RISK FOR VIOLENCE: SELF-DIRECTED OR OTHER-DIRECTED

Definition: Behaviors in which an individual demonstrates that he or she can be

physically, emotionally, and/or sexually harmful to self or to others.

Related/Risk Factors ("related to")

[Fixation in earlier level of development]
[Negative role modeling]
[Dysfunctional family system]
[Low self-esteem]
[Unresolved grief]
[Psychic overload]
[Extended exposure to stressful situation]
[Lack of support systems]
[Biological factors, such as organic changes in the brain]
Body language---rigid posture, clenching of fists and jaw, hyperactivity, pacing,
breathlessness, and threatening stances
History or threats of violence toward self or others or of destruction to property of
others
Impulsivity
Suicidal ideation, plan, available means
[Anger; rage]
[Increasing anxiety level]
[Depressed mood]

Goals/Objectives

Short-Term Goals

1. Client will seek out staff member when hostile or suicidal feelings occur.
2. Client will verbalize adaptive coping strategies to use when hostile or suicidal
feelings occur.

Long-Term Goals

1. Client will demonstrate adaptive coping strategies to use when hostile or

suicidal feelings occur.
2. Client will not harm self or others.

Interventions with Selected Rationales

1. Observe client's behavior frequently. Do this through routine activities and
interactions; avoid appearing watchful and suspicious. Close observation is
required so that intervention can occur if required to ensure client's (and
others') safety.
2. Observe for suicidal behaviors: verbal statements, such as "I'm going to kill
myself'" and "Very soon my mother won't have to worry herself about me any
longer," and nonverbal behaviors, such as mood swings and giving away
cherished items. Clients who are contemplating suicide often give clues
regarding their potential behavior. The clues may be very subtle and require
keen assessment skills on the part of the nurse.
3. Determine suicidal intent and available means. Ask direct questions, such as
"Do you plan to kill yourself?" and "How do you plan to do it?" The risk of
suicide is greatly increased if the client has developed a plan and particularly
if the client has means to execute the plan.
4. Obtain verbal or written contract from client agreeing not to harm self and to
seek out staff if suicidal ideation occurs. Discussion of suicidal feelings with a
trusted individual provides a degree of relief to the client. A contract gets the
subject out in the open and places some of the responsibility for his or her
safety with the client. An attitude of acceptance of the client as a worthwhile
individual is conveyed.
5. Assist client to recognize when anger occurs and to accept those feelings as his
or her own. Have client keep an "anger notebook," in which feelings of anger
experienced during a 24-hour period are recorded. Information regarding
source of anger, behavioral response, and client's perception of the situation
should also be noted. Discuss entries with client and suggest alternative
behavioral responses for responses identified as maladaptive.
6. Act as a role model for appropriate expression of angry feelings and give
positive reinforcement to client for attempting to conform. It is vital that the
client express angry feelings because suicide and other self-destructive
behaviors are often viewed as the result of anger turned inward onthe self.
7. Remove all dangerous objects from client's environment (e.g., sharp items,
belts, ties, straps, breakable items, smoking materials). Client safety is a
nursing priority.
8. Try to redirect violent behavior with physical outlets for the client's anxiety
(e.g., punching bag, jogging). Physical exercise is a safe and effective way of
relieving pent-up tension.
9. Be available to stay with client as anxiety level and tensions begin to rise. The
presence of a trusted individual provides a feeling of security and may help
prevent rapid escalation of anxiety.
10. Staff should maintain and convey a calm attitude to client. Anxiety is
contagious and can be transmitted from staff members to client.
 11. Have sufficient staff available to indicate a show of strength to client if
necessary. This conveys to the client evidence of control over the situation
and provides some physical security for staff.
12. Administer tranquilizing medications as ordered by physician or obtain an
order if necessary. Monitor client response for effectiveness of the medication
and for adverse side effects. Tranquilizing medications, such as anxiolytics
and antipsychotics, are capable of inducing a calming effect on the client
and may prevent aggressive behaviors.
13.Use of mechanical restraints or isolation room may be required if less
restrictive interventions are unsuccessful. Follow policy and procedure
prescribed by the institution in executing this intervention. The Joint
Commission on Accreditation of Healthcare Organizations requires that the
physician issue a new order for restraints every 4 hours for adults and every 1
to 2 hours for children and adolescents. If the client has previously refused
medication, administer it after restraints have been applied. Most states
consider this intervention appropriate in emergency situations or in situations in
which a client would likely harm self or others.
14. Observe the client in restraints every 15 minutes (or according to institutional
policy). Ensure that circulation to extremities is not compromised (check
temperature, color, pulses). Assist client with needs related to nutrition,
hydration, and elimination. Position client so that comfort is facilitated and
aspiration can be prevented. Client safety is a nursing priority.
15. As agitation decreases, assess client's readiness for restraint removal or
reduction. Remove one restraint at a time, while assessing client's
response. This minimizes risk of injury to client and staff.

Outcome Criteria

1. Anxiety is maintained at a level at which client feels no need for aggression.

2. Client denies any ideas of self-destruction.
3. Client demonstrates use of adaptive coping strategies when feelings of hostility
or suicide occur.
4. Client verbalizes community support systems from whom assistance may be
requested when personal coping strategies are not successful.

SOCIAL ISOLATION/IMPAIRED SOCIAL INTERACTION

Definition: Social isolation is the condition of aloneness experienced by the
individual and perceived as imposed by others and as a negative or threatened state;
impaired social interaction is the state in which an individual participates in an
insufficient or excessive quantity or ineffective quality of social exchange.
Possible Etiologies ("related to")
[Developmental regression]
[Egocentric behaviors (which offend others and discourage relationships)]
Disturbed thought processes [delusional thinking]
[Fear of rejection or failure of the interaction]
[Impaired cognition fostering negative view of self]
[Unresolved grief]
Absence of available significant others or peers

Defining Characteristics ("evidenced by")

Sad, dull affect
Being uncommunicative, withdrawn; lacking eye contact
Preoccupation with own thoughts; performance of repetitive, meaningless actions
Seeking to be alone
[Assuming fetal position]
Expression of feelings of aloneness or rejection
Verbalization or observation of discomfort in social situations
Dysfunctional interaction with peers, family, and others

Goals/Objectives

Short-Term Goal

Client will develop trusting relationship with nurse or counselor within reasonable
period of time.

Long-Term Goals

1. Client will voluntarily spend time with other clients and nurse or therapist in
group activities by discharge from treatment.

2. Client will refrain from using egocentric behaviors that offend others and
discourage relationships by discharge from treatment.

Interventions with Selected Rationales

1. Spend time with client. This may mean just sitting in silence for a while. Your
presence may help improve client's perception of self as a worthwhile person.
2. Develop a therapeutic nurse-client relationship through frequent, brief contacts
and an accepting attitude. Show unconditional positive regard. Your presence,
acceptance, and conveyance of positive regard enhance the client's feelings
of self-worth.
 3. After client feels comfortable in a one-to-one relationship, encourage
attendance in group activities. May need to attend with client the first few times
to offer support. Accept client's decision to remove self from group situation if
anxiety becomes too great. The presence of a trusted individual provides
emotional security for the client.
4. Verbally acknowledge client's absence from any group activities. Knowledge
that his or her absence was noticed may reinforce the client's feelings of self-
worth.
5. Teach assertiveness techniques. Interactions with others may be negatively
affected by client's use of passive or aggressive behaviors. Knowledge of
assertive techniques could improve client's relationships with others.
6. Provide direct feedback about client's interactions with others. Do this in a
nonjudgmental manner. Help client learn how to respond more appropriately in
interactions with others. Teach client skills that may be used to approach others
in a more socially acceptable manner. Practice these skills through role
play. Client may not realize how he or she is being perceived by others. Direct
feedback from a trusted individual may help alter these behaviors in a
positive manner. Practicing these skills in role play facilitates their use in
real situations.
7. The depressed client must have a lot of structure in his or her life because of
impairment in decision-making and problem-solving ability. Devise a plan of
therapeutic activities and provide client with a written time
schedule. Remember: The client who is moderately depressed feels best early
in the day, whereas the severely depressed individual feels better later in the
day; choose these times for the client to participate in activities.
8. Provide positive reinforcement for client's voluntary interactions with
others. Positive reinforcement enhances self-esteem and encourages
repetition of desirable behaviors.

Outcome Criteria

1. Client demonstrates willingness and desire to socialize with others.

2. Client voluntarily attends group activities.
3. Client approaches others in appropriate manner for one-to-one interaction.