L. F.

Gonzales College of Science and Technology Institute

Maharlika Highway, San Leonardo, Nueva Ecija

Submitted by:
Balajadia, Enrick D.
Feliciano, Geruel D.
Garcia, Patria Rose Anne
Oberez, James Dohn G.
Reyes, Glaiza M.

Submitted to:
Florida Sarmiento RN, MAN, PhD
Dean, College of Nursing

TABLE OF CONTENTS
I. Introduction
II. Objectives
III.Nursing Process
A. Assessment

1. General Data
Name:

Age:

Address:

Civil Status:

Date Admitted:

Chief Complaint:

Diagnosis:

Informant:

2. Reason for hospitalization

3. Family history of mental illness
4. History of present illness
5. Related events/situations to present health condition
6. Pre-morbid personality assessment
7. Course in the ward
8. Personal/educational/occupational/marital history and
significant person to patient
9. Mental status examination
a) General description

(1) Appearance
(2) Behavior and psychomotor activity
(3) Attitude toward examiner

b) Psychopathophysiology and Psychodynamics

B. Planning
C. Nursing management
Process recoding
D. Evaluation and learning derived
E. Conclusion / recommendation

IV. Drug study

A. Generic name
B. Brand name
C. Classification
D. Mechanism of action
E. Patient dosage
F. Contraindications
G. Adverse effect
H. Nursing interventions

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 individuals 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:
Age:
Address:
Civil Status:
Date Admitted:
Chief complaint:

Informant:

Nestor
42
Nueva Ecija
Married
August 5, 2007
1. Pananakit
2. Poor sleep
3. Nambabato ng bahay
4. Nagbabasag ng gamit
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 fathers 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
Substance abuse
Sleep deprivation
Stress

Non-Modifiable Factors
Genetic factors

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

Walking aimlessly
Decreased sleep
Increased involvement in pleasure
seeking activity
Hallucinations
Agitation
Delusions

Signs and Symptoms

(Book based)
Abnormal and persistent elevation of
mood
Agitative
Gradiosity
Decreased need for sleep
Increase involvement in goal
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 Jungs 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
CUES
Subjective:
puro mga
sinungaling ang
andito, as
verbalized by the
patient.

NURSING
DIAGNOSIS
Disturbed thought
process related to
inability to trust as
evidenced by
suspiciousness of
others, resulting in
alteration in
societal
participation.

GOAL/OBJECTIVES
Short-Term Goal
Within 1 week, client
will start to recognize
and verbalize when
thinking is non-reality
based.

INTERVENTIONS
Prioritize safety of the
client.

Frequently orient
client to reality and
surroundings.

Long-Term Goal
Client will experience
no delusional thinking
by discharge from
treatment.

Try to redirect violent

behavior with physical
outlets for the client's
anxiety.

RATIONALE
Client may harm
self or others in
disoriented,
confused state.
Disorientation may
endanger client
safety if he or she
unknowingly
wanders away from
safe environment.
Physical exercise is
a safe and effective
way of relieving
pent-up tension.

Encourage the client

to verbalize true
feelings. The nurse
should avoid
becoming defensive
when angry feelings
are direct at him.

Verbalizing feelings
with a trusted
individual may help
client work through
unresolved issues.

EVALUATION

Goal met.
After a week of
intervention, the
client able to
recognize and
verbalize when
thinking is nonreality based.

C. Nursing management
Process recording
Client initials:
Sex:
Age:
Date of birth:
Address:
Nationality:
Physical appearance:
Description of the environment:
Tentative diagnosis:
Goals of intervention/Objective:

Nestor
Male
42 years old
March 26, 1967
Jaen, Nueva Ecija
Filipino
In blue MMH uniform, short hair, short nails, poorly kept and no slippers.
Sunny day, clear environment and good atmosphere under the big mango tree.
Bipolar manic with psychotic features
To help the client to express thought and feeling.

Student question

Patient response

Therapeutic communication

Ako po ay si Patria. Kayo po

ba, pwede ko po ba
malaman ang inyong
pangalan?

Ako si Nestor.

Giving information

Maari po ba kayong makinig

at sumagot sa mga bagaybagay na itatanong ko sa
inyo?

Sige.

Accepting

Rationale/Defense mechanism
Informing the client of facts
increases his knowledge
about a topic or let the client
know what to expect. The
nurse is functioning as a
resource person. Giving
information also builds trust
with the client.
Accepting response indicates
that the client has heard and
followed the train of
thoughts.

 Ano po ba ang trabaho ninyo

bago kayo mapunta dito?

Dati akong tricycle driver

tapos nagtitinda din ako ng
mais kasama ang asawa ko.

Exploring

When client deals with topic

superficially, exploring can
help them examine the issue
more fully.

Kuya, mayroon po ba kayong Wala. Magtanung ka na lang.

gustong ikuwento o sabihin
sa akin?

Broad openings

Make explicit that the client

has the lead in the
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

nalulungkot ka?

Encouraging description of
perception

To understand the client. The

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.

Nakikipagkwentuhan ako sa
kaibigan ko na si Inggo.

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
name
Lithium
carbonate

Biperiden

Brand
name
Priadel

Classification
Antimanic
drug

Akineton Antiparkinsonian

Mechanism of
Action
Thought to disrupt
sodium exchange
and transport in
nerves and muscles
and control reuptake of
neurotransmitters.

Biperiden has an
antropine-like
blocking effect on
all peripheral
structures that are
parasympathetic
innervated.

Patient
Dosage
600mg
BID

2mg
OD

Contraindications

Adverse Effect

Nursing Interventions

(none)

CNS: Dizziness,
drowsiness, headache,
tremor, ataxia, slurred
speech, hallucination
CV: bradycardia,
hypotension

Advise patient to take

with food or milk to
minimize G.I. upset.
Advise to limit foods
and beverages
containing caffeine.
Tell patient to maintain
adequate fluid intake.
Emphasize importance
of having regular blood
tests to help detect and
prevent serious adverse
reactions.

Caution should be
observed in patient
with manifest
glaucoma thought no
prohibitive rise in
intraocular pressure has
been noted following
either oral or parenteral
administration. Patient
with prostatism
epilepsy or cardiac
arrhythmia should be
given this drug with
caution.

Dry mouth

Advise the client to

avoid dry, bulky, and
irritating foods and
fluids such as tobacco
and alcohol.
Advise client to talking
too much if not
necessary.

Generic
name

Brand
name

Classification

Diphenhyramine

Benadryl Antihistamine
, antitussive,
antiemetic,
antivertigo
agent,
antidyskinetic

Chlorpromazine
hydrochloride

Antipsychotic
, anxiolytic,
antiemetic

Mechanism of
Action

Patient
Dosage

Interferes with
25mg PO
histamine effect at HS
histamine receptor
sites; prevents but
does not reverse
histamine-mediated
response. Also
possesses CNS
depressant and
anticholinergic
properties.
May block
postsynaptic
dopamine receptors
in brain and depress
areas involved in
wakefulness and
emesis. Also
possesses
anticholinergic,
antihistaminic, and
adrenergic-blocking
properties.

10mg
BID

Contraindications

Adverse Effect

Nursing Interventions

Hypersensitivity to
drug
Alcohol intolerance
Acute asthma attack
MAO inhibitor use
within 14 days
Breastfeeding
Neonates, premature
infants

CNS: drowsiness,
headache, paradoxical
stimulation
CV: hypotension,
tachycardia,
palpitations
EENT: blurred vision,
tinnitus
GI: diarrhea,
constipation, dry
mouth

Advise patient to avoid

alcohol and other
depressant such as
sedatives.
Caution patient to
avoid driving and other
hazardous activities
until he knows how
drug affects
concentration and
alertness.

Hypersensitivity to
drug
Angle-closure
glaucoma
Bone marrow
depression
Severe hepatic or
cardiovascular
disease

CNS: sedation,
drowsiness,
extrapyramidal
reaction, tardive
dyskinesia,
pseudoparkinsonism,
seizure
CV: tachycardia,
hypotension
EENT: blurred vision,
dry eyes, lens
opacities, nasal
congestion
GI: constipation,
ileus, anorexia, dry
mouth
Hepatic: jaundice,
hepatitis

Tell patient to take

capsule or tablets with
a full glass of water,
with or without food.
Instruct patient not to
crush sustained-release
capsules.
Tell patient to mix oral
concentrate in juice,
soda, applesauce, or
pudding.
Caution patient to
avoid driving and other
hazardous activities
until he knows how
drug affects
concentration and
alertness.