Case Presentation of Bipolar Affective Disorder, Current Episode, Manic with Psychotic Disorder

A. INTRODUCTION

Psychiatric area is one area of exposure of the nursing students. Our group was lucky enough to

be assigned at the psychiatric area at BGHMC (Baguio General Hospital and Medical Center). The group

had encountered several common psychiatric disorders like the different types of schizophrenia and

bipolar disorders. The group had chosen to study Bipolar Affective Disorder, current episode, manic

with psychotic disorder. The group had chosen this type of disorder for us to understand and appreciate

this type of psychiatric ailment.

Bipolar disorder or manic-depressive disorder which causes mood swings that ranges from the

lows of depression to the highs of mania. In some cases, bipolar disorder causes symptoms of

depression and mania at the same time. Bipolar disorder causes serious shifts in mood, energy, thinking

and behavior from the highs of mania on one extreme to the lows depression on the other. More than

just a fleeting good or bad mood swings, the cycles of bipolar disorder last for days, weeks, months or

even a year. Unlike ordinary mood swings, the mood changes, bipolar disorder is so intense that it

interferes with your ability to function.

If the client is under mania, the common signs and symptoms includes feeling that are unusually

high, optimistic and very irritable, unrealistic, grandiose belief about one’s abilities or powers, sleeping

less but feeling extremely energetic, talking so rapidly, racing thoughts, jumping quickly from one idea to

the next, highly distractible, impaired judgement and impulsiveness, acting recklessly without thinking

about the consequences and lastly in severe cases, delusions and hallucinations may appear.

If the client is under depressive, the common signs and symptoms are decreased energy, easy

fatigability, lethargic, has diminished activities, insomnia or even hypersomnia, usually lost of interest in

pleasurable activities and lastly social withdrawal.

B. PATIENT’S PROFILE

Name: Mr. I.E.R

Age: 56 years old

Birthday: July 4, 1953

Civil Status: Married

Address: Km8 Asin road, Tuba, Benguet

Religion: Roman Catholic

Nationality: Filipino

Date of Admission: June 11, 2010

Time of Admission: 7:35 PM

Admitting Diagnosis: Bipolar Affective Disorder, Current

Episode, Manic with Psychotic Disorder

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C. ASSESSMENT

1. Psychiatric History/Developmental History

The patient is born via NSVD (normal spontaneous vaginal delivery), no known

complications and abortion attempts of the mother. According to the patient he was both

breastfed and bottlefed up to 1 ½ years of age. He was also toilet trained by his parents.

He further claimed that he was pampered by his parents with love and affection as well as

with other things like toys, books and clothing. Basically, he had a good childhood

experience as claimed.

During his school age, he remembered that he does not participate in school activities

and seldom mingle with his classmates. He further claimed that he is respectful to elders

especially to his parents and grandparents. During his high school years, he experienced

being involved with fist fights with the bullies. He remembered he was never separated

from his family and was able to finish his degree in mechanical engineering.

He was married at the age of 36 years old. After how many years, his wife gave birth to a

baby boy. They then decided that the husband will go abroad in Saudi Arabia and work as

a mechanical Engineer while his wife is left with the son in the Philippines. After how many

years, they decided to switch, the husband was left with the baby and his wife went

abroad to Saudi to work as a nurse at a hospital. With this set up of a long distance

relationship which is too hard to handle. Being away from your wife and being with your

son for several years. His wife has only quality time for them whenever she comes home

for vacation. Whenever his wife comes home for a vacation, he is usually very happy.

According to the patient, the most traumatic experience he had is the death of his

sister. It was during this time that he knew that his sister died to an accident, due to

financial matters he wasn’t able to attend his sister’s burial. That is the time he feels very

sad because he claimed that he was really close to his sister. For his other siblings, he

visits them occasionally and whenever there was a problem with one of the member of

the family he and the others would lend their hands and intervene to any problem to

resolve it.

He and his neighbor misunderstood each other, but not identified, every now and then

they are almost having an argument. The son saw his change of reactions and behaviors 5

days prior to admission like auditory hallucinations, illusions, mood swings, he keeps on

digging at their backyard and always saying that “may ginto sa likod ng bahay natin”.

Now at his age of 56 years old, he was admitted because of the presence of

hallucinations, illusions and delusions. He claimed that he was brought to the hospital

because of his hypertension. Often times he sits on his bed or lie down and sleep, he

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usually don’t mingle with the other patients but feels comfortable when talking to student

nurses.

2. History of Present Illness

The patient could remember that his mother told him that when he was sick with chickenpox and measles, he had high fever and convulsion. Aside from this, patient claimed he was generally healthy as a child.

During his school age, he claimed that he was shy. He does not participate in

school activities and seldom mingle with his classmates but as he grows up, he further

claimed that he feels more comfortable with girls and so he has more female friends than

boys. At the age of 15, after he graduated from high school, he then have to be separated

to his family because he enrolled to one of the schools in Baguio to finish his college

degree. It was his first time to be separated from his family and so he felt so sad.

During his college years, he learned to be independent and so he was able to finish his

chosen field of mechanical engineering. After graduating, he decided to work abroad in

Saudi to earn his own money. He then met his wife who is a registered nurse in one of the

Hospitals in Saudi. They got married and blessed with a son. In order to sustain their needs

of the family, he continued to work abroad leaving his family in Zamboanga. They decided

that his wife will go abroad also leaving their son with him. With this set up of a long

distance relationship which is too hard to handle. Being away from your wife and being

with your son for several years. His wife has only quality time for them whenever she

comes home for vacation. Whenever his wife comes home for a vacation, he is usually

very happy.

According to the patient, the most traumatic experience he had is the death of his sister.

It was during this time that he learned that his sister died from an accident, due to

financial matters he wasn’t able to attend his sister’s burial. That is the time he feels very

sad because he claimed that he was really close to his sister. For his other siblings, he

visits them occasionally and whenever there was a problem with one of the member of

the family he and the others would lend their hands and intervene to any problem to

resolve it.

In the case of our patient there was no mental illness in the family. However, he was

only diagnosed with hypertension before admission at the Psychiatric Hospital. The time he

was firstly observed with manifestations of the disorder the patient was into treasure

hunting. He claimed that he met an old woman that was dictating him what to do and

where to hunt. He claimed that the old woman manipulated him to do it. Since then, the

patient would dig around their backyard and was preoccupied with doing unnecessary

things, but the patient wouldn’t forget his position in the family and would do household

chores and would act accordingly. He was helpful with doing house chores but noticed that

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he had lost his social life. His friends were not visiting him anymore and vice versa. Soon

after, the patient’s wife came home from Saudi, and around that time he was observed to

be normal again, the patient stopped his treasure hunting activities and also claimed that

he stopped seeing the old woman. He was observed to be happy during those times. The

wife then went back to Saudi and after sometime the patient resumed his usual activities of

digging around their house. The patient started to mumble, and would walk around the

house to and fro and he would utter incoherent words.

Five days prior to admission, the patient felt abnormally good, high, excited, hyperactive

and irritable. This was extreme since the patient lost contact with reality and started to

believe strange things. He had poor judgment and behaved in harmful ways which was

dangerous. This was accompanied by an elevated mood and he had reduced sleep. He had

optimistic ideas and plans were expressed. The patient developed symptoms of

hallucination and delusion. One day prior to admission, the patient kept on saying S.B, who

was the patient’s relative who worked in a mining company. After he went to Balatoc

Mines, during the night when his son was watching t.v. the patient came close to him

saying, “Sino ka… sino ka?... P.F. (their neighbor whom he always had an argument with).

So, the son introduced himself. Afterwards, the patient went to his room shouting over and

over again. Out of fear, the son called their relatives and asked help from the nearby police

station to get the patient. The patient was seen half naked, praying on the road, kissing the

ground and saying that he is the savior. The patient had a bag of stones and books saying

he would go home to Zamboanga leaving the treasure to his son. He was held and brought

to the institution hence the admission. Hence patient I.R., 56 years old was admitted and

diagnosed with bipolar affective disorder, current episode, manic with psychotic

symptoms.

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3. Mental Status Examination

A. APPEARANCE

The client appears to be well groomed. Mr. I.R. has a noticeably proper cut hair and

is well combed. Mr. I.R. wears clothing appropriately depending on his mood and with the

weather. Mr. I.R. refers wearing long sleeves but when it is hot, he wears the usual t-shirt

along with his shorts or any available pants he has. For 3 consecutive days of duty, it was

observed that he only took a bath on the third day then changed his clothes; the patient is

observed to brush his teeth before and after meals. His nails are trimmed and his beard and

mustache are neatly shaved. The client appeared as the stated age of 56 years old with

visibly white hair and some noticeably wrinkles on his face.

B. BEHAVIOR

1. MANNER OF RELATING

Mr. I.R. is participative during discussion. He actively and openly answers queries being asked to him by the student nurses. He sometimes cracks jokes that make the conversation lively. He usually prefers to talk with student nurses rather than to his co-patients inside the ward.

2. PSYCHOMOTOR ACTIVITES The patient has a good posture. However, he sometimes slouches during

conversation with his legs and arms crossed and sometimes with his hands on his lap, swaying his feet while looking around the room. He usually stay on bed sitting or if not, sleeping. Patient has good posture, gait and station. He was observed to walk straight. He has mild hand tremors observed.

3. SPEECH/LANGUAGEThe client talks with normal rate, rhythm and intensity. He speaks clearly and has

good articulation of words. He elaborates his answers to questions asked and sometimes, he shares some topics to be discussed. It was also observed that he can easily find the right words to use when lost during conversation. To explain further what are his thoughts. Patient is able to talk in English, Tagalog and Ilokano fluently.

4. RELEVANCE/COHERENCEThe client was able to answer relevantly and coherently. He used simple,

concrete and easy to understand responses to the topics being discussed during the NPI (Nurse-Patient-Interaction).

5. DEVIATIONSThere were no deviation like inventing, rhyming, stammering, clanging of words,

repetition of words and speeches in particular questions being asked by the student nurses noted.

6. VOCABULARYThe patient uses appropriate terms to use when conversing. He sometimes use

terms related to his field of engineering such as the different machineries and gadgets he encountered while he is still studying and working abroad. Patient is able to adjust his choice of words depending on whom he is talking to. He would use simple words to his co-patient while he uses more complex vocabularies to the health care providers.

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C. MOOD and AFFECT

Mr. I.R. stated “okay naman pero minsan nadedepress”. It was observed during

the conversation that whenever the discussion deals with his wife finding time visiting

him, he feels very happy and is seen smiling. However, when the topic is about the

incident where he wasn’t able to visit his sister and dad’s burial, he becomes very sad

with teary eyes.

D. THINKING

During the conversation, Mr. I.R. was able to discuss topics concerning religion,

philosophy and history. He was able to discuss recent events of the world and how

these are predicted by previous events. He also talks about his work and how was he as

an employee when he works abroad. He talks about his family often and mentioned

“Yung asawa ko nagwork sa Saudi at may isa akong anak.. Maaga nakapag asawa. May

isa na akong apo.” There was no paranoid delusions observed from the client. However

the patient was observe to avoid topics which concern on the reasons why he was

brought to the hospital. Mr. I.R. is oriented to person, place, time and self. He can

identify who brought him to the ward.

The patient is able to recall recent and past events in his personal history. He can

still recall up to now that he’s 56 years old the memorable experience he had when he

was 6 years old which made his parents got mad. He said “May ilog kasi doon malapit sa

bahay namin. Naliligo kami ng walang paalam kaya pag-uwi namin, palagi kaming

nabubuking kaya napapalo kami”.

When the patient was asked to tell the name of one of our co-student nurse that

was introduced to him for no longer than 15 minutes, he said “ Si Earl, oo yung mataba.

Siya yung una kong nakita nung pagpasok niyo. Malaking tao kasi.”.

E. ABSTRACTION

When the patient was asked of how did he understand the saying “A hard

beginning maketh a good ending.” He responded immediately “ Parang ganito sa

situation ko, para akong nakakulong ngayon pero there’s a purpose why I am here

however taking that all into consideration, I am positive that this turmoil is to make me

and my family stronger than before”.

1. CALCULATION AND CONCENTRATION

The patient was able to compute simple mathematical equations as fast as 5 to

10 seconds when asked to answer “9 x 23=___”. He can concentrate even if the ward

seems so noisy.

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2. INSIGHT

When he was asked how can he sees himself as a father to his child, he simply

said “ I have been a good father or a parent. In fact not only that, I know I have been a

good husband to my wife kasi ginawa ko lahat para mabigyan sila ng magandang buhay

sa pamamagitan ng pagtatrabaho ko at pagtitiis ko sa Iran for income out of hard

work.”He also claimed “Hypertension talaga problema ko. Hindi naman ako baliw. Wala

akong nakikita o nakakausap o naririnig na gaya ng naririnig at nakikita nung iba kong

kasamahan dito”.The patient mentioned also “ Magbabakasyon muna ako sa

Zamboanga pagnakalabas ako dito para makapagpahinga na din. Kasama ko ang asawa

kong pupunta siguro.”

3. JUDGMENT

The client mentioned along with the discussion that he had some fight with his neighbor and was asked of what he will do when he sees his neighbor again and he said “Makikipag ayos na ako. Siguro nga talagang kailangan na ng peace-of-mind kaya makipag=ayos na”.

F. SUPEREGO FUNCTIONING/IMPULSE CONTROLThe client stated that “Noong hindi ko natulungan yung ate ko financially at

noong hindi ako nakapunta nung burol nya” when he was asked what he or makes him guilty or what he regrets the most.

G. SELF- CONCEPTThe patient has low self-esteem as he is shy and he doesn’t mingle or talk with

the other patients in the ward. When conversing with him he often focuses on his positive behavior like being a good husband to his wife and father to his son, which indicates that he is trying to elevate his self-esteem.

H. PHYSICAL COMPLAINTS/PROBLEMSThe client doesn’t have any physical deformities. He is slow when walking because

of aging. He has tremors and claimed that “Ganito ‘to kasi side effect ng gamot”, which indicates a circulatory problem because of HPN.

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D. DIAGNOSTIC EXAMINATION

Date of Procedure Diagnostic Procedure

Description Results Normal Values Significance

June 12, 2010 Urinalysis This test detects ion concentration of the urine. Small

amounts of protein or ketoacidosis tend to elevate results of the specific gravity.

Specific gravity is an expression of the weight of a substance

relative to the weight of an equal volume of water.

Color: yellow

Transparency: Slightly Turbid

Reaction/pH: 6.0

Specific Gravity: 1.020

Protein: Neg

WBC: None

Epithelial Cells: Rare

Bacteria: None

Amorphous urates/PO4: Occasional

Normal

Normal

Normal

Concentrated urine

Normal

Normal

Normal

Normal

There is a presence of amorphous urates due to

prolong refrigeration.

The specific gravity of your urine is measured by using a

urinometer. Knowing the specific gravity of your urine

is very important because the number indicates

whether you are hydrated or dehydrated.

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Date of Procedure Diagnostic Procedure

Description Results Normal Values Significance

June 17, 2010 CBC (Complete Blood Count)

The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood.

RBC - 4.32 x 1012/L

WBC -10.4 x 109/L

Lymph # -2.7 x 109/L

Mid # -0.9 x 109/L

Gran # -6.8 x 109/L

Lymph % -26.2 %

Mid % -8.2%

Gran % - 65.65

Hgb - 141 g/L

HCT - 0.433/L

MCV - 99.8/L

MCH -32.4 pg

MCHC -325 g/L

4.6 – 6.2 x 1012/L

4.5 – 11.0 x 109/L

0.8 – 4.0 x 109/L

0.1 – 0.9 x 109/L

2.0 – 7.0 x 109/L

20.0 – 40.0 %

3.0 – 9.0 %

50.0 – 70.0 %

135 -180 g/L

0.4 – 0.54/L

78.0 - 100.0/L

27.0 – 31.0 pg

320 – 360 g/L

The significance of this laboratory procedure is to mainly includes the care and treatment of patients with conditions that will result in increases or decreases in the cell populations

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RDW-CV - 13.1 %

RDW-SD - 48.6/L

PLT - adequate

MPV - 6.8/L

PDW - 15.5/L

PCT - 0.184 %

11.5 – 14.5 %

35 – 56/L

7.0 – 11.0/L

15.0 – 17.0/L

0.108 – 0.282 %

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E. PSYCHOPATHOLOGY

1. Biological Cause

A. Neurotransmitter Alteration

A.1 Increase Dopamine

- Overproduction of dopamine causes the nerve circuits to misfire and create a

split state in the mind where delusions and hallucinations make the reality of the

outside world easier to accept

A.2 Increase Serotonin level

- An increase in serotonin levels indicates Mania / Manic in Bipolar Disorder.

Because he has the three signs of mania which are Auditory Hallucinations,

delusions and paranoia

A.3 Decrease Serotonin Level

- A decrease in serotonin levels indicates depression. He has the symptoms of

depression like social withdrawal, low self-esteem and persistent sadness

B. Genetic Predisposition

B.1 Being Shy

- He has the presence of the type A personality, which is inherently acquired

thus he has poor IPR to others

2. Psychosocial Causes

A. Development of Mistrust

- It is according to Freud’s Psycho-social theory. Presented by poor IPR to other

people, unable to express feelings, lack of close friends, isolates self, social

withdrawal

B. Cultural Norms

- Because they have a close-knit family

C. Traumatic Experience

C.1 Separation from family members

- Being alone and independent in an area that is unfamiliar

C.2 Death of his Sister

- As presented by Long term depression

C.3 Living alone for several years

- As manifested by anxiety and fear

D. Use of Defense Mechanism

- Ineffective use of Denial as manifested by unrealistic perception of the situation

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PSYCHODYNAMICS

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Neurotransmitter Alteration

Dopamine

Auditory hallucinations

Serotonin

Increase Decrease

Manic Depressive

Signs and Symptoms:

-Agitation-Hyperactivity-Racing Thoughts-Delusions of Grandeur-Illusions-Hallucinations

Signs and Symptoms:

-Insomnia-Persistent sadness-Social withdrawal-Low self-esteem-Difficulty Concentrating

Chronic Low Self-esteem

Genetic Predisposition

Type A personality

Psychosocial Causes

Development vs. Mistrust

Cultural norms

Poor IPR to other people

Close-knit family

-Unable to express feelings

-Lack of close friends

-Isolates self

-Social withdrawal

Traumatic Experience

Separation from family

Death of his sister

Living alone for several

years

Anxiety

Long term depression

Use of defense mechanism

Activation of the SNS (fight or flight response)

Stress

Blood Pressure, pulse rate, respiration

Altered cardiovascular

status

Ineffective

Unrealistic perception of the

situation

Risk for injury

Bipolar Affective Disorder, Current Episode, Manic with Psychotic Disorder

Denial

Over production of dopamine causes nerve circuits to misfire and create a split state in the mind

Delusions

Paranoia

Hypertension

Causing disturbed visual

field and postural

imbalancePoor compliance to treatment regimen

-medicine

Possible separation to wife

Risk for relapsed episode

Being shy

F. DRUG STUDY

Generic name

Trade name

Classification DosageStart and

Completion of Medication

Mechanism of Action Indication Side Effects Nursing Consideration

Amlodipine besylate

Norvasc

Calcium channel blocker

Antianginal drug

Antihypertensive

Dosage: 10 mg 1 tab OD

Date started:06/17/10

Blocks the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. coronary artery disease

>Essential hypertension, or in combination with other agents

CNS: dizziness, light-headedness, headache, fatigueCV: peripheral edema, arrhythmiasDERMATOLOGIC:Flush, rashGI: nausea, abdominal discomfort.

>Monitor the patient’s BP, cardiac rhythm, and output while adjusting drug to therapeutic dose.>instruct client to swallow the tablet whole with or without food as directed by the physician.>Instruct client to take with meals if stomach upset occurs.> tell the client to report irregular heartbeat, shortness of breath, swelling of hands and feet, pronounced dizziness or constipation.

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Generic name

Trade name




Clonidine hydrochloride

Catapres

Antihypertensive Dosage: 75 mg. 1 tab SL fo BP ≥ 140/90

Date started:06/14/10

Stimulates CNS alpha2

adrenergic receptors, inhibits sympathetic cardioaccelerator and vasoconstrictor centres, and decreases sympathetic outflow from CNS.

>For hypertension CNS: drowsiness, sedation, dizzinessCV: CHF, orthostatic hypotension, tachycardia, palpitationsGI: dry mouth, constipation, nauseaGU: impotence, decreased sexual activity, diminished libido

>monitor BP carefully, when discontinuing clonidine, hypertension usually returns within 48 hours.>Take the drug exactly as prescribed. The drug should be put under the tongue. >Do not discontinue drug unless so instructed.> tell the patient that discontinuing abruptly, life threatening adverse effects may occur.

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Generic name

Trade name




Lithium carbonate

Carbolith

Antimanic drug Dosage: 450 mg 1 tab BID

Date started: 06/12/10

Alters sodium transport in nerve and muscle cells, inhibits release of norepinephrine and dopamine, but not serotonin from stimulated neurons, slightly increases intraneural stone of cathecolamines; decrease intraneuronal content of second messengers and may the by selectively modulate the responsiveness of hyperactive neurons that might contribute to the manic state.

Treatment of manic episodes of manic-depressive illness.

CNS: lethargy, slurre d speech, muscle weaknessGI: nausea, vomiting, diarrheaGU: pyloria

>Give drug with food or milk after meals.>Monitor clinical status closely>take this drug exactly as prescribed, after meals or with food or ,milk>Instruct client to open mouth and lift tongue to check for the drugs.

>tell the patient to eat a normal diet with a normal salt intake, maintain adequate fluid intake.

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Generic name

Trade name




Haloperidol

haldol

antipsychotic Dosage: 10 mg deep IMx 3 doses PRN for severe psychotic agitation.


Haloperidol interferes with the effects of neurotransmitters in the brain which are the chemical messengers that nerves manufacture and release to communicate with one another. It blocks receptors for the neurotransmitters (specifically the dopamine and serotonin type 2 receptors) on the nerves. As a result, the nerves are not "activated" by the neurotransmitters released by other nerves

Management of manifestation of psychotic disorders.

CNS: drowsiness, insomnia, headacheautonomic: drymouth, salivation, nasal congestionCV: hypotensionhematologic: eosinophilia, leukopenia

>Take the drug with food or exactly as prescribed.>Do not dilute this with coffee, tea, colas or apple juice - the medication may lose effectiveness.>Do not stop taking this drug suddenly without consulting your doctor.>Instruct client to open mouth and lift tongue to check for the drugs.>Instruct client to Avoid engaging in other dangerous activities. If dizziness or drowsiness or vision changes occurs.

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Generic name

Trade name




diphenhydramine

Benadryl

AntihistamineAntiparkinsonian

Dosage: 50 mg. IM q 1 hr. x 3 doses PRN for severe psychotic agitation with BP precaution


Competitively blocks the effects of histamine at H1-

receptor sites, Diphenhydramine also blocks the action of acetylcholine (anticholinergic effect) and is used as a sedative because it causes drowsiness

Parkinsonism (including drug induced parkinsonism and extrapyramidal reactions), in the elderly tolerant of the more potent agens, for milder form of disorders in other age groups, and in combination of centrally acting anticholinergic antiparkinsonian drugs.

CNS: drowsiness, sedation, dizzinessCV: hypotension, palpitation, bradycardiaGI: epigastric distress, anorexia, GU: urinary frequency, dysuria thrombocytopeniaHepatic: hemolytic anemia

>Administer with food if GI upset occurs.>Monitor patient’s response.>take as prescribed, avoid excessive dosage>Instruct client to open mouth and lift tongue to check for the drugs.>tell the client to report difficulty of breathing, tremors, unusual bleeding or brusing, irregular heart beat.

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Generic name

Trade name




Chlorpromazine

Thorazine

Antipsychotics Dosage: 200 mg. ½ tab AM; 1 tab in HS

Date Started: 06/12/10

Block dopamine receptors in the brain; also alter dopamine release and turnover.

Management of manifestation of psychotic disorders; control of manic phase of manic depressive illness.

CNS: neuroleptic malignant syndrome, sedation, CV: hypotension EENT: blurred vision, GI: constipation, dry mouth, anorexia, GU: urinary retentionHematologic: leukopenia

>Assess mental status prior to and periodically during therapy.>Monitor BP and pulse prior to and frequently during the period of dosage adjustment.>Observe patient carefully when administering medication.>Instruct client to open mouth and lift tongue to check for the drugs.>Advice patient to take medication as missed doses as soon as remembered, witih remaining doses evenly spaced throughout the day.

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Generic name

Trade name




Biperiden

akineton

antiparkinsonian Dosage:2 mg. 1 tab OD

Date started:

06/12/10

Anticholinergic activity in the CNS that is believed to helpnormalize the hypothesized imbalance of cholinergic and dopaminergic neurotransmitter in the basal ganglia of the brain of a parkinsonism patient. Reduces severity of rigidity, and to lesser extent, akinesia and tremor characterizing parkinsonism.

Adjunct in the therapy of parkinsonism (post encephalitic, arterioschlerotic, and idiopathic types)

CNS: disorientation, confusion, memory loss, hallucinationCV: tachycardia, palpitations, hypotensionDermatologic: rash, urticariaGI: dry mouth, constipation, dilatation of colon

>Give with meals if GI upset occurs, give before meals for clients who have dry mouth, give after meals if drooling or vomiting occurs.>Take the drug as prescribed.>Instruct client to open mouth and lift tongue to check for the drugs.> tell patient to report difficult or painful urination; constipation, rapid pounding of the heart, confusion, eye pain or rash.

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G. PRIORITIZATION

RANKING NURSING DIAGNOSIS/ PROBLEMS JUSTIFICATION

1

Altered cardiovascular status related to increase pressure secondary to

Hypertension

Airway, breathing and circulation concept states that circulation should

always be the third to be assessed. And if the heart doesn’t work normally, the

other systems and their functions will be affected. The aorta is the largest artery of the body that extends from the left

ventricle of the heart to begin the distribution of oxygenated blood throughout the rest of the body,

narrowing and clogging of aorta brought about by fatty deposits causes a

decrease in the blood flow from the left ventricle into the systemic circulation. This obstruction creates a resistance to ejection and increased pressure in the

left ventricle.

2 Chronic low self-esteem related to impaired cognitive self-appraisal AEB negative feedback about self

We ranked this as our second priority because People with chronic low self esteem

issues often spend more time worrying about the future, or dwelling on mistakes

that they've made in the past, that they fail to enjoy the here and now moments in life. Without the self esteem to believe they can accomplish something new, fear keeps the

sufferer from asking for that promotion; going on a date with the person they're

attracted to; or even getting on that roller coaster with their kids.

3

Ineffective denial related to inability to tolerate the consequences of

known disorder

For most persons, everyday life includes its share of stressors and demands, ranging from family, work, and professional role

responsibilities to major life events such as divorce, illness, and the death of loved ones. How one responds to such stressors depends

on the person’s coping resources. Such resources can include optimistic beliefs,

social support networks, personal health and energy, problem-solving skills, and material

resources. Socio-cultural and religious factors may influence how people view and

handle their problems. Vulnerable populations such as elderly patients, those in adverse socioeconomic situations, or those

who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic

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stressors.

4

Risk for injury related to imbalanced between oxygen supply and demand

secondary to hypertension

Risk for injury is one of the most common complications of hypertension that is why it

is the prioritized potential problem. Patient’s having hypertension are prone to injury

because of the imbalance in their oxygen supply and demand causing disturbed visual field and postural imbalance. If this potential

problem is not given immediate attention, this may cause a more serious problem to

the patient.

5 Risk for relapsed episode maybe R/T poor medical treatment regimen

compliance

We ranked this as the least priority because the chances of having relapse episode are

about 40% is needs are not satisfied, majority of psychiatric clients are r/t poor

compliance to medical treatment

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H. NURSING CARE PLAN

NCP ACTUAL #1: ALTERED CARDIOVASCULAR STATUS R/T INCREASE PRESSURE SECONDARY TO HYPERTENSION

ASSESSMENT EXPLANATION OF THE PROBLEM

GOALS AND OBJECTIVES

NURSING INTERVENTION RATIONALE EVALUATION

S>” Problema ko tong BP ko, tumataas” Bp- 150/100

O> Fluctuating BP of 140/100 to 150/100

>Feeling of dizziness like when going to the comfort room

>Increase respiratory rate

>Fast breathing

A> Altered cardiovascular status related to increase pressure secondary to Hypertension

Patient has a history of hypertension. During admission until the third day patient has a fluctuating BP of 130/100 to 150/100, this was caused by over excitement when his wife came home from Saudi and stress that causes sympathetic nervous system (that stimulates the fifgt or flight response) over activity increasing hearts contractility over stress.

Source:

Brunner and Suddarth’s Medical-Surgical Nursing 7th

edition

STO: After 1 hour of health teaching, patient will be able to demonstrate understanding of techniques and ways to prevent further increase of blood pressure like:

a. Waking up slowly on bed and resting before walking

b. Proper Deep breathing exercises

LTO: After 3 days of nursing intervention, the Blood pressure will be maintained at 130/90 from 150/100

Dx: >Monitored vital signs especially BP>Assessed contributory factors of increase BP

Tx: >Assisted in getting up slowly from bed to bedside or from supine to moderate high back rest>Assisted in going to the comfort room or using the commode if necessary>Promoted adequate rest by decreasing stimuli, providing quiet environment and scheduling activitiesEdx: >Instructed to report shortness of breath, chest pain or any discomfort>Emphasized importance of diet low fat, low sodium >Reiterated religious taking of medication>Encouraged rest periods as necessary

>Note response to activities>To know the appropriate intervention>Patient might be getting up of bed in the wrong way which may add up in the increase BP

>To provide safety

>To maximize sleep periods that provide good energy source

>Immediate interventions will be done

>To maintain normal BP

>To help regulate BP

>To prevent sudden increase of BP

STO: Goal met, patient was able to demonstrate understanding and techniques to prevent increase of BP

LTO: Goal met, patient’s Bp was maintained at 130/90

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NCP ACTUAL #2: CHRONIC LOW SELF-ESTEEM R/T IMPAIRED COGNITIVE SELF-APPRAISAL AEB NEGATIVE FEEDBACK ABOUT SELF

ASSESSMENT EXPLANATION OF THE PROBLEM GOALS AND OBJECTIVES INTERVENTION RATIONALE EVALUATION

S>“ang asawa ko ang nagtratrabaho para sa min, ako pa man din ang lalaki wala akong magawa”

O> Feels guilty and shame when talking about his wife who works for them

>Noted attitude of shyness

> Unable to communicate with this co-patient

> Took a bath on the third day only

A> Chronic low self-esteem related to impaired cognitive self-appraisal AEB negative feedback about self

Mr. ICI wife is a nurse working in Saudi. She is the one who’s working for their family, taking charge for all their expenses, providing support for their family and taking already the seat as the bread winner of their family. Mr. ICI felt so bad with that because he should be the one who’s doing all of that stuff. He felt shame and guilty to his present situation. To compensate to his shortcomings he made use himself by doing household chores and becoming responsible in taking care of his son but these were not enough to show that he is useful and not enough to show his worth as father. All of the things that he did were in turn inadequate for him which led him to have a chronic low self-esteem.

Source:

LTO: After 3 days of nursinginterventions, the client will be able to verbalize understanding of individual’s role in the society regardless of their gender

STO: After 8 hours of appropriate nursing interventions, the client will be able to increase self-esteem through:

a. Giving positive feedback

b. Focusing topics such as on the client’s accomplishments in life

c. Reinforcing the personal strengths and positive perceptions that the client identifies

PDx > Established

Rapport

>Assessed presence of negative attitude and or self talk

> Assessed existing strengths and coping abilities, and provide opportunities for their expression and recognition

>Notednon-verbalbehavior

>Usedpositivemessages

Individuals with low self-esteem are reluctant to discuss true feelings

Re-enforcement of communicating and interacting with others could stimulate to enhance self-esteem

Incongruence’sbetweenverbal/non-verbalcommunications requireclarification.

To assist client to develop internal sense of self-esteem

Supporting a client’s beliefs and self-rejection and helping them cope can affect self-esteem

LTO: Goal met if

The client is able to verbalize understanding of individual’s role in the society regardless of their gender

STO: Goal met

The client was able to increase self-esteem through giving positive feedback, was able to appreciate his accomplishments in life and was able to

identify his strengths and positive perceptions

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www.medscape.com/viewprogram rather thanpraise.

Tx>Maintained therapeutic communication

> Rendered positive feedback

>Focused on accomplishments

Edx> Encouraged participation in group activities. Caregiver may need to accompany client at first, until he or she feels secure that the group members will be accepting, regardless of limitations in verbal communication

>Encouraged client's attempts to communicate. If verbalizations are not understandable,

To facilitate trust during interaction

To increase self-esteem

To lift self-esteem

Positive feedback from group members will increase self-esteem

The ability to communicate effectively with others may enhance self-esteem

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express to client what you think he or she intended to say. It may be necessary to reorient client frequently

>Reinforced the personal strengths and positive perceptions that the client identifies.

>Gavereinforcementfor progressnoted.

Clients with low self-esteem need to have their existence and value confirmed

Givereinforcementfor progressnoted.

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ASSESMENT

S>” Hypertension naman talaga ang problema ko. Hindi ako baliw. Wala naman akong nakikita o nakakausap o naririnig na gaya ng naririnig at nakikita ng ibang kasamahan ko dito.”

O> Does not mingle to other roommates.

>Always stays in his bed.

>Only interacts to nurses, doctors, family members and student nurses.

A> Ineffective denial related to inability to tolerate the

EXPLANATION OF THE PROBLEM

One cause of bipolar disorder is stressful life events these are thought to be the main element in the development of bipolar disorder. In our patients case one factor that could be seen is the loss of his job making his wife work for him and one more thing is that he is left alone while his wife is abroad.

A symptom of bipolar that contributes for the patient to deny his known illness is exaggerated self-esteem.

Source: http://bipolar.about.com/cs/bpbasics/a/what

_causes_bp.htm

.

GOALS AND OBJECTIVES

STO:After 1-2 hours of appropriate nursing intervention the patient will verbalize feelings congruent with behavior.

LTO: After 2-3 days of appropriate nursing interventions the patient will meet psychological needs as evidence by appropriate expression of feelings.

INTERVENTIONS

P/Dx> Observed behavioral responses

>Assessed ability to respond or interpret questions.

> Assessed triggering factor that may stop your client from talking to you.

Tx> Minimized discussion of negative personal problems within clients hearing.

>Listened attentively to what the patient says.

>Provided positive reinforcement.

RATIONALE

> Shows if the patient could interact and interested to therapeutic regimen

> To explore hidden thoughts and feelings that the patient might not show through his facial expressions.> knowing the trigger factors could help you determine what to do if the patient shows.> Client may misinterpret and believe references are to him.

> Showing interest while the patient talks boost his confidence to share more.

> Positive reinforcement will help the patient change his mood like sadness, but

EXPECTED OUTCOME

STO:Goal met if the patient was able to feelings congruent with behavior.

LTO:Goal met if patient meet psychological needs as evidence by appropriate expression of feelings.

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NCP ACTUAL #3: INEFFECTIVE DENIAL R/T INABILITY TO TOLERATE THE CONSEQUENCES OF KNOWN DISORDER

http://bipolar.about.com/cs/bpbasics/a/what_causes_bp.htm

http://bipolar.about.com/cs/bpbasics/a/what_causes_bp.htm

consequences of known disorder.

Edx> Encouraged patient to continue verbalizing thoughts and feelings.

>Encouraged SO to talk and touch client frequently.

limitations should be set so that you won’t be giving negative result to the behavior of the client.

>help the client relieve stress and you will be able to know how to be therapeutic towards him.

>Helps on faster recovery of the patient.

NCP POTENTIAL #1: RISK FOR INJURY R/T IMBALANCE BETWEEN OXYGEN SUPPLY AND DEMAND SECONDARY TO HYPERTENSION

Assessment Explanation of the Problem Objectives Interventions Rationale of the Interventions

Expected Outcome

Blood pressure above normal parameters ranges from 120/70 to 150/100

Intake of hypertensive agents like catapres and norvasc

Complains of easy fatiguability

A> Risk for injury

The client is then experiencing hypertension

that causes imbalance between the oxygen

supply and demand. This imbalance causes

alteration in the brain cell functioning leading to decreased perceptual

function as manifested by dizziness when standing

suddenly, decreased concentration and easy

fatigability

STO: After 8 hours of nursing intervetions, the patient will be able to verbalize understanding of individual factors that contribute to possibility of injury.

Dx> Monitored and recorded vital signs, noting blood pressure > Noted treatment-related factors, such as side effects or interactions of medications > Noted client’s age, gender, developmental stage, decision-making ability, level of cognition or competence

Tx> Provided information

> this will serve as baseline data

> sometimes these are not recognized by the clients, therefore increasing their susceptibility to injury> these affects clients ability to protect self and/or others and influences choice of interventions and/or teachings> this helps the patient to

Goal met if the patient is able to verbalize understanding of individual factors that contribute to possibility of injury.

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related to imbalanced between oxygen supply and demand secondary to hypertension.

Source:

Brunner and Suddarth’s Medical-Surgical Nursing

7th edition

LTO: After 1 to 2 days of nursing interventions, the patient will be able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

regarding disease or conditions that may result in increased risk of injury > Assisted client to develop plan for activity and exercises within individual ability > Provided diversional activities, avoiding overstimulation and understimulation

Edx> Cautioned the patient to avoid activities requiring alertness until the effects of medications are known > Instructed client to request assistance as needed > Advised the patient to report any adverse reactions or side effects of the medication taken

control his condition, thus preventing the risk for injury> to promote active and positive view of self

>participating in pleasurable activities can refocus energy and diminish feelings of unhappiness, sluggishness and worthlessnesss> antihypertensive agents usually causes drowsiness which is one of the most common cause of injury> to protect self from injury

> to prevent risk for injury and give prompt attention to side effects as necessary

Goal met if the patient is able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

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NCP POTENTIAL #2: RISK FOR RELAPSED EPISODE MAYBE R/T POOR MEDICAL TREATMENT REGIMEN COMPLIANCE

Assessment Explanation of the Problem Objectives Nursing Interventions Rationales EvaluationO > Has interest in treasure hunting and going outside naked when the wife goes back to Iran. > Returns back to his usual self when the wife is back home.

A > Risk for relapsed episode maybe r/t poor medical treatment regimen compliance

Worked as a farmer with family early in the morning to afternoon from childhood to adult. Completed his education till college level and later got married and have children. Went to Iran and worked abroad to help support his family. Came back to the Philippines and continue working for his family. Wife had gone back to Iran to work, leaving the husband and son in Philippines. Then husband

STO > After 6-8 hours of nursing intervention patient is able to show signs coping measures.

LTO > After 1-2 hours of nursing intervention patient is able to understand the importance of his treatment and verbalize his feelings.

Dx > Assessed client’s perception of self and noted use of defense mechanisms. > Assessed clients coping behaviors already present. > Reviewed laboratory and medication chart.Tx > Developed therapeutic nurse-patient relationship. > Maintained straight forward communication. > Listened to feelings that he expresses. > Being truthful when giving

> to determine causative factors

> to determine signs of relapse.> to determine contributing factors.> promotes sense of trust, allowing patient to discuss feelings openly.> to avoid reinforcing manipulative behavior.> offer emotional support and understanding.> builds trust, enhancing

STO > Patient was able to demonstrate coping mechanism as evidenced by relaxed posture and calm behavior.

LTO > Patient was able to understand about his treatment by taking his medications as scheduled and informing any changes of behaviors.

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start acting strange with interest of treasure hunting and going outside naked. But returns normal when wife comes back home.

information and dealing with patient. > Invited client to do activities. > Gave positive reinforcement for client’s efforts. > Maintained calm, matter of fact, nonjudgmental attitude.Edx > Encouraged client to get adequate sleep. > Instructed client to take medication as ordered. > Explained to client symptoms improve gradually and not immediately. >Advised client to report mood changes immediately. > Educated client to not stop on medication without physician’s order.

therapeutic relationship.

> for positive distraction.

> encourages continuation of treatment.

> decreases defense response.

> to prevent fatigue.

> to help to deal with stress.

> to understand that it is a long term treatment.

> to make adjustments in the treatment.

> to prevent relapse.

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I. DISCHARGE PLAN

DIET AND NUTRITION ACTIVITY HEALTH TEACHINGS

Instructed client to eat frequent small meals

Instructed to have high protein, high

carbohydrate diet for energy

Mental health professionals try to steer people away from sedentary activities such as TV where the mind and body are not fully engaged. Cleaning, reorganizing, reading, or raising goldfish could all be great indoor activities.

Creative activities like occupational therapy, drawings

Medications should be given regularly everyday for a certain period of time

Make client be more active and cooperative in any activities given to him

Instruct client to do activities that do not require alertness because one side effect of medication is drowsiness, thus may cause injury to the client

Teach client to take medications regularly

Instruct the wife that whenever she see signs

and symptoms of Bipolar Disorder to refer him

immediately

Teach the client on the side effects of his

medicines when not taken

Advise the client to go back to the institution

after discharge for follow-up check-up and

consultation

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J. CONCLUSIONS AND RECOMMENDATIONS

Bipolar disorder causes serious shifts in mood, energy, thinking and behavior from the

highs of mania on one extreme to the lows depression on the other. More than just a fleeting

good or bad mood swings, the cycles of bipolar disorder last for days, weeks, months or even a

year. Unlike ordinary mood swings, the mood changes bipolar disorder is so intense that they

interfere with your ability to function. People experiencing a manic episode often talk a mile a

minute, sleep very little and are hyperactive.

Interaction with the patient for more than 3 days is not enough to cover from his

childhood up to now. We should interact with the patient more and more to know about his

history and different traumas that he encountered. Well preparation to go on duty at the area

should be done before the actual duty by conducting self awareness test. We should also be

well knowledgeable to psychiatric disorders prior to duty to enhance more our interventions

and interactions.

Since the client has Bipolar Disorder, the group concluded that this disorder has

different symptoms as compared to the other psychiatric disorders. Therefore, in the making of

this case study and understanding how this disorder affects a person through appreciating it’s

pathophysiology. This study makes us student nurses more competent and gained more

confidence in handling patients with Bipolar Disorder.

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Case Presentation of Bipolar Affective Disorder, Current Episode, Manic with Psychotic Disorder

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