NURSING DIAGNOSIS: risk for violence
CAUSE ANALYSIS: n manic phase, the negative, uncontrolled thoughts, feeling and behaviors pose a threat or danger to harm self or others. They areaggressive,
hostile and cannot evaluate the consequences of their behaviors
Cues
Subjective:
“Samok kay ka. Pahawa dari.
Dadto ra ka, basin maunsa
tika ron.” as verbalized by the
patient
Objective:
- With rigid posture
- With clenching of fists
- With annoyed facial
expression
- Pacing
- Hyperactive
- Has the tendency to
verbally threatened
others
Objectives
STO:
Patient will report:
- demonstrate self-control.
LTO:
The patient demonstrate self-
control as evidenced by relaxed
posture and non- violent
behavior.
Nursing Interventions Rationale Evaluation
1. Assess client’s 1. To assess causative/ The client demonstrated self-
perception of self and contributing factors. control as evidenced by relaxed
situation. Note use of posture, non- violent behavior.
defense mechanism. Goal met.
2. Observe/ listen for early 2. May indicate possibility
cues of distress/ of loss of control and
increasing anxiety. intervention at this point
can prevent a blow up.
3. To determine violent
intent.
3. Ask directly if the person
is thinking of acting on
thoughts/ feelings.
4. Promotes person’s sense
4. Develop and maintain of trust, allowing client
therapeutic nurse-client to discuss feelings
relationship. openly.
5. To assist client to accept
5. Make time to listen to responsibility for
expressions of feelings. impulsive behaviour and
Acknowledge reality of potential for violence.
 client’s feelings.
6. To assist client in
controlling behavior.
6. Approach in positive
manner, acting as if the
client has control and is
responsible for own
behavior. 7. To encourage
continuation of desired
7. Give positive behaviors.
reinforcement for
client’s efforts.
8. Decreases defensive
response.
8. Maintain calm, matter-
of-fact, non-
judgemental attitude. 9. To promote safety in
event of violent
9. Provide a safe/ quiet behavior.
environment and
remove items from the
client’s environment that
could be use to inflict
harm to others. To promote wellness

Encourage walking or exercise as

activities that may diffuse
aggression
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