KRISTIAN KARL B.

KIW-IS

DAY 2

F: Risk for Self-Directed Violence

D: Received sitting on bed Dressed appropriately for the season. Grooming is good. The patient appears
older than stated age, had good eye contact and reports reduced socialization. Her mood at the time of
interview was depressed, and anxiety level is moderate. With consistent with mood. Able to explain
what she will do if when she gets to a stop sign while driving, she responded: “I will stop”. She states
that she needs help with her mental health. “I have been feeling depressed, anxious, and under stress”
history of violence behavior

A:

>intervened immediately if the client demonstrates aggressive behavior toward self or others.

> listened for verbal threats or hostile remarks towards self or others.

> Helped the client manage angry, inappropriate or intrusive behaviors in a therapeutic but firm direct
manner

> Reduced milieu noise and stimulation or accompany client to a calmer, quieter environment at early
signs of anger, frustration or agitation

> reminded the client to continue seeking staff when first experiencing frustration, anger, hostility or
suspiciousness rather than waiting until the negative thoughts and feelings are out of control, which can
lead to violence.

> praised the clients efforts made to control anger or hostility to self and others.

> taught the client and the family to recognize early signs and symptoms of escalating agitation or
hypomanic behaviors (yelling, cursing, threatening, pacing, intrusiveness, suspiciousness) that can lead
to full blown mania, self-harm, assault or violence.

R: The client maintains a non-hostile behavior and doesn’t injure itself or others.

Day 3

F: Sleep Pattern Disturbance r/t psychological stress

D: Received sitting on bed Dressed appropriately for the season. Grooming is good. The patient appears
older than stated age, had good eye contact and reports reduced socialization. Her mood at the time of
interview was depressed, and anxiety level is moderate. With consistent with mood. Able to explain
what she will do if when she gets to a stop sign while driving, she responded: “I will stop”. She states
that she needs help with her mental health. “I have been feeling depressed, anxious, and under stress”
She has obstructive sleep apnea

A:

> Decreased environmental stimuli in room and common areas.

>Restricted intake of caffeine (e.g., coffee, tea, cocoa, cola drinks).

> Offered small snack/warm milk at bedtime or when awake during the night.

> Encouraged engaging in physical activities/exercise during morning and afternoon. Restrict activity in
the evening prior to bedtime.

> Encouraged routine bedtime activities, relaxation techniques.

> Rerouted to bed matter-of-factly, without providing the distraction of other activities.

R: The client reports that she rested well but still she appears tensed and restless.