Ateneo de Zamboanga University

Zoo209 A – Psychopathology
Deliverable: Nursing Care Plan on Mr. Jones (1993)
Name: Tan, Patrick Elmo D.
PLANNING
ASSESSMENT NURSING DIAGNOSIS IMPLEMENTATION EVALUATION
OUTCOMES INTERVENTIONS
After 24 hours of nursing After 24 hours of
Subjective Cues: interventions, 1. Provide structured 1. Provided structured nursing
- “ Im a plane! Im Risk for Injury related solitary activities with solitary activities interventions,
gonna swoop to  Patient will respond to the assistance of a nurse with the assistance
down! Im gonna extreme or aide. of a nurse or aide.  Patient
fly!” as hyperactivity/physical the medication within the Rationale: Structure
verbalized by the agitation. therapeutic levels. provides focus and 2. Provided frequent responded to
patient. security. rest periods. the
 Patient will sustain medication
- “Im a big 2. Provide frequent rest 3. Provided frequent
optimum health through within the
personality! Im periods. high-calorie fluids
grandiose!” as medication management Rationale: Prevents (e.g., fruit shake, therapeutic
verbalized by the and therapeutic regimen. exhaustion. milk). levels.
patient.
Objective Cues:  Patient will have stable 3. Provide frequent high-  Patient
- Restlessness calorie fluids (e.g., fruit 4. Maintained a low
cardiac status while in the sustained
- Hopelessness shake, milk). level of stimuli in
- Despair hospital. Rationale: Prevents the client’s optimum
risk of serious environment (e.g.,
 Patient will drink 8 oz health
dehydration. loud noises, bright
of fluid every hour light, low- through
temperature medication
throughout the day while
4. Maintain a low level of ventilation).
on acutely manic stage. management
 Patient will remain free stimuli in client’s and
environment (e.g., loud 5. Acute mania might
from falls and abrasions noises, bright light, low- warrant the use of therapeutic
every day while in the temperature phenothiazines and regimen.
hospital. ventilation). seclusions to
Rationale: Helps decrease any  Patient
 Patient will be free of minimize escalation of physical harm. has stable
anxiety.
dangerous levels of 6. Observed for signs cardiac
hyperactive motor 5. Acute mania might of lithium toxicity status while
behavior with the aid of warrant the use of (e.g., nausea, in the
phenothiazines and vomiting, diarrhea,
medications and nursing seclusions to decrease drowsiness, muscle hospital.
interventions within the any physical harm. weakness, tremor,
Rationale: Exhaustion lack of  Patient
first 24 hours.
and death result from coordination, drank 8 oz of
 Patient will spend time dehydration, lack of blurred vision, or fluid every
sleep, and constant ringing in your
with the nurse in a quiet physical activity. ears). hour
environment three to throughout
four times a day between 6. Observe for signs of the day while
lithium toxicity (e.g.,
7 am and 11 pm with the nausea, vomiting, on acutely
aid of nursing guidance. diarrhea, drowsiness, manic stage.
muscle weakness,
 Patient will take short tremor, lack of  Patient
voluntary rest periods coordination, blurred remained
vision, or ringing in your
during the day. ears). free from
Rationale: There is a falls and
 Patient will be free of small margin of safety abrasions
 every day
while in the
excessive physical
hospital.
agitation and purposeless
motor activity within 2  Patient
weeks. was free of
dangerous
 Patient will be free of
levels of
injury within 2 to 3
hyperactive
weeks: between therapeutic
motor
and toxic doses.
o Stable cardiac behavior
status. with the aid
of
o Skin free of
medications
abrasions and scrapes.
and nursing
o Well interventions
dehydrated. within the
first 24
hours.