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

Objectives

Subjective:

STO:

Samok kay ka. Pahawa dari.

Patient will report:

Dadto ra ka, basin maunsa

- demonstrate self-control.

tika ron. as verbalized by the

patient

LTO:
The patient demonstrate
self- control as evidenced
by relaxed posture and
non- violent behavior.

Nursing Interventions
1. Assess clients
perception of self
and situation. Note
use of defense
mechanism.
2. Observe/ listen for
early cues of
distress/ increasing
anxiety.

With rigid posture

With clenching of
fists
With annoyed facial
expression
Pacing
Hyperactive
Has the tendency to
verbally threatened
others

1. To assess causative/
contributing factors.

2. May indicate
possibility of loss of
control and
intervention at this
point can prevent a
blow up.
3. To determine violent
intent.

Objective:
-

Rationale

3. Ask directly if the

person is thinking of
acting on thoughts/
feelings.
4. Develop and
maintain
therapeutic nurseclient relationship.

4. Promotes persons
sense of trust,
allowing client to
discuss feelings
openly.

Evaluation
The client demonstrated
self- control as evidenced
by relaxed posture, nonviolent behavior.
Goal met.

5. Make time to listen

to expressions of
feelings.
Acknowledge reality
of clients feelings.

5. To assist client to
accept
responsibility for
impulsive behaviour
and potential for
violence.
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. Give positive
reinforcement for
clients efforts.

8. Maintain calm,
matter- of-fact, nonjudgemental
attitude.
9. Provide a safe/ quiet
environment and
remove items from
the clients

7. To encourage
continuation of
desired behaviors.

8. Decreases
defensive response.

9. To promote safety in
event of violent
behavior.

To promote wellness

environment that
could be use to
inflict harm to
others.
Encourage walking or
exercise as activities that
may diffuse aggression
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