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Asuhan Keperawatan
Gangguan Persepsi Sensori

Dr. Ns. Heri Kristianto, MKep.,Sp.Kep.MB

Introduction

• Sensory-perceptual alteration can be defined as

when there is a change in the pattern of sensory
stimuli followed by an abnormal response to such
stimuli

• Such perceptions could be increased, decreased, or

distorted with the patient's hearing, vision, touch
sensation, smell, or kinesthetic responses to stimuli

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The cause of sensory-perceptual alteration depends on

the underlying condition and risk factors

Factors that may increase the risk of sensory

perceptual alterations include:

• Psychiatric Conditions • Electrolyte Imbalance

• Sleep Disorders • Alcohol or Illicit Drug Use

• Delirium in Intensive Care • Chronic Medical Problems

• Neurological Disorders

• Visual Dysfunction

• Hearing Problems

Psychiatric Conditions

1. Autism spectrum disorder (ASD)

2. Attention deficit hyperactivity

Alterations in sensory-dedicated neural disorder (ADHD)

circuits, including neuro-molecular and

Individuals with ADHD have a reduced
anatomical changes in primary sensory
ability to filter intrusive sensory, motor,
regions of the brain, are responsible for
and/or cognitive information
autism-associated sensory symptoms.
GABAergic (gamma-aminobutyric acid)
signaling is often affected and responsible
for these alterations

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Psychiatric Conditions

3. Schizophrenia 4. Sensory processing disorder (SPD):

• Altered sensory processing and perceptual

• SPD is a neurological condition in children when
inference are responsible for the positive
the brain is unable to process incoming
symptoms of schizophrenia.
information in an accurate and organized
• Aberrant neurotransmitter signaling in
manner resulting in inaccurate processing and
the sensory pathway and abnormal
judgment of sensory information.
cortical plasticity mechanisms are
implicated in the pathology of
• Children can experience difficulty with
schizophrenia. One of the core features of
both schizophrenia and ASD are regulating emotions, problems in attention,
dysfunctional face emotion recognition and adapting responses
and motion processing.

Sleep Disorders

• Altered sleep or sleep deprivation can cause delirium leading to

sensory and perceptual alterations.

• The decrease in rapid eye movement (REM) sleep has been

ascertained as a possible factor that can cause delirium

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Delirium in Intensive Care

• Sensory and altered perceptions can occur due to host factors, acute illness,
and environmental factors.

Causes of disturbed sleep in the ICU may be due to:

• Mechanical ventilation and medication (benzodiazepines used to treat

• Delirium: due to impaired
delirium can also adversely contribute to delirium particularly in elderly cognitive function
patients)[3] • Prolonged neurocognitive
dysfunction
• A decrease in quality of life
• Continuous exposure to light which will disrupt the circadian rhythm
• Impaired immune function
• Noise exposure: sound from equipment, alarms, conversations amongst
healthcare staff or patients

• Patient care activities: vital signs, nursing procedures, imaging, lab draws

Neurological Disorders

These can be due to acute changes related to trauma, metabolic and electrolyte
imbalance, medication, infections, or vascular changes.

1. Alzheimer's disease

2. Parkinson's disease

3. Seizure disorder

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Visual Dysfunction

Common causes of visual dysfunction in the

elderly are:
These dysfunctions lead to impairment in
• visual acuity
• Age-related changes in the optics of the eye
• contrast sensitivity
• Diabetic retinopathy • color discrimination
• motion perception
• Glaucoma
• peripheral visual field sensitivity

• Cataract • temporal sensitivity

• visual speed processing
• Age-related maculopathy

• Visual hallucinations due to Bonnets syndrome

Hearing Problems

Hearing loss can cause auditory hallucinations, such as Anton's syndrome.

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Electrolyte Imbalance

This can cause an altered sensorium, especially hyponatremia and hypocalcemia, which
can induce delirium in elderly patients

Alcohol or Illicit Drug Use

This can lead to neurocognitive

impairments resulting in altered
sensory and perceptual alterations

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Chronic Medical Problems

• Liver failure, renal failure, and acquired immunodeficiency syndrome (AIDS) can cause
sensory-perception alterations.

• Other causes can include hospitalized elderly patients, ventilation-perfusion mismatch,

polypharmacy, patients with a terminal illness, post-surgical status, or patients with a
high fever

Epidemologi

• The prevalence of delirium can range from 3% to 42% during hospital admission

• Delirium can be high as 80% in critically ill patients

• Such variations depend upon the cause and the host factors.

• The prevalence of hallucination in the general population has been reported to be as high
as 12% and has a significant impact on functional impairment.

• Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006 Jul;35(4):350-64. [PubMed]
• Devlin JW, Brummel NE, Al-Qadheeb NS. Optimising the recognition of delirium in the intensive care unit. Best Pract Res Clin Anaesthesiol. 2012 Sep;26(3):385-93. [PubMed]
• Temmingh H, Stein DJ, Seedat S, Williams DR. The prevalence and correlates of hallucinations in a general population sample: findings from the South African Stress and Health Study. Afr J Psychiatry (Johannesbg).
2011 Jul;14(3):211-7. [PMC free article] [PubMed]

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Definisi Gangguan Persepsi Sensori (SDKI)

Penyebab
1.Gangguan penglihatan
Perubahan presepsi stimulasi 2.Gangguan pendengaran
baik internal maupun 3.Gangguan penghirupan
eksternal yang disertai 4.Gangguan perabaan
dengan respon yang 5.Hipoksia serebral
berkurang, berlebihan atau 6.Penyalahgunaan zat
terdistrosi 7.Usia lanjut
8.Pemajanan toksin lingkungan

Gejala dan Tanda Mayor

Subjektif

• Mendengar suara bisikan atau melihat bayangan

• Merasakan sesuatu melalui indera perabaan, penciuman, perabaan, atau pengecapan

Objektif

• Distorsi sensori

• Respons tidak sesuai

• Bersikap seolah melihat, mendengar, mengecap, meraba, atau mencium sesuatu

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Gejala dan Tanda Minor

Subjektif: Menyatakan kesal Objektif

1. Menyendiri

2. Melamun

3. Konsentrasi buruk

4. Disorientasi waktu, tempat, orang atau situasi

5. Curiga

6. Melihat ke satu arah

7. Mondar-mandir

8. Bicara sendiri

Intensive Care Delirium Screening Checklist (ICDSC)

The Confusion Assessment Method for the ICU (CAM-ICU)

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Kondisi Klinis Terkait

• Glaukoma • Malfungsi alat bantu dengar

• Katarak • Delerium

• Gangguan refraksi (miopia, hiperopia, astigmastisma, • Demensia

presbipio)
• Gangguan amnestik
• Trauma okuler
• Penyakit terminal
• Trauma pada saraf kranalis II, III, IV akibat stroke,
• Gangguan psikotik
aneurisma intrakranial, trauma/tumor otak)

• Infeksi okuler

• Presnikusis

Kriteria Hasil
1. Verbalisasi mendengar bisikan menurun

2. Verbalisasi melihat bayangan menurun

3. Verbalisasi merasakan sesuatu melalui indera perabaan menurun

4. Verbalisasi merasakan sesuatu melalui indera penciuman menurun

5. Verbalisasi merasakan sesuatu melalui indera pengecapan menurun

6. Distorsi sensori menurun

7. Perilaku halusinasi menurun

8. Respons sesuai stimulus membaik

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Intervensi

Manajemen halusinasi

Minimalisasi rangsangan

Pengekangan kimiawi

Manajemen Halusinasi
Manajemen halusinasi adalah intervensi yang dilakukan oleh perawat untuk mengidentifikasi dan mengelola
peningkatan keamanan, kenyamanan, dan orientasi realita.

Terapeutik Edukasi
Observasi
1. Anjurkan memonitor sendiri situasi terjadinya
halusinasi

1.
1. Monitor perilaku yang
2.
mengindikasikan halusinasi
2. Monitor dan sesuaikan tingkat
aktivitas dan stimulasi lingkungan
3.
Pertahankan lingkungan yang aman
Lakukan Tindakan keselamatan Ketika tidak
dapat mengontrol perilaku (mis: limit setting,
pembatasan wilayah, pengekangan fisik,
seklusi)
Diskusikan perasaan dan respons terhadap
2. Anjurkan bicara pada orang yang dipercaya untuk
memberi dukungan dan umpan balik korektif
terhadap halusinasi
3. Anjurkan melakukan distraksi (mis: mendengarkan
musik melakukan aktivitas dan Teknik relaksasi)
4. Ajarkan pasien dan keluarga cara mengontrol
halusinasi

3. Monitor isi halusinasi (mis: kekerasan halusinasi Kolaborasi

atau membahayakan diri) 4. Hindari perdebatan tentang validitas Kolaborasi pemberian obat antipsikotik dan antiansietas,

halusinasi jika perlu

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Minimalisasi rangsangan
Minimalisasi rangsangan adalah intervensi yang dilakukan oleh perawat untuk mengurangi jumlah atau pola
rangsangan yang ada (baik internal atau eksternal)

Observasi Terapeutik Edukasi

Periksa status mental, status sensori, dan 1. Diskusikan tingkat toleransi terhadap Ajarkan cara meminimalisasi stimulus (mis:

beban sensori (mis: bising, terlalu terang) mengatur pencahayaan ruangan,

tingkat kenyamanan (mis: nyeri,
mengurangi kebisingan, membatasi
kelelahan)
2. Batasi stimulus lingkungan (mis: cahaya, kunjungan)
suara, aktivitas)
Kolaborasi
3. Jadwalkan aktivitas harian dan waktu
Kolaborasi dalam meminimalkan
istirahat
prosedur/tindakan

4. Kombinasikan prosedur/Tindakan dalam

Kolaborasi pemberian obat yang
satu waktu, sesuai kebutuhan
mempengaruhi persepsi stimulus

Pengekangan Kimiawi
Pengekangan kimiawi adalah penatalaksanaan, pemantauan, dan penghentian agen psikotropika yang
digunakan untuk mengendalikan perilaku ekstrim individu.

Observasi Terapeutik Edukasi

1. Identifikasi kebutuhan untuk dilakukan

1. Lakukan supervisi dan survelensi dalam 1. Jelaskan tujuan dan prosedur
pengekangan (mis: agitasi, kekerasan)
memonitor Tindakan pengekangan
2. Monitor Riwayat pengobatan dan alergi
2. Beri posisi nyaman untuk mencegah 2. Latih rentang gerak sendi sesuai
3. Monitor respon sebelum dan sesudah
pengekangan aspirasi dan kerusakan kulit kondisi pasien

4. Monitor tingkat kesadaran, tanda-tanda 3. Ubah posisi tubuh secara periodik Kolaborasi
vital, warna kulit, suhu, sensasi dan kondisi
secara berkala 4. Libatkan pasien dan/atau keluarga Kolaborasi pemberian agen

5. Monitor kebutuhan nutrisi, cairan, dan dalam membuat keputusan psikotropika untuk pengekangan
eliminasi kimiawi

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Non-pharmacological intervention to prevent and manage delirium in

the ICU includes

1. The use of earplugs and eye masks

2. Noise control strategies and music therapy

3. Bright light therapy

4. Cognitively stimulating activities

5. Medication review

Bannon L, McGaughey J, Clarke M, McAuley DF, Blackwood B. Impact of non-pharmacological interventions on prevention and treatment of delirium in critically ill patients: protocol for a
systematic review of quantitative and qualitative research. Syst Rev. 2016 May 04;5:75

Effect of the use of earplugs and eye mask on the quality of

sleep in intensive care patients: a systematic review

Locihová, H., Axmann, K., Padyšáková, H., & Fejfar, J. (2018). Effect of the use of earplugs and eye mask on
the quality of sleep in intensive care patients: a systematic review. Journal of sleep research, 27(3),
e12607.

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Effectiveness of music therapy: a summary of systematic reviews based on

randomized controlled trials of music interventions

MT treatment improved the following: global and social

functioning in schizophrenia and/or serious mental
disorders, gait and related activities in Parkinson’s
disease, depressive symptoms, and sleep quality

• The Best Relaxing Piano

and Flute Music Ever
• Dosis: 5 hari/minggu, 4
minggu, 1 sesi 30 menit
• Mata tertutup, duduk
tegak, suhu 20-22 C
• Tidak boleh bicara dan Kamioka, H., Tsutani, K., Yamada, M., Park, H., Okuizumi, H., Tsuruoka, K., ... & Mutoh, Y. (2014). Effectiveness of music
tidur selama prosedur therapy: a summary of systematic reviews based on randomized controlled trials of music interventions. Patient
preference and adherence, 8, 727.

Bright light therapy

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Cognitively stimulating activities

1. improve memory

2. activities of daily living

3. depressive symptoms

4. dementia ratings

Cafferata, R. M., Hicks, B., & von Bastian, C. C. (2021). Effectiveness of cognitive stimulation for dementia: A systematic review and meta-analysis. Psychological bulletin, 147(5), 455.

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Medication review

The majority of the studies (57.9%) showed

improvement in medication adherence. Fee-
for-service pharmacist-led medication
reviews showed positive benefits on
patient outcomes. Interventions that
include a clinical review had a significant
impact on patient outcomes by
attainmentof target clinical biomarkers and
reduced hospitalization

Hatah, E., Braund, R., Tordoff, J., & Duffull, S. B. (2014). A systematic
review and meta‐analysis of pharmacist‐led fee‐for‐services medication
review. British journal of clinical pharmacology, 77(1), 102-115.

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Complications

• The main complication is stress and potential harm to the patient due to an unsafe environment.

• Alterations not only increase the stress upon the patient, but patients can be at risk of falls, injuries, and
perhaps can be a danger to themselves or to others due to their violent behaviors.

• A careful evaluation is needed to ascertain the cause while assisting the patient and preventing them from any
further distress or injuries.

Referensi

• PPNI. (2017). Standar Diagnosis Keperawatan Indonesia:Definisi dan

Indikator Diagnostik, Edisi 1 Cetakan III (Revisi). Jakarta: PPNI

• PPNI. (2019). Standar Luaran Keperawatan Indonesia: Definisi dan

Kriteria Hasil Keperawatan, Edisi 1 Cetakan II. Jakarta: PPNI

• PPNI. (2018). Standar Intervensi Keperawatan Indonesia: Definisi

dan Tindakan Keperawatan, Edisi 1 Cetakan II. Jakarta: PPNI

• Khan I, Khan MAB. Sensory and Perceptual Alterations. [Updated

2022 Oct 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK563136/

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