Name: Azarcon, Rogen Kate

Section: N31
Subject: Psychiatric Nursing RLE

NURSING CARE PLAN NO. 1

CUES NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective cues: Impaired social Short term goal: Independent: Short term goal:
● No subjective interaction related
cues were noted difficulty communication Within 1 hour of nursing 1.Assess with client 1.Increased anxiety can After 1 hour of nursing
intervention, the patient symptoms he intensify agitation, intervention, the patient
and inadequate
will be able to experiences when he or aggressiveness, and was able to
Objective cues: emotional response demonstrate trust in she begins to feel suspiciousness. demonstrate trust in
caregiver as evidenced anxious around others. caregiver as evidenced
● Inappropriate by facial by facial
emotional responsiveness and responsiveness and
response/ Flat eye contact within 2. Keep client in an 2.Client might respond eye contact within
affect specified time environment as free of to noises and crowding specified time
● Unable to make stimuli (loud noises, with agitation, anxiety,
eye contact Long term goal: crowding) as possible. and increased inability Long term goal
● Observed use of to concentrate on
unsuccessful Within 3 days of nursing outside events. After 3 days of nursing
social intervention the patient intervention the patient
interactions will initiate social 3. Develop a 3.Therapeutic was able initiate social
behaviors interaction (physical, therapeutic nurse-client relationship promotes interaction (physical,
● Use of verbal, nonverbal) with relation through understanding and can verbal, nonverbal) with
monotone caregiver by discharge frequent brief contacts help establish a caregiver by discharge
● Lack of gestures from treatment and an accepting constructive from treatment
when speaking attitude. relationship between
● Unable to the nurse and the client.
respond to
some questions 4.Avoid touching the 4.Touch by an unknown
● Slow to respond client. person can be
questions misinterpreted as a
sexual or threatening
gesture. This is
particularly true for a
paranoid client.
5.Structure activities 5.Client can lose
that work at the client’s interest in activities that
pace and activity. are too ambitious,
which can increase a
sense of failure.

6. If client is unable to 6.An interested

respond verbally or in a presence can provide a
coherent manner, sense of being
spend frequent, short worthwhile.
period with clients.

7.Provide opportunities 7. Social skills training

for the client to learn helps the client adapt
adaptive social skills in and function at a higher
a non-threatening level in society, and
environment. Initial increases the client’s
social skills training quality of life.
could include basic
social behaviors (e.g.,
appropriate distance,
maintain good eye
contact, calm
manner/behavior,
moderate voice tone).

8.Try to incorporate the 8.Increase likelihood of

strengths and interests client’s participation and
the client had when not enjoyment.
as impaired into the
activities planned.

9. Offer to remain with 9.Presence of a trusted

client during initial individual provides a
interactions with others. feeling of security to the
client.
 10. Act as role for client 10. Role modeling of a
through appropriate respected individual is
interactions with others one of the strongest
form of learning

NURSING CARE PLAN NO. 2

CUES NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective cues: Disturbed thought Short term goal: Independent: Short term goal:
“Hi my name is Bill…. I process related to
like T-shirts…. I like ice neurobiological Within 3 hours of 1. Assess attention 1. Determine ability to After 3 hours of nursing
cream…” as verbalized alteration related to nursing intervention, the span/distractibility and participate in planning intervention, the pt was
by the pt. Schizoaffective pt will be able to show ability to make and executing care able to show increased
Disorder increased concentration decisions or problem concentration
solve.
Objective cues:
● Alogia Long term goal: 2. Orient client 2.Brief frequent Long term goal:
● Flat affect continuously to actual orientation helps the pt
● Unable to make Within 3 days of nursing environment, place, to realize the reality. After 3 days of nursing
eye contact intervention the patient persons, time and date, intervention the patient
● Looseness of will be able to maintain when needed. was able to maintain
association is reality orientation and reality orientation and
 noted; “I..my communication with communication with
name is Bill. I others. 3. Use touch cautiously, 3. Clients who are others.
am from a particularly if thoughts suspicious may
different country. reveal ideas of perceive touch as
There are many persecution. threatening and may
bugs in my respond with
house” aggression.
● Flight of ideas is
observed; chair 4. Give positive 4.Positive
and table= reinforcement as client reinforcement
“They are not is able to differentiate enhances self-esteem
the same. One between reality based and encourages
is plastic the and non-reality based repetition of desirable
other one… I thinking behaviors
have some blue
chairs”
● Circumstantiality 5.Use the techniques of 5. These techniques
is noted; Poetry consensual validation reveal to the client how
and Painting= and seeking clarification he is being perceived
“Red, yellow, when communication by others, while the
green, blue, reflects alteration in responsibility for not
frame. They are thinking (Examples: “Is understanding is
not the same” it that you mean ...?” or accepted by the nurse.
“I don’t understand
what you mean by that.
Would you please
explain?”)

6. Use of real situations

6. Reinforce and focus and events to divert
on reality. Talk about client away from long,
real events and real purposeless, repetitive
people. verbalizations of false
ideas.

7. Perform periodic 7.Early recognition of

neurological/behavioral changes promotes
assessments, as proactive modifications
indicated, and compare to plan of care.
with baseline.
8. This helps patient to
8. Help the patient concentrate on reality
focus on one idea at a based issues.
time

9. Encourage patient to 9. These will serve as

participate in therapies, diversional activities
activities and exercises. decreasing the anxiety

10. Teach client some 10. These are

coping skills that he will fundamental skills for
need such as dealing with the world,
conversational and which everyone uses
assertiveness skills daily with more or less
skill.