ASSESSMENT

Subjective:
Dumudugo
yung ilong ko
oh.
Objective:
-Nose bleeds
whenever he
picks his nose
-Bangs the
door every
time he feels
upset
-Hyperactive
-Verbally
abused other
people
-Pacing

Risk for injury

related to
extreme
hyperactivity

EXPLANATION OF
THE PROBLEM
Bipolar
disorderinvolves
periods
of excitability
(mania)alternating
with periodsof
depression. The
mood swings
between
mania and
depressioncan be
very abrupt.Mania
is the
signaturecharacteri
stic of
bipolardisorder
and,depending on
itsseverity, is how
thedisorder is
classified.People
commonlyexperien
ce an increasein
energy. Due to
excess in energy,
there can be
accident hence,
Risk for Injury. Risk
for

GOALS OF
CARE
Long term
Objective:
After 72 hours
of nursing
intervention
the client will
no longer
exhibit
potentially
injurious
movement
Short Term
Objective:
After 8 hours
of nursing
intervention
the client will
demonstrate
decrease
acting out
behavior.

NURSING
INTERVENTION
Build a trust
relationship with
this client

Assess stimuli that

increase the
likelihood of violent
behavior or
agitation.

Remove all possible

hazards in
environment such
as razors,
medications and
matches

RATIONALE
Familiarity with and
trust in the staff
members can
decrease the clients
fears and facilitate
communication.

Knowing the stimuli

of the violent
behavior of the
patient can help
decrease the
escalation of anxiety.
In hyperactive state,
client is extremely
distractible,
responses even the
slightest stimuli are
exaggerated

Removing of
stimulus in the
environment of the
patient will lessen
the likelihood of
episodes of

EVALUATIO
N
Long term
Objective:
Goal met if
after 72
hours of
nursing
interventio
n the client
will no
longer
exhibit
potentially
injurious
movement
Partially
met if after
72 hours of
nursing
interventio
n the client
will exhibit
2-3
potentially
injurious
movement.
Not met if

as
evidenced by
excessive and
constant
motor
activity

Injurydefined as th
e statein which a p
erson is at risk for i
njury as a result of
environmental con
ditions interacting
with the individual'
s adaptive anddefe
nsive resources. An
y pathophysiologic
al condition such as
altered level of con
sciousness, impaire
d sensoryperceptio
n, tissue hypoxia, a
nd pain or fatigue c
an contribute to or
be the cause of per
sonal injury.

REFERENCE:
Tierra,N (2013).
Bipolar Disorder.
Retrieved from:
https://www.scribd.
com/doc/66225943
/ncp-psyche2

Stay with client

and divert
clientaway from
stimulating
situations.

Provide activities
such as art therapy
as a substitutefor
purposeless
hyperactivity

Frequently orient
client to reality
andsurroundings.

destructive behavior.
The things also will
not be used as a
weapon in injuring
himself or others.
(Videbeck 2008)

Presence of the
nurse can provide
sense of security to
the patient. Diverting
the attention of the
client will lessen the
client from noticing
the stimulus in the
environment.

Provide a safe and

effective means
of relieving pentuptension.

Disorientation
may endanger
client safety if he or

after 72
hours of
nursing
interventio
n the client
will not
exhibit
potentially
injurious
movement
Short Term
Objective:
Goal met if
After 8
hours of
nursing
interventio
n the client
will
demonstra
te
decrease
acting out
behavior
Partially
met if After
8 hours of

sheunknowingly
wandersaway from
safeenvironment
Use mechanical
restraints as
necessary to protect
client if excessive
hyperactivity
accompanies the
disorientation

Ask the family to

stay with patient

Advise the client to

walk slowly when
holding the pail with
hot water

Restraints in a
medical setting are
items that limit a
patient's movement.
Restraints can help
keep a person from
getting hurt or doing
harm to others,
including their
caregivers. They are
used as a last resort.
To ensure that
someone will look
after the client and
will stop the client if
there is an attempt
in injuring himself.

This will prevent

spilling of hot water
into his body
Demonstrate
Relaxation

nursing
interventio
n the client
will
sometimes
demonstra
te acting
out
behavior
Not met if
After 8
hours of
nursing
interventio
n the client
will not
demonstra
te
decrease
acting out
behavior

Technique
Relaxation technique
activity that helps a
person to relax; to
attain a state of
increased calmness;
or otherwise reduce
levels
of pain, anxiety, stre
ss or anger