SOP Orientasi realitas

Pengantar
Maksud orientasi realitas adalah untuk membantu seseorang untuk mempertahankan atau
memperoleh kembali kesadarannya terhadap identitasnya, lingkungannya, dan referensi waktu yang
benar. Hal ini juga mendukung sosialisasi, penguatan perilaku yang dapat diterima secara sosial,
mendukung kemandirian dalam aktivitas sehari-hari, dan membantu membangun keyakinan,
kehormatan, dan harga diri.
Patients who need reality orientation are found in all age-groups; however, most are elderly. There
are two categories of people for whom this program is appropriate. One category includes patients
who are confused or disoriented from any cause, regardless of their age or diagnosis. The patient's
confusion can result from such things as arteriosclerosis, sensory deprivation, overmedication,
metabolic imbalance, nutritional deficiency, or emotional stress. The other category includes patients
who are oriented but face a stressful situation, which could cause confusion. Examples are changes in
living arrangements, surgery, loss of a spouse, or even visual or hearing problems. Both groups are
encountered in all areas of nursing, including extended care, medical-surgical, and psychiatric units as
well as in urgent care and clinic settings.

Peralatan yang dibutuhkan:

Persiapan alat orientasi realitas:

1. Jam analog
2. Tanda arah
3. Gambar
4. Kartu
5. Mementos
6. Bulletin boards
7. Surat kabar
8. Majalah
9. Televisi
10. Radio
11. Lampu tidur
12. Kalender
13. Cermin
14. Lukisan

The above equipment should be used frequently in the patient's environment, such as in hallways,
rooms, and dining rooms, to aid in orientation as the patient moves about. Label these items using
large lettering for patients with visual deficits.

Implementasi

 Lakukan hand higin.123

 Confirm the patient's identity using at least two patient identifiers according to your facility's
policy.4
 Assess the patient's current orientation status by observing for specific behaviors, such as
wandering, getting lost, using rambling speech, or withdrawing from social situations. Ask
questions about time, place, and person as well as recent and remote memories.
 If the patient is confused, use reality orientation props such as a calendar, and orient him
through verbal interaction. For example, say, "Mr. George, look at the calendar; today is
Monday. Your wife will come to visit you on Wednesday." Or, "This is your bed, Mr. Peters.
See your name on the end of the bed?" Orient the patient frequently as you interact with the
patient throughout the day.
  Teach family members and visitors how to reorient the patient.
 Establish and maintain a regular routine for daily activities, and avoid changes of room, unit,
or furniture as possible to provide consistency in all interventions.
 Address the patient by his correct title and last name to promote self-esteem, dignity, and
orientation.
 Always identify yourself and your role, and state what you expect the patient to do. Explain
one step at a time, employing good eye contact, touch, and a positive attitude.
 Provide a calm environment, but recognize that it's also important to plan for and provide
some stimulation to prevent monotony.
 Socialize and talk with the patient, and relate time, place, and person to current activities. For
instance, you might say, "Hi, Ms. Pearson, it's Alison Parker, your nurse. It's noon, and we're
going to walk together to the dining room for you to get lunch."
 Give praise and recognition, such as a smile, warm handshake, pat on the back, or sincere
verbal praise for each positive response. Positive reinforcement helps improve self-esteem
and increases the likelihood that the positive response will be repeated.
 Encourage the patient to take an interest in personal appearance by using a mirror to
maintain awareness of the patient's body image. Encourage self-care within the patient's
known limitations.
 Correct rambling speech or actions. Offer reminders in a nonthreatening and noncritical way.
 Perform hand hygiene.123
 Document the procedure.5

Pertimbangan khusus

 Reality orientation may be used for individual therapy or with a group. When used in a group,
the leader reviews facets of reality with a small group of confused patients. Group sessions
also promote socialization.
 Some patients may experience a phenomenon known as sundown syndrome, in which
agitation and confusion may develop towards the end of the day and continue into the night.
It may result from tiredness and less stimuli at night compared with mealtimes and when
spending time with others.6

Komplikasi

Patients who are confused and require reality orientation are at increased risk for wandering, falls,
and sleep deprivation.

Dokumentasi

Document all interventions as well as the patient's response in the progress notes. An interdisciplinary
treatment care plan should be written with attainable goals and interventions. Update this as needed.

Referensi

1. World Health Organization. (2009). "WHO guidelines on hand hygiene in health care: First global patient
safety challenge, clean care is safer care" [Online]. Accessed June 2013 via the Web at
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf (Level I)
2. The Joint Commission. (2013). Standard NPSG.07.01.01. Comprehensive accreditation manual for
hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission. (Level I)
3. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:
Recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51 (RR-16),
1–45. Accessed June 2013 via the Web at http://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level I)
4. The Joint Commission. (2013). Standard NPSG.01.01.01. Comprehensive accreditation manual for
hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission. (Level I)
5. The Joint Commission. (2013). Standard RC.01.03.01. Comprehensive accreditation manual for
hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission. (Level I)
 6. Stuart, G. W. (2013). Principles and practices of psychiatric nursing (10th ed.). St. Louis, MO: Mosby.

Referensi tambahan

 Akanuma, K., et al. (2011). Improved social interaction and increased anterior cingulate metabolism
after group reminiscence with reality orientation approach for vascular dementia. Psychiatry Research,
192, 183–187. (Level IV)
 Mohr, W. K. (2012). Psychiatric-mental health nursing: Evidence-based concepts, skills, and practices
(8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
 Videbeck, S. L. (2011). Psychiatric-mental health nursing (5th ed.). Philadelphia, PA: Lippincott Williams
& Wilkins.
 Woods, B., et al. (2012). Cognitive stimulation to improve cognitive functioning in people with dementia.
Cochrane Database of Systematic Reviews, 2012(2), Art. No. CD005562. (Level I)
Reality orientation
Objective: To demonstrate reality orientation according to the standard of care.
Perform hand hygiene.
Confirm the patient's identity using at least two patient identifiers.
Assess the patient's current orientation status.
Use reality orientation props and orient the patient through verbal interaction.
Teach family members and visitors how to reorient the patient.
Establish and maintain a regular daily routine.
Address the patient by his correct title and last name.
Identify yourself and your role, and state your expectations for the patient one step at a time.
Provide a calm environment with some stimulation.
Socialize with the patient, relating time, place, and person to current activities.
Provide positive reinforcement.
Encourage the patient to take an interest in personal appearance.
Correct rambling speech or actions.
Perform hand hygiene.
Document the procedure.
Reality orientation

 Perform hand hygiene.

 Confirm the patient's identity.
 Assess the patient's current orientation status.
 Use reality orientation props and orient the patient through verbal interaction.
 Teach family members and visitors how to reorient the patient.
 Establish and maintain a regular daily routine.
 Address the patient by his correct title and last name.
 Identify yourself and your role, and state your expectations for the patient one step at a time.
 Provide a calm environment.
 Socialize with the patient, relating time, place, and person to current activities.
 Provide positive reinforcement.
 Encourage the patient to take an interest in personal appearance.
 Correct rambling speech or actions.
 Perform hand hygiene.
 Document the procedure.