NURSING CARE PLAN

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Disturbed sensory Short-term Goal:  Observed client  Early interventionAfter a week of
 “Naririnig ko perception secondary Within a week of for signs of may nursing interventions,
prevent
silang pinag to schizophrenia as nursing interventions hallucinations aggressive the client was able to
uusapan ako! Sabi manifested by sensory client will be able to: (listening pose, responses discuss content of
to
nila wala daw distortions  discuss content of laughing or talking command hallucinations with
akong kwenta!” (hallucinations) hallucinations with to self, stopping in hallucinations. nurse or therapist and
 “Naaamoy nyo ba nurse or therapist mid-sentence). demonstrated
‘yon? Takpan nyo  demonstrate  Avoided touching techniques that help
ilong nyo dali! techniques that the client before  Client may distract him or her
May lason yung help distract him warning him that perceive touch as from the voices.
hangin!” or her from the you are about to threatening and
Objective: voices. do so. respond in an
 Noted to be aggressive
mumbling to Long-term Goal  Showed an manner.
himself and often Client will be able to attitude of  This is important
pausing as if he define and test reality, acceptance that in order to prevent
were listening to eliminating the encouraged the possible injury to
someone. occurrence of client to share the the client or others
 Suspicious hallucinations. content of his from command
behavior hallucination. hallucinations.
 Did not reinforce  Words like “they”
the hallucination. validate that the
Used words such voices are real.
as “the voices”
instead of “they”
when referring to
the hallucination.
 Tried to connect  If client can learn
the times of the to interrupt
hallucinations to escalating anxiety,
times of increased hallucinations may
anxiety. Helped be prevented.
the client to
understand this
 Involvement in
connection.
interpersonal
  Distracted the activities and
client away from explanation of the
the hallucination actual situation
by engaging client will help bring the
in reality-based client back to
activities such as reality; acceptable
card playing, activities can
writing, drawing, decrease the
doing simple arts possibility of
and crafts or acting on
listening to music. hallucinations and
help distract from
voices.
 Decrease the
potential for
 Decreased anxiety that might
environmental trigger
stimuli when hallucinations.
possible (low Helps calm client.
noise, minimal  The client can
activity). sometimes learn to
 Stayed with client push voices aside
when starting to when given
hallucinate, and repeated
directed him to tell instructions.
the “voices they especially within
hear” to go away. the framework of
Repeat often in a a trusting
matter-of-fact relationship.
manner.

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Disturbed thought Short-term Goal:  Conveyed  It is important to Within 2 weeks of
 Pt verbalized processes secondary Within 2 weeks of acceptance of communicate to nursing interventions
delusions of to schizophrenia as nursing interventions client’s need for the client that you the client was able to
reference and manifested by client will be able to the false belief, do not accept the recognize and
persecution such as delusions. recognize and while letting him delusion as reality. verbalize that false
sound of blasts and verbalize that false or her know that ideas occur at times of
 a relative inflicting ideas occur at times of you do not share  Arguing with the increased anxiety
him of some increased anxiety. the belief. client or denying
mantras Long-term Goal  Did not argue or the belief serves
Objective: By time of discharge denied the belief. no useful purpose,
 Suspicious from treatment, Used reasonable because delusional
behavior client’s speech will doubt as a ideas are not
 Restless reflect reality-based therapeutic eliminated by this
 Irritable thinking. technique: “I approach, and the
 During understand that development of a
conversation, there you believe this is trusting
were blank true, but I relationship may
intervals and personally find it be impeded.
tangentiality in his hard to accept.”  If the client can
train of thoughts, learn to interrupt
with changes in escalating anxiety,
pitch.  Helped client try delusional
 Generalizations to connect the thinking may be
based on in- false beliefs to prevented.
appropriate or times of increased
limited anxiety. Discussed
information techniques that
 was not able to could be used to
understand and use control anxiety
the concepts (e.g., deep-
easily. breathing
exercises, other
relaxation
exercises, thought  Discussions that
stopping focus on the false
techniques). ideas are
 Reinforced and purposeless and
focused on reality. useless, and may
Discourage long even aggravate the
ruminations about psychosis.
the irrational
thinking. Talk
about real events
and real people  Verbalization of
  Assisted and feelings in a
supported client in nonthreatening
his attempt to environment may
verbalize feelings help client come to
of anxiety, fear, or terms with long-
insecurity. unresolved issues.

Assessment Diagnosis Planning Interventions Rationale Evaluation

Patient had an Risk for other- Short-term Goal:  Maintained low  Anxiety level rises Within 2 weeks of
incident of a violent directed violence Within 2 weeks of level of stimuli in in a stimulating nursing intervention
attack on his mother related to nursing intervention client’s environment. A client was able to
just before the arrival suspiciousness and client will be able to: environment (low suspicious, recognize signs of
in the health care perception of the  recognize signs of lighting, few agitated client may increasing anxiety and
center. environment as increasing anxiety people, simple perceive agitation and report to
threatening secondary and agitation and decor, low noise individuals as staff for assistance
to schizophrenia report to staff for level). threatening. with intervention and
assistance with  Observed client’s  So as to avoid did not harm self or
intervention. behavior creating others.
 not harm self or frequently (every suspiciousness in
others. 15 minutes). Did the individual.
Long-term Goal: this while carrying Close observation
 Client will not out routine is necessary so
harm self or activities that intervention
others. can occur if
required to ensure
client’s (and
others’) safety.
 So that in his or
her agitated,
 Removed all
 dangerous objects confused state
from client’s client may not
environment use them to harm
self or others.
 Physical exercise
 Tried to redirect is a safe and
the violent effective way of
behavior with relieving pent-up
physical outlets tension.
for the client’s
anxiety (e.g.,
punching bag).  Anxiety is
 Maintained and contagious and
conveyed a calm can be
attitude toward transmitted from
client. staff to client.
 This shows the
client evidence
 Had sufficient of control over
staff available to the situation and
indicate a show of provides some
strength to client if physical security
it becomes for staff.
necessary.
 The avenue of
the “least
Dependent: restrictive
 Administered alternative” must
tranquilizing be selected when
medications as planning
ordered by interventions for
physician. a psychiatric
Monitored client.
medication for its
effectiveness and
for any adverse
side effects.
 Drug Study
Drugs Classification Mechanism of Indications Caution and Side and Adverse Nursing
Action Contraindications Effects Considerations
Generic PHARMACO Antagonizes PO: Management Cautions: Disorders Frequent: Monitor B/P, serum
Name: THERAPEU alpha1- of manifestations in which CNS Drowsiness, glucose, lipids, LFT.
olanzapine TIC: Second- adrenergic, of schizophrenia. depression is agitation, insomnia, Assess for tremors,
Brand generation Dopamine, Treatment of acute prominent; cardiac headache, changes in gait,
Name: (atypical) histamine, mania associated disease, hemodynamic nervousness, abnormal muscular
Zyprexa antipsychotic. muscarinic, with bipolar instability, prior MI, hostility, dizziness, movements, behavior.
CLINICAL: serotonin disorder as ischemic heart rhinitis. Occasional: Supervise suicidal-risk
Antipsychotic. receptors. monotherapy or in disease; Anxiety, pt closely during early
Produces combination with hyperlipidemia, pts at constipation, therapy (as depression
anticholinergic, lithium or risk for aspiration nonaggressive lessens, energy level
histaminic, CNS valproate. pneumonia, decreased atypical behavior, improves, increasing
depressant IM: ZyPREXA. GI motility, urinary dry mouth, weight suicide potential).
effects. Controls acute retention, BPH, gain, orthostatic Assess for therapeutic
Therapeutic agitation in narrow-angle hypotension, fever, response (interest in
Effect: schizophrenia and glaucoma, diabetes, arthralgia, surroundings,
Diminishes bipolar mania. elderly, pts at risk for restlessness, cough, improvement in self-
psychotic Relprevv: Long- suicide, Parkinson’s pharyngitis, visual care, increased ability
symptoms. acting disease, severe changes (dim to concentrate, relaxed
antipsychotic for renal/hepatic vision). facial expression).
IM impairment, Adverse Reactions: Assist with ambulation
injection for predisposition to Rare reactions if dizziness occurs.
treatment of seizures. include seizures, Assess sleep pattern.
schizophrenia. Contraindications: neuroleptic Notify physician if
Hypersensitivity to malignant syndrome, extrapyramidal
olanzapine a potentially symptoms (EPS)
fatal syndrome occur.
characterized by Patient/family
hyperpyrexia, teaching
 muscle rigidity,  Avoid dehydration,
irregular pulse or particularly during
B/P, tachycardia, exercise, exposure
diaphoresis, cardiac to extreme heat,
arrhythmias.  concurrent use of
Extrapyramidal medication causing
symptoms dry mouth, other
(EPS), dysphagia drying effects.
may occur. Overdose  Sugarless gum, sips
(300 mg) produces of water may
drowsiness, slurred relieve dry mouth.
speech.  Report suspected
pregnancy.
 Take medication as
prescribed; do not
stop taking or
increase dosage.
 Slowly go from
lying to standing.
 Avoid alcohol.
 Avoid tasks that
require alertness,
motor skills until
response to drug is
 established.
 Monitor diet,
exercise program to
prevent weight
gain.
Generic PHARMACO Directly increases Monotherapy/ Cautions: Children Frequent: Nausea, Monitor CBC, LFT,
Name: THERAPEU concentration of adjunctive therapy younger than 2 yrs. drowsiness. serum ammonia.
Divalproex TIC: Histone inhibitory of complex partial Pts at risk for Occasional: Antimanic: Question
sodium or deacetylase neurotransmitter seizures, simple hepatotoxicity. Asthenia, abdominal for suicidal ideation.
valproic inhibitor. gammaaminobuty and complex History of hepatic pain, dyspepsia, rash Assess for therapeutic
acid CLINICAL: ric absence seizures. impairment, bleeding Adverse Effects: response (Interest in
Brand Anticonvulsant acid (GABA). Adjunctive therapy abnormalities, pts at Hepatotoxicity may surroundings,
Name: , antimanic, Therapeutic of multiple seizures high risk for suicide, occur, particularly in increased ability to
Depakote antimigraine. Effect: Decreases including elderly pts. first 6 mos of concentrate, relaxed
seizure activity, absence seizures. Contraindications: therapy. May be facial expression).
stabilizes mood, Hypersensitivity to preceded by loss of Patient/ family
prevents migraine valproic acid. Active seizure control, teaching
headache. hepatic disease, urea malaise, weakness,  Do not abruptly
cycle disorders, lethargy, anorexia, discontinue
known mitochondrial vomiting rather than medication after
disorders; migraine abnormal LFT long-term use (may
prevention in pregnant results. Blood precipitate
women. dyscrasias may seizures).
occur.  Strict maintenance
of drug therapy is
essential for seizure
control.
 Avoid tasks that
require alertness,
motor skills until
response to drug is
established.
 Drowsiness usually
disappears during
continued therapy.
 Avoid alcohol.
 Report liver
problems such as
nausea, vomiting,
lethargy, altered
mental status,
weakness, loss of
appetite, abdominal
pain, yellowing of
skin, unusual
bruising/bleeding.
 Report if seizure
control worsens,
suicidal ideation
(depression,
unusual changes in
behavior, suicidal
 thoughts) occurs.
Generic Central Phenothiazine Management of Cautions: CNS: Drowsiness, Assessment & Drug
Name: Nervous similar to manifestations of Previously detected insomnia, dizziness, Effects
Trifluopera System Agent; chlorpromazine. psychotic breast cancer; agitation,  Monitor HR and
zine Psychotherape Produces less disorders; "possibly compromised extrapyramidal BP. Hypotension is
Brand utic; sedative, effective" control respiratory function; effects, neuroleptic a common adverse
Name: Antipsychotic cardiovascular, of excessive seizure disorders. malignant syndrome. effect.
Espazine Phenothiazine and anxiety and tension Special Senses:  Hypotension and
anticholinergic associated with Contraindications: Nasal congestion, extrapyramidal
effects and more neuroses or somatic Hypersensitivity to dry mouth, blurred effects (especially
prominent conditions. phenothiazines; vision, pigmentary akathisia and
antiemetic and comatose states; CNS retinopathy. dystonia) are most
extrapyramidal depression; blood Hematologic: likely to occur in
effects than other dyscrasias; children Agranulocytosis. patients receiving
phenothiazines. <6 y; bone marrow Skin: high doses or
Antipsychotic depression; Photosensitivity, parenteral
effects thought preexisting liver skin rash, sweating. administration and
related to disease; pregnancy GI: Constipation. in older adults.
blockade of (category C), CV: Tachycardia, Withhold drug and
postsynaptic lactation. hypotension. notify physician if
dopamine Respiratory: patient has
receptors in the Depressed cough dysphagia, neck
brain. reflex. Endocrine: muscle spasm, or if
Therapeutic Gynecomastia, tongue protrusion
Effect: Indicated galactorrhea. occurs.
by increase in  Monitor I&O ratio
mental and and bowel
physical activity. elimination pattern.
Strong Check for
antipsychotic abdominal
drug with more distention and pain.
prolonged Encourage adequate
pharmacologic fluid intake as
effects than that prophylaxis for
of constipation and
chlorpromazine. xerostomia. The
depressed patient
may not seek help
 for either symptom
or for urinary
retention.
 Be aware that since
trifluoperazine
potentiates
analgesics, its use
may reduce amount
of narcotic required
in painful long-term
illness such as
cancer.
 Agitation,
jitteriness, and
sometimes
insomnia may
simulate original
neurotic or
psychotic
symptoms. These
adverse effects may
disappear
spontaneously.
 Expect maximum
therapeutic
response within 2–3
wk after initiation
of therapy.
Patient & Family
Education
 Take drug as
prescribed; do not
alter dosing
regimen or stop
medication without
consulting
physician.
 Consult physician
 about use of any
OTC drugs during
therapy.
 Do not take alcohol
and other
depressants during
therapy.
 Avoid potentially
hazardous activities
such as driving or
operating
machinery, until
response to drug is
known. Drowsiness
and dizziness may
be prominent during
this time.
 Cover as much skin
surface as possible
with clothing when
you must be in
direct sunlight. Use
a SPF >12
sunscreen on
exposed skin.
 Urine may be
discolored or
reddish brown and
this is harmless.
 Do not breast feed
while taking this
drug.