crisis intervention: psychiatric nursing nursing care plan
TRANSCRIPT
B. Nursing Care Plan
DIAGNOSIS NEEDDESIRED
OUTCOMEINTERVENTIONS RATIONALE
EVALUATION STATEMENT
INTERVENTIONS RATIONALE
Disturbed Thought Process related to disintegration on thinking as manifested by disorientation with date and place and impaired judgment
Cues:
Subjective:
>Keeps on verbalizing when asked of date, ”Lunes Mayo 25, 1952”
>says ”Orange Juice” instead of carrot
Objective:
> Non–reality-based thinking
>With delusion of grandeur
COGNITIVE
NEED
Within 2 hours of Nursing Interventions, the patient will be able to:
General:
> Respond to reality-based interactionsinitiated by others
Specifically,
> Interact on reality-based topics >Sustain attention and concentrationto complete tasks or activities
INDEPENDENT
Establish rapport to the patient
Be sincere and honest when communicating with the client. Avoid vague or evasive remarks
Monitor vital signs frequently especially blood pressure and
To gain client’s trust and cooperation
Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions
Assess condition of the patient before giving medications
Goal is partially met.
Ms. MB was able to respond in a reality-based interaction still with the aid of the student nurse. However, there are times that she could not be able to answer directly and properly to the simple questions the student nurse is asking. She sustained her attention was
Continue Nursing Interventions especially bringing back the patient to reality
Continue to encourage patient comply all medications prescribed to her
It is healthy for her and may lead her to be more productive and more functioning self
For faster recovery from the mental illness
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>Disorientation
>Blunted affect
>Short attention span
>Impaired judgment
Background Knowledge:
Identifying and managing one’s own health needsare primary concerns for everyone, but this is a particularchallenge for clients with schizophrenia becausetheir health needs can be complex and their ability tomanage them may be impaired. The nurse helps theclient to manage his or her illness and health needs asindependently as
interpret it accurately
Be consistent in setting expectations, enforcing rules, and so forth
Do not make promises that you cannot keep
Encourage the client to talk but do not pry or cross-examine for information
Explain procedures, and try to be sure the client understands the procedures before
Clear, consistent limits provide a secure structure for the client
Broken promises reinforce the client’s mistrust of others
Probing increases the client’s suspicion and interferes with the therapeutic relationship
When the client has full knowledge of procedures, she is less likely to feel tricked
fortunately, she was able to complete her task.
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possible. This can be accomplishedonly through education and ongoing support.Teaching the client and family members to preventor manage relapse is an essential part of a comprehensiveplan of care. This includes providing factsabout schizophrenia, identifying the early signs of relapse,and teaching health practices to promote physicaland psychological well-being. Murphy and Moller(1993) have identified symptom triggers, or factorsthat increase the risk for relapse, in the areas of theclient’s health, the environment, and the client’s attitudesor behaviors (Box 14-4). Early identification
carrying them out
Give positive feedback for the client’s successes
Recognize the client’s delusions as the client’s perception of the environment
Initially, do not argue with the client or try to
Positive feedback for genuine success enhances the client’s sense of well-being and helps to make non-delusional reality a more positive situation for the client
It is important to recognize the client’s environmental perceptions to understand the feelings she is experiencing
Logical argument does not dispel
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of these risk factors has been found to reduce the frequencyof relapse; when relapse cannot be prevented,early identification provides the foundation for interventionsto manage the relapse. For example, if thenurse finds that the client is fatigued or lacks adequatesleep or proper nutrition, interventions to promoterest and nutrition may prevent a relapse orminimize its intensity and duration.
Reference:
Videbeck, Sheila. Psychiatric Mental Health Nursing.5th Ed. Lippincott Williams & Wilkins. Philadelphia. 2004
convince the client that the delusions are false or unreal
Interact with the client on the basis of real things; do not dwell on the delusional material
Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups
Recognize and support the client’s
delusional ideasand can interfere with the development of trust
Interacting about reality is healthy for the client
The client who is distrustful can best deal with one person initially. Gradual introduction of others when the client can tolerate it is less threatening
Recognition of accomplishments can
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accomplishments (activities or projects completed, responsibilities fulfilled, interactions initiated)
Show empathy regarding the client’s feelings; reassure the client of your presence and acceptance
Do not be judgmental or belittle or joke about the client’s beliefs
lessen the client’s anxiety and the need for delusions as a source of self-esteem
The client’s delusions can be distressing. Empathy conveys your acceptance of the client and your caring and interest
The client’s delusions and feelings are not funny to him or her. The client may feel rejected by you or feel unimportant if approached by attempts at humor
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Never convey to the client that you accept thedelusions as reality
DEPENDENT
Administer Chlorpromazine as prescribed
It would reinforce the delusion (thus, the client’s illness) if you indicated belief in the delusion
An Antipsychotic that could treat psychiatric illness such as this schizo-phrenia
DIAGNOSIS NEEDDESIRED
OUTCOMEINTERVENTIONS RATIONALE
EVALUATION STATEMENT
INTERVENTIONS RATIONALE
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Disturbed Sensory Perception: Auditory/Visual Hallucinations related to alteration in the function of brain as manifested by inappropriate response and disorientation
Cues:
Subjective:
>”Cheche manghud ko”
>”Piyesta sa Pavillion”
Objective:
>inappropriate response
>disoriented with date and place
>claims she owns a garden inside the cell
Background Knowledge:
COGNITIVE
NEED
Within 2 hours of Nursing Interventions, the patient will be able to:
General:
>test reality,eliminating the occurrence of hallucinations.
Specifically,
>recognize present reality via activities prepared by the student nurse
INDEPENDENT
Establish rapport to the patient
Monitor vital signs frequently and interpret it accurately
Observe client for signs of hallucinations (listening pose, laughing or talking to self, stopping in midsentence)
Avoid touching the client without warning
To gain client’s trust and cooperation as well as have a quality assessment
To assess whether medications could be given or contraindicated
Early intervention may prevent aggressive response to command hallucination
Client may perceive touch as threatening and may respond in an
Goal is partially met.
Ms. MB was oriented by the student nurse with the date and time. However, if being asked again, she will still answer incorrectly. She still claims that she there is a fiesta going on and she needs to go there. Fortunately, she was able to recognize reality because of diverting her attention to the activity.
Continue Nursing Interventions especially in bringing her back to reality and let her focus on her present activity
Administer physician’s prescribed medicine
To improve her perception and make it into reality and not fantasy
For faster treatment that will lead to recovery
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Cognitive impairment associated with schizophrenia isnow viewed as a potential psychopharmacological targetfor treatment (Hyman and Fenton 2003). Although cognitionis not a formal part of the current diagnostic criteriafor schizophrenia, DSM-IV-TR (American PsychiatricAssociation 2000) includes seven references to cognitivedysfunction in the description of the disorder. Diagnosticand scientific experts increasingly have expressed the ideathat neurocognitive impairment is a core feature of the illnessand not simply the result of the symptoms or the current
An attitude of acceptance will encourage the client to share the content of the hallucination with you
Do not reinforce the hallucination. Use “the voices” instead of words like “they” that imply validation. Let the client know that you do not share the perception. Say, “Even though I realize the voices are real to you, I do not hear any voices”
aggressive manner
This is important to prevent possible injury to the client or others from command hallucination
Client must accept the perception as unreal before hallucinations can be eliminated
If client can
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treatments of schizophrenia.There is some evidence that neurocognitive impairmentin patients with schizophrenia may worsen over time in atleast a subgroup of elderly patients with schizophrenia.Prominent cognitive impairments resembling dementiahave been reported in older schizophrenic patients with alifetime of poor functional outcome (Arnold et al. 1995;Davidson et al. 1995; Harvey et al. 1996).On the basis of cross-sectional studies, elderly patientswith schizophrenia appear to show some decline in cognitivefunction toward the end of life. However, this
Help the client understand the connection between anxiety and hallucinations.
Try to distract the client from the hallucination.
DEPENDENT
Administer Chlorpromazine as prescribed by the physician
learn to interrupt escalating anxiety, hallucinations may be prevented
Involvement in interpersonal activities and explanation of the actual situation will help bring the client back to reality
To treat the psychiatric illness which is Schizo-phrenia
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declinemay be restricted to those patients who had an early onsetof illness followed by a lifetime of poor functioning(Heaton et al. 1994; Hyde et al. 1994; Jeste et al. 1995;Zorrilla et al. 2000). Some of the inconsistency of theseresults may derive from the subject selection processes inthese studies.
Reference:
Lewis, et al. Textbook Schizophrenia.2003
DIAGNOSIS NEEDDESIRED
OUTCOMEINTERVENTIONS RATIONALE
EVALUATION STATEMENT
INTERVENTIONS RATIONALE
Impaired Verbal Communication S Within 2 hours
of Nursing INDEPENDENT
Goal is partially Continue
Nursing It is healthy
for her and
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related to regression as manifested by associative looseness, echolalia, and neologism
Cues:
Objective:
>Repeats words and phrases uttered by the student nurse, thus, echolalic
>Ideas are sometimes not organized
>Associative Looseness observed
>neologism observed >Mumbles when speaking; words are not clearly stated
Background Knowledge:
Most cognitive
ELF-ESTEEM
NEED
Interventions, the patient will be able to:
General:
>communicateappropriatelyand comprehensivelywith others
Specifically,
>talk not only with her student nurse but also other to other people present in the activity area including other student nurses, instructors, and fellow patients
Establish rapport to the patient
Monitor vital signs frequently especially respiration and interpret it accurately
Attempt to
decode incomprehensible communication patterns. Seek validation and clarification by stating, “Is it that you mean…?” or “I don’t understand what you mean by that. Would you please clarify it for me?”
To gain client’s trust and cooperation as well as have a quality assessment
To assess whether or not to give medications prescribed
These techniques reveal how the client is being perceived by others, while the responsibility for not understanding is accepted by the nurse
met.
Ms. MB was able to communicate to others not just to her student nurse. However, the fluency of her words is sometimes not clear making it hard for others to understand what is she saying.
Interventions especially bringing back the patient to reality
Continue to encourage patient comply all medications prescribed to her
may lead her to be more productive and more functioning self
For faster recovery from the mental illness
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assessments in treatment studies of schizophreniahave included measures of verbal fluency as a separatedomain of functioning (Harvey and Keefe 2001;Keefe et al. 1999; Meltzer and McGurk 1999). Most ofthese tests measure either phonological fluency (alsoreferred to as letter fluency) or semantic fluency. Phonologicalfluency refers to a patient’s ability to produce asmany words as possible beginning with a particular letterwithin, for instance, 60 seconds. Semantic fluency refersto the ability to produce words within a particular meaning
Facilitate trust and understanding by maintaining assignments as consistently as possible. The technique of verbalizing the implied is used with the client who is mute (unable or unwilling to speak). Example: “That must have been a very difficult time for you when your mother left. You must have felt very alone”
Anticipate and fulfill client’s needs until functional communication pattern returns
Orient client to reality as required. Call
This approach conveys empathy and may encourage the client to disclose painful issues
Client’s safety and comfort are nursing priorities
These techniques may facilitate
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Reference:
Lewis, et al. Textbook Schizophrenia.2003
the client by name. Validate those aspects of communication that help differentiate between what is real and not real
DEPENDENT
Administer Chlorpromazine as indicated
restoration of functional communication patterns in the client
To treat the psychiatric illness which is schizo-phrenia
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