CUES

SUBJECTIV
E:
Higit pa
ako sa
Dios, as
verbalized
by the
patient.
OBJECTIVE:
-Delusion of
grandiose
Inappropriat
e thinking
about reality
-Flight of
Ideas

NURSING CARE PLAN -March 11, 2016NURSING

BACKGROUND PLANNIN
NURSING
DIAGNOSIS
KNOWLEDGE
G
INTERVENTIO
NS
Independent:
Substance
ShortEstablished
Disturbed
abuse
term:
therapeutic
thought
(Methampetha
After 8
relationship
process
mine)
hours of
with the client.
related to
nursing
substance
interventio
abuse as
Disturbed
n the
evidenced of neurotransmitte clients
delusion of r and absorption experience Reoriented to
grandiose
will be
time, place,
and flight of Neurotransmitte validated
and person, as
ideas.
r imbalances
and these
needed.
feelings
Disturbed
will be
thought process identified.
Listened with
positive
Longregard.
term:
After 1 2
weeks of
nursing
Presented
interventio reality
n the
concisely and
client will
briefly and do
regain
not challenge
level of
illogical
cognition.
thinking.

RATIONALE

EVALUATIO
N

To provide
an
emotionally
milieu that
enables
interpersona
l interaction
to gain
trust.

Shortterm:
After 8 hours
of nursing
intervention
the clients
experience
was
validated
and these
feelings
were
identified.
-Expressed
his feelings
about his
condition.

Inability to
maintain
orientation
is a sign of
deterioratio
n.
To convey
interest and
worth to
individual.

-Accepted
the reality
between
God and
Communicat man.
ing
therapeutica
lly about
reality is
healthy for
Long-term:

the client.
Provided
nutritionally
well-balanced
diet an
encouraged to
eat.
Dependent:
Administered
antipsychotic
drugs as
ordered by the
physician.
-Risperidone
2mg tab BID
-Clozapine 50
mg tab AM,
100 mg tab
PM
- Fluphenazine
decanoate 25
mg/cc 1 cc IM
(w/ BP
precaution)
monthly.

Enhances
intake and
general
well-being.

After 2
weeks of
nursing
intervention
the client
was able
regain his
usual level
of cognition
as
manifested
by decrease
episodes of
delusions
and absence
of flight of
ideas,

CUES
SUBJECTIV
E:
May
bumubulong
sakin na
kumain ng
dumi ng
pusa, as
verbalized
by the
patient.
OBJECTIVE:
-Irritable
Restlessness
-Auditory
hallucination
s

NURSING CARE PLAN -March 11, 2016NURSING

BACKGROUND PLANNING
NURSING
DIAGNOSIS
KNOWLEDGE
INTERVENT
IONS
ShortIndependent
Disturbed
Substance
term:
:
sensory
abuse
After 8 hours Established
perception: (Methampetha
of nursing
therapeutic
auditory
mine)
intervention relationship
related to
the clients
with the
substance
experience
client.
abuse as
Disturbed
will be
evidenced
neurotransmitte validated
by irritability r and absorption and these
and
feelings will
restlessness. Neurotransmitte be
Reoriented
r imbalances
identified.
to time,
place, and
Disturbed
person, as
sensory
needed.
perception:
Long-term:
auditory
After 1 2
weeks of
nursing
Listened
intervention with positive
the clients
regard.

RATIONALE

EVALUATIO
N

ShortTo provide
term:
an
After 8 hours
emotionally of nursing
milieu that
intervention
enables
the clients
interpersona experience
l interaction was
to gain
validated
trust.
and these
feelings
Inability to
were
maintain
identified.
orientation
-Expressed
is a sign of
his feelings
deterioratio about what
n.
were his
auditory
hallucination
To convey
s
interest and
worth to
-Gained

frequency
and
intensity of
hallucination
s will
decrease as
evidenced
by minimal
episodes of
auditory
hallucination
s. (none or
once per
day)

individual.
Presented
reality
concisely.

Provided
nutritionally
wellbalanced
diet an
encouraged
to eat.
Limitations
were set.

Dependent:
Administere
d
antipsychoti
c drugs as
ordered by
the
physician.
-Risperidone

control over
his
Communicat hallucination
ing
s.
therapeutica
lly about
reality is
Long-term:
healthy for
After 2
the client.
weeks of
nursing
intervention
Enhances
the client
intake and
reported two
general
episodes of
wellauditory
hallucination
s the whole
2 wees] and
gained
To establish
control over
organized
it
interaction
with the
client.
To treat
psychotic
manifestatio
ns.

2mg tab BID

-Clozapine
50 mg tab
AM, 100 mg
tab PM
Fluphenazin
e decanoate
25 mg/cc 1
cc IM (w/ BP
precaution)
monthly.

CUES

SUBJECTIV
E:
Di ako
nakatulog
ng maayos
kagabi, as
verbalized
by the
patient.
OBJECTIVE:
-Eye bags

NURSING
DIAGNOSIS

Disturbed
sleep
pattern
related to
neuroanato
mic
dysfunction
as
evidenced
by eyebags
& frequent
yawning.

NURSING CARE PLAN -March 11, 2016BACKGROUND PLANNING

NURSING
RATIONALE
KNOWLEDGE
INTERVENTI
ONS
ShortIndependent:
Substance
term:
Assess
To gather
abuse
After 1 hour
clients
baseline
(methampheta of nursing
sleeping
data about
mine
intervention pattern.
the clients
the client
sleeping
will verbalize
pattern.
Neuroanatomic understandi
dysfuction
ng the
To aid in
importance
Encouraged
stress
of having a
regular
control and
Disturbed
complete
exercise
release of
circadian cycle sleep and
during the
energy.
activities
day.
that will
To promote

EVALUATIO
N
Shortterm:
After 1 hour
of nursing
intervention
the client
verbalized
understandi
ng the
importance
of having a
complete
sleep and
activities
that will

-Frequent
yawning

Disturbed sleep promote

pattern
good night
sleep.

-Sluggish
Long-term:
After 2 days
of nursing
intervention
the client
will achieve
a 6-8 hours
of sleep.

Discouraged
daytime
naps.

Dependent:
Administered
Diphenhydra
nine HCl 50
mg/cap
OOHS prn x
poor sleep

sleepiness
during night
time.

promote
good night
sleep.

Induces
sleepiness

Long-term:
After 2 days
of nursing
intervention
the client
will achieve
a 6-8 hours
of sleep.