General Safety Guidelines
■ Safety:Your safety ALWAYS comes first!
■ Awareness:Watch for nonverbal indicators of aggression or violence; clinched fists, pacing, raised tone of voice, increased respirations, profanity, verbal threats, weapons, wide-eyed stare.
■ Exit: Always position yourself between the Pt and an exit. Never allow a Pt to block your means of escape.
■ Be Assertive: Make your boundaries known, set limits, and stick to them. Avoid arguing or bargaining with Pts.
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Component
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Document: assessment, interventions,
outcomes
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Appearance
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Grooming, hygiene, posture, eye contact,
correlation between appearance and
developmental stage and age.
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Motor Activity
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Tremors, tics, mannerisms, gestures, gait,
hyperactivity, restlessness, agitation,
echopraxia, rigidity, aggressiveness.
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Speech Pattern
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phasia, volume, impairments, stutter.
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General Attitude
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Cooperative, uncooperative, friendly, hostile,
defensive, guarded, apathetic.
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Mood
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Depressed, sad, anxious, fearful, labile,
irritable, elated, euphoric, guilty, despairing.
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Affect
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Congruent with mood, flat, inappropriate.
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Thought Process
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Form of thought: tangentiality,
word salads,
neologisms, echolalia, attention span.
Content of thought: delusional,
suicidal,
homicidal, obsessive, paranoid, suspicious,
religiosity, phobic, magical.
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Perceptual
Disturbances
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Hallucinations (auditory, visual, tactile,
olfactory, gustatory), illusions
(depersonalization, derealization).
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Sensory/Cognitive
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Alertness/orientation/memory/abstract.
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Impulse Control
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Aggression, fear, guilt, affection, sexual.
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Judgment/Insight
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Decision making, problem-solving, coping.
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