1. Disturbed sensory perception R/T altered sensory reception AEB mistrust and suspiciousness of others. (Doenges, Moorhouse, & Murr, 2013, p. 838).
1.1. Outcome: Client will recognize and correct or compensate for sensory impairments within 2-3 days. (Doenges, Moorhouse, & Murr, 2013, p. 838).
1.1.1. Interventions:
1.1.2. Nurse will approach pt. In a serious, straightforward manner. Reasoning: Being straightforward is essential to the success of the nurse-client relationship. (Videbeck, S. , 2017, p.343).
1.1.3. Nurse will provide explanations of plan of care w/client Involving client as much as possible. This enhances client commitment to and continuation of plan by allowing the client to feel in control, therefore optimizing outcomes. (Videbeck, S. , 2017, p.343).
1.1.3.1. Evaluation: Goal un-met. The patient remains suspicious of others. Nurse will discuss patient medication regimen with provider, noting possible toxic side effects of both prescription and over the counter drugs. Prompt recognition of side effects allows for timely intervention/change in drug regimen. Client will correct and compensate for sensory impairments within next clinical evaluation. Rational: This diagnosis will focus on the prevention of the client from acting on paranoid ideas. (Doenges, Moorhouse, & Murr, 2013, p. 840).
1.1.4. Nurse will help client validate ideas before taking action. This requires the ability to trust and listen to one person. Client can avoid problems if he can refrain from taking action until he validates his ideas w/ another person. (Doenges, Moorhouse, & Murr, 2013, p. 840).
2. Risk for other-directed violence R/T paranoid delusions and threatening stance(Doenges, Moorhouse, & Murr, 2013, p. 1024).
2.1. Outcome: Client will demonstrate self-control as evidenced by relaxed posture and refraining from use of derogatory and profane language upon leaving appointment today(Doenges, Moorhouse, & Murr, 2013, p. 1026).
2.1.1. Interventions:
2.1.2. The nurse will decrease environmental stimuli by providing a private room for patient. Reasoning: This helps decrease escalation((Doenges, Moorhouse, & Murr, 2013, p. 1029).
2.1.3. The nurse will use short, simple, and brief explanations. Reasoning: short attention spans limit understanding to small pieces of information(Doenges, Moorhouse, & Murr, 2013, p. 1027).
2.1.3.1. Evaluation Outcome partially met, no harm brought to anyone. Client suspicious of others but body language is non threatening and client is not using derogatory or harmful language. nurse will reassess anxiety and guarded behavior throughout visit to determine decreasing escalation of behaviors. The client will validate ideas before acting on them.
2.1.4. The nurse will administer prescribed medications ordered and any PRN medications if needed. Reasoning: medications will decrease anxiety and agitation(Doenges, Moorhouse, & Murr, 2013, p. 1029).
3. Assessment Client appears guarded and suspicious of people in clinic. The client is distorting interactions with others in the clinic. Clients body language appears to be in a threatening stance with hands on hips. Client is suspicious of other people in waiting room and calls out a derogatory name and tells the women to stop talking about him. Client is untrusting of nursing staff and medication. Client states “ You think you are so smart, but I know what you put in those pills. Don't think you fooled me, and don't put that in my chart.” The client has a history of holding a grudge against his mother for 10 years. The client followed his wife everywhere she went and tried to keep her home, this pertains to suspicions of infidelity without justification. The client will not socialize with neighbors because they are not to be trusted and could turn against him for no reason at all if he were to let them in. The client is suspecting the neighbors will exploit, harm, or deceive him without sufficient basis for such thoughts. The client is also angry at mother for giving him a white American father because he wasn't accepted by white or black Americans growing up. There is no basis for this, client perceives other kids growing up knew his ethnicity and he just wouldn't fit in. This is perceived as an attack on his ethnicity and projecting blame onto his mother. The client's history and actions at this visit conform with the DSM-IV criteria for paranoid personality disorder.
4. Client Profile: Stan is a 32 year-old single male. Stan lives alone in a government-subsidized apartment and receives social security disability income (SSDI). He says he stays away from his neighbors, as they are not to be trusted and could turn against him for no reason at all if he were to let them into his apartment.
4.1. S/S include: Paranoia, isolation, grudge building, anger, verbal outbursts, and jealous behavior
4.2. Psychosocial: Paranoia limits and distorts interactions with others.
4.3. Current treatment:Stan gets psychiatric care through the county outpatient mental health center clinic. He has a non-nurse case manager who take vital signs, supervises him in taking his daily medication, helps home with managing his money, and transports him to appointments at the clinic where he sees the psychiatric mental health nurse for all his medication reviews and health assessments.
4.4. Pharmacologic: Captopril in combination with hydrochlorthiazide, Lorazepam (Ativan), Olanzapine (Zyprexa).
5. Risk for Social Isolation R/T mistrust of others and delusional thinking AEB statement that neighbors "are not to be trusted and could turn against him for no reason", isolation of self from mother, and escalating distrust of wife. (Doenges, Moorhouse, & Murr, 2013, p. 887).
5.1. Before discharge, client will be able to identify causes of and actions to help correct further isolation. Reasoning: Because of the chronic paranoid thoughts and delusions, the patient is often unaware of abnormality of their thought process that lead to personal isolation and disruption of interpersonal relationships.(Doenges, Moorhouse, & Murr, 2013, p. 887).
5.1.1. The nurse will educate the patient about proper coping techniques dealing with feelings of anger and anxiety. Example: Journaling and Though Stopping. Reasoning: Because of the chronic nature of the patient's mental diagnosis, proper coping techniques are needed to manage, rather than eliminate, the hostile thoughts they feel(Doenges, Moorhouse, & Murr, 2013, p. 888).
5.1.2. The nurse will education the patient about the medications he is prescribed and the need for strict compliance. Reasoning: Because the of the chronic nature of the patient's mental diagnosis, strict adherence to the pharmacological regiment may allow for lessening of signs and symptoms, but not elimination of feelings that lead to aggressive and isolationist behaviors(Doenges, Moorhouse, & Murr, 2013, p. 888).
5.1.2.1. Evaluation: Goals mostly unmet. Patient does not clearly see the detriment of his behaviors that are based upon his paranoid dellusions. What little understanding he has, there is limited positive skills to take the place of any lacking negative ones, though what few positive interactions where made, client responded well to positive reinforcement. Consideration needs to be made for introduction to anger management classes in community, if available. Client has agreed to be compliant with his medications.
5.1.3. The nurse will provide positive reinforcement when client makes appropriate social interactions with others.Example: Publicly praising client to others when proper communication techniques displayed. Reasoning: Encourages continuation of efforts(Doenges, Moorhouse, & Murr, 2013, p. 889)