Mania-Nursing Care Plan
Content
NURSING CARE PLAN Mania
NURSING DIAGNOSIS
Risk for Injury: related to dehydration and faulty judgment, as evidenced by inability to meet own physiological needs and set limits on own behavior.
Supporting Data ■ Has not slept for days. ■ Has not taken in food or fluids for days. ■ Constant physical activity — is unable to rest.
Outcome Criteria: Client’s cardiac status will remain stable during manic phase.
S HORT -T ERM G OAL
I NTERVENTION
R ATIONALE
E VALUATION GOAL MET
1. Client will be well hydrated, as evidenced by good skin turgor and normal urinary output and specific gravity within 24 hours.
1a. Give haloperidol intramuscularly immediately and as ordered.
1a. Continuous physical activity and lack of fluids can eventually lead to cardiac collapse and death. 1b. Monitor cardiac status. 1c. Reduce environmental stimuli — minimize escalation of mania and distractibility. 1d. Nurse’s presence provides support. Ability to interact with others is temporarily impaired. 1e. Proper hydration is mandatory for maintenance of cardiac status. 1f. Client’s concentration is poor; she is easily distracted. 1g. Client is unable to sit; snacks she can eat while pacing are more likely to be consumed. 1h. Enables staff to make accurate nutritional assessment for client’s safety.
After 3 hours, client takes small amounts of fluids (2 – 4 ounces per hour).
1b. Check vital signs frequently (every 1 – 2 hours). 1c. Place client in private or quiet room (whenever possible).
1d. Stay with client and divert client away from stimulating situations.
1e. Offer high-calorie, high-protein drink (8 ounces) every hour in quiet area. 1f. Frequently remind client to drink: “Take two more sips.” 1g. Offer finger food frequently in quiet area.
After 5 hours, client starts taking 8 ounces per hour with a lot of reminding and encouragement.
1h. Maintain record of intake and output.
Copyright
2006 by Elsevier Inc. All rights reserved.
S HORT -T ERM G OAL
I NTERVENTION
R ATIONALE
E VALUATION GOAL MET
1i. Weigh client daily.
1i. Monitoring nutritional status is necessary. 2a. Lower levels of stimulation can decrease excitability. 2b. Directing client to paced, nonstimulating activities can help minimize excitability.
2. Client will sleep or rest 3 hours during the first night in the hospital with aid of medication and nursing interventions.
2a. Continue to direct client to areas of minimal activity. 2b. When possible, try to direct energy into productive and calming activities (e.g., pacing to slow, soft music; slow exercise; drawing alone; or writing in quiet area). 2c. Encourage short rest periods throughout the day (e.g., 3 – 5 minutes every hour) when possible. 2d. Client should drink decaffeinated drinks only — decaffeinated coffee, tea, or colas. 2e. Provide nursing measures at bedtime that promote sleep — warm milk, soft music. 3a. Continue to monitor blood pressure and pulse frequently throughout the day (every 30 minutes). 3b. Keep staff informed by verbal and written reports of baseline vital signs and client progress.
After 24 hours, specific gravity is within normal limits. Client is awake most of the first night. Sleeps for 2 hours from 4 AM to 6 AM. Client is able to rest on the second day for short periods and engage in quiet activities for short periods (5 – 10 minutes).
2c. Client may be unaware of feelings of fatigue. Can collapse from exhaustion if hyperactivity continues without periods of rest. 2d. Caffeine is a central nervous system stimulant that inhibits needed rest or sleep. 2e. Promotes nonstimulating and relaxing mood.
3. Client’s blood pressure (BP) and pulse (P) will be within normal limits within 24 hours with the aid of medication and nursing interventions.
3a. Physical condition is presently a great strain on client’s heart.
3b. Alerting all staff regarding client status can increase medical intervention if a change in status occurs.
Baseline measure on unit is not obtained because of hyperactive behavior. Information from family physician states BP 130/90 and P 88 baseline. BP at end of 24 hours is 130/70; P is 80.
Copyright
2006 by Elsevier Inc. All rights reserved.
NURSING DIAGNOSIS
Risk for Injury: related to dehydration and faulty judgment, as evidenced by inability to meet own physiological needs and set limits on own behavior.
Supporting Data ■ Has not slept for days. ■ Has not taken in food or fluids for days. ■ Constant physical activity — is unable to rest.
Outcome Criteria: Client’s cardiac status will remain stable during manic phase.
S HORT -T ERM G OAL
I NTERVENTION
R ATIONALE
E VALUATION GOAL MET
1. Client will be well hydrated, as evidenced by good skin turgor and normal urinary output and specific gravity within 24 hours.
1a. Give haloperidol intramuscularly immediately and as ordered.
1a. Continuous physical activity and lack of fluids can eventually lead to cardiac collapse and death. 1b. Monitor cardiac status. 1c. Reduce environmental stimuli — minimize escalation of mania and distractibility. 1d. Nurse’s presence provides support. Ability to interact with others is temporarily impaired. 1e. Proper hydration is mandatory for maintenance of cardiac status. 1f. Client’s concentration is poor; she is easily distracted. 1g. Client is unable to sit; snacks she can eat while pacing are more likely to be consumed. 1h. Enables staff to make accurate nutritional assessment for client’s safety.
After 3 hours, client takes small amounts of fluids (2 – 4 ounces per hour).
1b. Check vital signs frequently (every 1 – 2 hours). 1c. Place client in private or quiet room (whenever possible).
1d. Stay with client and divert client away from stimulating situations.
1e. Offer high-calorie, high-protein drink (8 ounces) every hour in quiet area. 1f. Frequently remind client to drink: “Take two more sips.” 1g. Offer finger food frequently in quiet area.
After 5 hours, client starts taking 8 ounces per hour with a lot of reminding and encouragement.
1h. Maintain record of intake and output.
Copyright
2006 by Elsevier Inc. All rights reserved.
S HORT -T ERM G OAL
I NTERVENTION
R ATIONALE
E VALUATION GOAL MET
1i. Weigh client daily.
1i. Monitoring nutritional status is necessary. 2a. Lower levels of stimulation can decrease excitability. 2b. Directing client to paced, nonstimulating activities can help minimize excitability.
2. Client will sleep or rest 3 hours during the first night in the hospital with aid of medication and nursing interventions.
2a. Continue to direct client to areas of minimal activity. 2b. When possible, try to direct energy into productive and calming activities (e.g., pacing to slow, soft music; slow exercise; drawing alone; or writing in quiet area). 2c. Encourage short rest periods throughout the day (e.g., 3 – 5 minutes every hour) when possible. 2d. Client should drink decaffeinated drinks only — decaffeinated coffee, tea, or colas. 2e. Provide nursing measures at bedtime that promote sleep — warm milk, soft music. 3a. Continue to monitor blood pressure and pulse frequently throughout the day (every 30 minutes). 3b. Keep staff informed by verbal and written reports of baseline vital signs and client progress.
After 24 hours, specific gravity is within normal limits. Client is awake most of the first night. Sleeps for 2 hours from 4 AM to 6 AM. Client is able to rest on the second day for short periods and engage in quiet activities for short periods (5 – 10 minutes).
2c. Client may be unaware of feelings of fatigue. Can collapse from exhaustion if hyperactivity continues without periods of rest. 2d. Caffeine is a central nervous system stimulant that inhibits needed rest or sleep. 2e. Promotes nonstimulating and relaxing mood.
3. Client’s blood pressure (BP) and pulse (P) will be within normal limits within 24 hours with the aid of medication and nursing interventions.
3a. Physical condition is presently a great strain on client’s heart.
3b. Alerting all staff regarding client status can increase medical intervention if a change in status occurs.
Baseline measure on unit is not obtained because of hyperactive behavior. Information from family physician states BP 130/90 and P 88 baseline. BP at end of 24 hours is 130/70; P is 80.
Copyright
2006 by Elsevier Inc. All rights reserved.
