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10 Identified Problems
1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar Disorder
2.) Self- care Deficit: Dressing and Grooming r/t Depression
3.) Disturbed Thought Process r/t Mood Alteration
4.) Risk for Suicide r/t Mood Alteration Secondary to Bipolar Disorder
5.) Chronic Low Self- Esteem r/t Anxiety
6.) Hopelessness r/t Feeling of Abandonment
7.) Defensive Coping r/t to Anxiety
8.) Risk for other Directed Violence r/t Bipolar Disorder
9.) Interrupted Family Process r/t Deterioration of Family Functioning
10.) Disturbed Energy Field r/t Bipolar Disorder
5 Prioritized Problems
1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar Disorder
2.) Self- care Deficit: Dressing and Grooming r/t Depression
3.) Disturbed Thought Process r/t Mood Alteration
4.) Risk for Suicide r/t Mood Alteration Secondary to Bipolar Disorder
5.) Chronic Low Self- Esteem r/t Anxiety
Cues Nursing Diagnosis
Rationale Evaluation
Subjective:
“Pakiramdam ko kasi may mananakit sa kin pag natutulog ako eh kaya hindi ako makatulog sa gabi. Konting tunog lang nagigising ako agad.” as verbalized by the patient.
“Pakiramdam ko paggising ko sa umaga parang pagod na pagod parin ako.” as verbalized by the patient.
Objective:
Problem:Disturbed Sleep Pattern
Etiology:Related to Episodes of Delusion Secondary to Bipolar Disorder
As evidenced by:
Subjective:
“Pakiramdam ko kasi may mananakit sa kin pag natutulog ako eh kaya hindi ako makatulog sa gabi. Konting tunog lang nagigising ako agad.” as verbalized by the patient.
During the depressed phase of the bipolar disorder, it's common to experience insomnia, characterized by difficulty falling asleep, staying asleep, or waking up too early. Bipolar depressed patients are also particularly sensitive to hypersomnia -- characterized by too much sleep, sometimes up to 18 hours per day, and daytime fatigue. What's especially problematic with bipolar patients is that sometimes deprivation of sleep for any
Short Term:
After 1-2 days of nursing intervention the patient will indentify individually appropriate interventions to promote sleep.
Long Term:
After 3-4 Days of Nursing Intervention the patient will report improvements in quality of sleep pattern as evidenced by: Verbalization of feeling of satisfaction after waking up in the morning. No
Independent:
1. Arrange care to provide for uninterrupted periods of rest, especially allowing for longer periods of sleep at night when possible.
2. Encourage client to establish a bedtime routine to facilitate transition from wakefulness to sleep.
3. Encourage client to eliminate stressful situations before bedtime.
Dependent:
1. A silent and clam environment during sleep will help to lengthen the range of sleep.
2. Rituals and routines induce comfort, relaxation, and sleep.
3. Stress interferes with a person’s ability to relax, rest, and sleep.
Short Term:
After 2 days of nursing intervention, the patient had indentified individually appropriate interventions to promote sleep.GOAL MET
Long Term:
After 3 days of nursing intervention, the patient reported improvements in quality of sleep pattern as evidenced by: “Mas masarap yung tulog ko kagabi kesa
Weakness Restlessn
ess Dark
circles under the eyes
Dissatisfaction with sleep
Frequent yawning
“Pakiramdam ko paggising ko sa umaga parang pagod na pagod parin ako.” as verbalized by the patient.
Objective: Weaknes
s Restlessn
ess Dark
circles under the eyes
Dissatisfaction with sleep
Frequent yawning
reason -- such as caffeine consumption -- could lead to a switch into mania -- which could be a big problem.
Reference: Psychiatric Nursing Care Plans 5th Edition, Fortinash, Holoday Worret page 185-202
feeling of fatigue after waking up. Not restless and weak, no frequent yawning and dark eyes.
1.1.1.
Administer Chlorpromazine as ordered.
1. Has a therapeutic effect of sedation that may induce sleep.
noong isang gabi.” as verbalized by patient. No feeling of fatigue after waking up. Not restless and weak, no frequent yawning and dark eyes.GOAL PARTIALLY MET
Cues Nursing Diagnosis
Rationale Objective Intervention Rationale Evaluation
Subjective: Problem: Hygienic care Short Term: Independent: Short Term:
“wala akong ganang mag-ayos sa sarili ko,hindi ko naman talaga malaman kung minsan bakit ako biglang nagwawala,tapos minsan sobrang lungkot ko naman…” as verbalized by the patient.
”lagi yaan ang suot niya,(pointing to her red turtle neck sleeveless blouse) paag tinatanong naman naming siya hindi naman niya masagot kung bakit…” as verbalized by the nurse in charge.
Self Care Deficit: Dressing and Grooming
Etiology:Related to Depressed Mood secondary to Bipolar Disorder
As manifested by:
Subjective:“wala akong ganang mag-ayos sa sarili ko,hindi ko naman talaga malaman kung minsan bakit ako biglang nagwawala,tapos minsan sobrang lungkot ko naman…” as verbalized by
promotes cleanliness, provides relaxation, improves self- image, and promote healthy skin. Client hygiene is an extension of providing client safety and protecting the client’s defense mechanisms. Body image is associated with the client’s emotion, mood, attitude, and values. A client’s body image directly affects the type of personal hygiene practiced; this may change if the client body image is altered because of illness.
After 1- 2 hours of nursing intervention the patient will verbalized ways how to improve hygienic care/ self care
Long Term:
After 2- 3 days of nursing intervention the patient will consistently performs self care activities and consistent with developmental stage as evidenced by being dependent in providing self care
1.Monit
or continually the extent to which self care deficits interfere with the client’s function
2. Establish routine goals for self care
3. Initiate grooming and hygiene tasks when the client is best able to comply
1. Monitor the client’s functional abilities in an ongoing way helps to determine the client’s strength and areas needing assistance
2. Routine and structure organize the client’s chaotic world and promote success
3. Depressed clients have more brighter affect later in the day; and client with anxiety and hyperactive behaviors are more attentive to self care after taking
After 8 hours of nursing intervention, the patient improved hygienic care with a verbalization of “alam ko na ngayon na importanteng bigyan ko ng pansin ang pag-aayos ko sa’kin sarili…”GOAL MET.
Long Term:
After 3 days of nursing intervention the patient was able to perform self care activities.GOAL PARTIALLY MET.
Objective: Repeatedly
used of clothing
Demonstrate infrequent bathing
Displays inadequate personal hygiene: foul odor
Gingivitis
the patient.
”lagi yaan ang suot niya,(pointing to her red turtle neck sleeveless blouse) paag tinatanong naman naming siya hindi naman niya masagot kung bakit…” as verbalized by the nurse in charge.
Objective: Repeatedly
used of clothing
Demonstrate infrequent bathing
Displays inadequate personal hygiene: foul odor
4. Provide privacy for self care without comprising client’s safety
5. Praise the client for attempts at self care and each successfully completed task
Dependent:
1. Administer mood stabilizing drug: Lithium Carbonate 450
medication
4. Providing as much as privacy as possible helps to preserve the client’s dignity
5. Positive reinforcement increases feelings of self worth and promotes continuity of functional behavior
1. Normalizes the reuptake of certain neuro-Transmitters
Gingivitismg OD
2. Administer antipsychotic drug: Chlorpromazine Hydrochloride 5 mg ODHS
and reduces release of norepinephrine
2. May bloclk pst synaptic dopamine receptors in the brain.
Cues Nursing Diagnosis
Rationale Objective Nursing Intervention
Rationale Evaluation
Subjective:
“Nagwawala kasi siya
Problem: Disturbed Thought Process
Bipolar disorder or manic- depressive disorder (also
Short term:
After 30 mins.- 1 hr of nursing
Independent:
1. Orient client and call
1. These steps help
Short term:
After 1 hr. of nursing
noon, hindi naming siya mapigilan. Maraming beses na rin naulit un kaya nag-decide na rin kaming ipadala siya doon.” as verbalized by the relative of the patient
“May mga time na pakiramdam ko talaga may mananakit sa akin, sumusunod lang sila sakin lage.” as verbalized by the patient.
Objective:
Distractibilit
Etiology: Related to Mood Alteration
As manifested by:
Subjective:
“Nagwawala kasi siya noon, hindi naming siya mapigilan. Maraming beses na rin naulit un kaya nag-decide na rin kaming ipadala siya doon.” as verbalized by the relative of the patient
“May mga time na pakiramdam ko talaga may mananakit sa akin, sumusunod lang sila sakin lage.” as verbalized by
referred to a bipolarism or manic depression) is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both
intervention, the patient will responds coherently to simple, concrete statements as evidenced by:
Exhibiting judgment, insights, coping skills, and problem solving abilities. Client’s expresses logical, goal-oriented thoughts with absence of delusion. Demonstrates socially appropriate for age and status. Demonstrates
client by name, introduce self on each contact; frequently mention time, date, and place.
2. Provide validation of thoughts and feelings of client.
3. Do not attempt to argue or change the client’s belief.
4. Check mouth if hoarding medicines.
5. An assertive, matter- of- fact, yet genuine
reinforce reality and provide cues that maintain orientation.
2. Validation seeks to help the caregiver, encouraging empathy.
3. Acceptance promotes trust.
4. To verify that client is swallowing the tablets or capsules.
5. The suspicious client does not have the capacity to relate to an
intervention, the patient responded coherently to simple, concrete statements as evidenced by:
Demonstrated orientation to person, place and time. Exhibiting judgment, insights, coping skills, and problem solving abilities.GOAL PARTIALLY MET
Long Term:
After 3 days of nursing intervention the patient established reality orientation as evidenced by:
Appropria
y Social Withdrawal Depression Blocking Fear Anxiety
the patient.
Objective:
Distractibility Social Withdrawal Depression Blocking Fear Anxiety
mania and
depression are present at the same time. These episodes are usually separated by periods of “normal” mood, but in some individuals, depression and mania may rapidly alternate known as rapid cycling.
Reference:
Keltner, Norman L., Scwecke Lee Hilyard, Bostron, Carole. Psychiatric Nursing. Fifth Edition. Mosby. Pg. 396- 398
orientation to person, place and time.
Long Term:
After 1- 3 days of nursing intervention, the patient will maintain reality orientation as evidenced by:
Appropriateness of interactions and willingness to participate in the therapeutic community. Solves problems and makes decisions appropriate for age and status.
approach is the least threatening to the suspicious person.
Dependent:
1. Administer anti- psychotic drug: Chlorpromazine Hydrochloride
2. Administer mood stabilizing drug: Lithium Carbonate
Collaborative1. Continue to support and monitor psychosocial
overly friendly, overly cheerful attitude.
1. May block postsynaptic dopamine receptors in the brain.
2. Normalizes the reuptake of certain neurotransmitters and reduces the release of norepinephrine.
1. Prevent anxiety from escalating to unmanageable levels.
teness of interactions and willingness to participate in the therapeutic community.GOAL PARTIALLY MET
Maintain residual sensory-perceptual functions.
treatment plans.
CUES NURSING DIAGNOSIS
RATIONALE NURSING OBJECTIVES
INTERVENTION RATIONALE EVALUATION
Subjective:
“Wala na akong nagawang tama sa buhay ko. Lahat nalang nangyari sa buhay ko mali.
Problem:Risk for Suicide
Etiology:Related to Mood Alteration Secondary to Bipolar
Clients who express feeling of worthlessness, helplessness, hopelessness, and other feelings associated with depressive
Short term:
After 1-2 days of nursing intervention, the patient will demonstrate absence of suicidal attempts, and
Independent:
1. Check the client’s room for potentially destructive implements: sharp objects, belt, chemicals, hoarded
1 The nurse first priority is provide for the client’s safety and protect the client from self-inflicted life threatening
Short term:
After 2 days of nursing intervention, the patient demonstrated consistent, optimistic, and hopeful
Nakakahiya kasi nandito ako ngayon, gastos pa ako imbes na ako yung nag-tratrabaho para sa mga anak ko” as verbalized by the patient.
“wala ng silbi buhay ko, hindi na dapat ako nabubuhay pa. hindi ko alam kung para saan pa kung buhay parin ako” as verbalized by the patient.
Objective: frequently
agitated impaired
grooming
Disorder
As manifested by:
Subjective:
“Wala na akong nagawang tama sa buhay ko. Lahat nalang nangyari sa buhay ko mali. Nakakahiya kasi nandito ako ngayon, gastos pa ako imbes na ako yung nag-tratrabaho para sa mga anak ko” as verbalized by the patient.
“wala ng silbi buhay ko, hindi na dapat ako nabubuhay pa. hindi ko alam kung para
states are at increase risk for suicide.Depressed person see suicide as a means of escaping from anxiety provoking and intensely frightening situations. They are frightened by their overwhelming anxiety, isolation, hopelessness, and helplessness. Clients considering suicide may also experience feelings of excessive guilt, self blame, and frustration.
display consistent, optimistic, and hopeful attitude.
Long term:
After 3-4 days of nursing intervention, the patients will expresses desire to live. Display consistent, optimistic, and hopeful attitude.
medications; and take steps to protect client through appropriate therapeutic interventions.
2. Listen actively to the client’s story regarding how the client came to the point of suicide, using therapeutic skills such as reflection, clarification, and validation, and indicate acceptance of the client’s thought and feelings.
3. Tell the client to come to staff whenever the
injury or death.
2. Allowing the client to verbalize helps the client relieve pent-up thoughts, feelings and emotions related to suicide and is in itself therapeutic. It also gives the nurse information about the critical events that influenced the client’s story promotes trust and instill hope.
3. Constant staff support and protection reduce the
attitude by showing brighter affect, smiling, and upon conversation she focuses on present activities.GOAL PARTALLY MET
Long term:
After 4 days of nursing intervention, the patient expressed a desire to live, display consistent, optimistic, and hopeful attitude towards betterment of own life.GOAL PARTIALLY MET.
saan pa kung buhay parin ako” as verbalized by the patient.
Objective: frequently
agitated impaired
grooming
Suicidal clients often experience severe anger.
Reference:Mental Health Psychiatric Nursing, by Norris, Connell, Stockard, Ehrhart, Newton. P.772
client
experiences such thoughts or feelings.
4. Help the client to see that suicide is not an alternative to life’s problems but is rather a temporary experience often brought by an actual illness and exacerbated by life stressors.
Dependent:1. Administer Lithium as ordered.
Collaborative:1. Continue to support and monitor
client’s fear of suicidal impulses and offer hope for survival.
4. Educating the client about the temporary nature/ experience of suicide and depression promotes the client’s insight about the threatability of the disease process and offers hope for the future.
1. To stabilize the mood of the patient.1. Prevent
anxiety from escalating to unmanageable levels.
psychosocial treatment plans.
Cues Nursing Diagnosis
Rationale Nursing Objectives
Interventions Rationale Evaluation
Subjective:
“Dati masiyahin siya at may tapang ng loob sa mga ginagawa niya, pero ngayon naging withdrawn na
Problem:Chronic Low Self-esteem
Etiology:Related to Anxiety
as evidenced by:
Depression is a feeling involving an element of sadness and helplessness. There is little drive for socialization or communication
Short Term:
After 1-2 days of nursing intervention the patient will: Client demonstrate self-care appropriate for
Independent:1. Note non-verbal behavior.
2. Use
1. Incongruence’s between verbal/non-verbal communication require clarification.
Short Term:
After 2 days of nursing intervention the patient demonstrated self-care appropriate for age and
siya,” as verbalized by the patient’s relative.
“wala na akong nagawang tama sa buhay ko, lahat nalang ng nangyare sa buhay ko mali…” as verbalized by the patient
“nakakahiya kasi nandito ako ngayon, gastos pa ako imbes na ako ung nagtatrabaho para sa mga anak ko…” as verbalized by the patient.
Objective:
Social Withdrawal
Depression
Subjective:
“Dati masiyahin siya at may tapang ng loob sa mga ginagawa niya, pero ngayon naging withdrawn na siya,” as verbalized by the patient’s relative.
“wala na akong nagawang tama sa buhay ko, lahat nalang ng nangyare sa buhay ko mali…” as verbalized by the patient
“nakakahiya kasi nandito ako ngayon, gastos pa ako imbes na ako ung
,
although depression is the predominant, outward feeling shown, the fear, anger and guilt components of anxiety are internalized or turned inward upon the self. The fear of unleashing anger or hostility or of exposing guilt-producing unacceptable thoughts and wishes to others reinforces the learning of internalization of anxiety. The individual has learned during the socialization
age and status Uses techniques to decrease anxiety.
Long Term:
After 3-4 days of nursing intervention the patient will: Verbalize increased sense of self-worth in relation to current situation. Demonstrate behaviors and/or lifestyle changes to promote positive self image.
positive messages rather than praise.
3. Give reinforcement for progress noted.
4. Encourage client to progress at own rate.
5. Encourage techniques such as deep breathing.
Dependent:
2. To assist client to develop internal sense of self-esteem.
3. Positive words of encouragement promote continuation of efforts, supporting development of coping behaviors.
4. Adaptation to change in self-concept depends on its significance to individual, disruption to lifestyle, length of illness/debilitation.5. To decrease anxiety level.
status,used techniques to decrease anxiety and had a verbalization of “nalaman ko na importanteng alagaan ko sarili ko, hindi lang para sa sarili ko kundi para rin sa mga taong importante sakin…”GOAL MET
Long Term:
After 4 days of nursing intervention the patient had verbalized increased sense of self-worth in relation to current situation. GOAL PARTIALLY
Fails to attend to hygiene
Demonstrates difficulty communicating or interacting with others: poor eye contact and soft voice
nagtatrabaho para sa mga anak ko…” as verbalized by the patient.
Objective:
Social Withdrawal
Depression Fails to
attend to hygiene
Demonstrates difficulty communicating or interacting with others: poor eye contact and soft voice
process to anticipate rejection, disapproval and loss of love leading to disruption in interpersonal relations.
Reference:Page 127, Psychiatric Nursing by Manfreda & Krampitz, 10 Edition
1. Adminis
ter Lithium as ordered.
2. Administer Chlorpromazine as ordered.
Collaborative:
1. Continue to support and monitor psychosocial treatment
1. Used to balance biogenic amines of norepinephrine and serotonin in CNS area involved in emotional response.
2. Depress cerebral cortex, hypothalamus, and limbic systems which control activity an aggression; blocks neurotransmission produced by dopamine and synapse.
1. To help the patient
MET
plans.
establish sense of worth.
