Short-term Goals[Depressed mood] [Inaccurate perception of the environment]Body lang uage —rigid post ure, clenching of fiInterventions with Suicidal ideation, plan, available meansCognitive impairment 3. Remove all potentially dangerous objects from client’s en- 1. Assess client’s level of anxiety and behaviors that indicate 1. Client will maintain agitation at manageable level so as not to 2. Client will not harm self or others.Long-term GoalClient will not harm self or others. 2. Maintain low level of stimuli in client’s environment (low Goals/Objectivesactivity, pacing, breathlessness, and threatening stancesthe anxiety is increasing. vironment. become violent.increases in a highly stimulating environment.lighting, few people, simple decor, low noise level). may be able to intervene before violence occurs.Impairment of impulse control]Disorientation or confusionIn a disoriented, confused state, client may use Delirium, Dementia, and Amnestic Disorders Selected RationalesRecognizing these behaviors, nurse sts and jaw, hyper-Anxiety ●^61
2506_Ch03_054-070.indd 61 2506 Ch 03 054 - 070 .indd 6. Interrupt periods of unreality and reorient. 6 7. Use tranquilizing medications and soft restraints, as pre-^ 5. Maintain a calm manner with client. Attempt to prevent 8. Sit with client and provide one-to-one observation if assessed 4. Have suffi 1 these objects to harm self or others.periods of elevated anxiety. transferred to client.provide for physical safety of client or primary nurse or both.agitation sometimes increases; however, they may be required to ensure client safety.tion, if necessary. frightening client unnecessarily. Provide continual reas-to be actively suicidal.jeopardized during periods of disorientation. Correcting and one-to-one observation may be necessary to prevent a suicidal attempt.misinterpretations of reality enhances client’s feelings of self-worth and personal dignity.surance and support. scribed by physician, cient staff available to execute a physical confronta-Assistance may be required from others to for protection of client and others during Client safety is a nursing priority, Anxiety is contagious and can be Use restraints judiciouslyClient safety is , because 1 10/1/10 9:33:40 AM 0 / 1 / 10 9 : 33 : 40 AM