NURSING DIAGNOSIS
ASSESSMENT DIAGNOSIS
Subjective Cues:
- Mary reports about having two
suicide attempts and chronic suicidal
ideation, explaining that it gives her
relief to think about suicide as a “way
out.”
- Mary verbalized that she often
“zones out,” even in the middle of
conversations or while at work under
stress.
- Describes a longstanding pattern of
changing her hobbies, style of
clothing, and sometimes even her job
based on who is in her social group.
- Mary thinks that her
partner is “the best thing that’s ever
happened to me”, other times she
admits to
thinking “I can’t stand him,”
 Anger
 Anxiety
 Concentration Difficulties
 Emotion Dysregulation
 Impulsivity
 Mood Cycles
NURSING GOALS
PLANNING INTERVENTION
Risk for suicide related After 8 hours of nursing
to mood alteration 1.Render
interventions, the patient is
secondary to bipolar supervision
disorder expected to: sustaining observation
 Patient will remain free from
any self-harm.
 Patient will express her
feelings about why she wants
to harm herself.
 Patient will verbalize
understanding that self-harm is
a choice, not something
uncontrollable at discharge.
 Patient will assist in
identifying thoughts, feelings,
and behavior that leads up to
her wanting to commit suicide.
 Patient will verbalize 3
techniques on developing
copings skills to help her
handle stressful situations.
NURSING OUTCOME
RATIONALE EVALUATION
After 8 hours of nursing
close patient 1.Suicide may be an interventions, the goals were
by always impulsive act with little or no partially met and:
or warning. Close supervision is
awareness of the patient. a must. • Patient remained free from
any self-harm.
2. Frequently assess patient’s
behavior for signs of increased • Patient expressed her feelings
agitation and hyperactivity. 2. Early detection and about why she wants to harm
intervention of escalating herself.
mania will prevent the
3.Provide a safe environment. possibility of harm to self or •Patient did not verbalize
Weapons and pills should be others. understanding that self-harm is
removed by relatives, or the a choice, not something
nurse. 3.Removing potentially uncontrollable at discharge.
harmful objects prevents the
patient from acting or sudden Patient assisted in identifying
4. Obtain a no self-harm self-destructive impulses. thoughts, feelings, and behavior
contract. that leads up to her wanting to
4. A contract can help the commit suicide
patient resist suicide by
5. Educate the patient providing a way of resisting Patient verbalized 3 techniques
cognitive-behavioral self- impulses. on developing copings skills to
management responses to help her handle stressful
suicidal thoughts. 5. Patient learns to identify situations.
negative thoughts and
develops positive approaches
and positive thinking.
  Risky Behaviors

 Self-Injury

 Suicidal thoughts

Reference(s):

https://nurseslabs.com/bipolar-disorders-nursing-care-plans/2/

https://nurseslabs.com/risk-for-suicide/

https://www.registerednursern.com/nursing-care-plan-and-diagnosis-for-risk-for-self-harm-related-to-suicide-depression-nanda-nursing-interventions-and-outcomes/

Planning
Assessment Implementation Evaluation
Objectives of Care Intervention Rationale
SUBJECTIVE CUE: Within the span of  Intervene immediately if the  Immediate intervention in clients  Intervened immediately when
care the client will client demonstrates harm or assault risk behaviors the client demonstrated
- Patient aggressive behavior towards may prevent harm or injury aggressive behavior towards After nursing
demonstrate
verbalizes others. others. interventions, the
feelings of absence of violent
 Listen for verbal threats or  The client verbal threats, physical  Listened for verbal threats or client will be able to
anger or aggressive
hostile remarks towards contact and acting out may be hostile remarks towards maintain a non-
- “I can’t behavior and will
others. precursors or cues to impending others. hostile behavior
stand him.” not injure others.
violence. and will not injure
others.
OBJECTIVE CUE:
 Encourage to express anger by  This helps client let out what she  Encouraged client to express
- Anger saying or verbally instead of feels and express rather than anger by saying or verbally
- Impulsivity acting out. lashing out. instead of acting out.
 - Risky
Behaviors  Help the client manage angry,
- Overt and inappropriate, or intrusive
aggressive behaviors in a therapeutic but
acts firm direct manner.
- Ignores and
lashes out
at her  Reduce milieu noise and
partner stimulation or accompany
- Yells and client to a calmer, quieter
throws environment at early signs of
things when anger, frustration, or
angry agitation.
Nursing Diagnosis:  Remind the client to continue
seeking help from you or
Risk for Other –
other care-providers when
Directed Physical starting to feel frustration,
Violence anger, hostility, and
suspiciousness rather than
waiting until the negative
thoughts and feelings are out
of control, which can lead to
violence.
 Praise the client’s efforts
made to control anger or
hostility to others.
 Teach the client and the
family to recognize early signs
and symptoms of escalating
agitation or hypomanic
behaviors (yelling, cursing,
threatening, pacing,
intrusiveness, suspiciousness)
that can lead to full blown
 Helping the client manage angry
inappropriate or intrusive
behaviors early in the escalation
of phase may prevent assault or
violence.
 A calm external environment
often helped to promote a
relaxed internal state within the
client and may lessen agitation
and prevent violence.
 Being there can help the client
prevent negative feelings from
reaching destructive levels if they
know the client’s state in
advance. You may also engage
client in therapeutic
activities/exercises and can offer
medications when necessary.
 Positive feedback reinforces
repetition of positive functional
behaviors.
 It is important to equip the
client’s family effectively with
resources and interventions when
the client’s behaviors threaten
the safety of others and the
integrity of the environment.
 Helped the client manage
angry, inappropriate or
intrusive behaviors in a
therapeutic but firm direct
manner.
 Reduced milieu noise and
stimulation and accompanied
client to a calmer, quieter
environment at early signs of
anger, frustration, or agitation.
 Reminded the client to
continue seeking help from
you and other care-providers
when starting to feel
frustration, anger, hostility,
and suspiciousness rather than
waiting until the negative
thoughts and feelings are out
of control, which can lead to
violence.
 Praised the client’s efforts
made to control anger or
hostility to others.
 Taught the client and the
family to recognize early signs
and symptoms of escalating
agitation or hypomanic
behaviors (yelling, cursing,
threatening, pacing,
intrusiveness, suspiciousness)
that can lead to full blown
 mania, self-harm, assault, or
violence.
 Teach client deep breathing
and relaxation techniques.
 Redirect agitation and
potentially violent behaviors
with physical outlets in an
area of low stimulation (e.g.,
punching bag).
 Chart, in nurse’s notes,
behaviors; interventions; what
seemed to escalate agitation;
what helped to calm agitation;
when as-needed (PRN)
medications were given and
their effect; and what proved
most helpful.
NURSING
ASSESSMENT PLANNING
DIAGNOSIS
 Deep breathing can help cool the
client’s emotions when she is
angry. Taking a deep breath takes
her focus off whatever
is angering her, which can help
her “de-escalate”.
 Can help to relieve pent-up
hostility and relieve muscle
tension.
 Staff will begin to recognize
potential signals for escalating
manic behaviors and have a
guideline for what might work
best for the individual client.
INTERVENTIONS & RATIONALES
mania, self-harm, assault, or
violence.
 Taught client deep breathing
and relaxation techniques.
 Helped and suggested redirect
agitation and potentially
violent behaviors with physical
outlets in an area of low
stimulation (e.g., punching
bag).
 Charted in nurse’s notes,
behaviors; interventions; what
seemed to escalate agitation;
what helped to calm agitation;
when as-needed (PRN)
medications were given and
their effect; and what proved
most helpful
IMPLEMENTATION EVALUATION
 CUES
Subjective:
Mary thinks that her partner
is “the best thing that’s ever
happened to her” and will
impulsively buy him lavish
gifts, send caring text
messages, and the like;
however, at other times she
admits to thinking “I can’t
stand him,” and will ignore
or lash out at him, including
yelling or throwing things.
Immediately after doing so,
she reports feeling regret
and panic at the thought of
him leaving her.
Mary says that she often
“zones out,” even in the
middle of
conversations or while at
work when she is stress.
Objective:
 Anxiety
 Impulsivity
 Emotion dysregulation
 Concentration
Difficulties
When less manic, the client might join
one or two other clients in quiet, non-
At the end of nursing intervention, the At the end of the nursing intervention
stimulating activities (e.g., drawing,
client will be able to: the patient was able to:
board games, cards).
 initiate and maintains goal-directed Provided the client a non-  initiated and maintained goal-
and mutually satisfying stimulating activity (e.g., directed and mutually satisfying
Rationale: As mania subsides,
activities/verbal exchanges with drawing, board games). activities/verbal exchanges with
involvement in activities that provide a
others. others.
focus and social contact becomes more
 find one or two solitary activities  found one or two solitary activities
appropriate. Competitive games can
that can help relieve tensions and that helped relieved tensions and
stimulate aggression and can increase
minimize escalation of anxiety. minimized escalation of anxiety.
psychomotor activity.
 focus on one activity requiring a  focused on one activity requiring a
short attention span for 5 minutes short attention span for 5 minutes
Impaired Social three times a day with nursing When possible, provide an environment three times a day with nursing
Interaction assistance. with minimum stimuli (e.g., quiet, soft assistance.
Provided an environment
related to  sit through a short, small group music, dim lighting).  sat through a short, small group
with minimum stimuli (e.g.,
biochemical meeting free from disruptive soft music, dim lighting). meeting free from disruptive
imbalances outbursts. Rationale: Reduction in stimuli lessens outbursts.
 demonstrate an ability to remove distractibility.  demonstrated an ability to remove
self from a stimulating self from a stimulating environment
environment to “cool down” by to “cool down” by discharge.
discharge. Solitary activities requiring short  participated in unit activities
 participate in unit activities without attention spans with mild physical without disruption or demonstrating
disruption or demonstrating exertion are best initially (e.g., writing, inappropriate behavior by
Provided solitary activities
inappropriate behavior by taking photos, painting, or walks with discharge; and
requiring short attention
discharge; and staff).  has put feelings into words instead
span (e.g., writing, taking
 put feelings into words instead of photos). of actions when experiencing
actions when experiencing anxiety Rationale: Solitary activities minimize anxiety or loss of control before
or loss of control before discharge. stimuli; mild physical activities release discharge.
tension constructively.
PLANNING
 ASSESSMENT OBJECTIVE INTERVENTION RATIONALE IMPLEMENTATION EVALUATION
OF CARE
  At the end of 24 Develop caring The patient must  Developed caring rapport At the end of 24 hours,
Chief complain/ Subjective Data: The hours, the patient rapport agree to a contract with client. the patient was able to:
patient stated that when she is stressed she will be able to: with client. not to harm Regularly assessed client
self or others for
often “zones out” even in the middle of
Regularly assess during safety. The patient remains
conversations or while at work.
To be free of injury client for hospital stays. free of injury
The patient stated that, “I don’t know who during inpatient safety. during inpatient
Mary really is,” and describes a hospital Reviewed unit rules with hospital
longstanding pattern of changing her stay. client and gave him any stay.
hobbies, style of clothing, and sometimes Review unit rules with The patient needs necessary reminders to
client and give him to follow unit help him display The patient follows
even her job based on who is in her social
any rules. acceptable behavior. the unit’s rules
group. To be able to
necessary reminders with minimal
follow the unit’s
The patient stated that her partner is “the rules to difficulty.
best thing that’s ever happened to me” with help him display Observed client for
minimal changes
and will impulsively buy him lavish gifts, difficulty. acceptable behavior. The patient displays a
in psychotic ideation. calming energy
send caring text messages, and the like;
however, at other times the patient admits Because the client level base within 24
Observe client for needs to hours.
to thinking “I can’t stand him,” and will To be able to
changes experience a
ignore or lash out at him, including display a calming in psychotic ideation. decrease in or Assessed client for Interacts coherently
yelling or throwing things. Immediately energy level base cessation substance with staff
after doing so, the patient reports feeling within 24 hours. of psychotic abuse/misuse. and peers.
regret and panic at the thought of him To interact ideation.
leaving her. coherently with The patient has no
staff and peers. signs of
The client must not Monitored sleep and substance abuse, with
Objective Data: To have no signs of Assess client for engage in promoted a
substance abuse, substance substance positive sleep hygiene. normal blood alcohol
-Impulsivity with a abuse/misuse. abuse/misuse. Monitored food and fluid level
- Emotion Dysregulation normal blood intake for adequacy. and drug screen.
alcohol level
- Mood Cycles and drug screen. Will sleep at least The patient is sleeping
- Anger Monitor sleep and 6 hours for at least 6
To be able to sleep promote per night. continuous hours
- Concentration Difficulties for at least 6 positive sleep Will achieve during the
Nursing Diagnosis continuous hours hygiene. adequate Discussed plans for future night.
during the Monitor food and food and fluid career options. Discussed
Low self-esteem related to Emotion night. fluid intake. the The patient has
Dysregulation, as evidenced by intake for adequacy. Will bathe and importance of ongoing appropriate food
dissociation to colleagues and confused To have appropriate groom daily. follow-up care in the and fluid intake and is
feelings for food prevention of relapse. appropriately
significant other and fluid intake and engaging in
is Will participate in self-care and is
Medical Impression:
appropriately unit groomed.
Bipolar Disorder engaging in activity schedule.
self-care and is Discuss plans for Will make The patient is
groomed. future appointment beginning to talk
career options. for follow-up care about her relationship
To be able to talk Discuss the with situation and is
about her importance of psychiatric and expressing appropriate
relationship ongoing counseling center feelings of sadness
situation and is follow-up care in the before and anger.
expressing prevention of relapse. discharge.
appropriate The patient is
feelings of sadness demonstrating
and anger. appropriate behavior
with
To be able to staff and peers on the
demonstrate unit
appropriate and is beginning to
behavior with discuss
staff and peers on her need for follow-up
 the unit care
and will begin to for her bipolar
discuss disorder. Makes
her need for follow- appointment for
up care two days after planned
for her bipolar discharge date.
disorder. Makes
appointment for
two days after
planned
discharge date.

Reference: Nursing Care Plan Sample.pdf (jbpub.com)