nursing diagnosis for suicide/hallucinations

  1. 0
    I'm a nursing student taking a psych. class. My book isn't given me enough information. Maybe someone can help. Please???
    I have a pt who tryed to commite suicide (second time) & is hallucinating.

    I want to use Disturbed sensory perception: visual, but I'm not sure the related to part:______ (the book has panic anxieity, extreme loneliness & withdrawal into the self) would just putting anxiety but correct??
    evidence by: Pt states, "I see black eye on the walls, I I don't want to go back into that room because of all the eyes"

    Deborah :uhoh21:

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  2. 7 Comments...

  3. 1
    Hmm.. By what you wrote that the patient stated I would use panic because it sounds like the patient is afraid of the eyes.

    Did the patient OD on anything to cause the hallucinations or stop taking something to have the episode?

    Is this the only ND that you have?
    motherinlaw likes this.
  4. 1
    It sound to me like he has Disturbed sensory perception, visual r/t hallucinations. If he is seeing black, and eyes, those are hallucinations. I think that book is just a guide when it comes to the R/T part.
    motherinlaw likes this.
  5. 0
    pt did stop taking her medications. She is dx. with major depression recurrent. I'm not sure if her hallucinations is something new. Other family members are also suffering from hallucinations
  6. 2
    After thinking about this.......

    Remember, a care plan is a building block that YOU have to build, not a book! Look at the here and now, what is going on with your patient at this moment. Setting goals based on your diagnosis is gonna be tricky. Don't use your book, use your observations and common sense as a guide when you are making a care plan. Look at what you can do in the next 8 or so hours of your shift that can keep your patient safe, healthy and happy.
    If this was my patient #1 I would want to know if he is still having suicidal thoughts. If so, what was the subj. and obj. (he said he wanted to kill himself, he has a hx of suicide attempt(s)) that would lead me to my nsg dx Risk for suicide, R/T suicidal thoughts, evident by my subj. and obj. data. Then, what am I going to do as his nurse to keep try and keep him from committing suicide on my shift...1)check him every 5 min 2) check his room and remove anything that he could use to harm himself 3) keep him busy 4) administer meds as prescribed. Explain why these interventions are being done. And if this guy has not committed suicide by the end of my shift...JACKPOT I have met my goal and my patient is safe!
    Don't try to overanalyze, or all you will be doing is depending on a book and spending hrs. doing a care plan that should take you 5 min.
    I hope I helped a little...GOOD LUCK!
    nath2chris6 and motherinlaw like this.
  7. 2
    diagnosing is always based on the assessment you have done of the patient. you have a patient here who tried to kill themselves which indicates ineffective coping of some situation in their life as well as a self-esteem problem. don't forget that because that is the reason they have been institutionalized. the hallucinations are something else they brought along with them. they indicate ineffective coping as well as acute confusion and disturbed thought processes. this website has some information that might be helpful in putting together a care plan: http://www.fadavis.com/townsend4e/ad...gcareplans.asp

    the foundation of any care plan is the assessment. mental health assessment is particularly difficult. there is some information on how to do a mental and psych assessment on this sticky thread on the student forums: http://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms
    Angel@MyTable and motherinlaw like this.
  8. 0
    Think priorities. A "risk for injury" diagnosis trumps everything else if I were care planning for this patient. Safety would be first priorty. A care plan is a way of thinking. I really think the NANDA models should be a guide but not the be all end all. There is a primary assessment and a secondary assessment. This patient is critically ill and at risk for death. That's primary. Secondary assessments could address ineffective coping, nutrtional deficits, body image deficits, etc.

    Let your diagnosis flow from the presentation.
    Last edit by wonderbee on Nov 15, '08
  9. 0
    Thanks to all who responded, and especially the links for the nursing care plans/diagnosis.
    Much food for thought
    Deborah


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