Assessment Nursing diagnosis Goals Intervention Implementation Evaluation

Subject Disturbed thought The client  Be sincere and honest  Be sincere and The client
data: processes related to will respond when communicating honest when responded to
Patient says disruption in to reality- with the client. commnicating with reality-based
that his wife cognitive based Avoid vague or evasive the client interactions
has relations operations and interactions remarks. initited by
with other activities evidenced initiated by others
man. by non-reality- others  Be consistent in setting  Be consistent in
based thinking. expectations, enforcing setting expectations,
rules, and so forth. enforcing rules, and
so forth.
 Do not make promises  Do not make
that you cannot keep promises that you
cannot keep

 Encourage the client to  Encourage the client

talk with you, but do not to talk with you, but
pry or cross-examine for do not pry or cross-
information examine for
information
 Explain procedures, and  Explain procedures,
try to be sure the client and try to be sure the
understands the client understands
procedures before the procedures
carrying them out. before carrying them
Objective
data: out.
He looks
 Give positive
suspicious  Give positive feedback feedback for the
and does not for the client’s sucesses. client’s successes
even eat
food.
Assessment Nursing Diagnosis Goals Intervention Implementation Evaluation
Subjective Disturbed personal To establish  Reasssure the client that  Reasssured the client Established
Data: identity related to contact with the environment is safe that the environment contact with
Patient inability to reality by briefly and simply is safe by briefly and reality
complains distinguish between evidenced by explaining routines simply explaining evidenced by
that his wife self and non-self client will routines client
is not faithful evidenced by participate in  Protect the client from  Protected the client participate in
to him bizarre behavior. the harming himself or from harming the therapeutic
therapeutic others himself or herself or milieu
milieu others
 Remove the client from  Removed the client
from the group if his or from the group if his
her behavior becomes or her behavior
too bizarre, disturbing, becomes too bizarre,
or dangerous to others. disturbing, or
dangerous to others.
 Help the client’s group  Help the client’s
accept the client’s group accept the
“strange” behavior. client’s “strange”
behavior.
 Consider the other  Considered the other
client’s needs. Plan for clients needs. Plan
at least one staff for at least one staff
member to be available member to be
to other clients available to other
Objective
data: clients
 Explain to other clients  Explained to other
He express that they have not done
irritable clients that they have
anything to warrant the not done anything to
behavior. client’s verbal or warrant the client’s
physical threats verbal or physical
threats

Assessment Nursing Goals Inntervention Implementation Evaluation

 Diagnosis
Subjective Social isolation Increase  Provide attention in a  Provided attention in a Increased
data: patient related to feelings of sincere, interested sincere, interested feeling of
says that he aloneness self-worth manner. manner. self-worth
does not experienced by evidenced by evidenced
want to talk the individual and client will  Support any successes  Supported any successes by client
to anybody. perceived as demonstrate or responsibilities or responsibilities demonstrate
imposed by others appropriate fulfilled, projects, fulfilled, projects, appropriate
and as a negative emotional interactions with staff interactions with staff emotional
or threatening responses members and other members and other responses
state evidenced clients clients
by poor
interpersonal  Avoid trying to  Avoided trying to
relationships. convince the client convince the client
verbally of his or her verbally of his or her
Objective own worth. own worth.
data: patient
stays away  Teach the client social  Taught the client social
from all skill. Describe and skills. Describe and
people in the demonstrate specific demonstrate specific
ward. skills, such as eye skills, such as eye
contact, attentive contact, attentive
listening, nodding listening, nodding

 Help the client to  Assisted client in

improve grooming; improving grooming
assist when necessary when necessary

Assessment Nursing Goals Intervention Implementation Evaluation

diagnosis
Subjective Self-Care deficit Establish an  Be alert to the client’s  Alert to the client’s Established
data: the related to adequate physical needs physical needs an adequate
patient’s impaired ability balance of  Observe the client’s  Observed the client’s balance of
relative said to perform or rest, sleep, pattern of food and fluid pattern of food and fluid rest, sleep,
he does not complete and activity intake; you may need to intake; you may need to and activity
maintain bathing/hygiene evidenced monitor and record monitor and record evidenced
person activities for by the client intake,output, and daily intake,output, and daily by the client
hygiene. oneself will weight weight will
evidenced by complete  Monitor the client’s  Monitored the client’s complete
poor personal daily tasks elimintion patterns elimintion patterns daily tasks
hygiene with with
Objective  Exlain any task in short,  Exlained any task in
minimal minimal
data: he simple steps short, simple steps
assistance assistance
looks untidy  Using clear, direct  Using clear, direct
and umkept. sentences, instruct the sentences, instruct the
client to do one part of the client to do one part of
task at a time the task at a time
 Tell the client your  Told the client your
expectations directly. expectations directly.
Do not ask the client to Do not ask the client to
choose unnecessarily. choose unnecessarily.
 Allow the client ample  Allowed the client ample
time to comlete any task. time to comlete any task

Assessment Nursing Goals Intervention Implementation Evaluation

 dignosis
Subjective Ineffective Complete  If the client has delusions  The client has delusions Completed
data: the health necessary that prevent or limit rest, that prevent or limit rest, necessary daily
patient says maintence daily sleep, or food or fluid sleep, or food or fulid activies with
that he does related to activities intake , it may be intake, it is necessary to minimal
not have inability to with necessary to institute institute measures that assistance
intrest in identify, ma minimal measures that deal directly deal directly with health.
doing any assistanc with physical health.
activities e
 If the client thinks that his  The client thinks that his
or her food is poisioned or or her food is poisioned or
that he or she is not that he or she is not
worthy of food, it may be worthy of food, it may be
Objective necessary to alter necessary to alter
data: patient rountines. rountines.
does not take
care of self.
The does not  If the client is too  The client is too
sleep suspicious to sleep, try to suspicious to sleep, try to
properly. allow the client to choose allow the client to choose
a place and time in which a place and time in which
he or she will feel most he or she will feel most
comfortable sleeing. comfortable sleeing.
Sedatives as needed may Sedatives as needed may
be indicated be indicated
HEALTH EDUCATION

I. Patient teaching on discharge plan

 Instruct the patient to take more protein and vitamins Rehabilitation
 Residential treatment
 Local support groups
 Addiction counseling
 Advise the patient to take bath daily
 Advise to change cloths daily
 Encourage social interaction.
 Improve the self-care needs (personal hygiene) independently
 Sleep and hygiene techniques.
 Instruct to use relaxation when getting aggressive
 Taught about the positive coping methods
 Prevention o self-harm and others.
 Advised to spend more time with family
 Advice the patient for regular checks up and follows up.
II. Family teachng on discharge plan
 Family’s to use alternative coping methods
 Educated regarding medication-dosage and side effects of the medication
 Advise to spend more time with patient

SUMMARY

Mr. Govind Wadiyar was brought to the psychiatric ward with the complaints of disturbed sleep
and irritable behavior. He would not sleep at night and would go out of the house, roam in the
nerby area and would come back on its own. He would watch T.V all throughout the night ,
saying that he does not feel tired and doesn’t need to sleep. At times, he would become abusive
towards the family, under the influence of alcohol. Wife reports that he would mutter and smile
for no apparent reason. On being asked, he would say that he was communicating with birds. His
mother and siblings who had expired long ago, came back in the form of birds to interact with
him. Then he is diagnosed as a case of schizophrenia.
 THEORY APPLICATION

Paplau’s Interpersonal theory:

The core of peplau’s approach is interpersonal relations. The theory includes the concept such as:

 Communication,
 Roles and
 Growth and development.
Communication us a problem solving process whereby the nurse the client collaborate to
meet the clients need. The nurse may assume the roles of:
 Counselor,
 Leader,
 Resource,
 Surrogate, and
 Teacher.

These roles are designed to lead to growth and development

 Growth and development

Orientation

- Estblished working relationship

- Collected history of illness
- Oriented to hospital
Identification
- Classify perceptions
- Identify problems
Teacher - Discussed the solutions

Resource Exploitation
Nurse Patient
- Create a non threatening atmosphere
Counselor
- Encourage client participation inCOMMUNICATION
problem solving
Resolution
Leader - Evaluated the outcomes
- Reduced anxiety
- Increased problems solving activities
Surrogate

Peplau’s Nurse-client Interpersonal Framework