A.
ASSESSMENT
1.
The identity of the
patient
a.
Name: An. A
b.
Age: 13 years
c.
Gender: male
d.
Address: Starch
e.
Occupation: Student
f.
Education: -
g.
Medical Diagnosis:
Schizophrenia Not Listed
Identity Penaggung
replied:
a.
Name: Ny. S
b.
Age: 35 years
h.
Address: Starch
c.
Occupation: -
d.
Relationship: Mother
Ward: XII (Madrim)
Log Date: March 13, 2012
Assessment dated: March 14, 2012
2.
Reason entered (March
13, 2012)
Approximately 4 days
before admission to hospital rampage beating up his client. Clients also
have always said rude. When given pocket money, the client always use the
money to buy cigarettes. The cigarette clients share with friends naughty. In
addition, the client also denied the love of their parents. Clients also
obsessed with becoming like those punk kids television d.
3.
Now the Main Complaint
(March 14, 2012)
Clients say annoyed. When
irritated clients such as hearing voices that told him to hit people, so that
the client forgot his own. Clients agitated, confused, like screaming.
4.
Predisposing factors and
precipitation
a.
Factors predisposing
Clients have never been
sick like this. Clients say since his father died 4 years old. Since
that time the client was always scolded by her mother and the client is always
blamed. Clients say because it is always blamed, he likes being naughty
and ditching.
MK: Low Self-Esteem
b.
Factors precipitation
A few days before
entering the hospital said he had clients dipalak by classmates. Feeling
irritated, client rampage and beat his friends.
MK: Behavioral Risk violence
5.
Physical Assessment
a.
Vital signs
BP: 110/70 mmHg
HR: 84 x / min
RR: 20 x / min
Temperature: 36 ° C
b.
Size:
TB: cm
BB: kg
c.
's. A complain of
shortness of breath after every smoke and heart palpitations.
d.
Physical examination (head
to toe):
Head: Short hair, black color, looks clean,
Eyes: The conjunctiva was not anemic, not jaundiced sclera.
Nose: Clean, symmetrical right and left, there was no injury and
discharge from the nose.
Mouth: Clean and no injury.
Thorax: Development of symmetrical chest ka = ki, palpation:
symmetrical chest expansion ka = ki, percussion: resonant and breath sounds
vesicular
Heart: ICTUS cordis invisible, S1 and S2 sound pure.
Abdomen: There is no tenderness and no period
Genetalia: Not terkaji
Upper extremities: There is no weakness. Muscle strength: 5/5
and 5/5, Capilary refill = <2 seconds.
Lower extremities: There is no weakness. Muscle strength: 5/5
and 5/5, Capilary refill = <2 seconds.
Integument: No lesion anywhere, skin turgor <2 seconds and
clammy skin.
|
Data
|
Problem
|
TTD
|
|
|
1
|
Subjective Data:
·
Approximately
4 days before admission to hospital rampage beating up his client. Clients
also have always said rude.
·
Clients
say like his parents denied.
·
Clients
say annoyed.
·
A few
days before entering the hospital said he had clients dipalak by classmates. Feeling
irritated, client rampage and beat his friends.
Objective Data:
·
Affective
instability.
·
Clients
agitated, confused, like screaming.
·
Clients
speak quickly and loudly.
·
Clients
tense, restless and could not settle (hipermatorik).
|
Violent behavior (PK)
|
Dinny
|
|
2
|
Subjective Data:
·
Clients
say if given pocket money, the client always use the money to buy cigarettes. The
cigarette clients share with friends naughty.
·
Clients
say when exasperated clients such as hearing voices that told him to hit
people, so that the client forgot his own.
·
Clients
say because it is always blamed, he likes being naughty and ditching.
·
Clients
say like smoking with her friends naughty to reduce stress.Clients also said
sometimes taking pills Mix (THP).
Objective Data:
·
Clients
tense, restless and could not settle (hipermatorik).
|
The risk of injuring yourself and
others
|
Dinny
|
|
3
|
Subjective Data:
·
Clients
say since his father died 4 years old. Since that time the client was
always scolded by her mother and the client is always blamed.
·
's. A
student said he was a junior male, but he likes ditching.
·
Clients
also obsessed with becoming like those punk kids television d.
·
Clients
do not like being told as a child.
·
Clients
say is meaningless now to keluaganya because clients are always troublesome
and always blamed.
·
As a
friend, client admitted often generous with his friends, but when angry
clients do not remember his friends.
·
Clients
say does not match with friends garden now because the client just wants to
be friends with punk kids.
·
The
client said he wanted to be a punk. Clients want to get a 17 year old,
shaved his head in the style of punk kids and paint. The client said he
wanted to be a punk because clients assume that children's independent punk.
Objective data: -
|
Disorders of self-concept: low
self esteem
|
Dinny
|
|
Nursing Diagnosis
|
Destination
|
Action Plan
|
Rational
|
||
|
Criteria for evaluation
|
Nursing actions
|
||||
|
March 14, 2012
|
Violent Behavior
|
TUM:
Clients do not injure themselves, other people and the
environment
TUK:
1.
Clients can build a trusting
relationship.
2.
Clients can identify the causes of
violent behavior.
3.
Clients can identify the signs and
symptoms of violent behavior.
4.
Clients can identify the usual
violent behavior.
5.
Clients can be identified as a
result of violent behavior.
6.
Clients can demonstrate a physical
way to prevent violent behavior
7.
Clients can demonstrate social way
to prevent violent behavior
8.
Clients can demonstrate spiritual
way to preventviolent behavior
9.
Clients can demonstrate compliance
with taking medication to prevent violent behavior
10.
Clients can follow TAK: simulation
perception prevention of violent behavior.
11.
Clients have the support of family
|
After the 4 X interaction, k spleen showed signs of
confidence in the nurse:
·
Facial expressions are friends
·
Shows pleasure
·
There is eye contact
·
Want to shake hands
·
Want to name
·
Want to reply regards
·
Want to deal with nurses
·
Being able to express the problems
faced
After the 4 X interaction, the client:
·
Still recognize nurses
·
Want to answer the question of
nurses
·
Able to reveal the cause of upset
experienced.
After the 4 X interaction, the client is able to:
·
Reveal upset experienced by the
client
·
Reveal signs and symptoms of upset
experienced by the client
·
Clients cooperative when
intervention
After the 4 X interaction, the client is able to:
·
Clients know the 4 kinds of
violent behavior (physical, psychological, social and spiritual).
·
Independently classify the
behavior of the usual rigors san e r done.
After the 4 X interaction, clients can:
·
Mention 2 due to violent behavior
is usually done by the client.
After the 4 X interaction, clients can:
·
Knowing one way to prevent violent
behavior that is physically denagn I: deep breath.
·
The client is able to demonstrate
a deep breath properly.
·
The client said it would try to
control the way the PK with a deep breath and put them on the schedule of
daily activities.
After the 4 X interaction, the client is able to:
·
Knowing how to prevent social
violent behavior.
·
The client is able to demonstrate 3
ways to prevent social PK (ask nicely, rejecting well and express feelings
well).
·
The client said he would try and
put it in a way the daily schedule.
After the 4 X interaction, the client is able to:
·
Reveal the usual religious
activities.
·
The client is able to demonstrate
that selected religious activities. .
·
The client said it would conduct
these activities and include them in the daily schedule
After the 4 X interaction, the client is able to mention:
·
The benefits of taking medication
·
Losses are not taking medication
·
Name, color, dosage, therapeutic
effects and side effects of drugs
·
demonstrate the use of medications
properly
·
due to stop taking the medication
without consulting your doctor
After the 4 X interaction, clients can follow TAK with
expected outcomes:
·
Clients were able to follow 75% NO
·
Clients can name 3 ways to control
/ prevent PK before her.
·
Clients Demonstrate one way to
prevent / control the PK.
·
Clients say delighted to be
hanging out with friends.
·
After approaching via Phone family
agreed to participate in the meeting with the nurse
·
After interaction with keluaraga,
the family is able to:
·
mention understanding PK
·
Mention 6 of 11 signs and symptoms
of PK
·
Mention four types of PK
·
Knowing how to control / prevent
PK namely the physical, spiritual, social and psikofarmaka therapy.
|
1.
Construct a trusting relationship
with the therapeutic use of the principles of communication:
·
Sapa client with verbal and
non-verbal
·
Introduce yourself to the polite
·
Ask your full name and the name of
the client preferred call
·
Describe the purpose and
interaction contract
·
Give a sense of security and show
empathy and receiving clients what it is
·
Pay attention to the basic needs
of the client and the client's attention
·
Do it short but frequent contacts.
1.
Give clients the opportunity to
express his feelings.
2.
Help clients express feelings of
annoyance / upset
1.
Encourage clients to express the
experienced and perceived when annoyed / upset.
2.
Observation of signs and symptoms
ofviolent behavior on the client.
3.
Conclude with a client signs and
symptoms of irritated / annoyed that experienced by the client.
1.
Encourage reveals the usual
violent behavior (verbal, on others, on the environment and on yourself).
2.
Help play a role in accordance
with the usual violent behavior.
3.
Ask "is the way in which the problem
is solved?"
1.
Talk consequence / loss of the way done.
2.
Concludes with a client as a
result of the methods
used.
3.
Ask if you want to learn new healthy ways.
1.
Discuss physical activities
commonly conducted by the Client
2.
Give praise for regular physical
activity performed Clients
3.
Discuss two physical easiest way
to prevent violent behavior that is take a deep breath and at the mattress /
pillow
4.
Discuss how to take a deep breath
with Clients
5.
Give an example of how to take a
deep breath right on the Client
6.
Ask the client to follow the
example of as much as 5 times
7.
Give positive praise for the
ability of clients to demonstrate how to take a deep breath
8.
Ask the client feeling after
completion
9.
Advise Clients using previously
learned when angry / annoyed
10.
Do the same thing with 6.2.1 to
6.2.6 for another physical way in meeting other
11.
Discuss with the client regarding
the frequency of exercises to be performed
12.
Arrange a schedule of activities
to train the way they have learned
13.
Clients evaluate the
implementation of the exercise, prevention of violent behavior that has been
done by filling in the daily activity schedule (self-evaluation)
14.
The client's ability to carry out
the validation exercise
15.
Give credit for the success of
Clients
16.
Ask the Client:â € œ Is prevention
of violent behavior can reduce angry?
1.
Discuss how good talk with Clients
2.
Give an example of a good speech:
·
Ask nicely
·
Rejecting fine
·
Express feelings well. Ask the client to follow the good
example of how to talk
·
Well ask: I asked for money to buy
food
·
Refusing well: â € œ Sorry, I can
not do that because there are other activities
·
Express feelings well: I'm upset
because my request was not fulfilled accompanied by a low tone of voice
3.
Ask the client to repeat itself
4.
Give credit for the success of
Clients
5.
Discuss with the client on time
and conditions that can be trained how to talk to all subjects, for example
asking for medicine, clothes etc.. ; say
no to smoking, do not sleep on time, tell the nurse resentment
6.
Arrange a schedule of activities
to train the way they have learned
7.
Clients evaluate the
implementation of good practice talking with filling schedules
8.
The client's ability to carry out
the validation exercise
9.
Give credit for the success of
Clients
1.
Discuss with Clients worship ever
done
2.
Help clients assess religious activities to do at the
nursing station.
3.
Help clients choose religious
activities to be performed
4.
Ask the client to demonstrate
religious activities selected
5.
Give credit for the success of
Clients
6.
Discuss with the client regarding
the execution time of worship.
7.
Arrange a schedule of activities
to train religious activities
8.
Clients evaluate the
implementation of religious activities by filling out the daily activity
schedule.
9.
The client's ability to carry out
the validation exercise
10.
Give credit for the success of the
client.
1.
Discuss with the client about the
type of medication he takes (name, color, size); time
to take medication, how to take medicine
2.
Discuss with the client the
benefits of taking medication on a regular basis:
·
Different feelings before taking
the medication and after taking medication
·
Explain that the dose should only
be modified by the physician
·
Clients take the medicine at the
right time
3.
Discuss the process of taking the
medication:
·
The client asks the nurse (if in
hospital), the family (if at home)
·
Clients check the appropriate
medication dosage
·
Clients take the medicine at the
right time
4.
Arrange schedule for taking the
medication with Clients
5.
Evaluating the client to take medication to fill the
daily activity schedule
6.
Validation of the implementation
of the client to take medication
7.
Give credit for the success of
Clients
8.
Clients Ask: How do you
feel to take medication on a regular basis?Is the desire for reduced upset?
1.
A njurkan client to participate
TAK: perceptual stimulation to prevent violent behavior
2.
Clients follow TAK: stimulation
perception prevention of violent behavior
3.
Discuss with the client about the
activities during TAK
4.
The client facilitation activities
to practice TAK results and give credit for the success of the Client
5.
Discuss Client's premises on
schedule TAK
6.
Enter TAK schedule into daily
activity schedule Clients
7.
Clients evaluate pelaksanaa NOT to
fill the daily activity schedule
8.
The client's ability to perform
validation TAK
9.
Give praise for the ability to
follow TAK
10.
Ask the Client:â € œ How did you
feel after participating TAK?
1.
Identification of a family's
ability to care for clients in accordance with the families that have been
made against the Client during the
2.
Explain the advantages and the
role of the family in caring for Clients
3.
Explain ways of caring for
Clients:
·
Related to how to control angry
behavior constructively
·
Attitude and speech
·
Helping Clients know the cause of
anger and how to prevent the behavior of force
4.
Help the family to express his
feelings after a demonstration
5.
Encourage the family to practice
on clients during hospital and continue after returning home.
|
Trusting relationship is the foundation for the smooth
interaction
Once the cause is known, it can be used as a starting
point handling
Improving client insight
Being able to express angry assertively.
Clients realize the effects of aggressive behavior toward
self and others who have done
Channeling anger constructively can avoid violent behavior
How social can help reduce violent behavior.
Spiritual way can reduce violent behavior.
Take medicine properly will reduce recurrence
NOT in addition to helping clients socialization is also
able to increase the cognitive Clients can be applied directly to other
clients.
The family is the primary support system for healing
clients.
|
|
Nursing Diagnosis / TUK
|
Implementation
|
Evaluation
|
TTD
|
|
|
Wednesday/ March 14, 2012 / 17:00
|
Violent behavior / SP 1
|
1.
Me m
facilitating clients to eat and drink
2.
Greetings and greeting clients.
3.
Introduce yourself.
4.
Asking the client's full name and
nickname are favored clients.
5.
Explaining the purpose of the
meeting.
6.
Delivering the contract time,
place and subject of the meeting.
7.
Asking the reason the client was
taken to the hospital.
8.
Discuss with client causes anger.
9.
Discuss
with the client regarding the signs and symptoms of upset.
10.
Discuss
with client regarding violent behavior committed.
11.
Discuss
with the client due to his anger.
12.
Observing
the behavior of clients associated with violent behavior.
13.
Teach
clients how angry denan mengonrol inhale deeply.
14.
Terminate the contract for the
meeting and any subsequent meetings.
15.
Facilitating clients to take
medication
16.
Facilitating clients to eat and
drink
|
S:
·
The client says, â € œ My name
Andrika Dahwan Pamungkas, usually called Andrew. I entered the hospital because I
was furious and naughty, I hit my friends at school.
O:
·
Sharp eye sight.
·
Clients agitated, confused, like
screaming.
·
Clients speak quickly and loudly.
·
Clients tense, restless and could not settle (hipermatorik).
A:
Clients can build a relationship of trust premises nurse. Clients can reveal the problem.
P:
Nurse: Repeat SP 1
Client: Motivation clients to
identify anger.
|
Dinny
|
|
Thursday / March 15, 2012 / 12:00
|
Violent behavior / SP 1
|
1.
Facilitating clients to eat and
drink
2.
Measuring TTV.
3.
Greetings and greeting clients.
4.
Recall the name of the nurse.
5.
Validate the client's feelings.
6.
Explaining the purpose of the
meeting.
7.
Delivering the contract time,
place and subject of the meeting.
8.
Asking the reason the client was
taken to the hospital.
9.
Discuss with client causes anger.
10.
Discuss with the client regarding
the signs and symptoms of upset.
11.
Discuss with client regarding
violent behavior committed.
12.
Discuss with the client due to his
anger.
13.
Observing the behavior of clients
associated with violent behavior.
14.
Teach
clients how angry denan mengonrol inhale deeply.
15.
Terminate the contract for the
meeting and any subsequent meetings.
16.
Facilitating clients to eat and
drink
17.
Facilitating clients to take
medication
|
S: Client
says:
·
I was brought here because my
rampage and beat my friends.
·
I'm annoyed because it continues
to be scolded and blamed.
·
â € œ Time annoyed me so shortness
of breath and heart palpitations.
·
â € œ If I hit the annoyance of my
friends, but I am good at my friends, but when I'm angry, I forget my
friends.
·
â € œKalau upset me vent to hit,
so my friend in pain, I also added scolded the parents.
O:
·
Sharp eye sight.
·
Clients agitated, confused, like
screaming.
·
Clients speak quickly and loudly.
·
Clients tense, restless and could not settle (hipermatorik).
·
BP:
110/70 mmHg
A:
The client is able to recognize violent behavior they
experienced, but have not been able to control angry with the breathing.
P:
Nurse: Repeat
SP 1. Teaches how to control violent behavior in a deep breath.
Client: Motivation
client to call the nurse if you experience upset.
|
Dinny
|
|
Friday / March 16, 2012 / 17:00
|
Violent behavior / SP 1
|
1.
Facilitating clients to eat and
drink
2.
Validate the client's feelings.
3.
Mend iskusikan physical easiest
way to prevent violent behavior that is take a deep breath.
4.
Mend iskusikan mela way kukan
inhale deeply with k lien
5.
Memb eri example of how to take a
deep breath right on k lien
6.
M eminta k lien follow the example
as much as 5 times
7.
Memb eri k positive praise for the
ability of spleen demonstrated how to take a deep breath
8.
Ask k lien feeling after
completion
9.
Menga njurkan k lien using
previously learned when angry / annoyed
10.
Terminate the contract for the
meeting and the next meeting.
11.
Facilitate client's eating and
taking medication.
|
S: Client
says:
·
I love
sports and learn martial arts.
·
I'll try
to take a deep breath when angry / annoyed
O:
·
Sharp eye sight.
·
The client had not screaming.
·
Clients speak quickly and loudly.
·
Clients tense, restless and could not settle (hipermatorik).
·
The
client is able to demonstrate breathing in correctly.
A:
The client is able to demonstrate breathing in correctly.
P:
Nurse: Go
to SP 2. Teaches how to control the violent behavior at pillow / mattress.
Client: Motivation
client to control the schedule angry with the breathing exercises.
|
Dinny
|
|
Sunday /March 18, 2012 / 12:00
|
Violent behavior / SP 2
|
1.
Facilitating
clients to eat and drink
2.
Measuring
TTV.
3.
Greetings
and greeting clients.
4.
Validate
the client's feelings.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Advise
the client to repeat the deep breathing exercises that have been taught.
8.
Give
positive praise for the ability of clients to demonstrate how to take a deep
breath
9.
Teach
clients how to control angry with hitting the pillow / mattress.
10.
Encourage
clients to try to control the way angry with hitting the pillow.
11.
Give
positive praise for the ability of clients to demonstrate how to hit the
pillow.
12.
Men anyakan
feelings of clients upon completion.
13.
Terminate
the contract for the meeting and the next meeting.
14.
Facilitate client's eating and
taking medication.
|
S: Client
says:
·
I've
often tried to control angry with breathing, but sometimes I still feel
angry.
·
â €
œWith hit the pillow / mattress will not reduce my anger.
O:
·
Sharp eye sight.
·
The client had not screaming.
·
Clients spoke more softly in a
tone notrising.
·
Clients tense, restless and could not settle (hipermatorik).
·
The
client has not been able to demonstrate how to control the violent behavior
at pillow / mattress.
A:
The client has not been able to
demonstrate how to control the violent behavior at pillow / mattress.
P:
Nurse: Repeat
SP 2. Teaches how to control the violent behavior
at pillow / mattress.
Client: client
motivation to learn how to control angry by hitting the pillow.
|
Dinny
|
|
Monday / March 19, 2012 / 19:00
|
Violent behavior / SP 2
|
1.
Facilitating
clients to eat and drink
2.
Greetings
and greeting clients.
3.
Validate
the client's feelings.
4.
Explaining
the purpose of the meeting.
5.
Delivering
the contract time, place and subject of the meeting.
6.
Advise
the client to repeat the deep breathing exercises that have been taught.
7.
Give
positive praise for the ability of clients to demonstrate how to take a
deep breath
8.
Teach
clients how to control angry with hitting the pillow / mattress.
9.
Encourage
clients to try to control the way angry with hitting the pillow.
10.
Give
positive praise for the ability of clients to demonstrate how to hit the
pillow.
11.
Men anyakan
feelings of clients upon completion.
12.
Terminate
the contract for the meeting and the next meeting.
13.
Facilitate
client's eating and taking medication.
|
S: Client
says:
·
â € œ Every inhale deeply upset me, but sometimes I still
feel angry.
·
â € œ and I'll try to control the
angry with memukulbantal / mattress.
·
I'm sad, I want to go home, I miss
my mother.
O:
·
Sharp eye sight.
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients tense, restless and could
not settle(hipermatorik).
·
The client has not been able to
demonstrate how to control the violent behavior at pillow / mattress.
A:
The client has not been able to demonstrate how to control
the violent behavior at pillow / mattress.
P:
Nurse: Repeat
SP 2. Teaches how to control the violent behavior
at pillow / mattress.
Client: client
motivation to learn how to control angry by hitting the pillow.
|
Dinny
|
|
Tuesday / March 20, 2012 / 12:00
|
Violent behavior / SP 2
|
1.
Tation Menfasili clients
to eat and drink.
2.
Measuring
TTV
3.
Greetings
and greeting clients.
4.
Validate
the client's feelings.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Advise
the client to repeat the deep breathing exercises that have been taught.
8.
Give
positive praise for the ability of clients to demonstrate how to take a deep
breath
9.
Teach
clients how to control angry with hitting the pillow / mattress.
10.
Encourage
clients to try to control the way angry with hitting the pillow.
11.
Give
positive praise for the ability of clients to demonstrate how to hit the
pillow.
12.
Men anyakan
feelings of clients upon completion.
13.
Terminate
the contract for the meeting and the next meeting.
14.
Facilitate
client's eating and taking medication.
|
S: Client
says:
·
â € œSetiap upset my breathing in,
but sometimes I still feel angry.
·
â € œNanti I will try to control
the angry with memukulbantal / mattress.
·
I'm sad, I want to go home, I miss
mymother, I want to go to school.
O:
·
Sharp eye sight.
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients tense, restless and could
not settle (hipermatorik).
·
The client has not been able to
demonstrate how to control the violent behavior at pillow / mattress.
.
A:
The client has not been able to demonstrate how to control
the violent behavior at pillow / mattress.
P:
Nurse: Optimizing
SP 2. Teaches how tocontrol the violent behavior at
pillow / mattress.
Client: client
motivation to learn how to control angry by hitting the pillow.
|
Dinny
|
|
Wednesday/ March 21, 2012 / 12:00
|
Violent behavior / SP 2
|
1.
Tation Menfasili clients
to eat and drink.
2.
Measuring
TTV
3.
Greetings
and greeting clients.
4.
Validate
the client's feelings.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Advise
the client to repeat the deep breathing exercises that have been taught.
8.
Give
positive praise for the ability of clients to demonstrate how to take a deep
breath
9.
Teach
clients how to control angry with hitting the pillow / mattress.
10.
Encourage
clients to try to control the way angry with hitting the pillow.
11.
Give
positive praise for the ability of clients to demonstrate how to hit the
pillow.
12.
Men anyakan
feelings of clients upon completion.
13.
Terminate
the contract for the meeting and the next meeting.
14.
Facilitate
client's eating and taking medication.
|
S: Client
says:
·
â € œSetiap upset my breathing in,
but sometimes I still feel angry.
·
I will try to control the angry
with memukulbantal / mattress.
·
I'm sad, I want to go home, I miss my mother, I want to go to school,
he said I was allowed to go home.
O:
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients tense and restless.
·
The client is able to demonstrate
how to control the violent behavior at pillow /mattress.
A:
Clients are able to apply the method to control violent
behavior at the pillow / mattress.
P:
Nurse: Go
to SP 3. Teach you how to control
the violence with verbal behavior (requesting, rejecting, and speak well).
Client: client motivation to learn how to
control angry by hitting the pillow.
|
Dinny
|
|
Thursday / March 22, 2012 / 12:00
|
Violent behavior / SP 3
|
1.
Menfasili tation
clients to eat and drink.
2.
Measuring
TTV
3.
Greetings
and greeting clients.
4.
Validate
the client's feelings.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Advise
the client to repeat the exercise in a breath and hit the pillow /
mattress that has been taught.
8.
Give
positive praise for the ability of clients to demonstrate how to take a deep
breath
9.
Teach
clients how to control angry with verbal (requesting, rejecting, and
speak well). .
10.
Encourage
clients to try to control the way angry with hitting the pillow.
11.
Give
positive praise for the ability of clients to demonstrate how to control
angry with how verbal (requesting, rejecting, and
speak well) .
12.
Men anyakan
feelings of clients upon completion.
13.
Terminate
the contract for the meeting and the next meeting .
14.
Facilitate
client's eating and taking medication.
|
S: Client says:
·
â € œSetiap upset my breathing in,
but sometimes I still feel angry, I continue to control it by hitting the
pillow / mattress .
·
I will try to control the angry by asking,
refused, and spoke well.
·
I am happy because today I walk to
the zoo .
O:
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients tense and restless.
·
The client is able to demonstrate
how to control the violent behavior at pillow / mattress.
·
Afek labile
A:
The client has not been able to apply the method to
control the violence with verbal behavior (asking, refuse and speak well).
P:
Nurse: Repeat SP 3. motivation how to
control violent behavior with verbal (requesting, rejecting, and speak well).
Client: client motivation to learn how to
control angry with verbal (requesting, rejecting, and speak well) ..
|
Dinny
|
|
Friday / March 23, 2012 / 12:00
|
Violent behavior / SP 3
|
1.
Menfasili tation
clients to eat and drink.
2.
Measuring
TTV
3.
Greetings
and greeting clients.
4.
Validate
the client's feelings.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Advise
the client to repeat the exercise in a breath and hit the pillow / mattress
that has been taught.
8.
Give
positive praise for the ability of clients to demonstrate how to take a deep
breath
9.
Teach
clients how to control angry with verbal (requesting, rejecting, and
speak well). .
10.
Encourage
clients to try to control the way angry with hitting the pillow.
11.
Give
positive praise for the ability of clients to demonstrate how to control
angry verbal manner (ask, refuse, and speak well).
12.
Men anyakan
feelings of clients upon completion.
13.
Terminate
the contract for the meeting and the next meeting .
14.
Facilitate
client's eating and taking medication.
|
S: Client says:
·
Often I've practiced to control
anger by asking, refused, and spoke well.
·
I miss mom, I pengin go home .
O:
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients calm
·
The client is able to demonstrate
how to control the violent behavior by means of verbal (requesting,
rejecting, and speak well) .
A:
Clients are able to apply how to control the violence with
verbal behavior (asking, refuse and speak well).
P:
Nurse: Go to SP 4. Teach controlling
violent behavior in a spiritual way.
Client: client motivation to learn how to
control angry with verbal (requesting, rejecting, and speak well).
|
Dinny
|
|
Saturday / March 24, 2012 / 12:00
|
Violent behavior / SP 4
|
1.
Me m
facil tation clients to eat and drink.
2.
Measuring
TTV
3.
Greetings
and greeting clients.
4.
Validate
the client's feelings.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Advise
the client to repeat the deep breathing exercise, hitting the pillow /
mattress, and requesting, refusing, as well as the good that has been taught
to speak.
8.
Give
positive praise for the ability of clients to demonstrate how tocontrol
anger.
9.
Teach
clients to control angry withthe spiritual way.
10.
Encourage
clients to try to control angry in a spiritual way.
11.
Give
positive praise for the ability of clients to demonstrate control angry
in a spiritual way.
12.
Men anyakan
feelings of clients upon completion.
13.
Terminate
the contract for the meeting and the next meeting .
14.
Facilitate
client's eating and taking medication.
|
S: Client says:
·
I've been taught how to control
angry with breathing in, hit the pillow / mattress, and asked, refused,
and good talk.
·
I miss mom, I pengin go home.
O:
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients calm
·
The client is able to demonstrate
how to control the violent behavior by means of verbal (requesting,
rejecting, and speak well).
A:
The client has not been able to control violent behavior
in a spiritual way.
P:
Nurse: Repeat to SP 4. motivation how to
control violent behavior in a spiritual way.
Client: client motivation to learn how to
control angry in a spiritual way.
|
Dinny
|
|
Monday / March 26, 2012 / 19:00
|
Violent behavior / SP 4
|
1.
Me m
facil tation clients to eat and drink.
2.
Measuring
TTV
3.
Greetings
and greeting clients.
4.
Validate
the client's feelings.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Advise
the client to repeat the deep breathing exercise, hitting the pillow /
mattress, and requesting, refusing, as well as the good that has been taught
to speak.
8.
Give
positive praise for the ability of clients to demonstrate how tocontrol
anger.
9.
Teach
clients to control angry in a spiritual way .
10.
Encourage
clients to try to control angry in a spiritual way.
11.
Give
positive praise for the ability of clients to demonstrate control angry
in a spiritual way.
12.
Men anyakan
feelings of clients upon completion.
13.
Terminate
the contract for the meeting and the next meeting .
14.
Facilitate
client's eating and taking medication.
|
S: Client says:
·
I've been taught how to control
angry with breathing in, hit the pillow / mattress, requesting, refusing, as
well as a good talk, and with forgiveness and prayer.
·
I miss mom, I pengin go home.
O:
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients calm
A:
The client has not been able to control violent behavior
in a spiritual way.
P:
Nurse: Go to SP 5. Suggest ways to control violent
behavior by means of taking the medication.
Client: client motivation to learn how to control angry in
a spiritual way.
|
Dinny
|
|
Tuesday / March 27, 2012 / 12:00
|
Violent behavior / SP 5
|
1.
Me m
facil tation clients to eat and drink.
2.
Measuring
TTV
3.
Greetings
and greeting clients.
4.
Validate
the client's feelings.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Advise
the client to repeat the deep breathing exercise, hitting the pillow /
mattress, requesting, refusing, as well as a good talk that has been
taught, and spiritual ways.
8.
Give
positive praise for the ability of clients to demonstrate how tocontrol
anger.
9.
5
principles of client Mengjarkan right in taking the medication .
10.
Teach
the client the names of drugs consumed client.
11.
Encourage
clients to take medication on a regular basis.
12.
Give
positive praise over thewillingness of clients to take medication on a
regular basis.
13.
Men anyakan
feelings of clients upon completion.
14.
Terminate
the contract for the meeting and the next meeting .
15.
Facilitate
client's eating and taking medication.
|
S: Client says:
·
I do not understand the true
meaning principle 5 drugs and drug names that are taught.
·
I will take medication on a
regular basis.
O:
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients calm
A:
The client has been unable to control the violent behavior
by way of taking medication on a regular basis.
P:
Nurse: Repeat SP 5. Suggest ways to
control violent behavior by means of taking the medication.
Client: client motivation to learn how to
control angry with taking medication on a regular basis.
|
Dinny
|
|
Wednesday/ March 28, 2012 / 12:00
|
Violent behavior / SP 5
|
1.
Me m
facil tation clients to eat and drink.
2.
Measuring
TTV
3.
Greetings
and greet the client's family.
4.
Validating
feelings of the client's family.
5.
Explaining
the purpose of the meeting.
6.
Delivering
the contract time, place and subject of the meeting.
7.
Provide
health education to families about the violent behavior and how to handle it
at home.
8.
Encourage the
family to motivate clients to take medication regularly.
9.
Mengnjurkan
family to provide support to clients.
10.
Men anyakan
feeling of family clients after completion.
11.
The
termination meeting .
12.
Facilitate
client's eating and taking medication.
|
S: Client says:
·
I am happy, already listed drug
name and color, so I menginat easier.
·
I will take medication on a
regular basis.
O:
·
The client had not screaming.
·
Clients spoke more softly in a
tone not rising.
·
Clients calm
A:
The client is able to control the violent behavior by way
of taking medication on a regular basis.
P:
Nurse: Go to SP 1 Family.
Clients: Clients return, motivated the
client to take medication regularly.
|
Dinny
|
Description: An. A
is a boy and only child. An upbringing in the family system. A done
with the democratic system. Decision-making is done by the head of the
family on the basis of deliberation / discussion Ny. S (client's mother)
and Ny. M (grandmother client).
b. The concept of self-
2. Body image: An. A mediocre and said he
liked all the parts of his body. 's. A says every part of his body
has the function and benefits of their own.
2. Identity: An. A student said he was a
junior male, but he likes ditching. Clients do not like being told as a
child.
3. The role of self: Clients say is meaningless now
to keluaganya because clients are always troublesome and always blamed. As
a friend, client admitted often generous with his friends, but when angry
clients do not remember his friends.
4. Ideal self: The client said he wanted to be a
punk. Clients want to get a 17 year old, shaved his head in the style of
punk kids and paint. The client said he wanted to be a punk because
clients assume that children's independent punk.
5. Self-esteem: The client says does not match with
friends garden now because the client just wants to be friends with punk kids.
MK: Disorders Self-Concept: Self-Esteem Low
c. Social relations:
Clients say those
closest to him are the client's mother. During the treatment the client in
the room seemed to have a close friend to chat.
d. Spiritual
4. Values and beliefs: An. A Bergama Islam.
2. Worship: Client never worship (prayer) during
care at RSJD Amino Gondhohutomo, but not 5 times.
7. Mental status
a. Appearance: An. A look neat, clean look.
b. Discussion: The client spoke quickly and loudly.
c. Motor activity: Client tense, restless and could
not settle (hyperactivity).
d.
Natural feeling: The
client said that he felt sad.
e.
Afek: labile. Emotions
fickle clients.
f.
Interaction during the
interview: An. A cooperative when interviewed. Eye contact with the
other person's good. The client is able to express feelings and opinions
with both a nurse and want to listen to the statement.
g.
Perception: An. A
voice told him to never hear beat others, but the sound it appears only when
the client is angry.
MK: The risk of injuring themselves, other people and the environment
h.
The process of thought:
There is no thought process disturbance, the client talks coherent, able to
answer the question properly.
i.
The contents of thought:
An. A is able to think clearly, there is no data that indicate the
presence of delusions.
j.
Level of consciousness:
An. A is able to orient people, time, and place well. 's. A
knowing that he was in the mental hospital, now dated March 14, 2012, and was
able to remember the name well.
k.
Memory: The client was
able to recall long-term memory and short-term well. 's. A still
remember his father who had passed away and find out the reason he entered the
asylum.
l.
Concentration levels and
counting: Clients are able to concentrate well. When asked 5 +17 22 clients
responded that result.
m.
Ability assessment: no
distractions. Clients are able to make short-term decisions well as a bath
before eating.
n.
Power look yourself:
deny client's illness, that he was not ill and physically and mentally healthy.
8.
Preparation needs home
a.
Eating: the client is
able to eat independently with frequency 3x / day.
b.
BAK / CHAPTER: the
client is able to urinate 5x, 1x day and bowel movements / day with
independently.
c.
Bath: the client is able
to bathe 2x / day independently.
d.
Dressed / decorated: the
client is able to dress and adorn independently
e.
Rest and sleep: the
client is able to rest enough nap from 13:00 to 14:00 hours, sleep late
afternoon after hours of eating, and slept the night till morning.
f.
The use of drugs: a client
to take medication to be reminded by the nurse.
g.
Health Maintenance:
Clients say if I get home and take medicine to control on a regular basis.
h.
Activity in the home:
The client said after returning home will help parents at home.
i.
Activities outside the home:
Clients say when he will be returned back to school.
9.
Coping mechanisms:
maladaptive, ie clients say like smoking with her friends naughty to reduce
stress. Clients also said sometimes taking pills Mix (THP).
MK: Ineffective individual coping
10.
Psychosocial and
environmental problems: Clients want to hang out and chat with other clients.
11.
Less Knowledge: An. A
does not know about her illness.
12.
Medical Aspects
a.
Medical diagnosis:
Schizophrenia Not Listed
b.
Medical therapy:
Olandos 1 x 5 mg
1 x 0.5 mg alprazolam
Kalxetin 1 x 10 mg
B.
DATA
ANALYSIS
C.
PROBLEM
LIST OF NURSING
1.
Violent behavior (PK)
2.
Disorders of
self-concept: low self esteem
3.
The risk of injuring
yourself and others
4.
Ineffective individual
coping
D.
TREE
PROBLEM
The
risk of injuring yourself and others
Core Problem
Disorders of self-concept: low self esteem
E.
Nursing
Diagnosis
1.
Violent behavior
2.
Disorders of
self-concept: low self esteem
F.
ACTION
PLAN NURSING
G.
NOTE
NURSING
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