Nurses' Notes
2210:
A client with bipolar I disorder is admitted during a manic episode. The client slept less than two hours nightly for three nights and remained continuously active. Speech is rapid, and the client changes topics before questions are completed. The client selected brightly colored clothing and several pieces of costume jewelry. The client announces, I will leave tonight and drive 120 miles per hour because my reflexes are perfect. The client walks rapidly in the hallway, redirects near the nurses' station, and maintains personal space when reminded. The client accepts a high-calorie sandwich and bottled water while continuing to move. After another client asks for quiet, the client lifts a chair and says it will be thrown if anyone interferes. The client describes plans for three new businesses and says every plan will succeed. A family member reports, the client can access a large savings account and plans to buy a sports car before morning. The client agrees to discuss prescribed medication in a quiet room with one staff member. The nurse moves other clients away, calls for assistance, reduces stimulation, and begins the facility's least-restrictive safety process.
護理紀錄
2210:
一位第一型雙相情緒障礙症的個案於躁症發作期間入院。個案連續三晚每晚睡眠少於兩小時，且持續活動不停。說話快速，個案在問題完成前就更換話題。個案挑選了顏色鮮豔的衣物及數件裝飾性珠寶。個案宣布，我今晚要離開，並以每小時120英里的速度駕駛，因為我的反應完美無缺。個案在走廊快速走動，在護理站附近被引導，並在被提醒時保持個人空間。個案接受了一份高熱量三明治及瓶裝水，同時持續移動。在另一位個案要求安靜後，個案舉起一張椅子，並說若有人干擾就會丟擲。個案描述了三項新事業的計畫，並說每個計畫都會成功。一位家屬報告，個案可取得一個大筆儲蓄帳戶，並計畫在早上前購買一輛跑車。個案同意在一間安靜的房間與一位工作人員討論處方藥物。護理師將其他個案移開、尋求協助、減少刺激，並啟動機構最少限制的安全處理流程。