Vous êtes sur la page 1sur 3

Subjective cues "Ganahan nako Mugawas diri, kay mangtapas nako ug tubo sa amu" as verbalized by the patient

Objective cues -wearing a ninja-like outfit -with the visual hallucination -limited attention span -laughing and talking to himself without apparent reason

Nursing diagnosis Disturbed thought processes related to psychological and cognitive disturbances as manifested by limited attention span, hallucination , and laughing and talking to himself without any reason Definition: disruption in cognitive operation and activities Source: Doenges , M.E. et a.l.(2008) Nurses Pocket Guide, Diagnosis, Prioritized interventions and Rationales . 11th edition

Scientific reference One hallmark symptom of schizophrenic psychosis is hallucinations. Hallucination can involve the five senses and bodily sensation. They can be threatening and frightening for the client ; less frequently, client's report hallucinations as pleasant. Initially client perceives hallucinations as real, but later in the illness ,he or she may recognize them as hallucination. Hallucinations, however, have

Goal That after 3 weeks of Nursing Care Management, Patient will be able to: 1. Demonstrate behavior/ lifestyle changes to prevent, minimize changes in mentation 2. Respond to reality-based interactions initiated by others 3. Sustain attention and concentration to complete tasks and activities 4. Verbalize recognition of hallucinations if they persist

Intervention Independent: 1. Interact with the client on the basis of real things; do not dwell on the hallucination al material. 2. Assess attetntion span/distrac tibility and ability to make decisions/ problem solution 3. Schedule structured activity and rest periods 4. Reduce provocative stimuli, negative criticism, arguments and confrontatio


Expected outcome Patient was able to recognize the presence of hallucinations, and verbalized feelings of comfort, wanted to go home and continue his work

. -interacting about reality is healthy for the client

-determines ability to participate in planning/ executing care

-provides stimulation while reducing fatigue -to avoid triggering fight/ fight responses


Disturbed Thought Process pages 696-700

no such basis and reality. Source: Videbecks, S. L.(2006). Psychiatric Mental Health Nursing #rd Edition Sensorium and intellectual page 288

ns 5. Refrain from forcing activities and communicat ion Dependent: 1. Administer antipsychoti c med as prescribed Collaborative: 1. Assist in identifying ongoing treatment needs/ rehabilitatio n program for the individual -

may feel threaten ed and may withdraw /rebel to treat psycholo gical and cognitive disturban ce to maintain gains and continue progress if able