BIPOLAR DISORDERS

DSM-IV
296.xx Bpoar I dsorder
296.0x Snge manc epsode
296.40 Most recent epsode hypomanc
296.4x Most recent epsode manc
296.6x Most recent epsode mxed
296.7 Most recent epsode unspeced
296.5x Most recent epsode depressed
296.89 Bpoar II dsorder (recurrent ma|or depressve epsodes wth hypomana)
301.13 Cycothymc dsorder
296.80 Bpoar dsorder NOS
Bpoar dsorders are characterzed by recurrent mood swngs of varyng degree
from depresson to eaton wth ntervenng perods of normacy. Mder mood swngs
such as cycothyma may be manfested or vewed as everyday creatvty rather than
an ness requrng treatment. Hypomana can actuay enhance artstc creatvty and
creatve thnkng/ probem-sovng.
Ths pan of care focuses on treatment of the manc phase. (Note: Bpoar II
dsorder s characterzed by perods of depresson and hypomana, but wthout manc
epsodes.) Refer to CP: Depressve Dsorders for care of depressve epsode.
ETIOLOGICAL THEORIES
Psychodynamcs
Psychoanaytca theory expans the cycc behavors of mana and depresson as
a response to condtona ove from the prmary caregver. The chd s mantaned n
a dependent poston, and ego deveopment s dsrupted. Ths gves way to the
deveopment of a puntve superego (anger turned nward or depresson) or a strong
d (uncontroabe mpusve behavor or mana). In the psychoanaytca mode, mana
s vewed as the mrror mage of depresson, a "dena of depresson."
Bo!o"ca!
There s ncreasng evdence to ndcate that genetcs pays a strong roe n the
predsposton to bpoar dsorder. Research suggests a combnaton of genes may
create ths predsposton. Incdence among reatves of ahected ndvduas s hgher
than n the genera popuaton. Bochemcay there appear to be ncreased eves of
the bogenc amne norepnephrne n the bran, whch may account for the ncreased
actvty of the manc ndvdua.
#am!y Dynamcs
Ob|ect oss theory suggests that depressve ness occurs f the person s
separated from or abandoned by a sgncant other durng the rst 6 months of fe.
The bondng process s nterrupted and the chd wthdraws from peope and the
envronment. Re|ecton by parents n chdhood or spendng formatve years wth a
famy that sees fe as hopeess and has a chronc expectaton of faure makes t
dmcut for the ndvdua to be optmstc. The mother may be dstant and unovng,
the father a ess-powerfu person, and the chd expected to acheve hgh soca and
academc success.
CLIENT ASSESSMENT DATA BASE $MANIC EPISODE%
Act&ty'Rest
Dsrupted seep pattern or extended perods wthout seep/decreased need for seep
(e.g., fees we rested wth 3 hours of seep)
Physcay hyperactve, eventua exhauston
E"o Inte"(ty
Inated/exated sef percepton, wth unreastc sef-condence
Grandosty may be expressed n a range from unreastc pannng and persstent
oherng of unsocted advce (when no expertse exsts) to grandose deusons of
a speca reatonshp to mportant persons, ncudng God, or persecuton
because of "specaness"
Humor atttude may be caustc/hoste
#ood'#!)d
Weght oss often noted
Hy"ene
Inattenton to ADLs common
Groomng and cothng choces may be napproprate, amboyant, and bzarre;
excessve use of makeup and |ewery
Ne)(osenso(y
Prevang mood s remarkaby expansve, "hgh," or rrtabe
Reports of actvtes that are dsorganzed and amboyant or bzarre, dena of
probabe outcome, percepton of mood as desrabe and potenta as mtess
Menta! Stat)s: Concentraton/attenton poor (responds to mutpe rreevant stmu
n the envronment), eadng to rapd changes n topcs (ght of deas) n
conversaton and nabty to compete actvtes
Mood: abe, predomnanty euphorc, but easy changed to anger or despar wth
sghtest provocaton; mood swngs may be profound wth ntervenng perods of
normacy
De!)sons: paranod and grandose, psychotc phenomena (usons/haucnatons)
*)d"ment: poor, rrtabty common
S+eech: rapd and pressured (oquacousness), wth abrupt changes of topc; can
progress to dsorganzed and ncoherent
Psychomotor agtaton
Sa,ety
May demonstrate a degree of dangerousness to sef and others; actng on
msperceptons
Se-)a!ty
Increased bdo; behavor may be unnhbted
Soca! Inte(actons
May be descrbed or vewed as very extroverted/socabe (numerous acquantances)
Hstory of overnvovement wth other peope and wth actvtes; ambtous,
unreastc pannng; acts of poor |udgment regardng soca consequences
(uncontroed spendng, reckess drvng, probematc or unusua sexua behavor)
Marked mparment n soca actvtes, reatonshp wth others (ack of cose
reatonshps), schoo/occupatona functonng, perodc changes n
empoyment/frequent moves
Teachn"'Lea(nn"
Frst fu epsode usuay occurs between ages 15 and 24 years, wth symptoms
astng at east 1 week
May have been hosptazed for prevous epsodes of manc behavor
Perodc acoho or other drug abuse
DIAGNOSTIC ST.DIES
D()" Sc(een: Rue out possbty that symptoms are drug-nduced.
E!ect(o!ytes: Excess of sodum wthn the nerve ces may be noted.
Lth)m Le&e!: Done when cent s recevng ths medcaton to ensure therapeutc
range between 0.5 and 1.5 mEq/ter.
N.RSING PRIORITIES
1. Protect cent/others from the consequences of hyperactve behavor.
2. Provde for cents basc needs.
3. Promote reaty orentaton, reastc probem-sovng, and foster autonomy.
4. Support cent/famy partcpaton n foow-up care/communty treatment.
DISCHARGE GOALS
1. Remans free of n|ury wth decreased occurrence of manc behavor(s).
2. Baance between actvty and rest restored.
3. Meetng basc sef-care needs.
4. Communcatng ogcay and ceary.
5. Cent/famy partcpatng n ongong treatment and understands mportance of
drug therapy/montorng.
6. Pan n pace to meet needs after dscharge.
N.RSING DIAGNOSIS TRA.MA/ (s0 ,o('VIOLENCE/ (s0 ,o(
d(ected at othe(s
Rs0 #acto(s May Inc!)de: Emotona dmcutes; rrtabty and mpusve
behavor; deusona thnkng; angry response
when deas are refuted/wshes dened
Manc exctement
Hstory of assautve behavor
1Poss2!e Indcato(s:3 Body anguage, ncreased motor actvty
Dmcuty evauatng the consequences of own
actons
Overt and aggressve acts; hoste, threatenng
verbazatons
Des(ed O)tcomes'E&a!)aton C(te(a4 Demonstrate sef-contro wth decreased
C!ent 5!!: hyperactvty.
Acknowedge why behavor occurs.
Verbaze feengs (anger, etc.) n an approprate
manner.
Use probem-sovng technques nstead of voent
behavor/threats or ntmdaton.
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Decrease envronmenta stmu, avodng exposure Cent may be unabe to focus attenton on
ony
to areas or stuatons of predctabe hgh stmuaton reevant stmu and w be
reactng/respondng
and removng stmuaton from area f cent to a envronmenta stmu.
becomes agtated.
Contnuay reevauate cents abty to toerate Factates eary nterventon and asssts cent to
frustraton and/or ndvdua stuatons. manage stuaton ndependenty, f possbe.
Provde safe envronment, removng ob|ects and Grandose thnkng (e.g., "I am Superman") and
rearrangng room to prevent accdenta/purposefu hyperactve behavor can ead to
destructve actons
n|ury to sef or others. such as tryng to run through the wa/nto others.
Intervene when agtaton begns to deveop, wth Interventon at earest sgn of agtaton can assst
strateges such as beng verbay drect, promptng cent n reganng contro, preventng
escaaton to
more ehectve behavor, redrectng or removng voence and aowng treatment n east
restrctve
from the provokng stuaton, vountary "Tme out" manner.
n room or a quet pace, physca contro (e.g.,
hodng).
Defer probem-sovng regardng preventon of Ouestons regardng preventon ncrease
voence and nformaton coecton about frustraton because agtaton decreases abty to
precptatng or provokng stmu unt agtaton/ anayze stuaton.
rrtabty s dmnshed (e.g., no "why," anaytca
questons).
Communcate ratonae for stah acton n a concrete Agtated persons are unabe to process
compcated
manner. communcaton.
Aow cent to enter areas of ncreased stmu Toerance of envronmenta stmu s reduced,
and
graduay when he or she s ready to eave "Tme gradua reentry fosters copng abty.
out" secuson area.
Avod argung when cent verbazes unreastc or Prevents trggerng agtaton n predctaby
touchy
grandose deas or "put-downs." areas.
Ignore/mnmze attenton gven to undesred Avods gvng renforcement to these behavors,
behavors (e.g., bzarre dress, use of profanty), whe provdng contro for potentay dangerous
whe settng mts on destructve actons. actvtes.
Avod unnecessary deay of gratcaton. Gve In hyperactve state, cent does not toerate
concrete and non|udgmenta ratonae f refusa s watng or dea we wth abstractons, and
necessary. unnecessary deay can trgger aggressve
behavor.
Oher aternatves when avaabe ("I dont have any Uses cents dstractbty to hep
decrease the
cohee. Woud you ke a gass of |uce?") frustraton of beng refused.
Provde nformaton regardng more ndependent Improves retenton, as agtated person w not be
and aternatve probem-sovng strateges when abe to reca or use strateges dscussed.
cent s not abe or rrtabe.
Encourage cent, durng cam moments, to recognze Promotes eary recognton of deveopng
probem,
antecedents/precptants to agtaton. aowng cent to pan for aternatve responses
and ntervene n a tmey fashon.
Assst cent n dentfyng aternatve behavors that Cent w be more apt to foow through
on
are acceptabe to both cent and stah. Roe-pay, f aternatves f they are mutuay
acceptabe.
ndcated. Intervene as necessary to protect centPractce n a nonagtated tme heps cent earn
when behavor s provocatve or ohensve (Refer to new behavor. Cent may become
physcay
ND: Soca Interacton, mpared.) voent wth others when behavor s socay
unacceptabe/re|ected.
Provde renforcement/postve feedback when Increases feeng of success and the kehood of
cent attempts to hande frustratng ncdents cent repeatng that behavor agan.
wthout voence.
Co!!a2o(at&e
Anayze any voent ncdents wth nvoved stah/ Informaton s used to deveop ndvduazed and
observers, dentfyng antecedents or provokng proactve nterventons based on experence.
stuatons, cent ndcators of ncreasng agtaton,
cent response(s) to nterventon attempted, etc.
Admnster medcatons, as ndcated:
Antmanc drugs, e.g., thum carbonate
(Lthobd,
Lthum s the drug of choce for mana. It s
Eskath);
ndcated for aevaton of hyperactve
symptoms.
Antconvusants, e.g., conazepam (Konopn),
Have been found to be usefu for the
aevaton of carbamazepne (Tegreto),
vaproc acd
manc symptoms.
(Depakene);
Cacum channe bockers, e.g.,
Some cncans have acheved satsfactory
resuts
verapam (Isoptn);
wth these drugs aone, or n combnaton
wth
thum.
Antpsychotc drugs, e.g., chorpromazne
Usefu n decreasng the eve of extreme
(Thorazne), haoperdo (Hado).
hyperactvty and ameoratng accompanyng
thought dsorder unt therapeutc eve of
thum
can be acheved, or when thum s
nehectve.
Provde secuson and/or restrant (accordng to May be requred for bref perod when other
agency pocy). measures fa to protect cent, stah, or others.
Prepare for eectroconvusve therapy as ndcated. ECT may be requred n presence of severe
manc
decompensaton, when cent does not
toerate/fas to respond to thum or other drug
treatments. (Refer to CP: Depresson Dsorders,
ND: In|ury, rsk for.)
N.RSING DIAGNOSIS N.TRITION: a!te(ed/ !ess than 2ody
(e6)(ements
May Be Re!ated to: Inadequate ntake n reaton to metaboc
expendtures
Poss2!y E&denced 2y: Body weght 20% or more beow dea weght
Observed nadequate ntake
Inattenton to meatmes; dstracton from task of
eatng
Laboratory evdence of nutrtona
dects/mbaances
Des(ed O)tcomes'E&a!)aton C(te(a4 Verbaze mportance of adequate ntake.
C!ent 5!!: Dspay ncreased attenton to eatng behavors.
Demonstrate weght gan toward goa.
Dspay normazaton of aboratory vaues
reectng mproved nutrtona status.
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Montor/record nutrtona and ud ntake Heps determne dects/needs and progress
(ncudng caore count) and actvty eve on an toward goa.
ongong bass.
Wegh routney. Provdes nformaton about therapeutc
needs/ehectveness.
Oher meas n area wth mnma dstractng stmu. Promotes focus on task of eatng and
prevents
dstractons from nterferng wth food ntake.
Wak or st wth cent durng meas/snack tmes. Provdes support and encouragement to eat
adequate amounts of nutrtous foods even f
cent
s unabe to st through mea tme.
Have snack foods and |uces avaabe at a tmes. Nutrtous ntake s requred on a reguar
bass to
compensate for ncreased caorc requrements
resutng from hyperactvty.
Provde opportunty to seect foods when cent s Can provde favored foods, sense of contro, f
ready to dea wth choces. aternatves do not add confuson.
Co!!a2o(at&e
Refer to dettan. Hepfu n determnng cents ndvdua needs
and most approprate optons to meet needs.
Oher hgh-proten hgh-carbohydrate det. ProvdeMaxmzes nutrtona ntake and aows
nterva feedngs, usng nger foods. addtona opportunty to "boost" detary ntake
as
cent may eat foods that are easy pcked up
and/or carred around. Note: As mana subsdes,
caorc requrements decne, necesstatng
ad|ustment of det based on cents weght,
heath
status, and actvty eve.
Revew aboratory studes as ndcated (e.g., Indcates nutrtona status, dentes therapeutc
chemstry proe |ncudng eectroytes| and needs/ehectveness.
urnayss).
Admnster suppementa vtamns and mneras. Corrects detary decences, mprovng
nutrtona status.
N.RSING DIAGNOSIS SLEEP PATTERN dst)(2ance
May Be Re!ated to: Psychoogca stress, ack of recognton of
fatgue/need to seep, hyperactvty
Poss2!y E&denced 2y: Dena of need to seep
Interrupted nghttme seep, one or more nghts
wthout seep
Changes n behavor and performance, ncreasng
rrtabty/restessness
Dark crces under eyes
Des(ed O)tcome'E&a!)aton C(te(a4 Recognze cues ndcatng fatgue/need for seep.
C!ent 5!!: Reestabsh seep pattern as ndvduay
approprate.
Report feeng we rested and appear reaxed.
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Decrease envronmenta stmu n room and Manc cent s unabe to reax and decrease
common areas. attenton to stmu, ahectng abty to fa aseep.
Note: May need prvate room, secuson.
Restrct ntake of cahene (e.g., cohee, tea, cocoa, May stmuate CNS, nterferng wth
reaxaton,
coa drnks). abty to seep.
Oher sma snack/warm mk at bedtme or when Inattenton to persona needs may have ed to a
awake durng the nght. ess than adequate ntake, and hunger at nght
may dstract from seep. Aso, L-tryptophan n
mk may promote seep.
Encourage engagng n physca actvtes/exercse Enhances sense of fatgue and promotes
durng mornng and afternoon. Restrct actvty n seep/rest. Evenng actvty may actuay
stmuate
the evenng pror to bedtme. cent and nterfere wth/deay seep.
Encourage routne bedtme actvtes, reaxaton Renforces need for rest, "settng stage" for cent
technques. to quet mnd and prepare for seep.
Reroute to bed matter-of-facty, wthout provdng Avods stmu that may stmuate cent or
the dstracton of other actvtes. provde rrtabty.
Co!!a2o(at&e
Admnster medcatons as ndcated, e.g.:
Sedatves;
Carefu use may assst n reestabshng seep
pattern.
Antpsychotcs, e.g., oanzapne (Zyprexa).
Produces a camng ehect, reducng
hyperactvty
and promotng rest/seep.
N.RSING DIAGNOSIS SEL# CARE DE#ICIT: "(oomn"'hy"ene/
mana"ement o, +e(sona! 2e!on"n"s
May Be Re!ated to: Lack of concern; mpusvty; poor |udgment
Hyperactvty
Poss2!y E&denced 2y: Unkempt appearance, drty, wearng nadequate
and/or napproprate cothng
Gvng away cothng, money, etc., spendng or
"chargng" extravaganty
Des(ed O)tcomes'E&a!)aton C(te(a4 Perform sef-care actvtes wthn eve of own
C!ent 5!!: abty.
Use resources/assstance as needed.
Take responsbty for/manage persona
beongngs appropratey.
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Assess current eve of functonng; reevauate day. Provdes nformaton about changes n
ndvdua
abtes necessary for pannng/aterng care.
Provde physca assstance, supervson and smpe Heps focus attenton on task. Provdng
ony
drectons/remnders, encouragement and support, requred assstance fosters autonomous
as needed. functonng.
Acqure needed suppes, ncudng cothng, f not May not have own necesstes f dsorganzed
pror
mmedatey avaabe. Obtan cents own toetres/ to hosptazaton or hosptazed as an
cothng as soon as possbe. emergency measure. Havng own
suppes/cothng supports autonomy, sef-esteem.
Lmt the seecton of cothng avaabe, as ndcated. May be necessary durng tme of extreme
hyperactvty and dstractbty unt cent s abe
to refran from bzarre dress and/or care for
persona beongngs.
Montor abty to manage money and vauabes as May gve possessons away, spend money
we as other persona ehects. extravaganty, or become nvoved n grandose
pans.
Intervene to protect cent from own mpusvty Provdes protecton from deeterous
consequences
and from expotaton, f ndcated, decreasng of mpusvty wthout compromsng or undue
restrctons as soon as possbe. restrcton of cv/persona bertes or
autonomous functonng.
Set goas to estabsh mnmum standards for sef-Promotes dea that cent can begn to assume
care as condton mproves (e.g., take a bath every responsbty for sef, enhances sense of
sef-
other day, brush teeth twce a day). worth.
N.RSING DIAGNOSIS SENSOR7'PERCEPT.AL a!te(atons
1o&e(!oad3
May Be Re!ated to: Decrease n sensory threshod; psychoogca
stress (narrowed perceptua eds)
Chemca ateraton: endogenous
Seep deprvaton
Poss2!y E&denced 2y: Increased dstractbty and agtaton (n
areas/tmes of ncreased envronmenta stmu);
anxety
Dsorentaton; poor concentraton; bzarre
thnkng; audtory/vsua haucnatons
Motor ncoordnaton
Des(ed O)tcomes'E&a!)aton C(te(a4 Verbaze awareness/causes of sensory overoad.
C!ent 5!!: Demonstrate behavors to reduce/manage
sensory nput (e.g., sts quety, attends to smpe
tasks and competes them).
Intate and/or take "Tme out" n queter area
when prompted.
Attend and be appropratey nvoved n actvtes
(e.g., unt meetng, groups).
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Orent to reaty (e.g., dentfy prmary caregver, May be dsorented/confused as a resut of
change
where room s). Keep communcatons smpe. of surroundngs, mutpe dstractons.
Assst cent n focusng on nput or task (e.g., Decreases dstractons/choces that are avaabe,
address by name; use short, 1-stage drectons; hepng to gan cents attenton n presence of
provde a ow-stmuus area for ntervew, meas, mutpe dstractons.
tasks).
Avod ookng at watch, takng notes, takng to Causes dstractng stmu, addng to stmuaton,
others when focusng on cent. whch can ncrease hyperactvty.
Remove to area of ower envronmenta stmuus Reduces dstractons, thereby reducng
stmuaton
eve f cent shows ncreasng agtaton or and dmnshng hyperactve behavor.
dstractbty.
Expan upcomng events, necessary treatments n Stmu may be ess overwhemng when
cent s
advance, gvng reasons and usng smpe terms. prepared.
Lmt nvason of persona space (e.g., touchng Reduces stmu, shows respect for cent, who
cothng, tems n room). Use physca touch may vew touch as threatenng.
|udcousy.
Observe/montor for ndcators of mproved Aows greatest possbe partcpaton n
treatment
toerance for mutpe sensory stmu; and ncrease meu, persona freedom.
exposure toward envronment, peope, actvtes
accordngy.
N.RSING DIAGNOSIS SOCIAL INTERACTION/ m+a(ed
May Be Re!ated to: Poor |udgment; mpusvty; sef
focus/egocentrcty
Hyperactvty
Poss2!y E&denced 2y: Inapproprate behavor (e.g., nterrupts; s
ntrusve, demandng, hypercrtca and verbay
caustc/hoste, provocatve and/or teasng; does
not respect others persona space)
Inapproprate and/or amboyant soca behavor
wth bzarre dress
Probematc sexua behavor
Des(ed O)tcomes'E&a!)aton C(te(a4 Lsten/converse wthout consstent nterruptons.
C!ent 5!!: Partcpate appropratey or constructvey n 1:1,
group, OT.
Demonstrate soca behavor and dress
ndvduay consstent wth soca norms of the
cents peer group.
Respect the prvacy and persona property of
others.
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Observe for, genty confront manpuatve behavors Grandose behavor may be
nappropratey used
(e.g., not takng responsbty for own actons, wth cent becomng demandng and
overbearng,
gettng others to do thngs they normay woud not nterferng wth reatonshps wth others.
Cents
do). who are manc are attuned to sources of conct
and may conscousy or unconscousy escaate
the
conct to refocus attenton from sef, thus
puttng
others on the defensve.
Dscuss consequences of cents behavor and ways Cent needs to accept responsbty for
own
n whch cent attempts to attrbute them to others. behavor before adaptve change can
occur.
Redrect or suggest more approprate behavor usng Avods trggerng agtated/angry response.
Heps
ow-key, matter-of-fact, non|udgmenta stye. reduce and contro exaggerated/unreastc
thnkng and behavors.
Ask cent to wat unt a speced tme and gve When the cent beeves stah responses have
ratonae f gratcaton of a request s not possbe. reasons, refusas w provoke ess
agtaton.
Mantan a nondefensve response to crtcsm or A ow-key response can reduce the voatty of
the
suggestons regardng better ways to run thngs, stuaton. (Ths may be frustratng when the cent
such as the unt. Use suggestons when approprate. s ether outrageous or party correct.)
Act, as needed, to protect the cent when behavor When the cent s not takng ths
responsbty,
s provocatve or ohensve. the nurse must be responsbe for protectng the
cents safety.
Oher feedback (postve as we as negatve) The manc cent s "outward orented" and
regardng the mpact of soca behavor, n 1:1, OT, responsve to renforcement.
group therapy.
Hep cent dentfy postve aspects about sef, As sef-esteem s ncreased, cent w fee ess
recognze accompshments, and fee good about need to manpuate others for own gratcaton.
them.
Probem-sove wth cent (when abe) regardng When abty and poor concentraton have
more ehectve ways to acheve goas. mproved, cent w be abe to focus and to
contro behavor enough to earn/"try out" new
behavors.
N.RSING DIAGNOSIS SEL# ESTEEM/ ch(onc !o8
May Be Re!ated to: Retarded ego deveopment; unmet dependency
needs; ack of postve feedback
Unreastc sef-expectatons; persona
vunerabty
Perceved ack of contro n some aspect of fe;
experence of rea or perceved faures
Poss2!y E&denced 2y: Demonstraton of exaggerated expectatons or
sense of own abtes; grandosty
Unsatsfactory nterpersona reatonshps;
mperous, demandng behavor; crtcsm of
others
Hypersenstvty to sghts or crtcsm;
excessvey seekng reassurance
Des(ed O)tcomes'E&a!)aton C(te(a4 Verbaze approprate/reastc evauaton of own
C!ent 5!!: abtes.
Identfy feengs and methods for copng wth
underyng negatve percepton of sef.
Formuate reastc pans for recovery.
Descrbe strateges for mnmzng future mpact
of persona actons, whch can contrbute to
contro of ness.
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Ask how cent woud ke to be addressed. Avod Grandosty s thought actuay to reect ow sef-
approaches that mpy a dherent percepton of the esteem.
cents mportance.
Expan ratonae for requests by stah, unt routne, Nursng approaches shoud renforce
patent
etc. Mantan a nondefensve stance; strcty adhere dgnty, worth. Understandng reasons
enhances
to respectfu/courteous approaches, matter-of-fact cooperaton wth regmen. Nondefensve
stance
stye, passve, frendy atttude. promotes reasoned response, may reduce
conct.
Encourage verbazaton and dentcaton of Probem-sovng begns wth agreeng on "the
feengs reated to ssues of chroncty, ack of probem."
contro mpactng sef-concept.
Hep cent dentfy aspects n whch contro s Aows cent to "practce," provdes experence of
possbe n the therapeutc settng and encourage assumng contro.
approprate asserton of persona contro/autonomy.
Provde choces of actvtes (e.g., when to bathe, Ths strategy reduces the cents sense of
food desred, partcpaton n soca nteractons), poweressness.
when possbe.
Assst cent, as reasonabe, to mantan persona Provdes sense of apprecaton for the cents
prvacy. dgnty.
Oher matter-of-fact feedback regardng unreastc Provdes an opportunty to cast doubt on
pans, sef-evauaton; use 1:1, group, OT, etc. unreastc sef-evauaton n the context of
acceptng reatonshps. Note: These ndvduas
may form therapeutc reatonshps easy as they
are eager to pease and apprecate attenton.
However, the nteractons tend to reman
shaow.
Identfy and renforce successes and gans made n Addressng ssues of sef-esteem aows
the cent
1:1, group, and OT settngs. to be postvey renforced for reastc successes.
Ascertan regous beefs and sprtua concerns Grandose behavor s often dspayed n over-
and dscuss as ndcated, avodng renforcng exaggerated actvtes reated to regous beefs.
regosty. Athough t s mportant to support sprtua
needs, regosty does not hep cent to dea wth
these needs n an approprate manner.
Encourage cent to vew fe after dscharge and Roe rehearsa heps return cent to eve of
dentfy aspects over whch contro s possbe. ndependent functonng. When ndvdua s
Identfy how the cent w demonstrate that functonng we, sense of sef-esteem s
enhanced.
contro.
Frame reatonshp wth heathcare provder after Enhances the cents sef-percepton and sense of
dscharge as one of coaboraton. Emphasze contro n reaton to "experts" promotng feengs
choces, decsons, persona contro that w be of sef-worth.
possbe.
Hep cent dentfy a pan that w prevent/ Estabshes some concrete gudenes and a pan
mnmze severe recurrence of ness. Encourage that w aow communty-based care provders to
dentcaton of sgns of recurrence and concrete ntervene, perhaps preventng an acute epsode.
response to symptoms (e.g., "If I go two nghts
wthout seep, I w ca my doctor.").
Co!!a2o(at&e
Dscuss communty resources as approprate, e.g., Addtona resources can hep cent
manage day
sef-management group (such as Natona Depressve ves n the presence of hghs and ows of
ths
and Manc-Depressve Assocaton, Recovery, Inc.), ness.
soca servces, sprtua advsor.
N.RSING DIAGNOSIS POISONING/ (s0 ,o( 1!th)m to-cty3
Rs0 #acto(s May Inc!)de: Narrow therapeutc range of drug
Cents abty (or ack of) to foow through wth
medcaton regmen
Dena of need for nformaton
Poss2!y E&denced 2y: |Not appcabe; presence of sgns and symptoms
estabshes an actual dagnoss.|
Des(ed O)tcomes'E&a!)aton C(te(a4 Lst the symptoms of thum toxcty and
C!ent 5!!: approprate actons to take.
Identfy factors that cause thum eve to change
and ways of avodng ths.
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Observe for/revew sgns of mpendng drug As there s a very narrow margn between
toxcty (e.g., burred vson, ataxa, tnntus, therapeutc and toxc eves, toxcty can occur
persstent nausea/vomtng, and severe darrhea). qucky and requres mmedate nterventon. The
Dherentate from common sde ehects (e.g., mdcommon sde ehect of tremor may be essened
by
nausea, oose stoos, thrst/poyura, metac taste, use of ow doses of propranoo (Indera) or
headache, tremor). atenoo (Tenormn).
Assess current understandng, perceptons about Identes msnformaton/msconceptons about
medcatons. Evauate abty to sef-admnster drug therapy and estabshes earnng needs and
medcaton correcty. kehood of successfu medcaton routne.
Provde nformaton regardng thum, usng a Structured cent educaton s more ehectve.
structured format and nformatona handout. Handout provdes a memory prompt.
Frame adherence to medcaton and foow-up Lnkng foow-up treatment to the cents goas
treatment, attenton to festye as ways of assumng for sef-contro may enhance feengs of
sef-esteem
persona contro. and contnued partcpaton n care.
Draw parae to other knds of chronc ness (e.g., Supports the need for ongong care and
normacy
dabetes, epepsy). of feong medcaton.
Stress mportance of adequate sodum and ud n Sodum and ud are requred for
approprate
det. thum excreton, whch s necessary to the
preventon of toxcty.
Dscuss use of nonsteroda, ant-nammatory drugs Use of NSAIDs and some duretcs can
ater rena
(e.g., buprofen |Motrn, Adv, Nuprn|) or thazdecearance of thum, ncreasng bood eves and
duretcs. rsk of toxcty. Note: Potassum-sparng duretcs
(e.g., amorde |Mdamon| or tramterene
|Dyrenum|) appear to have a hgher eve of
safety n combnaton wth thum therapy.
Encourage nvovement of famy n regmen/ Enhances understandng of reason for/mportance
montorng. of drug therapy.
Provde opportunty for cent to demonstrate Determnes success of cent educaton/addtona
earnng after nta cass and at east once agan needs and heps to pan approprate foow-up.
before dscharge. Carfy msconceptons, confuson
about drug use/foow-up care.
Document nformaton that has been gven and Provdes contnuty, communcates to other
how cent/famy demonstrate earnng. provders the eve of cents/famys knowedge.
Co!!a2o(at&e
Montor serum thum eves at east twce a weekNarrow therapeutc range ncreases rsk of
upon ntaton of drug therapy unt serum eves deveopng toxcty. Eary detecton and prompt
are stabe, then weeky to bmonthy, as ndcated. nterventon may prevent serous
compcatons.
Provde a schedue for reguar aboratory testng Asssts cent to stay on medcaton and mantan
and foow-up appontments at dscharge. mproved state.
N.RSING DIAGNOSIS #AMIL7 PROCESSES/ a!te(ed
May Be Re!ated to: Stuatona crses (ness, economc, change n
roes)
Euphorc mood and grandose deas/actons of
cent
Manpuatve behavor and mt-testng, cents
refusa to accept responsbty for own actons
Poss2!y E&denced 2y: Statements of dmcuty copng wth stuaton
Lack of adaptaton to change or not deang
constructvey wth ness; nehectve famy
decson-makng process
Faure to send and to receve cear messages;
napproprate boundary mantenance
Des(ed O)tcomes'E&a!)aton C(te(a4 Express feengs freey and appropratey.
#am!y 5!!: Demonstrate ndvdua nvovement n probem-
sovng processes drected at approprate
soutons.
Verbaze understandng of ness, treatment
regmen, and prognoss.
Encourage and aow member who s to hande
stuaton n own way, progressng toward
ndependence.
ACTIONS'INTERVENTIONS RATIONALE
Inde+endent
Determne ndvdua stuaton and feengs of Lvng wth a famy member wth bpoar ness
ndvdua famy members (e.g., gut, anger, engenders a muttude of feengs and probems
poweressness, despar, and aenaton). that can ahect nterpersona reatonshps/
functonng and may resut n dysfunctona
responses/famy dsntegraton.
Observe patterns of communcaton (e.g., Are Provdes cues to degree of probem beng
feengs expressed freey? Who makes decsons? experenced by ndvdua famy members and
What s the nteracton between famy members?). copng sks beng used to hande crss of
ness.
Identfy boundares of famy members (e.g., Do Degree of symbotc nvovement/dstancng of
members share famy dentty and have tte sense famy members ahects abty to resove
probems
of ndvduaty, or do they seem emotonay reated to behavor of dented patent.
dstant?).
Determne patterns of behavor dspayed by cent These behavors are typcay used by the
manc
n reatonshps wth others (e.g., manpuaton of ndvdua to manpuate others. These cents are
sef-esteem of others, perceptveness to vunerabty senstve to others vunerabty and can
and conct, pro|ecton of responsbty, progressve ntentonay escaate conct, shftng
mt-testng, and aenaton of famy members). responsbty from sef to others and puttng the
other person on the defensve. Famy members
assume bame and contnuay try to keep peace
at
any cost. The cent w test mts, constanty
gettng concessons from others and creatng
feengs of gut and ambvaence. The resut of
these behavors s aenaton and hgh rate of
dvorce.
Assess roe of cent n famy (e.g., nurturer, When the roe of the person s not ed,
provder) and how ness ahects the roes of other dssonance and famy dsntegraton can
occur.
members. The spouse and chdren of the manc ndvdua
may not understand what s happenng and react
n an adversara manner, escaatng the concts
that exst.
Identfy other sources of conct such as sprtua Cents behavor has an mpact on a areas of
fe,
vaues/regous beefs, nanca ssues. resutng n mutpe concts that must be
addressed to acheve stabty.
Acknowedge dmcutes observed whe renforcng Provdes support for famy members who
may
that some degree of conct s to be expected and fee hepess to change the cent and/or
what s
can be used to promote growth. happenng n hs or her fe.
Provde nformaton (ncudng books and artces) Ths knowedge may reeve gut and promote
about behavor patterns and expected course of the famy dscusson of the probems and
soutons.
ness. Encourage dscusson of the acute epsodeFamy members tend to hde the ness of the
wth the cent. Assst fames to understand norma cent and excuse the mancs behavor
wth a
aspects of bpoar ness. varety of ratonazatons. The use of
bbotherapy can enhance earnng and the
process of change.
Encourage famy members to confront cents Famy may be afrad to dscuss the behavor
behavor. because of the cents voate temper.
Confrontaton can promote nsght nto the
dynamcs of the ness and brng about a postve
resouton of the famy stuaton.
Instruct n use of stress management technques Asssts ndvduas to deveop copng sks to dea
(e.g., approprate expresson of feengs, use of wth the cent and dmcut stuatons. Imagery
reaxaton exercses, magery |when approprate|). may be counterproductve for the cent
when not
n touch wth reaty.
Co!!a2o(at&e
Invove famy members n pannng of treatment Agreement wth goas and therapeutc regmen
regmen. enhances commtment. Famy support can be
nstrumenta n cents success/faure.
Encourage partcpaton of cent and famy May provde addtona assstance n deang wth
members n support groups (such as, Fames of day fe and ncorporatng festye changes that
Depressves and Depressve Support Group), may be hepfu.
psychoogca counseng/famy therapy.
Refer to addtona resources as approprate (e.g., Manc behavor and grandose behavor may have
sprtua advsor, soca servces, ega counse). entanged cent n stuatons that requre specc
assstance.