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10 Identified Problems

1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar Disorder

2.) Self- care Deficit: Dressing and Grooming r/t Depression

3.) Disturbed Thought Process r/t Mood Alteration

4.) Risk for Suicide r/t Mood Alteration Secondary to Bipolar Disorder

5.) Chronic Low Self- Esteem r/t Anxiety

6.) Hopelessness r/t Feeling of Abandonment

7.) Defensive Coping r/t to Anxiety

8.) Risk for other Directed Violence r/t Bipolar Disorder

9.) Interrupted Family Process r/t Deterioration of Family Functioning

10.)Disturbed Energy Field r/t Bipolar Disorder

5 Prioritized Problems

1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar Disorder

2.) Self- care Deficit: Dressing and Grooming r/t Depression

3.) Disturbed Thought Process r/t Mood Alteration

4.) Risk for Suicide r/t Mood Alteration Secondary to Bipolar Disorder

5.) Chronic Low Self- Esteem r/t Anxiety


Cues Nursing Rationale Evaluation
Diagnosis
Rationale Nursing Interventions
Objectives
Subjective: Problem: During the Short Term: Independent: Short Term:
Disturbed depressed phase
“Pakiramdam Sleep Pattern of the bipolar After 1-2 days 1. Arrange care to 1. A silent and After 2 days of
ko kasi may disorder, it's of nursing provide for clam nursing
mananakit sa Etiology: common to intervention the uninterrupted environment intervention,
kin pag Related to experience patient will periods of rest, during sleep the patient had
natutulog ako Episodes of insomnia, indentify especially will help to indentified
eh kaya hindi Delusion characterized by individually allowing for lengthen the individually
ako Secondary to difficulty falling appropriate longer periods of range of appropriate
makatulog sa Bipolar asleep, staying interventions to sleep at night sleep. interventions
gabi. Konting Disorder asleep, or promote sleep. when possible. to promote
tunog lang waking up too sleep.
nagigising As evidenced early. Bipolar Long Term: 2. Encourage 2. Rituals and GOAL MET
ako agad.” as by: depressed client to establish routines
verbalized by patients are also After 3-4 Days a bedtime routine induce
the patient. Subjective: particularly of Nursing to facilitate comfort, Long Term:
sensitive to Intervention the transition from relaxation, and
“Pakiramdam “Pakiramdam hypersomnia -- patient will wakefulness to sleep. After 3 days of
ko paggising ko kasi may characterized by report sleep. nursing
ko sa umaga mananakit sa too much sleep, improvements intervention,
parang pagod kin pag sometimes up to in quality of 3. Encourage 3. Stress the patient
na pagod natutulog ako 18 hours per sleep pattern client to eliminate interferes with reported
parin ako.” as eh kaya hindi day, and daytime as evidenced stressful a person’s improvements
verbalized by ako fatigue. What's by: situations before ability to relax, in quality of
the patient. makatulog sa especially • Verbaliz bedtime. rest, and sleep pattern
gabi. Konting problematic with ation of feeling sleep. as evidenced
tunog lang bipolar patients of satisfaction by:
nagigising is that after waking • “Mas
ako agad.” as sometimes up in the masarap
verbalized by yung tulog ko
Objective: the patient. kagabi kesa
• Weakn 1. Has a noong isang
“Pakiramdam deprivation of morning. Dependent: therapeutic gabi.” as
ess
ko paggising sleep for any • No 1. Administer effect of verbalized by
• Restles
ko sa umaga reason -- such feeling of Chlorpromazine sedation that patient.
sness
as caffeine fatigue after as ordered.
• Dark parang may induce • No
pagod na consumption -- waking up. sleep.
circles feeling of
pagod parin could lead to a • Not
under the fatigue after
ako.” as switch into mania restless and
eyes waking up.
verbalized by -- which could be weak, no
• Dissati • Not
the patient. a big problem. frequent
sfaction restless and
yawning and weak, no
with sleep
Objective: dark eyes. frequent
• Freque Reference:
nt yawning • Weakn yawning and
Psychiatric
ess dark eyes.
Nursing Care
• Restle GOAL
Plans 5th Edition,
ssness PARTIALLY
Fortinash,
• Dark Holoday Worret
MET
circles page 185-202
under the
eyes
• Dissati
sfaction
with sleep
• Frequ
ent
yawning
Cues Nursing Rationale Evaluation
Diagnosis
Rationale Objective Intervention
Subjective: Problem: Hygienic care Short Term: Independent: Short Term:
“wala akong Self Care promotes
ganang mag- Deficit: cleanliness, After 1- 2 hours 1. Monitor 1. Monitor After 8 hours
ayos sa sarili Dressing and provides of nursing continually the of nursing
ko,hindi ko Grooming relaxation, intervention the the extent client’s intervention,
naman talaga improves self- patient will to which function the patient
malaman Etiology: image, and verbalized self care al improved
kung minsan Related to promote healthy ways how to deficits abilities hygienic care
bakit ako Depressed skin. Client improve interfere in an with a
biglang Mood hygiene is an hygienic care/ with the ongoing verbalization
nagwawala,ta secondary to extension of self care client’s way of “alam ko na
pos minsan Bipolar providing client function helps to ngayon na
sobrang Disorder safety and Long Term: determi importanteng
lungkot ko protecting the ne the bigyan ko ng
naman…” as As client’s defense After 2- 3 days client’s pansin ang
verbalized by manifested mechanisms. of nursing strengt pag-aayos ko
the patient. by: Body image is intervention the h and sa’kin sarili…”
associated with patient will areas GOAL MET.
”lagi yaan Subjective: the client’s consistently 2. Establish needing
ang suot “wala akong emotion, mood, performs self routine assista Long Term:
niya,(pointing ganang mag- attitude, and care activities goals for nce
to her red ayos sa sarili values. A client’s and consistent self care After 3 days of
turtle neck ko,hindi ko body image with 2. Routine nursing
sleeveless naman talaga directly affects developmental and intervention
blouse) paag malaman the type of stage as structur the patient
tinatanong kung minsan personal hygiene evidenced by e was able to
naman bakit ako practiced; this being organiz perform self
naming siya biglang may change if dependent in 3. Initiate e the care activities.
hindi naman nagwawala,t the client body providing self grooming client’s GOAL
niya masagot apos minsan image is altered care and chaotic PARTIALLY
kung bakit…” sobrang world MET.
as verbalized lungkot ko and
by the nurse naman…” as promot
in charge. verbalized by because of hygiene e
the patient. illness. tasks when succes
Objective: the client is s
best able
• Repeatedly ”lagi yaan
ang suot to comply 3. Depres
used of
clothing niya,(pointing sed
to her red clients
• Demonstrat turtle neck have
e infrequent sleeveless more
bathing blouse) paag brighter
tinatanong affect
• Displays naman later in
inadequate naming siya the day;
hindi naman 4. Provide and
personal privacy for
hygiene: niya masagot client
kung bakit…” self care with
foul odor without
as verbalized anxiety
by the nurse comprising and
• Gingivitis client’s
in charge. hyperac
safety tive
Objective: behavio
• Repeatedly rs are
used of more
clothing attentiv
5. Praise the e to self
client for care
• Demonstrat
attempts at after
e infrequent
self care taking
bathing
and each medicat
successfull ion
• Displays y
inadequate
personal 4. Providi
hygiene: ng as
foul odor completed much
task as
• Gingivitis privacy
as
possibl
e helps
to
preserv
e the
client’s
dignity
Dependent:
5. Positive
1. Administer reinforc
mood ement
stabilizing increas
drug: es
Lithium feelings
Carbonate of self
450 mg worth
OD and
promot
es
continui
ty of
function
2. Administer al
antipsychot behavio
ic drug: r
Chlorprom
azine
Hydrochlori
de 5 mg
ODHS

1. Normali
zes the
reuptak
e of
certain
neuro-
Transm
itters
and
reduces
release
of
norepin
ephrine

2. May
bloclk
pst
synapti
c
dopami
ne
recepto
rs in the
brain.
Cues Nursing Rationale Objective Nursing Rationale Evaluation
Diagnosis Intervention
Subjective: Problem: Bipolar Short term:
Disturbed
“Nagwawala Thought 1. These After 1 hr. of
kasi siya Process disorder or Short term: Independent: steps help nursing
noon, hindi manic- reinforce reality intervention, the
naming siya Etiology: depressive After 30 mins.- 1. Orient patient
1 hr of nursing and provide
mapigilan. Related to disorder (also client and call cues that responded
Maraming Mood referred to a intervention, client by name, coherently to
the patient will maintain
beses na rin Alteration bipolarism or introduce self orientation. simple, concrete
naulit un manic responds on each statements as
kaya nag- As manifested depression) is a coherently to contact; evidenced by:
decide na rin by: psychiatric simple, frequently
kaming diagnosis that concrete mention time, • Demonstr
Subjective: statements as ated orientation
ipadala siya describes a date, and 2. Validatio
doon.” as category of evidenced by: place. to person, place
“Nagwawala n seeks to help
verbalized by kasi siya noon, mood disorders and time.
• Exhibiti the caregiver,
the relative hindi naming defined by the 2. Provide encouraging
ng judgment, • Exhibiting
of the patient siya mapigilan. presence of one validation of empathy.
insights, judgment,
Maraming or more thoughts and
“May mga coping skills, insights, coping
beses na rin episodes of feelings of 3. Accepta
time na and problem skills, and
naulit un kaya abnormally client. nce promotes
pakiramdam solving problem solving
nag-decide na elevated mood trust.
ko talaga abilities. abilities.
rin kaming clinically 3. Do not
may referred to as attempt to
ipadala siya • Client’s GOAL
mananakit mania or, if argue or
doon.” as expresses PARTIALLY
sa akin, milder, change the
verbalized by logical, goal- 4. To verify MET
sumusunod hypomania. client’s belief.
the relative of oriented that client is
lang sila Individuals who Long Term:
the patient thoughts with swallowing the
sakin lage.” experience 4. Check
absence of tablets or
as verbalized “May mga time manic episodes mouth if After 3 days of
delusion. capsules.
by the na also commonly hoarding nursing
patient. pakiramdam experience • Demon medicines. intervention the
5. The
ko talaga may depressive strates patient
suspicious
mananakit sa episodes or socially established
akin, 5. client does not reality
sumusunod 5. have the orientation as
Objective: lang sila sakin 5. capacity to evidenced by:
lage.” as symptoms, or appropriate An assertive, relate to an
• Distra mixed episodes for age and • Appropria
verbalized by matter- of- fact, overly friendly,
ctibilit in which status. teness of
the patient. yet genuine overly cheerful
y features of both interactions and
• Demon approach is the attitude.
• Social mania and least willingness to
Withdr depression are strates participate in
orientation to threatening to
awal Objective: present at the the therapeutic
person, place the suspicious
• Depre same time. person. 1. May community.
• Distracti These episodes and time.
ssion block
bility are usually GOAL
• Blocki Dependent: postsynaptic
• Social separated by PARTIALLY
ng dopamine
Withdra periods of MET
• Fear Long Term: 1. Administ receptors in
wal “normal” mood,
• Anxiet er anti- the brain.
• Depress but in some After 1- 3 days psychotic drug:
y
ion individuals, of nursing Chlorpromazine 2. Normaliz
• Blocking depression and intervention, Hydrochloride es the
• Fear mania may the patient will reuptake of
• Anxiety rapidly alternate maintain certain
known as rapid reality 2. Administ neurotransmitt
cycling. orientation as er mood ers and
evidenced by: stabilizing drug: reduces the
• Approp Lithium release of
Reference: riateness of Carbonate norepinephrine
interactions .
Keltner,
Norman L., and
Scwecke Lee willingness to
1. Prevent
Hilyard, participate in
anxiety from
Bostron, Carole. the
escalating to
Psychiatric therapeutic
Collaborative unmanageable
Nursing. Fifth
levels.

Edition. Mosby. community. 1. 1. Co


Pg. 396- 398 ntinue to
• Solves support and
problems and monitor
makes psychosocial
decisions treatment
appropriate plans.
for age and
status.

• Maintai
n residual
sensory-
perceptual
functions.
CUES NURSING RATIONALE EVALUATION
DIAGNOSIS
RATIONALE NURSING INTERVENTION
OBJECTIVES
Subjective: Problem: Clients who Short term: Independent: Short term:
Risk for express feeling
“Wala na Suicide of After 1-2 days 1. Check the 1 The nurse After 2 days of
akong worthlessness, of nursing client’s room for first priority is nursing
nagawang Etiology: helplessness, intervention, potentially provide for the intervention,
tama sa buhay Related to hopelessness, the patient will destructive client’s safety the patient
ko. Lahat Mood and other demonstrate implements: sharp and protect the demonstrated
nalang Alteration feelings absence of objects, belt, client from self- consistent,
nangyari sa Secondary to associated with suicidal chemicals, inflicted life optimistic, and
buhay ko mali. Bipolar depressive attempts, and hoarded threatening hopeful
Nakakahiya Disorder states are at display medications; and injury or death. attitude by
kasi nandito increase risk consistent, take steps to showing
ako ngayon, As manifested for suicide. optimistic, and protect client brighter affect,
gastos pa ako by: Depressed hopeful through smiling, and
imbes na ako person see attitude. appropriate upon
yung nag- Subjective: suicide as a therapeutic conversation
tratrabaho means of Long term: interventions. 2. Allowing the she focuses
para sa mga “Wala na escaping from client to on present
anak ko” as akong anxiety After 3-4 days 2. Listen actively verbalize helps activities.
verbalized by nagawang provoking and of nursing to the client’s story the client GOAL
the patient. tama sa buhay intensely intervention, regarding how the relieve pent-up PARTALLY
ko. Lahat frightening the patients will client came to the thoughts, MET
“wala ng silbi nalang situations. expresses point of suicide, feelings and
buhay ko, nangyari sa They are desire to live. using therapeutic emotions Long term:
hindi na dapat buhay ko mali. frightened by Display skills such as related to
ako Nakakahiya their consistent, reflection, suicide and is After 4 days of
nabubuhay pa. kasi nandito overwhelming optimistic, and clarification, and in itself nursing
hindi ko alam ako ngayon, anxiety, hopeful validation, and therapeutic. It intervention,
kung para gastos pa ako isolation, attitude. indicate also gives the the patient
saan pa kung imbes na ako nurse expressed a
buhay parin yung nag- information desire to live,
ako” as tratrabaho about the display
verbalized by para sa mga hopelessness, acceptance of the critical events consistent,
the patient. anak ko” as and client’s thought that influenced optimistic, and
verbalized by helplessness. and feelings. the client’s hopeful
Objective: the patient. Clients story promotes attitude
considering
• frequently trust and instill towards
“wala ng silbi suicide may hope. betterment of
agitated
buhay ko, also own life.
• impaired
hindi na dapat experience 3. Constant GOAL
grooming
ako feelings of staff support PARTIALLY
nabubuhay pa. excessive guilt, 3. Tell the client to and protection MET.
hindi ko alam self blame, and come to staff reduce the
kung para frustration. whenever the client’s fear of
saan pa kung Suicidal clients client experiences suicidal
buhay parin often such thoughts or impulses and
ako” as experience feelings. offer hope for
verbalized by severe anger. survival.
the patient.
Reference: 4. Educating
Objective: Mental Health 4. Help the client the client about
Psychiatric to see that suicide
• frequently the temporary
Nursing, by is not an nature/
agitated
Norris, alternative to life’s experience of
• impaired
Connell, problems but is suicide and
grooming
Stockard, rather a temporary depression
Ehrhart, experience often promotes the
Newton. P.772 brought by an client’s insight
actual illness and about the
exacerbated by life threatability of
stressors. the disease
process and
offers hope for
the future.
Dependent:
1. Administer 1. To
Lithium as stabilize the
ordered. mood of the
patient.
1. Prevent
Collaborative: anxiety from
1. Continue to escalating to
support and unmanageab
monitor le levels.
psychosocial
treatment plans.

Cues Nursing Rationale Nursing Interventions Rationale Evaluation


Diagnosis Objectives
Subjective: Problem: Short Term:
Chronic Low 1. Incongru
“Dati Self-esteem ence’s After 2 days of
masiyahin siya Depression is a Short Term: Independent: between nursing
at may tapang Etiology: feeling 1. Note verbal/non- intervention the
ng loob sa mga Related to involving an After 1-2 days non-verbal verbal patient
ginagawa niya, Anxiety element of of nursing behavior. communicatio demonstrated
pero ngayon sadness and intervention the n require self-care
naging as evidenced helplessness. patient will: clarification. appropriate for
withdrawn na by: There is little • Client age and
siya,” as drive for demonstrate 2. To status,used
verbalized by Subjective: socialization or self-care assist client to techniques to
the patient’s communication appropriate for 2. Use develop decrease
relative. “Dati , although age and status positive internal sense anxiety and
masiyahin siya depression is • Uses messages of self-esteem. had a
“wala na akong at may tapang the techniques to rather than verbalization of
nagawang ng loob sa mga predominant, decrease praise. 3. Positive “nalaman ko na
tama sa buhay ginagawa niya, outward feeling anxiety. words of importanteng
ko, lahat pero ngayon shown, the 3. Give encouragemen alagaan ko
nalang ng naging fear, anger and reinforcement t promote sarili ko, hindi
nangyare sa withdrawn na guilt for progress continuation of lang para sa
components of Long Term: noted.
buhay ko siya,” as efforts, sarili ko kundi
mali…” as verbalized by anxiety are supporting para rin sa
internalized or After 3-4 days
verbalized by the patient’s development mga taong
turned inward of nursing
the patient relative. of coping importante
upon the self. intervention the
behaviors. sakin…”
The fear of patient will:
“nakakahiya “wala na akong GOAL MET
kasi nandito nagawang unleashing • Verbaliz 4. Adaptati
ako ngayon, tama sa buhay anger or e increased 4. Encoura on to change Long Term:
gastos pa ako ko, lahat hostility or of sense of self- ge client to in self-concept
imbes na ako nalang ng exposing guilt- worth in progress at depends on its After 4 days of
ung nangyare sa producing relation to own rate. significance to nursing
nagtatrabaho buhay ko unacceptable current individual, intervention the
thoughts and situation.
para sa mga mali…” as disruption to patient had
anak ko…” as verbalized by lifestyle, length verbalized
verbalized by the patient of increased
the patient. wishes to • Demons 5. Encoura illness/debilitat sense of self-
“nakakahiya others trate behaviors ge techniques ion. worth in
Objective: kasi nandito reinforces the and/or lifestyle such as deep 5. To relation to
ako ngayon, learning of changes to breathing. decrease current
internalization promote
• Social gastos pa ako anxiety level. situation.
imbes na ako of anxiety. The positive self Dependent: GOAL
Withdrawal
ung individual has image. PARTIALLY
• Depression
nagtatrabaho learned during 1. Administ MET
• Fails to the
para sa mga er Lithium as
attend to socialization
anak ko…” as ordered. 1. Used to
hygiene process to
• Demonstrates verbalized by anticipate
balance
difficulty the patient. biogenic
rejection, amines of
communicatin disapproval
g or Objective: norepinephrin
and loss of love e and
interacting leading to
with others: • Social serotonin in
disruption in CNS area
poor eye Withdrawal
interpersonal 2. Administ involved in
contact and • Depression
relations. er emotional
soft voice • Fails to
Chlorpromazi response.
attend to Reference: ne as
hygiene Page 127, ordered. 2. Depress
• Demonstrates Psychiatric
difficulty cerebral
Nursing by cortex,
communicatin Manfreda &
g or hypothalamus
Krampitz, 10 , and limbic
interacting Edition
with others: systems
poor eye which control
contact and activity an
soft voice aggression;
blocks
neurotransmi
ssion
Collaborative: produced by
dopamine
1. Continu and synapse.
e to support
and monitor
psychosocial
treatment 1. To help
plans. the patient
establish
sense of
worth.