NURSING DIAGNOSE

NURSING OUTCOME

INTERVENTION

EVALUATION

• Provide patient with honest and consistent feedback in a nonthreatening manner.
• Avoid challenging the content of patient’s behaviors.
• Focus interactions on patient’s behaviors.
• Administer drugs as prescribed while monitoring and documenting patient’s response to the drug regimen.
• Use simple and clear language when speaking with patient.
• Explain all procedures, tests, and activities to patient before starting them, and provide written or video material for learning purposes.

• Encourage patient to talk about feelings in the context of a trusting, supportive relationship.
• Allow patient time to reveal delusions to you without engaging in a power struggle over the content or the reality of the delusions.
• Use a supportive, empathic approach to focus on patient’s feelings about troubling events or conflicts.
• Provide opportunities for socialization and encourage participation in group activities.
• Be aware of patient’s personal space and use touch judiciously.
• Help patient to identify behaviors that alienate significant others and family members.

• Assess patient’s response to prescribed antipsychotic drug.
• Collaborate with patient and occupational and physical therapy specialists to assess patient’s ability to perform ADLs.
• Collaborate with patient to establish a daily, achievable routine within physical limitations.
• Teach strategies to manage adverse effects of antipsychotic drug that affect patient’s functional status, including:
  • Change positions slowly
  • Gradually increase physical activities
  • Limit overdoing it in hot, sunny weather
  • Use sun precautions
  • Use caution in activities if extrapyramidal symptoms develop.

• Encourage patient to express feelings.
• Focus on patient’s feelings and behavior.
• Provide honest perceptions of reality and feedback about symptoms and behaviors.
• Encourage patient to explore adaptive behaviors that increase abilities and success in socializing and accomplishing ADLs.
• Decrease environmental stimuli.

• Monitor patient for behaviors that indicate increased anxiety and agitation.
• Collaborate with patient to identify anxious behaviors as well as the causes.
• Tell patient that you will help with maintaining behavioral control.
• Establish consistent limits on patient’s behaviors and clearly communicate these limits to patient, family members, and health care providers.
• Secure all potential weapons and articles from patient’s room and the unit environment that could be used to inflict an injury.
• To prepare for possible continued escalation, form a psychiatric emergency assist team and designate a leader to facilitate an effective and safe aggression-management process.
• Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action.
• Frequently monitor patient within the guidelines of facility’s policy on restrictive devices and assess the patient’s level of agitation.
• When patient’s level of agitation begins to decrease and self-control is regained, establish a behavioral agreement that identifies specific behaviors that indicate self-control against a reescalation of agitation.