Nursing Diagnosis : Disturbed Sensory Perception hearing / vision related to:
- freaking out
- withdraw
- strss heavy, threatening the weak ego.
Defining characteristics:
- talking and laughing themselves
- behave like listening to something (tilt the head to one side as if someone was listening to something).
- stop talking in the midst of a sentence to listen to something.
- disorientation
- low concentrations
- rapidly changing minds
- chaos groove mind
- response is not appropriate.
Expected outcomes:
- Patients can be admitted that the hallucinations occur during extreme anxiety increased.
- Patients can say signs of increased anxiety and use certain techniques to break the anxiety.
Planning:
General purpose :
Patients are able to define and examine the reality, reducing the occurrence of hallucinations.
Specific purpose :
Patients can discuss the content of the hallucinations to nurse within 1 week.
Intervention and Rationale :
1. Observe the patient of the signs of hallucinations (attitude like listening to something, talk or laugh alone, silent in the midst of the conversation).
Rationale :
Early intervention will prevent aggressive response that ruled from hallucinations.
2. Avoid touching the patient before beckoned.
Rationale :
Patients can only interpret the touch as a threat and respond in an aggressive way.
3. Acceptance will encourage the patient to tell the contents of hallucinations with nurses.
Rationale :
It is important to prevent the possibility of injury to the patient or another person because of the command of hallucinations.
4. Do not support hallucinations. Use the words "voice" instead of the words "they", which indirectly will validate it. Let the patient know that nurses are not being distributed perception. Say "although I realize that these sounds real to you, I did not listen to the voices that speak anything."
Rationale :
Nurses need to be honest with the patient so that the patient realizes that the hallucinations are not real.
5. Try to connect the timing of the hallucinations, with a time of increased anxiety. Help the patient to understand this relationship.
Rationale :
If the patient can learn to stop the increase in anxiety, hallucinations can be prevented.
6. Try to divert patients from hallucinations.
Rationale :
Patient involvement in activities interpersonal and explain about the situation of these activities, it will help the patient to return to reality.
