Mental Health fall17 – Nurse Care Plan- Schizophrenia – Flashcards

Previous history with schizophrenia Previous suicidal ideation Current support system Client's perception of current situation Non-reality-based thinking Disorientation Labile affect Short attention span Impaired judgement Distractibility

Immediate: The client will be fee of injury throughout hospitalization. Demonstrate decreased anxiety level within 24 to 48 hours. Respond to reality-based interactions initiated by others, for example, verbally interact with staff for 5 to 10 minutes within 24 to 48 hours Stabilization: The client will interact on reality-based topics such as daily activities or local events. 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.

-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 for information. -Explain procedures, and try to be sure the client understands the procedures before carrying them out. -Give positive feedback for the client's success. -Recognize the client's delusions as the client's perception of the environment. -Initially, do not argue with the client or try to convince the client that the delusions are false or unreal. -Interact with the client on the basis of real things; do not dwell on the delusional material. -Engage the client in one to one activities at first, then activities in small groups and gradually activities in larger groups. -Recognize and support the client's accomplishments. -Show empathy regarding the client's feelings; reassure the client of your presence and acceptance. -Do not be judgemental or belittle or joke about the client's beliefs. -Never convey to the client that you accept the delusions as reality. -Directly interject doubt regarding delusions as soon as the client seems ready to accept this. Do not argue, but present a factual account of the situation. -As the client begins to doubt the delusions or is willing to discuss the possibility that they may not be accurate, talk with the client about his or her perceptions and feelings. Give the client the support for expressing feelings and concerns. -Ask the client if he or she can see that the delusions interfere with or cause problems in his or her life. -If the delusions are persistent but the client can acknowledge the consequences of the beliefs, help him or her understand the difference between holding a belief and acting on it or sharing it with others.

-Promoting safety of client and others and right to privacy and dignity (minimal stimulation) -Establishing therapeutic relationship by establishing trust -Using therapeutic communication -Interventions for delusions --Do not openly confront the delusion or argue with the client --Establish and maintain reality for the client --Use distracting techniques --Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs -Interventions for hallucinations: --help present and maintain reality by frequent contact and communication with client --elicit description of hallucination to protect the client and others. --Engage client in reality based activities such as card playing, occupational therapy, or listening to music -Coping with socially inappropriate behaviors --Redirect the client away from problem situations --Deal with inappropriate behaviors in a nonjudgmental and matter of fact manner; give factual statements; do not scold --Reassure others that the client's inappropriate behaviors or comments are not his or her faults --Try to reintegrate the client into the treatment milieu as soon as possible --Do not make the client feel punished or shunned for inappropriate behaviors --Teach social skills through education, role modeling, and practice -Client and family teaching -Establishing community support systems and care

How to recognize illness and symptoms Recognizing early signs of relapse Developing a plan to address relapse signs Importance of maintaining prescribed medication regimen and regular follow-up Avoiding alcohol and other drugs Self care and proper nutrition Teaching social skills through education, role modeling and practice Seeking assistance to avoid or manage stressful situations Counseling and educating family about the biologic causes and clinical course of schizophrenia and the need for ongoing support Importance of maintaining contact with community and participating in supportive organizations and care

-Drink sugar-free fluids and eat sugar-free hard candy to ease the anticholinergic effects of dry mouth -Avoid calorie laden beverages and candy due to dental issues, weight gain, and they do little to relieve dry mouth -Constipation can be prevented or relieved by increasing intake of water and bulk forming foods in the diet and exercise -Stool softeners are permissible but laxatives should be avoided -Use sunscreen to prevent burning -Rising slowly from a lying or sitting position prevents falls from orthostatic hypotension or dizziness due to a drop in blood pressure. -Monitor the amount of sleepiness or drowsiness you experience. Avoid driving until you know how you will react to the medication -If you forget a dose of medication, take it if the dose is only 3-4 hours late. If more than 4 hours late or next dose is due, omit the forgotten dose.

-risk for other-directed violence -risk for suicide -disturbed thought processes -disturbed sensory perception -disturbed personal identity -impaired verbal communication

-self care deficits -social isolation -deficient diversional activity -ineffective health maintenance -ineffective therapeutic regimen management