Disturbed sensory perceptionR/T altered sensory receptionAEB mistrust and suspiciousnessof others. (Doenges, Moorhouse,& Murr,2013, p. 838).
Outcome:Client will recognize and correct orcompensate for sensory impairments within2-3 days. (Doenges, Moorhouse, & Murr,2013, p. 838).
Nurse will approach pt. In a serious,straightforward manner. Reasoning: Beingstraightforward is essential to the success ofthe nurse-client relationship
Nurse will provide explanations of plan ofcare w/client Involving client as much aspossible.
Nurse will help client validate ideas beforetaking action. This requires the ability to trustand listen to one person.
Risk for Social Isolation R/Tmistrust of others and delusionalthinking AEB statement thatneighbors "are not to be trustedand could turn against him for noreason", isolation of self frommother, and escalating distrust ofwife. (Doenges, Moorhouse, & Murr,2013, p. 887).
Before discharge, client will be able to identifycauses of and actions to help correct furtherisolation. Reasoning: Because of the chronicparanoid thoughts and delusions, the patientis often unaware of abnormality of theirthought process that lead to personalisolation and disruption of interpersonalrelationships.(Doenges, Moorhouse, & Murr,2013, p. 887).
The nurse will educate the patient aboutproper coping techniques dealing withfeelings of anger and anxiety. Example:Journaling and Though Stopping.
The nurse will education the patient aboutthe medications he is prescribed and theneed for strict compliance. Reasoning:Because the of the chronic nature of thepatient's mental diagnosis, strict adherenceto the pharmacological regiment may allowfor lessening of signs and symptoms
Evaluation: Goals mostly unmet. Patient doesnot clearly see the detriment of his behaviorsthat are based upon his paranoid dellusions. What little understanding he has, there islimited positive skills to take the place of anylacking negative ones, though what fewpositive interactions where made, clientresponded well to positive reinforcement.
The nurse will provide positive reinforcementwhen client makes appropriate socialinteractions with others