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care plan for client with schizophrenia

nursing diagnosis! outcomes! Interventions!

Shahd Alqahtani

on 8 March 2013

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Transcript of care plan for client with schizophrenia

Nursing Care plan for Schizophrenia Nursing Interventions Nursing Diagnosis RATIONALE Disturbed sensory perception:
auditory/visual Related to panic anxiety extreme loneliness and withdrawal into the self as manifested by Inappropriate responses, disordered thought sequencing,
rapid mood swings, poor concentration,
disorientation. Disturbed thought processes Related to Inability to trust, panic anxiety, possible hereditary or biochemical factors as Manifested by inability to concentrate; impaired volition; inability to problem solve, abstract or conceptualize; extreme suspiciousness of
others. delusional thinking; Social isolation Related to trust, panic anxiety, weak ego
development, delusional thinking, regression inability to as manifested by dull affect, need-fear dilemma,
preoccupation with own thoughts,
expression of feelings of rejection or of
aloneness imposed by others. withdrawal, sad, Risk for violence:[self-directed or other-directed] Related to suspiciousness, panic anxiety, catatonic excitement, rage reactions, command hallucinations. extreme as Manifested by and aggressive acts, goal-directed
destruction of objects in the environment,
self-destructive behavior or active
aggressive suicidal acts. overt Impaired verbal communication Related to panic anxiety, regression, withdrawal, disordered, unrealistic thinking as Manifested by association of ideas, neologisms, word salad, clang association, echolalia, verbalizations that reflect concrete
thinking, poor eye contact. loose Self care deficit Related to withdrawal, regression, panic anxiety, perceptual or cognitive impairment, inability to trust as Manifested by difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, toileting. Disable family coping Related to difficulty coping with client illness as Manifested by the client in regard to basic human needs or illness treatment, extreme denial or prolonged overconcern regarding client's illness. neglectful care of Out Come Criteria TREA Individual psychotherapy Group Therapy Behavioral Therapy Social Skill Training "done By Shahd & Tahani" Psychological Treatments MENTS short term goal client will discuss content of hallucinations with nurse or the therapist within 1 week. long term goal client will be able to define and test reality, reducing or eliminating the occurrence of hallucinations.
client will be able to verbalize under standing that the voices are a result of his or her illness and demonstrate ways to interrupt the hallucination. short term goal client will be able to recognize and verbalize that false ideas occur at times of increased anxiety.
long term goal client will experience (verbalize evidence of) no delusional thoughts.
client will be able to differentiate between delusional thinking and reality. short term goal client will willingly attend therapy activities accompanied by trusted staff member within 1 week. long term goal client will voluntarily spend time with other clients and staff members in group therapeutic activities. short term goal client will be able to recognize signs of increasing anxiety and agitation and report to staff for assistance with intervention. long term goal client will not harm self or others. short term goal client will be able to demonstrate the ability to remain on one topic, using appropriate, intermittent eye contact. long term goal client will be able to demonstrate ability to carry on a verbal communication in a socially acceptable manner with helath care provider and peers. short term goal client will be able to verbalize a desire to perform ADLs by end of 1 week. long term goal client will be able to perform ADLs in an independent manner and demonstrate a willingness to do so by time of discharge from treatment. short term goal family will identify more adaptive coping strategies for dealing with client's illness and treatment regimen. long term goal family members will be able to take action to alter behaviors that contribute to dysfunctional coping. observe client for signs
of hallucinations(listening pose,
laughing or talking to self,
stopping in midsentence) avoid touching without warning the
client that you are about to do so.
an attitude of acceptance will encourage
the client to share content of hallucination
with you.
don't reinforce the hallucination use
"the voice" instead of words like "they",
let client know that you don't share
the perception.
help the client understand the
connection between increase
anxiety and the presence of
try to distract the client from the hallucination.
listening to the radio or watching the tv helps distract some clients from attention to the voice convey acceptance of client's need for the false belief, but indicate that you don't share the belief.
don't argue or deny the belief use reasonable doubt as a therapeutic technique"i understand that you believe this is true, but i personally find it hard to accept"
reinforce and focus on reality. discourage long ruminations about the irrational thinking. if client is highly suspicious use same staff as much as possible be honest and keep all promises.
avoid physical contact warn client before touching to perform a procedure.
avoid laughing, whispering or talking quietly where client can see but can't hear.
provide canned food or serve food family style.
provide activities that encourage a one to one relationship with the nurse
convey an accepting attitude by making brief, frequent contacts.
show unconditional positive regard.
offer to be with client during group activities that client find frightening or difficult.
give recognition and positive reinforcement for client's voluntary interactions with others. maintain low level of stimuli in client's environment(low lighting, few people, simple decor, low noise level).
observe client's behavior frequently.
remove all dangerous objects from client's environments.
maintain calm attitude toward the client, talking about the situation, taking anxiety medications attempt to decode incomprehensible
communication patterns, seek validation
and clarification by stating"is it that what
you mean?" "i don't understand what you
mean by that explain it to me "
maintain staff assignments as consistently as possible.

orient client to reality as required
call the client by name, validate those
aspects of communication that help differentiate between what is real and not.
explanation must be provided at the client's level Example"pick up the spoon, scoop some mashed potatoes
into it and put it in your mouth". provide assistance with self care
needs as required.
encourage client to perform
independently as many activities as
possible, provide positive reinforcement for
independent accomplishments.
creative approaches may need to be taken
with client who is not eating,"allowing
client to open own canned or packaged foods.
if toileting needs are not being met,
establish a structured schedule. provide information for the family about the client's illness, what will be required in the treatment regimen, and long term prognosis.
practice how to respond to bizarre behavior and communication patterns. early intervention may prevent aggressive response.
client may perceive touch as threatening and may respond in an aggressive manner.
this is important to prevent possible injury to the client or others.
explanation of the situation helps the client back to reality.
activities assist the client to exert some conscious control over the hallucination. client must understand that you don't view the idea as real.
arguing with the client or denying the belief are no useful because delusional idea are not eliminated.
discussion that focus on the false idea are purposeless.
familiar staff and honesty promotes trust.
suspicious clients often perceive touch as threatening and may respond in an aggressive.
client may have ideas and believe they being talked about.
suspicious clients may believe they are being poisoned and refuse to eat.
competitive activities are very threatening. an accepting attitude increases feelings of self worth and facilitates trust.
this conveys a belief in the client as a worthwhile human being.
the presence of a trusted individual provides emotional security for the client
positive reinforcement enhances self esteem. knowledge and understanding about what to expect may facilitate the family's ability to successfully integrate the client into the system.
a plan of action will assist the family to respond adaptively in the face of what they may consider to be a crisis. client safety and comfort are a nursing priorities.
independent accomplishment and positive reinforcement promote repetition of desirable behaviors.
techniques may be helpful with paranoid clients or suspicious.
a structured schedule will help client to develop a habit of toileting independently. these techniques reveal how the client is being perceived by others.
(maintain staff assignments) facilitates trust and understanding between client and nurse.
(orient client to reality) facilitate restoration of functional communication patterns in the client.
the form of individual psychotherapy include problem solving, reality testing, psycheducation and supportive and cognitive behavioral techniques. the goal of individual psychotherapy are to improve medication compliance, enhance social and occupational functioning and prevent relapse. generally focuses on real life plans, problems and relationships. group therapy is effective in social isolation, increasing the sense of cohesiveness and improving reality testing for patients with schizophrenia. reducing most useful over long term course. has a story of qualified success in reducing the frequency of bizarre, disturbing and deviant behaviors and increasing appropriate behaviors behavioral therapy can be undesirable behaviors. a powerful treatment tool for helping clients change social skill training include combination of simpler behaviors #nonverbal behaviors.
#paralinguistic features.
#verbal content.
#interactive balance. restraints may be necessary if client is not calmed by talking down or medication.
observe client in restraints at least every 15 minutes to ensure that circulation to extremities is not compromised.
asses the client's readiness for restraint removal or reduction anxiety level rises in a stimulating environment.
observation during routine activities avoids creating suspiciousness on the part of the client, close observing is necessary.
removal of dangerous objects prevents client in an agitated, confused state from using them
to harm self and others. offering alternatives to the client gives him or her a feeling of some control over the situation.
restraints should be used only as a last resort after all interventions have ben unsuccessful.
assessing the client readiness for removing restraints minimizes the risk of injury to client and staff.
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