Cues Psych Nursing Psychodynamics Planning Therapeutic Rationale with Evaluation

Diagnosis Approach theories

Subjective: Disturbed Short Term Outcome: Independent:
”Nasakin young tumor Thought Process After 2 weeks of 1. Maintain the 1.The nurse’s first
ni mama mary at related to nursing intervention safety of client priority is to
jesus” disintegration of the client will be able and others in the protect the client
boundaries to: environment from and others if the
Objective: between self and • Demonstrate possible harmful delusions or
-GA: others and self reality based effects of the thought disorder
• Blank facial and the thinking in clients thought contains paranoid
expression environment verbal and non disorder. or grandiose
-Motor Behavior secondary to verbal behavior content that may
• Tics and undifferentiated result in harm or
spasms on the schizophrenia as injury. Quiet
chin evidenced by Long Term Outcome: time/seclusion or
-Sensorium and client’s After 2 months of restraint may be
Cognition: statements reflect nursing intervention used along with
• No sense of combined the client will be able medications
concentration segment of reality to: according to
• Visual and fantasy. • Demonstrate facility policies.
hallucination absence of Abraham
-Attitude: psychosis, Maslow’s
• Perplexed delusions and Hierarchy of
-Defense Mechanism illogical speech. Needs states the
second level
• Supression-
involves safety
changing topic
and security needs
when asked
which includes
how she feels
protection, security
• Isolation-
and freedom from
“Naiinip ako
the harm and
 wala akong threatened from
magawa at the harm and
kaibigan dito. threatened
Gusto ko pang deprivation.
mahiga buong
araw.” 2. A calm
-Affective State: approach helps to
• Flat affect 2. Approach the avoid distorting the
-Thought process: client in a slow, client’s sensory-
• Flight of ideas calm, matter of perceptual field,
• Religious fact manner. which could
Delusions promote disturbed
“Oo, nakita ko si St. thoughts and
Gabriel dun sa may perceptions
puno.” Peplau defined
• Neologism psychodynamics
nursing as being
able to understand
one’s own
behavior to help
others identify felt
difficulties and to
apply principlesof
human relations to
the problems that
arise at all levels
of experience.

3. Client’s with
disturbed thought
process interpret
3. Use simple, abstractions
concrete or literal concretely and
explanations, and may
avoid use of misunderstand or
abstractions or misinterpret the
metaphors. meaning of the
message.
According to
B.F.Skinner, thnat
consequences
result from
behavior-broadly
speaking, reward
and punishment.

4. Presenting
reality in a matter
of fact manner
4. Interpret the assists
client’s
misconceptions 5. Satisfying
and misperceived experiences with
environmental others tend to
events in a calm decrease, replace
matter of fact hallucinations.
manner. Correcting
misconceptions or
ideas of reference
without
challenging the
client’s belief
 system.
According to
Roger’s theory, he
described a
variation of self as
the inherent
potentialities of the
actualizing
tendencies that
can suffer the
distorted
expression when
maladjustment
occur resulting in
behavior
destructive to
oneself and
others.
5. Discussing
predelusional
experiences helps
5. Encourage the the client identify
client to gradually threatening
discuss thoughts feelings
experiences that or events and
occurred before associate them
the onset of with reality rather
delusion. than with the
delusional content.
According to B.F.
Skinner Operant
 Conditioning,
positive reinforce
that follow a
behavior increase
the likelihood that
behavior will recur.

Collaborative: 1. Olanzapine is a
1. Continue to medication that is
administer and used to treat
monitor schizophrenia,
prescribed acute manic
medication disorder with
Olanzapine bipolar disorder 1.
(Zydis) 10mg OD It belongs to
itab HS atypical
antipsychotics.
Exact mechanism
is not known. It
may work by
blocking several
neurotransmitters
in the brain.