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Monday, January 16, 2012

Nanda Nursing Diagnosis - Risk for Self-Mutilation and Other related to Auditory Hallucinations

Nanda Nursing Diagnosis


Risk for Self-Mutilation and Other related to Auditory Hallucinations


General Objectives: The client does not injure others.

Specific Objectives 1. Clients can build a trusting relationship

Expected Outcomes:
- Facial expressions are friends.
- Showing a sense of fun.
- There is eye contact or want to shake hands.
- Want to name.
- Want to call and answer the greeting.
- Want to sit down and side by side with the nurses.
- Want to express the problems encountered.

Nursing Intervention:

Construct a trusting relationship with the principles of therapeutic communication.
a. Greet the client with a friendly both verbally and non verbally.
b. Introduce yourself politely.
c. Ask the client's full name and nickname are preferred clients.
d. Explain the purpose of the meeting.
e. Honest and keep their promises.
f. Show empathy and clients receive what they are.
g. Pay attention to the client and the client base kebutuan notice.
Rationalization: The relationship of mutual trust is the foundation for a smooth relationship interactions.


Specific Objective 2. Clients can recognize hallucinations
Expected Outcomes:

a. Clients can mention the time, content, frequency of hallucinations.
b. Clients can express her feelings towards hallucination.
c. Help clients recognize hallucinations.
1) If it finds a client who was hallucinating, ask what is being heard.
2) Tell the client that the nurse believes that voice heard, but the nurse did not see it.
3) Tell them that other clients also like the client.
4) Tell the nurse is ready to assist clients.
d. Discuss with the client
1) The situation that creates or does not cause hallucinations.
2) Time and frequency occur hallucinations.
e. Discuss with the client what is felt in the event of a hallucination.

Specific Objective 3. Clients can control the hallucinations

Expected Outcomes:
- Clients can mention what you can do to control hallucinations.
- Clients can mention a new way.
- Clients can choose how you have chosen to control hallucinations.
- Klin can follow the therapy group activities.

Nursing Interventions:

a. Identify with the client how to do in case of hallucination.
Rational: an attempt to break the cycle of hallucinations.

b. Discuss the ways in which benefits the client, if the beneficial give a compliment.
Rational: positive reinforcement can increase the client's self-esteem.

c. Discuss new ways to control the onset of hallucinations.

1) Say "I do not want to hear you"
2) Meet with others to converse.
3) Looking at the schedule of daily activities that hallucinations could not appear.
4) Ask the nurse / friend / family to say hello if the client is daydreaming.
Rational: provides alternative mind for clients

d. Help clients decide to train and hallucinations gradually.
Rational: Motivating can enhance the client's desire to try to choose one way of controlling hallucinations.

e. Give a chance to perform the way they are trained, the evaluation of the results and give praise if successful

f. Encourage clients to follow the orientation of reality.
Rational: The stimulation can reduce the perception of reality changes in the interpretation of the client.

Nursing Care Plan Risk for Self-Mutilation and Other related to Auditory Hallucination

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