Nursing Care Plan
Nursing Diagnosis: Risk for Self-Directed Violence/Risk for Other – Directed Violence
Cause Analysis: In manic phase, the negative, uncontrolled thoughts, feeling and behaviors pose a threat or danger to harm self or others. They are
aggressive, hostile and cannot evaluate the consequences of their behaviors.
Reference: Fortinash, Psychiatric Nursing Care Plans 5th ed. pp. 122
Cues Objectives of Care Interventions
Within the span of care > intervene immediately if the client
the client will demonstrate demonstrates aggressive behavior
absence of violent or toward self or others.
O: aggressive behavior and
> history of will not injure itself or > listen for verbal threats or hostile
assaultive others. remarks towards self or others.
behavior
> threatening
verbalization
> overt and > help the client manage angry,
aggressive acts inappropriate or intrusive behaviors in a
> therapeutic but firm direct manner
> Reduce milieu noise and stimulation
or accompany client to a calmer, quieter
environment at early signs of anger,
frustration or agitation
> remind the client to continue seeking
staff when first experiencing frustration,
anger, hostility or suspiciousness
rather than waiting until the negative
thoughts and feelings are out of control,
which can lead to violence.
> praise the clients efforts made to
control anger or hostility to self and
others.
> teach the client and the family to
recognize early signs and symptoms of
Rationale Evaluation
> immediate intervention in clients Goal met:
harm or assault risk behaviors may The client maintains a
prevent harm or injury non-hostile behavior
and doesn’t injure itself
> the client verbal threats, physical or others.
contact and acting out may be
precursors or cues to impending
violence.
> helping the client manage angry
inappropriate or intrusive behaviors
early in the escalation of phase may
prevent assault or violence
> a calm external environment often
helped to promote a relaxed internal
state within the client and and may
lessen agitation and prevent
violence
> staff can help the client prevent
negative feelings from reaching
destructive levels if they know the
clients state in advance. Staff can
engage client in therapeutic
activities/exercises and can offer
medications when necessary.
> positive feedback reinforces
repetition of positive functional
behaviors
> it is important to equip the client
family effectively with resources and
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escalating agitation or hypomanic
behaviors (yelling, cursing, threatening,
pacing, intrusiveness, suspiciousness)
that can lead to full blown mania, self-
harm, assault or violence.
interventions when the client’s
behaviors threatens the safety of
self or others and the integrity of the
environment.
Fortinash, Psychiatric Nursing Care
Plans 5th ed. pp. 122 -123
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Nursing Diagnosis: Risk for Injury r/t hyperactivity and increased internal stimulation
Cause Analysis: The client is susceptible to injury as a result to excessive interaction or collision with the environmental obstacle because of intrusive
behaviors.
Cues Objectives of Care
Within the span of care the
client will maintain physical
and emotional integrity and
exhibits decreased
hyperactivity
Nursing Care Plan
References: Fortinash, Psychiatric Nursing Care Plans 5th ed. pp. 122
Interventions
> Protect the client from self-injury
and maintain the safety of others and
the environment; may need to use
seclusion/quiet time to reduce self-
injurious behaviors
> reduce or minimize environmental
stimulation
> engage client in basic stress-
reduction exercise such as deep-
breathing and muscle relaxation (if
the client is able to focus and take
direction)
> praise the client for efforts on efforts
made to use physical energy
productively and avoid accident or
injury
> continue to support and monitor
clients’ prescribed medical and
psychosocial treatment plan.
Rationale Evaluation
> the nurse’s first priority is to Goal met: the client
protect the client from harm or injury remains free of injury
and to maintain the safety of others and demonstrates
and the environment. decreased hyperactivity
> a soothing external environment
helps to calm the client’s internal
state, reduces hyperactivity and
prevents accidents or injury.
> these basic exercises help client
to reduce stress by slowing heart
rate and respirations
> positive feedback reinforces safe
adaptive behaviors and increases
the clients’ self-esteem.
> effective, consistent treatment
helps to prevent escalating agitation
and subsequent accident related to
mania or hypomania
Reference:
Fortinash, Psychiatric Nursing Care
Plans 5th ed. pp. 122 - 123
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 Nursing Care Plan
Nursing Diagnosis: Impaired Social Interaction r/t social isolation and history of unsatisfactory relationships
Cause Analysis: For the client who is depressed, they find it difficult to communicate interpersonally due to distrust to others, low self-esteem and social
isolation. They have difficulty fulfilling their roles and responsibilities and often they avoid family and social relationships because they find no pleasure from
interaction.
References: Fortinash, Psychiatric Nursing Care Plans 5th ed. pp. 100
Videbeck, Psychiatric Mental Health Nursing 2nd ed. pp. 343
Cues Objectives of Care Interventions Rationale Evaluation
S: “Dili kayo na Within the span of care the > engage client in interaction on a > clients with depression resists Goal partially met: the
sya gagawas- client will demonstrate regular basis becoming involved in a therapeutic client participated in the
gawas makig abi- comfort and enjoyment alliance, which necessitates interactions and
abi sa silingan ky during interactions and acceptance and persistence. demonstrates
maulaw na sya” as expresses awareness of > conduct a suicide assessment as > an effective suicide assessment enjoyment. However,
verbalized by the some problems that necessary may prevent harm, injury or death. she doesn’t expresses
clients’ sister precipitated impaired social awareness or share her
interaction. > actively listen, observe and respond > active listening lets the client problem that
to the clients verbal and non-verbal know they are worthwhile precipitated impaired
O: expressions respected. The client will be social interaction.
> avoids eye encouraged seeking out to others
contact  remain with the client if he or > the client who is severely
> unable to relax she doesn’t engage in depressed and energy depleted
or be still conversation, and offer brief, may be unable to engage in
> demonstrates accepting comments. conversation. The presence of
discomfort in concerned caregiver offers the
social interaction client comfort and security and
increases self-worth
> a nondemanding approach avoids
> use low-key, matter of fact threatening clients with the
approach when offering the client expectations they cannot meet
simple choices
> often, clients continue to use
> explore with the client alternative ineffective methods of interacting
social interaction that may be because change is difficult and
appropriate and effective. results are uncertain
> provides the client with the
> practice the client alternative confidence to try learned skills with
interactive technique in a safe setting, others in the environment
while offering tactful but honest
feedback.

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> help the client set realistic goals
and limits in interactions with others
> Inform the client that all needs will
not be meet through interactions
> teach the client to give and accept
appropriate praise and compliments
during social exchanges.
> limit setting helps the client
develops more realistic
expectations of self from others
> such information helps to promote
realistic expectations and outcomes
 giving and accepting
positive feedback helps to
ensure mutually satisfying
social interactions.
References: Fortinash, Psychiatric
Nursing Care Plans 5th ed. pp. 100
– 102
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 Nursing Care Plan
Nursing Diagnosis: Sleep Pattern Disturbance r/t psychological stress
Cause Analysis: Clients with depression often cannot sleep or still feel exhausted no matter how much time they spend on bed.

Reference: Videbeck, Psychiatric Mental Health Nursing 2nd ed. pp. 343

Cues Objectives of Care Interventions Rationale Evaluation

S: “Dili man na sya Within the span of care the > Decrease environmental stimuli in > Manic client is unable to relax and Goal Partially met:
makatarong ug client will report of feeling room and common areas. decrease attention to stimuli, The client reports that
tulog ky usahay well rested and appear affecting ability to fall asleep. she rested well but still
perme na sya mag relaxed. Restrict intake of caffeine (e.g., > May stimulate CNS, interfering she appears tensed
mata-mata.” as coffee, tea, cocoa, cola drinks). with relaxation, ability to sleep. and restless.
verbalized by the
clients cousin. > Offer small snack/warm milk at > Inattention to personal needs may
bedtime or when awake during the have led to a less than adequate
O: night. intake, and hunger at night may
> Interrupted distract from sleep. Also, L-
nighttime sleep tryptophan in
> Changes in milk may promote sleep.
behavior and
performance, > Encourage engaging in physical > Enhances sense of fatigue and
activities/exercise during morning and promotes sleep/rest. Evening
> restlessness afternoon. Restrict activity in the activity may actually stimulate client
evening prior to bedtime. and interfere with/delay sleep.

> Encourage routine bedtime > Reinforces need for rest, “setting
activities, relaxation techniques. stage” for client to quiet mind and
prepare for sleep.

> Reroute to bed matter-of-factly, > Avoids stimuli that may stimulate
without providing the distraction of client or provide irritability.
other activities.

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 Nursing Care Plan
Nursing Diagnosis: Chronic Low Self – Esteem r/t experience of real or perceived failures and presence neglectful, abusive & overprotective relationship
Cause Analysis: A depressed client shows a pervasive low self – esteem derived from negative, unrealistic values that the individual ascribes to self-
concept. The person with low self esteem thinks, feels, and behaves as if unworthy and incapable of achieving or performing at a level of consistent with
own expectations or those of others.
References: Fortinash, Psychiatric Nursing Care Plans 5th ed. pp. 103

Cues Objectives of Care Interventions Rationale Evaluation

S: “Dili na sya Within the span of care the > Ask how client would like to be > Grandiosity is thought actually to Goal Partially Met:
naga istorya kayo client will: Identify feelings addressed. Avoid approaches reflect low self esteem. The client was able to
bahin sa iyang and methods for coping that imply a different perception of the identify methods of
mga kaagi, gusto with underlying client’s importance. coping but doesn’t
pud na nya mag negative perception of self demonstrate or
inusara usahay.” and; verbalizes realistic > Encourage verbalization and > Problem-solving begins with verbalize her positive
as verbalized by positive statements about identification of feelings related to agreeing on “the problem.” self – aspects.
the clients sister. self and others issues of chronicity, lack of control
impacting self-concept.
O:
> Unsatisfactory > Help client identify aspects in which > Allows client to “practice,”
interpersonal control is possible in the therapeutic provides experience of assuming
relationships; setting and encourage control.
> grandiosity appropriate assertion of personal
(religious) control/autonomy.
> fails to attend to
hygiene > Provide choices of activities (e.g., > This strategy reduces the client’s
> demonstrates when to bathe, food desired, sense of powerlessness.
difficulty participation in social interactions),
communicating or when possible.
interacting with
others: poor eye > encourage client to wash, dress, > the act of attending to groom and
contact, reticent comb hair and attend to other the results increase confidence and
paucity of speech personal hygiene esteem
> anxious
> expressed > engage the family to give genuine > some families need reminders to
suicidal ideation praise to the client when warranted support one another. Positive praise
from significant others greatly
increases the clients’ self-
worth/esteem
> teach the client to identify positive > the more the client expresses

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aspects of self through different
methods (verbalize, write, draw)
> Assist client, as reasonable, to
maintain personal privacy.
positive aspects of self, the less
likely the client to focus on negative
aspects.
> Provides sense of appreciation for
the client’s dignity.
Reference:
Fortinash, Psychiatric Nursing Care
Plans 5th ed. pp. 103 - 105
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 Nursing Care Plan
Nursing Diagnosis:
Cause Analysis:

Cues Objectives of Care Interventions Rationale Evaluation

Nursing Care Plan

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Nursing Diagnosis:
Cause Analysis:

Cues Objectives of Care Interventions Rationale Evaluation

Nursing Care Plan

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Nursing Diagnosis:
Cause Analysis:

Cues Objectives of Care Interventions Rationale Evaluation

Nursing Care Plan

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Nursing Diagnosis:
Cause Analysis:

Cues Objectives of Care Interventions Rationale Evaluation

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