Nursing Care Plan for Altered Sensory Perception - Hallucinations

Altered Sensory Perception - Hallucinations

Hallucinations is sensory experiences without external stimuli occurs in a state of full consciousness that describes the loss of ability to judge reality. (Sunaryo, 2004)

Hallucinations is perceptions of disorders in which the client perceives something that does not happen, the perception of the senses without any external stimuli. (Maramis, 1998).

Signs and symptoms:
  • Talk, smile, laugh alone.
  • Said listening to the sound, see, taste, breathe and feel an unreal.
  • Damaging own self, others and the environment.
  • Can not distinguish between real and unreal.
  • Unable to focus or concentration.
  • Suspicious and hostile attitude.
  • Discussion chaotic sometimes unreasonable.
  • Pulling away, shy away from others.
  • Difficult to make a decision.
  • Fear.
  • Unwilling to perform self care: bathing, brushing teeth, dressing, decorated with neat.
  • Irritable, annoyed, angry.
  • Self blame themselves, or others.
  • Sometimes angry face pale.
  • Tense facial expressions.
  • Increased blood pressure.
  • Panting breath.
  • Rapid pulse.
  • Lots of sweat.
That cause hallucinations, among others; client withdraws and low self esteem. Due to low self-esteem and lack of social activity, clients become withdrawn from the environment. Further impact the client will be more focused on self-own. Internal stimuli become more dominant than the external stimulus. Clients gradually lose the ability to distinguish internal stimuli with external stumulus.
These conditions lead to hallucinations.

Signs and symptoms:
  • Physical aspects:
  • Eating and drinking less.
  • Less sleep or disturbed.
  • Self-less appearance.
  • Courage less.
  • Emotional aspects:
  • Slurred speech, whining, crying like a child.
  • Feeling ashamed, guilty.
  • Easy to panic and suddenly angry.
  • Social aspects:
  • Sitting alone.
  • Always subject.
  • Looks dreamy.
  • No matter the environment.
  • Shy away from others.
  • Depending on others.
  • Intellectual aspects:
  • Hopeless.
  • Feeling alone, no support.
  • Lack of confidence.
Clients who experience hallucinations can lose control of himself, so it could be a danger to themselves, other people or damage the environment (risk of injuring themselves, others and the environment). This occurs if the hallucinations had to phase IV, where the client is experiencing panic and its behavior is controlled by the content of the hallucinations. Clients really lost the ability assessment of the environmental reality. In this situation the client can commit suicide, kill others even damage the environment.

Signs and symptoms:
  • Red face.
  • Sharp outlook.
  • Tense muscles.
  • High tone.
  • Arguing.
  • Obtrude: rob food, hit if not happy.

Nursing Diagnosis :
  1. Risk for injury: self, others and the environment.
  2. Altered Sensory Perception : hallucinations.
  3. Social isolation: withdrawal.

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