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A. BASIC CONCEPT a.

Definition Hallucinations are disturbances or changes perceptions where clients perceive something that does not happen. An application of the senses without any external stimuli. An appreciation experienced by a perception through the senses without stimulus ekstren: false perceptions (Maramis, 2005). Hallucinations are impressions, responses and sensory experiences that one (Stuart, 2007). From some of that raised by the experts regarding hallucinations above, the authors conclude that the hallucination is a sensory perception of the client through the environment without any real stimulus or stimuli.

Type Hallucinations According to ( According to Stuart , 2007) , among other types of hallucinations : a. Auditory hallucinations (auditory) 70% Characteristics characterized by hearing voices, especially voices - the voices, the client usually hear people who are talking about what he was thinking and ordered to do something. b. Visual hallucinations ( Visual ) 20 % The characteristics of the visual stimulus in the form of a light beam , the geometric picture, cartoon image and / or extensive and complex panorama. Vision can be fun or scary . c. Hallucinations of smell (olfactory) Marked by a characteristic smell of rotten, putrid and disgusting odor such as blood, urine or feces. Sometimes inhaled the scent. Usually associated with strokes, tumors, seizures and dementia. d. Hallucinations of touch ( tactile ) Characteristics characterized by pain or discomfort no visible stimulus . Examples : electric sensation coming from the ground , inanimate objects or other people . e. Hallucinations of taste ( gustatory )

Characteristics characterized by feeling something rotten , putrid and disgusting , to feel a sense of taste flavors like blood , urine or feces . f. hallucinations synesthetes Characteristics characterized by feeling of bodily functions such as blood flow through the vein or artery , or the formation of urine ingested food . g. hallucinations Kinesthetic Sensing movement while standing without moving .

Phase Hallucinations There are hallucinations Phase 4 ( Stuart and Laraia , 2001) : a. Comforting Clients experience deep feelings such as anxiety being , loneliness , guilt and fear and tried to focus on pleasant thoughts to relieve anxiety . Here the client smiling or laughing is not appropriate , move the tongue without sound , rapid eye movement , silent and absorbed . b. condemning In severe anxiety disgusting and frightening sensory experiences . Clients began to spiral out of control and may try to distance themselves with the perceived source . Here an increase in the signs of the autonomic nervous system such as anxiety due to an increase in vital signs ( heart rate , respiration and blood pressure ) , preoccupied with sensory experience and lose the ability to distinguish hallucinations with reality . c. control In severe anxiety , client resistance to stop the hallucinations stopped and gave up on the hallucinations . Here the client is difficult to relate to other people , sweating , tremors , unable to comply with the orders of others and are in a condition that is very stressful , especially if it will relate to other people . d. Consquering Occurs in sensory experience into a panic threatening if the client follows the command hallucinations . Here occurred violent behavior , agitation , withdrawal , not able to respond to complex command and not able to respond more than 1 person . The condition is very harmful to the client .

b. Signs And Symptoms Patients with hallucinations tend to withdraw , often found sitting with eyes fixated on one particular direction , smile or speak for themselves , suddenly angry or attack others , anxiety , such movement is enjoying something . Also, information from patients themselves about the hallucinations they experienced ( what is seen, heard or felt ) . The following is based on the clinical symptoms of hallucinations ( Budi Anna Keliat , 1999) : a. Stage 1 : hallucinations are not fun Clinical symptoms : 1) Grin / laugh does not fit 2) Move the lips without speaking 3) rapid eye movement 4) Talk slowly 5) Shut up and mind filled with something exciting b. Phase 2 : hallucinations are disgusting Clinical symptoms : 1) Anxious 2) The concentration decreases 3) inability to distinguish real and unreal c. Stage 3 : hallucinations are controlling Clinical symptoms : 1) Tend to follow hallucinations 2) Difficulty relating to others 3) Attention or concentration decreased and rapidly changing 4) severe anxiety ( sweating , shaking , unable to follow instructions ) d. Stage 4 : hallucinations are conquering Clinical symptoms : 1) Patient follow hallucinations 2) Not being able to control themselves 3) Do not follow orders capable of real 4) Risk of injuring themselves , other people and the environment .

c. Predisposition factor According to Stuart (2007 ) , factors that cause hallucinations are : a. Biological Developmental abnormalities of the nervous system associated with maladaptive neurobiological responses are just beginning to be understood. This is shown by the following studies : 1) Brain imaging studies have shown greater brain involvement in the development of schizophrenia . Lesions in the frontal , temporal and limbic associated with psychotic behavior . 2) Some of the chemicals in the brain such as dopamine neurotransmitter excessive and problems in the system dopamine receptors were associated with the occurrence of schizophrenia . 3) ventricular enlargement and decreased cortical mass showed significant atrophy in the human brain . On brain anatomy clients with chronic schizophrenia , was found lateral ventricle dilation , cortical atrophy and atrophy of the front of the brain (cerebellum ) . The findings of anatomical abnormalities of the brain is supported by autopsy ( post - mortem ) . b. Psychological Families , caregivers and client environments greatly affect the response and psychological condition of the client . One of the attitudes or circumstances that may affect the orientation disruption or denial of reality is a violent act in the client's life span . c. Social Culture Social and cultural conditions affecting reality orientation disorders such as : poverty , social and cultural conflicts ( wars , riots , natural disasters ) and isolated life with stress .

d. Precipitation factors In general, clients with hearing disorders hallucinations arise after the hostile relationship , stress , isolation , feeling useless , hopeless and helpless . Individual assessment of stressors and coping problems can indicate the likelihood of recurrence ( Keliat , 2006) . According to Stuart (2007 ) , precipitation factor hallucinations interference is : a. Biological

Breakdown in communication and round behind the brain, which regulate the process of information as well as abnormalities in the entrance mechanism in the brain that result in the inability to selectively respond to stimuli received by the brain for interpretation . b. environmental stress Threshold of tolerance to stress the environmental stressors that interact to determine the occurrence of behavioral disorders . c. sources coping Sources coping affect individual response in response to a stressor .

e. Management Management of hallucinations in patients with: a. Creating a therapeutic environment To reduce the level of anxiety, panic and fear in patients affected by hallucinations, preferably at the beginning of the approach is done on an individual basis and keep the eye contact occurs, if the patient can touch or hold. Patients not in isolation either physically or emotionally. Each nurse came into the room or close to the patient , talk with the patient. So also when it will leave the patient should be notified . The patient was told that action will be undertaken. In that room should provide a means in which to stimulate attention and encourage patients to get in touch with reality, such as wall clocks , pictures or wall hangings , magazines and games b. Implement treatment programs doctor Often patients refuse medication that is given with respect to the stimuli in receipt hallucinations. The approach should be persuasive but instructive. Nurses must observe in order to give the right drug in his swallow, and drug reactions is given. c. Explores the problems of patients and help overcome existing problem Once the patient is more cooperative and communicative, nurses can explore issues that are causing the patient's hallucinations and help resolve any problems. This data collection can also be through the patient's description of the family or others close to the patient. d. Giving activity in patients Patients were invited to enable themselves to perform physical movements, such as exercising, playing or doing activities. This activity can help steer patients to real life

and cultivate relationships with other people. Patients in whom draw up a schedule of activities and choose appropriate activities. e. Involving the family and other officers in the care process The patient's family and other officials should be notified about the patient data so that there is unity and continuity in the opinion of the nursing process, for example from a conversation with the patient in the know when it is alone, he often heard the man mocked. But if there are others nearby voices were not audible. The nurse suggested that the patient should not be alone and get busy in a game or activity there. This conversation should be in the patient's family and let the other officers not to let the patient alone and advice that is given is not contradictory.

B. PATHWAY

The risk of injuring themselves, others and the environment

Sensory perceptual changes: hallucination

Social isolation: withdrawal

Low self esteem

C. ASSESSMENT a. Nursing Issues and the Need to Assess Data 1. Nursing problems a. The risk of injuring themselves , others and the environment b. Sensory perceptual changes : hallucination c. Social isolation : withdrawal

2. The data that needs to be studied a. The risk of injuring themselves , others and the environment Subjective Data : Clients say hate or upset with someone Clients shout and attack people who bother her if I am angry or upset history of violent behavior or other mental disorders

Objective Data : Red eyes , face slightly red . Tone was high and loud , talk to master : yelling , screaming , hitting himself / others. Angry expression when talking about people , a sharp look . Destructive and throwing stuff .

b. Sensory perceptual changes : hallucination Subjective Data : Clients say hear sounds that are not related to the real stimulus Clients say look at a picture without any real stimulus Clients say smell without stimulus Clients feel eating something The client felt something on her skin Clients are afraid to voice / sound / image is seen and heard The client wanted to hit / throw things

Objective Data: Client talking and laughing to himself Clients behave like hearing / seeing something Client paused amid sentence to listen to something Disorientation

c. Social isolation: withdrawal Subjective Data: Clients say I can not afford, can not, do not know anything, stupid, self-criticism, expressing feelings of shame about themselves. Objective Data:

Clients look more like themselves, are confused when asked to choose an alternative action, want to injure yourself / want to end life, Apathy, sad expression, less verbal communication, decreased activity, fetal position during sleep, associated Refuse, less attention to hygiene.

b. Nursing Diagnosis 1. Changes in sensory perception: hallucinations 2. Social isolation: withdrawal

c.Nursing Action Plan Diagnosis I: changes in sensory perception hallucinations general objective: the clients do not injure themselves, other people and the environment Specific objectives: 1. Clients can build trusting relationships basic to the smooth interaction further action: 1.1 Construct a trusting relationship with the therapeutic use of the principles of communication by means of: a. with friendly greet clients both verbal and non-verbal b. Introduce yourself politely c. Ask the client's full name and nickname are preferred d. Explain the purpose of the meeting e. Honest and keep promises f. Show empathy and receives the client what it is g. Pay attention to the basic needs of the client and the client's attention

2. Clients can recognize hallucinations action: 2.1 Conduct frequent contact and gradually brief 2.2 Observation of client behavior associated with hallucinations : a stimulus talk and laugh without looking to the left / right / forward as if there is someone to talk to 2.3 Assist clients to know hallucinations a. Ask if there is a voice that is heard b. What is said hallucinations c. Tell the nurse believes the client to hear the voice, but the nurses themselves are not heard . d. Other clients also say that there is such a

e. Say that the nurse will help clients 2.4 Discuss with the client : a. Situations that cause / not cause hallucinations b. Time and frequency of occurrence of hallucinations ( morning , noon , afternoon, evening ) 2.5 Discuss with the client what is perceived in the event of hallucinations ( angry , fearful , sad , happy ) give the client an opportunity to express their feelings

3. Clients can control the hallucinations action: 3.1 Identification with the client how the actions taken in case of hallucinations ( sleeping , upset , fussing , etc. ) 3.2 Discuss ways in which the client benefits , if beneficial Air compliment 3.3 Discuss new ways to cut / control the onset of hallucinations : a. Say " I do not want to hear " b. Meet others c. Creating a schedule of daily activities d. Ask family / friends / caregivers to say hello if clients seem to speak their own 3.4 Assist clients to select and train hallucinations gradually dis3.5 Give a chance to do the way they are trained 3.6 Evaluation of the results and give praise if successful 3.7 Encourage clients to follow TAK , orientation , reality , perception stimulation.

4. The client has the support of the family in control of his hallucinations action: 4.1 Encourage clients to notify families when experiencing hallucinations 4.2 Discuss with the family ( at the time of visit / at home visits ) : a. Symptoms of hallucinations experienced by clients b. How do clients and families to break the hallucinations c. How to care for family members at home hallucinations , given the activity , do not let yourself , eat together , travel together d. Give the time of follow-up information or why the need to get help : hallucinations are not controlled , and the risk of injuring themselves or others

5. Clients utilizing medications properly action:

5.1 Discuss with the client and family about the dosage , frequency and benefits of taking medication 5.2 Encourage clients to ask himself the drug in nursing and feel the benefits 5.3 Encourage clients to talk to your doctor about the benefits and side effects of taking medication perceived 5.4 Discuss the result of stopping medications without consulting 5.5 Assist clients to use the drug with 6 correct principles.

Diagnosis II : Social isolation withdrawn A common goal: the client is not a change in sensory perception : hallucinations Specific objectives : 1. Clients can build a trusting relationship action: 1.1 Construct a trusting relationship : therapeutic greetings , introduce yourself , explain the purpose of the interaction , creating a quiet environment , make a deal with the obvious about the topic , place and time . 1.2. Give attention and awards : accompany clients though not answer . 1.3. Listen with empathy : give a chance to talk , do not rush , show that nurses follow a client talks.

2. Clients can mention the cause withdraw action: 2.1 Assess the client's knowledge about the behavior of withdrawn and the signs 2.2 Give an opportunity for clients to express feelings cause to withdraw or want to hang out 2.3 Discuss with the client about withdrawn behavior , the signs and causes of emerging 2.4 Give praise to the client's ability to express his feelings

3. Clients can mention the advantages relate to others and losses not related to anyone else action: 3.1 Assess the client's knowledge about the benefits and advantages associated with others a. Give an opportunity for clients to express their feelings about the advantages associated with another prang b. Discuss with clients about the benefits of dealing with others

c. Give positive reinforcement of the ability to express feelings about the advantages relate to others 3.2 Assess the client's knowledge about the loss when not associated with other people a. Give an opportunity for clients to express their feelings with others b. Discuss with the client about the loss does not relate to other people c. Give positive reinforcement of the ability to express feelings about the loss does not relate to other people

4. Clients can implement social relations action: 4.1 Assess the client's ability to build relationships with others 4.2 Encourage and help client to connect with other people through the stages : KP K - P - P other K - P - P else - another K K - Family / Group / Community

4.3 Give positive reinforcement to the success that has been achieved 4.4 Assist clients to evaluate the benefits associated 4.5 Discuss the daily schedule is done with the client in filling time 4.6 Motivation clients to participate in the room 4.7 Give positive reinforcement for the activities of clients in indoor activities

5. Clients can express his feelings after dealing with others action: 5.1 Encourage clients to express their feelings when dealing with others 5.2 Discuss with the client about the feelings associated with others advantage 5.3 Give positive reinforcement for the ability of the client to express feelings related to benefit others.

6. Clients can empower or family support system action: 6.1 Construct a trusting relationship with the family: Greeting, introduction of self Explain the purpose of Create a contract Exploration client feeling

6.2 Discuss with family members on: Conduct withdraw Cause withdrawn behavior Due happens if the behavior is not addressed withdraw How families facing clients withdraw

6.3 Encourage family members to provide support to clients to communicate with others 6.4 Encourage family members and alternates regularly visit clients at least once a week 6.5 Give positive reinforcement positive for the things that have been achieved by the family

REFERENCE 1. 2. 3. Stuart GW, Sundeen, Buku Saku Keperawatan Jiwa, Jakarta : EGC, 1995 Keliat Budi Ana, Proses Keperawatan Kesehatan Jiwa, Edisi I, Jakarta : EGC, 1999 Keliat BA. Asuhan Klien Gangguan Hubungan Sosial: Menarik Diri. Jakarta : FIK UI. 1999 4. 5. Keliat BA. Proses kesehatan jiwa. Edisi 1. Jakarta : EGC. 1999 Aziz R, dkk, Pedoman Asuhan Keperawatan Jiwa Semarang : RSJD Dr. Amino Gonohutomo, 2003 6. Tim Direktorat Keswa, Standar Asuhan Keperawatan Jiwa, Edisi 1, Bandung, RSJP Bandung, 2000