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 effects of medication to ensure Alex is getting required treatments
3. Reassure Alex of their safety to decrease stressor that might trigger hallucination
4. Assess the content of hallucination to prevent harm to self and others
5. Ensure environment is less stimulating
6. Monitor for any stressors that can trigger hallucination to decrease possible anxiety
7. Have one to one discussion with Alex or administer medication as ordered when needed in order to deescalate anxiety. Other forms of restraints and hospital protocols should be used when needed.
Evaluation
1. At third week, Alex states on a scale of 1 to 10, voices are 2, Alex states he can control the voices by participating in activities
2. At fifth week, Alex stated colouring…
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