Вы находитесь на странице: 1из 1

Assessment Subjective Data: Tam-an gid ka suya si tiyo ko sa akon, as verbalized by the patient Objective Data: Diagnosed with

h Paranoid Schizophrenia With persecutory delusion towards his uncle and the people around him. Disordered thought sequencing or Flight of ideas Loose association Impaired ability to problem solve

Nursing Diagnosis Disturbed thought process related to presence of psychological conflicts (delusion of persecutory) as evidenced by impaired ability to problem solve, loose association and disordered thought sequencing.

Outcome Criteria Short Term Goal: After 3 weeks of nursing intervention, the patient will be able to: 1. Verbalize a decrease in the presence of persecutory delusions. Long Term Goal: After 3-4 months of nursing intervention, the patient will be able to: 1. Demonstrate the ability to function without responding to persistent delusional thoughts.

Nursing Intervention Independent: - Be consistent in setting expectation, enforcing rules, and so forth - Do not make promises that you cannot keep. - Recognize the clients delusions as the clients perception of the environment

Rationale Independent: Clear, consistent limits provide a secure structure for the client Broken promises reinforce the clients mistrust of other Recognizing the clients perception can help you understand the feelings he is experiencing Interacting with reality is healthy for the client Indicating belief in delusions reinforces the delusion (and the clients illness) As the client begins to trust you, he may become willing to doubt the delusion if you express your doubt.

Evaluation Short Term: (MET) After 3 weeks of nursing intervention, the patient was able to: 1. Verbalize a decrease in the presence of persecutory delusions. Long Term Goal: (UNMET) After 3-4 months of nursing intervention, the patient was not able to: 1. Demonstrate the ability to function without responding to persistent delusional thoughts

Discharge Planning M Advise patient and folks to adhere strictly with the medication course. E Provide a calm and non-stimulating environment. T Take anti-psychotic drugs as indicated by the physician. H Educate the client regarding the side effects of anti-psychotic drugs such as dry mouth, weight gain, lethargy and sexual dysfunction. O Instruct the patient to have follow-up check up as prescribed by the physician. D Tell the client to avoid stimulating beverages such as coffee, tea and energy drinks. S Encourage the family members to support the patient emotionally and spiritually.

- Interact with the client on the basis of real things; do not dwell on the delusional material - Never convey to the client that you accept the delusions are reality -Directly interject doubt regarding delusions as soon as the client seems ready to accept this. Do not argue but present a factual account of the situation as you see it.

-Engage the client in one- A distrustful client can to-one activities at first, be best deal with one then activities in small person initially. groups, and gradually Gradual introduction of activities in larger groups others as the client tolerate is less threatening.