| PLAN |
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- Assess and document patient's orientation to person, place, time, and situation.
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- Assess for causative and contributing factors and history of patient.
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- Assist patient to differentiate internal stimuli from the outside world.
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- Educate patient/family regarding ways to regulate and control hallucinations, effective communication, problem-solving skills, coping strategies, and signs and symptoms of recurrent illness.
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- Encourage patient to verbalize delusions or hallucinations before acting on them.
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- Modify patient's environment to decrease situations that may precipitate sensory alteration providing a safe environment, close supervision and reality orientation, as needed.
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- Monitor patient for medication side effects and desired therapeutic effects.
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- Observe for verbal and nonverbal behaviors associated with hallucinations or delusions
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- Other
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| DESIRED OUTCOME |
Disruption in cognitive processes, such as conscious thought, reality
social behavior.1, 2
References:
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
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