- Assess and document patient's orientation to person, place, time, and situation.
- Assess for causative and contributing factors and history of patient.
- Assist patient to differentiate internal stimuli from the outside world.
- Educate patient/family regarding ways to regulate and control hallucinations, effective communication, problem-solving skills, coping strategies, and signs and symptoms of recurrent illness.
- Encourage patient to verbalize delusions or hallucinations before acting on them.
- Modify patient's environment to decrease situations that may precipitate sensory alteration providing a safe environment, close supervision and reality orientation, as needed.
- Monitor patient for medication side effects and desired therapeutic effects.
- Observe for verbal and nonverbal behaviors associated with hallucinations or delusions
Disruption in cognitive processes, such as conscious thought, reality
social behavior.1, 2
1 NANDA International (2005). Nursing Diagnoses: Definitions &
Classification 2005-2006. Philadelphia: Author.
2Carpenito, L. J. (2000). Nursing Diagnosis: Application to Clinical
Practice (8th ed.). Philadelphia: Lippincott.
orientation, problem solving, and judgment that is related to coping, or
a personality and/or mental disorder. 1, 2
Defining Characteristics: Cognitive dissonance; Memory deficit;
Inaccurate interpretation of stimuli (internal and/or external);
Hypovigilance; Hypervigilance; Distractibility; Egocentricity;
Inappropriate nonreality-based thinking (delusions, hallucinations,
phobias, obsessions); Ritualistic behavior; Impulsivity; Inappropriate