Assessment

Shows signs of
religious
grandiosity and
delusion of
grandeur:
"Doktor ako sa
probinsya ko'
"Binaba ako
mula langit"

Nursing
Diagnosis

Sensory and
perceptual
alteration
related to
hallucinations

Scientific
Rationale
Lack of
concentration,
inappropriate
reactions and
response to
reality are
common among
schizophrenic
patients which
may be caused
by either visual
or auditory
infection

Objective
After 2 weeks, the
patient will

Verbalize a
reduction of
hallucination
s

Nursing
Interventions

Rationale

1. Encourage
the
verbalziation
of
hallucination

1. To assess
whether the
hallucinations
are trash ion
hand

2. Place the
patient in a
calm, quiet
environment

2. To prevent
overstimulation

3. Reorient
the patient to
reality

3.To prevent an
onset of
hallucination

4. Divert the
patients
attention
from the
whole

4.To prevent
the onset of
hallucinations

5. Encourage
the patient to

5. To reorient
the patient back
to reality

Evaluation
After 2 weeks, the
patient:

Verbalized a
reduction of
hallucinations

join group
therapies

Disruption, in
cognitive
operation and
With rapid
Altered thought with any ideas
speech, flight of
process
remembered
ideas, auditory
hallucinations

After 2 weeks, the

patient will:
Have a slight
improvement
in thought
pattern

1.Speak in
short and
simple
sentences

1. To prevent
confusion in
the part of the
patient

2. Maintain a
calm, quiet
environment

2. To prevent
from
overstimulating
the patients

3. Reorient
the patient on
time, place
and person

3.To prevent
further
deterioration of
the patient's
thought process

4. Present
reality
concisely and
briefly. Do
not challenge

4. Patient may
become
defensive and
may become
violent

After 2 weeks, the

patient:
Has a slight
improvement in
thought pattern

illogical
thinking
5. Encourage
to participate
in activity
therapies

After 2 weeks, the

Communication patient will:
Patient talks in
can be impaired
Have an
a rapid speech,
when an
improvement
which is hard to
Impaired
individual has a
in verbal
comprehend.
verbal
rapid/ fast rate
communicati
Has manifested communication of speech, since
on
signs of
the nurse will
manifested
tangentiality
have a difficult
by a normal
when
time
speech
communicating.
understanding
pattern
the patient
which is
easy to
comprehend

5. To promote
thought
reinforcement

1.Encourage
the patient to
try and slow
down his
speech

1. In order for
the patient to
be understood
by the others

2. Inform the
patient once
that his
speech
becomes fast

2. This is to set
limits on the
fast paced
speech of the
patient

3. Explore on
the reason
behind the
rapid speech
of the patient

3. To uncover
the reason
behind his
rapid speech
pattern

4. Provide a

4. To allow the

After 2 weeks, the

patient:
Have an
improvement in
verbal
communication
manifested by a
normal speech
pattern which is
easy to
comprehend

calm, quiet
environment
which is free
from
distraction

patient to focus
on the
interaction

5.Do deep
breathing
exercises

5. In order to
relax the
patient,
allowing for
better
communication