c
  

     

 



 



 

 


Subjective: misturbed 


 After 2 hrs of 


 After 2 hrs of
thought melusions, nursing nursing
process magical intervention, the ×0aintain the safety ×Œirst priority is to intervention,
related to thinking, loose client will be able of client and others protect the client the client
disintegration associations, to maintain reality in the environment and others if the was able to
Objective: thinking impaired orientation, from possible client͛s thought maintain
×melusion of judgement. demonstrate harmful effects of disorder contains reality
grandeur reality based the clients thought grandiose or orientation.
×memonstrates 



 thinking in verbal disorder. paranoid that He is
thought Rnaccurate and nonverbal may result in oriented to
insertion interpretations behavior, harm or injury. time when
×Rncoherent of the demonstrate the asked what
speech environment. ability to abstract, ×Approach the client ×A calm approach day it is and
×aresence of conceptualize, in a slow, calm, helps to avoid he was able
auditory c

 reason and matter-of-fact distorting the to exhibit a
hallucinations Alteration in calculate manner. client͛s sensory- positive
×Rncoherent thought consistent perceptual field, abstract,
speech processes which could reason, and
×aatient does promote judgment,
not answer 

 disturbed calculation
questions 
 thoughts and abilities.
directly unless perceptions.
it is repeated.
×^isten attentively ×Ôeen listening
for key themes and helps to elicit
reality-oriented problem areas,
phrases or promotes the
thoughts in the client͛s
client͛s willingness to
communication relate to another
with staff and other person, and helps
clients. meet the client͛s
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needs.

×àe sincere and ×clients are

honest when extremely
communicating sensitive about
with the client. others and can
recognize
insincerity.
—vasive remarks
reinforce
mistrust.

×Assess client͛s ×ºhis assessment

nonverbal may help to meet
behavior, such as the client͛s needs
gestures, facial that cannot be
expression and conveyed through
posture. speech.

×—ncourage the ×arobing increases

client to express client͛s suspicion
feelings and do not and interferes
pry cross examine with the
for information therapeutic
relationship

×Show empathy to ×ºhe client͛s

the client͛s feelings, experiences can
reassure the client be distressing.
of your presence —mpathy conveys
and acceptance acceptance of the
client your caring
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and interest.

×Avoid laughing, × Suspicious

whispering, or clients often
talking quietly believe others
where client can are discussing
see but not hear them, and
what is being said. secretive
behaviors
reinforce the
paranoid
feelings.

×Ñive simple × Ñiving simple

directions using directions lessen
short words and or prevent
simple sentences. confusion of the
patient

×|ever convey to ×ºhe delusion or

the client that his hallucination
delusions and would be
hallucinations are reinforcing if it͛s
real. accepted.

×0aintain reality × 0aintaining

oriented reality based
relationship and relationship and
environment environment lets
the patient know
that the
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relationship is
temporary and
prevents
separation
anxiety

×Ñive positive × aositive

feedbacks and feedback
acknowledge the enhances sense
client of well-being and
makes a more
positive situation
for the client.

×mo not judge or × èhat the client

belittle client͛s feels or thinks is
beliefs. not funny for
him. ºhe client
may feel rejected
if approached by
attempts of
humor.
×Rnstruct the client × Ônowing staff is
to approach staff available to
when frightening protect the client
thoughts occur. helps to reduce
fear and anxiety
when the client
is experiencing
͞scary͟ cognitive
disturbances.
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×Avoid challenging × melusions cannot
the client͛s be changed
delusional system through logic,
or arguing with the and challenging
client. the belief, no
matter how
irrational, may
force the client
to cling to it and
defend it.
×Avoid pursuing the × aersistence of
details of the delusional details
client͛s delusion. may reinforce
the client͛s false
belief and
further distance
the client from
reality.
×mistract the client × mwelling on
from the delusion delusional
by engaging the content may
client in a less increase the
threatening or client͛s anxiety,
more comforting aggression or
topic or activity at other
the first sign of dysfunctional
anxiety or behaviors.
discomfort.

ºeach cognitive ºhis exercise may be

replacement one method of
strategies if the bringing the client
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client is capable, closer to reality,
such as interrupting although it may not
irrational thoughts be appropriate for
with realistic the all client.
thoughts.

c
   
     

 


 



 

 


SUà —cºR
—: Rmpaired Rmmediate: After 3 days of 


 After 3 days of
memory related sometimes nursing ×arovide ×^ong-term nursing
ºhe clarified
to neurological are unable to intervention, the opportunities for memory may intervention
when exactly
disturbances recall client will be able reminiscence or persist after loss the client was
was the 2
information, to verbalize recall past events of recent able to
months he
awareness of memory. verbalize
was referring
Rntermediate: memory problems Reminiscence is awareness of
about his last
—ffects of and accept usually an memory
used of
general limitations of enjoyable activity problems and
marijuana, he
medical current condition for the client. the patient
verbalized ͞
condition or was able to
anong date͟
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ongoing × èritten cues verbalize
Objective: effects of ×—ncourage the decrease the acceptance of
× misorientati substance. client to use client͛s need to his limitations
on to time environment. written cues such recall activities, due to his
× Observed as calendars or plans and so on conditions
experience Root cause: notebooks. from memory.
of Rmpaired
forgetting memory
×ºo lessen feelings
× Scratches ×—ncourage
of
his head 

 ventilation of
powerlessness/h
when he is 
 feelings of
opelessness
unable to frustration,
recall helplessness, and
informatio so forth. Refocus
n attention to areas
× Rnability to of focus and
determine progress.
if a
× ºo avoid
behavior is ×arovide for proper
fatigue
performe pacing of activities
and having
appropriate rest
×Rt is important to
×Allow the client to
maximize
do tasks on his
independent
own, but do not
function, assist
rush him to do it.
the client when
0ake the client feel
memory has
that he can still do
deteriorated
things
further.
independently.
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× ºo meet
×Assist the client individual
deal with functional needs,
limitations and maximizing
identify resources. independence.

×client with
×arovide single step memory
instructions when impairment
instructions are cannot
needed. remember
multistep
instructions.

×ºherapeutic
×mo not contradict
responses
the client who
promote reality
experiences an
while offering
illusion. Rnstead,
solutions that
simply explain
help enhances
reality, and find
the client͛s sense
some practical
and may reduce
solutions to the
fear, anxiety, and
problem
confusion.

×0onitor client͛s
×ºo reduce
behavior and assist
frustration
in use of stress-
management
technique
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Subjective: Self- care deficit Rmmediate: After 2 hrs of 


 After 2 hrs of
͞|ahihirapan related to side Unable to nursing  nursing
ako sa effects of pass soft stool intervention, the ×metermined stool ×Assist in intervention,
pagdumi͟ as psychotropic need to strain patient will color, consistency, identifying the patient was
verbalized by medication as more than verbalize frequency and causative or able to verbalize
the client. evidenced by usual understanding of amount. contributing understanding
changes in bowel the cause and factors and of the cause and
Objective: elimination Rntermediate: appropriate appropriate appropriate
×Altered aain and solutions for the interventions. solutions for the
bowel discomfort changes in bowel changes in
sounds. upon elimination. ×Auscultate bowel ×àowel sounds are bowel
×Used of defecating sounds generally elimination.
chlorprom decreased in
azine Hc^ Root cause: constipation.
as constipation
medicatio ×—ncouraged ×Sufficient fluid
n increased fluid intake is


 intake, unless necessary for the

 contraindicated. bowel to absorb
sufficientamount
s of liquid to
promote proper
stool consistency

×Rnstruct on a high- ×Œiber absorbs

fiber diet as water, which
appropriate adds bulk and
softness to the
stool and speeds
up passage
through the
intestines.

×Rnstruct client on ×Œiber without

the relationship of adequate fluid
diet, exercise and can aggravate,
 fluid intake to not facilitate,
constipation and bowel
impaction. ×function.

c



×consult with the ×Œiber resists
physician or enzymatic
dietician to provide digestion and
well-balance diet absorbs liquids in
high in fiber. its passage along
the intestinal
tract and thereby
produces bul
which acts as a
stimulant for
defecation.
 c
   
     

 


 



 

 


Subjective:  . After 2 hrs of
nursing
×Assist in intervention,
Objective: identifying the patient was
causative or able to verbalize
contributing understanding
factors and of the cause and
appropriate appropriate
interventions. solutions for the
changes in
×àowel sounds are bowel
generally elimination.
decreased in
constipation.

×Sufficient fluid
intake is
necessary for the
bowel to absorb
sufficientamount
s of liquid to
promote proper
stool consistency

×Œiber absorbs
water, which
adds bulk and
softness to the
stool and speeds
up passage
through the
intestines.

×Œiber without
adequate fluid
can aggravate,
 not facilitate,
bowel
×function.

×Œiber resists
enzymatic
digestion and
absorbs liquids in
its passage along
the intestinal
tract and thereby
produces bul
which acts as a
stimulant for
defecation.