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Nursing Concept Map for Bipolar Patient

This nursing concept map summarizes the care plan for a patient with bipolar disorder who is experiencing delusions of grandeur. The plan includes 6 nursing interventions: 1) convey acceptance of the patient's beliefs while not sharing the delusion, 2) use reasonable doubt as a technique without arguing, 3) use techniques of consensual validation and clarification, 4) reinforce and focus on reality, 5) provide positive reinforcement as the patient distinguishes reality-based from non-reality based thinking, and 6) teach thought-stopping techniques. The short-term goal is for the patient to recognize and verbalize non-reality based thinking within 1 week.

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BillynTarplain
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290 views2 pages

Nursing Concept Map for Bipolar Patient

This nursing concept map summarizes the care plan for a patient with bipolar disorder who is experiencing delusions of grandeur. The plan includes 6 nursing interventions: 1) convey acceptance of the patient's beliefs while not sharing the delusion, 2) use reasonable doubt as a technique without arguing, 3) use techniques of consensual validation and clarification, 4) reinforce and focus on reality, 5) provide positive reinforcement as the patient distinguishes reality-based from non-reality based thinking, and 6) teach thought-stopping techniques. The short-term goal is for the patient to recognize and verbalize non-reality based thinking within 1 week.

Uploaded by

BillynTarplain
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

MEDGAR EVERS COLLEGE

City University of New York


School of Science Health and Technology

DEPARTMENT OF NURSING
NUR 131

MEC Nursing Concept Map


November 10, 2019
Student Name: Billyn Tarplain Date:

Patient Initials: AA
Nursing Interventions
Data

Patient says that he does not 1. Convey acceptance of client's need for false, while
Subjective Data: letting him know that I do not share the delusion.
have a problem. Rationale: A positive response woruld convey to the
Patient says that his mother patient I do not accept the delusion as reality.
forced his admission because
Do not argue or deny the belief. Use reasonable doubt as a
he works from home and 2. therapeutic technique: " I understand that you believe this is
does not work a 9-5 job true, but I personally find it hard to accept." Rationale: Arguing
with the patient or denying the belief serves no useful purpose,
Flight of Ideas because delusional ideas are not eliminated by this approach
and the development of a trusting relationship may be impeded.

Use the techniques of consensual validation and seeking clarification when


Objective Data: Patient is bipolar (chart 11/2/2019) communication reflects alteration in thinking. Rationale: These
3.
Vital signs: 98.3 (Temp) techniques reveal to the client how he is being perceived by others, and the
responsibility for not understanding is accepted by the nurse
Heartrate: 72
Respiratory: 18
4. Reinforce and focus on reality. Talk about real events and real people.
Blood pressure: 121/86 Rationale: Use real situations and events to divert patient from long
tedious, repetitve verbalizations of false ideas

Give positive reinforcement as patient is able to differentiate between


4. reality-based and non-reality based thinking. Rationale: Positive
reinforcement enhances self esteem and encourages repetition of
desirable behaviors
Nursing Diagnosis/Problems
Teach patient to intervene, using thought-stopping techniques, when irrational
Priority #1 5. thoughts prevail. Thought stopping involves using the comman "Stop!" or a loud noise
(such as hand clapping) to interrupt unwanted thoughts. Rationale: This noise or command
distracts the individual from undesirable thinking, which often preceded undesirable
Disturbed thought processes related to emotions or behaviors.

psychotic process evidenced by delusions of


grandeur 6.

Evaluation

Short Term Goal


At time of discharge from treatment, client's
Within 1 week, patient will be able to recognize verbalizations reflect reality-based
and verbalize when thinking is non-reality thinking with no evidence of delusional
based. ideation.

1
Nursing Interventions
Data

N/A 1. N/A
Subjective Data:

2. N/A

Objective Data: N/A


N/A

3. N/A

4. N/A
Nursing Diagnosis/Problems
Priority #2

N/A
5. N/A

6. N/A
Short Term Goal

N/A

Evaluation

References N/A

Patient chart from Coney Island hospital


Townsend, M., Nursing Diagnoses in Psychiatric
Nursing, 8th Ed 2011
2

mlg:2017

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