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Bipolar 1 Disorder presenting with sxs of mania, Hx (Reports past suicide…
Bipolar 1 Disorder presenting with sxs of mania
sxs
Suspicious, guarded
Poor impulse control
Excessive Energy
Reports sleeping 3 hrs or less in the past few days
self-destructive behavior
persecutory and grandiose delusions
rapid rate of voice
flight of ideas
Scratches on back
Expansive Affect
euphoric mood
reports racing thoughts
limited awareness of illness
inc. sexual libido and social activity
reports spending money on drugs and rare books
reports eating 1 small meal per day in last week and low appetite
reports not really paying attention to fluid intake
dirty, disheveled clothing
Priority Nursing Diagnosis:
Risk of injury
Outcome: Pt will report 4-6 hours of sleep per night before discharge
Sleep deprivation can exacerbate mania.
Provide relaxation techniques
encourage frequent rest periods
keep pt in areas of low stimuli
Outcome: Pt will remain free from injury as evidenced by full physical examination by the end of my shift.
move patient to private room
coordinate with staff for frequent checks
remove anything that could cause injury; personal items, sharp objects, or hazardous materials
provide pt with structured solitary activities that do not present risk for injury
Nursing Diagnosis: Self-Care Deficit
Outcome: Pt will be well hydrated as evidenced by, good skin turgor and normal I&O within 24 hours.
Offer high-calorie protein drinks and finger foods
Monitor I&O
obtain starting skin turgor and continue to assess
Give frequent reminders to eat and sip
Outcome: Pt will tend to hygiene as evidenced by brushing teeth, cleaning dirt from skin, and dressing in clean clothing by the end of my shift.
Provide pt with cleansing wipes
encourage appropriate clothing
provide step by step instructions/reminders for hygiene and dress
Outcome: Pt will complete at least 75% of all meals within 24 hours
Medications: MAR doesn't report any medications, but Mood stabilizers such as Lithium can be used to stabilize Bipolar pts.
Hx
Reports past suicide attempt
Denies current suicidal thoughts
Visible Scars on both wrist
reports cocaine use; last use 7 days ago
drug screening came back negative
diagnosed with depression by psychiatrist 3 years ago following suicide attempt
prescribed antidepressants
reports not taking anymore due to side effects; unreported to physician
reports episodes of depression followed by euphoria
happens a couple times a year
reports sleeping in car
fired from multiple jobs
expelled from college
family discord