c.

Psychiatric Nursing Care Plans

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
 Lack of support of Long Term INDEPENDENT: OUTCOME
his family Outcome: ACHIEVED
SUBJECTIVE: Ineffective (According to 1.) Providing general 1. These clients
coping related to Maslow we have After 2 weeks of leads to the client and frequently deny Long Term Outcome:
“Pag may inadequate nursing intervention, encourage the client responsibility for
problema ako, to satisfied our After 2 weeks of
social support needs). the client will be to identify the actions consequences of
mas gusto ko created by able to: that precipitated their own actions. nursing intervention,
sinasarili kaysa family hospitalization . the client
sabihin sa ibang relationship as • meet 2. Honest
tao” as stated psychological 2.) Give a positive identification of • meet
evidenced by psychological
by the client failure to accept needs of the feedback for honesty. the
Inability to share The client may try to consequences of needs of the
or handle client
the problems and avoid responsibility by client
problem the client’s
his insights to • by acting as though he behavior is
OBJECTIVE: others (according • by demonstrate
demonstrate or she is sick or necessary for
to Erickson, this nondestructiv nondestructive
• Failure to helpless. future behavior
case she didn’t e ways to ways to deal
accept or change.
develop of deal with with stress and
handle
trusting other stress and 3. This may frustration
problem 3.) Encourage the
people). frustration facilitate the
client to identify • Identifying ways
• Decreas client’s ability to
• Identifying sources of frustration, to meet own
ed use of accept
ways to meet how he or she dealt needs that do
social responsibility to
own needs with it previously and not violate on
supports his or her own
that do not any unpleasant the rights of
Inability to ask for behavior.
• Low violate on the consequences that others.
help
frustratio rights of resulted 4. Unpleasant
Short Term Outcome:
n others. consequences
tolerance may help After 2 days of nursing
4.) Develop decrease or intervention, the client
• Inability eliminate
to ask for Hidden problems Short Term Consequences for unacceptable • Identify
help and concerns are Outcome: unacceptable behaviors. The ineffective
developed behaviors (e.g. the consequences coping
After 2 days of client may not watch must be related behaviors and
nursing intervention, television) to something the consequences
the client will be client enjoys
able to: 5.)Treat the client being effective. • Verbalized
Tendency to with courtesy and awareness of
• Identify respect. Converse at 5. Enhance
become own coping
ineffective client level, providing therapeutic
egocentric and abilities
coping meaning conversation relationship.
arrogant (by
behaviors while performing • Assess the
Freud its better to 6. For the patient to
and care. current situation
use ego to control become aware
consequence accurately
our self).
s that these type of
feelings are • Identify ways to
• Verbalize 6.)Encourage meet own
normal.
awareness of verbalization and needs that do
own coping fears and anxieties 7. For the client to not violate on
Failure to accept abilities and expression of trust other the rights of
or handle feeling of denial , people, so that others.
problem • Assess the depression and he/she can easily
current anger. Let the client express their Recommendation:
situation know that these are feelings.
accurately Terminate the Plan.
normal reaction.
8. Dealing with
• Identify ways consequences
to meet own and working are
needs that do 7.)Active listen and
responsible
not violate on identify the clients behaviors. The
the rights of perception of what is
client may have
others. happening had little or no
successful
experience in
these areas and
may benefit from
COLLABORATIVE: assistance

9. Psychiatrist will
help the patient
1.) Discuss job
more about his or
seeking, work
her mental health
attendance and so
forth when working to 10. Medications may
the client together be necessary to
with the educator in decrease anxiety
business starters in to a level at
anticipation of which the client
discharge can feel safe

REFERENCE:

Psychiatric Mental
Health Nursing 4th
2.) Refer client to
edition pages 349-
Psychiatrist as
351 by Sheila L.
necessary
Videbeck, PhD, RN

3.) Administer
medications such as
anxiolytics as
prescribed

Diphenhy-dramine
Hydrochloride 500mg/
cap OD

Risperidone 2mg 1tab

BID
 ASSESSMENT PSYCHIATRIC SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
NURSING EXPLANATION
DIAGNOSIS
SUBJECTIVE: Anxiety related Lack of support LONG TERM INDEPENDENT: Outcome Achieved
“Mag isa na lang to lack of social of his family OUTCOME: INDEPENDENT: LONG TERM
ako, may sari- sarili interaction as (According to 1.) Asses the level 1.) Nursing OUTCOME:
na silang buhay kasi evidenced by Maslow we have After a weeks of of anxiety ( mild, strategies differ
mga magulang ko being worried to satisfied our nursing intervention, moderate, severe depending on After a weeks of
patay na.” As stated needs). the client will be able and panic) the level of nursing intervention,
by the client. to : anxiety the client will be able
• decreased level 2.) Remain calm to :
Inability to share of anxiety and in your approach • decreased level
OBJECTIVE: the problems verbalized to the client 2.) The client of anxiety and
• Being worried and his insights concerns will feel more verbalized
• Decreased to others regarding his secure if you concerns
ability to solve (according to thought and are calm and if regarding his
problem Erickson, this feelings 3.) Support the client feels thought and
case she didn’t presenting cope you are in feelings
develop of SHORT TERM mechanisms control of the
trusting other OUTCOME ( allow patient to situation SHORT TERM
people). talk or cry) and do OUTCOME
After 2 days of nursing not confront or 3.) Providing
intervention , the client argue with his emotional After 2 days of nursing
Inability to ask will be able to : defense support and intervention , the client
for help • Verbalize mechanisms encouraging will be able to :
awareness of sharing may • Verbalize
feelings of help the client awareness of
Hidden problems anxiety 4.) Convey a clarify and feelings of
and concerns • Identify healthy sense of emphatic verbalize her anxiety
are developed understanding (ex. fears, allowing
 ways to deal Quiet the nurse to • Identify healthy
with and environment) give realistic ways to deal
express anxiety feedback and with and
• Demonstrate reassurance express anxiety
Tendency to the ability to 5.) Avoid asking or 4.) Providing • Demonstrate
become perform forcing the client to emphatic the ability to
egocentric and relaxation make choices understanding perform
arrogant (by techniques encourages relaxation
Freud its better such as deep client to share techniques such
to use ego to breathing 6.) Encourage the and clarify his as deep
control our self). exercise, client to fears breathing
guided imagery participate in exercise,
and distraction relaxation 5.) The client guided imagery
Failure to accept to decrease exercises such as may not make and distraction
or handle anxiety level deep breathing, sound decisions to decrease
problem • Manage the progressive or may be anxiety level
anxiety muscle relaxation, unable to make • Manage the
response to meditation and decisions or anxiety
stress being quiet and in solve problems response to
effectively peaceful place 6.) Using stress
relaxation effectively
7.) Teach the techniques can
client to use give the client RECOMMENDATION:
relaxation confidence in Terminate the Plan.
techniques having control
independently over anxiety
such as deep 7.) Using
breathing exercise, relaxation
guided imagery techniques can
and distraction give the client
confidence in
having control
over anxiety
COLLABORATIVE

1.) medications 1.) Medications

may be indicated may be
for high levels of necessary to
anxiety ,delusions decrease
disorganized anxiety to a
thoughts and so level at which
forth such as the client can
anxioltytics feel safe
Diphenhy-dramine
Hydrochloride REFERENCE:
500mg/ cap OD
Risperidone 2mg Psychiatric –
1tab BID Mental Health
. Nursing 4th
edition by
Videbeck pp
247-248