Angelite Nurses: 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

Angelite Nurses