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Disturbed Sensory Perception

The patient is experiencing auditory hallucinations and disturbed sensory perceptions related to schizophrenia. She claims to hear voices telling her to harm herself. The nurse's goals are to orient the patient to reality, divert her attention away from hallucinations, and decrease stimuli that could exacerbate her symptoms. Interventions include lowering environmental stimulation, not reinforcing hallucinations, correcting inaccurate perceptions, reassuring the patient, and teaching her techniques to recognize and cope with hallucinations. The overall objectives are to maintain the patient's orientation, decrease recurrence of hallucinations, and help her manage her condition through diversionary activities.

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James Lozano
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12K views3 pages

Disturbed Sensory Perception

The patient is experiencing auditory hallucinations and disturbed sensory perceptions related to schizophrenia. She claims to hear voices telling her to harm herself. The nurse's goals are to orient the patient to reality, divert her attention away from hallucinations, and decrease stimuli that could exacerbate her symptoms. Interventions include lowering environmental stimulation, not reinforcing hallucinations, correcting inaccurate perceptions, reassuring the patient, and teaching her techniques to recognize and cope with hallucinations. The overall objectives are to maintain the patient's orientation, decrease recurrence of hallucinations, and help her manage her condition through diversionary activities.

Uploaded by

James Lozano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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ASSESSMENT

DIAGNOSIS

Cues:
Naririnig ko sila.
Pinaguusapan nila
ako. Gusto nilang icontrol lahat ng
iisipin at sasabihin
ko

Disturbed sensory
perception related to
schizophrenia

Claimed to hear a
voice and said
Patayin ko na lang
daw sarili ko
When asked to
explain about the
first statement, she
said I read an article
from the Philippine
Daily Inquirer
warning me of an
imminent danger. My
brother has plans on
killing me.

SCIENTIFIC
RATIONALE
Patients diagnosed
with schizophrenia
manifests a series of
symptoms that are
classified as negative
symptoms that
include
hallucinations. A
hallucination is a
perception in the
absence of external
stimulus that has
qualities of real
perception. Since she
claims to hear things
that were not really
said, she is having
auditory
hallucinations.

OBJECTIVES

INTERVENTIONS

RATIONALE

Short-Term Goal:

1. Decrease the
amount of stimuli
in the client's
environment (e.g.,
low noise level,
few people,
simple decor).

1. This decreases t
he possibility of
forming
inaccurate
sensory
perceptions.

2. Do not reinforce
the hallucination.
Let client know
that you do not
share the
perception.

2. Reality orientation
decreases false
sensory
perceptions and
enhances client's
sense of selfworth and
personal dignity.

Within the whole


shift, with assistance
from the nurse, the
client will:
1. Maintain
orientation to
time, place,
person, and
circumstances for
specified period of
time.
2. Divert attention
away from
hallucinations.
3. Identify activities
that would help
keep attention
away from
hallucinations
Long-Term Goal:

Clues:
Noted to be
mumbling to herself
and often pausing as
if she were listening
to someone else
Suspicious and
unpredictable
demeanor

Within each day, the


client will:
1. Be oriented with
time, place,
person, and
circumstances for
specified period of
time
2. Decrease or cease
recurrence of

3. Maintain reality
through
reorientation and
focus on real
situations and
people.
4. Provide
reassurance of
safety if client
responds with fear
to inaccurate
sensory
perception.
5. Correct client's
description of
inaccurate
perception, and
describe the

3. Keeping the
patient grounded
to reality clarifies
altered sensory
perception
4. Client safety and
security is a
nursing priority.

5. Explanation of,
and participation
in, real situations
and real activities
interferes with the
ability to respond

hallucination
3. Manage self
through activities
that would divert
attention away
from
hallucinations.

situation, as it
exists in reality.

6. Provide a feeling
of security and
stability in the
client's
environment by
allowing for care
to be given by
same personnel
on a regular basis,
if possible.
7. Teach the client
how to recognize
signs and
symptoms of
clients inaccurate
sensory
perceptions.
Explain
techniques they
may use to
restore reality to
the situation.
8. Instruct the client
to call for the
nurse at times
when
hallucinations
occur.

to hallucinations.
6. To lessen anxiety,
suspiciousness
and self-harm.

7. Diversionary
activities help in
diverting attention
away from
hallucinations,
which may cause
self-harm,
suspicions or
harm to others.
8. Some
hallucinations
might push the
client to commit
suicide. Close
observation is
needed.

ASSESSMENT DIAGNOSIS SCIENTIFIC RATIONALE OBJECTIVES INTERVENTIONS RATIONALE Cues: “Naririnig ko sila. Pinaguusapan nila a
hallucination 3. Manage self through activities that would divert attention away from hallucinations. situation, as it

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