Disturbed sensory perception (visual) r/t biochemical imbalance AEB client’s statement
of, “I have hallucinations that strangers are chasing me.”
Client will demonstrate techniques
to help distract him from the visual hallucinations as measured by client’s performance
of those techniques on a 0 to 10 scale (0 being not able to perform them at all
and 10 being able to perform them flawlessly) by [Month] 8, [Year] at 1400.
Client will state, using
a scale from 0 to 10 (0 being that he is experiencing no hallucinations at all and
10 being that he experiences hallucinations multiple times a day and they are extremely
frightening), that the hallucinations he experiences are less frequent and threatening
when aided by medication and nursing intervention by [Month] 14, [Year] at 1400.
1: Engage client in simple
physical activities or tasks that channel energy (examples: writing, drawing, interacting
with familiar people).
Rationale: Redirecting client’s
energies to acceptable activities can decrease the possibility of acting on hallucinations
(Varcarolis, pg. 237).
2: Keep to simple, basic,
reality based topics of conversation. Help client focus on one idea at a time.
Rationale: Client’s focus
might be confused and disorganized; this intervention helps client focus and comprehend
reality-based issues (Varcarolis, pg. 236).
1: Help the client to identify
times that the hallucinations are most prevalent and frightening.
Rationale: Helps both the
nurse and the client identify situations and times that might be most anxiety producing
and threatening to the client (Varcarolis, pg. 237).
2: Explore how the hallucinations
are experienced by the client.
Rationale: Exploring the
hallucinations and sharing the experience can help give the person a sense of power
that he might be able to manage hallucinations.
3: Inform client that medications
should be taken as prescribed by the
physician. Tell the client
that side effects are expected, medication may take several weeks until it is effective,
and that medication should not be stopped unless directed by prescribing physician
the medicine regimen will support compliance (Boyd, pg. 299).
Techniques to help distract
R.S. from visual hallucinations have been explained. Evaluation of client’s performance
of those techniques is set for the end of the session with student nurse on [Month]
8, [Year]. Client has made no progress toward meeting goal stating that he has not
had a chance to practice techniques because he has not had any hallucinations recently.
As of [Month] 14, [Year]
client states that he has been taking his medications as prescribed and has not
experienced any hallucinations. He rates his hallucinations as a 0 indicating that
he has not experienced them and thus does not feel threatened by them.
Nursing student noted that
the client did not experience any hallucinations while they were meeting. She continued
to keep the conversation to simple, basic, reality based topics and instructed the
client that there are ways to channel his energy when experiencing hallucinations
in an attempt to manage them. Those activities include writing, drawing, and interacting
with familiar people.
Client identifies that hallucinations
are most prevalent and frightening when he is in public and sees strangers. He states
that he often hallucinates that the strangers he sees in public are chasing him
but knows that they are not real. Although he knows they are not real, he feels
very anxious when he is experiencing them and can’t help but to act on them. The
nursing student provided R.S. with information about the medication used to reduce
the amount of hallucinations he experiences. Client verbalizes an understanding
of the side effects and that the medication is to not be stopped for any reason
unless he is told to do so by his physician.