Nursing Care Plan - Diagnosis and Interventions for Hallucinations

Nursing Diagnosis and Interventions for Hallucinations

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.
Daily activities (Actifity Daily Living)
  • 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
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.
Therapeutic Environment
  • 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.
Health Education:
  • 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.
Daily activities (ADL)
  • 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.
Therapeutic Environment
  • 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.
Health Education
  • 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.