I

Nursing care plan

Assessment

Objective:
- Active
- Agitated
- Irritable
-Seen bumping her
head against the wall
and kicking her bed.

Nursing
Diagnosis
Violence:
Self directed
related to
impaired sensory
perception
secondary to
schizophrenia

Planning

Interventions

Rationale

Outcomes

After 2days of
nursing
intervention the
client
will not harm to
others as
evidenced by:
- good interpersonal
relationship with copatients and staf
- Patient
demonstrate selfcontrol as evidenced
by relaxed posture,
nonviolent behavior.
- Client will not
harmself or others.

Observed and
maintained or
listen to the client
for early cues of
distress and a
calm attitude to
client.

For client safety.

After 2days of nursing

intervention the goal
was met as evidenced
by:

Re-orient the
client to person,
place, and time.

Repeated
presentation of
reality is concrete
reinforcement for
the client.

Provide emotional
support, positive
reinforcement.

Providing support
and
encouragement
during the
experience
increases the
patients sense of
security and
control. Positive
reinforcement
enhances selfesteem.

Developed a
therapeutic

Presence,
acceptance and

- Maintained good
interpersonal
relationship with copatients and staf.
- Patient demonstrate
self-control as
evidenced by relaxed
posture nonviolent
behavior.
- Client will not harm
self or others.

nurse-client
relationship
through frequent,
brief and an
accepting
attitude. Show
unconditional
positive regard.
Encouraged to
verbalize feelings.

conveyance of
positive regard
enhance the
clients feeling of
self worth.

Verbalization of
feelings in a
nonthreatening
environment may
help client come
to terms with long
unresolved
issues.

Reestablish the
client what is real
and unreal.
Validate clients
real perceptions,
and correct the
clients
misperception.

Reality must be
reinforced.
Reinforced reality
and behavior will
recur more
frequently.

Assessed type of
hallucination the
patient
experiencing.
Encouraged
patient to
gradually discuss

To rule out proper

intervention for a
specific
Hallucination.
So the client has
the chance to
seek others and

experiences that
occurred before
the onset of
hallucination.

to cope problems
caused by
hallucination.

Assessed for any

suicidal ideation
or violent
behavior.

Patient
experiencing
hallucination may
tend to be violent.

Maintained
distance from
client.
Provided client
with a sense that
caregiver is in
control of the
situation.
Administered
prescribed
medication.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Patient will be
violent.
To provide feeling
of safety.

To calm the client

and may prevent
aggressive
behavior.

RATIONALE

EVALUATION

SUBJECTIVE
Hi ate ako nurse,
ikaw pasyente; lika
ate laro tayo, akyat
tayo sa taas as
verbalized.
OBJECTIVE :
- Not oriented to
time, date
- Olfactory
hallucination
noted as
evidence of
Ayaw ko po
kumain nung
pagkain nila
dito, iba po
yung amoy,
masarap po
kasi yung
pagkain naming
dun sa amin.
- Circumstantialit
y
- Rapid shift of
mood.
- Short attention
span.
- Answers
questions being
asked
inappropriately.

Disturbed thought
process related to
mental disorder.

ST :
After 8 hours of
therapeutic
nursing
intervention the
patient will be
responding to
questions being
asked
appropriately.

Approach in a calm
manner.

To established nursepatient relationship.

Assess signs and

symptoms of
physical illness.

To determine immediate
and appropriate nursing
intervention.

Re- orient client to

time, date, place,
person.

To bring back to reality.

LT :
After 2 days of
therapeutic and
holistic nursing
intervention the
patient will be able
to eat foods being
served at the
institution and
continuing
compliance to
medications.

Encouraged to do
activity of daily
living
independently.

For the patient not to

remember or feel the
triggering factors and to
maintain body functions.

Interact with the

client on a real
basis.

Interacting about reality

in healthy.

Encouraged
verbalization of
feelings and
concerns.

For appropriate and

immediate nursing
intervention.

Supervised in
giving oral
medications.

To ensure the patient

swallowed medications
being given.

Seen from time to

time.

To ensure safety and for

assessment of other
signs and symptoms.

ST :
After 8 hours of
continuous
nursing
intervention
patient still
doesnt answers
questions being
asked
appropriately.

LT :
After 2 days of
nursing
intervention
patient still
doesnt want to
eat foods being
served from the
institution
because she said
she could smell
something
diferent from the
food.