NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 Attempt to understand  Important clues to

the significance of underlying fears and
Objective cues: Disturbed thought process Within my 3 weeks of nursing these beliefs to the issues can be found in After my 3 weeks of nursing
related to panic level of care patient will be able to client at the time of the client’s seemingly care plan patient was able to
 Thiniking not based in their presentation. illogical fantasies.
anxiety Patient will demonstrate demonstrate effective coping
reality effective coping skills that  Recognizes the client’s  Recognizing the client’s skills that minimize delusional
 Imapired judgement delusions as the client’s perception can help you
minimize delusional thoughts.
 Disorientation thoughts. perception of the understand the feelings
 Delusions environment. he or she is
 Identify feelings related experiencing.
to delusions. For  When people believe
example: If client that they are
believes someone is understood, anxiety
going to harm him/her, might lessen.
client is experiencing  When the client has full
fear. If client believes knowledge of
someone or something procedures, he or she is
is controlling his/her less likely to feel tricked
thoughts, client is by the staff.
experiencing  Arguing will only
helplessness. increase client’s
 Explain the procedures defensive position,
and try to be sure the thereby reinforcing
client understand the false beliefs. This will
procedures before result in the client
carrying them out. feeling even more
 Initially do not argue isolated and
with the client’s beliefs misunderstood,
or try to convince the  The client’s delusion
client that the delusions can be distressing.
are false and unreal. Empathy conveys your
caring, interest and
 Show empathy acceptance of the
regarding the client’s client.
 When client is ready,
 feelings; reassure the teach strategies client
client of your presence can do alone.
and acceptance.  During acute phase,
client’s delusional
 Teach client coping thinking might dictate
skills that minimize to them that they might
“worrying” thoughts. have to hurt others or
Coping skills include: self in order to be safe.
 Going to a gym. External controls might
 Phoning a helpline. be needed.
 Singing or Listening to a
song.
 Talking to a trusted
friend.
 Thought-stopping
techniques.
 Utilize safety measures
to protect clients or
others, if the client
believe they need to
protect themselves
against a specific
person. Precautions are
needed.