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FOCUS Expected Outcome/s PLAN: Nursing Interventions
/Nursing (of PRIORITY
Diagnosis diagnosis)
Disturbed Thought STO:
Process related to After 8 hours of nursing
neurochemical care and health education,
alterations in the the patient will be able to:
brain.
a. Patient will sustain
attention and concentration
to complete tasks or
activities.
b. Patient will talk about
concrete happenings in the
environment without talking
about delusions for at least
5 minutes.
LTO:
Within 3 days of nursing
intervention, the patient will
manifest signs of:
a. Patient will demonstrate
two to three effective
coping skills that minimize
delusional thoughts.
b. Patient will verbalize
minimal delusions or
demonstrate the ability to
function without responding
to persistent delusional
thoughts.
Dx:
-Monitor vital signs.
-Explain the procedures and try to
be sure the client understands the
procedures before carrying them
out.
-Perform a comprehensive
MSE.
-Assess the incoherent speech if it
is chronic or sudden
Tx:
- Assess the patient's ability to
carry out the activities of daily
living, paying special attention to
his nutritional status.
- Maintain a safe
environment,minimizing stimuli.
-Do not argue or deny the belief of
the client
-Do not touch the client; use
gestures carefully.
-Administer Medication as ordered
Edx:
- Educate patient on reinforcement
and focusing on reality, talk about
Rationale
-Provides baseline data of the
improvement of the client.
-When the client has full
knowledge of procedures, she
is less likely to feel tricked by
the nurses.
-The MSE provides important
information for diagnosis and for
assessment of the disorder's
course and response to
treatment.
-This helps the nurses to know
if she can verbalize her
concerns clearly to check for
non verbal cues and to help the
client to verbalize in other ways.
-It is to provide dietary changes
appropriate to the body’s ideal
needs and to provide support
when needed.
-To avoid harm, to minimize
distractions and to lessen
triggers of the patient.
-Arguing or denying the belief
does not eliminate the
delusions, it can increase
clients anxiety.
-Suspicious clients 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.
-Assisting the patient helps to
check if the client complies with
the medication.
-In order for the patient to have
an orientation on reality, to
avoid aggravation of the
reality. symptoms.

-Educate patient on ways of -To prevent possible injury to

effective coping skills that minimize the client and to help reduce the
delusional thoughts. symptoms to help the patient
calm down.

-Teach the client to understand the -Teaching the client about this
connection between anxiety and can interrupt escalating anxiety
hallucination to help prevent hallucinations.