Care Plan

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Assess/Analyze| Plan | Implement| Evaluate|
Mental Health DX------------------------------------------------- Schizophrenia(DSM-IV TR)Axis I| ------------------------------------------------- Nursing Diagnosis based on Maslow’s Hierarchy of Needs:------------------------------------------------- Safety & Security| Long-Term Goal| Short-Term Goal| Nursing Actions| Scientific Rationale| Evaluation| Related to:Predisposing Factors:Precipitating factors:Noncompliance with medicationsAs Manifested by:(signs and symptoms)Poor hygieneDelusional Thinking| Disturbed Thought ProcessR/TNoncompliance with medication regimenAEBHyper vigilance, distractibility, inaccurate interpretation of the environment, | By time of discharge from treatment client will be able to verbalize the difference between delusional thinking and reality| 1. By week 1 of treatment client will verbalize evidence of no delusional thinking2. By week 1 of treatment client will recognize and verbalize when false ideas occur.| 1a. Nurse will convey her acceptance of clients needs for false beliefs while letting them know they do not share this belief1b. Nurse will use reasonable doubt as a form of therapeutic communication 2a. Nurse will help client connect the false beliefs to times of increased anxiety and teach client relaxation techniques to decrease anxiety2b. Nurse will administer medications as ordered by the physician| 1a. It is important to communicate to the client that you do not share their delusions1b. You should never argue or deny the belief this will cause mistrust 2a. If the client can learn to interrupt increasing levels of anxiety delusional thinking may be prevented2b. Medications assist id=n restoring a client back to a higher level of functioning if compliant| LTGGoal metClient was able to verbalize the difference between delusional thinking and realitySTG1Goal MetClient was able to verbalize evidence of no...
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