Disturbed Sensory Perception: Auditory/Visual: Impaired communication (inappropriate responses), disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in midsentence, tilts head to side as if to be listening
Observe the client for signs of hallucinations.
Help client understand connections between anxiety and hallucinations.
Distract the client from hallucinations.
Disturbed Thought Processes: Delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract, or conceptualize; extreme suspiciousness of others; inaccurate interpretation of the environment
Do not argue or deny the belief.
Reinforce and focus on reality.
Risk for Violence: Risk factors: Aggressive body language (e.g., clenching fists and jaw, pacing, threatening stance); verbal aggression; catatonic excitement; command hallucinations; rage reactions; history of violence; overt aggressive acts; goal-directed destruction of objects in the environment; self-destructive behavior; active, aggressive suicidal acts
Observe client’s behavior.
Maintain calm attitude.
Have sufficient staff on hand.
Impaired Verbal Communication: Loose association of ideas, neologisms, word salad, clang associations, echolalia, verbalizations that reflect concrete thinking, poor eye contact, difficulty expressing thoughts verbally, inappropriate verbalization
Facilitate trust and understanding.
Orient the client to reality.