Nursing Interventions ^*denotes collaborative interventions

Rationale

Protect the client from harming himself or herself or others. See Care Plan 26: Suicidal Behavior.

Client safety is a priority. Self-destructive ideas may come from hallucinations or delusions.

Reassure the client that the environment is safe by briefly and simply explaining routines, procedures, and so forth.

The client is less likely to feel threatened if the surroundings are known.

Decrease excessive stimuli in the environment. The client may not respond favorably to competitive activities or large groups if he or she is actively psychotic.

The client is unable to deal with excess stimuli. The environment should not be threatening to the client.

Be aware of as needed (PRN) medications and the client’s varying need for them.

Medication can decrease psychotic symptoms and can help the client gain control over his or her own behavior.

Reorient the client to person, place, and time as indicated (call the client by name, tell the client where he or she is, etc.).

Repeated presentation of reality is concrete reinforcement for the client.

Spend time with the client even when he or she is unable to respond coherently. Convey your interest and caring.

Your physical presence is reality. Nonverbal caring can be conveyed even when verbal caring is not understood.

Limit the client’s environment to enhance his or her feelings of security.

Unknown boundaries or a perceived lack of limits can foster insecurity in the client.

Help the client establish what is real and unreal. Validate the client’s real perceptions, and correct the client’s misperceptions in a matter-of-fact manner. Do not argue with the client, but do not give support for misperceptions.

The unreality of psychosis must not be reinforced; reality must be reinforced. Reinforced ideas and behavior will recur more frequently.

Stay with the client when he or she is frightened. Touching the client can sometimes be therapeutic. Evaluate the effectiveness of the use of touch with the client before using it consistently.

Your presence and touch can provide reassurance from the real world. However, touch may not be effective if the client feels that his or her boundaries are being invaded.

Remove the client from the group if his or her behavior becomes too bizarre, disturbing, or dangerous to others.

The benefit of involving the client with the group is outweighed by the group’s need for safety and protection.

Help the client’s group accept the client’s “strange” behavior. Give simple explanations to the client’s group as needed (e.g., “[Client] is very sick right now; he [or she] needs our understanding and support”).

The client’s group benefits from awareness of others’ needs and can help the client by demonstrating empathy.

Consider the other clients’ needs. Plan for at least one staff member to be available to other clients if several staff members are needed to care for this client.

Remember that other clients have their own needs and problems. Be careful not to give attention only to the “sickest” client.

Explain to other clients that they have not done anything to warrant the client’s verbal or physical threats; rather, the threats are the result of the client’s illness.

Other clients may interpret verbal or physical threats as personal or may feel that they are doing something to bring about the threats.

Set limits on the client’s behavior when he or she is unable to do so (when the behavior interferes with other clients or becomes destructive). Do not set limits to punish the client.

Limits are established by others when the client is unable to use internal controls effectively. Limits are intended to protect the client and others, not to punish inappropriate behaviors.

Make only promises that you can realistically keep.

Breaking your promise can result in increasing the client’s mistrust.

Be simple, direct, and concise when speaking to the client.

The client is unable to process complex ideas effectively.

Talk with the client about simple, concrete things; avoid ideological or theoretical discussions.

The client’s ability to deal with abstractions is impaired.

Direct activities toward helping the client accept and remain in contact with reality.

Increased reality contact decreases the client’s retreat into unreality.

Initially, assign the same staff members to work with the client.

Consistency can reassure the client.

Begin with one-to-one interactions, and then progress to small groups as tolerated (introduce slowly).

Initially, the client will better tolerate and deal with limited contact.

Establish and maintain a daily routine; explain any variation in this routine to the client.

The client’s ability to adapt to change is impaired.

Make the client aware of your expectations for him or her.

The client must know what is expected before he or she can work toward meeting those expectations.

Set realistic goals. Set daily goals and expectations.

Unrealistic goals will frustrate the client. Daily goals are short term and therefore easier for the client to accomplish.

At first, do not offer choices to the client (“Would you like to go to activities?” “What would you like to eat?”). Instead, approach the client in a directive manner (“It is time to eat. Please pick up your fork.”).

The client’s ability to make decisions is impaired. Asking the client to make decisions at this time may be very frustrating.

Gradually, provide opportunities for the client to accept responsibility and make personal decisions.

The client needs to gain independence as soon as he or she is able. Gradual addition of responsibilities and decisions gives the client a greater opportunity for success.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Provide attention in a sincere, interested manner.

Flattery can be interpreted as belittling by the client.

Support any successes, responsibilities fulfilled, interactions with others, and so forth.

Sincere and genuine praise that the client has earned can improve self-esteem.

Avoid trying to convince the client verbally of his or her own worth.

The client will respond to genuine recognition of a concrete behavior rather than to unfounded praise or flattery.

Initially, interact with the client on a one-to-one basis. Manage nursing assignments so that the client interacts with a variety of staff members, as the client tolerates.

Your social behavior provides a role model for the client. Interacting with different staff members allows the client to experience success in interactions within the safety of the staff-client relationship.

Introduce the client to other clients in the milieu and facilitate their interactions on a one client to one client basis. Gradually facilitate social interactions between the client and small groups, then larger groups.

Gradually increasing the scope of the client’s social interactions will help the client build confidence in social skills.

Teach the client social skills. Describe and demonstrate specific skills, such as approaching another person for interaction, eye contact, attentive listening, and so forth. Discuss the type of topics that are appropriate for casual social conversation, such as the weather, local events, and so forth.

The client may have little or no knowledge of social interaction skills. Modeling provides a concrete example of the desired skills.

Talk with the client about his or her interactions and observations of interpersonal dynamics.

Awareness of interpersonal and group dynamics is an important part of building social skills. Sharing observations provides an opportunity for the client to express his or her feelings and receive feedback about his or her progress.

Help the client improve his or her grooming; assist when necessary in bathing, doing laundry, and so forth.

Good physical grooming can enhance confidence in social situations.

Help the client accept as much responsibility for personal grooming as he or she can (do not do something for the client that he or she can do alone).

The client must be encouraged to be as independent as possible to foster self-esteem and continued self-care practices.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Be alert to the client’s physical needs.

The client may be unaware of or unresponsive to his or her needs. Physical needs must be met to enhance the client’s ability to meet emotional needs.

Monitor the client’s food and fluid intake; you may need to record intake, output, and daily weight.

The client may be unaware of or may ignore his or her needs for food and fluids.

Offer the client foods that are easily chewed, fortified liquids such as nutritional supplements, and high-protein malts.

If the client lacks interest in eating, highly nutritious foods that require little effort to eat may help meet nutritional needs.

Try to find out what foods the client likes, including culturally based foods or foods from family members, and make them available at meals and for snacks.

The client may be more apt to eat foods he or she likes or has been accustomed to eating.

Monitor the client’s elimination patterns. You may need to use PRN medication to establish regularity.

Constipation frequently occurs with the use of major tranquilizers, decreased food and fluid intake, and decreased activity levels.

Encourage good fluid intake.

Constipation may result from inadequate fluid intake.

Explain any task in short, simple steps.

A complex task will be easier for the client if it is broken down into a series of steps.

Using clear, direct sentences, instruct the client to do one part of the task at a time.

The client may not be able to remember all the steps at once.

Tell the client your expectations directly. Do not ask the client to choose unnecessarily, that is, tell the client it is time to eat or get dressed rather than asking if he or she wants to eat or dress.

The client may not be able to make choices or may make poor choices.

Do not confuse the client with reasons as to why things are to be done.

Abstract ideas will not be comprehended and will interfere with task completion.

Allow the client ample time to complete any task.

It may take the client longer to complete tasks because of a lack of concentration and short attention span.

Remain with the client throughout the task; do not attempt to hurry the client.

Trying to rush the client will frustrate him or her and make completion of the task impossible.

Assist the client as needed to maintain daily functions and adequate personal hygiene.

The client’s sense of dignity and well-being is enhanced if he or she is clean, smells good, looks nice, and so forth.

Gradually withdraw assistance and supervise the client’s grooming or other self-care skills. Praise the client for initiating and completing activities of daily living.

It is important for the client to gain independence as soon as possible. Positive reinforcement increases the likelihood of recurrence.