AssessmentAt this stage the nurse explore the factors that have the following :
1. Predisposing factors.
Is a risk factor that affects 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, physiological and genetic risk factors which affect the type and amount of resources that can be generated by individuals to cope with stress.
* Growth Factors
If the task and hampered the development of interpersonal relationships disrupted the individual will experience stress and anxiety.
* Sociocultural factors
Various factors may cause the community to feel excluded by a loneliness to the environment where the client in exaggerated.
Biochemical factors
Have an influence on the occurrence of mental disorders. Given the excessive stress experienced by a person inside the body will then produce a substance that can be as halusinogenik neurochemistry Buffofenon and Dimetytranferase (DMP).
* Psychological Factors
Interpersonal relationships are not harmonious and the existence of conflicting roles and are often accepted by the child will result in stress and high anxiety disorders and ends with reality orientation.
* Genetic factors
What genes skizoprenia influential in unknown, but research shows that family factors indicate that the relationship is very influential in this disease.
2. Precipitation Factor
Stimulus is perceived by individuals as a challenge, threat / demand that requires extra energy to köping. The existence of a common environmental stimuli such as the participation of clients in the group, invited communication for too long, there are objects which are also quiet environment / isolation is often the impetus of the hallucinations because it can increase stress and anxiety that stimulate the body excrete halusinogenik.
3. Behavior
Client response to the hallucinations can be a suspicion, fear, insecurity, anxiety and confusion, self destructive behavior, lack of attention, not able to make decisions and can not distinguish the real situation and not real. According to Rawlins and Heacock, 1993 trying to solve problems based on the hallucinatory nature of an individual existence as a creature that was built on the basis of elements of bio-psycho-socio-spiritual that hallucinations can be seen from the dimensions namely:
Physical Dimensions
Built 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 up to delirium, alcohol intoxication and the difficulty to sleep in a long time.
Emotional Dimensions
Excessive anxiety on the basis of problems that can not be overcome is the cause hallucinations that happen. The content of command hallucinations can be coercive and intimidating. Clients no longer able to resist the order with the condition the client to do something about these fears.
* Dimensions of Intellectual
In this intellectual dimension explained that individuals with hallucinations would show a decrease in ego function. At first hallucination is a business of his own ego to resist the impulse to press, but it is something that raises awareness that can take the entire attention of the client and not infrequently will control all client behavior.
Social Dimensions
Social dimension in individuals with hallucinations showed a tendency to be alone. Individuals preoccupied with hallucinations, as if it is a place to meet the need for social interaction, self-control and self-esteem that is not obtainable in the real world. The contents of hallucinations made by the individual control system, so if the command hallucinations in the form of threat, himself or others individuals tend to it. Therefore, an important aspect in the implementation of nursing interventions with clients seeking an interaction process which led to a satisfying interpersonal experiences, as well as client mengusakan outs so that clients do not always interact with their environment and hallucinations did not last.
Spiritual Dimensions
God created human beings as social beings, so that interaction with other human beings is a fundamental requirement. In these individuals tend to be alone until the above process does not occur, the individual is not aware of the existence and hallucination into the control system in these individuals. When hallucinations through her individual lost control of life itself.
4. Source köping
An evaluation of options and strategies köping someone. Individuals can overcome stress and anxiety by using köping source environments. Köping sources such as capital to solve problems, social support and cultural beliefs, can help a person integrate the experience that causes stress and köping adopt a successful strategy.
5. Mechanism köping
Every effort is directed at the implementation of stress, including direct problem resolution efforts and defense mechanisms used to protect themselves.
The Nursing Diagnosis Appear 1. Risk of violent behavior in yourself and others associated with hallucinations.
2. Changes in sensory perception: hallucinations associated with withdrawal
3. Social isolation: withdrawal associated with low self-esteem.
InterventionDiagnoasa 1.:
Risk of violent behavior in yourself and others associated with hallucinations
Objectives: There is no violent behavior in yourself and others.
Results Criteria:
1. Patients can express their feelings in the current situation verbally.
2. Patients can mention the usual acts as hallucinations, hallucinations and decide how to carry out an effective way for patients to use
3. Patients can use the patient's family to control hallucinations in a way often interact with the family.
Intervention:
* Construct a trusting relationship
* Give clients an opportunity to express his feelings.
* Listen to the client expression of empathy
* Hold a brief contact, but often stages (time adjusted to the condition of the client).
* Observation of behavior: verbal and non verbal hallucinations associated with.
* Explain to the client signs describing hallucinations hallucinatory behavior.
* Identification with the client and create a situation that does not cause hallucinations, content, time, frequency.
* Give clients an opportunity to express his feelings as a natural hallucination.
* Identification with the client when the action taken is having hallucinations.
* Discuss the ways to decide hallucinations
* Give clients an opportunity to express how to decide the appropriate hallucinations with clients.
* Encourage clients to participate in group activity therapy
* Instruct the client to notify the family when he was hallucinating.
* Discuss with the client about the benefits of the drug to control hallucinations.
* Help clients use the drug correctly.
Diagnosis 2.:
Changes in sensory perception: hallucinations associated with withdrawal
Objectives: The client can control the hallucinations
Results Criteria:
1. Patients can and want to shake hands.
2. Patients want to mention names, would call a nurse and want to sit together.
3. Patients may mention the cause of the client withdrew.
4. Patients want to connect with other people.
5. After a client home visits may be associated with the family gradually
Intervention:
* Construct a relationship of trust.
* Create a contract with the client.
* Make introductions.
* Call a favorite.
* Encourage patients to talk with a friendly.
* Review client's knowledge about the behavior of withdrawn and the signs
and give clients a chance to cause the patient to express her feelings would not get along / pull away.
* Explain to the client about the behavior of withdrawn, and signs that may be the cause.
* Give praise to the client's ability to express feelings.
* Discuss the benefits of touch.
* Slowly and patients in the room with the activity through the stages specified.
* Give credit for that success has been achieved.
* Instruct the patient to evaluate independently the benefits of touch.
* Discuss the daily schedule of patients that can be done to fill time.
* Motivation of patients in the activity room.
* Give credit for participation in the activities room.
* Cultivated a relationship of trust with the family.
* Discuss with the family about withdrawing behavior, causes, and a family car deal.
* Encourage family members to communicate.
* Instruct the patient's family members regularly visit patients at least once a week.
Diagnosis 3.:
Social isolation: withdrawal associated with low self-esteem
Objectives: Patients may be associated with other people in stages.
Results Criteria:
1. Patients can name that can be used köping
2. Patients can cite the effectiveness köping used
3. Patients can begin to evaluate themselves
4. patients are able to make a realistic plan in accordance with existing capabilities in him
5. Patients are responsible for any actions taken in accordance with rencanan
Intervention:
* Encourage the patient to mention that there are positive aspects to her physical terms.
* Discuss with the patient about his expectations.
* Discuss with the patient's outstanding skills for at home and in hospital.
* Give a compliment.
* Identify the problems being faced by patients
* Discuss köping commonly used by patients.
* Discuss köping an effective strategy for patients.
* Together with the identification of patients and how the stressor to stressor penialian patients.
* Explain that the confidence of the stressor affecting the patient's mind and behavior.
* Together with the identification of patients illustrates the belief that goals are not realistic.
* Together with the patient identification and source of power owned köping
* Show the concept of success and failure with the perception that match.
* Discuss the adaptive and maladaptif köping.
* Discuss the losses and due köping a maladaptive response.
* Help the patient to understand that only patients who can transform themselves rather than someone else
* Encourage the patient to formulate a plan / goal itself (not a nurse).
* Discuss the consequences and realities of the planning / goal.
* Help the patient to clearly menetpkan expected changes.
* Encourage the patient to start a new experience to develop suitable potential that exists in him.
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