Nursing Care Of Mr.

T With Primary Nursing Disorders Sensory Perception: Auditory Hallucinations In The Setiyaki Ward Soeroyo Magelang Hospital
Dessy Rakhmawati Dian Setiowati Dini Ratmayanasari Diany Novita Arumsari Galuh Enjang Hartimah Hikmah Fadil Ina Alfiah Fani Estihana Ira Nurhayati Isa Bela R. Lilis haryati

Asessment
I. IDENTITY A. patient identity Name: Mr. T Age: 19 years Gender: male Address: Brebes Occupation: Education: SMK class II Medical diagnosis: F 3.20 Skizoferenia no detailed

II. REASON FOR ENTRY AND FACTORS precipitation

The client was taken to hospital on 28 November 2011 by his father because of angry, irritable, destroying household tools, threatened, lazy to work and laughed to himself. Clients have experienced mental illness in the past, but the treatment is less successful because of the clients experiencing drug withdrawal.

III. predisposing Factors

Clients never been sick like this and cared in orpan house Boja Kendal. But less successful treatment outcomes. Patients had to do is kick his father's physical abuse. In the family patient no suffering mental illness as a natural T today. Patients are told there is an unpleasant experience when breaking up with her boyfriend, since then the client feeling confused. The client also requested a motorcycle, but because the parents lack the economy, so the client's wishes are not met.

MENTAL STATUS
G. perception Clients usually hear male voices, but the client does not know what its contents. The sound is a long time appeared about 10 minutes and more often appear at night. Clients usually only silence when she heard the voice.

Data Analysis
Focus data Ds: the patient described hearing a male voice but do not know what its contents, the appearance of longer, more frequent at night, I usually remained silent. DO: prefer own, daydreaming, fidgeting, pacing, his own smile, eye contact and lack of communication nurses problem hallucinations

Implementation
Date Nursing action Evaluation And Response S: the client asks to hear a male voice but do not know what its contents, the appearance of longer, more frequent at night, usually the patient's response was silent. O: daydreaming, restlessness, occasionally seen their own smile, eye contact and lack of concentration, communication preceded, looking confused, incoherent verbal, Verbal softly Beyond interaction: prefer looks alone, daydreaming, pacing back and forth, NOT participate but less concentration. A: The client is able to identify hallucinations P: - validation identification techniques taught hallucinations and rebuked 13/12/1 Sp I 1 haluinasi: 12.30 -identify the type, content, timing, frequency and response to hallucinatio ns

Date

Nursing action

Evaluation And Response S: client still hear noises that bother you, but do not know its contents. O: communication with the preceded, coherent verbal, verbal softly, eyes and lack of concentration, not the focus, the client will demonstrate how to scold but have not been able to independently Beyond interaction: the client is still often daydreaming, smiling himself, pacing back and forth, prefer alone, TAK participate but lack of concentration A: The client has been unable to rebuke, still need help P: - guiding clients to control the hallucinations by way rebuked - Practice how to control the hallucinations by way of rebuke

14/12/11 Validate the 12.40 identification of

hallucinations and hallucinations with rebuked teach control

Date

Nursing action Evaluation And Response

15/12/ Validate the 11 identificatio n of 12.45 hallucinatio ns and hallucinatio ns with rebuked teach control

S: client still hear the voices say the male friend, the sound was told to do naughty O: communication preceded, coherent verbal, verbal softly, eyes and lack of concentration, control would scold, but have not been able to independently. Beyond interaction: clients still daydreaming smile smile alone, pacing back and forth, prefer alone, TAK want but lack of concentration A: The client has not been able to independently rebuke P: - guided back to control hallucinations with rebuked the technique -training how to control the hallucinations by way rebuked

 MERCI AND PARDON US