- Disturbed thought processes related to sleep deprivation and psychotic process as evidenced by impaired decision-making and Delusional thinking
- Insomnia related to hyperactivity and distractibility as evidenced by difficulty falling asleep and wakening very early
- Insomnia related to hyperactivity and distractibility as evidenced by difficulty falling asleep and wakening very early
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalize about imaginary thoughts Objective Data: -Disorientation to person, place and time -Memory deficit, altered at tensions an, and decreased ability to grasp ideas -Impaired ability to make decisions -Disturbed thought processes – Hallucinations | Disturbed thought processes related to sleep deprivation and psychotic process as evidenced by impaired decision-making and Delusional thinking | Patient will display reality-based thinking with an absence of delusions by discharge Patient will recognize and verbalize when thoughts are not reality-based Patient will verbalize an absence of hallucinations | 1. Reorient and focus on reality. Reorient the patient to person, place, and time as needed. Focus on reality during conversation such as discussing current events to divert from false ideals. 2. Provide positive reinforcement. When the patient differentiates between reality and delusions provide positive and supportive reinforcement. 3. Do not accept nor deny beliefs. The nurse should not accept the patient’s delusions as facts as this only reinforces false thinking. The nurse should also not outwardly deny or argue beliefs as this will only alienate the patient and harm a therapeutic relationship. 4. Teach thought-stopping techniques. Instruct the patient on techniques to stop intrusive thoughts such as yelling “stop!” or clapping the hands when the patient has an unwanted thought as this can prevent further harmful emotions and behaviors. | Patient displayed reality-based thinking with an absence of delusions by discharge Patient recognized and verbalized when thoughts are not reality-based Patient verbalized an absence of hallucinations |
| Subjective Data: Verbalizes unable to sleep Objective Data: -Difficulty falling asleep -Decreased need for sleep -Sleeping for only short periods -Awakening very early -Increase in errors or accidents -Missing appointments, late for work or school | Insomnia related to hyperactivity and distractibility as evidenced by difficulty falling asleep and wakening very early | Patient will sleep at least 6-7 hours per night by discharge Patient will apply two interventions to improve sleep Patient will exhibit decreased restlessness and exhaustion due to adequate sleep | 1. Administer benzodiazepines. New research shows that clonazepam and lorazepam may be safer for sleep as they may improve symptoms of mania. 2. Trial dark therapy. Dark therapy is a behavioral treatment that enhances melatonin naturally by keeping patients in a pitch-dark room during nighttime hours. Blue-light blocking glasses can improve circadian rhythms once insomnia has dissipated. 3. Promote relaxation. Promote relaxation and improve sleep hygiene by instituting soft music, dim lighting, and non-caffeinated teas before bedtime. 4. Prohibit stimulants. Caffeinated beverages should be prohibited for the patient with insomnia. 5. Recommend CBT for insomnia. Cognitive behavioral therapy for insomnia for bipolar disorder has proven not only to improve sleep but also to lessen the number of days in a mood episode. Patients can utilize apps that can coach on CBT for insomnia. | Patient’s sleep got improved Patient exhibited decreased restlessness and exhaustion after adequate sleep |
| Subjective Data: Expressed aggressive behaviour to self-harm and harm others Objective Data: -Extreme hyperactivity -Destructive behaviors -Disinhibition -Poor judgment -Risk-taking behavior -Aggression -Alcohol and drug use -Delusional thinking -Self-harm | Risk for Injury related to extreme hyperactivity and risk-taking behavior as evidenced by aggression and delusional thinking | Patient will not harm themselves or others during a manic episode Patient will display a calm and subdued energy level before discharge Patient will cooperate with unit rules without aggression or inappropriate behavior | 1. Reduce stimuli. Provide a private room if possible, that is quiet with low lighting to reduce hyperactivity and distraction. 2. Remove dangerous objects. Remove any objects that could be used as a weapon or to potentially harm themselves. 3. Provide physical activities. Patients experiencing mania have endless energy. Offer exercise classes or housekeeping duties to help relieve hyperactivity as well as distract them from unsafe activities. 4. Administer tranquilizing medication. Anti-psychotic medications are often prescribed to relieve symptoms of hyperactivity and agitation. | Patient displayed a calm and subdued energy level before discharge Patient cooperated with unit rules without aggression or inappropriate behavior |