Date Formulate: June 20, 2019

Problem 1: Disturbed auditory sensory perception related to excessive environmental stimuli as evidence by hallucination
Level of Prioritization: High

Cause Analysis: Bipolar disorder, or manic depression, is a brain chemistry disorder. It’s a chronic illness that causes alternating mood
episodes. These mood swings range from depression to mania. Hallucinations are more likely to be auditory than visual in people with bipolar
disorder. You’re more likely to have hallucinations if you experience severe mood swings.

Cues Desired outcomes Interventions Rationale Evaluation

Subjective:
“Naa koy gaka dungog nga
tingog nga saba kayo, ug
usahay mag dikta nako.”
as patient verbalized
Short Term: Independent: Short Term:
1. Determine the patient  This information
At the end of 2 days in understands of the provides a foundation At the end of 2 days of
providing nursing stressful situation. for planning care and providing nursing
intervention the patient choosing relevant intervention the patient
will be able to focuses on interventions. was able to focuses on the
the present. present.
2. Observe for strengths  It is necessary to
such as the ability to verbally praise them
relate the facts and to for their strength and
acknowledge the to use those strengths
source of stressors to aid functioning

3. Monitor risk of  A patient with

Objective: Long Term: harming self or others hopelessness and an
and intervene inability to problem Long Term:
- restlessness At the end of 1 week in appropriately. solve often runs the
- providing nursing risk of self injury At the end of 1 week of
intervention the patient providing nursing
- suddenly shut up will be able to verbalize 4. Assist patient set
better feelings related to realistic goals and
- sleep disturbances
emotional state. identify personal skills
- poor concentration and knowledge
5. Assist patients with
accurately evaluating
the situation and their
own accomplishments
 Involving patient in intervention the goal was
decision making helps met and the patient
them to move toward verbalized better feelings
independence related to emotional state
evidence by
 It can be helpful for
the patient to
recognize that he or
she has the skills and
reserves of strength to
effectively manage the
situation.

6. Encourage patient to  To let him/her live

focus in the present today and forget the
pain from the past

7. Provide a chance to  To develop a close

express concerns fears
and expectations
relationship to gain
the trust of the client
for him to share
perceived or actual
threats and it helps to
reduce anxiety.

 Aerobic exercise
8. Encourage moderate
improves one’s ability
aerobic exercise.
to cope with acute
stress.
Collaborative/Dependent:  Tranquilliser substance
1. Administer that induces sedation
sedatives as by reducing irritability
necessarily or excitement.
ordered