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NCP Psychosis

The patient is experiencing disturbed thought processes manifested by hallucinations, limited attention span, and laughing/talking to himself without reason. The nursing diagnosis is disturbed thought processes related to psychological and cognitive disturbances. The goal is for the patient to recognize hallucinations, sustain attention, and respond to reality-based interactions after 3 weeks of nursing care. Interventions include interacting with the patient based on reality, assessing attention/distractibility, scheduling structured activities, reducing provocative stimuli, and administering antipsychotic medication as prescribed. The expected outcome is for the patient to feel able to recognize hallucinations and verbalize feelings of comfort, wanting to go home and continue work.

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Kristian Karl Bautista Kiw-is
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2K views3 pages

NCP Psychosis

The patient is experiencing disturbed thought processes manifested by hallucinations, limited attention span, and laughing/talking to himself without reason. The nursing diagnosis is disturbed thought processes related to psychological and cognitive disturbances. The goal is for the patient to recognize hallucinations, sustain attention, and respond to reality-based interactions after 3 weeks of nursing care. Interventions include interacting with the patient based on reality, assessing attention/distractibility, scheduling structured activities, reducing provocative stimuli, and administering antipsychotic medication as prescribed. The expected outcome is for the patient to feel able to recognize hallucinations and verbalize feelings of comfort, wanting to go home and continue work.

Uploaded by

Kristian Karl Bautista Kiw-is
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Subjective Objective cues Nursing diagnosis Scientific Goal Intervention Rationale Expected

cues reference outcome


"Ganahan -wearing a ninja- Disturbed thought One hallmark
nako like outfit processes related symptom of That after 3 weeks of Independent:
Mugawas diri, -with the visual to psychological schizophrenic Nursing Care . Patient was able
kay mangtapas hallucination and cognitive psychosis is Management, Patient 1. Interact with -interacting about to recognize the
nako ug tubo -limited disturbances as hallucinations. will be able to: the client on reality is healthy for presence of
sa amu" as attention span manifested by Hallucination can the basis of real the client hallucinations,
verbalized by -laughing and limited attention involve the five 1. Demonstrate things; do not and verbalized
the patient talking to span, senses and bodily behavior/ dwell on the feelings of
himself without hallucination , and sensation. They lifestyle changes hallucinational comfort, wanted
apparent laughing and can be to prevent, material. to go home and
reason talking to himself threatening and minimize 2. Assess -determines ability continue his work
without any reason frightening for the changes in attetntion to participate in
client ; less mentation span/distractibi planning/ executing
Definition: frequently, 2. Respond to lity and ability care
disruption in client's report reality-based to make
cognitive operation hallucinations as interactions decisions/
and activities pleasant. Initially initiated by problem
client perceives others solution -provides
Source: Doenges , hallucinations as 3. Sustain attention 3. Schedule stimulation while
M.E. et a.l.(2008) real, but later in and structured reducing fatigue
Nurses Pocket the illness ,he or concentration to activity and rest
Guide, Diagnosis, she may recognize complete tasks periods -to avoid triggering
Prioritized them as and activities 4. Reduce fight/ fight
interventions and hallucination. 4. Verbalize provocative responses
Rationales .11th Hallucinations, recognition of stimuli,
edition Disturbed however, have no hallucinations if negative
Thought Process such basis and they persist criticism,
pages 696-700 reality. arguments and
Source: confrontations - Client may
Videbecks, S. L. 5. Refrain from feel
(2006). Psychiatric forcing threatened
Mental Health activities and and may
Nursing #rd communication withdraw/r
Edition Sensorium ebel
and intellectual Dependent:
page 288
1. Administer - to treat
antipsychotic psychologic
med as al and
prescribed cognitive
Collaborative: disturbance

1. Assist in - to maintain
identifying gains and
ongoing continue
treatment progress if
needs/ able
rehabilitation
program for
the individual
.

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