NURSING CARE PLAN FOR HALLUCINATIONS

ASSESSMENT NURSING PLAN OF CARE NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Subjective: Disturbed sensory SHORT TERM INDEPENDENT: GOAL MET.

Patient verbalizes perception: GOAL: 1. Establish rapport with - To have a trusting
“Visionary kasi ako Auditory/visual After 8 hours of the patient relationship with the SHORT TERM
ni God and Mama related to mental nursing interventions, patient. GOAL:
Mary. Pinapatawag illness as the patient will be After 8 hours of
nila ako sa Rome manifested by able to acknowledge 2. Re-orient the client to - Repeated reinforcement of nursing
for a special grandiose disturbed sensory person, place, and reality will reduce interventions, the
message. hallucinations. perceptions as time. confusion and provide a patient
Pinipigilan lang ako evidenced by sense of normalcy. acknowledged
niyan ni devil verbalization of (Nurse’s Pocket Guide disturbed sensory
Karen, Devil Ian, acceptance. 16th Ed, 2023) perceptions as
Devil Abet evidenced by
Marasigan, Devil LONG TERM GOAL: 3. Encourage the client to - Help the client come to verbalization of
Jack at Devil After 1 week of verbalize feelings. terms with long unresolved acceptance.
Butch…” nursing interventions, issues.
the patient will be LONG TERM
Patient shouts “ able to learn ways to 4. Listen actively and - To increase patients' GOAL:
Hindi ko na kaya refrain from converse with the knowledge and After 1 week of
ang responding to patient using understanding, enhance nursing
pangdedemonyo hallucinations as therapeutic techniques. trust and self-health skills, interventions, the
nyo! Isa kayong evidenced by increase adherence, patient will be able
satanas! Layuan decreased provide comfort, and to learn ways to
nyo ako!” towards auditory/visual facilitate the management refrain from
the wall. (auditory hallucinations. of emotions key to patients' responding to
and visual health and well-being hallucinations as
hallucinations (Biomed, 2019) evidenced by
perceived by the decreased
patient) 5. Eliminate extraneous - To avoid distractions and auditory/visual
noise and stimuli assist the patient in hallucinations.
Objective: focusing.
● Grandiose
Hallucinations 6. Observe the patient’s - To determine emotional
● Irritability behavioral responses. problems (Nurse’s Pocket
● Poor Guide 16th Ed, 2023)
concentration
● Visual response 7. Explored how the - Help the patient have a
to stimuli hallucinations are sense of power that might
(constantly experienced by the be able to manage the
looking at the client. voices.
side of the
person she’s 8. Present reality to the - To help the client
talking to) patient when she is differentiate the fantasy to
● Looks frightened calm and oriented. the reality.
and projects
aggression 9. Help the client identify - To help the patient and the
towards voices. times when voices are nurse to identify situations,
more prevalent or times that might be mood
frightening. and anxiety producing, and
threatening to her.

10. Help client in learning - To help the client

techniques to differentiate the fantasy to
differentiate the reality.
hallucinations from
reality.

11. Assess patient’s - Clients often obey

suicide risk. Clearly hallucinatory commands to
document what client kill self or others. Early
said. assessment and
interventions might save
lives.
12. Engage the patient in - To redirect the patient’s
reality-based energies to acceptable
conversations and activities that can decrease
activities such as the relapse of
reading books, hallucinations and help
dancing, drawing. distract her from voices.

DEPENDENT:
1. Administer Clozapine, - In order to prevent relapse
 as prescribed, and of the positive and
ensure client is negative symptoms of
compliant to her Schizophrenia
medication.

COLLABORATIVE:
1. Refer to - For further assessment
psychologist/psychiatri and intervention.
st

References:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Disturbed Sensory Perception. In Nurse's pocket guide: Diagnoses,
prioritized interventions, and rationales (16th ed., pp. 874–879). essay, F.A. Davis Company.