ncp psych (1).docx

ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
SY 2022-2023 SECOND SEMESTER
_____________________________________________________________________
NURSING CARE PLANS
Patient Name: J.F.I. Age: 26 yrs old Sex: Female
Cell No: Isolation B9 Admitting Diagnosis: Schizophrenia
NCP #: Disturbed Sensory Perception related to altered sensory reception
SUBJECT
IVE
OBJECTIVE NURSING
DIAGNOSIS
SCIENTIFIC
ANALYSIS
PLANNING INTERVENTIONS RATIONALE EXPECTED
OUTCOMES
“  Restlessness
 Disorientati
on
 Poor
Concentratio
n
 Hallucinatio
ns
 Inappropriat
e responses
Disturbed
Sensory
Perception
related to
altered sensory
reception
Definition:
Sensory
perceptual
alteration can
be defined as
when there is a
change in the
pattern of
sensory stimuli
followed by an
abnormal
response to
such stimuli.
Such
perceptions
could be
increased,
decreased, or
Patients with
schizophrenia may
experience
disturbed sensory
perception,
particularly
auditory and
visual
hallucinations,
due to
abnormalities in
the brain’s
processing of
sensory
information.
These
hallucinations
can be
distressing and
interfere with
the patient’s
ability to
function in daily
life.
Additionally,
Short Term Goal:
After 5 hours of
nursing
interventions,
that patient
will be able to:
 Regain or
maintain
usual level
of cognition
 Recognize,
correct or
compensate
for sensory
impairments.
 The patient
will
maintain
role
performance.
 will maintain
social
Independent:
 Address client
by name and
have personnel
wear name tags
and
reintroduce
self as
needed.
 Reorient to
person, place,
time and
events as
necessary.
 Accept the
fact that the
voices are
 To
preserve
client’s
sense of
identity
and
orientati
on.
 To reduce
confusion
and
provide
sense of
normalcy
to
client’s
daily
life.
 Validatin
g that
your
 Patient
will
learn
ways to
refrain
from
respondin
g to
hallucina
tions.
 Patient
will
state
three
symptoms
they
recognize
when
their
stress
levels
are high.
 Patient
will

COLLEGE OF NURSING
_____________________________________________________________________
distorted with
the patient's
hearing,
vision, touch
sensation,
smell, or
kinesthetic
responses to
stimuli.
Altered sensory
processi-ng and
perceptual
inference are
responsible for
the positive
symptoms of
schizophrenia.
Aberrant neuro-
transmitter
signaling in
the sensory
pathway and
abnormal
cortical
plasti-city
mechanisms are
implicated in
the pathology
of
schizophrenia.
One of the core
features of
both
patients may have
difficulty
distinguishing
between reality
and their
hallucinations,
leading to
further confusion
and
disorientation.
Reference:
Weilnhammer V,
Röd L, Eckert AL,
Stuke H, Heinz A,
Sterzer P.
Psychotic
Experiences in
Schizophrenia and
Sensitivity to
Sensory Evidence.
Schizophr Bull.
2020 Jul
08;46(4):927-936
relationship
s.
The patient will
identify
personal
interventions
that decrease or
lower the
intensity or
frequency of
hallucinations
(e.g, listening
to music,
wearing
headphones,
reading out
loud, jogging,
and
socializing).
 The patient
will
demonstrate
one stress
reduction
technique.
Long term Goal:
After 5 days of
nursing
real to the
client, but
explain that
you do not hear
the voices.
Refer to the
voices as
“your voices”
or “voices
that you
hear”.
 Avoid
isolating
client,
physically or
emotionally.
 Be alert for
signs of
increasing
fear, anxiety
or agitation.
reality
does not
include
voices
can help
client
cast
“doubt”
on the
validity
of his
voices.
 To
prevent
sensory
deprivati
on and
limit
confusion
.
 Might
herald
hallucina
tory
activity,
which can
be very
frighteni
ng to
client,
state
that the
voices
are no
longer
threateni
ng, nor
do they
interfere
with his
or her
life.
Evaluation:
Goal unmet:
After five
days of nursing
interventions,
patient was not
able to regain
or maintain
usual level of
cognition and
recognize,
correct or
compensate for
sensory
impairments.

COLLEGE OF NURSING
_____________________________________________________________________
schizophrenia
and ASD are dys-
functional face
emotion recog-
nition and
motion
processing.
Reference:
Doenges,
Moorehouse,
Murr, A, C.
(2020). Nurses
Pocket Guide
(15th ed). F.A
Davis Company
pp. 790
interventions,
that patient
will be able to:
 Learn ways to
refrain from
responding to
hallucinatio
ns.
 The patient
will
demonstrate
techniques
that help
distract him
or her from
the voices.
 Stay with
clients when
they are
starting to
hallucinate,
and direct
them to tell
the “voices
they hear”
to go away.
Repeat often
in a matter-
of-fact
manner.
and
client
might act
upon
command
hallucina
tions
(harm
self or
others).
 The
client
can
sometimes
learn to
push
voices
aside
when
given
repeated
instructi
ons.
especiall
y within
the
framework
of a
trusting
relations
hip.

COLLEGE OF NURSING
_____________________________________________________________________
 Decrease
environmenta
l stimuli
when
possible
(low noise,
minimal
activity).
Dependent:
 If voices
are telling
the client
to harm self
or others,
take
necessary
environmenta
l
precautions.
 Notify
others and
police,
physician,
and
administrati
on according
 Decrease
the
potential
for
anxiety
that
might
trigger
hallucina
tions.Hel
ps calm
client.
 People
often
obey
hallucina
tory
commands
to kill
self or
others.
 Early
assessmen
t and
intervent
ion might
save
lives.

COLLEGE OF NURSING
_____________________________________________________________________
to unit
protocol.
 Intervene
with one-on-
one,
seclusion,
or PRN
medication
(as ordered)
when
appropriate.
Collaborative:
 Collaborate
with other
health team
members in
providing
rehabilitati
ve therapies
and
stimulating
modalities.
 It is
very
important
to
intervene
before
anxiety
begins to
escalate.
 To achieve
maximal
gains in
function
and
psychosoc
ial well-
being.

COLLEGE OF NURSING
_____________________________________________________________________
NCP #: Impaired verbal communication related to altered perceptions as evidenced by disturbances in cognitive associations
SUBJECT
IVE
OBJECTIVE NURSING
DIAGNOSIS
SCIENTIFIC
ANALYSIS
OUTCOMES
“  Stuttering
or slurring
words
 Blunt
affect
 Flat affect
 Thought
blocking
 Alogia
 Perseverati
on
 Neologism
Impaired verbal
communication
related to
altered
perceptions as
evidenced by
Disturbances in
cognitive
associations
Definition:
Verbal
communication
includes any mode
of communication
containing words,
spoken, written,
or signed. People
communicate
verbally through
the vocalization
of a system of
sounds that has
been formalized
into a language.
Our capability to
communicate with
a language that
Patients
with
schizophreni
a often
experience
impaired
verbal
communicatio
n due to
various
factors such
as
disorganized
thinking,
difficulty
concentratin
g, and
auditory
hallucinatio
ns. These
symptoms can
interfere
with the
patient’s
ability to
express
clearly and
coherently,
Short Term Goal
After 5 hours of
nursing
intervention,
the patient
will be able to:
 Express
thoughts
and
feelings
in a
coherent,
logical,
goal-
directed
manner.
 Demonstra
te
reality-
based
thought
processes
in verbal
communica
tion.
Independent:
 Keep voice
in a low
manner and
speak slowly
as much as
possible.
 Keep the
environment
calm, quiet,
and as free
of stimuli
as possible.
 Plan short,
frequent
periods with
a client
 A high-
pitched/lou
d tone of
voice can
elevate
anxiety
levels while
slow
speaking
aids
understandi
ng
 Keep anxiety
from
escalating
and
increasing
confusion
and
hallucinati
ons/delusio
ns.
 Short
periods are
less
stressful,
Short Term:
After 5 hours
of nursing
interventions
the patient
will:
 Express
thoughts
and
feelings
in a safe
and
socially
acceptabl
e manner
 Participa
te in
prescribe
d
therapeut
ic
intervent
ions
 establish
a method
to

COLLEGE OF NURSING
_____________________________________________________________________
is supported by
an organized
system of words,
rather than
merely sounds, is
what sets us
apart from lower
species. It
indicates the
sending of
information and
receiving of
information.
Clarification is
a key component
of verbal
communication.
Effective
communication
does not only
requires the
transmission of
information but
also
clarification of
points made,
expansion of
ideas and
concepts, and
exploration of
factors that fall
out of the
making it
challenging
to engage in
meaningful
conversation
s.
 Spend time
with one
or two
other
people on
structure
d
activity-
neutral
topics.
 Spend two
to three
5-minute
sessions
with the
nurse
sharing
observati
ons in the
environme
nt within
3 days.
 Learn one
or two
diversion
ary
tactics
that work
for
him/her to
decrease
anxiety,
throughout
the day.
 Use clear or
simple
words, and
keep
directions
simple as
well.
 Anticipate
patient
needs and
pay
attention to
nonverbal
cues
and periodic
meetings
give a
client a
chance to
develop
familiarity
and safety.
 The client
might have
difficulty
processing
even simple
sentences.
 The nurse
should set
aside enough
time to
attend to
all of the
details of
patient
care. Care
measures may
take longer
to complete
in the
presence of
a
communicati
on deficit.
communica
te
clearly
to meet
their
needs
 participa
te in
speech
therapy
or other
therapy
to assist
with
effective
communica
tion
 Build
reality-
based
cognitive
process.
Evaluation
Goal unmet:

COLLEGE OF NURSING
_____________________________________________________________________
original thoughts
transmitted.
A variety of
challenges may
arise when using
verbal
communication to
express oneself.
Misunderstanding
s can arise
because of
impaired
communication.
The
responsibility of
the nurse,
whether
encountering the
patient in the
hospital or in
the community,
becomes
recognizing when
communication has
become
ineffective and
then using
strategies to
improve the
transmission of
information.
hence
improving
the
ability to
think
clearly
and speak
more
logically
.
 Assess and
monitor the
patient’s
coherence of
speech and
cognitive
ability.
 Ensure that
the patient
receives
anti-
psychotic
medications
on time,
with the
right dosage
and route.
Have the
patient take
the
medication
in front of
you.
 To help
establish
baseline, as
well as
short-term
and long-
term goals.
 Correct
administrat
ion of anti-
psychotic
mediations
helps the
patient have
clear
thinking and
a more
functional
cognitive
ability.
Patients
with mental
health
problems
such as
having
schizophren
ia may not
take
medications
correctly,

COLLEGE OF NURSING
_____________________________________________________________________
Reference:
Doenges, M. E.,
Moorhouse, M. F.,
& Murr, A. C.
(2008). Nurse’s
Pocket Guide
Diagnoses,
Prioritized
Interventions,
and Rationales
(11th ed.). F. A.
Davis Company.
 Educate the
patient on
ways to
improve
verbal
communicati
on, such
as: Focusin
g on
important
activities
of daily
living and
meaningful
tasks;
Replacing
irrational
thoughts
with
rational
thoughts;
or at all,
so it is
crucial for
the nurse or
carer to
ensure that
the patient
has
swallowed
the oral
medication
completely.
 To gradually
help the
patient
achieve
effective
cognitive
thinking and
functional
speech.

COLLEGE OF NURSING
_____________________________________________________________________
Performing
deep
breathing
exercises
and calming
techniques;
Seeking
support from
staff,
carer,
family, or
other
supportive
people.
 Use
therapeutic
techniques
(clarifying
feelings
when speech
and thoughts
are
disorganize
d) to try to
understand
the client’s
concerns.
 Even if the
words are
hard to
understand,
try getting
to the
feelings
behind them.
NCP #: Disturbed thought process related to mental disorder as evidenced by different types of symptoms indicative of disordered
thinking
SUBJECT
IVE
OBJECTIVE NURSING
DIAGNOSIS
SCIENTIFIC
ANALYSIS
OUTCOMES

COLLEGE OF NURSING
_____________________________________________________________________
“Masaki
t po ang
braso
ko, baka
mamatay
ako, as
verbali
zed by
patient
.”
 Exhibits
thought
blocking
 Alogia
 Rambling
speech
 Word Salad
 Flight of
Ideas
 Loose
association
s
Disturbed thought
process related
to mental
disorder as
evidenced by
different types
of symptoms
indicative of
disordered
thinking
Definition:
The diagnosis of
Disturbed Thought
Processes
describes an
individual with
altered
perception and
cognition that
interferes with
daily living. The
alteration can
result in
cognitive and
perceptual
deficits,
including
difficulty
concentrating,
organizing
thoughts, and
communicating
Patients
with
schizophreni
a may
experience
disturbed
thought
processes
due to
abnormal
brain
activity
that affects
their
ability to
organize and
express
their
thoughts in a
coherent and
logical
manner. This
can lead to
disorganized
speech,
delusions,
hallucinatio
ns, and
difficulty
with
communicatio
n and social
interaction.
Short Term Goal
After 5 hours of
nursing
intervention,
the patient
will be able to:
 Demonstra
te a
decreased
anxiety
level.
 Refrain
from
acting on
delusiona
l
thinking.
 Develop
trust with
the
student
nurses
Long Term
Goals:
After 5 days of
nursing
intervention,
the patient
will be able to:
Independent:
 Maintain a
pleasant,
quiet
environment
and
approach in
a slow,
calm
manner.
 Present
reality
concisely
and briefly
and do not
challenge
illogical
thinking.
 Refrain
from
forcing
activities
and
communicati
ons.
 Listen with
regard.
 Client may
respond
with
anxious or
aggressive
behaviors
if startled
or
overstimula
ted.
 Defensive
reactions
may result.
 Client may
feel
threatened
and may
withdraw
and rebel.
 To convey
interest
and worth
Short Term:
After 5 hours
of nursing
interventions
the patient
will:
 Express
thoughts
and
feelings
in a safe
and
socially
acceptabl
e manner
 Participa
te in
prescribe
d
therapeut
ic
intervent
ions
 establish
a method
to
communica
te
clearly
to meet

COLLEGE OF NURSING
_____________________________________________________________________
effectively.
Disturbed thought
processes can be
caused by various
conditions, such
as mental
illness,
substance abuse,
brain injury, or
medication side
effects.
Reference:
Doenges, M. E.,
Moorhouse, M. F.,
& Murr, A. C.
(2008). Nurse’s
Pocket Guide
Diagnoses,
Prioritized
Interventions,
and Rationales
(11th ed.). F. A.
Davis Company.
 Verbalize
recogniti
on of
delusiona
l thoughts
if they
persist.
 Sustain
attention
and
concentra
tion to
complete
tasks or
activitie
s.
 Demonstra
te two
effective
coping
skills
that
minimize
delusiona
l
thoughts.
 Show
empathy
regarding
the
client’s
feelings;
reassure
the client
of your
presence
and
acceptance.
 Reorient to
time/place/
person as
needed.
 Keep voice
in a low
manner and
speak
slowly as
much as
possible.
to
individual
 The
client’s
delusion
can be
distressing
. Empathy
conveys
your
caring,
interest,
and
acceptance
of the
client.
 Inability
to maintain
orientation
is a sign
of
deteriorati
on.
 A high-
pitched/lou
d tone of
voice can
elevate
anxiety
levels
while slow
speaking
their
needs
 participa
te in
speech
therapy
or other
therapy
to assist
with
effective
communica
tion
 Build
reality-
based
cognitive
process.
Evaluation:
Goal unmet:

COLLEGE OF NURSING
_____________________________________________________________________
 Plan short,
frequent
periods
with a
client
throughout
the day.
aids
understandi
ng.
 Short
periods are
less
stressful,
and
periodic
meetings
give a
client a
chance to
develop
familiarity
and safety.

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