Substance Abuse and Abuse Q 51
Mr. Peterson, 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an argument over Mr. Peterson is staying up all night playing loud music. Mr. Peterson is hyperactive, intrusive, and has rapid, pressured speech. He has not slept in three days and appears thin and disheveled. Which of the following is the most essential nursing action at this time?
A. Providing a meal and beverage for Mr. Peterson to eat in the dining room.
B. Providing linens and toiletries for Mr. Peterson to attend to his hygiene.
C. Consulting with the psychiatrist to order a hypnotic to promote sleep.
D. Providing for client safety by limiting his privileges.
Correct Answer: D. Providing for client safety by limiting his privileges.
Mr. Peterson has been assaultive with the landlord, and it is reasonable to expect that he may be with peers and staff. His mental illness produces a hyperactive state and poor judgment and impulse control. External controls such as limiting of unit privileges will assist in feelings of security and safety. Maintain a consistent approach, employ consistent expectations, and provide a structured environment. Clear and consistent limits and expectations minimize potential for client’s manipulation of staff.
Option A: Food and fluids are necessary. However, Mr. Peterson’s hyperactivity does not allow him to sit quietly to eat. Finger foods “on the run” will provide needed nourishment. Encourage frequent high-calorie protein drinks and finger foods (e.g., sandwiches, fruit, milkshakes). Constant fluid and calorie replacement are needed. The client might be too active to sit at meals. Finger foods allow “eating on the run”.
Option B: When hyperactivity decreases, then approach Mr. Peterson’s. regarding hygiene and grooming needs. Give simple step-by-step reminders for hygiene and dress (e.g.,” Here is your toothbrush. Put the toothpaste on the brush”). Distractibility and poor concentration are countered by simple, concrete instructions.
Option C: Medications will be ordered. However, a thorough evaluation must be done first. Chart, in nurse’s notes, behaviors; interventions; what seemed to escalate agitation; what helped to calm agitation; when as-needed (PRN) medications were given and their effect; and what proved most helpful. Staff will begin to recognize potential signals for escalating manic behaviors and have a guideline for what might work best for the individual client.