Asuhan Keperawatan

Pada Nn. M dengan

Risiko Perilaku
Kekerasan Di Ruang
Kronis Wanita RSJ
Abepura
 Pengertian
● Perilaku kekerasan adalah hasil dari marah
yang ekstrim (kemarahan) atau ketakutan
(panik) sebagai respon terhadap perasaan
terancam, baik berupa ancaman serangan
fisik atau konsep diri ( Stuart, 2013)
● Perilaku kekerasan adalah salah satu respon
marah yang diekspresikan dengan
melakukan ancaman, mencederai orang lain
dan merusak lingkungan (Keliat, 2012).
 Penyebab
Faktor Predisposisi dan presipitasi

Faktor Sosial
Faktor Biologi Faktor Psikologis
Budaya
Genetik, Abnormalitas Intelegensi , Ketrampilan usia, jenis kelamin,
perkembangan syaraf, verbal, Moral, Kepribadian, pendidikan, pekerjaan,
Status nutrisi, Kondisi Pengalaman masa lalu, agama, keikutsertaan
kesehatan secara umum Konsep diri, motivasi dalam politik
 Tanda dan Gejala
Subjektif :
- Mengungkapkan perasaan kesal dan marah
- Keinginan untuk melukai diri sendiri, orang lain dan
lingkungan
- Klien suka membentak dan menyerang orang lain.

Objektif :
Mata melotot, pandangan tajam, tangan mengepal,
rahang mengatup, muka merah, mengancam,
mengumpat dengan kata kata kotor, suara keras, bicara
kasar, menyerang orang lain, melukai diri sendiri/
orang lain, merusak lingkungan, mengamuk
 Pengkajian Keperawatan Jiwa
Tanggal Masuk Rumah Sakit : 10 April 2022

Tanggal Pengkajian : 19 April 2022

Nomor Register : 00496

Ruangan/Rumah sakit : Ruangan Kronis Wanita/ RSJ Abepura

Diagnosa Medis : F20. 0

1. Identitas
Klien
NAMA : Nn. M
UMUR : 25 Tahun
AGAMA : Kristen Protestan

2. Alasan Masuk
Nn. Rumah Sakit
M masuk Rumah sakit untuk yang 10 kali karena di
rumah marah-marah, mengamuk, merusak, memukul
teman dekat dan ,mengancam teman dekatnya kadang
bicara dan tertawa sendiri,namun mengingkari bila
mendengarkan suara berbisik di telinga .
 Faktor Predisposisi dan presipitasi
1. Biologi
Riwayat sakit sejak tahun 2020,
masuk RSJ 10x berobat tidak
sembuh , tidak ada riwayat
jatuh/trauma tidak ada, tidak ada
riwayat penggunaan NAPZA,
tidak ada riwayat anggota
keluarga dengan gangguan jiwa,
tidak ada riwayat minum
alcohol.
2. Psikologis
Perasaan kesal karena teman
menghianati klien berkepribadian
terbuka, pola asuhan dalam
keluarga otoriter sehingga klien
merasa tidak dapat mengambil
keputusan, merasa tidak disukai
ayahnya. Pengalaman yang tidak
menyenangkan adalah ketika orang
tua bertengkar,dan tinggal di RSJ.
 KONSEP DIRI
Gambara
n Diri Identitas
Klien tidak menyukai Klien merupakan anak ke 9

01
seluruh tubuhnya dan klien
berharap bisa menjadi 02 dari Sembilan bersaudara
klien sedang berkuliah di
laki-laki. uncen jurusan biologi.
01
Ideal Harga
Peran Diri
Klien berperan Diriberharap agar
Klien Klien mengatkan bahwa
beliau tidak di terima di
03 sebagai anak dan
adik di dalam 04 cepat sembuh dan bisa
segera pulang agar 05 keluarga dank klien merasa
keluarganya tidak
keluarganya dapat bekerja dan
melanjutkan kuliah menyayanginya dan lebih
menyayangi kakanya .
Faktor Predisposisi dan presipitasi
Sosial dan Budaya
Riwayat pendidikan mahasiswa, tidak
bekerja, klien anak 9 dari 9
bersaudara, kebutuhan klien masih
tergantung pada kedua orang tua dan
yang menanggung biaya selama
dirawat adalah kedua orang tua
Penilaian Terhadap Stresorr
❏Kognitif : Mendominasi pembicaraan, agresif, mudah curiga
❏Afektif : mudah jengkel, labil
❏Fisiologis : pandangan tajam, wajah tegang
❏Perilaku : kooperatif namun nada suara keras, menyukai sesama
jenis, kadang tertawa sendiri
❏Sosial : keluarga klien mengatakan bahwa klien sangat aktif dalam kegiatan
masyarakat yang ada di lingkungannya seperti kerja bakti dan
kegiatan 17 agustus,dan lain sebagainya , klien juga mengatakan bahwa
dia sangat aktif dalam segalah kegiatan yang di adakan di kampusnya
 Analisa Data
DATA MASALAH
DS: Resiko perilaku kekerasan
• Klien mengatakan dulu pernah memukul suami
kekasinya karna marah pacarnya di nikahi.
• Keluarga klien mengatakan saat klien marah klien suka
memukul benda dan menghancurkan barang-barang
seperti kaca, dan lain sebagainya.
DO:
• Klien tampak mengepalkan tanngan dan tampak
pandangan mata klien tajam
• Klien menggunakan nada bahasa yang tinggi saat
bicara dank lien selalu mendominasi pembicaraan
 Analisa Data
DATA MASALAH
DS: Harga Diri Rendah
• Pasien mengatakan bahwa dia tidak menyukai
dirinya sendiri dan berharap menjadi laki-laki
• Pasien mengatakan bahwa dia meras bahwa
dirinya buka bagian dari keluarganya dan juga
klien mengatakan bahwa keluarganya sudah
tidak menerimanya lagi
DO:
• klien tampak sedih,dan tampak tidak menerima
dirinya sendiri
• klien sering duduk sendiri dan menangis.
 Analisa Data
DATA MASALAH
DS: Halusinasi Pendegaran
Klien mengatakan mendengar suara-
suara yang berfisik di telingannya

DO :
• Klien tampak berbicara sendiri dan
marah tanpa alasan yang jelas.
• Klien tidak dapat memfokuskan
pikiran dank lien juga mudah lupa.
 Physical Examination

Neptune Saturn Mars Venus Mercury

45% 12% 78% 36% 62%

To change the size of Yes, Saturn is the Mars is a cold place Venus has a beautiful Mercury is the closest
the graph, click the ringed one. It’s a gas full of iron oxide dust, name and is the planet to the Sun and
arc of the circle and giant, composed which gives the planet second planet from the smallest one our
drag one of the orange mostly of hydrogen its reddish cast the Sun. It’s terribly the Solar System
handles and helium hot
Results
Mercury is the closest planet to the Sun and
the smallest one in the Solar System—it’s
only a bit larger than our Moon. The planet’s
name has nothing to do with the liquid metal,
since it was named after the Roman
messenger god
 POHON
MASALAH
 Findings
Evolution Prevalence

32%
Pluto
24%
Venus

12%
Saturn
32%
Mars

If you want to modify this graph, click on it,

follow the link, change the data and replace it 200,000,000
Big number
 02
Discussion
You could enter a subtitle here if you need it
Discussions

“Neptune is the farthest planet from the Sun

and the fourth-largest in our Solar System’’ Dr. John Doe

“Venus has a beautiful name and is the second

planet from the Sun. It’s terribly hot’’ Dr. Jenna James

“Mercury is the closest planet to the Sun and Dr. Daniel

the smallest one in our Solar System’’
Patterson
Discussions Summary

01
Venus has a beautiful name and is the second
planet from the Sun. It’s terribly hot and its
atmosphere is extremely poisonous

02
Jupiter is a gas giant and the biggest planet in our
Solar System. It’s also the fourth-brightest object
in the sky

03
Mercury is the closest planet to the Sun and also
the smallest one in our Solar System. It’s only a
bit larger than our Moon
 03
Diagnosis
You could enter a subtitle here if you need it
 Diagnosis
Neptune Mercury
Neptune is the fourth-largest Mercury is the closest planet to
planet by diameter in our Solar the Sun and the smallest one in
System our Solar System

Saturn Mars
Saturn is the ringed one. It’s a Despite being red, Mars is
gas giant, composed mostly of actually a cold place. It’s full of
hydrogen and helium iron oxide dust

Venus Jupiter
Venus has a beautiful name and It’s the fourth-brightest object in
is the second planet from the the sky and the biggest planet in
Sun. It’s terribly hot our Solar System
 Comparison

01 02 03 04
Saturn

Venus

Jupiter

Pluto
 04
Treatment
You could enter a subtitle here if you need it
 Treatment
Mars is full of iron oxide
Week 1 dust, which gives the planet
its reddish cast

Saturn is the ringed one. It’s

a gas giant, composed of
hydrogen and helium
Week 2

Venus has a beautiful name

Week 3 and is the second planet
from the Sun

Jupiter is a gas giant and the

biggest planet in our Solar
System
Week 4
A Picture
Always
Reinforces the
Concept
A Picture Is
Worth a
Thousand
Words
05
Patient Monitoring
You could enter a subtitle here if you need it
 Patient Monitoring
Week 1 Week 2
To change the size of the graph, click the circle and drag the colored handle
Venus has a beautiful name and is the
second planet from the Sun
Venu Satur
Mars Pluto
Venus s n

Mars

Saturn Week 3
Mercury is the
Venu Satu
Marss rn
closest planet to the
Pluto Sun Plut
o
 Contraindications - Indications
Saturn is the ringed one. It’s a Despite being red, Mars is
gas giant, composed of actually a cold place. It’s full
hydrogen and helium of iron oxide dust

Jupiter is a gas giant and the

Neptune is the fourth-largest
fourth-brightest object in the
planet in our Solar System
sky

Venus has a beautiful name Pluto is in the Kuiper belt and

and is the second planet from is considered a dwarf planet
the Sun since 2006

Mercury is the closest planet Ceres is a dwarf planet and

to the Sun and the smallest in the biggest object in the
our Solar System asteroid belt
 Post-prevention

Jupiter is a gas giant and

the biggest planet in our
Jupiter Mercury Mercury is the smallest
planet in our Solar
Solar System System

Venus is terribly hot and

its atmosphere is
Venus Mars Despite being red, Mars
is actually a cold place
extremely poisonous

Neptune is the fourth-

largest planet in our
Neptune Saturn It’s a gas giant,
composed mostly of
Solar System hydrogen and helium
 Case Timeline

Phase 1 Phase 2 Phase 3 Phase 4

Neptune is the fourth- Saturn is the ringed one. Venus has a beautiful name Mars is full of iron oxide
largest planet in our Solar It’s a gas giant, composed and is the second planet dust, which gives the planet
System of hydrogen and helium from the Sun its reddish cast
 Conclusions
Mercury is the closest planet to the Sun
and the smallest one in the Solar
System—it’s only a bit larger than our
Moon. The planet’s name has nothing to
do with the liquid metal, since it was
named after the Roman messenger god,
Mercury
 References

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

 Our Team

Helena James John Doe Jenna

Here you can talk a bit Here you can talk a bit Patterson
Here you can talk a bit
about this person about this person about this person
Thank
s Do you have any questions?

youremail@freepik.com

+91 620 421 838

yourcompany.com

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