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ASSESSMENT

S:
Minsan masaya siya,
minsan naman bigla nalang
siya nagagalit at
nagwawala, nakakasakit
din sin minsan ng ibang
tao. As verbalized by
significant other/s.
O:
The patient hit the police
officer.
Aggressive
Nsg. Dx:
Risk for other- directed
violence r/t impulsivity
and impaired judgment
and persuasive disregard
for the rights of others
AEB risk-taking
behaviors, irritability,
anger and aggressiveness,
conflict with authority,
history of previous
violence, and impulsive,
explosive behavior

OBJECTIVE OF CARE

After 24-32 hours nursepatient intervention, the


client will be able to:
Understand and to identify
individually appropriate
interventions that prevent
injury, promote good
health holistically.

INTERVENTION

Assist clients to identify


precipitants of
dysfunctional mood,
differentiating what can
and cannot be changed.
Help them identify
available resources and
personal strengths. Teach
new problem-solving and
coping skills.

Use a calm and firm


approach.

RATIONALE

Knowledge of precipitants
helps clients develop
strategies to prevent mood
changes. Using personal
strengths and abilities
enhances feels of control.

Provides structure and


control for a client who is
out of control.

Use short, simple and brief


explanations or statements.

Short attention span limits


understanding to small
pieces of information.

Decrease environmental
stimuli (e.g., by providing a
calming environment or
assigning a private room)

Helps decrease escalation


of anxiety and manic
symptoms.

Maintain a consistent
approach, employ
consistent expectations,
and provide a structured
environment.
Redirect agitation and
potentially violent
behaviors with physical
outlets in an area of low
stimulation (e.g., punching
bag).

Clear and consistent limits


and expectations minimize
potential for clients
manipulation of staff.
Can help to relieve pent-up
hostility and relieve muscle
tension.

IMPLEMENTATION

EVALUATION

Review treatment
strategies. Identify which
interventions in the plan of
care are most important in
meeting therapeutic goals
and which are least
amenable to compliance
involve family and friends
in health planning
conferences

Encouraged client to take


prescribed medications
such as mood stabilizers
(Lithium)

Client will be more likely


to follow-through on goals
the participated in
developing. Sets priorities
and encourages problem
solving areas of conflict
Family members need to
understand that care is
planned to focus on what is
most important to the
patient. This enables the
patient to maintain a sense
of autonomy.
To balance
certain brain chemicals
(neurotransmitters) that
control emotional states and
behavior.

.
REFERENCE:
AMERICAN
PSYCHITRIC
ASSOCIATION 2015

Nursing Diagnosis
Bathing Self-Care Deficit
Impaired ability to perform or complete bathing activities for self.
Dressing Self-Care Deficit
Impaired ability to perform or complete dressing activities for self.
Feeding Self-Care Deficit
Impaired ability to perform or complete self-feeding activities.
Toileting Self-Care Deficit
Impaired ability to perform or complete toileting activities for self.

ASSESSMENT DATA

Inability to take responsibility for meeting basic health and self-care needs
Inadequate food and fluid intake
Inattention to personal needs
Impaired personal support system
Lack of ability to make judgments regarding health and self-care needs
Lack of awareness of personal needs
Hyperactivity
Insomnia
Fatigue

EXPECTED OUTCOMES
Immediate
The client will
Participate in self-care activities, such as bathing, grooming, with nursing assistance, within 24 hours
Establish adequate nutrition, hydration, and elimination, with nursing assistance, within 24 to 48 hours (e.g., eat at least 30% of
meals)
Establish an adequate balance of rest, sleep, and activity, within 48 to 72 hours (e.g., sleep at least
3 hours per night within 48 hours)
Stabilization
The client will
Maintain adequate nutrition, hydration, and elimination, for example, eat at least 70% of meals by a specified date
Maintain an adequate balance of rest, sleep, and activity, for example, sleep at least 5 hours by a specified date

Community
The client will
Meet personal needs independently
Recognize signs of impending relapse

IMPLEMENTATION
Nursing Interventions
* denotes collaborative interventions

Rationale

Monitor the clients calorie, protein, and fluid intake.


You may need to record intake and output.

The client may be unaware of physical needs or may


ignore feelings of thirst and hunger.

The client may need a high-calorie diet and


supplemental feedings.

The clients increased activity increases nutrition


requirements.

Provide foods that the client can carry with him or her
(fortified milkshakes, sandwiches, finger foods). See
Care Plan 52: The Client Who Will Not Eat.

If the client is unable or unwilling to sit and eat, highly


nutritious foods that require little effort to eat may be
effective.

Monitor the clients elimination patterns.

The client may be unaware of or ignore the need to


defecate. Constipation is a frequent adverse effect of
antipsychotic medications.

Provide time for a rest period during the clients daily


schedule.

The clients increased activity increases his or her need


for rest.

Observe the client for signs of fatigue and monitor his


or her sleep patterns.

The client may be unaware of fatigue or may ignore the


need for rest.

Decrease stimuli before bedtime (dim lights, turn off


television).

Limiting stimuli will help encourage rest and sleep.

Use comfort measures or sleeping medication if


needed.

Comfort measures and medications can enhance the


ability to sleep.

Encourage the client to follow a routine of sleeping at


night rather than during the day; limit interaction with
the client at night and allow only a short nap during
the day. See Care Plan 38: Sleep Disorders.

Talking with the client during night hours will interfere


with sleep by stimulating the client and giving attention
for not sleeping. Sleeping excessively during the day
may decrease the clients ability to sleep at night.

If necessary, assist the client with personal hygiene,


including mouth care, bathing, dressing, and
laundering clothes.

The client may be unaware of or lack interest in


hygiene. Personal hygiene can foster feelings of wellbeing and self-esteem.

Encourage the client to meet as many of his or her


own needs as possible.

The client must be encouraged to be as independent as


possible to promote self-esteem.

DRUG/ROUTE/FREQUENCY

ACTION AND S/E

NURSING CONSIDERATION

MOOD STABILIZERS

LITHIUM CARBONATE ((Eskalith,


Lithobid)
PO 600 mg 3 times daily or 900 mg twice
daily (slow-release forms) Maintenance
dose, PO 300 mg 3 or 4 times daily to
maintain a serum lithium level of 0.61.2
mEq/L

Mood stabilizers balance


certain brain chemicals
(neurotransmitters) that control
emotional states and behavior.
Mood stabilizers can help to
treat mania and to prevent the
return of both manic and
depressive episodes in bipolar
disorder. They may also help for
treat the mood problems associated
with schizophrenia, such
as depression.
Mood stabilizers, especially
lithium, valproic acid, and
carbamazepine, may provide relief
from acute episodes of mania
or depression and can help prevent
them from recurring.
Nausea, vomiting,
and diarrhea.Trembling,Increased
thirst and increased need to
urinate,Weight gain in the first few
months of use,Drowsiness.

This medication is used to treat


manic-depressive disorder
(bipolar disorder). It works to
stabilize the mood and reduce
extremes in behavior by restoring
the balance of certain natural
substances (neurotransmitters) in
the brain.
Some of the benefits of continued
use of this medication include
decreasing how often manic
episodes occur and decreasing the
symptoms of manic episodes
such as exaggerated feelings of
well-being, feelings that others
wish to harm you, irritability,
anxiousness, rapid/loud speech,
and aggressive/hostile behaviors.
Drowsiness, dizziness, tiredness,
increased thirst, increased
frequency of
urination, weight gain, and mildly
shaking hands (fine tremor) may
occur.
Reference:

Before taking lithium, tell your


doctor or pharmacist if you are
allergic to it; or if you have any
other allergies. This product may
contain inactive ingredients,
which can cause allergic reactions
or other problems. Talk to your
pharmacist for more details.
Before using this medication, tell
your doctor or pharmacist your
medical history, especially
of: heart disease, kidney disease,
urinary problems (such as
difficulty urinating),
underactive thyroid (hypothyroidi
sm), seizures, Parkinson's
disease, leukemia,
severe dehydration (severe loss of
body water), any infection
with high fever, a
certain skin disorder (psoriasis).
Drink 8 to 12 glasses (8 ounces or
240 milliliters each) of water or
other fluid each day, and eat a

http://www.webmd.com/drugs/2/drug5887-795/lithium-carbonateoral/lithium-controlled-release---oral

healthy diet with normal amounts


of salt (sodium) as directed by
your doctor or dietician while
taking this medication

Lithium Citrate
Optimal patient response to Lithium Oral
Solution usually can be established and
maintained with 10 mL (2 full teaspoons
(16 mEq of lithium)) t.i.d. Such doses will
normally produce an effective serum
lithium level ranging between 1 and 1.5
mEq/L.
the desirable serum lithium levels are 0.6
to 1.2 mEq/L. Dosage will vary from one
individual to another, but usually 5 mL (1
full teaspoon) (8 mEq of Lithium) of
Lithium Oral Solution t.i.d. or q.i.d. will
maintain this level.

DEPAKOTE
Generic Name: divalproex sodium (dye
val PRO ex)
Brand Names: Depakote, Depakote ER,
Depakote Sprinkles
Generic name: DIVALPROEX SODIUM
125mg
Dosage form: capsule, sprinkles
Generic name: DIVALPROEX SODIUM
250mg

This medication is used to treat


manic-depressive disorder
(bipolar disorder). It works to
stabilize the mood and reduce
extremes in behavior by restoring
the balance of certain natural
substances (neurotransmitters) in
the brain.
Drowsiness, dizziness, tiredness,
increased thirst, increased
frequency of
urination, weight gain, and mildly
shaking hands (fine tremor) may
occur.
It may take 1 to 3 weeks to
notice improvement in your
condition.

REFERENCE:
http://www.webmd.com/drugs/2/drug14374/lithium-citrate-oral/details

Depakote (divalproex sodium) affects


chemicals in the body that may be
involved in causing seizures.
Depakote is used to treat various types of
seizure disorders. It is sometimes used
together with other seizure medications.
Depakote is also used to treat manic
episodes related to bipolar disorder (manic
depression), and to prevent migraine
headaches.

Before taking lithium, tell your


doctor or pharmacist if you are
allergic to it; or if you have any
other allergies. This product may
contain inactive ingredients (such
as propylene glycol), which can
cause allergic reactions or other
problems
Before using this medication, tell
your doctor or pharmacist your
medical history, especially
of: heart disease, kidney disease,
urinary problems (such as
difficulty urinating),
underactive thyroid (hypothyroidi
sm), seizures, Parkinson's
disease, leukemia,
severe dehydration (severe loss of
body water), any infection
with high fever, a
certain skin disorder (such
as psoriasis).
Drink 8 to 12 glasses (8 ounces or
240 milliliters each) of water or
other fluid each day, and eat a
healthy diet with normal amounts
of salt (sodium)

If you take Depakote for seizures or manic


episodes: Do not start or stop taking the
medicine during pregnancy without your
doctor's advice. Divalproex sodium may
cause harm to an unborn baby, but having
a seizure during pregnancy could harm
both the mother and the baby.

You should not use Depakote if you have


liver disease, a urea cycle disorder, or a
genetic disorder such as Alpers' disease or
Alpers-Huttenlocher syndrome (especially
in a child younger than 2 years old).

To make sure this medicine is safe for you,


tell your doctor if you have:

liver problems caused by a

Dosage form: tablet, extended release


Initial dose: 750 mg orally per day in
divided doses
Maximum dose: 60 mg/kg/day

genetic mitochondrial disorder;

a history of depression, mental


illness, or suicidal thoughts or actions;

Common side effects of Depakote


include: abdominal pain, dizziness,
drowsiness, nausea, weakness, and

anorexia. Other side effects


include: abnormality in thinking, alopecia,
ataxia, nystagmus, tremor, weight loss,
fever, and skin rash. See below for a
comprehensive list of adverse effects.

REFERENCE:
https://www.drugs.com/depakote.html

a family history of a urea cycle


disorder or infant deaths with unknown
cause; or
HIV or CMV (cytomegalovirus)
infection.