Help: Care Plan

I have tried to be a sponge and try to understand care plans, with experience I am getting better. Thanks to all of you nurses on this site!!!This care plan I am suppose to complete has me at a loss (maybe my brain is just overloaded at this point) Please help!! Guide me!!

Assessment Data: (not in any order)

client 3.5 years old born 24 weeks gestation with multiple cardio abnormalities was on ventilator for 4 months

Current Assessment:

lungs clear, vitals WNL, skin brown, W&D

receives nutrition via pureed food PO

sleeps in crib turnning schedule Q2 hours x 24 hours

only rolls side to side

can grab at developmental level of 0-6 month old

cannot speak,

recent parents move out of state and has new guardian (hard for parents, best for client)

DNR

has NOT had seziure past 2 years

last aspirated one year ago

for the year 2005 received no follow up care

miminal medication ie chewable vita, pedicare PRN, Nasal spray daily, and stool softner PRN.

Primary Med DX congential heart disease W/ASD 2nd to premature

Seizure disorder, s/p ligation of PDA. Current neuro consult indicates scoliosis-POC monitor and re-eval annually and recently-

MD found NO significant heart disease.

MRI findings of white matter volume loss-chronic peri ventricular leukomalacia and complete loss of R cerebellar hemisphere

Theraputic interventions include weekly PT, OT,

Is currently in LTC and is receiving great care. I know there are multiple issues but right now current problems are maintenance issues and I do not want to use Risk for or developmental delay as client will never reach goals, never recover will always be at developmental level of 0-6 months. I ahve grouped all assessments together and just am unsure of nursing diagnoses. I am leaning towards some type of feeding pattern as number one priority and the reason is because you need food to live, immobility and then I am not sure??????Help please. Thank you to all who respond

[Daytonite, BSN, RN]

care planning relies on following the steps of the nursing process:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

all care planning begins with assessment. you said, "i have grouped all assessments together and just am unsure of nursing diagnoses." i went through the data you posted and this is how i assembled it for step #2 of the nursing process.

• historical
  • 3.5 years old
    
  • born 24 weeks gestation with multiple cardio abnormalities
    
  • congential heart disease w/asd (atrial septal defect) 2nd to prematurity
    
  • seizure disorder - last one 2 years ago
    
  • s/p ligation of pda (patent ductus arteriosus)
    
  • scoliosis (abnormal spinal curve)
    • signs and symptoms
      • uneven shoulder height or an uneven shoulder blade prominence
        
      • asymmetrical waistline
        
      • uneven hip height
        
      • a sideways lean

      [*]complications

      • chronic back pain
        
      • deformity
        
      • reduced pulmonary function
        
      • increased risk of cor pulmonale in middle age
        
      • disturbed self-image

    [*]mri findings of white matter volume loss-chronic peri ventricular leukomalacia and complete loss of r cerebellar hemisphere

    [*]history of aspiration one year ago

  [*]abnormal data

  • pureed diet
    
  • sleeps in crib turned q2 hours
    
  • only able to roll side to side
    
  • can grab
    
  • 3.5 year old with the mental/developmental age of 0-6 month old
    • http://healthguide.howstuffworks.com/developmental-milestones-record-3-years-dictionary.htm
      
    • http://www.nncc.org/child.dev/ages.stages.3y.html

    [*]cannot speak

    • http://www.baptistonline.org/health/library/chil3085.asp - speech development in 2-5 year olds
      
    • http://www.baptistonline.org/health/library/chil3086.asp - speech problems in children

    [*]recent parents have moved out of state and has new guardian

the choice of using any nursing diagnosis is dependent on the evidence you have to support it. that is why you need to have the abnormal nursing assessment data and it needs to be as developed and refined as you can make it. yes, he is developmentally delayed. he has signs and symptoms of this that need to be addressed or he will never survive and i'm guessing that is what you were meaning. his physical condition is never going to allow him to advance much farther mentally. he's got a lot of physical mobility problems.

let me digress a moment because i worked off and on in long term care as well as in acute hospitals for many years. it is a misconception that medicine and nursing can "cure". more properly, there are three options available to the goals (outcomes) of the care we provide:

• improvement/remedy of the patient's condition
  
• stabilization of the patient's condition
  
• support for the deterioration of the patient's condition

a lot of people would not like to even consider that patients can deteriorate and die, but they do. some of the hardest care plans for students to write for the first time are care plans on cancer patients who expected to die. we would like for all our interventions to return people to a useful, productive life. it isn't always gonna happen. during my student clinicals years ago, i did a rotation at a pediatric nursing home and i saw the kind of patient you are writing this care plan for. and, yes, it is basically a plan about dealing with day to day accomplishments of adls.

so, part of your assessment should include the patient's level to help at all in performing adls of

• bathing - can the patient do this at all?
  
• dressing - can the patient do this at all?
  
• mobility - sleeps in crib turned q2 hours, only able to roll side to side, can grab
  • transferring from bed or chair - ???
    
  • walking - ???

  [*]eating - eats a pureed diet. how? is he fed? by who?

  [*]toilet use - continent or incontinent?

  [*]grooming - can the patient do this at all?

the results of the above is your evidence that will support the nursing diagnoses you will use with regard to self-care deficits, and there are 4 of them.

however, you have other abnormal pieces of assessment data that i think you should not ignore. the fact that this child cannot speak and has communication problems ([color=#3366ff]impaired verbal communication), an emotional/bonding issue with a new guardian on board, a risk for injury because of seizures ([color=#3366ff]risk for injury). i would also be concerned about potential respiratory problems ([color=#3366ff]risk for infection) and pain as issues with a scoliosis problem ([color=#3366ff]chronic pain).

hope that gives you some direction.

http://cyfernet.ces.ncsu.edu/cyfdb/browse_2pageanncc.php?subcat=children+with+special+needs&search=nncc&search_type=browse - children with special needs

[Neats, BSN]

Oh Daytonite you are such a wonderful mentor. You are the reason nurses are so thought of highly.

My client does not perform any ADL's, and has no control over bowl/bladder and is fed by staff, you guessed right about my thoght process in regards to nutrition.

Your response has pointed me in the right direction and I suppose I do have to use Risk for I was hoping I would not have to. I will look a little more to see if I can be creative and use critical thinking skills.

Again thank you so very much...I hope you write a book about ND I would be the first to buy it.

[Daytonite, BSN, RN]

Most of your nursing problems (nursing diagnoses) will be actual ones and will be related to self-care deficits. This is very common with long-term care patients. Just sequence them in priority order (food, elimination, mobility, comfort). You should address the communication and emotional need problems (everybody needs love of some kind) as well. That's going to end up being a big care plan for this patient. Mobility issues and treatment alone is going to be a big part of your care plan. Finally, at the end, you can tack on a couple of potential problems if you want. I didn't even think about skin breakdown, but it is a potential complication of the immobility.

[Nat71]

Hello Daytonite,

I would like to find out if you could help me with my POC? I read a lot of books but when it comes to write simple POC I don't think I get it...I haven't practice Nursing in more than 5 years.

Bob is a 34 year old homosexual male, living with his partner of 14 years who is a newly diagnosed with leukemia.

Client should have 3 problems.

Refresher Course gave me sample POC:

Problem #1

Outcome/Goal:

Interventions:

Evaluation:

I wrote 3 problems but I am not sure if I done that correctly, Please help/guide me...

Problem # 1: Knowledge Deficit regarding disease, prognosis, treatment, self-care.

Outcome/Goal: Illness care.

Interventions: Teaching disease process, review pathology of specific form

leukemia and various treatment options.

Evaluation: Knowledge of illness care, patient understanding of

condition/disease process and potential complication, verbalize

of understanding of therapeutic needs, participate in treatment

regimen.

Problem #2: Risk for Infection

Outcome/Goal: Knowledge of Infection Control

Interventions:Infection Protection. Screen/limit visitors as indicated, prohibit

use of live plants/cut flowers. Use alcohol gels to clean hands

when water not available. Restrict fresh fruits and vegetables or

make sure they are washed or peeled. Inspect oral mucous

membranes. Provide good oral hygiene. Use a soft toothbrush,

ponge, or swabs for frequent mouth care. Avoid/limit invasive

procedures. Check for Gram's stain cultures/sensitivity, HIV

test for partner.

Evaluation: Client will:

Identify actions to prevent/reduce risk of infection.

Demonstrate techniques, lifestyle changes to promote safe

environment, achieve timely healing.

Problem #3: Ineffective Role Performance--change in physical capacity and

activity intolerance.

Outcome/Goal: Endurance

Interventions: Energy Management- Evaluate reports of fatigue, noting inability

to participate in activities or ADLs. Encourage client to keep a

diary of daily routines and energy levels, noting activities that

increase fatigue. Implement energy -saving techniques; e.g., sitting, rather than standing.

Provide supplemental oxygen.

Evaluation: Client reports a measurable increase in activity tolerance.

Participates in ADLs to level of ability.

Demonstrates a decrease in physiological signs of

intolerance; e.g.

pulse, respiration, and BP remain within client's normal range.

Client/significant other are participating in ongoing

treatment/support programs.

[Daytonite, BSN, RN]

hello daytonite,

i would like to find out if you could help me with my poc? i read a lot of books but when it comes to write simple poc i don't think i get it...i haven't practice nursing in more than 5 years.

bob is a 34 year old homosexual male, living with his partner of 14 years who is a newly diagnosed with leukemia.

client should have 3 problems.

refresher course gave me sample poc:

problem #1

outcome/goal:

interventions:

evaluation:

i wrote 3 problems but i am not sure if i done that correctly, please help/guide me...

problem # 1: knowledge deficit regarding disease, prognosis, treatment, self-care.

outcome/goal: illness care.

interventions: teaching disease process, review pathology of specific form

leukemia and various treatment options.

evaluation: knowledge of illness care, patient understanding of

condition/disease process and potential complication, verbalize

of understanding of therapeutic needs, participate in treatment

regimen.

problem #2: risk for infection

outcome/goal: knowledge of infection control

interventions:infection protection. screen/limit visitors as indicated, prohibit

use of live plants/cut flowers. use alcohol gels to clean hands

when water not available. restrict fresh fruits and vegetables or

make sure they are washed or peeled. inspect oral mucous

membranes. provide good oral hygiene. use a soft toothbrush,

ponge, or swabs for frequent mouth care. avoid/limit invasive

procedures. check for gram's stain cultures/sensitivity, hiv

test for partner.

evaluation: client will:

identify actions to prevent/reduce risk of infection.

demonstrate techniques, lifestyle changes to promote safe

environment, achieve timely healing.

problem #3: ineffective role performance--change in physical capacity and

activity intolerance.

outcome/goal: endurance

interventions: energy management- evaluate reports of fatigue, noting inability

to participate in activities or adls. encourage client to keep a

diary of daily routines and energy levels, noting activities that

increase fatigue. implement energy -saving techniques; e.g., sitting, rather than standing.

provide supplemental oxygen.

evaluation: client reports a measurable increase in activity tolerance.

participates in adls to level of ability.

demonstrates a decrease in physiological signs of

intolerance; e.g.

pulse, respiration, and bp remain within client's normal range.

client/significant other are participating in ongoing

treatment/support programs.

did i read this scenario correctly? would this problem have made any difference if it had been written as bob is a 34 year old man, whose wife of 14 years has been newly diagnosed with leukemia? at least, that is how i am reading this statement. bob is the significant other of the patient. so, bob is most likely going to end up being the caregiver or support person. the focus of the care plan needs to be on bob, not the person with the leukemia. the person with leukemia, while important, is secondary. so, along with that legal issues might come up, as many states do not recognize a homosexual partner when it comes to next of kin issues, bob is probably going to end up as the caregiver of his partner if i read this correctly.

physical assessment is really not an issue for bob. however, assessing things like finances, health insurance coverage of the patient, his knowledge of the patient's disease, disease process, the treatment that is being planned and how that is going to be accomplished, his flexibility to be able to cope, social networks that he has available to him, or not, and cultural practices must all be examined. anything abnormal becomes the data that will form the foundation for the problems that will be part of this care plan for bob.

problem #2: risk for infection

outcome/goal: knowledge of infection control

interventions:infection protection. screen/limit visitors as indicated, prohibit

use of live plants/cut flowers. use alcohol gels to clean hands

when water not available. restrict fresh fruits and vegetables or

make sure they are washed or peeled. inspect oral mucous

membranes. provide good oral hygiene. use a soft toothbrush,

ponge, or swabs for frequent mouth care. avoid/limit invasive

procedures. check for gram's stain cultures/sensitivity, hiv

test for partner.

evaluation: client will:

identify actions to prevent/reduce risk of infection.

demonstrate techniques, lifestyle changes to promote safe

environment, achieve timely healing.

this diagnosis is unnecessary. bob, the caregiver, isn't at a risk for infection and this doesn't apply to him, so i'm not even going to address anything about what you have posted here.

problem: ineffective role performance--change in physical capacity and activity intolerance.

outcome/goal: endurance

interventions: energy management- evaluate reports of fatigue, noting inability

to participate in activities or adls. encourage client to keep a

diary of daily routines and energy levels, noting activities that

increase fatigue. implement energy -saving techniques; e.g., sitting, rather than standing.

provide supplemental oxygen.

evaluation: client reports a measurable increase in activity tolerance.

participates in adls to level of ability.

demonstrates a decrease in physiological signs of

intolerance; e.g.

pulse, respiration, and bp remain within client's normal range.

client/significant other are participating in ongoing

treatment/support programs.

bob is definitely going to have a change in his role, but is it going to be

ineffective role performance

? this is where doing an assessment points the way to a correct diagnosis since each diagnosis has a set of defining characteristics of which the patient must possess at least one. psychosocial/cultural assessments are more complex and difficult to do.

when you are working with a nursing diagnosis that you never worked with before you should always look at its definition since that is the true expression of the problem.

ineffective role performance

is merely its label (diagnosis). the true problem defined is

patterns of behavior and self-expression that do not match the environmental context, norms, and expectations

(page 180,

nanda-i nursing diagnoses: definitions & classification 2007-2008

). that does not fit with the

change in physical capacity and activity intolerance

that you have listed next to the diagnosis of

ineffective role performance

. i am going to suggest that a

change in physical capacity and activity intolerance

is more along the lines of

caregiver role strain,

or

risk for caregiver role strain

. this is why:

caregiver role strain

(page 29-31,

nanda-i nursing diagnoses: definitions & classification 2007-2008

)

definition:

difficulty in performing family caregiver role.

[this is very different from being ineffective, incompetent, or inefficient at performing the role.]

related factors

(causes of the problem, etiologies) [these are things that would have been revealed during an interview and assessment]

• care receiver health status
  • addiction
    
    
  • codependency
    
    
  • illness chronicity
    
    
  • illness severity [leukemia fits here]
    
    
  • increasing care needs [leukemia probably fits here too]
    
    
  • instability of care receiver's health [leukemia probably fits here too]
    
    
  • problem behaviors
    
    
  • psychological problems unpredictability of illness course
  [*]
  caregiver health status
  • addiction
    
    
  • codependency
    
    
  • cognitive problems
    
    
  • inability to fill one's own expectations
    
    
  • inability to fulfill other's expectations
    
    
  • marginal coping patterns
    
    
  • physical problems
    
    
  • psychological problems
    
    
  • unrealistic expectations of self
  [*]
  caregiver-care receiver relationship
  • history of poor relationship
    
    
  • mental status of elder inhibiting conversation
    
    
  • presence of abuse
    
    
  • presence of violence
    
    
  • unrealistic expectations of caregiver by care receiver
  [*]
  caregiving activities
  [these are the etiologies that support your idea of
  change in physical capacity and activity tolerance in bob, the caregiver
  ]
  • 24-hour care responsibilities
    
    
  • amount of activities
    
    
  • complexity of activities
    
    
  • discharge of family members to home with significant care needs
    
    
  • ongoing changes in activities
    
    
  • unpredictability of care situation
    
    
  • years of caregiving
  [*]
  family processes
  • history of family dysfunction
    
    
  • history of marginal family coping
  [*]
  resources
  • caregiver is not developmentally ready for caregiver role
    
    
  • deficient knowledge about community resources [this may be a possibility - here is where you may need to do a little research about what is available to the gay community]
    
    
  • difficulty assessing community resources
    
    
  • emotional strength
    
    
  • formal assistance
    
    
  • formal support
    
    
  • inadequate community services (e.g., respite services, recreational resources)
    
    
  • inadequate equipment for providing care
    
    
  • inadequate physical environment for providing care (e.g., housing, temperature, safety)
    
    
  • inadequate transportation
    
    
  • inexperience with caregiving [a very good possibility in this situation]
    
    
  • informal assistance
    
    
  • informal support
    
    
  • insufficient finances
    
    
  • insufficient time
    
    
  • lack of caregiver privacy
    
    
  • lack of support
    
    
  • physical energy
  [*]
  socioeconomic
  • alienation from others [cancer is often a disease that alienates patients from others in their lives]
    
    
  • competing roles commitments [job responsibilities]
    
    
  • insufficient recreation
    
    
  • isolation from others

defining characteristics

(the abnormal data, the signs and symptoms that are the evidence of this problem--the patient, bob, must have one or more of them)

• caregiving activities
  • apprehensive about care receiver's care if caregiver unable to provide care
    
    
  • apprehension about the future regarding care receiver's health
    
    
  • apprehension about the future regarding caregiver's ability to provide care
    
    
  • apprehension about possible institutionalization of care receiver
    
    
  • difficulty completing required tasks [a symptom of change in physical capacity and activity intolerance]
    
    
  • difficulty performing required tasks [a symptom of change in physical capacity and activity intolerance]
    
    
  • dysfunctional change in caregiving activities
    
    
  • preoccupation with care routine
  [*]
  caregiver health status
  • physical
    • cardiovascular disease
      
      
    • diabetes
      
      
    • fatigue
      
      
    • gi upset
      
      
    • headaches
      
      
    • hypertension
      
      
    • rash
      
      
    • weight change
    [*]
    emotional
    • anger
      
      
    • disturbed sleep
      
      
    • feeling depressed
      
      
    • frustration
      
      
    • impaired individual coping
      
      
    • impatience
      
      
    • increased emotional lability
      
      
    • increased nervousness
      
      
    • lack of time to meet personal needs
      
      
    • somatization
      
      
    • stress
    [*]
    socioeconomic
    • changes in leisure activities
      
      
    • low work productivity
      
      
    • refuses career advancement
      
      
    • withdraws from social life

  [*]
  caregiver-care receiver relationship
  • difficulty watching care receiver go through the illness
    
    
  • grief regarding changed relationship with care receiver
    
    
  • uncertainty regarding changed relationship with care receiver
  [*]
  family processes
  • concerns about family members
    
    
  • family conflict

i posted all of the above from the nanda taxonomy to help you with assessing this kind of situation and to clarify exactly what this specific nursing problem is. it should also give you an idea of what the significant other of an ill person can experience--and those are the kinds of things you need to be assessing for.

in looking at what you have posted,

endurance

cannot

be an outcome/goal since the definition of this diagnosis is "

patterns of behavior and self-expression that do not match the environmental context, norms, and expectations".

to me

endurance

is not a pattern of behavior, but an ability that one either has or doesn't have.also, i looked at the things you have listed under interventions and evaluation and i am not clear that they refer to bob or the person with leukemia.

problem: knowledge deficit regarding disease, prognosis, treatment, self-care.

knowledge deficit

is more correctly written as

deficient knowledge (specify).

that means you must state the subject of what is lacking. since the nursing diagnosis is only a label (tag, title) it needs to be as short as possible. so, saying

regarding disease, prognosis, treatment, self-care

is saying too much in the diagnosis label. just say

knowledge deficit, leukemia

or

deficient knowledge, leukemia.

outcome/goal: illness care.

a person has a knowledge deficit because they are dumb, don't want to learn, apathetic, don't have access to the information, or just don't know where to go to find the information in the first place. often it's due to a lack to information, but occasionally you'll run into patients that don't want to learn. you can see the nanda information for this diagnosis listed on this webpage:

[color=#3366ff]deficient knowledge (specify)

. the goal(s) need to match with and be the predicted results of your interventions.

interventions: teaching disease process, review pathology of specific form leukemia and various treatment options.

there are four types of nursing interventions (actions), they include the following:

• assess/monitor/evaluate/observe (to evaluate the patient's condition)
  
  
• care/perform/provide/assist (performing actual patient care)
  
  
• teach/educate/instruct/supervise (educating patient or caregiver)
  
  
• manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

it is appropriate for a deficient knowledge problem that you are going to assess, evaluate or observe what bob knows and doesn't know about leukemia, it's prognosis, the treatment that his partner is going to be undergoing, what his partner is going to need assistance with and specifically bob's assistance and what bob may know already about caregiving. so, you will have interventions for that. then, you will have interventions to specifically teach/educate/instruct bob in procedures, if that is something you feel might be necessary. return demonstrations are part of supervision interventions. you also want to include interventions that give bob instructions and direction on who to contact for more information if that becomes necessary. you never discharge a person from your care without a line of contact.

evaluation: knowledge of illness care, patient understanding of

condition/disease process and potential complication, verbalize

of understanding of therapeutic needs, participate in treatment

regimen.

everything you list here is a outcome/goal. evaluation is a

determination

as to whether or not goals and outcomes have been met. i don't see where you have to write goal statements. a goal statement is the exact opposite of a nursing diagnostic statement. both list the evidence (symptoms) that support them. a nursing diagnostic statement has

abnormal assessment data

as its evidence; a goal statement has

normal assessment data

as its evidence. so, evaluation of outcomes/goals will include normal assessment data that you expect to find. if you met the outcomes/goals of your interventions, what was once abnormal will now either be totally resolved (gone), improved or stable.

so if your interventions are

teaching disease process, review pathology of specific form leukemia and various treatment options

then your evaluation is going to be

will be

able to verbalize what leukemia is, how the disease proceeds and the current treatment for it.

these are the positive outcomes/actions/behaviors you expect to occur.

the care plan is a big circle of stuff that is all related to each other. much of it is based up what is found during assessment. that information found during assessment (abnormal data) is then used to develop nursing diagnoses, interventions and outcomes. it is one big circle of rational decision making.

possible other diagnoses for bob here are (any can be turned into a "risk for" diagnosis):

• powerlessness ([color=#3366ff]powerlessness)
  
• hopelessness ([color=#3366ff]hopelessness)
  
• ineffective coping ([color=#3366ff]ineffective coping)
  
• spiritual distress ([color=#3366ff]spiritual distress)
  
• anxiety ([color=#3366ff]anxiety)

[Nat71]

hello daytonite,

thank you very much for the time and effort you put in to answer my question.

after i read your notes i realized that i didn't read this problem correctly. i thought that bob was diagnosed with leukemia, not his partner, but at this point i think that the partner was diagnosed.

i was very confused about this problem.

it would be my dream to have a mentor like you.

thanks again!

[Daytonite, BSN, RN]

Well, kiddo, unless I get sick, I check this forum first every day for care plans questions.

[Nat71]

Great to know that someone willing to help :) Thank you again very very much, I might have some more questions...still working on my refresher course online :)

[Nat71]

Well, kiddo, unless I get sick, I check this forum first every day for care plans questions.

Hello Daytonite,

I received another problem and this is first time I would have to write POC for patient with mental illness. If you just give me some guidance. Your help greatly appreciated.

Steve is a homeless 53 year old schizophrenic. He wanders the streets convinced that the CIA is watching him and trying to take his ‘collection of evidence’ (his paper bag of discarded cups, cans, etc). When he is given medication, sometimes he will take it, if he believes it is for something other than ‘mind control dictated by the CIA’.

[Daytonite, BSN, RN]

Just based on the information in this thread, what should you do first to get started on this?

[Nat71]

Hello Daytonite,

I just realized that I didn't paste my plan, silly me...here is situation:

Steve is a homeless 53 year old schizophrenic. He wanders the streets convinced that the CIA is watching him and trying to take his 'collection of evidence' (his paper bag of discarded cups, cans, etc). When he is given medication, sometimes he will take it, if he believes it is for something other than 'mind control dictated by the CIA'.

I got this simple nursing plan of care...cold you please check and point me to the right direction:

Problem #1 - Impaired Thought Processes.

Outcome/Goal: Promote appropriate interaction (reality orientation)between client and environment. Enhance physiologic stability/health maintenance,

medication compliance. Provide protection; ensure safety need.

Intervention: Determine severity of client's altered thought processes.

Establish a therapeutic nurse-client relationship. Approach slowly with a non-demanding manner, allow periods of silence. Use therapeutic communications (e.g., reflection, paraphrasing) to intervene effectively.Express desire to understand client's thinking by clarifying what is

unclear, focusing on the feeling rather than the content, endeavoring to

understand (in spite of the client's unclearness), listening carefully, and

regulating the flow of the thinking as needed (Active-listening).

Reinforce congruent thinking. Refuse to argue/agree with disintegrated

thoughts. Present reality and demonstrate motivation to understand client

(model patience). Share appropriate thinking and set limits (cognitive

therapy) if client tries to respond impulsively to altered thinking.

Assess rest/sleep pattern by observing capacity to fall asleep, quality of sleep. Graph sleep chart as indicated until acceptable pattern is

established. Assess presence/degree of factors affecting client's

capacity for diversional activities.

Monitor medication regimen, observing for therapeutic effect and side

effects (e.g., anticholinergic [dry mouth, etc.], sedation, orthostatic

hypotension, photosensitivity, hormonal effects, reduction of seizure

threshold, extrapyramidal symptoms, and fatigue/weakness with sore

throat or signs of infection [agranulocytosis]). Administer medications

as indicated.

Evaluation: Client recognizes changes in thinking/behavior. Client identifies

delusions and increases capacity to cope effectively with them by

reduction of pathological thinking, establishes interpersonal

relationships, maintains reality orientation. Patients maintains treatment

compliance.

Problem #2 Disturbed Sensory Perception- Illusions, delusions, and hallucinations.

Outcome/Goal: Client will identify self in relationship to environment, recognize reality

and dismiss internal voice. Demonstrate improved cognitive, perceptual,

affective and psychomotor abilities.

Intervention: Assess the presence/severity of alterations in client's perceptions. Note

possible causative/contributing factors (e.g., anxiety, substance abuse,

fever, trauma, or other organic illnesses/conditions).

Spend time with client, listening with regard and providing support for

changes client is making. Provide a safe environment by not arguing

with or ridiculing the client. Orient to reality by communicating

effectively (clear, concise); reinforcing reality of client's altered

perceptions; and clarifying time, place, and person. Set limits on

client's impulsive response to altered perceptions. Remain with the

client and provide distraction when possible. Be honest in expressing

fears, especially if potential for violence is perceived.

Evaluation: Client orients to reality; verbalizes absence of hallucination, absence

of paranoid statements and delusions; verbal expressions of trust. Client orients in time, place and person.

Problem #3 Anxiety /Fear - Disintegration of thought processes; delusion that others

want to do him harm. Increased perception of danger; focus on self.

Outcome/Goal: Client will respond appropriately to feelings of anxiety by decreasing

regressive or aggressive behaviors (disintegrated thinking/perception

affect), will verbalize no perceived danger in interactions with others.

Intervention: Note the level of the client's anxiety, considering severity, unfulfilled

needs, misperceptions, present use of defense mechanisms, and coping

skills. Establish trust through a patient, supportive, caring, and accepting

relationship. Encourage the client to verbalize fears. Assist client to

identify/communicate sources of anxiety and areas of concern. Assess

for drug effectiveness/side effects. Demonstrate/encourage use of

effective, constructive strategies for coping with anxiety (e.g., relaxation

and thought-stopping techniques, meditation, physical exercise). Use

role-modeling, positive reinforcement. Remain with the client and clarify

reality. Involve client in planning treatment (participation in treatment

increases client's sense of control and provides opportunity to practice

problem-solving skills). Provide information about shelters, support

group for patients with mental illnesses.

Evaluation: Client responds appropriately to feelings of overwhelming anxiety (fears

of being watched by CIA, loss of control, feelings of rejection) by

decreasing regressive or aggressive behaviors (disintegrated

thinking/perception affect), communicates anxious feelings openly in an

acceptable manner. Orient to reality as evidenced by interpreting milieu

correctly. Verbalize no perceived danger in interactions with others.