Interventions with Selected Rationales
- Observe client’s behavior frequently. Do this through routine activities and interactions; avoid appearing watchful and suspicious. Close observation is required so that intervention can occur if required to ensure client's (and others') safety.
- Observe for suicidal behaviors: verbal statements, such as "I’m going to kill myself." and "Very soon my mother won’t have to worry herself about me any longer," and nonverbal behaviors, such as giving away cherished items and mood swings. Clients who are contemplating suicide often give clues regarding their potential behavior. The clues may be very subtle and require keen assessment skills by the nurse.
- Determine suicidal intent and available means. Ask direct questions, such as "Do you plan to kill yourself?" and "How do you plan to do it?" The risk of suicide is greatly increased if client has developed a plan and particularly if means exist for the client to execute the plan.
- Obtain verbal or written contract from client agreeing not to harm self and to seek out staff in the event that suicidal ideation occurs. Discussion of suicidal feelings with a trusted individual provides some relief to client. A contract gets the subject out in the open and places some of the responsibility for his or her safety with client. An attitude of acceptance of client as a worthwhile individual is conveyed.
- Help client recognize when anger occurs and accept those feelings as his or her own. Have client keep an "anger notebook" in which feelings of anger experienced during a 24-hour period are recorded. Information regarding source of anger, behavioral response, and client’s perception of the situation should also be noted. Discuss entries with client, and suggest alternative behavioral responses for those identified as maladaptive.
- Act as a role model for appropriate expression of angry feelings, and give positive reinforcement to client for attempting to conform. It is vital that client express angry feelings, because suicide and other self-destructive behaviors are often viewed as the result of anger turned inward on the self.
- Remove all dangerous objects from client’s environment (e.g., sharp items, belts, ties, straps, breakable items, smoking materials). Client safety is a nursing priority.
- Try to redirect violent behavior by means of physical outlets for client’s anxiety (e.g., punching bag, jogging). Physical exercise is a safe and effective way of relieving pent-up tension.
- Be available to stay with client as anxiety level and tensions begin to rise. Presence of a trusted individual provides a feeling of security and may help to prevent rapid escalation of anxiety.
- Staff should maintain and convey a calm attitude to client. Anxiety is contagious and can be transmitted from staff members to client.
- Have sufficient staff available to indicate a show of strength to client if necessary. This conveys to the client evidence of control over the situation and provides some physical security for staff.
- Administer tranquilizing medications as ordered by physician, or obtain an order if necessary. Monitor client response for effectiveness of the medication and for adverse side effects. Short-term use of tranquilizing medications such as anxiolytics or antipsychotics can induce a calming effect on the client and may prevent aggressive behaviors.
- Use of mechanical restraints or isolation room may be required if less restrictive interventions are unsuccessful. Follow policy and procedure prescribed by the institution in executing this intervention. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that the physician reevaluate and issue a new order for restraints every 4 hours for adults age 18 years and older. If client has previously refused medication, administer after restraints have been applied. Most states consider this intervention appropriate in emergency situations or in the event that a client would likely harm self or others.
- Observe client in restraints every 15 minutes (or according to institutional policy). Ensure that circulation to extremities is not compromised (check temperature, color, pulses). Assist client with needs related to nutrition, hydration, and elimination. Position client so that comfort is facilitated and aspiration can be prevented. Client safety is a nursing priority.
- As agitation decreases, assess client’s readiness for restraint removal or reduction. Remove one restraint at a time while assessing client’s response. This minimizes risk of injury to the client and staff.
Source : http://davisplus.fadavis.com/townsend-essentials4/Care_Plans/CarePlan12-01.cfm?title=Risk%20for%20Self-Directed%20or%20Other-Directed%20Violence
