Sample Nursing Documentation

Here is a sample nursing narrative note for a client recently admitted who is currently experiencing an acute phase of a manic episode.

S: Patient reports feeling “very happy” with “high energy”’ and “no need for sleep.” She states, “I’ve got lots to accomplish today; now move out of my way.”

O: Euphoric mood with full range affect. Denies suicidal or homicidal ideation. Is skipping in the hallways and singing loudly with rapid, pressured speech. Is easily distracted and unable to focus on the current conversation. Is intrusive with others with a poor sense of personal boundaries; she is giving away clothing items and going into other patients’ rooms and taking their belongings. Dressing in multiple layers of clothes and unable to sit to eat or finish meals. She has experienced weight loss of four pounds in the past three days.

A: Acute mania nearing exhaustion with disruptive behaviors.

P: Reduce stimuli with calming milieu and redirect firmly to maintain appropriate personal boundaries with others. Encourage nutritional intake with hydration and finger foods, along with rest periods twice a day. Refrain from large group activities with short 1:1 time for unit programming needs.