Cues

Psychiatric Nursing Diagnosis Disturbed Thought Process related to paranoia as evidenced by voicing out of nonexistent matters.

Psychodynamics (RATIONALE)

Planning

Therapeutic Approach

RATIONALE (With Theories)

Evaluation

Subjective: I know that some of the patients here are very close with the nurses and that they gang up against me. As verbalized by the client. Objective: GA Good personal grooming Good eye contact Serious facial expression Motor Behavior None Sensory & Cognition Conscious, oriented to time, place & place Hesitation to answer questions about staff Attitude None Affect

Risk factors are heredity, socioeconomic & biochemical

Short term After 8 hours of nursing interventions, the client would be able to: Demonstrat e decreased anxiety level. Respond to realitybased interactions initiated by others

Neurodevelopmen tal failure

Alteration of function in cognitive and perceptive fields

Be sincere and honest when communicating with the client. Avoid vague or evasive remarks. Delusional clients are extremely sensitive about others and can recognize insincerity . Be consistent in setting expectations, e nforcing rules, and so forth Do not promises that you cannot keep. make

Evasive comments or h esitation reinforces mistrust or delusions.

Outcome achieved. The client was able to do all the health teachings given.

Clear, consistent limits provide a secure structure for the client.

Alteration of function in cognitive and perceptive fields

Broken promises reinforce the c lients mistrust of others. Probing increases the clients suspicion and interferes with the therapeutic relationship When the client has full knowledge of procedures, he or sheis less likely to feel tricked by the staff. Positive feedback for genuine success enhances the clients sense of well-being and

Fantasize ideal self and family while being aloof to others

Encourage the client to talk with you, but do not pry for information. Explain procedures, and try to be sure the client understands the procedures before carrying them out. Give positive feedback for the clients successes.

Inaccurate interpretation of incoming information

Suspicions noted DISTURBED THOUGHT PROCESS

Recognize the clients de lusions as the clients perception of the environment.

helps make nondelusional reality a more positive situation for the client. Recognizing the clients perceptions can help yo u understand the feelings he or she is experiencing.