NCP 2 in RLE 117

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NURSING CARE PLAN

Cues Need Nursing Objective of Nursing Intervention Expected


Diagnosis Care Outcome/Evaluation

Subjective cues: P Impaired verbal Within the span Independent: After the span of care the
When talked to, he S communication of care the client  Attempt to decode incomprehensible communication patterns, seek client able to express
would not answer Y related to will be able to validation and clarification. ideas, needs concerns as
but was observed C neurologic express ideas, R. These techniques reveal how the client is being perceived by others. evidenced by minimal
mumbling H impairement. needs concerns.  Maintain non-verbal communication is not very successful looseness of association,
incomprehensible O R. Presence of nurse is a contact with reality for the client and can also neologisms and concrete
sounds to self. L Schizophrenia demonstrate the nurse’s interest and care for the client. thinking.
O refers to a group of  Call client by name, make reference to the day and time and
Objective cues: G severe, disabling comment on the environment.
 Poorly I psychiatric R. They’re all helpful ways to continue to contact with a client having
groomed, C disorders marked problems with reality orientation and verbal communication.
NEED by withdrawal from  Maintain frequent contact and spent time with client.
 Poor eye reality, illogical R. Clients who are left alone for long periods of time become more deeply
contact Safety and thinking, possible involved in their psychosis.
security delusions and  Listen for themes, or recurrent statements, ask clarifying questions
 Refuses to eat hallucinations, and or cues.
Maslow's emotional, R. To promote increased understanding.
 Answered hierarchy of behavioral, or  Let client know that her meaning is not clear.
questions with needs intellectual R. It is never useful to pretend to understand: it violates the trust
looseness of disturbance. The relationship between client and nurse.
assocation. most common early
warning signs of Ref: Psychiatric Mental Health Nursing by: Sheila Videbeck page
 Noted with schizophrenia are 313
thought usually detected
blocking ( as until adolescence.
evidence by These include
past 3 mos, he depression, social
has been withdrawal, unable
observed to to concentrate,
be always hostility or
staring blankly suspiciousness,
in space) poor expressions of
emotions,
insomnia, lack of
 Difficulty in
personal hygiene,
falling asleep
or odd beliefs.
(as admitted
by the
Ref.
patient)
Paul Martin, BSN,
R.N., 2019
 He denied
https://nurseslabs.c
any forms of
om/schizophrenia-
hallucinations
nursing-care-plans/

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