XII.

NURSING CARE PLAN

2) POTENTIAL PROBLEM

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATI
ON

RATIONALE

EVALUATION

Subjective:
Nadinig ko nuon na
saktan yung inmate
ko kaya hinampas ko
sya ng dumbbell sa
ulo

Objective:
Assaultive
toward others
and
environment
Presence of
pathophysiolo
gic risk
factors:
hallucination

Risk for
violence
related to
frightened
feelings,
secondary to
auditory
hallucination
and delusional
thinking

At the end of 4
weeks of nursing
care, the patient
will be able to:
* Avoid hurting
self or assaulting
other patients.
* Decrease
agitation and
aggression

* Acknowledge
patients fear,
hallucinations,
and delusions.
Be genuine and
empathetic.
Assure patient
that you will help
him control
behavior and
keep him safe.
Begin to
establish a
trusting
relationship.

* Hallucinations
and delusions
change an
individuals
perception of
environmental
stimuli. Patient
is truly
frightened and is
responding out
of his need to
preserve his own
safety.

* Offer patient
choices of
maintaining
safety: staying in
the seclusion
room,
medications to
help him relax
and praying to
God and
ignoring the
voices whenever
he hears the
voices in his

* By giving
patient choices,
he will begin to
develop a sense
of control over
his behavior.
Seclusion and
restraint are
options only for
persons
exhibiting
serious,
persistent
aggression. The

GOAL MET
* After 4 weeks
of nursing
intervention, RG
was less
agitated and
less aggressive

RG verbalized
Pag may
nadidinig ako na
power of love at
power of god di
ko na lang
pinapansin at
nagdadasal na
lang ako

head to hurt
others.

persons safety
must be
protected at all
times.

* Observe
patients
behavior during
routine patient
care

* Close
observation is
necessary to
protect from
self-harm and
harm to others

* Self-esteem
enhancement,
give positive
feedback

* Hallucination
managementassess, help
client describe
needs that might
be reflected in
the content of
the hallucination,
identify triggers
of hallucinations.

* To improve
self-esteem and
avoid risk for
aggression
towards others
* To determine
the need for
prompt
intervention