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Patients name: Clinical Instructor: Date:Age: Sex: Student nurse: Diet:Physician: Clinical area:Medical diagnosis: Room no:

Subjectivecues

Objective cues Nursingdiagnosis

Scientificreference

Goal Intervention Rationale Expectedoutcome

"GanahannakoMugawasdiri, kaymangtapasnako ugtubo saamu" asverbalizedby thepatient

-wearing aninja-likeoutfit

-with thevisualhallucination

-limitedattentionspan

-laughing andtalking to

himselfwithoutapparentreason

Disturbedthoughtprocessesrelated topsychologicaland cognitivedisturbances asmanifested bylimitedattention span,hallucination ,

and laughingand talking tohimself withoutany reason

Definition:disruption incognitiveoperation andactivities

Source:Doenges , M.E.

et a.l.(2008)Nurses PocketGuide,Diagnosis,

One hallmarksymptom ofschizophrenicpsychosis ishallucinations.Hallucinationcan involvethe five sensesand bodilysensation.They can be

threateningandfrightening forthe client ;lessfrequently,client's reporthallucinationsas pleasant.Initially clientperceiveshallucinationsas real, but

later in theillness ,he orshe mayrecognize

That after 3 weeksof Nursing CareManagement,Patient will be ableto:

1. Demonstratebehavior/lifestylechanges to

prevent,minimizechanges inmentation

2. Respond toreality-basedinteractionsinitiated byothers

3. Sustainattention andconcentrationto complete

tasks andactivities4. Verbalize

recognition of

Independent:

1. Interact withthe client onthe basis ofreal things;do not dwellon thehallucinational material.

2. Assessattetntionspan/distractibility andability tomakedecisions/problemsolution

3. Schedulestructuredactivity andrest periods

4. Reduceprovocativestimuli,negative

.-interactingabout reality ishealthy for theclient

-determinesability toparticipate inplanning/executing care

-providesstimulationwhile reducingfatigue

-to avoidtriggering fight/fight responses

Patient wasable torecognize thepresence ofhallucinations,and verbalizedfeelings ofcomfort,wanted to go

home andcontinue hiswork

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Prioritizedinterventionsand Rationales .11th editionDisturbedThoughtProcess pages696-700

them ashallucination.Hallucinations,however, haveno such basisand reality.Source:Videbecks, S.L.(2006).PsychiatricMental HealthNursing #rdEditionSensorium andintellectualpage 288

hallucinationsif they persist

criticism,argumentsandconfrontations

5. Refrain fromforcingactivitiesandcommunication

Dependent:

1. Administerantipsychotic med asprescribed

Collaborative:

1. Assist inidentifyingongoingtreatmentneeds/rehabilitation programfor theindividual

- Clientmay feelthreatened andmaywithdraw/rebel

- to treatpsychological andcognitivedisturbance

- tomaintaingainsandcontinueprogressif able

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