HALLUCINATIONS

I. Main Problems

Impaired sensory perception: hallucinations

II. Process of Problem Occurrence

A. Definition

Halisination is a sensory perception that mistakenly involves panca senses in

schizophrenia, auditory hallucinations are hallucinations the most common (Isaacs,
2010).
According to Maramis (2005) hallucinations are without absorption the presence
of anything in the patient's senses, which occurs inside conscious state or wake up,
basically maybe organic, functional, psychotic or hysterical. Hallucinations are loss of
ability humans in distinguishing internal stimuli (thoughts) and external stimuli (the
outside world). The client gives a perception or opinion about the environment without
any real objects or stimuli. For example, the client says he hears a sound even though it
doesn't exist people who speak (Kusumawati & Hartono, 2010)

B. Etiology

Brain disorders due to brain damage, poisoning, drugs halusiogenic, mental

disorders, such as certain emotions that can resulting in illusion, psychosis that can
cause hallucinations, and influence of different socio-cultural, socio-cultural
environments give rise to different perceptions or people who are from socioculture
different (Sunaryo, 2004). Definitely that causes hallucinations not yet known but
there are several theories that reveal about hallucinations (Stuart 2007) include:

a. Interpersonal Theory
Hallucinations develop in a long time where someone experience severe and
stressful anxiety. Individuals will trying to reduce that anxiety by using coping
mechanisms commonly used, but if the situation is not can be handled then the
 individual will melanin, handling so that individuals will be more alone and feel
happy in his world regardless of others and surrounding environment.
b. Psychoanalysis Theory

Hallucinations are an ego defense to fight stimuli from the outside which is
suppressed and self-threatening finally appears inside consciousness.

c. Genetic Factors

The influencing gene is unknown, but the results of the study show that
family factor shows a very strong relationship effect on disease, this is evidenced by
examination chromosome body, indention is very high in children with one or both
parents who suffer or identical twins.

C. The process of hallucinations

Individuals who experience hallucinations often assume causes of hallucinations

come from the environment, even though stimulation these hallucinatory disorders arise
after interference hostile, pressure, isolation, useless feelings, despair and helpless.
Individual assessment of stressors and problems Coping can indicate the possibility of
recurrence, the individual tend to avoid interaction so that he is prevented from stressors
those who threaten in the end the individual feels very comfortable with conditions
alone so that it can interfere with metabolism neukochemistry such as Bufotamine and
Dimetyltransferase (DMT), this is stimulates the emergence of hallucinations (Sunaryo
2004).

D. Range of Neurobiological Responses

Perception sensory disorders: hallucinations are caused by function disrupted
brain. Individual response to orientation disorders focusing throughout the response
range from adaptive to maladaptive, can be seen in the picture below: Adaptive
response is a response that can be accepted by norms social and cultural in general that
apply in society, where individuals solve problems within normal limits includes:
1. A logical mind is everything that is said and carried out by individuals according to
reality.
 2. Accurate perception is the acceptance of messages realized by the senses feeling,
which can distinguish one object from another and regarding its quality according to
various sensations produced.
3. Emotions consistent with experience are given responses individually according to
the stimulus coming.
4. Behavior is in accordance with the way in which individuals are in accordance with
its role.
5. Harmonious social relationships where individuals can interact and communicate
with other people without suspicion, guilt and not happy. While the adaptive mall is
a response that cannot be accepted by general social and cultural norms that apply
in the community, where individuals in solving problems are not based on norms
the appropriate ones are:
1. Disruption of the thought / understanding process is the inability of the brain to
process data accurately which can cause interference thought process, like fear,
feeling great, believing, mind controlled,mind filled and others.
2. Hallucinations are a disruption of identification of information-based stimuli the
brain receives from the five senses such as sound, touch, smell, and vision
3. Damage to the emotional process is the response given. Individuals do not
according to the stimulus that comes.
4. Unorganized behavior is a way of not acting individually according to the role.
5. Social isolation is where individuals isolate themselves from environment or do
not want to interact with the environment.

E. Various hallucinations
Hallucinations consist of several types. Types of hallucinations such as
auditory hallucinations, visual hallucinations and others. Hallucinations are a wrong
perception by the five senses without the existence of external stimuli. In clients with
mental disorders there are several types of hallucinations with certain characteristics,
including:
 1. Hearing hallucinations: characteristics characterized by hearing voice, especially
the voices of people, usually the client hears the voice of people who are talking
about what is he thought and ordered to do something.
2. Vision hallucinations: characteristics in the presence of a stimulus vision in the
form of a beam of light, a geometric picture, broad and complex cartoon images
and or panoramas. Vision can be fun or frightening.
3. Pengidu hallucinations: characteristics characterized by odor rotten, fishy and
disgusting odors like: blood, urine or feces. Sometimes it smells good. Usually
related with strokes, tumors, seizures and dementia.
4. Feeling hallucinations: characteristics characterized by pain or not tasty without
visible stimulus. Example: feel the sensation of electricity comes from the ground,
inanimate objects or other people.
5. Hallucinations of taste: characteristics characterized by feeling something rotten,
fishy and disgusting.
6. Synestetic hallucinations: characteristics characterized by feeling functions the
body like blood flows through a vein or artery, food digestion or formation of
urine

F. Clinical Manifestations
According to Hamid (2000), client behavior is related to hallucinations are as follows:
1. Talk to yourself.
2. Smile yourself.
3. Laugh yourself.
4. Move the lips without sound.
5. Fast eye movements
6. Slow verbal response
7. Withdraw from others.
8. Trying to avoid others.
9. Cannot distinguish between real and unreal.
10. An increase in heart rate, breathing and blood pressure.
 11. Attention to a lacking environment or only a few seconds.
12. Concentrate with sensory experience.
13. Difficult to connect with others.
14. Tense facial expression.
15. Easy to be offended, irritated and angry.
16. Not able to follow orders from the nurse.
17. Looks like tremor and sweating.
18. Panic behavior.
19. Agitation and kataton.
20. Suspicious and hostile.
21. Acting damaging yourself, others and the environment.
22. Fear.
23. Can't take care of yourself
24. Usually there is a disorientation of time, place and people.
According to Stuart and Sundeen (2005), someone who experiences hallucinations
usually show typical symptoms:
1. Grinning or laughing that is not appropriate.
2. Move his lips without making a sound.
3. Abnormal eye movements.
4. Slow verbal response.
5. Shut up.
6. Acting as if filled with something exciting.
7. Increased autonomic nervous system that shows anxiety for example an increase in
pulse, breathing and blood pressure.
8. Refinement of concentration skills.
9. Filled with sensory experience.
10. May lose the ability to distinguish between hallucinations with reality.
11. More likely to follow the instructions given by hallucination rather than reject it.
12. Difficulties in dealing with others.
13. The attention span is only a few minutes or seconds.
14. Sweating a lot.
 15. Tremor.
16. Inability to follow instructions.
17. Behavior of attacking terror is like panic.
18. Very potential to commit suicide or
19. Physical activities that reflect the contents of hallucinations such as amok and
agitation.
20. Attractive or catatonic.
21. Not able to respond to complex instructions.
22. Not able to respond to more than one person

G. Nursing problems and data that need to be studied

1. Nursing problems:
a. Risk of injury
b. Hallucinations
c. Social isolation
Perceptual sensory disorders: Hallucinations Risk of self-injury, others, and
environment Self-concept disorder: Low self-esteem Social Isolation: Withdraw
d. Low self-esteem
2. Data that needs to be studied
a. Impaired sensory perception: hallucinations
Subjective data :
 Patients say they hear voices or noise.
 The patient says he hears the voice that is inviting
 The patient says he hears the voice that is inviting talking.
 The patient says he hears the voice telling to do something dangerous.
Objective data:
 Patients talk or laugh alone
 Patients is angry for no reason
 Patients suck their ears in a certain direction
 Patients cover their ears
IV. Nursing diagnoses
Persistent sensory disorders: auditory hallucinations

IMPLEMENTATION STRATEGY FOR HALUSINATION PATIENTS

Diagnosis IMPLEMENTATION STRATEGY
Hallucinations Patient Family
SP I SP I
1. Identify types of patient 1. Discuss problems perceived by
hallucinations the family in caring for patients
2. Identify the contents of the 2. Explain the definition, signs
patient's hallucinations and symptoms of hallucinations,
3. Identify hallucination time and the types of hallucinations
4. Identify the frequency of experienced by the patient and the
hallucinations process of their occurrence
5. Identify situations that cause 3. Explain how to treat
hallucinations hallucinations patients
6. Identify patient response to
hallucinations SP II
7. Teach patients to scold 1. Train families to practice
hallucinations treating patients with
8. Encourage patients to include hallucinations
ways to rebuke hallucinations in 2. Train families to take care of
the daily activity schedule patients directly hallucinations

SP II
1. Evaluate the patient's daily
activity schedule
2. Train patients to control
hallucinations with how to talk
with other people
3. Advise patient enter on
schedule daily activities
SP III
1. Helping families make a
schedule of activities at home
including taking medication
(discharge planning)
2. Explain the follow-up of the
patient after going home

SP III
1. Evaluate schedule of activities
patient's daily
2. Train patients control
hallucinations with do activities
(activities usual done by patient)
3. Advise patient enter to
schedule of activities routine

SP IV
1. Evaluate schedule of activities
patient's daily
2. Give education health about
drug use regularly
3. Advise patient enter on
schedule daily activities
 HALLUCINATIONS

GROUP 5 :

1. Anggun Desy Laras Ati W. (P1337420316011)

2. Riski Dia Filantika (P1337420316028)
3. Didik Umar Jalaludin (P1337420316029)
4. Dwi Octaviani (P1337420316043)
5. Nur Susiyamti Ningsih (P1337420316048)

POLTEKKES KEMENKES SEMARANG

PRODI D II KEPERAWATAN PEKALONGAN
2018