Psychosis is a severe mental condition characterized by a disconnection from reality, affecting perception, thoughts, and behavior. This nursing diagnosis focuses on identifying symptoms, managing acute episodes, preventing harm, and supporting recovery while maintaining patient safety and dignity.
Causes (Related to)
Psychosis can develop due to various factors that affect brain function and mental health:
- Psychiatric conditions such as:
- Schizophrenia
- Bipolar disorder
- Major depressive disorder with psychotic features
- Schizoaffective disorder
- Medical conditions including:
- Brain tumors
- Traumatic brain injury
- Infections affecting the brain
- Metabolic disorders
- Neurological conditions
- Substance-related factors:
- Drug-induced psychosis
- Alcohol withdrawal
- Medication side effects
- Environmental and psychological factors:
- Severe stress or trauma
- Sleep deprivation
- Social isolation
- Genetic predisposition
Signs and Symptoms (As evidenced by)
Psychosis presents with distinct manifestations that nurses must recognize for accurate assessment and intervention.
Subjective: (Patient reports)
- Hearing voices or sounds others don’t hear
- Seeing things that aren’t there
- Feeling paranoid or persecuted
- Having unusual beliefs or delusions
- Difficulty organizing thoughts
- Feeling that thoughts are not their own
- Sensing that others can read their mind
Objective: (Nurse assesses)
- Disorganized speech patterns
- Inappropriate emotional responses
- Poor personal hygiene
- Isolation from others
- Decreased attention span
- Impaired judgment
- Altered sleep patterns
- Disorganized behavior
- Catatonic states
- Agitation or restlessness
Expected Outcomes
The following outcomes indicate successful management of psychosis:
- The patient will maintain safety
- The patient will demonstrate improved reality testing
- The patient will exhibit decreased hallucinations and delusions
- The patient will demonstrate improved self-care
- The patient will adhere to the prescribed medication regimen
- The patient will develop effective coping strategies
- The patient will establish appropriate social interactions
- The patient will maintain activities of daily living
Nursing Assessment
Evaluate Mental Status
- Assess orientation level
- Monitor thought processes
- Evaluate perceptual disturbances
- Check cognitive function
- Document behavioral changes
Assess Safety Risk
- Screen for suicidal ideation
- Evaluate risk of harm to self/others
- Monitor environmental safety
- Check for aggressive behaviors
- Assess impulse control
Monitor Physical Health
- Check vital signs
- Assess nutritional status
- Monitor sleep patterns
- Review medication effects
- Document physical complaints
Evaluate Support Systems
- Assess family involvement
- Check community resources
- Document social connections
- Review living situation
- Evaluate financial resources
Review Treatment History
- Document past hospitalizations
- Check medication compliance
- Note previous interventions
- Review trigger patterns
- Assess coping mechanisms
Nursing Care Plans
Nursing Care Plan 1: Disturbed Thought Processes
Nursing Diagnosis Statement:
Disturbed Thought Processes related to altered perceptual state as evidenced by delusions, hallucinations, and disorganized thinking.
Related Factors:
- Neurochemical imbalance
- Sensory processing disruption
- Cognitive impairment
- Psychological stress
Nursing Interventions and Rationales:
- Establish reality-based communication
Rationale: Helps maintain patient’s connection with reality - Monitor and document thought content
Rationale: Tracks progression of symptoms and treatment effectiveness - Provide structured environment
Rationale: Reduces stimuli that may exacerbate symptoms
Desired Outcomes:
- The patient will demonstrate improved reality testing
- The patient will report decreased frequency of hallucinations
- The patient will exhibit more organized thought processes
Nursing Care Plan 2: Risk for Self-Directed or Other-Directed Violence
Nursing Diagnosis Statement:
Risk for Violence related to altered thought processes and paranoid ideation as evidenced by aggressive behavior and threatening statements.
Related Factors:
- Command hallucinations
- Paranoid delusions
- Impaired impulse control
- History of violence
Nursing Interventions and Rationales:
- Implement safety precautions
Rationale: Prevents harm to self or others - Monitor for warning signs
Rationale: Enables early intervention - Maintain calm environment
Rationale: Reduces potential triggers
Desired Outcomes:
- The patient will maintain safety
- The patient will demonstrate self-control
- The patient will use appropriate coping mechanisms
Nursing Care Plan 3: Self-Care Deficit
Nursing Diagnosis Statement:
Self-Care Deficit related to altered mental state as evidenced by poor hygiene and inability to perform ADLs.
Related Factors:
- Cognitive impairment
- Decreased motivation
- Social withdrawal
- Energy deficit
Nursing Interventions and Rationales:
- Assist with ADLs
Rationale: Ensures basic needs are met - Establish daily routine
Rationale: Promotes independence and structure - Provide positive reinforcement
Rationale: Encourages self-care behaviors
Desired Outcomes:
- The patient will demonstrate improved self-care abilities.
- The patient will maintain personal hygiene
- The patient will participate in daily activities
Nursing Care Plan 4: Impaired Social Interaction
Nursing Diagnosis Statement:
Impaired Social Interaction related to altered thought processes as evidenced by social withdrawal and inappropriate social behaviors.
Related Factors:
- Communication barriers
- Altered perception
- Social anxiety
- Trust issues
Nursing Interventions and Rationales:
- Encourage appropriate social interaction
Rationale: Promotes social skills development - Provide structured group activities
Rationale: Offers a safe environment for social interaction - Teach communication skills
Rationale: Improves social functioning
Desired Outcomes:
- The patient will engage in appropriate social interactions
- The patient will demonstrate improved communication skills
- The patient will participate in group activities
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to psychotic symptoms as evidenced by agitation, restlessness, and increased vital signs.
Related Factors:
- Altered perceptions
- Loss of control
- Environmental stressors
- Fear of rejection
Nursing Interventions and Rationales:
- Implement anxiety reduction techniques
Rationale: Helps manage symptoms - Provide reassurance
Rationale: Reduces fear and promotes trust - Teach coping strategies
Rationale: Enables self-management of anxiety
Desired Outcomes:
- The patient will demonstrate decreased anxiety
- The patient will use effective coping mechanisms
- The patient will report an improved sense of control
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Julayanont P, Suryadevara U. Psychosis. Continuum (Minneap Minn). 2021 Dec 1;27(6):1682-1711. doi: 10.1212/CON.0000000000001013. PMID: 34881732.
- Schrimpf LA, Aggarwal A, Lauriello J. Psychosis. Continuum (Minneap Minn). 2018 Jun;24(3, BEHAVIORAL NEUROLOGY AND PSYCHIATRY):845-860. doi: 10.1212/CON.0000000000000602. PMID: 29851881.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Weiss, A., Chaudhry, S., Marhefka, A., & Khunkhun, V. (2024). Early Intervention in the Treatment of Psychosis. Child and Adolescent Psychiatric Clinics of North America, 33(4), 645-658. https://doi.org/10.1016/j.chc.2024.07.001
