Patient’s name: Clinical Instructor: Date:

Age: Sex: Student nurse: Diet:

Physician: Clinical area:
Medical diagnosis: Room no:

Subjective Objective cues Nursing Scientific Goal Intervention Rationale Expected

cues diagnosis reference outcome
"Ganahan -wearing a Disturbed One hallmark
nako ninja-like thought symptom of That after 3 weeks Independent:
Mugawas outfit processes schizophrenic of Nursing Care . Patient was
diri, kay -with the related to psychosis is Management, 1. Interact with -interacting able to
mangtapas visual psychological hallucinations. Patient will be able the client on about reality is recognize the
nako ug hallucination and cognitive Hallucination to: the basis of healthy for the presence of
tubo sa -limited disturbances as can involve real things; client hallucinations,
amu" as attention manifested by the five senses 1. Demonstrate do not dwell and verbalized
verbalized span limited and bodily behavior/ on the feelings of
by the -laughing and attention span, sensation. lifestyle hallucination comfort,
patient talking to hallucination , They can be changes to al material. wanted to go
himself and laughing threatening prevent, 2. Assess -determines home and
without and talking to and minimize attetntion ability to continue his
apparent himself without frightening for changes in span/distrac participate in work
reason any reason the client ; mentation tibility and planning/
less 2. Respond to ability to executing care
Definition: frequently, reality-based make
disruption in client's report interactions decisions/
cognitive hallucinations initiated by problem
operation and as pleasant. others solution -provides
activities Initially client 3. Sustain 3. Schedule stimulation
perceives attention and structured while reducing
Source: hallucinations concentration activity and fatigue
Doenges , M.E. as real, but to complete rest periods
et a.l.(2008) later in the tasks and 4. Reduce -to avoid
Nurses Pocket illness ,he or activities provocative triggering fight/
Guide, she may 4. Verbalize stimuli, fight responses
Diagnosis, recognize recognition of negative
Prioritized them as hallucinations criticism,
interventions hallucination. if they persist arguments
and Rationales . Hallucinations, and
11th edition however, have confrontatio - Client
Disturbed no such basis ns may feel
Thought and reality. 5. Refrain from threaten
Process pages Source: forcing ed and
696-700 Videbecks, S. activities may
L.(2006). and withdraw
Psychiatric communicat /rebel
Mental Health ion
Nursing #rd
Edition Dependent: - to treat
Sensorium and psycholo
intellectual 1. Administer gical and
page 288 antipsychoti cognitive
c med as disturban
prescribed ce
Collaborative:
- to
1. Assist in maintain
identifying gains
ongoing and
treatment continue
needs/ progress
rehabilitatio if able
n program
for the
individual
.