NURSING CARE ON MR. M.

A WITH
HALLUCINATIONS PROBLEM
IN MAN'S INTENSIVE ROOM

presented by Group “3”

Profession Ners Program
Lambung mangkurat University
What is hallucinations?
Hallucinations are the loss of the human ability to distinguish
internal stimuli (thoughts) and external stimuli (the outside world).
Patients give perception or opinions about the environment about
the existence of real object or stimuli (Izzudin, 2006)
 Types of hallucinations (According to Yosef, 2009):

Hearing Hallucinations Visual Hallucinatios

Olfactory Tasting
Hallucinations Hallucinations

Tactil Hallucinations Sexual Hallucinations

Kinesthetic
Visceral Hallucinations
Hallucinations
 Hallucinations Phases

1. First phase 2. Two Phase 3. Three Phase 4. Four Phase

(comforting / f (comdemming) (controlling) (Conquering/P
un) anic)
 PATIENT
IDENTITY

Initials : Tn. M.A (Men)

Age : 21years old
Education : Vocational high school 
Job : Swasta (Music Shopkeeper)
Date of MRS : July 22, 2018
Informant : Patient and medical record
Marital Status : Single
Medical Record : 02. 56.xx
Date of Review : August 17, 2018
Medical Diagnosis :
F.19.5 (Drug-Induced mental and behavioral disordes)
F.20.3 (Schizophrenia Not Detailed)
REASONS FOR SIGNING
IN
The Patient said that his
father took him RSJD
Sambang Lihum because he
went on a rampage at home,
destroyed thing, fought with
his parents and even
threatened to use a sharp
weapon (knife)
Nursing Problems: Violent
Behavior
CURRENT PATIENTS
The Patient is currently in a neat
and clean state. When invited to
communicate, The patient is
willing to talk and is cooperative,
The patient’s eye contact can be
maintened, the patients does not
appear anxious. The patient said he
heard whispers and saw his lover
while being treated in the room
Nursing Problems: Visual
Hallucinations and vision
 PRECIPITATION & PREDISPOSING FACTORS

• PRECIPITATION
Patients experience depression because they are required to be responsible for the immoral actions they have committed. 
The patient was asked to marry his lover with a dowry of 100 million rupiah, because he felt that he was unable to finally
become depressed and the patient decided to take 5 tablets of CTM per day each and drink it every morning and night, the
beginning of use in 2018 and lastly using it.  1 day before entering RSJD Sambang Lihum.
 When at home the patient sees the shadow of a snake wrapped around his lover and talks to him to immediately marry his
lover, otherwise the snake will eat the girl.
 

• PREDISPOSING
1. The patient has never had a mental disorder in the past and a history of previous psychiatric medication
 2. The patient has committed acts of violence against parents using sharp weapons (knives) & the patient also breaks things
at home and goes berserk.
 3. Drug Use History
 4. The patient is asked to give a dowry of 100 million.  Patients feel inadequate and eventually feel depressed and often
throw tantrums
 
 UNHAPPY PAST EXPERIENCES

The patient said that he often made fun of his friends at school when he was in grade VII
MTS.  He is often ridiculed as fat and stupid when he taunts him not to do anything but when
he is at home he goes berserk.  The patient also said that on this basis he had no friends and the
syringe was locked up in a room.  The patient also said that when he was at home, he often
broke his heart / had love problems which led to him getting drunk frequently

Nursing Problems: Ineffective coping

• PHYSICAL EXAMINATION: No Problem
• PSYCHOSOSIAL: No Problem
• Self-concept: No Problem
• Social Relations: No Nursing Problem
• Spiritual: No Nursing Problem
• Mental status: No Nursing Problem
• Talk: No Nursing Problems
• Motor Activity:  The Patient Appears Calm, Not Restless Or Confused.  The Patient's Face Looked Tense When His
Friend Scolded Him.  The Patient's Eyes Are Sharp When He Is Angry With His Friend / Nurse And Sometimes The
Patient Gets Angry With His Friend In Harsh Tones
• Affect: No Nursing Problems
• Interaction During Interview: No Nursing Problems
• Perception: The Patient Said He Heard The Whisper Of His Lover And Saw The Lover Where His Lover Said He Asked
Him To Quickly Marry Her And If He Was Not Married Then He Would Report The Patient To The Police And In
Prison.  This Can Happen Once A Day When The Patient Wants To Sleep At Night And What Patients Often Do Is Close
Their Eyes And Read Istigfar.  Patients Sometimes Close Their Eyes To Reduce Their Sexual Desire When They See The
Reflection Of Their Lover And Read Istigfar While On The Move
• Thought Process: No nurse Problem
• Content Thought: No nurse Problem
• Level Of Consciousness: No nurse Problem
• Memory:No nurse Problem
• Concentration Level Count: No nurse Problem
• Assessment Ability: No nurse Problem
• Perception: No nurse Problem
• Needs for home preparation: Patients Can Be Well Dressed And Decorated, Neat And Clean
• Rest And Sleep: Activities Before Bedtime Usually Pray While The Habit After Waking Up Is Usually Making The Bed
• Drug Use: Patients Can Actively Participate In Drug Use
• Health Care: Patients Will Undergo Further Treatment, Namely Outpatient Treatment
• Activities In The House: The Patient Is Able To Do Activities In The House Properly Such As Cleaning The House,
Washing Clothes And Preparing Food But Cannot Manage Finances
• Activities Outside The Home: No Nursing Problems
• Koping Mechanism: Maladaptive
• Nursing Problems: Ineffective Coping, Ineffective Health Management
• Psychosocial and environmental problems: No Nursing Problems
• Less Knowledge: Ineffective Coping
 LIST OF NURSING PROBLEMS

1. The Risk of Violent Behavior

2. Sensory Perception Disorders: Hallucination

3. Social Isolation: Withdrawal

4. Self-Concept disorder: low self-esteem

 TREE PROBLEMS

Effect Risk of Violent Behavior

Sensory Perception Disorders:

Core Problem Hallucination

Causa Coping ineffectiveness

Causa Ineffectiveness of health management

PERCEPTUAL, SENSORY
DISORDERS: HALLUCINATIONS OF
HEARING AND VISION

DS:
• The patient said he heard a whisper and saw his lover while being
treated in the room
• The patient said when he was at home the patient saw the shadow of a
snake wrapped around his lover and talked to him to immediately marry
his lover, otherwise the snake will eat the gasdis.
• The patient said he heard a whisper from his lover and saw his lover
where his lover said asked him to quickly marry her and if he was not
married then he would report the patient to the police and in
prison.  This can happen once a day when the patient wants to sleep at
night and what patients often do is close their eyes and read istigfar.
 DO:
•  The patient's response when he sees the image is to reply to the snake's
words (talking to himself)
 Risk of Violent Behavior

DS:
• The patient said that his cock was taken because he went berserk at
home, destroyed things, had an argument with his parents and even
threatened to use a sharp weapon (knife)
 DO:
•  The patient's face looks tense when angry with his friend.
• The patient's eyes are sharp when scolded by a friend / nurse
•  Sometimes patients get angry with their friends in harsh tones
COPING INEFFECTIVENESS

DS:
•  The patient said he knew about the use of 70% alcohol for nail
cleaners, CTM for allergy medication but used the drugs to calm the
mind from depression and problems
• The patient said that he was often teased by his friends at school when
he was grade VII MTS. 
 DO:
•  Drug history: Inhaling fox glue, addictive substance abuse using
addictive substances of 70% alcohol mixed with 1 bottle of extra joss
and hemaviton
INEFFECTIVENESS OF HEALTH MANAGEMENT

DS:
•  The patient said that he took 5 tablets of CTM per day and drank
every morning and night, the beginning of use in 2018 and lastly using
1 day before entering RSJD Sambang Lihum.  According to the
patient, if he takes the drug he can sleep peacefully, not go berserk and
forget about his problems
 DO:
•  The patient consumes CTM, alcohol and fox glue to calm the mind
whenever the patient has a problem that cannot be solved
KELOMPOK 3