CHAPTER IX

Nursing Care Plan

Modificati
GOAL &
NURSING on Rationale
NURSING DIAGNOSIS NEED OUTCOME RATIONALE EVALUATION
INTERVENTION Interventi
CRITERIA
on
Altered thought processes S Within 2 weeks of Independent:
(hallucinations) related to A nurse patient 1. Thoroughl -to evaluate Goal met. Continue Continuation
traumatic emotional event F interaction, the y explore role of Patient is nursing of nursing
E patient should be evolution hallucinations oriented to interventio intervention
Subjective cues: T able to: and in the reality. ns in order s will be
 “Ilusyonada baya ko. Y experienc patient’s to achieve able to
Feelingon man ko kay 1. Feel e of individual optimum make sure
magpakasal na mi ni & protected hallucinati dynamics and wellness. that these
Luigi.” and safe ons for to identify are met in
 “Madunggan nako si S 2. Redirect the patient areas of based on
Ramil (laughs)” E attention conflict and the absence
 “Madunggan nako siya, C and involve concern of the
sige U the patient manifestatio
R in 2. Ask for -evaluate the ns.
I interesting the extent degree of
T and of the impact of
Y meaningful experienci hallucinations

143
 activities, ng the on role
especially hallucinati performance
those ons as and activities
involving a real; and of daily living.
verbal to what
response or extent can
she
differentiat
e
experienc
e from
reality
 balik balik.” 3. those 3. Assess -to identify if
 “Bugo man ko.” involving side signs and
information effects of symptoms

Objective cues: processing medicatio are brought

 Inability to attend to self activities ns about by

care needs 4. Identify 4. Help the medications

stares at walls underlying patient to or not

 Forgets some of the feelings and develop self- -teaching the

important events in life dynamics of monitoring patient with

(father of her daughter, hallucinatio and self- hallucination

ns regulatory control

144
 financial source) strategies to strategies
 Poor posture deal with the helps the
 Low self-esteem hallucination patient limit

 Experienced s such as hallucinatory

hallucinations since the self- experiences

recurrent onset of instruction,

psychotic disorder on increased

March 10, 2011 involvement

in

Background meaningful

Knowledge: activities,

Altered thought processes decreased

(hallucinations) are false involvement

sensory experiences not in stressful

based on reality that may be activities,

triggered by external or strategies to

internal stimuli. deal with

emotion and

Reference: stress
McFarland, Gertrude K. 1992.
Nursing Diagnoses and Process Dependent -to treat
in Psychiatric Mental Health 1. Administer psychotic
nd
Nursing, 2 ed., J. B. Lippincott

145
Company, Philadelphia neurolepti disorder
cs as
prescribed

This drug is
used to treat
broad
spectrum of
psychotic
disorders.

146
 Modificati
GOAL &
NURSING on Rationale
NURSING DIAGNOSIS NEED OUTCOME RATIONALE EVALUATION
INTERVENTION Interventi
CRITERIA
ons
Depression related to S Within 2 weeks of Independent:
frustration over loss of A nurse patient 1. Establish -to increase Goal met. Continue Continuatio
partner F interaction, the therapeuti patient’s Patient now nursing n of nursing
E patient should be c participation with increased interventio intervention
Subjective cues: T able to: relationshi for self esteem ns in order s will be
 magpakasal na mi ni Y p intervention and able to do to achieve able to
Luigi.” 1. Make -to divert activities of optimum make sure
Objective Cues: & positive 2. Encourag attention from daily living wellness. that these
 Sleeplessness statements e physical stressor that are met in

 Poor personal S about self activity feeds up the based on

hygiene E 2. Performs patient’s mind the absence

 Forgetfulness C activities of of the

U daily living -to decrease manifestatio
 Limited interaction
R risk for ns
3. Prevent
I depressive
isolation
T state to recur
from
Y
others
-Activities are
needed to
divert
4. Teach
attention from
patient to
stressors that
identify
feeds up the
behaviors 147
mind
that will
help
Nursing Diagnosis Need GOAL & Intervention Rationale Evaluation Modificati Rationale
OUTCOME on
CRITERIA interventi
on
Extreme Aggression related Safety Within 2 weeks of Independent: Goal met. Continue Continuation
to interpersonal conflicts and nurse patient 1. Have -to analyze Patient is nursing of nursing
Securi interaction, the patient perceptions relaxed and interventio intervention
Subjective cues: ty patient should be practice of client and she identified ns in will ensure
 “Hawa diri! (referring able to: verbalizing how she behaviors on order to the optimum
to room mate), angry or sees the how to control attain wellness has
patient verbalized” 1. Assist hostile situation aggression. optimum bee
Mother verbalized, “Gisipa patient in feelings in well achieved
niya tong Ka-ingod namo reducing a minimally being. based on the
nga pasyente kay nasuko aggression threatening response of
siya. Gi-away man gud Mutually situation the client.
atong isa ka pasyente iyang develop 2. Assist -allow
manghod. goals with patient to patient
Objective Cues: patient or identify maximum
 Kicked patient’s more activity autonomy
roommate appropriate groups, and control

 Clenched fist expression punching over own

 Agitation of anger. bags, clay, situation

sports, Energy and
 Negativism
arts, to divert
 Irritability
music) attention into
something
Background Knowledge:
enjoyable
Aggression is a forceful,
and fun 148
generally inappropriate and
3. Prov -serve as
nonadaptive verbal or
ide peer reference
149