Question

John continues to become very agitated and is pacing back and forth. He is holding his incision and grimacing and appears to be in pain but refuses any medication, accusing the nurse of trying to drug him so that he can be kidnapped by the government. He is muttering to himself and says, “Tell that government agent to get out of my room!” 6. What is the nurse’s appropriate response to John’s hallucination?

Answer 1

These are the Guidelines for responding to a person who is experiencing hallucination:

1. Arrange for a review of the person’s medication for hallucinations and an initial or follow-up psychiatric assessment if their care plan needs reviewing. A mental health assessment may be appropriate to undertake.

2. A person’s cultural background can influence the way symptoms of mental illness are
expressed or understood. It is essential to take this into account when formulating diagnosis and care plans.

3. Watch for cues that the person may be experiencing hallucinations. These include watching an empty space in the room with eyes darting back and forth, speaking to an invisible person, talking to himself or herself, and appearing to listen to someone when no one is speaking.

4. If your relationship is appropriate, directly ask the person whether he or she is experiencing hallucinations.

5. It may be difficult for the person to concentrate on what you are saying because of the distraction of the hallucinations. Without being condescending, speak clearly and keep sentences simple.

6. Do not deny the person’s experience, but suggest your own perceptions. For example, you could say: ‘I understand that you are feeling worried now. I don’t see or hear anything, but I can understand that it may be difficult, worrying or unpleasant for you’.

7. Help the person to identify symptoms, symptom triggers and symptom management
strategies.

8. Help the person to cope with auditory hallucinations by providing diversions. For example,
you could make conversation or undertake simple projects or physical activity with the
person.

9. Help the person to compare his or her thoughts and ideas with those of others to see if the
impressions are similar (reality testing).

10. LMonitor recovery, compliance with medication and general physical health (including
nutrition, weight, blood pressure etc.). Provide education on possible side effects to any
medication and work with the person to develop appropriate actions to address any issues.

11. Be aware of your own feelings when caring for a person experiencing hallucinations. Arrange
for debriefing for yourself or any colleague who may need support or assistance — this may
occur with a clinical supervisor or an Employee Assistance Service counsellor.