Nursing Care of Client with
Bipolar Disorder
Nursing diagnosis: Risk for Injury
• Risk for injury
• Related to: Extreme hyperactivity, poor
impulse control, anger directed at the
environment, or self.
• Evidenced by: Increased agitation and lack of
concentration, purposeless and potentially
injurious movements, hitting hand or head to
the wall when angry, temper tantrum,
destroys own things when angry.
Outcome criteria: Risk for Injury
• Short term goal:
– Client will not exhibit self harming behaviour in
the next 24 hours, with the administration of PRN
medication
• Long Term Goal:
– Client will experience no physical injury
Nursing Intervention: Risk for Injury
• Assign one nurse to stay with the client to
limit number of people interacting with the
client, for this will decrease distractibility and
agitation, offers support & provide sense of
safety & security for the client
• Provide structured schedule of activities that
includes rest periods (one – to – one activities
provide sense of security)
Nursing Intervention: Risk for Injury
• Decrease number of environmental stimuli
that might provoke anxiety, agitation and
distractibility by:
– Assign private room ( prevent taking patient to
crowded areas, and if the patient has to be in a
crowded place, do not stay for a long time ).
– Do not include patient in group activities until
ready (gradual inclusion)
Nursing Intervention: Risk for Injury
– Keep low level of noise at the unit
– Provide a wide space for patient to move
around.
– Low lightening.
– Simple decoration with no bright colours.
– Limited number of furniture that is fixed.
– Prevent patient from eloping (running
away) from the hospital.
Nursing Intervention: Risk for Injury
• Provide safe environment By:
– Remove hazardous materials from the
environment (even smoking)
– Observe patient every 15 minutes to prevent any
injury
– Be calm and talk to the patient in a firm, kind, lowpitched voice and in a matter of fact way to help
decrease anxiety. (loud demanding tone provokes
hostile and aggressive behavior).
Nursing Intervention: Risk for Injury
• Redirect excessive energy by providing a
physical activities such as: exercise, gathering the
linen, helping in cleaning the unit (but make sure
not to exploit the client), this will release tension
and give a focus that is productive. (planned
activities should not be competitive for it may
precipitate an aggressive behavior, and should
put to use large muscle movement that does not
need concentration and not fine muscle use that
needs concentration).
Nursing Intervention: Risk for Injury
• Plan for periods of rest in between activities to
prevent exhaustion and to give a sense of
security to the patient.
• Administer medication, as ordered. Haldol,
Largactil, and observe for side effects.
Nursing Diagnosis: Impaired Social Interaction
• Impaired social interaction
• Related to: Egocentric and narcissistic behaviour, delusion
of grandeur, low self esteem
• Evidenced by: Inability to develop satisfying
relationships and manipulation of others for own
desires (pretends to be helpless, pits (‫ )يحرض‬staff
against each other, insincere complimenting of a staff
member to his face, followed by negative comments
about him for others, makes on going demands for
nurse’s time continues to act out- demand, yell..
even when told his behaviour is unacceptable),
inability to delay gratification.
Outcome Criteria: Impaired Social Interaction
• Short Term Goal:
– Client will verbalize the difference between the
appropriate and inappropriate behaviours he/she
exhibits within 1 week
– Client will demonstrate ability to interact with
staff and other clients within the therapeutic
milieu
• Long Term Goal:
– Client will demonstrate appropriate use of
interaction behaviour and marked decrease in
manipulative behaviour.
Nursing Interventions: Impaired Social Interaction
• Develop a therapeutic nurse-client relationship
– Assess the client’s behavior, attitudes, problems,
and needs.
– Obtain the client’s perception of his or her
problems and what the client expects to gain from
the relationship or hospitalization.
– Make your expectations for the relationship clear
to the client
– Be honest in all interactions with the client. Avoid
glossing over any unpleasant topics or
circumstances (complements the staff while
criticizing another)
Nursing Interventions: Impaired Social Interaction
– Let the client know that you will work with him or
her for a specified period of time and that the
relationship will end when the client is no longer
in treatment.
– Be consistent with the client at all times.
– Show the client that you accept him or her as a
person
– Avoid becoming the only one the client can talk to
about his or her feelings and problems
Nursing Interventions: Impaired Social Interaction
• Teach the client social skills. Describe and
demonstrate specific skills, such as eye
contact, attentive listening, nodding, and so
forth, and not interrupting others. Discuss the
types of topics that are appropriate for social
conversation, such as the weather, news, local
events, and so forth.
• Assist the client in identifying more effective
methods of dealing with stress.
Nursing Interventions: Impaired Social Interaction
• Provide an environment with minimal stimuli
• Recognize the purpose or rewards that the
patient gets from manipulative behaviour,
does it reduce insecurity by increasing feeling
of power of control. understand motivation
behind the manipulative behaviour.
Nursing Interventions: Impaired Social Interaction
• Set limits on manipulative behaviour
– Establish realistic, enforceable consequences for
breaking and keeping rules.
– Explain to the patient what you expect from him
and what are the consequences of violating the
limits.
– Make sure that limits are consistently affirmed by
all staff member by recording the instruction &
information you give to the patient in the nursing
care plan so that patient will not be able to
change distort or ignore the communication.
Nursing Interventions: Impaired Social Interaction
– Evaluate the effects of limits
– Assign one nurse to give information and help
patient.
– Keep family informed of what you are doing and
teach them how to handle this behaviour if it
occurs..
– Confront the patient with his manipulative
behaviour then ignore manipulative behaviour
when possible.
– provide positive reinforcement for nonmanipulative behaviours.
Nursing Interventions: Impaired Social Interaction
– Do not argue , bargain, or try to reason with the
patient. State what the limits are and what is
expected. Be sure to follow through with
consequences if limits are violated.
– Help client to explore own feelings, and recognize
consequences of own behaviours and refrain from
attributing them to others. Take responsibility for
own behaviour before adaptive change can occur.
Nursing Interventions: Impaired Social Interaction
– Set and maintain limits on the client’s “negative”
or unacceptable behavior; withdraw your
attention from the client if necessary
– Teach patient to set limits on self.
– Give feedback on the effect of manipulative
behaviour on others.
– Set with the patient on regular times that is not
related to his demands.
– Discuss alternative behaviours in dealing with
certain situations and help patient rehearse the
alternatives
Nursing Interventions: Impaired Social Interaction
– Do not allow the client to bargain to obtain
special favors, to avoid responsibilities, or to
gain privileges
– When limiting the client’s behaviors, offer
acceptable alternatives
– Do whatever you say you will do, and
conversely, do not make promises you
cannot keep
Nursing Interventions: Impaired Social Interaction
• Plan daily routine activities with the patient
deciding who is responsible for exactly what
care, communicate this arrangement to all
staff, both verbally and in written plan.
• Arrange for solitary activities that requires
short attention span with mild physical
activities.
• When the client improves, provide noncompetitive activities with other clients. (
competitive games might lead to aggression ).
Nursing Interventions: Impaired Social Interaction
• Establish a regular schedule for meeting with the
client (such as 1 hour each day or 10 minutes every
hour) and discuss:
– Assist the client in identifying personal behaviors
or problem areas in his or her life situation that
interfere with relationships or interactions with
others.
– Help patient identify positive aspects about self,
recognize accomplishments, and feel good about
them. As self esteem increases need for
manipulation decreases
Nursing Interventions: Impaired Social Interaction
– Point out to the client that his or her
success in relationships in the hospital can
serve as learning experiences to be used in
establishing and maintaining other types of
relationships after discharge
– Teach patient how to approach others in
order to meet needs
Nursing Interventions: Impaired Social Interaction
– Anticipate the client’s anxiety or insecurity about
being discharged from the hospital and
terminating the therapeutic relationship, including
the possibility that the client may revert to
manipulative behavior or his or her presenting
problem behavior as termination approaches
– Assist the client in identifying sources of support
outside the hospital, including agencies or
individuals in the community, as well as significant
others in his or her personal life.
– Assist the client in making plans for discharge
Nursing Interventions: Impaired Social Interaction
• Assessment: of manipulative behaviour:
– Identify the range of manipulative
behaviours being used by the patient
– Note what or who becomes the major focus
of manipulative behaviours.
– Determine what problems is the patient is
avoiding or what needs are met.
– Observe for situational factors that tend to
increase the manipulative behaviour.
– Assess level of aggression or anxiety
Nursing Interventions: Impaired Social Interaction
– Assess for patient’s ability to identify own
feelings and wants.
– Assess patient’s pattern of relating with
family and significant others.
– Evaluate family members response.
– Describe the reward that the patient is
getting for engaging in this behaviour.
– Examine your own responses and feelings
about patient’s behaviour.
Nursing Diagnosis: Imbalanced Nutrition
• Imbalanced Nutrition/ less than body weight
• Related to: Refusal or inability to sit still long
enough to eat, lack of interest in food, excessive
physical agitation
• Evidenced by: Refusal or inability to sit still long
enough to eat, lack of interest in food, excessive
physical agitation, loss of weight, pale conjunctiva
and mucous membrane, Poor muscle tone,
amenorrhea, poor skin turgor, anemia, electrolyte
imbalance
Outcome criteria: Imbalanced Nutrition
• Short term goal:
– Client will eat sufficient finger foods and
between meals snacks to meet
recommended daily requirement
• Long Term Goal:
– Client will have no sign and symptoms of
malnutrition
Nursing Interventions: Imbalanced Nutrition
• Monitor intake, out put, vital signs and weight
daily. To ensure adequate fluid and caloric intake,
minimize dehydration and cardiac collapse.
• Provide high protein, high calorie foods and drinks
that can be taken while the patient is moving
around).
• Provide with juice and snacks on regular basis.
• Provide the patient with his favorite food if
possible..
• Provide with vitamins as order by psychiatrist
Nursing Interventions: Imbalanced Nutrition
• Stay with the patient until the snack or meal is
finished, and offer support and
encouragement for it may decrease agitation
during food intake.
• Explain the importance of food and teach
patient and family about amount and type of
food that is important to
• Monitor daily laboratory values & Assess
lithium carbonate level, electrolytes
Nursing Diagnosis: Sleep Pattern Disturbance
• Sleep pattern disturbance
• Related to: Excessive hyperactivity and
agitation
• Evidenced by: Difficulty falling asleep and
sleeping only short periods, pacing in the hall
during sleep hours, Numerous periods of
wakefulness during the night
Outcome Criteria: Sleep Disturbance
• Long Term Goal: The client will be able to
sleep for 7-8 hours / day by discharge.
Nursing Interventions: Sleep Disturbance
• Provide a quiet environment, with low level of
stimulation.
• Monitor sleep pattern and provide a structured
schedule of activities that includes established times
for naps or rest
• Observe for signs of fatigue such as increased
restlessness, fine tremors, slurred speech and puffy
dark circles under eyes to prevent from collapsing
exhaustion.
• Prohibit caffeine intake in drinks such as tea, coffee
colas.
• Administer sedatives as ordered