TEOPIZ, MARK JOVAN JR.

BSN 3-A3

CASE STUDY ON BIPOLAR II DISORDER

A . CASE
SN, a 45year old, she losses her job as a retail associate and had an argument with her
supervisor and unable to pay rent. Inability to support self, had a feeling worthlessness with little
motivation to seek for an employment. She experienced increase level of agitation, anhedonia and
difficulty concentrating according to her brother these symptoms exist 9 months ago prior to present
consultation. who presented with the chief complaints,” I Just can’t sleep no more, Nobody can talk to
me- “I don’t want to be around; they all get on my nerves. Patient was agitated, shouting at the clinic.
History of past illness reveals that patient SN has a history of taking marijuana 2-3x a week,
she claimed that this could aid in her insomnia episode. She does not drink alcohol or use other drugs
and patient denies a history of psychotic symptoms. Assessment revealed no history of manic episodes
but careful inquiry suggest that she experience hypomanic episodes. During her 20’s the patient describe
herself as unusually productive, creative and sociable and able to go all night on 3 hours of sleep. She
even get troubled with traffic enforcer and she loves do shopping and at several times she was facing
troubled using her credit cards. She has either been treated with monotherapy antidepressants and
benzodiazepine. The patient also received tradozone treatment for her insomnia which she finds very
effective. Received treatment for her mood three years ago , she’s not compliant to his treatment
regimen for she believed herself to be well.
Patient’s family mental history is positive for bipolar ( maternal grandmother, sister) no one in
patients’s family has been admitted for psychiatric case admission.
Patient SN was diagnosed as BIPOLAR II and the psychiatrist prescribe her with lower dose of
trazadone treatment for her insomnia 25mg at bedtime. And lithium carbonate 3gm/day.
Psychiatrist Suggest to maintain a calm environment and maintain patient rapport during
therapeutic management.

B. MENTAL HEALTH ASSESSMENT FINDINGS

List down significant mental health assessment findings and provide brief discussion of each finding.
You may add more spaces if you believe there are more assessment findings in the case.

ASSESSMENT FINDINGS DISCUSSION

Inability to support self, had a feeling
worthlessness with little motivation to seek for an
employment
increase level of agitation, anhedonia and difficulty
concentration
Clients often have exaggerated self-esteem; they
believe they can accomplish anything. They rarely
discuss their self-concept realistically. Nevertheless, a
false sense of well-being masks difficulties with
chronic low self-esteem
Cognitive ability or thinking is confused and jumbled
with thoughts racing one after another, which is often
referred to as flight of ideas. Clients cannot connect
concepts, and they jump from one subject to
another. Circumstantiality and tangentiality also
characterize thinking. At times, clients may be unable
to communicate thoughts or needs in ways that
others understand. These clients start many projects
at one time but cannot carry any to completion.
There is little true planning, but clients talk nonstop
about plans and projects to anyone and everyone,
insisting on the importance of accomplishing these
activities. Sometimes they try to enlist help from
others in one or more activities. They do not consider
risks or personal experience, abilities, or resources.

experience hypomanic episodes
Impaired social interaction
Clients start these activities as they occur in their
thought processes.
a period of abnormally and persistently elevated,
expansive, or irritable mood lasting 4 days and
including three or four of the additional symptoms
described earlier
During the hypomanic period, mood brightens, the
need for sleep decreases as energy noticeably
increases, and psychomotor activity accelerates. For
some patients, hypomanic periods are adaptive
because they produce high energy, creativity,
confidence, and supernormal social functioning. Many
do not wish to leave the pleasurable, euphoric state.
Some function quite well, and functioning is not
markedly impaired. However, in some patients,
hypomania manifests as distractibility, irritability, and
labile mood, which the patient and others find less
attractive

C. PSYCHOSOCIAL THEORY
Discuss the particular psychosocial stage where the client is in. Highlight either the positive resolution
or negative resolution findings provided in the case and expected in the client.

Psychosocial Stage Age Range:

GENERATIVITY VS. STAGNATION approximate ages of 40 and 65

Discussion:

The focus of this stage is to contribute to society and the next generation. Adults in this stage are
often at the height of their careers. Many people are raising children.

Generativity: People may offer guidance to the next generation through parenting or mentorship.
They may also offer lead the way by leaving a legacy. Contributing to society’s future can give
people a sense of community and purpose.

Stagnation: Some people may feel as if they have no impact on society. If people do not find their
work meaningful, they may feel restless or isolated. Some may feel they have “peaked” and that
their lives will only get worse in the future. When people reach their 40s, they enter the time known
as middle adulthood, which extends to the mid-60s.

The social task of middle adulthood is generativity vs. stagnation. Generativity involves finding your
life’s work and contributing to the development of others through activities such as volunteering,
mentoring, and raising
children.

During this stage, middle aged adults begin contributing to the next generation, often through
childbirth and
caring for others; they also engage in meaningful and productive work which contributes positively
to society.
 Those who do not master this task may experience stagnation and become frustrated that they’re
unable to raise a family, succeed at work, or contribute to society, they may feel disconnected. They
may not feel motivated to invest in personal growth or in productivity, they tend to feel as though
they are not leaving a mark on the world in a meaningful way.

Virtue: Care

Maldevelopment: Rejectivity

Example: Engagement with the next generation through parenting, coaching, or teaching. Source:
https://www.goodtherapy.org/blog/psy

Source: https://www.verywellmind.com/generativity-versus-stagnation-2795734

D. DIAGNOSIS
Discuss the pathophysiology/progression of the diagnosis of the specified case

Diagnosis:

BIPOLAR II DISORDER

ANATOMY:
 PATHOPHYSIOLOGY:

DISEASE DEFINTION

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme
mood swings that include emotional highs (mania or hypomania) and lows (depression).

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most
activities. When your mood shifts to mania or hypomania (less extreme than mania), you may feel
euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, activity,
judgment, behavior and the ability to think clearly.

Episodes of mood swings may occur rarely or multiple times a year. While most people will experience
some emotional symptoms between episodes, some may not experience any.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other
symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medications and
psychological counseling (psychotherapy).

SIGNS & SYMPTOMS

There are several types of bipolar and related disorders. They may include mania or hypomania and
depression. Symptoms can cause unpredictable changes in mood and behavior, resulting in significant
distress and difficulty in life.

❖ Bipolar I disorder - You've had at least one manic episode that may be preceded or followed by
hypomanic or major depressive episodes. In some cases, mania may trigger a break from reality
(psychosis).
 ❖ Bipolar II disorder - You've had at least one major depressive episode and at least one
hypomanic episode, but you've never had a manic episode.

❖ Cyclothymic disorder - You've had at least two years — or one year in children and teenagers
— of many periods of hypomania symptoms and periods of depressive symptoms (though less
severe than major depression).

❖ Other types - These include, for example, bipolar and related disorders induced by certain drugs
or alcohol or due to a medical condition, such as Cushing's disease, multiple sclerosis or stroke.

Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic
episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be
depressed for longer periods, which can cause significant impairment.

Although bipolar disorder can occur at any age, typically it's diagnosed in the teenage years or early 20s.
Symptoms can vary from person to person, and symptoms may vary over time.

TYPES OF EPISODES

Mania and hypomania are two distinct types of episodes, but they have the same symptoms. Mania is
more severe than hypomania and causes more noticeable problems at work, school and social activities,
as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require
hospitalization.

Both a manic and a hypomanic episode include three or more of these symptoms:

❖ Abnormally upbeat, jumpy or wired

❖ Increased activity, energy or agitation
❖ Exaggerated sense of well-being and self-confidence (euphoria).
❖ Decreased need for sleep
❖ Unusual talkativeness
❖ Racing thoughts
❖ Distractibility
❖ Poor decision-making — for example, going on buying sprees, taking sexual risks or making foolish investments.

MAJOR DEPRESSIVE EPISODE

A major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in
day-to-day activities, such as work, school, social activities or relationships. An episode includes five or
more of these symptoms:
❖ Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens,
depressed mood can appear as irritability)
❖ Marked loss of interest or feeling no pleasure in all — or almost all — activities
❖ Significant weight loss when not dieting, weight gain, or decrease or increase in appetite
(in children, failure to gain weight as expected can be a sign of depression)
❖ Either insomnia or sleeping too much
❖ Either restlessness or slowed behavior
❖ Fatigue or loss of energy
❖ Feelings of worthlessness or excessive or inappropriate guilt
❖ Decreased ability to think or concentrate, or indecisiveness
king about, planning or attempting suicide

Source:
://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.frontiersin.org%2Farticles%2F10.3389%2Ffpsyt.2014.00098%2Ffull&psig=
0LAPTJnu&ust=1649685401390000&source=images&cd=vfe&ved=0CAoQjRxqFwoTCNCDyZbTifcCFQAAAAAdAAAAABAV
 E. MEDICATION REVIEW (DRUG STUDY)
Create a Medication Review for all medications provided in the case. Use the format provided below:

Medication Indication Mechanism of action Contraindication Adverse Effects Nursing Responsibilities

Before:
Treatment for Drugs you should not use with
Generic Name: Trazodone is an trazodone. Doing so can cause Nausea, vomiting, • Monitor pulse rate and regularity.
insomnia. Trazodone
antidepressant that dangerous effects in your body. diarrhea, drowsiness, • Observe patient's level of activity.
TRAZADONE is approved by the
works by inhibiting Examples of these drugs dizziness, tiredness, • Check patient for symptoms of
FDA as a prescription both serotonin
Brand Name: include: Monoamine oxidase blurred vision, changes in hypotension.
drug used for the transporter and
inhibitors (MAOIs), such as weight, headache,
Classification: medical treatment of serotonin type 2 During:
dicarboxamide, phenelzine, muscle ache/pain, dry
depression. In receptors. It is a
SEROTONIN addition to triazolopyridine tranylcypromine, or selegiline. mouth, bad taste in the • Discontinue if reduction of
MODULATORS You shouldn't take trazodone mouth, stuffy nose, white blood cells
depression, this drug derivative.
Dosage: may also be Trazodone inhibits with MAOIs or within 14 days of constipation, or change • Discontinue if a prolonged or
the reuptake of taking them. in sexual interest/ability inappropriate erection occurs
prescribed by a
25mg serotonin and blocks may occur. If any of • Perform white blood cell count and
doctor or mental
the histamine and these effects persist or differential with fever, sore throat, or
Route: health professional as
alpha-1-adrenergic worsen, tell your doctor other signs or symptoms of infection
PO a treatment for
receptors. or pharmacist promptly.
insomnia, and may After:
Frequency:
also be used to treat
OD
anxiety and panic • May cause orthostatic low blood
Timing: pressure and fainting; use with
AT BEDTIME caution.
• QT prolongation with or without
torsade de pointes
and ventricular rapid heart
rate reported
• Use caution in patients who may have
seizures including head trauma,
alcoholism, and brain damage
 Medication Indication Mechanism of Contraindication Adverse Effects Nursing Responsibilities
action
Generic Name: Treat the symptoms of bipolar Lithium acutely stimulates • Diarrhea CNS: Tremor, muscle hyperirritability Before:
LITHIUM disorder. Lithium is used to the NMDA receptor, • Vomiting (fasciculations, twitching, clonic • Advise patient that this drug
treat and prevent episodes of increasing glutamate • Stomach pains movements of whole limbs),
hypertonicity, ataxia, choreoathetotic may cause serious fetal harm
Brand Name: mania (frenzied, abnormally availability in the • Fatigue
movements, hyperactive and cannot be used during
Priadel, Camcolit, excited mood) in people with postsynaptic neuron. After • Tremors
Liskonium, Li-Liquid bipolar disorder (manic- deep tendon reflex, extrapyramidal pregnancy; urge use of
chronic administration, • Uncontrollable
symptoms including acute dystonia barrier contraceptives.
depressive disorder; a disease lithium induces NMDA movements
Classification: that causes episodes of downregulation, this way • Muscle weakness • Monitor clinical status closely,
BIPOLAR DISORDER CV: cardiac arrhythmia, hypotension,
depression, episodes of mania, lithium modulates • Drowsiness peripheral circulatory collapse, especially during initial stages
AGENTS and other abnormal moods). glutamate bradycardia, sinus node dysfunction with of therapy; monitor for
Lithium is in a class of neurotransmission. severe bradycardia (which may result in therapeutic serum levels of
Dosage:
medications called antimanic syncope)
3gm/day 0.6–1.2 mEq/L
agents.
GI: anorexia, nausea, vomiting, diarrhea,
Route: During:
gastritis, salivary gland swelling,
PO • Give with caution and daily
abdominal pain, excessive salivation,
monitoring of serum lithium
flatulence, indigestion.
levels to patients with renal
Frequency:
or CV disease, debilitation, or
OD Genitourinary: glycosuria, decreased
dehydration or life-
creatinine clearance, albuminuria,
threatening psychiatric
Timing: oliguria, and symptoms of nephrogenic
disorders.
AFTER MEALS diabetes insipidus including polyuria,
• Decrease dosage after the
thirst and polydipsia.
acute manic episode is
controlled; lithium tolerance
Derm: drying and thinning of hair,
is greater during the acute
alopecia, anesthesia of skin, acne, chronic
manic phase and decreases
folliculitis, xerosis cutis, psoriasis or its
when manic symptoms
exacerbation, generalized pruritus with or
subside.
without rash, cutaneous ulcers,
• Take this drug exactly as
angioedema. prescribed, after meals or
with food or milk.
EEG Changes: diffuse slowing, widening
of frequency spectrum, potentiation and
disorganization of background rhythm.

EKG Changes: reversible flattening,

isoelectricity or inversion of T-waves.
 After:

• Ensure that patient maintains

adequate intake of salt and

adequate intake of fluid

(2,500–3,000 mL/day).

• Report diarrhea or fever.

Source:
https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/lithium/
F. PROBLEM LIST
Based on the case provided above, cite the top 3 Nursing Diagnosis of the identified client. Provide your
rationale/discussion on your choice and discuss briefly about the Nursing Diagnosis.
Problem Rationale
1. Disturbed sleep pattern r/t Clients can go days without sleep or food and not
even realize they are hungry or tired. They may be
hyperactivity on the brink of physical exhaustion but are unwilling
or unable to stop, rest, or sleep. They often ignore
personal hygiene as “boring” when they have “more
important things” to do. Clients may throw away
possessions or destroy valued items. They may
even physically injure themselves and tend to
ignore or be unaware of health needs that can
worsen.
2. Risk for self-directed or other Because of the safety risks that clients in this phase
take, safety plays a primary role in care, followed by
directed issues related to self-esteem and socialization. A
primary nursing responsibility is to provide a safe
environment for clients and others. The nurse
assesses clients directly for suicidal ideation and
plans or thoughts of hurting others. In addition,
clients in the manic phase have little insight into
their anger and agitation and how their behaviors
affect others. They often intrude into others’ space,
take others’ belongings without permission, or
appear aggressive in approaching others. This
behavior can threaten or anger people who then
retaliate. It is important to monitor the clients’
whereabouts and behaviors frequently
3. Impaired social interaction Clients rarely can fulfill role responsibilities. They
have trouble at work or school (if they are even
attending) and are too distracted and hyperactive to
pay attention to children or activities of daily living.
Although they may begin many tasks or projects,
they complete few. These clients have a great need
to socialize but little understanding of their
excessive, overpowering, and confrontational social
interactions. Their need for socialization often leads
to promiscuity. Clients invade the intimate space
and personal business of others. Arguments result
when others feel threatened by such boundary
invasions. Although the usual mood is elation,
emotions are unstable and can fluctuate (labile
emotions) readily between euphoria and hostility.
Source: Psychiatric–Mental Health Nursing fifth edition, Sheila l. Videbeck, page 298
 F. NURSING CARE PLAN
Formulate an NCP for each of the 3 Nursing Diagnosis in your Problem List which applicable for the
client using the format below:
Defining Nursing Scientific Goals of Nursing Rationale
Characteristics Diagnosis Analysis Care Intervention
Subjective Disturbed Bipolar II After 8 hours 1. Assess past -provide baseline
Data: sleep pattern disorder of care patterns of sleep in and identify the
“I Just can’t sleep r/t patient will normal problems that
involves
no more, Nobody hyperactivity be able to environment: hinder sleep. Sleep
periods of report amount, bedtime, patterns are
can talk to me- I
depression and feeling rituals, depth, unique to each
don’t want to be
periods of rested and length, positions, individual
around; they all
get on my elevated mood, show aids, and interfering
improvement agents
nerves” as stated called
in sleep/rest
by the patient hypomania. pattern 2.Instruct patient to
This is like follow as consistent
Objective Data: mania but less a daily daily -promotes
-Patient was extreme. All schedule for retiring regulation of the
agitated, and arising as circadian rhythm,
forms of bipolar
restlessness and possible reduces energy
disorder involve required for
irritability is noted
shifts in mood 3.Increase daytime adaptation to
- V/S is taken as
and levels of activities as changes
follows: possible
T: 36.5 o C energy and
-reduces
P: 54 activity. Bipolar
hyperactivity and
R: 12 II causes 4.Recommend promotes sleep
BP: 110/80 hypomania, a environment
period in which conducive to sleep -to promote sleep
mood and or rest (quiet,
comfortable,
behavior are
ventilation,
elevated darkness, closed
beyond what door)
most people
experience. In Collaborative
-Administer
a state of
sedatives as
hypomania, a ordered -different drugs
person may are prescribed
feel elated, depending on
energized, or whether the
patient has trouble
even irritable
sleeping or staying
asleep
Source: Nursing Care Plan Edition 7, Doegenes and Murr

Defining Nursing Scientific Goals of Nursing Rationale

Characteristics Diagnosis Analysis Care Intervention
Subjective Risk for People Patient will 1. Frequently -Early detection and
Data: “She was self- with bipolar di verbalize intervention of
assess client’s
agitated, shouting directed or control of
sorder, depres behavior for escalating mania will
at the clinic” as other feelings,
directed sion, and respond to signs of prevent the possibility
verbalized by the other mood of harm to self or
external increased
SO
disorders often controls, and agitation and others, and decrease
have episodes be safe and the need for
Objective Data: hyperactivity.
free from
-Agitated when they feel seclusions.
injury
Behaviors extremely sad,
-Delusional hopeless,
Thinking anxious, or
-Hallucinations confused.
-Poor Impulse When these - Provides structure
control 2. Use a calm and control for a client
emotions get
-Provocative too intense, and firm who is out of control.
behaviors the person approach.
may struggle
with how to
cope with
overwhelming - Short attention span
3. Use short, limits understanding
emotions, and
simple and to small pieces of
for some
brief information. Client can
 people, efforts explanations or use inconsistencies
at coping with statements. and value judgments
distress may Remain neutral as justification for
take the form as possible; Do arguing.
of acts of self- not argue with
injury. the client;
- Can help to relieve
pent-up hostility and
relieve muscle tension

4. Redirect
agitation and
potentially
violent
behaviors with
physical outlets -relieve symptoms
in an area of feel
low stimulation

Collaborative

-Administer
medications as
ordered

Source: Nurselabs and webmed for Bipolar

Defining Nursing Scientific Goals of Care Nursing Rationale

Characteristics Diagnosis Analysis Intervention
Subjective Impaired Bipolar The patient 1.The patient - When less manic,
Data: social disorder is will be able to may be exposing patients to
“ I don’t want to interaction an affective verbalize encouraged to social situations
be around; they and mood thoughts involve helps develop his/her
all get on my disorder when they themselves in social skills.
nerves” as stated characterized become activities that However, this should
by the patient by its uncontrollable require social be done non-
chronicity and will be interaction competitively as
Objective Data:
and doing when less competition
- Elevated or
complexity. activities manic. stimulates
euphoric mood
Patients with without aggressive behavior
this disorder manifesting and may trigger
-Extreme lability manifest inappropriate hypomanic episodes
with two behaviors.
- Easy
“poles” of
distractibility - Fewer stimuli mean
mood states,
the 2. Provide the lesser distractibility
-Lack of patient with a and lesser trigger for
hypomanic
concentration calming hypomanic episodes.
and
depressed environment
-Illogical with fewer
states. A
condensation stimuli, such
lesser
And Flight of as an
degree of
ideas environment
these mood
states such with dim light - Solitary activities
- Sad or elegiac
as and soft music. help release stress
mood with sad
hypomania and minimize
affect
and mixed 3. Solitary triggers for
states may activities must hypomanic episodes
also be also be and distractibility
observed in encouraged
these such as
patients. writing, taking
photos, -Reduces hypomanic
painting, or episodes and
walking. improves
communication
Collaborative
1.Psychotherapy
as recommended
 -to elevate mood

2.Administer
medication as
ordered

Source: Nurselabs and webmed for Bipolar