University of St.

La Salle
College of Nursing

Nursing Care Plan

Name of Student: _Aljean Altheo L. Artillo__________________________________________ Section and Group: __BSN-3B / Group 1 / Case ________
Name of CI: __Tita Senal RN, MN, PhD _________________________________________________ Area of Exposure: _Bacolod City Mental Health Care Center ___

Rationale/Pathophysiologic
Assessment Cues Nursing Diagnosis Goals/Desired Outcome Nursing Intervention Rationale Evaluation
Basis 

Subjective Cues: Disturbed thought Predisposing factors: After 8 hours of nursing Independent:
Patient verbalized process r/t ➢ Female intervention the patient
“May Schizophrenia aeb ➢ History of abuse will be able to:  Attempt to  Important clues to
gakabatyagan gid Irritability, understand the underlying fears and
ako nga tawo nga behavioral change, Precipitating factors: Short Term significance of these issues can be found in
gusto ako sakiton.” suspiciousness & ➢ Drug abuse beliefs to the client the client’s seemingly
wandering aimlessly
-Patient will verbalize at the time of their illogical fantasies.
High “Expressed Emotion”
recognition of delusional presentation.
Definition: Living in a n environment with
Objective Cues: Disturbed Thought extensive negative comments thoughts if they persist.
-Irritability Processes describes expressed towards the patient (↑  Recognizes the  Recognizing the
-Behavioral an individual with risk of relapse) -Patient will demonstrate client’s delusions as client’s perception
changes altered perception satisfying relationships the client’s can help you
Suspiciousness and cognition that with real people. perception of the understand the
-Wandering interferes with daily environment. feelings he or she is
aimlessly living. Causes are Suspected usage of prohibited -Patient will demonstrate experiencing.
-Looks unkempt biochemical or drug as influenced by her decrease anxiety level.
psychological current boyfriend.  Identify feelings  When people believe
disturbances like -Patient will refrain from related to delusions. that they are
Strength: depression and acting on delusional For example: understood, anxiety
personality Abnormalities of
-Strong family thinking. A. ) If client believes might lessen.
disorders. The focus neurotransmitter (mainly
support someone is going to harm
of nursing is to dopamine) transmission in
reduce disturbed various regions of the brain -Patient will sustain him/her, client is
Weakness: thinking and attention and experiencing fear.
-Incomprehensible promote reality concentration to complete B. ) If client believes
orientation. ↑ dopaminergic transmission in task or activities. someone or something is
mesombolic projection controlling his/her
Source/Reference: -Patient will state that the thoughts, client is
Herdman, H. T., & “thoughts” are less experiencing
Kamitsuru, S.
(2019). Supplement Dopaminergic neurons here to
to NANDA project into the limbic system,
International responsible for behaviors and
Nursing Diagnoses: emotions.
Definitions and
Classification,
2018–2020 (11th Abnormal dopamine
Edition): New transmission here is thought to
things you need to
cause symptoms of
know (1st ed.).
Schizophrenia
Thieme.
Suspiciousness (general fear of
others’ intentions)
Wandering aimlessly
(persistent, unusual thoughts or
beliefs)
Irritability (Difficulty of
thinking clearly)
Behavioral change (mood
swings)
Disturbed thought process r/t
Schizophrenia aeb Irritability,
behavioral change,
suspiciousness & wandering
aimlessly
intense and less frequent
with the help of the
medications and nursing
interventions.
-Patient will demonstrate
two effective coping skills
that minimize delusional
thoughts.
-Patient will talk about
concrete happenings in
the environment without
talking about delusions
for 5 minutes.
Long Term
-Patient will be free from
delusions or demonstrate
the ability to function
without responding to
persistent delusional
thoughts.
helplessness.
 Explain the  When the client has
procedures and try full knowledge of
to be sure the client procedures, he or she
understand the is less likely to feel
procedures before tricked by the staff.
carrying them out.
 Interact with clients  When thinking is
on the basis of focused on reality-
things in the based activities, the
environment. Try to client is free of
distract client from delusional thinking
their delusions by during that time.
engaging in reality- Helps focus attention
based activities (e.g., externally.
card games, simple
arts and crafts
projects etc).
 Do not touch the  Suspicious clients
client; use gestures might misinterpret
carefully. touch as either
aggressive or sexual
in nature and might
interpret it as
threatening gesture.
People who are
psychotic need a lot
of personal space.
 Initially do not argue  Arguing will only
with the client’s increase client’s
beliefs or try to defensive position,
convince the client thereby reinforcing
that the delusions false beliefs. This will
are false and unreal. result in the client
feeling even more
isolated and
misunderstood.
Reference:
Munir S, Quintanilla Rodriguez
BS, Waseem M. Addison
Disease. [Updated 2022 Jan 9].
In: StatPearls [Internet].
Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available
from:
https://www.ncbi.nlm.nih.gov/b
ooks/NBK441994/
 Encourage healthy  All are vital to help
habits to optimize keep the client in
functioning: remission.
-Maintain medication
regimen.
-Maintain regular sleep
pattern.
-Maintain self-care.
-Reduce alcohol and drug
intake.
 Show empathy  The client’s delusion
regarding the client’s can be distressing.
feelings; reassure the Empathy conveys
client of your your caring, interest
presence and and acceptance of the
acceptance. client.
 Teach client coping  When client is ready,
skills that minimize teach strategies client
“worrying” 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.
 Utilize safety  During acute phase,
measures to protect client’s delusional
clients or others, if thinking might dictate
the client believe to them that they
they need to protect might have to hurt
themselves against a others or self in order
specific person. to be safe. External
Precautions are controls might be
needed. needed.