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 clients 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
as Injurydefined as th destructive behavior. 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. 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. An stimulating Presence of the injurious
y pathophysiologic situations. nurse can provide movement
al condition such as sense of security to
altered level of con the patient. Diverting Short Term
sciousness, impaire the attention of the Objective:
d sensoryperceptio client will lessen the
n, tissue hypoxia, a client from noticing Goal met if
nd pain or fatigue c the stimulus in the After 8
an contribute to or environment. hours of
be the cause of per Provide activities nursing
sonal injury. such as art therapy interventio
as a substitutefor n the client
purposeless Provide a safe and will
REFERENCE: hyperactivity effective means demonstra
Tierra,N (2013). of relieving pent- te
Bipolar Disorder. uptension. decrease
Retrieved from: acting out
https://www.scribd. Frequently orient behavior
com/doc/66225943 client to reality
/ncp-psyche2 andsurroundings. Disorientation Partially
may endanger met if After
client safety if he or 8 hours of
 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. behavior
disorientation Restraints can help
keep a person from Not met if
getting hurt or doing After 8
harm to others, hours of
including their nursing
Ask the family to caregivers. They are interventio
stay with patient used as a last resort. 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
Technique

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