XII.

NURSING CARE PLAN

1) ACTUAL PROBLEM

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATI
ON

RATIONALE

EVALUATION

Subjective:
Paminsan-minsan
may naririnig akong
power of love sa
kaliwang utak ko at
parang power of
GOD sa kanan

Objective:
Delusion of
persecution
Thought
insertion
Demonstrates
a disturbance
in sleep
pattern
Presence of
auditory
hallucinations

Disturbed
thought
process
related to
disintegration
thinking

(Rationale)
It is the
disruption in
cognitive
operations and
activities.
Cognitive
processes
include those
mental
processes by
which
knowledge is
acquired. These
mental
processes
include reality
orientation,
comprehension,
awareness, and
judgment. A
disruption in

At the end of 4
weeks of nursing
care, the patient
will be able to:

* Be sincere and
honest when
communicating
with the client.

* Maintain
reality
orientation;
* Demonstrate
reality based
thinking in
verbal and
nonverbal
behavior; and
* Demonstrate
the ability to
abstract,
conceptualize
and reason

* Assess clients
nonverbal
behavior, such as
gestures, facial
expression and
posture.

* Encourage the
client to express
feelings and do
not pry cross
examine for
information
* Show empathy
to the clients
feelings,
reassure the
client of your
presence and
acceptance

* Clients are
extremely
sensitive about
others and can
recognize
insincerity.
Evasive remarks
reinforce
mistrust.
* This
assessment may
help to meet the
clients needs
that cannot be
conveyed
through speech.
* Probing
increases
clients
suspicion and
interferes with
the therapeutic
relationship
* The clients
experiences can
be distressing.
Empathy

GOAL PARTIALLY
MET
* The client was
able to maintain
reality
orientation. He is
oriented to time
when asked
what day it is.
But he is still
preoccupied with
his delusions
about something
controlling him
The client was
not able to
demonstrate
reality-based
thinking in
verbal and
nonverbal
responses.
However, he
was able to
exhibit a positive
reason,
judgment and

these mental
processes may
lead to
inaccurate
interpretations
of the
environment
and may result
in an inability to
evaluate reality
accurately.
Alterations in
thought
processes are
not limited to
any one age
group, gender,
or clinical
problem

* Avoid laughing,
whispering, or
talking quietly
where client can
see but not hear
what is being
said.

* Give simple
directions using
short words and
simple
sentences.
* Never convey
to the client that
his delusions and
hallucinations
are real
* Maintain reality
oriented
relationship and
environment

conveys
acceptance of
the client your
caring and
interest.
* Suspicious
clients often
believe others
are discussing
them, and
secretive
behaviors
reinforce the
paranoid
feelings.
* Giving simple
directions lessen
or prevent
confusion of the
patient
* The delusion or
hallucination
would be
reinforce if its
accepted.

* Maintaining

calculation
abilities

* Give positive
feedbacks and
acknowledge the
client

reality based
relationship and
environment lets
the patient know
that the
relationship is
temporary and
prevents
separation
anxiety
* Positive
feedback
enhances sense
of well-being
and makes a
more positive
situation for the
client.