THEORITICAL BACKGROUND

OF HALLUCINATION

Definition
1. hallucinations is one of the symptoms of a mental disorder in which the client is
experiencing sensory changes, such as experiencing a false sensation in the form of
sound, sight, taste, touch, or smell. Clients feel the stimulus that was not there. In
addition, changes in sensory perception: hallucinations can also be interpreted as a
sensory perception of an object, picture, thoughts that often occur in the absence of
external stimuli include all perception sensory (hearing, sight, touch, or smell).
The condition when someone perform exchange on stimulus that close (initial or
extinal factors ) (Townsend, 1998).
2. Theories that explain hallucinations (stuart and Sundeen, 1995)
Theory biochemistry
Metabolism occurs in response to stress that resulted in the release of
hallucinogenic substances neurotic (boffofenon and dimethytransferase).
The theory of psychoanalysis
An defend response ego against external stimulus that threatment and press to
appear in consciousness.
3. Kind of hallucination with objective and subjective
Kind of hallucination
Objetive data
Subjective data
Hearing hallucination
1. Talk or laugh
1. Hearing voices or
(client heard a voice /
yourself
noise
2. Anger
without
2. Hearing a voice that
sound that has nothing to
cause
invites conversation
do
with
the
real
3.
Closing
the
ear
3.
Hearing sound told
stimulus / environment)
towards tertantu
to do something
4. Close the ear
dangerous
visual hallucinations
1. Designate
a
1. Seeing
shadows,
(clients see a clear
particular direction
light,
geometric
2.
Non-compliance
picture / vague for the
shapes, cartoon, saw
with
something
presence of a real
a ghost, or a
that
is
not
obvious
stimulus
from
the
monster.
environment and other
people do not see it)

olfactory hallucinations
(client smelled an odor
that arises from a
particular source without
apparent stimulus)

1. Sniff sniff sniffing

like being certain
odors
2. Closing the nose

hallucinations tasting
(clients feel something
that
is
not
real,
commonly feel bad
meal)
Hallucinations
palpability (clients feel
on the skin without any
real stimulus)
Hallucinations
kinesthetic (feeling his
client engaged in a room
or move his limbs)
Hallucinations visceral
(certain feelings arise in
the body)

1. Frequent spitting
2. Vomiting

1. Scratching
the
surface of the skin

1. Holding
legs
moving considers
itself
1. Holding his chest
which he considers
transformed and
normal as usual

1. smelling odors such

as the smell of
blood, Utin, feces,
and sometimes the
unpleasant odors for
clients
1. Feeling taste like
blood, urine, or
feces

1. Say no insects on the

surface of the skin
2. Feels like an electric
shock
1. Saying body floating
in the air

1. Telling her stomach

became smaller after
drinking soft drink

4. Factors predisposing
Predisposing factors are risk factors that affect the type and amount of submber that
can be generated by an individual to cope with that stress. Obtained either from the
client or his family. Predisposing factors may include developmental factors, sociocultural, biochemical, psychological and genetic.
Factors development
If the developmental tasks encountered resistance and impaired interpersonal
relationships, then the individual will experience stress and anxiety.
sociocultural factors
Employed several factors in society can cause a person to feel excluded, so that the
person feels lonely in the neighborhood who raised
Biochemical factors
Have an influence on the occurrence of mental disorders. If someone experiencing
excessive stress, the body will result in a substance that can be hallucinogenic
neurochemical like buffofenon and dimethytransferase (Dmp)

 psycolgy Factors
The dual role that often received conflicting someone will lead to stress and anxiety
and ended in disorder reality orientation.
Genetic factors
Genes that affect in schizophrenia is unknown, but studies show that family factors
indicate a relationship that dross effect on this disease.
5. Presipitasion factor
Precipitation factors that stimuli perceived by the individual as a challenge, threat,
or demands that require extra energy to deal with it. The stimulation from the
environment such as the client's participation in the group, too long to
communicate, objects that exist in the environment, and also the atmosphere of
quiet or isolated terjdinya often trigger hallucinations. It can boost the stress and
anxiety that stimulates the body to release hallucinogenic substances.
6. Behavior
Client respon about hallucination such as paranoid , afraid , unsafety , anxiety and
confiusion , show characther to injury hi self , lack of attention , cant chose different real
and unreal (Rawlins and heacock , 1993)
Five dimension hallucination follow are :
- Dimension physic
- Dimension emosional
- Dimension intelectual
- Dimension social
- Dimension spiritual
7. Source of coping
A evaluation to choose coping and individual strategy , individual can solve stress an
axiety with using source of coping on the environment, source of coping as a modal
for problem solving. Supported by social and sosioculture can help someone
elaboration his experience can showing stress and adapt effective coping strategy.
8. Coping mechanism
Coping mechanism is any effort aimed at controlling stress, including resolving
directly and other defense mechanisms used to protect themselves.

9. Manifistation clinic
Phase 1 (non-psychotic)

At this stage, hallucinations able to provide comfort to the client, the level of
moderate orientation. Generally at this stage of hallucination is a pleasant
thing for the client.
Characteristics:
a. Experiencing anxiety, loneliness, guilt, and fear
b. Trying to focus on thoughts that can relieve anxiety
c. Mind and experience of remaining in the control of consciousness

Behavior that appears:

a. Smile or teratawa own
b. Lips moving soundlessly
c. Rapid eye movement
d. Verbal response is slow, silent, and concentrate
Phase 2 (non-psychotic)
At this stage the client usually be blamed and suffered severe anxiety level. In
general, there are hallucinations that can cause antipathy.
Characteristics:
a. Sensory experience that is scary or harassed by the experience
b. Began to feel the loss of control
c. Pulling away from others
Behavior that appears:
a. An increase in heart rate, respiration, and blood pressure
b. Attention to environmental decline
c. To experience decreased concentration sensoripun
d. Lost the ability to distinguish between hallucination with reality
Phase 3 (psychotic)
Clients usually can not control her own natural, rate of severe anxiety, and
hallucinations can not be denied again.
Characteristics:
a. Clients give and receive sensory experience
b. Fill hallucinations become attractive
c. Clients become lonely when sensory experience ends
Behavior that appears:
a. Clients obey hallucinations
b. It is difficult to relate to others
c. Attention to the environment little or shortly
d. Not being able to follow commands real
e. Clients seem tremor and sweating

 Stage 4 (psychotic)
Clients have been very favored by hallucinations and clients usually seen
panic
Perliaku that appears:
a. High risk of harm
b. Agitation / kataton
c. Not able to respond to stimuli that exist.
PATHWAY
High risk of violent behavior

Exchage sensory perception :

Hallucination

Social Isolation

Cronic low self-estreem

Nursing Diagnose can appear :
1. High risk of violent behavior
2. Changes in sensory perception: hallucinations
3. Social Isolation

Data for assessment

Nursing Problem

Data for assessment

Effect

Core Problem

Cause

Exchange Sensory perception : Hallucination

Subjective :
-

Client said hear something

Client said look white shadow
Client said smell undileious , lie a

fases
Client said his head is fly on the sky
Client said felt something to happen
on his self

Objective :
-

Look talk or laugh alone

Look hear something
Talk hear something
Disorientation
Low of concetration
Quick to changes mine

Anti Physcotic

Arthan
Trihexypenide

Anti

Nursing diagnose
Change sensory perception : Hallucination
Nursing intervention
1. Nursing intervention for client
Sp1 :
- Identify type of hallucination
- Identify contant of hallucination
- Identify time of hallucination
- Identify frequent of hallucination
- Identify situation can make hallucination
- Teach client to revent hallucination ( Scold )
- Suggest client to make daily activity to prevent halucination

Sp2 :
-

Evaluation daily activity client

Teach client to prevent hallucination with daily compresion
Suggest client to make daily activity to prevent hallucination

Sp3 :
-

Evaluation daily activity client

Teach client to do activity like their live at home
Suggest client to make daily activity to prevent hallucination

Sp4 :
-

Evaluation daily activity client

Give information about take drug avery day
Suggest client to make daily activity to prevent hallucination

Nursing action

Help client to know hallucination

Discuss is one of manner we can do for help client know about hallucination
Teach client to control hallucination
We can teach 4 sp to handle hallucination for client

Sp for family
Sp1 :
-

Discuss about problem family within caring to client

Explain about mining , sight and symptom hallucination to happen and process to

happen
Explain about how to manner caring client hallucination

Sp2 :
-

Teach family to practice how to care client

Teach family doing how to cure client

Nursing intervention to family

Family is vital factor in caring client with impaired phsycological in hospital , cause family is
support client can keep client on 24 hours.
Healthy education can do in 3 step
-

Step 1 explain about client problem

Step 2 teach family to caring client
Step 3 practice family to carring client

Information need to explaint family such as the meaning of hallucination sight and
symptoms , drug , how to communitation with client.

REFERENCE
Fontaine and cook . 2003 , Mental health nursing new jersy , prentice hall
Stuart and sundeen . 1995 Principles and practice of psyciatric Nursing 5th ed. St. Louis
Masby year book
To lunsend , Mary C . 1998 Diagnosa Keperawatan Psikiatri edisi 3 Jakarta EGC
Jallo Harnawati A. 2008 . Prilaku Kekerasan 9 maret 2008 .
www.harnawaty.wordpress.com , 11 mei 2009 pukul 19.05