Name of patient: Mr.

Admission date:

DSM IV TR Diagnosis: substance induced psychotic disorder

implementation date: may 9 2015

Nursing diagnosis: Risk for other directed violence

Cause analysis: at risk for behaviors in which an individual demonstrates that he can be physically, emotionally harmful
to self or others.

Cues
Subjective
Apil man kog
gira sauna,
igsoon man
mi ni hitler as
verbalized by
the patient

Objectives
Intervention
STO:
NURESE-PATIENT
INTERACTION
After 30
Intervene
minutes of
nurse-patient
immediately yo
interaction the
protect the client
patient will
and others from
exhibit socially
harm or injury if
acceptable
the client
behavior.
demonstrates
behaviors that
LTO
threaten safety.
Review the clients
After 3 weeks
history for violent
of nursing
or self destructive
duty, NPI and
behaviors as a
effective
result of alcohol or
nursing
drug use.
intervention
the patient will
exhibit socially

Rationale

The safety of the

client and others
in the
environment is
the first priority
of the nurse and
staff

A history of
violence is the
best predictor of
violence and
prediction is the
most effective
means of

Evaluation

acceptable
behavior
related to
increased self
esteem.

prevention.

Monitor the client

for symptoms of
withdrawal from
alcohol or drugs

Administer
appropriate
medications to
individuals who
demonstrate
withdrawal
behaviors

Check the client

for symptoms of
organic psychosis
(eg. Dementia,

Assessing early
for withdrawal
symptoms helps
to protect the
client and others
from destructive
behaviors as a
result of
agitation,
irritability,
excitement,
paranoia,
euphoria, or
mania.

Administering
appropriate
medications for
withdrawal helps
to relieve
symptoms
maintain health
and safety, and
prevent
destructive acts.

hallucinations,
illusions,
delusions)

Assessing for
organic
psychosis helps
the nurse and
staff evaluate
the extent of the
clients reality
orientation and
intervenes to
prevent
aggression or
violence.

Provides the
client with an
opportunity to
identify with
peers and
respond to
confrontation
about ineffective
coping or
dysfunctional
behavior, the
client has an
opportunity to
improve
communication
skills as he

Milue Therapy:
Group therapy

Pharmacology:
Haloperidol
20mg/tab tab
OD
Biperidine 2g/tab
Chlorpromazine
100g/tab 11tab qhr

receives
emotional
support from the
group. Feelings
of hopelessness,
discouragement,
and
demoralization
are shared with
peers