- Disturbed Sensory Perception related to altered sensory perception and Misuse of medications, alcohol, or illegal substances as evidenced by Talking or laughing to self and seeing or hearing things that aren’t there (hallucinations)
- Impaired Social Interaction related to disturbed thought processes and inability to perceive or interpret the intentions of others as evidenced by Difficulty focusing or paying attention and disorganized speech or thoughts
- Risk For Self/Other-Directed Violence Related to suspiciousness of others and Delusional thinking as evidenced by signs of wanting to harm themself or others
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalize and Expressed by the patient Hallucinations Objective data: -Talking or laughing to self -Rapid mood swings -Seeing or hearing things that aren’t there (hallucinations) -Inappropriate responses -Disorientation -Tilting head as if to listen to something | Disturbed Sensory Perception related to altered sensory perception and Misuse of medications, alcohol, or illegal substances as evidenced by Talking or laughing to self and seeing or hearing things that aren’t there (hallucinations) | Patient will identify and modify external factors that contribute to alterations in perception Patient will maintain safety until the psychotic episode resolves Patient will verbalize an understanding that hallucinations are not reality-based and demonstrate how to interrupt them | 1. Remove the client from chaotic environments. Reduce stimulation that may cause worsening hallucinations. If around people, move to an area that is solitary (with supervision) and reduce noise and lighting. 2. Provide safety. Safety is always the #1 priority, especially when a patient is mentally and emotionally unstable. 1:1 supervision may be necessary and the removal of items that could be potentially harmful. 3. Aid distraction. Patients can distract themselves from hallucinations by listening to music, wearing headphones, writing, drawing, or playing games. It can also be helpful to remind the patient that when experiencing a hallucination to loudly state “Go away!” or “Leave me alone!” to gain control. 4. Help the patient recognize triggers. Attempt to decrease delusional behavior by uncovering triggers such as during times of intense stress or anxiety and learning how to cope with these feelings. | Patient identified and modified external factors that contribute to alterations in perception Patient will maintain safety until the psychotic episode resolves Patient verbalized that hallucinations are not reality-based and demonstrate how to interrupt them |
| Subjective data: Verbalizes and Reported Poor Social Interaction Objective data: -Difficulty focusing or paying attention -Fearful or anxious around others -Inappropriate emotional responses -Poor eye contact -Spends time alone -Disorganized speech or thoughts | Impaired Social Interaction related to disturbed thought processes and inability to perceive or interpret the intentions of others as evidenced by Difficulty focusing or paying attention and disorganized speech or thoughts | Patient will develop a social support system Patient will verbalize factors, behaviors, and feelings that prevent social interaction Patient will incorporate techniques that improve social interaction Patient will verbalize feeling safe and comfortable in social situations by participating in group activities Patient will build a trusting relationship and speak openly with the nurse by discharge | 1. Develop a trusting relationship. Patients with schizophrenia may be distrusting of others. By acknowledging and actively listening to the patient’s thoughts the nurse is establishing rapport and building trust. 2. Provide positive reinforcement. When a patient takes a step to improve social interaction such as walking outside of their room acknowledge and support their efforts. 3. Encourage group activities. Schizophrenia can cause a lack of motivation. Patients should never be forced to socialize but offering opportunities to interact may help with negative symptoms they may be experiencing such as the inability to express emotions. 4. Refer to specialists for social skills training. Social skills training is conducted in small groups by trained clinicians. Patients learn communication skills, appropriate and inappropriate behaviors in public, and how to develop personal relationships as well as maintain jobs and live independently. | Patient developed a social support system Patient verbalized factors, behaviors, and feelings that prevent social interaction Patient incorporated techniques that improve social interaction Patient verbalized feeling safe and comfortable in social situations by participating in group activities Patient built a trusting relationship and spoke openly with the nurse by discharge |
| Subjective data: Expresses Violent behaviour Objective data: -Delusional thinking -History of threats or violence against self or others -Suicidal ideation -Perception of a threatening environment -Paranoia -Rage reactions | Risk For Self/Other-Directed Violence Related to suspiciousness of others and Delusional thinking as evidenced by signs of wanting to harm themself or others | Patient will remain free from injury and self-harm Patient will not harm other staff, patients, or family members Patient will recognize and report signs of wanting to harm themself or others | 1. Maintain and convey a calm attitude. Staff should remain calm so as not to further escalate a situation. When interacting with the patient communication should be straightforward to prevent the patient from feeling suspicious or manipulated. 2. Maintain distance from the patient. While constant supervision may be required, staff should keep themselves safe by never turning their back on the patient and never touching them without permission (unless required). 3. Keep the patient safe. A safe environment includes removing any object that could be used as a weapon by the patient to injure themself or someone else. 4. Administer tranquilizers. A patient that cannot be “talked down” or presents a risk to others may require the use of anti-anxiety or anti-psychotic medications. 5. Apply restraints. Manual restraints are a last resort when all other interventions have failed. The patient’s safety remains a priority for the nurse and a patient in restraints should be monitored per facility policy and restraints should be removed as soon as the patient’s agitation subsides. | Patient remained free from injury and self-harm Patient not harmed other staff, patients, or family members Patient recognized and report signs of wanting to harm themself or others |