You are on page 1of 15

ASUHAN KEPERAWATAN

PADA PASIEN DENGAN DIAGNOSA MEDIS SCHIZOPHRENIFORM


DI RUANG SRIKANDI RSJ dr. ARIF ZAINUDIN DAERAH
SURAKARTA

Disusun oleh :

Wulandari Ristyo
Ayuningtyas
J230195056

PROGRAM PROFESI NERS

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH SURAKARTA

2019
ASUHAN KEPERAWATAN
PADA PASIEN DENGAN DIAGNOSA MEDIS SCHIZOPHRENIFORM
DI RUANG SRIKANDI RSJ dr. ARIF ZAINUDIN DAERAH
SURAKARTA

Nama ruang : Ruang Srikandi


Tanggal pengkajian : 13 Juni 2019

A. IDENTITAS PASIEN
Name : Ny. M
Usia : 39 tahun
Jenis kelamin : Perempuan
Alamat : Sragen
Pendidikan terakhir : Sekolah Dasar
Tanggal pengkajian : 13 Juni 2019
Informan : Pasien, rekam medis pasien

B. FAKTOR PRESDIPOSISI
Pasien mengatakan memiliki ganggu
The client said his aunt and grandfather had a history of mental illness. Client
has had a mental disorder for the first time and was taken to a mental hospital. The
client said he was fired from his desk as an electrician at a company in Jakarta 2 months
ago. While working there the client felt he was discriminated against by his friends
because he was the only employee from Central Java while his friends were all from
Sundanese. After receiving the discrimination treatment and being fired from his job,
the client felt very stressed and returned to Wonosobo. While at home the client
becomes emotionally easy, especially towards his wife and in-laws.

C. PRESIPITATION FACTORS
Since a week ago the client began to look talking and laughing to himself, and
angry without cause.
D. PHYSICAL
1. Vital Sign : TD = 120/70 mmHg N = 84 x/menit
RR = 20 x/menit S = 36.7°C
2. Heigth = 167 cm Weight = 57 kg
3. There are no physical complaints

E. GENOGRAM

Information :

: Male

: Female

: Client

: Married

------- : Live in one house

: Passed away
F. PSICHOSOCIAL
1. Picture of the Self
The client said he was grateful and very happy with all parts of his body. The client
said he liked his belly not the most, his hair was loose and easily arranged, and his
nose was sharp.
2. Identity
The client said that he was a male and only child who was now married and became
the head of the family. The client said there were no problems with his status as
male, single child and family head.
3. Role
4. Pasien mengatakan bahwa dia adalah seorang janda yang bekerja untuk mencukupi
kebutuhannya dan ibunya yang tinggal satu rumah dengan cara mencari bunga
kamboja setiap hari untuk dijual
The client said that he was the head of the family who had the task of earning a
living for his wife. The client said he was able to work well to support his wife, but
after being fired from his job as an electrician he felt unable to find enough money
for his needs and his wife.
5. Ideal yourself
6. Pasien mengatakan bahwa dirinya bercita-cita menjadi seorang
The client said that he really wanted to work as an electrician in a good environment,
along with good coworkers, and the income was enough to support his wife and
needs.
7. Self-esteem

Pasien mengatakan
The client said that he felt less satisfied with his inability to carry out his duties as
a family head properly. But while being treated at the Soerojo Psychiatric Hospital
of Magelang, he was eager and firmly believed after returning later he would work
even harder.

G. SOCIAL RELATIONS
1. People who matter
The client said that he was very close to his mother and wife and in-laws.
2. Participation in group / community activities
The client said that he was quite active in participating in community activities such
as community service.
3. Barriers to dealing with others
Clients say they don't experience obstacles in socializing with others.
H. SPIRITUAL
1. Value and confidence
The client said that the mental illness that he experienced was one reason because
he was not close to Allah SWT. Clients do not associate their condition with
mystical things. The client said that the people in his village did not comment too
much on mental disorders.
2. Worship activities
The client said that while at home he held five daily prayers only at home and rarely
went to the mosque. While being treated at RSJ Soerojo Magelang the client did not
leave the five daily prayers and sometimes the prayer congregated with friends in
the room.

I. MENTAL STATUS
1. Appearance
The client's appearance is quite neat, hair is not messy, teeth and mouth are clean,
face is clean, clothes are neat, body is not smelly, fingernails are clean and not long.
2. Talks
The client is able to speak well (coherently)
3. Motor activity
There is an agitation movement where the client always moves his legs while
talking. The client often changes his sitting position with an worried facial
expression.
4. Nature of feeling
The client looks anxiety and worried.
Nursing Problems: Anxiety
5. Affect
There is no emotional abnormality in the client, the client's emotions appear to be
in accordance with the stimulus or feeling he expresses.
6. Interaction during interviews
The client is cooperative and there is good eye contact
7. Perception
The client experiences auditory hallucinations. The client says feeling anxious and
disturbed when the voice of the whisper appears. The client said the whispers that
told him to repent and get better. These voices often appear when clients are alone
or daydreaming with a frequency of 2-4 times a day. When the voices appear the
client feels anxious. The client's response is to close his ears and sometimes the
client gets angry himself.
Nursing Problems: Disturbace of auditory sensory perception (hallucinations)
8. Thinking process
The client's thought process is good. The client is not convoluted and there is no
blocking when chatting.
9. Fill in thought
There is no thought content abnormality. The client thinks of his wife and really
wants to go home soon.
10. Level of awareness
The client can mention the time and place where he is now well.
11. Memory
There is no memory disruption to the client. The client can remember and tell the
reason why he was taken to Soerojo Psychiatric Hospital of Magelang.
12. Level of concentration and counting
The client seems to focus while talking. Clients are able to count well and correctly.
13. Assessment ability
There is no rating disruption. The client is able to assess his feelings and illness
well. The client considers his illness to be a warning from Allah SWT.
14. Self-power
The client does not deny his illness now and does not blame others.

J. PREPARATION REQUIREMENTS
1. Eat, the client is able to meet the needs of eating three meals and drinking well,
independently and regularly.
2. Urinate/Deficate, the client is able to carry out urinate / defecate independently.
3. Bathing, clients are able to attend independently and regularly twice a day.
4. Dress, clients are able to dress independently, neatly, clean, and politely.
5. Rest and sleep, the client says there are no problems in his sleep. Clients usually
take a nap for 1 hour and sleep for 6-7 hours a night.
6. Use of drugs, clients take medicine given by nurses on the ward.
7. Health care, clients must still undergo outpatient and routine control after being
allowed to go home.
8. Activities in the house, the client is able to prepare food, clean the room, maintain
the neatness of the room, wash clothes and arrange finances with his wife.
9. Activities outside the home, clients are able to transport independently and work.

K. COPING MECHANISM
The client says confused by overcoming the hallucinations and wants to know the right
way. When hallucinations appear, he only covers his ears.
Nursing Problems: Knowledge deficiency

L. PSYCHOSOSIAL AND ENVIRONMENT PROBLEMS


The client has a problem in terms of his work because he was expelled from the
company where he worked in Jakarta. The client feels unable to fulfill the needs of his
family and wife. There are no environmental and group problems and their support.

M. KNOWLEDGE OF LESS ABOUT


Clients do not know about the appropriate coping mechanism.

N. MEDICAL ASPECT
Medical diagnosis : Undifferentiated Schizophrenia
Medical therapy : Resperidone 2 mg / 12 hours
O. DATA ANALYSIS
DATA PROBLEM
DS:
- The client says he hears whispers that tell him to
repent and get better.
- The client said he was very stressed after getting Disturbance of auditory
discriminatory behavior from the theme of his sensory perception
coworkers and was fired from the company where (hallucinations)
he worked
DO:
- Clients are sometimes seen closing their ears.
DS:
- The client said he was still confused by how to
deal with the sounds of whispers he heard
Deficit of knowledge about
- Clients want to know the right way to deal with
dealing with hallucinations
the whisper sounds that they often hear.
DO:
- Clients sometimes appear to close their ears
DS:
- The client says anxious and worried about the
situation now
- The client says anxious and disturbed when
whispering noises appear
Anxiety
DO:
- There is an agitation movement at the client's feet
when talking
- Client's medical diagnosis is Undifferentiated
Schizophrenia

P. DIAGNOSIS OF NURSING
1. Disturbance of auditory sensory perception (hallucinations)
Changes to the amount or stimulus received that is accompanied by a response to
the stimulus that is omitted, exaggerated, distorted or corrupted.
Domain 5: Perception / Cognition Class 3: Perception / Sensation
2. Deficiency of knowledge about appropriate coping mechanisms
Absence or deficiency of cognitive information related to a particular topic.
Domain 5: Perception / Cognition Class 5: Cognition
3. Anxiety
Discomfort or vague worries accompanied by an autonomous response, fear caused
by anticipation of danger.
Domain 9: Coping / Stress Tolerance Class 2: Coping Response
Q. INTERVENTION
No
NOC NIC Rationale
Dx
1 After being given nursing 1. Observation for client 1. Early intervention
treatment for 1 x 24 hours, the hallucinatory signs can prevent
disturbance of the client's 2. Identify hallucinations aggressive
auditory sensory perception can (Type, Content, Time, response to
be resolved by the results Situation, Response) hallucinations.
criteria: 3. Help clients understand the 2. If the client can
- Clients can recognize their relationship between anxiety learn to interrupt
hallucinations and hallucinations. the escalation of
- Clients can understand the 4. Teach the technique of anxiety,
causes of hallucinations distraction or hallucination hallucinations can
- Clients can control their control. be prevented.
hallucinations 5. Involve clients in therapeutic 3. Engagement in
modalities (Group Activity interpersonal
Therapy / TAK) activities and an
6. Collaboration of drug explanation of the
administration or actual situation
psychopharmaceuticals will help bring
clients back to
reality.
4. Psychopharmaca
as a form of
medical therapy
for healing clients
2 After being given nursing 1. Give an assessment to the 1. Knowing the level
action for 1 x 24 hours the client about the level of of understanding
deficiency of the client's knowledge about and knowledge of
knowledge of the hallucination hallucinations clients about the
coping mechanism is expected 2. Give information effectively disease to
to be resolved with the results about hallucinations that determine
criteria: clients experience intervention.
- Client's knowledge of 3. Provide information and 2. Understanding the
hallucinations increases teach coping or hallucination client about the
- Clients can get to know and control mechanisms. situation he is
understand the hallucinations experiencing now
they experience 3. The right coping
- The client is able to explain mechanism will be
again what the nurse explained more effective and
- Clients can practice the efficient for
hallucination control controlling
techniques properly and hallucinations.
correctly
3 After being given nursing 1. Observing signs of anxiety 1. Knowing the
action for 1 x 24 hours, client symptoms. client's non verbal
anxiety is expected to be 2. Help clients recognize reactions as a sign
resolved by the results criteria: situations that cause anxiety of anxiety.
3. Identify the level of anxiety
- Clients do not show verbal 4. Teach and instruct clients to 2. Understanding the
expression and no verbal use relaxation techniques anxiety
anxiety experienced can
- Clients express anxiety of reduce anxiety.
being reduced or not anxious 3. Knowing the
- Clients are able to recognize development of
the causes of anxiety client anxiety to
- Clients are able to control or determine
eliminate anxiety intervention.
4. Relaxation
decreases tension
and anxiety.

R. IMPLEMENTATION
Day/Date/Time Implementation Respon Sign
Tuesday, January 1, 2019
07.30 WIB Giving DS: -
resperidone DO:
medicine 2 mg / The drug resperidone 2 mg has been eaten
12 hours by the client

09.00 WIB Identify DS:


hallucinations in The client said: "I often hear whispers
the form, type, that tell me to repent, usually the sound is
time, situation, heard when I'm alone and daydreaming,
and response the sound can be heard 2-4 times a day.
Usually I just cover my ears with a pillow
".
DO:
 The client looks worried
 Client sometimes appear to close
their ears

09.45 WIB Engaging clients DS:


in following The client said he understood the
TAK knows hallucinations
about DO:
hallucinations  Client take part in TAK activities
from beginning to end well
 Client is able to express their
hallucinations
 Client is able to answer evaluation
questions in TAK

10.30 WIB Observing DS: -


hallucinatory DO:
signs  The client still looks worried
 The client is still seen covering his
ears on the bed

12.30 WIB Teaches the DS:


client to control  Client say they are willing to be
hallucinations taught techniques to control
by rebuking hallucinations
 The client said that he understood
how to rebuke hallucinations
 The client said he would practice
the rebuke technique when a
whispering sound appeared.
DO:
 Client cooperative
 There is eye contact
 Clients practice how to rebuke
well
Wednesday,
January 2, 2019
07.30 WIB Giving oral DS: -
Respiredon DO:
medicine 2 mg /  The 2 mg respiredon drug has
12 hours been eaten by the client

08.30 WIB Involving clients DS:


in TAK  Clients say they can rebuke
activities does hallucinations
not scold DO:
hallucinations  Clients follow TAK from
beginning to end well
 Client cooperative

09.20WIB Observing DS:


hallucinatory  The client said he still heard
signs hallucinations last night
DO:
 The client looks still nervous
 The client is not seen closing his
ears

10.30 WIB Teach DS:


hallucinatory  The client said he was willing to
control by give an explanation of
talking hallucinatory conversations
 The client says he will practice
chatting when a whisper appears
DO:
 Clients practice chatting with
nurses.
Thursday,
January 4, 2019
07.30 WIB Giving DS: -
Risperidone 2 DO:
mg medicine  The respiredone 2 mg drug has
been eaten by the client.

08.30 WIB Accompanying DS: -


clients to take  Client says he like taking therapy
therapy in the in rehabilitation
rehabilitation DO:
room  Client is passionate about taking
therapy in rehabilitation
 Client attend therapy from the
beginning to the end conducive

09.45 WIB Teaches DS:


hallucinatory  Client says he is willing to be
control by doing taught hallucinatory control by
activities doing activities
 The client said he likes to do
house cleaning activities
DO:
 Client seem to listen well to nurse
explanations
 Client is able to mention ways to
control hallucinations

12.30 WIB Identifying signs DS:


of hallucinations  The client says he still hears the
whispers
DO:
 The face looks more relaxed
 The client is seen talking to
himself and smiling to himself
 Client is seen scolding
hallucinations
S. EVALUATION
Nursing
Day/Date/Time Evaluation Sign
Diagnose
Tuesday, Disturbance of S: The client said: "I often hear whispers that tell
January 1, 2019 auditory sensory me to repent, usually the sound is heard when I'm
14.00 WIB perception alone and daydreaming, the sound can be heard 2-
(hallucinations) 4 times a day. Usually I just cover my ears with a
pillow ".
O:
 The client looks worried
 Client can practice scolding hallucinations
A: Auditory hallucinations, the problem has not
been resolved.
P:
 Evaluate the technique of scolding
hallucinations.
 Teach hallucinatory control by talking.
 Involve in TAK activities
 Therapy for respiredone medicine 2 mg / 12
hours
Wednesday, Disturbance of S: The client said: "I still hear voices prompting me
January 2, 2019 auditory sensory to repent, usually the sound is heard when I will
14.00 WIB perception start taking a nap or night 2-3 times a day. I have
(hallucinations) practiced mengahrdik hallucinations and chatting
with my friends in the mas ".
O:
 The client looks worried
 Clients can practice scolding hallucinations
A: Auditory hallucinations, the problem has not
been resolved.
P:
 Evaluate the technique of scolding
hallucinations.
 Teach hallucination control techniques with
activities.
 Involve in TAK activities
 Therapy for respiredone medicine 2 mg / 12
hours

Thursday, Disturbance of S: The client said: "Last night I still heard voices
January 3, 2019 auditory sensory whispering that told me to repent, I have tried to
14.00 WIB perception rebuke, chat with friends next to me, and I have
(hallucinations) also switched to taking care of the room, mas."
O:
 The face looks more relaxed
 Clients seem to talk and smile to themselves
 Clients are able to practice scolding
hallucinations and diverting them by talking
and doing activities.
A: Auditory hallucinations, the problem has not
been resolved.
P:
 Evaluate the technique of scolding
hallucinations.
 Involve in TAK activities
 Therapy for respiredone medicine 2 mg / 12
hours

T. DISCUSSION

Mental disorders are complex neurological brain diseases, one of which is


schizophrenia. Schizophrenia occurs because of abnormalities in the structure of the
brain that affect thoughts, emotions, and social behavior. Schizophrenia is one of the
medical diagnoses of severe mental disorders. Schizophrenia attacks more than 21
million people worldwide (WHO, 2016). Schizophrenia is a mental disorder
characterized by related disorders, affecting language, perception and sense of self
(Harkomah, Arif, & Basmanelly, 2018). Undifferentiated schizophrenia is
characterized by disorganized behaviors and psychotic symptoms (e.g., delusions,
hallucinations, incoherence, and grossly disorganized behavior) that may appear in
more than one category (Townsend, 2011). Based on this case, the symptoms of
undifferentiated schizophrenia that appears is hallucination. There were no other
symptoms of schizophrenia in the patient, so he was categorized as undifferentiated
schizophrenia. Auditory: Auditory hallucinations are false perceptions of sound. Most
commonly they are of voices, but the individual may report clicks, rushing noises,
music, and other noises. Command hallucinations may place the individual or others in
a potentiallymdangerous situation. “Voices” that issue commands for violence to self
or others may or may not be heeded by the psychotic person. Auditory hallucinations
are the most common type in psychiatric disorders (Townsend, 2011).
In this case patient said that after receiving the discrimination treatment and
being fired from his job, the client felt very stressed. While at home the client becomes
emotionally easy, especially towards his wife and in-laws. And he said too that his aunt
and grandfather have a history of mental illness. Townsend (2011) said that the cause
of schizophrenia is still uncertain. Most likely no single factor can be implicated in the
etiology; rather, the disease probably results from a combination of influences including
biological, psychological, and environmental factors.
REFERENCES

Harkomah, Isti., Arif, Yulastri., Basmanelly., 2018. Pengaruh Terapi Social Skill
Training (SST) dan Terapi Suportif Terhadap Keterampilan Sosialisasi pada
Klien Skizofrenia di Rumah Sakit Jiwa Daerah Provinsi Jambi. Indonesian
Journal for Health Sciences. Vol. 02 No. 01, Maret 2018: ISSN 2549 – 2721
(Print), ISSN 2549 – 2748 (Online).
http://journal.umpo.ac.id/index.php/IJHS/article/viewFile/818/700.
Townsend, Mary.C. (2011). Nursing Diagnoses in Psychiatric Nursing. Care Plans and
Psychotropic Medications. Eight Edition. Philadelphia : Davis Company