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TimeanddateCues Need NursingDiagnosisObjectives Interventions Evaluation

August2,2008@4:10 pmSubjective:“naa man gud babae akongasawa, maglagotunya mawalaannakog controlusahay” asverbalized by the patient.Objectives:1. History of violence tofamily members.2. Suspicious3. Irritable behavior.4. Degree of client’s potentialfor violence- 4. SELFR ELATIO NSHIPPATTER NRisk other directedviolence r/tlack of developmentaltrust.® Violencecan causedevastatingaction that isconsciouslydone by anindividual.One of itsmajor causesare lack of developmentof trust to onesown self or toothers.Though it may be prevented,violenceshould not betaken for granted because it canlead toharassment,homicide andThat within the patient’s stay, she willnot manifest anyviolent action that canharm others asevidence by:a. verbalization of nodesire or intension toharm others. b. patient will be freefrom injury.c. verbalization of decreased feelings of mistrust and anxiety.1. Build a trust relationshipwith this client as soon as possible.® Familiarity, with trust inthe staff and other healthcare members candecreased the client’sanxiety and facilitatecommunication.2. Assess the presence

degree of client’s potential for violence(toward others) on a 1–10scale.® Information is veryessential for planningnursing careand documents degree of intent.3. Provide protectivesupervision for the client.® For the safety of theclient and others as a priority.4. Be aware of theindications after the clientis having her auditoryAugust 21 2008 @ 4:00 pm“GOAL MET”After the course of intervention,the client had able to:a. verbalized of no desire or intension to harm others asevidence by “tama bitaw ka, pramis dli na nako awayunakong bana.” b. be free from injury.c. verbalized decreased feelingsof mistrust and anxiety asevidenced by “mag tiwala nakosa akong bana, dli na nako siyaawayon. Dili napud ko mahadluk kung ingnan ko na naaykabit akong bana.”

other incidence.Bibliography:Ackley, Betand Ladwig. NursingDiagnosisHandbook. 7

Edition,MosbyElsevier, St.LouisMoussori ©2006.hallucinations again.® The client may act aswhat she hears. Earlyresponse to indicationsdecreases the change of acting out what she fears.5. Provide a structured andsafety environment for theclient.® providing a safeenvironment for the clientshould prioritize.6. Be careful in offering a pat on the shoulder

hug,etc.® Touch may bemisinterpreted as anaggressive gesture.7. Encourageverbalizations of feelingsand promote acceptableverbal outlet(s) for expression, e.g., yelling inroom, pounding pillows.® Ventilation of feelingsmay reduce need for inappropriate physicalaction.8. Help client define

alternatives to aggressive behaviors. Monitor competitive activities; usewith caution.® Enables client to learnand handle situations in asocially acceptable manner.Anxiety and fear mayescalate during activities inwhich the client perceivesself in competition withothers and can trigger violent behavior.9. Set limits, stating in aclear, specific, firm manner what isacceptable

unacceptable.Use demands only whensituation requires.® Being clear andremaining calm increasechance that client willcooperate, lessening potential for violence.Having few but importantlimits enhances chances of having them observed.10. Accept verbal hostilitywithout retaliation or defense. Be aware of ownresponse to client behavior (e.g., tendanger

fear).