B.

Nursing Care Plan

DIAGNOSIS Disturbed Thought Process related to disintegration on thinking as manifested by disorientation with date and place and impaired judgment Cues: Subjective: >Keeps on verbalizing when asked of date, Lunes Mayo 25, 1952 >says Orange Juice instead of carrot Objective: > Nonrealitybased thinking >With delusion of grandeur >Disorientation

NEED

C O G N I T I V E N E E D

DESIRED OUTCOME Within 2 hours of Nursing Interventions, the patient will be able to: General: > Respond to reality-based interactions initiated by others Specifically, > Interact on reality-based topics >Sustain attention and concentration to complete tasks or activities

INTERVENTIONS INDEPENDENT Establish rapport to the patient

RATIONALE

EVALUATION STATEMENT Goal is partially met. Ms. MB was able to respond in a reality-based interaction still with the aid of the student nurse. However, there are times that she could not be able to answer directly and properly to the simple questions the student nurse is asking. She sustained her attention was fortunately,

INTERVENTIONS

RATIONALE

Continue
Nursing Interventions especially bringing back the patient to reality Continue to encourage patient comply all medications prescribed to her

It is healthy
for her and may lead her to be more productive and more functioning self For faster recovery from the mental illness

To gain clients trust and cooperation Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions Assess condition of the patient before giving medications

Be sincere and
honest when communicatin g with the client. Avoid vague or evasive remarks

Monitor vital signs frequently especially blood pressure and interpret it accurately

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>Blunted affect >Short attention span >Impaired judgment

Be consistent
in setting expectations, enforcing rules, and so forth Do not make promises that you cannot keep Clear, consistent limits provide a secure structure for the client Broken promises reinforce the clients mistrust of others

she was able to complete her task.

Background Knowledge: Identifying and managing ones own health needs are primary concerns for everyone, but this is a particular challenge for clients with schizophrenia because their health needs can be complex and their ability to manage them may be impaired. The nurse helps the client to manage his or her illness and health needs as independently as possible. This can be accomplished only through education and

Encourage the
client to talk but do not pry or crossexamine for information

Probing
increases the clients suspicion and interferes with the therapeutic relationship When the client has full knowledge of procedures, she is less likely to feel tricked

Explain
procedures, and try to be sure the client understands the procedures before carrying them out Give positive

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ongoing support. Teaching the client and family members to prevent or manage relapse is an essential part of a comprehensive plan of care. This includes providing facts about schizophrenia, identifying the early signs of relapse, and teaching health practices to promote physical and psychological well-being. Murphy and Moller (1993) have identified symptom triggers, or factors that increase the risk for relapse, in the areas of the clients health, the environment, and the clients attitudes or behaviors (Box 14-4). Early identification of these risk factors has been found to reduce the frequency of relapse; when relapse cannot be prevented,

feedback for the clients successes

Positive feedback for genuine success enhances the clients sense of well-being and helps to make nondelusional reality a more positive situation for the client It is important to recognize the clients environment al perceptions to understand the feelings she is experiencing Logical argument does not dispel delusional ideas and can interfere with

Recognize the clients delusions as the clients perception of the environment

Initially, do not argue with the client or try to convince the client that the delusions are false or unreal

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early identification provides the foundation for interventions to manage the relapse. For example, if the nurse finds that the client is fatigued or lacks adequate sleep or proper nutrition, interventions to promote rest and nutrition may prevent a relapse or minimize its intensity and duration. Reference: Videbeck, Sheila. Psychiatric Mental Health Nursing.5th Ed. Lippincott Williams & Wilkins. Philadelphia. 2004

the development of trust Interact with the client on the basis of real things; do not dwell on the delusional material Engage the client in oneto-one activities at first, then activities in small groups, and gradually activities in larger groups Interacting about reality is healthy for the client

The client who is distrustful can best deal with one person initially. Gradual introduction of others when the client can tolerate it is less threatening Recognition of accomplishm ents can lessen the clients anxiety and the need for delusions as

Recognize and support the clients accomplishme nts (activities or projects completed, responsibilities fulfilled, interactions

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initiated)

a source of self-esteem

Show empathy
regarding the clients feelings; reassure the client of your presence and acceptance

The clients
delusions can be distressing. Empathy conveys your acceptance of the client and your caring and interest

Do not be judgmental or belittle or joke about the clients beliefs

The clients
delusions and feelings are not funny to him or her. The client may feel rejected by you or feel unimportant if approached by attempts at humor

Never convey to the client that you accept the delusions as reality

It would
reinforce the delusion (thus, the clients illness) if you

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indicated belief in the delusion

DEPENDENT

Administer
Chlorpromazin e as prescribed

An
Antipsychotic that could treat psychiatric illness such as this schizophrenia

DIAGNOSIS Disturbed Sensory Perception: Auditory/Visual Hallucinations related to alteration in the function of

NEED

DESIRED OUTCOME Within 2 hours of Nursing Interventions, the patient will be able to:

INTERVENTIONS INDEPENDENT Establish rapport to the patient

RATIONALE

EVALUATION STATEMENT Goal is partially met.

INTERVENTIONS

RATIONALE

Continue
Nursing Interventions especially in bringing her back to reality

To improve
her perception and make it into reality and not

To gain clients trust and cooperation

Ms. MB was
oriented by

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brain as manifested by inappropriate response and disorientation Cues: Subjective: >Cheche manghud ko >Piyesta sa Pavillion Objective: >inappropriate response >disoriented with date and place >claims she owns a garden inside the cell Background Knowledge: Cognitive impairment associated with schizophrenia is now viewed as a potential psychopharmacolo gical target

O G N I T I V E N E E D

General: >test reality,

eliminating the occurrence of hallucination s.

Specifically, >recognize present reality via activities prepared by the student nurse

as well as have a quality assessment Monitor vital signs frequently and interpret it accurately To assess whether medications could be given or contraindicat ed

Observe client
for signs of hallucinations (listening pose, laughing or talking to self, stopping in midsentence) Avoid touching the client without warning

Early
intervention may prevent aggressive response to command hallucination

the student nurse with the date and time. However, if being asked again, she will still answer incorrectly. She still claims that she there is a fiesta going on and she needs to go there. Fortunately, she was able to recognize reality because of diverting her attention to the activity.

and let her focus on her present activity Administer physicians prescribed medicine

fantasy

For faster
treatment that will lead to recovery

Client may
perceive touch as threatening and may respond in an aggressive manner

An attitude of
acceptance will encourage

This is
important to

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for treatment (Hyman and Fenton 2003). Although cognition is not a formal part of the current diagnostic criteria for schizophrenia, DSM-IV-TR (American Psychiatric Association 2000) includes seven references to cognitive dysfunction in the description of the disorder. Diagnostic and scientific experts increasingly have expressed the idea that neurocognitive impairment is a core feature of the illness and not simply the result of the symptoms or the current treatments of schizophrenia. There is some evidence that neurocognitive impairment in patients with schizophrenia may worsen over time in at

the client to share the content of the hallucination with you

prevent possible injury to the client or others from command hallucination

Do not reinforce the hallucination. Use the voices instead of words like they that imply validation. Let the client know that you do not share the perception. Say, Even though I realize the voices are real to you, I do not hear any voices Help the client understand the connection between anxiety and hallucinations.

Client must
accept the perception as unreal before hallucination s can be eliminated

If client can
learn to interrupt escalating anxiety, hallucination s may be prevented

Try to distract

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least a subgroup of elderly patients with schizophrenia. Prominent cognitive impairments resembling dementia have been reported in older schizophrenic patients with a lifetime of poor functional outcome (Arnold et al. 1995; Davidson et al. 1995; Harvey et al. 1996). On the basis of cross-sectional studies, elderly patients with schizophrenia appear to show some decline in cognitive function toward the end of life. However, this decline may be restricted to those patients who had an early onset of illness followed by a lifetime of poor functioning (Heaton et al. 1994; Hyde et al. 1994; Jeste et al. 1995; Zorrilla et al. 2000). Some of the

the client from the hallucination.

Involvement
in interpersonal activities and explanation of the actual situation will help bring the client back to reality

DEPENDENT

Administer
Chlorpromazin e as prescribed by the physician

To treat the
psychiatric illness which is Schizophrenia

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inconsistency of these results may derive from the subject selection processes in these studies.

Reference: Lewis, et al. Textbook Schizophrenia. 2003

DIAGNOSIS Impaired Verbal Communication related to regression as manifested by associative looseness, echolalia, and neologism Cues: Objective: >Repeats words and phrases uttered by the

NEED

S E L F E S T

DESIRED OUTCOME Within 2 hours of Nursing Interventions, the patient will be able to: General: >communicate appropriately and comprehensively with others Specifically, >talk not only

INTERVENTIONS INDEPENDENT Establish rapport to the patient

RATIONALE

EVALUATION STATEMENT Goal is partially met.

INTERVENTIONS Continue Nursing Interventions especially bringing back the patient to reality Continue to encourage patient comply all medications prescribed to her

RATIONALE It is healthy for her and may lead her to be more productive and more functioning self For faster recovery from the mental illness

To gain clients trust and cooperation as well as have a quality assessment

Ms. MB was
able to communicate to others not just to her student nurse. However, the fluency of her words is sometimes

Monitor vital signs frequently especially respiration and interpret it

To assess
whether or not to give medications prescribed

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student nurse, thus, echolalic >Ideas are sometimes not organized >Associative Looseness observed >neologism observed >Mumbles when speaking; words are not clearly stated Background Knowledge: Most cognitive assessments in treatment studies of schizophrenia have included measures of verbal fluency as a separate domain of functioning (Harvey and Keefe 2001; Keefe et al. 1999; Meltzer and McGurk 1999). Most of these tests measure either

E E M N E E D

with her student nurse but also other to other people present in the activity area including other student nurses, instructors, and fellow patients

accurately Attempt to decode incomprehensi ble communicatio n patterns. Seek validation and clarification by stating, Is it that you mean? or I dont understand what you mean by that. Would you please clarify it for me?

These
techniques reveal how the client is being perceived by others, while the responsibility for not understandin g is accepted by the nurse

not clear making it hard for others to understand what is she saying.

This Facilitate trust

and understanding by maintaining assignments as consistently as possible. The technique of verbalizing the implied is used with the client who is mute (unable or unwilling to speak). Example: approach conveys empathy and may encourage the client to disclose painful issues

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phonological fluency (also referred to as letter fluency) or semantic fluency. Phonological fluency refers to a patients ability to produce as many words as possible beginning with a particular letter within, for instance, 60 seconds. Semantic fluency refers to the ability to produce words within a particular meaning Reference: Lewis, et al. Textbook Schizophrenia. 2003

That must have been a very difficult time for you when your mother left. You must have felt very alone

Anticipate and
fulfill clients needs until functional communicatio n pattern returns

Clients
safety and comfort are nursing priorities

Orient client to
reality as required. Call the client by name. Validate those aspects of communicatio n that help differentiate between what is real and not real DEPENDENT Administer Chlorpromazin e as indicated To treat the psychiatric illness which is schizo-

These
techniques may facilitate restoration of functional communicati on patterns in the client

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phrenia

61