Cues
Subjective:
The pt. was a known case
of bipolar affective
disorder.
Objective:
Pt. has history of
psychiatric illness with
complaints of decreased
sleeps, decreased
appetite, over
talkativeness and
grandiose ideas, irritability
(mainly on provocation),
restlessness and poor self-
care for about 15 days.
VS taken as ff:
T- 36.4-37.5
P-96 bpm.
R-15 cpm.
BP- 98/55 mmHg
Nsg dx Scientific Rationale Goals & objectives
Self-care deficit r/t Due to a combination of
cognitive dysfunction affective, cognitive, and
secondary to bipolar d/o psychomotor factors that
AEB poor self-care. can affect their judgment,
impulsivity, and
coordination.
Furthermore, bipolar
disorder is associated with
neurologic imbalances,
which can further increase
the risk of injury.
Exhaustion, dehydration,
and rage may also
contribute to the risk of
injury in clients with
bipolar disorder. The main
complications of bipolar
disorder, or manic-
depressive illness (MDI)
are suicide, homicide, and
addictions (Soreff & Xiong,
2022). Clients with bipolar
disorder may also
experience neurologic
imbalances that can
contribute to the
development of manic
episodes, psychotic
symptomatology, and
rage. During manic
episodes, clients may
engage in impulsive and
reckless behavior,
including aggression and
violence toward
themselves or others.
Additionally, the presence
Nsg interventions Rationale Evaluation
After 1 week of nsg. Independent: Independent: After 1 week of nsg.
Interventions, the pt. is Interventions, the pt. is
expected to participate in 1. Establish rapport 1. To gain there trust expected to participate in
activities that will help the with the pt. and and cooperation for activities that will help the
pt. cope with bipolar S.O. a more efficient & pt. cope with bipolar
disorder: effective nsg. Care. disorder:
2. Assess the client’s
1. The client will current mood and 2. To determine 1. The client has
respond to the behavior, observe whether the client is regained from the
medication within for signs of a currently medication within
the therapeutic manic or experiencing a the therapeutic
levels. depressive manic, depressive, or levels.
episode, as well as stable state. This
2. The client will any impulsive or information will 2. The client has
sustain optimum reckless behavior identify potential sustained
health through that may increase risks for injury and optimum health
medication the risk of injury. take measures to through
management and a prevent harm to the medication
therapeutic 3. Assess the client’s client or others. management and
regimen. cognitive function, a therapeutic
including 3. The client’s cognitive regimen.
3. The client will drink attention, function will identify
8 oz of fluid every memory, and any deficits or 3. The client was able
hour throughout the decision-making impairments that to drink 8 oz of
day while in the skills. may increase their fluid every hour
acutely manic stage. risk of injury. throughout the
4. Provide structured day while in the
4. The client will be solitary activities 4. The structure acutely manic
free of dangerous with the assistance provides focus and stage.
levels of hyperactive of a nurse or aide. security.
motor behavior with 4. The client was free
the aid of 5. Provide frequent 5. This prevents of dangerous
medications and rest periods. exhaustion. levels of
nursing hyperactive motor
interventions within 6. Encourage the 6. This can help the behavior with the
the first 24 hours. client to client develop coping aid of medications
and nursing
of psychotic symptoms
and rage can further
increase the risk of violent
behavior in individuals
with bipolar disorder.
Aggressive behavior in
bipolar disorder shows a
direct prognostic value,
being linked to suicide
attempts and more
frequent hospitalizations,
the severity of mania, the
presence of mixed
symptoms, and
comorbid borderline
personality disorder (Fico
et al., 2020). In addition,
because of pts. Condition
there is an ineffective
response on self-care that
can affect maternal care
and lead into serious
problem is the pts. Fetus
will be also affected.
5. The client will spend communicate strategies and interventions
time with the nurse openly about their problem-solving within the first 24
in a quiet feelings and skills to manage their hours.
environment three concerns, and symptoms and
to four times a day provide a minimizes the risk of 5. The client has
between 7 am and nonjudgmental impulsive or risky spent time with
11 pm with the aid and supportive behaviors. the nurse in a
of nursing guidance. environment. quiet environment
7. This helps minimize three to four times
6. The client will take 7. Maintain a low the escalation of a day between 7
short voluntary rest level of stimuli in anxiety. am and 11 pm
periods during the the client’s with the aid of
day. environment (e.g., 8. Exercise has been nursing guidance.
loud noises, bright shown to have
7. The client will be light, low- mood-stabilizing 6. The client was able
free of excessive temperature effects and can help to take short
physical agitation ventilation). minimize the voluntary rest
and purposeless severity and periods during the
motor activity within 8. Encourage the frequency of mood day.
two weeks. client to engage in swings in clients with
activities that are bipolar disorder.222 7. The client was able
8. The client will safe and to obtain free of
verbalize control of structured, such as 9. Physical exercise can excessive physical
feelings. exercise or decrease tension and agitation and
creative activities. provide focus. purposeless motor
9. The client will activity within two
respond to external 9. Redirect violent 10. The safety plan can weeks.
controls behavior. help clients
(medications, recognize when they 8. The client was able
seclusion, nursing 10. Work with the are at risk for injury to verbalize
interventions) when client to develop a and take steps to control of feelings.
potential or actual safety plan that prevent it. It also
loss of control includes methods ensures a rapid 9. The client was able
occurs. to manage mood response in case of a to participate in
swings and crisis. external controls
10. The client will prevent injury, as (medications,
initiate and maintain well as emergency 11. Early detection and seclusion, nursing
goal-directed and contacts and intervention of interventions)
mutually satisfying resources. escalating mania will when potential or
activities/verbal prevent the actual loss of
 exchanges with possibility of harm to control occurs.
others. 11. Frequently assess self or others, and
the client’s decrease the need 10. The client was able
11. The client will report behavior for signs for seclusions. to initiate and
an absence of of increased maintain goal-
delusions, racing agitation and 12. The tendency directed and
thoughts, and hyperactivity. towards violent mutually satisfying
irresponsible actions behavior increases in activities/verbal
as a result of 12. Assess for the presence of exchanges with
medication predictors of substance misuse, others.
adherence and aggressive and irrespective of the
environmental violent behavior. presence of 11. The client has
structures. underlying mental reported an
13. Perform a mental disorders (Adeniyi, absence of
12. The client will cease status 2021). delusions, racing
the use of examination. thoughts, and
manipulation to 13. To uncover the irresponsible
obtain needs and 14. Use a calm and underlying etiology actions as a result
control others. firm approach. of the client’s of medication
aggressive and adherence and
13. The client will 15. Use short, simple, violent behavior environmental
demonstrate an and brief (Adeniyi, 2021). structures.
absence of explanations or
destructive behavior statements. 14. This provides 12. The client was able
toward self or structure and control to cease the use of
others. 16. Remain neutral as for a client who is manipulation to
possible; do not out of control. obtain needs and
14. The family members argue with the control others.
and/or significant client. 15. Simple sentences are
others will discuss easier to understand, 13. The client has
with the 17. Maintain a especially for clients demonstrated an
nurse/counselor consistent who may be absence of
three areas of family approach, employ experiencing destructive
life that are most consistent agitation. Clear behavior toward
disruptive and sek expectations, and communication can self or others.
alternative options provide a reduce
with aid of structured misunderstandings 14. The family
nursing/counseling environment. and potential members and/or
interventions. triggers for significant others
18. Decrease aggressive behavior. have discussed
15. The family members environmental with the
and/or significant stimuli (e.g., by 16. Using brief nurse/counselor
others will state providing a sentences to three areas of
their understanding calming maintain control of family life that are
of the need for environment or the conversation and most disruptive
medication assigning a private prevent the client and seek
adherence, and be room) from becoming more alternative options
able to identify agitated or with aid of
three signs that 19. Chart, in nurse’s escalating the nursing/counseling
indicate a possible notes, behaviors; situation. interventions.
need for interventions;
intervention when what seemed to 17. Setting limits, clients 15. The family
their family escalate agitation; understand what is members and/or
member’s mood what helped to expected of them significant others
escalates. calm agitation; and what is not has state their
when as-needed tolerated, which can understanding of
16. The family members (PRN) medications reduce the likelihood the need for
and/or significant were given and of aggressive medication
others will their effect; and behavior in the adherence, and be
demonstrate an what proved most future. able to identify
understanding of helpful. three signs that
what bipolar 18. This helps decrease indicate a possible
disorder is, the 20. Assess the client’s the escalation of need for
medications, and current mood anxiety and manic intervention when
the need for state and level of symptoms. their family
adherence to agitation or member’s mood
medication and hyperactivity. 19. Staff will begin to escalates.
treatment. recognize potential
21. Assess the client’s signals for escalating 16. The family
17. The client will eat communication manic behaviors and members and/or
half to one-third of abilities and ability have a guideline for significant others
each meal plus one to interpret social what might work had demonstrated
snack between cues. best for the an understanding
meals with aid of individual client. of what bipolar
nursing intervention. 22. Explore any past disorder is, the
experiences with 20. These medications, and
18. The client will have social relationships communication the need for
normal bowel and determine any barriers can affect adherence to
movements within 2 underlying factors the individual’s medication and
days with the aid of that may be ability to engage in treatment.
 high-fiber foods, contributing to the social interactions
fluids, and if needed, client’s difficulties and form meaningful 17. The client had
medication. with social relationships with obtained eat half
interaction, such others. to one-third of
as anxiety or each meal plus
19. The client will sleep previous traumas. 21. To build a better one snack
six to eight hours understanding of the between meals
per night. 23. Solitary activities client. with aid of nursing
requiring short intervention.
20. The client will have a attention spans 22. These factors can
weight within with mild physical guide effective 18. The client regains
normal limits for age exertion are best management a normal bowel
and height. initially (e.g., strategies and help movement within
writing, taking address the origin of 2 days with the aid
21. The client will dress photos, painting, the client’s social of high-fiber
and groom herself in or walks with difficulties. foods, fluids, and if
an appropriate staff). needed,
manner consistent 23. Solitary activities medication.
with the pre-crisis 24. Provide minimize stimuli;
level of dress and information to the mild physical 19. The client was able
grooming. client and family activities release to sleep six to
on bipolar disorder tension eight hours per
22. The client will be and its impact on constructively. These night.
able to manage social interaction. activities can also
pregnancy and keep help promote 20. The client was able
the fetus in a well 25. Anticipate the relaxation, improve to obtain a weight
state. need to use mood, and provide a within normal
cognitive- sense of purpose limits for age and
23. The client will behavioral therapy and height.
promote maternal (CBT) techniques accomplishment.
care that will keep such as social skills 21. The client was able
any fetal problems. training, cognitive 24. Educating the to dress and
restructuring, patients and families groom herself in
exposure therapy, about the symptoms, an appropriate
and problem- causes, and manner consistent
solving training. treatments of bipolar with the pre-crisis
disorder enables a level of dress and
26. Collaborate with good understanding grooming.
other healthcare of the condition. This
providers, such as will minimize the 22. The client was able
 psychiatrists and stigma and to manage
social workers. misconceptions pregnancy and
surrounding the keep the fetus in a
27. Encourage the disorder, which can well state.
client to consume in turn improve
adequate and communication and 23. The client has
nutritious foods relationships obtained
and to engage in between clients and promoting
physical exercise. their loved ones. maternal care that
Administer will help her from
pharmacologic 25. CBT techniques can any fetal
treatment as be helpful for clients problems.
indicated. with bipolar disorder
who are
28. Observe for experiencing
destructive impaired social
behavior toward interaction by
self or others. helping the client
Intervene in the develop coping
early phases of strategies, improve
escalation of social skills, and
manic behavior. decrease social
Assess the client’s anxiety.
ability to cope
with the disorder. 26. A multidisciplinary
approach can
29. Encourage the provide clients with
client to exercise a more
regularly. comprehensive
treatment plan that
30. Promote the use addresses their
of positive coping physical, emotional,
skills and social needs

31. Provide accurate 27. Nutrition and

information and physical exercise play
honest answers. a critical role in both
the mental and
32. Encourage physical health of
verbalization of clients with bipolar
 feelings and fears. disorder.

33. Encourage friends 28. Early detection and

and family intervention can
members to prevent harm to the
support the client client or others in
in all aspects. the environment.

34. Identify and 29. Both exercise and a

encourage the use regular schedule are
of previously keys to surviving this
successful coping illness (Soreff &
behaviors. Xiong, 2022).

35. Evaluate and 30. Positive coping

discuss family methods such
goals and as deep
expectations. breathing exercises,
relaxation activities,
36. During the first or using problem-
second day of solving steps, and
hospitalization, solving problems by
spend time with discussion should be
family identifying recommended to the
their needs during client. These
this time. techniques help
reduce the client’s
37. Encourage family anxiety, calming
members to them down and
participate in avoiding the
family therapy progression to a
sessions to manic state.
promote open
communication 31. Honest answers and
and address any accurate information
family dynamics facilitate the
issues. development of
rapport. These
38. Encourage enable the client to
expression and use their own
 acknowledgment experiences and
of feelings. knowledge to make
decisions.
39. Stress the
importance of 32. Accept the client’s
continuous open statements in a non-
dialogue between judgmental manner
family members. when they verbalize
their feelings. A non-
40. Help the family judgmental approach
recognize the may diminish the
needs of all client’s fear, establish
members. trust, provide
opportunities to
41. Encourage identify problems,
frequent rest and facilitate the
periods during the problem-solving
day. process. Clients
should be
42. At night, encouraged to
encourage warm express their moods
baths, soothing and ideas in an
music, and acceptable way.
medication when
indicated. Avoid 33. Social support is a
giving the client key factor in helping
caffeine. participants in a
study to manage the
43. Monitor intake, challenges of
output, and vital accepting a bipolar
signs. disorder diagnosis
and coping with it.
44. Frequently remind
the client to eat. 34. This focuses on
strengths and
45. Encourage reaffirms an
frequent high- individual’s ability to
calorie protein handle current roles.
drinks and finger The more frequent
foods (e.g., use of the strategies
 sandwiches, fruit, of active coping,
protein shakes). planning, positive
Avoid giving the reframing, and
client too many humor by the client’s
sugary foods and relatives or
carbohydrates. caregivers provides
Provide vitamins indications of
and supplements preserved cognitive
to the client as function that could
indicated. play a protective role
against the
46. Monitor bowel development of
habits; offer fluids psychiatric disorders.
and foods rich in
fiber. Evaluate the 35. This enabled insight
need for a laxative. into family
Encourage the adjustment (Backer
client to go to the et al., 2016).
bathroom.
36. It is necessary to
47. +/Give simple investigate the
step-by-step manner in which
reminders for clients and family
hygiene and dress members employ
(e.g., “Here is your coping strategies and
toothbrush. Put how to intervene to
the toothpaste on achieve better
the brush”). management of
these factors,
48. Arrange understanding which
appointments for groups need
occupational interventions to help
therapy for the clients and relatives
client, as to better manage
indicated. these situations
(Bridi et al., 2018).
49. Encourage the
client to perform 37. Involving family
at an optimal level members in therapy
of function; can help develop
 however, do not coping strategies and
rush the client. communication skills
to manage potential
50. Encourage the crises and provide
client to promote ongoing support for
maternal care. the patient.

51. Give proper advice 38. Do not deny or

on how to manage assure the client or
pregnancy during family members that
its condition. everything will be all
right. Because it is
not possible to
Dependent:
predict the outcome,
it is more helpful to
1. Observe for signs assist the person to
of atypical deal with feelings
antipsychotics about what is
toxicity (e.g., happening instead of
nausea, vomiting, giving false
diarrhea, reassurances.
drowsiness,
muscle weakness, 39. This provides an
tremor, lack of opportunity to get
coordination, feelings out in the
blurred vision, or open. Recognition
ringing in the and awareness
ears). promote the
resolution of guilt
2. Administer and anger.
pharmacologic
agents as 40. In a study about
indicated. families with parents
diagnosed with
3. Provide vitamins bipolar disorder,
and supplements children were given
to the client as additional
indicated. responsibilities, and
what was evident
was the importance
 of support for these
children, whether
from another parent,
extended family
members, or friends.
Having someone to
talk to, support,
distract, and be
consistent was
valued (Backer et al.,
2016).

41. This promotes

relaxation and
minimizes manic
behavior. Sleep
disturbances are
common in bipolar
disorder, and a
minimal stimuli
environment can
help the client to
improve their sleep
quality this can be
particularly
important during
manic or hypomanic
episodes when the
client may have a
decreased need for
sleep.

42. The clients with

bipolar disorder in a
study spent longer in
bed, had more
fragmented sleep,
and had more
unstable and
irregular sleep-wake
 patterns (Bradley et
al., 2017).

43. This promotes

relaxation, rest, and
sleep. The client
should engage in a
relaxing routine
before bedtime, such
as taking a warm
bath, practicing
relaxation
techniques such as
meditation or deep
breathing, or reading
a book. Stimulating
activities such as
watching TV or using
electronic devices
before bed should be
avoided. Caffeine
and alcohol can
disrupt sleep,
therefore, they must
also be avoided,
especially in the
evenings.

44. This ensures

adequate fluid and
caloric intake and
minimizes
dehydration and
cardiac collapse.
Poor diet habits can
contribute to
obesity, diabetes,
hypertension, and
dyslipidemia, which
in turn, increase the
 risk for
cardiovascular
disease. At any rate,
these risk factors
should be targeted
since it has been
shown that obesity
can also impact
cognitive
functioning, and in
turn, cognitive
impairment can
influence one
another (Bonnin et
al., 2019).

45. The manic client is

unaware of bodily
needs and is easily
distracted. Poor
nutrition access or
limited diet options
for clients with
bipolar disorder may
directly contribute to
poor diet quality.
(Beyer & Payne,
2015)

46. Constant fluid and

calorie replacement
are needed. The
client might be too
active to sit at meals.
An unhealthy diet
may actually cause
or worsen bipolar
disease (Beyer &
Payne, 2015).
47. This also assists the
client in maintaining
dignity. Respondents
in a study who
needed some
assistance in
dressing were only
able to choose and
prepare the clothes
to be used. They also
needed assistance in
determining the
suitability of the
clothes for the time.
The client’s inability
to fulfill these needs
is influenced by the
client’s awareness
that they had not
fully recovered so
the client still
sometimes
experiences
disorientation
toward reality.
Therefore, the client
needs special
guidance from the
nurse to restore their
basic abilities
(Syahrir, 2021).

48. The nurse may

discuss these with
clients, check their
needs for client
hygiene practices,
and provide accurate
and adequate
information. This
 helps increase the
level of
independence from
the partially assisted
category to the
independent
category (Syahrir,
2021).

49. Occupational
therapy is the
science and art of
directing one’s
participation to carry
out certain
predetermined tasks.
This therapy focuses
on the introduction
of abilities that still
exist in a person,
maintenance, and
improvement aim to
form a person to be
independent, not
dependent on the
help of others. The
purpose of this
therapy is to restore
mental function to
create certain
conditions so that
the client can
develop the ability to
be able to relate to
other people and the
surrounding
community, as well
as restore physical
function, increase
movement, muscles,
 and joints, and teach
ADLs (Syahrir, 2021).

50. This will help the

client or the mother
to manage and take
care of her fetus the
best way of
delivering it.

51. Advice and educate

mother about coping
with her situation.

Dependent:

1. There is a small
margin of safety
between therapeutic
and toxic doses.

2. A study found that

clients enhanced
both their work
functional outcome
and QOL after
receiving
prophylactic
lamotrigine therapy
at a six-month
follow-up (Bonnin et
al., 2019).

3. Vitamin D and folate

are essential for
good neuronal
functioning and have
been shown to be
helpful in
depression. Low
levels of vitamin D
have been
associated with
bipolar disorder.
Folic acid and folate
have been
increasingly used in
depressive disorders
(Beyer & Payne,
2015).