Subjective:

hindi ako makatulog

sa gabi. Ang hyper
ko kasi. as
verbalized by the
patient.
Objective:
Dark circles
under the eyes
Dissatisfaction
with sleep
Frequent
yawning

Problem:
Disturbed
Sleep
Pattern
Related to
Episodes of
Delusion
Secondary to
Bipolar
Disorder

During the
depressed phase
of the bipolar
disorder, it's
common to
experience
insomnia,
characterized by
difficulty falling
asleep, staying
asleep, or waking
up too early.
Bipolar depressed
patients are also
particularly
sensitive to
hypersomnia -characterized by
too much sleep,
sometimes up to
18 hours per day,
and daytime
fatigue.
Reference:
Psychiatric
Nursing Care
Plans 5th Edition,
Fortinash,
Holoday Worret
page 185-202

Short Term:

Independent:

After 1-2 days of

nursing intervention
the patient will
indentify individually
appropriate
interventions to
promote sleep.

1. Arrange care to
provide for
uninterrupted periods
of rest, especially
allowing for longer
periods of sleep at
night when possible.

Long Term:

2. Encourage client to
establish a bedtime
routine to facilitate
transition from
wakefulness to sleep.

After 3-4 Days of

Nursing Intervention
the patient will report
improvements in
quality of sleep
pattern as evidenced
by:

Verbalization
of feeling of
satisfaction after
waking up in the
morning.

No feeling of
fatigue after waking
up.

Not restless
and weak, no
frequent yawning
and dark eyes.

3. Encourage client to
eliminate stressful
situations before
bedtime.

Dependent:
1. Administer
Chlorpromazine as
ordered.

Short Term:
1. A silent and
clam
environment
during sleep will
help to lengthen
the range of
sleep.
2. Rituals and
routines induce
comfort,
relaxation, and
sleep.
3. Stress
interferes with a
persons ability
to relax, rest,
and sleep.

1. Has a
therapeutic
effect of
sedation that
may induce
sleep.

After 2 days of
nursing intervention,
the patient had
indentified
individually
appropriate
interventions to
promote sleep.
GOAL MET
Long Term:
After 3 days of
nursing intervention,
the patient reported
improvements in
quality of sleep
pattern as evidenced
by:

Mas
masarap yung tulog
ko kagabi kesa
noong isang gabi.
as verbalized by
patient.

Not restless
and weak, no
frequent yawning
and dark eyes.
GOAL PARTIALLY
MET

Cues
Subjective:
wala akong
ganang magayos sa sarili
ko,hindi ko
naman talaga
malaman kung
minsan bakit ako
biglang
nagwawala,tapo
s minsan
sobrang lungkot
ko naman as
verbalized by the
patient.
Objective:
Repeatedly
used of
clothing
Demonstrate
infrequent
bathing
Displays
inadequate
personal
hygiene
Gingivitis

Nursing
Diagnosis
Problem:
Self Care
Deficit:
Dressing and
Grooming
Related to
Depressed
Mood
secondary to
Bipolar
Disorder
Objective:
Repeatedly
used of
clothing
Demonstra
te
infrequent
bathing
Displays
inadequate
personal
hygiene
Gingivitis

Inference

Objective

Intervention

Hygienic care
promotes
cleanliness,
provides relaxation,
improves selfimage, and
promote healthy
skin. Client hygiene
is an extension of
providing client
safety and
protecting the
clients defense
mechanisms. Body
image is associated
with the clients
emotion, mood,
attitude, and
values. A clients
body image directly
affects the type of
personal hygiene
practiced; this may
change if the client
body image is
altered because of
illness.

Short Term:

Independent:

After 1- 2 hours
of nursing
intervention the
patient will
verbalized ways
how to improve
hygienic care/
self care

1. Monitor continually
the extent to which self
care deficits interfere
with the clients
function.

Long Term:
After 2- 3 days
of nursing
intervention the
patient will
consistently
performs self
care activities
and consistent
with
developmental
stage as
evidenced by
being dependent
in providing self
care

2. Establish routine
goals for self care
3. Initiate grooming and
hygiene tasks when the
client is best able to
comply

Rationale
1. Monitor the clients
functional abilities in an
ongoing way helps to
determine the clients
strength and areas
needing assistance
2. Routine and structure
organize the clients
chaotic world and
promote success

4. Provide privacy for

self care without
comprising clients
safety

3. Depressed clients
have more brighter affect
later in the day; and client
with anxiety and
hyperactive behaviors are
more attentive to self care
after taking medication

5. Praise the client for

attempts at self care
and each successfully
completed task

4. Providing as much as
privacy as possible helps
to preserve the clients
dignity

Dependent:
1. Administer mood
stabilizing drug: Lithium
Carbonate 450 mg OD
2. Administer
antipsychotic drug:
Chlorpromazine
Hydrochloride 5 mg
ODHS

5. Positive reinforcement
increases feelings of self
worth and promotes
continuity of functional
behavior
1. Normalizes the
reuptake of certain neuroTransmitters and reduces
release of norepinephrine
2. May bloclk pst
synaptic dopamine
receptors in the brain.

Evaluation
Short Term:
After 8 hours of
nursing
intervention, the
patient improved
hygienic care with a
verbalization of
alam ko na ngayon
na importanteng
bigyan ko ng
pansin ang pagaayos ko sakin
sarili
GOAL MET.
Long Term:
After 3 days of
nursing intervention
the patient was
able to perform self
care activities.
GOAL PARTIALLY
MET.

Subjective:
wala na akong
nagawang tama sa
buhay ko, lahat nalang
ng nangyare sa buhay
ko malipasaway kasi
ako as verbalized by
the patient
Nahihiya ako kapag
nalaman ng anak ko
nandito ako at hindi na
ako lalaabs dito kasi
yung pamilya ko nag
advance payment pa
ditto parang ayaw nila
ako lumabas as
verbalized by the
patient.
Objective:
Fails to attend to
hygiene
Frone facial
expression

Problem:
Low Self-esteem
Related to
Anxiety

Depression is a
Short Term:
feeling involving
an element of
After 1-2 days of
sadness and
nursing
helplessness.
intervention the
There is little
patient will:
drive for

Client
socialization or
demonstrate selfcommunication,
care appropriate
although
for age and
depression is the status
predominant,

Uses
outward feeling
techniques to
shown, the fear,
decrease anxiety.
anger and guilt
components of
Long Term:
anxiety are
internalized or
After 3-4 days of
turned inward
nursing
upon the self.
intervention the
The fear of
patient will:
unleashing

Verbalize
anger or hostility increased sense
or of exposing
of self-worth in
guilt-producing
relation to current
unacceptable
situation.
thoughts and

Demonstr
wishes to others
ate behaviors
reinforces the
and/or lifestyle
learning of
changes to
internalization of
promote positive
anxiety. The
self image.
individual has
learned during
the socialization
process to

Independent:
1.
Note nonverbal behavior.
2.
Use positive
messages rather
than praise.
3.
Give
reinforcement for
progress noted.
4.
Encourage
client to progress
at own rate.
5.
Encourage
techniques such
as deep
breathing.
Dependent:
1.
Administer
Lithium as
ordered.
2.
Administer
Chlorpromazine
as ordered.

Collaborative:
1.
Continue to
support and
monitor

Short Term:
1.
Incongruence
s between
verbal/non-verbal
communication
require clarification.
2.
To assist
client to develop
internal sense of
self-esteem.
3.
Positive
words of
encouragement
promote
continuation of
efforts, supporting
development of
coping behaviors.
4.
Adaptation to
change in selfconcept depends on
its significance to
individual, disruption
to lifestyle, length of
illness/debilitation.
5.
To decrease
anxiety level.
1.
Used to
balance biogenic
amines of
norepinephrine and

After 2 days of
nursing
intervention the
patient
demonstrated
self-care
appropriate for
age and
status,used
techniques to
decrease anxiety
and had a
verbalization of
nalaman ko na
importanteng
alagaan ko sarili
ko, hindi lang
para sa sarili ko
kundi para rin sa
mga taong
importante
sakin
GOAL MET
Long Term:
After 4 days of
nursing
intervention the
patient had
verbalized
increased sense
of self-worth in
relation to

anticipate
rejection,
disapproval and
loss of love
leading to
disruption in
interpersonal
relations.
Reference:
Page 127,
Psychiatric
Nursing by
Manfreda &
Krampitz, 10
Edition

psychosocial
treatment plans.

serotonin in CNS
area involved in
emotional
response.
2.
Depress
cerebral cortex,
hypothalamus, and
limbic systems
which control
activity an
aggression; blocks
neurotransmission
produced by
dopamine and
synapse.
1.
To help the
patient establish
sense of worth.

current situation.
GOAL
PARTIALLY
MET

Cues
Objective:

Has not
slept for
days.
Has not
taken uids
for days.
Constant
physical
activityis
unable to
rest.

Nursing
Diagnosis
Problem:
Risk for Injury:
related to
dehydration and
faulty judgment,
as evidenced by
inability to meet
ownphysiological
needs and set
limits on own
behavio

Nursing Objectives

Interventions

Short Term:
After 1 hour of NPI the
client will verbalized
understanding
regarding
healthteaching
imparted.

1a. Give haloperidol

intramuscularly
immediately and as
ordered.
1b. Check vital signs
frequently (every 12
hours).

Long Term:
After 3 days of nursing
intervention the:

1c. Place client in private

or quiet room (whenever
possible).

1. Client will be well

hydrated, as evidenced by good skin
turgor and normal
urinaryoutput and
specicgravity within
24hours.
2. Client will sleep or
rest 3 hours dur-ing
the with aid of
medication and
nursing interventions.
3. Clients blood pressure (BP) and
pulse(P) will be
withinnormal
limitswithin 24
hourswith the aid of
medication
andnursing interven-

1d. Stay with client and

divert client away from
stimulating situations.
1e. Offer high-calorie,
high-protein drink (8
ounces) every hour in
quiet area.

Rationale
1a. Continuous physical activity
and lack of fluids can eventually
lead to cardiac collapse and death.
1b. Monitor cardiac status
1c. Reduce environmental stimuli
minimize escalation of mania
and distractibility.
1d. Nurses presence provides
support. Ability to interact with
others is temporarily impaired.
1e. Proper hydration is mandatory
for maintenance of cardiac status.
1f. Clients concentration is poor;
she is easily distracted.

1f. Frequently remind

client to drink: Take two
more sips.

1g. Client is unable to sit; snacks

she can eat while pacing are more
likely to be consumed.

1h. Maintain record of

intake and output.
2a. Continue to direct
client to areas of minimal
activity
2b. When possible, try to
direct energy into
productive and calming
activities (e.g., pacing to

1h. Enables staff to make accurate

nutritional assessment for clients
safety
1i. Monitoring nutritional status is
necessary.
2a. Lower levels of stimulation can
decrease excitability. 2b. Directing

Evaluation
After 24 hours,
specific gravity
is within
normal limits
Client is
awake most of
the first night.
Sleeps for 2
hours from 4
AM to 6 AM.
Client is able
to rest on the
second day for
short periods
and engage in
quiet activities
for short
periods (510
minutes).

tions.

slow, soft music; slow

exercise; drawing alone;
or writing in quiet area).

client to paced, nonstimulating

activities can help minimize
excitability

2c. Encourage short rest

periods throughout the
day (e.g., 35 minutes
every hour) when
possible.

2c. Client may be unaware of

feelings of fatigue. Can collapse
from exhaustion if hyperactivity
continues without periods of rest.

2d. Client should drink

decaffeinated drinks only
decaffeinated coffee,
tea, or colas.

2d. Caffeine is a central nervous

system stimulant that inhibits
needed rest or sleep.
2e. Promotes nonstimulating and
relaxing mood.

2e. Provide nursing

measures at bedtime that 3a. Alerting all staff regarding client
promote sleepwarm
status can increase medical
milk, soft music.
intervention if a change in status
occurs.
3a. Keep staff informed
by verbal and written
reports of baseline vital
signs and client
progress.

Cues
Subjective:
Nagwawala ako
dati minsan
sinasaktan ko sarili
ko o ung iba as
verbalized by the
client.
Objective:
Loud
hyperactive

Nursing
Diagnosis
Problem:
Risk for self or
other- directed
violence r/t
History of
previous
violence

Objective

Intervention

Rationale

Evaluation

Short-Term Goal:
After 3 hourse of
nurse-patient
interaction the
client will be able
to verbalize
understanding
regarding health
teachings
imparted.

Long term
intervention:

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

The client has

demonstrated progress
toward this goal by
identifying that he now
knows when he is
becoming angry and
what usually results
when he does not control
his impulses. He has
also demonstrated less
aggressive behaviors
towards his peers during
conflicts.

Long-Term Goal:
After 2 weeks of
nursing
intervention the
client will identify
impulse behaviors
and demonstrate
appropriate selfcontrol behaviors
to refrain from
harming self and
others by.

1.) 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.
2.) Develop a
behavioral
management plan that
is implemented
consistently among all
healthcare providers.
3.) Have client keep an
anger diary and
discuss alternative
responses together.
Teach cognitive
behavioral techniques
for self- evaluation from
the client
4.) Identify stimuli that
initiate violence and the
means of dealing with
the stimuli, such as

2. Consistency about
rules and expectations
reduce power struggles
and promote feelings of
security for clients.
Positive feedback for
desired behaviors helps
reinforce them.
3. : Clients with anger

management difficulties
may not be aware of
changes and cues that
they are becoming
angry or of a time delay
in the stimulus to their
angry response. By
using cognitive behavior
techniques and
reviewing the diary with
staff, the client can
identify though
processes leading u to
anger and the space
between the stimulus
and response.

walking away.
5.) Emphasize that the
client is responsible for
his choices and
behavior. Introduce
descriptions of possible
effects of a clients
aggressive/violent
behavior on others
6.) Redirect possible
violent behaviors into
physical activities such
as doing pushups and
sit-ups.

4. Assisting the client to

identify situations and
people that upset him
provides information
needed for problem
solving. The client can
then identify alternative
responses: leaving the
stimulus, initiating a
distracting activity, or
responding assertively
rather than aggressively.
5. In many cases clients

operate from a
worldview that
perceives others as
instruments of the
clients gratification.
Clients must gain that
they are dealing with
other human beings
who experience pain.
Clients behaviors
influence how others
respond to them.
6. Activities that distract

while draining excess

energy help to build a
repertoire of alternative
behaviors for stress
reduction.