NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE CUES: Disturbed sensory Short term: 1.Explore how the 1.Exploring the Short term:
“She has perception related After nursing 1-2 hallucinations are hallucinations and After nursing 1-2
complained of to altered sensory hours of nursing experienced by the sharing the hours of nursing
hearing voices and perception as intervention the client. experience can help intervention the
seeing things for a evidence by patient will be able give the person a patient was able to:
week’s telling her auditory and visual to: sense of power that - State two-three
that she is ‘no good’ distortion - State two-three he or she might be symptoms they
as verbalized by the symptoms they able to manage the recognized when
patient. recognize when hallucinatory their stress levels
their stress levels voices. are high.
are high. -State, using a
OBJECTIVE CUES: -State, using a 2.Assess ability to 2.To obtain an scale from 1 to 10,
scale from 1 to 10, speak, hear, overview of client’s that “the voices” are
that “the voices” are interpret, and mental and less frequent and
less frequent and respond to simple cognitive status and threatening when
threatening when commands ability to interpret aided by medication
aided by medication stimuli. and nursing
and nursing intervention
intervention 3.Minimize 3.client may - Identified to
- Identify to discussion of misinterpret and personal
personal negatives (e.g. believe references interventions that
interventions that client’s personal are to herself. decreases the
decrease the problem) within intensity or
intensity or client’s hearing frequency of
frequency of hallucinations (e.g,
hallucinations (e.g, 4. Intervene with 4. Intervene before listening to music,
listening to music, one-on-one, anxiety begins to wearing
wearing seclusion, or PRN escalate. If the headphones,
headphones, medication (As client is already out reading out loud,
reading out loud, ordered) when of control, use jogging,
jogging, appropriate. chemical or socializing).
socializing). physical restraints
Long term: After 2-3 following unit Long term: After 2-3
days of nursing protocols. days of nursing
intervention the intervention the
patient will be able 5. Work with the 5. If clients’ stress patient was able to:
to: client to find which triggers - Learned ways to
- Learn ways to activities help hallucinatory refrain from
refrain from reduce anxiety and activity, they might responding to
responding to distract the client be more motivated hallucinations.
hallucinations. from a hallucinatory to find ways to -Demonstrate one
-Demonstrate one material. Practice remove themselves stress reduction
stress reduction new skills with from a stressful technique.
technique. the client. environment or try - Demonstrate
- Demonstrate distraction techniques that help
techniques that help techniques. distract him or her
distract him or her from the voices.
from the voices. 6. Collaborate with 6.To achieve - Maintained social
- Maintain social other health-team maximal gains in relationships.
relationships. members in function and
providing psychosocial well-
rehabilitative being.
therapies and
stimulating
modalities