Care Plan 27 Bipolar Disorder, Manic Episode

CARE PLAN 27
Bipolar Disorder, Manic Episode
Nursing Diagnosis

Risk for Other-Directed Violence

At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally,
and/or sexually harmful to others.

RISK FACTORS
Restlessness

Hyperactivity
Agitation
Hostile behavior
Threatened or actual aggression toward self or others
Low self-esteem

EXPECTED OUTCOMES
Immediate
The client will
Be safe and free from injury throughout hospitalization
Demonstrate decreased restlessness, hyperactivity, and agitation within 24 to 48 hours
Demonstrate decreased hostility within 2 to 4 days
Refrain from harming others throughout hospitalization
Stabilization
The client will
Be free of restlessness, hyperactivity, and agitation
Be free of threatened or actual aggression toward self or others
Community
The client will
Demonstrate level moods
Express feelings of anger or frustration verbally in a safe manner

IMPLEMENTATION

Nursing Interventions Rationale

* denotes collaborative interventions

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27
Provide a safe environment. See Care Plan 26:
Suicidal Behavior, Care Plan 46: Hostile
Behavior, and Care Plan 47: Aggressive
Behavior.
Administer PRN medications judiciously,
preferably before the clients behavior becomes
destructive.
Set and maintain limits on behavior that is
destructive or adversely affects others.
Decrease environmental stimuli whenever
possible. Respond to cues of agitation by
removing stimuli and perhaps isolating the client;
a private room may be beneficial.
Provide a consistent, structured environment. Let
the client know what is expected of him or her.
Set goals with the client as soon as possible.
Give simple direct explanations (e.g., for
procedures, tests, etc.). Do not argue with the
client.
Encourage the client to verbalize feelings such as
anxiety and anger. Explore ways to relieve
tension with the client as soon as possible.
Encourage supervised physical activity.
Nursing Diagnosis
Defensive Coping
Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends
against underlying perceived threats to positive self-regard.
ASSESSMENT DATA
Denial of problems
Exaggeration of achievements
Grandiose schemes, plans, or stated self-image
Buying sprees
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Bipolar Disorder, Manic Episode
Physical safety of the client and others is a
priority. The client may use many common items
and environmental situations in a destructive
manner.
Medications can help the client regain self-control
but should not be used to control the clients
behavior for the staffs convenience or as a
substitute for working with the clients problems.
Limits must be established by others when the
client is unable to use internal controls effectively.
The physical safety and emotional needs of other
clients are important.
The clients ability to deal with stimuli is
impaired.
Consistency and structure can reassure the client.
The client must know what is expected before he
or she can work toward meeting those
expectations.
The client is limited in the ability to deal with
complex stimuli. Stating a limit tells the client
what is expected. Arguing interjects doubt and
undermines limits.
Ventilation of feelings may help relieve anxiety,
anger, and so forth.
Physical activity can diminish tension and
hyperactivity in a healthy, nondestructive manner.
Care Plan 27 Bipolar Disorder, Manic Episode

Inappropriate, bizarre, or flamboyant dress or use of makeup or jewelry

Flirtatious, seductive behavior
Sexual acting-out

EXPECTED OUTCOMES
Immediate
The client will
Demonstrate more appropriate appearance (dress, use of makeup, etc.) within 2 to 3 days
Demonstrate increased feelings of self-worth within 4 to 5 days
Stabilization
The client will
Verbalize increased feelings of self-worth
Demonstrate appropriate appearance and behavior
Community
The client will
Use internal controls to modify own behavior

IMPLEMENTATION

Nursing Interventions Rationale

* denotes collaborative interventions
Ignore or withdraw your attention from bizarre
appearance and behavior and sexual acting-out,
as much as possible.
Set and maintain limits regarding inappropriate
behaviors. Convey expectations for appropriate
behavior in a nonjudgmental, matter-of-fact
manner.
You may need to limit contact between the client
and other clients or restrict visitors for a period
of time. Discuss the situation with the client as
tolerated.
Initially, give the client short-term, simple
projects or activities. Gradually increase the
number and complexity of activities and
responsibilities. Give feedback at each level of
accomplishment.
Minimizing or withdrawing attention given to
unacceptable behaviors can be more effective than
negative reinforcement in decreasing unacceptable
behavior.
The client needs to learn what is expected before
he or she can meet expectations. Limits are
intended to help the client learn appropriate
behaviors, not as punishment for inappropriate
behavior.
The client may need to gain self-control before he
or she can tolerate the presence of other people and
behave in an appropriate manner.
The client may be limited in the ability to deal with
complex tasks. Any task that the client is able to
complete provides an opportunity for positive
feedback.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode

Give client positive feedback whenever Positive feedback provides reinforcement for the
appropriate. clients growth and can enhance self-esteem. It is
essential to support the client in positive ways and
not to give attention only for unacceptable
behaviors.

Nursing Diagnosis

Disturbed Thought Processes*

Disruption in cognitive operations and activities.
*Note: This nursing diagnosis was retired in NANDA-I Nursing Diagnoses: Definitions & Classification
20092011, but the NANDA-I Diagnosis Development Committee encourages work to be done on retired
diagnoses toward resubmission for inclusion in the taxonomy.

ASSESSMENT DATA
Disorientation

Decreased concentration, short attention span

Loose associations (loosely and poorly associated ideas)
Push of speech (rapid, forced speech)
Tangentiality of ideas and speech
Hallucinations
Delusions

EXPECTED OUTCOMES
Immediate
The client will
Demonstrate orientation to person, place, and time within 24 hours
Demonstrate decreased hallucinations or delusions within 24 to 48 hours
Demonstrate decreased push of speech, tangentiality, loose associations within 24 to 48 hours
Demonstrate an increased attention span, for example, talk with staff about one topic for 5 minutes, or
engage in one activity for 10 minutes, within 2 to 3 days
Talk with others about present reality within 2 to 3 days
Stabilization
The client will
Demonstrate orientation to person, place, and time
Demonstrate adequate cognitive functioning
Community

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27
The client will
Sustain concentration and attention to complete tasks and function independently
Be free of delusions or hallucinations
IMPLEMENTATION
Nursing Interventions
* denotes collaborative interventions
Set and maintain limits on behavior that is
destructive or adversely affects others.
See Care Plan 21: Delusions, Care Plan 22:
Hallucinations, and Care Plan 46: Hostile
Behavior.
Initially, assign the client to the same staff
members when possible, but keep in mind the
stress of working with a client with manic
behavior for extended periods of time.
See Care Plan 1: Building a Trust Relationship.
Decrease environmental stimuli whenever
possible. Respond to cues of increased agitation
by removing stimuli and perhaps isolating the
client; a private room may be beneficial.
Reorient the client to person, place, and time as
indicated (call the client by name, tell the client
your name, tell the client where he or she is,
etc.).
*Provide a consistent, structured environment.
Let the client know what is expected of him or
her. Set goals with the client as soon as possible.
Spend time with the client.
Show acceptance of the client as a person.
Use a firm yet calm, relaxed approach.
Make only promises you can realistically keep.
Limit the size and frequency of group activities
based on the clients level of tolerance.
Help the client plan activities within his or her
scope of achievement.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Bipolar Disorder, Manic Episode
Rationale
Limits must be established by others when the
client is unable to use internal controls effectively.
The physical safety and emotional needs of other
clients are important.
Consistency can reassure the client. Working with
this client may be difficult and tiring due to his or
her agitation, hyperactivity, and so on.
The clients ability to deal with stimuli is impaired.
Repeated presentation of reality is concrete
reinforcement for the client.
Consistency and structure can reassure the client.
The client must know what is expected before he or
she can work toward meeting those expectations.
Your physical presence is reality.
The client is acceptable as a person regardless of
his or her behaviors, which may or may not be
acceptable.
Your presence and manner will help to
communicate your interest, expectations, and
limits, as well as your self-control.
Breaking a promise will result in the clients
mistrust and is detrimental to a therapeutic
relationship.
The clients ability to respond to others and to deal
with increased amounts and complexity of stimuli
is impaired.
The clients attention span is short, and his or her
ability to deal with complex stimuli is impaired.
Care Plan 27 Bipolar Disorder, Manic Episode

Avoid highly competitive activities.
*Evaluate the clients tolerance for group
activities, interactions with others, or visitors,
and limit these accordingly.
Encourage the clients appropriate expression of
feelings regarding treatment or discharge plans.
Support any realistic plans the patient proposes.
See Care Plan 18: Dual Diagnosis.
Competitive situations can exacerbate the clients
hostile feelings or reinforce low self-esteem.
The client is unable to provide limits and may be
unaware of his or her impaired ability to deal with
others.
Positive support can reinforce the clients healthy
expression of feelings, realistic plans, and
responsible behavior after discharge.
Substance abuse often is a problem in clients with
bipolar disorder.

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

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27 Bipolar Disorder, Manic Episode

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

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27
Community
The client will
Meet personal needs independently
Recognize signs of impending relapse
IMPLEMENTATION
Nursing Interventions
* denotes collaborative interventions
Monitor the clients calorie, protein, and fluid
intake. You may need to record intake and output.
The client may need a high-calorie diet and
supplemental feedings.
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.
Monitor the clients elimination patterns.
Provide time for a rest period during the clients
daily schedule.
Observe the client for signs of fatigue and
monitor his or her sleep patterns.
Decrease stimuli before bedtime (dim lights, turn
off television).
Use comfort measures or sleeping medication if
needed.
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.
If necessary, assist the client with personal
hygiene, including mouth care, bathing, dressing,
and laundering clothes.
Encourage the client to meet as many of his or
her own needs as possible.
Nursing Diagnosis
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Bipolar Disorder, Manic Episode
Rationale
The client may be unaware of physical needs or
may ignore feelings of thirst and hunger.
The clients increased activity increases nutrition
requirements.
If the client is unable or unwilling to sit and eat,
highly nutritious foods that require little effort to
eat may be effective.
The client may be unaware of or ignore the need
to defecate. Constipation is a frequent adverse
effect of antipsychotic medications.
The clients increased activity increases his or her
need for rest.
The client may be unaware of fatigue or may
ignore the need for rest.
Limiting stimuli will help encourage rest and
sleep.
Comfort measures and medications can enhance
the ability to sleep.
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.
The client may be unaware of or lack interest in
hygiene. Personal hygiene can foster feelings of
well-being and self-esteem.
The client must be encouraged to be as
independent as possible to promote self-esteem.
Care Plan 27 Bipolar Disorder, Manic Episode

Deficient Knowledge (Specify)

Absence or deficiency of cognitive information related to a specific topic.

ASSESSMENT DATA
Inappropriate behavior related to self-care

Inadequate retention of information presented

Inadequate understanding of information presented

EXPECTED OUTCOMES
Immediate
The client will
Acknowledge his or her illness and need for treatment within 48 hours
Participate in learning about his or her illness, treatment, and safe use of medications within
4 to 5 days
Stabilization
The client will
Verbalize knowledge of his or her illness
Demonstrate knowledge of adverse and toxic effects of medications
Demonstrate continued compliance with chemotherapy
Verbalize knowledge and acceptance of the need for continued therapy, chemotherapy, regular blood
tests, and so forth
Community
The client will
Participate in follow-up care, for example, make and keep follow-up appointments
Manage medication regimen independently

IMPLEMENTATION

Nursing Interventions Rationale

* denotes collaborative interventions
*Teach the client and family or significant others
about manic behavior, bipolar disorder, and other
problems as indicated.
*Teach the client and family or significant others
about signs of relapse, such as insomnia,
decreased nutrition, and poor personal hygiene.
The client and family or significant others may
have little or no knowledge of disease processes or
need for continued treatment.
If the client and his or her family or significant
others can recognize signs of impending relapse,
the client can seek treatment to avoid relapse.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 27
*Inform the client and family or significant
others about chemotherapy: dosage, need to take
the medication only as prescribed, the toxic
symptoms, the need to monitor blood levels, and
other considerations.
*Stress to the client and family or significant
others that medications must be taken regularly
and continually to be effective; medications
should not be discontinued just because the
clients mood is level.
*Explain information in clear, simple terms.
Reinforce teaching with written material as
indicated. Ask the client and significant others to
state their understanding of the material as you
explain. Encourage the client to ask questions and
to express feelings and concerns.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincotts Manual of Psychiatric Nursing Care Plans, 9th edition.
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Bipolar Disorder, Manic Episode
Some medications, such as oxcarbazepine
(Trileptal), lamotrigine (Lamictal), valproic acid
(Depakote), and gabapentin (Neurontin) may be
contraindicated in clients with impaired liver,
renal, or cardiac functioning. Safe and effective
use of medications may require maintenance and
monitoring of therapeutic blood levels. When the
therapeutic level is exceeded, toxicity can result.
See Appendix E: Psychopharmacology for a
listing of signs and symptoms that may indicate
toxic or near-toxic blood levels.
A relatively constant blood level, within the
therapeutic range, is necessary for successful
maintenance treatment with lithium and valproic
acid.
The client and significant others may have little or
no understanding of medications and toxicity.
Asking for the clients perception of the material
and encouraging questions will help to eliminate
misunderstanding and miscommunication.