Date

Cues

Need

Nursing Diagnosis Risk for violence: directed towards others related to impaired sensory perception secondary to schizophrenia
Schizophrenic clients suffer with hallucination, These may be things like seeing movement in peripheral vision, or hearing faint noises and/or voices. Auditory hallucinations are very common in paranoid schizophrenia. They may be benevolent (telling the patient good things about themselves) or malicious, cursing the patient etc. Auditory hallucinations of the malicious type are frequently heard like people talking about the patient behind their back. Like auditory hallucinations, the source of their visual counterpart can also be behind the patient's back. Their

Goal of Care

Intervention Plan

Evaluation

D E C E M B E R 11 2010 @

Objective: Active hallucinations Looking at others suspiciously History of violence against his mother Fisting of the hands Unresolved grief

7:00 am

S E L F P E R C E P T I O N S E L F C O N C E P T P A T T E R

after 3 weeks of nursing intervention the client will not harm others as evidenced by: a. Maintain good interpersonal relationship with coresidents and staff b. Client will seek out staff member when hostile or suicidal feelings occur. c. Client will not harm self or others.

1. Observe clients behavior

frequently. Do this through routine activities and interactions; avoid appearing watchful and suspicious. Close observation is required so that intervention can occur if required to ensure client's (and others') safety. 2. Observe for suicidal behaviors: verbal statements, such as "Im going to kill myself." and "Very soon my mother wont have to worry herself about me any longer," and nonverbal behaviors, such as giving away cherished items and mood swings. Clients who are contemplating suicide often give clues regarding their potential behavior. The clues may be very subtle and require keen assessment skills by the nurse. 3. Determine suicidal intent and available means. Ask direct questions, such as "Do you plan to kill yourself?" and "How do you plan to do it?" The risk of suicide is greatly increased if client has developed a plan and particularly if means exist for the client to execute the plan.

Jan 8,2010 @5:00pm Goal Partially Met At the end of the 3 weeks or nursing intervention the client did not harm others as evidenced by: a. Maintained good interpersonal relationship with co-residents and staff c. Client did not harm self or others.

visual counterpart is the feeling of being looked-stared at, usually with malicious intent. Frequently, auditory hallucinations and their visual counterpart are experienced by the patient together.

4. Obtain verbal or written

contract from client agreeing not to harm self and to seek out staff in the event that suicidal ideation occurs. Discussion of suicidal feelings with a trusted individual provides some relief to client. A contract gets the subject out in the open and places some of the responsibility for his or her safety with client. An attitude of acceptance of client as a worthwhile individual is conveyed. 5. Act as a role model for appropriate expression of angry feelings, and give positive reinforcement to client for attempting to conform. It is vital that client express angry feelings, because suicide and other self-destructive behaviors are often viewed as the result of anger turned inward on the self. 6. Remove all dangerous objects from clients environment (e.g., sharp items, belts, ties, straps, breakable items, smoking materials). Client safety is a nursing priority. 7. Try to redirect violent behavior by means of physical outlets for clients anxiety (e.g., punching bag, jogging).Physical exercise is a safe and effective way of

relieving pent-up tension. 8. Be available to stay with client as anxiety level and tensions begin to rise. Presence of a trusted individual provides a feeling of security and may help to prevent rapid escalation of anxiety. 9. Staff should maintain and convey a calm attitude to client. Anxiety is contagious and can be transmitted from staff members to client. 10. Administer tranquilizing medications as ordered by physician, or obtain an order if necessary. Monitor client response for effectiveness of the medication and for adverse side effects. Shortterm use of tranquilizing medications such as anxiolytics or antipsychotics can induce a calming effect on the client and may prevent aggressive behaviors. 11. Use of mechanical restraints or isolation room may be required if less restrictive interventions are unsuccessful. Follow policy and procedure prescribed by the institution in executing this intervention. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that the physician reevaluate and issue a new order for

restraints every 4 hours for adults age 18 years and older. If client has previously refused medication, administer after restraints have been applied. Most states consider this intervention appropriate in emergency situations or in the event that a client would likely harm self or others. 12. Observe client in restraints every 15 minutes. Ensure that circulation to extremities is not compromised (check temperature, color, pulses). Assist client with needs related to nutrition, hydration, and elimination. Position client so that comfort is facilitated and aspiration can be prevented. Client safety is a nursing priority. 13. As agitation decreases, assess clients readiness for restraint removal or reduction. Remove one restraint at a time while assessing clients response. This minimizes risk of injury to the client and staff.