Asuhan Keperawatan Halusinasi
May 7, 2019 | Author: Fikri Nabiha | Category: N/A
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Laporan Pendahuluan dan Konsep Asuhan Keperawatan Klien Dengan Halusinasi...
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HALUSINASI
-----Nasrullah-----
Halusinasi merupakan gangguan persepsi dimana klien mempersepsikan sesuatu yang sebenarnya tidak terjadi. Halusinasi adalah gangguan penyerapan atau persepsi panca indra tanpa adanya rangsangan dari luar yang dapat terjadi pada sistem penginderaan dimana terjadi pada saat kesadaran individu itu penuh dan baik. Maksudnya rangsangan tersebut terjadi pada saat klien dapat menerima rangsangan dari luar dan dari dalam diri individu. Dengan kata lain klien berespon terhadap rangsangan yang tidak nyata, yang hanya dirasakan oleh klien dan tidak dapat dibuktikan (Nasution, 2003). Halusinasi merupakan gangguan atau perubahan persepsi dimana klien mempersepsikan sesuatu yang sebenarnya tidak terjadi. Suatu penyerapan panca indra tanpa ada rangsangan dari luar. Suatu penghayatan yang dialami suatu persepsi melalui panca indra tanpa stimulus eksteren: persepsi palsu (Maramis, 2005). Halusinasi adalah salah satu gejala gangguan jiwa dimana klien mengalami perubahan persepsi sensori, seperti merasakan sensasi palsu berupa suara, penglihatan, pengecapan, perabaan atau penghiduan. Klien merasakan stimulus yang sebetulnya tidak ada. Selain itu, perubahan persepsi sensori (halusinasi) bisa juga diartikan sebagai persepsi sensori tentang suatu objek, gambaran dan pikiran yang sering terjadi tanpa adanya rangsang dari luar meliputi semua sistem pengindraan (pendengaran, penglihatan, penciuman, perabaan atau pengecapan) (Cook & Fontaine dalam Fitria, 2009) Halusinasi berbeda dengan ilusi, yang merupakan persepsi yang salah tentang stimulus lingkungan aktual. Misalnya, ketika berjalan melewati hutan seseorang berpikir bahwa ia melihat seekor ular di sisi jalan, tetapi ketika diamati lebih dekat, ternyata hanya sebuah tongkat berlekuk. Hal ini adalah suatu
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Faktor perkembangan Jika tugas perkembangan mengalami hambatan dan hubungan interpersonal terganggu, maka individu akan mengalami stres dan kecemasan
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Faktor sosiokultural Berbagai faktor di masyarakat dapat menyebabkan seseorang merasa disingkirkan, sehingga orang tersebut merasa kesepian di lingkungan yang membesarkannya. Misalnya terdapat konflik yang berhubungan dengan RAS dalam lingkungan tempat tinggal seseorang
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Faktor biokimia Faktor biokimia memiliki pengaruh terhadap terjadinya gangguan jiwa. Jika seseorang mengalami stres yang berlebihan, maka di dalam tubuhnya akan dihasilkan
suatu
zat
yang
bersifat
halusinogenik
neurokimia
seperti
buffofenon dan dimethytrasnferase (DMP)
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Faktor psikologis Hubungan interpersonal yang tidak harmonis serta adanya peran ganda yang bertentangan yang sering diterima oleh seseorang akan mengakibatkan stres dan kecemasan yang tinggi dan berakhir pada gangguan orientasi realita.
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Faktor genetik Gen yang berpengaruh dalam skizofrenia belum diketahui, tetapi hasil studi menunjukkan bahwa faktor keluarga menunjukkan hubungan yang sangat berpengaruh pada penyakit ini.
Faktor presipitasi yaitu stimulus yang dipersepsikan oleh individu sebagai ancaman, tantangan atau tuntutan yang memerlukan energi ekstra untuk
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lingkungan dan juga suasana sepi atau terisolasi sering menjadi pencetus terjadinya halusinasi. Hal tersebut dapat meningkatkan stres dan kecemasan yang merangsang tubuh mengeluarkan zat halusinogenik.
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Berbicara, senyum dan tertawa sendirian.
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Mengatakan mendengar suara, melihat, menghirup, mengecap dan merasa sesuatu yang tidak nyata.
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Merusak diri sendiri, orang lain dan lingkungan.
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Tidak dapat membedakan hal yang nyata dan hal tidak nyata, serta tidak mampu melakukan asuhan keperawatan mandiri seperti mandi, sikat gigi, berganti pakaian dan berhias yang rapi.
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Sikap curiga, bermusuhan , menarik diri, sulit membuat keputusan, ketakutan, mudah
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Tersinggung, jengkel , mudah marah, ekspresi wajah tegang, pembicaraan kacau dan tidakmasuk akal, banyak keringat.
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Resiko mencederai diri sendiri, orang lain dan lingkungan
Perilaku Kekerasan
Perubahan Sensori Persepsi: Halusinasi
Isolasi sosial: Menarik Diri
Kerusakan komunikasi verbal
Kerusakan Interaksi Sosial
Defisit perawatan diri
Gangguan Konsep Diri : Harga diri
Koping Individu Inefektif
Berduka Disfungsional
Koping keluarga inefektif
Ketidakmampuan merawat anggota keluarga
Respon pasca trauma Kurang pengetahuan
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Risiko perilaku mencederai diri
Gangguan pemeliharaan kesehatan
Gangguan sensori/persepsi: halusinasi
Isolasi sosial: menarik diri
Defisit perawatan diri: mandi dan berhias
Gangguan konsep diri: harga Keliat, 2006
diri rendah kronis
Respon Adaptif
Respon Maladaptif
- Pikiran logis - Persepsi akurat - Emosi konsisten dengan pengalaman
- Distorsi pikiran - Ilusi - Reaksi emosi berlebihan atau kurang
- Perilaku sesuai Berhub ubun un an sosi sosial al - Berh
- Perilaku aneh atau tidak biasa
.
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Gangguan pikir Halusinasi Sulit berespon Perilaku disorganisasi disorganisasi Isolasi sosial
Stuart&Laria, 2001
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Pendengaran (auditorik)
Mendengar suara-suara atau kebisingan, paling sering suara orang. Suara berbentuk kebisingan yang kurang jelas sampai kata-kata yang jelas berbicara tentang klien bahkan sampai ke percakapan lengkap antara 2
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Penglihatan (visual)
Stimulus visual dalam bentuk kilatan cahaya, gambar geometris, gambar kartun, bayangan yang rumit atau kompleks, bayangan bisa menyenangkan atau menakutkan seperti melihat monster.
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Penghidu (olfactory)
Membaui bau-bauan tertenru seperti bau darah, urine atau feces. Umumnya bau-bauan yang tidak menyenangkan . -
Pengecapan (gaustatory)
Merasa mengecap rasa seperti rasa darah, urine atau feces. -
Perabaan (tactile)
Mengalami nyeri atau ketidaknyamanan tanpa stimulus yang jelas, Rasa tersetrum listrik yang datang dari tanah, benda mati atau orang lain.
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Cenesthetic
Merasakan fungsi tubuh seperti aliran darah di vena atau arteri, pencernaan makanan atau pembentukan urine
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Kinesthetic
Klien merasakan pergerakan sementara klien hanya berdiri tanpa bergerak Penderita Penderita merasa bahwa anggota tubuhnya tubuhnya terlepas dari tubuhnya, tubuhnya, mengalami mengalami perubahan perubahan bentuk dan bergerak sendiri. Hal ini sering terjadi pada penderita penderita Schizopphrenia dan pencandu narkoba
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Halusinasi Hipnogogik
Halusinasi yang terjadi pada orang normal, yaitu halusinasi yang terjadi saat peergantian antara waktu tidur dan waktu bangun
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Tahap I (Non-Psikotik)
Pada tahap ini halusinasi mampu memberikan rasa nyaman pada klien, tingkat orientasi sedang. Secara umum pada tahap ini halusinasi merupakan hal yang menyenangkan bagi klien Karakteristik
Mengalami kecemasan, kesepian, rasa bersalah dan ketakutan
Mencoba berfokus pada pikiran yang dapat menghilangkan kecemasan
Pikiran dan pengalaman sensorik masih adalah dalam kontrol kesadaran
Perilaku yang muncul
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Tersenyum atau tertawa sendiri
Menggerakkan bibir tanpa suara
Pergerakan mata yang cepat
Respon verbal lambat, diam dan berkonsentrasi
Tahap II (Non-Psikotik)
Pada tahap ini biasanya klien bersikap menyalahkan dan mengalami tingkat kecemasan berat. Secara umum halusinasi yang ada dapat menyebabkan antipati
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Perilaku yang muncul
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Terjadi peningkatan denyut jantung, pernapasan dan tekanan darah
Perhatian terhadap lingkungan menurun
Konsentrasi terhadap pengalaman sensoripun menurun
Kehilangan kemampuan dalam membedakan antara halusinasi dan realita
Tahap III (Psikotik)
Klien biasanya tidak dapat mengontrol dirinya sendiri, tingkat kecemasan berat dan halusinasi tidak dapat ditolak lagi Karakteristik
Klien menyerah dan menerima pengalaman sensorinya
Isi halusinasi menjadi atraktif
Klien menjadi kesepian bila pengalaman sensori (halusinasi) berakhir
Perilaku yang muncul
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Klien menuruti perintah halusinasi
Sulit berhubungan dengan orang lain
Perhatian terhadap lingkungan sedikit atau sesaat
Tidak mampu mengikuti perintah yang nyata
Klien tampak tremor dan berkeringat
Tahap IV (Psikotik)
Klien sudah sangat dikuasai oleh halusinasi dan biasanya klien terlihat panik
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1. Risiko tinggi perilaku kekerasan 2. Perubahan persepsi sensori: halusinasi 3. Isolasi sosial: menarik diri 4. Gangguan konsep diri: Harga diri rendah 5. Gangguan pemeliharaan kesehatan 6. Defisit perawatan diri: mandi dan berhias
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KONSEP ASUHAN KEPERAWATAN
Pengkajian
Pengumpulan data Validasi data Identifikasi masalah
Diagnosis Keperawatan
Perencanaan (Intervensi)
Prioritas masalah Penetapan tujuan dan kriteria hasil
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PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA PETUNJUK TEKNIS PENGISIAN FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA Setiap melakukan pengkajian, tulis tempat klien dirawat dan tanggal dirawat I.
II.
IDENTITAS 1. Perawat yang merawat klien melakukan perkenalan dan kontrak dengan klien tentang : nama perawat, nama klien, panggilan perawat, panggilan klien, tujuan, waktu, tempat pertemuan, topik yang akan dibicarakan. 2. Usia dan No. RM Lihat RM 3. Alamat 4. Pekerjaan 5. Mahasiswa menuliskan sumber data / informan
ALASAN MASUK Tanyakan kepada klien/keluarga : 1. Apa yang menyebabkan klien/keluarga klien/keluarga datang ke Rumah Sakit saat ini? 2. Bagaimaa gambaran gejala tersebut ?
III. FAKTOR PREDISPOSISI 1. Tanyakan riwayat timbulnya gejala gangguan jiwa saat ini
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2. Tanyakan pengalaman masa lalu lain yang tidak menyenangkan baik bio, psiko, sosio, kultural, spiritual seperti (kegagalan, kehilangan / perpisahan / kematian, trauma selama tumbuh kembang) yang pernah dialami klien pada masa lalu 3. Bagaimana kesan kepribadian klien ?
RIWAYAT PENYAKIT KELUARGA 1. Tanyakan kepada klien / keluarga apakah ada anggota keluarga lainnya yang mengalami gangguan jiwa, jika ada beri tanda 3 pada kotak ya dan jika tidak beri tanda 3 pada kotak tidak. Apabila ada anggota keluarga lain yang mengalami gangguan jiwa maka tanyakan bagaimana hubungan klien dengan anggota keluarga terdekat. Tanyakan apa gejala yang dialami serta riwayat pengobatan dan perawatan yang pernah diberikan pada anggota keluarga tersebut. Masalah keperawatan ditulis sesuai dengan data
V.
STATUS MENTAL Beri tanda 3 pada kotak sesuai dengan keadaan klien boleh lebih dari satu : 1. Penampilan Data ini didapatkan melalui hasil observasi perawat / keluarga a. Penampilan tidak rapi jika dari ujung rambut sampai ujung kaki ada yang tidak rapi. Misalnya : rambut acak-acakan, kancing baju tidak tepat, resleting tidak dikunci, baju terbalik, baju tidak diganti-ganti. b. Penggunaan pakaian tidak sesuai. Misalnya : pakaian dalam dipakai di luar baju c. Cara berpakaian tidak seperti biasanya jika penggunaan pakaian tidak tepat (waktu, tempat, identitas, situasi/kondisi) d. Jelaskan hal-hal yang ditampilkan klien dan kondisi lain yang tidak tercant um e. Masalah keperawatan ditulis sesuai dengan data
2. Kesadaran
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3. Orientasi waktu, tempat dan orang jelas Jelaskan data objektif dan subjektif terkait hal-hal diatas 4. Aktivitas Motorik Motorik Data ini didapatkan melalui hasil observasi perawat / keluarga Kelambatan a. Hipokinesa, hipoaktifitas b. Sub stupor katatonik c.
Katalepsi
d. Flexibilitas serea Peningkatan a. Hiperkinesa, hiperaktivitas b. Gaduh gelisah katonik c. Tik d. Grimase e. Tremor f. Kompulsif
g. Mannerism h. Ekhopraksia i. Verbegerasi
: gerakan atau aktivitas yang berkurang : reaksi terhadap lingkungan sangat berkurang gerakan dan aktivitas menjadi lambat : mempertahankan secara kaku posisi badan tertentu juga bila hendak diubah orang lain : mempertahankan posisi yang dibuat orang lain
: gerakan atau aktivitas yang berlebihan : aktivitas motorik yang tidak bertujuan yang berkali-kali seakan tidak dipengaruhi rangsang luar : gerakan involunter sekejap dan berkali-kali mengenai sekelompok oto yang relatif kecil : gerakan otot muka yang berubah-ubah yang tidak dapat dikontrol : jari-jari yang tampak gemetar ketika klien menjujurkan tangan : kegiatan yang dilakukan berulang-ulang, seperti berulangkali mencuci tangan, mencuci muka, mandi, mengeringkan tangan : pergerakan yang stereotipe dan testrsi (seperti bermain sandiwara) : meniru gerakan orang lain pada saat dilihatnya. : berkali-kali mengucapkan sebuah kata yang yang tidak
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6. Persepsi a. Apakah ada halusinasi ? kalau ada termasuk jenis apa ? b. Apakah ada ilusi ? kalau ada deskripsikan Jenis-jenis halusinasi sudah jelas Jelaskan isi halusinasi, frekuensi gejala yang tampak pada saat klien berhalusinasi Masalah keperawatan sesuai dengan data c. Apakah ada depersonalisasi : perasaan aneh tentang dirinya atau perasaan bahwa pribadinya tidak seperti biasanya, tidak menurut kenyataan. d. Derealisasi : perasaan aneh tentang lingkungannya dan tidak menurut kenyataan Jelaskan hal-hal yang tidak tercantum Masalah keperawatan ditulis sesuai dengan data
7. Proses pikir Data diperoleh dari observasi pada saat wawancara 7.1 Arus pikir a. Koheren : kalimat / pembicaraan dapat dipahami dengan baik b. Inkoheren : kalimat kalimat tidak terbentuk, pembicaraan sulit dipahami c. Sirkumstansial : pembicaraan yang berbelit-belit tapi sampai pada tujuan pembicaraan d. Tangensial : pembicaraan yang berbelit-belit tapi tidak sampai pada tujuan e. Asosiasi longgar : pembicaraan tak ada hubungan antara satu kalimat dengan kalimat lainnya, dan klien tidak menyadarinya f. Flight of Ideas : pembicaraan yang melompat mel ompat dari satu topik ke topik lainnya masih ada hubungan yang tidak logis dan tidak sampai pada tujuan g. Bloking : pembicaraan terhenti tiba0tiba tanpa gangguan eksternal kemudian dilanjutkan kembali h. Perseverasi : berulang-ulang menceritakan sesuatu ide, tema secara berlebihan i. Logorea pembicaraan cepat tidak terkontrol
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h. Preokupasi i. Alienasi j. Rendah diri k. Pesimisme l. Waham Agama
: pikiran yang terpaku pada satu ide : perasaan bahwa dirinya sudah menjadi lain, berbeda, asing : merendahkan atau menghina diri sendiri, menyalahkan diri sendiri tentang suatu hal yang pernah atau tidak pernah dilakukan : mempunyai pandangan yang suram mengenai banyak hal dalam hidupnya
: Keyakinan terhadap suatu agama secara berlebihan dan diucapkan secara berulang tetapi tidak sesuai dengan kenyataan Somatik / hipokondrik : Klien mempunyai mempunyai keyakinan tentang tubuhnya dan dikatakan secara berulang yang tidak sesuai dengan kenyataan Kebesran : Klien mempunyai keyakinan yang berlebihan terhadap kemampuannya yang disampaikan secara berulang yang tidak sesuai dengan kenyataan Curiga : Klien mempunyai keyakinan bahwa ada seseorang atau kelompok yang berusaha merugikan atau mencederai dirinya yang disampaikan secara berulang dan tidak sesuai dengan kenyataan Nihilistik : Klien yakin yakin bahwa bahwa dirinya sudah tidak ada di dunia / meninggal meninggal yang dinyatakan secara berulang yang tidak sesuai dengan kenyataan Kejaran : Yakin bahwa ada orang / kelompok yang mengganggu, dimatamatai atau kejelekan sedang dibicarakan orang banyak
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d. Amnesia e. Paramnesia contoh : De javu
: Sebutkan macamnya Amnesia retrograde / anterograde : Ingatan yang keliru karena distorsi pemanggilan kembali :
Seperti sudah pernah melihat sesuatu tetapi sebenarnya belum : Seperti belum pernah melihat sesuatu tetapi sebenarnya Jamais vu sudah : Secara tidak sadar mengisi lubang-lubang dalam Konfabulasi ingatannya dengan cerita yang tidak sesuai dengan kenyataan : Pengenalan kembali yang keliru, merasa bahwa itu benar Fasse reconaisance tetapi sesungguhnya tidak benar f. Hipermnesia : Pemahaman dalam ingatan dan pemanggilan kembali yang berlebihan Jelaskan sesuai dengan data terkait Masalah keperawatan sesuai dengan data
9. Tingkat konsentrasi dan berhitung Data diperoleh melalui wawancara
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b. Menyalahkan hal-hal diluar dirinya
: Menyalahkan orang lain / lingkunagn yang menyebabkan kondisi saat ini
Jelaskan sesuai dengan data terkait Masalah keperawatan sesuai dengan data
12. Interaksi selama wawancara Data ini didapatkankan melalui hasil wawancara dan observasi perawat / keluarga a. Bermusuhan, tidak kooperatif, mudah tersinggung sudah jelas b. Kontak mata kurang : tidak mau menatap lawan bicara c. Defensif : selalu berusaha mempertahankan pendapat dan kebenaran dirinya d. Curiga : menunjukkan sikap/perasaan tidak percaya pada orang lain Jelaskan sesuai dengan data terkait Masalah keperawatan sesuai dengan data
VI.
FISIK Pengkajian fisik difokuskan pada sistem fungsi organ :
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Penilaian / penghargaan orang lain terhadap diri dan kehidupannya
Masalah keperawatan ditulis sesuai dengan data
2. Genogram a. Buatlah genogram minimal tiga generasi yang dapat menggambarkan hubungan klien dan keluarga, contoh :
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b. Jelaskan masalah yang terkait dengan komunikasi, pengambilan keputusan dan pola asuh c. Masalah keperawatan ditulis sesuai dengan data
3. Hubungan sosial a. Tanyakan pada klien siapa orang terdekat dalam kehidupannya, tempat mengadu, tempat bicara, minta bantuan atau sokongan b. Tanyakan pada klien kelompok apa saja yang diikuti dalam masyarakat c. Tanyakan pada klien sejauh mana ia terlibat dalam kelompok di masyarakat d. Masalah keperawatan ditulis sesuai dengan data
4. Spiritual a. Nilai dan keyakinan : Tanyakan tentang, Pandangan dan keyakinan, terhadap gangguan jiwa sesuai dengan norma budaya dan agama yang dianut Pandangan masyarakat setempat tentang gangguan jia b. Kegiatan ibadah : Tanyakan, Kegiatan ibadah di rumah secara individu dan kelompok Pendapat klien/keluarga tentang kegiatan ibadah Masalah keperawatan ditulis sesuai dengan data
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6. Penggunaan Obat a. Observasi dan tanyakan kepada klien dan keluarga tentang : Penggunaan obat : frekuensi, jenis, dosis, waktu dan cara pemberian Reaksi obat
7. Pemeliharaan Kesehatan a. Tanyakan kepada klien dan keluarga tentang : Apa, bagaimana, kapan dan kemana perawat lanjut Siapa saja sistem pendukung yang dimiliki (keluarga, teman, instituisi dan lembaga pelayanan kesehatan) dan cara penggunaannya
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1. Risiko tinggi perilaku kekerasan 2. Perubahan persepsi sensori: halusinasi 3. Isolasi sosial: menarik diri 4. Gangguan konsep diri: Harga diri rendah 5. Gangguan pemeliharaan kesehatan 6. Defisit perawatan diri: mandi dan berhias
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No
1
Diagnosa Keperawatan
Risiko perilaku mencederai diri berhubungan dengan halusinasi pendengaran
Tujuan
Kriteria Evaluasi
Intervensi
TUM Klien tidak mencederai diri, orang lain dan lingkungan TUK 1. Klien dapat membina hubungan saling percaya
1.1. Ekspresi wajah bersahabat, menunjukkan rasa senang, terdapat kontak mata, mau berjabat tangan, mau
1.1.1. Bina hubungan saling percaya dengan mengungkapkan prinsip komunikasi terapiutik Sapa klien dengan ramah baik verbal maupun maupun nonverbal nonverbal Perkenalkan diri dengan
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ke kiri, ke kanan atau ke depan seolah-olah ada teman yang diajak bicara 2.1.3. Bantu klien mengenal halusinasinya menemukan klien sedang sedang Jika menemukan berhalusinasi tanyakan apakah ada suara yang didengarkannya Jika klien menjawab menjawab ada, ada, lanjutkan: apa yang dikatakan suara itu? Katakan bahwa perawat percaya klien mendengar suara itu, namun perawat sendiri tidak mendengarnya (dengan nada bersahabat
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3. Klien dapat mengontrol halusinasinya.
3.1. Klien dapat menyebutkan tindakan yang biasanya dilakukan untuk mengendalikan halusinasinya.
3.1.1. Identifikasi bersama klien tindakan yang dilakukan jika terjadi halusinasi (tidur, marah, menyibukkan diri dll) 3.1.2. Diskusikan manfaat dari cara yang digunakan klien, jika bermanfaat beri pujian kepada klien
3.2. Klien dapat menyebutkan cara baru mengontrol halusinasi
3.2.1. Diskusikan Diskusikan dengan klien tentang cara baru mengontrol halusinasinya: Menghardik/mengusir/ tidak memperdulikan halusinasi Bercakap-cakap Bercakap-cakap dengan orang lainjika halusinasinya muncul
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“bagaimana perasaan mas/mbak setelah menghardik? Apakah halusinasinya berkurang?” berkurang? ” beri
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3.5.4. Tanyakan kepada klien: “Bagaimana perasaan mbak/mas setelah melakukan kegiatan
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- Klien memeriksa obat sesuai dosisnya - Klien meminum obat pada
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klien) Cara merawat anggota keluarga yang mengalami
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STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
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