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Disturbed Sensory Perception

This nursing note documents the care of a client on January 22, 2016 at 4pm. The client has a nursing diagnosis of disturbed sensory perception related to a biochemical imbalance causing sensory distortion. The objectives are for the client to demonstrate awareness of reality within 1 day by being oriented, free from delusions and hallucinations. Interventions include establishing trust, continuously orienting the client, correcting inaccurate perceptions, observing for symptoms, ensuring safety, avoiding arguing about hallucinations, providing a calm environment, encouraging compliance and promoting physical activity.

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Joenna Galolo
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1K views3 pages

Disturbed Sensory Perception

This nursing note documents the care of a client on January 22, 2016 at 4pm. The client has a nursing diagnosis of disturbed sensory perception related to a biochemical imbalance causing sensory distortion. The objectives are for the client to demonstrate awareness of reality within 1 day by being oriented, free from delusions and hallucinations. Interventions include establishing trust, continuously orienting the client, correcting inaccurate perceptions, observing for symptoms, ensuring safety, avoiding arguing about hallucinations, providing a calm environment, encouraging compliance and promoting physical activity.

Uploaded by

Joenna Galolo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Date

Cues

Need

Nursing Diagnosis

and
Time
January
22,
2016
@
4pm

Objectives of

Nursing

Care

Interventions

Evaluation

O:

Disturbed sensory

Within our 1

1. Establish trust

Goal partially

Bestfriend nako

perception related to

day span of

and rapport to the

met

si Satanas.

biochemical imbalance for

care, client will

client.

After

Nakita nako siya

sensory distortion

demonstrate

R: To gain clients

days span of

sa langit. As

awareness as

cooperation.

care,

verbalized by

Rationale:

evidenced by:

2. Continuously

demonstrate

the client.

Neurotransmitters also

a. oriented to

orient the client to

awareness to

known as chemical

reality

reality.

reality

messengers, are

b. absence of

R: to help client

evidenced by:

endogenous chemicals that

delusions

remain oriented

a. orientation

S:
- history of

my

client

as

substance use

enable neurotransmission.

c. absence of

3. Correct clients

to reality

(amphetamine,

Neurotransmitter imbalance

hallucinations

description of

b. absence of

alcohol and

s within the brain are the

inaccurate

hallucinations

cigarrete)

main causes

perception.

c. but still with

- smiles to self

of psychiatric conditions.

R: to limit

delusions

- poor attention

Such conditions are often

misinterpretation

span

accompanied by positive

of external stimuli

- often excuses

symptoms of hallucination

4. Observe

self from the

and delusions which is a

behavioral

activity

disturbance in the sensory

responses.

- (+) flight of

perception.

ideas

R: Progression of
symptoms may

- (+) delusion of

Source:

indicate

infidelity

Townsend, M. C.

impending

- already clients

(2011). Nursing diagnoses

hallucinations.

4th admission

in psychiatric nursing: Care

5. Provide safety.

- Medications:

plans and psychotropic

R: to protect the

Risperidone and

medications (8th ed.).

client and others.

Rivotril

Philadelphia, PA: F.A. Davis

6. Do not argue

Co

with the client


about the
hallucination.
R: so that client
may not feel
threatened or
attacked
7. Provide a calm
environment.
R: to reduce
external stimuli.
8. Encourage
compliance to

treatment and
medications.
R: to lessen the
occurrence of
psychotic
symptoms.
9. Promote
physical activities.
R: To divert
clients attention.

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