When the client has
environment
 Demonstrate understands the full knowledge of
correctly.
satisfying procedures before procedures, he or
relationships carrying them out. she is less likely to  demonstrate
with real feel tricked by the satisfying
people. Interact with clients staff. relationships
on the basis of with real people.
 Demonstrate things in the
decrease environment.  demonstrate
anxiety level. When thinking is decrease
focused on reality- anxiety level.
 Refrain from based activities, the
acting on Try to distract client  refrain from
client is free of
delusional from their delusions acting on
delusional thinking
thinking. delusional
 thinking.
At the end of 2 by engaging in during that time.
weeks of nursing reality-based  develop trust
intervention, the activities. Helps focus in at least one
patient will be able attention externally. staff member
to: Do not touch the within 1 week.
client; use gestures
 Develop trust carefully.  sustain
in at least attention and
one staff Suspicious concentration to
member clients might complete task or
within 1 misinterpret touch activities.
week. as either aggressive  state that the
or sexual in nature “thoughts” are
 Sustain and might interpret it
attention and less intense and
as threatening less frequent
concentration gesture. People who
to complete Initially do not with the help of
argue with the are psychotic need the medications
task or a lot of personal
activities. client’s beliefs or try and nursing
to convince the space. interventions.
 State that the client that the
“thoughts” Arguing will only  talk about
delusions are false
are less increase client’s concrete
and unreal.
intense and defensive position, happenings in
less frequent thereby reinforcing the environment
with the false beliefs. This without talking
help of the will result in the about delusions
medications client feeling even for 5 minutes.
and nursing more isolated and
misunderstood.  demonstrate
interventions. two effective
 Talk about coping skills that
 concrete minimize
happenings delusional
in the thoughts.
environment
 free from
without
delusions or
talking about
demonstrate the
delusions for
ability to
5 minutes.
function without
 Demonstrate responding to
two effective persistent
coping skills delusional
that minimize thoughts.
delusional
thoughts.
 Be free from
delusions or
demonstrate
the ability to
function
without
responding to
persistent
delusional
thoughts.

ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTIONS
“Gi hapak ko Risk for At the end of 8 Frequently assess Early detection Goal Met
sa akong anak” violence: other hours of nursing client’s behavior for and intervention
as sverbalized directed r/t intervention, the signs of increased of escalating After 2 weeks of
by the mother. psychotic patient will be able agitation mania will prevent nursing
symptomatolog to: and hyperactivity. the possibility of intervention, the
y as evidenced harm to self or patient was able to:
by  Verbalize others and
hallucinations control of decrease  Verbalize
feelings. the need for control of
seclusions. feelings.
 Refrain from
verbal threats Provides structure  Refrain from
and loud, Use a calm and and control for a verbal
profane firm approach. client who is out threats and
language of control. loud, profane
toward language
others. Short attention toward
Use short, simple others.
span limits
 Respond to and brief
understanding to
external explanations or  Respond to
small pieces of
controls statements. external
information.
when controls
Remain neutral as when
potential or Client can use
possible; Do not potential or
actual loss of inconsistencies
argue with the actual loss of
control and value
client. control
occurs. judgments as
justification for occurs.
 Refrain from arguing and
provoking escalating mania.  Refrain from
others to provoking
physical Client can use others to
 Maintain a
harm. consistent approach, inconsistencies physical
employ consistent and value harm.
 Display expectations, and judgments as
nonviolent provide a structured justification for  Display
behavior environment. arguing and nonviolent
toward escalating mania. behavior
others. toward
Can help to others.
At the end of 2 Redirect agitation relieve pent-up
weeks of nursing and potentially hostility and  Seek help
intervention, the violent behaviors relieve muscle when
patient will be able with physical outlets tension. experiencing
to: in an area of low aggressive
stimulation. impulses.
 Seek help
when Helps decrease  Be safe and
Decrease
experiencing escalation of free from
environmental
aggressive anxiety and manic injury.
stimuli.
impulses. symptoms.

 Be safe and
free from
injury.