SOUL NURSING PRACTICES REPORT

IN TENGKU AMPUAN AFZAN HOSPITAL KUANTAN PAHANG MALAYSIA

Period 19 November 2018 to 15 December 2018

Present By :
Team of Soul Nursing Students

MASTER OF NURSING
POSTGRADUATE PROGRAM
UNIVERSITAS MUHAMMADIYAH YOGYAKARTA
INTERNATIONAL ISLAMIC UNIVERSITY OF MALAYSIA
2019

Presentation on February 23, 2019

 SCHIZOPHRENIA WITH COMORBID SUBSTANCE ABUSE

1. Selection of patient
Date of assessment : 27 Nopember 2018
Provisional Diagnosis: Schizophrenia With Comorbid Substance Abuse
Rujukan : Wad DahliaLaki
2. Personal Biodata
Name : Mr. SNM
Sex : Male
Race :Melayu
Religion : Islam
Marital status : Single
Language spoken : Melayu
Address :TamantasKuantan Pahang.
No RM : 890128xxxx
Data of admission : 15 Nopember 2018
 MEDICAL HISTORY PAST AND PRESENT ILLNESS

a. Presenting Complaints
The patient said he was in a mental hospital because he felt
stressed, could not sleep for 2 weeks, and behaved aggressively.

b. The patient said that at the age of 17 he had taken drugs such as
marijuana, shabu-shabu and metamine. The reason he uses these
items is based on his own volition and also sometimes invited by
friends who are in his neighborhood. When patients use these illicit
items, patients are often found out and scolded by their siblings and
patients feel depressed and stressed as a result of being often
scolded. The patient had worked for a while and the money from his
work was always spent buying marijuana and methamphetamine.
He said he had consumed the item for a long time. As long as the
patient consumes marijuana and methamphetamine, the patient
feels that he is experiencing hallucinations such as seeing a snake,
hearing whispers that disturb his mind and asking him to keep
running because the world wants to end. As long as the patient
experiences hallucinations he feels stressed, angry, aggressive,
angry, unable to sleep and had time to complain to the family to kill
someone.
History of Past Illness : The patient said he had relapsed with the
same pain.

• Family History
The patient said that the first father and siblings had
schizophrenic mental illness similar to the current
patient.
Nursing Management (Nursing Process Approach)
• The patient said he felt stressed, could not sleep for 2
weeks, the family said he bulldozed the siblings' child
with a sticky cloth and had a desire to kill.
• When Assessment: Clients look cooperative when
invited to talk, clear voice, not sharp eyesight and eye
contact when interacting with nurses.
 Psychosocial
Self-concept
a) Self-image
The patient said that he was very grateful for his current condition and condition.
b) Self identity
I as a man must be able to work and earn my own living.
c) Self role
The patient said he wanted to be someone useful and useful for others, especially
for patient families.
d) Ideal self
The patient said that after returning from this hospital, in the future he would like
to work as a cow or goat keeper. He was sure that he could recover completely and
be able to live life like normal people in general.
e) Self-esteem
The patient said that even though he had behaved badly in the past, in the future I
would change him better. Because I still feel expected and still receive by the
family.
 Social relations
• People who mean: Patients say mother
• Participation in group / community activities: Patients never
take part in community activities
• Obstacles in dealing with others: the patient said that he had
never experienced any obstacles in undergoing social relations
with friends in the hospital both with the medical staff and
with the care nurse.
Spiritual
Patients are Muslim. The patient said that even though he had
previously behaved aggressively and was detrimental to the
family, the patient felt confident that he would recover and
always hoped to live like a normal person.
 Mental status
1) Appearance
• The patient looks neat and looks clean.
2) Talks
• Patients speak clearly, understandably and in a normal tone.
3) Motor activity
• Patients appear to be active while on the move or following all kinds of activities carried out during treatment at the hospital
4) Nature of Feeling
• Pasienmengatakandiamerasabaik-baiksajadansangatinginpulangberkumpulkeluarga.
5) Affect
• Expressions when talking with friends and patients do not show a feeling of being flat, blunt or labile.
6) Interaction during interviews
• During the assessment the patient shows good and cooperative eye contact,
namundiagelisahdanpergiapabilamelakukankomunikasiterlalu lama.
7) Perception
• The patient said that he had not heard a whisper or seen a shadow that made him feel disturbed.
8) Thinking Process
• When conducting a study and interview the patient does not show any disturbance of thought processes such as
circumference, tangential, flight of idea or blocking. Patients do not experience disorientation of time, place and other
people.
10) Contents of Thought
• The patient did not find any disturbance in the thought process.
11) Awareness Level
• Patients appear to be fully conscious, cooperative, able to name, day, date and year.
12) Memory
• The patient still remembers the beginning of the incident he experienced a change in behavior, still able to remember the
family name, name of the drug and the name of the area of residence.
13) Level of concentration and counting
Patients are able to count summations in the form (+), (-) and (x) with nominal numbers 1-10.
14) Assessment skills
• Not Assessed.
15) Self-assessment
• The patient said that he felt very guilty about all his behavior first. He regretted that he had taken inappropriate actions and
would try to improve himself after returning from the hospital. Will obey the drug and release it forever.
 Home Preparation Needs
1) Eat and Drink
Patients eating and drinking alone were not helped by a room nurse.
2) BAB / BAK
Patients when defecating and small themselves are not helped by nurses or
other people.
3) Bathing
The patient took a bath himself and was not helped by a nurse.
4) Dress / decorate
Patients dress themselves and are not assisted by nurses.
5) Rest and Sleep
Patients are not in accordance with sleep, usually patients sleep after eating
or before eating.
6) Drug Use
Patients take medication according to the advice given by the doctor and
drink regularly. During treatment the patient is always reminded by the
nurse to always take medication. The patient plans to go home and the
patient says that will remind him to abide by treatment is his sibling, but
patients sometimes feel afraid to relapse again because there were no
siblings who reminded or motivated him to take medicine. Therefore, he
often relapsed and was hospitalized with the same problems.
7) Supporting Aspects
urine test (+) has benzodiazepines.
 Previous psychiatric history (note the history of admission type of drugs received)

Medici Doca Function 24/11/18 25/11/18 26/11/18 27/11/18

ne ge
Risperid 2 To overcome certain mental 10 pm 10 pm
o
m disorders / moods, such as
N
g schizophrenia, bipolar
disorder, and irritability
associated with autistic
disorders. This treatment
can help patients to think
clearly and move normally in
their daily lives. This drug
works to help improve the
balance of certain natural
substances in the brain.
PREVIOUS PSYCHIATRIC HISTORY (NOTE THE HISTORY OF ADMISSION TYPE OF DRUGS RECEIVED)

Medicine Docage Function 24/11/18 25/11/18 26/11/1 27/11/18

8
Benzodiazepin 2 mg Overcome 8 pm
2x1
various
psychological
problems
such as
insomnia,
anxiety
disorders,
panic
disorders, and
acute
depression.
PREVIOUS PSYCHIATRIC HISTORY (NOTE THE HISTORY OF ADMISSION TYPE OF DRUGS RECEIVED)

Medicine Docag Function 24/11/18 25/11/18 26/11/18 27/11/18

e
Benzhexol 2 Benzhexol is 8 pm
m used for the
g symptomatic
B control of all
D forms of
Parkinsonism
 NURSING CARE
Symptom Etiology Problem Priority
Diagnosi
s

DS DO

The patient said that he would remind him  The patient's view appears to Conflict in Management of 1
to adhere to treatment as his siblings, but droop deciding therapy an ineffective
patients sometimes felt afraid to relapse  Her eyes looked out of the and deficits in therapeutic
again because there were no siblings who room and out of focus social support regimen
reminded or motivated him to take
medicine. Therefore, he often relapsed and
was hospitalized with the same problems.

The patient said that all of his siblings  The patient appears nervous Family Family coping 2
were family members, his mother had died and confused when relationships are disability
and his father was still mentally ill and interviewed by the nurse. very ambivalent
was still taking medication from the  The patient seems to want to
hospital. decide on the ongoing
interview process
 IMPLEMENTATION
27/11/1 28/11/18 29/11/18
No. 8
Evaluation
Diag
nos
a
DS : DS : DS : S:
1 The patient The patient said he The patient says if a The patient said he already understood how to take
said he would would work as a feeling of the right medicine, understood how to distance
take scheduled cattle rancher to hallucinations arises himself from the risk factors for the recurrence of
treatment from keep himself busy and feels schizophrenia, and was always ready to report
the hospital so as not to relapse uncomfortable then himself to the nearest health worker if signs and
DO : again and keep he immediately symptoms of schizophrenia relapsed.
Patients himself away from reports his situation O:
understand and dadah. to the family or the  Patients appear to be improving and active in
are able to DO: nearest health service all rehabilitation activities provided
mention the The patient looks DO :  Able to be able to mention how to take the
time and excited and looks The patient right medicine and understand the adverse
method of better. understands and is effects that can be obtained when breaking
taking the able to mention the up
right medicine signs of recurrence in  Patients are able to mention the signs and
. schizophrenia that he symptoms of relapse and understand how to
has suffered avoid the causes of relapse.
 A : Nursing problems are resolved
 P : Intervention is continued by the family
 27/11/18
IMPLEMENTATION 28/11/18 29/11/18
No. Evaluation
Diag
nos
a
DS : DS: DS : S:
2 Patients say it will The patient said he would The patient said that Patients say they will always
always be routine every occupy himself by he would always draw involve the family in the care
two weeks to examine working as a cattle rancher closer to God by process at home and ask the
themselves at the nearest in his residence. praying and try to family to routinely accompany
mental clinic. participate in social them in re-examining their
activities around his health status.
DO: DO: residence O:
The patient looks The patient still looks accompanied by one The patient seemed happy
better but still nervous and gets bored of his siblings. because he wanted to be picked
feels anxious and quickly when given DO : up by his family to go home.
quickly gets nursing intervention . The patient seems to A:
bored when given understand and look Nursing problems are resolved
nursing better P:
intervention Intervention continued by the
family.
 SUMMARY & CUNCLUSION

Schizophrenia is one of the chronic mental illnesses,

paralyzing and having a negative impact on the quality of life
of sufferers.Patients with schizophrenia often experience
recurrence even during the treatment phase and around 10%
of patients must return to the hospital to undergo
rehospitalization or re-treatment.
The recurrence of schizophrenia certainly has a major
impact on sufferers, families, mental health services to the
country's economy. In general, the recurrence form of
patients with schizophrenia is characterized by rampant
behavior, acting anarchistly like destroying things, injuring and
killing themselves and killing other people. From these
problems it is necessary to have comprehensive nursing
interventions to restore coping and family support functions in
providing care to people with schizophrenia.
 REFERENCES
• Dotchterman, J. M., &Bulecheck, G. M 2004.Nursing Intervention Classification (NIC) (5thed.)
America : Mosby Elsevier
• Fatani, B. Z., Aldawod, R. A. and Alhawaj, F. A. (2017) ‘Schizophrenia : Etiology, Pathophysiology
and Management : A Review’, The Egyptian Journal of Hospital Medicine, 69(6), pp. 2640–
2646. doi: 10.12816/0042241.
• Jockers-Scherübl, M. C. et al. (2004) ‘Brain-derived neurotrophic factor serum concentrations are
increased in drug-naïve schizophrenic patients with chronic cannabis abuse and multiple
substance abuse’, Neuroscience Letters, 371(1), pp. 79–83. doi:
10.1016/j.neulet.2004.08.045.
• Kanahara, N. et al. (2013) ‘Onset Pattern and Long-Term Prognosis in Schizophrenia: 10-Year
Longitudinal Follow-Up Study’, PLoS ONE, 8(6), pp. 1–8. doi:10.1371/journal.pone.0067273.
• Kelley, M. E. et al. (2016) ‘Marijuana use in the immediate 5-year premorbid period is associated
with increased risk of onset of schizophrenia and related psychotic disorders’, Schizophrenia
Research, 171(1–3), pp. 62–67. doi: 10.1016/j.schres.2016.01.015.
• Moorhead, S., Jhonson, M., Maas, M & Swanson L. 2008.Nursing Outcomes Classification (NOC)
(5thed.). United sates of America : M0sby Elsevier.
• Muslim, Rusdi. 2013. Diagnosis GangguanJiwa, RujukanRingkas PPDGJ-III dan DSM 5. Penerbit :
PT Nuh Jaya-Jakarta.
• Nanda International. 2015. Nursing Diagnostic : Define and classification 2015-2017 (10th ed.).
Jakarta : EGC
• Stuart, G.W&Laraia, M.T. (2013).Principles and Practice of Psychiatric
Nursing. (7 th Ed) St. Louis: Mosby.
• Yosep, Iyus.,Sutini, Titin. (2014). Buku Ajar KeperawatanJiwa (dan Advance mental healyh
nursing). Bandung: RefikaAditama.
• Woodruff, Peter W R, D Ph, M R C Psych, Anthony S David, F R C Psych, Robin M Murray, D Sc, et
al. 2000. “Meta-Analysis of Regional Brain Volumes in Schizophrenia,” no.January.
https://doi.org/10.1176/ajp.157.1.16
THANKS
DOCUMENTATION