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Assessment

Subjective: Nakikita at nakakausap ko yung mga Hapon at Iglesia dito. Minsan kapag alas-tres ng madaling araw nagkakausap kami sa isip lang, as verbalized by the client. Objective: (+) memory deficit/problems (+)distractibility Inappropriate/non reality-based thinking

Nursing Diagnosis
Disturbed thought processes related to disintegration of thinking processes as evidenced by presence of delusional system.

Scientific Rationale
Presence of external stimuli delusion

Planning
After 1-2 weeks of nursing intervention, the client will verbalize recognition of delusional thoughts if they persist.

Intervention
1. Be sincere and honest when communicating with the client. Avoid vague or evasive remarks. 2. Avoid physical contact.

Rationale
Delusional clients are extremely sensitive about others and can recognize insincerity.

Evaluation
After 1-2 weeks of nursing intervention, the goal is partially met. The client verbalizes recognition of delusional thoughts when asked.

Disintegration of thinking processes

Suspicious clients may perceive touch as threatening gesture. Clear, consistent limits provide a secure structure for the client. Broken promises reinforce the clients mistrust of others. Probing increases the clients suspicion and interferes with the therapeutic relationship. When the client has full knowledge of procedures, he is less likely to feel tricked. Positive feedback for genuine success enhances the clients sense of well-being and helps make non-

Disturbed thought processes

3. Be consistent in setting expectations, enforcing rules, and so forth. 4. Do not make promises that you cant keep. 5. Encourage the client to talk with you, but do not pry for information.

6. Explain procedures and try to be sure the client understands the procedures before carrying them out. 7. Give positive feedback for the clients successes.

delusional reality a more positive situation for the client. 8. Recognize the clients delusions as the clients perception of the environment. 9. Initially, do not argue with the client or try to convince the client that the delusions are false or unreal. Recognizing the clients perceptions can help you understand the feelings he is experiencing. Logical argument does not dispel delusional ideas and can interfere with the development of trust.

10. Interact with the client on the basis of real things; do not dwell on delusional matter. 11. Show empathy regarding the clients feelings; reassure the client of your presence and acceptance.

Interacting about reality is healthy for the client. The clients delusions can be distressing. Empathy conveys your caring, interest and acceptance of the client. Discussion of the problems caused by the delusions is a focus on the present and is reality based.

12. Ask the client if he can see that the delusions interfere with or cause problems in his or her life.

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