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Patient initials: A.C. Age: 40y/o GENERAL OBJECTIVES: Maintain good hygiene and promote safety.

CUES NURSING DIAGNOSIS >High risk for self and otherdirected Violence related to inability to discharge emotions verbally PSYCHOPATHOPHYSIOLOGY
SCHIZOPHRENIA

Date of admission: March 28, 2011 Diagnosis: Schizophrenia, chronic

SPECIFIC OBJECTIVES -Verbalize understanding of why behavior occurs

NURSING INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Kadali sa akon mangakig, ginsumbag ko manghod ko kag ginlampos ko amon dvd player.

HISTORY OF: 1) Violence against self and others >hitting his younger brother >arguing with younger brother >jumping over the bridge 2) Indirect violence >destructiveness -broke things at home, door and facilities in jail where he has been safe kept. -kicking the dining table

1. Premorbid personality: individuals use the compensatory mechanisms of the withdrawn pattern of behavior. 2. Severe emotional problems: although unrecognized begin early in life. 3. Chronic insecurity and an almost total failure in interpersonal relationships. 4. Etiology is still unknown; however, some interesting findings in genetics, biochemistry, psychology, family therapy, and sociology present hope for a breakthrough. 5. Regardless of the ultimate etiology, a disturbed relationship with the environment and the family is an almost universal characteristic. Symptoms Delusions Hallucinations Bizarre behavior Disorganized thinking and speech Social withdrawal Others symptoms -difficulties with memory, attention span, abstract thinking, and planning ahead -problems with anxiety, depression, and suicidal thoughts

-Remains free from injury from self and others

INDEPENDENT: Observe or listen for early cues of distress/increasing anxiety Ask directly if the person is thinking of acting on thoughts/feelings Develop therapeutic nurse-client relationship. Provide consistent caregiver when possible. Maintain straightforward communication Discuss motivation for change

=may indicate possibility of loss control. =to determine violent intent =Promotes sense of trust, allowing client to discuss feelings openly =to avoid reinforcing manipulative behavior =crisis situation can provide impetus for change, but requires timely therapeutic intervention to sustain efforts =in domestic violence situations, individual may be remorseful after incident and will apologize and say that it won t happen again =provides an opportunity for client to look at reality of choices and potential outcomes =Promotes acceptance and sense of safety =to lessen sense of anxiety and associated physical manifestations =enhances self-esteem, promotes confidence in ability to change behavior =builds trust, enhancing therapeutic relationship and prevents manipulative behavior =they can be use as basis for change =encourages continuation of desired behaviors =decreases defensive response =to provide feeling of safety

-Patient verbalizes that he easily gets mad thus such behavior occurs

Confront client s tendency to minimize situation or behavior

-Verbalizations or body language demonstrates a reduction in anxiety

Acknowledge reality of suicide/homicide as an option Accept client s anger without reacting on emotional basis Help client identify more appropriate solutions/behaviors Give client as much control as possible Be truthful in giving information and dealing with client Identify current/ past successes and strengths Give positive reinforcement for client s efforts Maintain calm, matter-of-fact, nonjudgmental attitude Provide client with a sense that caregiver is in control of the situation COLLABORATIVE: Identify support systems

-Patient stated that he can control himself now and try not to happen it again -Patient is calm when being interacted but keeps on moving his feet and scratching his head -Patient said that he is given an IV medication which is Fluphenazine decanoate monthly. ->goal partially met

-Continues taking prescribed medication

Nursing Diagnosis High risk for self and other-directed Violence related to inability to discharge emotions verbally
Reference: MOSBY S COMPREHENSIVE REVIEW OF NURSING Phil. Edition, p372

=in addition to client, those around him need to learn how to be positive role models and display a broader array of skills for resolving problems

Refer to formal resources, as indicated