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CUES/DATA

DIAGNOSIS

RATIONALE

GOALS AND OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Kapag ako nagkaroon ng maraming pera magtatayo ako ng karinderia. Tapos papakainin ko lahat ng Pilipino dun ng libre as verbalized by the patient. Objective: Has inappropriate Thinking Has inaccurate Interpretation of environment

Disturbed thought processes related to mental disorders as manifested by innacurate interpretation of environment

Schizophrenia are defined by psychotic symptoms. Psychotic symptoms are produced by a severe impairment of reality testing, and include prominent delusions.

After 15 minutes of Independent: nursing intervention y Monitor and patient will be able document vital to identify signs periodically interventions to as appropriate deal effectively y Reorient the patient with situation to time place and person

Reference: Lippincott Manual Nursing Practice 3rdedition

Perform periodic neurological/behavi oral assessments, as indicated and compare with baseline. Note changes in level of consciousness and cognition Provide safety measures

After 15 minutes of nursing intervention the client was able To prevent further to identify interventions to deal deterioration of effectively with situation patients level of function Inability to maintain orientation is a sign of deterioration Early recognition of changes promotes proactive modifications to plan of care

Schedule structured activity and rest periods. Maintain a pleasant, quiet environment

To prevent further deterioration of patients level of function Provides stimulation while reducing fatigue Client may respond with

and approach patient in a slow, calm manner.

Maintain realityoriented relationship and environment Listen with regard

Present reality concisely and briefly and do not challenge illogical thinking Use touch judiciously, respecting personal needs/cultural beliefs, but keeping in mind physical and psychological importance of touch Refrain from forcing activities and communications Provide nutritionally wellbalanced diet,

anxious or aggressive behaviors if startled or overstimulated To create therapeutic milieu and assist patient to develop coping strategies To convey interest and worth to individual Illogical thinking can result to defensive reactions to the patient To create therapeutic milieu and assist patient to develop coping strategies

Client may feel threatened and may withdraw or rebel Enhances intake and general wellbeing

incorporating clients preferences as able. Encourage client to eat. Provide pleasant environment and allow sufficient time to eat. Dependent:

Adminiter antipsychotic medication as prescribed by the physician.

Used to treat certain mental/mood disorders.

CUES/DATA

DIAGNOSIS

RATIONALE

GOALS AND OBJECTIVES After 30 minutes of nursing intervention the patient will be able to establish in therapeutic communication in which needs can be expressed.

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Paminsannahihirapanak onaiexpresssarili as verbalized by the patient. Objective: Has difficulty in comprehending/maintainin g usual communication pattern Has a fair eye contact Speaks/verbalizes with slurring Medications: Clonazepam

Impaired Verbal Communication related to side effects of medications as manifested by slurred speech

Decreased, delayed or absent ability to receive process, and transmit communication. Clonazepam as a side effect also of making the patient be slurred in speech

Independent: -Reduce environmental noise that can interfere with comprehension. Provide adequate lighting, especially if client is reading lips or attempting to write. -Establish relationship with the client, listening carefully and attending to clients verbal/non-verbal expression -Maintain eye contact, preferably at clients level -To assist client to establish a means of communication to express needs, wants, ideas and questions.

After 30 minutes of nursing intervention the patient was able to establish in therapeutic communication in which needs can be expressed.

Reference: Nurse Pocket Guide 11th edition Drug Handbook 5th Edition

-This can conveys interest and concern with the client

- To assist client to establish a means of communication to express needs, wants, ideas and questions. -Individuals with expressive aphasia may talk more

-Maintain calm, unhurried manner. Provide sufficient

time for client to respond. Downplay errors and avoid frequent corrections.

easily when they are rested and relaxed and when they are talking to one person at a time -Validating the meaning of her non-verbal communication may be wrong

-Validate meaning of nonverbal communication; do not make assumptions. Be honest if you dont understand seek assistance from others. -Provide environmental stimuli as needed or reduce stimuli

-To maintain contact with reality. In reducing in helps to lessen the anxiety that may worsen the problem

CUES/DATA

DIAGNOSIS

RATIONALE

GOALS AND OBJECTIVES After 30 minutes of nursing intervention the client will be able to modify environment as indicated to enhance safety.

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Lagi ako nahihilo at parang umiikot yung paningin ko as verbalized by the patient Objective: Seeing patient touching her head Seen patient swaying while standing for few seconds Medications: Abilify Clonazepam Palliperidone

Risk for falls related to medications as manifested by dizziness

Increased susceptibility to falling may cause physical harm to the a patient. Anti-psychotic medications can also have the side-effects in making the client dizzy at all times Reference: NANDA 11th edition Drug Handbook 5th edition

Independent: -Observe individuals general and health status -Noticing factors that might affect safety, such as chronic or debilitating conditions, use of medications, recent trauma. -Altering coordination, gait, and balance

After 30 min utes of nursing intervention the client was able to modify environment as indicated to enhance safety.

-Assess muscle strength, gross and fine motor coordination. -Evaluate clients cognitive status

-Affects ability to perceive own limitations or recognize danger -Individuals temperament, typical bahaviors, stressors and level of self esteem can affect attitude toward safety issues, resulting in carelessness or increased risk-taking

-Assess mood, coping abilities, personality styles

without consideration of consequences. -Consider environmental hazards in the care setting and home environment -Identifying needs/deficits provides opportunities for intervention and instruction -Use of certain medications such as anti-psychotics can contribute to dizziness, confusion, balance

-Review medication regimen and how it affects the client. Instruct the client to monitor the sideeffects of the medications. -Stress importance of monitoring conditions/risks that may contribute to occurrence of falls -Practice client safety

-To assist client and the caregiver to reduce or correct individual risk factors -Demonstrates behaviors for client and caregiver to emulate

CUES/DATA

DIAGNOSIS

RATIONALE

GOALS AND OBJECTIVES After 30 minutes of health teaching the client will be able to identify individually appropriate interventions to promote sleep

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Hindi pa kompleto yung tulog ko ngayon kasi, mga 12am o 1am na ko nakatulog kagabi as verbalized by the patient Objective: (+) Fatigue (+)Acute Confusion (+) Drowsiness

Disturbed Sleep Pattern related to medications as manifested by verbal complaints of not feeling well-rested

Abilify drug has proven to have a side effect of having Insomnia to the patient. Hence the patient has a great chance having a disturbed sleep pattern Reference: Drug Handbook 12th edition

Independent: -Encourage the client to develop plan to restrict caffeine and other stimulating substances from late afternoon/evening intake and avoid eating large evening meals -Promote adequate physical exercise activity during day. -These factors are known to disrupt sleep patterns

After 30 minutes of health teaching the client was able to identify individually appropriate interventions to promote sleep

Medications: Abilify -Recommend quiet activities, such as reading /listening to soothing music in the evening

-Enhances expenditure of energy release of tension so that client feels ready for sleep/rest -To reduce stimulation so client can relax

-Limit evening fluid intake if nocturia is present -Provide calm, quiet environment and manage controllable sleep-disrupting factor

-To reduce need for night time elimination

-To assist client to establish optimal sleep pattern