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NCP Michael Flores

The patient is experiencing impaired social interaction that may be related to delusional thinking. The short-term goal is for the patient to be able to respond appropriately to environmental stimuli within 4 hours of nursing intervention. The plan includes avoiding behaviors that could reinforce paranoia, keeping the patient in a low-stimulus environment, being sincere, consistent, and developing a therapeutic relationship. The long-term goal is for the patient to have lesser delusions after 8 weeks of nursing intervention.

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Kyle Audrie Arcalas
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46 views1 page

NCP Michael Flores

The patient is experiencing impaired social interaction that may be related to delusional thinking. The short-term goal is for the patient to be able to respond appropriately to environmental stimuli within 4 hours of nursing intervention. The plan includes avoiding behaviors that could reinforce paranoia, keeping the patient in a low-stimulus environment, being sincere, consistent, and developing a therapeutic relationship. The long-term goal is for the patient to have lesser delusions after 8 weeks of nursing intervention.

Uploaded by

Kyle Audrie Arcalas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING

ASSESMENT PLANNING INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS
Subjective: Impaired social Short term goal: 1. Avoid laughing, Suspicious patients  Within 4 hours of nurse
“May time na hindi interaction may be  Within 4 hours of whispering or often believe others patient interaction and
ako makatulog, related to nurse patient talking quietly are discussing them nursing intervention
Di makakain. Lalo alterations in interaction and when patient and secretive
patient able to respond
nap ag nakakita ako delusional nursing intervention can see but not behaviors reinforce
ng kaedad nya, thinking““May patient will be able to hear what is the paranoid appropriately to
naiisip ko siya.” As time na hindi ako respond appropriately being said. feelings environmental stimuli
verbalized by the makatulog, to environmental
patient Di makakain. Lalo stimuli 2. Keep client in  After 8 weeks of nurse
na pag nakakita an environment To avoid patient interaction and
Objecitve: ako ng kaedad Long term goal: as free of reinforcement of
nursing intervention
nya, naiisip ko stimuli as paranoid feelings.
 Client is patient able to know
siya.” As  After 8 weeks of possible.
looking weak verbalized by the nurse patient reality and will have
and anxious. patient interaction and 3. Be sincere and lesser delusions
 Difficulty with nursing intervention honest when Delusional patients
concentration patient will be able to communicating. are extremely
know reality and will sensitive about
have lesser delusions others and can
recognize
insincerity. Evasive
comments or
hesitation reinforces
mistrust or
delusions.
4. Be consistent in Clear, consistent
setting limits provide a
expectations, secure structure for
and enforcing the patient.
rules.

5. Develop a Your presence,


therapeutic acceptance, and
nurse patient conveyance of
relationship positive regard
through enhance the
frequent, brief patients’ feelings of
contact and an self-worth
accepting
attitude. Show
unconditional

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