Name of patient: Mr. Admission date:

DSM IV TR Diagnosis: substance induced psychotic disorder implementation date: may 9 2015

Nursing diagnosis: Risk for other directed violence

Cause analysis: at risk for behaviors in which an individual demonstrates that he can be physically, emotionally harmful to self or others.

Cues

Objectives

Intervention

Rationale

Evaluation

Subjective

Apil man kog gira sauna, igsoon man mi ni hitler as verbalized by the patient

STO:

After 30 minutes of nurse-patient interaction the patient will exhibit socially acceptable behavior.

LTO

After 3 weeks of nursing duty, NPI and effective nursing intervention the patient will exhibit socially acceptable behavior related to increased self esteem.

NURESE-PATIENT INTERACTION

Intervene immediately yo protect the client and others from harm or injury if the client demonstrates behaviors that threaten safety.

Review the clients history for violent or self destructive behaviors as a result of alcohol or drug use.

Monitor the client for symptoms of withdrawal from alcohol or drugs

Administer appropriate medications to individuals who demonstrate withdrawal behaviors

Check the client for symptoms of organic psychosis (eg. Dementia, hallucinations, illusions, delusions)

Milue Therapy:

Group therapy

Pharmacology:

Haloperidol 20mg/tab tab OD

Biperidine 2g/tab

Chlorpromazine 100g/tab 11tab qhr

The safety of the client and others in the environment is the first priority of the nurse and staff

A history of violence is the best predictor of violence and prediction is the most effective means of prevention.

Assessing early for withdrawal symptoms helps to protect the client and others from destructive behaviors as a result of agitation, irritability, excitement, paranoia, euphoria, or mania.

Administering appropriate medications for withdrawal helps to relieve symptoms maintain health and safety, and prevent destructive acts.

Assessing for organic psychosis helps the nurse and staff evaluate the extent of the clients reality orientation and intervenes to prevent aggression or violence.

Provides the client with an opportunity to identify with peers and respond to confrontation about ineffective coping or dysfunctional behavior, the client has an opportunity to improve communication skills as he receives emotional support from the group. Feelings of hopelessness, discouragement, and demoralization are shared with peers