CASE STUDY ON

BIPOLAR AFFECTIVE
DISORDER

SUBMITTED TO –

Madam Kalyani Saha

Professor SUBMITTED BY –
Apollo College of Nursing, Kolkata
Shubhrima Khan
M.Sc. Nursing 2nd year
Apollo College of Nursing, Kolkata
IDENTIFICATION DATA:

Name: Prasenjit Mondal

Age: 32 years
sex: Male
Father/spouse: Dulal Mondal (Father)
Hospital Reg. No.: 1110/2021
Address: Vill – Jhikra
PO – Jhikra, PS – Gaighata
Dist – North 24 Parganas
Pin: 743245
Education: Graduate
Occupation: Service
Income: Rs. 20,000/ month
Religion: Hinduism
Marital status: Married
Name of hospital: Pavlov Mental Hospital
Date of admission: 06.11.2021
Under doctor: Dr. M. Ghosh.
Name of Informant: Not present
Relationship with Informant: N.A
Reliability of information: Not fully reliable
Diagnosis: F31.0 (Bipolar Affective Disorder), current episode: Hypomania

PRESENTING CHIEF COMPLAINT:

According to patient:

Ager bochor amar chakri chole jawar por mon mejaj khub kharap thakto  5 months ago
Ektutei matha gorom hoye jeto, rege giye jinispotra chure fele ditam  4-5 months ago
Kokhono kokhno bondhu bandhab der sathe ektu nesha kortam  4-5 months ago
Parar lokjoner sathe taka poisa niye jhogra jhamela hoto kokhno kokhno  4-5 months ago
Nesar ghore ki kortam kichu mone thaktona, matha vari hoye thakto  4-5 months ago
Tarpor ekhane baba niye elo chikitsa koranor jonno  4 months ago
Kintu ora sorojontro kore amake ekhane vorti kore dei  4 months ago
According to Family member:

O age shopping mall e kaj korto, durga pujar pore porei okhane kichu ekta jhamela hoyechilo
karor sathe tarpor kaj take khowalo  5-6 months ago
Amra kichu jiggas korlei ba onno kaj khujar kotha bollei rege jeto, jinispotro chure felto 5
months ago
Taka poisa dhar dena kore berato lok joner kache  4-5 months ago
Parar lokjon, bondu bandhab der sathe prai dini maramari kore asto  4-5 months ago
Lokjon barite ese humki dito  4-5 months ago
Nesha kore ese barite asanti korto, gala gali korto, mardhor korto  4-5 months ago
Barite thaktoina, jokhn tokhn bari theke beriye jeto  4-5 months ago
Kokhno kokhno bari firtana khuje ante hoto  4 months ago
Ekdin ratre mod kheye ese or bou ke khub mardhor korechilo tarporei amra oke niye asi
ekhane  4 months ago

HISTORY OF PRESENT ILLNESS:

 Duration: 5 months
 Onset: Acute
 Course: Continuous
 Intensity: Increasing
 Precipitating factors: Loss of job, financial crisis
 Predisposing factors: Not known
 Perpetuating factors: Not known
 Description of present illness: Patient was apparently well before 5 months when he
suddenly lost his job. After 2 3 weeks of this incident, he shows irritability, aggressive
behaviour towards the family members, run out from home, used abusive languages,
became addicted to substances, quarreled and fight with friends, neighbors. There was a
history of fighting with some people in his work place, but the reason cannot be elicited.
After that he lost his job. After losing job, he used to borrow money from others and was
unable to repay the money. So, people always threaten him. His abnormal behaviour
gradually increased and one day he severely beat his wife after drinking. Then he was
taken to the Pavlov mental hospital by his father and brother, get admitted to the hospital
and was diagnosed with Bipolar Affective Disorder. Since then, he is under continuous
treatment.
HISTORY OF PAST ILLNESS

 Past psychiatric history: Nothing significant

 Past medical and surgical history: He has no history of diabetes, hypertension,
tuberculosis or any other major medical or surgical illness.
 Hospitalization: he has no previous history of hospitalization due to psychiatric illness.
 Allergies: Nothing significant
 Past history of injury/accident: Nothing significant

TREATMENT HISTORY

 Drugs
Tab. THP 2mg 1–x–1
Tab. Risperidone 2mg 1–x–1
Tab. Diazepam 5mg x–x–2
Tab. HPL 5 mg deep IM SOS
Tab. Lithosum 300 mg 1–x–1
 ECT: Not given
 Psychotherapy: Not given
 Family Therapy: Not given
 Rehabilitation: Not given

FAMILY HISTORY:

 Type of family: Joint family

 No. of family members: six
 Name of head of family: Dulal Mondal (Father)
 Total monthly income: Rs. 15,000
 Source of income: Job
 History of illness among family members: No psychiatric illness in family, no history of
diabetes or Hypertension in family.

There is a joint family lived in north 24 pargana, total number of family members are 6. The
patient’s father and mother are still alive. His father is a hawker, 62 years old and mother is
housemaker 55 years old. The patient has a younger brother, 27 years old work in a bakery
factory. The patient is married, his wife is housemaker, 24 years old and they have a son who
is 4 years old now. In family genogram no similar illness is found in the family.
FAMILY GENOGRAME

Father-in- Mother-in-
r law,58 years law, 51
years
Father, 62 years Mother, 55 years

Elder Younger 30 years,

Wife, 24
sister brother, brother-in-
years
27 years law
36 years Self-32 years

Son, 4
years

Sl. no. Symbol Meaning

1. Male

2. Female

3. Married

4. Separated

5. Divorced

6. Index case

7. Mentally ill

8. Death
PERSONAL AND SOCIAL HISTORY:

 Antenatal history: He was a full-term baby, no maternal complications were seen during
antennal period
 Intra-natal history: He was born by Normal Delivery
 Postnatal history: He cried at birth and started breast-feeding after birth till 6 months.
 Childhood history:
(i) Primary caregiver: Mother
(ii) Attachments: well-attached
(iii) Childhood habits: Nail biting
(iv) Milestones: Achieved at appropriate age
 Educational history: Up to class viii
 Play history: He had a healthy relationship with playmates
 Puberty: Achieved at appropriate age
 Menstrual history: Not applicable
 Occupational history: worked at a private company
a. Age at starting work: 20 years
b. Jobs held in chronological order: Worked in a shop from 2010 - 2013, then
as a security guard in a company from 2014 to 2016 then in a shopping mall 2018 -
2021
c. Current job satisfaction: He did not have job satisfaction. At present he is
unemployed due to illness.
d. Whether Job is appropriate to patient’s background: Appropriate
 Obstetrical history: Not applicable
 Sexual and marital history-
(a) Duration of marriage: 5 yrs.
(b) Interpersonal relationship: Good
(c) Extramarital affairs: No history of extra-marital relationship

PRE-MORBID PERSONALITY:

 Family and social relationships: Well-adjusted prior illness

 Use of leisure time: Watched TV
 Usual reaction to stressful event: Used to become a slight anxious and angry at any
stressful situation
 Attitude to self and others: Satisfactory
 Attitude towards work and responsibility: Not so responsible
 Religious belief and moral attitude: Believe in God
 Fantasy or daydreaming: Nothing Significant

HABITS:

 Eating pattern: Non-vegetarian, regular

 Sleep: Difficulty in falling asleep, early morning awakening,
drowsiness
 Elimination: Regular
 Use of drugs, tobacco, alcohol: Had a habit of drinking for more than 10 years

PERSONAL HYGIENE:

 No. of times brushing per day: Once

 No. of bathing per day: Once
 Elimination pattern: regular
 Bladder habit: regular
MENTAL STATUS EXAMINATION

[A] General Appearance and Behaviour:

 Appearance: Looking one's age

 Facial expression: Anxious
 Level of grooming: Normal
 Level of cleanliness: Inadequate
 Level of consciousness: Fully conscious and alert
 Mode of entry: Persuaded
 Cooperativeness: Normal, sometimes irritated
 Eye-to-eye contact: Maintained eye to eye contact properly,
intermittently
 Psychomotor activity: Normal
 Rapport: Spontaneous
 Gesturing: Normal
 Posturing: Normal posture
 Other movements: Not present
 Other catatonic phenomena: There is no other catatonic phenomena.
 Conversion and dissociative signs: Not present
 Compulsive acts or rituals: Not present
 Hallucinatory behaviour: Not present

[B] Speech

Nurse: what is your name and where are you from?

Patient: ‘Prasenjit Mondal, Gaighata.
 Initiation : Speaks when spoken to
 Reaction time : React immediately when asked
 Rate : Rapid
 Productivity : Normal
 Tone : Normal variation
 Relevance : Not fully relevant.
 Stream : Normal
 Coherence : Coherent
  Others : Nil

[C] Mood and affect

Nurse: How are you feeling today?

Patient: “Ekhane ki r valo thaka jai”.
 Predominant mood state: Irritable.
 Affect: Anxious
Inference: Affect is congruent to mood and appropriate to situation

[D] Thought

Nurse: How many children do you have??

Patient: ‘Amar ektai chele, 4 bochor boyos.’
Form: Taught formation is normal.
Stream: Taught progression is normal.
Content
 Delusion:
Nurse: Do you think that anybody wants to harm you?
Patient: ‘Naa’
Nurse: Have you ever felt that some people are gossiping about you?
Patient: ‘Naa’
Nurse: Have you felt that you are being controlled by someone?
Patient: ‘Naa’

 Ideas:
Nurse: Do you ever feel that your life is worthless?
Patient: “Ha age mone hoto majhe majhe”
Nurse: Do you ever wishes to take your own life or wish to die?
Patient: “Na na”

 Thought Alienation Phenomena:

Nurse: Do you think that someone is inserting though in you or withdrawing your
thought?
Patient: “Naa”

 Obsessive Phenomena:
Nurse: Do you have any thought that comes to your mine repeatedly?
 Patient: “Chinta to lehei ache. Eto dhar dena ivabe sodh korbo janina.”

 Phobia:
Nurse: Do you have any fearful feeling about some object or anything else?
Patient: “Naa.”

Inference: He had worthleeness ideas and obsessional taught, phobia is not found.

[E] Perception

Illusion: Nothing significant

Hallucination:
Nurse: Have you seen anything which has not seen by others?
Patient: “Naa.”
Nurse: Have you smelt anything which has not smelled by others?
Patient: “Naa.”
Nurse: Have you heard anything which has not heard by others?
Patient: “Naa.”
Nurse: Have you feel anything moving on your skin?
Patient: “Naa.”
Somatic passivity: Nothing significant
Deja vu/ Jamais vu: Nothing significant
Depersonalization: Nothing significant
Inference: No such illusion or hallucinatory behavior is found.

[F] Cognitive function

 Consciousness : Fully conscious

 Orientation :
Time:
Nurse: What time of the day it is?
Patient: ‘Akhn sokal’
Place
Nurse: Where are you now?
Patient: ‘Mental Hospital’.
Person
Nurse: who am I?
 Patient: ‘Sisrer’
Inference: She is oriented to time place and person.

 Attention
Nurse: I will tell you few numbers, you have to repeat them after me. Say 1, 3
Patient – ‘1, 3’
Nurse: Now say 1,3, 5
Patient: ‘1, 3, 5’
Nurse: say again 1,3,5,7
Patient: ‘1, 3 ,5, 7’
Inference: Attention is aroused normally.

 Concentration
Nurse - subtract 3 from 40 and repeat 5 times?
Patient – ’37, 34, janina parchina r’
Inference: Concentration is sustained with difficulty.

 Memory
Immediate memory: -
Nurse: I will tell you 5 words, you have to repeat them after 5 minutes: Tree, leaf,
flower, fruit, bird
Patient: ‘Gaach, pata, ful, fol, pakhi’
Recent memory: -
Nurse- what did you take in dinner last night?
Patient- ‘Vat, dal, peper tarkari, dim. Didi ekhaner khabar ekdom valo noi’
Remote memory: -
Nurse- Do you remember your son’s birthday?
Patient- ’10th October’
Inference- Immediate, Recent and Remote memory is intact

 Intelligence
Nurse -Who is the Prime minister of West Bengal?
Patient – ‘Narendra Modi'
Nurse -Tell me the answer of 11 × 2 + 78?
Patient – ‘100’
 Inference – Intelligence is intact

 Abstraction
Nurse- Do you able to say one similarity and dissimilarity between an orange and a ball?
Patient – ‘Dutoi gol dekhte. Lebu amra khai r bol diye khela kora hoi’.
Inference: His abstract thinking ability is impaired.

 Judgement
Personal:
Nurse - What you will do if you get discharge from here?
Patient – ‘Bari fire jabo.’
Social judgement:
Nurse: What you will do if some guest will come to your house?
Patient: ‘Ami r ki korbo, barir lok join ke dakbo’

Test judgement:
Nurse – What you will do seeing fire in a place?
Patient – ‘aro lokjon deke nevanor chesta korbo.’
Inference: His personal and social judgement is impaired but test judgement is
intact.

[G] Insight
Nurse - Why are you come to this hospital?
Patient – ‘Amar mathar thik thaktona, ragaragi kortam barite, tai ekhane chikitsa koranor
naam kore sorojontro kore vorti kore dilo’
Inference – He has grade 4 insight about his illness. The patient knows that he is sick,
but explains it is due to something which is unknown to him.

[H] Disease with ICD Code:

History taken from patient and his father shows that, the symptoms exhibit by the patients
were similar to the clinical manifestation of bipolar disorder affective disorder, according to
ICD 10. But his current Mental status examination shows that, now the patient does not
exhibit any aggressive or assaultive behaviour, he had poor concentration level, poor persona
and social judgement, does not had true insight about his illness. At present he was diagnosed
with F31.0: Bipolar affective disorder, current episode: Hypomania.
 PHYSICAL EXAMINATION

Central nervous system 16.04.22 17.04.22 18.04.22

Level of consciousness (alert/conscious/drowsy Conscious Conscious Conscious

/comatose)
Orientation
Time – Oriented Oriented Oriented
Place –
Person –
Speech (aphasia, slurred, relevant, irrelevant) Relevant Relevant Relevant
Paralysis (hemiplegia, paraplegia, hemiparesis, Absent Absent Absent
quadriplegia, others)
Respiratory system
Chest shape-Normal/ Barrel Chest Normal Normal Normal
Chest movement-Bilateral/ Lt. Lateral/ Rt. Lateral Bilateral Bilateral Bilateral
Respiratory pattern- Normal/ Tachypnea/ Normal Normal Normal
Bradypnea/ Dyspnea
Respiratory rate- 20 breath/ min 19 breath/ min 20 breath/ min
Respiratory sound- Stridor/ Wheezing/ Granting Normal Normal Normal
Chest drain- Present/Absent Absent Absent Absent
Cardiovascular system
Blood pressure 130/80 mmhg 124/80 mmhg 110/70 mmhg
Heart rate 83 beats/min 84 beats/min 90 beats/min
Heart sound – S1 And S2 S1 And S2 S1 And S2
S1 Audible Audible Audible
S2
S3
S4
Pulse –
Carotid
Temporal
Brachial Present Present Present
Radial
Femoral
Dorsalis pedis
Popliteal
Posterior tibial
Clubbing- yes/ no No No No
Cyanosis- yes/ no No No No
Pallor- yes/ no No No No
Neck vein distention- yes/ no No No No
CRT < 3sec < 3sec < 3sec
Chest pain No No No
E. N. T
Eye- clean/ discharge Clean Clean Clean
Sclera Whitish Whitish Whitish
Conjunctiva Pale Pale Pale
Periorbital edema- yes/ no No No No
Ear- clean/ wax/ blood / cerumen/ others Cerumen Cerumen Cerumen
present present present
Nose- clean/ epistaxis/ others Clean Clean Clean
G.I system
Lip- moist/ crack/ dry Dry Dry Dry
Teeth- clean/ plague/ decay/ others Clean Clean Clean
Mouth- clean/dirty/others Clean Clean Clean
Halitosis- yes/no No No No
Tongue- clean/coated/ dry/moist/others Dry Dry Dry
Nutritional route Oral Oral Oral
Nausea No No No
Vomiting No No No
Constipation Yes Yes Yes
Diarrhea No No No
Melaena No No No
Genitourinary system
Voids- freely/ catheter freely freely freely
Urine –
Colour Straw Straw Straw
Appearance Clear Clear Clear
Sedimentation No No No
Hematuria No No No
Retention / incontinence No No No
Integumentary system
Skin- intact/ break down/ rash/ blister Intact Intact Intact
Wound- incisional / injury Absent Absent Absent
Site NA NA NA
Condition-redness/discharge/apposition/ NA NA NA
edema/healthy/others
Invasive line- central/ peripheral Absent Absent Absent
Site-
Patency- NA NA NA
Pain-
Musculoskeletal system
Joint- mobile/ contracture/ painful/ stiff mobile mobile mobile
Bed sore
Site- Absent Absent Absent
Condition-
Degree-
 DESCRIPTION OF THE DISEASE

INTRODUCTION:

This is characterized by recurrent episodes of mania and depression in the same patient at
different times. Typically, the patient experiences extreme highs (mania or hypomania)
alternating with extreme lows (depression); interspersed between the highs and lows are
periods of normal mood.

EPIDEMIOLOGY

 Bipolar disorder affects 6.9% as compared to other psychiatric illness.

 In 2017, 7.6 million people had bipolar disorder in India.
 In terms of gender, the incidence of bipolar disorder is roughly equal, with a ratio of women
to men of about 1.2 to 1.
 The average age of onset for bipolar disorder is 25 years, and following the first manic
episode, the disorder tends to be recurrent.
 Unlike depressive disorders, bipolar disorder appears to occur more frequently among the
higher socioeconomic classes.
 Bipolar disorder is the sixth-leading cause of disability in the middle-age group, but for
those who respond to lithium treatment (about 33% of those treated with lithium), bipolar
disorder is completely treatable, with no further episodes. Unfortunately, many individuals
go for years without an accurate diagnosis or treatment, and for some the consequences can
be devastating.

TYPES OF BIPOLAR DISORDERS

A bipolar disorder is characterized by mood swings from profound depression to extreme

euphoria (mania), with intervening periods of normalcy.

During a manic episode, the mood is elevated, expansive, or irritable. The disturbance is
sufficiently severe to cause marked impairment in occupational functioning or in usual social
activities or relationships with others, or to require hospitalization to prevent harm to self or
others.

Motor activity is excessive and frenzied. Psychotic features may be present.

A somewhat milder degree of this clinical symptom picture is called hypomania. Hypomania
is not severe enough to cause marked impairment in social or occupational functioning or to
require hospitalization, and it does not include psychotic features.

The diagnostic picture for depression associated with bipolar disorder is similar to that
described for major depressive disorder, with one major distinction: the client must have a
history of one or more manic episodes. When the presentation includes symptoms associated
with both depression and mania, the diagnosis is further specified as with mixed features.

Bipolar I Disorder

 Bipolar I disorder is the diagnosis given to an individual who is experiencing a manic

episode or has a history of one or more manic episodes.
 The client may also have experienced episodes of depression.
 This diagnosis is further specified by the current or most recent behavioural episode
experienced. For example, the specifier might be single manic episode (to describe
individuals having a first episode of mania) or current (or most recent) episode manic,
hypomanic, mixed, or depressed (to describe individuals who have had recurrent mood
episodes).
 Psychotic or catatonic features may also be noted.

Bipolar II Disorder

 The bipolar II disorder diagnostic category is characterized by recurrent bouts of major

depression with episodic occurrence of hypomania.
 The individual who is assigned this diagnosis may present with symptoms (or history) of
depression or hypomania. The client has never experienced a full manic episode, and the
symptoms are “not severe enough to cause marked impairment in social or occupational
functioning or to necessitate hospitalization”.
 The diagnosis may specify whether the current or most recent episode is hypomanic,
depressed, or with mixed features. If the current syndrome is a major depressive episode,
psychotic or catatonic features may be noted.

Cyclothymic Disorder

The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years’
duration, involving numerous periods of elevated mood that do not meet the criteria for a
hypomanic episode and numerous periods of depressed mood of insufficient severity or
 duration to meet the criteria for major depressive episode. The individual is never without the
symptoms for more than 2 months.

Substance/Medication-Induced Bipolar Disorder

 The disturbance of mood associated with this disorder is considered to be the direct result
of physiological effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse
or a medication).
 The mood disturbance may involve elevated, expansive, or irritable mood with inflated
self-esteem, decreased need for sleep, and distractibility.
 The disorder causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
 Mood disturbances are associated with intoxication from substances such as alcohol,
amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedatives,
hypnotics, and anxiolytics.
 Symptoms can also occur during withdrawal from substances.

Bipolar Disorder Due to Another Medical Condition

This disorder is characterized by an abnormally and persistently elevated, expansive, or

irritable mood and excessive activity or energy judged to be the direct physiological
consequence of another medical condition. The mood disturbance causes clinically significant
distress or impairment in social, occupational, or other important areas of functioning. Types
of physiological influences are included in the discussion of predisposing factors associated
with bipolar disorders.

The type of bipolar disorder my client is suffering from is Bipolar I Disorder.

CLASSIFICATION:

ACCORDING TO BOOK IN MY PATIENT

 F31.0: Bipolar affective disorder. current F31.0: Bipolar affective disorder. current
episode hypomania episode hypomania
 F31.1: Bipolar affective disorder, current
episode mania without psychotic symptoms
 F31.2: Bipolar affective disorder, current
episode mania with psychotic symptoms
 F31.3: Bipolar affective disorder, current
episode mild or moderate depression
 F31.4: Bipolar affective disorder, current
episode severe depression without psychotic
symptoms
 F31.5: Bipolar affective disorder, current
episode severe depression with psychotic
symptoms
 F31.6: Bipolar affective disorder, current
episode mixed.

ETIOLOGY:

ACCORDING TO BOOK IN MY PATIENT

BIOLOGICAL INFLUENCE
 Genetic-Research suggests that bipolar disorder strongly reflects an Not known
underlying genetic vulnerability.
- Twin Studies-Twin studies have indicated a concordance rate for
bipolar disorder among monozygotic twins at 60 to 80 percent,
compared to 10 to 20 percent in dizygotic twins. Because
monozygotic twins have identical genes and dizygotic twins share
only approximately half their genes.
- Family Studies-family studies have shown that if one parent has a
mood disorder, the risk that a child will have a mood disorder is
between 10 and 25 percent
 Biochemical influence- Not known
- Biogenic Amines-studies have associated symptoms of mania with a
functional excess of norepinephrine and dopamine.
 Physiological Influences Not known
- Neuroanatomical Factors- Neuroanatomical changes have been
correlated with dysfunction in the prefrontal cortex, basal ganglia,
 temporal and frontal lobes of the forebrain, and parts of the limbic
system including the amygdala, thalamus, and striatum
- Medication Side Effects-Certain medications used to treat somatic
illnesses have been known to trigger a manic response. The most
common of these are the steroids frequently used to treat chronic
illnesses such as multiple sclerosis and systemic lupus erythematosus
No significant
PSYCHOSOCIAL THEORIES: studies have confirmed a link between
childhood trauma
childhood trauma (emotional, physical, and sexual abuse) and the development
events
of bipolar disorder. childhood trauma interacts with genes along several
different pathways, which influences not only an increased risk for bipolar
disorder but also earlier onset, more severe symptoms, substance use, and
suicide risk
Triggered by
stressful event,
STRESSFUL EVENTS:
loss of job
Those associated with past experiences, existing conditions, and the individual’s
perception of the event

SIGNS AND SYMPTOMS:

ACCORDING TO BOOK IN MY PATIENT

Manic phase:
 Expansive, grandiose or hyperirritable mood  Increased
 Increased psychomotor activity, such as agitation pacing or hand psychomotor
wringing activity
 Excessive social extroversion  Rapid speech
 Rapid speech with frequent topic changes  Decreased need for
 Decreased need for sleep and food sleep and food
 Impulsivity  Low self-esteem
 Impaired judgement
Depressive phase:  Feelings of
 Low self esteem hopelessness
 Overwhelming inertia  Irritable mood
 Feelings of hopelessness, apathy or self-reproach  Fluctuating mood
 Difficulty concentrating or thinking clearly  Poor concentration
 Psychomotor retardation and judgement
 Anhedonia
 Suicide ideation

In hypomania:
Mood:
 The mood of a hypomanic person is cheerful and expansive.
 An underlying irritability surfaces rapidly when the person’s
wishes and desires go unfulfilled.
 The nature of the hypomanic person is volatile and fluctuating

Cognition and perception:

 Perceptions of the self are exalted—the individual has ideas of great
worth and ability.
 Thinking is flighty, with a rapid flow of ideas.
 Perception of the environment is heightened, but the individual is so
easily distracted by irrelevant stimuli that goal-directed activities
are difficult

Activity and behavior:

 Hypomanic individuals exhibit increased motor activity.
 They are perceived as being extroverted and sociable and thus
attract numerous acquaintances.
 they lack the depth of personality and warmth to formulate close
friendships. They talk and laugh a great deal, usually very loudly
and often inappropriately.
 Increased libido is common.
 anorexia and weight loss.
 INVESTIGATIONS AND DIAGNOSES

ACCORDING TO BOOK IN MY PATIENT

 Physical examination  Physical examination to rule out signs and symptoms
 Psychiatric examination and  Mental Status Examination (elevated mood, loud
medical history speech, impulsivity, etc.)
 Based on ICD10 criteria Total Blood Count:

 Blood testing  Hb: 10.0 gm

 Bipolar depression rating scale  TLC: 6400

 Bipolar affective disorder  Platelet: 216000

dimension scale Blood Glucose (Random):

 CT scan and MRI show enlarged  FBS: 110

ventricles, enlargement of the
sulci on the cerebral surface and
atrophy of the cerebellum
 PPBS: 132
Kidney function Test
 Bl. Urea: 15 mg/dl
 S. Creatinine: 0.5mg/dl
Electrolyte Estimation
 Serum Na+: 135 mmol/L
 Serum K+: 4.7 mmol/L
HbsAg: Non-reactive
RTPCR: Negative
Urine R/E, M/E: NAD
 CT brain: NAD

TREATMENT:

ACCORDING TO BOOK IN MY PATIENT

 PHARMACOTHERAPY:  Drugs:
Tab. THP 2mg 1–x–1
 Lithium
Tab. Risperidone 2mg
 Valproic acid
1–x–1
 Carbamazepine
Tab. Diazepam 5mg
 Antipsychotics (if necessary)
x–x–2
 Antidepressants
Tab. HPL 5 mg deep IM SOS
 INDIVIDUAL PSYCHOTHERAPY- bipolar-specific Tab. Lithosum 300 mg
psychotherapies in conjunction with medication treatment 1–x–1
have better outcomes than medication alone.  Individual Psychotherapy is

 GROUP THERAPY- Once an acute phase of the illness has given

passed, groups can provide an atmosphere in which  Supportive psychotherapy-

individuals may discuss issues in their lives that cause, ventilation is given

maintain, or arise from having a serious affective disorder.  Behaviour therapy- activity

The element of peer support may provide a feeling of scheduling is done

security, as troublesome or embarrassing issues are

discussed and resolved. A sense of hope is conveyed when
the individual is able to see that he or she is not alone or
unique in experiencing affective illness

 COGNITIVE THERAPY- In cognitive therapy, the

individual is taught to control thought distortions that are
considered a factor in the development and maintenance of

mood disorders. The individual perceives the self as highly

valued and powerful. Life is experienced with overstated
self-assurance, and the future is viewed with unrealistic

optimism.

 FAMILY THERAPY- Provides support, reduces

depressive symptoms, relapses occurrence, resolves
interpersonal and familial disputes or conflicts or problems

 MARITAL THERAPY- to resolve marital conflicts,

interpersonal, emotional conflicts among couple and within
family and familial disputes or conflicts or problems.

 SUPPORTIVE PSYCHOTHERAPY- ventilation,

reassurance, and relaxation technique, guidance,
counselling education sessions.

 BEHAVIOUR THERAPY- learning principles, varied

techniques, self-control methods, activity scheduling,
decision making, assertiveness training, etc.
 ELECTROCONVULSIVE THERAPY- Episodes of acute
mania are occasionally treated with electroconvulsive
therapy (ECT), particularly when the client does not
tolerate or fails to respond to lithium or other drug
treatment or when life is threatened by dangerous
behaviour or exhaustion
 ASSESSMENT NURSING GOAL PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Dysfunctional To improve  Stage of fixation in grief  stage of fixation in grief His cognitive
 Feelings of grieving related to cognitive process is to be assessed. process is assessed. functions are
worthlessness loss as evidenced by function improved, he
 Patient should be accepted  Patient is accepted in a
 Feelings of inappropriate cleans his bed
in a positive manner and positive manner and time is
hopelessness expression of anger, regularly by own
time is spent with him. spent with him.
Objective data: inability to carry out self
 Inability to carry activities of daily  Feelings of anger should be  feelings of anger are
out activities of living explored explored.
daily living
 simple activities which can  Provided simple activities
be easily and quickly like cleaning his bed
accomplished should be
provided.
ASSESSMENT NURSING GOAL PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Risk for violence,  The patient  Maintained low level of  Low level of stimuli is Patient not injured
 Feelings of self-directed or will not injure stimulus in the patient’s maintained in patient’s self or others.
anger directed to others self and others environment environment
Objective data: related to manic  verbalize  Observed the patient’s  Patient’s behavior is
 Verbal excitement feelings of behavior frequently observed in every 15
expression of anger or minutes
 Removed all dangerous
Aggressive frustration
objects from the patient’s  all the sharp obbjects, glass
behaviour by
environment. etc. are kept away from the
family
patient.
member  Provided a structured
environment with scheduled  Daily activities are
routine activities of daily scheduled for the patient.
living.
 Patient is approached with
 Interact with the patient with a calm voice
low calm voice
 Prescribed medications are
 Medications should be provided.
administered as per advice
when needed
ASSESSMENT NURSING GOAL PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Anxiety related to To reduce anxiety  Anxiety level should be  Anxiety level is assessed Anxiety is reduced
 Restless hospitalization as assessed to some extend
 Calm, non-threatening
 Agitated evidenced by
 A calm, non-threatening environment is maintained
Objective data: facial expression,
environment should be
 Anxious look poor impulse  A trusting relationship is
maintained
 poor impulse control maintained with the patient
 A trusting relationship with
control
patient should be established  Reassurance is provided to the
and maintained client
 Reassurance should be
 Client not forced to make
provided to the client
choices
 Avoid forcing client to make
choices  Anxiolytic drug (diazepam
5mg) is administered.
 Administer anti-anxiety drugs
as and when required.
ASSESSMENT NURSING GOAL PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Imbalanced  To improve  Nutritional status should be  Nutritional status is assessed. Patient eats
 Loss of nutrition, less his intake of assessed. adequately.
appetite than body food  Patient’s like and dislike  Patient’s like and dislike
regarding food should be regarding food are identified.
 Dislike of requirements,  To improve
identified.
hospital diet related to reduced nutritional  High-protein, high caloric,
 High-protein, high caloric,
Objective data: food intake as status finger food is provided which
finger food should be
the patient can hold and eat
 Poor intake of evidenced by provided which the patient
while walking.
food Anorexia. can hold and eat while
walking.
 Food is served in a pleasant
 Food should be served in a environment as per patient’s
pleasant environment as per choice.
patient’s choice.
 Patient is to be encouraged to  Patient is encouraged to take
take meals timely. meals timely.
 Sit with patient while she eats.
 Sit with patient while she eats.
 Body weight should be
checked regularly
 Body weight is checked
regularly
ASSESSMENT NURSING GOAL PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Sleep pattern To improve  Daytime activities should be  Daytime activities should be Sleep is improved
 Early disturbances sleeping pattern according to the patient's according to the patient's
morning related to anxiety, interests, should not allow interests, should not allow him
awakening hospitalization as him to sit idle. to sit idle.
evidenced by
 A quiet and peaceful  A quiet and peaceful
Objective data: difficulty in
environment should be environment should be ensured
 drowsiness falling asleep,
ensured when the patient is when the patient is preparing
early morning
preparing for sleep. for sleep.
awakening and
drowsiness  comfort measures are to be  comfort measures are to be
provided. provided.

 The patient should not be  The patient should not be

allowed to sleep for long time allowed to sleep for long time
during the day. during the day.
ASSESSMENT NURSING GOAL PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Self-care deficit To meet the  patient’s ability to meet self-  patient’s ability to meet self- Self-care ability is
 Inability to related to hygiene care activities should be care activities is assessed. improved. He
carry out own withdrawal, as adequately and assessed. becomes able to
 Assistant is provided to
activities evidenced by to improve self- perform some
 Assistant should be provided to meet self-care needs.
difficulty in care activities
meet self-care needs.
carrying out tasks  A structured schedule for independently.
Objective data:
associated with  A structured schedule for patient’s routine of hygiene,
 Poor personal
patient’s routine of hygiene, toileting, meals is developed
hygiene hygiene, dressing,
toileting, meals should be
grooming, eating,  Patient is encouraged to
developed
sleeping perform daily activities
 Patient should be encouraged to independently.
perform daily activities
independently.
ASSESSMENT NURSING GOAL PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Impaired social To enable the  Patient should accept as here  Patient is accepting as here Patient
 Unwilling interaction related patient to accept and now and now demonstrates the
ness to to short attention by others  Factors that alleviating patient’s  Factors that alleviating acceptable
participate in span, high level of To help the performance should be patient’s performance are interaction with
group distractibility and patient to identified. identified. others.
activities. labile mood as improve  Environmental stimuli should  Environmental stimuli are
 Rejection by evidenced by interpersonal be kept minimum initially to kept minimum initially to
others. insufficient and relationship avoid distraction. avoid distraction.
Objective data: ineffective social  Patient should be instructed  Patient is instructed slowly
 Poor exchange slowly in concreate direction in concreate direction for
communicatio for each activity. each activity.
n with others  Positive reinforcement should  Positive reinforcement is
 Labile mood be given in completion of each given in completion of each
 Impulsive of desirable activities. of desirable activities.
behaviour  Gradually patient should be  Gradually patient is
encouraged to participate in encouraged to participate in
group activities. group activities.
PSYCHOEDUCATION

Psychoeducation was given regarding the following points:

 Management of grief.
 Relaxation techniques to deal with anger, excitement and anxiety.
 Advised the client to share his feelings with people who would understand.
 Motivated him to participate in group therapy and occupational therapy.
 Advised him to practice deep breathing exercise whenever he feels anxious
 Encouraged him to formulate short-term goals and work on them to improve self-
esteem.
 Informed the client and the family about the importance of taking the medicines
regularly and not to discontinue the drug until the doctor tells. And also, the side
effects and sign of toxicity of antipsychotic drugs and the need to seek medical
attention immediately.
 Personal hygiene and nutrition: advised the patient to have daily bath, neat dress and
to do exercise. Instructions have given on the importance of nutritious diet on health

CONCLUSION

The symptoms of Bipolar Affective Disorder manifest with the individual experiencing
episodes of mania or elation followed by low mood or depression. The number of manic and
depressive episodes varies greatly from person to person and most individuals experience level
or balanced periods between their manic and depressive episodes. There is no cure for manic
depression at present, but many people have benefited from the use of monitored medication
programs; it is sometimes possible to smooth out and reduce the frequency of the highs and
lows, and in some cases the episodes may be altogether prevented.

BIBLIOGRAPHY

 Neeraja KP. Essentials of mental health & psychiatric nursing. 1 st ed. Vol. 1. 2008; New
Delhi: Jaypee Brothers Medical Publishers (P) Ltd; p. 232-34
 Sreevani R. A guide to mental health and psychiatric nursing; 4 th ed. 2016; New Delhi:
Jaypee Publishers. p.144-50
 Townsend CM. Psychiatric mental health nursing. 9 th ed. New Delhi: Jaypee brothers’
medical publishers (P) LTD; p. 948-49