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Nursing Care Plan

Assessment

Risk for disturbed thought processes related to biochemical imbalances, neurocognitive dysfunction, and psychological stress as evidenced by delusions, disorganized speech and illogical thinking.

Interventions

  • Establish a trusting and therapeutic relationship with the patient.

  • Avoid arguing with delusions while validating the patients feeling.

  • Monitor and assess delusions by asking the patient about the nature of the delusions.

  • Assess the potential risk to self or others and document the freguency and intensity of the delusions.

  • Provide reality orientation by gently directing the patient.

  • Encourage medication adherence.

Goals & Outcomes

  • Short-term: The patient will be able to distinguish between delusional thoughts and reality with assistance.

  • Long-term: The patient will be able to verbalize and differentiate between reality and delusions independently.

Evaluation

  • The patient is able to successfully be redirected.

  • The patient is compliant with taking medications.

  • The patient is able to distinguish between delusions and reality.

  • The patient is having decreased frequency of delusions.

Assessment

Risk for self-directed or other-directed violence related to command hallucinations, paranoid delusions, and poor impulse control as evidenced by paranoia, agitation, verbal threats, or a history of violence.

Interventions

  • Ensure a safe, low stimulus enviroment and remove any dangerous items.

  • Provide supervision by assigning a staff member to monitor the patient if the risk is high.

  • De-escalate agitated behavior by using a calm and reassuring tone.

  • Administer PRN medications for anxiety or agitation.

  • Teach the patient anger management and coping skills.

Goals & Outcomes

  • Short-term: The patient will remain free of injury to self or others.

  • Long-term: The patient will be able to identify triggers for violent behavior and be able to demonstrate non-violent coping mechanisms.

Evaluation

  • The patient has remained free of harm.

  • The patient has not been the cause of harm to other individuals.

  • The patient is able to identify triggers to aggressions.

  • The patient is able to verbalize non-violent ways to cope with their stress and recognizes what has helped them.

Assessment

Risk for impaired verbal communication related to disorganized thinking and disordered thinking as evidenced by illogical sentence structure and the inability to maintain a topic of conversation.

Interventions

  • Use clear, simple communication with the patient by asking one question at a time.

  • Assess communication patterns and document any instances of illogical speech.

  • Provide a calm environment for communication.

  • Teach basic communication skills

Goals & Outcomes

  • Short-term: The patient will use understandable communication with staff at least two times per day.

  • Long-term: The patient will be able to communicate thoughts clearly and logically.

Evaluation

  • The patient is able to successfully communicate their needs.

  • The patient expresses organized thoughts when they are communicating with others.

  • The patient has clear coherent speech.

  • The patient is able to communicate in a basic social interaction.

  • The patient is able to carry a conversation about one specific topic for the duration of the conversation.

Assessment

Risk of social isolation related to mistrust of others, paranoia, flat affect, and social withdrawal as evidenced by remaining isolated, avoiding eye contact, and showing little interest in group activities.

Interventions

  • Spend time with the patient to build trust with the patient.

  • Offer small structured group activites.

  • Provide positive reinforcement for any social effort the patient makes.

  • Refer the patient to a therapist to develop social skills.

  • Explore the patients feelings about social interactions to help them identify and address the cause of social avoidance.

Goals & Outcomes

  • Short-term: The patient will participate in one group activity per week with gentle encouragement.

  • Long-term: The patient will initiate conversations with a staff member daily.

Evaluation

  • The patient is attending small group activities weekly.

  • The patient begins to trust staff members.

  • The patient is attending therapy regularly.

  • The patient is making eye contact during conversations.

  • The patient is not remaining isolated.

Assessment

Risk of self-care deficit related to the negative symptoms of schizophrenia and disorganized thinking as evidenced by unwashed hair, body odor, and dirty clothing.

Interventions

  • Establish a trusting and non-judgmental relationship.

  • Break the tasks of daily hygiene down into smaller more manageable steps.

  • Develop a specific schedule of daily hygiene tasks for the patient to follow.

  • Ensure the patient has the supplies needed to complete each hygiene task.

  • Let the patient be a part of choosing their own hygiene supplies.

Goals & Outcomes

  • Short-term: The patient will complete at least one personal hygiene task with prompting.

  • Long-term: The patient will independently complete all necessary daily hygiene tasks with minimal or no prompting.

Evaluation

  • The patient will begin completing daily hygiene tasks.

  • The patient will learn a routine of daily hygien tasks that they will complete daily.

  • The patient will present themselves in clean clothing each day.

  • The patient will not feel overwhelmed by daily hygiene tasks.

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