Nursing Component Task
Nursing procedures & clinical learning

Registered Mental Health Nursing (RMN)

MANAGEMENT OF A PATIENT WITH INAPPROPRIATE PERCEPTION (HALLUCINATION AND ILLUSION)

This is the process of helping a psychiatric patient with inappropriate perception to gain an awareness of the symptoms and be in touch with reality. It involves the use of a sequence of psychological steps that the nurse can assist the patient use to organize and interpret information from the environment.

Purpose

  • Help increase awareness of the symptoms to interpret reality
  • Promote recovery
  • Prevent patient’s condition from worsening
  • Avoid the misinterpretation of a message
  • Prevent injury to self and others

Equipment

  • Table
  • Chair
  • Pen and paper
  • Patient’s folder (Electronic/Manual)
  • Serene environment

Procedure steps

  • Approach patient in a calm manner and establish rapport (refer procedure)
  • Explain procedure to the patient
  • Assess content of command hallucination/illusion
  • Observe for verbal and nonverbal cues for hallucinations/illusions (e.g. inappropriate laughter)
  • Identify and verify the type of hallucinations/illusions patient is experiencing
  • Acknowledge and accept patient’s feelings and experiences
  • Identify precipitating factors
  • Interrupt the hallucination and engage the patient’s attention in another area
  • Direct the focus of the patient from the hallucinational/illusional expressions to the discussion of reality-centered situation
  • Set limits for discussing repetitive hallucinational/illusional expressions (e.g. you have already told me about this, let’s talk about something realistic)
  • Validate interpretation of what is being said (e.g. is this what you mean? who are they? etc.)
  • Teach voice dismissal when possible (e.g. singing out loud, listening to an audio player or reading out loud etc.)
  • Serve prescribed medications and monitor desired and adverse effects
  • Express appreciation to patient and direct patient to the next activity
  • Document procedure and indicate patient’s level of co-operation in the nurses’ notes/patient’s folder

References and further reading

Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.

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