NCP psych

Assessment

Subjective Data: “Yun, may narinig akong trials (but actually no one said the word trials), ganun na nga yun kasi trials and challenges are just the same.” as stated

Objective Data: • Diagnosed

with Paranoid Schizophrenia • Auditory hallucination • Exaggerated emotional

responses • Impaired

communicatio n • Poor concentration

Nursi ng ng Diagnosis

Scientific Explanation

Disturbed auditory sensory perception related to anxiety associated with multiple stressors as evidenced by auditory hallucination.

Although the etiology & pathogenesis have not been fully determined, here are some etiologies: Stressful life circumstances, genetic & biochemical defects, & brain damage in the fetus by prenatal complications or viral infection ↓

Reduced gray matter in the temporal lobes

Planning

Short Term Goal: After 3 weeks of nursing intervention, the patient will be able to 1.Recognize and correct/compensa te for sensory impairments. 2. Identify/modify Identify/modify 2/3 external factors that contribute to alterations in sensory/perceptu al abilities.

Nursing Intervention Independent: - Help present and maintain reality by frequent contact and communication with the client - Elicit description of hallucination to protect client and others.

Discharge

system)

Outcome:

↓

Excessive dopamine secretions ↓

Enlarged third and lateral ventricles ↓

Decreased blood flow to the frontal lobes ↓

Abnormalities of neuro- transmitters and neuro-endocrine systems. ↓

Sensory overload and hyperarousal.

After months or upon discharge, the client will be able to 1. Not respond to hallucinatory commands, and hallucinations will subside. 2. Be free form injury.

-Focus on the feelings about, rather than

details of, the hallucination.

• Presenting reality is

healthy for the client (1)

• The nurse’s

understanding of hallucination helps her know how to calm or reassure the client (1)

Reference: Pathophysiology for the Health Professions 3rd

Edition by Barbara E. Gould Page 588-589

Goal Fully Achieved After hour of nursing intervention, the client was able to recognize and correct/compensate correct/compensate for sensory impairments. Identify/modify 2/3 external factors like stress and effects of medications, which contribute to alterations in sensory/perceptual abilities.

the client with active hallucinations hallucinations in a secure environment Recommendation: is essential to Terminate the Plan maintain safety of the client & others. Discharge Outcome: Excessive sensory stimulation could overwhelm and Outcome Fully Achieved; agitate the client. Upon discharge, the client was able to not respond to • Focusing on the

client’s feelings, which are real, minimizes emphasis on the hallucination.

- Do not argue with • Arguing with the the client about client or expressing whether the disbelief in the hallucinations are real; hallucinations does state, if asked, that not affect the client’s belief in the you do not perceive reality of the the auditory stimuli hallucination and that the client can disrupt trust & perceives. the therapeutic rel. Expressing that you not hear the hallucinatory stimuli indirectly encourages him to question the reality Collaborative: of the experience.

↓

Auditory hallucination

Evaluation

Short Term:

• Close observation of

-Keep client in a safe, protected, restricted environment. Avoid excessive activity and stimulation

↓

Abnormal cells in the hippocampus (part of the limbic

Rationale

- Engage client in reality-based activities • To achieved such as card playing, maximal gains in occupational therapy, function and or listening to music. psychosocial wellbeing

Reference: (1)

Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 268 (2) Psychiatric-Mental Health Nursing by Mohr page 650

hallucinatory commands, and hallucinations will subside. The client reported a decrease in, and eventually the total cessation of hallucinations. And the client was free from injury Recommendation: Terminate the Plan

responses

system)

• Impaired

Outcome:

↓

communicatio n • Poor concentration

Excessive dopamine secretions ↓

Enlarged third and lateral ventricles ↓

Decreased blood flow to the frontal lobes ↓

Abnormalities of neuro- transmitters and neuro-endocrine systems.

After months or upon discharge, the client will be able to 1. Not respond to hallucinatory commands, and hallucinations will subside. 2. Be free form injury.

↓

Sensory overload and hyperarousal.

details of, the hallucination.

client’s feelings, which are real, minimizes emphasis on the hallucination.

- Do not argue with • Arguing with the the client about client or expressing whether the disbelief in the hallucinations are real; hallucinations does state, if asked, that not affect the client’s belief in the you do not perceive reality of the the auditory stimuli hallucination and that the client can disrupt trust & perceives. the therapeutic rel. Expressing that you not hear the hallucinatory stimuli indirectly encourages him to question the reality Collaborative: of the experience.

hallucinatory commands, and hallucinations will subside. The client reported a decrease in, and eventually the total cessation of hallucinations. And the client was free from injury Recommendation: Terminate the Plan

↓

- Engage client in reality-based activities • To achieved such as card playing, maximal gains in occupational therapy, function and or listening to music. psychosocial wellbeing

Auditory hallucination

Reference: Pathophysiology for the Health Professions 3rd

Reference: (1)


Assessment

Subjective Data:

Nursi ng Diagnosis

Disturbed thought process related to “I really don’t presence of understand my psychological father. Why conflicts (delusion can’t he of persecutory) as understand me? evidenced by Hindi niya impaired ability to maappreciate problem solve and yung work ko. Is disordered it ingenuity or thought creativity? sequencing. Dalawang beses ako binaril ng

father ko.,” as stated

Objective Data:


Although the etiology & pathogenesis have not been fully determined, here are some etiologies: Stressful life circumstances, genetic & biochemical defects, & brain damage in the fetus by prenatal complications or

viral infection ↓

Reduced gray matter in the temporal lobes ↓

• Diagnosed

with Paranoid Schizophrenia

Abnormal cells in the hippocampus (part of the limbic


Planning

Short Term Goal: After 3 weeks of nursing intervention, the patient will be able to 1. Verbalize recognition of delusional thoughts if they persist. 2. Respond to reality-based

interactions initiated by others; for example, verbally interact with staff for specified time period.

Nursing Intervention

Rationale

Evaluation

Independent:

Short Term:

- Be consistent in • Clear, consistent setting expectation, limits provide a enforcing rules, and so secure structure for forth the client

Goal Partially Achieved After hour of nursing intervention, the client was able to 1. Verbalize recognition of delusional thoughts if they persist. 2. Respond to reality-based interactions initiated by others; for example, verbally interact with staff for specified time period.

- Do not make promises that you cannot keep.

• Broken promises

reinforce the client’s mistrust of other

- Recognize the • Recognizing the client’s delusions as client’s perception the client’s perception can help you of the environment understand the

feelings he is experiencing - Interact with the client on the basis of real things; do not dwell on the delusional material - Never convey to the

Recommendation: Terminate the plan

• Interacting with

reality is healthy for the client

Discharge Outcome: Outcome Partially Achieved;


Assessment

Subjective Data:

Nursi ng Diagnosis

Disturbed thought process related to “I really don’t presence of understand my psychological father. Why conflicts (delusion can’t he of persecutory) as understand me? evidenced by Hindi niya impaired ability to maappreciate problem solve and yung work ko. Is disordered it ingenuity or thought creativity? sequencing. Dalawang beses ako binaril ng


Objective Data:


Although the etiology & pathogenesis have not been fully determined, here are some etiologies: Stressful life circumstances, genetic & biochemical defects, & brain damage in the fetus by prenatal complications or

viral infection ↓


• Diagnosed

•

•

• •

with Paranoid Schizophrenia With a delusion to his father (delusion of persecutory) Disordered thought sequencing or Flight of ideas Loose association Impaired ability to problem solve

Abnormal cells in the hippocampus (part of the limbic system)


Planning

Short Term Goal: After 3 weeks of nursing intervention, the patient will be able to 1. Verbalize recognition of delusional thoughts if they persist. 2. Respond to reality-based


↓

Enlarged third and lateral ventricles

Discharge Outcome:

Upon discharge, the client will be Decreased blood able to be free flow to the frontal from delusions or lobes demonstrate the ↓ ability to function Abnormalities of neuro- transmitters without and neuro-endocrine responding to persistent systems. delusional ↓ thoughts. • With a delusion to his father (delusion of persecutory) • Disordered thought sequencing or ↓

Rationale

Short Term:

- Be consistent in • Clear, consistent setting expectation, limits provide a enforcing rules, and so secure structure for forth the client

Goal Partially Achieved After hour of nursing intervention, the client was able to 1. Verbalize recognition of delusional thoughts if they persist. 2. Respond to reality-based interactions initiated by others; for example, verbally interact with staff for specified time period.

- Do not make promises that you cannot keep.

• Broken promises

reinforce the client’s mistrust of other

- Recognize the • Recognizing the client’s delusions as client’s perception the client’s perception can help you of the environment understand the

feelings he is experiencing - Interact with the client on the basis of real things; do not dwell on the delusional material

Pathophysiology for the Health Professions 3rd Edition by Barbara




• Indicating belief in

delusions reinforces the delusion (and the client’s illness)

Discharge Outcome: Outcome Partially Achieved; Upon discharge, the client was able to free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts.

-Directly interject doubt regarding • As the client begins delusions as soon as to trust you, he may the client seems ready become willing to to accept this. Do not doubt the delusion if Recommendation: argue but present a Continue the Plan you express your factual account of the doubt. situation as you see it.

Collaborative: -Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups

• A distrustful client

can be best deal with one person initially. Gradual introduction of others as the client tolerate is less threatening.

Flight of ideas

Reference:

Evaluation

Independent:

- Never convey to the client that you accept the delusions are reality

↓

Excessive dopamine secretions


Reference: Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 264


viral infection ↓

Reduced gray matter in the temporal lobes

Objective Data:

↓ • Diagnosed

•

•

• •


with Paranoid Schizophrenia With a delusion to his father (delusion of persecutory) Disordered thought sequencing or Flight of ideas Loose association Impaired ability to problem solve


↓

Enlarged third and lateral ventricles

- Interact with the client on the basis of real things; do not dwell on the delusional material - Never convey to the client that you accept the delusions are reality

↓

Excessive dopamine secretions

feelings he is experiencing

Discharge Outcome:

Upon discharge, the client will be Decreased blood able to be free flow to the frontal from delusions or lobes demonstrate the ↓ ability to function Abnormalities of neuro- transmitters without and neuro-endocrine responding to persistent systems. delusional ↓ thoughts. • With a delusion to his father (delusion of persecutory) • Disordered thought sequencing or ↓




• Indicating belief in

delusions reinforces the delusion (and the client’s illness)

Discharge Outcome: Outcome Partially Achieved; Upon discharge, the client was able to free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts.

-Directly interject doubt regarding • As the client begins delusions as soon as to trust you, he may the client seems ready become willing to to accept this. Do not doubt the delusion if Recommendation: argue but present a Continue the Plan you express your factual account of the doubt. situation as you see it.

Collaborative: -Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups

• A distrustful client

can be best deal with one person initially. Gradual introduction of others as the client tolerate is less threatening.

Flight of ideas Reference: Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 264

Reference: Pathophysiology for the Health Professions 3rd Edition by Barbara E. Gould Page 588-589

Assessment

Subjective Data: “Ang pagkakaalam ko dahil ata nagdrawing ako sa wall, uhm not wall, it’s not

Nursi ng Diagnosis

Impaired verbal communication related to loose associations and flight of ideas as evidenced by vague, diffuse, unfocused


Although the etiology & pathogenesis have not been fully determined, here are some etiologies: Stressful life circumstances,

Planning

Short Term Goal: After 3 weeks of nursing intervention, the patient will be able 1.Participate in therapeutic


Rationale

Evaluation

Independent:

Short Term:

- Reorient the client to • Repeated person, place, and presentation of time as indicated. reality is concrete reinforcement for the client - Spend time with the client • Your physical

Goal Partially Achieved After hour of nursing intervention, the client was able to participate in therapeutic communication like using silence, acceptance, reflecting and

Flight of ideas Reference: Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 264


Assessment

Subjective Data: “Ang pagkakaalam ko dahil ata nagdrawing ako sa wall, uhm not wall, it’s not also a table basta di ko alam tawag dun (seemed confused then live it hanging and continued to talk),” as stated

Objective Data: • Loose association of ideas • Paranoid Schizophrenia Diagnosis • Flight of ideas • Difficulty in forming words. • Vague, diffuse,

unfocused sequences of concepts • Switch of subjects that are difficult to follow the train of thought

Nursi ng Diagnosis


Impaired verbal communication related to loose associations and flight of ideas as evidenced by vague, diffuse, unfocused sequences of concepts and switch of subjects that are difficult to follow the train of thought.




Planning

Short Term Goal: After 3 weeks of nursing intervention, the patient will be able 1.Participate in therapeutic communication to get needs met and to 2.Relate effectively with persons and his or her environment. 3.Verbalize or indicate n understanding of the communication difficulty and plans for ways of handling.

↓

↓

Decreased blood

flow to the frontal lobes

Discharge Outcome:

Upon discharge, the client will be ↓ able to Abnormalities of neuro- transmitters demonstrate and neuro-endocrine congruent verbal and nonverbal systems. communication ↓ and 2. Establish • Flight of ideas

Rationale

Evaluation

Independent:

Short Term:

- Reorient the client to • Repeated person, place, and presentation of time as indicated. reality is concrete reinforcement for the client - Spend time with the client • Your physical presence is reality. Allows client to - Encourage the client think. to talk with you, but do not pry for • Probing increases information. the client’s suspicion

Goal Partially Achieved After hour of nursing intervention, the client was able to participate in therapeutic communication like using silence, acceptance, reflecting and active listening. Relate effectively with persons and his or her environment. Verbalize or indicate n understanding of the communication difficulty but not the plans for ways of handling.

- When first communicating with the client, use simple, direct sentences; avoid complex sentences or directions. - Use confrontation skills, when appropriate, within an established nurseclient relationship

↓

Excessive dopamine secretions Enlarged third and lateral ventricles


- Give positive feedback for the

client’s successes.

and interferes with the therapeutic relationship. • The client’s ability to

perceive and respond to complex stimuli is impaired.

• To clarify

discrepancies between verbal and nonverbal cues.

• Positive feedback for

genuine success enhances the client’s sense of well-being.

Collaborative: - Engage client in reality-based activities • To achieved such as card playing, maximal gains in

Recommendation: Continue the Plan

Discharge Outcome: Outcome Partially Achieved; Upon discharge, the client was able to demonstrate congruent verbal and nonverbal communication. He established partially method of communication

in which needs can be expressed. Recommendation: Continue the Plan

Subjective Data: “Ang pagkakaalam ko dahil ata nagdrawing ako sa wall, uhm not wall, it’s not also a table basta di ko alam tawag dun (seemed confused then live it hanging and continued to talk),” as stated

Objective Data: • Loose association of ideas • Paranoid Schizophrenia Diagnosis • Flight of ideas • Difficulty in forming words. • Vague, diffuse,


Impaired verbal communication related to loose associations and flight of ideas as evidenced by vague, diffuse, unfocused sequences of concepts and switch of subjects that are difficult to follow the train of thought.




Short Term Goal: After 3 weeks of nursing intervention, the patient will be able 1.Participate in therapeutic communication to get needs met and to 2.Relate effectively with persons and his or her environment. 3.Verbalize or indicate n understanding of the communication difficulty and plans for ways of handling.

↓

↓

Decreased blood


Discharge Outcome:

Upon discharge, the client will be ↓ able to Abnormalities of neuro- transmitters demonstrate and neuro-endocrine congruent verbal and nonverbal systems. communication ↓ and 2. Establish • Flight of ideas method of • Difficulty in communication in forming words. which needs can • Vague, diffuse, be expressed. unfocused sequences of concepts • Switch of subjects that are difficult to follow the train of thought


Short Term:

- Reorient the client to • Repeated person, place, and presentation of time as indicated. reality is concrete reinforcement for the client - Spend time with the client • Your physical presence is reality. Allows client to - Encourage the client think. to talk with you, but do not pry for • Probing increases information. the client’s suspicion

Goal Partially Achieved After hour of nursing intervention, the client was able to participate in therapeutic communication like using silence, acceptance, reflecting and active listening. Relate effectively with persons and his or her environment. Verbalize or indicate n understanding of the communication difficulty but not the plans for ways of handling.

- When first communicating with the client, use simple, direct sentences; avoid complex sentences or directions. - Use confrontation skills, when appropriate, within an established nurseclient relationship

↓

Excessive dopamine secretions Enlarged third and lateral ventricles

Independent:

- Give positive feedback for the


and interferes with the therapeutic relationship. • The client’s ability to

perceive and respond to complex stimuli is impaired.

• To clarify

discrepancies between verbal and nonverbal cues.

• Positive feedback for


Collaborative: - Engage client in reality-based activities • To achieved such as card playing, maximal gains in occupational therapy, function and or listening to music. psychosocial wellbeing

Reference: (1) Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 264 & 292

Recommendation: Continue the Plan

Discharge Outcome: Outcome Partially Achieved; Upon discharge, the client was able to demonstrate congruent verbal and nonverbal communication. He established partially method of communication




Upon discharge, the client will be ↓ able to Abnormalities of neuro- transmitters demonstrate and neuro-endocrine congruent verbal and nonverbal systems. communication ↓ and 2. Establish • Flight of ideas method of • Difficulty in communication in forming words. which needs can • Vague, diffuse, be expressed. unfocused sequences of concepts • Switch of subjects that are difficult to follow the train of thought




Collaborative: - Engage client in reality-based activities • To achieved such as card playing, maximal gains in occupational therapy, function and or listening to music. psychosocial wellbeing

Reference: (1) Psychiatric-Mental Health Nursing 5th Edition by Sheila L. Videbeck page 264 & 292


NCP psych

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