-
Anxiety (Specify level)
ASB:
- Vigilance
- apprehension
- facial tension/flushing
- shakiness
- voice quivering
- heart pounding
- diminished learning ability
- rumination
-
Coping, Ineffective (describe what they are not coping well with)
ASB:
- Inability to ask for help
- lack of goal-directed behavior
- inadequate problem solving skills
- inappropriate use of defense mechanisms
-
Hopelessness
ASB:
- Sighing
- lack of initiative
- decreased affect
- turning away from speaker
- despondent
- “I can’t ….”
-
Impulse control, ineffective
ASB:
- Acting without thinking
- asking personal questions of others despite their discomfort
- sensation seeking
- temper outbursts
-
Insomnia (or use Sleep Pattern, Disturbed if related to environmental problems)
ASB:
- Alterations in sleep pattern
- dissatisfaction with sleep
- lack of energy
-
Noncompliance (Ineffective Adherence) (Specify with what)
ASB:
- Behavior indicative of failure to adhere
- exacerbation of symptoms
- failure to progress (meet outcomes)
-
Post-Trauma Syndrome
ASB:
- Rage
- flashbacks
- intrusive thoughts
- avoidance behavior
- dissociative amnesia
- hypervigilance
- panic attacks
- substance use
- history of detachment
-
Relapse, Risk for
ASB:
- Strong urges to use despite negative consequences
- intention to use substances
- sees drugs as medicinal
- relapse on pass or in the facility
- desires substance for “self-medicating”
- difficulty managing physical or emotional S&S of withdrawal
- discharge plan includes a high risk environment
-
Social Interaction, Impaired
ASB:
- Discomfort in social interactions
- dysfunctional interactions with others
-
Social Isolation
ASB:
- Desire to be alone
- absence of supportive significant others
- values unacceptable to the dominant cultural norms
- hostility
- withdrawal
-
Though Process, Disturbed/Altered
ASB:
- Responding to internal stimuli
- behaviors consistent with experiencing hallucination, illusions and delusions
- disorganized speech
- bizarre behavior
- poverty of speech/thought
-
Violence: Other-Directed, Risk for
ASB:
- Possession of weapons (or item that could be used as a weapon)
- history of violence/threats of violence
- history of experiencing/witnessing violence
- psychotic behavior
- intoxication
- negative body language (pacing, clenching fists, threatening stances)
-
Violence: Self-Directed, Risk for (or use Suicide, Risk for; Self-Mutilation, Risk for)
ASB:
- History of attempts
- suicidal ideation
- suicide plan
- availability of method
- lethal plan
- behavioral and verbal clues
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