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X.

NURSING CARE PLAN


I. Risk of Self-Violence and Directed Towards Others
II. Sensory and Perceptual Alterations
III. Disturbed Thought Process
IV. Impaired Social Interaction
V. Interrupted Family Process

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I. RISK OF SELF-VIOLENCE AND DIRECTED TOWARDS OTHERS

CUES NURSING GOALS OF CARE/ NURSING IMPLEMENTATION EVALUATION


DIAGNOSIS OUTCOME CRITERIA INTERVENTION

Subjective cues: Risk of self- After 2 weeks of nursing Establish a therapeutic


violence and intervention and follow relationship with client
“Nagtangka akong directed towards up visits, the patient will R: This study demonstrated
magsuicide noon others related to be able to: the importance of this
sa Malaysia kasi feelings of  relationship in identifying
namimiss ko nanay helplessness, and preventing suicide
ko. Hindi ako loneliness, or (Rudd et al, 2000).
kumain sa loob ng hopelessness
isang linggo, tubig secondary to Monitor, document, and
lang” the patient psychiatric report client's potential for
explained. disorder suicide.
schizophrenia. R: Traits such as impulsivity,
Objective cues: poor social adjustment, and
mood disorders are
associated with adolescent
suicide attempts (Brent et
al, 1994).

Be alert for warning signs of


suicide:
R: Verbalizations such as, "I
can't go on," "Nothing
matters anymore," "I wish I
were dead"
 Becoming depressed or
withdrawn
 Behaving recklessly
 Getting affairs in order

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and giving away valued
possessions
 Showing a marked
change in behavior,
attitudes, or appearance
 Abusing drugs or alcohol
 Suffering a major loss or
life change
 Suicide is rarely a spur-
of-the-moment decision.
In the days and hours
before people kill
themselves, there are
usually clues and
warning signs
(Befrienders
International, 2001).

Assess for suicidal ideation


when the history reveals:
 Depression
 Alcohol or other drug
abuse
 Other psychiatric
disorder
 Attempted suicide
 Recent divorce
and/or separation
 Recent
unemployment
 Recent bereavement
 Chronic pain
 Clinicians should be
alert for suicide when
the above factors are

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present in
asymptomatic
persons (National
Guideline Clearing
House, 2001).

R: This study revealed that


clients with chronic pain and
depression expressed
suicidal ideation (Fisher et al,
2001). The process leading
to suicide in young people is
often untreated depression
(Houston, Hawton,
Shepperd, 2001).

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II. SENSORY AND PERCEPTUAL ALTERATIONS

CUES NURSING GOALS OF CARE/ NURSING INTERVENTION IMPLEMENTATION EVALUATION


DIAGNOSIS OUTCOME CRITERA

Subjective Altered sensory and After 2 weeks of nursing  Accept the fact that the  At the end of 2 weeks of
Cues: perceptions related to interventions, the voices are real to the nursing intervention,
hallucination as patient is expected to: patient, but explain that patient was able to:
“May evidenced by: you do not hear the
bumubulong  Auditory  Learn ways to voices. Refer to the 
sakin na distortions. refrain from voices as “your voices”
bilangin ko daw  Change in a responding to or “voices that you hear”.
ang mga motor problem- hallucinations. R: Validating that reality
na dumadaan solving pattern.  State symptoms does not include voices
pati ang mga  Disorientation they recognize can help client cast
butas butas sa to when their stress “doubt” on the validity of
dingding” as person/place/ti levels are high. his or her voices.
verbalized by me.  State that the
the patient.  Hallucinations. voices are no
 Inappropriate longer  Be alert for signs of
“May nakikita responses. threatening, nor increasing fear, anxiety
akong malaking  Mumbling to do they interfere or agitation.
pusa” as stated self, talking or with his or her R: Might herald
by the patient. laughing to life. hallucinatory activity,
self.  Verbalize using a which can be very
Objective  Reported or scale from 1 to frightening to patient,
Cues: measured 10, that “the and she might act upon
change in voices” are less command hallucinations
sensory acuity. frequent and (harm self or others).
 Tilting the head threatening
as if listening when aided by
 Explore how the
to someone. medication and
hallucinations are
nursing
experienced by the
intervention.
patient.

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 Maintain role R: Exploring the
performance and hallucinations and
social sharing the experience
relationships. can help give the person
 Monitor intensity a sense of power that
of anxiety. she might be able to
 Identify stressful manage the hallucinatory
events that voices.
trigger
hallucinations.  Help the patient to
 Identify to identify the needs that
personal might underlie the
interventions hallucination.
that decrease or R: Hallucinations might
lower the reflect needs for:
intensity or
frequency of • Anger
hallucinations • Power
(e.g, listening to • Self-esteem
music, wearing • Sexuality
headphones,
reading out loud,  Help patient to identify
jogging, times that times that the
socializing). hallucinations are most
 Demonstrate prevalent and
one stress frightening.
reduction R: Helps both nurse and
technique. patient identify situations
 Demonstrate and times that might be
techniques that most anxiety producing
help distract him and threatening to
or her from the the client.
voices.

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 Notify others and police,
physician, and
administration according
to unit protocol if voices
are telling the patient to
harm self or others, take
necessary environmental
precautions.
R: People often obey
hallucinatory commands
to kill self or others. Early
assessment and
intervention might save
lives.

 Stay with patient when


she is starting to
hallucinate, and direct
them to tell the “voices
they hear” to go away.
Repeat often in a matter-
of-fact manner.
R: Patient can
sometimes learn to push
voices aside when given
repeated instructions.
especially within the
framework of a trusting
relationship.

 Decrease environmental
stimuli when possible
(low noise, minimal
activity).
R: Decrease potential for

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anxiety that might trigger
hallucinations. Helps
calm patient.

 Intervene with one-on-


one, seclusion, or PRN
medication (As ordered)
when appropriate.
R: Intervene before
anxiety begins to
escalate. If the patient is
already out of control,
use chemical or physical
restraints following unit
protocols.

 Keep to simple, basic,


reality-based topics of
conversation. Help
patient focus on one idea
at a time.
R: Patient’s thinking
might be confused and
disorganized; this
intervention helps patient
focus and comprehend
reality-based issues.

 Work with the patient to


find which activities help
reduce anxiety and
distract the client from a
hallucinatory material.
Practice new skills with
the patient.

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R: If patient’s stress
triggers hallucinatory
activity, she might be
more motivated to find
ways to remove herself
from a stressful
environment or try
distraction techniques.

 Engage patient in reality-


based activities such as
card playing, writing,
drawing, doing simple
arts and crafts or
listening to music.
R: Redirecting patient’s
energies to acceptable
activities can decrease
the possibility of acting
on hallucinations and
help distract from voices.

III. DISTURBED THOUGHT PROCESS

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CUES NURSING DIAGNOSIS OUTCOME CRITERIA NURSING INTERVENTION IMPLEMENTATION EVALUATION

Subjective Disturbed thought After 2 weeks of Attempt to understand the At the end of one month
Cues: process related to drug nursing interventions significance of these beliefs nursing intervention and
chemical alteration as and follow up visits, the to the patient at the time of follow up treatment at
Objective evidenced by: patient is expected to: their presentation. home:
Cues: R: Important clues to
• Delusions. • Verbalize recognition underlying fears and issues
• Inaccurate of delusional thoughts if can be found in the patient’s
interpretation of they persist. seemingly illogical fantasies.
environment. • Perceive environment
• Inappropriate non- correctly.
reality-based thinking. • Demonstrate Recognizes the patient’s
• Memory satisfying relationships delusions as her perception
deficit/problems. with real people. of the environment.
• Self-centeredness • Demonstrate decrease R: Recognizing the patient’s
anxiety level. perception can help you
• Refrain from acting on understand the feelings she
delusional thinking. is experiencing.
• Develop trust in at
least one staff member Identify feelings related to
within 1 week. delusions. For example:
• Sustain attention and • If she believes someone is
concentration to going to harm her, she is
complete task or experiencing fear.
activities. • If she believes someone or
• State that the something is controlling her
“thoughts” are less thoughts, she is
intense and less experiencing helplessness.
frequent with the help R: When people believe that
of the medications and they are understood, anxiety
nursing interventions. might lessen.
• Talk about concrete
happenings in the Explain the procedures and

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environment without try to be sure the patient
talking about delusions understands the procedures
for 5 minutes. before carrying them out.
• Demonstrate effective R: When the patient has full
coping skills that knowledge of procedures,
minimize delusional she is less likely to feel
thoughts. tricked by the staff.
• Be free from
delusions or Interact with patient on the
demonstrate the ability basis of things in the
to function without environment. Try to distract
responding to her from her delusions by
persistent delusional engaging in reality-based
thoughts. activities (e.g., card games,
simple arts and crafts
projects etc).
R: When thinking is focused
on reality-based activities,
the patient is free of
delusional thinking during
that time. Helps focus
attention externally.

Encourage healthy habits to


optimize functioning:
• Maintain medication
regimen.
• Maintain regular sleep
pattern.
• Maintain self-care.
• Reduce alcohol and drug
intake.
R: All are vital to help keep
the patient in remission.

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Show empathy regarding
the patient’s feelings;
reassure her of your
presence and acceptance.
R: The patient’s delusion
can be distressing. Empathy
conveys your caring, interest
and acceptance of the
patient.

Teach patient coping skills


that minimize “worrying”
thoughts. Coping skills
include:
• Going to a gym.
• Phoning a helpline.
• Singing or listening to a
song.
• Talking to a trusted friend.
• Thought-stopping
techniques.
R: When patient is ready,
teach strategies she can do
alone.

Utilize safety measures to


protect patient or others, if
she believes she needs to
protect herself against a
specific person. Precautions
are needed.
R: During acute phase,
patient’s delusional thinking
might dictate to her that she

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might have to hurt others or
herself in order to be safe.
External controls might be
needed.

IV. IMPAIRED SOCIAL INTERACTION

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CUES NURSING GOAL/ OUTCOME NURSING INTERVENTION IMPLEMENTATION EVALUATION
DIAGNOSIS CRITERIA

Subjective Impaired social After 2 weeks of nursing Assess if the medication has At the end 2 weeks nursing
Cues: interaction related to intervention, patient will reached therapeutic levels. intervention:
hallucinations as be able to: R: Many of the positive
“Dalawa lang evidenced by  Attend one symptoms of schizophrenia
ang kaibigan ko dysfunctional structured group (hallucinations, delusions,
dito” as interaction with other activity within 5-7 racing thoughts) will subside
verbalized by patients days. with medications, which will
the patient.  Seek out supportive facilitate interactions.
social contacts.
Objective  Improve social Identify with client
Cues: interaction with symptoms he experiences
other patients. when he or she begins to
 Use appropriate feel anxious around others.
social skills in RL Increased anxiety can
interactions. intensify agitation,
 Engage in one aggressiveness, and
activity with a nurse suspiciousness.
by the end of the
day. Keep client in an
 Maintain an environment as free of
interaction with stimuli (loud noises,
another client while crowding) as possible.
doing an activity R: Client might respond to
(e.g., simple board noises and crowding with
game, drawing). agitation, anxiety, and
 Demonstrate increased inability to
interest to start concentrate on outside
coping skills training events.
when ready for
learning. Avoid touching the client.
 Engage in one or R: Touch by an unknown

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two activities with person can be misinterpreted
minimal as a sexual or threatening
encouragement from gesture. This particularly
nurse or family true for a paranoid client.
members.
 State that he or she Ensure that the goals set are
is comfortable in at realistic; whether in the
least three hospital or community.
structured activities R: Avoids pressure on the
that are goal client and sense of failure on
directed. part of nurse/family. This
 Use appropriate sense of failure can lead to
skills to initiate and mutual withdrawal
maintain an
interaction. Structure activities that work
at the client’s pace and
activity.
R: Client can lose interest in
activities that are too
ambitious, which can
increase a sense of failure.

Structure times each day to


include planned times for
brief interactions and
activities with the client on
one-on-one basis.
R: Helps client to develop a
sense of safety in a non-
threatening environment.

If client is unable to respond


verbally or in a coherent
manner, spend frequent,

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short period with clients.
R: An interested presence
can provide a sense of being
worthwhile.

If client is found to be very


paranoid, solitary or one-on-
one activities that require
concentration are
appropriate.
R: Client is free to choose
his level of interaction;
however, the concentration
can help minimize distressing
paranoid thoughts or voice.

If client is
delusional/hallucinating or is
having trouble concentrating
at this time, provide very
simple concrete activities
with client (e.g., looking at a
picture or do a painting).
R: Even simple activities
help draw client away from
delusional thinking into
reality in the environment.

If client is very withdrawn,


one-on-one activities with a
“safe” person initially should
be planned.
R: Learn to feel safe with
one person, then gradually
might participate in a

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structured group activity.

Try to incorporate the


strengths and interests the
client had when not as
impaired into the activities
planned.
R: Increase likelihood of
client’s participation and
enjoyment.

Teach client to remove


himself briefly when feeling
agitated and work on some
anxiety relief exercise (e.g.,
meditations, rhythmic
exercise, deep breathing
exercise).
R: Teaching client skills in
dealing with anxiety and
increasing a sense of control.

Incorporate useful coping


skills that client will need
including conversational and
assertiveness skills.
R: These are fundamental
skills for dealing with the
world, which everyone uses
daily with more or less skill.

Remember to give
acknowledgment and
recognition for positive steps

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client takes in increasing
social skills and appropriate
interactions with others.
R: Recognition and
appreciation go a long way
to sustaining and increasing
a specific behavior.

Provide opportunities for the


client to learn adaptive social
skills in a non-threatening
environment. Initial social
skills training could include
basic social behaviors (e.g.,
appropriate distance,
maintain good eye contact,
calm manner/behavior,
moderate voice tone).
R: Social skills training helps
client adapt and function at
a higher level in society, and
increases client’s quality of
life.

Eventually engage other


clients and significant others
in social interactions and
activities with the client
(card games, ping pong,
sing-a-songs, group sharing
activities) at client’s level.
R: Client continues to feel
safe and competent in a
graduated hierarchy of
interactions.

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V. INTERRUPTED FAMILY PROCESS

CUES NURSING GOAL/ OUTCOME NURSING INTERVENTION IMPLEMENTATION EVALUATION


DIAGNOSIS CRITERIA

Subjective Interrupted family After 2 weeks of nursing Assess the family members’
Cues: process related to intervention, family current level of knowledge
situational crisis or and/or significant about the disease and
“Broken family transition as others will discuss the medications used to treat
kami” as stated evidenced by: disease the disease.
by the patient. R: Family might have
(schizophrenia)
•Changes in misconceptions and
knowledgeably:
expression of conflict misinformation about
 Know about
Objective in family. schizophrenia and treatment,
community
Cues: •Changes in or no knowledge at all.
resources (e.g., help
communication
with self-care
Has not visited patterns. Teach client’s and family’s
activities, private
by her family •Changes in mutual level of understanding and
respite).
since admission. support. readiness to learn.
 Support the ill family
•Changes in Inform the client family in
member in
participation in clear, simple terms about
maintaining
decision making. psychopharmacologic
optimum health.
•Changes in therapy: dose, duration,
 Understand the
participation in indication, side effects, and
need for medical
problem solving. toxic effects. Written
adherence.
•Changes in stress information should be given
reduction behavior. to client and family members
•Knowledge deficit as well.
regarding community R: Understanding of the
and health care disease and the treatment of
support. the disease encourages
•Knowledge deficit greater family support and
regarding the disease client adherence.

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and what is
happening with ill Identify family’s ability to
family member cope (e.g., experience of
(might believe client loss, caregiver burden,
is more capable than needed supports).
they are). R: Family’s need must be
•Inability to meet the addressed to stabilize family
needs of family and unit.
significant others
(physical, emotional, Teach the client and family
spiritual). the warning symptoms of
relapse.
R: Rapid recognition of early
warning symptoms can help
ward off potential relapse
when immediate medical
attention is sought.

Provide information on
disease and treatment
strategies at family’s level of
understanding.
R: Meet family members’
needs for information.

Provide an opportunity for


the family to discuss feelings
related to ill family member
and identify their immediate
concerns.
R: Nurses and staff can best
intervene when they
understand the family’s
experience and needs.

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Provide information on client
and family community
resources for the client and
family after discharge: day
hospitals, support groups,
organizations,
psychoeducational programs,
community respite centers
(small homes), etc.
R: Schizophrenia is an
overwhelming disease for
both the client and the
family. Groups, support
groups, and
psychoeducational centers
can help:
• Access caring.
• Access resources.
• Access support.
• Develop family skills.
• Improve quality of life for
all family members.
• Minimizes isolation.

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