related to:
- Less confidence: suspicion of others.
- Freaking Out.
- Stimulation catatonic.
- Angry reactions.
- Instruction from hallucinations.
- Delusional mind.
- Walking back and forth.
- Stiff jaw; clenched hands, rigid posture.
- Aggressive action: direct damage destination objects that are in the surrounding environment.
- Self-destructive behavior or active; aggressive suicide.
- Threatening words were hostile; action brag, to torment others psychologically.
- Increased motor activity, footsteps, arousal, irritability, restlessness.
- Environment perceives as a threat.
- Receive a "command" through hearing or vision as a threat.
Planning:
Goal / Purpose:
General Purpose:
The patient will not injure themselves, other people and the environment.
Specific purpose:
In 2 weeks the patient can recognize signs of increased anxiety and report to the nurse to be given intervention as needed.
Expected outcomes:
- Anxiety is maintained at a level where the patient does not become aggressive.
- The patient showed a sense of trust in others around them.
- The patient maintains the reality orientation.
Intervention and rational:
1. Keep the patient environment at low stimulus levels (low irradiation, little people, the decor is simple, low noise level).
Rational:
Anxiety level will increase in an environment full of stimulus. Individuals that there might be perceived as a threat because of suspicious, so eventually make the patient agitation.
2. Observe the behavior of the patient closely (every 15 minutes). Do this as a routine activity to avoid suspicion in the patient.
Rational:
Close observation is important, because then appropriate interventions can be given immediately and to always make sure that patients are safe.
3. Remove any objects that could harm the environment around the patient.
Rational:
If the patient is in a state of agitated, confused, patients will not use these objects to harm themselves or others.
4. Try directed self-destructive behavior to physical activity, to reduce the patient's anxiety (eg, hitting sandbags).
Rational:
Physical exercise is a safe and effective way to eliminate the latent tensions.
5. Staff should maintain calm and show behavior towards the patient.
Rational:
Anxiety is contagious and can be transferred from the nurse to the patient.
6. Have enough physically strong staff that can help secure the patient if needed.
Rational:
It is necessary to control the situation and also provide physical security to the staff.
7. Provide appropriate tranquilizer drugs therapeutic treatment program. Monitor the effectiveness of drugs and their side effects.
Rational:
How to achieve the "alternative minimum limits" should be selected when planning interventions to psychiatry.
8. If the patient does not become calm by way of "saying something more important than what is said by the patient (stops talking)" or with drugs, use tools restriction of movement (fixation). Make sure that you have enough staff to help. Follow the protocol established by the institution. If the patient has a history of refusing medication, give medication after fixation is done.
9. Observe the patient in a state of fixation every 15 minutes (at the discretion of the institution). Make sure that the patient is not compromised circulation (check the temperature, color and pulse on the patient's extremities). Help the patient to meet, their needs for nutrition, hydration and elimination. Give a position that gives a sense of comfort for the patient and can prevent prevent aspiration.
Rational:
The patient's safety is a priority nursing.
10. Once the anxiety decreased, assess the patient's readiness to be released from fixation. Remove one by one fixation of the patient or reduced gradually, not all at once, while continuing to assess the patient's response.
Rational:
Minimize the risk of injury for patients and nurses.