[Low tolerance for frustration]^44 Goals/ObjectivesSuicidal ideation, plan, [available means]ImpulsivityCommon Nursing Diagnoses and Interventions for the Client with Tourette’s Disorder(Interventions are applicable to various health care settings, such as in-patient and partial hospitalization, community outpatient clinic, home health, and private practice.)●[History or threats of violence toward self or others or of Body lang uage (e.g., rigid post ure, clenching of fi[Abnormalities in brain neurotransmitters]DefiShort-term GoalsRelated/Risk Factors (“related to”)strates that he or she can be physically, emotionally, and/or sexually harmful [either to self or to others]^ peractivity, pacing, breathlessness, and threatening stances)^ destruction to the property of others]OTHER-DIRECTED VIOLENCERISK FOR SELF-DIRECTED OR nition:●^ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION At risk for behaviors in which an individual demon- sts and jaw, hy-
2 2506_Ch02_014-053.indd Sec1:44 506 Ch 02 014 - 053 .ind 4. Redirect violent behavior with physical outlets for frustra- 1. Observe client’s behavior frequently through routine activities Long-term Goal 3. Provide hand coverings and other restraints that prevent Client will not harm self or others.Interventions with 2. Monitor for self-destructive behavior and impulses. A 2. Client will not harm self or others. 1. Client will seek out staff or support person at any time if d Snition of behaviors that precede the onset of aggression may mutilation. thoughts of harming self or others should occur.staff member may need to stay with client to prevent self-provide the opportunity to intervene before violence occurs.tion. and a feeling of relaxation is induced.in agitation. and interactions. Become aware of behaviors that indicate a rise client from self-mutilative behaviors. ternal controls against self-aggressive behaviors.ec 1 : 44 Excess energy is released through physical activities Client safety is a nursing priority.Stress commonly increases tic behaviors. Recog- Selected RationalesProvide immediate ex- 1 10/1/10 9:33:25 AM 0 / 1 / 10 9 : 33 : 25 AM
