Nursing c a r e p l a n schizophrenia.drjma

Nursing c a r e p l a n schizophrenia.drjma

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  Nursing C AR E P L A N Schizophrenia ASSESSMENT DATA EXPECTED OUTCOMES Nursing Diagnosis (or Planning) • Non–reality-based thinking • Disorientation • Labile affect • Short attention span • Impaired judgment • Distractibility ➤ Disturbed Thought Processes Disruption in cognitive operations and activities Dr. James Malce Alo,RN,MAN,MAPsycho,PhD Immediate The client will: • Be free of injury • Demonstrate decreased anxiety level • Respond to reality-based interactions initiated by others Stabilization The client will: • Interact on reality-based topics • Sustain attention and concentration to complete tasks or activities Community The client will: • Verbalize recognition of delusional thoughts if they persist • Be free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts EVALUATION IMPLEMENTATION Nursing Interventions *denotes collaborative interventions Nursing Interventions Be sincere and honest when communicating with the client. Avoid vague or evasive remarks. Be consistent in setting expectations, enforcing rules, and so forth. Do not make promises that you cannot keep. Encourage the client to talk with you, but do not pry or crossexamine for information. RATIONALE Rationale Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions. Clear, consistent limits provide a secure structure for the client. Broken promises reinforce the client’s mistrust of others. Probing increases the client’s suspicion and interferes with the therapeutic relationship. 1