mental health question

Cosper123 · May 12, 2008

is risk for violence a proper nursing diagnosis? don't have my book here so just going with what you have, but if you haven't looked it up yet you may want to. sounds like it should be something more like risk for trauma/risk of violence directed towards others. but again, not 100% certain.

here some i used during my psych rotation. btw if you haven't created a collection of interventions and rationales you may want to start saving them in a word document or something. cut and paste can really be your friend.

plus, when you get further along in the program you can look back and it's freaking amusing to see how dumb you were when you started

also, if you are having a great deal of trouble in general with careplans there are many good careplan books out there. overall though you should be ok with a basic pocket sized nursing diagnosis book.

interventions

[color=#3366ff]rationale

decrease environmental stimuli, avoiding exposure to areas or situations of predictable high stimulation and removing stimulation from area if client becomes agitated.

[color=#3366ff]client may be unable to focus attention on only relevant stimuli and will be reacting/responding to all environmental stimuli.

continually reevaluate client's ability to tolerate frustration and/or individual situations.

[color=#3366ff]facilitates early intervention and assists client to manage situation independently if possible.

provide safe environment, removing objects and rearranging room to prevent accidental/purposeful injury to self or others.

[color=#3366ff]grandiose thinking (e.g., "i am superman") and hyperactive behavior can lead to destructive actions such as trying to run through the wall/into others.

intervene when agitation begins to develop, with strategies such as being verbally direct, prompting more effective behavior, redirecting or removing from the provoking situation, voluntary "time out" in room or a quiet place, physical control (e.g., holding).

[color=#3366ff]intervention at earliest sign of agitation can assist client in regaining control, preventing escalation to violence and allowing treatment in least restrictive manner.

communicate rationale for staff action in a concrete manner.

[color=#3366ff]agitated persons are unable to process complicated communication.

ignore/minimize attention given to undesired behaviors (e.g., bizarre dress, use of profanity), while setting limits on destructive actions.

[color=#3366ff]avoids giving reinforcement to these behaviors, while providing control for potentially dangerous activities.

offer alternatives when available ("i don't have any coffee. would you like a glass of juice?")

[color=#3366ff]uses client's distractibility to help decrease the frustration of being refused.

encourage client, during calm moments, to recognize antecedents/precipitants to agitation.

[color=#3366ff]promotes early recognition of developing problem, allowing client to plan for alternative responses and intervene in a timely fashion.

assist client in identifying alternative behaviors that are acceptable to both client and staff. role-play if indicated. intervene as necessary to protect client when behavior is provocative or offensive. (refer to nursing diagnosis [nd]: impaired social interaction.)

[color=#3366ff]client will be more apt to follow through on alternatives if they are mutually acceptable. practice in a nonagitated time helps client learn new behavior. client may become physically violent with others when behavior is socially unacceptable/rejected.

provide reinforcement/positive feedback when client attempts to handle frustrating incidents without violence.

[color=#3366ff]increases feeling of success and the likelihood of client repeating that behavior again.

Daytonite, BSN, RN · May 12, 2008

When you use a "Risk for" diagnosis you must have a specific problem, in this case, a behavior, in mind. So, what specific type of violence and what are the symptoms or manifestations you would expect to see. You must establish that first. Interventions for these nursing diagnoses are limited to:

strategies to prevent the problem from happening in the first place
monitoring for the specific signs and symptoms of the chosen problem
reporting any symptoms that do occur to the doctor or other concerned professional

If symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis

See post #8 on this thread: https://allnurses.com/forums/f50/help-care-plans-286986.html (Assistance - Help with Care Plans), for more information about "Risk for" diagnoses.