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Medical Diagnoses: Disturbed sensory perception (visual) r/t biochemical imbalance

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders

I

Evaluation

Goals

Interventions

Disturbed sensory perception (visual) r/t biochemical imbalance AEB client’s statement of, “I have hallucinations that strangers are chasing me.”

           

Long Term

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.

Short Term

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.

           


Long Term

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).

Short Term

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 Rationale: Understanding the medicine regimen will support compliance (Boyd, pg. 299).

       

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Long Term

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.

Short Term

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.


Long Term

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.

Short Term

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.

Assessment

Subjective Data:

Client’s statements of:

“I have hallucinations that strangers are chasing me.”

“I know that if I take my medicines I can function in public.”

“I know that the hallucinations are not real, but I can’t help but to act on them because I feel extremely anxious when they are happening.”

Objective Data

Appears paranoid at first meeting with nursing students;  R.S. questioned them several times about why they were there and who had sent them to speak to him.

           


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