Assessment Nursing Diagnosis Outcome Criteria Nursing Intervention Rationale Evaluation Discharge Planning

Subjective Data:

“Tam-an gid ka suya si tiyo ko sa akon,” as verbalized by the patient

Objective Data:

Diagnosed with Paranoid Schizophrenia

With persecutory delusion towards his uncle and the people around him.

Disordered thought sequencing or Flight of ideas

Loose association Impaired ability to

problem solve

Disturbed thought process related to presence of psychological conflicts (delusion of persecutory) as evidenced by impaired ability to problem solve, loose association and disordered thought sequencing.

Short Term Goal:After 3 weeks of nursing intervention, the patient will be able to:1. Verbalize a decrease in the presence of persecutory delusions.

Long Term Goal:After 3-4 months of nursing intervention, the patient will be able to:1. Demonstrate the ability to function without responding to persistent delusional thoughts.

Independent:

- Be consistent in setting expectation, enforcing rules, and so forth

- Do not make promises that you cannot keep.

- Recognize the client’s delusions as the client’s perception of the environment

- 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

-Directly interject doubt regarding delusions as soon as the client seems ready to accept this. Do not argue but present a factual account of the situation as you see it.

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

Independent:

Clear, consistent limits provide a secure structure for the client

Broken promises reinforce the client’s mistrust of other

Recognizing the client’s perception can help you understand the feelings he is experiencing

Interacting with reality is healthy for the client

Indicating belief in delusions reinforces the delusion (and the client’s illness)

As the client begins to trust you, he may become willing to doubt the delusion if you express your doubt.

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

Short Term:(MET)After 3 weeks of nursing intervention, the patient was able to:1. Verbalize a decrease in the presence of persecutory delusions.

Long Term Goal:(UNMET)After 3-4 months of nursing intervention, the patient was not able to:1. Demonstrate the ability to function without responding to persistent delusional thoughts

M – Advise patient and folks to adhere strictly with the medication course.

E – Provide a calm and non-stimulating environment.

T – Take anti-psychotic drugs as indicated by the physician.

H – Educate the client regarding the side effects of anti-psychotic drugs such as dry mouth, weight gain, lethargy and sexual dysfunction.

O – Instruct the patient to have follow-up check up as prescribed by the physician.

D – Tell the client to avoid stimulating beverages such as coffee, tea and energy drinks.

S – Encourage the family members to support the patient emotionally and spiritually.