Professional Documents
Culture Documents
Risk for self-directed violence: At risk for behaviors in which an individual demonstrates
that he/she can be physically, emotionally, and/or sexually harmful to self.
Risk factors
Biochemical/neurologic imbalances.
Impulsivity.
Manic excitement.
Psychotic symptomatology.
Rage reaction.
Restlessness.
Possibly evidenced by
May be related to
May be related to
Erratic and out-of-control behavior of one family member with the potential for
dangerous behavior affecting all family members (violence, leaving family in debt,
risky behaviors in relationships and business, fragrant infidelities, unprotected and
promiscuous sex).
Family role shift.
Nonadherence to antimanic and other medications.
Shift in the health status of family member.
Situational crisis or transistion (e.g., illness, manic episode of one member).
Possibly evidenced by
Family members and/or significant others will discuss with nuse/counselor three
areas of family life that are most disruptive and seek alternative options with aid of
nursing/counseling interventions.
Family members and/or significant others will state and have in writing the names
and telephone numbers of at least two bipolar support groups.
Family members and/or significant others will state that they have gained support
from at least one support group on how to work with family member when he or
she is manic.
Family members and/or significant others will state their understand the need for
medication adherence, and be able to identify three signs that indicate possible
need for intervention when their family members mood escalates.
Family members and/or significant others will briefly discuss and have in writing,
the names and addresses of two bipolar organizations, two Internet site
addresses, and medication information regarding bipolar disorder.
Family members and/or significant others will state that they find needed support
and information in a support group (s).
Family members and/or significant others will identify the signs of increase manic
behavior in their family member.
Family members and/or significant others will state what they will do (whom to
call, where to go) when clients mood begins to escalate to dangerous levels.
Family members and/or significant others will demonstrate an understanding of
what a bipolar disorder is, the medications, the need for adherence to medication
and treatment.
Nursing Interventions Rationale
During the first or second day of hospitalization, This is a disease that can devastate and
spend time with family identifying their needs destroy some families. During an acute
during this time; for example: manic attack, families experience a great
1. Need for information about the deal of disruption and confusion when
their family members begins to act
disease.
bizarre, out of control and at times
2. Need for information about lithium or aggressive. Families need to understand
other antimanic medications (e.g., about the disease what can and cannot be
done to help control the disease, and
need for adherence, side effects,
where to go for help for their individual
toxic effects).
3. Knowledge about bipolar support
groups in the familys community and issues.
how they can help families going
through crises.
May be related to
Observation or valid report of inability to eat, bathe, toilet, dress, and/or groom
self independently.
Desired Outcomes
Patient will sleep 6 hours out of 24 with aid of medication and nursing measures
within 3 days.
Patient will eat half to one third of each meal plus one snack between meals with
aid of nursing intervention.
Patient will have normal bowel movements within 2 days with the aid of high-fiber
foods, fluids, and, if needed, medication.
Patient will wear appropriate attire each day while in the hospital.
Patient will bathe at least every other day while in hospital.
Patient will sleep 6 to 8 hours per night.
Patient will have a weight within normal limits for age and height.
Patient will have bowel habits within normal limits.
Patient will dress and groom self in appropriate manner consistent with pre-crisis
level of dress and grooming.
Nursing Interventions Rationale
Disturbed Sleep Pattern:
Keep client in areas of low
Promotes relaxation and minimizes manic behavior.
stimulation.
Encourage frequent rest periods
Lack of sleep can lead to exhaustion and death.
during the day.
At night, encourage warm baths,
soothing music, and medication
Promotes relaxation, rest, and sleep.
when indicated. Avoid giving the
client caffeine.
Imbalanced Nutrition:
Monitor intake, output, and vital Ensures adequate fluid and caloric intake;
signs. minimizes dehydration and cardiac collapse.
Frequently remind the client to eat
The manic client is unaware of bodily needs and is easily
(e.g.,Rob, finish your pancake,
distracted. Needs supervision to eat.
Sandra, drink this apple juice.).
Encourage frequent high-calorie
Constant fluid and calorie replacement are needed. Client
protein drinks and finger foods
might be too active to sit at meals. Fingers foods allow
(e.g., sandwiches, fruit,
eating on the run.
milkshakes).
Constipation:
Monitor bowel habits; offer fluids
and foods rich in fiber. Evaluate the Prevents fecal impaction resulting from dehydration and
need for a laxative. Encourage decreased peristalsis.
client to go to the bathroom.
Dressing/Grooming Self-Care Deficit:
If warranted, supervise choice of
Lessens the potential for inappropriate attention, which
clothes; minimize flamboyant and
can increase the level of mania, or ridicule, which lowers
bizarre dress, and sexually
self-esteem and increases the need for manic defense.
suggestive dress, such as bikini tops
Assists client in maintaining dignity.
and bottoms.
Give simple step-by-step reminders
for hygiene and dress (e.g.,Here is Distractability and poor concentration are countered by
your toothbrush. Put the toothpaste simple, concrete instructions.
on the brush).
Risk factors