Let's think about nursing diagnosis.
Remember, nursing diagnosis is not specific to a person's diagnosis that is medical.
Nursing diagnosis is looking at the individual
and finding out, assessing what that person's needs are in that minute.
So for our patient with a diagnosis of mania,
hypomania, bipolar 1, bipolar 2 or depression
with or without mixed features,
these patients are at a high risk of injury.
We have to be able to identify this particular patient
and why this patient is at risk for injury,
whether it is harm to self or harm by others,
or not being able to control impulses.
So what are our expected outcomes for the patient?
We want to make sure that that patient is not going to harm themselves or others.
And in these situations, we can make a contract with the patient.
We can say, promise me, let's write this down.
"Before I do anything that would hurt myself,
I promise I will call Dr. Marshall,
I will call the nurse on call.
I will make sure I go to the front desk
and let someone know I'm having these thoughts of hurting myself."
People do not mind being able to make that kind of contract.
In a lot of cases, it's that they've never had anybody who was there
that they could share these thoughts with.
And so giving them that opportunity really works.
If it is a patient who is manic,
you want to be able to say before you cut yourself, before you
do something that might harm yourself or harm someone else,
you will come and tell a staff member that you're having these thoughts.
It's very hard with a person who has mania,
because it happened so fast, it is so unpredictable.
And we cannot blame a person nor should we say, "You promised."
Because a contract is not necessarily a promise,
a contract between the patient and the staff is really
an attempt at achieving a behavior
that may be really, really hard for them to achieve.
So what is our nursing intervention?
We're going to be able to put together a caring rapport,
you know, be able to talk to them,
establish that therapeutic relationship with them,
so that they understand that their safety is important to us.
We're going to discuss with them what they might want to do
and how they can help themselves.
But also, we want to make sure that we assess them for suicide.
We need to ask them directly,
"Do you want to kill yourself?
Are you thinking about suicide?"
If the person says, "No, I'm not thinking about it."
We can say to them, "If you have these thoughts,
it's really important to come and talk to us."
If they say yes,
"Yes, I want to kill myself,
I can't be left alone because I know I'm going to kill myself."
If that happens, it's super important for us to say,
"How do you think you would do it?"
Because if they actually have a plan,
they have to be put on one-to-one.
We have to make sure that there is a person with them at all times,
so that there is no time they are left alone, that they can hurt themselves.
We want to make sure that we respect the patient.
And we want to respect their autonomy
but not if it means that we are going to put them at risk for death.
So as long as a person has been able to live within the contract,
as long as that person is able to show that they are being able to move forward,
then we're going to be able to reduce that likelihood and necessity
for a one-to-one constant observation on them.
But if not, this is an important feature that we can actually call for.
We can say,
JJ just said to me that
suicide is the only alternative that is possible
to get out of the way JJ is feeling right now
and tell the practitioner who can then put this person
on a one-to-one constant observation.
You never want to be the last person someone talks to
before they take their own life by suicide.
Another diagnosis that we often see with patients who have mood disorders
is ineffective coping.
And when we think about ineffective coping,
we want to think about what kind of outcomes do we hope for the patient.
We want to make sure that patient is going to be able
to have an adaptive coping system.
Something that when they feel sad or when they are going to take risks,
and they feel anxious, that they have a go to coping mechanism that will work
to bring them back to a place where they are safe.
So we have to think about, what are the strengths that this person have?
What can this person do that will help them?
One of the best things that you could possibly ever do with a patient is say,
what has worked for you in the past?
Do you like to ride bikes? Is going for a walk really something that is good for you.
let the patient work with you to try to problem solve,
to figure out what other coping mechanisms are available to that person
that they're used to, that gives them back a bit of their routine.
You want to make sure that that person can ask for what they want,
and at least be able to assert themselves
come over and say, you know, I'm feeling anxious.
Now, in the past, when I've taken my Xanax, its help.
And I'm wondering whether I should not take it to see if I can, you know,
bully through this.
And we're able to say the reason why you have a PRN
for this medication is so that you don't have to.
So let's take the medication, I'll give you the medication,
work with me and when you start feeling less anxious,
let's try out some other things you might be able to do.
Once the person is feeling the anxiety,
once they are feeling the slide into depression,
it is not the time to try and get them to use
a coping skill that they're not used to.
So the rationale for trying to build upon what the person knows
and trying to give them some other alternative
is to be able to give them some autonomy back
to be able to help them understand that when they have frustrations,
when they have their anger building up,
when they're starting to feel really anxious,
it is really important that before it gets out of hand
to know what you can do to reduce that kind of stress
to give you back yourself control over what is going to happen next.
Sometimes we have patients who really have an impaired social interaction,
whether it is from the depression, or whether it's from the mania,
their ability to connect with others becomes really impaired.
And what we want is to be able to have that person have some mechanisms
that they're able to make connections, maybe make small connections
that are slow at first, and then expand upon those.
So they start having a social
group that they can feel comfortable with.
We all know that when you have your family, when you have your friends,
having that social group is a protective factor.
If our anxiety, if our mania or a depression
gets in the way of us being able to connect with others
that really puts our isolation very high and puts us at risk.
So we want to be able to help them to repair social interactions.
So how can we do that?
What kind of nursing intervention can we use for that?
Well, we can start developing that therapeutic relationship
ourselves with that person.
We can be honest and respectful of them.
We can help them to accept when we want to talk
or when we don't want to talk,
we can help them to learn how to have boundaries,
so that when they are able to then go out of the unit
when they're able to go back into their own lives
perhaps they can get involved in a self-help group,
or a church or temple or mosque group of people who like themselves
need to have a small group to get together with.
It's so important for us to let them know
that there are people for them that they can connect with,
that they can have control over how close that person gets.
And also how much they want to divulge to that person
that they can have a group of friends that they can count on
and that they can be counted on by them.
So we want to make sure that we also work with families
so that we repair some of the family interactions
that have fallen by the wayside, secondary to this mental illness.
It's always important to remember that mental illness is a diagnosis
like heart disease, like diabetes that needs an intervention,
that needs to be taken care of
and that people can move towards recovery.