Está en la página 1de 4

c 

April 27, 2011


  Disturbed Thought Processes


        
c 
 ë!uagi ni kay c   # 1. Assess extent of 1. Manic Phase may # At the
nagdali ko, naa !"    Within impairment in thinking , cause delusion of end of 30 minutes
pa koy flight  #!  $ 30 minutes of delusions, flight of ideas grandeur, flight of of Nursing
 !"%  Nursing and associative looseness ideas and associative interventions the
 Every minute # interventions, looseness that may patient was able to
the patient will alter patient͛s determine usual
ko maligo ug
be able to thought process reality orientation
mag-
verbalize 2. Note patient͛s attention 2. as manifested by
toothbrush.͟ span or difficulty in -Reorienting patient to the
logical and the patient asking
reality based concentrating simple basic information͛s of her the student nurse
͞Okay ra man ideas activities or events environment leads to initial for reorientation
kay ako man reality orientation of patient. each time she
ang tag iya # -To divert patient͛s thinking to experiences
aning Hospital.͟   Within 3 3.Orient patient to time place reality hallucinations
 days of nursing and date c    
 interventions, &!'()'*++
-Delusion of the patient will -Discussing things that
grandeur be able to 4.Reorient patient to reality triggers Hallucination helps # After 3
-Flight of ideas express logical, each time the experiences the patient identify days of nursing
-narrowed focus goal directed hallucination threatening thoughts, interventions, the
-auditory ideas with the feelings or events and patient was able to
hallucination absence of 5. Identify ways on how to associate them in reality express logical, goal
-agitated delusions, prevent or ignore hallucination rather than with the directed ideas with
-irritable flight of ideas with patient hallucination content the absence of
-poor eye contact and associative delusions as
looseness -Therapeutic communication verbalized by the
consciously influences a patient
client to verbalize feelings ë 
and thoughts
 
     
6.Utilize therapeutic  

communication in interacting -Patient could identify 
  
to patient hallucination from reality and   
ignore things which are not 
 
real.     
    
7. Encourage patient to -So the client has the chance 
gradually discuss experiences to seek others (in reality) and c    
that occurred before the onset to cope problems caused by &!,*)'*++
of the hallucination hallucination

8.Encourage patient to tell the -To ensure continuous reality


staff or student nurse if he/she orientation
experiences hallucination

9.Encourage the significant


others to reorient patient to
reality each time he/she - As it may reinforce patient͛s
experiences hallucination false belief and further
distance from reality

-Providing positive regard


10. Instruct significant others increases likelihood of
not to pursue the details of the desired behaviors
patients hallucination and
delusions
11. Respond verbally and
reinforce the client͛s -
conversation when he/she
refers to realit
Date Identified: April 27, 2011

        
c 
 ë   &$ # 1. Assess type of Hallucination -To rule out proper # At the
 
 !"!    Within 1 the patient is experiencing intervention for a specific end of 1 hour of

  #!  $ hour of Nursing Hallucination Nursing
   !"%  interventions, 2. Assess for any suicidal -Patients experiencing interventions the
 
 # the patient will ideation or violent behaviors Hallucination may tend to be patient was able to
 be able to violent determine usual
 determine reality orientation
-experiences usual reality 3.Orient patient to time place -Reorienting patient to the as manifested by
auditory orientation. and date basic information͛s of her the patient asking
hallucination environment leads to initial the student nurse
-Delusion of # reality orientation of patient. for reorientation
grandeur   Within 3 4.Reorient patient to reality -To divert patient͛s thinking to each time she
-Flight of ideas days of nursing each time the experiences reality experiences
-narrowed focus interventions, hallucination hallucinations
-agitated the patient will c    
-irritable be able to 5. Identify ways on how to -Discussing things that &!'()'*++
-poor eye contact express logical, prevent or ignore hallucination triggers Hallucination helps
goal directed with patient the patient identify # After 3
ideas with the threatening thoughts, days of nursing
absence of feelings or events and interventions, the
delusions associate them in reality patient was able to
rather than with the express logical, goal
hallucination content directed ideas with
the absence of
6.Utilize therapeutic -Therapeutic communication delusions as
communication in interacting consciously influences a verbalized by the
to patient client to verbalize feelings patient
and thoughts ë 

 
     
-Patient could identify  

7. Encourage patient to hallucination from reality and 
  
gradually discuss experiences ignore things which are not   
that occurred before the onset real. 
 
of the hallucination     
-So the client has the chance     
8.Encourage patient to tell the to seek others (in reality) and 
staff or student nurse if he/she to cope problems caused by c    
experiences hallucination hallucination &!,*)'*++

-To ensure continuous reality


9.Encourage the significant orientation
others to reorient patient to
reality each time he/she
experiences hallucination

- As it may reinforce patient͛s


10. Instruct significant others false belief and further
not to pursue the details of the distance from reality
patients hallucination and
delusions -Providing positive regard
11. Respond verbally and increases likelihood of
reinforce the client͛s desired behaviors
conversation when he/she
refers to reality