Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation

Subjective Data: Short Term Goal: Independent: Short Term:

Disturbed auditory Although the etiology &
“Yun, may narinig sensory perception pathogenesis have not After 3 weeks of nursing - Help present and maintain  Presenting reality is healthy Goal Fully Achieved
akong trials (but related to anxiety been fully determined, here intervention, the patient reality by frequent contact and for the client (1) After hour of nursing intervention,
actually no one said associated with multiple are some etiologies: will be able to communication with the client the client was able to recognize and
the word trials), stressors as evidenced Stressful life circumstances, 1.Recognize and correct/compensate for sensory
ganun na nga yun by auditory hallucination. genetic & biochemical correct/compensate for - Elicit description of  The nurse’s understanding impairments.
kasi trials and defects, & brain damage in sensory impairments. hallucination to protect client of hallucination helps her Identify/modify 2/3 external factors
know how to calm or
challenges are just the fetus by prenatal 2. Identify/modify 2/3 and others. like stress and effects of
reassure the client (1)
the same.” as stated complications or viral external factors that medications, which contribute to
infection contribute to alterations alterations in sensory/perceptual
 Close observation of the
Objective Data:  in sensory/perceptual -Keep client in a safe, client with active abilities.
Reduced gray matter in the abilities. protected, restricted hallucinations in a secure
 Diagnosed with temporal lobes environment. Avoid excessive environment is essential to Recommendation:
Paranoid  activity and stimulation maintain safety of the client Terminate the Plan
Schizophrenia Abnormal cells in the & others. Excessive sensory
 Auditory stimulation could overwhelm Discharge Outcome:
hippocampus (part of the
hallucination and agitate the client.
limbic system) Discharge Outcome:
 Exaggerated
 -Focus on the feelings about, Outcome Fully Achieved;
emotional  Focusing on the client’s
responses Excessive dopamine After months or upon rather than details of, the feelings, which are real, Upon discharge, the client was able
 Impaired secretions discharge, the client will hallucination. minimizes emphasis on the to not respond to hallucinatory
communication  be able to 1. Not hallucination. commands, and hallucinations will
 Poor concentration Enlarged third and lateral respond to hallucinatory subside. The client reported a
ventricles commands, and - Do not argue with the client  Arguing with the client or decrease in, and eventually the total
hallucinations will about whether the expressing disbelief in the cessation of hallucinations. And the

subside. hallucinations are real; state, if hallucinations does not client was free from injury
Decreased blood flow to the 2. Be free form injury. asked, that you do not affect the client’s belief in
frontal lobes perceive the auditory stimuli the reality of the Recommendation:
 that the client perceives. hallucination and can disrupt Terminate the Plan
trust & the therapeutic rel.
Abnormalities of neuro-
Expressing that you not hear
transmitters and neuro- the hallucinatory stimuli
endocrine systems. indirectly encourages him to
 question the reality of the
Sensory overload and experience.
hyperarousal. Collaborative:

Auditory hallucination - Engage client in reality-  To achieved maximal gains
based activities such as card in function and psychosocial
playing, occupational therapy, well-being

Reference: or listening to music.

Reference: (1) Psychiatric-

Pathophysiology for the Mental Health Nursing 5th
Health Professions 3rd Edition by Sheila L. Videbeck
Edition by Barbara E. Gould page 268
Page 588-589 (2) Psychiatric-Mental Health
Nursing by Mohr page 650
 Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation

Subjective Data: Short Term Goal: Independent: Short Term:

Disturbed thought Although the etiology &
“I really don’t process related to pathogenesis have not After 3 weeks of nursing - Be consistent in setting  Clear, consistent limits Goal Partially Achieved
understand my father. presence of been fully determined, here intervention, the patient expectation, enforcing rules, provide a secure structure After hour of nursing intervention, the
Why can’t he psychological conflicts are some etiologies: will be able to and so forth for the client client was able to
understand me? Hindi (delusion of persecutory) Stressful life circumstances, 1. Verbalize recognition 1. Verbalize recognition of delusional
niya maappreciate as evidenced by impaired genetic & biochemical of delusional thoughts if - Do not make promises that  Broken promises reinforce thoughts if they persist.
yung work ko. Is it ability to problem solve defects, & brain damage in they persist. you cannot keep. the client’s mistrust of other 2. Respond to reality-based
ingenuity or and disordered thought the fetus by prenatal 2. Respond to reality- interactions initiated by others; for
creativity? Dalawang sequencing. complications or viral based interactions - Recognize the client’s  Recognizing the client’s example, verbally interact with staff
beses ako binaril ng infection initiated by others; for delusions as the client’s perception can help you for specified time period.
father ko.,” as stated  example, verbally perception of the environment understand the feelings he
Reduced gray matter in the interact with staff for is experiencing
Objective Data: temporal lobes specified time period. Recommendation:
 - Interact with the client on the  Interacting with reality is Terminate the plan
 Diagnosed with Abnormal cells in the basis of real things; do not healthy for the client
Paranoid hippocampus (part of the dwell on the delusional
Schizophrenia limbic system) material Discharge Outcome:
 With a delusion to 
his father (delusion Excessive dopamine - Never convey to the client  Indicating belief in delusions Outcome Partially Achieved;
of persecutory) secretions Discharge Outcome: that you accept the delusions reinforces the delusion (and Upon discharge, the client was able to
 Disordered thought  are reality the client’s illness) free from delusions or demonstrate
sequencing or Enlarged third and lateral Upon discharge, the the ability to function without
Flight of ideas ventricles client will be able to be -Directly interject doubt  As the client begins to trust responding to persistent delusional
 Loose association  free from delusions or regarding delusions as soon you, he may become willing thoughts.
 Impaired ability to Decreased blood flow to the demonstrate the ability as the client seems ready to to doubt the delusion if you
problem solve frontal lobes to function without accept this. Do not argue but express your doubt. Recommendation:
 responding to persistent present a factual account of Continue the Plan
Abnormalities of neuro- delusional thoughts. the situation as you see it.
transmitters and neuro-
endocrine systems. Collaborative:
  -Engage the client in one-to-
 With a delusion to his one activities at first, then  A distrustful client can be
father (delusion of activities in small groups, and best deal with one person
persecutory) gradually activities in larger initially. Gradual introduction
 Disordered thought groups of others as the client
sequencing or Flight of tolerate is less threatening.
ideas
Reference: Psychiatric-Mental
Health Nursing 5th Edition by
Reference: Sheila L. Videbeck page 264

Pathophysiology for the

Health Professions 3rd
Edition by Barbara E. Gould
Page 588-589
 Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation

Subjective Data: Short Term Goal: Independent: Short Term:

Impaired verbal Although the etiology &
“Ang pagkakaalam ko communication related to pathogenesis have not After 3 weeks of nursing - Reorient the client to person,  Repeated presentation of Goal Partially Achieved
dahil ata nagdrawing loose associations and been fully determined, here intervention, the patient place, and time as indicated. reality is concrete After hour of nursing intervention, the
ako sa wall, uhm not flight of ideas as are some etiologies: will be able 1.Participate reinforcement for the client client was able to participate in
wall, it’s not also a evidenced by vague, Stressful life circumstances, in therapeutic therapeutic communication like using
table basta di ko alam diffuse, unfocused genetic & biochemical communication to get - Spend time with the client  Your physical presence is silence, acceptance, reflecting and
tawag dun (seemed sequences of concepts defects, & brain damage in needs met and to reality. Allows client to think. active listening. Relate effectively with
confused then live it and switch of subjects the fetus by prenatal 2.Relate effectively with persons and his or her environment.
hanging and that are difficult to follow complications or viral persons and his or her - Encourage the client to talk  Probing increases the Verbalize or indicate n understanding
continued to talk),” as the train of thought. infection environment. with you, but do not pry for client’s suspicion and of the communication difficulty but not
stated  3.Verbalize or indicate n information. interferes with the the plans for ways of handling.
Reduced gray matter in the understanding of the therapeutic relationship.
Objective Data: temporal lobes communication difficulty Recommendation:
 Loose association  and plans for ways of - When first communicating  The client’s ability to Continue the Plan
of ideas Abnormal cells in the handling. with the client, use simple, perceive and respond to
 Paranoid hippocampus (part of the direct sentences; avoid complex stimuli is impaired.
Schizophrenia limbic system) complex sentences or
Diagnosis  directions. Discharge Outcome:
 Flight of ideas Excessive dopamine
 Difficulty in forming secretions - Use confrontation skills,  To clarify discrepancies Outcome Partially Achieved;
words.  when appropriate, within an between verbal and Upon discharge, the client was able to
 Vague, diffuse, Enlarged third and lateral established nurse-client nonverbal cues. demonstrate congruent verbal and
Discharge Outcome: relationship nonverbal communication. He
unfocused ventricles
sequences of  established partially method of
Upon discharge, the - Give positive feedback for communication in which needs can be
concepts Decreased blood flow to the  Positive feedback for
client will be able to the client’s successes. expressed.
 Switch of subjects frontal lobes
demonstrate congruent genuine success enhances
that are difficult to  verbal and nonverbal the client’s sense of well-
follow the train of Abnormalities of neuro- being. Recommendation:
communication and 2. Continue the Plan
thought transmitters and neuro- Establish method of
endocrine systems. Collaborative:
communication in which
  needs can be
 Flight of ideas
 Difficulty in forming
words.
 Vague, diffuse,
unfocused sequences of
concepts
 Switch of subjects that
are difficult to follow the
train of thought
- Engage client in reality-
expressed. based activities such as card
playing, occupational therapy,
or listening to music.
 To achieved maximal gains
in function and psychosocial
well-being
Reference: (1) Psychiatric-
Mental Health Nursing 5th
Edition by Sheila L. Videbeck
page 264 & 292

Reference:

Pathophysiology for the

Health Professions 3rd
Edition by Barbara E. Gould
Page 588-589