Assessment Nursing diagnosis Goals Intervention Implementation Evaluation

Subject Disturbed thought The client  Be sincere and honest  Be sincere and The client
data: processes related to will respond when communicating honest when responded to
Patient says disruption in to reality- with the client. commnicating with reality-based
that his wife cognitive based Avoid vague or evasive the client interactions
has relations operations and interactions remarks. initited by
with other activities evidenced initiated by others
man. by non-reality- others  Be consistent in setting  Be consistent in
based thinking. expectations, enforcing setting expectations,
rules, and so forth. enforcing rules, and
so forth.
 Do not make promises  Do not make
that you cannot keep promises that you
cannot keep

 Encourage the client to  Encourage the client

talk with you, but do not to talk with you, but
pry or cross-examine for do not pry or cross-
information examine for
information
 Explain procedures, and  Explain procedures,
try to be sure the client and try to be sure the
understands the client understands
procedures before the procedures
carrying them out. before carrying them
Objective
data: out.
He looks
 Give positive
suspicious  Give positive feedback feedback for the
and does not for the client’s sucesses. client’s successes
even eat
food.
Assessment Nursing Diagnosis Goals Intervention Implementation Evaluation
Subjective Disturbed personal To establish  Reasssure the client that  Reasssured the client Established
Data: identity related to contact with the environment is safe that the environment contact with
Patient inability to reality by briefly and simply is safe by briefly and reality
complains distinguish between evidenced by explaining routines simply explaining evidenced by
that his wife self and non-self client will routines client
is not faithful evidenced by participate in  Protect the client from  Protected the client participate in
to him bizarre behavior. the harming himself or from harming the therapeutic
therapeutic others himself or herself or milieu
milieu others
 Remove the client from  Removed the client
from the group if his or from the group if his
her behavior becomes or her behavior
too bizarre, disturbing, becomes too bizarre,
or dangerous to others. disturbing, or
dangerous to others.
 Help the client’s group  Help the client’s
accept the client’s group accept the
“strange” behavior. client’s “strange”
behavior.
 Consider the other  Considered the other
client’s needs. Plan for clients needs. Plan
at least one staff for at least one staff
member to be available member to be
to other clients available to other
Objective
data: clients
 Explain to other clients  Explained to other
He express that they have not done
irritable clients that they have
anything to warrant the not done anything to
behavior. client’s verbal or warrant the client’s
physical threats verbal or physical
threats

Assessment Nursing Goals Inntervention Implementation Evaluation

 Diagnosis
Subjective Social isolation Increase  Provide attention in a  Provided attention in a Increased
data: patient related to feelings of sincere, interested sincere, interested feeling of
says that he aloneness self-worth manner. manner. self-worth
does not experienced by evidenced by evidenced
want to talk the individual and client will  Support any successes  Supported any successes by client
to anybody. perceived as demonstrate or responsibilities or responsibilities demonstrate
imposed by others appropriate fulfilled, projects, fulfilled, projects, appropriate
and as a negative emotional interactions with staff interactions with staff emotional
or threatening responses members and other members and other responses
state evidenced clients clients
by poor
interpersonal  Avoid trying to  Avoided trying to
relationships. convince the client convince the client
verbally of his or her verbally of his or her
Objective own worth. own worth.
data: patient
stays away  Teach the client social  Taught the client social
from all skill. Describe and skills. Describe and
people in the demonstrate specific demonstrate specific
ward. skills, such as eye skills, such as eye
contact, attentive contact, attentive
listening, nodding listening, nodding

 Help the client to  Assisted client in

improve grooming; improving grooming
assist when necessary when necessary

Assessment Nursing Goals Intervention Implementation Evaluation

diagnosis
Subjective Self-Care deficit Establish an  Be alert to the client’s  Alert to the client’s Established
data: the related to adequate physical needs physical needs an adequate
patient’s impaired ability balance of balance of
relative said to perform or rest, sleep,  Observe the client’s  Observed the client’s rest, sleep,
he does not complete and activity pattern of food and fluid pattern of food and fluid and activity
maintain bathing/hygiene evidenced intake; you may need to intake; you may need to evidenced
person activities for by the client monitor and record monitor and record by the client
hygiene. oneself will intake,output, and daily intake,output, and daily will
evidenced by complete weight weight complete
poor personal daily tasks daily tasks
hygiene with  Monitor the client’s  Monitored the client’s with
minimal elimintion patterns elimintion patterns minimal
assistance assistance
Objective  Exlain any task in short,  Exlained any task in
data: he simple steps short, simple steps
looks untidy
and umkept.  Using clear, direct
sentences, instruct the  Using clear, direct
client to do one part of the sentences, instruct the
task at a time client to do one part of
the task at a time

 Tell the client your  Told the client your

expectations directly. expectations directly.
Do not ask the client to Do not ask the client to
choose unnecessarily. choose unnecessarily.

 Allow the client ample  Allowed the client ample

time to comlete any task. time to comlete any task

Assessment Nursing Goals Intervention Implementation Evaluation

 dignosis
Subjective Ineffective Complete  If the client has delusions  The client has delusions Completed
data: the health necessary that prevent or limit rest, that prevent or limit rest, necessary daily
patient says maintence daily sleep, or food or fluid sleep, or food or fulid activies with
that he does related to activities intake , it may be intake, it is necessary to minimal
not have inability to with necessary to institute institute measures that assistance
intrest in identify, ma minimal measures that deal directly deal directly with health.
doing any assistanc with physical health.
activities e
 If the client thinks that his  The client thinks that his
or her food is poisioned or or her food is poisioned or
that he or she is not that he or she is not
worthy of food, it may be worthy of food, it may be
Objective necessary to alter necessary to alter
data: patient rountines. rountines.
does not take
care of self.
The does not  If the client is too  The client is too
sleep suspicious to sleep, try to suspicious to sleep, try to
properly. allow the client to choose allow the client to choose
a place and time in which a place and time in which
he or she will feel most he or she will feel most
comfortable sleeing. comfortable sleeing.
Sedatives as needed may Sedatives as needed may
be indicated be indicated
HEALTH EDUCATION

Family teachng on discharge plan

 Family’s to use alternative coping methods

 Educated regarding medication-dosage and side effects of the medication
 Advise to spend more time with patient

CONCLUSION

Schizophrenia involves a loss of contact with reality. People experiencing psychosis may exhibit
personality changes and thought disorder. Depending on its severity, this may be accompanied
by unusual or bizarre behavior, as well as difficulty with social interaction and impairment in
carrying out daily life activities.
 THEORY APPLICATION

Paplau’s Interpersonal theory:

The core of peplau’s approach is interpersonal relations. The theory includes the concept such as:

 Communication,
 Roles and
 Growth and development.
Communication us a problem solving process whereby the nurse the client collaborate to
meet the clients need. The nurse may assume the roles of:
 Counselor,
 Leader,
 Resource,
 Surrogate, and
 Teacher.

These roles are designed to lead to growth and development

Nursing diagnosis

 Disturbed thought processes related to disruption in cognitive operations and activities

evidenced by non- reality-based thinking
 Disturbed personal identity related to inability to distinguish between self and non-self
evidenced by bizarre behavior.
 Social isolation related to aloneness experienced by the individual and perceived as
imposed by others and as a negative or threatning state evidenced by poor interpersonal
relationships.
 Self-care deficit related related to impaired ability to perform or complete
bathing/hygiene activities for oneself evidenced by poor personal hygiene
 Ineffective health maintenance related to inability to identify, manage and seek out help
to maintain health evidenced by poor hygiene
 Disturbed auditory perception related to change in the patterning of incoming stimuli
accompanied by an impaired response to such stimuli evidenced by talking out loud when
no one is present.
 Growth and development

Orientation

- Estblished working relationship

- Collected history of illness
- Oriented to hospital
Identification
- Classify perceptions
- Identify problems
Teacher - Discussed the solutions

Resource Exploitation
Nurse Patient
- Create a non threatening atmosphere
Counselor
- Encourage client participation inCOMMUNICATION
problem solving
Resolution
Leader - Evaluated the outcomes
- Reduced anxiety
- Increased problems solving activities
Surrogate

Peplau’s Nurse-client Interpersonal Framework