Nursing Assessment for Hallucinations

Hallucinations are the most frequent form of the disorder of perception. This can be a form of hallucinatory voices or buzzing noise, but the most frequent form of words arranged in a somewhat imperfect tenses. Usually the sentence had been talking about the sad state of the patient or the patient is addressed. As a result, patients can fight or speak with a voice hallucinations. Patients can also be seen as being in the hearing or speaking loudly as if he was answering a question someone or lips moving. Sometimes patients consider hallucinations come from any body or outside body. These hallucinations are sometimes fun example is lying, threats, and others.

Nursing Assessment for Hallucinations


At this stage the nurse explore the factors that exist, namely:

1. Predisposing Factors

Are risk factors that affect the type and amount of resources that can be generated by individuals to cope with stress. Obtained either from patients or their families, the social development of cultural factors, biochemical, psychological and genetic risk factors that influence the type and amount of resources that can be generated by individuals to cope with stress.

- Development Factor
If the task of development experience obstacles and disturbed interpersonal relationships then the individual will experience stress and anxiety.

- Sociocultural Factors
Various factors could cause the community to feel excluded by a lonely place on the environment at the client's exaggerated.

- Biochemical Factors
Have an influence on the occurrence of mental disorders. With the excessive stress experienced by a person then the body will produce a substance that can be hallucinogenic and neurochemistry as Buffofenon Dimetytranferase (DMP).

- Psychological Factors
Interpersonal relationships are not harmonious and the presence of conflicting multiple roles and often received by children will result in stress and anxiety is high and ended with impaired reality orientation.

- Genetic Factors
What genes are influential in skizoprenia not yet known, but the findings indicate that family factors showed a highly influential in this disease.


2. Precipitation Factors

Stimulus that is perceived by individuals as a challenge, threat / demands that require extra energy for coping. The existence of a common environmental stimuli such as the participation of clients in the group, invited communication for too long, objects that exist in the environment is also the atmosphere of quiet / isolation is often a trigger hallucinations because it can increase stress and anxiety that stimulates the body to excrete hallucinogenic.


3.Behavior

Client response to the hallucinations may be a suspicion, fear, insecurity, anxiety and confusion, self-destructive behavior, lack of attention, unable to make decisions and can not distinguish between real and unreal circumstances. According to Rawlins and Heacock, 1993 trying to solve the problem of hallucinations based upon the nature of the existence of an individual as a creature that is built on the basis of the elements of bio-psycho-socio-spiritual so that hallucinations can be seen from the dimensions:

- Physical Dimensions
Constructed by human sensory system to respond to external stimuli provided by the environment. Hallucinations can be caused by some physical conditions such as fatigue, drug use, fever to delirium, alcohol intoxication and difficulty to sleep in a long time.

- Emotional Dimensions
Excessive feelings of anxiety on the basis of problems that can not be overcome is the cause of hallucinations that happen. The content of the hallucinations may be a command, and frightening force. Clients no longer able to oppose the order until the client's condition to do something to fear.

- Intellectual Dimensions
In this intellectual dimension explained that individuals with hallucinations would show a decrease in function of the ego. At first hallucination is a business of his own ego to fight the impulse to press, but it is a matter that raises awareness that can take the whole attention of the client and not infrequently will control all the behaviors of clients.

- Social Dimensions
Social dimension in individuals with hallucinations showed a tendency to be alone. Individuals caught up in hallucinations, as if it is a place to meet the need for social interaction, self control and self-esteem that is not found in the real world. The contents of hallucinations made by the individual control system, so if the command hallucinations in the form of threat, the individual himself or anyone else inclined to it. Therefore, an important aspect in implementing nursing interventions with clients seeking a process of interpersonal interactions that lead to a satisfying experience, as well as the client does not seek to be alone so that the client always interacts with its environment and hallucinations did not last.


4. Source of Coping

An evaluation of options and coping strategies of individuals. Individuals can cope with stress and anxiety by using coping resources in the environment. Source of capital for coping such as problem solving, social support and cultural beliefs, can help a person integrate the stressful experience and adopt coping strategies that work.


5. Coping Mechanisms

Every effort is directed at the implementation of stress, including the direct problem-solving efforts and defense mechanisms are used to protect themselves.
- Spiritual Dimensions
Humans are social beings, so that interaction with other human beings is a fundamental requirement. At the individual is likely to be alone until the above process does not occur, the individual is not aware of its existence and hallucinations into a system of control in these individuals. When hallucinations mastered, the individual loses control of life.