IX. NURSING CARE PLAN Name: Rodelo Agacita Physician: Dova M.

Sayon, MD Age: 25 y/o Sex: Male Diagnosis: Schizophreniform

DATE

ASSESSMENT NEED

NURSING DIAGNOSIS Deficient diversional activity related to activity restriction due to hospitalization and treatment

OBJECTIVES OF CARE After 2 hours of nursing care, the following are to be observed and accomplished: -Client will engage in satisfying activities within personal limitations -absence of droopy eyes lessen the occasions of staring blankly

INTERVENTIONS

EVALUATION

January S- Unsa man 18, akong pwede 2012 buhaton nurse? Gilaay nako, as verbalized. O - is usually found sitting in one corner - stares blankly for long periods - droopy eye - yawning

A C T I V I T Y E X E R C I S E

Hospitalization places the patient in a situation wherein activities are limited. This is especially true in patients who are mentally disabled since most of them require close monitoring.

Some of the most common side effects of ant- psychotic

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1. Assessed and reviewed clients physical, cognitive, emotional, and environmental status. Validates reality of environmental deprivation when it exists, or considers potential for loss of diversional activities in order to plan for prevention or early interventions. 2. Reviewed history of lifelong activities and hobbies client has enjoyed. Discuss whether client would like to resume activities to determine the activities which may be included in the

drugs are drowsiness and dizziness. These side effects may hinder patients activity.

Deficient diversional activity Mental Health Medications. Retrieved on January 23, 2012 @ http://www.nimh.nih.g ov/health/publications /mental-healthmedications/complete -index.shtml

plan of activities. 3. Encouraged mix of desired activities. Activities need to be personally meaningful and not physically/emotionall y overwhelming for client to derive the most benefit. 4. Encouraged client to assist in scheduling required and optional activity choices to enhance clients sense of control. 5. Refrained from making changes in schedule without discussing with client. It is important for staff to be responsible in making and following through on commitments to client.

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DATE

ASSESSMENT

NEED

NURSING DIAGNOSIS Impaired self-concept: low self-esteem r/t lack of recognition by s/o 2 chronic alcoholism, smoking and drug addiction Chronic alcoholism, smoking and drug addiction Alcohol impairs judgement, memory, concentration and coordination; as well as inducing extreme mood swings and emotional outbursts; Nicotine makes you anxious, nervous, moody, and depressed after you smoke; Drugs may cause deterioration of the nerves, blood vessels, which may finally affect the brain, as a result of which brain damage occurs.
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OBJECTIVES OF CARE After 2 hours of nurse-patient interaction, client will be able to: a. Express positive selfappraisal through verbalization of self as a worthwhile, important person who functions well both interpersonally and occupationally. b. Droopy eyes and sad face not noted c. Minimal staring

INTERVENTIONS

EVALUATION

J A N U A R Y 21, 2 0 1 2 11 am

S: Dili lage ko kaingon sa iya hangtod nalang migraduate mi ug high school kay maulaw ko kay siya arangan human kami dili, nag eskwela napud siya ug college human ako wala. Objectives: Loneliness AEB droopy eyes and sad face Staring blankly for a long time as if he is thinking deeply of someone/somet hing Eye contact is not maintained during the conversation

S E L F E S T E E M N E E D

INDEPENDENT: 1. Encouraged expression of feelings and anxiety. Facilitates grieving the loss. 2. Encouraged relaxation techniques. To promote positive sense of self. 3. Spend time with client. This may mean just sitting in silence for a while. Your presence may help improve clients perception of self as a worthwhile person. 4. Developed a therapeutic nurseclient relationship through showing an accepting attitude. Show an unconditional positive regard. Your acceptance and conveyance of positive

 May cause undesirable behaviors May hinder good relationship with S/O Lack of recognition by S/O Low self-esteem Ref: therightmix.gov/ resources/ documents/ P01994A_Effects_of_Alc ohol.pdf Drugs, Alcohol, and Smoking << girlshealth.gov/ retrieved Jan. 23, 2012

regard enhance the clients feelings of selfworth. 5. Taught assertiveness techniques. Interactions with others may be negatively affected by clients use of passive or aggressive behavior especially when he is drunk or when using additive drugs. Knowledge of assertive techniques could improve clients relationship with others. 6. Provided positive reinforcement for clients voluntary interactions with others. Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors.

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DATE

ASSESSMENT

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

INTERVENTIONS

EVALUATION

J A N U A R Y 21, 2 0 1 2 11 am

S: Naay nagahunghong pa sa ako maong maglisod ko ug sabot kung tama ba o mali ang akong ginabuhat ug ginaingon. O: Worried face Eye contact is not maintained during the conversation Delayed response when questions are asked frequent blinking of the eyes and grimacing

S A F E T Y A N D S E C U R I T Y N E E D

Disturbed sensory perception: After 2 hours of Auditory r/t neurologic nurse-patient changes 2 schizophreniform interaction, client will be Schizophreniform able to: dopamine a. Maintains social neurologic changes such as relationship altered behavior and cognition, voluntary b. Maintains movement, motivation and role reward, sleep, mood, performance attention, and learning c. Learned disturbed sensory perception: ways to refrain auditory from responding to Reference: hallucinations http://www.newsmedical.net/health/DopamineFunctions.aspx/ retrieved January 23, 2012

INDEPENDENT: 1. Used therapeutic communication To have an effective communication with the client. 2. Provided reassurance of safety if client responds with fear to inaccurate perceptions. Clients safety and security is a nursing priority. 3. Used touch and eye contact. These gain patients attention. 4. Decreased environmental stimuli when possible (low noise, minimal activity)

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Confused

potential for anxiety that might trigger hallucinations. Helps calm patient. 5. Helped the client to identify the needs that might underlie the hallucinations. Hallucinations might reflect needs for power, selfesteem, anger and sexuality. 6. Do not reinforce the hallucination. Let the client know that you dont share the perception. Maintain reality through reorientation and focus on real situations and people. Reality orientation false sensory perception and enhances
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clients sense of self-worth and personal dignity. 7. Corrected clients description of inaccurate perception and described the situation as it exists in reality. Explanation of, and participation in real situation and real activities interferes with the ability to respond to hallucinations. 8. Kept to simple, basic, reality-based topics of conversation. Help client to focus on one idea at a time. Clients thinking might be confused and disorganized; this intervention helps client focus and comprehend reality-based issues.
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9. Be alert for signs of fear, anxiety or agitation. Might herald hallucinatory activity, which can be very frightening to client, and client might act upon command hallucinations (harm self or others).

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