CHAPTER IX

NURSING CARE PLAN

Nursing Care Plan of Disturbed Thought Process

Health Nursing Desired Evaluation

Assessment Intervention Rationale Evaluation
Pattern Diagnosis Outcome Modification
Subjective Cognitive Note: Use P-E-S General Independent Goal >Continued
Cues: Health format Objectives: Intervention: Partially met. evaluation is
Perceptua After 2 necessary.
“Ako diay si Disturbed thought After 2 > Present the >To be able to
l weeks of
Boning, process related to weeks of reality to the re-align the >Reiteration
nursing
CPA” as alteration in nursing patient. patient’s and
intervention
verbalized by mental status as intervention, orientation of reinforcement
patient was
the patient. evidenced by patient will reality. of the
able to:
grandiose be able to: interventions.
“Nakagraduat > >To easily
delusions,respons Maintain
e man sya sa >Maintain Communicate build the trust >Schizophreni
e, and short usual
college, pero usual to the patient in from the a requires
attention span. orientation to
wala sya naka orientation to the most client and to
reality with long- term
take ug board Background reality with therapeutic have a therapy and
assistance,
exam kay Knowledge: the assistance way successful
Although the evaluation and
wala mi of student nurse-patient usually takes
delusions are
kwarta A delusion is a nurses. interaction. time to control
still present,
pambayad.” false belief held the student the
by a person. It Specific >Patients may
As verbalized > Maintain a nurses manifestations
contradicts reality Objectives: respond with
by the pleasant and correct it in of the
or what is anxious or
informant. quiet accordance condition.
commonly >Verbalize aggressive
environment with reality.
Objective considered true. concrete behaviors if
and approach
Cues: The strength of a environmenta patients in a startled or
Patient
delusion is based l happenings slow and calm overstimulate
verbalizes
Patient on how much the without d
responds person believes it. talking about manner in a concrete
inaccurately Specifically, a delusions in a specified time environmenta
to the delusion of specified l happenings
>Recognize the >Recognizing
questions grandeur is a time without
client’s the client’s
person’s belief talking about
>Patient will delusion and perception
that they are delusions in a
be able to do perception of can help
someone other specified
assigned the understand
than who they are, time but
tasks given environment. the feelings he
such as a there are still
by student is
supernatural times that the
nurses. experiencing.
figure or a patient
celebrity. A >Provide >When experiences
delusion of >Maintain grandiose
attention and structured thinking is
grandeur may also activities for focused on delusions
be a belief that concentration related to her
to complete the patient by reality-based
they have special engaging him activities, the occupation
abilities, activities. and career;
in reality-based client is free
possessions, or activities such of delusional Patient was
powers. as: thinking able to do
(Chaunie Brusie, - simple arts during that assigned
2017) and crafts time. Helps tasks given
project focus by the
attention student nurse
externally. such as
>Initially do simple arts
not argue with >Arguing will and crafts
the client’s only increase project like
beliefs or try to defensive drawing and
convince the position, coloring
client that the thereby activities.
delusions are reinforcing
false and false beliefs.
unreal. This will
 result in the
client feeling
even more
isolated and
misunderstoo
>Encourage d.
healthy habits
to optimize >All are vital
functioning: to help keep
- Maintain the client in
medication remission
regimen
- Maintain
regular sleep
pattern

>Show
empathy
regarding the
client’s
feelings;
reassure the
client of your
presence and
acceptance

>Refrain from
forcing
activities and
communication
s
 >Helps
Dependent patients learn
Intervention: to recognize
and change
>Discuss the thought
use of patterns and
Cognitive- behaviors that
behavioral lead to
therapy (CBT) troublesome
feelings.

>This
medication
eases
>Administer symptoms
prescribed such as
medication delusions and
such as hallucinations
Olanzapine . These drugs
decanoate, work on
clozapine chemicals in
the brain such
as dopamine
and serotonin

Collaborative >FT helps

 Intervention: families deal
more
>Collaborate effectively
with a family with a loved
and cognitive one who is
behavioral delusional,
therapist enabling them
to contribute
to a better
outcome for
the patient.

> CBT help

people with
schizophrenia
improve their
social and
problem-
solving skills,
lessen the
severity of
their
symptoms,
and reduce the
chance of
relapse

Nursing Care Plan of Impaired Verbal Communication

Assessmen Health Nursing Desired Evaluation
Intervention Rationale Evaluation
t Pattern Diagnosis Outcome Modification
Subjective Role Note: Use P- General Independent -Continuity of
Cues: relationshi E-S format Objectives: Intervention: Goal partially care and
p pattern met. After 2 evaluation are
“The Impaired >After 2 >Maintain a >This weeks of necessary to
activity Verbal weeks of calm, promotes time nursing
identify
was Communicatio nursing unhurried for the patient intervention,
improvements.
presented it n on related to intervention, manner. to comprehend the patient was
comes altered mental the patient will Provide or understand able to: - Impaired
from status as be able to: sufficient time the verbal
within not evidenced by for the patient information he Participate in communicatio
from inappropriate >Express to respond. received. therapeutic n due to
without.” verbalization feelings and communication schizophrenic
thoughts in >Maintaining . There are
as conditions
Background reasonable and >Maintain communicatio times when the
verbalized require long
knowledge: logical, goal- established n with the patient can
by the therapy and
directed communication patient will express
patient. Disorganized evaluation.
manner. with the patient improve their thoughts and
speech is a This means
Objective daily. expression of feelings
symptom that the
Cues: Specific feelings and coherently in a
common in intervention
Objectives: thoughts and logical, goal-
schizophrenia provided
Patient has at the same directed
. should be
difficulty >Actively time will manner but is continuously
expressing participate in allow them to still
Schizophrenia rendered in
his thought therapeutic preserve inconsistent At
patients have a order to
and communicatio communicatio Times, the
variety of maintain and
constantly n n skills patient can also
cognitive improve the
mentioning abnormalities, >Use clear, communicate communicatio
phrase that >Communicat >To provide
including simple words, in a clear and n capability of
isn’t e in a clear better
slower speak slowly, comprehensive the patient
related to and understanding
processing keep your manner with within limits
the comprehensiv as the client
speed and poor voice low, and the help of of the
questions. e manner, with might have
cognitive the help of keep difficulty medication and condition.
control. Poor medication instructions processing student nurses
cognitive and attentive simple as well. even simple as well.
control task listening from sentences.
performance the nurse and Loud or high-
has been linked family pitched voices
to disorganized may trigger
speech anxiety,
symptoms, agitation, or
such as confusion in
communication patients with
difficulties schizophrenia.
(Merril, >Maintain eye
Karcher, contact with >Patient need
Cicero, Becker, patients when to see the
Docherty, speaking. stand nurse's face or
Kerns, 2017). close within lips to enhance
the patient line their
In patient’s of vision understanding
case, when (generally of what is
asked what can midline). being
she say about communicated
the activity, she >Use .
answered “It therapeutic
comes from communication >Encourage
within not from : the patient to
without” that is - Silence: verbalize,
obviously not Absence of provided that
related to the verbal it is interesting
question. communication and expectant.
, which Give time to
provides time recognize
for the client to thoughts,
direct the topic
put thoughts or of interaction,
feelings into or focus on
words, regain issues that are
composure most
important.
>Presenting
reality- >When a
Offering for patient is
consideration misinterpretin
on that which g reality, the
is real. nurse can
indicate what
is real. The
nurse does this
by calmly and
quietly
expressing the
nurse’s
perception or
the facts not
by way of
arguing with
> Offering self the patient or
belittling his
experience.

Offering time
and presence
>Translating initiates
into feelings interest and
understanding
to the patient.

>Seeks to
>Voicing verbalize the
doubt patient’s
feelings that
he expresses.

>This permits
the patient to
become aware
Dependent that others do
Intervention: not necessarily
perceive
>Administer events in the
prescribed same way or
medication draw the same
such as conclusion.
Olanzapine
decanoate, >This
clozapine medication
eases
symptoms
such as
delusions and
hallucinations.
These drugs
work on
>Discuss the chemicals in
use of the brain such
Cognitive- as dopamine
behavioral and serotonin.
therapy (CBT)
>Helps
patients learn
to recognize
Collaborative and change
 Intervention: thought
patterns and
>Collaborate to behaviors that
a speech and lead to
language troublesome
therapist feelings.

>To address
the patient’s
symptoms
with regards to
expressing his
thoughts

Nursing Care Plan of Impaired Social Interaction

Health Nursing Desired Evaluation

Assessment Intervention Rationale Evaluation
Pattern Diagnosis Outcome Modification
Subjective Role Note: Use P- General Independent After 2 weeks -Continuity of
Cues: relationship E-S format Objectives: Intervention: of nursing care and
pattern intervention, assessment
“Nakakulong Impaired After 2 weeks >Keep the >Patient might
the patient are necessary
ra man gud social of nursing patient in an respond to
was able to: in order to
na sya sa interaction intervention, environment as noises and
evaluate the
among balay related to the patient free of stimuli crowding with >Able to course of
ma’am kay altered will be able (loud noises, agitation, attend condition.
gapanglabay thought to: crowding) as anxiety, and structured
sya ug bato if process as possible. increased activities in -
naa sya sa evidenced by >State that she inability to social Schizophrenia
gawas.” as inappropriate is comfortable concentrate on situations is a long-term
verbalized by emotional in at least outside events. settings with condition
informant response, three the help and which
>Give >Recognition
structured
Objective spends time activities that acknowledgmen and of student requires
Cues: alone by self, are goal t and appreciation nurses that consistent
Unable to directed. recognition for go a long way encourages reinforcement
Observed maintain eye positive steps to sustaining her to do so and support
discomfort contact Specific the client takes and increasing >The patient from the
during the Objectives: in increasing a specific was able to health care
course of Background social skills and behavior state that she provider and
assessment; knowledge: >Able to use appropriate was the family.
Unable to appropriate interactions comfortable Patients with
initiate social Behavior and social skills in with others. and happy a progressive
interaction; functional interaction s. >Social skills
with the form of the
inability to deficiencies >Provide training helps
structured disease are
maintain eye seen in > attend one opportunities the patient
activities that increasingly
contact; schizophrenic structured for the client to adapt and
are goal socially
Blunted patients, one group activity learn adaptive function at a
oriented. isolated.
affect; Sits of within 6-11 social skills in a higher level in
alone during the signs and days. non-threatening society, and >She was
activities. symptoms are environment. increases the able to attend
negative > use client’s quality
Initial social on the
symptoms appropriate of life.
skills training structured
(Kibe, social skills in
could include activities for
2021). interactions.
basic social 11 days.
> maintain behaviors such
as starting a >Used
interaction
conversation appropriate
with another
and exchanging social skills
client while
of nonverbal in
doing an
signals like interactions.
activity (e.g.,
simple frowns, or >Encourages
smiles continuation of >Maintains
drawing) interaction
desired
>Provide behaviors and with another
positive efforts for client while
reinforcement doing the
for change activity.
improvement in
social behaviors others but
and interactions >Group there are
therapy/interac times that the
>Involve patient t ions helps patient would
in group individuals feel
interaction or as develop uncomfortabl
the situation communicatio e and
allows. n skills and annoyed
socialization because of
skills, and this he cannot
allows clients be forced to
to learn how to interact with
express their others as it
issues or may cause
problems. him to get
angry and
>Well- combative.
>Assist client to developed
develop positive social
social skills interaction
through practice skills are
of skills in real critical for
social situations developing
such as: positive self-
- Listening to esteem, and
others; building
- staying calm relationships.
with others; Social skills
getting along training helps
with others and the client
by following the adapt and
steps and rules function at a
accompanied by higher level in
a support society.
person.

>Encourage the >These

client’s interventions
engagement and measures are
participation in to help the
Physical and patient in
Social overcoming
Activities the sense of
isolation in
impaired
social
interaction
Dependent with
Intervention: individuals of
various age
>Administer groups
prescribed
medication such >This
as Olanzapine medication
decanoate, eases
clozapine symptoms
such as
delusions and
hallucinations.
These drugs
work on
chemicals in
the brain such
>Conduct as dopamine
Social and serotonin.
interaction
therapy, as >Social skills
ordered training (SST)
is a type of
behavioral
therapy used
to improve
Collaborative social skills in
Intervention: people with
mental
>Refer to disorders or
psychiatric developmental
mental health disabilities.
nurse
practitioners for >A PMHNP
additional assesses,
assistance when diagnoses and
indicated. treats patients.
By
incorporating
their scientific,
clinical and
theoretical
knowledge,
PMHNPs help
patients who
are coping
with and
managing
physical and
mental health
concerns.
 Nursing Diagnosis
Disturbed thought process
related to alteration in mental
status as evidenced by grandiose
delusion
Impaired Verbal
Communication on related to
altered mental status as
evidenced by inappropriate
verbalization
Impaired social interaction
related to altered thought
process as evidenced by
inappropriate emotional
response, spends time alone by
self, unable to maintain eye
contact.
Prioritizati Rationale
on on
High 1 Disturbed thought process is considered
high 1 priority because the patient
presents disturbed thinking and
distorted reality orientation, the patient
experiences delusion, this mental
process may lead to inaccurate
interpretation of the situation and may
result in an inability to evaluate reality
accurately. Delusional disorder may
progress to develop life-long illness,
common complications of delusional
disorder include depression, violence
and legal problems, and isolation.
High 2 Impaired verbal communication is
considered high 2 priority. The patient
exhibits poor communication function.
Patient present sudden stops in thought
process, respond inaccurately and do not
maintain eye contact, inability to
communicate enhances a patient's sense
of isolation and may promote a sense of
helplessness.
High 3 Impaired social interaction is
considered a high 3 priority nursing
diagnosis.
Patient isolates himself and doesn't
want to interact with others that may
lead to poor physical, emotional, and
cognitive function. Perceive social
isolation with adverse health
consequences including depression,
poor sleep quality and poor physical
health.