Risk factors may include
Neurological impairment: head trauma, seizure disorders
Cognitive impairment: decreased intellectual functioning, learning disabilities
Hormonal imbalance; toxic reactions to medication; physical health—chronic or terminal illness
Mental health issues: severe depression, substance abuse or withdrawal; delusions, hallucinations
Emotional responses: hopelessness, despair, increased anxiety, anger, hostility
Conflictual interpersonal relationships; lack of personal or social resources; employment problems
Impulsivity; self-destructive behavior; suicidal ideation or behavior
Verbal clues: talking about death, “better off without me,” asking questions about lethal dosages of drugs
Behavioral clues: writing forlorn notes, giving away personal items, threatening letters
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Acknowledge realities of the situation.
Verbalize understanding of reason(s) for behavior/precipitating factors.
Express increased self-concept.
Demonstrate self-control, as evidenced by relaxed posture and nonviolent behavior.
Nursing intervention with rationale:
1. Observe for early signs of distress and investigate possible causes.
Rationale: Irritability, pacing, shouting or cursing, lack of cooperation, and demanding behavior may all be signs of increasing anxiety or indicate change in health status of confused client that requires further evaluation.
2. Maintain straightforward communication and assist client to learn assertive rather than manipulative, nonassertive, or aggressive behavior.
Rationale: Avoids reinforcing manipulative behavior and enhances positive interactions with others, accomplishing the goal of getting needs met in acceptable ways.
3. Help client identify more adequate solutions and behaviors such as motor activities or exercise. Redirect and provide directions for actions client can take.
Rationale: Promotes release of energies in acceptable ways. Redirecting confused client can minimize escalation of agitation.
4. Give as much autonomy as is possible in the situation.
Rationale: Enhances feelings of power and control in a situation in which many things are not within individual’s control.
5. Monitor for suicidal or homicidal ideation, for example, morbid or anxious feelings while with the client; thoughts expressed by, or warning from, the client, “It doesn’t matter, I’d be better off dead”; and mood swings, putting affairs in order, and previous suicide attempt.
Rationale: Indicators of need for further assessment and intervention or psychiatric care.
6. Assess suicidal intent (scale of 1 to 10) by asking directly if client is thinking of killing self, has plan, means, and so on.
Rationale: Provides guidelines for necessity and urgency of interventions. Direct questioning is most helpful when done in a caring, concerned manner.
7. Acknowledge reality of suicide or homicide as an option. Discuss consequences of actions if client were to follow through on intent. Ask how it will help client resolve problems.
Rationale: Client may focus on suicide, or possibly homicide, as the “only” option and this response provides an opening to look at and discuss other options. Note: Be aware of own responsibility under Tarasoff’s rule to warn possible victim( s) when client is expressing homicidal ideation. (Under Tarasoff’s rule, the counselor/care provider has a legal responsibility to notify a third party of a credible threat made by the client.)
8. Accept client’s anger without reacting on an emotional basis.
Rationale: Responding with anger is not helpful in resolving the situation and may result in escalating client’s behavior. Anger is usually not directed at the nurse, but at the situation and feelings of powerlessness.
9. Refer to psychiatric resource(s): —psychiatric clinical nurse specialist, psychiatrist, psychologist, social worker, and classes such as anger management.
Rationale: More in-depth assistance may be needed to deal with client and defuse situation. Learning new ways to deal with feelings can provide opportunity for individual to manage life in a more optimal way.
10. Administer medications, such as anti-anxiety or antipsychotic agents, sedatives, and narcotics.
Rationale: May be indicated to quiet or control behavior. Note: May need to be withheld if they are suspected to be the cause of, or contribute to, the behavior.