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NCP for Hallucinations - Assessment and Nursing Diagnosis

 

Hallucinations

Definition

Perception

Perception is the process of receiving stimuli until the stimuli are realized and understood by the senses or sensations: the process of receiving stimuli.

So perceptual disorders are human inability to distinguish between stimuli arising from internal sources such as thoughts, feelings, somatic sensations with external impulses and stimuli.


Hallucinations

Hallucinations are one of the perceptual disorders, where there is a sensory experience in the absence of sensory stimulation (false sensory perception). According to Cook and Fotaine (1987), hallucinations are sensory perceptions of an object, image and thought that often occur in the absence of external stimuli which can include all sensory systems (hearing, seeing, smelling, touching or tasting), while according to Wilson (1983) ), hallucinations are disturbances of absorption/perception of the five senses without any external stimulation that can occur in the sensory system which occurs when the individual's consciousness is good.


Causative Factors

According to Yosep (2009), the risk factors that cause hallucinations are divided into 2, namely:

1. Predisposing Factors

  • Development factor. Disrupted developmental tasks of clients, for example, low control and family warmth cause clients to be unable to be independent since childhood, easily frustrated, lose self-confidence and are more susceptible to stress.
  • Sociocultural factors. A person who feels unaccepted by the environment since he was an infant (unwanted child) will feel excluded, lonely, and distrustful of his environment.
  • Biochemical factors. Biochemical factors have an influence on the occurrence of mental disorders. The presence of excessive stress experienced by a person then in the body will produce a substance that can be neurochemical hallucinogenic such as Buffofenon and Dimetytransferase (DMP). Due to prolonged stress causes activation of brain neurotransmitters. For example, there is an imbalance of acetylcholine and dopamine.
  • Psychological factors. Weak and irresponsible personality types easily fall into addictive substance abuse. This affects the client's inability to make the right decisions for his future. Clients prefer momentary pleasures and flee from the real world to the imaginary realm.
  • Genetic factors and parenting. Research shows that healthy children raised by schizophrenic parents are more likely to develop schizophrenia. The results of the study show that family factors show a very influential relationship in this disease.

 

2. Precipitation Factor
The client's response to hallucinations can be in the form of suspicion, fear, feelings of insecurity, anxiety, and confusion, self-destructive behavior, lack of attention, inability to make decisions and unable to distinguish real and unreal situations.
According to Rawlins and Heacock (in Yosep, 2009) trying to solve the problem of hallucinations based on the nature of the existence of an individual as a creature that is built on the basis of bio-psycho-socio-spiritual elements so that hallucinations can be seen from five dimensions, namely:

  1. Physical Dimension. Hallucinations can be caused by several physical conditions such as extreme fatigue, drug use, fever to delirium, alcohol intoxication and difficulty sleeping for a long time.
  2. Emotional Dimension. Excessive feelings of anxiety on the basis of insurmountable problems are the cause of the hallucinations. The content of hallucinations can be coercive and frightening commands. The client is no longer able to oppose the order until the client does something about this fear.
  3. Intellectual dimension. In the intellectual dimension, it is explained that individuals with hallucinations will show a decrease in ego function. At first hallucinations are an attempt by the ego itself to fight the pressing impulses, but it is something that causes alertness that can take all the attention of the client and often will control all the behavior of the client.
  4. Social dimension. The client experiences social interaction disorders in the early and comfortable phase, the client considers that social life in the real world is very dangerous. The client is engrossed in his hallucinations, as if he were a place to fulfill needs for social interaction, self-control and self-esteem that are not found in the real world. The content of the hallucinations is used as a control system by the individual, so that if the hallucinations command a threat, he or other individuals tend to do so.
  5. The spiritual dimension. Spiritually, client hallucinations begin with the emptiness of life, meaningless routines, loss of worship activities and rarely spiritual efforts to purify themselves. His circadian rhythm is disturbed, because he often sleeps late at night and wakes up very late. When he wakes up feeling empty and not clear about his purpose in life. He often curses fate but is weak in trying to pick up fortune, blaming the environment and other people for causing his destiny to worsen.


 

Assessment

In the assessment process, important data that needs to be studied are adjusted to the type of hallucination, namely, as follows:

1. Types of hallucinations

a. Auditory Hallucinations

  • Objective Data: Talking or laughing alone, getting angry for no reason, tilting the ear in a certain direction, covering the ears.
  • Subjective Data: Hearing voices or noise, hearing voices that invite conversation, hearing voices telling to do something dangerous.

b. Visual Hallucinations

  • Objective Data: Pointing in a certain direction, fear of something that is not clear.
  • Subjective Data: Seeing shadows, rays, cartoon shapes, seeing ghosts or monsters.

c. Smell Hallucinations

  • Objective Data : Smells like certain odors, covers the nose.
  • Subjective Data: Smelling odors such as the smell of blood, urine, feces, sometimes the smell is pleasant.

d. Taste Hallucinations

  • Objective Data: Frequent spitting, vomiting.
  • Subjective Data : Feel the taste like blood, urine or faeces.

e. Touching Hallucinations

  • Objective Data : Scratching the skin surface.
  • Subjective Data : Says there are insects on the skin surface, feels like being electrocuted.



Nursing Diagnosis :

  1. Disturbed Sensory Perception : Auditory Hallucinations
  2. Risk for violence
  3. Ineffective Therapeutic Regimen Management
  4. Post Traumatic Stress Disorder
  5. Social isolation
  6. Low self-esteem
  7. Disturbed Thought Processes

 

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