Date

Cues

Need

Nursing Diagnosis

and
Time
January
22,
2016
@
4pm

Objectives of

Nursing

Care

Interventions

Evaluation

O:

Disturbed sensory

Within our 1

1. Establish trust

Goal partially

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perception related to

day span of

and rapport to the

met

si Satanas.

biochemical imbalance for

care, client will

client.

After

Nakita nako siya

sensory distortion

demonstrate

R: To gain clients

days span of

sa langit. As

awareness as

cooperation.

care,

verbalized by

Rationale:

evidenced by:

2. Continuously

demonstrate

the client.

Neurotransmitters also

a. oriented to

orient the client to

awareness to

known as chemical

reality

reality.

reality

messengers, are

b. absence of

R: to help client

evidenced by:

endogenous chemicals that

delusions

remain oriented

a. orientation

S:
- history of

my

client

as

substance use

enable neurotransmission.

c. absence of

3. Correct clients

to reality

(amphetamine,

Neurotransmitter imbalance

hallucinations

description of

b. absence of

alcohol and

s within the brain are the

inaccurate

hallucinations

cigarrete)

main causes

perception.

c. but still with

- smiles to self

of psychiatric conditions.

R: to limit

delusions

- poor attention

Such conditions are often

misinterpretation

span

accompanied by positive

of external stimuli

- often excuses

symptoms of hallucination

4. Observe

self from the

and delusions which is a

behavioral

activity

disturbance in the sensory

responses.

- (+) flight of

perception.

ideas

R: Progression of
symptoms may

- (+) delusion of

Source:

indicate

infidelity

Townsend, M. C.

impending

- already clients

(2011). Nursing diagnoses

hallucinations.

4th admission

in psychiatric nursing: Care

5. Provide safety.

- Medications:

plans and psychotropic

R: to protect the

Risperidone and

medications (8th ed.).

client and others.

Rivotril

Philadelphia, PA: F.A. Davis

6. Do not argue

Co

with the client

about the
hallucination.
R: so that client
may not feel
threatened or
attacked
7. Provide a calm
environment.
R: to reduce
external stimuli.
8. Encourage
compliance to

treatment and
medications.
R: to lessen the
occurrence of
psychotic
symptoms.
9. Promote
physical activities.
R: To divert
clients attention.