MENTAL NURSING CARE PATIENT MS.

H WITH MENTAL
NURSING DIAGNOSIS OF THE RISK OF VIOLENCE
AT SAMBANG LIHUM MENTAL HOSPITAL

MEMBER OF GROUP 1:
CHUMAIRA ANINDAYUDINA
DENY WAHYUNI
NOOR LAILA SARI
WAHDATUR RAHMI ANNISA
• Admission Date : March 19, 2019
• Room : Women Intensive Unit

1. PATIENT IDENTITY
• Initial : Ms. H (F)
• Date of Assessment : March 20, 2019
• Age : 31 years
• No.Reg : 00.XX.XX
2. Reasons For Admission

Patient said the reason brought by her mother to a mental hospital because of
the patient was not taking the medicine for 3 days, the patient also got rage and
cried.

3. Main Complaint

Patient said her emotions got increase and still mad by the incident that
happened before the hospital admission because there was a stranger who
were in the shop and sat on the table, the patient seemed annoyed face
expression with a high tone voices.
 Predisposing Factors

Based on medical records, patient got changes

in behavior since 2001 and she had a history of
out 11 times from 2014 until 2019. When the
patient refused to take the medicine as usual,
patient often got berserk, but it happens if there
is a trigger like a new person.
5. Past Experience
Patient also said her mother once told me that she
had been left by his father since she was in the
womb of her mother so that she felt the lack of
affection and anger to her father.
Nursing Problem:The Risk of Violent Behavior,
Ineffective Individual Coping and Ineffective
Family Coping.
6. Genogram
There is no family have got mental health
7. Self Concept
There is no problem
8. Social Relationship
The emotions of patients improved if there are triggers that make
patients uncomfortable with high direct intonation, patients
sometimes irritable and seemed annoyed facial expression.
Nursing Problem: The risk of Violent Behavior and Ineffective
Individual Coping
9. Talks
Patients respond fast and patient response to a given question is
always coherent, but when the patient tell that too upset the patient
will begin talk with high intonation.
Nursing Problem :The Risk of Violent Behavior
10. Natural Feeling
Patient says she feel annoyed when recalling the incidents that make
emotions increasing, hitting the person. When the incident facial
expressions tell the patient still seemed annoyed.
Nursing Problem : The risk of Violent Behavior
11. Affect

Volatile emotions of patients and patient intonation when talking about issues that
upset him slightly elevated and facial expressions seemed annoyed. Patients were also
admitted he tempered.

Nursing Problem :The Risk of Violent Behavior

12. Interaction During the Interview

When invited to communicate uncooperative patients, patients were able to maintain

eye contact, the patient was calm, able to take a joke and always excited when told,
but when asked about the previous problems that upset him seem intonation rising.

Nursing Problem:The Risk of Violent Behavior

13. Coping Mechanism
Unable to make decisions, to deny patients
disease, and the patient is not able to
resolve the problem that happened to her,
causing emotional and unable to express his
feelings.
 Nursing Problems
No. Nursing Etiology
Maladaptive Data
Problem
1. SD: The Risk of
- Patient says it rages on the market and hit the Violent
man with a broom Behavior
- Patient says increases when there is a trigger
emotions that make the patient uncomfortable
- Patient sometimes mad and seemed annoyed
on facial expression.
- Patient admitted she is tempered

OD:
- Patient admitted to hospital because of the
raging and hitting people on the market
- Patient's face expression seemed annoyed with
increasing the intonation
- Emotion of patient improved if there is a trigger
that makes the patient uncomfortable
 Nursing
Data Maladaftif
Problem Etiology
2. SD: Ineffective Perception
- Patient say was taken to the hospital by her Individual Control What
mother because of the raging Coping Not Adequate
- Patient say often treated in Mental Hospital
- Patient say sometimes the patient buried
itself to the problems that
- Patient admitted she eaisly got tempered
- Patient say when she was at home after the
incident in the market he refused to take the
medication

OD:
- Patient are not able to solve problems that
happen to him independently
- The patient went to mental hospital because
she was not taking the medicine for 3 days,
rage and hit people
- When patient tell that to upset the patient will
begin rising intonation.
 Nursing
Data Maladaftif Etiology
Problem
3. SD: Therapeutic
- Patient say often treated in mental Regimen
hospital Not
- Patient said that she often in and out Effective
because of refused to take the
medication for 3 days
OD:
- Based on medical records, she got
change of behavior since 2001 in junior
high school, when she was at camping
and than got possessed by then. The
patient was first admitted to mental
hospital since June, 13th 2014, a history
of she entered to sambang lihum mental
hospital 11 times, the first time in 2014,
2 times in 2015, 2 times in 2016, two
times in 2017, 2 times in 2018 and 2
times in 2019.
 Data Maladaftif Nursing issues Etiology
4. SD: Ineffective Feelings
- Patient said his mother once told me that family coping Undisclosed In
he had been left by her father since she Chronic By
was in the womb of her mother so that he Individuals
felt the lack of affection and anger at her
father.
- Patient said she was only live with her
mother, because her father never meet the
her since she was in the womb of her
mother until today because her father
remarried.
OD:
- When she was had a appoinment for
control to the doctor her mother never bring
the patient with her and just explained the
condition of the patient to the doctor
- Based on medical records, she got change
of behavior since 2001 in junior high school,
when she was at camping and than got
possessed by then. The patient was first
admitted to mental hospital since June,
13th 2014 and has a history of out 11
times, which is 1 times 2014, 2 times in
2015, 2 times in 2016, two times in 2017, 2
times in 2018 and 2 times on 2019.
 Maladaptif Data Nursing Problem Etiology
5. SD: The risk of harm
- Patient said before she was to self, others and
entering the hospital she was the
hitting a stranger with a broom
when she was in the market
- Patient said she was hit the people
- Patients said she was dink cleaning
fluid for floor but it had no intention
to commit suicide
OD:
- The patient went to mental hospital
because she was not taking the
medicine for 3 days, rage and hit
people
 Priorities Problem
• The risk of violent behavior

• Ineffective individual coping relation with Perception of

Control Inadequate
 Pathway
The risk of harm to self, others and the environment
(EFFECT)

The risk of violent behavior

(CORE PROBLEM)

Family coping Ineffective Therapeutic Regimen Ineffective

(Causa)

Individual Coping Ineffective

 IMPLEMENTATION AND EVALUATION
Day/ Evaluation Initials
Nursing diagnoses Implementation
date
March 20, 2019 The risk of violent SP 1 S:
(13:00) behavior - Identifying the - Patients say the
causes, signs and emotions of
symptoms of patients improved
violent behavior if there are
were carried out triggers that make
and as a result of the patient
violent behavior uncomfortable
- Describes how to - Patients say hit
control the people and as a
behavior of result the patient
violence: physical, thinks about home
medicine, verbal patients do not
and spiritual take medication
- Practice how to - Patients say
control the capable of doing
behavior of physical exercises
physical violence: such as take a
take a deep breath deep breath and
and at the angry at pillows to
mattress and control
pillows independently
- Incorporate
physical exercise
activity to the
daily schedule
Day/ Evaluation Initials
Nursing diagnoses Implementation
date

O:
• Patients said the cause
angry that happened, a
sign of symptoms,
response and result of
anger experienced
• Patients were able to
mention a way to control
angry
• Patients are able to do
physical exercise and
take a deep breath at
the pillow independently
• Good eye contact
• The patient was
cooperative when asked
and answered the
question correctly
 Day/ Evaluation Initials
Nursing diagnoses Implementation
date
March 20, 2019 The risk of violent
A:
(13:00) behavior
The risk of violent
behavior
P:
patient:
• Deep breathing
exercises 3 x 1 daily
before meals 07:00,
12:00 and 18:00.
• Training at the
pillow 2 x 1 day
after waking up and
before going to bed
early 0600, 21:00
• Practice deep
breathing exercises
and pillows at the
time arises angry
 Day/ Evaluation Initials
Nursing diagnoses Implementation
date
March 20, 2019 The risk of violent Nurse: SP 2
(13:00) behavior
• Evaluation of the daily
schedule for the two
physical way (take a
deep breath and at the
pillow)
• Teach you how to
control the violent
behavior by drug
• Teach the patient to
take medication
regularly in a manner
true principle 8 (right
person, right drug, in
order, the dose,
frequency, method,
expiration, and
documentation)
• Arrange to take
medication regularly
schedule
2. Second Strategy Implementation on March, 21st 2019
3. Third Strategy Implementation on March, 22nd -25th
2019
4. Forth Strategy Implementation March, 26th
5. Fifth Strategy Implementation March, 27th
6. Sixth Strategy Implementation March, 28th
7. Seventh Strategy Implementation March, 29th