Medical ward : Sadewa Ward Grhasia Hospital

Date of treatment : September 8, 2014

A. ASSESSMENT
I. Client Identity
Name : Mr. T
Gender : Male
Date of assessment : Tuesday, September 16, 2014
Age : 30 years old
Address : Dawang Sapdodadi Bantul
Latest education : Junior high school
Informant : Client, medical records, officer and physical
examination.
Medical record number : 016213

II. Reason for entry

The client said he was taken to a mental hospital by the government but did
not know the cause. he often hears whispers since junior high school wants harm
him like ordering to beat people, steal, and arrive
now the complaint still often arises.
The client said he had hit his friend for following whispers that. The client
also hit his neighbor because he thought his neighbor was stealing his chicken.
And the client said that the drug had been broken for two years because of
economic problems.

III. Predisposing Factors

1. History of mental illness
The client said he had been treated in a mental hospital twice before, the first
when grade 2 high school asked to buy a motorcycle but it was not followed.
then the client is angry.
2. Treatment history
The client says he often controls when the medicine runs out.
 but because of economic conditions, then the client does not control or break
the drug for two years.
3. Persecution history and criminal acts
The client said he had hit his friend when he was 14 years old.
4. Family History
The client said he did not have a family with a history of mental illness.
5. An unpleasant past experience.
The client said an unpleasant experience was a problem in his work when
being a bus driver was often shouted and the client only harbored the problem.

IV. Precipitation factor

Patients never take medicine and patients in Yogyakarta live alone. There is no
family because all of his family is in NTB and there is only one uncle but did not
know his house because his uncle often moved houses.

V. Physical examination
1. Vital sign
blood pressure: 120/70 mmHg
2. Anthropometry
Height: 165 cm
Weight: 62 kg
3. Physical complaints
The client said physically he was fine.

VI. Psychosocial
1. Genogram
2. Family Disease History
The client said the client stayed home alone because of his mother
have died while the client's father is not responsible and now in NTB with
his stepmother and stepbrother. The client says
no family has a history of mental illness.
3. Self-concept
a. Self-image : Client says his name is T. Section the body that the client
likes is the five senses.
b. Identity : The client said he was a man, and he was dressed like a man.

c. Role : The client acts as a child. At home often gardening and raising
chickens.

d. Ideal self : Clients hope to be able to quickly return from a mental

hospital because he wants to work again.

e. Self-esteem : Clients often gather with friends. He does not feel shy or
insecure.

4. Social Relations

a. Meaningful person

The client says the person who matters most in the client's life is his
parents.

b. Participation in society

The client said that as residents in his village often attend activities in his
village such as community service and patrol.

c. Obstacles in social relations

The client says he has no obstacles in dealing social with other people.

5. Spiritual

a. Values and beliefs : The client said he was a Muslim.

b. Religious activities : The client said that he is currently trying to pray

VII. Mental Status

1. Appearance

The client looks neat.

2. Talk

Clients can speak clearly and can answer questions correctly. the client can
talk well with his friends.

3. Motor Activities

The patient does not experience impaired motor activity.

4. Natural feelings

The client said at this time his feelings were fine.

5. Affect

From the results of observation, client affection is blunt. The client laughs
when something is funny and when the client's serious condition also
displays a serious expression.

6. Interaction during interviews

During the conversation the client is cooperative and can answer

according to the question.

7. Perception

Clients say they often hear promptings since junior high school who want
to harm themselves, such as telling people to beat, steal, and still appear
frequently. The client said when the hallucinations appeared the client
immediately took a shower and sometimes listened music to get rid of the
whisper.

8. Thinking Process

The client does not experience thought processes.

9. Fill in the thought

The content of the client's thought is an obsession.

10. Level of awareness

Good client awareness, composmentis. When asked about time,

 place and day, the client can answer correctly that is Tuesday at 15.00 at
Grhasia Hospital.

11. Memory

The client does not have a problem with his memory.

12. Level of concentration and counting

During the interview, the client concentrates. The ability to count well.

13. Assessment ability

Good client assessment skills.

14. Self-view

The client's self-viewability is good. The client realizes that he is sick.

VIII. Preparation Needs Home

1. Eat

Clients eat 3 times a day according to schedule, Clients can eat

independently.

2. toileting

Clients can urinate and defecate independently in the toilet.

3. Take a shower

Clients say that bathing can be more than 2x a day independently because

if the whisper comes again, the client immediately takes a shower.

4. Dress / decorated

Clients can dress independently. In one day, the client changed clothes
twice

5. Rest / Sleep

The client said he was sleeping the night starting at 9:00 p.m. or more
and wake up at 5:00. Clients sometimes take a nap for 2 hours.
 6. Use of drugs
During treatment, clients take medication regularly. While at home, the
client said the drug was broken for 2 years due to economic problems.
7. Health care
The client said, first before breaking up the medication when he was sick
at the hospital and the client usually routinely controls the mental hosital if
the medicine runs out or when it is time for control.
8. Activities at home
The client said the client's activities at home were gardening and raising
chicken.

IX. Koping mechanism

1. Adaptive:
- the client talks with other people
- clients can do relaxation and constructive activities
2. Maladaptif:
- Avoid problems
- rampage
- Damaging others

X. Psychosocial and Environmental Issues

1. Problems with group support, specific: -
2. Problems with environmental support, specifically: -
3. Problems with education, specific: clients do not graduate from high school
only up to grade 2 high school.
4. Problems with work, specific: clients do not have permanent work.
5. Problems with housing, specifically: -
6. Problems with specific economies: clients do not work and do not have money to buy
medicine.
7. Problems with specific health services: -
B. DATA ANALYSIS

Data Problem
DS:
- The client said he was taken to a Sensory perception disorder :
mental hospital by the government Auditory hallucinations
but did not know
the cause. he often heard whispers
from middle school that wanted to
hurt him like telling
beat people, steal, and still appear
frequently.
DO:
- Patients appear to close their ears
occasionally.
- Patients often look for activities
such as chatting to be distracted by
hallucinations.

DS:
- The client said he had hit his Risk of violent behavior
friend because he followed
whispers. The client also hit his
neighbor because he thought
his neighbor has stolen his chicken.
DO: -

DS:
- The client says he often controls Regimen management
when the medication runs out, but ineffective therapeutic
because of the economic conditions
the client does not control or break
the drug for two years.

XII. MEDICAL ASPECT

1. Multiaxial Diagnosis

Axis I: F 20.0

Axis II: tends to be schizoid

Axis III: there is no diagnosis

Axis IV: no information

Axis V: ugly
 2. Medical Therapy (September 16, 2014)
no drug name dose indications side effects
1 Haloperidol 5 mg 1/2-0-1/2 Acute psychosis insomnia, euphoria,
and chronic. agitation, dizzy,
Hallucinations on depressed, tired,
schizophrenia headache, sleepiness,
confused, vertigo,
seizures.
2 Clozapine NI 25 1/2-0-1/2 Antipsychotics, Drowsiness, weight
mg calm the mind up, saliva increases,
and eliminate dizziness, constipation,
hallucinations nausea,
hard to breathe,
bedwetting during
sleep
3 Trihexypenidyl 2 0-0-1 Rigid-stiff body Drowsiness, dizziness
mg and reduce blurred vision,
trembling disorientation,
hypotension,
nausea, vomiting,
retention
urine

XIII. REGISTER OF NURSING PROBLEMS

Risk of Violent Behavior Consequences

Hearing Hallucinations Core Problem

Ineffective therapeutic regimen management Cause

XIV. LIST OF NURSING DIAGNOSIS

1. Sensory perception disorder: auditory hallucinations

2. Risk of violent behavior

3. Effective therapeutic regimen management

C. NURSING INTERVENTIONS

Client inisial : Mr. T

Room : Sadewa Ward

NO. RM : 01 62 13

Nursing Interventions
Nursing Purpose Evaluation Intervention Rational
Diagnosis criteria
Auditory September 16, September 16, September 16, September 16,
hallucinations 2014 2014 2014 2014
At 3:00 p.m. At 3:00 p.m. At 3:00 p.m. At 3:00 p.m.
TUM: Clients After 1x client Build trusting Mutual trust
can control interaction relationships is the basis for
hallucinations shows signs with the the smooth
TUK 1: trust nurses principle of relationship of
Clients can with outcome therapeutic subsequent
build trusting criteria: communication. interactions
relationships a. Greet clients
-Friendly facial kindly verbally
expression and non-verbal.
- Showing b. Introduce
feeling yourself
happy politely.
- There is eye c. Ask your full
contact name
- Want to client and
shake hands nickname
- Want to name the client likes.
- Want to d. Explain the
answer purpose of the
greetings meeting.
- Want to sit e. Be honest
side by side and keep
with the nurse promises.
- Willing to f. Show
reveal empathy and
problems accept clients
encountered as they are.
g. Pay attention
to client and
pay attention to
needs
client base.
TUK 2: After 2x client 1. Identify with 1. is an effort
Clients can interaction client ways to
control can control which is done if break the
hallucinations hallucination hallucinations hallucination
with occur. cycle.
Result criteria: 2. Discuss the 2. positive
a. The client benefits of the reinforcement
can mention method can
actions that used by the increase client
can be done to client, if useful self esteem.
control give praise. 3. provide
hallucinations. 3. Discuss new alternative
b. Clients can ways to control thoughts for
mention new the emergence clients
ways. hallucinations. 4. Motivating
c. Clients can 4. Help clients can increase
choose a train and client desires
method decide to try to choose
who has been hallucinations wrong
chosen for gradually one method of
control controlling
hallucinations. hallucinations.
d. Clients can
follow
group activity
therapy.

TUK 3 After 3x the 1. Encourage 1. to get help

Client gets client gets clients to give family in
family support deep family know medium control
in controlling support family hallucinations.
hallucinations control hallucinations. 2. To improve
hallucinations 2. Discuss with knowledge of
with result family hallucinations.
criteria: about
a. Clients can a. Symptoms of
intertwine hallucinations
relationship of experienced by
trust with clients.
nurses b. How to do it
b. Families can client and exit
mention for
understanding, break
sign and action hallucinations.
for control c. How to care
hallucinations for members
families who
hallucinate in
home, give
activities
don't leave it
 alone.
d. Give
information
about
when do
patients need it
help.
TUK 4 After 3x client 1. Discuss with 1. by knowing
Clients make interaction clients the effect
use of it can use and family next to the
medicine well medicine about dosage, drug the client
with result frequency and knows what
criteria: benefits of what to do
1. Clients and drugs. after
families 2. Discuss the taking
able to dangers medication.
mention medicine 2. Help clients
benefits, without use
dosage and consultation. old principle is
side effects 3. Help clients correct.
2. Clients can using old 3. knowing the
inform principles principle
benefits and correct. then client
side effects of independence
drugs about
3. Clients can treatment can
understand gradually
due to drug use increased.
without
consultation
4. The client
can mention
principle 5
correct use of
drugs

Implementation September 16, September 16, September 16, September 16,

The 2014 2014 2014 2014
Therapeutic At 3:00 p.m. At 3:00 p.m. At 3:00 p.m. At 3:00 p.m.
Regimen does TUM: After 1x 1. Establish a 1. The
not Effective Families can interaction relationship of relationship of
care for clients family knows mutual trust mutual trust is
who experience client problems with family the basis for
disruption with a. Greet family smoothness
Soul so Result criteria: with interaction
management can identify friendly. relationship
effective the problem of b. Explain the next.
therapeutic the originator purpose of 2. Knowing
regimen. of the client treatment patient
TUK 1: relapse, which and its role knowledge
Families can is affected during about
recognize by family with clients. patient
problems that attitudes, c. Encourage behavior
can cause the community the family to 3. Know
client to relapse. and clients express family
own. for problems. attention to
meetings 2. Assess mental
next perception disorder
family about patient
client behavior 4. Giving
the maladaptive knowledge of
3. Discuss ways
with several treating
families patients
problems that 5. Family
can become can determine
causative actions
factors of the if the patient
client relapse, recurs
as :
a. Don't
appreciate
clients.
b. Isolating
clients.
c. Not paying
attention
client / not
giving
activities at
home.
4. Discuss with
family about
that attitude
must be done
by family,
community and
individuals
towards
maladaptive
behavior
from the client.
5. Help the
family
know attitude
and
 behavior that
can
trigger and can
cause the client
to relapse
TUK 2 :