JOANNE BERNADETTE C.

AGUILAR BSN-3

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE

INTERVENTION
Objectives: Disturbed sleeping pattern r/t After 2 hours of Independent
Lithium toxicity nursing interventions interventions:
1. Dark circles under the patient will be 1. Assessed - High percentage
eyes able to achieve sleep pattern of sleep
2. Restlessness optimal amount of disturbances that disturbances are
3. Irritability sleep as evidenced by are associated with affected by
4. Diarrhea rested appearance, specific underlying illnesses
verbalization illnesses
of feeling rested, and 2. Observed and - To determine
improvement in sleep obtained usual
pattern feedback from sleep pattern
clients regarding and provide
usual bedtime, appropriate
routines, #of hours intervention.
of sleep ,and
environmental
needs
3. Explained - So that patient
necessity will have an
of disturbances for  understanding
monitoring VS and of the importance
care when of care being
hospitalized. done to him.
Minimizes
complaints
4. Monitor mental - Lithium should
and emotional prevent mood
 status. Observe for swings.
mania and/or
extreme
depression - Lithium is a salt
5. Monitor affected by
electrolyte balance dietary intake of
other salts such as
sodium chloride.
Insufficient
dietary salt intake
causes the
kidneys to
conserve lithium,
increasing serum
lithium levels
6. Monitor fluid - Lithium causes
balance. polyuria by
blocking effects
of antidiuretic
hormone
Dependent Interventions
1. Offer fluids as - To Replace fluids
ordered by the and electrolytes
physician ( D5LR
1000cc @ 30-
35gtts/min)
1. NURSING CARE PLAN FOR LITHIUM TOXICITY
 2. SUICIDAL PATIENT
ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE
DIAGNOSIS
Objectives: Risk for Suicide r/t After 2 hours of Independent
1. Excessive Mood Alteration nursing intervention the Interventions:
sadness or Secondary to Bipolar patient will be able to 1. Check the client’s room - The nurse first priority
moodiness Disorder demonstrate absence of for potentially destructive is provide for the
2. Long-lasting suicidal attempts. implements: sharp client’s safety and
sadness Display consistent, objects, belt, chemicals, protect the client from
3. Mood optimistic, and hopeful hoarded medications; and self-inflicted life
swings and attitude. Express desire take steps to protect threatening injury or
unexpected to live client through death.
rage. appropriate therapeutic
4. Hopelessnes interventions.
s 2. Listen actively to the - Allowing the client to
client’s story regarding verbalize helps the
how the client came to client relieve pent-up
the point of suicide, thoughts, feelings and
using therapeutic skills emotions related to
such as reflection, suicide and is in itself
clarification, and therapeutic. It also gives
validation, and indicate the nurse information
acceptance of the client’s about the critical events
thought and feelings that influenced
the client’s story
promotes trust and in
still hope.

3. Tell the client to staff - Constant staff support

whenever the client and protection reduce
experiences such the client’s fear of
thoughts or feelings suicidal impulses and
 offer hope for survival
- Educating the client
4. Help the client to see that about the temporary
suicide is not an nature/experience of
alternative to life’s suicide and depression
problems but is rather a promotes the
temporary experience
often brought by an
actual illness and
exacerbated by life
stressors
- To verify the patient is
5. Check the patient has swallowing tablets
medications
- Prevent anxiety from
6. Continue to support and escalating to
monitor psychosocial unmanageable levels
treatment

Dependent
Interventions: - To stabilize the mood of
1. Administer the patient.
medications as
ordered by the
physician(Lithium,
Xalipro,Prozac) - To improve
2. Collaborate to wellbeing(mental and
continue to support, physical)and prevent
attending therapy anxiety from escalating
sessions (DBT and to unmanageable level
CBT) and monitor
psychosocial
treatment plans.
 ASSESSMENT NURSING PLANNING NURSING RATIONALE
DIAGNOSIS INTERVENTION
Objectives: Chronic Low Self- After 2 hours of nursing Independent
1. Depressed Esteem r/t unrealistic intervention the patient Interventions:
mood expectation of self will be able to maintain 1. Allow the patient to - Paying attention to grooming
2. Worthlessness self-esteem. perform personal serves as a first step towards
or guilt care activities. achieving positive self-image.
3. Sensitivity to 2. Give positive - Positive reinforcement has a
criticism feedback after a task big part in building self-
4. Social is achieved. esteem.
withdrawal 3. Allow the patient to - Patient may feel overwhelmed
5. Hostility engage in simple at the start when participating
6. Excessive recreational in a group setting.
preoccupation activities, advancing
with personal to a more complex
problems activities in a group
7. Physical environment.
symptoms 4. Teach visualization - To promote a healthier and
such as techniques that can more realistic self-image by
fatigue, help the client helping the client choose
insomnia and replace negative more positive thoughts and
headaches self-images with actions.
more positive
images and thought.
5. Encourage the client - To minimize the feelings of
to participate in a isolation and provide an
group therapy where atmosphere where positive
the members share feedback and a more realistic
the same appraisal of self are available.
 situations/feelings
that they have.
Dependent
Interventions:
1. Collaborate to - To improve wellbeing(mental
continue to and physical)and prevent
support, anxiety from escalating to
attending therapy unmanageable level
sessions (DBT
and CBT) and
monitor
psychosocial
treatment plans.

3. TREATMENT RESISTANT DEPRESSION