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Bipolar Disorder Case Study

Morgan Cole

Nursing Department, Youngstown State University

NURS 4842: Mental Health Nursing

Nursing Instructor- Bill Church

March 14, 2023

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Abstract

The following case study focuses on the disease process of a 37-year-old female patient

with Bipolar 1 disorder who was admitted to a psychiatric floor during a manic episode. The

subject of the study is V.S and was brought to the Trumbull ER because she was not speaking

coherently and making threats of self-harm. Bipolar 1 Disorder will be described and evaluated

using the DSM-5. Numerous references were utilized throughout the paper to provide a

comprehensive overview of the disease process of Bipolar 1 disorder and its effect on the patient.

Various treatment options available for this patient with Bipolar 1 disorder, including

pharmacological interventions, psychotherapy, and lifestyle changes. Nursing diagnoses and

plans for discharge for V.S will also be discussed.

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Bipolar Disorder Case Study

Objective Data

Before interviewing the client, I took the time to evaluate the safety measures on a

psychiatric floor that can differ from other units in the hospital. Psychiatric floors or mental

health units typically have several safety precautions in place to ensure the well-being of both

patients and staff. Psychiatric floors typically have restricted access to prevent unauthorized

entry. Staff use keys to control access to certain areas of the unit. Additionally, suicide

precautions are put in place for patients who are at risk of self-harm or suicide. This can include

one-to-one observation, monitoring of belongings, removal of potentially harmful items, and

specialized door knobs that a ligature cannot be tied to. The staff working on psychiatric floors

are typically trained in crisis intervention, de-escalation techniques, and the proper use of

restraints if necessary. Medications are closely monitored to prevent patients from taking more

than prescribed or sharing medication with others. The nurse hands the patient a fresh bottle of

water and ensures that they take all pills as given right on the spot.

V.S is a 37-year-old female patient that was admitted to the floor on March 9th, 2023,

with a diagnosis of Bipolar 1 disorder who was admitted to the psych floor following a manic

episode. V.S has a history of Bipolar 1 disorder, polysubstance abuse, ADHD, hypothyroidism,

hyperlipidemia, and hypokalemia. The patient’s family called EMS because she “wasn’t making

any sense.” This patient stopped taking suboxone a month ago for substance abuse.

During the interview, V.S provided a history of her mental health and substance abuse

disorder. She was involved in a car accident when she was a teenager which caused her to

become addicted to opioids. Eventually, this also led her to taking other recreational drugs. The
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patient stated that she is unemployed and her last job was at a restaurant in December of 2019.

She is a white/caucasian woman with a highschool education. The patient lives with her

boyfriend and has her mother and 4 children as her support system. V.S admitted that she was in

a state of spiritual distress and was looking for a church that was not going to place judgment

upon her. Upon evaluation, the patient was properly dressed, but was a bit under groomed with

matted and tangled hair. The patient was about 5’5, and 360 pounds which put her BMI at 56,

which is categorized as severely obese. She had many tattoos and some visible scars. She held

appropriate eye contact and had good posture.

Her motor activity and speech patterns showed some variability. She spoke consistently

with her hands and at several points in the interview, would stand up and start to sway. There was

a rapid speech pattern as she answered our questions. The patient's general attitude was

cooperative, friendly and interested in the topics. Throughout this interview, there were several

points where the patient got emotional. Whenever she would mention her children, she would cry

because she lost custody of 2 of them which caused her substance abuse to increase. She was

very fearful and guilty about how her addiction will affect her kids. V.S kept repeating,

“Everyone in the next generation is going to die from addiction, but I am going to save them all.”

Her mood could be labile, going from apathetic to angry in seconds.

This patient demonstrated a flight of ideas during interrogation. She was constantly

losing focus of the questions that were being asked and changing the subject. V.S was unable to

concentrate for long periods of time and was presenting with some mild mania. The patient was

obsessed with trying to solve other people's problems in her life, but did acknowledge that, “I

have to start focusing on myself and fixing myself, so I can stop drugs killing children.” V.S was
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alert and oriented and could consistently remember things from her past, but it was difficult to

put together the chronological order of the events that she had recalled. In terms of coping

mechanisms, the patient was able to name a few, but they were mostly maladaptive. This

involved partaking in recreational drugs and turning to food for comfort.

V.S is currently taking medications to alleviate her mental health symptoms. She did

admit to me that she struggles with compliance at times because she prefers to self-medicate with

marijuana. For her Bipolar Disorder diagnosis, she is taking 2 mg of risperidone twice a day, 5

mg of haloperidol every 6 hours, and 0.5 mg of benztropine mesylate twice a day. An additional

medication she is taking to stabilize her mood is 450 mg of oxcarbazepine twice a day. During

the interview, the patient expressed concern because she also has an ADHD diagnosis and was

not prescribed her proper medication that she takes at home. I made sure to alert the nurse about

this information.

On the day of care, the patient had labs drawn and there were some notable results. Her

glucose was 140, which is slightly elevated, but that could be increased due to a number of

factors such as psych medication, stress, and overeating. Her hemoglobin was dropped a bit and

was 11.3, but there was no active bleeding going on. Her TSH was elevated at 9.66, which could

be expected due to her diagnosis of Hashimoto's disease. The patient’s drug toxicology was

positive for amphetamines and opiates.

Summary of Bipolar Diagnosis

Bipolar 1 Disorder is a mental health condition characterized by episodes of manic and

depressive symptoms. The diagnosis of Bipolar 1 Disorder involves a thorough evaluation of a

person's symptoms, medical history, and family history. The Diagnostic and Statistical Manual of
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Mental Disorders, Fifth Edition (DSM-5) provides the diagnostic criteria for Bipolar 1 Disorder.

To meet the criteria for this disorder, a person must have experienced at least one manic episode.

A manic episode is defined as a distinct period of abnormally elevated, expansive, or irritable

mood lasting at least one week or any duration if hospitalization is necessary. During the

episode, the person experiences three or more of the following symptoms:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep

3. More talkative than usual or pressured speech

4. Racing thoughts or flight of ideas

5. Distractibility

6. Increased goal-directed activity or psychomotor agitation

7. Excessive involvement in pleasurable activities that have a high potential for painful

consequences.

The assessment process for Bipolar 1 Disorder involves a comprehensive evaluation of the

person's symptoms, medical history, and family history. The clinician will use various tools to

assess the person's symptoms and determine whether they meet the diagnostic criteria for Bipolar

1 Disorder. The clinician will also assess the person's medical history, including any medications

or substances that may be contributing to their symptoms. Finally, the clinician will review the

person's family history of mental illness, as bipolar disorder has a genetic component.

Medications such as mood stabilizers and antipsychotics can help manage manic and depressive

symptoms, reducing the risk of hospitalization and improving overall functioning.

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Psychotherapy, such as cognitive-behavioral therapy and family-focused therapy, can also be

helpful in managing symptoms and improving quality of life.

Stressors and Behaviors that Precipitated Hospitalization

V.S had many stressors that had factored into her current hospitalization. Some of these

include; unemployment, losing custody of 2 of her children, not following her medication

regimen and abusing opiates and amphetamines. The patient stated that she was in a constant

cycle of trying to get clean to take care of her children, but then eventually relapsing. She

described her relationship with her significant other that she has children with as a “best friend”

and said that he also struggled with substance abuse and being adequately able to take care of

their children. The patient was also overwhelmed because her oldest son was starting to smoke

weed and have mental health issues. V.S was tearful that her children would inherit her mental

health and addictive behaviors.

Milieu Therapy and Evidence Based Nursing Care

Milieu therapy is a form of psychiatric treatment that focuses on the individual's

environment, including the physical, social, and psychological aspects, to promote healing and

recovery. The goal of milieu therapy is to create a therapeutic environment that supports the

individual's recovery and encourages positive behaviors (Maramba et al., 2020). Patients arriving

at the psychiatric unit have all hazardous objects removed from the premise. Additionally, the

lights are kept dim in the patient's room and group therapies offer an ideal social opportunity for

discussion of feelings, goals, and thought processes. During group therapy, the client was able to
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list potential positive coping mechanisms to utilize upon discharge and interact with the other

patients on the floor. Some evidence-based nursing interventions may include using

cognitive-behavioral therapy or interpersonal therapy to treat specific mental health conditions

such as Bipolar Disorder. These interventions have been shown to be effective in improving

patient outcomes and may be integrated into milieu therapy to create a comprehensive and

evidence-based treatment plan (Maramba et al., 2020). By using evidence-based nursing

interventions within a therapeutic milieu, nurses can help patients achieve better mental health

outcomes.

Ethic, Spiritual, and Cultural Influences

V.S is a white, caucasian female that claimed to not identify with a certain religion. However, she

did state that she was looking for a church to join where the members would treat her in a

nonjudgmental way. A couple times she would mention that she was “like jesus” in the way she

would save the entirety of future generations from the harm of drugs. It could be deduced from

the interview that V.S was in a low socioeconomic class because is unemployed and reliant on

the government for food and housing

Evaluation of Patient Outcomes

Throughout inpatient treatment for V.S, there were documented signs of improvement. She was

able to speak in coherent sentences and showed signs of reduced mania. For example, she was

able to answer questions before jumping to another topic. Additionally, the patient took the

medications as prescribed and advocated for her own care by requesting her ADHD medication.
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V.S was able to verbalize that she needed to put herself first and get her mental health under

control to better take care of her children. Finally, the patient was able to attend group therapy

and make a list of positive coping techniques which included things like reading, going for a

walk and journaling.

Discharge Plans

The discharge plans included the patient moving back to her significant other's house. V.S is to

take all prescribed medications that she is currently taking on the unit. This requires medication

education for the patient and the adverse side effects that they can cause. To reduce opioid

dependence, the patient is ordered to resume taking suboxone. To address the client’s BMI and

health status, teaching about a proper diet and exercise will be important. V.S is optimistic about

discharge and wants to use her story to help others that are struggling with addiction and mental

illness.

Prioritized List of Nursing Diagnosis

Risk-Prone Health Behavior related to drug abuse, overeating, and maladaptive thinking

Risk for complicated grieving due to losing custody of two of her children

Disturbed thought process related to biochemical alterations in the brain as evidenced by flight of

ideas and a short attention span

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Interrupted family process as evidenced by losing custody of her children and the inability to fill

the role of being a provider for her children

Potential Nursing Diagnosis

Risk for Spiritual Distress

Risk for Loneliness

Ineffective Impulse Control

Ineffective Health Maintenance

Imbalanced Nutrition: More than Body Requirements

Ineffective Coping

Risk for Impaired Parenting

Conclusion

In conclusion, V.S proved to be a great candidate for this case study. I truly believe that this

patient has what it takes to get control of her mental illness through medication compliance and

cognitive-behavioral therapies. Doing this will allow for her to start taking steps to better her life
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such as regaining custody of her children, gaining employment, and overcoming her substance

abuse.
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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders.

nnnnnnnhttps://doi.org/10.1176/appi.books.9780890425596

Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The Lancet,

nnnnnnn387(10027), 1561–1572. https://doi.org/10.1016/s0140-6736(15)00241-x

Mullen, A., Harman, K., Flanagan, K., O’Brien, B., & Isobel, S. (2020). Involving mental health

nnnnnnnconsumers in nursing handover: A qualitative study of nursing views of the practice and

nnnnnnnits implementation. International Journal of Mental Health Nursing, 29(6), 1157–1167.

nnnnnnnhttps://doi.org/10.1111/inm.12756

Townsend, M. C., & Morgan, K. I. (2020). Essentials of Psychiatric Mental Health Nursing:

nnnnnnnConcepts of care in evidence-based practice. F.A. Davis Company.