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