Cues

Subjective:
akong igsoon naa
sa likod sakong
uloas verbalized by
the patient
Objective:

Visual
Hallucination)
Inaapropiate
response(ako
maning
magulang ang
naa sakong
luyo)
Engages in
communicatio
n with ate
behind his
head

Psychiatric
Nursing
Diagnosis
Disturbed
sensory
perception
related to
alteration in
function of the
brain

Goal Of Care
STO:
After 1 hour and
half, the patient will
be able to:
1. Establish
rapport and
trust
2. Verbalize
feelings and
thoughts
3. Determine
reality than
false
perceptions
4. Divert
thoughts in
other things
or activities
LTO:
Within 2
weeks of
nursing
intervention,
the patient
will be able
to:
1. Show
understanding
towards the
problem
2. Be free from

Interventions
1. Established
trust and
rapport to
client
2. Continuously
oriented the
client to
actual/real
environment,
in a nonchallenging
way.
3. Reinforced
and focused
on reality,
talk about
real events,
and real
people
4. Corrected
patients
description of
inaccurate
perception,
and describe
the situation
as it exist in
reality
5. Observed for
verbal and
non-verbal
behaviors

Rationale

Evaluations

>the client must

trust the nurse
before talking
about
hallucination
>Frequent
orientation
helps to present
reality to the
client with
Altered sensory
perception.
>Working with
reality lessens
patient initiation
of her
hallucination.
>Explanation of
and
Participation in
real situation
and real
activities
interferes with
the ability to
respond to her
hallucination.

After 2 weeks of
nurse- patient
interaction and
nursing
intervention the
goals is partially
met as evident of :

>Early
recognition of
sensory
perceptual

1. The patient
has
established
trust and
rapport
2. The patient
was able to
verbalized
thoughts
and feelings
3. However
the client
was not
able to
demonstrat
e accurate
sensory
perception
on the
environmen
t as evident
by still
presence of
visual

unrealistic
thoughts
3. Participate in
any activities

associated
with his
hallucinations

disturbances
helps the nurse
promotes timely
intervention and
recognizes
potential harm
for her patient
and others.

hallucinatio
ns