Nursing care for Mrs.

K by
Diagnosis Auditory
Hallucinations in Women's
Intensive Room of Sambang
Lihum Mental hospital in
G
Banjarmasin
R
Women's O
Intensive Room U
Present by :
P
Devy Silvia
Martesy
Mia Ari Andayani
Putri Ariyanti
1
Thrie Rhenie Anastasia
 Problem Tree
Definition of auditory
hallucination
RISK OF
LOW SELF-
BEHAVIORAL
ESTEEM
Auditory TURBIDITY
hallucination are
hearing sounds that
HALLUCINATIONS
range from simple
sounds to sounds
that speak about the FAMILY
INDIVIDUAL
patient so that they COPING IS NOT
COPING IS
NOT
respond to sound. EFFECTIVE
EFFECTIVE
List of Nursing Problem
A. Hallucination
B. Risk of behavioral turbidity
C. Individual coping is not effective
D. Family coping is not effective
E. Thought process disorder
A. Assesment
Patient identity
Name : Mrs. K
Age : 24 years old
Gender : Female
Religion : Islam
Education : Junior High School
Marital status : Married (Divorced)
Addres : Banjarbaru
Work : Housewife
Medical Diagnosis : F.20.0 (skizofrenia,
Paranoid)
Date of entry : October 18, 2018
 Priority
of Nursing Problems:
Auditory Hallucinations.

 Reason of entry:
Approximately three months, the patients
experienced a change in behavior, talking to herself,
wandering around, lying on the road and rampage.

Nursing Problem:
 Main complain : The patients says when she wants
to sleep there is hearing voice like someone
whispering in her ear.
 Nursing Problem :
Hallucination
a.Precipitation Factors
The patients said before she was often beaten by
her husband, after the Eid Mubarak day, she said her head
was banged to the wall and her husband took a gold that
her husband used to remarried.

Problem of nursing
1. Individual coping is not effective
2. Familly coping is not effective

b. Predisposition Factors
The patients said she had never experienced a
mental disorder in the past and patients have no previous
treatment history.
N Data focus Nursing Problem
O
1 DS : The patients says when she wants to
sleep there is hearing voices like
someone whispering in her ear.

DO : -The patients looks calm

Sensory Perception
-The patient's emotions are stable
Disorders: auditory
-The patients are quite cooperative
hallucinations
-The patient sometimes appear to
speak for herself
-Sometimes the patient's mouth looks
mumbled

Nursing diagnoses :

Sensory perception disorders are associated with Audiotory

hallucinations
Nursing Intervention
 Build a trusting relationship.
 Help the patients know her hallucinations.
 Give the patients the opportunity to express her
feelings.
 Discuss how to control the hallucinations by
providing 1-4 implementation strategies
1 how to rebuke the hallucinations,
2 obedient medication,
3 invite to conversation with someone else,
4 conduct the activities.
 Observation of the patients general situation.
Nursing Implementation
NO Date Diagnosis Implementation

1. October Sensory 1) Fostering trusting relationships with

24, 2018 perception patients.
disorders are 2) Helps patients recognize their
associated hallucinations.
with hearing 3) Give patients the opportunity to
hallucinations express her feelings.
4) Teach patients how to control
hallucinations with the
implementation strategy 1, which is
how to rebuke the hallucinations.
Progress Note
N Date Diagnosis Evaluation
O
1 October Sensory S: The patient says when she wants to
24, 2018 perception sleep there is hearing voices like
disorders are someone whispering in her ear.
associated O: - The patient seems calm, Patients
with hearing sometimes talk to herself, Less eye
hallucinations contact, cooperative patients
A: Diagnosis: sensory perception disorder is
associated with auditory hallucinations
P: Continue Intervention:
1) Build a trusting relationship Repeat
implementation srategy 1
hallucinations: how to rebuke the
hallucinations.
2) Give patients the opportunity to
express her feelings.
 Evaluation
N Date Diagnosis Evaluation
O
1 Octob Sensory S: The patients says no longer listening to the
er 29, perception sound like someone talking.
2018 disorders are The patients says the name of the medicine is
associated with "Heloperidol"
hearing O: - Patients is calm.
hallucinations - The patients no longer speaks alone.
- Stable emotions.
- Cooperative patients.
- Patients concentration is easily diverted.
- Patients follow Group Activity Therapy (TAK)
and exercises every day.
A: Diagnosis: sensory perception disorder
associated with auditory hallucinations .
P: Continue intervention:
1) Continue implementation strategy 3 invite to
conversation with someone else.
2) Give the patients an opportunity to reveal her
feelings.
THANK
YOU