Time Cues Need Nursing Objectives Interventions Evaluation

and Diagnosis
date
August Subjective: S Risk other That within the 1. Build a trust relationship August 21 2008 @ 4:00 pm
2, “naa man gud E directed patient’s stay, she will with this client as soon as
2008 babae akong L violence r/t not manifest any possible. “GOAL MET”
@ asawa, maglagot F lack of violent action that can ® Familiarity, with trust in
4:10 unya mawalaan developmental harm others as the staff and other health After the course of intervention,
pm nakog control R trust. evidence by: care members can the client had able to:
usahay” as E ® Violence a. verbalization of no decreased the client’s a. verbalized of no desire or
verbalized by the L can cause desire or intension to anxiety and facilitate intension to harm others as
patient. A devastating harm others. communication. evidence by “tama bitaw ka,
T action that is b. patient will be free pramis dli na nako awayun
Objectives: I consciously from injury. 2. Assess the akong bana.”
1. History of O done by an c. verbalization of presence/degree of client’s b. be free from injury.
violence to N individual. decreased feelings of potential for violence c. verbalized decreased feelings
family members. S One of its mistrust and anxiety. (toward others) on a 1–10 of mistrust and anxiety as
2. Suspicious H major causes scale. evidenced by “mag tiwala nako
3. Irritable I are lack of ® Information is very sa akong bana, dli na nako siya
behavior. P development essential for planning awayon. Dili napud ko ma
4. Degree of of trust to ones nursing care hadluk kung ingnan ko na naay
client’s potential P own self or to and documents degree of kabit akong bana.”
for violence- 4. A others. intent.
T Though it may
T be prevented, 3. Provide protective
E violence supervision for the client.
R should not be ® For the safety of the
N taken for client and others as a
granted priority.
because it can
lead to 4. Be aware of the
harassment, indications after the client
homicide and is having her auditory
other hallucinations again.
incidence. ® The client may act as
what she hears. Early
Bibliography: response to indications
Ackley, Bet decreases the change of
and Ladwig. acting out what she fears.
Nursing
Diagnosis 5. Provide a structured and
Handbook. 7th safety environment for the
Edition, client.
Mosby ® providing a safe
Elsevier, St. environment for the client
Louis should prioritize.
Moussori ©
2006. 6. Be careful in offering a
pat on the shoulder/hug,
etc.
® Touch may be
misinterpreted as an
aggressive gesture.

7. Encourage
verbalizations of feelings
and promote acceptable
verbal outlet(s) for
expression, e.g., yelling in
room, pounding pillows.
® Ventilation of feelings
may reduce need for
inappropriate physical
action.

8. Help client define

alternatives to aggressive
behaviors. Monitor
competitive activities; use
with caution.
® Enables client to learn
and handle situations in a
socially acceptable manner.
Anxiety and fear may
escalate during activities in
which the client perceives
self in competition with
others and can trigger
violent behavior.

9. Set limits, stating in a

clear, specific, firm manner
what is
acceptable/unacceptable.
Use demands only when
situation requires.
® Being clear and
remaining calm increase
chance that client will
cooperate, lessening
potential for violence.
Having few but important
limits enhances chances of
having them observed.

10. Accept verbal hostility

without retaliation or
defense. Be aware of own
response to client behavior
(e.g., tend
anger/fear).
® Behavior is not usually
directed at nurse
personally, and responding
defensively will tend to
exacerbate situations.
Looking at meaning behind
the words will be more
productive. Awareness of
own response allows nurse
to express/deal with those
feelings.