GRACIOUS COLLEGE OF NURSING ABHANPUR

RAIPUR (C.G.)

SUBJECT- MENTAL HEALTH NURSING

NURSING CARE PLAN

ON

MANIA

SUBMITTED TO SUBMITTED BY

MSS. HEMLATA SAPHA MSS. DEEPTI SAHU

LECTURER M.Sc. NURSING 1st YEAR

DEPT. OF MENTAL HEALTH NURSING GRACIOUS COLLEGE OF NURSING

GRACIOUS COLLEGE OF NURSING

 CARE PLAN

IDENTIFICATION DATA: -

Patient’s Name :Mr. Rajeevpaul..

Father’s Name : Shri. Vikas lal.
Age : 24 yrs
Sex :Male
Reg. No. : 6675/10
IPD No. : 942/10
Ward :Male Ward.
Bed No. :17
Date of Admission :1/04/2023.
Address :Ward n. 6, pathelgave, post-pathelgave, District
Jeshpur (C.G.)
Marital Status : Unmarried.
Religion : Christian.
Mother tongue : Chhattisgarhi.
Diagnosis :Mania.
Informant :Mr. Vikas lal.
Relation with patient:Father.
SOCIO-ECONOMIC STATUS:

Education :B.Sc.(plain)
Occupation :Student.
Income :Rs.6000/-per month
Marital status :Unmarried
No. of family members :four
Diet :Non-vegetarian
Housing :Own House
Water supply :Bore
Disposal of waste :Proper disposal of wastes
Drainage system :Closed.
Custom related to healthy practice: follow Christian religious customs and their traditions.
FAMILY HISTORY: My patient Mr. Rajeev pual is the elder son and he has one sister. His father. Mr.
Vikas lal is the head of the family and is working as an office staff and mother is a house wife. There are
total four members in his family and they belongs to Christian religion. Patient studied up to B.Sc.(plain)
and very sensitive.

Family Tree:

(42yrs) (39yrs)

(24yrs) (21yrs)
No other family member is suffered with Paranoid depression. Health status of all other members are
good.
PRESENT COMPLAINT
According to patient : loss of appetite, sleeplessness.
According to informant : Violent behavior, sleeplessness.
HISTORY OFPAST ILLNESS:
Medical history : Patient has no past medical history.
Psychiatric history :There was no any past history of psychiatric illness.
PERSONAL HISTORY:
Antenatal & Perinatal History: Antenatal period was uneventful. Client born as a full term baby by
normal delivery postnatal period was also uneventful. Mother & baby both were healthy during postnatal
period and had normal brest feeding.
Childhood History: Growth & development was normal & there is no delay in achieving milestone and
having interest towards society regular follower of custom, tradition as per their caste.
Educational History: He is literate. He studied up to B.Sc (plain), having no problems with peers.
Marital & sexual history: He is unmarried and having normal sex history.
TYPE OF PERSONALITY: Premorbid personality

MENTAL – STATUS – EXAMINATION

IN GENERAL IN PATIENT
GENERAL – APPEARANCE:-
 Well kempt & tidy Present
 Overly made-up
 Unkempt & tidy
 Healthy
 Sickly Present
 Angry
 Frightened
 Apathetic Present
 Perplexed
 Masculine
TOUCH WITH THE SURROUNDINGS:-
 Present
 Partial
 Absent Present
EYE CONTACT:-
 Present
 Partial
 Absent Present
DRESS:-
 Appropriate
 Shabby
  Sloppy
 Inappropriate Present
 Dirty
 Stinking
HAIR:-
 Well – groomed Present
 Negligent
 Disheveled

FINGER – NAILS:-
 Appropriate
 Excessively cared for Present
 Negligent but not dirty
 Negligent & dirty
RAPPORT:-
 Easily established
 Established with difficulty Present
 Not-possible
ATTITUDE TOWARDS EXAMINER:-
 Cooperative
 Attentive
 Interested
 Frank
 Seductive
 Exhibitionistic
 Playful
 Hostile
 Evasive Present
 Guarded
 Attention-seeking
 Suspicious Present
 Ingratiating
MOTOR – BEHAVIOUR:-
 Appropriate Present
 Inappropriate
 Hyperactive
 Awakward Present
 Destructive
 Aggressive
 Abusive
 Trying to runaway
 Assaultive
  Violent Present
 Self-injuries
 Ticks
 Mannerisms
 Preoccupied
 Retarded Present
 Waxy-flexibility
 Odd postures
 Rigid
 Touching examiner
 Preservation
 Stereotypes
 Gestures Present
 Grimaces
 Hallucinatory
SPEECH:-
Intensity
 Audible Present
 Excessively-Loud
 Abnormally soft
Pitch
 Normal fluctuations
 Monotonous Present
Reaction time
 Normal Present
 Delayed
Speed
 Normal
 Slow
 Rapid
 Pressure of speech Present

Ease of speech
 Spontaneous
 Hesitant
 Mute
 Slurring
 Whispering Present
 Muttering Present
 Speaks when questioned Present
Relevance
  Relevant
 Irrelevant Present
 Flight of ideas
Coherence
 Coherent
 Incoherent Present
Goal direction
 Goal directed
 Circumstantial Present
 Tangential
Productivity
 Normal
 Overabundant Present
 Scant
Manner
 Relaxed
 Excessively formal
 Tensed up
 Inappropriately familiar Present
 Disinterested
Deviation
 Nil
 Rhyming & punning Present
 Talking past the point
 Clang associations Present
 Stereotype Present
 Preservation
VOLITION:-
 Suggestibility
 Ambivalence Present
 Passivity phenomenon
 Automatic obedience
 Echolalia
 Echopraxia
 Negativism
AFFECT:-
 Normal
 Anxious
 Panicky
 Fearful Present
 Terrified
 Depressed
  Euphoric
 Elated
 Ecstatic
 Empty
 Irritable
 Enraged
 Blunted
 Apathetic
 Feeling estrangement
 Labile
 La-belle-indifference
 Weeping spells
 Appropriate Present
 Inappropriate
 Quality
 Self-contemptuous
THOUGHT:-
Stream
 Normal
 Retarded Present
 Accelerated
Possession
 Thought-blocking
 Thought-insertion
 Thought-echo
 Thought-broadcasting Present
 Thought-withdrawal
 Thought-alienation
 Neologisms
 Word-salad Present
 Over inclusion
 Condensation
CONTENT:-
 Obsessive
 Compulsions
 Phobias
 Religious preoccupation
 Hopelessness
 Helplessness
 Suicidal ideas
 Hypocondrical ideas
 Derealisation
 Depersonalization Present
 Homicidal
Delusions
  Reference Present
 Persecutory
 Grandeur Present
 Love
 Infidelity Present
 Sin/guilt
 Poverty
 Nihilistic
 Hypochondria cal
 Control/possession Present
PRECEPTION:-
Hallucinations
 Auditory
 Visual
 Olfactory
 Gustatory
 Tactile
 Illusions
MEMORY:-
 Remote
 Recent past
 Recent Present
 Immediate
ORIENTATION:-
 Time Oriented
 Place Disoriented
 Person Oriented
INTELLIGENCE:-
 Average Present
 Above-average
 M.R. – mild, moderate,
 Severe, profound
JUDGEMENT:-
 Social
 Personal Present
INSIGHT:-
 Present
 Absent Present
PHYSICAL EXAMINATION
1. General Examination:

Pulse - 78/min
B. P. - 120/80mm Hg.
 Anemia
Oedema nil
Jaundice
Cyanosis
Clubbing nil
Lymph glands

SYSTEMIC EXAMINATION:

 General appearance Conscious, well nourished, personal hygiene maintained, Ht – 160cm, wt-
56kg, body built – Normal.

 Head Size & shape normal, no abnormalities, no mark of any head injury.

 Eyes Appears normal no eye discharge, vision normal (6/6).

 Ear Normal hearing parent, no discharge.

 Mouth Mucus membrane intact no foul small present.

 CVS system Pulse-82/min, T-98.40F, BP-128/82 mm of Hg, Rate & rhythm regular.

 Respiratory system R.R-16 b/min regular, chest expansion bilaterally equal.

 CNS system Motor activity adequate, involuntary movement not seen, co-ordination
intact.
 Gastro-intestinal system Appetite – normal, Bowel sound present.

 Genito – urinary system Bowel & bladder habits normal, reflex normal.

 Muscular – skeletal Normal joint movement, no other bone deformity present.

system
 Skin Dry skin no cyanosis, no pallor, no edema, no enlargement of lymph
nodes.

DIAGNOSIS:
Present mania
BIBLIOGRAPHY:-

1. Townsend Mary C., 2007, “Psychiatric Mental Health Nursing”, 5 thedition, Jaypee Brothers
Medical Publishers (P) Ltd., pp-500-503.
2. Frisch Noreen Cavan& Frisch Lawrence E., 2007, “Psychiatric Mental Health Nursing”, 3 rdedition,
Published by Thomson, pp- 205.
3. Neerja KP, 2008, Essential of Mental Health Nursing”, 1 stedition, Jaypee Brothers Medical
Publishers (P) Ltd., pp- 372-374.
4. Fortinash Katherine M., &WorretHoloday Patricia A., 2000, “Psychiatric Mental Health Nursing”,
Published by Mosby, pp- 404.