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UNIT 3 ■ Care of Patients With Psychiatric Disorders
Table 15–2 | CARE PLAN FOR THE PATIENT WITH SCHIZOPHRENIA NURSING DIAGNOSIS: DISTURBED SENSORY PERCEPTION: AUDITORY/VISUAL RELATED TO: Panic anxiety, extreme loneliness and withdrawal into the self EVIDENCED BY: Inappropriate responses, disordered thought sequencing, rapid mood swings, poor concentration, disori- entation, patient reports hearing voices that no one else can hear OUTCOME CRITERIA NURSING INTERVENTIONS RATIONALE
Short-Term Goal ■■ Patient will discuss content of hallucinations with nurse or therapist within 1 week. Long-Term Goals ■■ Patient is able to define and test reality, reducing or eliminating the occurrence of hallucinations. (This goal may not be realistic for the individual with severe and persistent illness who has experienced auditory hallu- cinations for many years.) A more realistic goal may be: ■■ Patient will verbalize understanding that the voices are a result of the illness and demonstrate ways to interrupt the hallucination.
1. Early intervention may prevent aggres- sive response to command halluci- nations. Since the patient may not recognize these voices as hallucina- tions, it is better to ask the patient what they are hearing rather than use the word hallucinations . 2. Patient may perceive touch as threaten- ing and may respond in an aggressive manner. 3. Touch is often perceived as threaten- ing to a patient who is already anxious and suspicious.
1.
Assess for signs of hallucinations (listening pose, laughing or talking
to self, stopping in midsentence). Ask, “Are you hearing something else?” or “Are you hearing other voices?” If the patient is experiencing command hallucinations, assess the content for evidence of risk of violence toward self or others. 2. Avoid touching the patient without warning them that you are about to do so.
3.
An attitude of acceptance will encourage the patient to share the
content of the hallucination with you. Ask, “What do you hear the voices saying to you?” 4. Do not reinforce the hallucination. Use “the voices” instead of words like they that imply validation. Let patient know that you do not share the percep- tion. Say, “Even though I realize the voices are real to you, I do not hear any voices speaking.” 5. Help the patient understand the connec- tion between increased anxiety and the presence of hallucinations. 6. Try to distract the patient from the halluci- nation. Encourage the patient to listen to music or audiobooks with headphones. 7. For some patients, auditory hallucina- tions persist after the acute psychotic episode has subsided. Listening to the radio or watching television helps dis- tract some patients from attention to the voices. Others have benefited from an intervention called voice dismissal . With this technique, the patient is taught to say loudly, “Go away!” or “Leave me alone!” in a conscious effort to dismiss the auditory perception.
4. It is important for the nurse to be hon- est, and the patient must accept the perception as unreal before hallucina- tions can be eliminated.
5. If the patient can learn to interrupt escalating anxiety, hallucinations may be prevented. 6. Involvement in interpersonal activities and explanation of the actual situation facilitates reality orientation. 7. These activities assist the patient to exert some conscious control over the hallucination. Listening to music or other content distracts the patient’s focus away from auditory hallucina- tions and may help to decrease asso- ciated anxiety.
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