Anda di halaman 1dari 27

Assessment S:

Nursing Diagnosis Risk for injury: self

Scientific explanation Schizophrenia is a mental illness in which patients experience symptoms such as delusions, (mistaken beliefs) hallucinations, and disorganized behavior. Hallucinations are sounds or other sensations experienced as real when they exist only in the person's mind. While hallucinations can involve any of the five senses, auditory hallucinations (e.g. hearing voices or some other sound) are most common in schizophrenia. Visual

Planning Short Term: After 4 hours of NI the patient will not harm himself

Nursing Interventions Observe patients behaviour during routine patient care.

Rationale Close observation is necessary to protect from self harm. To determine the need for prompt intervention Such behaviours are critical clues regarding risk for self harm. To improved self esteem and avoid risk for suicidal ideations

Expected Outcome Short Term: After the NI the patient shall not have harmed himself Long Term: After the NI the patient shall have refrained from suicidal threats or behaviour gestures.

O: patient manifested:

directed r/t command hallucinations

Patient may manifest: Restlessness Panic Delirium Self mutilation

Long Term: After 2 days of NI the patient will refrain from suicidal threats or behaviour gestures.

Assess the congruency of behaviors Listen carefully suicidal statements and observe for non-verbal indications of suicidal intent. Self esteem enhancement-self esteem journal, give positive feedback, Hallucination managementassess, help client describe needs that might be reflected

To determine the need for prompt

hallucinations are also relatively common. Research suggests that auditory hallucinations occur when people misinterpret their own inner selftalk as coming from an outside source. People with schizophrenia have a high risk of attempting suicide. Any suicidal talk, threats, or gestures should be taken very seriously. People with schizophrenia are especially likely to commit suicide during psychotic episodes, during periods of depression, and in the first six months after

in the content of the hallucination, identify triggers of hallucinations

intervention

Ask direct questions to determine suicidal intent , plans for suicide, and means to commit suicide .

Suicide risk increases when plans and means exists

theyve started treatment thus confirming the diagnosis.

Assessment S:

Nursing Diagnosis
Disturbed sensory

Scientific explanation

Planning

Nursing Interventions

Rationale

Expected Outcome

Schizophrenia is a Short Term: mental illness in which patients experience symptoms such as delusions, (mistaken beliefs) hallucinations, and disorganized behavior. It is the
change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response

Continuously orient Brief,

frequent Short Term:

the client to actual orientation helps

O: patient manifested:
y Auditory

perception related to alteration in

and visual function of hallucinati brain tissue ons y Misinterpr ets actions of others y Inability to make

After 2 hours of NI the pt will demonstrate accurate perception of the environment by responding appropriately to stimuli in the surroundings Long Term: After 2 days of NI the pt has
lessened visual and auditory hallucinations

environmental

to present reality Long Term:

events or activities to the client with in a nonchallenging sensoryway. perception disturbance Working with Reinforce and focus reality lessens on reality. Talk patients initiation of his about real events hallucinations. and real people. Use real situations and events client tedious, to from divert long,

simple decisions y Inappropri ate responses

repetitive of

verbalizations false ideas

Patient may

to such stimuli.

client's Explanation of, and participation description of in, real situations and Correct

manifest: Restlessness Panic Delirium Self mutilation

inaccurate

real activities interferes with perception, and the ability to describe the respond to hallucinations. situation as it exists in reality the Explore the content Exploring of hallucinations to content of the the hallucination helps the nurse possibility to harm self, others or the identify if the determine environment sensoryperceptual disturbance threatening is or

dangerous to the client, such as a command type

of hallucination that may be

telling the client to harm or kill the client or The

others.

nurse can then reinforce treatment safety precautions. and

Use clear, direct, Unclear directions or verbal instructions can communication confuse the rather than unclear client and promote or nonverbal distorted perceptions or gestures misinterpretatio ns of reality.

TIME AND DATE Januar y 21, 2009 @ 7:00 A.M

CUES

NEED

NURSING DIAGNOSIS

GOAL OF CARE

INTERVENTIONS

EVALUATION

SUBJECTIVE Magpatambal ko. Kani man gud akong utok, naa niy grasa. as verbalized by the patient

C O G N I T I

Disturbed thought process related to disintegration thinking.

At the end of 2 hours of nursing care, the patient will be able to y Maintain reality

1. Be

sincere

and January 21, 2009 when @ 12:30 PM

honest

communicating with the client. GOAL PARTIALLY Clients are MET y The client

It is the disruption in cognitive operations and activities. Cognitive processes include those mental processes by which knowledge is acquired. These mental y y

orientation; Demonstrat e reality

extremely sensitive about others and can recognize

OBJECTIVE y Delusion persecution y Delusion paranoia y y y Thought insertion Incoherent speech Demonstrates disturbance sleep pattern y Presence auditory hallucinations

V of E of P E R C

was able to maintain reality orientation. He is

based thinking in verbal and nonverbal behavior; and Demonstrat e the ability to abstract, conceptuali ze, reason

insincerity. Evasive remarks mistrust. reinforce

oriented to 2. Assess clients time when nonverbal behavior, such as gestures, facial expression

a E in P T of U A L

asked what day it is.

But he is still preoccupied

and posture.

This

assessment

with

his

processes P A T T E R N include reality orientation, comprehension, awareness, and judgment. A disruption in these mental processes may lead to inaccurate interpretations of the environment and may result in an inability to evaluate reality accurately. Alterations in thought processes are not limited to any one age

and calculate consistent with ability to

may help to meet the clients needs that cannot be

delusions about being jealous him to his

conveyed speech.

through

3. Encourage client to

the express

The

client

was not able to demonstrate realitybased

feelings and do not pry cross examine for information

Probing increases clients suspicion

thinking in verbal and

and interferes with the therapeutic

nonverbal responses. His mannerism

relationship

4. Show empathy to the feelings, clients reassure

is

largely

observed and he

the client of your presence and

wasnt able to establish

group, gender, or clinical problem. (http://www1.us. elsevierhealth.c om/MERLIN/Gu lanick/Construct or/index.cfm?pl an=53.01)

acceptance

eye contact with any of

The

clients

the interviewer. y However, he was able to exhibit a positive abstract, reason,

experiences can be distressing. Empathy conveys

acceptance of the client your caring and interest.

5. Avoid

laughing, or quietly

judgment and calculation abilities.

whispering, talking

where client can see but not hear what is being said.

Suspicious clients often believe others are discussing

them, and secretive behaviors reinforce the paranoid

feelings.

6. Give directions short

simple using and

words

simple sentences.

Giving simple directions lessen or prevent confusion

of the patient

7. Never convey to the client that his delusions hallucinations real and are

The delusion or hallucination would be reinforce if its accepted.

8. Maintain oriented relationship environment

reality

and

reality

Maintaining based and lets

relationship environment

the patient know that the relationship is temporary and prevents separation anxiety

9. Give feedbacks

positive and the

acknowledge client

Positive feedback enhances sense of well-being and

makes positive

more situation

for the client.

10. Do not judge or belittle beliefs. clients

What the client feels or thinks is not funny for him. The client may feel rejected approached if by

attempts of humor.

TIME AND DATE .Janua ry 21, 2010 @ 12 :30 PM

CUES

NEED

NURSING DIAGNOSIS

GOAL OF CARE

INTERVENTIONS

EVALUATION

SUBJECTIVE: Maulaw man gyud ko basta ing-ana

S E L F

Situational low self-esteem related to cognitive impairment

At the end of 2 hours of nursing care, will: the patient

1. Encourage client to express honest

January 21, 2010 @ 2:30 PM

feelings in relation to loss of prior level of functioning. y The patient GOAL UNMET

OBJECTIVE: y Lacking contact y Lack interaction y

eye P E social R C

y It is the state in which an individual who previously had positive selfesteem experience a negative feeling towards self due to a certain situation y

Verbalize understandi ng of things that precipitate current situation; and Demonstrat e behaviors that show

Acknowledge pain of loss. Support through

was unable to verbalize understanding of things that

client

process of grieving. Client may be fixed in anger stage of grieving process, which is turned inward on the self, resulting in diminished selfesteem. 2. Devise methods for assisting client to

Has little interest E P in activities Talks only when T I asked O N

lead to current situation y The patient

was unable to demonstrate behaviors show that

positive self-esteem

positive as by

self-esteem evidenced

Handbook of Nursing

inability to have

Diagnosis by Lynda Juall CarpenitoMuyet

express properly..

feelings

an eye-contact as well as

looking down at To explore the feelings of the client thereby allowing him to acknowledge his own strength and weakness. 3. Encourage client's attempts communicate. verbalizations to If are during interview. the

not understandable, express to client

what you think he or she intended to say. It may be to client

necessary reorient frequently.

The ability to communicate effectively with others may enhance self-esteem. 4. Encourage reminiscence and

discussion of life review. Also

discuss present-day events. Sharing

picture albums, if possible, is

especially good. Reminiscence and life review help the client resume

progression through the grief process associated disappointing with life

events and increase

self-esteem successes reviewed. 5. Encourage participation group

as are

in

activities.

Caregiver may need to accompany client at first, until he or she feels secure that the group members will be accepting, regardless of

limitations in verbal communication. Positive feedback from group members will increase selfesteem. 6. Offer support and empathy when

client

expresses at to people,

embarrassment inability remember

events, and places. Focus on

accomplishments to lift self-esteem. 7. Encourage client to be as independent as possible in selfcare activities. The ability to perform independently preserves selfesteem. 8. Listen to patients concerns verbalizations without comment and

or judgment. It enables the client to develop trust and thereby establish communication 9. Provide feedback to clients feelings. To allow the client experience a different view. negative

TIME AND DATE January 21, 2010 @12:30 PM

CUES

NEED

NURSING DIAGNOSIS

GOAL OF CARE

INTERVENTIONS

EVALUATION

SUBJECTIVE: The clarified when exactly was the 2 months he was referring about his last used of marijuana, he verbalized Kadtong 2007 man to, aw 2008 diay

C O G N I T I V E

Impaired memory related to neurological disturbances Impaired memory is directly related to effects of general medical condition or ongoing effects of substance. Depending o n the areas of the brain, the client are unable to recall information, either remote or recent. The

At the end of 3 day nursing care, the patient will be able to: y Verbalize awareness of memory problems; and y Accept limitations of current

1. Provide opportunities reminiscence recall past events Long-term memory may

January 21, 2010 for @ 2:30 PM or GOAL MET y The patient was able to verbalize awareness of memory problems as he

persist after loss of recent memory. is an activity

Reminiscence usually enjoyable

OBHECTIVE: y

Disorientation to P time E R of C E

for the client.

verbalized Usahay the

Observed experience forgetting

condition 2. Encourage client to use written cues such as or y

gyud makalimot na ko The patient was able to

his P head when he is T unable to recall U Scratches information A to L

calendars notebooks Written decrease

cues the

verbalize acceptance

Inability

determine if a behavior performe is

client may confabulate to fill in those lost memories.

clients recall

need

to

of

his

activities,

limitations due to his conditions

plans and so on from memory. 3. Encourage ventilation feelings frustration, helplessness, and so forth. Refocus of of

attention to areas of focus and progress. To lessen feelings of powerlessness/hope lessness 4. Provide for proper pacing of activities and having

appropriate rest To avoid fatigue 5. Allow the client to do tasks on his

own, but do not rush him to do it. Make the client feel that he can still do things independently. It is important to maximize independent function, assist the client memory when has

deteriorated further. 6. Assist the client

deal with functional limitations and

identify resources. To individual maximizing independence. 7. Provide single step instructions when meet needs,

instructions needed. Client memory

are

with

impairment cannot remember multistep instructions 8. Do not contradict the client who an Instead, explain and find

experiences illusion. simply reality, some solutions problem Therapeutic

practical to the

responses promote reality offering while solutions

that help enhances the clients sense and may reduce

fear, anxiety, and confusion. 9. Monitor clients

behavior and assist in use of stressmanagement techniques To frustration 10. Determine clients response medication medications prescribe to to reduce

improve attention, concentration, memory process

and to lift spirits and emotional responses. Helpful deciding in whether modify

quality of life is improved using medications prescribed. TIME AND DATE January 21, 2010 @ 12:30 P.M. SUBJECTIVE: Makatamad usahay maligo. Wala pa gani ko ligo ron. Kapoy pud manlimpyo ug kuko, as verbalized by the patient. OBJECTIVE: Unkempt hair noted food stains visible on clothing untrimmed fingernails and toenails with visible dirt noted A C T I V I T Y E X E R C I Self care deficit: bathing / hygiene related to lack of motivation The patient has an impaired ability to provide self care requisites due to environmental and psychological factors. After 2 hours of nursing care, the client will be able to: a) verbalize self need b) Demonstrat e techniques to meet care 1. Establish rapport. R: to gain clients trust and facilitate a good working relationship. 2. Identify reason for difficulty in selfcare. R: underlying cause affects choice of interventions/ strategies. 3. Determine hygienic needs and provide assistance needed as with After 2 hours of nursing care, the client was able to: a) verbalize self need b) but unable was to care January 21, 2009 @ 2:30 PM CUES NEED NURSING DIAGNOSIS GOAL OF CARE INTERVENTIONS EVALUATION when the

GOAL PARTIALLY MET

self-care needs

S E

activities like care of nails and

demonstrate techniques to meet selfcare needs.

brushing teeth. P A T T E R N R: basic hygienic needs may be forgotten. 4. Discuss importance hygiene. R: makes client aware of how hygiene is vital in caring for oneself. 5. Orient client to on of

different equipment for self-care like various toiletries. R: increases the clients awareness of different materials for self-care. 6. Let the patient enumerate his ideas on the importance of hygiene. R: Encourages the

patient to understand the need for hygiene. 7. Discuss the possible negative

implications of not taking a bath such as infections and odor. R: Broadens the

patients idea about the problem and

encourages him to meet the need. 8. Encourage client to perform self-care to the maximum of ability as defined by the client. Do not rush client. R: promotes independence and sense of control, may decrease feelings of

helplessness. 9. Allot plenty of time to perform tasks. R: cognitive impairment may interfere with ability to manage even simple activities. 10. Assist with

dressing neatly or provide clothes. R: Enhances esteem and convey aliveness. colorful