Nervous Process And Manifested By Auditory Hallucinations

1708 Words Aug 7th, 2015 7 Pages
Nursing Diagnosis 1
Disturbed sensory perception related to schizophrenic process and manifested by auditory hallucination.
Goal
1. Voices are less frequent using a scale of 1 to 10 by third week of treatment
2. Alex will be able to identify and demonstrate a technique to distract him from the voices by the sixth week of treatment
Expected outcome
1. Alex states he no longer hear voices
2. Compliant with medication(s) and other treatments
3. Will be able to participate in discharge planning
4. Eat food brought in by parents and hospital
5. Starts participating in group activities
Nursing Intervention and rationale
1. Orient Alex to the reality with clear and simple communication and do not deny the existence of heard voices
2. Assess
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Outcome
1. Socialize with co-patients and family
2. Comes out of room and participate in activities
3. Use appropriate communication and social skills
4. Have appropriate behaviour, mood and affects
Nursing Intervention
1. Spend frequent short time sessions with patient to trigger communication and create sense of being in Alex
2. Avoid touching Alex this might trigger violence because of paranoia
3. Create and structure activities with client and at client own pace to increase interest
4. Administer medications
5. Provide appropriate social skills training
6. Heath teaching about social isolation, feeling agitated or anxious due to environment will increase patient sense of control and help Alex address anxiety
Evaluation
1. Witness client participate in group activities 3 times a week
2. Alex have appropriate behavior and affect for 5 days out of 7days
3. Both goals are met by the appointed time. If not, goals will be re-evaluated and changed

Nursing diagnosis 3
Self-care deficit – hygiene and feeding Goal:
1. Client is interested in perform activities of daily living without assistance or difficulty
2. Alex will eat healthy to acquire all nutrients
Outcome-
1. Fully participate and carry out self-care activities and daily activities by the end of fifth week
2. Alex eat and having interest in solid and cooked foods by Fourth week
Nursing intervention
1. Encourage Alex to participate in ADL, eat and provide options on time he wants to
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