NAME; HUMPREY MURERI

INSTITUTION: CONSOLATA NKUBU NURSING SCHOOL

TITLE: PSYCHIATRY CASE STUDY (BIPOLAR MOOD DISORDER)

YEAR: MARCH 2022

ADM: D/NURS/881/22

TUTOR: MADAM GROLY

COURSE: KENYA REGISTERED COMMUNITY HEALTH NURSING

DATE OF COMPLETION:
Biographic data

Name: Josephine Kanana

Age: 29 years.

Gender: Female

Religion: Christian

Residence : Amwathi

Next of kin : Joseph Mureithi(husband)

Diagnosis : Bipolar mood disorder

Chief complaint

Husband reported that she has been talking to herself a lot, loitering around market places and
singing for the last five days before admission

History of presenting illness.

Florence is known psychotic since 2016 and she has been on follow up clinics since then. Patient
was well until when she started loitering aimlessly around markets and singing songs that praise
God. Florence has been on oral medications 200mg carbamazepine twice a day and artane 5mg
once a day, huasband also reported incompliance to prescribed medications.

Personal history

Born in hospital via SVD at term. There were no complications after birth and received all
vaccines as KEPI immunization schedule.

Milestone history

No delayed milestone

Social history

So social and jovial with friends and relatives.

Does not work

Married

Occasionally takes alcohol

Past medical and surgical history

No history of chronic illnes

No surgical history.

No history of blood transfusion.

No known food and drug allergies

Past psychiatry history

Known psychiatric patients whom has been on treatment as outpatient.

Forensic history

No history of imprisonment

No criminal allegations

No any conviction

Family history

No family history of any chronic illness or any psychiatric illness.

3rd born in a family of 4boys 3 girls

Good relationship with parents and siblings

MENTAL STATUS ASSESSMENT ON ADMISSION

General appearance:
Personal hygiene- generally well kempt.
Mode of dressing- appropriate
Posture- upright
Mannerisms- absent
Facial expression- happy.
Behavior- inappropriate.
Nutritional status- nourished
Rapport- established and maintained.
Speech- pressured speech.
Mood- labile
Affect- congruent
Thought content- no delusions nor overvalued ideas
Thought process- flight of ideas
Perception- visual hallucinations
Cognition assessment
Concentration- poor
Attention- poor
Orientation- oriented to time, place and person.
Judgment- poor
Memory- intact
Insight- absent

PHYSICAL EXAMINATION
HEAD TO TOE
Hair and scalp
The hair is black in color and evenly distributed around the head. There are no scars on the scalp.
No masses felt on palpation.
Face
It is symmetrical with no scars or lesions. No masses felt and no abnormal muscle movements.
Eyes
The eyes were well aligned and symmetrical. The outer canthus is in line with the end of the
pinna.The conjunctiva is pink and the sclera is white. No excessive tearing nor edematous
eyelids or dryness of the eyes. The pupils are equal, round and reactive to light during the test of
accommodation.
Nose
The nasal septum is midline and continuous. The nostrils are asymmetrical with no polyps. There
is no discharge from the nose. The maxillary and the frontal sinuses are not tender.
Ears
The ears are in line with the outer canthus of the eye. There is no discharge from the ears. The
mastoid bones are not swollen. No swollen pre and post auricular lymph nodes.
Mouth
The mouth is moist and pink. No oral thrush or halitosis the lips are pink and well moist. There
are no tonsil stones.
Neck
The neck color is same with that of the body. The jugular veins are not distended. The trachea is
midline. No scars nor swellings. The thyroid gland is not swollen. The carotid pulse can be felt
on palpation and on auscultation, there no bruits.
Chest
The chest is symmetrical with no lesions nor scars.
No masses seen or felt
There is resonance on percussion.
Upper limbs.
On Inspection; the upper limbs are equal. No clubbing of fingers and the palms are very pink, the
capillary refill is fast within 1 seconds. The radial and brachial pulses are present.
Abdomen.
The abdomen is not distended. The skin is intact no masses seen or felt. The umbilicus has
healed completely and no umbilical hernia.
Lower limbs
They are equal and non-edematous with no scars or lesions.
No deformities noted on the legs.
The joint movements are normal and joints are non-tender and flexible
LITERATURE REVIEW
Bipolar disorder, formerly called manic depression, is a mental health condition that is
characterized by a cycling between depression, normal mood and mania.

When one becomes depressed, they may feel sad or hopeless and lose interest or pleasure in most
activities. When the mood shifts to mania it exhibits hyperactivity, agitation, irritability and
accelerated speaking and thinking. Behaviours may include pathological gambling, wearing
excessive attire and jewellery of bright colours in unusual combinations. The client may be
preoccupied with religious, sexual, financial, political or persecutory thoughts that can develop
into complex delusional systems. 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 counselling (psychotherapy).

TYPES OF BIPOLAR MOOD DISORDER

Bipolar I disorder: has prevalence of about 0.7% to 1.6% with occurrence equally in both men
and women and across the races ( Kupfer, 2004; Sadock, 2008). Characterized by one or more
manic episodes with or without a history of a depressive disorder. The individual experiences
rapidly alternating moods accompanied by symptoms of a manic mood and a major depressive
episode. During manic episode, the individual exhibits an abnormal, persistently elevated or
irritable mood that lasts for at least 1 week. Impairment in various areas of functioning,
psychotic symptoms and the possibility of self-harm exist. Psychiatric comorbidities that are
common in clients with bipolar 1 include: adult antisocial behaviour, alcohol dependence, drug
dependence and anxiety disorders.

Bipolar II disorder: Characterized by recurrent major depressive episodes with hypomania- a

mood between euphoric and excessive elation- episodes occurring with a particular severity,
frequency and duration. According to the DSM-IV-TR, the client with Bipolar II has a presence
or history of one or more major depressive episodes, alternating with at least one hypomanic
episode, but no manic episode. Although clients with BP II are not prone to psychotic symptoms
or behaviour, they may exhibit psychotic, catatonic, melancholic or atypical features that can
cause significant impairment in various areas of functioning. Occur majorly in women than in
men.

Cyclothymic disorder: has symptoms of BP II, except that they are generally not severe.
Changes in the mood are irregular, sometimes occurring within hours. 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.

Mania and hypomania

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.
Diagnostic criteria of Manic episode.

1. A distinct period of abnormally and persistently elevated, expansive or irritable mood.

Mood disturbance and increased energy or activity plus 3 of the following ( four if the mood is
only irritable):

More talkative that usual or pressure to keep talking.

Flight of ideas / racing thoughts.

Distractibility.

Increase in goal directed activity or psychomotor agit

Major depressive episode.

Diagnostic characteristics.

Evidence of at least five clinical symptoms in conjunction with depressed mood or loss of
interest or pleasure.

Symptoms occurring most of the day and nearly every day during the same 2-week period
representing an actual change in the person’s previous level of functioning.

Significant distress or marked impairment in the person’s functioning such as in social or

occupational areas.

Symptoms not related to a medical condition or use of a substance.

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 hypersomnia.

Psychomotor agitation or retardation.

Fatigue or loss of energy.

Feelings of worthlessness or excessive or inappropriate guilt.

Decreased ability to think or concentrate, or indecisiveness.

Recurrent thoughts of death, suicidal ideation, suicidal attempt or plan of committing suicide.

Risk factors.

Factors that may increase the risk of developing bipolar disorder or act as a trigger for the first
episode include:

 Having a first-degree relative, such as a parent or sibling, with bipolar disorder

 Periods of high stress, such as the death of a loved one or other traumatic event

 Drug or alcohol abuse.

 Endocrine disorders such as Cushing’s syndrome, thyrotoxicosis.

Complications
Left untreated, bipolar disorder can result in serious problems that affect every area of your life,
such as:
  Problems related to drug and alcohol use

 Suicide or suicide attempts

 Legal or financial problems.

 Damaged relationships.

 Poor work or school performance

Diagnosis.

A medical professional will diagnose bipolar disorder using criteria set out in the DSM-5.

The National Institute of Mental Health (NIMH) explain that in order to receive a diagnosis of
bipolar I disorder, a person must have had symptoms for at least 7 days or less if symptoms were
severe enough to need hospitalization. They may also have had a depressive episode lasting at
least 2 weeks.

To receive a diagnosis of bipolar II, a person will have experienced at least one cycle of
hypomania and depression.

A doctor may carry out a physical examination and some diagnostic tests, including blood and
urine tests, to help rule out other causes.

It can be challenging for a doctor to diagnose bipolar disorder, as people are more likely to seek
help with a low mood than a high mood. As a result, it can be hard for them to distinguish it
from depression.

If the person has psychosis, a doctor may misdiagnose their condition as schizophrenia.

Other complications that may occur with bipolar disorder are:

 use of drugs or alcohol to cope with symptoms

 post-traumatic stress disorder (PTSD)

  anxiety disorder

 attention-deficit hyperactivity disorder (ADHD)

Healthcare providers should look for signs of mania in the person’s history, to prevent
misdiagnosis. Some antidepressants can trigger mania in susceptible people.

A person who receives a diagnosis of bipolar disorder has a lifelong diagnosis. They may enjoy
long periods of stability, but they will always live with the condition.

Treatment.

Treatment aims to stabilize the person’s mood and reduce the severity of symptoms. The goal is
to help the person function effectively in daily life.

Treatment involves a combination of therapies, including:

-pharmacotherapy such as mood stabilisers, antidepressants

-counselling

-psychotherapy such client motivated interventions, cognitive behavioural therapy, group therapy

-lifestyle remedies.

-Hospitalisation.

-Electroconvulsive therapy.

It can take time to get a correct diagnosis and find a suitable treatment, as individuals react
differently, and symptoms vary widely.

Pharmacotherapy

Drug treatments can help stabilize mood and manage symptoms. A combination of the following
are often prescribed:
  mood stabilizers, such as lithium

 antidepressants

 second-generation antipsychotics (SGAs)

 Anticonvulsants, to relieve mania.

 Medication to help with sleep or anxiety.

 The medication may need some adjustments over time over time. Some drugs have side
effects, and they can affect individuals differently. If an individual has concerns about
their drug treatment, they should talk to their doctor.

 tell the doctor about any other mediations they are using, to reduce the risk of interactions
and adverse effects

 follow the doctor’s instructions regarding medication and treatment

 discuss any concerns about adverse effects, and if they feel the treatment is working

 continue taking medication unless the doctor says it is safe to stop

 bear in mind that the drugs can take time to work

If the person discontinues their treatment, symptoms may worsen and even devolop
complications.

.
 NURSING CARE PLAN ON BIPOLAR MOOD DISORDER

ASSESSMENT DATA. NURSI GOAL INTER RATIONALE IMPLEME EVALUATION

NG VENTI NTATION
DIAG ON
NOSIS

Disturb With the aid Provide To achieve I encourage The client is able to sleep for 6
ed of sedatives, quite sleep and rest the patient hours.
The patient reports that
sleep the patient environ to take day
she does not get enough To prevent
pattern will sleep 4 ment time naps
sleep. collapse and
related to 6 hours when other
to without Assess to achieve patients
On observation, the
bioche awakening client’s rest. were away
patient is always awake
mical activitie from the
very early . To help the
alterati s levels. ward.
patient
ons Adminis achieve sleep
evidenc I gave the
ter restoring thus patient
ed by sedative normal
the amitriptylin -the patient
medicati sleeping e every
patient ons; pattern. participated in the group
having evening.
amitript therapy sessions.
difficul yline
On observation the ty in
The patient is
patient seems restless sleepin
seen to be
g.
calm and free The patient gained weight and
from injury.
Relatives reports of the was able to verbalize the
patient being loitering. The patient importance of adequate
will consume -Provides nutrition.
sufficient focus and
On observation, the foods and in security I
patient sings and dances, between encouraged
meals to meet Provide the patient
talking and laughing to
recommende structur to
herself.
d daily ed participate
Risk solitary To provide
for nutrients. in group
activitie adequate therapy
injury The client s with knowledge
related meeting as
will be able the regarding
to to recognize assistan good nutrition it improves The patient is able to
bioche and verbalize ce of a and overall focus. differentiate between reality an
mical when she is nurse or wellness. unrealistic situations.
imbala interpreting aide.
nces. the To prevent
I encourage
environment. Explain aggressive
the patient
Imbala the responses to
to take her
nced importa command
meals and
nutritio nce of hallucinations
n less drink
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e
body fluids.
nutrition
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and
ments
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Disturb
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Conclusion.
In conclusion, bipolar disorder is a mental illens that affects individuals in their daily doings and
can be managed by the pharmacotherapy and family social counselling therapy . Though the
individual can live fully productive with the right diagnoes if made.
Recommendation.
Comparing the ideal management and actual management given at the facility I present the
following recommendations: Good Therapy can restore self-esteem, build emotional coping
strategies and even restore patients full potentialliaty

Regular reviews by a clinical psychiatrist to assess the progress of the patients will be essential in
taking care of patients

More personalized care to each patient will facilitate timely and accurate capturing of changes
and monitoring of patient's progress in the ward and those attend clinics.

References.
1. Jackson, J. G., Diaz, F. J., Lopez, L., & de Leon, J. (2015). A combined analysis of
worldwide studies demonstrates an association between bipolar disorder and tobacco
smoking behaviors in adults. Bipolar disorders, 17(6), 575-597.
2. Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
Arlington, VA: American Psychiatric Publishing; 2013.
3. R, Harvey PD. Systematic study of structured diagnostic prodecures in outpatient
psychiatric rehabilitation: a three-year, three-cohort study of the stability of psychiatric
diagnoses. Innov Clin Neurosci. 2013 May–Jun;10(5–6):14–9. PMID: 23882436. [PMC
free article] [PubMed]
4. A, Baxter A, Whiteford H. A systematic review of the global distribution and availability
of prevalence data for bipolar disorder. J Affect Disord. 2011;134(1–3):1–13. [PubMed]

5. A, King-Kallimanis B, Kohn R. Prevalence of mood, anxiety, and substance-abuse

disorders for older Americans in the national comorbidity survey-replication. Am J
Geriatr Psychiatry. 2009;17:769–81. [PubMed]