NURSING CARE REPORT

1. ASSESSMENT
- Date of Assessment : December 4th 2018 - Register Number : 02-32-94
- Ward : Men Special Program - Medical diagnosis : F.19.5
- Date of Treatment : November 15th 2018

A. Client Identity
Name : Mr. M.I
Sex : Male
Age : 27 years old
Marital Status : Singgle
Religion : Islam
Nationality : Indonesian
Date of Treatment : November 15th 2018
Education : Elementry School
Address : Alalak Selatan, Banjarmasin
Informan : Patient

B. REASON FOR ENTERING

Client said he was taken by family to hospital because he hit the car and starched it with
nails.

C. PREDIPOSITION FACTOR
1. Ever experienced mental disorder in the past ?
(√) Yes ( ) No
Explain :
Client have mental disorder because drug abuse
2. Previous treatment ?
(√) Successed ( ) Less successful ( ) Not successful
3. Actor/age victim/age of witness/age
Age Actor Victim Witness
( ) Physical abuse ( ) ( ) ( ) ( )
( ) Sexual abuse ( ) ( ) ( ) ( )
( ) Rejection ( ) ( ) ( ) ( )
( ) Violent of family ( ) ( ) ( ) ( )
( ) Criminal action (27) (Patient) (Car) (Neighbor)
- Explain :
Client hit the car and starched it with nails.
- Nursing problem :
Risk of violent behavior
4. Are there family members experience mental disorders ?
( ) Yes (√) No
5. Bad past experience ?
Client have not bad experience

D. PHYSICAL ASSESSMENT
1. Vital sign : BP : 110/80 mmgh P : 85 t/m T : 36.7oC RR : 20 t/m
2. Measuring : BW : 53 kg BH : 168 cm
3. Physical complain : No complain
- Explain : -
- Nursing problem : -
E. PSIKOSOSIAL
1. Genogram
 Male Died Living together

Femal Patient
e
- Explain :
Client live with his mother ang brother, client can’t explain about father and mother’s
family
2. Self concept
- Body image
No body parts are liked or hated
- Identity
Client education is graduate from elementary school, and client work as laborer at
wood factory
- Role
Client as child from his mother and as brother from his brothers
- Self ideal
Client wan to able to get ride his drinking habits
- Self regard
Client’s mother loves the client
3. Social realtions
- Meaningful person :
Mother
- Participation in group activities
Client action as child in home, and client don’t participate in community activities
- Barriers in relationship with other people
Client silent and can’t start mommunication
4. Spiritual
- Values and believe
Client is a muslim
- Religious activities
Client pray with other patient

F. MENTAL STATUS
1. Appearance
(√) Not neat ( ) Use of clothing is not appropriate
( ) Dressed in unusual
- Explain :
Client dressed not too neatly like as other patient
- Nursing problem : -
2. Talks
( ) Fast ( ) Loud ( )Suttering ( ) Incoherant ( ) Apatis
( ) Slow (√) Silent, can’t start communication
- Explain :
Client can’t start communication, just can answer when give ask.
- Nursing problem : -
3. Motoric activities
(√) sluggish ( ) Tense ( ) Restless ( ) Agitation
( ) Tik ( ) Grimasen ( )Tremor ( ) complusif
- Explain :
Client look often quiet and sleepy
- Nursing problem : -
4. Feeling
(√) Sad ( ) Afraid ( ) Hopeless ( ) Worried ( ) Very happy
- Explain :
Client sad about his condition and wan to meet his mother
- Nursing diagnosis : -
5. Afek
 (√) Flat ( ) Blunt ( ) Unstable ( ) Not accordance
- Explain :
Wwhen communication client face looks statics
- Nursing problem : -
6. Interacting when interview
( ) Hostile ( ) Not cooperative ( ) Easily offended
(√) Less eye contact ( ) Defensif ( ) Suspicious
- Explain :
When communication, client eyes contact is less
- Nursing problem : -
7. Perception
(√) Hearing ( ) vision ( ) Touch
( ) Tasting ( ) Olfaction
- Explain :
Client often hear female whispers sine 2 years ago that can’t be understood, happens
almost everyday, appears at an uncertain time, and client just let the voice.
- Nursing problem : Hallucination
8. Memory
(√) Long-term memory disorders
(√) Short-term memory disorders
( ) Current memory disorders
( ) konfabulasi
- Explain :
Client difficult to remember yesterday incident and can’t to remember fatrer’s and
mother’s family
- Nursing problem : -
9. Self-power
( ) Deny the disease suffered
( ) Blaming things outside of him
- Explain :
Client realizes the mistake in him self
- Nursing problem : -

G. COPING MECHANISM
Adaptif Maladaptif
( ) Talk to other people ( ) Drink alcohol
( ) Able to solve problems ( ) Slow reaction
( ) Relaxation techniques ( ) Over work
( ) Constructive activity (√) Dodge
( ) Sports ( ) Injure self
( ) Other……………… ( ) Other………………
- Explain :
Client said he he stay away when get a problem
- Nursing problem :
Individual coping is not effective

H. PSHYCOSOCIAL AND ENVIRONMRNTAL PROBLEMS

( ) Problem with group support, specific
(√ ) Problem related to the environment, specific client live in environment with using drug
abuse.
(√ ) Problem with education, specific client education is graduate from elementry school.
(√ ) Problem with work, specific client work as laborers carrying timber, with habits of
people there using drug abuse
( ) Problem with environmental support, specific
( ) Economical Problem, specific
( ) Problem with health service. Specific
( ) Other problems, specific
 - Nursing Problem : Individual coping is not effective

I. LESS KNOWLEDGE ABOUT

( ) Support system ( ) Precipitation factor
( ) Physical illness ( ) Coping
( ) Drugs ( ) Others
- Nursing problem : -

J. MEDICAL ASPECTS
1. Medical diagnosis
F.19.5
Mental and behavior disorder cause use of psychoactive substances

2. Medical Therapy
Name Indication Contra Indication Side Effect
Clozapine Antipsikosis - ACS, liver - Disturbance
25 mg 2x1 oral (hallucination) and kidney of heart and b;ood
disorder cells
- Galukoma - Headache
- Intestinal - Sleepy
disorder - Blurer
- Respiratory vision
disorder - Dizzy,
nausea
Trihexypheenidyl Antiparkinsonian, - Glaucoma - Blurer
(THP) 2mg reduce anxiety due - Obs. vision
2x1 oral to calm drug Duodenum - Constipatio
- Obs. n
Urinary track - Difficult to
- Myasthenia mixi
gravis - Dizzy when
change position
Haloperidol Antipsikosis - Less of - insomnia
(HLP) 5 mg (excessice anxiety, consciousness - depresi,
2x1 oral skizofrenia, - excessive sleepy
emotional and depression - sluggish
mental disorder, - epilepsy, - sinkop,
excessive parkinson Katalepsia
nervousness) - confused,
nervous
- vertigo

DATA ANALYSIS

Initial Name : Mr. M.I Ward : Men Special Program No MR : 02-32-49

Date Focus data Nursing Diagnosis
Tuesday, SD : Client said he hit thee car and starched Risk of violent
December, it with nails before he taken to this behavior
04 2018 hospital
OD : -
Tuesday, SD : Client often hear female whispers sine hallucination
December, 2 years ago that can’t be understood,
04 2018 happens almost everyday, appears at an
uncertain time, and client just let the
voice.
OD : Client turn his ears to side
Tuesday, SD : Client said he get away when get a Individual coping is
December, problem not effective
04 2018 OD : - Client live in environment with using
drug abuse
- Client is graduate from elementary
school
- Client work as laborer carrying
timber with habits of people there
using drug abuse

A. PROBLEM TREE

Hallucination Risk of violent behavior Problem

Drug Abuse Core Problem

Individual coping is not effective Cause

B. NURSING DIAGNOSIS
1. Hallucination
2. Risk of violent behavior

C. NURSING PLANNING
No Nursing Planning
DX Diagnosis Goal Criteria Nursing Action
1 Hallucination After 3x24 hours - Client say 1. Teach SP
implementation not hear wishper hallucination
hallucination can again 2. Collaboration to give
disapper medicine
2 Risk of violent After 3x24 hours - Client can 1. Teach SP for Risk of
behavior calient can mention 4 ways to volent behavior
understand ways avoid violent
to avoid violent behavior
behavior

D. IMPLEMENTATION AND EVALUATION

Time Nursing Act Evaluation Signature
Wedesday SD : Client often hear female S : client said this morning
05-12-18 whispers sine 2 years ago that He hear female whispers
10:00 can’t be understood, happens O : client understand Sp 1
almost everyday, appears at an hallucination
uncertain time, and client just let A : problem is not resolved
the voice. P : continue intervention Sp 2
OD : Client turn his ears to side hallucination

NRS DX : Hallucination
NRS Act : Teach patient SP 1
hallucination
Thursday SD: - client said this day not hear S: client said this day not hear
06-12-18 whispers whispers
10:00 - Client say not rememb Sp O: client can practice SP 1
1 hallucination hallucination
OD: clien face looks confuse A: problem is not resolved
P : continue intervention Sp 2
NRS DX : Hallucination hallucination
NRS Act : Teach patient SP 1
hallucination
Fryday SD: client said this day is not hear S: - client said this day is not
07-12-18 whispers again hear whispers again
10:00 OD: - - Client can mention his
NRS DX : Hallucination drugs treatment
NRS Act : Teach patient SP2 O:-
hallucination A: problem is resolver partially
P: continue intervention Sp 3
hallucination

Saturday SD: - client said this day is not S: - client said this day is not
08-12-18 hear whispers again hear whispers again
10:00 - Client said not remember - Client can mention his
Sp2 hallucination drugs treatment
OD: clien face looks confuse O:-
NRS DX : Hallucination A: problem is resolver partially
NRS Act : Teach patient SP2 P: stop intervention
hallucination

Time Nursing Act Evaluation Signature

Wedesday SD : Client said he hit thee car
05-12-18 and starched it with nails before
10:00 he taken to this hospital
OD : -
NRS DX : Risk of violent
behavior
NRS Act : Teach patient SP 1 Risk
of violent behavior
S : client said understand about
Sp 1 Risk of violent behavior
O : client can practice Sp 1
Risk of violent behavior
A : problem is not resolved
P : continue intervention Sp 2
Risk of violent behavior

Thursday SD : Client said he not remember S : client said understand about

06-12-18 about Sp 1 Risk of violent Sp 1 Risk of violent behavior
10:00 behavior O : client can practice Sp 1
OD : client face looks confuse Risk of violent behavior
A : problem is not resolved
NRS DX : Risk of violent P : continue intervention Sp 2
behavior Risk of violent behavior
NRS Act : Teach patient SP 1 Risk
of violent behavior

Fryday SD : Client said he remember S : client said understand about

07-12-18 about Sp 1 Risk of violent Sp 2 Risk of violent behavior
10:00 behavior O : client can mention his drug
OD : client face looks calm treatment
A : problem is resolved
NRS DX : Risk of violent partially
behavior P : continue intervention Sp 3
NRS Act : Teach patient SP 2 Risk Risk of violent behavior
of violent behavior

Saturday SD : Client said he not remember S : client said understand about

08-12-18 about Sp 2 Risk of violent
10:00 behavior
OD : client face looks confuse
NRS DX : Risk of violent
behavior
NRS Act : Teach patient SP 2 Risk
of violent behavior
Sp 2 Risk of violent behavior
O : client can mention his drug
treatment
A : problem is resolved
partially
P : stop intervension