Violence
Violence
(_)Actual (_) Potential
| (_)
Acute agitation (_) Poor impluse coordination (_) Mania (_) Feelings of helplessness (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major:
(Must be present) |
(_)
History of harm to others (_) Destruction of property (_) Overt aggressive acts |
| Minor:
(May be present) |
(_)
Acute agitation (_) Suspiciousness (_) Persecutory
delusions (_) Inflexible (_) Verbal threats of physical assault (_) Low frustration tolerance (_) Poor impulse control (_) Feelings of helplessness (_) Excessively controlled |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Experience control of behavior with assistance from others. (_) Describe causation and possible preventative measures. (_) Other: |
(_)
Assess patient's potential for violence and past history. (_) Maintain patient's personal space, (i.e. allow 5 times greater space than that for individual in control). (_) Seclusion: Check q _____ (_) Restraints:__________ Check q ___ (_) Set limits:_____________________ (_) Decrease noise level. (_) Provide
environment that provides safety and reduces agitation: (_) Acknowledge feelings. (_) Explore the precipitating event. (_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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