DATE /TIME

CUES

NEEDS

NSG. DIAGNOSIS

OBJECTIVE OF CARE

INTERVENTION

EVALUATION

M A R C H

Subjective cue: Ginagmay lng

S L E E P

Sleep pattern Within 2 days 1. disturbance related span of

Assess

client

and

Goal partially

care, family usual sleep pattern, met, within 2 changes and at that what the have days span of was care, time. patient was the was

akong tulog mam as verbalized by the patient.

to the patient will any

mental illness be able to sleep occurred, secondary to for Bipolar about 6-8 happening if

1 hours per night Identify without disturbances.

there event

a able to sleep

2, Objective cues: 2011 y poor sleep pattern (2-3 hours per night) T y Frequent P A

Disorder Manic Phase.

precipitating

around for about 4-5

onset of sleep problem or if hours per night its chronic. Information from without both client and family disturbances. sleep

clarifies Scientific

specific

disturbance.

Yawning y y y y Restlessness Irritability Lethargy dark circles under eyes y Daytime

T E R N

Basis: Studies indicate abnormal sleep electroencep halograms in many individuals with mood disorders. This has led to the theory that disorder mood many

2.

Instruct patient to

follow as consistent a daily schedule for retiring and arising as possible. This promotes regulation of the circadian rhythm, and reduces the energy required for adaptation to changes. 3. Instruct to avoid large

Sleepiness y y Poor eye contact Decrease attention span y decrease ability to function

fluid intake before bedtime. This helps patients who otherwise may need to void during the night. 4. Increase daytime

physical activities as

reflects abnormal regulation of circadian rhythm Source: Doenges, Moorhuse and Murr. 2011.Davis Nurses Pocket Guide. Edition 12th

indicated. This reduces stress and promotes sleep. 5. Discourage pattern of

daytime naps unless deemed necessary to meet sleep requirements or if part of ones usual pattern. Napping can disrupt normal sleep patterns; however, elderly patients do better with frequent naps during the day to counter their shorter nighttime sleep schedules. 6. Suggest to client that if

he does not feel drowsy after 20 minutes, get up and

engage in quiet activity that is boring- not stimulating. Waiting that will not come can increase anxiety and frustration. Doing something monotonous at bedtime might have the client become drowsy. 7. Develop a sleep

relaxation program with client (e.g., progressive muscle imagery). both physical

relaxation, Employing

and mental relaxation can help minimize anxiety and promote sleep.

8.

Review sleep hygiene with the client.

measures

Determine if the client does any of the ff: refrain from naps, alcohol and caffeine at night; follow a regular retiring and arising schedule;

exercise pattern. Identifying baseline helps target

needed interventions.

DATE /TIME

CUES

NEEDS

NSG. DIAGNOSIS

PLAN OF CARE

INTERVENTION

EXPECTED OUTCOME

M A R C H

Subjective:

S E L

Objective cues: Somatic Delusion Flight of ideas Circumstantiality Excessive talking Decrease attention span y Poor eye contact

y 2, y y 2011 y y

P E R C

Risk for Impaired Within 1 hour 1. Establish rapport to the social interaction span of care, patient. establishing related to patient will be rapport will promote disturbed able to develop participation and trust. thought process trusting 2. Observe patient while secondary to relationship relating to family. To Bipolar 1 with the note prevalent Disorder Manic student nurse interaction pattern. Phase. within the 3. Determine patients use of reasonable coping skills and defense period of time. mechanism affects Scientific ability to be involved in

Within 1 hour span of care, patient was

able to develop trusting relationship with student within reasonable period of time. the nurse the

E P T I O N

Basis: Impaired social

social situation. 4. Provide positive reinforcement for improvement in social behaviors and interaction. or encourages continuation of desired behaviors and effort s for change. 5. Correct clients

interaction is an insufficient excessive quantity ineffective quality of social exchange. REFERENCE: Doenges, Moorhuse Murr. Davis Pocket and 2011. Nurses Guide. or

description of inaccurate perception, and describe the situation as it exists in reality. Explanation of, and participation in, real situations and real

12th Edition

activities interferes with the ability to respond delusions or hallucinations. 6. Do not argue or deny the belief. Use reasonable doubt as a therapeutic technique. Arguing with the client or denying the belief serves no useful purpose, because delusional ideas are not eliminated by approach and the development of a trusting relationship

may be impeded. 7. Give positive reinforcement when client is able to differentiate between reality- based and non-reality- based thinking. Positive reinforcement enhances self- esteem and encourages repetition of desirable behaviors. 8. Provide supportive group therapy when indicated. Positive feedback from group members will increase self- esteem.

9. Provided feedback to patients negative feelings. To allow the patient experience different views. 10. Encourage to validate perception with others. help patient prioritize those behaviors needing change.