ASSESSMENT

NURSING DIAGNOSIS Risk for Other/SelfDirected Violence related to delusional thoughts and hallucinatory commands

RATIONALE

PLANNING

NURSING INTERVENTIONS

RATIONALE

EVALUATION

After 5 days of nursing interventions, the client will: y y y Not harm self or others Remain free from injury Acknowledge realities of situation Express realistic self-evaluation and increase sense of selfesteem

1. Ascertain clients perception of self/situation 2. Observe or listen for early cues of distress/increasing anxiety such as irritability, lack of cooperation 3. Ask directly if the client is thinking or acting on thoughts/ feelings 4. Monitor patient for behaviors that indicate increased anxiety and agitation. 5. Let the patient know that he or she has control of, and is responsible for, own actions. Help the patient identify situations that interfere with his or her control during conferences with the patient.

1. Assesses the causative/contributing factors 2. May indicate possibility of loss of control and intervention at this point can prevent a blow-up 3. Determines violent intent 4. Allows the nurse/caregiver to ensure the safety of the client

5. Enhances self-esteem, promotes confidence in ability to change behavior