ASSESSMENT EXPLANATION OF GOALS AND NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM OUTCOMES

Seen and examined a 23-year Due to biochemical or SHORT TERM  Assess Level of  measurement of a person's Fully met:
old male patient, awake, psychological OBJECTIVE: consciousness LOC arousability and patient was able to
conscious, disturbances responsiveness answer questions
coherent, fair, poor grooming like depression and per After 16 hours of to stimuli from the that is answerable
and have a have a poor sonality disorders. And Nursing Intervention environment and also serves by YES or NO and
hygiene, appropriately due to non compliance patient will be able as a baseline data on shows improve
dressed for age, weather and of medication and also to answer questions neurological examination social interaction
sex, conversant, slightly due to combination of that is answerable and absence of
cooperative, fair eye contact, physical, genetic, by YES or NO. destructive behavior
low tone and volume of psychological and  Assess using BRIEF  BPRS provide a standardized toward self or others
speech, spontaneous and environmental factors LONG TERM PSYCHIATRIC RATING method to asses/re-assess and manifest and
euthymic mood, blunt affect. can make a person OBJECTIVE: SCALE the changes in symptoms in absence of
Poor concentration, poor more likely to develop response to the medication delusions, racing
insight, poor interaction noted. the condition. Also Due After 6 days of and therapies in outcome thoughts, and
to alterations of Nursing Intervention studies irresponsible actions
Past Medical History Reveals chemical and patient will be able as a result of
that he was diagnosed with hormonal imbalances to manifest and  Assess if the medication  Many of the positive medications
Acute Transient Psychotic in the body absence of has reached therapeutic symptoms of schizophrenia adherence and
Disorder in March,27,2013 neurotransmitters that delusions, racing levels. (hallucinations, delusions, environmental
after on his graduation. lead/urges the patient thoughts, and racing thoughts) will subside structures.
`With Initial Vital Signs of: BP: condition irresponsible actions with medications, which will
130/90 mmHg, CR:95 bpm, as a result of facilitate interactions. Partially met:
RR: 18 cpm, T: 36.8 medications Patient was able to
deg.centigrade and SPO2 of adherence and answer questions
95% environmental that is answerable
NURSING DIAGNOSIS: structures. by Yes or NO and
Impaired Social Interaction  Assess and identify  This would be the baseline still shows
related to chemical thoughts and behavior on therapeutic management destructive behavior
alterations in the body as and to see if there’s a and shows
evidenced by poor improvement on the therapy. delusions, racing
concentration thoughts, and
 Asses and explore how  Exploring the hallucinations irresponsible actions
the hallucinations are and sharing the experience as a result of
experienced by the can help give the person a medications
client. sense of power that he or she adherence and
might be able to manage the environmental
hallucinatory voices. structures.

 Assess and identify  Helps both nurse and client Not met:
times that the identify situations and times the patient was not
hallucinations are most that might be most anxiety- able to demonstrate
prevalent and producing and threatening to to answer questions
frightening. the client. that is answerable
by YES or NO and
still shows
 Assess Mental Status  Mental Status Exam (MSE) destructive behavior
is and shows
the psychological equivalent delusions, racing
of a physical exam that thoughts, and
describes the mental irresponsible actions
state and behaviors of the as a result of
person being seen. It medications
includes adherence and
both objective observations environmental
of the clinician and subjective structures.
descriptions given by the
patient
 Assess Social  Assessing social interaction
Interaction are one of. important factors
in predicting the physical
health and well-being of
everyone, ranging from
childhood through older
adults.
 Decrease  Decrease the potential for
environmental stimuli anxiety that might trigger
when possible (low hallucinations. Helps calm
noise, minimal activity). client.

 Keep to simple, basic,  Client’ thinking might be

reality-based topics of confused and disorganized;
conversation. Help the this intervention helps the
client focus on one idea client focus and comprehend
at a time. reality-based issues.

 Engage client in reality-  Redirecting the client’s

based activities such as
card playing, writing,
drawing, doing simple
arts and crafts or
listening to music.
energies to acceptable
activities can decrease the
possibility of acting on
hallucinations and help
distract from voice

 Utilize safety measures  During acute phase, client’s

to protect clients or
others, if the client
believe they need to
protect themselves
against a specific
person. Precautions are
needed.
delusional thinking might
dictate to them that they
might have to hurt others or
self in order to be safe.
External controls might be
needed.
  Administer  Appropriate antimanic
an antimanic medication medications allow
and PRN tranquilizers, psychosocial and nursing
as ordered, and interventions to be effective.
evaluate for efficacy,
and side and toxic
effects.(Clozapine,
Risperidone and
Haloperidol)

 Maintain a consistent  Clear and consistent limits

approach, employ and expectations minimize
consistent expectations, potential for client’s
and provide a structured manipulation of staff.
environment.

Coping Skills Training should be

available to him/her (nurse, staff
or others). Basically the  Increases client ability to
process: derive social support and
 Define the skill to be decrease loneliness. Clients
learned. will not give up the substance
 Model the skill. of abuse unless they have
 Rehearse skills in a alternative means to facilitate
safe environment, then socialization they belong
in the community.
 Give corrective
feedback on the
implementation of skills.
 Encourage healthy
habits to optimize
functioning:  All are vital to help keep
 Maintain medication the client in remission.
regimen.
 Maintain
regular sleep pattern.
 Maintain self-care.
 Reduce alcohol and
drug intake.

 Encourage to join  Occupational therapy and

occupational therapy activities will improve the
and other ward social interaction of the
therapies patient.