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?