Nurse's Pocket Guide

• Identify precipitating factors.
• Express realistic self-evaluation and increased sense of selfesteem.
• Participate in care and meet own needs in an assertive manner.
• Demonstrate self-control as evidenced by relaxed posture,
nonviolent behavior.
• Use resources and support systems in an effective manner.
Actions/Interventions
(Addresses both “other-directed” and “self-directed”)
NURSING PRIORITY NO.1.To assess causative/contributing factors:
• Determine underlying dynamics as listed in the Risk Factors.
• Ascertain client’s perception of self/situation. Note use of
defense mechanisms (e.g., denial, projection).
• Observe/listen for early cues of distress/increasing anxiety
(e.g., irritability, lack of cooperation, demanding behavior,
body posture/expression). May indicate possibility of loss of
control and intervention at this point can prevent a blow-up.
• Identify conditions such as acute/chronic brain syndrome,
panic state, hormonal imbalance (e.g., PMS, postpartal psychosis),
drug-induced, postanesthesia/postseizure confusion,
traumatic brain injury. These physical conditions may interfere
with ability to control own behavior and will need specific
interventions to manage.
• Review laboratory findings (e.g., blood alcohol, blood glucose,
ABGs, electrolytes, renal function tests).
• Observe for signs of suicidal/homicidal intent (e.g., perceived
morbid or anxious feeling while with the client; warning from
the client, “It doesn’t matter,” “I’d/They’d be better off dead”;
mood swings; “accident-prone”/self-destructive behavior;
suicidal attempts; possession of alcohol and/or other drug(s)
in known substance abuser). (Refer to ND risk for Suicide.)
• Note family history of suicidal/homicidal behavior. Children
who grow up in homes where violence is accepted tend to
grow up to use violence as a means of solving problems.
• Ask directly if the person is thinking of acting on thoughts/
feelings to determine violent intent.
• Determine availability of homicidal means.
• Assess client coping behaviors already present. Note: Client
believes there are no alternatives other than violence,
especially if they have come from a family background of
violence.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 769
[actual/] risk for VIOLENCE