1. Nursing C A R E P L A N Schizophrenia
ASSESSMENT DATA
EXPECTED OUTCOMES
Nursing
Diagnosis (or Planning)
• Non–reality-based
thinking
• Disorientation
• Labile affect
• Short attention span
• Impaired judgment
• Distractibility
➤ Disturbed
Thought
Processes
Disruption in
cognitive operations
and activities
Dr. James Malce Alo,RN,MAN,MAPsycho,PhD
Immediate
The client will:
• Be free of injury
• Demonstrate decreased
anxiety level
• Respond to reality-based
interactions
initiated by others
Stabilization
The client will:
• Interact on reality-based
topics
• Sustain attention and
concentration
to complete tasks or activities
Community
The client will:
• Verbalize recognition of
delusional
thoughts if they persist
• Be free from delusions or
demonstrate
the ability to function without
responding to persistent
delusional
thoughts
EVALUATION
IMPLEMENTATION
Nursing Interventions *denotes
collaborative interventions
Nursing Interventions
Be sincere and honest when
communicating with the client.
Avoid vague or evasive remarks.
Be consistent in setting
expectations, enforcing rules,
and so forth.
Do not make promises that you
cannot keep.
Encourage the client to talk with
you, but do not pry or crossexamine for information.
RATIONALE
Rationale
Delusional clients are
extremely sensitive about
others and can recognize
insincerity. Evasive
comments or hesitation
reinforces mistrust or
delusions.
Clear, consistent limits
provide a secure structure
for the client.
Broken promises reinforce
the client’s mistrust of
others.
Probing increases the
client’s suspicion and
interferes with the
therapeutic relationship.
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