|Assessment Data||Goals & Outcome||Nursing Interventions.||Rationale||Outcome Evaluation &Replanning|
|Subjective: Hallucinations, feeling of being watched (paranoia), change in personality, inability to sleep, and inability to concentrate. . |
Objective: Decline in academic or work performance, inappropriate behavior, extreme preoccupation with religion or the occult, unprovoked outbursts or uninhibited actions, and anxious or erratic movements.
|Patient will state that the voices are no longer threatening, nor do they interfere with his or her life within 2 to 3 days of nursing intervention. |
Patient will state, using a scale from 1 to 10, that “the voices” are less frequent and threatening when aided by medication and nursing intervention within 2 to 3 days of nursing intervention.
The nurse will help the client to identify the needs that might underlie the hallucination. What other ways can these needs be met?
The nurse will engage client in reality-based activities such as card playing, writing, drawing, doing simple arts and crafts or listening to music.
The nurse will accept the fact that the voices are real to the client, but explain that you do not hear the voices. Refer to the voices as “your voices” or “voices that you hear. .
The nurse will decrease environmental stimuli when possible (low noise, minimal activity.
The nurse will explore how the hallucinations are experienced by the client
Hallucinations might reflect needs for anger, power, self-esteem, and sexuality.
Redirecting the client’s energies to acceptable activities can decrease the possibility of acting on hallucinations and help distract from voices.
Validating that your reality does not include voices can help client cast “doubt” on the validity of his or her voices.
Decrease the potential for anxiety that might trigger hallucinations. Helps calm client.
Exploring the hallucinations and sharing the experience can help give the person a sense of power that he or she might be able to manage the hallucinatory voices
|Patient stated that the voices are no longer threatening, nor do they interfere with his or her life within 2 to 3 days after nursing intervention. |
Patient stated using a scale from 1 to 10 that “the voices” are less frequent and threatening when aided by medication and nursing intervention within 2 to 3 days after nursing intervention.