You are on page 1of 8

Assessment

Nursing Diagnosis

Scientific Explanation

Planning

Nursing Intervention Independent: - Help present and maintain reality by frequent contact and communication with the client - Elicit description of hallucination to protect client and others.

Rationale

Evaluation

Subjective Data: Yun, may narinig akong trials (but actually no one said the word trials), ganun na nga yun kasi trials and challenges are just the same. as stated Objective Data: Diagnosed with Paranoid Schizophrenia Auditory hallucination Exaggerated emotional

Disturbed auditory sensory perception related to anxiety associated with multiple stressors as evidenced by auditory hallucination.

Although the etiology & pathogenesis have not been fully determined, here are some etiologies: Stressful life circumstances, genetic & biochemical defects, & brain damage in the fetus by prenatal complications or viral infection Reduced gray matter in the temporal lobes Abnormal cells in the hippocampus (part of the limbic

Short Term Goal: After 3 weeks of nursing intervention, the patient will be able to 1.Recognize and correct/compensa te for sensory impairments. 2. Identify/modify 2/3 external factors that contribute to alterations in sensory/perceptu al abilities.

Short Term: Presenting reality is healthy for the client (1) Goal Fully Achieved After hour of nursing intervention, the client was able to recognize and correct/compensate for sensory impairments. Identify/modify 2/3 external factors like stress and effects of medications, which contribute to alterations in sensory/perceptual abilities. Recommendation: Terminate the Plan Discharge Outcome: Outcome Fully Achieved; Upon discharge, the client was able to not respond to

The nurses understanding of hallucination helps her know how to calm or reassure the client (1) Close observation of the client with active hallucinations in a secure environment is essential to maintain safety of the client & others. Excessive sensory stimulation could overwhelm and agitate the client. Focusing on the

-Keep client in a safe, protected, restricted environment. Avoid excessive activity and stimulation

Discharge

-Focus on the feelings about, rather than

responses Impaired communicatio n Poor concentration

system) Excessive dopamine secretions Enlarged third and lateral ventricles Decreased blood flow to the frontal lobes Abnormalities of neuro- transmitters and neuro-endocrine systems. Sensory overload and hyperarousal. Auditory hallucination

Outcome: After months or upon discharge, the client will be able to 1. Not respond to hallucinatory commands, and hallucinations will subside. 2. Be free form injury.

details of, the hallucination.

clients feelings, which are real, minimizes emphasis on the hallucination.

- Do not argue with Arguing with the the client about client or expressing whether the disbelief in the hallucinations are real; hallucinations does state, if asked, that not affect the clients belief in the you do not perceive reality of the the auditory stimuli hallucination and that the client can disrupt trust & perceives. the therapeutic rel. Expressing that you not hear the hallucinatory stimuli indirectly encourages him to question the reality Collaborative: of the experience. - Engage client in reality-based activities To achieved such as card playing, maximal gains in occupational therapy, function and or listening to music. psychosocial wellbeing

hallucinatory commands, and hallucinations will subside. The client reported a decrease in, and eventually the total cessation of hallucinations. And the client was free from injury Recommendation: Terminate the Plan

Reference: Pathophysiology for the Health Professions 3rd

Reference: (1)

Edition by Barbara E. Gould Page 588-589

Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 268 (2) Psychiatric-Mental Health Nursing by Mohr page 650

Assessment Subjective Data:

Nursing Diagnosis

Scientific Explanation Although the etiology & pathogenesis have not been fully determined, here are some etiologies: Stressful life circumstances, genetic & biochemical defects, & brain damage in the fetus by prenatal complications or

Planning Short Term Goal: After 3 weeks of nursing intervention, the patient will be able to 1. Verbalize recognition of delusional thoughts if they persist. 2. Respond to reality-based

Nursing Intervention Independent:

Rationale

Evaluation Short Term: Goal Partially Achieved After hour of nursing intervention, the client was able to 1. Verbalize recognition of delusional thoughts if they persist. 2. Respond to reality-based interactions initiated by others; for example, verbally interact with staff for specified time period.

Disturbed thought process related to I really dont presence of understand my psychological father. Why conflicts (delusion cant he of persecutory) as understand me? evidenced by Hindi niya impaired ability to maappreciate problem solve and yung work ko. Is disordered it ingenuity or thought creativity? sequencing. Dalawang beses ako binaril ng

- Be consistent in Clear, consistent setting expectation, limits provide a enforcing rules, and so secure structure for forth the client - Do not make promises that you cannot keep. Broken promises reinforce the clients mistrust of other

- Recognize the Recognizing the clients delusions as clients perception the clients perception can help you of the environment understand the

father ko., as stated Objective Data: Diagnosed with Paranoid Schizophrenia With a delusion to his father (delusion of persecutory) Disordered thought sequencing or Flight of ideas Loose association Impaired ability to problem solve

viral infection Reduced gray matter in the temporal lobes Abnormal cells in the hippocampus (part of the limbic system) Excessive dopamine secretions Enlarged third and lateral ventricles Decreased blood flow to the frontal lobes Abnormalities of neuro- transmitters and neuro-endocrine systems. With a delusion to his father (delusion of persecutory) Disordered thought sequencing or

interactions initiated by others; for example, verbally interact with staff for specified time period.

feelings he is experiencing - Interact with the client on the basis of real things; do not dwell on the delusional material - Never convey to the client that you accept the delusions are reality Interacting with reality is healthy for the client

Recommendation: Terminate the plan Discharge Outcome: Outcome Partially Achieved; Upon discharge, the client was able to free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts. Recommendation: Continue the Plan

Discharge Outcome: Upon discharge, the client will be able to be free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts.

-Directly interject doubt regarding As the client begins delusions as soon as to trust you, he may the client seems ready become willing to to accept this. Do not doubt the delusion if argue but present a you express your factual account of the doubt. situation as you see it. Collaborative: -Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups

Indicating belief in delusions reinforces the delusion (and the clients illness)

A distrustful client can be best deal with one person initially. Gradual introduction of others as the client tolerate is less threatening.

Flight of ideas Reference: Pathophysiology for the Health Professions 3rd Edition by Barbara E. Gould Page 588-589 Reference: Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 264

Assessment

Nursing Diagnosis

Scientific Explanation

Planning

Nursing Intervention

Rationale

Evaluation

Subjective Data: Ang pagkakaalam ko dahil ata nagdrawing ako sa wall, uhm not wall, its not also a table basta di ko alam tawag dun (seemed confused then live it hanging and continued to talk), as stated Objective Data: Loose association of ideas Paranoid Schizophrenia Diagnosis Flight of ideas Difficulty in forming words. Vague, diffuse,

Impaired verbal communication related to loose associations and flight of ideas as evidenced by vague, diffuse, unfocused sequences of concepts and switch of subjects that are difficult to follow the train of thought.

Although the etiology & pathogenesis have not been fully determined, here are some etiologies: Stressful life circumstances, genetic & biochemical defects, & brain damage in the fetus by prenatal complications or viral infection Reduced gray matter in the temporal lobes Abnormal cells in the hippocampus (part of the limbic system) Excessive dopamine secretions Enlarged third and lateral ventricles Decreased blood

Short Term Goal: After 3 weeks of nursing intervention, the patient will be able 1.Participate in therapeutic communication to get needs met and to 2.Relate effectively with persons and his or her environment. 3.Verbalize or indicate n understanding of the communication difficulty and plans for ways of handling.

Independent: - Reorient the client to Repeated person, place, and presentation of time as indicated. reality is concrete reinforcement for the client - Spend time with the client Your physical presence is reality. Allows client to - Encourage the client think. to talk with you, but do not pry for Probing increases information. the clients suspicion and interferes with the therapeutic - When first relationship. communicating with the client, use simple, The clients ability to direct sentences; perceive and avoid complex respond to complex sentences or stimuli is impaired. directions. - Use confrontation skills, when appropriate, within an established nurseclient relationship

Short Term: Goal Partially Achieved After hour of nursing intervention, the client was able to participate in therapeutic communication like using silence, acceptance, reflecting and active listening. Relate effectively with persons and his or her environment. Verbalize or indicate n understanding of the communication difficulty but not the plans for ways of handling. Recommendation: Continue the Plan

Discharge Outcome: Outcome Partially Achieved; Upon discharge, the client was able to demonstrate congruent verbal and nonverbal communication. He established partially method of communication

To clarify discrepancies between verbal and nonverbal cues. Positive feedback for

Discharge Outcome:

- Give positive feedback for the

unfocused sequences of concepts Switch of subjects that are difficult to follow the train of thought

flow to the frontal lobes Abnormalities of neuro- transmitters and neuro-endocrine systems. Flight of ideas Difficulty in forming words. Vague, diffuse, unfocused sequences of concepts Switch of subjects that are difficult to follow the train of thought Reference: Pathophysiology for the Health Professions 3rd Edition by Barbara E. Gould Page 588-589

clients successes. Upon discharge, the client will be able to demonstrate congruent verbal and nonverbal communication and 2. Establish method of communication in which needs can be expressed.

genuine success enhances the clients sense of well-being.

in which needs can be expressed. Recommendation: Continue the Plan

Collaborative: - Engage client in reality-based activities To achieved such as card playing, maximal gains in occupational therapy, function and or listening to music. psychosocial wellbeing Reference: (1) Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 264 & 292