NURSING CARE OF HALLUCINATION

This exercise to complete English Task

Guided by Mr. M. Yulius and Mrs. Eka









GROUP 9 / II A
Agnes Ashianti (120110000)
Aprilia Puspita N (1201100031)
Faiz Prianata (1201100043)
Achmad Tirmidzi (12011000)



POLITEKNIK KESEHATAN KEMENKES MALANG
JURUSAN KEPERAWATAN
PROGRAM STUDI DIII KEPERAWATAN MALANG
APRIL 2014
A . Nursing Assessment
1. Identity
a. Client Identity
Name : Mr. RR
Age : 37 years old
Sex : Male
Religion : Kr. Protestan
Education : Senior High School
Job : -
Address : Manado
Ethnic/ Nation : Minahasa / Indonesia
Date of entry : 09 4 2014
Date of assessment : 10 4 2014
Registration number : 2233
Medical diagnosis : Schizophrenia
b. Responsible person
Name : Mrs. A.R.
Age : 56 years old
Sex : Female
Job : Housewife
Religion : Kr. Protestan
Address : Manado
Relation : Mother
2. Health History
a. Reason in hospital: Want to do the treatment so he can recover his condition.
b. Main complaints
When i hospital: client angry - furious, raging and throwing things.
When examined:
* Clients say hear the voice/whisper told
* Karate training.
* Clients talkative, love to laugh and talk to himself
* Client move his hand as he spoke.
3. Predisposision Factor
a. Previously, clients have experienced mental disorder, 4 times hospitalized history.
Number Date of entry hospital Date of hospital discharge
1 29-01-1997 10-12-1997
2 11-10-2001 02-06-2003
3 06-07-2003 09-12-2003
4 Now -
b. Previous treatment
Previous treatment had unsuccessful because clients do not want to take medication
again (the client withdrawal)
c. Family members who experience mental disorder
Only client who has experience mental disorder.
d. Past experience pleasant and unpleasant
- As assessed, clients say pleasant experience is when he became winner of karate
champion.
- Family says client wasnt able to join college due to illness, so that clients get angry,
yell and throw things.
e. Nursing problems:
- Violent behavior
- The risk of injuring other people and the environment
4. Physical Assessment
a. Vital Sign
BP : 110/80 mmHg
T : 37 C
P : 82 x/mnt
RR : 21 x/mnt
Weight : 54 kg
Height : 160 cm
b. Consiousness: Compos mentis
5. Psychosocial
a. Self Concept
- Body Image
Client says that he likes all the parts of his body, when nurse ask which body part
that he likes the most, he prefer hand.
- Identity
Client can mention his identity , the client says that he is a man .
- Role
Before the client was sick, he has the responbility as the son. Client can do the
house course. Client regularly takes part in worship activities. But after ill, client
treated in a mental institution. Client says that in the hospital, he is a patient who
gets treatment.
- Self ideal
Client hope he can return home soon, so he can help his parents and do karate
training.
- Self-esteem
Client says if he returns home, he wants to hang out with his friends and client
receive his consition as a client, and he says that he isn't shy living in mental
hospital.
b. Social relationship
- People nearby: the client 's mother
- Participation in society
Before ill, client often follows community activities such as community service and
youth activities. Once at the hospital, client rarely follows the activity of the
msociety. Client only follows the activities which he likes in the hospital.
c. Barriers in dealing with others
Before ill, client is shy man, but after ill he has a lot of talk, frequency of talk is fast
currently at hospital. Client likes to be alone and doesnt want to talk with his
roommates. He spends almost of his time sitting in his bedroom.
Nursing problems: social isolation; withdraw




6. Mental Status
a. Appearance
Neat dressing , age-appropriate appearance , cleanliness enough, has average body posture ,
facial expression sometimes serious when telling a story, sharp eyes contact, general health
status (no serious illness ), style of walk is normal.
b . Talks
Frequency of talking is fast, speak in high volume, the spoken words are clear but the answer
is too long.
c . Motoric activities
- Client likes to walk along all rooms in hospital, he can do activity which is asked by
the nurse.
- Client seems excited , likes to move his hands during conversation.
d . Interaction during the interview
Client is cooperative, he can answer the question properly, less eyes contact, serious
expression as she spoke, client looks happy when nurse speak to him, client looked
embarrassed as he spoke.
Nursing issues : social isolation ; withdraw .
e . Natural feelings
Client says that he is feeling happy.
f . Affection
Labile (not appropriate)
g . Perception
Client says that he often hears the voice/whisper telling him to do karate practice.
Nursing Issues : Hearing Hallucinations.
h . The contents of mind
The client says that he will practice karate, client says that he will win the game and will be a
champion . When told this, the expression of client becomes serious .
Nursing problems: Changes in content of minds.
i . Thought process
Flow think is good enough , the client is able to answer questions, ekspresi themselves when
talking sometimes less obvious , but it is difficult for clients ts to change the subject if not
asked the nurse .
j . level of consciousness
Orentasi time , person and place both
7. k . memory
8. Good long- term memory , short-term memory either . clients can mention crucial events he
experienced .
9. l . The level of concentration and calculation
10. Clients can calculate simple example 20-7 = 13
11. Clients can perform calculations and reduce sequentially as reducing three of 100
respectively .
12. m . ability assessment
13. Clients can take a simple decision , the client can provide an assessment of the object / thing
seen when prompted .
14. n . Power self -teller
15. The client said that he was in hospital and the patients who were treated in hospital . clients
said that the client had recovered and wanted to go home .