CHAPTER III

REVIEW OF CASES

Tn. M was treated at the Marzuki Mahdi hospital with a medical diagnosis of Skizophrenia, then
by the client's family brought to the hospital. According to the client's family always hear
someone whisper a whisper and told him to do things that are not good. The client's sister said
that the client had been treated in a mental hospital in 2011 with the same complaint, before the
client went to the kyai to recover but the treatment was less successful. Over the course of 3
years after healing the client never controls irregularly taking the medicine because they feel
healed. During the day the patient was angry and beat his mother.

A. Nursing Assessment
The assessment was conducted in the Wijaya Kusuma RS Marzuki Mahdi room. The data
obtained that the client entered the hospital room with the register number with medical
diagnosis F20.3 (Skizophrenia).

1. Client Identity
Initials : Mr. M
Age : 25 Years old
Information : Client, Family and Medical Records

2. Reasons for admission

The client speaks sluggish and angry.

3. Main Complaint: the client said he heard someone whisper a whisper and told him to do
something that was not good (example: told to hit, told to sincere his mother).
4. Predisposing factors
a. Ever experienced a mental disorder in the past? Yes
b. Previous Treatment? Less successful
c. Experience
Physical abuse : clients have experienced physical abuse
Sexual Abuse : the client has never experienced sexual abuse.
Family violence : clients have experienced violence.
Criminal acts : clients never commit a crime.
The client's sister said that the client had been treated in a mental hospital in 2011 with
the same complaint, before the client went to the kyai to recover but the treatment was
less successful. Over the course of 3 years after healing the client never controls
irregularly taking the medicine because they feel healed. During the day the patient was
angry and beat his mother.

5. Physical
a. Vital Sign: Blood Pressure 120/80 mmHg, Pulse : 84x/min, Temperature : 36oC,
Respiration : 19x/min
b. Height : 174cm, weight : 59kg
c. Physical complaints : thereisn’t
d. Explain : while in the mental hospital clients never experience pain.

6. Mental status
a. Appearance : Not neat
Explain : clients look neat, hair is never combed, wear a messy sheath for the crease.
b. Talks : Slow and unable to start a conversation
Explain : the client speaks as necessary with a slow tone of voice.
c. Motor activity : Weak
Explain : clients often aloof the room, ADL directed by officers
d. Feeling : Worried
Explain : the client said he was worried if he heard the whisper coming.
e. Affect
Explain : clients can smile and sad when given stimulus
f. Interaction : Less eye contact
Explain: the client is more silent, eyes look in the other direction when talking to.
g. Hearing
Explain: the client says he often hears a whispering whisper telling him to do
something (for example, told to hit, told to administer his mother), when the client is
pacing, when asked that someone is whispering to go home and give his mother a
salary. The client's response when hearing the voice of the client's voice follows the
voice command. Also pacing, always talking to yourself.
B. DATA ANALYSIS
Date Data Etiology Problem
DS : - Auditory
- Clients say often listen to whispers that hallucinations
told him to do something (told to hit, etc.)
- The client's response follows the prompt.
- Clients in the study heard a whisper to go
home and told to sincere his mother.
- The client says that the voice really
exists.

DO :
-Client pacing
- Clients are always alone can not interact
with other patients
- Clients always speak "sent home"
- The client is talking slurred

C. NURSING INTERVENTION
Diagnosis 1 : Sensory perception disturbances: hallucinations
General purpose : so that clients do not harm others.
Special Purpose 1 : for clients to build trusting relationships with others.
Intervention :
1. Greet and ask for the client's favorite nickname.
2. Name the nurse, shaking hands.
3. Explain the purpose of the interaction relationship.
4. Explain about the contract to be made.
5. Give a sense of security and empathy.
6. Make short but frequent contacts.
Special Purpose 2 :
Helps clients recognize hallucinations (type, content, time, frequency, situation, response).
Intervention :
Help clients recognize hallucinations that include content, time of hallucinations, frequency,
triggering situations, and feelings when hallucinations occur.

Special Purpose 3 :
Describes ways to control hallucinations.
Intevention :
Describes ways to control hallucinations when the client experiences hallucinations

Special Purpose 4: Teaches clients to control hallucinations in a way that is:

1. Rebuke.
2. Traveling with others
3. Doing the usual activities
Intervention : demonstrating or educate way to control hallucination with :
1. How to rebuke.
2. Chatting with others.
3. Doing the usual activity.

Special Purpose 5:
The client can use the medicine correctly (according to the treatment program)
Intervention:
1. Explain the types of drugs clients take on clients and families.
2. Discuss the benefits of taking medication and stop taking medication without a doctor's
permission.
3. Explain the principle 5 right to take medication (client's name, medicine, dose, manner
and time).
4. Encourage clients to ask for drugs and take medication on time
5. Advise clients to report to nurses or doctors if they feel any unpleasant effects.
6. Give praise if the client is taking medication properly.
 D. IMPLEMENTATION DAN EVALUATION
Nursing IMPLEMENTATION EVALUATION
Diagnoses
Sensory SP I S : The client answered his name Mr. Mahmudi
perception Fostering a relationship of Affandi, happy to be called fandi.
changes: trust O:
Hallucinations of - Orientation - the client answers accordingly
hearing "Good afternoon Mr, - less eye contact
introduce my name Amirullo - clients look confused
Ashadi, can be called Amir. I A : SP I not yet achieved
am a student of poltekkes P: Repeat SP I
akper. May I know whose
name mas?, Mr happy to be
called who?
- Work
"How do you feel today?"
"May I know your job?"
"Do you want to tell me, why
are you here?"
- Termination
"Well Mr. fandi, tomorrow
we talk again, now mas can
rest
Sensory SP 1 S : The client says he wants to learn to control
perception How to control her hallucinations
changes: hallucinations: rebuke O:
Hallucinations of - Orientation - The client is able to express its hallucinations.
hearing "Good afternoon mas fandi, - There is eye contact.
how are you doing today?" - The client is capable of repeating the way he
"Today we are going to talk rebukes his hallucinations.
about the sounds that Mr. A : SP 1 achieved
Fandi often heard". P : continue to SP 2
-Work
"Is the whisper that Mr. Fandi
listen continuously / at times?
Why do not we learn to
practice to rebuke that
whisper? "
"When the whisper was heard
Mr. fandi said," I do not want
to hear "so mas repeatedly.
Try mas demonstrate. "
- Termination
"Trained to continue ya Mr.
fandi, tomorrow we meet
again to overcome the
whisper in a second way, how
to Mr. fandi? yes it's , mr.
fandi you can rest again. "
Sensory SP 2 S : Clients say they want to learn how to
perception The patient can control his control the 2nd hallucination
changes: hallucinations O:
Hallucinations of - Orientation - The patient is able to reveal the hallucinations
hearing "Good morning Mr. fandi, - There's eye contact
how are you today Mr. Fandi? - Patient looks calm
What did I teach yesterday - Patients are able to rebuke hallucinations
already Mr. fandi do? Have A : SP 2 achieved
you done a regular practice of P : Continue to SP 3
rebuking when the
hallucinations show up? "
- Work
"What if we repeat what I
taught yesterday to mas
fandi? Yeah nice Mr. fandi,
keep it that way. Now I will
tell Mr. Fandi the second way
is when mas fandi hear
whisper, immediately can
chatting with other people or
with me. "" Mr. fandi can say,
accompany me chatted yes
the voices began to be heard
again, because by chatting
voice -the voice will be gone
".
- Termination
"Trained to continue ya Mr.
fandi, what I teach. Mr. fandi
also do not like to be alone. If
mas fandi need friends
chatting mas fandi can call
me. Now Mr. fandi can rest
again. "

Sp 3 S : clients say want to chat with others and

Clients can control their want to go home quickly and whisper
hallucinations by doing whispering has decreased
activities O:
- Orientation - The presence of eye contact.
"Good morning mr fandi, - Clients interact with others.
have breakfast Mr? " - Client looks calm.
"What Mr. Fandi still hear - The client is able to express his feelings
whispers? " A : SP 3 achieved
"What did I teach yesterday P : Continue to SP 4
already Mr. fandi do? "
"What's it like to chat with
other people? "
- Work
"What if we repeat what I
taught yesterday? "
Keep it like that yes Mr.
fandi, good Mr. fandi "how
about we make a list of
activities for Mr. fandi
tomorrow"
- Termination
"The activities that have been
made earlier was done mas
Mr. fandi"
"Mr fandi if you can not be
alone, and have to interact
with others"
"Tomorrow we meet again
yes Mr. fandi in this place“

Sp 4 S : The client says it has been reduced to hear

The client is capable of whispers and the client is able to do the ways
performing scheduled already given to control the hallucinations.
activities O:
- Orientation - There's eye contact
"Good morning Mr. fandi, - Friendly face
how is it now? " - The client is able to express his feelings
"Does Mr. fandi have - Client looks calm
breakfast? " A : SP 4 achieved
"How Mr. fandi what P : intervention stopped
activities we have made
yesterday already Mr. fandi
do right? "
"Is there still a whisper in the
ears of Mr. fandi? "
- Work
"What if we repeat what I
taught from the beginning of
our meeting until the meeting
yesterday Mr. fandi?"
"Yeah Mr. fandi nice, try Mr.
fandi demonstrate, later if
forgot to remind me again
Mr? "
"Maintain the way it is yes
Mr. fandi? "
- Termination
"Trained on the Mr. fandi,
sure Mr. fandi can to control
the hallucinations that Mr.
fandi hear"
"Well Mr. fandi, tomorrow
we meet again to talk about
drugs that Mr. fandi drink,
now rest again"