bipolar- nursing

  1. bipolar disorder- prognosis and clinical course
    • historically perceived as recurrent with cycles of mania and depression interspersed with periods of euthymia
    • patterns fluctuate from person to person with wide variation
    • high relapse rate
    • many recurrences can be controlled with proper treatment medications, therapy and monitoring
  2. assessment
    • medical work up
    • mental health diagnostic assessment
    • medical work up; labs, ekg, mri, drug screen, thyroid studies, electrolyes
    • mental health mental status exam. level of functioning assessment, social work assessment
    • 1 priority here is safety
  3. Risk for self-directed/other directed violence
    • Outcome: pt will describe early symptoms of escalation that may lead to violence. demonstrate absence of violence/aggressive or self harm behaviors
    • interventions:
    • - risk assessment, risk for violence, suicide, psychosis
    • - identify escalating behaviors/excitment, do NOT participate in the escalation (when pt ready for feedback let them know you are a little high right now, why don't you)
    • - decrea stimuli in environment- no competition
    • - attempt talking/physical activity (non-competitive) if doesnt work, consider prn meds
  4. risk for self-directed/other directed violence
    more intervention
    • journal writting for hyperverbal pt/those constantly engaged in intellectual conversations that often lead to anger and frustration
    • positive reinforcement for good behaviors
    • use simple clear communication- kind words
    • set limits on angry, inapproriate, instrusive behaviors in therapeutic but firm direct manner- no throwing chairs
    • seclusion restraints if pt out of control
    • teaching pt and fam the s/s of escalation
    • identify resources for family support, self-help
  5. risk for injury r/t agitation and hyperactivity
    • outcome: pt will decrease hyperactivity (bumping into things, falling, unaware of thirst, hunger, heat or cold); think safety prevention of injury- others may assault them since manic patient can be annoying, can enrage others
    • interventions:
    • - safe milieu
    • - private room
    • - dec stimuli- lighting, noise
    • - accompany on walks, provide gross motor activity
    • - fluid replacement, ten to nutritional needs, hi energy foods, finger foods (apples, bananas, sandwich, protein drinks
    • hand it to them still moving and walking
  6. risk for injury
    • decrease group involvment too stimulating
    • set limits: on inapproriate behaviors, matter of fact not scolding approach, setting limits on manipulative behaviors, including pitting on staff member against another, borrowing thinkgs from another pt etc, invading others space (they do not recognize the needs of others)- model behaviors
    • PRN antipsychotic until mood stabilizer takes effect/works
  7. altered thought processes
    • outcome: pt will demonstate inc orientation, incr concentration etc. (must have time frame, be realstic, measurable)
    • interventions: r/t psychotic symptoms-delusions and or hallucinations, decreased concentrations, short attention span, easily distracted, impaired problem solving, grandiosity
    • orient, enagage in reality based, concrete activities
    • med management
    • same caregivers, consistency
  8. alterned thought process interventions
    • with delusions/hallucinations- accept their need for their beliefs, but indicate you don't share the preceptions dont argue or reason with pt, cant talk to them out of it. connect with the emotion, not argue about the reality
    • instill reasonable doubt: 'i found that hard to believe' ' i know you believe that but i find it hard to accept' etc pt improvement demonstrated when able to statr they know their thinking is bizzare
    • staff must be consistent not give mixed messages and be clear on what behavior is acceptable and what is not
  9. impaired social interactions
    • outcome: patient will interact approriately with one person by end of the week
    • interventions: r/t highly dysfunctional interactions, grandiosity, excessive talking, egocentricity, impulsivity, unwillingness and inability to accept responsibility for impact on others, manipulative behavior
    • may need to mediate between the pt and others
  10. impaired social interaction
    • role modeling honesty and respect for others
    • limit setting manipulative, consistently set them, staff must agree on the limits
    • set consequences on negative behavior, enforce consistently
    • the pt has control issues- leave yours at home, be calm, do not make too many demands
    • use their distractability to move away from potential conflictual situation
  11. Self care deficit
    • outcome: ex pt will demonstrate ability to complete ADLs by discharge
    • interventions: r/t feeding, bathing tioleting, dressing and grooming. some or all may apply r/t inadequate food and/or fluid intake, refusal to bathe, lack of interst in grooming- approariateness of appearance
    • assit with grooming as needed
    • positive reinforcement/acknowledge their efforts
  12. self care deficit intervention
    • assist to batheroom q 1-2 hours, incontinence and constipation often a problem
    • monitor i&o, calorie count/nutritional intake
    • frequent small snacks, for the pt on the go, they are unable to sit down
    • high calorie foods, finger foods, frequently
    • nutritional consult
  13. sleep pattern disturbance
    • outcome: pt will sleep __ hours/daily discharge. rest/sleep. exhausation even death can result. roaming pacing short naps, those with hypomania gloat that they are getting 3-4 hours sleep or less
    • second in line priority for pt with bipolar disorder after safety is the need for rest
  14. sleep pattern disturbance interventions
    • assessment: how many hours do you sleep on avaerage at night and what is the quality of your sleep
    • encourage rest periods, avoid extended naps during the day
    • encourage quiet prior to sleep, baths, relaxation exercises music
    • medication for sleep (ambien) non benxon, sedative-hypnotic
  15. some additional NANDA
    • impaired adjustment
    • impaired verbal communication
    • caregiver role strain
    • defensive coping
    • ineffective coping
    • ineffecting denial
    • interrupting family processes
    • chronic low self esteem
    • impaired social interaction
    • risk for suicide
    • disturbed thought processes
  16. some addtional nanda
    • noncompliance
    • risk for deficient fluid volume
    • ineffective health maintenance
    • imbalanced nutrition
    • self-care deficit
    • disturbed sensory perception
    • disturbed sleep pattern
    • sexual dysfunction
    • ineffective therapeutic regimen management
Card Set
bipolar- nursing
nursing dx/tx