Summary of Nursing Diagnoses

• Risk for violence directed to self and others risk factor: irritability and aggressive verbal remarks of harming others

Sleep pattern disturbance R/T external factors present in the facility such as noise of other clients who are manic and drug’s side effects

• Disabled family coping related to knowledge deficit of significant person regarding illness and management • Fatigue related to sleep deprivation • Fatigue related to medication side effects.
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Impaired skin integrity related to bruises. Risk for noncompliance related to extrapyramidal effects of the medication.

and have quick capillary refill (<6 seconds). be free of impairment (scratches. and alleviating factors. Rationale: Healthy skin varies from individual to individual. Rationale: Identifying the related factors with fatigue can aid in determining possible causes and establishing a collaborative plan of care.  Assess the patient’s emotional response to fatigue.  Assess general condition of skin. imbalanced nutritional intake and increased responsibilities and demands at the rehab. medication side effects. and feeling upon awakening. excoriation. Other rating scales can be developed using pictures or descriptive words. time taken to fall asleep. sleep disorders. quantity.Additional Nursing Management  Assess characteristics of fatigue: Severity. This method allows the nurse to compare changes in the patient’s fatigue level over time. changes in severity over time. Rationale: Changes in the person’s sleep pattern may be a contributing factor in the development of fatigue. bruises. Rationale: Anxiety and depression are the more common emotional responses associated with fatigue. Rationale: Using a quantitative rating scale such as 1 to 10 can help the patient describe the amount of fatigue experienced. aggregating factors. depression.  Assess for possible causes of fatigue: recent physical illness. . It is important to determine if the patient’s level of fatigue is constant or if it varies over time. emotional stress. rashes). These emotional states can add to the person’s fatigue level and create a vicious cycle. feel warm and dry to the touch. but should have good turgor (an indication of moisture).  Evaluate the patient’s sleep patterns for quality.

• Channel client’s need for movement into socially acceptable motor activities. Keep the bruised area raised above the heart to helps keep blood from pooling in the bruised tissue. simple sentences to communicate.I. First aid on bruises treatment you can remember as R. I : Ice or cold pack on the bruise to reduce the swelling also relieve the pain for 30 to 60 minutes at a time for a day or two after the injury.  Meeting physiologic needs • Decreasing environmental stimulation to promote relaxation. high protein) while moving around are the best options to improve nutrition.  Providing Therapeutic Communication • Use short. but not too tight. and giving attention t others when thay need it. • Remind the client to respect distances between self and others. • Assess clients for suicidal ideation and plans or thoughts of hurting others. E : Elevate the injured area.  Providing for safety • Set limits on client’s behavior when needed.E R : Rest the injured part. • Treat clients with dignity and respect despite their inappropriate behavior. . • Observing and supervising clients at meal times are also important to prevent clients from taking food from others. Wrap a bandage firmly round the bruise area. do not overwork muscles in bruise area. C : Compression bandaging. • Promote sleep and rest • “Finger foods” or things client can eat (high caloric. • Monitor food and fluid intake and hours of sleep until clients routinely meet these needs without difficulty.C.  Promoting appropriate behaviors • Protect the client from their pursuit of socially unacceptable and risky behaviors. • Clarify the meaning of client’s communication • The nurse sets limits regarding taking turns speaking and listening.

 Managing medications • Periodic serum lithium levels are used to monitor the client’s safety and to ensure that the dose given has increased the serum lithium level to a treatment level or reduced it ti a maintenance level. • Assess for signs of toxicity and ensure that clients and their families have this information prior to discharge • Assess renal function .

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