Crisis Intervention: Psychiatric Nursing Nursing Care Plan

B. Nursing Care Plan

DIAGNOSIS NEEDDESIRED

OUTCOMEINTERVENTIONS RATIONALE

EVALUATION STATEMENT

INTERVENTIONS RATIONALE

Disturbed Thought Process related to disintegration on thinking as manifested by disorientation with date and place and impaired judgment

Cues:

Subjective:

>Keeps on verbalizing when asked of date, ”Lunes Mayo 25, 1952”

>says ”Orange Juice” instead of carrot

Objective:

> Non–reality-based thinking

>With delusion of grandeur

COGNITIVE

NEED

Within 2 hours of Nursing Interventions, the patient will be able to:

General:

> Respond to reality-based interactionsinitiated by others

Specifically,

> Interact on reality-based topics >Sustain attention and concentrationto complete tasks or activities

INDEPENDENT

Establish rapport to the patient

Be sincere and honest when communicating with the client. Avoid vague or evasive remarks

Monitor vital signs frequently especially blood pressure and

To gain client’s trust and cooperation

Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions

Assess condition of the patient before giving medications

Goal is partially met.

Ms. MB was able to respond in a reality-based interaction still with the aid of the student nurse. However, there are times that she could not be able to answer directly and properly to the simple questions the student nurse is asking. She sustained her attention was

Continue Nursing Interventions especially bringing back the patient to reality

Continue to encourage patient comply all medications prescribed to her

It is healthy for her and may lead her to be more productive and more functioning self

For faster recovery from the mental illness

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>Disorientation

>Blunted affect

>Short attention span

>Impaired judgment

Background Knowledge:

Identifying and managing one’s own health needsare primary concerns for everyone, but this is a particularchallenge for clients with schizophrenia becausetheir health needs can be complex and their ability tomanage them may be impaired. The nurse helps theclient to manage his or her illness and health needs asindependently as

interpret it accurately

Be consistent in setting expectations, enforcing rules, and so forth

Do not make promises that you cannot keep

Encourage the client to talk but do not pry or cross-examine for information

Explain procedures, and try to be sure the client understands the procedures before

Clear, consistent limits provide a secure structure for the client

Broken promises reinforce the client’s mistrust of others

Probing increases the client’s suspicion and interferes with the therapeutic relationship

When the client has full knowledge of procedures, she is less likely to feel tricked

fortunately, she was able to complete her task.

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possible. This can be accomplishedonly through education and ongoing support.Teaching the client and family members to preventor manage relapse is an essential part of a comprehensiveplan of care. This includes providing factsabout schizophrenia, identifying the early signs of relapse,and teaching health practices to promote physicaland psychological well-being. Murphy and Moller(1993) have identified symptom triggers, or factorsthat increase the risk for relapse, in the areas of theclient’s health, the environment, and the client’s attitudesor behaviors (Box 14-4). Early identification

carrying them out

Give positive feedback for the client’s successes

Recognize the client’s delusions as the client’s perception of the environment

Initially, do not argue with the client or try to

Positive feedback for genuine success enhances the client’s sense of well-being and helps to make non-delusional reality a more positive situation for the client

It is important to recognize the client’s environmental perceptions to understand the feelings she is experiencing

Logical argument does not dispel

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of these risk factors has been found to reduce the frequencyof relapse; when relapse cannot be prevented,early identification provides the foundation for interventionsto manage the relapse. For example, if thenurse finds that the client is fatigued or lacks adequatesleep or proper nutrition, interventions to promoterest and nutrition may prevent a relapse orminimize its intensity and duration.

Reference:

Videbeck, Sheila. Psychiatric Mental Health Nursing.5th Ed. Lippincott Williams & Wilkins. Philadelphia. 2004

convince the client that the delusions are false or unreal

Interact with the client on the basis of real things; do not dwell on the delusional material

Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups

Recognize and support the client’s

delusional ideasand can interfere with the development of trust

Interacting about reality is healthy for the client

The client who is distrustful can best deal with one person initially. Gradual introduction of others when the client can tolerate it is less threatening

Recognition of accomplishments can

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accomplishments (activities or projects completed, responsibilities fulfilled, interactions initiated)

Show empathy regarding the client’s feelings; reassure the client of your presence and acceptance

Do not be judgmental or belittle or joke about the client’s beliefs

lessen the client’s anxiety and the need for delusions as a source of self-esteem

The client’s delusions can be distressing. Empathy conveys your acceptance of the client and your caring and interest

The client’s delusions and feelings are not funny to him or her. The client may feel rejected by you or feel unimportant if approached by attempts at humor

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Never convey to the client that you accept thedelusions as reality

DEPENDENT

Administer Chlorpromazine as prescribed

It would reinforce the delusion (thus, the client’s illness) if you indicated belief in the delusion

An Antipsychotic that could treat psychiatric illness such as this schizo-phrenia





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Disturbed Sensory Perception: Auditory/Visual Hallucinations related to alteration in the function of brain as manifested by inappropriate response and disorientation

Cues:

Subjective:

>”Cheche manghud ko”

>”Piyesta sa Pavillion”

Objective:

>inappropriate response

>disoriented with date and place

>claims she owns a garden inside the cell


COGNITIVE

NEED

Within 2 hours of Nursing Interventions, the patient will be able to:

General:

>test reality,eliminating the occurrence of hallucinations.

Specifically,

>recognize present reality via activities prepared by the student nurse

INDEPENDENT


Monitor vital signs frequently and interpret it accurately

Observe client for signs of hallucinations (listening pose, laughing or talking to self, stopping in midsentence)

Avoid touching the client without warning

To gain client’s trust and cooperation as well as have a quality assessment

To assess whether medications could be given or contraindicated

Early intervention may prevent aggressive response to command hallucination

Client may perceive touch as threatening and may respond in an

Goal is partially met.

Ms. MB was oriented by the student nurse with the date and time. However, if being asked again, she will still answer incorrectly. She still claims that she there is a fiesta going on and she needs to go there. Fortunately, she was able to recognize reality because of diverting her attention to the activity.

Continue Nursing Interventions especially in bringing her back to reality and let her focus on her present activity

Administer physician’s prescribed medicine

To improve her perception and make it into reality and not fantasy

For faster treatment that will lead to recovery

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Cognitive impairment associated with schizophrenia isnow viewed as a potential psychopharmacological targetfor treatment (Hyman and Fenton 2003). Although cognitionis not a formal part of the current diagnostic criteriafor schizophrenia, DSM-IV-TR (American PsychiatricAssociation 2000) includes seven references to cognitivedysfunction in the description of the disorder. Diagnosticand scientific experts increasingly have expressed the ideathat neurocognitive impairment is a core feature of the illnessand not simply the result of the symptoms or the current

An attitude of acceptance will encourage the client to share the content of the hallucination with you

Do not reinforce the hallucination. Use “the voices” instead of words like “they” that imply validation. Let the client know that you do not share the perception. Say, “Even though I realize the voices are real to you, I do not hear any voices”

aggressive manner

This is important to prevent possible injury to the client or others from command hallucination

Client must accept the perception as unreal before hallucinations can be eliminated

If client can

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treatments of schizophrenia.There is some evidence that neurocognitive impairmentin patients with schizophrenia may worsen over time in atleast a subgroup of elderly patients with schizophrenia.Prominent cognitive impairments resembling dementiahave been reported in older schizophrenic patients with alifetime of poor functional outcome (Arnold et al. 1995;Davidson et al. 1995; Harvey et al. 1996).On the basis of cross-sectional studies, elderly patientswith schizophrenia appear to show some decline in cognitivefunction toward the end of life. However, this

Help the client understand the connection between anxiety and hallucinations.

Try to distract the client from the hallucination.

DEPENDENT

Administer Chlorpromazine as prescribed by the physician

learn to interrupt escalating anxiety, hallucinations may be prevented

Involvement in interpersonal activities and explanation of the actual situation will help bring the client back to reality

To treat the psychiatric illness which is Schizo-phrenia

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declinemay be restricted to those patients who had an early onsetof illness followed by a lifetime of poor functioning(Heaton et al. 1994; Hyde et al. 1994; Jeste et al. 1995;Zorrilla et al. 2000). Some of the inconsistency of theseresults may derive from the subject selection processes inthese studies.

Reference:

Lewis, et al. Textbook Schizophrenia.2003





Impaired Verbal Communication S Within 2 hours

of Nursing INDEPENDENT

Goal is partially Continue

Nursing It is healthy

for her and

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related to regression as manifested by associative looseness, echolalia, and neologism

Cues:

Objective:

>Repeats words and phrases uttered by the student nurse, thus, echolalic

>Ideas are sometimes not organized

>Associative Looseness observed

>neologism observed >Mumbles when speaking; words are not clearly stated


Most cognitive

ELF-ESTEEM

NEED

Interventions, the patient will be able to:

General:

>communicateappropriatelyand comprehensivelywith others

Specifically,

>talk not only with her student nurse but also other to other people present in the activity area including other student nurses, instructors, and fellow patients


Monitor vital signs frequently especially respiration and interpret it accurately

Attempt to

decode incomprehensible communication patterns. Seek validation and clarification by stating, “Is it that you mean…?” or “I don’t understand what you mean by that. Would you please clarify it for me?”

To gain client’s trust and cooperation as well as have a quality assessment

To assess whether or not to give medications prescribed

These techniques reveal how the client is being perceived by others, while the responsibility for not understanding is accepted by the nurse

met.

Ms. MB was able to communicate to others not just to her student nurse. However, the fluency of her words is sometimes not clear making it hard for others to understand what is she saying.

Interventions especially bringing back the patient to reality

Continue to encourage patient comply all medications prescribed to her

may lead her to be more productive and more functioning self

For faster recovery from the mental illness

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assessments in treatment studies of schizophreniahave included measures of verbal fluency as a separatedomain of functioning (Harvey and Keefe 2001;Keefe et al. 1999; Meltzer and McGurk 1999). Most ofthese tests measure either phonological fluency (alsoreferred to as letter fluency) or semantic fluency. Phonologicalfluency refers to a patient’s ability to produce asmany words as possible beginning with a particular letterwithin, for instance, 60 seconds. Semantic fluency refersto the ability to produce words within a particular meaning

Facilitate trust and understanding by maintaining assignments as consistently as possible. The technique of verbalizing the implied is used with the client who is mute (unable or unwilling to speak). Example: “That must have been a very difficult time for you when your mother left. You must have felt very alone”

Anticipate and fulfill client’s needs until functional communication pattern returns

Orient client to reality as required. Call

This approach conveys empathy and may encourage the client to disclose painful issues

Client’s safety and comfort are nursing priorities

These techniques may facilitate

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Reference:

Lewis, et al. Textbook Schizophrenia.2003

the client by name. Validate those aspects of communication that help differentiate between what is real and not real

DEPENDENT

Administer Chlorpromazine as indicated

restoration of functional communication patterns in the client

To treat the psychiatric illness which is schizo-phrenia

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Documents

Crisis Intervention: Psychiatric Nursing Nursing Care Plan