Patient’s identifier: medical history patient’s medical diagnosis: intermittent explosive disorder.
Nursing diagnosis: risk for Violence: self-directed of other directed as evidence by the patient previous fight with a boy, the patient had also threaten to kill himself.
| Assessment data | Goals and outcome | Nursing intervention | Rationale | Outcome evaluation and replanning |
| Objective data: The patient is a fifteen year old boy with two younger siblings and a single mother.The patient was diagnosed with a bipolar disorder 2 years ago.The patient has also been diagnosed with post-traumatic stress disorder and intermittent explosive disorder.The patient has been admitted in the hospital for four times in two years and four additional admissions to the children crisis center.The patient has recently beaten up a boy after school for making fun of his weight and is currently suspended from school.The patient has since withdraw from all the social activities and tends to stay in his room and play video games. Subjective data : The patient is five fit tall and weighs 170 pounds.The patient has gained 40 pounds in six months since he was prescribed Olanzapine.The weight gain has been accompanied with increased depression and suicidal thoughts.The patient was hospitalized two days ago after locking himself in his room with a knife and threatening to kill himself. | To ensure that the patient is able to control his feelings. To ensure that the patient openly discusses his fears and what causes those fears.To ensure the patient is able to effectively use coping behaviors and resume normal activities.To ensure that the patient will be able to refrain from physically harming others with aids such as seclusions.To ensure that the patient respond well to external controls such as medications, nursing interventions and seclusion.To ensure the patient is informed on the condition and is informed on when to seek medical assistance. To ensure that the patient is safe and free from injury to self and to those around him. To ensure that the patient seek help when he starts to experience aggressive impulse. | Assess and observe the patient frequently for any signs of agitation and fear. Use a firm and calm approach while chatting with the patient Redirect the patient violent behaviors with physical outlets such as the use of a punching bag . Provide the patient with a quiet and calm environment; away from environmental stimuli. Including in the charts what help to calm the patient agitation and what escalated it; when medications were given and their effect. Encourage and teach the patient on healthy coping techniques Coaching the patient and family interaction | Frequent checkup help I early detection and introduction of interventions; this in turn will prevent the patient from harming others and self. It also decreases the patients need for seclusion.This nursing practitioner should set limit of the unacceptable behavior ; this provide a structure and control of a patient in case he is out of control.This helps the patient by reducing muscle tension and as well as relieving any pent up hostility. a calm environment helps decrease the patient anxiety and as well prevent escalation of manic symptoms . the nursing staff should recognize all the potential signals escalating the maniac symptoms and develop a guideline on what may work best for the patient. Nurses should encourage the patients to implement positive coping strategies such as relaxation techniques, listening to music and self-talk. The nursing practitioner should provide s and teach the parents age related activities and expectations for patients such as household responsibilities, reasonable curfews and acceptable behaviors . | The patient was informed s about the condition and he fully participated in his treatment.The able demonstrated effective use of problem solving and coping skills.The client was able to use age appropriate and acceptable behavior’s while interacting with others.The patient was able to verbalize positive statement to self and was able the best coping mechanism. The patients parent were educated on the condition and how to handle the client .The patient was taught on various methods of weight management to help reduce his weight. |
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