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NURSING CARE PLAN

TIME

CUES

NEED

AND
DATE
Januar

SUBJECTIVE:
C
Naay
nagahung- O
y 21,
G
hung sa akoa usahay
2009
N
nga mag-wild daw ko I
@
T
ug maglagot as
12:30
I
verbalized by the V
P.M.
E
patient
P
OBJECTIVE
E
Disoriented
R
C
to time
Auditory and E
P
visual
T
hallucination U
A
s
L
Misinterprets
actions
of P
A
others
T
Inability to T
E
make simple
R
decisions
N
Inappropriate

NURSING

GOAL OF CARE

INTERVENTIONS

EVALUATION

DIAGNOSIS
Disturbed sensory At the end of 2
perception related hours

of nursing

to alteration in care,

the

patient

function of brain will be able to


maintain
tissue
It is the change
in the amount or
patterning

distorted,

or

time,

other sensory-perceptual

place,
and

specified

period

diminished,
exaggerated,

about hallucinations and

for

accompanied by a

client
The client must trust
the nurse before talking

circumstances

incoming stimuli

build trust with the @ 2:30 PM

orientation to
person,

of

1. Establish rapport and January 21, 2009

of

time;
demonstrate
accurate

alterations
2. Continuously

orient

GOAL UNMET

The

patient was able


to maintain
orientation to

the client to actual

time, place,

environmental events

person and

or

situation.

activities

in

nonchallenging way.
Brief,
frequent

Huwebes

orientation helps to

udto na man

present reality to the

siguro. Naa ko

client with sensory-

sa Mental

impaired

perception of

response to such

the

stimuli.

environment

Schultz,

by responding

M.J.;Videback,

appropriately

on reality. Talk about

S.L.; Lippincotts

to stimuli in

real events and real

perception disturbance
3. Reinforce and focus

karon. Mga

hospital para
magpacheckup
However,

responses

Manual

of

Psychiatric
Nursing

Care

Plans 7th edition

the

people.

surroundings;

situations and events

not able to

and
lessen visual

to divert client from

demonstrate

long,

accurate

and

repetitive

perception of

verbalizations of false

the environment

ideas

Working

as evidenced by

auditory

hallucinations

Use

real

tedious,

reality

with
lessens

patients initiation of
his hallucinations.
4. Correct
client's
description

of

inaccurate perception,
and

describe

the

situation as it exists in
reality
Explanation of,
and participation in,
real situations and real
activities

interferes

with the ability to


respond

to

hallucinations.
5. Observe for verbal

the client was

the presence of
delusion and
hallucination
Presence
of auditory
hallucination is
still evident.

and

nonverbal

behaviors

associated

with hallucinations
Early recognition of
sensory-perceptual
disturbance promotes
timely

interventions

and alleviation of the


clients symptoms.
6. Describe
the
hallucinatory
behaviors

to

the

client.
The client may be
unable

to

disclose

perceptions and the


nurse

can

openly

facilitate disclosure by
reflecting

on

observations of the
clients

behaviors,

which helps the client


engage in more open
discussion with the

nurse, which in itself


brings relief.
7. Explore the content of
hallucinations

to

determine
possibility

the
to

harm

self, others or the


environment

Exploring

the

content

the

of

hallucination helps the


nurse identify if the
sensory-perceptual
disturbance

is

threatening

or

dangerous
client,

to

such

command

the
as

type

a
of

hallucination that may


be telling the client to
harm or kill the client
or others. The nurse
can

then

reinforce

treatment and safety


precautions.
8. Use clear,

direct,

verbal communication
rather than unclear or
nonverbal gestures
Unclear directions
or

instructions

can

confuse the client and


promote

distorted

perceptions

or

misinterpretations

of

reality.
9. Modify

the clients

environment
decrease

to
situations

that provoke anxiety


Decreased anxiety
can

reduce

occurrence

of

hallucinations
10. Reassure the
(frequently
necessary)

the

client
if

that

the

client is safe and will


not be harmed
Alleviation of fear is
necessary

for

the

client to begin to trust


the environment and
to feel safe.

Assessment
Subjective:

Diagnosis
Analysis
Impaired social Loss of Job

Planning
Intervention
Rationale
E
The client will 1.Be
sincere 1.Depressed client are G

huh? Naku hindi ako masaydo interaction related


magaling maglaro
As verbalized by the patient

to low self esteem

Interact
Feels worthless

others STG

(Depersonalization)

After

Objetive
Depersonalization

Flight of ideas

Anxiety

with and

months
Low self esteem

honest extremely

when

about others and can C

5 communicating
,the with the client.

client will by:

Interaction

Social

ve

recognize insincerity.

2.This can reinforce the

2.Do not make clients mistrust

1.cooperati promises
Impaired

sensitive

and 3

that lose of cooperation.To

you cant keep. Develop

trusting

2.verbalize Attend Clients relationship with client


feeling

needs

3. Recognizing clients

3.gain

3.Recogniuze

perception

trust

of the

can

help

cl;ients nurse understand the

patient

problem s as the feelinf

LTG:

clients

interact
reality

of 4.Interact about reality

patient the

will

is healthy for the client

be environment.

5.to

boost

with 4. Interact with -esteem


based the client on the

topic

as basis of the real

evidence by

things;do

not

1.cooperative

dwell

on

2.inter

act delusional

with

material .

people(real)

5.appreciate

is

experiencing.

After 1 year perception


,the

he

client had done

its

self

ASSESSMENT
Subjective:
nung

april

DIAGNOSIS ANALYSIS PLAN


INTERVENTION RATIONALE
EVALUATION
Risk
for Confined at The client will engage 1.Be sincere and 1.Be
sincere Goal met
lang loneliness

Metro

nakapunta un asawa related

to psyche

ko tapos din a sya loss

of facility

pumunta

nitong support

in social activities.

honest

STG:

communicating

After

when and

nursing with the client.

intervention

honest

when

Client was able

communicating to:

the 2.Do not make with the client.

1. inter act with

buwansabi niya sa person( Clien

client1.cooperative promises that you 2.Do not make people

august siya babalik ts wife)

2.verbalize feeling

para kunin ako .

Wife

3.gain

Objetive

support

patient

Depersonalization

person cant LTG:

Flight of

visit

ideas

anymore

Sad

client After

trust

cant keep. Attend promises

of Clients needs

verbalize

3.Recogniuze the Attend Clients 3. cooperative


cl;ients problem s needs

2.

you cant keep. feeling

year

,the as

the

clients 3.Recogniuze

patient will be interact perception of the the


with

that

reality

based environment.

topic as evidence by

4.

cl;ients

problem s as

Support the

clients

The eye contact with


patient was lost

1.cooperative
Risk

for 2.inter

loneliness

act

people(real

expression
with negative
perceptions

of perception

of

the
of environment.

others and wether 4.

Support

client agrees .

expression

5.Identify

negative

individual

perceptions of

strength ,areas of others


interest.

wether

6.Encourage

agrees .

attendance
group activitie

of

and
client

oat 5.Identify
individual
strength ,areas
of interest.
6.Encourage
attendance oat
group activitie

ASSESSMENT
Subjective:

DIAGNOSIS ANALYSIS PLAN


INTERVENTION RATIONALE
EVALUATION
Disturbed
Medicine The
client .Be sincere and honest 1.depressed
Goal met

meron, un

sleep

reisperdal,ka

related

so lang

injteruption

nahihirapan

of

akong
makatulog

Side will be able to when

to effect

communicating client

are

identify

with the client.

extremely

appropriate

2.Do not make promises sensitive

Increses

interventions

that you cant keep. about

therapeutic

stimulatio

for sleep.

Attend Clients needs

maedicine

n in brain

STG:

3.Recogniuze

Client was to identify


interventions

others promote slep like :

and

can

Objetive

sleep

WILL
at ABLRE

B clients perception of the 2.This


TO environment.

the recognize

reinforce

Hyperactive in
the morning

THE CLIENT cl;ients problem s as the insincerity.


Cant

that

Positioning in

can

comfortable

the

position.

Depersonalizatio

night

Flight of

IDENTIFY

4.

Interact

with

THE

client on the basis of the mistrust

FACTORS

real things;do not dwell lose

ideas

Disturbed

THAT

on delusional material .

Sad

sleep

DISTURBED

5..Have

The eye

pattern

SLEEP

contact with
patient was
lost

Anergic

client

/lower or resist

of

environmental

cooperation.T

drink o

morning .

BY

6.inform

Develop

1.VERBALIZ

factors

relationship
client

that

about with client

disturbed 3.

E 3 FACTORS sleep pattern like:


CAN

Recognizing

Hypoactive at

clients

DISTURBED

the morning and

perception

SLEEP

hyperactive in

can help nurse

PATTERN .

the evening

understand

LTG:

Medication

the feelinf she

The client will

Environmental

is

be

able

to

know

disturbances like

unterventions
that
sleep .

promote

experiencing.
4.Interact

noise

about
7.Inform

client

about

interventions
promoting sleep like:

in

reality

is healthy for
the client
5.Giving

Decease

and

AS medicine given in the trusting

EVIDENCE

THAT

the clients

stimli

Hyperactive in

medication in

the morning

the

Positioning in

(which

comfortable

effect

position.

disturbed

morning
side
is

Decease /lower or resist sleep pattern )


may lower the
environmental stimli
effect

of

medication at
night and not
produced
insomia.
6.Becoming
hypoactive at
the

morning

makes

our

energy shift at
night that may
disturbed
sleep.
Medication
always

had

side effects
Environment
that

produce

unnecessary
stimuli

like

noise

may

interfere with
sleep.
7.
This promote
sleep at night
Placing

in

comfortablr
position
promote sleep
Environment
that

produce

unnecessary
stimuli

like

noise

may

interfere with
sleep