Sample NCP: Disturbed Thought Processes

Assessment	Diagnosis	Scientific Explanation	Planning	Interventions	Rationale	Evaluation
Subjective:      “ Businessman ako ng mga isda for export at mga scraps”      “Dati akong general sa AFP”      “Nakuha ko ang ‘college degree’ sa abroad” Objective: ·   Records show that the client was unemployed prior to the admission to the facility. It was also indicated that he was never part of the army, and was never affiliated with it. Lastly, he only attained education up to the fifth grade only. ·   The client speaks in a loud tone, as if superior. ·   The client has difficulty in admitting mistakes, often uses projection, or blames others.	Disturbed thought processes related to biochemical and neurologic imbalances as evidenced by confabulations and delusions	Genetic vulnerability Prenatal, drugs, alcohol, maternal viral infection, etc. Chronic heightened glucocorticoid release   Hippocampal  damage   Impaired hypothalamus-pituitary-adrenal axis feedback system Disturbed thought processes	Discharge outcome      Upon discharge, the client will be able to: a.    Verbalize correct perception of environment Short Term outcome      After 2 weeks of nursing interventions, the client will be able to: a.  State that the “thoughts” are less intense and less frequent b.  Converse with the nurse regarding concrete happenings in the environment without talking about delusions for 5 minutes or more.	Independent: ·   Utilize safety measures to protect the clients or others. ·   Attempt to understand the significance of these beliefs to the client at the time of presentation. ·   Be aware that client’s delusions represent the way that he experiences reality ·   Do not argue with the client’s beliefs or try to correct false beliefs using facts. ·   Do not touch the client; use gestures carefully ·   Interact with the client on the basis of things in the environment Try to distract the client from his delusion by engaging in reality-based activities (cards, simple board games etc.) ·   Teach client coping skills that minimize worrying thoughts. (talking to a friend, singing, going to the gym etc) Collaborative: ·   Maintain medication regimen. -          haloperidol -          chlorpromazine	Precautions are needed. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Identifying the client’s experience allows the nurse to understand the client’s feelings. Arguing will only increase client’s defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood. A psychotic person might misinterpret touch as either aggressive or sexual in nature. When thinking is focused on reality based activities, the client is free of delusional thoughts during that time. It helps him focus his attention externally. When the client is ready, he can perform these techniques alone. Aims to have the client stay in remission. Alters the effects of dopamine in the CNS Block dopamine receptors in the brain. Reference: Varcarolis, Elizabeth M., Psychiatric NCP, pp. 239-241	Discharge outcome Outcome Achieved      Upon discharge, the client was able to verbalize correct perception of environment. Short Term outcome Outcome Achieved      After 2 weeks of nursing interventions, the client was able to state that the “thoughts” are less intense and less frequent and converse with the nurse regarding concrete happenings in the environment without talking about delusions for 5 minutes or more. Recommendation: Terminate the Plan