ASSESSMENT O> insistent demand for privileges >ignoring instructions

DIAGNOSIS Risk for otherdirected violence related to psychotic symptomatology (loose thought processes) secondary to mental illness

PLANNING Short term: After 2 hours of nursing intervention, client will maintain orientation to time, place, person and circumstances. Long term: Client will demonstrate accurate perception of environment by responding appropriately to stimuli indigenous to the surroundings

INTERVENTION 1. Decrease amount of stimuli in the client s environment (eg. Low noise level, few people, few dcor)

RATIONALE - To decrease possibility of forming inaccurate sensory perception To decrease false sensory perception and enhance client s sense of self-worth and dignity

2. Reinforce reality - Correct client s description of inaccurate perception - Reorient and let client focus on real situations and people 3. Remove dangerous objects (sharps and breakable things) from the client s environment 4. Allow nursing care to be given by the same personnel on a regular basis, if possible

EVALUATION After 2 hours of nursing intervention, client maintained orientation to time, place, person and circumstances and demonstrated accurate perception to the environment

To provide safety to the client, other patients and personnel To provide feeling of security and stability to prevent agitation To prevent transmission of anxiety to the client

5. Maintain and convey a calm attitude towards the client

6. Redirect behavior by activities like music, art and exercises 7. Be clear and consistent with the instructions 8. Provide reassurance of safety if client responds with fear to inaccurate sensory perception

To relieve pent up tension To avoid confusion

To provide safety and security to prevent agitation due to fear