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Kultur Dokumente
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I. RISK OF SELF-VIOLENCE AND DIRECTED TOWARDS OTHERS
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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).
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present in
asymptomatic
persons (National
Guideline Clearing
House, 2001).
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II. SENSORY AND PERCEPTUAL ALTERATIONS
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.
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.
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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.
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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.
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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.
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might have to hurt others or
herself in order to be safe.
External controls might be
needed.
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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.
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short period with clients.
R: An interested presence
can provide a sense of being
worthwhile.
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.
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structured group activity.
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.
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V. INTERRUPTED FAMILY PROCESS
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.
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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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