Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychotropic Medications

(Barré) #1
Interventions with 1. Within [a specifi[Perception of the environment as threatening][Receiving auditory or visual commands of a threatening na- 1. Maintain low level of stimuli in client’s environment (low Goals/ObjectivesShort-term Goals 3. Remove all dangerous objects from client’s environment Suicidal ideation, plan, available meansLong-term Goal 2. Client will not harm self or others 2. Observe client’s behavior frequently (every 15 minutes). Client will not harm self or others.ture] tance with intervention.increasing anxiety and agitation and report to staff for assis-creating suspiciousness in the individual. Close observation that in his or her agitated, confused state client may not use Do this while carrying out routine activities is necessary so that intervention can occur if required to lighting, few people, simple decor, low noise level). ensure client’s (and others’) safety.ety level rises in a stimulating environment. A suspicious, agitated client may perceive individuals as threatening.Schizophrenia and Other Psychotic Disorders Selected Rationales ed time], client will recognize signs of so as to avoid ●Anxi-^111 so

2 2506_Ch05_105-124.indd 0111 506 Ch 05 105 - 124 .indd 4. Try to redirect the violent behavior with physical outlets for 5. Staff should maintain and convey a calm attitude toward 0 7. Administer tranquilizing medications as ordered by physi- 8. I f c l i e n t i s n o t c a l m e d b y “ t a l k i n g d o w n ” o r b y m e d i c a t i o n , u s e 6. Have suffi 111 for a psychiatric client.a safe and effective way of relieving pent-up tension.of mecha n ic a l re st ra i nt s may be nece s sa r y. Re st ra i nt s shou ld be used only as a last resort, after all other interventions have been unsuccessful, and the client is clearly at risk of harm the client’s anxiety (e.g., punching bag). to client if it becomes necessary. client. evidence of control over the situation and provides some physical security for staff.them to harm self or others.cian. Monitor medication for its effectiveness and for any adverse side effects. staff to client.alternative” must be selected when planning interventions Anxiety is contagious and can be transmitted from cient staff available to indicate a show of strength The avenue of the “least restrictive This shows the client Physical exercise is 1 10/1/10 9:34:18 AM 0 / 1 / 10 9 : 34 : 18 AM

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