Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychotropic Medications

(Barré) #1
8. Word saladContent of Thought 13. Ability to concentrate and disturbance of attention 1. Delusions (Does the person have unrealistic ideas or 12. Poverty of speech 7. C l a n g a s s o c i at io n s 9. Perseverat ion 11. Mut ism^ 10. Echolalia a. Persecutory: A belief that someone is out to get him or beliefs?) a. Speaking in puns or rhymes; using words that sound alike a. Persistently repeating what another person says a. Persistently repeating the last word of a sentence spo- a. Does not speak (either cannot or will not) a. Using a mixture of words that have no meaning together; a. Speaks very little; may respond in monosyllables a. Does the person hold attention to the topic at hand? b. Is the person easily distractible? c. Is there selective attention (e.g., blocks out topics that but have different meaningslunch.” George: “lunch, lunch, lunch, lunch”) sounding incoherentken to the client. (e.g., Nurse: “George, it’s time to go to create anxiety)? APPENDIX M ●^615

2506_Appendix_M_610-617.indd 615 2506 _AppendixM 610 - 617 2. Suicidal or homicidal ideas.indd b. Grandiose: An idea that he or she is all-powerful or of a. Is the individual expressing ideas of harming self or others? f. Nihilistic: A belief that he or she, or a part of the body, or e. Somatic: A belief that he or she has a dysfunctional body d. Control or infl c. Reference: An idea that whatever is happening in the en- 61 her in some way (e.g., “The FBI will be here at any time to even the world does not exist or has been destroyed (e.g., on TV tonight. It is about my life.”).great importance (e.g., “I am the king...and this is my kingdom! I can do anything!”).thoughts are being controlled by external forces (e.g., “I get my orders from Channel 27. I do only what the forces vironment is about him or her (e.g., “Just watch the movie “I am no longer alive.”). take me away.”).part (e.g., “My heart is at a standstill. It is no longer beat-ing.”).dictate.”). 5 uence: A belief that his or her behavior and 1 10/1/10 9:31:50 AM 0 / 1 / 10 9 : 31 : 50 AM

Free download pdf