Assessment Diagnosis Outcome Intervention Rationale Evaluation

Identification

Subjective: Disturbed sensory Short Term: Independent

“Hindi ako magkaon, perception: After 4 Hours of 1. Encourage same staff to 1. To promote Goals are met
may hilo na. May Auditory related to nursing work with client as much development of as evidenced
gahutik sakun na altered perception intervention, The as possible trusting relationship. by:
may caused by Nurse will be able
hilo ang pagkaun nga schizophrenia to present reality 2. Avoid physical contact. 2. Suspicious clients may Patient was
na, to the patient. perceive touch as a able to
gusto nyo ko threatening gesture. recognize that
madula”, Rationale: Long Term: hallucinations
as verbalized by the Psychosis from After 3 days of 3. Be honest and keep all 3. This Honesty and occur at times
patient schizophrenia nursing promises. dependability promote of extreme
may result in a intervention, a trusting relationship. anxiety.
Objective: disconnection patient will be able
 History of from reality with to verbalize 4. Mouth checks may be 4. To verify that client is
paranoid symptoms of understanding that necessary after swallowing the tablets Patient was
delusions delusions and the voices are medication or capsules. Suspicious able to
 Difficulty in hallucinations result of his illness administration. clients may believe recognize signs
sleeping and demonstrate they are being of increasing
 Experienced Source: ways to interrupt poisoned with their anxiety and
auditory https:// hallucinations. medication and employ
hallucinations nurseslab.com/ attempt to discard the techniques to
 Irritability schizophrenia- pills. interrupt the
noted nursing-careplans response.
5. Encourage client to 5. Verbalization of
 Agitation
verbalize true feelings. feelings in a
 Hostile The nurse should avoid nonthreatening
behavior becoming defensive environment may help
 Threatened when angry feelings are client come to terms
toward self directed at him or her. with long-unresolved
issues.
6. An assertive, matter-of-
 fact, yet genuine 6. The suspicious client
approach is the least does not have the capacity
threatening to the to relate to an overly
suspicious person. friendly, overly cheerful
attitude.
7. Encourage client to
verbalize true feelings. 7. Verbalization of feelings
The nurse should avoid in a nonthreatening
becoming defensive environment may help
when angry feelings are client come to terms with
directed at him or her. long-unresolved issues

Dependent:
1. Administer
medications 1. In order to prevent
especially antipsychotic relapse of the positive
drugs as ordered by the and negative
physician such as; symptoms of the disorder

a) Biperiden 2mg ½
tablet twice a dayng, and
singing

b) Risperidone 2mg
twice a day

c)Chlorpromazine 100
mg OD HS
 Assessment Diagnosis Outcome Intervention Rationale Evaluation
Identification

Subjective: Self-care deficit relatedShort Term: Independent: Goals are met as

“He wears the same to alteration in After 8 Hours of 1. Develop 1. 1. To establish trust and evidenced by:
clothes every day cognitive functioning nursing intervention, therapeutic allow the client to
and seldom bathed. (erratic and threatening the patient will be relationship with express his emotions and Patient was able
He no longer behavior) able to independently the patient. concerns. to independently
seemed to care address self-care address self-care
about his physical Rationale: needs and begin to 2. There is less chance needs and begin
appearance,” as Self-care deficit is a utilized resources 2. Use a for a suspicious to utilize
verbalized by the situation where that will address his nonjudgmental, client to misinterpret resources that will
patient’s sister. experiencing barriers to needs. respectful and intent or meaning if address his needs.
perform self-care neutral approach content is neutral
Objective: activities, such as Long Term: with the client. and approach is Patient was able
 Disheveled bathing, changing After 24 hours of respectful and to verbalize and
appearance clothes, eating and nursing intervention, nonjudgmental. identify the ways
with dirty eliminating. patient will be able to techniques of
stained Barriers/interference verbalize and identify 3. This provides a taking care of self
clothing ability to take care of the ways techniques 3. Observe self-care baseline about how and execute
 Poorly themselves at of taking care of self tasks. dependent the behavior that
groomed schizophrenic client and execute behavior patient is and how promote good
 Uncombed caused by cognitive or that promote good much help the hygiene and
hair perceptual hygiene and patient needs. grooming.
disturbances (Wilkinson grooming.
& Ahern 2013). 4. Involve the 4. Including the patient
patient in the in the plan of care
development of provides a sense of
the care plan. autonomy. The
patient is also more
likely to comply if he
or she helped work
on the plan.
5. Assess the reason 5. Knowing why the
for the patient’s patient is unable to
impaired self- care for himself or
care. herself allows the
nurse to focus on the
6. Establish a cause and improve
routine with the it.
patient 
6. Routines provide a
sense of security. The
patient feels much
more confident
knowing repetitive
7. Assess the individual steps of a
patient’s ability to specific process. 
bathe on his or
her own. 7. This provides
information about
how much help the
8. Provide privacy. patient needs. 

8. This fosters trust in

the relationship
between the patient
and the healthcare
staff. 
9. Dressing and
grooming: Adapt 9. This ensures that the
to the pace of the patient has
patient. assistance available
if needed but also
can be as
10. Let the patient independent as he or
select clothes and she is able.
 accessories. 10. The patient feels
included in the care
Dependent: and more motivated
Administer to participate in the
medications plan of care.  
especially
antipsychotic
drugs as ordered by
the physician such
as;

a) Biperiden 2mg ½
tablet twice a
dayng, and singing

b) Risperidone 2mg
twice a day

c)Chlorpromazine
100
mg OD HS