Nursing Interventions ^*denotes collaborative interventions

Rationale

Search the client’s belongings carefully for weapons; also search the client’s vehicle, if at the facility.

Clients with paranoid behavior may carry or conceal weapons.

Be calm and nonthreatening in all your approaches to the client, using a quiet voice; do not surprise the client.

If the client is feeling threatened, he or she may perceive any person or stimulus as a threat.

Note environmental factors (e.g., noise level, the number of other people) that precipitate or exacerbate symptoms, and try to decrease these factors (see Care Plan 47: Aggressive Behavior).

Assessment provides information on which to base interventions. The client’s ability to deal with stimuli or other people is impaired.

Observe the client closely for agitation, and decrease stimuli or move the client to a less stimulating area or secluded area if indicated.

Whenever possible, it is best to intervene before the client loses control. The client’s ability to deal with stimuli may be impaired.

Be aware of PRN medication orders and prepare to administer them if needed.

The client’s agitation may require medication if he or she becomes dangerous to others or to himself or herself.

Administer medications in liquid or injectable form as needed to ensure ingestion.

The client may hide an oral medication in his or her mouth, then discard when not being observed. Note: some oral medications are irritating to mucous membranes; observe precautions as indicated.

Observe the client’s interactions with visitors. The length, number, or frequency of visits may need to be limited.

The client’s ability to deal with other people may be impaired.

Do not argue with the client about delusions or ideas of reference, but interject reality when appropriate (you might say, “I don’t see it that way.”). Do not give any indication that you believe as the client does.

Introducing and reinforcing reality may help diminish psychotic symptoms.

Do not joke with the client regarding his or her beliefs.

The client’s ability to understand and use abstractions, such as humor, is impaired.

Do not enter into political, religious, or other controversial discussions with the client.

Controversial discussions may precipitate arguments and increase hostility or aggression.

Encourage the client to discuss topics other than delusions such as home life, work, or school.

Concrete or familiar topics may be helpful in directing the client’s attention to reality.

Do not allow the client to ruminate about delusions; if the client refuses to discuss other topics, talk with the client about his or her feelings regarding the delusions or withdraw your attention, stating your intent to return.

It is important to minimize reinforcement of psychotic symptoms. Talking about feelings may help the client begin to deal with emotional issues. It must be clear that you accept the client as a person even if you reject his or her behavior.

^*If the client has religious delusions, referral to the facility chaplain may be indicated (if the chaplain has education or experience in this area).

Areas beyond nursing’s scope require referral to appropriate people or agencies.

You may need to reassure the client that his or her fears are internal and not based on external reality.

Reassurance of the safety of his or her environment may help diminish the client’s fears.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Introduce and identify yourself as a staff member on your first approach to the client (and thereafter if necessary). Be nonthreatening in all your approaches to the client.

The client may be fearful, suspicious, or not in contact with reality.

Assure the client that the environment is safe and protective, that the staff will help him or her maintain control, and that he or she will not be “in trouble” for having feelings.

The client may fear that personal feelings may be overwhelming or unacceptable, or that experiencing feelings may cause him or her to lose control.

Give the client clear information regarding his or her safety, confidentiality, identity and function of staff members, and so forth.

Giving matter-of-fact information will help to reassure and reorient the client.

If the client is pacing, walk with the client to converse if necessary.

You must meet the client at his or her level of functioning. Your willingness to walk with the client indicates caring and can interrupt ruminating or other symptoms.

If the client is experiencing hallucinations or illusions, try to talk with him or her in an area of decreased stimuli.

External stimuli may be misperceived by the client, and he or she is unable to deal with excess stimuli.

Let the client see the notes that you take during interviews. Answer questions honestly with little or no hesitation.

Open and direct behavior on your part may help decrease suspicion.

Include the client in the formulation of the treatment plan when possible and appropriate.

Including the client may help build trust and decrease suspicion and feelings of powerlessness.

Do not be secretive or whisper to others in the presence of the client.

Secretive behavior will reinforce the client’s suspicion.

Approach the client at least once per shift and encourage him or her to express feelings. Determine the length of interactions by the client’s tolerance.

Expressing feelings can help the client identify, accept, and work through feelings, even if they are painful or otherwise uncomfortable.

If the client seems to be experiencing intense emotions, point this out and explain what leads you to think this (e.g., the client’s facial expression). Ask for the client’s perceptions.

The client may be unaware of emotions he or she is experiencing. Giving the client feedback in a nonthreatening way may help him or her recognize emotional cues.

Encourage the client to express feelings verbally or in other outward ways (such as physical activity).

Physical exercise and talking about feelings can help the client decrease tension and deal with feelings directly.

Use role-playing to elicit the expression of feelings (“Pretend that I’m your [husband, wife, etc.]. What would you like to say to me?”).

Role-playing allows the client to explore feelings and try out new behaviors in nonthreatening situations.

Demonstrate honest interest in and concern for the client; do not flatter the client or be otherwise dishonest.

Clients with low self-esteem do not benefit from flattery or undue praise. These can be seen as dishonest and belittling.

Support the client for his or her participation in activities, treatment, and interactions.

Positive feedback can reinforce desired behaviors.

Provide opportunities for the client to perform activities that are easily accomplished or that the client likes to do. Provide recognition and support for their completion or success.

The client’s abilities to deal with complex tasks may be impaired. Any task that the client can complete provides an opportunity for positive feedback to the client.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Initially, the staff may need to protect the client from other clients’ responses to his or her paranoid or grandiose behavior.

The client may be hostile or abusive to other clients who may not recognize this as the client’s illness.

Initially, limit the number of different staff members assigned to interact with the client.

Limiting the number of new contacts initially will provide consistency and promote trust.

After the client’s initial days on the unit, begin assigning different staff members to him or her and encourage other staff members to approach him or her for brief interactions.

The number of people interacting with the client should increase as soon as possible to facilitate communication and relationships with a variety of people.

^*Help the client make individual contacts with staff members and other clients; progress to small groups, then larger groups as the client tolerates.

The client’s ability to respond to others may be impaired, so it is best to begin with a single person, then progress to more difficult situations as the client’s comfort and skills increase.

Observe the client’s interactions with other clients, and encourage the development of appropriate relationships with others. Give the client feedback on his or her interactions and relationships.

The client may be unaware of interpersonal dynamics. Feedback can help increase insight and give support to the client’s efforts to develop relationships.

Give the client support for any attempts to interact with others.

Positive feedback may reinforce desired behaviors.

^*Involve the client in activities that are noncompetitive at first, then progress to more competitive activities as tolerated.

Competition may reinforce the client’s low self-esteem or hostile feelings.

^*Help the client build social skills through leisure-time counseling and referral to community resources (e.g., occupational or recreational therapy, outpatient social groups).

The client’s relationships with others in the community may be limited or impaired and need to be re-established.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Give the liquid form of a medication when possible if the client is reluctant to take medication or if there is a question whether the client is ingesting medication.

Giving liquid medications helps ensure that the client ingests the medication. Note: Some liquid medications are irritating to oral membranes; observe precautions as indicated.

Tell the client that the medications are a part of the treatment plan and you expect him or her to take them as prescribed. Check the client’s mouth if necessary after giving oral medications (have the client open mouth, raise tongue, etc.).

It is important to know if the client is ingesting medications. Being direct with the client will help him or her know what is expected.

Be straightforward with the client when giving information about medications, including the name and desired effects (e.g., “to help clear your thinking” or “to make the voices go away”).

Clear information will help build trust and decrease suspicion.

Observe the client’s eating, drinking, and elimination patterns, and assist the client as necessary (see Care Plan 52: The Client Who Will Not Eat).

The client may be unaware of physical needs or may ignore feelings of thirst, hunger, the urge to defecate, and so forth.

If the client is overactive, offer juice, milk, or finger foods that can be ingested while walking.

If the client is unable to sit and eat, providing nutritious foods that require little effort to eat may be effective.

Assess and record the client’s caffeine intake and limit it if necessary.

Caffeine consumption, especially in large amounts, may increase anxiety or paranoid feelings.

Monitor the client’s sleep patterns, and prepare him or her for bedtime by decreasing stimuli and administering comfort measures or medications (see Care Plan 38: Sleep Disorders).

Limiting noise and other stimuli will encourage rest and sleep. Comfort measures and sleeping medications will enhance the client’s ability to relax and sleep.