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CHAPTER 15 ■ Schizophrenia Spectrum and Other Psychotic Disorders
Table 15–2 | CARE PLAN FOR THE PATIENT WITH SCHIZOPHRENIA—cont’d
OUTCOME CRITERIA
NURSING INTERVENTIONS
RATIONALE
5. Offering alternatives to the patient gives them a feeling of some control over the situation.
5. It is important to maintain a calm atti- tude toward the patient. As the patient’s anxiety increases, offer some alterna- tives: participating in a physical activity (e.g., physical exercise), talking about the situation, taking some antianxiety medication. 6. Have sufficient staff available to indi- cate a show of strength to the patient if it becomes necessary. 7. If patient is not calmed by “talking down” or by medication, use of mechanical restraints may be necessary. 8. If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow the protocol established by the institution. 9. Ensure that the patient in restraints is assessed at least every 15 minutes to ensure that circulation to extremities is not compromised (check temperature, color, pulses); to assist the patient with needs related to nutrition, hydration, and elimination; and to position the patient so that comfort is facilitated, and aspiration is prevented. Maintain continuous one-to-one monitoring of restrained patients, to assess level of agitation and to prevent injury. 10. As agitation decreases, assess the patient’s readiness for restraint removal or reduction. Remove one restraint at a time while assessing the patient’s response.
6. This shows the patient evidence of control over the situation and pro- vides some physical security for staff. 7. The avenue of the “least restrictive alternative” must be selected when planning interventions for a violent patient. Restraints should be used only as a last resort after all other interventions have been unsuccess- ful and the patient is clearly at risk of harm to self or others. 8. These interventions are necessary for the protection of patient and staff.
9. Patient safety is a nursing priority.
10. This minimizes the risk of injury to patient and staff.
Continued
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