NURSING CARE PLAN

Rationale / Goals / Desired Evaluation

Assessment Cues Nursing Diagnosis Nursing Intervention Rationale
Pathophysiologic basis Outcomes

Subjective: Nursing Diagnosis: Predisposing Factor(s): After 8 hours of Independent: After 8 hours of
● Patient verbalized: Disturbed thought ● Age = 38 y.o nursing intervention, the nursing intervention, the
“gaka kita ko akon process, related to ● Sex = F patient will be ● Accept that the voices ● Stating to the patient patient was able to:
tatay di permi, ngaa Overwhelming stressful ● Genetic able to: were real to the that you do not sense
hambal nila wala?” life events and Panic level patient, but explain or perceive the voices ● Having difficulty
● Patient was seen of anxiety as evidenced by Precipitating Factors: SHORT TERM that you did not hear and sightings will help discussing the content
acting suspicious and behavioral changes, ● History of sexual ● Discuss content of them. the patient become of hallucinations as
irritable without hallucinations, abuse and traumatic hallucination uncertain of the the contents were
reason. suspiciousness. events (separation of ● Recognize and validity of what she irrelevant and false.
● At one point, patient parents during verbalize that false sees/hears Patient was also seen
was caught singing Definition: childhood) ideas occur at times dazed and confused
“Nay, Tay ka dako Schizophrenia refers to a ● Dopamine hypothesis of increased anxiety. ● Keep environment ● Keep anxiety from during discussion -
sang moon…” group of severe, disabling (hyperactivity of D2 ● Sustain attention and calm, quiet and as escalating and Goal Partially Met
psychiatric disorders receptor concentration to free of stimuli as increasing confusion
Objective: marked by withdrawal neurotransmission in complete task or possible. and ● Recognized and
● Patient looks from reality, illogical subcortical and limbic activities hallucinations/delusio verbalized that false
physically unkempt thinking, possible brain regions ● Spend time with one ns. ideas occur at times
● Patient wanders delusions and contributes to or two other people of increased anxiety
aimlessly hallucinations, and positive symptoms of in structured activity ● Involve the patient in ● Being engaged in as evidenced by “Ang
● Irritable and easily emotional, behavioral, or schizophrenia) neutral topics. reality based reality based activity mga hallucinations ko
gets annoyed intellectual disturbance. activities such as provides a healthy na ni indi gali tuod
● Speaks in a rapid and therapies (drawing, diversion and kag pwede man ni
high-pitched tone NANDA Definition: Abnormalities of listening music, prevents patient from matrato sang bulong”
● Verbalizes irrelevant Disruption in cognitive neurotransmitter (mainly After 3 days of nursing dancing) acting out her Goal Met.
thoughts operations and activities dopamine) transmission intervention, the patient hallucination
● Anxious/paranoid in various regions in the will be able to: ● Patient was not able
mood, and dull affect Source: Nanda Herdman, brain ● Explain the ● When the patient has to sustain attention
when wandering T.; Kamitsuru, S. (2019). procedures and try to full knowledge of and concentration to
aimlessly Supplement to NANDA be sure the patient procedures, he or she complete task or
● Demonstrate
● Hallucinations noted International Nursing
reality-based thought understand the activities. Patient is
● Thoughts of homicide Diagnoses: Definitions Increase dopaminergic processes in verbal procedures before is less likely to feel often seen dazed and
and suicide noted and Classification, transmission in communication. carrying them out. tricked by the staff. often confused about
● Limited judgment (2018-2020) 11th Edition. mesolimbic projection ● Demonstrate ways to the current situation.
Thieme Publishing reduce stress ● Reinforce and focus ● Discussions that focus But when asked the
● Express thoughts and on reality. Discourage on the false ideas are patient responds. But
Strength Dopaminergic neurons feelings in a coherent, long ruminations purposeless and when tasked the
● Strong family support project into the limbic logical, goal-directed about irrational useless, and may even patient does not
● Hard-working system (responsible for manner. thinking. Talk about aggravate the follow - Goal Not Met
● Cooperative real events and real psychosis.
behaviors and emotions)
people. ● Patient was able to
Weaknesses spend time with one
● Bad-influence from Abnormal dopamine ● Assist and support ● Verbalization of or two other people
significant other patients in his or her feelings in a in structured activity
transmission causes
● Possibly attempt to verbalize nonthreatening neutral topics as
Suicidal/Homicidal positive symptoms of feelings of anxiety, environment may evidenced by
due to mental schizophrenia fear, or insecurity. help patient come to participation in group
disorder terms with therapy. - Goal Met
long-unresolved
Delusions, hallucinations, issues.
speech disorganization or Collaborative:
● Consult with a ● To assist with the After 3 days of nursing
senselessness, grossly
psychiatrist treatment and intervention, the patient
disorganized motor will be able to:
therapeutic regimen
behavior

Disturbed thought ● Patient was having

process, related to difficulty in
Overwhelming stressful Demonstrating
reality-based thought
life events and Panic level
processes in verbal
of anxiety as evidenced by
communication. at
behavioral changes, some point during the
hallucinations, interaction, the
suspiciousness. patient was seen
reaching her arms out
Reference: as if flying. - Goal
Partially Met
Schizophrenia:
Pathogenesis and
Symptoms | Calgary
Guide. (2015, May 28).
https://calgaryguide.ucalg
ary.ca/schizophrenia-path ● Express thoughts and
ogenesis-and-symptoms/
● Patient was able to
Demonstrate ways to
reduce stress. Patient
is very stress free-
Goal Met
feelings in a coherent,
logical, goal-directed
manner as evidenced
by “Akon pamatyagon
subong daw ka kapoy.
Wala man ko
mahambal pa bi.”
Goal Partially Met