URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student: Alipio, Rosemarie T. Year Level: BSN-3

Affiliating Agency/Area: Month/Year of Exposure:

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

(at least 10)

Subjective: Problem, Etiology, Signs Short Term Goal: Independent: Short Term Goal Evaluation
(P.E.S.) format S.M.A.R.T. + Evidence  Be honest and keep all  Honesty and dependability
“I do not believe that I promises. promote a trusting After 8 hours of nursing intervention
have schizophrenia” as Disturbed thought process After 8 hours of nursing relationship. patient is able to respond appropriately
verbalized by the related to delusion intervention patient will be to environmental stimuli
patient able to respond appropriately  Attempt to understand the  Important clues to underlying
to environmental stimuli significance of these beliefs fears and issues can be found GOAL MET
to the client at the time of in the client’s seemingly
their presentation. illogical fantasies.
Objective: INFERENCE Long Term Goal: Long term Goal Evaluation
(at least 5) Scientific Explanation S.M.A.R.T.+ Evidence  Explain the procedures and  When the client has full
 Agitated and (Diagram Form) try to be sure the client knowledge of procedures, he
threatening After 8 weeks of nursing understand the procedures or she is less likely to feel After 8 weeks of nursing
 Distractibilit intervention the client will be before carrying them out. tricked by the staff. intervention the client is able to
y able to know the reality and know the reality and will have lesser
 Egocentric will have lesser delusion delusion
 Inaccurate Educative
interpretatio  Encourage client to verbalize  Verbalization of feelings in a GOAL MET
n true feelings. The nurse nonthreatening environment
 Memory should avoid becoming may help client come to
Deficit defensive when angry terms with long-unresolved
feelings are directed at him issues.
V/S taken as or her.
follows:
BP: 140/80  Encourage healthy habits to  All are vital to help keep the
RR: 16 optimize functioning: client in remission.
PR: 78  Maintain medication
BMI: 25 regimen.
 Maintain regular sleep
pattern.
  Maintain self-care.
 Reduce alcohol and drug
intake.

 Teach client coping skills  When client is ready, teach

that minimize “worrying” strategies client can do alone.
thoughts. Coping skills
include:
 Going to a gym.
 Phoning a helpline.
 Singing or Listening to a
song.
 Talking to a trusted friend.
 Thought-stopping techniques
.
Therapeutic
 An assertive, matter-of-fact,  The suspicious client does
yet genuine approach is the not have the capacity to
least threatening to the relate to an overly friendly,
suspicious person overly cheerful attitude.

 Show empathy regarding the  The client’s delusion can be

client’s feelings; reassure the distressing. Empathy conveys
client of your presence and your caring, interest and
acceptance. acceptance of the client.

Dependent
 Mouth checks may be
necessary after medication
administration  To verify that client is
swallowing the tablets or
capsules. Suspicious clients
may believe they arebeing
poisoned with their
medication and attempt to
discard the pills.

Checked by: _________________________________ Date: ____________________

Clinical Instructor’s Name and Signature