Nursing Care Plan

AXIS 1
(Admission Diagnosis)
Bipolar affective disorder with psychotic
features
*Rule out psychotic disorder

AXIS II through V
Axis II: Deferred
Axis III: Conjunctivitis, toxic encephalopathy, and
marijuana abuse.
Axis IV: Unspecified
Axis V: Global assessment of functioning on
admission = 30.

Patient Description
Socioeconomic/Cultural Orientation
(orientation, mood, affect, hygiene,
(education, source of income, support system,
thought process, attention, judgment,
religious and cultural preferences)
insight, memory, speech)
Orientation = pt. is oriented to time,
High school diploma; unemployed with living
place, person, and purpose.
mother involved in support system; religion not
Mood = expansive (readiness to talk after specified; Hispanic male.
breakfast about prior/current euphoric
delusions); pt. was neither sad nor happy
but stated satisfied that current
medications are helping to control
hearing voices in head and seeing ghosts
occasionally.
Affect = pt. was labile showing
likelihood of change w/ out medication
by presenting verbal discussion of prior

Discharge Referrals
(recommended follow up, d/c
plan)
Current legal status is voluntary
with ongoing evaluations per
Psychiatric MD; d/c plan not
specified.

Psychosocial Considerations
(presenting S/S, problem
behaviors: SI, HI, AH, VH,
substance abuse)
Presenting S/S = confusion, poor
insight, poor judgment, hostile &
agitated @ time of admission,
unreliable historian.
Problem behaviors = no self
injury, homicidal ideation with no
plan (feels need to protect
himself/family), auditory
hallucinations (hearing voices),
visual hallucinations (seeing
people trying to harm him) &
flight of ideas with delusions

delusions of hearing of voices if not

taking medication to control; pt. was not
blunted, flat, or constricted; pt. was
guarded when describing delusions of
people out to kill him; excited and
interested in sharing delusional
experiences.
Hygiene = pt. appeared showered,
groomed, and wearing clean clothes.
Thought process = during the course of
verbal interaction, pt. was able to
sometimes hold logical & coherent
conversations in respect to his purpose of
being hospitalized and reason for mental
sickness; however, at times, pt. would
have loose associations and
confabulations stating odd present
employment & fantasies not congruent
with reality; pt. was ruminating about
prior jobs held, but no evidence in
medical chart of such occupations; pt.
had flight of ideas concerning unrealistic
occupations of which he would like to
pursue, and implying that he was a
protector of his household because people
were out to kill him.
Attention = pt. was cooperative &
friendly; however, easily distracted at
times by his thought processes during
conversation.
Judgment/insight = pt. had poor

resulting from not taking

medication for 1 week; pt. was
positive for THC as evidenced by
urinalysis results, length of use not
stated in medical chart.

insight/judgment of realistic employment,

home environment, and daily living in
household; pt. was a poor historian as
evidenced by providing unreliable factual
information.
Memory = pt. was able to recall
information previously discussed in the
conversation, as well as the occurrence of
which prompted his hospitalization
stating he was protecting his household
from people in the street trying to harm
him.
Speech = normal rate, rhythm & tone; no
signs of slurred, spontaneous, pressured,
or prolonged speech.
History of Present Illness
(purpose of current hospitalization,
legal status)
On 4/18/2010 at 1700 pt. was put on
5150, a call was made to sheriff deputies
in response to a Hispanic male adult
walking around a residential street with a
fake pistol gun in hand; responding
deputies found the pt. laying next to gun,
the subject had replied that he is
bipolar/schizophrenic and hasnt taken
his medications in a week, as well as
requesting to speak with psychiatric MD
due to hearing voices; pt. verbally stated
I dont know what I will do if I dont get

Past Mental Health History

(Onset, previous hospitalizations, dates)
Previous hospitalization with dates not specified in
pt. chart.

Pertinent lab test (only related to

mental health)
No pertinent lab tests noted.

help.
Legal status = 5150 on 4/18/10 @ 1700
DTS; day of care = Voluntary on 4/21/10
Pathophysiology of admitting and/or related medical diagnosis
(with APA citations)
Mood disorders constitute a disruption in physical, emotional, and behavioral response patterns. These patterns of affect (mood)
range from extreme elation and agitation to extreme depression with a serious potential for suicide (Kneisl & Trigoboff, 2009).
Bipolar disorders are a cluster of mood disorders that include manic episodes, depressed episodes, and cyclothymic disorder. A
bipolar I disorder is one or more manic or mixed episodes, and the course of illness can be accompanied by major depressive
episodes. Bipolar II disorder is one or more major depressive episodes accompanied by at least one hypomanic episode. Mania is
characterized by an abnormal & persistently elevated, expansive, or irritable mood lasting at least one week, significantly impairing
social or occupational functioning, and generally requiring hospitalizationmust be accompanied by at least 3 additional symptoms
such as inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas (rapidly changing,
fragmentary thoughts), distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive
involvement in pleasurable activities with a high potential for painful consequences (Kneisl & Trigoboff, 2009). Conducted studies
reveal that the underlying biochemical process involves neurotransmitters dopamine, norepinephrine, serotonin, and gammaaminobutyric acid. Interferences with smooth transmission of impulses from one neuron to another, associated with depressive and
manic phases of bipolar disorder, can be explained by inadequate release of neurotransmitters or faulty storage mechanisms (Kneisl
& Trigoboff, 2009).

Functional Health
Pattern

Nursing Diagnosis
(Priority)

Role relationship
pattern

Risk for otherdirected violence

related to delusions
of grandeur as
evidenced by visual
hallucinations of
people trying to kill
him and the need to
protect himself.

Planning
( 2 Short
Term Goals
realistic and
measurable)
a.) Pt. will
show no
signs of
physical
aggression
during
therapeutic
communication.

b.) Pt. will

show
impulse
control
therapeutic

Rationale
Interventions
(1 rationale for
(2 interventions for
EACH
EACH goal)
intervention APA
citation )
1a.) Encourage pt.
1a.) Violence can
to express anger and have a pattern;
hostility verbally
detecting and
instead of acting
changing the pattern
out. Give positive can eliminate the
feedback.
violence (CarpenitoMoyet, 2008).
2a.) Give the client
control by offering
talking and art
therapy.

2a.) Although
people may
verbalize hostile
threats and take a
defensive stance,
most fear losing
control and want
assistance to
maintain their
control (CarpenitoMoyet, 2008).

1b.) Convey
empathy by
acknowledging the
pt.s feelings; let pt.

1b.) Crisis
management
techniques can help
prevent escalation

Evaluations
(1 evaluation for
EACH STG listed)
a.) Pt. did not
engage in
agitated or
impulsive
behaviors
that could
endanger
self or staff
during
therapeutic
communicati
on; pt. was
able to
verbally
express
feelings of
fear and
anger

b.) Pt. was able

to enumerate
safe ways of
relieving

communication.

Cognitiveperceptual pattern

Disturbed thought
processes related to
biochemical
alterations as
evidenced by
delusional beliefs
and hallucinations
secondary to
inaccurate
interpretation of
stimuli.

a.) Assist pt. to

differentiate
between
own
thoughts and
reality
during 30
min. of
therapeutic
communication.

know that you will

not let him/her lose
control.

of aggression and
help pt. achieve
self-control
(Carpenito-Moyet,
2008).

2b.) Provide music

if pt. is receptive.

2b.) The client is in

a mentally
compromised state;
music can help
clients reduce
anxiety and achieve
relaxation (Kneisl &
Trigoboff, 2009).
1a.) Helping the
person to identify
what specific
situations trigger
hallucinations gives
insight into possible
prevention
strategies
(Carpenito-Moyet,
2008).

1a.) Validate the

presence of
hallucinations by
assisting client to
analyze
hallucinations and
stay with person.

2a.) Assist client

with decreasing
irrational thoughts
by encouraging
differentiation of
stimuli arising from

2a.) Interventions
that require the
person to engage in
active mental work
(giving verbal
response) are

excess
tension by
participating
in group
music
therapy.

a.) Pt. was able

to selfrestrain
disruptions
in
perception,
thought
processes,
and thought
content by
giving
verbal
responses to
questions
being asked
with
minimal

b.) Assist pt.

with
disordered
thinking to
communicat
e more
effectively
during 30
min. of
therapeutic
communication

inner sources from

those from outside.

effective
(Carpenito-Moyet,
2008).

1b.) Be an attentive
listener; note both
verbal and
nonverbal
messages.

1b.) The nurse

provides a health
role model with
appropriate verbal
and nonverbal
responses
(Carpenito-Moyet,
2008).

2b.) During
communication ask
for the meaning of
what is said,
validate your
interpretation of
what is being said,
and refocus when
person changes the
subject in the
middle of an
explanation or
thought.

2b.) The client can

be helped to regain
contact with reality
by gently
introducing
conversation that
are oriented to the
here and now
(Carpenito-Moyet,
2008).

distractions;
pt. demonstrated
ability to
choose to
analyze
hallucinations
b.) Pt. displayed
cognitive
orientation
with the
ability to
identify
person,
place, and
time; pt. was
able to focus
on topics of
discussion
with
minimal
changes in
subject
manner.

Medication Information Sheet

Temp
98.6
Medications
(with APA
citations
Generic:
Aripiprazole
Trade:
Abilify

Pulse

Respiration

80
Purpose
(state WHY
Class
your pt is
on the med)
Antipsychotic, Tx of
Atypical;
bipolar
Dopamine
mania;
system
maintenance
stabilizer
in bipolar I
disorder.

22

Route
PO

Time
2100

Dose
(and
range)
30 mg HS;
Adult: PO
30mg once
daily, may
reduce to
15 mg/d
(Wilson,
Shannon,
Shields,
2009)

Blood Pressure
140/82
Mechanism
of action
Onset of
action
Partial
agonist
activity at D2
& 5HT
receptors.
Partial
dopaminergic
agonist
property.
(Wilson et
al., 2009).

Pain
0
Common
side effects

Nursing
considerations

Headache,
anxiety,
insomnia,
akathisia,
tremor, EPS,
blurred vision,
N/V, manic
reaction,
nervousness,
confusion,
cogwheel
rigidity.
(Wilson et al.,
2009).

-Monitor
cardiovascular
status; assess
for orthostatic
hypotension.
-Monitor body
temperature
likely to
elevate core
temperature.
-Monitor for
signs of TD
-Monitor &
report
immediately
S&S of NMS
-Monitor blood
glucose if
diabetic.
-Monitor
periodically

Generic:
Risperidone
Trade:
Risperdal

Antipsychotic, Tx of
Atypical
bipolar
disorder.

PO

BID

2MG BID;
Adult
(>10y):23MG once
daily for up
to 3 wk
(max:6
MG/d).
(Wilson et
al., 2009).

Interferes
with binding
of dopamine
to D2interlimbic
region of the
brain,
serotonin (5HT)
receptors,
and alphaadrenergic
receptors in
occipital
cortex; low
to moderate
affinity for
the other
serotonin (5HT)
receptors
(Wilson et
al., 2009).

Hct & Hgb.

-Monitor for
elevated CPK
&
myoglobinuria
Orthostatic
-Monitor
hypotension w/ diabetics for
initial doses,
loss of
sweating,
glycemic
sedation,
control.
drowsiness,
-Reassess pt.s
transient blurred periodically
vision,
and maintain
insomnia,
on the lowest
agitation,
effective drug
anxiety, EPS,
dose.
prolonged QTc -Monitor
interval,
neurological
tachycardia, dry status of older
mouth, elevated adults.
AST/ALT,
-Monitor
hyperglycemia, cardiovascular
photosensitivity, status; assess
urinary
orthostatic
retention,
hypotension
decreased
-Monitor those
sexual desire,
at risk for
sexual
seizures.
dysfunction
-Assess degree
of cognitive
(Wilson et al.,
impairment;

2009).

assess for envt

hazards.
-Monitor blood
glucose,
electrolytes,
liver function,
CBC