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Medical Diagnoses:Disturbed sensory perception related to hallucinations


1.      Disturbed sensory perception related to hallucinations.

·         Drug induced psychosis

·         Poly-substance abuse

·         Noncompliance with taking prescribed meds

·         Violent behavior (attacking sister)

·         Inability to concentrate

7. Risk for other-directed violence related to command hallucinations and delusions.

·         Drug induced psychosis

·         Poly-substance abuse

·         Noncompliance with taking prescribed meds

·         Violent behavior (attacking sister)

·         Involuntary admission into mental health hospital

2. Disturbed thought processes related to delusions.

·         Drug induced psychosis

·         Poly-substance abuse

·         Noncompliance with taking prescribed meds

·         Violent behavior (attacking sister)

·         Inability to concentrate

3. Distorted thought self-control related to irrational behaviors.

·         Hallucinations

·         Delusions

·         Poly-substance abuse

·         Noncompliance with taking prescribed meds

·         Violent behavior (attacking sister)

·         Involuntary admission into mental health hospital

·         Inability to concentrate

Chief Complaint: A 28 year old white male actively hallucinating and delusional because of drug induced psychosis and the noncompliance of him not taking his prescribed meds. Pt. also physically violent with others and is poly-substance abusing.

Priority Assessment: Monitor intentions of harming self and/or others.  Monitor vitals and labs (metabolic-Zyprexa). Monitor hallucinations and delusions.  Monitor for extrapyramidal side effects from antipsychotics.

5. Compromised family coping related to pt.’s drug induced psychosis.

·         Sister kicked him out of her house after physical assault

·         Mother passed away 6 months ago

·         Pt. displays behavior indicators that are hard to cope with

·         Involuntary admission into mental health hospital

8. Risk for self-directed violence related to command hallucinations

·         Hx of a suicide attempt

·         Violence towards others (sister)

·         Involuntary admission into mental health hospital

6. Self-care deficit related to irrational behaviors.

·         Car reposed

·         Work problems

·         Kicked out of his sister’s house

·         Involuntary admission into mental health hospital

·         Noncompliance with taking prescribed meds

4. Ineffective coping related to drug induced psychosis

·         Blunted affective state

·         Poly-substance abuse

·         Noncompliance with taking prescribed meds

·         Involuntary admission into mental health hospital

·         Hallucinations

·         Delusions


NANDA Diagnostic Statement: Disturbed sensory perception related to hallucinations AEB drug induced psychosis.

 

Behavioral Outcome / Goal: Pt. will establish adequate, balanced psychological functioning and will be compliant with the prescribed medication by 12/8/12.


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._________________________

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)_________________________

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.____________________________

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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