care plan help

[micmurph]

I'm an LPN who is at the end of my 1st year in an ADN program, we are doing our Psych rotation in clinicals and I have to do a care plan on a client with bipolar disorder, she is 20, a new dx, in her 2nd year at university. She was going to be discharged the day that I meet her after 2 weeks inpatient. I was not allowed access to her chart so I don't know what meds she was on, or therapy. She told me over the past year things have been getting out of control for her, that she switch majors and that she had 2 abortions, her mom brought her in because she was laughing inappropriatly. She has been in therapy for 2 weeks and is on 2 new meds. she was able to talk one on one with me with out difficulty, she was funny, bright and personable. I started my care plan with this...

Admission DX ( Medical) bipolar

nursing DX Risk for injury, related to faulty judgment, as evidence by, inablility to set limits on own behavior.

As subjective data I put the clients statement that she has 2 abortion this past year.

now I'm stuck...looking for objective data and I have no real concrete data such as labs to list, any suggestions as to how to proceed?

Thanks!

[Daytonite, BSN, RN]

you are care planning for someone with bipolar disorder. follow the steps of the nursing process.

step 1 assessment - part of the purpose of assessment is to find abnormal data because nursing problems are based upon abnormal data. assessment consists of:

• a health history (review of systems) - this is information you can obtain from questioning the patient
  
• performing a physical exam - this you obtain from your own examination of the patient
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you know that she has bipolar disorder and you need to learn about this disease, its signs and symptoms in order to find out if you missed seeing any of them or if you missed picking up on the patient's report of them when you interviewed her. your development of the care plan depends on this.
  
  • http://www.merck.com/mmpe/sec15/ch200/ch200c.html - bipolar disorders
    

  [*]reviewing the signs, symptoms and side effects of the medications they are taking - per your post, this was not available to you

step #2 determination of the patient's problem(s)/nursing diagnosis - make a list of the patient's abnormal symptoms. some you already listed were

• laughing inappropriately
  
• faulty judgment (how?)
  
• inability to set limits on behavior (how?)
  

these are defining characteristics (evidence) of nursing diagnoses.

• ineffective coping r/t biochemical and neurological changes in the brain secondary to bipolar disorder aeb destructive behavior toward self and use of poor judgment
  
• impaired social interaction r/t biochemical imbalances secondary to bipolar disorder aeb inappropriate laughing during conversations
  

---------------------------------

risk for injury, related to faulty judgment, as evidence by, inablility to set limits on own behavior

here are the problems with this diagnosis. the r/t must be a risk factor that can directly result in an injury to the patient. what injury is faulty judgment going to cause here? i am not coming up with anything.

also, "risk for" diagnoses are anticipated problems which means they do not exist yet. therefore, technically, there can be no

evidence

of the problem yet. now, your program may say differently, but that is not how nanda says a "risk for" diagnostic statement is supposed to be written. if your nursing program says you can list the symptoms, then what potential problem are you focusing on? i still am in the dark here. when someone reads a nursing diagnosis they should get a clear vision in their mind of what is going on without even seeing the patient.

[micmurph]

Thank you so much for your input. I know that risk for in a nursing diagnosis is for anticipated problems, I guess I ended up there because when I did my interview, she did not show and signs or symptoms of bipolar, I got the information from her about having 2 abortions in the past year... So I thought that she could be at risk for injury if in the future she stops her meds and starts to engage in risky behavior again( faulty jugdement), such as unprotested sex.

Your DX is awesome...but I can't add something like "inappropriate laughing during comversations" if is NOT some thing that I personally saw...? right. That was the initial reason he mom brought her in, when I saw her she symptom free.

Thanks a bunch. MM:nurse:

[Daytonite, BSN, RN]

this inappropriate laughing is a symptom of the manic phase she was in. no, it's not something you saw, but it is appropriate data that i think you should include. remember that she is now on medication to control her symptoms. she was manic and out of control and her mom had her hospitalized because she was a danger to herself when she was behaving like that and she needed to be in protective custody until they got some meds on board. by the time you saw her she was under control. when bipolars get manic they get goofy and do some crazy stuff. perhaps you might want to go with a teaching need of the patient. she certainly needs to be aware of her condition and when her behavior is a bipolar symptom. maybe deficient knowledge, bipolar disorder and treatment r/t lack of information would be appropriate.

when people are manic they are euphoric, extremely optimistic, have flight of ideas, speak rapidly, cannot concentrate, are reckless and use poor judgment (which is where she got into trouble with getting pg), they don't sleep, engage in overactivity, act with inflated self-esteem and when they slip into depression they can become suicidal. so, there is more to mania than just the pleasure seeking activities. when in a manic phase bipolars act grandiose, like they have inflated self-esteems, do not sleep much, talk all the time (almost non stop), are easily distracted, become agitated very easily and can become very irritable. because they become involved in pleasurable activities (such as sex) they can get into trouble quite easily.

i am looking at a chapter in my book on managing mood disorders and it has a long list of nursing diagnoses for both the depression and mania. these are all based on the symptoms of both depression and mania (which i listed in the paragraph above).

• anxiety
  
• impaired verbal communication
  
• ineffective coping
  
• anticipatory grieving
  
• dysfunctional grieving
  
• hopelessness
  
• risk for injury
  
• unilateral neglect
  
• noncompliance - i've had a few of these patients over the years
  
• imbalanced nutrition: less than body requirements
  
• imbalanced nutrition: more than body requirements
  
• post-trauma syndrome
  
• risk for post-trauma syndrome
  
• powerlessness
  
• ineffective role performance
  
• all the self-care deficits
  
• chronic low self-esteem
  
• situational low self-esteem
  
• risk for low self-esteem
  
• disturbed sensory perception
  
• sleep deprivation
  
• disturbed sleep pattern
  
• impaired social interaction
  
• social isolation
  
• disturbed thought processes
  
• risk for other-directed violenc3e
  
• risk for self-directed violence