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Care Plan 27 Bipolar Disorder, Manic Episode: Risk For Other-Directed Violence
Care Plan 27 Bipolar Disorder, Manic Episode: Risk For Other-Directed Violence
CARE PLAN 27
Bipolar Disorder, Manic Episode
Nursing Diagnosis
RISK FACTORS
• Restlessness
• Hyperactivity
• Agitation
• Hostile behavior
• Threatened or actual aggression toward self or others
• Low self-esteem
EXPECTED OUTCOMES
Immediate
The client will
• Be safe and free from injury throughout hospitalization
• Demonstrate decreased restlessness, hyperactivity, and agitation within 24 to 48 hours
• Demonstrate decreased hostility within 2 to 4 days
• Refrain from harming others throughout hospitalization
Stabilization
The client will
• Be free of restlessness, hyperactivity, and agitation
• Be free of threatened or actual aggression toward self or others
Community
The client will
• Demonstrate level moods
• Express feelings of anger or frustration verbally in a safe manner
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
IMPLEMENTATION
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
Nursing Diagnosis
Defensive Coping
Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends
against underlying perceived threats to positive self-regard.
ASSESSMENT DATA
• Denial of problems
• Exaggeration of achievements
• Grandiose schemes, plans, or stated self-image
• Buying sprees
• Inappropriate, bizarre, or flamboyant dress or use of makeup or jewelry
• Flirtatious, seductive behavior
• Sexual acting-out
EXPECTED OUTCOMES
Immediate
The client will
• Demonstrate more appropriate appearance (dress, use of makeup, etc.) within 2 to 3 days
• Demonstrate increased feelings of self-worth within 4 to 5 days
Stabilization
The client will
• Verbalize increased feelings of self-worth
• Demonstrate appropriate appearance and behavior
Community
The client will
• Use internal controls to modify own behavior
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
IMPLEMENTATION
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
Nursing Diagnosis
ASSESSMENT DATA
• Disorientation
• Decreased concentration, short attention span
• Loose associations (loosely and poorly associated ideas)
• Push of speech (rapid, forced speech)
• Tangentiality of ideas and speech
• Hallucinations
• Delusions
EXPECTED OUTCOMES
Immediate
The client will
• Demonstrate orientation to person, place, and time within 24 hours
• Demonstrate decreased hallucinations or delusions within 24 to 48 hours
• Demonstrate decreased push of speech, tangentiality, loose associations within 24 to 48 hours
• Demonstrate an increased attention span, for example, talk with staff about one topic for 5 minutes, or
engage in one activity for 10 minutes, within 2 to 3 days
• Talk with others about present reality within 2 to 3 days
Stabilization
The client will
• Demonstrate orientation to person, place, and time
• Demonstrate adequate cognitive functioning
Community
The client will
• Sustain concentration and attention to complete tasks and function independently
• Be free of delusions or hallucinations
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
IMPLEMENTATION
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
*Evaluate the client’s tolerance for group The client is unable to provide limits and may be
activities, interactions with others, or visitors, unaware of his or her impaired ability to deal with
and limit these accordingly. others.
Encourage the client’s appropriate expression of Positive support can reinforce the client’s healthy
feelings regarding treatment or discharge plans. expression of feelings, realistic plans, and
Support any realistic plans the patient proposes. responsible behavior after discharge.
See Care Plan 18: Dual Diagnosis. Substance abuse often is a problem in clients with
bipolar disorder.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
Nursing Diagnosis
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
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
Community
The client will
• Meet personal needs independently
• Recognize signs of impending relapse
IMPLEMENTATION
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
Nursing Diagnosis
ASSESSMENT DATA
• Inappropriate behavior related to self-care
• Inadequate retention of information presented
• Inadequate understanding of information presented
EXPECTED OUTCOMES
Immediate
The client will
• Acknowledge his or her illness and need for treatment within 48 hours
• Participate in learning about his or her illness, treatment, and safe use of medications within
4 to 5 days
Stabilization
The client will
• Verbalize knowledge of his or her illness
• Demonstrate knowledge of adverse and toxic effects of medications
• Demonstrate continued compliance with chemotherapy
• Verbalize knowledge and acceptance of the need for continued therapy, chemotherapy, regular blood
tests, and so forth
Community
The client will
• Participate in follow-up care, for example, make and keep follow-up appointments
• Manage medication regimen independently
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode
IMPLEMENTATION
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.