ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjectives: Disturbed Short- Term Attempt to Important clues to
"Nakita ko, nakita thought Goal: understand the underlying fears and
ko sa tv, habang processed related significance of these issues can be found in
nagsasalita yung to disruption in At the end of the beliefs to the client at the client’s seemingly
babae nakatitig cognitive shift of nursing the time of their illogical fantasies.
siya sa akin, operations and interventions, the presentation.
sinabi niyang activities as patient will: Recognizes the Recognizing the
dapat ko siyang evidenced by client’s delusions as client’s perception can
lapitan. inaccurate • perceive the the client’s help you understand
(beliefs that interpretation of environment perception of the the feelings he or she
the television environment correctly. environment. is experiencing.
was sending ( presence of • demonstrate When people believe
him messages;) delusions ) decrease anxiety Identify feelings that they are
Kailangan ko ng level within 24 related to delusions. understood, anxiety
lumabas dito, hours. For example: might lessen.
may magaganap • talk about
na digmaan. concrete - If client believes
Susugod sila dito, happenings in the someone is going
mga tikbalang, environment to harm him/her,
kapre at aswang, without talking client is
kailangan nating about delusions experiencing fear.
lumaban(belief for - If client believes
that someone or
mythological something is
creatures were Long- Term controlling his/her
trying to entice Goal: thoughts, client is
him to After 3 months of experiencing
battle;).Pina kita nursing helplessness. When the client has
kanina sa tv, interventions, the Explain the full knowledge of
nagpo propose patient will: procedures and try to procedures, he or she
sakin si Nadine be sure the client is less likely to feel
Lustre. Maganda • demonstrate understands the tricked by the staff.
naman siya, pero satisfying procedures before
hindi ko siya relationships with carrying them out. When thinking is
gusto. Pero okay real people. Interact with clients focused on reality-
lang naman. • demonstrate on the basis of things based activities, the
Papayag ba'ko? two effective in the environment. client is free of
(belief that a coping skills that Distract client from delusional thinking
celebrity on TV minimize their delusions by during that time. Helps
wanted to delusional engaging structured focus attention
marry him; )Six thoughts. reality-based externally.
six six it's hell, it's • verbalize activities (e.g., card
death, I am the recognition of games, simple arts
God of death, I delusional and crafts projects
am a God. thoughts if they etc.). Suspicious clients
(misinterpretat persist. might misinterpret
ion of numbers • refrain from Do not touch the touch as either
to indicate that acting on client; use gestures aggressive or sexual in
he was GOD)", delusional carefully. nature and might
as verbalized by thinking. interpret it as
the patient. • develop trust in threatening gesture.
at least one staff People who are
-He also reported member (within 1 psychotic need a lot of
feeling very week) personal space.
paranoid as if • Patient will
someone was sustain attention Arguing will only
going to harm and concentration increase client’s
him. He stated to complete task Initially do not argue defensive position,
that he believed or activities. with the client’s beliefs thereby reinforcing
some of the • state that the or convince the client false beliefs. This will
people in the “thoughts” are that the delusions are result in the client
restaurant looked less intense and false and unreal. feeling even more
like devils and less frequent with isolated and
were possessed the help of the misunderstood.
by demons. medications and
nursing
Objectives: interventions. All are vital to help
Presence of • be free from Encourage keep the client in
delusions: delusions or - healthy habits to remission.
(+) Referential demonstrate the optimize
delusions/ ability to function functioning:
ideas of without - Maintain
reference responding to medication
(+) Paranoid persistent regimen.
delusions delusional - Maintain regular
(+) Religious thoughts sleep pattern.
delusions - Maintain self-care.
- Reduce alcohol
and drug intake. The client’s delusion
Show empathy can be distressing.
regarding the client’s Empathy conveys your
feelings; reassure the caring, interest and
client of your acceptance of the
presence and client.
acceptance. When client is ready,
Teach client coping teach strategies client
skills that minimize can do alone.
“worrying” thoughts.
Coping skills include:
- Going to a gym.
- Singing or
Listening to a
song.
- Talking to a
trusted friend.
- Thought-stopping
techniques.
- During acute phase,
Utilize safety client’s delusional
measures to protect thinking might dictate
clients or others, if to them that they
the client believe might have to hurt
they need to protect others or self in order
themselves against a to be safe. External
specific person. controls might be
Precautions are needed.
needed.
Enhances client’s
Give positive sense of well-being
feedback for the and helps make
client’s successes nondelusional reality a
more positive situation
for the client.
Administered To balance dopamine
antipsychotic drugs level
such as haldol as
ordered.
Collaboration:
Collaboration:
Engaged patient in
cognitive behavioral
therapy and
occupational therapy.
Cognitive behavioral
therapy (CBT) is a
treatment approach
that helps you
recognize negative or
unhelpful thought and
behavior patterns. CBT
aims to help you
identify and explore
the ways your
emotions and thoughts
can affect your actions.
Occupational
therapy on the other
hand, is an allied
health profession that
involves the
therapeutic use of
everyday activities, or
occupations, to treat
the physical, mental,
developmental, and
emotional ailments that
impact a patient's
ability to perform day-
to-day tasks.
