Nursing Care Plan Case Study

This assignment presents a detailed nursing care plan for a patient diagnosed with schizophrenia. The plan includes subjective and objective data, short-term and long-term goals, interventions, and evaluation criteria. It highlights the importance of culturally safe care, patient communication, and collaboration with healthcare professionals.

Running head: NURSING CARE PLAN CASE STUDY
ASSESSMENT PLANNING AND IMPLEMENTATION EVALUATION
Data Collection and
Organization
Nursing Diagnosis Expected Outcome Planning Nursing
Interventions
Rationale Evaluation of Goal
Attainment
Reassessment
SUBJECTIVE
Patient verbalizes,
‘There aren’t any
people who want to
be friendly’
Patient verbalizes,
‘there’s man down
the street who says
he’s going to hurt
me’
Patient claims to be
hearing a man say
Risk for fall and
injury for the
patient and
violent
tendencies.
The patient has
been suffering
with severe
auditory
hallucinations and
have been
deluding
imaginary
scenarios in her
head.
Short term goal:
Patient will be
able to
communicate her
grievances clearly
with the nursing
staff.
The nurse will
attempt to
establish a
mutually
respectful
therapeutic
relationship with
the patient and use
interpersonal
communication
skills to reach out
to the patient and
establish trust.
Establish a safe,
warm and
A mutually
respectful;
relationship will
help the patient
feel free to
communicate with
the nursing staff
(Yesufu-Udechuku
et al., 2015).
Short term goal
partially met.
Patient able to
express her
thought to nursing
staff.
Short term goal
still met. After 1
week, patient
comfortably
expresses her
thoughts to staff
comfortably.

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NURSING CARE PLAN CASE STUDY
‘run away or they
will lock you up
forever’
The patient has no
sense of self
preservation or
hygiene, has
neither been
wearing warm
clothes fit for
wintry weather nor
has been paying
attention to
personal hygiene.
comfortable
environment for
the patient. The
nurse will place
call light within
reach and show
her how to call for
assistance.
Actively remove
all the possible
hazardous items
from the patient
environment, and
will undertake fall
assessment for the
patient.
A safe and warm
environment will
help the patient be
calm and relax her
mind (Stuart,
2014).
As the patient is
extremely
hypertensed and is
at high risk of fall
and injuring
herself, removing

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NURSING CARE PLAN CASE STUDY
OBJECTIVE
The patient is:
 A 62 year old
female
 Has no
children.
 Divorced and
remarried
with multiple
informal
relationships
 Diagnosed
with
schizophrenia
20 years ago
 Random
bouts of
Long term goal:
The patient
remains physically
healthy and safe
throughout her
stay in the facility
The nurse will
explore the factors
responsible for the
mental condition
of the patient.
The nurse will
avoid physical
restraints and
sedatives as much
as possible.
Nursing
intervention will
focus on therapies.
all the possible
hazardous items
will be beneficial.
Indentifying the
precedence will
help in creating
treatment plan for
the patient.
Restraining is
associated with
serious injuries
including
rhabdomyolosis,
neuropathy,
Long term goal
met. After 1 week
care, patient has
remained injury
free or violent
outbursts during
hospitalization.
Long term goal
still met. During
discharge note
patient remained
free of any injury
and any violent
tendencies.

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NURSING CARE PLAN CASE STUDY
violence at
the hotel
manager
threatening to
hit him.
 Extreme
auditory
hallucinations
and delusions.
 Is aboriginal
The patient’s
personal hygiene
and physical
health will be
addressed by the
nurse
dysrhythmias and
others (Yesufu-
Udechuku et al.,
2015).
Maintaining
physical fitness
and personal
hygiene will be
beneficial for the
patient.

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NURSING CARE PLAN CASE STUDY
ASSESSMENT PLANNING AND IMPLEMENTATION EVALUATION
Data Collection and
Organization
Nursing Diagnosis Expected Outcome Planning Nursing
Interventions
Rationale Evaluation of Goal
Attainment
Reassessment
SUBJECTIVE
Patient verbalizes,
‘There aren’t any
people who want to
be friendly’
Patient verbalizes,
‘there’s man down
the street who says
he’s going to hurt
me’
Patient claims to be
Patient is suffering
with extreme
auditory
hallucinations and
delusions. The
sensory perception
of the patient
seems to be
despaired which is
propelling her to
hallucinate.
Short term:
Patient will
identify with the
nurse the stress
triggers to
hallucinations
Nurse will provide
compassionate and
supportive
interaction to
explore the stress
triggers.
Communicate the
severity and
reality of the
hallucinations that
the patient is
Being
compassionate will
help nurse assess
the patient’s
thoughts and
generate
therapeutic
relationship with
patient (Yesufu-
Udechuku et al.,
2015).
The reality
orientation will be
beneficial for the
Short term goal
met. Patient able
to express and
identify current
stressful event that
might cause
trigger her
hallucinations.
Short term goal
still met. After 1
week, patient
comfortably
communicates to
staff the stressful
events in her life
and the voices she
hearing.

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NURSING CARE PLAN CASE STUDY
hearing a man say
‘run away or they
will lock you up
forever’
suffering with.
Communicate the
patient of the past
medical history to
find out any link.
patient.
The past medical
history might help
in discovering the
root cause
(Nieuwlaat et al.,
2014).

6
NURSING CARE PLAN CASE STUDY
OBJECTIVE
The patient is:
 A 62 year old
female
 Has no
children.
 Divorced and
remarried
with multiple
informal
relationships
 Diagnosed
with
schizophrenia
20 years ago
Long term:
The patient will
identify ways to
not respond to the
hallucination
triggers.
Educate the
patient about the
hallucinations and
its unrelatedness
with the reality.
Engage the patient
in diverting
activities like
drawing, writing,
music, etc.
Reality based
patient education
will help the
patient recover
(Nieuwlaat et al.,
2014).
Diversion
Long term goal
partially met.
After 1 week care,
patient still
reactive to the
voices she hearing
but not responding
to it.
Long term goal
met. During 1
month care patient
improve and ale to
refrain from
responding o
voices and can
control the voice
she heard.

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NURSING CARE PLAN CASE STUDY
 Random
bouts of
violence at
the hotel
manager
threatening to
hit him.
 Extreme
auditory
hallucinations
and delusions.
 Is aboriginal
Engage the patent
in calming
meditation
techniques.
activities will help
the patient
overcome the urge
to respond to the
hallucinations.
Calming
meditation will
help the patient
regain composure
(Roldán‐Merino et
al., 2013).

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NURSING CARE PLAN CASE STUDY
ASSESSMENT PLANNING AND IMPLEMENTATION EVALUATION
Data Collection and
Organization
Nursing Diagnosis Expected Outcome Planning Nursing
Interventions
Rationale Evaluation of Goal
Attainment
Reassessment
SUBJECTIVE
Patient verbalizes,
‘There aren’t any
people who want to
be friendly’
Patient verbalizes,
‘there’s man down
the street who says
he’s going to hurt
me’
Patient claims to be
The patient is
demanding the aid
of traditional
healers belonging
to her aboriginal
cultural
background.
Patient hyper-
reactive to the
modern health
care staff and
refusing to
cooperate.
Short term:
The patient will
develop a
therapeutic
relationship with
at least one staff.
The concerns of
the patient will be
heard patiently and
her preferences
will be taken into
account.
A culturally safe
treatment plan will
be created for her
and her cultural
believes will be
respected
Listening to the
patient will give
her a sense of
value (Purdie,
Dudgeon &
Walker, 2010).
Culturally safe
care plan keeping
her preferences
addressed will
calm her and will
urge her to
Short term goal
met, patient
willing to
cooperate.
Short term goal
met even after one
week.

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NURSING CARE PLAN CASE STUDY
hearing a man say
‘run away or they
will lock you up
forever’
Patient wants for
aboriginal healers.
A cultural safety
officer and
interpreter will be
appointed.
cooperate (Durey,
2010).
Cultural safety
officer will be
extremely
beneficial.

10
NURSING CARE PLAN CASE STUDY
OBJECTIVE
 A 62 year old
female
 Has no
children.
 Divorced and
remarried
with multiple
informal
relationships
 Diagnosed
with
schizophrenia
Long term:
The patient
cooperates with
entire health care
team.
A culturally safe
environment is
created for the
patient.
All the staff
maintains a
compassionate and
respectful
approach.
Aboriginal health
liaison officer
appointed.
Culturally safe
environment will
be extremely
beneficial (Durey,
2010).
Will help the
patient in
cooperating with
each of the staff
(Parker, 2010).
Long term goal
met, patient
actively
cooperating with
all staff.
long term goal met
even after one
month.

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NURSING CARE PLAN CASE STUDY
20 years ago
 Random
bouts of
violence at
the hotel
manager
threatening to
hit him.
 Extreme
auditory
hallucinations
and delusions.
 Is aboriginal.
Overlooks the
health benefits of
the aboriginal
patients (Jorm et
al., 2012).

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NURSING CARE PLAN CASE STUDY
References:
Durey, A. (2010). Reducing racism in Aboriginal health care in Australia: where does cultural education fit?. Australian and New Zealand Journal of
Public Health, 34(s1).
Jorm, A. F., Bourchier, S. J., Cvetkovski, S., & Stewart, G. (2012). Mental health of Indigenous Australians: a review of findings from community
surveys. Medical Journal of Australia, 196(2), 118.
Nieuwlaat, R., Wilczynski, N., Navarro, T., Hobson, N., Jeffery, R., Keepanasseril, A., ... & Sivaramalingam, B. (2014). Interventions for enhancing
medication adherence. The Cochrane Library.
Parker, R. (2010). Australia's Aboriginal population and mental health. The Journal of nervous and mental disease, 198(1), 3-7.
Purdie, N., Dudgeon, P., & Walker, R. (2010). Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and
practice.
Roldán‐Merino, J., García, I. C., Ramos‐Pichardo, J. D., Foix‐Sanjuan, A., Quilez‐Jover, J., & Montserrat‐Martinez, M. (2013). Impact of
personalized in‐home nursing care plans on dependence in ADLs/IADLs and on family burden among adults diagnosed with schizophrenia: a
randomized controlled study. Perspectives in psychiatric care, 49(3), 171-178.
Stuart, G. W. (2014). Principles and Practice of Psychiatric Nursing-E-Book. Elsevier Health Sciences.
Yesufu-Udechuku, A., Harrison, B., Mayo-Wilson, E., Young, N., Woodhams, P., Shiers, D., ... & Kendall, T. (2015). Interventions to improve the
experience of caring for people with severe mental illness: systematic review and meta-analysis. The British Journal of Psychiatry, 206(4),
268-274.