CUES/CLUES PSYCHIATRIC PSYCHODYNAMICS PLANNING THERAPEUTIC RATIONALE

EVALUATION
NURSING APPROACH
DIAGNOSIS

January 5, 2010 Risk for injury Increase Dopamine Long term DEPENDENT:
9:00 am related to extreme Increase outcome: Maintain low  Help decrease Long term
hyperactivity as norepinephrine After 2months of level of stimuli in escalation of
outcome:
evidenced by ⬇ nursing client’s anxiety
Subjective: excessive and Manic period intervention the environment partially
Stated: constant motor ⬇ client will be able such as away
achieved
“ayaw ko nga activity Overly excited to : from bright lights,
matulog e, gusto ⬇  be free of injury loud noises, and After 2months of
ko lang mag Talkative: racing  cardiac people.
nursing
videoke o kaya speech, speaking status Provide Structure provide
gumala, pero loudly, nervous, stable structured security and focus intervention the
pinasok ako ditto lavish, speeding  well solitary activities
client was able to:
e.” impulsive, prone to hydrated with nurse or
making unwise  skin free of aide Prevent serious  be free of injury
commercial abrasion Provide frequent dehydration  cardiac
Objective: decisions and scrapes high calorie fluids Physical exercise status
⬇ Be free of Redirect violent can decrease stable
Excessive and Risk for injury excessive behavior tension and  well
constant motor physical agitation provide focus. hydrated
activity Reference: and purposeless  skin free of
Lack of rest Psychiatric mental motor activity. Exhaustion and abrasion
and sleep health nursing and Take short COLLABORATIVE: death result from and scrapes
Inability to Videbeck pages: voluntary rest Acute mania dehydration,
control 317-326 periods during might warrant the lack of sleep and
behavior the day. use of constant
pnenothiazines physical activity
Short term and seclusion to Short term
outcome: minimize physical To promote
outcome:
After 2 weeks of harm. pharmacologic
nursing regimen. achieved
intervention the Administer
After 2 weeks of
client will be able medication such
to: as Seroquel and  There is a small nursing
Depakote. margin of safety
intervention the
Clients cardiac between
status will remain Observe for signs therapeutic and client was able to:
stable while in of lithium toxicity. toxic doses.
Clients cardiac
the hospital
status will remain
While acutely
stable while in
manic, client will  additional
the hospital
drink 8 oz of fluid  Collaborate with knowledge is
While acutely
every hour the psychiatrist needed to
manic, client will
throughout the about the conduct a
drink 8 oz of fluid
day. additional therapy
every hour
Client will spend knowledge for
throughout the
time with the the therapy.
day.
nurse in a quiet
Client will spend
environment 3 to
time with the
4 times a day
nurse in a quiet
between 7 am to
environment 3 to
11 pm with the
4 times a day
aid of nursing
between 7 am to
guidance.
11 pm with the
Client will be free
aid of nursing
of dangerous
guidance.
levels of
Client will be free
hyperactive
of dangerous
motor behavior
levels of
with the aid of
hyperactive
medications and motor behavior
nursing with the aid of
intervention medications and
within 24 hours. nursing
intervention
within 24 hours.