[Paranoid ideation][Biochemical alterations][Repetition of verbalizations (continuous complaints, requests, Suicidal ideation, plan, available meansImpulsivity●[History or threats of violence toward self or others or of Body language (e.g., rigid posture, clenching of fi[Rage reactions]Defi[Hallucinations][Delusions]strates that he or she can be physically, emotionally, and/or sexu-ally harmful [either to self or to others] Related/Risk Factors (“related to”)[Manic excitement]^150 [Threat to self-concept][Suspicion of others]^ destruction to the property of others]and demands)] hyperactivity, pacing, breathlessness, threatening stances)RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE^ nition:●^ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION At risk for behaviors in which an individual demon- sts and jaw,
2506_Ch07_145-160.indd 0150 2506 Ch 07 145 - 160 .indthe administration of tranquilizing medication during fiof treatment (decreasing risk of violence to self or others).Long-term GoalClient will not harm self or others.Interventions with 2. Observe client’s behavior frequently (every 15 minutes). Short-term GoalGoals/Objectives 1. Maintain^ Client’s agitation will be maintained at manageable level with d3. Remove all dangerous objects from client’s environment 0 Close observation is required so that intervention can occur if required to ensure client’s (and others’) safety.agitation rise in a stimulating environment. Individuals may be perceived as threatening by a suspicious, agitated client.(sharp objects, glass or mirrored items, belts, ties, smokinging, few people, simple decor, low noise level) 150 low level of stimuli in client’s environment (low light-Selected Rationales. Anxiety and rst week^1 10/1/10 9:34:49 AM 0 / 1 / 10 9 : 34 : 49 AM
