WORKING PLAN OF CARE

Subjective Findings: bizarre, catatonic behavior, not medication compliant, flat affect; was found staring at buildings
wearing inappropriate apparel for the weather; “They follow me around, watching me”. . He refused to communicate
with me when I interacted with Text
him. He stayed in his room for a majority of the clinical day.
Legal Status: PC2 Age: 66… Sex:Text M Employment ………………
Status: unemployed

DSM-5 Diagnosis Current Stressors/Reason For Hospitalization

Pt was found standing outside of businesses staring at them. He
Paranoid Schizophrenia was dressed in apparel that was not appropriate for the weather
conditions. He was also displaying bizarre, catatonic behavior. He
is not compliant with care plan or meds.
Assessment Tools Utilized Relevant Medications Cultural Needs
1. Therapeutic communication 1. lorazepam (Ativan) No cultural needs that affect
2. Information from chart 2. melatonin care
I was not able to utilize assessment tools that required the 3. NicoDerm CQ transdermal
client to speak with me because he was choosing not to patch
verbally communicate with me. 4. nicotine polarcrilex
(Nicorette)
5. acetaminophen (Tylenol)

1. NURSING DIAGNOSIS R/T AEB

Impaired verbal communication r/t psychological barriers as evidenced by refusal to speak.
INTERVENTIONS RATIONALES
1. Use therapeutic communication techniques: speak in a well- 1. Effective communication entails involving clients, being
modulated voice, use simple communication, maintain eye sensitive to client needs, and ensuring client understanding (
contact at the client's level, get the client's attention before O'Hagan et al, 2014 ).
speaking, and show concern for the client.
2. Ignoring clients was found to be a negative communication
2. Avoid ignoring the client with verbal impairment; be strategy ( O'Hagan et al, 2014 ).
engaged and provide meaningful responses to client concerns.
Place call light within reach of client who cannot verbally call 3. Viewing patients with communicative difficulties in a
for help. holistic manner cultivates empowering communication (
Parsloe & Carroll, 2018 )
3. Validate clients’ feelings, focus on their strengths, and assist
them in gaining confidence in identifying needs.
EVALUATION/CLIENT RESPONSE/PROGRESS
During clinical hours, the client did not verbally communicate with me. I utilized therapeutic communication techniques while
interacting with the client, I did not ignore him while he walked past me in the hallway, and I told him to let me know if he
needed anything. He had no verbal response to any interventions. What did work from these interventions was that the client
made eye contact with me as I spoke therapeutically to him.

2. NURSING DIAGNOSIS R/T AEB

Social Isolation r/t neurobehavioral manifestations as evidenced by isolation from others while on the unit.
INTERVENTIONS RATIONALES
1. Establish a therapeutic relationship with the client. 1. In her study, Skingley (2013) suggested that many of the
circumstances that contribute to social isolation are amendable
2. Promote social interactions. and that the community nurse is in the position to affect
changes.
3. Assist the client in identifying activities that encourage
socialization. 2. Positive social interactions may act as a basis for the client
to establish new social group relationships ( Cruwys et al, 2014
).

3. According to this study, the sooner the older client is

supported in mobility and social participation, the sooner he or
she will be able to experience a sense of well-being and
lessening of the feelings of social isolation ( Elbasan et al,
2013 ).
EVALUATION/CLIENT RESPONSE/PROGRESS
While on the unit with this client, I established a therapeutic relationship by introducing myself and why I was on the unit that
day. I told him about the groups that day and encouraged him to join the spirituality group that was currently happening. He did
not verbally respond to any of my interactions/suggestions, and he continued to pace the hallways and eventually went back into
his room. What did work from these interventions was that the client expressed a look of dissatisfaction when I told him about
the group that was currently happening.

3. NURSING DIAGNOSIS R/T AEB

Ineffective Health maintenance Behaviors r/t cognitive dysfunction as evidenced by medication and care plan noncompliance.
INTERVENTIONS RATIONALES
1. Assess the client's perception of health and health 1. A study of 681 older clients with diabetes or metabolic
maintenance. syndrome found that they often underestimate their
cardiovascular risk, with as many as 42% perceiving
2. Provide information that supports informed decision- themselves to be in good or excellent health ( Martell-Claros
making. et al, 2013 ).

3. Assess the client's feelings, values, and reasons for not
following the prescribed plan of care.
2. In a modified grounded theory study (N = 59), participants
endorsed the elements of informed decision-making, including
discussion of the role of the client, the clinical issue, the
alternatives, and benefits/risks/uncertainties; assessment of
client understanding and preference; soliciting input from
trusted others; and discussion of the effect on clients’ daily
lives ( Price et al, 2012 ).

3. A systematic review of 80 studies determined that personal

beliefs and values, decisional control preferences, and
perception of the decision-making process affect treatment
decision-making in older adults diagnosed with cancer (
Tariman et al, 2012 ).
EVALUATION/CLIENT RESPONSE/PROGRESS
I was not able to perform these interventions with the client, but I gathered my information from his chart to create this
intervention. If I were to implement these interventions, the client should be able to make more informed decisions on how to
properly manage his health to promote his health status. Revisions that I would make for next time would be to implement
interventions that did not require the client to speak so often.