NURSING DIAGNOSIS

Identify 3 Highest Priority Nursing Diagnosis:

#1 Nursing Diagnosis
Supporting data

Ineffective individual coping related to inadequate level of perception as evidenced by delusions.

#2 Nursing Diagnosis
Supporting data

Interrupted family processes related to non-adherence to medications as evidenced by family in crisis.

#3 Nursing Diagnosis
Supporting data

Risk for injury as evidenced by extreme hyperactivity.

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NURSING DIAGNOSIS #1 include stem, related to, as evidenced by:

Predicted Behavioral Outcome: The patient will…

Patient will report an absence of delusions and racing thoughts as a result of medications adherence and environmental structures

Nursing Strategies: Evidence based Rationale for Strategies: Patient’s Actual Responses (Evaluation):
1. Maintain a firm, calm, and neutral 1. To avoid escalation 1. Patient
approach at all times (Varcarolis) has remained
under
control with
no further
escalation
2. Administer PRN medications 2. Deescalate manic episodes 2. Patient
has remained
under
control after
PRN
medications
were given
due to
hallucination
s
3. 3. 3.
4. 4. 4.
5. 5. 5.
6. 6. 6.
7. 7. 7.
Evaluation: The patient has remained calm during her hospitalizations. She has complied to medication treatment. The patient
still remains focused on her mother’s death but shows improvement in her coping skills. The patient reports a decrease in her
delusions and racing thoughts. The patient represents with a decrease in her anxious behaviors.

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NURSING DIAGNOSIS #2 include stem, related to, as evidenced by:

Predicted Behavioral Outcome The patient will…

The patient’s significant other will state they understand the need for medication adherence, and are able to identify three signs that indicate
possible need for intervention when their family member’s mood escalates.

Nursing Strategies: Evidence based Rationale for Strategies: Patient’s Actual Responses (Evaluation):
1. Educate the family about the 1. Support for the patient and their families in 1. Patient has agreed to involve her
disorder and medications the order to provide a better discharge husband and has begun involving him
patient is taking environment in team meetings
2. 2. 2.
3. 3. 3.
4. 4. 4.
5. 5. 5.
6. 6. 6.
7. 7. 7.
Evaluation: The husband has taken part in the patient’s care. The husband has been educated about Bipolar Disorder and the
medications the patient is taking. The patient and her husband have agreed on a discharge plan that will involve collaboration
between the both of them and team members. The husband understands the signs and symptoms of mood escalation that would
prompt him to call the patient’s psychiatrist (Varcarolis).

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NURSING DIAGNOSIS #3 include stem, related to, as evidenced by:

Predicted Behavioral Outcome: The patient will…

Respond to the medication within therapeutic levels.
Nursing Strategies: Evidence based Rationale for Strategies: Patient’s Actual Responses (Evaluation):
1. Provide structure with the help from a 1. Structure provides focus and security 1. The patient has remained focus on her care
nurse or mental health worker (Varcarolis) and has participated in the activities
without disruption
2. Maintain a low level of stimulation 2. To help reduce anxiety and stress 2. The patient has remained free of stress in
environments free of stimulation but has
become anxious during meals and groups
3. 3. 3.
4. 4. 4.
5. 5. 5.
6. 6. 6.
7. 7. 7.
Evaluation: The patient has remained under control and has remained within normal limits of anxious behaviors. The patient has
remained free of falls and injury.

KBLSu2016, adaption by DFG- Fall2017

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 References

Varcarolis, E. M. (2016). Foundations of psychiatric mental health nursing. Elsevier.