Professional Documents
Culture Documents
S:
Minsan masaya siya,
minsan naman bigla nalang
siya nagagalit at
nagwawala, nakakasakit
din sin minsan ng ibang
tao. As verbalized by
significant other/s.
O:
The patient hit the police
officer.
Aggressive
Nsg. Dx:
Risk for other- directed
violence r/t impulsivity
and impaired judgment
and persuasive disregard
for the rights of others
AEB risk-taking
behaviors, irritability,
anger and aggressiveness,
conflict with authority,
history of previous
violence, and impulsive,
explosive behavior
OBJECTIVE OF CARE
INTERVENTION
RATIONALE
Knowledge of precipitants
helps clients develop
strategies to prevent mood
changes. Using personal
strengths and abilities
enhances feels of control.
Decrease environmental
stimuli (e.g., by providing a
calming environment or
assigning a private room)
Maintain a consistent
approach, employ
consistent expectations,
and provide a structured
environment.
Redirect agitation and
potentially violent
behaviors with physical
outlets in an area of low
stimulation (e.g., punching
bag).
IMPLEMENTATION
EVALUATION
Review treatment
strategies. Identify which
interventions in the plan of
care are most important in
meeting therapeutic goals
and which are least
amenable to compliance
involve family and friends
in health planning
conferences
.
REFERENCE:
AMERICAN
PSYCHITRIC
ASSOCIATION 2015
Nursing Diagnosis
Bathing Self-Care Deficit
Impaired ability to perform or complete bathing activities for self.
Dressing Self-Care Deficit
Impaired ability to perform or complete dressing activities for self.
Feeding Self-Care Deficit
Impaired ability to perform or complete self-feeding activities.
Toileting Self-Care Deficit
Impaired ability to perform or complete toileting activities for self.
ASSESSMENT DATA
Inability to take responsibility for meeting basic health and self-care needs
Inadequate food and fluid intake
Inattention to personal needs
Impaired personal support system
Lack of ability to make judgments regarding health and self-care needs
Lack of awareness of personal needs
Hyperactivity
Insomnia
Fatigue
EXPECTED OUTCOMES
Immediate
The client will
Participate in self-care activities, such as bathing, grooming, with nursing assistance, within 24 hours
Establish adequate nutrition, hydration, and elimination, with nursing assistance, within 24 to 48 hours (e.g., eat at least 30% of
meals)
Establish an adequate balance of rest, sleep, and activity, within 48 to 72 hours (e.g., sleep at least
3 hours per night within 48 hours)
Stabilization
The client will
Maintain adequate nutrition, hydration, and elimination, for example, eat at least 70% of meals by a specified date
Maintain an adequate balance of rest, sleep, and activity, for example, sleep at least 5 hours by a specified date
Community
The client will
Meet personal needs independently
Recognize signs of impending relapse
IMPLEMENTATION
Nursing Interventions
* denotes collaborative interventions
Rationale
Provide foods that the client can carry with him or her
(fortified milkshakes, sandwiches, finger foods). See
Care Plan 52: The Client Who Will Not Eat.
DRUG/ROUTE/FREQUENCY
NURSING CONSIDERATION
MOOD STABILIZERS
http://www.webmd.com/drugs/2/drug5887-795/lithium-carbonateoral/lithium-controlled-release---oral
Lithium Citrate
Optimal patient response to Lithium Oral
Solution usually can be established and
maintained with 10 mL (2 full teaspoons
(16 mEq of lithium)) t.i.d. Such doses will
normally produce an effective serum
lithium level ranging between 1 and 1.5
mEq/L.
the desirable serum lithium levels are 0.6
to 1.2 mEq/L. Dosage will vary from one
individual to another, but usually 5 mL (1
full teaspoon) (8 mEq of Lithium) of
Lithium Oral Solution t.i.d. or q.i.d. will
maintain this level.
DEPAKOTE
Generic Name: divalproex sodium (dye
val PRO ex)
Brand Names: Depakote, Depakote ER,
Depakote Sprinkles
Generic name: DIVALPROEX SODIUM
125mg
Dosage form: capsule, sprinkles
Generic name: DIVALPROEX SODIUM
250mg
REFERENCE:
http://www.webmd.com/drugs/2/drug14374/lithium-citrate-oral/details
REFERENCE:
https://www.drugs.com/depakote.html