PREDISPOSING FACTOR PRECING FACTORS

Stress Trauma

Increased SEROTONIN and Increased

or Decreased NOREPINEPHRINE and
DOPAMINE

DISORGANIZED SPEECH, FLIGHT OF IDEAS, GRANDIOSE DELUSIONS, NEGLECTED HYGIENE

NEOLOGISMS, PERSEVERATION, SEXUAL DELUSIONS, THOUGHT
MANIC EPISODES (GRANDIOSITY, MORE
BLOCKING, OTHER CLAIMS OF OCCUPATION, ASSOCIATIVE (+) Tooth Decay, Yellowish Teeth, (+)
ALKATIVE THAN USUAL,LIGHT OF IDEAS,
LOOSENESS, IRRITABLE, AGITATION, and PERSECUTORY DELUSIONS, Dental Carries, Halitosis, Visible Ear and
DISTRACTIBILITY)
ALOIA, AUDITORY AND VISUAL HLUCINATIONS, NIHILISTIC, BIZARRE Nose Hair, (+) Foul Body Odor
BEHVIOR, INATTENTION, CIRCUMSTANTIALITY 1.
LITHIUM
2. 2
Disturbed thought process related to Neurological Disturbances ANTICONVULSANTS

Ineffective coping related to inadequate social support

Risk for other directed violence related to mania

Impaired verbal communication related to altered perceptions

Risk for injury related to Hyperactivity

CLOZAPINE
Disturbed thought process related to neurological disturbances
OLANZAPINE

RISPERIDINE
Ineffective coping related to inadequate social support

1. Convey your acceptance your acceptance of client’s need for the false belief, while letting him know that you do not share the delusion.

2. Do not argue or deny the belief.

3. Encourage client to verbalize true feelings.

4. Use the techniques of consensual validation and seeking clarification when communication reflects alteration in thinking.

5. Reinforce and focus on reality.

6. Use touch cautiously, particularly if thoughts reveal ideas of persecution.

1. Assess the level of anxiety and coping on an ongoing basis.

2. Determine previous methods of dealing with life problems.
3. Determine alcohol intake, drug use, smoking habits, sleeping and eating patterns.
4. Provide for a quiet environment and position equipment out of view as much as possible.
5. Provide therapeutic environment.
6. Document findings.

Risk for other directed violence related to mania

1. Provide for the client’s physical safety and those around.

2. Develop therapeutic nurse – client relationship.
3. Use short, simple sentences to communicate.
4. Set and maintain limitation that is destructive or adversely others.
5. Limit the size and frequency of group activities.
6. Administer prescribed medications: Biperiden

Impaired verbal communication related to altered perceptions

1. Established rapport with client, initiated eye contact, addressed by preferred name, asked simple questions, engaged in brief social
conversation.
2. Established relationship with the client listened carefully and attended to client’s verbal or nonverbal expressions.
3. Spoke slowly and clearly, pitching voice low.
 4. Used confrontation skills, when appropriate, within an established nurse-client relationship.
5. Discussed ways to provide environmental stimuli as appropriate.

Self-care neglect related to avolition

1. Identify specific priorities and goals of clients.

2. Perform head to toe assessment noting personal hygiene and body odor.
3. Assess economic factors and living arrangements.
4. Perform environmental assessment
5. Develop multidisciplinary team specific to individual needs (occupational therapist)
6. Assist w/ setting up medication regimen as indicated.
7. Refer to support services (physical or occupational therapy)
8. Refer for counseling as indicated
9. Establish resocialization program when indicated.
10. Assessed client’s ability to bathe self through direct observation noting specific deficits and their causes
11. Instructed client to select bathe time when he is rested and unhurried
12. Encouraged independence, but intervene when patient cannot perform
13. Used consistent routines and allow adequate time for patient to complete tasks
14. Assisted patient with care of fingernails and toenails as required
15. Provided supervision for each activity until patient performs skill competently and is safe in independent care
16. Provided positive reinforcement for every accomplished made

Risk for injury related to hyperactivity

1. Provide structured activities with the nurse.

2. Identify interventions/safety devices.
3. Use short, simple sentences to communicate.
4. Set and maintain limits on behavior.
5. Avoid highly competitive activities.
6. Maintain low level of stimuli in the environment such as bright illustration, loud noise.