Cues and Evidences Nursing Diagnosis Date and time March 6, 2013 @ 1pm O: Risk for infection related

ed to open wound.

Rationale: Proper hygiene may Open wound at the prevent destruction of outer forearm noted our first line of upon inspection. Mild bleeding at the defences and site of wounds noted. strengthen our immune system to some infectious diseases

Nursing Intervention At the end of our 9 Established a therapeutic days duty, patient will not manifest any relationship sign and symptoms conveying empathy thus fostering of infection such as continuity of care. Redness Swelling Pain in the site Warm Loss of function

Objectives

Rationale

Evaluation Date and time March 15, 2013 @ 10:00am Our patient was not manifesting any signs of infection such as redness, pain in the site, swelling, warm, loss of function.

An ongoing relationship establishes trust as a basis for communicating feelings. Good hygiene is a Provided good defence against personal hygiene like infection. bathing and hand washing. Early detection of developing infection permits prompt Observed areas of impaired skin intervention and integrity and note prevention of further characteristics and complication. presence of inflammation. To prevent infection from developing.

Cleansed the site everyday with antibacterial soap.

Cues and Evidences Nursing Diagnosis Date and Time: March 6, 2013 @ 1pm O: Irritability noted Have history of violence (throwing of things to others). History of breaking the mirror of a car. Risk for violence directed to others related to reoccurrence of manifestation secondary to poor compliance Rationale: Mood changes may occur, including irritability, anger, depression, and violence if medications are not regularly maintained (Basic Concepts of Psychiatric Mental Health Nursing 5th edition by Shives).

Nursing Intervention At the end of our 9 Introduced self and conversed with the days duty, patient will not harm self or patient. others.

Objectives

Rationale To establish rapport to gain trust and cooperation.

Evaluation Date and Time: March 15, 2013 @ 10:00am

It may interfere with Our patient was not Identified conditions ability with ability to manifesting any sign control own self. of violence such as such as changes in throwing of stone or behaviour. Irritability, pacing, any things he may shouting or cursing, have in contact and Observe early signs lack of cooperation, able to participate in of distress. and demanding a therapy according behaviour all may be to scheduled signs of increasing activities. anxiety.

Ask directly if the patient is thinking of To determine violent acting of feelings. intent.

Give positive reinforcement

Encourages reinforcement for

patients effort. Be truthful in giving information and dealing with patient. Accept patients anger without acting on emotional basis. Help patient identify more appropriate solutions or behaviour like exercise and therapy. Continue administer anti-psychotic medication as prescribed.