ASSESSMEN

NURSING
DIAGNOSIS

OUTCOME
IDENTIFICA
TION
Subjective
Patient will be
Disturbed
data:
able to
thought
Patient
eliminate the
process
verbalizes
pattern of
related
to delusional
sister I am not
possible
able to trust
thinking and
biochemical
others, I feel
demonstrate
factors
as trust in others.
that the
evidenced by
strangers will
extreme
harm me.
Objective data: delusional
thinking.
Appear fearful
at times,
Social
withdrawal

PLAN OF ACTION

IMPLEMENTATION

EVALUATION

Assess the content of the

delusion without
appearing to probe.

Assessed the content of the

delusion without appearing
to probe.

Patient is able
to eliminate the
pattern of
delusional
thinking and
demonstrate
trust in others.

Assess the intensity,

Assessed the intensity,
frequency and duration of frequency and duration of
the delusion.
the delusion.
Assess the context and
environmental triggers
for the delusional
experience.
Distract the patient from
delusions that tend to
exacerbate aggressive or
potentially violent
episodes.
Discourage long
discussions about
irrational thinking.

Assessed the context and

environmental triggers for
the delusional experience.
Distracted the patient from
delusions that tend to
exacerbate aggressive or
potentially violent
episodes.
Discouraged long
discussions about irrational
thinking.

Subjective
data:
Patient
verbalizes
sister nobody is
coming to see
me in the
hospital, I think
they dont like
me
Objective data:
Family is
worried about
the repeated
admissions of
the patient.
High expressed
emotions in the
family.

The family will

demonstrate
coping ability
Altered family in dealing with
process
the patient.
related
to
euphoric
mood
as
evidenced by
irritability and
frequent mood
fluctuations.

Encourage the patient to

express feelings as much
as possible.

Encouraged the patient to

express feelings as much as
possible.

Determine individual
situation and feelings of
individual family
members like guilt, anger,
powerlessness, and
despair.

Determined individual
situation and feelings of
individual family members
like guilt, anger,
powerlessness, and despair.

Assess the pattern of

communication in the
family.

Assessed the pattern of

communication in the
family.

Determined the pattern of

Determine the pattern of behavior displayed by the
behavior displayed by the patient in her relationship
patient in her relationship with others.
with others.
Assessed the role of patient
Assess the role of patient in the family.
in the family.
Provided information about
Provide information
the behavior patterns and
about the behavior
expected course of the

The family
demonstrated
coping ability in
dealing with the
patient.

patterns and expected

course of the illness.
Encourage the family
members to clear their
doubts about the illness.

Subjective
data:
Patient
verbalizes
what will
happen to me?
Objective data:
Looks anxious,
continuous
questions.

Patient gains
adequate
knowledge
regarding her
Knowledge
disease
deficit related condition.
to
disease
condition and
medication
adherence as
evidenced by
frequent drug
defaults.

illness.
Encouraged the family
members to clear their
doubts about the illness.

Explain before doing

every procedure.

Explained before doing

every procedure.

Explain the disease

condition to the patient.

Explained the disease

condition to the patient.

Encourage the patient to

ask questions and clear
her doubts.

Encouraged the patient to

ask questions and clear her
doubts.

Provide psychological
support to the client.

Provided psychological
support to the client.

Explain the importance of Explained the importance

hospitalization and the
of hospitalization and the
need for medication
need for medication

Patient gained
adequate
knowledge
regarding her
disease
condition.

Subjective
data:
Patient
verbalizes
sister I always
feel hungry.

Imbalanced
nutrition more
than
body
Objective data: requirements
to
Always ask for related
increased
food, looks
intake of food.
obese. BMI26.1 kg/m2

adherence.

adherence.

Allow the patient to

interact with the
physician and clear her
doubts.
Explain the complications
of not following the
treatment plan.

Allowed the patient to

interact with the physician
and clear her doubts.
Explain the complications
of not following the
treatment plan.

Patient
Assess the dietary intake
maintain
pattern of the client.
regular pattern
for food intake. Restrict the food other
than usual timings.

Assess the dietary intake

pattern of the client.

Encourage the patient to

take adequate amount of
food during regular meal
timings.

Encourage the patient to

take adequate amount of
food during regular meal
timings.

Explain to the patient the

importance of

Explain to the patient the

importance of maintaining

Patient
maintained
Restrict the food other than regular pattern
usual timings.
for food intake.

maintaining proper diet to proper diet to avoid

avoid complications
complications related to
related to obesity.
obesity.
Encourage the patient to
avoid spicy and junk
foods.
Maintain intake output
chart.
Record the patients
weight regularly.

Objective data:
Manic
excitement,
Gets irritable
Risk
for
easily
violence self
directed, or at
others related
to
manic

Patient will be
able control her
behavior and
verbalize her
feelings.

Encourage the patient to

avoid spicy and junk foods.
Maintain intake output
chart.
Record the patients weight
regularly.

Observe the patient

behavior frequently.

Observed the patient

behavior frequently.

Provide a structured
environment with
scheduled routine
activities of daily living.

Provided a structured
environment with
scheduled routine activities
of daily living.

Talk with the patient in a

spoke with the patient in a

Patient is able
control her
behavior and
verbalize her
feelings.

excitement
and delusional
thinking.

low calm voice.

low calm voice.

Inform the staff to be

alert for the signs of
increasing anxiety, fear or
agitation so that they may
intervene as early as
possible and prevent
harm to the patient or
others.

Informed the staff to be

alert for the signs of
increasing anxiety, fear or
agitation so that they may
intervene as early as
possible and prevent harm
to the patient or others.

Remove all dangerous

objects from the patients
environment.
Administer tranquilizers
and mood stabilizers as
prescribed.

Removed all dangerous

objects from the patients
environment.
Administered tranquilizers
and mood stabilizers as
prescribed.