Nursing assessment nursing care Plans for Delusional Disorders
Assess for positive symptoms of schizophrenia. These symptoms reflect aberrant mental activity and are usually present early in the first phase of the schizophrenic illness.
Alterations in Thinking
* Delusion: false, fixed belief that is not amenable to change by reasoning. The most frequent elicited delusions include:
o Ideas of reference.
o Delusions of grandeur.
o Delusions of jealousy.
o Delusions of persecution.
o Somatic delusions.
* Loose associations: the thought process becomes illogical and confused.
* Neologisms: made-up words that have a special meaning to the delusional person.
* Concrete thinking: an overemphasis on small or specific details and an impaired ability to abstract.
* Echolalia: pathologic repeating of another’s words.
* Clang associations: the meaningless rhyming of a word in a forceful way.
* Word salad: a mixture of words that is meaningless to the listener.
Alterations in Behavioral Responses
* Bizarre behavioral patterns
o Motor agitation and restlessness
o Automatic obedience or robotlike movement
o Autonomic obedience or robotlike movement
o Negativism
o Stereotyped behaviors
o Stupor
o Waxy flexibility (allowing another person to reposition extremities)
* Agitated or impulsive behavior
* Assess for negative symptoms of schizophrenia that reflect a deficiency of mental functioning
o Alogia (lack of speech)
o Anergia ( inability to react)
o Anhedonia ( inability to experience pleasure)
o Avolition (lack of motivation or initiation)
o Poor social functioning
o Poverty of speech
o Social withdrawal
o Thought blocking
* Assess for associated symptoms of schizophrenia
o Substance use, abuse, or dependence
o Depression
o Fantasy
o Violent or aggressive behavior
o Water intoxication
o Withdrawal
Common nursing diagnosis found in Nursing Care Plans for Delusional Disorder
* Disturbed Thought Processes related to perceptual and cognitive distortions, as demonstrated by suspiciousness, defensive behavior, and disruptions in thought
* Social Isolation related to an inability to trust
* Activity Intolerance related to adverse reactions to psychopharmacologic drugs
* Ineffective Coping related to misinterpretation of environment and impaired communication ability
* Risk for Self-directed or Other-directed Violence related to delusional thinking and hallucinatory experiences
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