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Name: Erl Christy Pearl Joy Cañete Patient’s Data:

Year& Section: 4-A Name: G.M.P Age: 42 yrs. Old


Clinical Instructor: Diagnosis: Undifferentiated Schizophrenia Ward: Pavilion 9- Ward- 1
Physician: Dr. G

NURSING CARE PLAN


General Objectives: To promote the development of productive interpersonal relationships
Assessment Nursing Rationale Specific Objectives Nursing Rationale Evaluation
Diagnosis Intervention
Subjective: Disturbed thought Increased After 2 weeks of Independent: After 2 weeks of
“ Hi my name is process related to dopamine level nursing interventions, *Monitor patient’s *For continuous nursing
Georgie, I live inadequate (Dopamine the patient will be vital sign monitoring of the interventions, the
in that hospital support system as hypothesis) causes able to establish *Assess for signs client’s status patient was able to
over there for evidence by disturbed thought contract with reality and symptoms of *Client will not establish contract
110 years and I inappropriate processes. The as evidenced by: physical illness complain of pain with reality as
am 132 yrs old non-reality-based dopamine *Responding to or physical evidenced by:
now” as thinking neurotransmitter’s simple questions symptoms *Responding to
verbalized by secondary to function is for *Being able to (mutism) simple questions
the patient undifferentiated motor movements, provide self – care *Re-orient the client *Repeated *Being able to
schizophrenia. sensory integration such as urinating, to person, place and presentation of provide self – care
Objective: and emotional defecating and time. reality is concrete such as urinating,
*Inactivity behavior. bathing without reinforcement for defecating and
*Disoriented In my patients supervision the client. bathing without
*Silence when condition she has a *Eating foods and *Encourage the *Allowing the supervision
not asked flight of ideas in medication without patient to perform patient to *Eating foods and
*Reduced every question evidence of mistrust ADL’s (as tolerated) participate in self- medication without
emotional asked to her, and to participate in care promotes evidence of mistrust
expression occasionally she decisions about self- independence and
*Stares for a mumbles to herself care, independence. feelings of self-
minute in then smiles or Provide assistance as control
nowhere sometimes looks appropriate.
*Apathetic angry or apathetic.
*Social *Provide emotional *Providing support
isolation https://www.ncbi.n support, positive and
lm.nih.gov/pmc/art reinforcement. encouragement
icles/PMC4032934 during the
/ experience
increases the
patient’s sense of
security and
control. Positive
reinforcement
enhances self-
esteem

*Develop a *Presence,
therapeutic nurse- acceptance and
patient relationship conveyance of
through frequent, positive regards
brief contracts and enhance the
an acceptable client’s feelings of
attitude. Show self-worth
unconditional
positive regard.

*Spend time with *Your presence


the patient, sit in may help improve
silence for a while client’s perception
of self as a
worthwhile person.
Physical presence
is reality.

*Encourage client to *Verbalization of


verbalize feelings. feelings in a
nonthreatening
environment may
help client come to
terms with long
unresolved
problems.

*Help client *Reality must be


reestablish what is reinforced.
real and unreal. Reinforced reality
Validate the client’s and behavior will
misperception. recur more
frequently
Dependent:
*Collaborate with *Collaboration
the other members enhanced
of the health team. communication
and
interdisciplinary
teamwork
DISCHARGE PLAN
Diet:
Patient should promote the following:
* Eat a diet that will stabilizes blood sugar (known as a Low GL diet)
*eating fish at least twice a week (sardines)
*To ensure getting the proper types and amounts of antioxidants, eat lots of fresh (or frozen, but not tinned or dried) fruit and
vegetables with a variety of colors.
*High fiber diet (whole grain, wheat, brown rice or potatoes, sprouted beans or peas)
* include protein with every meal and snack.
* Try to drink plenty of water

* Base each meal on starchy foods such as potatoes, pasta or rice


Patient should avoid the following:
*salty foods (cured foods)

*sugar and refined carbohydrates


*eating fatty foods
*drinking alcohol and smoking
* Raw dairy products (including yogurt, kefir or raw cheeses), and pasture-raised poultry
Activity/Exercise
*Have at least 6-8 hours of sleep
*Plan adequate rest or nap
*Continue ADL
*Do meditation
*Practice proper breathing exercise
* Participate in moderate-to-vigorous aerobic exercise programs
Hygiene
*Proper skin care
*Daily bath
*Routine eyes, ears, nose, mouth and foot care
*Wash hands before and after meals, before and after urination and defecation
*Change clean comfortable clothes everyday
Medication
*fluphenazine decanoate ¼ cc
*respiredone 4mg HS
*ISMM(Isomrtamidium choride) 30mg HS
*diphenhydramine HCL 50mg/cap HS
*ISDN 5mg
*metoprolol 50mg
Community Support
*Keep records of telephone number of doctors, family members, neighbors and health agencies in case of emergency
Spiritual Support
*Encourage them to pray
*Suggest attending church every Sunday or Bible study meeting in the local church
*Advise to ask for guidance with their local priest
Financial Resources
*Phi Health Benefits
*PCSO
*WHO
Problem Identified Level of care Action Plan/ Health Teaching
Inability to fall asleep Promotive *Instruct to avoid caffeine and energy
drink 6-8hors before sleep

*Instruct to avoid napping during the day

*Advise to minimize sleep disturbance

*Encourage limit amount of time spent on


watching TV especially right before bed
Preventive
*Advise to avoid alcohol

*Emphasize not to go to bed hungry

Rehabilitative *Instruct significant other to call for


doctors assistance