This nursing care plan addresses a client experiencing mania. The goals are for the client to stay hydrated, sleep or rest for 3 hours during the first night, and have normal blood pressure and pulse within 24 hours. Interventions include medications, monitoring intake and output, encouraging rest, and monitoring vitals frequently.
This nursing care plan addresses a client experiencing mania. The goals are for the client to stay hydrated, sleep or rest for 3 hours during the first night, and have normal blood pressure and pulse within 24 hours. Interventions include medications, monitoring intake and output, encouraging rest, and monitoring vitals frequently.
Original Description:
Sample nursing care plan for mania-goals, interventions, rationales, and evaluation.
This nursing care plan addresses a client experiencing mania. The goals are for the client to stay hydrated, sleep or rest for 3 hours during the first night, and have normal blood pressure and pulse within 24 hours. Interventions include medications, monitoring intake and output, encouraging rest, and monitoring vitals frequently.
This nursing care plan addresses a client experiencing mania. The goals are for the client to stay hydrated, sleep or rest for 3 hours during the first night, and have normal blood pressure and pulse within 24 hours. Interventions include medications, monitoring intake and output, encouraging rest, and monitoring vitals frequently.
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45989 Varcarolis SAUNM pg19 BATCH RIGHT
top of RH base of RH top of text NURSING CARE PLAN Mania base of text
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
1. Client will be well 1a. Give haloperidol 1a. Continuous physi- GOAL MET hydrated, as evi- intramuscularly cal activity and After 3 hours, client denced by good immediately and lack of fluids can takes small amounts skin turgor and as ordered. eventually lead to of fluids (2 – 4 ounces normal urinary cardiac collapse per hour). output and specific and death. gravity within 24 hours. 1b. Check vital signs 1b. Monitor cardiac frequently (every status. 1 – 2 hours). 1c. Place client in pri- 1c. Reduce environ- vate or quiet room mental stimuli — (whenever possi- minimize escala- ble). tion of mania and distract- ibility. 1d. Stay with client 1d. Nurse’s presence and divert client provides support. away from stimu- Ability to interact lating situations. with others is temporarily im- paired. 1e. Offer high-calorie, 1e. Proper hydration After 5 hours, client high-protein drink is mandatory for starts taking 8 (8 ounces) every maintenance of ounces per hour hour in quiet area. cardiac status. with a lot of remind- 1f. Frequently remind 1f. Client’s concentra- ing and encourage- client to drink: tion is poor; she is ment. “Take two more easily distracted. sips.” 1g. Offer finger food 1g. Client is unable frequently in to sit; snacks she quiet area. can eat while pac- ing are more likely to be con- sumed. 1h. Maintain record 1h. Enables staff to of intake and out- make accurate nu- put. tritional assess- ment for client’s short safety. standard Copyright 䊚 2006 by Elsevier Inc. All rights reserved. base drop 45989 Varcarolis SAUNM pg20 BATCH LEFT
top of RH base of RH top of text base of text S HORT -T ERM G OAL I NTERVENTION R ATIONALE E VALUATION
1i. Weigh client daily. 1i. Monitoring nutri- GOAL MET
tional status is After 24 hours, spe- necessary. cific gravity is within normal limits. 2. Client will sleep or 2a. Continue to direct 2a. Lower levels of Client is awake most rest 3 hours dur- client to areas of stimulation can of the first night. ing the first night minimal activity. decrease excit- Sleeps for 2 hours in the hospital ability. from 4 AM to 6 AM. with aid of medi- 2b. When possible, 2b. Directing client to Client is able to rest cation and nurs- try to direct en- paced, nonstimu- on the second day ing interventions. ergy into pro- lating activities for short periods and ductive and can help mini- engage in quiet ac- calming activities mize excitability. tivities for short peri- (e.g., pacing to ods (5 – 10 minutes). slow, soft music; slow exercise; drawing alone; or writing in quiet area). 2c. Encourage short 2c. Client may be un- rest periods aware of feelings throughout the of fatigue. Can day (e.g., 3 – 5 collapse from ex- minutes every haustion if hyper- hour) when possi- activity continues ble. without periods of rest. 2d. Client should 2d. Caffeine is a cen- drink decaffein- tral nervous sys- ated drinks tem stimulant that only — decaffein- inhibits needed ated coffee, tea, or rest or sleep. colas. 2e. Provide nursing 2e. Promotes non- measures at bed- stimulating and time that promote relaxing mood. sleep — warm milk, soft music. 3. Client’s blood pres- 3a. Continue to moni- 3a. Physical condition Baseline measure on sure (BP) and pulse tor blood pressure is presently a unit is not obtained (P) will be within and pulse fre- great strain on cli- because of hyperac- normal limits quently through- ent’s heart. tive behavior. Infor- within 24 hours out the day (every mation from family with the aid of 30 minutes). physician states BP medication and 3b. Keep staff in- 3b. Alerting all staff 130/90 and P 88 nursing interven- formed by verbal regarding client baseline. tions. and written re- status can increase BP at end of 24 hours ports of baseline medical interven- is 130/70; P is 80. vital signs and cli- tion if a change in ent progress. status occurs.
short standard Copyright 䊚 2006 by Elsevier Inc. All rights reserved. base drop
