Nursing Prioritization (Schizophrenia)

7/29/2019 Nursing Prioritization (Schizophrenia)

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Nursing Prioritization

Date Identified Subjective Cues Problem/Nursing Diagnosis Justification

January 24, 2013 Minsan wala akong ganang kumain. Nutrition less than body requirement

as manifested by below the averageBMI.

This is the 1st to be prioritized because

according to Maslow, because food is one

of the basic needs of man, so the patientshould satisfy this first.

January 29, 2013 Ayaw ko ng umuwi sa barrio namin

dahil nalaman nilang nagkasakit ako

sa isip at pinagtsitsismisan ako.

Social Isolation related to traumatic

incidents causing emotional pain.

This is the 2r

to be prioritized becauseaccording to Maslow, the hierarchy

explains that before you attain thehigher level, you must surpass the

lowest level which is the physiologicneeds.

January 24, 2013 Pano ba sabihin yun? AhmBasta

ang hirap ipaliwanag kasi.

Impaired Verbal Communication as

manifested by flight of ideas.

This is the 3r to be prioritized because

according to Maslow, esteem need should besatisfy, because if the client cannot express his

feelings he cannot socialize with other people.

January 24 & 25, 2013 Jan. 24: Patay na yung tatay ko.Hindi man lang ako pinayagan na

makalabas para makapunta sa libingniya.

Jan. 25:Gusto kong umuwi paramakita yung tatay ko. Nakaratay kasi

siya dahil may sakit siya.

Disturbed thought process related tomental disorder (undifferentiated

schizophrenia).

This is the 4t

to be prioritized becauseyou need to surpass all the four levels

before attaining the highest levelwhich is self-actualization.

January 24, 2013 Nangangati ako dahil sa sugat sugat

ko.

Risk for impaired skin integrityrelated to broken skin.

This is the 5t

to be prioritized becauseaccording to the rule risk problem should

prioritized least, because actual problemshould be solve first.


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Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective cues:

Minsan wala akong

ganang kumain, asverbalized by the client.

Objective cues:

Weight: 110 lbs. BMI:18.3

(underweight)

Nutrition less than body

requirement as evidenced

by 18.3 BMI.

Long term:

After 1 day of nursing

intervention the client

will be able to:a. Demonstrate

behaviors, lifestylechanges to regain

and/or maintainappropriate weight.

Short term:

After 30 minutes ofnursing intervention the

client will be able to:a) verbalize specific

foods that the clientcan eat to help him

for fast recoveryand foods that he

will avoid.

Independent:

Provide informationregarding specific

nutritional needs. Emphasize

importance of well

balance, nutritiousintake of foods.

Provide informationregarding individual

nutritional needs andways to meet these

needs withinfinancial constraints.

Weigh at regularintervals anddocument result.

Helps to determinenutritional needs.

To impart knowledgeand to maintain theadequacy of intake of

nutrients needed.

To monitor clientsweight.

Goal met


intervention the client

has increase appetite.

Goal met

After 30 minutes ofnursing intervention the

client can verbalize foodthat the patient can take

and avoid to help him forfast recovery.


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Subjective Cues:Ayaw ko ng umuwi sa

barrio namin dahilnalaman nilang

nagkasakit ako sa isip at

pinagtsitsismisan ako,as verbalized by theclient.

Objective Cues:

Poor eye contact Not that cooperative

Social Isolation related to

traumatic incidents

causing emotional pain.

Long term:

After 2 days of nursing

intervention the clientwill be able to:

a. express increasesense of self worth.

Short term:

After 30 minutes of

nursing intervention theclient will be able to:

a. verbalizewillingness to be

involve with others.

b. participate inactivities.

Provide attention in asincere, interested

manner.

Support anysuccesses orresponsibilitiesfulfilled, projects,

interactions with staffmembers and other

clients, and so forth.

Avoid trying toconvince the clientverbally of his or her

own worth.

Teach the clientsocial skills. Describeand demonstrate

specific skills, suchas eye contact,attentive listening,

and so forth. Discussthe type of topics that

are appropriate forcasual social

conversation, such asthe weather, local

events, and so forth.

Flattery can beinterpreted as

belittling by theclient.

Sincere and genuinepraise that the clienthas earned canimprove self-esteem.

The client willrespond to genuinerecognition of a

concrete behaviorrather than to

unfounded praise or

flattery.

The client may havelittle or noknowledge of social

interaction skills.Modeling provides a

concrete example ofthe desired skills

Goal met

After 2 days of nursing

intervention the clientexpresses increase sense

of self worth.

Goal met

After 30 minutes of

nursing intervention theclient verbalize

willingness to beinvolved with others and

participate in activities.


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Help the clientimprove his or her

grooming.

Good physicalgrooming can

enhance confidencein social situations.


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Subjective Cues:Pano ba sabihin yun?

AhmBasta ang hirapipaliwanag kasi, as

verbalized by the client.

Objective Cues:

Speaks/verbalizeswith difficulty;stuttering; slurring.

Difficultyexpressing thoughts

verbally.

Inappropriateverbalization

[incessant, looseassociation of ideas;flight of ideas].

Impaired Verbal

Communication as

manifested by flight of

ideas.

Long term:


intervention the clientwill be able to:

a. Verbalize orindicate anunderstanding of thecommunication

difficulty and plansfor ways of

handling.b. Establish method of

communication inwhich needs can be

expressed.

Short term:After 30 minutes of

nursing intervention theclient will be able to:

a. Participate well intherapeutic

communication.

Listen attentivelywhen the patient

attempts tocommunicate.

Clarify your

understanding of thepatientscommunication.

Maintain eye contactwith the patient when

speaking. Standclose, within the

patients line ofvision.

Give the patientample time to

respond.

Avoid finishingsentences for the

patient. Be calm and

accepting duringcommunicationattempts. Do not say

Decreasesfrustration and

demonstrates caring.

Eye contact lets thepatient know that

they have yourattention when trying

to communicate.Patients with

artificial airways mayneed to lip words and

standing in front of

the patient will allowthe nurse a betterview to understand

the patient.

t may be difficult forpatients to respondunder pressure, they

may need extra timeto convey thoughts.

This may lead tofrustration anddecrease the patients

trust in you.

Goal met


intervention the clientVerbalize or indicate an

understanding of the

communication difficultyand plans for ways ofhandling and establish

method ofcommunication in which

needs can be expressed.

Goal met

After 30 minutes of

nursing intervention theclient participate well in

therapeutic

communication.


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you understand if youdont.

Orient the patient tosurroundings. State

procedural and taskintentions when

providing care.

Not knowing who isproviding care orwhere they are can be

a stressor to the

patient. Patient mayprefer that the nursegive them some

indication of whatthey will be

experiencing,especially if it will

cause discomfort.

Nursing Prioritization (Schizophrenia)

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