Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychotropic Medications

(^112) 10. As agitation decreases, assess client’s readiness for restraint 9. Observe the client in restraints every 15 minutes (or ac- Follow protocol established by the institution. The Joint (^) Outcome Criteria^ extremities is not compromised (check temperature, color, to self or others. Be sure to have suffiCommission formerly the Joint Commission on Acredita-tion of Healthcare Organizations [JCAHO]) requires that an in-person evaluation (by a physician, clinical psycholo-gist, or other licensed independent practitioner responsible for the care of the patient) be conducted within 1 hour of initiating restraint or seclusion (The Joint Commission, 2010). The physician must physician reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for assist. client and staff.cording to institutional policy). Ensure that circulation to assessing client’s response. pulses). Assist client with needs related to nutrition, hy-dration, and elimination. Position client so that comfort is facilitated and aspiration can be prevented. Continuous one-to-one monitoring may be necessary for the client who is highly agitated or for whom there is a high risk of self- or accidental injury. removal or reduction. Remove one restraint at a time while children and adolescents. ●^ ALTERATIONS IN PSYCHOSOCIAL ADAPTATIONClient safety is a nursing priority.This minimizes risk of injury to cient staff available to

2506_Ch05_105-124.indd 0112 2506 Ch 05 105 - 124 .ind 2. Client demonstrates trust of others in his or her environment.Defi 3. Client maintains reality orientation. 4. Client causes no harm to self or others.as imposed by others and as a negative or threatening state. Possible Etiologies (“related to”)[Lack of trust][Panic level of anxiety][Regression to earlier level of development][Delusional thinking][Past experiences of diffi●[Repressed fears]Unaccepted social behavior 1. Anxiety is maintained at a level at which client feels no need d 0 for aggression.SOCIAL ISOLATION 1 nition: 12 Aloneness experienced by the individual and perceived culty in interactions with others] 1 10/1/10 9:34:18 AM 0 / 1 / 10 9 : 34 : 18 AM