Nursing Care Plan

AXIS 1
(Admission Diagnosis)
AXIS II through V Discharge Referrals
(recommended follow u! d"c
lan)
Bipolar affective disorder with psychotic
features
*Rule out psychotic disorder
Axis II: Deferred
Axis III: Conjunctivitis, toxic encephalopathy, and
marijuana ause!
Axis I": #nspecified
Axis ": $loal assessment of functionin% on
admission & '(!
Current le%al status is voluntary
with on%oin% evaluations per
)sychiatric *D+ d,c plan not
specified!
Patient Descrition
(orientation! mood! affect! h#giene!
thought rocess! attention! $udgment!
insight! memor#! seech)
Socioeconomic"Cultural %rientation
(education! source of income! suort s#stem!
religious and cultural references)
Ps#chosocial Considerations
(resenting S"S! ro&lem
&eha'iors( SI! )I! A)! V)!
su&stance a&use)
%rientation & pt! is oriented to time,
place, person, and purpose!
*ood & expansive -readiness to tal. after
rea.fast aout prior,current euphoric
delusions/+ pt! was neither sad nor happy
ut stated 0satisfied that current
medications are helpin% to control
hearin% voices in head and seein% %hosts
occasionally!1
Affect & pt! was laile showin%
li.elihood of chan%e w, out medication
y presentin% veral discussion of prior
2i%h school diploma+ unemployed with livin%
mother involved in support system+ reli%ion not
specified+ 2ispanic male!
Presenting S"S + confusion, poor
insi%ht, poor jud%ment, hostile 3
a%itated 4 time of admission,
unreliale historian!
Pro&lem &eha'iors & no self
injury, homicidal ideation with no
plan -feels need to protect
himself,family/, auditory
hallucinations -hearin% voices/,
visual hallucinations -seein%
people tryin% to harm him/ 3
fli%ht of ideas with delusions
delusions of hearin% of voices if not
ta.in% medication to control+ pt! was not
lunted, flat, or constricted+ pt! was
%uarded when descriin% delusions of
people out to .ill him+ excited and
interested in sharin% delusional
experiences!
)#giene & pt! appeared showered,
%roomed, and wearin% clean clothes!
,hought rocess & durin% the course of
veral interaction, pt! was ale to
sometimes hold lo%ical 3 coherent
conversations in respect to his purpose of
ein% hospitali5ed and reason for mental
sic.ness+ however, at times, pt! would
have loose associations and
confaulations statin% odd present
employment 3 fantasies not con%ruent
with reality+ pt! was ruminatin% aout
prior jos held, ut no evidence in
medical chart of such occupations+ pt!
had fli%ht of ideas concernin% unrealistic
occupations of which he would li.e to
pursue, and implyin% that he was a
protector of his household ecause people
were out to .ill him!
Attention & pt! was cooperative 3
friendly+ however, easily distracted at
times y his thou%ht processes durin%
conversation!
-udgment"insight & pt! had poor
resultin% from not ta.in%
medication for 6 wee.+ pt! was
positive for 72C as evidenced y
urinalysis results, len%th of use not
stated in medical chart!
insi%ht,jud%ment of realistic employment,
home environment, and daily livin% in
household+ pt! was a poor historian as
evidenced y providin% unreliale factual
information!
*emor# & pt! was ale to recall
information previously discussed in the
conversation, as well as the occurrence of
which prompted his hospitali5ation
statin% he was protectin% his household
from people in the street tryin% to harm
him!
Seech & normal rate, rhythm 3 tone+ no
si%ns of slurred, spontaneous, pressured,
or prolon%ed speech!
)istor# of Present Illness
(urose of current hositali.ation!
legal status)
Past *ental )ealth )istor#
(%nset! re'ious hositali.ations! dates)
Pertinent la& test (onl# related to
mental health)
8n 9,6:,;(6( at 6<(( pt! was put on
=6=(, a call was made to sheriff deputies
in response to a 2ispanic male adult
wal.in% around a residential street with a
fa.e pistol %un in hand+ respondin%
deputies found the pt! layin% next to %un,
the suject had replied that he is
ipolar,schi5ophrenic and hasn>t ta.en
his medications in a wee., as well as
re?uestin% to spea. with psychiatric *D
due to hearin% voices+ pt! verally stated
0I don>t .now what I will do if I don>t %et
)revious hospitali5ation with dates not specified in
pt! chart!
@o pertinent la tests noted!
help!1
/egal status & =6=( on 9,6:,6( 4 6<((
D7A+ day of care & "oluntary on 9,;6,6(
Pathoh#siolog# of admitting and"or related medical diagnosis
(with APA citations)
*ood disorders constitute a disruption in physical, emotional, and ehavioral response patterns! 7hese patterns of affect -mood/
ran%e from extreme elation and a%itation to extreme depression with a serious potential for suicide -Bneisl 3 7ri%ooff, ;((C/!
Bipolar disorders are a cluster of mood disorders that include manic episodes, depressed episodes, and cyclothymic disorder! A
ipolar I disorder is one or more manic or mixed episodes, and the course of illness can e accompanied y major depressive
episodes! Bipolar II disorder is one or more major depressive episodes accompanied y at least one hypomanic episode! *ania is
characteri5ed y an anormal 3 persistently elevated, expansive, or irritale mood lastin% at least one wee., si%nificantly impairin%
social or occupational functionin%, and %enerally re?uirin% hospitali5ationDmust e accompanied y at least ' additional symptoms
such as inflated selfEesteem or %randiosity, decreased need for sleep, pressure of speech, fli%ht of ideas -rapidly chan%in%,
fra%mentary thou%hts/, distractiility, increased involvement in %oalEdirected activities or psychomotor a%itation, and excessive
involvement in pleasurale activities with a hi%h potential for painful conse?uences -Bneisl 3 7ri%ooff, ;((C/! Conducted studies
reveal that the underlyin% iochemical process involves neurotransmitters dopamine, norepinephrine, serotonin, and %ammaE
aminoutyric acid! Interferences with smooth transmission of impulses from one neuron to another, associated with depressive and
manic phases of ipolar disorder, can e explained y inade?uate release of neurotransmitters or faulty stora%e mechanisms -Bneisl
3 7ri%ooff, ;((C/!
0unctional )ealth
Pattern
Nursing Diagnosis
(Priorit#)
Planning
( 1 Short
,erm 2oals 3
realistic and
measura&le)
Inter'entions
(1 inter'entions for
4AC) goal)
Rationale
(1 rationale for
4AC)
inter'ention 3
APA citation )
4'aluations
(1 e'aluation for
4AC) S,2 listed)
Role relationship
pattern
Ris. for otherE
directed violence
related to delusions
of %randeur as
evidenced y visual
hallucinations of
people tryin% to .ill
him and the need to
protect himself!
a!/ )t! will
show no
si%ns of
physical
a%%ression
durin%
therapeutic
communE
ication!
!/ )t! will
show
impulse
control
therapeutic
6a!/ Fncoura%e pt!
to express an%er and
hostility verally
instead of 0actin%
out!1 $ive positive
feedac.!
;a!/ $ive the client
control y offerin%
tal.in% and art
therapy!
6!/ Convey
empathy y
ac.nowled%in% the
pt!>s feelin%s+ let pt!
6a!/ "iolence can
have a pattern+
detectin% and
chan%in% the pattern
can eliminate the
violence -CarpenitoE
*oyet, ;((:/!
;a!/ Althou%h
people may
verali5e hostile
threats and ta.e a
defensive stance,
most fear losin%
control and want
assistance to
maintain their
control -CarpenitoE
*oyet, ;((:/!
6!/ Crisis
mana%ement
techni?ues can help
prevent escalation
a!/ )t! did not
en%a%e in
a%itated or
impulsive
ehaviors
that could
endan%er
self or staff
durin%
therapeutic
communicati
on+ pt! was
ale to
verally
express
feelin%s of
fear and
an%er
!/ )t! was ale
to enumerate
safe ways of
relievin%
communE
ication!
.now that you will
not let him,her lose
control!
;!/ )rovide music
if pt! is receptive!
of a%%ression and
help pt! achieve
selfEcontrol
-CarpenitoE*oyet,
;((:/!
;!/ 7he client is in
a mentally
compromised state+
music can help
clients reduce
anxiety and achieve
relaxation -Bneisl 3
7ri%ooff, ;((C/!
excess
tension y
participatin%
in %roup
music
therapy!
Co%nitiveE
perceptual pattern
Distured thou%ht
processes related to
iochemical
alterations as
evidenced y
delusional eliefs
and hallucinations
secondary to
inaccurate
interpretation of
stimuli!
a!/ Assist pt! to
differentiate
etween
own
thou%hts and
reality
durin% '(
min! of
therapeutic
communE
ication!
6a!/ "alidate the
presence of
hallucinations y
assistin% client to
analy5e
hallucinations and
stay with person!
;a!/ Assist client
with decreasin%
irrational thou%hts
y encoura%in%
differentiation of
stimuli arisin% from
6a!/ 2elpin% the
person to identify
what specific
situations tri%%er
hallucinations %ives
insi%ht into possile
prevention
strate%ies
-CarpenitoE*oyet,
;((:/!
;a!/ Interventions
that re?uire the
person to en%a%e in
active mental wor.
-%ivin% veral
response/ are
a!/ )t! was ale
to selfE
restrain
disruptions
in
perception,
thou%ht
processes,
and thou%ht
content y
%ivin%
veral
responses to
?uestions
ein% as.ed
with
minimal
!/ Assist pt!
with
disordered
thin.in% to
communicat
e more
effectively
durin% '(
min! of
therapeutic
communE
ication
inner sources from
those from outside!
6!/ Be an attentive
listener+ note oth
veral and
nonveral
messa%es!
;!/ Durin%
communication as.
for the meanin% of
what is said,
validate your
interpretation of
what is ein% said,
and refocus when
person chan%es the
suject in the
middle of an
explanation or
thou%ht!
effective
-CarpenitoE*oyet,
;((:/!
6!/ 7he nurse
provides a health
role model with
appropriate veral
and nonveral
responses
-CarpenitoE*oyet,
;((:/!
;!/ 7he client can
e helped to re%ain
contact with reality
y %ently
introducin%
conversation that
are oriented to the
here and now
-CarpenitoE*oyet,
;((:/!
distractions+
pt! demonE
strated
aility to
choose to
analy5e
halluciE
nations
!/ )t! displayed
co%nitive
orientation
with the
aility to
identify
person,
place, and
time+ pt! was
ale to focus
on topics of
discussion
with
minimal
chan%es in
suject
manner!
*edication Information Sheet
,em Pulse Resiration 5lood Pressure Pain
C:!G :( ;; 69(,:; (
*edications
(with APA
citations
Class
Purose
(state 6)7
#our t is
on the med)
Route ,ime
Dose
(and
range)
*echanism
of action
%nset of
action
Common
side effects
Nursing
considerations
2eneric:
Aripipra5ole
,rade:
Ailify
Antipsychotic,
Atypical+
Dopamine
system
staili5er
7x of
ipolar
mania+
maintenance
in ipolar I
disorder!
)8 ;6(( '( m% 2A+
Adult: )8
'(m% once
daily, may
reduce to
6= m%,d
-Hilson,
Ahannon,
Ahields,
;((C/
)artial
a%onist
activity at D;
3 =27
receptors!
)artial
dopaminer%ic
a%onist
property!
-Hilson et
al!, ;((C/!
2eadache,
anxiety,
insomnia,
a.athisia,
tremor, F)A,
lurred vision,
@,", manic
reaction,
nervousness,
confusion,
co%wheel
ri%idity!
-Hilson et al!,
;((C/!
E*onitor
cardiovascular
status+ assess
for orthostatic
hypotension!
E*onitor ody
temperature
li.ely to
elevate core
temperature!
E*onitor for
si%ns of 7D
E*onitor 3
report
immediately
A3A of @*A
E*onitor lood
%lucose if
diaetic!
E*onitor
periodically
2ct 3 2%!
E*onitor for
elevated C)B
3
myo%loinuria
2eneric:
Risperidone
,rade:
Risperdal
Antipsychotic,
Atypical
7x of
ipolar
disorder!
)8 BID ;*$ BID+
Adult
-I6(y/:;E
'*$ once
daily for up
to ' w.
-max:G
*$,d/!
-Hilson et
al!, ;((C/!
Interferes
with indin%
of dopamine
to D;E
interlimic
re%ion of the
rain,
serotonin -=E
27/
receptors,
and alphaE
adrener%ic
receptors in
occipital
cortex+ low
to moderate
affinity for
the other
serotonin -=E
27/
receptors
-Hilson et
al!, ;((C/!
8rthostatic
hypotension w,
initial doses,
sweatin%,
sedation,
drowsiness,
transient lurred
vision,
insomnia,
a%itation,
anxiety, F)A,
prolon%ed J7c
interval,
tachycardia, dry
mouth, elevated
AA7,AK7,
hyper%lycemia,
photosensitivity,
urinary
retention,
decreased
sexual desire,
sexual
dysfunction
-Hilson et al!,
E*onitor
diaetics for
loss of
%lycemic
control!
EReassess pt!>s
periodically
and maintain
on the lowest
effective dru%
dose!
E*onitor
neurolo%ical
status of older
adults!
E*onitor
cardiovascular
status+ assess
orthostatic
hypotension
E*onitor those
at ris. for
sei5ures!
EAssess de%ree
of co%nitive
impairment+
;((C/! assess for env>t
ha5ards!
E*onitor lood
%lucose,
electrolytes,
liver function,
CBC
References
CarpenitoE*oyet, K!L! -6;
th
ed!/! -;((:/! Nursing diagnosis: Application to clinical practice!
)hiladelphia, )A: Kippincott Hilliams 3 Hil.ins
Bneisl, C! R!, 7ri%ooff, F! -;
nd
ed!/! -;((C/! Contemporary psychiatric-mental health nursing.
#pper Aaddle River, @L: )earson )rentice 2all!
Hilson, B!A!, Ahannon, *!7!, Ahields, B!*! -;((C/! Prentice hall nurses drug guide
2009. #pper Aaddle River, @L: )earson )rentice 2all!