NURSING CARE PLAN CUES Subjective: puro mga sinungaling ang andito, as verbalized by the patient.

NURSING DIAGNOSIS Disturbed thought process reated to inability to trust as evidenced by suspiciousness of others, resulting in alteration in societal participation. GOAL/OBJECTIVES INTERVENTIONS
Ensure that smoking materials and other potentially harmful objects are stored outside client's access. Frequently orient client to reality and surroundings.

RATIONALE
Client may harm self or others in disoriented, confused state.

EVALUATION

Disorientation may

endanger client safety if he or she unknowingly wanders away from safe environment.

Try to redirect violent behavior with physical outlets for the client's anxiety.

Physical exercise is a safe and effective way of relieving pent-up tension. Verbalizing feelings with a trusted individual may help client work through unresolved issues.

Encourage the client to verbalize true feelings. The nurse should avoid becoming defensive when angry feelings are direct at him.