Disturbed Sensory Perception : Auditory and Tactile Hallucinations

Nursing Care Plan for Auditory and Tactile Hallucinations

Goal : The client is able to define and test the reality / and get rid of sensory perception errors.

1. Short-term Goal : After the interaction, the client is able to build a trusting relationship.

Expected outcomes :

• Shows understanding of verbal , written or response signal.
• Indicates movement relaxed facial expression.
• Eye contact shows, want to shake hands, to answer greetings, names, would sit side by side or opposite.

Action Plans

• Develop a relationship of trust with the use of the principles of therapeutic communication :
• With friendly greet clients both verbal and non -verbal.
• Introduce the name , nickname and nurses purpose acquainted.
• Ask the full name of the client and the client's preferred nickname.
• Create an apparent contract.
• Show fairness, and occupies an appointment every time interaction.
• Show empathy and accept what is.
• Pay attention to clients and consider the needs of the client base.
• Ask the client's feelings and problems faced by the client.
• Listen attentively to the expression of the client's feelings.

2. Short-term Goal : After the interaction, the client is able to recognize auditory and tactile hallucinations.

Expected outcomes :

• The client is able to state the time, the content, the frequency of the appearance of hallucinations.
• The client is able to mention the usual behavior when hallucinations appear.
• The client is able to mention a result of the usual behavior when hallucinations occur.

Action Plans

• Perform frequent and brief contact gradually.
• Observation of behavior associated with hallucinations.
• Help clients recognize hallucination :

• Ask if the client is experiencing hallucinations.
• If the client answers yes , ask what is being experienced.
• Say that nurses believe the client is experiencing this, but the nurses themselves do not experience it.
• Say that there are other clients who experienced the same thing.
• Say that the nurse will help.

• If the client is not hallucinating clarification about their experience hallucinations discussed with the client : the content, timing, frequency of occurrence of hallucinations (morning, noon, afternoon, evening, often or sometimes). The circumstances that cause or not cause hallucinations.

3. Short-term Goal : After the interaction, the client is able to control the auditory and tactile hallucinations.

Expected outcomes :

• The client can mention a new way to control hallucinations.
• The client can choose and implement new ways to control hallucinations.
• The clients implement the preferred way to control hallucinations.

Action Plan :

• Discuss with the client how or action taken in case of hallucinations (sleep, angry, etc.)
• Discuss ways in which the client :

• If the method used adaptive give a compliment.
• If the method used maladaptive losses discuss the way.

• Discuss new ways to cut / control the onset of hallucinations.
• Help clients choose the method that has been encouraged and trained to give it a try.
• Give a chance to do what is selected and trained.
• Monitor the implementation of which has been selected and trained, if it managed to give a compliment.
• Encourage clients to follow the group activity therapy, reality orientation, perception stimulation.

4. Short-term Goal : After the interaction, the client can support the family in control of auditory and tactile hallucinations.

Expected outcomes :

• Families can build a trusting relationship with the nurse.
• Families can mention understanding, signs, and actions to address the hallucinations.

Action Plan :

• Make a contract with the family for the meeting (time, place, and topic).
• Discuss with family (at the time of meeting family / friendly visits)

• Definition, signs symptoms, the occurrence, drugs, family members how to prevent hallucinations.
• Provide information to control a hospital and how to seek help if hallucinations are not solved.

5. Short-term Goal : After the interaction, the client can take advantage of the drug well.

Expected outcomes :

• The client and family can mention the benefits of dose, drug side effects, and color name and dosage.
• The client is able to demonstrate the use of drugs correctly.
• The client and the family understand the effects stop taking the medication without recommendation.

Action Plan :

• Discuss with clients about the benefits and disadvantages of not taking medication, name, color, dosage, method, therapeutic effects and side effects of drug use.
• Monitor client when use of the drug.
• Give credit if the client is using the drug properly.
• Discuss due to stop taking the medication without consulting a physician.
• Encourage clients to consult to the doctor / nurse if things happen that are not desirable.