Nursing Care Plan

Cues Nursing
diagnosis
Rationale Goal and
Objectives
Nursing
Interventions
Rationale Evaluation
Altered
thought
processes
related to
disruption
in cognitive
operations
and
activities
secondary
to
Schizophre
nia .
Schizophrenia
often is
referred to as
thought
disorder
because that
is the primary
feature of the
disease;
thought
processes
become
disordered,
and the
continuity of
thoughts and
information
processing is
disrupted.
(Psychiatric
mental health
nursing by
Sheila L.
Videbeck,
th

edition, page
!"#$
Goal:
After all the
nursing
interventions,
the patient
will have an
enhanced
pschological
stabilit!
Objectives:
"! #he nurse
will be
able to
deter$ine
whether or
not the
patient
can
engage in
a
relationshi
p!
Initiate a
nurse%patient
relationship
with the
patient!
Establish a
ti$e each da
to $eet with
her to support
her as she
learns to cope
with her
disorder!
&e sincere
and honest
when
co$$unicatin
g with the
#hrough a
nurse%patient
relationship,
the patient can
learn about his
strengths and
li$itations!
Clients are
e'tre$el
sensitive about
others and can
recogni(e
insincerit!
After all the
nursing
interventions,
the patient had
an enhanced
pschological
stabilit as
evidenced b
the following:
#he patient
was able to
engage in a
relationship!
)! #he nurse
will be
able to
assess
whether or
not the
patient
can
process
infor$atio
n!
client! Avoid
vague or
evasive
re$ar*s!
&e consistent
in setting
e'pectations,
enforcing
rules and so
forth!
+o not $a*e
pro$ises ou
cannot *eep!
#each the
patient about
her disorder!
Assure hi$
that the
s$pto$s
can be
i$proved and
that he can
$anage the
disorder!
Encourage
the patient to
tal* to ou,
but do not pr
for
Evasive
co$$ents or
hesitations
reinforce
$istrust!
Clear,
consistent
li$its provide a
secure
structure for
client!
&ro*en
pro$ises
reinforce the
client,s $istrust
of others!
-elping the
patient
understand her
disorder will
give her a
sense of control
over her
disorder and
give her the
infor$ation she
needs to
$anage the
s$pto$s!
.robing
increases the
#he patient
showed that
he can
process
infor$ation!
/! #he nurse
will be
able to
deter$ine
situations
that cause
the patient
the $ost
proble$ in
co$$unic
ating!
0! #he
patient will
be able to
infor$ation!
E'plain
procedures,
and tr to be
sure the client
understands
the
procedures
before
carring the$
out!
Assist patient
in
co$$unicatin
g e1ectivel!
Encourage
patient to
attend
co$$unicatio
n groups!
Engage the
client in one%
to%one
activities at
2rst, then
activities in
s$all groups,
and graduall
in larger
client,s
suspicion and
interferes with
the therapeutic
relationship!
3hen the client
has full
*nowledge of
procedures, he
or she is less
li*el to feel
tric*ed b the
sta1!
.atients with
schi(ophrenia
tpicall have
proble$s
because of the
disordered
thought
process!
I$proving
co$$unication
s*ills will help
the patient
cope with the
disorder!
A distrustful
client ca best
deal with one
person initiall!
Gradual
#he patient
was able to
co$$unicat
e e1ectivel!
#he patient
was able to
engage in
social
interactions
during group
activities!
engage in
social
interaction
s!
4! #he
patient will
be able to
co$plete
self%care
activities!
groups!
Role%pla
aspects of
social
interactions
such as
initiating5ter$
inating a
conversation,
refusing a
re6uest,
as*ing for
so$ething,
interviewing
for a job,
as*ing
so$eone to
participate in
an activit
7going to a
$ovie8!
Give positive
feedbac* for
the client,s
successes!
Assess abilit
for self%care
introduction of
others as the
client tolerates
is less
threatening!
& practicing
speci2c s*ills,
patients will be
able to use
the$ in speci2c
situations! It is
then possible to
assign a patient
to practice a
speci2c social
s*ill!
.ositive
feedbac* for
genuine
success
enhances the
client,s sense
of well%being
and helps to
$a*e a $ore
positive
situation for the
#he patient
was able to
perfor$ self%
care
activities!
#he patient
willingl
9! #he
patient will
be able to
willingl
ta*e her
$edicatio
ns!
activities!
Identif areas
of phsical
care for which
the patient
needs
assistance!
Note level of
$otivation
and interest
in
appearance!
Ad$inister
$edication as
prescribed!
#each about
the action,
side e1ects,
and dosage of
$edication!
E$phasi(e
the
i$portance of
ta*ing
$edication,
even if
s$pto$s go
awa
co$pletel!
As* patient
for a
co$$it$ent
to ta*e the
$edication!
client!
#he negative
s$pto$s of
schi(ophrenia
can interfere
with the
patient,s abilit
to co$plete
dail living
activities!
Antipschotic
$edications are
indicated for
the
$anage$ent of
the
$anifestations
of pschotic
disorders!
too* her
$edications!