Assessment Subjective Verbalized in a loud voice Umalis ka dito, susuntukin kita.

Objective Present Problems regarding money matters with sister o has not slept o became violent blaming sister o tried to stab sister Past In 1963, failed Business Management Admission test at Ateneo week after: o Became restless pacing back and forth along neighborhood yelling and uttering vulgar words In 1973, knew girlfriend will migrate to US o Became violent punching self in the arms o Throwing objects at the relatives o Banging head at the sofa o Breaking valuable

Diagnosis Risk for Self and Other Directed Violence

Rationale Behaviors in which an individual demonstrates that he/she can be physically, emotionally, or sexually harmful to self or others. Due to the decrease in Na, KATPase activity neuronal membranes become irritable needing fewer stimuli to provide cell firing. Na then accumulates inside the cell, hyper polarizing functions of inhibitory neurotransmitters are diminished Increased norepinephrine and dopamin secretion due to perceived deficiency in Na-dependent calcium efflux of the pre-synaptic terminals resulting to mania manifested by aggression and violence.

Planning Short term At the end of 45 minute of patient interaction, the client would be able to: be aware of aggressive and violent behaviors by expression of feelings understand and repeat health teachings regarding self-control and anger management perform relaxation techniques Long term At the end of the shift, the client will demonstrate selfcontrol as evidenced by relaxed posture and nonviolent behavior not injure itself or others

Intervention > intervene immediately if the client demonstrates aggressive behavior toward self or others. > listen for verbal threats or hostile remarks towards self or others.

Rationale > immediate intervention in clients harm or assault risk behaviors may prevent harm or injury

Evaluation

> the client verbal threats, physical contact and acting out may be precursors or cues to impending violence. > It is important to equip the client family effectively with resources and interventions when the clients behaviors threatens the safety of self or others and the integrity of the environment.

> teach the client and the family to recognize early signs and symptoms of escalating agitation or hypomanic behaviors (yelling, cursing, threatening, pacing, intrusiveness, suspiciousness) that can lead to full blown mania, self-harm, assault or violence. > help the client manage angry, inappropriate or intrusive behaviors in a therapeutic but firm direct manner

> helping the client manage angry inappropriate or intrusive behaviors early in the escalation of phase may prevent assault or violence > a calm external environment often helped to promote a relaxed internal state within the client and and may lessen agitation and

> Reduce milieu noise and stimulation or accompany client to a calmer, quieter environment at early signs of anger,

things in the house

frustration or agitation > remind the client to continue seeking staff when first experiencing frustration, anger, hostility or suspiciousness rather than waiting until the negative thoughts and feelings are out of control, which can lead to violence. > praise the clients efforts made to control anger or hostility to self and others.

prevent violence > staff can help the client prevent negative feelings from reaching destructive levels if they know the clients state in advance. Staff can engage client in therapeutic activities/exercises and can offer medications when necessary. > positive feedback reinforces repetition of positive functional behaviors

>Administer antipsychotic drug, Lithium as ordered

> Alters of ion transport in muscle and nerve cells; increased receptor sensitivity to serotonin > Music therapy relaxes the mind and helps express feelings. Remotivational therapy Biblio therapy to retreat unhealthy defense of client and reflect on how

>involve client in activity therapies such as Music therapy, remotivational therapy and biblio therapy

Lithium Carbonate 450 mg 1 tab BID Classification: Mood Stabilizer Trade name: Eskalith, Lithane, Lithonate, Lithobid, Carbolith, Lithizine Indications: To treat bipolar manic-depressive psychosis, manic episodes. Action: Alteration of ion transport in muscle and nerve cells; increased receptor sensitivity to serotonin. Contraindications: Liver and renal dse., pregnancy, lactation, severe cardiovascular dse., severe dehydration, brain tumor damage, sodium depletion Side effects/ Adverse Reactions: Headache, lethargy, drowsiness, dizziness, tremors, slurred speech, dry mouth, anorexia, vomiting, diarrhea, polyuria, hypotension, abdominal pain, muscle weakness, restlessness, urinary incontinence, clonic movements, stupor, azotemia, leukocytosis, nephrotoxicity Nursing Considerations: 1. Observe client for signs and symptoms of depression: mood changes, insomia, apathy, or lack of interest in activities. 2. Record clients vital signs. Orthostatic hypotension is common. 3. Monitor for signs of lithium toxicity. 4. Monitor client for suicidal tendencies when marked depression is present. 5. Evaluate clients urine output and body weight. Fluid volume deficit may occur as a result of polyuria. 6. Observe client for fine and gross motor tremors and presence of slurred speed, which are signs of adverse reaction. 7. Check if clients cardiac status. Loss of fluids and electrolytes may cause cardiac dysrhythmias. 8. Monitor clients serum electrolytes. Report abnormal findings. 9. Emphasize the importance of adherence to the therapy, laboratory tests, and follow-up visits with the health care provider. 10. Encourage client to keep medical appointments.