Nursing Diagnosis: Risk for self-mutilation, others and the environment related to delusions.
General purpose:
Clients do not injure themselves, others, and the environment.
Specific purpose:
1. Clients can build a trusting relationship with the nurse.
Rationale: The relationship of trust is fundamental to facilitate the interaction.
Nursing Interventions:

• Construct a trusting relationship: therapeutic greetings, introduce yourself, explain the purpose of the interaction, create a quiet environment, create a clear contract (subject, time, place).
• Do not argue and support the client’s delusions: tell the nurse receives client confidence “I accept your beliefs” with expressions received, say nurses do not support, accompanied by expressions of doubt and empathy, did not discuss the content of delusions clients.
• Ensure clients are safe and secure: tell the nurse will accompany the client and the client is in a safe place, use the openness and honesty do not leave the client alone.
• Observation is delusional disrupt daily activities and self-care.

2. Clients can identify capabilities.
Rationale: By knowing the capabilities of the client, it will allow nurses to direct the activities that are beneficial to the client rather than just thinking about it.
Nursing Interventions:

• Give compliments on the appearance and capabilities of clients are realistic.
• Discuss with clients the capabilities of past and present realistic.
• Ask the client, what is usually done, and encourage clients to do it now (linked with daily activities and self-care).
• If the client is always talking about delusions, listen to the needs of suspicion does not exist. Show the client that the client is essential.

3. Clients can identify unmet needs.
Rationale: By knowing the needs of clients who have not met the nurse, can plan to meet them and pay more attention to the needs of the client, so the client feels comfortable and safe.
Nursing Interventions:

• Observation of daily client needs.
• Discuss the client’s needs are not being met, either for at home or in the hospital (pain, anxiety, anger).
• Connect the unmet needs and the emergence of delusions.
• Increase activities that can meet the needs of clients and require time and effort (for the schedule if possible).
• Set the circumstances that the client does not have time to use the delusions.

4. Clients can relate to reality.
Rationale: In reality, the client can open his mind, that the reality is more true, than on what he thinks the client, so the client can eliminate the existing delusions.
Nursing Interventions:

• Speaking with clients in the context of reality (self, other people, places and times).
• Include the client in group activity therapy: reality orientation.
• Give praise to the positive activities undertaken by the client.

5. Clients can use the drug properly.
Rationale: The use of medications regularly and properly, will affect the healing process and the effects and side effects of drugs.
Nursing Interventions:

• Discuss with the client about drug name, dosage, frequency, effects and side effects of medication.
• Help clients use the drug with the principle of true 5 (patient name, drugs, dose, method and time).
• Encourage clients to talk about the effects and side effects of the drug are felt.
• Give reinforcement when the client is taking the correct medication.

6. Clients have the support of the family.
Rationale: Support and care of the family in caring for clients will be helping with the healing process of clients.
Nursing Interventions:

• Discuss with the client’s family, through family meetings about: symptoms of delusions, how to care for the client, the family and follow-up drug.
• Give reinforcement on family involvement.

A. DefinitionHallucinations are disturbances of perception ( perception ) adanyarangsangan post without external senses which can include all sensing system in which individual consciousness occurs when the full / good .Hallucinations are the most common form of the disorder of perception . This can be a form of hallucinatory voices or buzzing noise , but most often in the form of words arranged in sentences rather perfect . Sentences usually talk about sad state of the patient or the patient 's addressed . As a result, patients can fight or talk with the hallucinatory voice . Can also be seen as being in the patient's hearing or speaking loudly as if he answered someone's question or his lips moving . Sometimes patients think hallucinations come from any body or outside the body . These hallucinations are sometimes fun example is lying , threats and others.According May Thomas Durant (1991 ) hallucinations can generally be found in patients with psychiatric disorders such as : Skizoprenia , Depression , Delirium and conditions associated with alcohol and substance use environment . Based on the assessment results in mental hospital patients found 85 % of patients with cases of hallucination . So I feel compelled to write the case by providing nursing care ranging from assessment to evaluation .B. classificationHallucinations classification as follows :

    Hallucinations of hearing ( acoustic , auditory ) , the patient was hearing voices talking about , mocked , laughed at , or threatened but no sound around it .
    See hallucinations ( visual ) , the patient was seen view of a person, animal or something that does not exist .
    Hallucinations of smell / inhale ( olfactory ) . Hallucinations are rare to get. Patients who have said kissing smells like the smell of flowers , the smell of incense , the smell of dead bodies , that there is no source.
    Hallucinations soy sauce ( gustatorik ) . Usually occurs simultaneously with hallucinations smell / inhale . The patient feels ( to taste ) a taste in his mouth .
    Allusions hallucinations ( tactile , kinaestatik ) . Individuals concerned feel someone touching or hitting . If this is rabaab sexual stimulation is called hallucination hallucination heptik .C. etiologyAccording to Mary Thomas Durant (1991 ) , Hallucinations may occur in clients with mental disorders such as skizoprenia , depression or state of delirium , dementia and conditions associated with the use of alcohol and other substances . Adapat hallucinations also occur with epilepsy , the condition of systemic infection with metabolic disorders . Hallucinations can also be experienced as side effects of various treatments , including anti- depressant, anti- cholinergic , anti -inflammatory and antibiotic , while the hallucinogenic drugs can make the same hallucinations as drug delivery above . Hallucinations may also occur during the normal individual circumstances in individuals who experience isolation , sensory changes such as blindness , hearing loss or lack of problems in the talks . Specific causes of auditory hallucinations is unknown but many factors influencing factors such as biological , psychological , social, cultural , and environmental stressors originators are stress , biological , trigger problems coping resources and coping mechanisms .D. PsychopathologyPsychopathology of hallucinations are not known . Many proposed theories that emphasize the importance of psychological factors , physiological and others. Some say that in the normal waking state of the brain are bombarded by a stream of stimuli that come from within the body or outside the body . This input will menginhibisi perception over to the natural appearance of the input attenuated sadar.Bila or nothing at all as we have encountered in normal or pathological conditions , the materials contained in or preconscious unconsicisus be released in the form of hallucinations .But others argue that the hallucinations began with a repressed desire to unconsicious and then because it was cracking personality and assess the reality of the destruction of desire was projected out in the form of external stimulus .E. Signs and SymptomsPatients with hallucinations tend to withdraw , often get stuck sitting with eyes on one particular direction , smiling or talking to himself , suddenly angry or attack others , restless , doing movements like he was enjoying something . Also, information from patients themselves about the hallucinations that in its natural ( what is seen , heard or felt in ) .F. managementManagement in patients with hallucinations ways :

    Creating a therapeutic environment
    To reduce the level of anxiety , panic and fear in patients affected by hallucinations , preferably at the beginning of the approach is done on an individual basis and make sure that happens knntak eyes , if you can touch the patient in or on hold . Patients not in isolation either physically or emotionally . Each nurse came into the room or close to the patient , talk with patients . So also when the patient should be told to leave . The patient was told that action will be undertaken .
    In that room should be provided the means to stimulate interest and encourage patients to get in touch with reality , such as wall clocks , picture or wall hangings , magazines and games .
    Implement the doctor's treatment program
    Often patients refuse medication that is provided in connection with the receipt stimuli hallucinations . Approach should be persuasive but instructive . Nurses must observe that a drug that is given right at telannya , as well as drug reactions is given .
    Explores the problems of patients and help overcome existing problems
    Once the patient is more cooperative and communicative , nurses can explore issues that are causing the patient's hallucinations and help resolve any problems . This data collection can also be through to the family that the patient or another person close to the patient .
    Giving activity in patients
    Patients were invited to enable themselves to perform physical movements , such as exercising, playing or doing activities . This activity can help steer patients to real life and cultivate relationships with other people . Patients were invited to schedule activities and choose appropriate activities .
    Involving family and other officers in the care process
    Patient's family and other officers should be informed about the patient data in order to have unity and continuity in the opinion of the nursing process , misalny of conversation with the patient in the know when it is alone, he often heard of men who mock . But if there are others nearby voices were not heard clearly . The nurse suggested that patients do not isolate and occupy themselves in games or activities. This conversation should be in the patient's family and tell petugaslain not to let the patient alone and advice that is given is not contradictory .