Senin, 14 Desember 2009


Nursing Management-Nursing Process


Outline of psychiatric history

Name, age , address of patient, name of informant if any and their relationship to the patient

History of present condition

Family History

Personal History

  • early development, health during childhood, nervous problems in childhood, education, occupation, menstrual history, sexual history, marriage,

Past illness

  • past physical illness, medical illness, forensic history


  • relationships, leisure activities, prevailing mood, character, attitudes and standards, premorbid personality

Drugs, alcohol, tobacco

Mental Status Examination

Appearance and behaviour

  • General appearance, facial appearance, posture and movement, social behaviour, consciousness, orientation

Speech –

  • coherent, relevant, goal-directed
  • rate and quantity
  • flow of speech


  • cheerful, elation, euphoric, exaltation
  • depression, anxiety
  • congruent or incongruent

Depersonalization and derealization


  • content and form-persecutory, grandiose, nihilistic, hypochondriacal, religious, reference, guilt, unworthiness, jealousy
  • Well-systematized


hallucinations-auditory or visual, command hallucinations, second person, third person

Attention and concentration

Memory-short term, recent and remote

Insight-Grade 1 to 5

A. Nursing Diagnosis Disturbed Thought Processes

-Disruption in cognitive operations and activities

Assessment Data

§ Non-reality-based thinking, Disorientation, Labile affect, Short attention span, Impaired judgment, Distractibility

Expected Outcomes

§ Be free from injury

§ Demonstrate decreased anxiety level

§ Respond to reality-based interactions initiated by others

§ Verbalize recognition of delusional thoughts if they persist

§ Be free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts



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

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

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

Clear, consistent limits provide a secure structure for the client.

Do not make promises that you cannot keep.

Broken promises reinforce the client’s mistrust of others.

Encourage the client to talk with you, but do not pry for information.

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

Explain procedures, and try to be sure the client understands the procedures before carrying them out.

When the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff.

Give positive feedback for the client’s successes.

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

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

Recognizing the client’s perceptions can help you understand the feelings he or she is experiencing.

Initially, do not argue with the client or try to convince the client that the delusions are false or unreal.

Logical argument does not dispel delusional ideas and can interfere with the development of trust.

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

Interacting about reality is healthy for the client.

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

A distrustful client can best deal with one person initially. Gradual introduction of others when the client can tolerates is less threatening.

Recognize and support the client’s accomplishments (projects completed, responsibilities fulfilled, or interactions initiated).

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

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

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

Never convey to the client that you accept the delusions as reality.

Indicating belief in the delusion reinforces the delusion (and the client’ illness).

Ask the client if he or she can see that the delusions interfere with or cause problems in his or her life.

Discussion of the problems caused by the delusions is a focus on the present and is reality based.

B. Nursing Diagnosis: Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory

-Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli


· Hallucinations (auditory, visual, tactile, gustatory, kinesthetic, or olfactory)

· Listening intently to no apparent stimuli

· Talking out loud when no one is present

· Rambling, incoherent, or unintelligible speech

· Inability to discriminate between real and unreal perceptions

· Attention deficits

· Inability to make decisions

· Feelings of insecurity

· Confusion

Expected Outcomes

· Demonstrate decreased hallucinations

· Interact with others in the external environment

· Verbalize knowledge of hallucinations or illness and safe use of medications

· Participate in the real environment

· Make sound decisions based on reality

· Participate in community activities or programs



Be aware of all surrounding stimuli, including sounds from other rooms (such as television or stereo in adjacent areas).

Many seemingly normal stimuli will trigger or intensify hallucinations. The client can be overwhelmed by stimuli.

Try to decrease stimuli or move the client to another area.

Decreased stimuli decreases chances of misperception. The client has a diminished ability to deal with stimuli.

Avoid conveying to the client the belief that hallucinations are real. Do not converse with the “voices” or otherwise reinforce the client’s belief in the hallucinations as reality.

You must be honest with the client, letting him or her know the hallucinations are not real.

Explore the content of the client’s hallucinations during the initial assessment to determine what kind of stimuli the client is receiving, but do not reinforce the hallucinations as real. You might say, "I don’t hear any voices-what are you hearing?"

It is important to determine if auditory hallucinations are "command" hallucinations that direct the client to hurt himself or herself or others. Safety is always a priority.

Use concrete, specific verbal communication with the client. Avoid gestures, abstract ideas

The client’s ability to deal in abstractions is diminished. The client may misinterpret your gestures

Avoid asking the client to make choices. Don’t ask “Would you like to talk or be alone?” Rather, suggest that the client talk with you.

The client’s ability to make decisions is impaired, and the client may choose to be alone (and hallucinate) rather than deal with reality (talking to you).

Respond verbally and reinforce the client’s conversation when he or she refers to reality.

Positive reinforcement increases the likelihood of desired behaviors.

Encourage the client to tell staff members about hallucinations.

The client has the chance to seek others (in reality) and to cope with problems caused by hallucinations.

If the client appears to be hallucinating, attempt to engage the client’s in conversation or a concrete activity.

It is more difficult for the client to respond to hallucinations when he or she is engaged in real activities and interactions.

Maintain simple topics of conversation to provide a base in reality.

The client is better able to talk about basic things; complexity is more difficult.

Provide simple activities that the client can realistically accomplish (such as uncomplicated craft projects).

Long or complicated tasks may be frustrating for the client. He or she may be unable to complete them.

Encourage the client to express any feelings of remorse or embarrassment once he or she is aware of psychotic behavior; be supportive.

It may help the client to express such feelings, particularly if you are a supportive, accepting listener.

Show acceptance of the client’s behavior and of the client as a person; do not joke about or judge the client’s behavior.

The client may need help to see that hallucinations were a part of the illness, not under the client’s control. Joking or being judgmental about the client’s behavior is not appropriate and can be damaging to the client.

C. Nursing Diagnosis: Disturbed Personal Identity

-Inability to distinguish between self and nonself

Assessment data

· Bizarre behavior, Regressive behavior, Loss of ego boundaries (inability to differentiate self from the external environment), Disorientation, Disorganized, illogical thinking, Flat or inappropriate affect, Feelings of anxiety, fear, or agitation, Aggressive behavior toward others or property

Expected Outcomes

· Be free from injury

· Not harm others or destroy property

· Establish contact with reality

· Demonstrate or verbalize decreased psychotic symptoms and feelings of anxiety, agitation, and so forth

· Participate in the therapeutic milieu

· Express feelings in an acceptable manner

· Reach or maintain his or her optimal level of functioning

· Cope effectively with the illness

· Continue compliance with prescribed regimen, such as medications and follow-up appointments



Reassure the client that the environment is safe by briefly and simply explaining routines, procedures, and so forth.

The client is less likely to feel threatened if the surroundings are known.

Protect the client from harming himself or herself or others

Client safety is a priority. Self-destructive ideas may come from hallucinations or delusions.

Remove the client from the group if his or her behavior becomes too bizarre, disturbing, or dangerous to others.

The benefit of involving the client with the group is outweighed by the group’s need for safety and protection.

Decrease excessive stimuli in the environment. The client may not respond favorably to competitive activities, or large groups if he or she is still actively psychotic.

The client is unable to deal with excess stimuli. The environment should not be threatening to the client.

*Be aware of SOS medications and the client’s varying need for them.

Medication can help the client gain control over his or her own behavior.

Reorient the client to person, place, and time as indicated (call the client by name, tell the client where he or she is, and so forth).

Repeated presentation of reality is concrete reinforcement for the client.

Spend time with the client even when he or she is unable to respond coherently. Convey your interest and caring.

Your physical presence is reality. Nonverbal caring can be conveyed to the client even when verbal caring is not understood.

Make only promises that you can realistically keep.

Breaking your promise can result in increasing the client’s mistrust.

Help the client establish what is real and unreal. Validate the client’s real perceptions, and correct the client’s misperceptions in a matter-of-fact manner. Do not argue with the client, but do not give support for misperceptions.

The unreality of psychosis must not be reinforced; reality must be reinforced. Reinforced ideas and behavior will recur more frequently.

Stay with the client when he or she is frightened. Touching the client can sometimes be therapeutic. Evaluate the effectiveness of the use of touch with the client before using it consistently.

Your presence and touch can provide reassurance from the real world. However, touch may not be effective if the client feels that his or her boundaries are being invaded.

Be simple, direct, and concise when speaking to the client.

The client is unable to process complex ideas effectively.

Talk with the client about simple, concrete things; avoid ideologic or theoretical discussions.

The client’s ability to deal with abstractions is impaired.

Direct activities toward helping the client accept and remain in contact with reality.

Increased reality contact decreases the client’s retreat into unreality.

Initially, assign the same staff members to work with the client.

Consistency can reassure the client.

Begin with one-to-one interactions, and then progress to small groups as tolerated (introduce slowly).

Initially, the client will better tolerate and deal with limited contact.

Set realistic goals. Set daily goals and expectations. Unrealistic goals will frustrate the client.

Daily goals are short term and easier for the client to accomplish.

At first, do not offer choices to the client (“Would you like to go to activities?” “What would you like to eat?”). Instead, approach the client in a directive manner (“It is time to eat. Please pick up your fork.”).

The client’s ability to make decisions is impaired. Asking the client to make decisions at this time may be very frustrating.

Gradually, as the client can tolerate it, provide opportunities for him or her to accept responsibility and make personal decisions.

The client needs to gain independence as soon as he or she is able. Gradual addition of responsibilities and decisions gives the client a greater opportunity for success.

D. Nursing Diagnosis: Impaired Social Interaction

“Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.”

Assessment data

· Inappropriate or inadequate emotional responses, Poor interpersonal relationships, Feeling threatened in social situations, Difficulty with verbal communication, Exaggerated responses to stimuli, Difficulty trusting others, Difficulties in relationships with significant others, Poor social skills

Expected Outcomes

· Report increased feelings of self-worth

· Identify strengths and assets

· Engage in social interaction

· Participate in the trust relationship

· Demonstrate ability to interact with staff and other clients within the therapeutic milieu

· Assume increasing responsibility within the context of the therapeutic relationship

· Use community support system successfully

· Participate in follow-up or outpatient therapy as indicated


* denotes collaborative interventions


Provide attention in a sincere, interested manner.

Flattery can be interpreted as belittling by the client.

Support any successes or responsibilities fulfilled, projects, interactions with staff members and other clients, and so forth.

Sincere and genuine praise that the client has earned can improve self-esteem.

Avoid trying to convince the client verbally of his or her own worth.

The client will respond to genuine recognition of a concrete behavior rather than to unfounded praise or flattery.

Teach the client social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, and so forth. Discuss the type of topics that are appropriate for casual social conversation, such as the weather, local events, and so forth.

The client may have little or no knowledge of social interaction skills. Modeling provides a concrete example of the desired skills.

Help the client improve his or her grooming; assist when necessary in bathing, doing laundry, and so forth.

Good physical grooming can enhance confidence in social situations.

E. Nursing Diagnosis: Noncompliance

Assessment data

· Objective tests indicating noncompliance, such as low neuroleptic blood levels

· Statements from the client or significant others describing noncompliant behavior

· Exacerbation of symptoms

· Appearance of side effects or complications

· Failure to keep appointments

· Failure to follow through with referrals

Outcome Identification

· Identify barriers to compliance

· Recognize the relationship between noncompliance and undesirable consequences (i.e., increased symptoms, hospitalization

· Verbalize acceptance of illness

· Identify risks of noncompliance

· Adhere to therapeutic recommendations independently

· Inform care provider of need for changes in therapeutic recommendations

Films on Schizophrenia

A beautiful Mind (1949)

The Fisher King (1991)

Birdy (1984)

The Madness of King George (1994)

Promise (1986)

Taxi Driver (1976)


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  5. Schultz, JM., Videbeck, SL. Psychiatric Nursing Care Plans. 7th Edition. LWW Philadelphia 2004