Published Mar 30, 2009
micmurph
5 Posts
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
1 Article; 14,604 Posts
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:
[*]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
these are defining characteristics (evidence) of nursing diagnoses.
---------------------------------
risk for injury, related to faulty judgment, as evidence by, inablility to set limits on own behavior
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:
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).