[Inappropriate responses]Hallucinationsment by responding appropriately to stimuli indigenous to the Client will demonstrate accurate perception of the environ-Long-term Goalof time.to time, place, person, and circumstances for specifiWith assistance from caregiver, client will maintain orientation Short-term GoalGoals/Objectives[Suspiciousness] Defi[Talking and laughing to self ]Poor concentrationSensory distortions^66 [Disorientation to time, place, person, or circumstances]surroundings.^ ning Characteristics (“evidenced by”)●Cerebral hypoxiaExposure to environmental toxinsAbuse of mood- or behavior-altering substancesVarious other physical disorders that predispose to cere-Hypertension^ bral abnormalities (see Predisposing Factors)]ALTERATIONS IN PSYCHOSOCIAL ADAPTATION ed period
2506_Ch03_054-070.indd 66 2506 Ch 03 054 - 070 .ind 4. Correct client’s description of inaccurate perception, and de- 3. Provide reassurance of safety if client responds with fear to 2. Do not reinforce the hallucination. Let client know that you Interventions with 5. Allow for care to be given by same personnel on a regular 1. Decrease the amount of stimuli in client’s environment d 6 (e.g., low noise level, few people, simple decor). scribe the situation as it exists in reality. nursing priorities.in client’s environment.basis, if possible, inaccurate sensory perception. client’s sense of self-worth and personal dignity.orientation decreases false sensory perceptions and enhances with the ability to respond to hallucinations.orientation and focus on real situations and people. do not share the perception. Maintain reality through re-perceptions.creases the possibility of client’s forming inaccurate sensory participation in real situations and real activities interfere 6 to provide a feeling of security and stability Selected RationalesClient safety and security are Explanation of and This de-Reality 10/1/10 9:33:41 AM 10 / 1 / 10 9 : 33 : 41 AM
