Nursing Diagnosis: Risk for self-mutilation, others and the environment related to delusions.
General purpose:
Clients do not injure themselves, others, and the environment.
Specific purpose:
1. Clients can build a trusting relationship with the nurse.
Rationale: The relationship of trust is fundamental to facilitate the interaction.
Nursing Interventions:

• Construct a trusting relationship: therapeutic greetings, introduce yourself, explain the purpose of the interaction, create a quiet environment, create a clear contract (subject, time, place).
• Do not argue and support the client’s delusions: tell the nurse receives client confidence “I accept your beliefs” with expressions received, say nurses do not support, accompanied by expressions of doubt and empathy, did not discuss the content of delusions clients.
• Ensure clients are safe and secure: tell the nurse will accompany the client and the client is in a safe place, use the openness and honesty do not leave the client alone.
• Observation is delusional disrupt daily activities and self-care.

2. Clients can identify capabilities.
Rationale: By knowing the capabilities of the client, it will allow nurses to direct the activities that are beneficial to the client rather than just thinking about it.
Nursing Interventions:

• Give compliments on the appearance and capabilities of clients are realistic.
• Discuss with clients the capabilities of past and present realistic.
• Ask the client, what is usually done, and encourage clients to do it now (linked with daily activities and self-care).
• If the client is always talking about delusions, listen to the needs of suspicion does not exist. Show the client that the client is essential.

3. Clients can identify unmet needs.
Rationale: By knowing the needs of clients who have not met the nurse, can plan to meet them and pay more attention to the needs of the client, so the client feels comfortable and safe.
Nursing Interventions:

• Observation of daily client needs.
• Discuss the client’s needs are not being met, either for at home or in the hospital (pain, anxiety, anger).
• Connect the unmet needs and the emergence of delusions.
• Increase activities that can meet the needs of clients and require time and effort (for the schedule if possible).
• Set the circumstances that the client does not have time to use the delusions.

4. Clients can relate to reality.
Rationale: In reality, the client can open his mind, that the reality is more true, than on what he thinks the client, so the client can eliminate the existing delusions.
Nursing Interventions:

• Speaking with clients in the context of reality (self, other people, places and times).
• Include the client in group activity therapy: reality orientation.
• Give praise to the positive activities undertaken by the client.

5. Clients can use the drug properly.
Rationale: The use of medications regularly and properly, will affect the healing process and the effects and side effects of drugs.
Nursing Interventions:

• Discuss with the client about drug name, dosage, frequency, effects and side effects of medication.
• Help clients use the drug with the principle of true 5 (patient name, drugs, dose, method and time).
• Encourage clients to talk about the effects and side effects of the drug are felt.
• Give reinforcement when the client is taking the correct medication.

6. Clients have the support of the family.
Rationale: Support and care of the family in caring for clients will be helping with the healing process of clients.
Nursing Interventions:

• Discuss with the client’s family, through family meetings about: symptoms of delusions, how to care for the client, the family and follow-up drug.
• Give reinforcement on family involvement.