2006. Townsend MC. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 5th ed. Philadelphia, PA.

F. A. Davis Company.

Bipolar Disorder, Mania

Nsg Dx: Risk for Injury

Nsg Dx: Risk for Self- or Other-Directed Violence

Nsg Dx: Imbalanced Nutrition: Less Than Body Requirements

Nsg Dx: Impaired Social Interaction

S & Sx: Increased agitation Extreme hyperactivity

S & Sx: Manic excitement Delusional thinking Hallucinations

S & Sx: Weight loss Amenorrhea

S & Sx: Unable to develop relationships Manipulation of others

Nursing Actions: Reduce stimuli Assign private room Remove hazardous objects from area Stay with client when he/she is agitated Provide physical activities Tranquilizers as ordered by physician

Nursing Actions: Observe client q 15 min Remove sharps, belts, and other dangerous objects from environment Maintain calm attitude Sufficient staff for show of strength if nesessary Tranquilizers as ordered Mechanical restraints if necessary

Nursing Actions: High protein, high calorie finger foods Juice and snacks on unit I&O, calorie count, daily weights Provide favorite foods Supplement with vitamins and minerals Sit with client during meals

Nursing Actions: Recognize purpose of manipulative behavior Set limits on manipulative behavior Positive reinforcement for appropriate behavior Consequences for inappropriate behavior Help client identify positive aspects of self

Medical RX: Olanzapine 15 mg PO daily

Outcomes: No evidence of physical injury No longer experiencing physical agitation

Outcomes: Client has not harmed self or others No evidence of delusions or hallucinations

Outcomes: Eats a wellbalanced diet Nutritional status restored Weight has stabilized

Outcomes: Accepts responsibility for own behaviors Does not manipulate others to gratify own needs Interacts well with others