The document provides 13 actions to address a client experiencing disturbed thought processes. The actions include: 1) establishing rapport and trust with the client; 2) continuously orienting the client to actual events; 3) reinforcing and focusing on reality; 4) correcting inaccurate perceptions and describing reality; 5) observing verbal and nonverbal behaviors associated with hallucinations; 6) describing hallucinatory behaviors to the client; 7) exploring hallucination content to identify risks of harm; 8) using clear communication; 9) modifying the environment to reduce anxiety; 10) reassuring the client of safety; 11) being sincere when communicating; 12) encouraging expression of feelings without prying; and 13) encouraging participation in group activities with
The document provides 13 actions to address a client experiencing disturbed thought processes. The actions include: 1) establishing rapport and trust with the client; 2) continuously orienting the client to actual events; 3) reinforcing and focusing on reality; 4) correcting inaccurate perceptions and describing reality; 5) observing verbal and nonverbal behaviors associated with hallucinations; 6) describing hallucinatory behaviors to the client; 7) exploring hallucination content to identify risks of harm; 8) using clear communication; 9) modifying the environment to reduce anxiety; 10) reassuring the client of safety; 11) being sincere when communicating; 12) encouraging expression of feelings without prying; and 13) encouraging participation in group activities with
The document provides 13 actions to address a client experiencing disturbed thought processes. The actions include: 1) establishing rapport and trust with the client; 2) continuously orienting the client to actual events; 3) reinforcing and focusing on reality; 4) correcting inaccurate perceptions and describing reality; 5) observing verbal and nonverbal behaviors associated with hallucinations; 6) describing hallucinatory behaviors to the client; 7) exploring hallucination content to identify risks of harm; 8) using clear communication; 9) modifying the environment to reduce anxiety; 10) reassuring the client of safety; 11) being sincere when communicating; 12) encouraging expression of feelings without prying; and 13) encouraging participation in group activities with
The document provides 13 actions to address a client experiencing disturbed thought processes. The actions include: 1) establishing rapport and trust with the client; 2) continuously orienting the client to actual events; 3) reinforcing and focusing on reality; 4) correcting inaccurate perceptions and describing reality; 5) observing verbal and nonverbal behaviors associated with hallucinations; 6) describing hallucinatory behaviors to the client; 7) exploring hallucination content to identify risks of harm; 8) using clear communication; 9) modifying the environment to reduce anxiety; 10) reassuring the client of safety; 11) being sincere when communicating; 12) encouraging expression of feelings without prying; and 13) encouraging participation in group activities with
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Columban College, Inc.
College of Nursing Rizal Ext., Bo. Barrette, Olongapo City Tel. No. (047) 222-9360 loc. 105
NAME OF CLIENT: Patient P AGE: N/A
FOCUS ACTION RESPONSE
Client Disturbed 1. Establish rapport and build trust with the client. participates Thought Processes The client must trust the nurse before talking about hallucinations another sensory-perceptual in group alterations activities.
2. Continuously orient the client to actual environmental events or activities in a Client
challenging way. appropriately Brief, frequent orientation helps to present reality to the client with sensory- perception interacts and disturbance. cooperates with the 3. Reinforce and focus on reality. Talk about real events and real people. Use reactivations student and events to divert client from long, tedious, repetitive verbalizations of false ideas. nurses and Working with reality lessens patient’s initiation of his hallucinations. peers during activities. 4. Correct client’s description of inaccurate perception, and describe the situation as it exists in reality. Explanation of, and participation in, real situations and real activities interferes with the ability to respond to hallucinations.
5. Observe for verbal and nonverbal behaviors associated with hallucinations.
Early recognition of sensory-perceptual disturbance promotes timely interventions and alleviation of the client’s symptoms.
6. Describe the hallucinatory behaviors to the client.
The client may be unable to disclose perceptions and the nurse can openly facilitate disclosure by reflecting on observations of the client’s behaviors, which helps the client engage in more open discussion with the nurse, which in itself brings relief. Columban College, Inc. College of Nursing Rizal Ext., Bo. Barrette, Olongapo City Tel. No. (047) 222-9360 loc. 105
7.Explore the content of hallucinations to determine the possibility to harm self, others or the environment. Exploring the content of the hallucination helps the nurse identify if the sensory-perceptual disturbance is threatening or dangerous to the client, such as command type of hallucination that may be telling the client to harm or kill the client or others. The nurse can then reinforce treatment and safety precautions.
8. Use clear, direct, verbal communication rather than unclear or nonverbal gestures. Unclear directions or instructions can confuse the client and promote distorted perceptions or misinterpretations of reality.
9.Modify the client’s environment to decrease situations that provoke anxiety.
Decreased anxiety can reduce the occurrence of hallucinations.
10. Reassure the client (frequently if necessary) that the client is safe and will not be harmed. Alleviation of fear is necessary for the client to begin to trust the environment and to feel safe.
11. Be sincere and honest when communicating with the client.
Clients are extremely sensitive about others and can recognize insincerity. Evasive remarks reinforce mistrust
12. Encourage the client to express feelings and do not pry cross examine for information Probing increases client’s suspicion and interferes with the therapeutic relationship
13. Encourage participation in-group activities. Caregiver may need to accompany client at first, until he or she feels secure that the group members will be accepting, regardless of limitations in verbal communication. Positive feedback from group members will increase self-esteem Columban College, Inc. College of Nursing Rizal Ext., Bo. Barrette, Olongapo City Tel. No. (047) 222-9360 loc. 105
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