Pete Cobraiti

Mental Health clinical

Professor Harrison

Nursing Care plan for Schizophrenia Nursing Interventions Nursing Diagnosis RATIONALE
Disturbed sensory perception:
auditory/visual Related to panic anxiety extreme loneliness and withdrawal into the self as manifested by
Inappropriate responses, disordered thought sequencing, rapid mood swings, poor concentration,
disorientation.
Short term Goal: Client will discuss content of hallucination w/ nurse or therapist within the 1 week.
Long term Goal: Client will be able to define and test reality, reducing or eliminating the occurrence of
hallucinations. Client will be able to verbalize understanding that the voices are a result of his /her illness
and demonstrate ways to interrupt the hallucination.
Nursing Intervention: Observe clients for signs of hallucinations action (listening pose, laughing or
talking to self -stopping in midsentence) avoid touching without warning the client that you are about to
do so. An attitude of acceptance will encourage the client t share content of the hallucination with you.
Don’t reinforce the hallucination use “the voice instead of words like “they”, let client know that you
don’t share the perception. Help the client understand the connection between increase anxiety and the
presence of hallucination. Try to distract the client from hallucination. Listening to the radio and watching
TV helps distract some clients from attention the voice.
Rationale: Early intervention may prevent aggressive response. Client may perceive touch as threatening
and may respond in an aggressive manner. This is important to prevent possible injury to the client or
others. Explanation of the situation helps the client back to reality. Activities assist the client to exert
some conscious control over the hallucination.

(2) Disturbed thought process Related to: Related to Inability to trust, panic anxiety, possible
hereditary or biochemical factors as Manifested by inability to concentrate; impaired volition; inability to
problem solve, abstract or conceptualize; extreme suspiciousness of other.

Short term goal: Client will be able to recognize and verbalize that false ideas occur at times of
increased anxiety.
Long term goal: Client will experience (verbalize evidence of) no delusional thoughts. Client will be
able to differentiate between delusional thinking and reality.
Nursing Intervention: Convey acceptance of clients need for the false beliefs but indicate that you don’t
share the belief. Don’t argue or deny the belief use reason doubt as a therapeutic technique” I understand
that you believe this is true, but I personally find it hard to accept” reinforce and focus on reality.
If client is highly suspicious use same staff as much as possible be honest and keep all promises. Avid
physical contact warn client before touching to perform a procedure. Avoid laughing, whispering or
talking where the client can see but can’t hear. Provide called food or family serve food family style.
Provide activities that encourage a one to one relationship with the nurse.
Rationale: Client must understand that you don’t view the idea as real. Arguing with the client or
denying the belief are not useful because delusional are not eliminated. Discussion that focus on the false
idea are purposeless. Familiar staff and honesty promoted trust. Suspicious clients often perceive touch as
threating and may respond in an aggressive. Client may have ideas believe they are being talked about.
Suspicious clients may believe they are being poisoned and refuse to eat. Competitive activities are very
threatening.

(3) Risk for Violence [self-directed or other-directed] Related to suspiciousness, panic anxiety,
catatonic excitement, rage reactions, command hallucinations. extreme as Manifested by and aggressive
acts, goal-directed destruction of objects in the environment, self-destructive behavior or active
aggressive suicidal acts.
Short term goal: Client will be able to recognize signs of increasing anxiety and agitation and report to
staff for assistance with intervention.
Long term goal: Client will not harm self or others.
Nursing Intervention: Maintain low level of stimuli in client’s environment (low lighting, few people,
simple décor, low nice level). Observe clients’ behavior frequently. Remove all dangerous objects from
client’s environments. Maintain calm attitude toward the client, talking about the situation, talking anxiety
medication. Restraints may be necessary if client is not calmed by talking down or medication. Observe
client in restraints at least every 15 min to ensure that circulation to extremities is not compromised.
Assess the client’s readiness for restraints removal or reduction anxiety level rises is stimulating
environment.
Rationale: Anxiety level rise in a stimulating environment. Observation during the routine activities
avoid creating suspicious on the part of the client, close observation is necessary. Removal of dangerous
objects is an agitated, confuse state from using them to harm self or others. Offering alternatives to the
client gives him/her a feeling of some control over the situation. Restraints should be used only as a last
resort after all interventions have been unsuccessful. Assessing the client readiness for removal restraints
minimize the risk of injury to client and staff.

4: Self-care deficit Related: to withdrawal, regression, panic anxiety, perceptual or cognitive

impairment, inability to trust as Manifested by difficulty carrying out tasks associated with hygiene,
dressing, grooming, eating, toileting.

Short term Goal: Client will be able to verbalize a desire to perform ADLs be end of week 1.
Long term Goal: Client will be able to perform ADLs in an independent manner and demonstrate a
willingness to do so by time of discharge from treatment.
Nursing Intervention: Provide assistance with self-care as required. Encourage client to perform
independently as many activities as possible, provide positive reinforcement for independent
accomplishment. Creative approaches may need to be taken with client who is not eating, allowing client
to open own canned or package foods. If toileting need are not meet being met, establish a structured
schedule.

Rationale: Client safety and comfort are nursing priorities. Independent accomplishment and positive
reinforcement promotes repetition of desirable behaviors. Technique may be helpful with paranoid
client’s or suspicious. A structured schedule will help client to develop a habit of toileting independently