Risk for self-directed or other-directed violence related to Manic excitement, Biochemical alterations, Threat to self-concept, Suspicion of others.
Imbalanced nutrition, less than body requirements related to Refusal of inability to sit still long enough to eat meals, lack of appetite.
Disturbed though processes related to Biochemical alterations, Psychotic process.
Disturbed sensory perception related to Biochemical imbalance, Electrolyte imbalance, Psychotic process.
Impaired social interaction related to Disturbed thought processes.
Sample of Nursing Care Plan for Bipolar Disorder (Mania)
Nursing Diagnosis and Interventions for Bipolar Disorder
1. Risk for injury related to biochemical dysfunction, psychological (affective orientation)
Short-term goal: client will no longer exhibit potentially injurious movements after 24 hours with administration of tranquilizing medication.
Long-term goal: client will experience no physical injury.
Interventions with selected rationales
Reduce environmental stimuli. Assign a private room, if possible, with soft lighting, low noise level, and simple room décor. Rationale in the hyperactive state, the client is extremely distractible, and responses to even the slightest stimuli are exaggerated.
Assign to a quiet unit, if possible. Rationale Milieu unit may be too distracting.
Limit group activities. Help client try to establish one or two close relationships. Rationale Client’s ability to interact with others is impaired. He or she feels more secure in a one-to-one relationship that is consistent over time.
Remove hazardous objects and substances from client’s environment (including smoking materials). Rationale: Client’s rationality is impaired, and he or she may harm self inadvertently. Client safety is a nursing priority.
Stay with the client to offer support and provide a feeling of security as agitation grows and hyperactivity increases.
Provide structured schedule of activities that includes established rest periods throughout the day. Rationale: A structured schedule provides a feeling of security for the client.
Provide physical activities as a substitution for purposeless hyperactivity (example: brisk walks, housekeeping chores, dance therapy, aerobics). Rationale: Physical exercise provides a safe and effective means of relieving pent-up tension.
Administer tranquilizing medication, as ordered by physician. Antipsychotic drugs are commonly prescribed for rapid relief of agitation and hyperactivity. A typical forms commonly used include olanzapine, ziprasidone, and aripiprazole. Example of the typical forms includes haloperidol and chlorpromazine. Observe for effectiveness and evidence of adverse side effects.