ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
OBJECTIVE: Ineffective SHORT TERM: Administer an antimanic Bipolar disorder is caused by
Presence of delusions coping Patient will medication and PRN biochemical/neurologic
(grandeur) related to respond to limit- tranquilizers, as ordered, and imbalances in the brain.
Using extremely poor inadequate setting evaluate for efficacy, and side Appropriate antimanic
judgment in financial level of techniques with and toxic effects. medications allow psychosocial
negotiation (buying perception of aid of and nursing interventions to be
spree) control medication effective.
Giving away variables during acute and
and financial savings severe manic Maintain a firm, calm, and These behaviors by the staff can
indiscriminately to phase. neutral approach at all times. escalate environmental
her psych mate. Patient will Avoid: stimulation and, consequently,
SUBJECTIVE: respond to - Arguing with the client. manic activity. Once the manic
As stated by the external controls - Getting involved in power client is out of control, seclusion
patient, “mahilig (medication, struggles. might be required, which can be
akong bumili ng mga seclusion, - Joking or “clever” repartee traumatic to the manic individual
bagay bagay. Tulad ng nursing in response and other as well as the staff.
mga branded na intervention) clients. to client’s “cheerful
damit.” when potential and humorous” mood.
Validated by her or actual loss of
sister, “mahilig siyang control occurs. Have valuables, credit cards, and Judgement and reality testing are
bumili ng mga gamit large sums of money sent home both impaired during acute mania.
lalo nap ag branded. with family or put in hospital Client might need legal advice and
Tapos para syang one safe until the client is protection against making
day millionaire, discharged. important decisions that are not in
pagbinibigyan siya ng their best interest.
pera ubos agad.”
Provide hospital legal service During manic episodes, people
when and if the client is involved give away valuables and money
in making or signing important indiscriminately to strangers,
legal documents during an acute often leaving themselves broke
manic phase. and in debt.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
OBJECTIVE: Sleep disturbance SHORT TERM: Keep client in areas of low Promotes relaxation and
Restlessness related to Patient will stimulation. minimizes manic behavior.
Irritability environmental achieve maximum
Fatigued stimulus. quantity of sleep Encourage frequent rest periods Lack of sleep can lead to
appearance as manifested by during the day. exhaustion and death.
Yawning rested appearance,
SUBJECTIVE: articulation of At night, encourage warm baths, Promotes relaxation, rest, and
Verbal complaints of feeling rested, and soothing music, and medication sleep.
difficulty falling enhancement in when indicated. Avoid giving the
asleep sleep pattern. client caffeine.
Verbal complaints
of not feeling rested Discourage pattern of daytime Napping can disrupt normal sleep
Verbalizations of naps unless considered patterns at night.
interrupted sleep necessary to meet sleep
Verbal complaints requirements or if part of one’s
of sleepless nights usual pattern.
when her co psych
patient is Stress the importance of the This will hinder the patient to
experiencing an need to avoid concentrating on experience a restful state.
attack during the the next day’s activities or on Planning a selected time during
night. one’s problems at bedtime. the next day to address these
concerns/problems may offer
permission to "let go" of the
worries at bedtime.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
OBJECTIVE: Risk for injury SHORT TERM: Maintain low level of stimuli in Helps decrease escalation of
Presence of scar in Patient will be free client’s environment: anxiety.
right index finger. from falls and - Away from bright lights, loud
Clumsy abrasions everyday noises, and people.
Hyperactivity while in the ward.
SUBJECTIVE: LONG TERM: Provide structured solitary Structure provides security and
Patient verbalized Patient will be free activities with nurse aide. focus.
history of fall of excessive
Patient verbalized physical agitation Provide frequent rest periods. Prevents exhaustion.
history of five suicide and purposeless
attempts. motor activity Assess environmental factors To lessen the risk for injury, safe
within two weeks. that may lead to injury. environment and promote client’s
comfort.
Protect client from giving away Client’s generosity is a manic
money and possessions. Hold defense that is consistent with
valuables in hospital safe until irrational, grandiose thinking.
rational judgment returns.
