PSYCHOD

NURSING YNAMICS GOAL AND OBJECTIVES NURSING

RATIONALE
ASSESSMENT & THEORY INTERVENTIONS
Disturbed sensory Within 6 hours of proper
perception related to nursing interventions, the - Assess sensory - Information is essential to
psychological stress patient will be able to awareness, client safety. All sensory
as evidenced by demonstrate behaviors and including response systems may be affected
auditory lifestyle changes to compensate to touch, hot/cold, by TBI, loss of or
hallucination. for, or overcome, deficit. dull/sharp, and difference in sensations,
awareness of as well as in the ability to
motion and location perceive and respond
Subjective: of body parts. Note appropriately to stimuli.
problems with
vision and other
senses.
Objective:
- Be alert for signs of - Might herald hallucinatory
increasing fear, activity, which can be
anxiety or agitation. very frightening to client,
Vital signs taken: and client might act upon
T- command hallucinations
RR- (harm self or others).
PR-
BP: - Explore how the - Exploring the
hallucinations are hallucinations and sharing
experienced by the the experience can help
client. give the person a sense of
power that he or she might
be able to manage the
hallucinatory voices.
- Help client to - Helps both nurse and client
identify times that identify situations and
the hallucinations times that might be most
are most prevalent anxiety-producing and
and frightening. threatening to the client.

- Stay with clients - The client can sometimes

when they are learn to push voices aside
starting to when given repeated
hallucinate and instructions. especially
direct them to tell within the framework of a
the “voices they trusting relationship.
hear” to go away.
Repeat often in a
matter-of-fact
manner.
- Decrease the potential for
- Decrease anxiety that might trigger
environmental hallucinations. Helps calm
stimuli when client.
possible (low noise,
minimal activity).
- Promotes consistency and
- Provide structured
reassurance, reducing
therapies, activities,
anxiety
and environment.
associated with the
Provide written
unknown. Promotes sense
schedule for
of control
client/family to
and cognitive retraining.
refer to on a
regular basis.
 PSYCHODYNAM GOAL AND
NURSING NURSING
ICS & THEORY OBJECTIVES RATIONALE
ASSESSMENT INTERVENTIONS
Disturbed sleep pattern Within 8 hours of - Assess the patient’s - Sleep pattern may vary
related to cognitive proper nursing sleep patter and take for each individual.
impairment as evidenced interventions, the note for the amount of Evaluating these
by reports of sleep patient will be able to sleep, sleep routine, patterns will provide
disturbance/auditory report increased sense and position general information
hallucination. of well-being and that needs to be
feeling rested. assessed or improved
Subjective:
- Observe for signs of - To attain baseline date.
Objective: sleep-wake problems
- Presence of eye and note for the
bags patient’s hours of sleep
- Restlessness
- Yawning - Encourage the patient - Consistent sleep and
- Lethargic to have a consistent rest schedule may help
- Less than 6 sleep schedule. to regulate and manage
hours of sleep Suggest to drink a cardiac rhythm.
glass of milk. Drinking a glass of
milk has been
correlated with sleep
Vital signs taken: promotion.
T-
RR- - Introduce relaxing - These activities
PR- activities such as calm provide relaxation and
BP: music, reading a book, distraction to prepare
and relaxation mind and body for
exercises before sleep.
bedtime.
- Restrict intake of - Caffeine may delay
caffeine-containing client’s falling asleep
foods and fluids. and interfere with
REM (rapid eye
movement) sleep,
resulting in client not
feeling well rested.

- Provide nursing aids - To promote rest.

(e.g., back rub,
bedtime care, pain
relief, comfortable
position, relaxation
techniques).