LAGUARDIA COMMUNITY COLLEGE
CITY UNIVERSITY OF NEW YORK
DEPARTMENT OF NATURAL & APPLIED SCIENCE
PRACTICAL NURSING PROGRAM
DOCUMENTION OF THE NURSING PROCESS
STUDENT NAME: MANOLITO GULLA___________________ DATE: ____1/22/07____________
MEDICAL DIAGNOSIS:
CLIENT’S INTIALS:
_SCHIZOAFFECTIVE DISORDER (BIPOLAR TYPE)_______________________
INSTRUCTOR
L.M.
ALVIN BRADLEY
CLIENT CARE OBJECTIVE (S):TO RELIEVE CLIENT’S SYMPTOMS THROUGH APPROPRIATE ANTIPSYCHOTIC MEDICATIONS AND BEHAVIOUR THERAPY.
_______
_______
ASSESSMENT
(SUBJECTIVE/OBJECTIVE)
Data Collection
Subjective:
“It is raining outside. John
Lennon’s spirit is inside my
body”
“I was feeling depressed that’s
why they put me here”
Objective:
CLIENT’S PROBLEM
(S)/NEED(S)
(USE NURSING
DIAGNOSIS
STATEMENTS)
Disturbed Thought Processes
related to inability to evaluate
reality as evidenced by flight of
ideas and grandiose delusions.
CLIENT SHORT TERM
GOAL/OUTCOME
(PLANNING)
Have reality-based thinking.
Have a brief reality-based
conversations with staff
Take medications regularly
NURSING
INTERVENTION
(APPROACH)/ (ACTION)
Provide antipsychotic medications as
ordered and monitor effects.
It is the responsibility of nurses to
access the client’s response to
medications for the purpose of
evaluating their effectiveness.
Look for the client’s strengths and
abilities when providing nursing
care
It is important to look for the
person’s strengths and to
acknowledge the normal parts of
the person.
Reinforce reality. Talk about what is
really happening.
Even conversations about the
simple realities of daily life focus
the client’s attention away from
disorganized thoughts and into the
here and now.
Do not argue with the client about
delusional thoughts.
Clients do not recognize that they
are delusions, and arguments can
force the client to focus on
defending the false ideas. Change
the subject to reality-based topics.
Disorganized sentences
Flight of ideas
Fast rambling speech
Internally preoccupied,
sometimes singing along the
hallway, other times performing
aerobic exercises
SCIENTIFIC RATIONALE
FOR
NURSING INTERVENTION
LAGUARDIA COMMUNITY COLLEGE
CITY UNIVERSITY OF NEW YORK
DEPARTMENT OF NATURAL & APPLIED SCIENCE
PRACTICAL NURSING PROGRAM
Encourage the client to express
feelings of fear or anxiety.
Expressing feeling to the nurse can
be affirming and helpful to clients.
Establish a trusting relationship in
which the client is safe to express
true feelings.
A non-threatening relationship
provides the opportunity to express
unresolved feelings
Offer medications in a confident
way, expecting the client to take
them.
The nurse’s confident attitude
promotes client’s trust.
Teach clients stress management
techniques such as going to their
rooms and doing relaxation
exercises.
Practicing new coping behavior
teaches adaptive coping skills.
Keep in touch with family and
important friends
Approach client with an accepting
attitude. Be honest and sincere.
Acceptance, honesty, and sincerity
promotes trust.
Maintain healthy social
interactions with family, close
friends and neighbors
Interact with the client individually
and model appropriate social
behavior (body language, topics of
conversation).
Clients often lack social skills and
benefit from role modeling as a
way to learn them.
Give positive reinforcement for
client’s voluntary interactions with
others.
Positive reinforcement is an
effective behavioral approach to
behavior change.
Encourage client to attend group
activities in the hospital. Accompany
client at first if necessary.
Client may respond positively to
encouragement from a trusted
nurse.
Grandiose delusions
Unpredictable and impulsive
Poor concentration, distractible
Ineffective Coping related to
internal conflicts as evidenced
by internal preoccupation and
by unpredictable and impulsive
behavior
Impaired Social Interactions
related to impulsivity and
hyperactivity as evidenced by
spontaneous singing and
performing aerobic exercises.
Client will use healthy coping
skills.
Have a routine daily and
weekly schedule
Include enjoyable activities in
schedule
Perform activities of daily
living independently
Reference:
Burke, Karen M., Priscilla LeMone, Elaine Mohn-Brown. Medical-Surgical Nursing Care. Upper Saddle River: Pearson Prentice Hall, 2006.