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Subjective Cue: Disturbed Thought 
³ Nung nasa Taiwan ako Processes related Short term outcome: INDEPENDENT:
napossess ako. Dinala ako to disruption in 1. Providing general 1. A calm approach Outcome
dito ng tatay ko sa Pilipinas cognitive After 8 hours of nursing leads helps to avoid Achieved:
tapos nasaktan ko yung operations and intervention, the pt will a. Approach the distorting the
nanay ko nung may kausap activities as be able to : client in slow, client¶s sensory ? The
siya sa phone ´, as evidenced by ? Demonstrate calm, matter-af- perceptual field patient
verbalized by the patient confused facial reality based fact manner which helps could demonstr
expression thinking in b. Maintain facial promote disturbed ated
Objective:  verbal and non expression and thoughts and reality
GA: verbal behavior behaviors that are perceptions based
? Poor personal ? Demonstrated consistent with Peplau defined thinking in
grooming reduction of verbal statements Psychodynamic verbal
? Confused facial frequency of nursing as being and non
expression delusions able to understand verbal
? r

 ? Participate in one¶s own behavior.
  social activities behavior to help ? The
and group others identify felt patient
Sensory & Cognition: therapies difficulties and to demonstr
? Conscious, oriented to apply principles of ated a
time, person & place human relations to reduction
? Impaired memory on the problems that of
personal information arise at all levels frequency
? Poor concentration of experience. of
regarding delusions.
specific topics ? The
2. Delusions cannot patient
 be changed thru participate
logic and d in social
challenging the activities
belief of the such as
patient, no matter group
how irrational. As therapies.
the client may be
forced to cling to it
and defend it.
Roger¶s described
2. Providing specific a variation of self
questions as the inherent
? Avoid challenging the potentialities of the
client¶s delusional actualizing
system or arguing tendencies that
with the client. can suffer the
distorted
expression when
maladjustment
occurs resulting in
behavior
destructive to
oneself and
others.

3. Presenting Reality 3. Dwelling to the

? Distract the client delusional content
from the delusion by may increase the
engaging him in a client¶s anxiety,
less threatening or a aggression and
 more comforting other
topic or activity at the dysfunctional
first sign of anxiety behavior.
and discomfort. Roger¶s revised
his previous
thinking
concerning this
incongruence. He
stated the
perversions of the
unitary actualizing
tendency. We do
not come into the
world estranged
from ourselves,
4. Offering praise socialization is
? Offer recognition as behind this
soon as the client alienation.
begins to differentiate
between reality 4. Positive
based and non reality reinforcement
based thoughts and increases self
behaviors. esteem and
encourage the
client to identify
and continue
5. Giving information reality based
? Offer the client clear, thoughts and
simple explanations behavior.
of environmental
events, activities and 5. Clear direct
 the behaviors of explanations of
other clients as environment
necessary, events help to
lessen the client¶s
suspiciousness
and fear or
mistrust of the
surroundings and
other. This can
prevent
aggressive
behavior.

COLLABORATIVE: CHLORPROMAZINE is
classified as a low
1. Continue to potency antipsychotic
administer and and in the past was used
monitor the effects of for the treatment of both
the prescribed acute and chronic
medication psychosis, including
? CHLORPROMAZINE Schizophrenia.
(Thorazine) It is still well
? Haloperidol recommended for short
? Fluprenazine term management of
severe anxiety and
aggressive episodes.