CUES/CLUES PSYCHIATRIC NURSING

DIAGNOSIS

PSYCHODYNAMICS PLANNING THERAPEUTICAPPROACH

RATIONALEEVALUATION

January 5, 20109:00 am

Subjective:Stated:“ayaw ko nga matulog e, gusto ko lang mag videoke o kaya gumala, pero pinasok ako ditto e.”

Objective:

Excessive and constant motor activity

Lack of rest and sleep

Inability to control behavior

Risk for injury related to extreme hyperactivity as evidenced by excessive and constant motor activity

Increase DopamineIncrease

norepinephrine⬇Manic period⬇

Overly excited⬇Talkative: racing speech, speaking loudly, nervous, lavish, speeding

impulsive, prone to making unwise

commercial decisions⬇

Risk for injury

Reference:Psychiatric mental health nursing and Videbeck pages: 317-326

Long term outcome:After 2months of nursing intervention the client will be able to :be free of injury

cardiac status stable

well hydrated

skin free of abrasion and scrapes

Be free of excessive physical agitation and purposeless motor activity.

Take short voluntary rest periods during the day.

DEPENDENT:Maintain low

level of stimuli in client’s environment such as away from bright lights, loud noises, and people.

Provide structured solitary activities with nurse or aide

Provide frequent high calorie fluids

Redirect violent behavior

COLLABORATIVE:Acute mania

might warrant the use of pnenothiazines

Help decrease escalation of anxiety

Structure provide security and focus

Prevent serious dehydration

Physical exercise can decrease tension and provide focus.

Exhaustion and death result from dehydration, lack of sleep and constant physical activity

Long term

outcome:

partially

achieved

After 2months of

nursing

intervention the

client was able to:

be free of injury cardiac

status stable

well hydrated

skin free of abrasion and scrapes

Short term outcome:After 2 weeks of nursing intervention the client will be able to:

Clients cardiac status will remain stable while in the hospital

While acutely manic, client will drink 8 oz of fluid every hour throughout the day.

Client will spend time with the nurse in a quiet environment 3 to 4 times a day between 7 am to 11 pm with the aid of nursing guidance.

Client will be free of dangerous levels of hyperactive motor behavior with the aid of

and seclusion to minimize physical harm.

Administer medication such as Seroquel and Depakote.

Observe for signs of lithium toxicity.

Collaborate with the psychiatrist about the additional knowledge for the therapy.

To promote pharmacologic regimen.

There is a small margin of safety between therapeutic and toxic doses.

additional knowledge is needed to conduct a therapy

Short term

outcome:

achieved

After 2 weeks of

nursing

intervention the

client was able to:

Clients cardiac status will remain stable while in the hospital

While acutely manic, client will drink 8 oz of fluid every hour throughout the day.

Client will spend time with the nurse in a quiet environment 3 to 4 times a day between 7 am to 11 pm with the aid of nursing guidance.

Client will be free of dangerous levels of hyperactive

medications and nursing intervention within 24 hours.

motor behavior with the aid of medications and nursing intervention within 24 hours.