needs/ problem alteration in thought processes---> lead to : potential for injury to others or self harm

rational :

Goal promotion and maintenance of reality based thoughts, patient will be able to differentiated between delusions and reality by discharge, promote reduced ego centricities and realistic expectation of self, also reduced anxiety related to thoughts.
Rational: the ability to differentiate real from unreal will assist patient in being able to return to the community and function.

Strategies: assess content of thought and level of mood/affect to obtain baseline date.
R : observe, record and report any changes in the patients mood, behaviours. prevent risk of self harm

Develop a therapeutic relationship by being sincere, honest, non judgemental , consistent, explanatory. don't make promises you can't keep
R: if a relationship based on trust is not developed, it will be difficult to accurately assess.

Be aware of all surroundng stimuli, including sounds from other rooms
R: many seemingly normal stimuli will trigger or intensify hallucinations, patient can be overwhelmed by stimuli.

protect the patient from self injury and maintain the safety to others.
R : the nurse first priority is to protect patient from harm or injury and others in the safety environment

encourage the patient to take prescribed medication
R: medication compliance helps to control psychotic symptoms.

Give positive feedback for patients successes
R: positive feedback for genuine success, enhance patients sense of well being and helps make reality.

Ask patient to verbalise feeling and fears help patient rationalise thoughts by providing education re-problem, explore with patient triggers to thoughts.
R: promotes therapeutic relationship ad reality based communication, increase self esteem if fears abolished to thoughts.