Psychiatric Mental Health Nursing by Videbeck

316 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS

NURSING CARE PLAN FOR A CLIENT WITH DELUSIONS

Nursing Diagnosis

➤Disturbed Thought Processes

Disruption in cognitive operations and activities

ASSESSMENTDATA

• Non–reality-based thinking


• Disorientation


• Labile affect


• Short attention span


• Impaired judgment


• Distractibility

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EXPECTEDOUTCOMES

Immediate

The client will:

• Be free of injury


• Demonstrate decreased anxiety level


• Respond to reality-based interactions
  initiated by others
  Stabilization
  The client will:


• Interact on reality-based topics


• Sustain attention and concentration
  to complete tasks or activities
  Community
  The client will:


• Verbalize recognition of delusional
  thoughts if they persist


• Be free from delusions or demon-
  strate the ability to function without
  responding to persistent delusional
  thoughts

IMPLEMENTATION

Rationale

Delusional clients are extremely sensitive about

others and can recognize insincerity. Evasive

comments or hesitation reinforces mistrust or

delusions.

Clear, consistent limits provide a secure structure

for the client.

Broken promises reinforce the client’s mistrust of

others.

Probing increases the client’s suspicion and inter-

feres with the therapeutic relationship.

Nursing Interventions

Be sincere and honest when communicating with

the client. Avoid vague or evasive remarks.

Be consistent in setting expectations, enforcing

rules, and so forth.

Do not make promises that you cannot keep.

Encourage the client to talk with you, but do not

pry or cross-examine for information.