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ASSESSMENT EXPLANATION OF GOALS OF NURSING RATIONALE EVALUATIO

THE PROBLEM CARE INTERVENTION N
Subjective: Bipolar Long term Build a trust Familiarity with and Long term
“Dumudugo disorderinvolves Objective: relationship with trust in the staff Objective:
yung ilong ko periods After 72 hours this client members can Goal met if
oh.” of excitability of nursing decrease the client’s after 72
(mania)alternating intervention fears and facilitate hours of
Objective: with periodsof the client will communication. nursing
-Nose bleeds depression. The no longer interventio
whenever he “mood swings” exhibit n the client
picks his nose between potentially Assess stimuli that Knowing the stimuli will no
-Bangs the mania and injurious increase the of the violent longer
door every depressioncan be movement likelihood of violent behavior of the exhibit
time he feels very abrupt.Mania behavior or patient can help potentially
upset is the Short Term agitation. decrease the injurious
-Hyperactive signaturecharacteri Objective: escalation of anxiety. movement
-Verbally stic of After 8 hours In hyperactive state,
abused other bipolardisorder of nursing client is extremely Partially
people and,depending on intervention distractible, met if after
-Pacing itsseverity, is how the client will responses even the 72 hours of
thedisorder is demonstrate slightest stimuli are nursing
classified.People decrease exaggerated interventio
commonlyexperien acting out Remove all possible n the client
ce an increasein behavior. hazards in will exhibit
energy. Due to environment such Removing of 2-3
excess in energy, as razors, stimulus in the potentially
Risk for injury there can be medications and environment of the injurious
related to accident hence, matches patient will lessen movement.
extreme Risk for Injury. Risk the likelihood of
hyperactivity for episodes of Not met if

scribd. hours of be the cause of per Provide activities nursing sonal injury. tissue hypoxia. after 72 evidenced by e statein which a p The things also will hours of excessive and erson is at risk for i not be used as a nursing constant njury as a result of weapon in injuring interventio motor environmental con himself or others. such as art therapy interventio as a substitutefor n the client purposeless Provide a safe and will REFERENCE: hyperactivity effective means demonstra Tierra. An stimulating Presence of the injurious y pathophysiologic situations.as Injurydefined as th destructive behavior.N (2013). of relieving pent. Disorientation Partially may endanger met if After client safety if he or 8 hours of . impaire the attention of the Objective: d sensoryperceptio client will lessen the n. n the client activity ditions interacting Stay with client (Videbeck 2008) will not with the individual' and divert exhibit s adaptive anddefe clientaway from potentially nsive resources. nurse can provide movement al condition such as sense of security to altered level of con the patient. Frequently orient behavior com/doc/66225943 client to reality /ncp-psyche2 andsurroundings. a client from noticing Goal met if nd pain or fatigue c the stimulus in the After 8 an contribute to or environment. te Bipolar Disorder. uptension. Diverting Short Term sciousness. decrease Retrieved from: acting out https://www.

behavior disorientation Restraints can help keep a person from Not met if getting hurt or doing After 8 harm to others. n the client will not To ensure that demonstra someone will look te after the client and decrease will stop the client if acting out Advise the client to there is an attempt behavior walk slowly when in injuring himself. holding the pail with hot water This will prevent spilling of hot water into his body Demonstrate Relaxation . sheunknowingly nursing wandersaway from interventio safeenvironment n the client Use mechanical will restraints as sometimes necessary to protect Restraints in a demonstra client if excessive medical setting are te acting hyperactivity items that limit a out accompanies the patient's movement. They are interventio stay with patient used as a last resort. hours of including their nursing Ask the family to caregivers.

to attain a state of increased calmness. anxiety. stre ss or anger .Technique Relaxation technique activity that helps a person to relax. or otherwise reduce levels of pain.