Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective: -Impaired Social - Encourage client -Spend time with -Your presence may -Client demonstrates
Interaction related to to express honest client. This may mean help improve client's willingness and desire
-“Wala akong kausap absence of available feelings in relation just sitting in silence perception of self as a to socialize with
sa loob ng ward.” significant others or to loss of prior level for a while. worthwhile person. others.
peers as evidenced by of functioning.
Objective: dysfunctional -Develop a -Your presence, -Client voluntarily
Acknowledge pain
interaction with peers, therapeutic nurse- acceptance, and attends group
-The client will family, and others. of loss. Support client relationship conveyance of activities.
develop trusting client through through frequent, positive regard
relationship with process of grieving. brief contacts and an enhance the client's -Client approaches
nurse within accepting attitude. feelings of self-worth. others in appropriate
reasonable period of - Encourage client's Show unconditional manner for one-to-one
time. attempts to positive regard. interaction.
communicate. If
verbalizations are -Provide positive -Positive
not understandable, reinforcement for reinforcement
express to client client's voluntary enhances self-esteem
interactions with and encourages
what you think he
others. repetition of desirable
or she intended to behaviors.
say. It may be
necessary to -Teach assertiveness -Knowledge of
reorient client techniques. assertive techniques
frequently. Interactions with could improve client's
others may be relationships with
negatively affected by others.
client's use of passive
or aggressive
behaviors.

SUBMITTED BY: CHARISA S. SIMBAJON

BSN IV
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective: - Disturbed Thought Within 4 hours of INDEPENDENT -After 4 hours of

- Keeps on verbalizing Process related to Nursing Interventions, Nursing Interventions
when asked of date, disintegration on the patient will be able - Establish rapport to the - To gain client’s trust the Client was able to
”Lunes Mayo 25, 1952” thinking as manifested to: patient and cooperation respond in a reality-
by disorientation with based interaction.
Objective: date and place and General: - Be sincere and honest - Delusional clients are
impaired judgment when communicating extremely sensitive
- Disorientation > Respond to reality- with the client. Avoid about others and can
based interactions vague or evasive recognize insincerity.
- Blunted affect initiated by others remarks Evasive comments or
hesitation reinforces
- Short attention span Specifically, mistrust or delusions

- Impaired judgment > Interact on reality- - Monitor vital signs - Assess condition of the
based topics frequently especially patient before giving
blood pressure and medications
>Sustain attention and interpret it accurately
concentration
to complete tasks or
activities - Be consistent in setting - Clear, consistent limits
expectations, enforcing provide a secure
rules, and so forth structure for the client

- Do not make promises - Broken promises

that you cannot keep reinforce the client’s
mistrust of others
- Encourage the client to
talk but do not pry or - Probing increases the
cross-examine for client’s suspicion and
information interferes with the
therapeutic relationship

- Explain procedures, - When the client has

and try to be sure the full knowledge of
client understands the procedures, she is less
procedures before likely to feel tricked
carrying them out
- Give positive feedback
for the client’s
successes
- Recognize the client’s
delusions as the client’s
perception of the
environment
- Initially, do not argue
with the client or try to
convince the client that
the delusions are false
or unreal
- Interact with the client
on the basis of real
things; do not dwell on
the delusional material
- Engage the client in
one-to-one activities at
first, then activities in
small groups, and
gradually activities in
larger groups
- Recognize and support
the client’s
accomplishments
(activities or projects
completed,
responsibilities fulfilled,
interactions initiated)
- Positive feedback for
genuine success
enhances the client’s
sense of well-being and
helps to make non-
delusional reality a
more positive situation
for the client
- It is important to
recognize the client’s
environmental
perceptions to
understand the feelings
she is experiencing
- Logical argument does
not dispel delusional
ideas
and can interfere with
the development of trust
- Interacting about
reality is healthy for the
client
- The client who is
distrustful can best deal
with one person
initially. Gradual
introduction of others
when the client can
tolerate it is less
threatening
- Recognition of
accomplishments can
lessen the client’s
anxiety and the need for
delusions as a source of
self-esteem
 - Show empathy - The client’s delusions
regarding the client’s can be distressing.
feelings; reassure Empathy conveys your
the client of your acceptance of the client
presence and acceptance and your caring and
interest
- Do not be judgmental
or belittle or joke about - The client’s delusions
the client’s beliefs and feelings are not
funny to him or her. The
client may feel rejected
by you or feel
unimportant if
approached by attempts
at humor
- Never convey to the
client that you accept
the delusions as reality - It would reinforce the
delusion (thus, the
client’s illness) if you
indicated belief in the
delusion

DEPENDENT - An Antipsychotic that

could treat psychiatric
- Administer illness such as this
Chlorpromazine as schizo-phrenia
prescribed.

SUBMITTED BY: CHARISA S. SIMBAJON

BSN IV
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Objective: - Disturbed Sensory Within 5 hours of INDEPENDENT

Perception: Nursing Interventions, Goal is partially
- inappropriate response Auditory/Visual the patient will be able - Establish rapport to the - To gain client’s trust and met.
Hallucinations related to to: patient cooperation as well as have a
>disoriented with date alteration in the function quality assessment - The client was
and place of brain as manifested General: oriented by the
by inappropriate - Monitor vital signs - To assess whether nurse with the date
response and >test reality, frequently and interpret it medications could be given or and time.
disorientation. eliminating the accurately contraindicated Fortunately, she was
occurrence of able to recognize
hallucinations. - Observe client for signs - Early intervention may reality because of
of hallucinations (listening prevent aggressive response to diverting her
Specifically, pose, laughing or talking to command hallucination attention to the
self, stopping in activity.
>recognize present midsentence)
reality via activities
prepared by the nurse - Avoid touching the client - Client may perceive touch as
without warning threatening and may respond
in an aggressive manner

- An attitude of acceptance - This is important to prevent

will encourage the client to possible injury to the client or
share the content of the others from command
hallucination with you hallucination

- Do not reinforce the - Client must accept the

hallucination. Use “the perception as unreal before
voices” instead of words hallucinations can be
like “they” that imply eliminated
validation. Let
the client know that you do
not share the perception.
Say, “Even though I realize
the voices are real to you, I
do not hear any voices”
 - Help the client - If client can learn to interrupt
understand the connection escalating anxiety,
between anxiety and hallucinations may be
hallucinations. prevented

- Try to distract the client - Involvement in interpersonal

from the hallucination. activities and explanation of
the actual situation will help
bring the client back to reality

DEPENDENT

- Administer - To treat the psychiatric

Chlorpromazine as illness which is Schizophrenia
prescribed by the physician

SUBMITTED BY: CHARISA S. SIMBAJON

BSN IV
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

- Impaired Verbal - Within 5 hours of

Objective: Communication related Nursing Interventions, - Establish rapport to the - To gain client’s trust -The client was able to
to regression as the patient will be able patient and cooperation as well communicate
manifested by to: as have a quality appropriately
- Mumbles when associative looseness, assessment and comprehensively
speaking; words are not echolalia, and General: with the nurse and also
clearly stated neologism. - Monitor vital signs - To assess whether or to other people present
- communicate frequently especially not to give medications in the activity.
- Associative Looseness appropriately respiration and interpret prescribed
observed and comprehensively it accurately
with others Specifically,
- Neologism observed talk not only with the - Attempt to decode - These techniques
nurse but also to other incomprehensible reveal how the client is
- Repeats words and people present in the communication patterns. being perceived by
phrases uttered by the activity. Seek validation and others, while the
student nurse, thus, clarification by stating, responsibility for not
echolalic “Is it that you mean…?” understanding is
or “I don’t understand accepted by the nurse
what you mean by that.
- Ideas are sometimes Would you please
not organized clarify it for me?”

- Anticipate and fulfill - Client’s safety and

client’s needs until comfort are nursing
functional priorities
communication pattern
returns

- Orient client to reality - These techniques may

as required. Call the facilitate restoration of
client by name. Validate functional
those aspects of communication patterns
communication that in the client
help differentiate
between what is real and
not real

SUBMITTED BY: CHARISA S. SIMBAJON

BSN IV
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective: -Impaired Social - Encourage client -Spend time with -Your presence may -Client demonstrates
Interaction related to to express honest client. This may mean help improve client's willingness and desire
-“Wala akong kausap absence of available feelings in relation just sitting in silence perception of self as a to socialize with
sa loob ng ward.” significant others or to loss of prior level for a while. worthwhile person. others.
peers as evidenced by of functioning.
Objective: dysfunctional -Develop a -Your presence, -Client voluntarily
Acknowledge pain
interaction with peers, therapeutic nurse- acceptance, and attends group
-The client will family, and others. of loss. Support client relationship conveyance of activities.
develop trusting client through through frequent, positive regard
relationship with process of grieving. brief contacts and an enhance the client's -Client approaches
nurse within accepting attitude. feelings of self-worth. others in appropriate
reasonable period of - Encourage client's Show unconditional manner for one-to-one
time. attempts to positive regard. interaction.
communicate. If
verbalizations are -Provide positive -Positive
not understandable, reinforcement for reinforcement
express to client client's voluntary enhances self-esteem
interactions with and encourages
what you think he
others. repetition of desirable
or she intended to behaviors.
say. It may be
necessary to -Teach assertiveness -Knowledge of
reorient client techniques. assertive techniques
frequently. Interactions with could improve client's
others may be relationships with
negatively affected by others.
client's use of passive
or aggressive
behaviors.

SUBMITTED BY: CHARISA S. SIMBAJON

BSN IV