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Wednesday, November 30, 2011

Nursing Interventions for Hallucinations or Delusions

A hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as Perceptions in a conscious and awake state in the absence of external stimuli the which have qualities of real perception, in That They are vivid, substantial, and located in external objective space. The latter definition distinguishes hallucinations from the related phenomena of dreaming, the which does not involve wakefulness; illusion, the which involves distorted or misinterpreted real perception; imagery, the which does not mimic real perception and is under voluntary control; and pseudohallucination, the which does not mimic real perception, but is not under voluntary control. [1Hallucinations also differ from "delusional Perceptions", in the which entered correctly sensed and interpreted a stimulus (ie a real perception) is given some additional (and typically bizarre) significance.

Nursing Interventions for Hallucinations or Delusions

Do not focus on hallucinations or delusions. Do interruption to the client by initiating interaction hallucinations one-on-one based on reality.

Tell them that you do not agree with the perception of the client, but the validation that you believe that the hallucinations are real to the client.

Do not argue with the client about the hallucinations or delusions.

Respond to the feelings that the client communicated at the time he was having hallucinations or delusions.

Divert and focus the client on a structured activity or task-based reality.

Move the client to a more quiet, less stimulating.

Wait until the client does not have hallucinations or delusions before starting the counseling session about it.

Explain that hallucinations or delusions are symptoms of psychiatric disorders.
Say that the anxiety or increased stimulus from the environment, can stimulate the onset of hallucinations.

Help clients control the hallucinations by focusing on the reality and take medication as prescribed.

If hallucinations persist, Help clients to ignore it and keep acting remedy properly despite an hallucination.

Teach a variety of cognitive strategies and tell the client to use conversations themselves ("the voices that makes no sense") and the cessation of mind ("I will not think about it").

Thursday, November 3, 2011

Nanda NIC NOC for Cataract

Nursing Diagnosis for Cataract

1. Impaired sensory perception (visual) related to Changes in sensory reception or sense organ of vision status.

Cataract Nursing Outcome Classification (NOC) : Vision Compensation Behavior (1611)

After nursing actions during 2x24 hours expected of patients with expected outcomes:
(161 102) Position the patient to improve eyesight.
(161 103) Instruct family members to use the techniques improve eyesight
(161 107) Use visual aids
(161 105) Use goggles

NOC criteria:
  1. Not done at all
  2. Rarely do
  3. Are underway
  4. Often performed
  5. Always do

Cataract Nursing Interventions Classification NIC : EYE CARE (1650)
  • Monitor the redness and the presence of exudate
  • Determine the degree of decrease in vision or sharp eyesight test
  • Instruct patient not to touch eyes
  • Monitor corneal reflex
  • Instruct the patient to use glasses cataract
  • Take action to help patients deal with limited vision.
  • Encourage the patient to express feelings about the loss of vision.

2. Anxiety related to changes in health status

NOC : Anxiety Control (1402)

After nursing actions during 2x24 hours expected of patients with expected outcomes:
(140 206) The use of effective coping strategies
(140 207) Respiratory Rate within the normal range
(140 211) There is an increasing social relationships
(140 214) patients feel as comfortable with the situation
(1402170) The patient was calm

NOC criteria:
  1. Not done at all
  2. Rarely do
  3. Are underway
  4. Often performed
  5. Always do
NIC: Anxiety Reduction (5820)
  • Trying to understand the client's circumstances
  • Give information about the diagnosis and action
  • Use a calm approach
  • Identify the level of anxiety
  • Help patients recognize situations that indicate anxiety
  • Encourage patients to express feelings and fears
  • Give the drug to reduce anxiety
  • Assess the level of anxiety and physical reactions at the level of anxiety
  • Instruct the patient to reduce anxiety with relaxation techniques
Coping Enhancement (5830)
  • Use a calm approach and provide assurance
  • Appreciate and discuss alternative responses to situations
  • Support the involvement of families in an appropriate manner
  • Respect the patient's understanding of disease processes
  • Supports the use of appropriate defensive mechanisms
  • Provide a realistic choices about aspects of current treatments

3. Low self esteem related to Impaired self-image

NOC: Body Image (1200)

After nursing actions performed in 3 x 24 hours the patient is expected to receive him, with the expected outcomes:
  • Receive the body have been affected
  • SatisfiedTebal with the appearance of the body
  • Satisfied with body functions
NOC criteria:
  1. Not done at all
  2. Rarely do
  3. Are underway
  4. Often performed
  5. Always do

NIC: Self estem enhancement (5400)
  • Monitor the patient statement about himself
  • Help the patient to improve the assessment itself to award him
  • Help the patient to increase her confidence
  • Provide a strong impetus for patients
  • Encourage eye contact in communication with everyone
  • Provide health education to families
  • Provide health education to clients about the disease