1 . Identification of the patient
a. Name : Mr. . S
b . Age : 42 years
c . Gender: male
d . Address : Unggaran
e . Occupation : Coolie building
f . Education : -
g . Medical Diagnosis : Schizophrenia Takterinci
Identity Penaggung replied :
a. Name : Mr. . D
b . Age : 46 years
h . Address : Unggaran
c . Occupation : -
d . Relationship : Brother
Ward : X ( Kresno )
Log Date : 27 November 2011
Assessment dated : December 13, 2011
2 . Reasons incoming ( 27 November 20011 )
The day before admission Tn . S act strangely ( cut trees ) , raging and speak for themselves .
3 . Complaints Home Now ( December 13, 2011 )
Clients only silent , speak if asked and empty eyes .
4 . Predisposing factors and precipitation
a. factors predisposing
The client had been treated in RSJD Dr . Amino Gondohutomo about 4 years ago . Previous treatment was successful and brought home by family clients . During the client's home and control never to take his medicine . According to the family , previous clients tantrums if his desire is not fulfilled , speak for themselves and beating people and raging . Clients have economic problems and problems with his wife . Family say no other family members who experience mental illness .
MK : Violent behavior
b . factors precipitation
Clients now have never seen angry / raging and more likely to be silent . Clients say with applicable not anyone here , interacting lazy and not supposed to be here .
MK : Pull Away
5 . Physical assessment
a. Vital signs
TD : 90/70 mmHg
HR : 88 x / min
RR : 20 x / min
Temperature : 36oC
b . Size :
TB : 165 cm
BB : 60 kg
c . Tn . S said no complaints of any illness that is felt for clients treated in RSJD Amino Gondohutomo .
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 : no tenderness and no period
Genetalia : not terkaji
Upper extremities : There is no muscle kelemahan.Kekuatan : 5/5 and 5/5 , Capilary refill = < 2 seconds .
Lower extremities : There is no muscle kelemahan.Kekuatan : 5/5 and 5/5 , Capilary refill = < 2 seconds .
Integument : no lesion elsewhere , skin turgor < 2 seconds and clammy skin .
a. The concept of self-
1 ) Body image : Tn . S said like all parts of his body .
2 ) Identity : Tn . S is a man who is married and has one daughter .
3 ) The role of self : Tn . S has a gardening job and as a construction worker .
4 ) Ideal self : Tn . S says it wants a speedy recovery and return home soon .
5 ) Self-esteem : Tn . S felt did not have any skills and be a husband who is less able to meet the economic needs of the family
MK : Low self-esteem .
b . Social relations :
Family says clients do not have the people closest and never joined any gathering . When a client assessment conducted only silent , eyes vacant clients , often looked down , never interacting with anyone , if asked to speak in the room and as long as the client is always aloof and out of the bedroom.
MK : withdrawal
c . spiritual
1 ) Values and beliefs : Tn . S Bergama Islam .
2 ) Activity of worship : The client said before admission client diligent worship prayers in the mosque . Clients do not want to say over here to worship pray because they feel dirty place .
MK : spiritual distress
6 . Mental status
a. Appearance : Tn . S look pretty neat , tidy ramput .
b . Discussion : Clients passive . Never start a conversation . Tone was low and flat .
MK : Damage to communication
c . Motor activity : Tn . S looks lazy , lethargic and not powered , Client rare move , just follow the routine of eating , bathing and rest well clients prefer to be alone in the room , in front of the TV or outdoors .
d . Natural feeling : Tn . S said he was sad because the family has not come to pick him up and felt missed by his son .
e . Afek : Flat indicated with clients face without expression when spoken to.
f . Interaction during the interview : Mr. . S less so cooperative when interviewed . Eye contact with the other person less . When spoken rather long getting lazy to answer and leave the other person .
MK : Damage to communication
g . Perception : Tn . S said if being alone is not never heard a voice - a voice that told him to get angry and so on .
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 : well , Tn . S is able to think clearly and not found data that indicate the presence of delusions .
j . Level of consciousness : Tn . S is able to orient people , time and place well . For example, being able to know if he was in the hospital .
k . Memory : the client is able to recall with good long-term memory , however , the client is not able to remember the reason was taken to hospital .
l . The level of concentration and arithmetic : the client is able to concentrate well demonstrated when Mr. . S asked 10 + 12-5 = 17 .
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 .
7 . Requirements return preparation
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 : the client is able to take medication independently in accordance with the provisions .
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 : The client said after returning home to start gardening with friends in the village .
8 . Coping mechanisms : maladaptive , ie the client says rather sit alone because they do not know anyone .
MK : Ineffective individual coping
9 . Psychosocial and environmental problems : Tn . S started to not want to hang out and meet with her friends .
10 . Less knowledge of : Mr . S does not know about her illness .
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