You are on page 1of 10

Risk For Violence: Self-Directed or Other Directed

Risk for self-directed violence: At risk for behaviors in which an individual demonstrates
that he/she can be physically, emotionally, and/or sexually harmful to self.

Risk factors

Biochemical/neurologic imbalances.
Impulsivity.
Manic excitement.
Psychotic symptomatology.
Rage reaction.
Restlessness.
Possibly evidenced by

Agitated behaviors (e.g., slamming doors, increased muscle tension, throwing


things over).
Delusional thinking.
Hallucinations.
Loud, threatening, profane speech.
Poor impulse control.
Provocative behaviors (e.g., argumentative).
Verbal threats against others.
Verbal threats against self (suicidal threats/attempts, hitting or injuring self,
banging head against the wall).
Desired Outcomes

Patient will verbalize control of feelings.


Patient will respond to external controls (medications, seclusion, nursing
interventions) when potential or actual loss of control occurs.
Patient will refrain from provoking others to physical harm, with the aid of
seclusion or nursing interventions.
Patient will display nonviolent behavior toward others in the hospital, with the aid
of medications and nursing interventions.
Patient will seek help when experiencing aggressive impulses.
Patient will refrain from verbal threats and loud, profane language toward others.
Patient will be safe and free from injury.
Nursing Interventions Rationale
Early detection and intervention of escalating
Frequently assess clients behavior for signs of mania will prevent the possibility of harm to
increased agitation and hyperactivity. self or others, and decrease the need for
seclusions.
Provides structure and control for a client who
Use a calm and firm approach.
is out of control.
Use short, simple and brief explanations or Short attention span limits understanding to
statements. small pieces of information.
Client can use inconsistencies and value
Remain neutral as possible; Do not argue with
judgments as justification for arguing and
the client;
escalating mania.
Maintain a consistent approach, employ Clear and consistent limits and expectations
consistent expectations, and provide a minimize potential for clients manipulation of
structured environment. staff.
Redirect agitation and potentially violent
Can help to relieve pent-up hostility and relieve
behaviors with physical outlets in an area of
muscle tension.
low stimulation (e.g., punching bag).
Decrease environmental stimuli (e.g., by
Helps decrease escalation of anxiety and manic
providing a calming environment or assigning
symptoms.
a private room)
Alert staff if a potential for seclusion appears
imminent. Usual priority of interventions
would be: If nursing interventions (quiet environment and
firm limit setting) and chemical restraints
Firmly setting limits. (tranquilizerse.g., haloperidol [Haldol]) have
Chemical restraints not helped dampen escalating manic behaviors,
(tranquilizers). then seclusion might be warranted.
Seclusions.
Chart, in nurses notes, behaviors;
Staff will begin to recognize potential signals
interventions; what seemed to escalate
for escalating manic behaviors and have a
agitation; what helped to calm agitation; when
guideline for what might work best for the
as-needed (PRN) medications were given and
individual client.
their effect; and what proved most helpful.

Ineffective Individual Coping


Ineffective Individual Coping: Inability to form a valid appraisal of the stressors,
inadequate choices of practiced responses, and/or inability to use available resources.

May be related to

Biochemical/neurologic changes in the brain.


Disturbance in tension release.
Inadequate level of perception of control.
Ineffective problem-solving strategies/skills.
Possibly evidenced by

Changes in usual communication patterns.


Destructive behavior toward self or others.
Giving away valuables and financial savings indiscriminately, often to strangers.
Inability to problem-solve.
Inability to meet basic needs.
Inability to ask for help.
Presence of delusions (grandeur, persecution).
Using extremely poor judgment in business and financial negotiations.
Desired Outcomes

Patient will report an absence of delusions, racing thoughts, and irresponsible


actions as a result of medications adherence and environmental structures.
Patient will return to pre-crisis level of functioning after acute/severe manic phase
is past.
Patient will cease use of manipulation to obtain needs and control others.
Patient will demonstrate an absence of destructive behavior toward self or others.
Patient will be protected from making any major life decisions (legal, business,
marital) during an acute or severe manic phase.
Patient will respond to limit-setting techniques with aid of medication during acute
and severe manic phase.
Patient will respond to external controls (medication, seclusion, nursing
intervention) when potential or actual loss of control occurs.
Patient will retain valuables or other possessions while in the hospital.
Patient will demonstrate a decrease in manipulative behavior.
Patient will demonstrate a decrease in demanding and provocative behavior.
Patient will seek competent medical assistance and legal protection when signing
any legal documents regarding personal or financial matters during manic phase
of illness.
Nursing Interventions Rationale
Assess and recognize early signs of
manipulative behavior, and intervene
appropriately: For example:
1. Taunting staff by pointing
out faults or oversights.
2. Pitting one staff member
against another (You are
more appreciative than Setting limits is an important step in the intervention
of bipolar clients, especially when intervening in
Nurse Paul Martin, do you manipulative behaviors. Staff agreement on limits set
know what she said to and consistency is imperative if the limits are to be
me?) or pitting one group carried out effectively.
against another (morning
shift versus night shift).
3. Aggressively demanding
behaviors that can trigger
exasperation and
frustration in staff.
Hostile verbal behaviors, poor impulse control,
provocative behaviors, and violent acting out against
Observe for destructive behavior toward
others or property are some of the symptoms of this
self or others. Intervene in the early
disease and are seen in extreme and/or acute mania.
phases of escalation of manic behavior.
Early detection and intervention can prevent harm to
client or others in the environment.
Maintain a firm, calm, and neutral
approach at all times. Avoid:
1. Arguing with the client.
These behaviors by the staff can escalate
2. Getting involved in power
environmental stimulation and, consequently, manic
struggles. activity. Once the manic client is out of control,
3. Joking or clever repartee seclusion might be required, which can be traumatic
in response and other to the manic individual as well as the staff.
clients. to clients cheerful
and humorous mood.
Have valuables, credit cards, and large
During manic episodes, people give away valuables
sums of money sent home with family
and money indiscriminately to strangers, often leaving
or put in hospital safe until the client is
themselves broke and in debt.
discharged.
Provide hospital legal service when and Judgement and reality testing are both impaired
if the client is involved in making or during acute mania. Client might need legal advice
signing important legal documents and protection against making important decisions
during an acute manic phase. that are not in their best interest.
Administer an antimanic medication Bipolar disorder is caused by biochemical/neurologic
and PRN tranquilizers, as ordered, and imbalances in the brain.
evaluate for efficacy, and side and toxic Appropriate antimanic medications allow
effects. psychosocial and nursing interventions to be effective.

Interrupted Family Processes

Interrupted Family Processes: Change in family relationships and/or functioning.

May be related to

Erratic and out-of-control behavior of one family member with the potential for
dangerous behavior affecting all family members (violence, leaving family in debt,
risky behaviors in relationships and business, fragrant infidelities, unprotected and
promiscuous sex).
Family role shift.
Nonadherence to antimanic and other medications.
Shift in the health status of family member.
Situational crisis or transistion (e.g., illness, manic episode of one member).
Possibly evidenced by

Changes in communication patterns.


Changes in participation in decision making.
Changes in participation in problem solving.
Changes in effectiveness in completing assigned tasks.
Deficient knowledge regarding disorder, need for medication adherence, and
available support systems.
Family in crisis.
Inability to deal with traumatic or crisis experiences constructively.
Desired Outcomes

Family members and/or significant others will discuss with nuse/counselor three
areas of family life that are most disruptive and seek alternative options with aid of
nursing/counseling interventions.
Family members and/or significant others will state and have in writing the names
and telephone numbers of at least two bipolar support groups.
Family members and/or significant others will state that they have gained support
from at least one support group on how to work with family member when he or
she is manic.
Family members and/or significant others will state their understand the need for
medication adherence, and be able to identify three signs that indicate possible
need for intervention when their family members mood escalates.
Family members and/or significant others will briefly discuss and have in writing,
the names and addresses of two bipolar organizations, two Internet site
addresses, and medication information regarding bipolar disorder.
Family members and/or significant others will state that they find needed support
and information in a support group (s).
Family members and/or significant others will identify the signs of increase manic
behavior in their family member.
Family members and/or significant others will state what they will do (whom to
call, where to go) when clients mood begins to escalate to dangerous levels.
Family members and/or significant others will demonstrate an understanding of
what a bipolar disorder is, the medications, the need for adherence to medication
and treatment.
Nursing Interventions Rationale
During the first or second day of hospitalization, This is a disease that can devastate and
spend time with family identifying their needs destroy some families. During an acute
during this time; for example: manic attack, families experience a great
1. Need for information about the deal of disruption and confusion when
their family members begins to act
disease.
bizarre, out of control and at times
2. Need for information about lithium or aggressive. Families need to understand
other antimanic medications (e.g., about the disease what can and cannot be
done to help control the disease, and
need for adherence, side effects,
where to go for help for their individual
toxic effects).
3. Knowledge about bipolar support
groups in the familys community and issues.
how they can help families going
through crises.

Total Self-Care Deficit

Self-Care Deficit: Impaired ability to perform or complete bathing/hygiene,


dressing/grooming, feeding, or toileting activities for oneself.

May be related to

Inability to concentrate on one thing at a time.


Manic excitement.
Perceptual or cognitive impairment.
Racing thoughts and poor attention span.
Severe anxiety.
Possibly evidenced by

Observation or valid report of inability to eat, bathe, toilet, dress, and/or groom
self independently.
Desired Outcomes

Patient will sleep 6 hours out of 24 with aid of medication and nursing measures
within 3 days.
Patient will eat half to one third of each meal plus one snack between meals with
aid of nursing intervention.
Patient will have normal bowel movements within 2 days with the aid of high-fiber
foods, fluids, and, if needed, medication.
Patient will wear appropriate attire each day while in the hospital.
Patient will bathe at least every other day while in hospital.
Patient will sleep 6 to 8 hours per night.
Patient will have a weight within normal limits for age and height.
Patient will have bowel habits within normal limits.
Patient will dress and groom self in appropriate manner consistent with pre-crisis
level of dress and grooming.
Nursing Interventions Rationale
Disturbed Sleep Pattern:
Keep client in areas of low
Promotes relaxation and minimizes manic behavior.
stimulation.
Encourage frequent rest periods
Lack of sleep can lead to exhaustion and death.
during the day.
At night, encourage warm baths,
soothing music, and medication
Promotes relaxation, rest, and sleep.
when indicated. Avoid giving the
client caffeine.
Imbalanced Nutrition:
Monitor intake, output, and vital Ensures adequate fluid and caloric intake;
signs. minimizes dehydration and cardiac collapse.
Frequently remind the client to eat
The manic client is unaware of bodily needs and is easily
(e.g.,Rob, finish your pancake,
distracted. Needs supervision to eat.
Sandra, drink this apple juice.).
Encourage frequent high-calorie
Constant fluid and calorie replacement are needed. Client
protein drinks and finger foods
might be too active to sit at meals. Fingers foods allow
(e.g., sandwiches, fruit,
eating on the run.
milkshakes).
Constipation:
Monitor bowel habits; offer fluids
and foods rich in fiber. Evaluate the Prevents fecal impaction resulting from dehydration and
need for a laxative. Encourage decreased peristalsis.
client to go to the bathroom.
Dressing/Grooming Self-Care Deficit:
If warranted, supervise choice of
Lessens the potential for inappropriate attention, which
clothes; minimize flamboyant and
can increase the level of mania, or ridicule, which lowers
bizarre dress, and sexually
self-esteem and increases the need for manic defense.
suggestive dress, such as bikini tops
Assists client in maintaining dignity.
and bottoms.
Give simple step-by-step reminders
for hygiene and dress (e.g.,Here is Distractability and poor concentration are countered by
your toothbrush. Put the toothpaste simple, concrete instructions.
on the brush).

Risk For Injury


Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with
the individuals adaptive and defensive resources, which may compromise health.

Risk factors

Affective, cognitive, and psychomotor factors.


Biochemical/neurologic imbalances.
Exhaustion and dehydration.
Extreme hyperactivity/physical agitation.
Rage reaction.
Possibly evidenced by

Abrasions, bruises, cuts from running/falling into objects.


Extreme hyperactivity.
Impaired judgment (reality-testing, risk behavior).
Lack of fluid ingestion.
Lack of control over purposeless and potentially injurious movements.
Desired Outcomes

Patient will respond to the medication within the therapeutic levels.


Patient will sustain optimum health through medication management and
therapeutic regimen.
Patient will have stable cardiac status while in the hospital.
Patient will drink 8 oz of fluid every hour throughout the day while on acutely
manic stage.
Patient will remain free from falls and abrasions every day while in the hospital.
Patient will be free of dangerous levels of hyperactive motor behavior with the aid
of medications and nursing interventions within the first 24 hours.
Patient will spend time with the nurse in a quiet environment three to four times a
day between 7 am and 11 pm with the aid of nursing guidance.
Patient will take short voluntary rest periods during the day.
Patient will be free of excessive physical agitation and purposeless motor activity
within 2 weeks.
Patient will be free of injury within 2 to 3 weeks:
o Stable cardiac status.
o Skin free of abrasions and scrapes.
o Well dehydrated.
Nursing Interventions Rationale
Provide structured solitary activities with the assistance
Structure provides focus and security.
of a nurse or aide.
Provide frequent rest periods. Prevents exhaustion.
Provide frequent high-calorie fluids (e.g., fruit shake, Prevents the risk of
milk). serious dehydration.
Maintain a low level of stimuli in clients environment
(e.g., loud noises, bright light, low-temperature Helps minimize escalation of anxiety.
ventilation).
Exhaustion and death result
Acute mania might warrant the use of phenothiazines
from dehydration, lack of sleep, and
and seclusions to decrease any physical harm.
constant physical activity.
Observe for signs of lithium toxicity (e.g., nausea,
vomiting, diarrhea, drowsiness, muscle weakness, There is a small margin of safety
tremor, lack of coordination, blurred vision, or ringing between therapeutic and toxic doses.
in your ears).
Protect client from giving away money and possessions. Clients generosity is a manic
Hold valuables in a hospital safe until rational judgment defense that is consistent with
returns. irrational, grandiose thinking.
Physical exercise can decrease
Redirect violent behavior.
tension and provide focus.