Perceptual field narrows to missing details
Garbled speech or inability to speak
Nursing interventions include speaking slowly and calmly.
Constructive if danger is identified, hindrance if unable to focus sharply on details
Learning and problem solving are suboptimal
Nursing interventions include removing the client from the stimuli.
Normal everyday life
Confusion and automatic behavior
Chest pain, shortness of breath, chills, flushed skin
Nursing interventions include moving to a safe space
Stay with the client and discuss the cause of elevated anxiety if possible.
Pacing, running, shouting, screaming
Fidgeting or nail biting
Perceptual field reduced to one detail or several scattered details
Stay with the client and keep safe from injury
Can be constructive
Reality in sharp focus
Nursing interventions include reducing stimulation
Intervention required d/t the loss of ability to make safe, logical decisions
Increased HR, respirations, perspiration, GI discomforts
Restlessness or irritability
Nursing Interventions - emotional support, encourage communication
HA, nausea, dizziness, trembling, hyperventilation
Unable to process reality