[Talking and laughing to self ][Panic level of anxiety]Sensory distortionsPoor concentrationDisorientation●[Inappropriate responses] [Disordered thought sequencing][Rapid mood swings]Defi[Stops talking in middle of sentence to listen][Listening pose (tilting head to one side as if listening)]stimuli [either internally or externally initiated] accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. Possible Etiologies (“related to”)^116 [Withdrawal into the self ][Stress suffiDefiGoals/Objectives^ AUDITORY/ VISUALDISTURBED SENSORY PERCEPTION:^ nition: ning Characteristics (“evidenced by”)●^ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION ciently severe to threaten an already weak ego] Change in the amount or patterning of incoming
2506_Ch05_105-124.indd 0116 2506 Ch 05 105 - 124 .indClient will be able to defisult of his or her illness and demonstrate ways to interrupt the hallucination.Interventions with Long-term Goalmay be:pist within 1 week.Short-term Goaloccurrence of hallucinations. (This goal may not be realistic Client will discuss content of hallucinations with nurse or thera-for the individual with chronic illness who has experienced auditory hallucinations for many years.) A more realistic goal 1. Observe client for signs of hallucinations (listening pose, d 0 hallucinations.Client will verbalize understanding that the voices are a re-intervention may prevent aggressive responses to command laughing or talking to self, stopping in mid-sentence). 116 Selected Rationales ne and test reality, eliminating the Early 1 10/1/10 9:34:19 AM 0 / 1 / 10 9 : 34 : 19 AM
