JEAN PEARL R.

CAOILI BSN3 NCB

DIAGNOSIS: PARANOID SCHIZOPHRENIA

PSYCHIATRIC NURSING CARE PLAN

ASSESSMENT EXPLANATION OF GOALS/ INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM OBJECTIVES

SUBJECTIVE: Paranoid STO: INDEPENDENT STO: Goal is met

schizophrenia is
"Parang lahat ng tao After 8 hours of • Develop a - Helps the client feel After 8 hours of
characterized by
nakasunod sakin, nursing intervention, therapeutic nurse- someone cares and to nursing intervention,
extreme
natatakot na ako, the client will patient relationship increase their trust in the client recognized
suspiciousness of
para bang may recognize signs of through frequent the healthcare team. signs of increasing
others and by
masama silang balak increasing anxiety brief and an anxiety and agitation
delusions and
sa akin", as verbalized and agitation and accepting attitude. and reported to staff
hallucinations of a
by the patient. report to staff for for assistance with
persecutory or • Encourage client to - helps client come to
assistance with intervention.
grandiose nature. verbalize feelings terms with long,
intervention.
When being unresolved issues
OBJECTIVE:
suspicious to others,
LTO: Goal is met
- active the individual is often • Reestablish the - Reality must be
LTO:
tense and guarded client what is real and reinforced After 3 days of
- agitated
and aggressive. They After 3 days of unreal. Validate nursing intervention,
may possibly harm nursing intervention, client's real the patient did not
- irritable and do violence to the patient will not perceptions and harm others as
those people around harm others as correct client's evidenced by good
- suspicious
them. evidenced by good misperception interpersonal
- guarded interpersonal - Anxiety level rises in relationship with co
• Maintain low level
relationship with co a stimulating patients and staff and
- looks afraid of stimuli in client’s
patients and staff and environment. demonstrated self
environment (low
demonstrate self control (relaxed
lighting, few people,
control (relaxed posture, nonviolent
NURSING DIAGNOSIS: simple decor, low
posture, nonviolent behavior)
noise level)
Risk for other- behavior)
- To avoid creating
directed violence • Observe client’s
suspiciousness in the
related to lack of behavior frequently
individual. Close
trust (suspiciousness (every 15 minutes).
observation is
of others) secondary Do this while carrying
necessary so that
to paranoid out routine activities
intervention can
schizophrenia
occur if required to
ensure client’s (and
others’) safety

- So that if agitated,
• Remove all confused state client
dangerous objects may not use them to
from client’s harm self or others.
environment

- Physical exercise is
a safe and effective
• Try to redirect the
way of relieving pent-
violent behavior with
up tension.
physical outlets for
the client’s anxiety
(e.g., punching bag) - Anxiety is

• Maintain and contagious and can

convey a calm be transmitted from

attitude toward staff to client.

client. - Increases client's

• Provide emotional sense of security and

support control.

- For prompt
• Encourage client to intervention
recognize increasing
signs of anxiety and
report it to the health
care provider
 DEPENDENT: - To reduce hostile,
aggressive, and
• Administer
violent behavior in
Clozapine as ordered
case it occurs.
by physician.

PSYCHIATRIC NURSING CARE PLAN

ASSESSMENT EXPLANATION OF GOALS/ INTERVENTIONS RATIONALE EVALUATION

 THE PROBLEM OBJECTIVES

SUBJECTIVE: Evidence suggests STO: INDEPENDENT: STO:Goal is met

that delusional
" Ayaw kong kumain After 8 hours of • Approach in a calm - To establish nurse- After 8 hours of
disorder can be
ng pagkain nila rito, therapeutic nursing manner patient relationship therapeutic nursing
triggered by stress.
natatakot ako, para intervention, client intervention, client
Alcohol and drug • Convey your - It is important to
bang may nilagay will recognize and recognized and
abuse also might acceptance of client’s communicate to the
silang kakaiba rito", verbalize false ideas verbalized false ideas
contribute to the need for the false client that you do not
as verbalized by the (delusions) (delusions)
condition. People belief, while letting accept the delusion
patient.
who tend to be her know that you do as reality
isolated appear to be not share the belief
more vulnerable to
OBJECTIVE: • Assist and support
developing delusional LTO: - Verbalization of LTO: Goal is met
client in his or her
- Uncomfortable disorder. With false feelings in a
After 2 days of attempt to verbalize After 2 days of
ideas in mind, the nonthreatening
- tense therapeutic and feelings of anxiety, therapeutic and
patient may environment may
holistic nursing fear, or insecurity holistic nursing
- guarded experience help client come to
intervention, the intervention, the
suspiciousness to terms with long-
- suspicious client will be able to client ate meals being
other people and may unresolved issues.
eat meals being served in the hospital
- decline in self-care lead to panic level of • Identify feelings
served in the hospital and continued
anxiety that may related to delusions. - When people
and continuing compliance to
cause the disturbance believe that they are
compliance to medications.
of his/her thought understood, anxiety
NURSING DIAGNOSIS: process. medications. might lessen.
• Interact with client
Disturbed thought on the basis of things - When thinking is
process related to in the environment. focused on reality-
panic level of anxiety Try to distract client based activities, the
as evidenced by from their delusions client is free of
delusional thinking by engaging in reality- delusional thinking
(false ideas) and based activities (e.g., during that time.
suspiciousness card games, simple Helps focus attention

arts and crafts externally.

projects etc).

• Do not touch the

client; use gestures - Suspicious clients

carefully. might misinterpret

touch as either
aggressive or sexual
in nature and might
interpret it as
threatening gesture.
People who are
psychotic need a lot
of personal space.
• Encourage healthy
habits to optimize - All are vital to help
functioning: keep the client in
remission.
- Maintain
medication regimen.

- Maintain regular
sleep pattern.

- Maintain self-care.

• Show empathy
regarding the client’s - The client’s delusion
feelings; reassure the can be distressing.
client of your Empathy conveys
presence and your caring, interest
acceptance. and acceptance of
the client.
• Teach client coping
skills that minimize - Thought-stopping
“worrying” thoughts. techniques.
Coping skills include:

- Phoning a helpline.

- Singing or Listening
to a song.
- Talking to a trusted
friend.

• Serve meals that

the client will actually - For him/her not to

open by be suspicious

himself/herself
(canned goods)

• Let the client watch

how the food was - To prove that
cooked and served there's nothing wrong
with the meal
• Supervised in taking
oral medications - To ensure client
swallowed
medications given
• Seen from time to
time
- To ensure safety and
for assessment of
other signs and
symptoms