NURSING CARE WITH A DIAGNOSIS OF VIOLENT BEHAVIOR IN THE MEN

INTENSIVE ROOM OF SAMBANG LIHUM MENTAL HOSPITAL

GROUP 2
ANDRA EGER (PO.62.20.1.16.006)
MARSELINO K MARBUN L B (PO.62.20.1.16.021)
PRISKA FITRIANI (PO.62.20.1.16.032)
SUDIR (PO.62.20.1.16.043)
WAHYU DWI LESTARI (PO.62.20.1.16.046)
 Problem tree
Definition of violent behavior
Risk of self-injury, → Effects
environment, and other people
Violent behavior is one of the angry
responses expressed by carrying out threats,
injuring others, and or damaging the Violent Behavior → Programming
environment. These responses usually arise
due to stressors. This response can cause Sensory Perception Disorders: Hallucinations
harm to both yourself, others, and the
environment (Keliat, et al., 2011: 180). → Causa
Individual coping is not effective

(Prabowo, 2014: 146)

Assessment

Client Indentity
Name : Mr. A
Age / date of birth : 33 years (June 7, 1985)
Gender : Male
Address : Sabamban Lama
Marital status : Not married
Religion : Moslem
Work : Not Working
Medical diagnosis : Paranoid schizophrenia (F.20.0)
Schizophrenia is not detailed (F.20.3)
Entry date : October 16, 2018

 Reason for entry

On October 16, 2018 patients were taken by the family to the Sambang Lihum Mental Hospital emergency
room, 1 week earlier the patient began to experience behavioral changes such as raging, difficulty sleeping,
wandering, throwing stones, and disturbing residents for carrying sharp weapons.

Nursing Problems: Risk of Violent Behavior

 Main complaint
On Tuesday, October 23, 2018 at 10:00 WITA in Male Intensive Room, the 8th treatment day. The general
condition of the patient is cooperative, talk is slow, daily activities such as personal hygiene, defecation and
urination and eating drink can be done independently. Patients are angry if they are noticed or seen
continuously by other people and if there is someone who interferes with their activities or is noisy around
them.
Nursing Problems: Risk of Violent Behavior

 Predisposing Factors

The patient said he had been treated at Sambang Lihum Hospital in 2012, but after returning home and returning
to the family the patient did not routinely take medication. The patient had been a victim of violence from his
siblings but the patient said that maybe he had done something wrong so he got violence from his family
members. The patient does not remember at what age he was having family violence

Nursing Problems: Ineffective Therapy Regiments

 Perception
Patients often speak at night or whisper that is not clear. The patient considers it to be a whisper from the devil.

Nursing Problems: Sensory Perception Disorders: auditory hallucinations

Medical Aspects
•Trifluperazine 3 x 5mg to treat mental disorders
•Trihexyphenidyl 3 x 2mg as a sedative
•Clozapine 3 x 25mg to symptoms psychosis
Data analysis

DATA PROBLEM
Subjective Data :
- Patients say they are angry if there are people who pay attention to it
continuously and if there is something that disturbs their activities and is
noisy around them
- The patient said he had been a victim of violence from his brother
-The patient said his relationship with his brother was not good and the
patient felt that the community did not respect him THE RISK OF VIOLENT
BEHAVIOR
Objective Data:
- From medical record data, approximately one week ago the patient went
berserk, had trouble sleeping, wandered, pelted stones, and disturbed the
people because they carried sharp weapons.
- The patient looks nervous
- Facial expressions upset
- Looks often holding his hand when looking at other patients
Implementation

Date Nursing Diagnoses Implementation

1. Build a trusting relationship
Tuesday, the risk of violent
October 23, behavior 2. Observation of general conditions
2018
3. Practice how to control violent behavior with implementation
strategy 1 channeling anger by breathing deeply and striking
pillows or mattresses

4. Practice how to control violent behavior with implementation

strategy 2 to drink drug regularly

5. Practice how to control violent behavior with implementation

strategy 3 express feelings, ask and reject correctly

6. Practice how to control violent behavior with implementation

strategy 4 spiritual activities
Evaluation
Day / Date / Nursing Date Evaluation
Time and Diagnoses
official Shift
Tuesday, The risk of violent DS: The patient said he was S: Patients say they want to go home
10/23/2018 behavior upset with the nurse because he and ask the nurse to open the trellis gate
Morning shift did not open the trellis gate of to the room
the room O: - The patient's expression appears
irritated and the patient's eyes on other
DO: The patient stood in front patients are sharp
of the trident door in 15 minutes - The patient stands in front of the
while staring at the nurse with a trellis gate in more than 15 minutes
sharp and angry look Vital sign :
Blood Pressure: 110/90 mmHg
Pulse: 92 x / minute
Respiration: 26 x / minute
temperature: 36.0
A: Risk of violent behavior
P: Build a trusting relationship
Observation of general conditions
Perform implementation strategy 1
Progres note

Day / Date / Nursing Date Evaluation

Time and Diagnoses
official Shift
Monday , The risk of violent DS: The patient said he was S: the patient said Mr. W took the
10/29/2018 behavior upset with Mr.W for snatching a drinking glass from his hand
Morning shift drinking glass from his hand O: - The patient scolded Mr. W
- Patients have not been able to do
DO: the patient hits the hand of implementation strategy 2
Mr.W - Vital sign:
Blood Pressure: 110/70 mmHg
Pulse: 94x / minute
Respiration: 20x / minute
Temperature: 36.6
A: Risk of violent behavior
P: - Maintain a trusting relationship
Repeat implementation strategy 2
Practice how to control violent behavior
by taking medication
THANK YOU