Cues Diagnosis Nursing Rationale

intervention
Impaired Social Develop a therapeutic nurse Therapeutic relationship promotes
February 17, 2017; Interaction r/t social
client relationship through understanding and can help establish
frequent, brief contacts and an a constructive relationship between
10:30 am isolation and history of accepting attitude. Show the nurse and the client
unsatisfactory unconditional positive regard.
Wala ko nagattend sa Your presence, acceptance,
relationships and conveyance of positive
amon dinner date sang
regard enhance the client's
friends ko sang
feelings of self-worth
valentines kay balan mo Increased anxiety can intensify
si princess nagluto te Identify with client symptoms agitation, aggressiveness, and
suya na siya sakon basi he experiences when he or suspiciousness
gin hiluan ya akon she begins to feel anxious
pagkaon. around others. Client might respond to noises and
Te gin hambalan ko iban Keep client in an environment crowding with agitation, anxiety, and
as free of stimuli (loud noises, increased inability to concentrate on
ko na friends na muna
crowding) as possible. outside events.
hindi ko magattend te
laban-laban sa to nanugid Touch by an unknown person can be
na to sila kay princess Avoid touching the client. misinterpreted as a sexual or
kag ginlibak naman ko threatening gesture. This particularly
nila tanan. true for a paranoid client.
An interested presence can provide a
Sa tuod-tuod lang hindi
If client is unable to respond sense of being worthwhile.
man gid ko na nila gusto verbally or in a coherent
maging friend, napilitan manner, spend frequent, short
 lang na sila kay gin period with clients. Client is free to choose his level of
hambalan sila ni maam If client is found to be very interaction; however, the
Muna umpisa ka to wala paranoid, solitary or one-on- concentration can help minimize
one activities that require distressing paranoid thoughts or
na ko na gaupod sila. concentration are appropriate voice.
Subong ako na lang isa
permi atleast wala na Try to incorporate the Increase likelihood of clients
may makipagplastikan strengths and interests the participation and enjoyment.
sakon. client had
Kagapon gani sang lunch Teach client skills in dealing
Teach client to remove himself with anxiety and increasing a sense
natulok gid ko nila tanan
briefly when feeling agitated of control.
samtang gakaon ko and work on
siguro gaplano sila kung some anxiety relief exercise
paano ko nila masuyaan (e.g., meditations,rhytmic
kay wala ko upod. exercise, deep breathing Recognition and appreciation go a
Manugid ko tani sa amon exercise). long way to sustaining and increasing
a specific behavior.
maestra galing, si maam
Remember to give
na na may favoritism acknowledgment and
man na hindi ya man ko recognition for positive steps
na japon pagpamatian client takes in increasing
Ligad gne ginsugiran ko social skills and appropriate the client verbal
na ginalibak libak mn sya interactions with others. threats, physicalcontact and acting
out may beprecursors or cues
ni princess sa isa pagd
listen for verbal threats or to impending violence
nga teacher, wala sa
hostile remarks towards self or
nagpati hy abi ya butigon others helping the client manage angry
ko kg syempre favorite inappropriate or intrusive behaviors
 nya day princess.
Help the client manage angry.
inappropriate or intrusive
behaviors in a therapeutic but
firm direct manner
early in the escalation of phase may
prevent assault or violence
Affects ability to be involved in social
situations

Determine clients use of Once recognized, client can choose

coping skills and defense to change as he or she learns to
mechanism listen and communicate in socially
acceptable ways
If possible have client list
behaviors that cause
discomfort to her. Review and
validate list to reality of
perceptions

References:

https://nurseslabs.com/schizophrenia-nursing-care-plans/2/
https://nurseslabs.com/schizophrenia-nursing-care-plans/2/

Nurses pocket guide 13th edition

(Fundamentals of Nursing, 8 th edition. Vol 2. Pg.467)