D.0132
Perilaku Kekerasan
Kategori : Lingkungan
Subkategori : Keamanan dan Proteksi
Definisi
Kemarahan yang diekspresikan secara berlebihan dan tidak terkendali secara verbal sampai dengan mencederai orang lain dan/ atau merusak lingkungan.
Penyebab
1. Ketidakmampuan mengendalikan dorongan marah
2. Stimulus lingkungan
3. Konflik terpersonal
4. Perubahan status mental
5. Putus obat
6. Penyalahgunaan zat/alkohol
Gejala dan Tanda
Mayor
Subjektif
1. Mengancam
2. Mengumpat dengan kata-kata kasar
3. Suara keras
4. Bicara ketus
Objektif
1. Menyerang orang lain
2. Melukai diri sendiri/orang lain
3. Merusak lingkungan
4. Perilaku agresif/amuk
Gejala dan Tanda Minor
Subjektif
(Tidak tersedia)
Objektif
1. Mata melotot atau pandangan tajam
2. Tangan mengepal
3. Rahang mengatup
4. Wajah memerah
5. Postur tubuh kaku
Kondisi Klinis Terkait
1. Attetion deficit/hyperactivity disorder (ADHD)
2. Gangguan perilaku
3. Oppositional defiant
disorder
4. Gangguan Tourette
5. Delirium
6. Demensia
7. Gangguan amnestik
Referensi
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Diagnosis Handbook,An Evidence- Based
Guide to Planning Care. 11Th Ed. St.
Louis: Elsevier
Carpemito-Moyet, L. J. (2013). Nursing Diagnosis Application to
Clinical Practice. 14) Ed. Philadelphia:
Lippincott Williams &
Wilkins.
Doenges, M. E ., Moorhouse, M. F ., & Murr, A. C. (2013). Nursing
Diagnosis Manual Planning, Individualizing and Documenting Client Care. 4" Ed. Philadelphia: F. A. Davis Company.
Herdman, T. H ., & Kamitsuru, S. (2014). Nursing Diagnosis
Definitions and Classification 2015- 2017.
10h Ed. Oxford: Wiley
Blackwell.
Lewis, M. I ., Dehn, D. S. (1999). Violence
against nurses in outpatient mental
health settings. J Psychosoc
Nurs, 37(6), 28
Newfield, S. A ., Hinz, M. D ., Tiley, D. S ., Sridaromont, K. L .,
Maramba, P. J. (2012).Cox's Clinical Applications of Nursing Diagnosis
Adult, Child, Women's,
Mental Health, Gerontic,
and Home Health Considerations. 6" Ed. Philadelphia: F.A. Davis Company.
Smith, J. E ., Czicman, S. P ., Early, J. A ., Green, P. T ., Lauck, D.
L ., Lindsay, K ., & ... Wright, G. (1994). Validation of the defining characteristics of potential
for violence. Nursing Diagnosis: ND: The Official
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Towsend (2011). Nursing
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