Nursing Plan of Care with vSimulation

vSImulation Client: S.C. 31-year-old Hispanic female. Admitted from the ED. She was brought in via ambulance after falling and breaking her ankle
from the stage at the bar, where 911 was called. She jumped on the stage and grabbed the microphone from the lead singer. Her husband was
contact from the ED, where he provided additional information. He diagnosed that she was diagnosed with bipolar 6 years ago, but for the past
two weeks, she has not been eating or sleeping. She has been in a maniac phase with her behavior. Per husband she is typically adheres to her
medication. She takes 600 mg of Lithium. ED did restart her lithium; she received her first dose. Since being admitted to the floor she is 1:1 and
very verbal. She did go through surgery for her ankle and does have a cast to her left a lower extremity. Pt does have a fentanyl PCA attached for
pain control. She is having grandiose thoughts ranging from issues in Washington to ideas to running the hospital better.

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Student Name: Fern Spencer

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V-sim name: Sharon Cole Primary Diagnosis (Mental Health

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Disorder): Bipolar

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Priority #1: Nursing Diagnosis #1 (3 Part Priority #2: Nursing Diagnosis #2 (3 Part Priority #3: Nursing Diagnosis #3 (3 Part

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NANDA). NANDA). NANDA).

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Risk for injury r/t left ankle broke after Ineffective individual coping r/t inadequate Interrupted family process r/t to
falling off stage. AEB destructive behavior toward self. situational crisis AEB pt went missing for
2 weeks and husband was looking for her.

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Interrelated Concepts (at least 4) Interrelated Concepts (at least 4) Interrelated Concepts (at least 4)
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Desired Outcome (Goal) Desired Outcome (Goal) Desired Outcome (Goal)
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Short Term: patient will respond to the Short Term: pt will respond to external Short Term: family members won’t
medication within therapeutic levels by controls (medication, seclusion, nursing experience verbal, physical, or emotional
end of shift. intervention) when potential or actual loss abuse within one hour after admission.
Long Term: Patient will be free of of control occurs by end of shift.
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dangerous levels of hyperactive motor Long Term: Patient will return to pre-crisis Long Term: Family members and/or
behavior with the aid of medications level of functioning after acute maniac significant others will state and have in
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and nursing interventions within the phase is past by date of discharge. writing the names and telephone
first 24 hours. numbers of at least two bipolar support
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This study source was downloaded by 100000822824878 from CourseHero.com on 04-05-2021 14:45:13 GMT -05:00
 Nursing Plan of Care with vSimulation
vSImulation Client: S.C. 31-year-old Hispanic female. Admitted from the ED. She was brought in via ambulance after falling and breaking her ankle
from the stage at the bar, where 911 was called. She jumped on the stage and grabbed the microphone from the lead singer. Her husband was
contact from the ED, where he provided additional information. He diagnosed that she was diagnosed with bipolar 6 years ago, but for the past
two weeks, she has not been eating or sleeping. She has been in a maniac phase with her behavior. Per husband she is typically adheres to her
medication. She takes 600 mg of Lithium. ED did restart her lithium; she received her first dose. Since being admitted to the floor she is 1:1 and
very verbal. She did go through surgery for her ankle and does have a cast to her left a lower extremity. Pt does have a fentanyl PCA attached for
pain control. She is having grandiose thoughts ranging from issues in Washington to ideas to running the hospital better.

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groups by 1 hours prior to discharge.

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Minimum of 3 Interventions: Asses, Minimum of 3 Interventions: Assess, Teach, Minimum of 3 Interventions: Assess,

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Teach & Do. & Do. Teach & Do.
 Maintain a low-level of stimuli

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in client’s environment (e.g. Maintain a firm, calm, and neutral During the first or second day of
loud noises, bright light, low- approach at all times. Avoid: hospitalization, spend time with family

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temperature ventilation) identifying their needs during this time;
1. Arguing with the client. for example:

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 Observe for signs of lithium
2. Getting involved in power
toxicity such as nausea
vomiting diarrhea drowsiness co rc struggles.
1. Need for information about
the disease.
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muscle weakness tremors 3. Joking or “clever” repartee in
2. Need for information about
blurred vision or ringing in ears. response and other clients. to
lithium or other antimanic
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client’s “cheerful and
medications (e.g., need for
 Inform the patient caregiver humorous” mood.
adherence, side effects, toxic
about the income respite
effects).
services adult day care and
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support groups for loved ones. 3. Knowledge about bipolar

 Explain all treatments and
support groups in the family’s
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procedures and answer patients

community and how they can
questions.
help families going through
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This study source was downloaded by 100000822824878 from CourseHero.com on 04-05-2021 14:45:13 GMT -05:00
 Nursing Plan of Care with vSimulation
vSImulation Client: S.C. 31-year-old Hispanic female. Admitted from the ED. She was brought in via ambulance after falling and breaking her ankle
from the stage at the bar, where 911 was called. She jumped on the stage and grabbed the microphone from the lead singer. Her husband was
contact from the ED, where he provided additional information. He diagnosed that she was diagnosed with bipolar 6 years ago, but for the past
two weeks, she has not been eating or sleeping. She has been in a maniac phase with her behavior. Per husband she is typically adheres to her
medication. She takes 600 mg of Lithium. ED did restart her lithium; she received her first dose. Since being admitted to the floor she is 1:1 and
very verbal. She did go through surgery for her ankle and does have a cast to her left a lower extremity. Pt does have a fentanyl PCA attached for
pain control. She is having grandiose thoughts ranging from issues in Washington to ideas to running the hospital better.

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 Refer patient for professional crises.
psychological counseling.

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 Refer to outside agencies, if

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need.

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 Meet with family members.

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co rc
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Rationale – Citation/EBP: Each Rationale – Citation/EBP: Each intervention Rationale – Citation/EBP: Each
intervention above requires a written above requires a written rationale. intervention above requires a written
rationale.  These behaviors by the staff can rationale.
 Helps minimize escalation of escalate environmental stimulation  This is a disease that can
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anxiety and, consequently, manic activity. devastate and destroy some

Once the manic client is out of families. During an acute manic
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 There is a small margin of control, seclusion might be attack, families experience a

safety between therapeutic and required, which can be traumatic to great deal of disruption
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This study source was downloaded by 100000822824878 from CourseHero.com on 04-05-2021 14:45:13 GMT -05:00
 Nursing Plan of Care with vSimulation
vSImulation Client: S.C. 31-year-old Hispanic female. Admitted from the ED. She was brought in via ambulance after falling and breaking her ankle
from the stage at the bar, where 911 was called. She jumped on the stage and grabbed the microphone from the lead singer. Her husband was
contact from the ED, where he provided additional information. He diagnosed that she was diagnosed with bipolar 6 years ago, but for the past
two weeks, she has not been eating or sleeping. She has been in a maniac phase with her behavior. Per husband she is typically adheres to her
medication. She takes 600 mg of Lithium. ED did restart her lithium; she received her first dose. Since being admitted to the floor she is 1:1 and
very verbal. She did go through surgery for her ankle and does have a cast to her left a lower extremity. Pt does have a fentanyl PCA attached for
pain control. She is having grandiose thoughts ranging from issues in Washington to ideas to running the hospital better.

a
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toxic doses. the manic individual as well as the and confusion when their family
staff. members begins to act bizarre,

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 To enhance the caregiver’s out of control and at times

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ability to cope.  To allay fear and allow patient to aggressive. Families need to

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regain sense of control. understand about the disease
what can and cannot be done to

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 If patient’s maladaptive behavior help control the disease, and
has high crisis potential, formal where to go for help for their
counseling helps ease nurse’s individual issues.

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frustration, increases objectivity,  To ensure continuing support.
and fosters collaborative approach  To establish levels of authority

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to patient’s care. and responsibility in the family.

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Evaluation (Goal Met, Not Met, Partially
Met) – Re-evaluation? co rc Evaluation (Goal Met, Not Met, Partially
Met) – Re-evaluation?
Evaluation (Goal Met, Not Met, Partially
Met) – Re-evaluation?
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Not met- pt’s husband was not available
Met- pt shows no sign physical or Met- patient cooperates with nurse plan of for patient’s stay.
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mental signs of abuse. care.

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