Paranoid Schizophrenia NCP

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The document discusses a nursing care plan and drug study. The care plan involves assessing a patient experiencing hallucinations and developing a plan to help bring the patient back to reality in a safe manner. The drug study provides information on chlorpromazine and trifluoperazine, including their classifications, dosages, indications, actions, contraindications, adverse reactions, and nursing considerations.

The patient is experiencing hallucinations, agitation, irritability, and disturbed thought processes related to paranoid schizophrenia.

The planned interventions include approaching the patient calmly, reorienting them to time/place/person, encouraging expression of feelings, validating perceptions while correcting misperceptions, and reinforcing reality. This is to help establish trust and bring the patient safely back to reality.

I.

Nursing Care Plan

Assessment Nursing Diagnosis Planning Interventions Rationale Outcomes


Subjective: Violence: After 2days of nursing Observe and maintain For client safety. After 2days of nursing
“The implant is gone” Self-directed intervention the client or listen to the client intervention the goal was met
-as verbalized by the patient related to will not harm himself and for early cues of as evidenced by:
impaired sensory the others. distress and a calm
perception attitude to client. - Maintained good
Objective: secondary to interpersonal relationship
  paranoid Re-orient the client to Repeated with the people in his
 - Irritable schizophrenia person, place, and presentation of reality surroundings.
- Agitated   time. is concrete
-Seen scratching an open reinforcement for the - Client did not harm self or
wound with some numbers in client. others.
it which the client thought
was an implant/code. Provide emotional Providing support and
support, positive encouragement
reinforcement. during the experience
increases the patient’s
sense of security and
control. Positive
reinforcement
enhances self-esteem.

Developed a Presence, acceptance


therapeutic nurse- and conveyance of
client relationship positive regard
through frequent, enhance the client’s
brief and an accepting feeling of self-worth.
attitude. Show
unconditional positive
regard.
Encouraged to Verbalization of
verbalize feelings. feelings in a
nonthreatening
environment may help
client come to terms
with long unresolved
issues.

Reestablish the client Reality must be


what is real and reinforced. Reinforced
unreal. Validate reality and behavior
client’s real will recur more
perceptions, and frequently.
correct the client’s
misperception.

.
Assessed for any Patient experiencing
suicidal ideation or hallucination may
violent behavior. tend to be violent.

Maintained distance Patient will be violent.


from client.

Provided client with a To provide feeling of


sense that caregiver is safety.
in control of the
situation.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE Disturbed thought After 8 hours of Approach in a calm To established nurse-patient After 8 hours of
“Let go of me! They are process related to therapeutic nursing manner. relationship. continuous nursing
Russians! They are Russians!” Paranoid intervention the patient intervention patient
-as verbalized by the patient Schizophrenia. will be responding to Assess signs and To determine immediate and was able to answer
when he was brought to the questions being asked symptoms of physical appropriate nursing questions being asked
mental institution
appropriately. illness. intervention. appropriately.
OBJECTIVE : Re- orient client to To bring back to reality.
- Agitated time, date, place,
- Irritable person.
- Rapid shift of mood.
- Answers questions Encouraged to do For the patient not to
being asked activity of daily living remember or feel the
inappropriately. independently. triggering factors and to
maintain body functions.

Interact with the client Interacting about reality in


on a real basis. healthy.

Encouraged For appropriate and


verbalization of feelings immediate nursing
and concerns. intervention.

.
Seen from time to time. To ensure safety and for
assessment of other signs and
symptoms.
DRUG STUDY

Name of Classsificatio Dosag Indicatio Action Contraindicatio Adverse Reaction Nursing Intervention
Drugs n e n n
Chlorpromazin Antipsychotic 25mg, Tsychosis Unknown, A Contraindicated CNS: Extrapyramidal Patient Teaching
e I.M piperidine in patients reactions, drowsiness,  Warm patient
Hydrochloride phenothiazin hypersensitive sedation, seizures, to avoid
e that to drug; in tardioe dyskinesia, activities that
probably those with CNS pseudodoparkinsonis require
blocks post depression, m, dizziness, neurotic alertness or
synaptic bone marrow malignant syndrome. good
dopamine or subcortical CV; Hypotension, coordination
receptors in damage, and tachycardia until effects of
the brain. those on coma. EENT: Ocular changes, drug are
blurred vision, nasal known.
congestion Drowsiness
GI: Dry mouth, and dizziness
constipation, nause usually
GU: Urine retention, subside after
priapism first few
SKIN: mild weeks.
photosensitivity  ALERT: Advise
reactions allergic patient not to
reactions, skin crush, chew,
pigmentation change. or break
extended
release
capsule form
before
swallowing.
 Tell patient to
avoid alcohol
while taking
drug.
 Have patient
report signs of
urine
retention or
constipation.
 Tell patient to
use sunblock
and to wear
protective
clothing to
avoid
oversensitivity
to the sun.
chlorpromazin
e is more
likely to cause
sun sensitivity
than any
other drug in
its class.
 Tell patient to
relieve dry
mouth with
sugarless gum
or hard candy.
Advise patient
receiving drug by any
method other than
by mouth to remain
lying down for I hour
afterward and to rise
slowly.

Name of Classsificatio Dosag Indication Action Contraindicatio Adverse Reaction Nursing Intervetion
Drugs n e n
Trifluoperazin Antipsychotic 5mg, Schizophrenia Unknown, A Contraindicated CNS: Extrapyramidal Patient Teaching
e P.O. , other piperidine in patient reactions, drowsiness,
Hydrochloride BID psychotic phenothiazin hypertensive to sedation, seizures,  Warm
disorder e that phenothiazines tardioe dyskinesia,
probably and in those pseudodoparkinsonis patient to
blocks post with CNS m, dizziness, neurotic
synaptic depression malignant syndrome. avoid
dopamine coma, or liver CV; Hypotension,
receptors in damage tachycardia activities
the brain. EENT: Ocular changes,
blurred vision, nasal that require
congestion
GI: Dry mouth, alertness
constipation, nause
GU: Urine retention, until effects
priapism
SKIN: mild of drug are
photosensitivity
reactions allergic known.
reactions, skin
pigmentation change.  Tell patient
to avoid

alcohol

while taking

drug.

 Instruct

patient to

properly

dilute liquid.

 Tell patient

to report

signs of

urine

retention or

constipation

Advise patient to
relieve dry mouth
with sugarless gum
or hard candy

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