BHOPAL (M.P.

Case presentation
On
Bipolar- manic

SUBMITTED TO: SUBMITTED BY:

Mrs. C. Gomthi Mrs. Geeta Choudhary
Professor M.Sc. Nursing Ist yr
hod of psychiatric nursing
Bipolar disorder

The illness tends to be highly genetic, but there are clearly

environmental factors that influences whether the illness is occur in a
particular child. Bipolar disorder can skip generations and take different in
different individuals.

The small group of studies that have been done vary in the estimate of
the risk to a given individual. For the general population a conservative
estimate individual’s risk of having full-bloom bipolar disorder one percent.
Disorder in the bipolar spectrum may affect 4-6%, who one parent has
bipolar disorder, the risk to each child is 15-30%, when both parents have
bipolar disorder, the risk increases to 50-75%. The risk in siblings and
fraternal twins is 15-25%, and the risk of identical twins is approximately
70%.

Bipolar disorder is classified into two, the bipolar I and the bipolar II.
The bipolar I disorder in which individual may experience one or more
manic episodes or mixed episodes. During a manic episode must be present
to a significant degree. Impairment in various of functioning, psychotic
symptoms, and the possibility of self-harm exist.

Bipolar II disorder is characterized by recurrent major depressive

episodes with hypomanic (a mood between euphoria and excessive elation)
episodes. It is believe to occur frequently in women than in men.
This case study aims to:

 Know the definition and the history of the development of

bipolar manic disorder.
 Identify the facts that may contribute in acquiring bipolar manic
disorder.
 Formulate appropriate diagnosis on which to base the necessary
psychiatric nursing interventions.
 Implement interventions and psychodynamic approach.
 Evaluate the actions done to clients and its effectivity.
 A. Assessment
1. General Data

Name: Nestor
Age: 42
Address: Nueva Ecija
Civil Status: Married
Date Admitted: August 5, 2007
Chief complaint: 1. Pananakit
2. Poor sleep
3. Nambabato ng bahay
4. Nagbabasag ng gamit
Informant: Wife

2. Reason for Hospitalization

Her wife brings him here at Mariveles Mental Hospital, August 5, 2007 11:05 in
the morning. She said that his husband Nestor is not in normal mental state again. He
refused to take his medicine, he had sleep disturbance and the last time he forced his
daughter to get money to her and bought him cigarettes. And before that day, his husband
threw a stone at his neighbors’ house.

3. Family History of Mental Illness

According to his wife, he is the only one in the family having this mental illness.
His parents and relatives have the normal state. His family work and do their daily tasks
like any individual and possess good intention of living except him.

4. History of Present Illness

The patient is previously confined in Mariveles Mental hospital last March 2001,
the client flow up until October 2003. The last admission was August 5, 2007 (with
relatives).
According to his wife, when they got home after the first exclusion, his husband
was able to help in their financial needs. He work as a tricycle driver but still the money
that they earned is not enough to continue and support his medication that is why they
decided to stop taking his medicine. After a few weeks, he started to have signs and
symptoms of relapses. He became destructive “Nagbabasag ng kasangkapan at
Nambabato ng kapitbahay.” He always walks and kept panic. When his mother seen his
situation, she brought him medicines but the patient refuses to take it because he thinks it
was a poison. She heard their neighbor said “Papatayin na lang namin yan.” Therefore,
she decided to take him here in this mental institution again.
 5. Related Events/Situations to Present Health Condition

According to the medical doctor, Mr. Nestor has mental illness because of trauma
he experienced. One day, he said that he saw his father stabbed by his father’s friend and
after that incident, he never forget that. He also said that they have financial problem and
he thinks that their younger 11-year-old son was not his son. He think that his wife
having an affair with another man. However, he never confronted his wife about it in
afraid that his wife got angry.

6. Pre-Morbid Personality Assessment

During our interaction with the patient, he seems to be kind to us and eager to
answer our question. He does not hesitate to answer although we ask about his personal
life. We also noticed his kindness during the session. We almost think that we are talking
to a normal person. In addition, he possesses silence quite some time as he is thinking
something that we do not ask.

7. Course in the Ward

From August 2007 until now, according to Mr. Nestor, he only got one trouble
inside the hospital. The reason of that commotion is a stick of cigarette. From then on, he
never do that again because he wants to go home and return to his normal life.

8. Personal/Educational/Occupational/Marital History and

Significant Person to the Patient

The client is a high school graduate, a farmer and tricycle driver in occupation.
Sometimes, he is also a balut vendor at night to sustain their financial needs. He has a
doubt on his wife that she is having an affair. They have seven children; his sister adopts
two of them. He never tried to have an affair to other woman because he only wants to
have a simple and happy family. His two daughters are the special person in his life.
 9. Mental Status Examination

a) General Description

(1) Appearance

Seen this adult male in blue MMH uniform with short hair and nails, poorly kept
with body odor. With no slippers, like any body inside the hospital. Not so nourished, and
slim in built.

(2) Behavior and Psychomotor Activity

He is not harmful as we first thought about him. He responds in every question

that we gave. He also participates in exercise, games, drawings, or any program or
activities that we planned for them. He won in the “pinoy henyo” game.

(3) Attitude toward Examiner

He is sitting straight in front of us. He just staring to us at first, but in few

moments, he answers our questions. He respects our presence in excusing himself every
time he will go to the comfort room or when he wants to walk for a while.
 b) Psychopathophysiology

Modifiable Factors Non-Modifiable Factors

Substance abuse Genetic factors
Sleep deprivation
Stress

Imbalance Serotonin
and Norephinephrine level

Increase in Serotonin and

Norephinephrine

Chemical changes in the

brain

Kindling

Spontaneous seizure activity

in the brain

Hyperactivity

Signs and Symptoms Signs and Symptoms

(Book based)
Walking aimlessly Abnormal and persistent elevation of
Decreased sleep mood
Increased involvement in pleasure Agitative
seeking activity Gradiosity
Hallucinations Decreased need for sleep
Agitation Increase involvement in goal
Delusions directed activity
Hallucinations
 Psychodynamics

Balance between physiological safety needs (low Socio-economic)

Abraham Maslow Hierarchy of Needs

Orally fixated (smoking and drinking)

(Oral stage – Jean Piaget)

Disturbed Psychological Aspects (Chained by his wife)

(Maslow Hierarchy of Needs)

Fear (auditory hallucination)

(Collective unconscious – Carl Jung’s Theory)

Family constellation – Alfred Adler

Intimidate (High School graduate only)

(Cognitive Impairment – Jean Piaget)

Anxiety – Self-searching, unproductive (unable to sustain the family needs)

(Generatively versus stagnation – Eric Erikson)

Frustration and self-deficit

(Dorothea Orem)

Bipolar manic
 B. Planning

NURSING CARE PLAN

NURSING EVALUATION
CUES GOAL/OBJECTIVES INTERVENTIONS RATIONALE
DIAGNOSIS
 Client may harm
Subjective: Disturbed thought  Prioritize safety of the self or others in Goal met.
Short-Term Goal
“puro mga process related to client. disoriented, After a week of
sinungaling ang inability to trust as Within 1 week, client confused state. intervention, the
andito,” as evidenced by will start to recognize client able to
verbalized by the suspiciousness of and verbalize when recognize and
thinking is non-reality  Frequently orient  Disorientation may verbalize when
patient. others, resulting in
based. client to reality and endanger client
alteration in thinking is non-
surroundings. safety if he or she
societal reality based.
unknowingly
participation.
Long-Term Goal wanders away from
safe environment.
Client will experience  Try to redirect violent
no delusional thinking behavior with physical  Physical exercise is
by discharge from outlets for the client's a safe and effective
treatment. anxiety. way of relieving
pent-up tension.
 Encourage the client
to verbalize true  Verbalizing feelings
feelings. The nurse with a trusted
should avoid individual may help
becoming defensive client work through
when angry feelings unresolved issues.
are direct at him.
 C. Nursing management
Process recording

Client initials: Nestor

Sex: Male
Age: 42 years old
Date of birth: March 26, 1967
Address: Jaen, Nueva Ecija
Nationality: Filipino
Physical appearance: In blue MMH uniform, short hair, short nails, poorly kept and no slippers.
Description of the environment: Sunny day, clear environment and good atmosphere under the big mango tree.
Tentative diagnosis: Bipolar manic with psychotic features
Goals of intervention/Objective: To help the client to express thought and feeling.

Student question Patient response Therapeutic communication Rationale/Defense mechanism

 Ako po ay si Patria. Kayo po  Ako si Nestor.  Giving information  Informing the client of facts
ba, pwede ko po ba increases his knowledge
malaman ang inyong about a topic or let the client
pangalan? know what to expect. The
nurse is functioning as a
resource person. Giving
information also builds trust
with the client.

 Maari po ba kayong makinig  Sige.  Accepting  Accepting response indicates

at sumagot sa mga bagay- that the client has heard and
bagay na itatanong ko sa followed the train of
inyo? thoughts.
 Ano po ba ang trabaho ninyo  Dati akong tricycle driver  Exploring  When client deals with topic
bago kayo mapunta dito? tapos nagtitinda din ako ng superficially, exploring can
mais kasama ang asawa ko. help them examine the issue
more fully.

 Kuya, mayroon po ba kayong  Wala. Magtanung ka na lang.  Broad openings  Make explicit that the client
gustong ikuwento o sabihin has the lead in the
sa akin? interaction. For the client
who is hesitate about talking,
broad opening may
stimulates him or her to take
the initiative.

 Ano ang ginagawa mo kapag  Nakikipagkwentuhan ako sa  Encouraging description of  To understand the client. The
nalulungkot ka? kaibigan ko na si Inggo. perception nurse must see things from
his perspective. Encouraging
the client to describe the
ideas fully may relieve the
tension the client is feeling,
and he might not be less
likely to take action or ideas
that are harmful or
frightening.
 D. Evaluation and learning derived

1. The client physical appearance improved from poor to good hygiene.

2. The students had learned how to interact and understand the emotions
and coping mechanism.

3. The client showed interest in each therapy.

4. The client was able to express his/her own feelings and thoughts
during nurse-client interaction.
 E. Conclusion / Recommendation

As a conclusion, bipolar is a serious mental disorder that could lead to

serious of harmful situation or even complications that they could be manic
or depressed. According to the stimuli, that they encounter this disorder
needs careful handling and attentive support emotionally, because they could
be lacking from emotional support or attention from immediate family. Like
our client with the help also of other mental personnel. These mental
institution patient can be managed well and be free from the said disorder.

We recommend careful management and careful attention plus

support to those affected by the disorder and for those with symptoms of
said disorder, kindly report immediately into different or nearest mental
institution.
 Generic Brand Mechanism of Patient
Classification Contraindications Adverse Effect Nursing Interventions
name name Action Dosage
Lithium Priadel Antimanic Thought to disrupt 600mg (none)  CNS: Dizziness,  Advise patient to take
carbonate drug sodium exchange BID drowsiness, headache, with food or milk to
and transport in tremor, ataxia, slurred minimize G.I. upset.
nerves and muscles speech, hallucination  Advise to limit foods
and control re-  CV: bradycardia, and beverages
uptake of hypotension containing caffeine.
neurotransmitters.  Tell patient to maintain
adequate fluid intake.
 Emphasize importance
of having regular blood
tests to help detect and
prevent serious adverse
reactions.
Biperiden has an
Biperiden Akineton Anti- antropine-like 2mg Caution should be  Dry mouth  Advise the client to
parkinsonian blocking effect on OD observed in patient avoid dry, bulky, and
all peripheral with manifest irritating foods and
structures that are glaucoma thought no fluids such as tobacco
parasympathetic prohibitive rise in and alcohol.
innervated. intraocular pressure has  Advise client to talking
been noted following too much if not
either oral or parenteral necessary.
administration. Patient
with prostatism
epilepsy or cardiac
arrhythmia should be
given this drug with
caution.
 Generic Brand Mechanism of Patient
Classification Contraindications Adverse Effect Nursing Interventions
name name Action Dosage
Diphenhyramine Benadryl Antihistamine Interferes with 25mg PO  Hypersensitivity to  CNS: drowsiness,  Advise patient to avoid
, antitussive, histamine effect at HS drug headache, paradoxical alcohol and other
antiemetic, histamine receptor  Alcohol intolerance stimulation depressant such as
antivertigo sites; prevents but  Acute asthma attack  CV: hypotension, sedatives.
agent, does not reverse  MAO inhibitor use tachycardia,  Caution patient to
antidyskinetic histamine-mediated within 14 days palpitations avoid driving and other
response. Also  Breastfeeding  EENT: blurred vision, hazardous activities
possesses CNS  Neonates, premature tinnitus until he knows how
depressant and infants  GI: diarrhea, drug affects
anticholinergic constipation, dry concentration and
properties. mouth alertness.

Chlorpromazine Antipsychotic May block 10mg  CNS: sedation,  Tell patient to take
 Hypersensitivity to
hydrochloride , anxiolytic, postsynaptic BID drowsiness, capsule or tablets with
drug
antiemetic dopamine receptors extrapyramidal a full glass of water,
 Angle-closure
in brain and depress reaction, tardive with or without food.
glaucoma
areas involved in dyskinesia,  Instruct patient not to
wakefulness and  Bone marrow
depression pseudoparkinsonism, crush sustained-release
emesis. Also seizure capsules.
possesses  Severe hepatic or
cardiovascular  CV: tachycardia,  Tell patient to mix oral
anticholinergic, hypotension concentrate in juice,
antihistaminic, and disease
 EENT: blurred vision, soda, applesauce, or
adrenergic-blocking pudding.
dry eyes, lens
properties.  Caution patient to
opacities, nasal
congestion avoid driving and other
 GI: constipation, hazardous activities
ileus, anorexia, dry until he knows how
mouth drug affects
 Hepatic: jaundice, concentration and
hepatitis alertness.