45989 Varcarolis SAUNM pg19 BATCH RIGHT

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NURSING CARE PLAN Mania base of text

NURSING DIAGNOSIS
Risk for Injury: related to dehydration and faulty judgment, as evidenced by inability to meet own
physiological needs and set limits on own behavior.
Supporting Data

■ Has not slept for days.

■ Has not taken in food or fluids for days.
■ Constant physical activity — is unable to rest.
Outcome Criteria: Client’s cardiac status will remain stable during manic phase.

S HORT -T ERM G OAL I NTERVENTION R ATIONALE E VALUATION

1. Client will be well 1a. Give haloperidol 1a. Continuous physi- GOAL MET
hydrated, as evi- intramuscularly cal activity and After 3 hours, client
denced by good immediately and lack of fluids can takes small amounts
skin turgor and as ordered. eventually lead to of fluids (2 – 4 ounces
normal urinary cardiac collapse per hour).
output and specific and death.
gravity within 24
hours. 1b. Check vital signs 1b. Monitor cardiac
frequently (every status.
1 – 2 hours).
1c. Place client in pri- 1c. Reduce environ-
vate or quiet room mental stimuli —
(whenever possi- minimize escala-
ble). tion of mania
and distract-
ibility.
1d. Stay with client 1d. Nurse’s presence
and divert client provides support.
away from stimu- Ability to interact
lating situations. with others is
temporarily im-
paired.
1e. Offer high-calorie, 1e. Proper hydration After 5 hours, client
high-protein drink is mandatory for starts taking 8
(8 ounces) every maintenance of ounces per hour
hour in quiet area. cardiac status. with a lot of remind-
1f. Frequently remind 1f. Client’s concentra- ing and encourage-
client to drink: tion is poor; she is ment.
“Take two more easily distracted.
sips.”
1g. Offer finger food 1g. Client is unable
frequently in to sit; snacks she
quiet area. can eat while pac-
ing are more
likely to be con-
sumed.
1h. Maintain record 1h. Enables staff to
of intake and out- make accurate nu-
put. tritional assess-
ment for client’s short
safety. standard
Copyright 䊚 2006 by Elsevier Inc. All rights reserved. base drop
45989 Varcarolis SAUNM pg20 BATCH LEFT

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S HORT -T ERM G OAL I NTERVENTION R ATIONALE E VALUATION

1i. Weigh client daily. 1i. Monitoring nutri- GOAL MET

tional status is After 24 hours, spe-
necessary. cific gravity is within
normal limits.
2. Client will sleep or 2a. Continue to direct 2a. Lower levels of Client is awake most
rest 3 hours dur- client to areas of stimulation can of the first night.
ing the first night minimal activity. decrease excit- Sleeps for 2 hours
in the hospital ability. from 4 AM to 6 AM.
with aid of medi- 2b. When possible, 2b. Directing client to Client is able to rest
cation and nurs- try to direct en- paced, nonstimu- on the second day
ing interventions. ergy into pro- lating activities for short periods and
ductive and can help mini- engage in quiet ac-
calming activities mize excitability. tivities for short peri-
(e.g., pacing to ods (5 – 10 minutes).
slow, soft music;
slow exercise;
drawing alone;
or writing in
quiet area).
2c. Encourage short 2c. Client may be un-
rest periods aware of feelings
throughout the of fatigue. Can
day (e.g., 3 – 5 collapse from ex-
minutes every haustion if hyper-
hour) when possi- activity continues
ble. without periods of
rest.
2d. Client should 2d. Caffeine is a cen-
drink decaffein- tral nervous sys-
ated drinks tem stimulant that
only — decaffein- inhibits needed
ated coffee, tea, or rest or sleep.
colas.
2e. Provide nursing 2e. Promotes non-
measures at bed- stimulating and
time that promote relaxing mood.
sleep — warm
milk, soft music.
3. Client’s blood pres- 3a. Continue to moni- 3a. Physical condition Baseline measure on
sure (BP) and pulse tor blood pressure is presently a unit is not obtained
(P) will be within and pulse fre- great strain on cli- because of hyperac-
normal limits quently through- ent’s heart. tive behavior. Infor-
within 24 hours out the day (every mation from family
with the aid of 30 minutes). physician states BP
medication and 3b. Keep staff in- 3b. Alerting all staff 130/90 and P 88
nursing interven- formed by verbal regarding client baseline.
tions. and written re- status can increase BP at end of 24 hours
ports of baseline medical interven- is 130/70; P is 80.
vital signs and cli- tion if a change in
ent progress. status occurs.

short
standard
Copyright 䊚 2006 by Elsevier Inc. All rights reserved. base drop