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Nursing Interventions:
1.
Meet with pt. each day for 30 minutes to establish trust
and support.
2.
Observe for signs of hallucinations. When these symptoms
are noted, engage the pt. in here-and-now, reality-oriented conversation or
involve the pt. in here-and-now activity.
3.
Communicate acceptance to the pt. to encourage the
sharing of the content of the hallucinations.
4.
If hallucinations place the pt. at risk for self-harm or
harm to others, place the pt. on one-to-one observation or in seclusion.
5.
Teach pt. to control hallucinations by:
·
Checking ideas out with trusted others.
·
Practicing thought stopping by singing to self,
telling the voices to go away.
·
Telling the voices to go away, using headphones
to listen to music, watching tv, or wearing ear plug in one ear.
6.
Refer the pt. to appropriate support systems in the
community._________________________
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Rationale:
1.
Short, consistent
meetings help decrease anxiety and establish trust. (Foundations, pg: 339)
2.
Interrupts
patterns of hallucinations. (Cox’s Clinical, pg: 504)
3.
Provide
information on the content of the hallucination so early intervention can be
initiated when content suggests harm to the client or others. (Cox’s Clinical,
pg: 504)
4.
Pt. and staff
safety are of primary importance. (Cox’s Clinical, pg: 504)
5.
Promotes the pt.’s
sense of control, and enhances self-esteem.
Provides control of auditory alterations. (Cox’s Clinical, pg: 504)
6.
Establishes continuity of
responses and support for the pt. after discharge. (Cox’s Clinical, pg:
505)_________________________
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Client Response:
1.
Met with pt. and
introduced myself and he introduced himself but was hesitated to engage. He sat
and watched tv and allowed me to sit with him while watching.
2.
Did not observe
any signs and symptoms of hallucinations.
3.
Pt. sat quietly in
lounge watching tv without engagement with others.
4.
Pt. did not appear
to be experiencing hallucinations and did not impose as a threat to self or
others.
5.
Show the pt. some
relaxation techniques and educate the pt. on the importance of the medication
and how the medication can alleviate the hallucinations or reduce them.
6.
Determining where the pt.
will be living after discharge, I will give pt. some supports groups that will
be in the area so the pt. can have support and guidance if he got off
path.____________________________
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Summarize impressions of client progress
toward outcomes / problem resolution:
Observing the pt. after being at the facility for a week it appears that the
medication that has been prescribed, Zyprexa, has controlled the pt.’s
hallucinations and delusions. Pt.
was out of his room walking around and watching tv and participated in snack. Pt. is over withdraws from alcohol. Pt. had a visitor during visiting
hours and interacted with eye contact, no agitation and self-control. Pt. is
showing signs of establishing a better, balanced psychological functioning. Pt.
will receive a referral for a treatment center for substance abuse once living
arrangements have been determined and a support group as well. If pt. remains compliant with
medication and does not mix/ abuse other substances, has a positive support
system and can care for self, pt. can then maintain at an adequate, balanced
psychologic functioning and live a stable
life_____________________________________________________________.
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