LAGUARDIA COMMUNITY COLLEGE

CITY UNIVERSITY OF NEW YORK

DEPARTMENT OF NATURAL & APPLIED SCIENCE
PRACTICAL NURSING PROGRAM

DOCUMENTION OF THE NURSING PROCESS

STUDENT NAME: MANOLITO GULLA___________________ DATE: ____1/22/07____________

CLIENTS INTIALS:

MEDICAL DIAGNOSIS: _SCHIZOAFFECTIVE DISORDER (BIPOLAR TYPE)_______________________

INSTRUCTOR

L.M.
ALVIN BRADLEY

CLIENT CARE OBJECTIVE (S):TO RELIEVE CLIENTS SYMPTOMS THROUGH APPROPRIATE ANTIPSYCHOTIC MEDICATIONS AND BEHAVIOUR THERAPY.
_______
_______

ASSESSMENT
(SUBJECTIVE/OBJECTIVE)
Data Collection

Subjective:
It is raining outside. John
Lennons spirit is inside my
body
I was feeling depressed thats
why they put me here
Objective:

CLIENTS PROBLEM
(S)/NEED(S)
(USE NURSING
DIAGNOSIS
STATEMENTS)
Disturbed Thought Processes
related to inability to evaluate
reality as evidenced by flight of
ideas and grandiose delusions.

CLIENT SHORT TERM

GOAL/OUTCOME
(PLANNING)

Have reality-based thinking.

Have a brief reality-based
conversations with staff
Take medications regularly

NURSING
INTERVENTION
(APPROACH)/ (ACTION)

Provide antipsychotic medications as

ordered and monitor effects.

It is the responsibility of nurses to

access the clients response to
medications for the purpose of
evaluating their effectiveness.

Look for the clients strengths and

abilities when providing nursing
care

It is important to look for the

persons strengths and to
acknowledge the normal parts of
the person.

Reinforce reality. Talk about what is

really happening.

Even conversations about the

simple realities of daily life focus
the clients attention away from
disorganized thoughts and into the
here and now.

Do not argue with the client about

delusional thoughts.

Clients do not recognize that they

are delusions, and arguments can
force the client to focus on
defending the false ideas. Change
the subject to reality-based topics.

Disorganized sentences
Flight of ideas
Fast rambling speech
Internally preoccupied,
sometimes singing along the
hallway, other times performing
aerobic exercises

SCIENTIFIC RATIONALE
FOR
NURSING INTERVENTION

LAGUARDIA COMMUNITY COLLEGE

CITY UNIVERSITY OF NEW YORK
DEPARTMENT OF NATURAL & APPLIED SCIENCE
PRACTICAL NURSING PROGRAM
Encourage the client to express
feelings of fear or anxiety.

Expressing feeling to the nurse can

be affirming and helpful to clients.

Establish a trusting relationship in

which the client is safe to express
true feelings.

A non-threatening relationship
provides the opportunity to express
unresolved feelings

Offer medications in a confident

way, expecting the client to take
them.

The nurses confident attitude

promotes clients trust.

Teach clients stress management

techniques such as going to their
rooms and doing relaxation
exercises.

Practicing new coping behavior

teaches adaptive coping skills.

Keep in touch with family and

important friends

Approach client with an accepting

attitude. Be honest and sincere.

Acceptance, honesty, and sincerity

promotes trust.

Maintain healthy social

interactions with family, close
friends and neighbors

Interact with the client individually

and model appropriate social
behavior (body language, topics of
conversation).

Clients often lack social skills and

benefit from role modeling as a
way to learn them.

Give positive reinforcement for

clients voluntary interactions with
others.

Positive reinforcement is an
effective behavioral approach to
behavior change.

Encourage client to attend group

activities in the hospital. Accompany
client at first if necessary.

Client may respond positively to

encouragement from a trusted
nurse.

Grandiose delusions
Unpredictable and impulsive
Poor concentration, distractible

Ineffective Coping related to

internal conflicts as evidenced
by internal preoccupation and
by unpredictable and impulsive
behavior

Impaired Social Interactions

related to impulsivity and
hyperactivity as evidenced by
spontaneous singing and
performing aerobic exercises.

Client will use healthy coping

skills.
Have a routine daily and
weekly schedule
Include enjoyable activities in
schedule
Perform activities of daily
living independently

Reference:
Burke, Karen M., Priscilla LeMone, Elaine Mohn-Brown. Medical-Surgical Nursing Care. Upper Saddle River: Pearson Prentice Hall, 2006.