Cues and Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: Impaired verbal At the end of our Evaluate degree/type of communication Degree of impairment of verbal/nonverbal communications will Within our 6 days
communication r/t 6 days of duty, impairment. affect client’s ability to interact with staff and others and to of duty, the coals
Client verbalizes “Wala.. psychological barriers the client will participate in care. were partially met
Wala po” to many questions secondary to substance manifest as evidenced by:
(orientation phase) abuse induced improved verbal Note level of anxiety present; presence of Presence of conflicting emotions may impair need and desire to
schizophrenia communication angry, hostile behavior, frustration talk answers in more
Client gives out confusing as evidenced by: coherent speech
answers in some moments Demonstrate a listening attitude within Enables the nurse to listen carefully, observe the client, and
answers in the nurse-client relationship. anticipate and watch certain patterns of client’s communication that reduced
Client answer words coherent speech may emerge. repetitions
repeatedly, sometimes
inappropriate to question improved Provide a nonthreatening environment Atmosphere in which a person feels free to express self without improved response
asked response time to (assuring client of privacy, fear of criticism helps to meet safety needs, increasing trust and time to questions
questions confidentiality, having therapeutic providing assurance for tolerance and validation of appropriate
Objective: distance, proper positioning and use of negative communications reduced
reduced body language) perseveration
Answers questions slowly perseveration Arguing is nontherapeutic and may cause the client to become
Avoid arguing or agreeing with defensive. Agreeing with the client’s expression of inaccurate reduced slurring
stares blankly for a seconds reduced slurring inaccurate communications; simply offer communication reinforces misinterpretation of reality.
reality view in nonjudgmental style improper affect
Perserveration (“daot” - displays proper Client’s flow of communications (too fast/too slow) may require displayed (blunt or
“daot ba”, “patay na ko” affect Use therapeutic communication skills, regulation. These techniques assist with reality orientation, thereby flat)
“patay”) such as Active Listening, paraphrasing, minimizing misinterpretation and facilitating accurate
reflecting, and restating. communications slurring is still
Alogia (one or two word present
answers) Client has increased sensitivity to nonverbal messages. Honesty
Be open and honest in therapeutic use of increases sense of trust, a loss of which is at the base of the client’s
Speaks in monotone voice verbal and nonverbal communications. problem. Openness and genuineness in expression of feelings
provide a role model for client.
Displays affect ranging from
blunt to flat or inappropriate Use a supportive approach to client by Recognizes that client’s past experiences have created distrust,
communicating desire to understand. which produces attempt to maintain distance by being vague and
neologisms (“bakiki”, “jun unclear in sending messages.
bo”)
Identify the symbolic, primitive nature of Recognition of the symbolism of the client’s primitive speech and
slurring of speech the client’s speech/communications thinking enables the nurse to better understand the client’s feelings.
shows difficulty finding the Without this recognition, the actual communications may be vague
right word to say and disorganized, indicating client’s inability to focus and perceive
clearly.
Dependent:
Administer medications:

Fluphenzaize Decanoate 2.5mg/mL IM Fluphenazine is a short-acting piperazine phenothiazine.

daily Phenothiazines are thought to elicit their antipsychotic effects via
interference with central dopaminergic pathways in the mesolimbic
zone of the brain. Extrapyramidal side effects are a result of
interaction with dopaminergic pathways in the basal ganglia.

Biperidine Hydrochloride 2mg BID PO The mechanism of action of centrally active anticholinergic drugs
such as biperiden is considered to relate to competitive antagonism
of acetylcholine at cholinergic receptors in the corpus striatum,
which then restores the balance.

A butyrophenone that probably exerts antipsychotic effects by

Haloperidol 5m 1tab OB @ H.S.
blocking postsynaptic dopamine receptors in the brain.