1. Risk for hurting themselves and others
Hear hallucinations
Long-term goals:
- Clients can control the hallucinations and not hurt themselves or others.
Interventions:
Psychotherapeutic:
- Conduct frequent and brief contact
- Observations of verbal and nonverbal behavior associated with hallucinations
- Give clients the opportunity to express what is felt the client in accordance with client's verbal and nonverbal responses.
- Hallucinations as the real thing for the client, and give the opinion that the hallucinations are not real to the nurse.
- Ask open-ended questions that require extensive answers.
- Together with the client to schedule activities to avoid loneliness
- With clients to discuss how to control the hallucinations Hear: like to join with others to talk, watch TV, take part in group activities.
- Guided clients on preferred activities
- Discuss with the client and family about drug therapy and side effects arise.
- Give drugs with five principles correctly.
- Facilitate client's current medication
- Make sure that the drug had been taken by the client.
- Give positive reinforcement when clients take medication regularly.
- Keep records after drug administration.
- Provide tools as time: clock and calendar.
- Give marks / names in the client room
- Call client by name calling, which is preferred by the client
- Nurses wore nameplate.
- Recommend to interact with the name of each client
- Facilitate clients in group activities gradually
- Increase client response to reality by way of showing calendar, clock, name space.
- Discussing with the client about trigger the onset of hallucinations.
- Encourage clients to report to the nurse if there is a hallucination
- Give information on the client where the client asked for assistance if it is difficult to control when hallucinations occur.
- Explain to the client signs of hallucinations, how to cope, a situation that causes hallucinations and facilities that can be used when experiencing difficulties.
2. Social Isolation
Long-term goals:
- Clients do not pull out and interacting with others
Interventions:
Psychotherapeutic
- Construct a trusting relationship
- Listen to what is disclosed by the client
- Perform frequent contact and a brief
- Support and encourage the client to communicate with the nurse if there is something they think.
- Give positive reinforcement
- Encourage clients to see the positive things about him.
- Limit the client to not daydream / outs by clients involved in routine activities in the room, such as preparing meals, sweeping, making beds, washing dishes.
Psikofarmaka
- Discuss with the client and family about drug therapy and side effects arise.
- Give drugs with five principles correctly.
- Facilitate client's current medication
- Make sure that the drug had been taken by the client.
- Give positive reinforcement when clients take medication regularly.
- Keep records after drug administration.
- Encourage clients to get acquainted with other people, one time each day.
- Discuss how to interact further.
- Accompany clients to be in addition to clients ranging from silent to verbally communicate a simple, phased according to the capacity of the client.
- Involve clients in interacting groups conducted in stages from small groups to large groups.
- Involve clients in activities of group activity (TAK: socialization)
- Provide a means of information and entertainment such as magazines, newspapers, TV.
- Involve the family to always to keep in contact with the client, such as family visiting clients at least one week.
- Teach client how to meet the other clients.
- Discuss with client events leading to withdrawal
- Provide information to families about how to care for clients by withdrawing
- Encourage the family mengikutisertakan clients in family and community environment.
- Provide a description of the importance of taking medication regularly on clients and families.