What are some nursing interventions to help patients experiencing visual and auditory hallucinations?
Now that we have discussed the symptoms and treatments for psychosis and schizophrenia, we will explain how to apply the nursing process to a client experiencing an acute psychotic episode related to schizophrenia. Show
AssessmentAssessment includes interviewing the client, observing verbal and nonverbal behaviors, and completing a mental status examination and a psychosocial assessment. Common findings during a mental status examination for a client with schizophrenia experiencing an acute psychotic episode are described in Table 11.4a. Review information about performing a mental status examination and psychosocial assessment in the “Application of the Nursing Process in Mental Health Care” chapter. It is also important to assess for suicide risk for clients with psychosis. Review how to assess for suicide risk in the “Foundational Mental Health Concepts” chapter. Table 11.4a Common Findings During a Mental Status Examination for Individual With Schizophrenia Experiencing an Acute-Psychotic Episode[1]
When assessing hallucinations, do not imply the perceptions are real. For example, a nurse should ask the client, “What do you hear?” not “What are the voices saying?” It is important to assess for command hallucinations, such as, “Are you hearing a voice that is telling you to do something,” followed by, “Do you believe what you hear is real?” If the answer is “Yes,” the client is at increased risk for acting on the command. Assess when the hallucinations began, their content, and the manner in which the client experiences them (i.e., Are they supportive or distressing? In the background or intrusive?). Ask what makes them worse or better, how the client responds, and what they do to cope with the hallucinations.[2] When assessing delusions, determine if the client is capable of reality testing (i.e., questioning their thoughts and determining what is real). Ask the client if they believe there is any danger related to the delusion.[3] Assess the client’s ability to perform activities of daily living. Are they getting adequate food, fluid, sleep, and rest? Are they completing daily hygiene tasks and dressing safely for weather conditions? Are they able to control their impulses and make safe decisions?[4] Determine if the client is taking their medications as prescribed, their effectiveness, and if they are experiencing side effects. Are there any barriers to medications or other treatment, such as cost, stigma, or mistrust of health care providers?[5] Nurses also assess for adverse effects of medications, such as involuntary movements associated with the use of antipsychotic medications (e.g., extrapyramidal side effects or tardive dyskinesia). Clients are routinely assessed for these adverse effects using scales like the Abnormal Involuntary Movement Scale. View a YouTube video[6] of a nurse performing an assessment using an Abnormal Involuntary Movement Scale: Mental Health AIMS Assessment When possible, assess family members and significant others’ knowledge of the client’s illness and their response. Are they overprotective, frustrated, or anxious? Are they familiar with family support groups, respite, and other community resources?[7] Diagnostic and Lab WorkEnsure the client has had a medical workup for other potential causes of psychosis. For example, dehydration, infection, electrolyte imbalances, abnormal blood glucose level, substance use, or withdrawal from substances can cause psychosis. Concurrent medical disorders are common and should be treated in addition to treating schizophrenia. If the client is currently taking psychotropic medications, therapeutic drug levels of some types of medications are required. As always, review current information from a medication reference before administering medications. DiagnosesMental health disorders like schizophrenia are diagnosed by mental health providers using the DSM-5. Nurses create individualized nursing care plans based on the client’s responses to their mental health disorders. See Table 11.4b for a list of common nursing diagnoses and human responses related to schizophrenia. Table 11.4b Common Nursing Diagnoses Related to Schizophrenia[8],[9]
Outcome IdentificationOutcomes should be consistent with the recovery model and emphasize hope, resilience, living a full and productive life, and recovery from illness. Expected outcomes are identified based on the client’s current phase of their illness: acute, stabilization, or maintenance[10]:
Planning InterventionsHospitalization is indicated during the acute phase of schizophrenia if the client is considered a danger to self (e.g., refuses to eat or is too disorganized to function in the community) or to others (e.g., is behaving in a threatening manner to others).[14] During the stabilization and maintenance phases, planning focuses on education, support, and skills training for the client and family. It also addresses how and where these needs can be met within the community. As explained previously in this chapter, relapse prevention efforts are vital. Each relapse can increase residual dysfunction and deterioration and can contribute to despair, hopelessness, and suicide risk. Additionally, recognizing early signs of relapse (e.g., reduced sleep, social withdrawal, and worsening concentration) and implementing intensive treatment are needed to minimize the disruption of the client’s life.[15] ImplementationDuring the acute phase of schizophrenia, hospitalization provides safety, structure, and support. As discussed earlier, anosognosia may impair the client’s ability to recognize their mental illness. In this case, court-ordered hospitalization may be required.[16] Read more about court-ordered hospitalization in the “Legal and Ethical Considerations in Mental Health Care” chapter. Nursing interventions focus on providing safety, promoting hygiene and nutrition, improving socialization, encouraging hope and self-esteem, preventing falls, using specific therapeutic techniques, addressing physiological needs, and implementing collaborative interventions. Provide SafetyClients with command hallucinations require close monitoring for suicide, homicide, and other violence risk. Implement interventions to reduce risk of suicide as described in the “Application of the Nursing Process in Mental Health Care” chapter. Interpersonal conflict, paranoia, delusions, impaired judgment, limited impulse control, fear, and disagreement with unit rules increase the risk for aggressive behavior.[17] Nursing interventions addressing increased risk for violence to self and others are described in the following box. Read more about recognizing signs of crisis and crisis interventions in the “Stress, Coping, and Crisis Intervention” chapter. Nursing Interventions Addressing Risk for Violence[18]
Promote Hygiene and NutritionPromote hygiene in clients experiencing psychosis by concisely and explicitly stating expected hygiene tasks. Break tasks into smaller, more manageable tasks and assist when needed. Use visual cues to prompt hygiene tasks, such as putting clean clothes on the bed or clean towels and a toothbrush in the bathroom. Share potential benefits of improved hygiene such as improved socialization with others. Reinforce progress in performing hygiene with verbal praise or concrete rewards like additional privileges on the unit.[19] Clients who are experiencing catatonia require assistance with nutrition, as well as other activities of daily living. Improve SocializationRegularly engage with the client. Initially interact briefly about low-anxiety topics like the weather and gradually increase the duration and frequency of interactions as they become more comfortable. Encourage clients to participate in unit activities without pressure, such as “We would like to see you at the morning meeting.” Reinforce the client’s control in their choices, such as, “If you become uncomfortable in the group, you can leave and try again on another day.” Provide positive reinforcement for attempts at socialization, such as, “It was nice to see you in the morning meeting today.”[20] Encourage Hope and Self-EsteemConvey unconditional acceptance, empathy, and support. For example, say, “Sometimes it can feel very discouraging when experiencing a mental health disorder. I am wondering how you are feeling?” If the client cannot identify their feelings, suggest words that may apply, such as, “Sometimes it is hard to say what you are feeling. Do you feel sad, frustrated, or anxious?” Validate the client’s feelings and assure them they are not alone. Help the client identify their positive traits or previous accomplishments. Suggest coping strategies such as journaling and attending a support group. Teach stress management techniques and coping strategies as outlined in the “Stress, Coping, and Crisis Intervention” chapter. Prevent FallsFall risk may be increased due to orthostatic hypotension, impaired balance, bradykinesia, or other movement disorders. Assess the client’s gait and for orthostatic hypotension. Teach the client to slowly change position from lying to sitting to standing and encourage the use of handrails or seeking assistance when feeling unsteady. Implement additional fall precautions as needed according to agency policy. Read more information about fall precautions in the “Safety” chapter of Open RN Nursing Fundamentals. Use Therapeutic Techniques for Delusions and HallucinationsRecall that clients with schizophrenia may have memory and attention impairments. Repetition with visual and verbal reminders is helpful to promote task completion. Additionally, short but frequent interactions may be less stimulating to the client and better tolerated.[21] Additional techniques for helping clients who are experiencing delusions and hallucinations are described below. Helping Clients Who Are Experiencing DelusionsDelusions feel very real to the client and can be frightening. Nurses should acknowledge and accept the client’s experience and feelings resulting from the delusion while conveying empathy. They can provide reassurance regarding their intentions to help the client feel safer. Avoid questioning the delusion. Until the client’s ability to test reality improves, trying to prove the delusion is incorrect can intensify it and cause the client to view the staff as people who cannot be trusted. Instead, focus on the fear and what would help the client feel safer. For example, if a client states, “The doctor is here. He wants to kill me,” the nurse could respond, “Yes, the doctor is here and wants to see you. They talk with all of the patients about their treatment. Would you feel more comfortable if I stayed with you during your meeting with the doctor?” Focusing of events in the present keeps the client focused on reality and helps them distinguish what is real.[22] If a client is exhibiting paranoia and is highly suspicious, it is helpful to maintain consistent staff assignments. Staff should avoid laughing, whispering, or talking quietly where the client can see these actions but cannot hear what is being said. Staff should ask permission before touching the client, such as before taking their blood pressure. Read additional strategies for working with clients with delusions from the British Columbia Schizophrenia Society: Steps for Working With Delusions. Helping Clients Who Are Experiencing HallucinationsHallucinations feel very real to the person experiencing them and can be distracting during their interactions with others. Hallucinations can be supportive or terrifying, faint or loud, or episodic or constant. For example, listen to simulations of auditory hallucinations in the following box. The nurse should focus on understanding the client’s experiences and responses and convey empathy. Command hallucinations, suicidal ideation, or homicidal ideation requires safety measures as previously discussed in the “Provide Safety” subsection. Simulations of Auditory Hallucinations British Columbia Schizophrenia Society created music tracks simulating what auditory hallucinations can feel like to clients. Similar to auditory hallucinations experienced by people living with schizophrenia, when people listen to these songs, they hear voices that can be frightening. Listen to these simulations on YouTube with discretion because some people can find them disturbing: Track 05: Mark Pelli – Everything (Songs of schizophrenia mix)[23] Track 06: Cassandra Vasik – Sadly mistaken (Songs of schizophrenia mix)[24] When working with a client who has a history of hallucinations, watch for hallucination indicators, such as eyes tracking an unheard speaker, muttering or talking to oneself, appearing distracted, suddenly stopping a conversation as if interrupted, or intently watching a vacant area of the room. Ask about the content of the hallucinations and if they are experiencing command hallucinations. Assess how the client is reacting to the hallucinations, especially if they are exhibiting anxiety, fear, or distress.[25] Avoid referring to the hallucinations as if they were real to promote reality testing. For example, do not ask, “What are the voices saying to you,” but instead ask, “You look as though you are hearing something. What do you hear?” Do not try to convince the client the hallucinations are not real, but instead offer your perception and convey empathy. For example, “I don’t hear angry voices that you hear, but that must be very frightening for you.” Address any underlying emotion, need, or theme indicated by the hallucination.[26] Focus on reality-based activities in the “here and now,” such as a conversation or simple project. Promote and guide reality testing. For example, guide the client to look around the room and see if others are frightened; if they are not, encourage them to consider what they are experiencing are hallucinations. Teach the client to compare their perceptions to trusted others.[27] See the information in the following box for teaching clients how to manage their hallucinations. Patient Education: Teaching Clients How to Manage Hallucinations[28]
Address Physiological NeedsThe client may also be experiencing physiological problems related to nutritional status, sleep, and elimination due to their symptoms of psychosis. Review nursing interventions to address these physiological needs in the “Bipolar Disorders” chapter. Implement Collaborative InterventionsSee the “Treatment” subsection of this chapter for medications and therapies prescribed for clients with psychosis. Nurses often assist in implementing these collaborative interventions. Categorizing Nursing Interventions According to the APNA Standard of ImplementationInterventions for clients experiencing psychosis previously discussed in this chapter can also be categorized by the standard of Implementation by the American Psychiatric Nursing Association (APNA). Read more about this standard in the “Application of the Nursing Process in Mental Health Care” chapter. See Table 11.4c for categorization of nursing interventions by this standard. Table 11.4c Nursing Interventions Based on the Categories of the APNA Implementation Standard[29]
EvaluationA client’s progress is continually assessed using their individualized SMART outcomes and current status. Full recovery can take months. By setting small goals, it is easier to identify and recognize progress that may occur in small increments.[30] What would be some interventions for patients with hallucinations?Psychosocial strategies including education, counselling and support for the person and his or her family can help with understanding, stress management and compliance with medication. Given that compliance with antipsychotic drugs may be an issue, you may need to provide close supervision.
Which is an appropriate intervention for a client having auditory hallucinations?Cognitive-behavioral therapy (CBT) can help patients cope with auditory hallucinations and reshape delusional beliefs to make the voices less frequent.
How should nurse respond to hallucinations?Nurses must display an attitude of acceptance to help the patient share the content of the hallucination. This sharing is important to avoid unwanted reactions towards the self or others, if command hallucinations are present.
What are the 5 nursing interventions?These are assessment, diagnosis, planning, implementation, and evaluation.
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