1. 1
NURSING CARE PLAN FOR MANIA
Problem Nursing
diagnosis
Goal Intervention Evaluation
1. Risk for
injury to self
and others
Risk for injury to
self and others
related to
hallucinations
evidenced by
breaking up
windows and
beating up people
To prevent
patient from
injuring him/
herself and
others
throughout
hospitalisation
Remove all injurious objects from the
patient’s room to prevent injuries.
Put the patient in seclusion room
when she/he is violent.
Administer tranquilizers such as
haloperidol or chlorpromazine to
quickly relief agitation.
Reduce environmental stimuli,
ensure soft lighting, low noise and
simple room décor
limit group activities and observe
patient’s behaviour frequently
Stay with the client when calm and
offer support and provide a feeling of
security.
.
Patient’s safety
maintained, evidenced
by patient exhibiting no
physical injury obtained
while experiencing
hyperactive behaviour
2. 2
2.Imbalanced
nutrition less
than body
requirements
Imbalanced
nutrition related to
patient’s inability
to sit long enough
to eat meals
evidenced by loss
of weight, poor
muscle tone and
pale mucous
membranes
To improve
the patient’s
nutrition by
ensuring
adequate
intake
throughout
hospitalization
Provide the client with high nutritious
finger meals and drinks that can be
consumed on the run
Ensure availability of snacks on the
unit all the time
Maintain accurate record of intake
and output.
Weigh the patient daily to asses’
nutritional status.
Determine the patient’s favourite
foods and ensure they are provided
Administer vitamins and mineral
supplements prescribed by the
physician
As agitation reduce sit with the
patient and encourage the patient to
eat.
Educate the client on the importance
of adequate nutrition.
Patient nutritional status
improved evidenced by
patient gaining and
maintaining weight
during hospitalization
and patient’s ability to
verbalize the importance
of good nutrition.
3. 3
3. Impaired
social
interaction.
Impaired social
interaction related
to confusion,
stigma evidenced
by patient
isolating
him/herself from
others,
Discomfort in
social situations
and vebal
manipulation of
others
To improve
social
interaction
with other
people and
relatives in
hospital and
after
discharge.
Encouraged her family to support the
patient.
Encourage the patient to interact with
others by involving patient in group
activities.
Set limits on manipulative behaviours
and explain to client what you expect
and what the consequences are if the
limits are violated.
Avoid arguing, bargain, or try to
reason with the client, instead follow
through with consequences if limits
are violated as consistency is
essential for success of this
intervention.
Provide positive reinforcement for
non-manipulative behaviours.
Help client recognize consequences
of own behaviours and refrain from
attributing them to others.
Patients’ interaction with
others improved and
maintained evidenced by
the patient’s ability to
open up to others and
relatives, relating with
others well without
manipulating them for
self-gratification.
4. 4
Help client identify positive aspects
about self, recognize
accomplishments, and feel good
about them to stop patient from
manipulating others for self-
gratification.
4.Insomnia Insomnia related
to excessive
hyperactivity
evidenced by
difficulty in falling
asleep and
pacing in the hall
during sleeping
hours.
To improve
the patient’s
sleeping
patterns
throughout
hospitalization.
Provide a quiet environment, with a
low level of stimulation to promote
sleep
Monitor the patient’s sleeping
patterns.
Provide structured schedule of
activities that includes established
times for naps or rest.
Asses client’s activity level and
intervene as patient may collapse
from high levels of exhaustion.
Before bedtime, provide nursing
measures that promote sleep, such
as back rub; warm bath; warm, non-
stimulating drinks; soft music; and
relaxation exercises.
The patient’s sleep
pattern improved
evidence by the patient’s
ability to sleep for 6 to 8
hours per night without
medication.
5. 5
Prohibit intake of caffeinated drinks,
such as tea, coffee, and Colas to
avoid stimulating the CNS which may
interfere with the client’s
achievement of rest and sleep.
Administer sedative medications, as
ordered, to assist client achieve
sleep until normal sleep pattern is
restored
5.Disturbed
sensory
perception
Disturbed
sensory
perception related
to Biochemical
imbalance
And Sleep
deprivation
evidenced by
Hallucinations
and
Disorientation
To improve
the patient’s
sensory
perception
within the first
72 hours of
hospitalization
Observe client for signs of
hallucinations such as laughing or
talking to self and intervene early.
Avoid touching the client before
warning him or her that you are about
to do so as client may perceive touch
as threatening and respond in an
aggressive manner
The patient’s sensory
perception normalized,
evidenced by the
patient’s ability
differentiate between
reality and unrealistic
events or situations and
the patient’s ability to
refrain from responding
to false sensory
perceptions.
6. 6
Portray an attitude of acceptance to
encourage the client to share the
content of the hallucination with you
in order to prevent possible injury to
the client or others from command
hallucinations.
Avoid reinforcing the hallucination by
using words such as “the voices”
instead of “they” when referring to the
hallucination because Words like
“they” validate that the voices are
real.
Try to distract the client away from
the misperception by Involvement in
interpersonal activities and
explanation of the actual situation,
this will bring the client back to
reality.
7. 7
6. Self-care
deficit
Self-care deficit
related to
cognitive
impairment
evidenced by
patient looking
untidy.
To improve
and maintain
the patient’s
hygiene
throughout
hospitalization
Encourage the patient to bath and
supervise the patient during bathing.
Encourage the patient to wash
his/her clothes when dirty.
Encourage the patient to brush teeth
every after each meal
Encourage and supervise the patient
in maintaining her/his hair.
The patient’s hygiene
status improved and
maintained evidenced by
the patient looking,
smart all the time .
8. 8
7.Disturbed
thought
processes
Disturbed thought
processes related
to Biochemical
alterations and
Sleep deprivation
evidenced by
decreased ability
to grasp ideas
, Impaired ability
to make
decisions,
delusions of
grandeur and
persecution
To normalize
the patient’s
thought
processes
within 1 week
of
hospitalization
Convey your acceptance of client’s
need for the false belief, while letting
him/her know that you don’t share
the delusion.
Do not argue or deny the belief to
avoid jeopardizing the development
of a trusting relationship.
Use reasonable doubt as a
therapeutic technique: e.g. “I
understand that you believe this is
true, but I personally find it hard to
accept.
Reinforce and focus on reality by
talking about real events and real
people. Use real situations and
events to divert patient from long,
tedious, repetitive verbalizations of
false ideas.
Give positive reinforcement to
enhances self-esteem as client
begins to differentiate between
reality-based and non–reality-based
thinking.
The patient’s thought
processes improved
evidenced by the
patient’s ability to reflect
an accurate
interpretation of the
environment.
