Violence

Violence

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Acute agitation
(_) Poor impluse coordination
(_) Mania
(_) Feelings of helplessness
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
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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