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1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar Disorder
4.) Risk for Suicide r/t Mood Alteration Secondary to Bipolar Disorder
5 Prioritized Problems
1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar Disorder
4.) Risk for Suicide r/t Mood Alteration Secondary to Bipolar Disorder
1. Normali
zes the
reuptak
e of
certain
neuro-
Transm
itters
and
reduces
release
of
norepin
ephrine
2. May
bloclk
pst
synapti
c
dopami
ne
recepto
rs in the
brain.
Cues Nursing Rationale Objective Nursing Rationale Evaluation
Diagnosis Intervention
Subjective: Problem: Bipolar Short term:
Disturbed
“Nagwawala Thought 1. These After 1 hr. of
kasi siya Process disorder or Short term: Independent: steps help nursing
noon, hindi manic- reinforce reality intervention, the
naming siya Etiology: depressive After 30 mins.- 1. Orient patient
1 hr of nursing and provide
mapigilan. Related to disorder (also client and call cues that responded
Maraming Mood referred to a intervention, client by name, coherently to
the patient will maintain
beses na rin Alteration bipolarism or introduce self orientation. simple, concrete
naulit un manic responds on each statements as
kaya nag- As manifested depression) is a coherently to contact; evidenced by:
decide na rin by: psychiatric simple, frequently
kaming diagnosis that concrete mention time, • Demonstr
Subjective: statements as ated orientation
ipadala siya describes a date, and 2. Validatio
doon.” as category of evidenced by: place. to person, place
“Nagwawala n seeks to help
verbalized by kasi siya noon, mood disorders and time.
• Exhibiti the caregiver,
the relative hindi naming defined by the 2. Provide encouraging
ng judgment, • Exhibiting
of the patient siya mapigilan. presence of one validation of empathy.
insights, judgment,
Maraming or more thoughts and
“May mga coping skills, insights, coping
beses na rin episodes of feelings of 3. Accepta
time na and problem skills, and
naulit un kaya abnormally client. nce promotes
pakiramdam solving problem solving
nag-decide na elevated mood trust.
ko talaga abilities. abilities.
rin kaming clinically 3. Do not
may referred to as attempt to
ipadala siya • Client’s GOAL
mananakit mania or, if argue or
doon.” as expresses PARTIALLY
sa akin, milder, change the
verbalized by logical, goal- 4. To verify MET
sumusunod hypomania. client’s belief.
the relative of oriented that client is
lang sila Individuals who Long Term:
the patient thoughts with swallowing the
sakin lage.” experience 4. Check
absence of tablets or
as verbalized “May mga time manic episodes mouth if After 3 days of
delusion. capsules.
by the na also commonly hoarding nursing
patient. pakiramdam experience • Demon medicines. intervention the
5. The
ko talaga may depressive strates patient
suspicious
mananakit sa episodes or socially established
akin, 5. client does not reality
sumusunod 5. have the orientation as
Objective: lang sila sakin 5. capacity to evidenced by:
lage.” as symptoms, or appropriate An assertive, relate to an
• Distra mixed episodes for age and • Appropria
verbalized by matter- of- fact, overly friendly,
ctibilit in which status. teness of
the patient. yet genuine overly cheerful
y features of both interactions and
• Demon approach is the attitude.
• Social mania and least willingness to
Withdr depression are strates participate in
orientation to threatening to
awal Objective: present at the the therapeutic
person, place the suspicious
• Depre same time. person. 1. May community.
• Distracti These episodes and time.
ssion block
bility are usually GOAL
• Blocki Dependent: postsynaptic
• Social separated by PARTIALLY
ng dopamine
Withdra periods of MET
• Fear Long Term: 1. Administ receptors in
wal “normal” mood,
• Anxiet er anti- the brain.
• Depress but in some After 1- 3 days psychotic drug:
y
ion individuals, of nursing Chlorpromazine 2. Normaliz
• Blocking depression and intervention, Hydrochloride es the
• Fear mania may the patient will reuptake of
• Anxiety rapidly alternate maintain certain
known as rapid reality 2. Administ neurotransmitt
cycling. orientation as er mood ers and
evidenced by: stabilizing drug: reduces the
• Approp Lithium release of
Reference: riateness of Carbonate norepinephrine
interactions .
Keltner,
Norman L., and
Scwecke Lee willingness to
1. Prevent
Hilyard, participate in
anxiety from
Bostron, Carole. the
escalating to
Psychiatric therapeutic
Collaborative unmanageable
Nursing. Fifth
levels.
• Maintai
n residual
sensory-
perceptual
functions.
CUES NURSING RATIONALE EVALUATION
DIAGNOSIS
RATIONALE NURSING INTERVENTION
OBJECTIVES
Subjective: Problem: Clients who Short term: Independent: Short term:
Risk for express feeling
“Wala na Suicide of After 1-2 days 1. Check the 1 The nurse After 2 days of
akong worthlessness, of nursing client’s room for first priority is nursing
nagawang Etiology: helplessness, intervention, potentially provide for the intervention,
tama sa buhay Related to hopelessness, the patient will destructive client’s safety the patient
ko. Lahat Mood and other demonstrate implements: sharp and protect the demonstrated
nalang Alteration feelings absence of objects, belt, client from self- consistent,
nangyari sa Secondary to associated with suicidal chemicals, inflicted life optimistic, and
buhay ko mali. Bipolar depressive attempts, and hoarded threatening hopeful
Nakakahiya Disorder states are at display medications; and injury or death. attitude by
kasi nandito increase risk consistent, take steps to showing
ako ngayon, As manifested for suicide. optimistic, and protect client brighter affect,
gastos pa ako by: Depressed hopeful through smiling, and
imbes na ako person see attitude. appropriate upon
yung nag- Subjective: suicide as a therapeutic conversation
tratrabaho means of Long term: interventions. 2. Allowing the she focuses
para sa mga “Wala na escaping from client to on present
anak ko” as akong anxiety After 3-4 days 2. Listen actively verbalize helps activities.
verbalized by nagawang provoking and of nursing to the client’s story the client GOAL
the patient. tama sa buhay intensely intervention, regarding how the relieve pent-up PARTALLY
ko. Lahat frightening the patients will client came to the thoughts, MET
“wala ng silbi nalang situations. expresses point of suicide, feelings and
buhay ko, nangyari sa They are desire to live. using therapeutic emotions Long term:
hindi na dapat buhay ko mali. frightened by Display skills such as related to
ako Nakakahiya their consistent, reflection, suicide and is After 4 days of
nabubuhay pa. kasi nandito overwhelming optimistic, and clarification, and in itself nursing
hindi ko alam ako ngayon, anxiety, hopeful validation, and therapeutic. It intervention,
kung para gastos pa ako isolation, attitude. indicate also gives the the patient
saan pa kung imbes na ako nurse expressed a
buhay parin yung nag- information desire to live,
ako” as tratrabaho about the display
verbalized by para sa mga hopelessness, acceptance of the critical events consistent,
the patient. anak ko” as and client’s thought that influenced optimistic, and
verbalized by helplessness. and feelings. the client’s hopeful
Objective: the patient. Clients story promotes attitude
considering
• frequently trust and instill towards
“wala ng silbi suicide may hope. betterment of
agitated
buhay ko, also own life.
• impaired
hindi na dapat experience 3. Constant GOAL
grooming
ako feelings of staff support PARTIALLY
nabubuhay pa. excessive guilt, 3. Tell the client to and protection MET.
hindi ko alam self blame, and come to staff reduce the
kung para frustration. whenever the client’s fear of
saan pa kung Suicidal clients client experiences suicidal
buhay parin often such thoughts or impulses and
ako” as experience feelings. offer hope for
verbalized by severe anger. survival.
the patient.
Reference: 4. Educating
Objective: Mental Health 4. Help the client the client about
Psychiatric to see that suicide
• frequently the temporary
Nursing, by is not an nature/
agitated
Norris, alternative to life’s experience of
• impaired
Connell, problems but is suicide and
grooming
Stockard, rather a temporary depression
Ehrhart, experience often promotes the
Newton. P.772 brought by an client’s insight
actual illness and about the
exacerbated by life threatability of
stressors. the disease
process and
offers hope for
the future.
Dependent:
1. Administer 1. To
Lithium as stabilize the
ordered. mood of the
patient.
1. Prevent
Collaborative: anxiety from
1. Continue to escalating to
support and unmanageab
monitor le levels.
psychosocial
treatment plans.