CASE STUDY 1

Bipolar Disorder: Case Study

Stacey M. Pezzenti

Centifonti School of Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

William Church

November 13, 2023

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Abstract

This case study provided follows the treatment of a patient presented with Bipolar 1 disorder, as

well as defining the disease process, and how this specific disease may affect this individual’s

daily life. The patient described and observed throughout this case study is a 56-year-old

Caucasian male who presented to the emergency department presenting manifestations of the

manic stage of Bipolar 1 disorder. He was accompanied by his aunt, who often houses the patient

and reported that he has not been taking his medication nor has been sleeping many hours. A

series of academic research articles were utilized to provide supplemental information related to

the disease process of Bipolar 1 disorder and symptoms or manifestations that can be seen when

providing care.
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Bipolar Disorder: Case Study

Objective Data:

GS is a 56-year-old Caucasian male who was brought into the Emergency Department on

October 17, 2023, along with his aunt, who has guardianship of him. His aunt states that she

believes he may have stopped taking his medication and wanted further evaluation to make sure

that this is the case. Those medications are Risperidone and Lithium which helps stabilize his

mood. She has noticed he has been more agitated than normal, paces more, and has not been

sleeping that many hours in the day. GS’s aunt also saw him binge drinking as well. Prior to being

brought into the ED, GS was on a three day stay in a medical-surgical unit following the

detoxification process. After being assessed in the ED, the patient was transferred to the Psych

Floor for further treatment and stabilization.

While interviewing the patient, GS demonstrates behaviors related to his diagnosis of

Bipolar 1 disorder. Currently, he is experiencing a manic episode of the Bipolar 1 disorder vs the

hypomanic stage. When asked if GS feels depressed or had a history of depression, he denies it

even though his aunt reports that three months ago he could not get out of bed and would barely

speak to anyone. GS was asked if he had thoughts of harming himself to which he denies. GS

states he has been hallucinating and having some delusional thinking as well. This is shown when

asked about finances, he states that “money talks” which indicates auditory hallucinations. He

states that “hearing voices is a gift.” GS is shown to have delusions of grandeur where he speaks

highly of himself by stating he taught himself the violin in two weeks, performed concerts in New

York, did painting for museums, and believed he was the conqueror of the world. He also stated

that he “taught farmers how to farm” while in Indiana. Following that, GS mentioned a farmer

assaulted him after telling the farmer he was a genius, showing he has a high sense of self.
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Another delusion he exhibited was referential when he stated, “everyone on the subway came to

see me.” GS can be described as an egomaniac since he states that “he knows better than anyone.”

Upon the interview, he speaks highly that he does not need sleep and states that “three hours is

enough for me.” GS’s speech was very rapid and pressured. GS can be seen to have automatisms

through his tapping of his foot, fidgeting with his hands, and shaking. Along with automatisms, he

has hyperactivity since he could not sit still during the interview. The patient shows indications of

Flight of Ideas and racing thoughts because he would go from one topic to the next without any

association. GS states his thoughts are like “a jet” or “a nuclear blast” because of this he mentions

he is unable to read since the thoughts just keep coming. Since his thoughts were racing, GS’s

voice became incoherent to understand what he was talking about. Clang association was noticed

when he said “same, lame, flame” in the same sentence which rhymes.

When asked about his sexual behaviors, GS states he engages in sexual contact with

strangers, which demonstrates his poor judgment and impulse control. GS was questioned about

his substance use history. He attempts to drink beer, champagne, and margaritas on the weekend

to which he blacks out, “things get fuzzy”, and he gets the shakes. GS tries to downplay any

notion of having problems with alcohol or any other substances especially because he mentions it

helps with his racing thoughts. Besides alcohol, he was asked about any other substance use such

as marijuana, which he first noted that it makes him paranoid. However, GS changed that

statement to say that he would use a vape pen with his friend. Well under the influence of the

vape pen, GS says he would “see trees coming out of my friend’s mouth” which contributes to the

idea of visual hallucinations. He states that his drinking and substance use is the reason he lost his

best friend after fighting and his job as a Walmart stocker but also believes it is because people

are paranoid of him since he is so talented. GS says his aunt and cousin checked him into rehab
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for a weekend. Lastly, the patient was asked about his nutritional status to which he states that

when he drinks, he forgets to eat. GS mentions he walks regularly and takes vitamins to care for

himself.

GS is currently on several medications related to his diagnosis of Bipolar 1 disorder. He is

on 600 mg of Lithium twice a day. This medication helps stabilize his mood. Risperidone 2 mg

once a day for his delusions and hallucinations related to psychosis. GS has a PRN order for

Haldol 5 mg for any agitation or delusional thinking. For his alcohol use, GS is ordered Ativan,

Librium 10 mg to help decrease withdrawal symptoms, multivitamin and folic acid. He is ordered

a Nico Derm patch to help with any nicotine withdrawal since he states he is a smoker.

GS’s labs were drawn during the day of care because of the patient’s current medication.

His potassium was 3.4, which is on the low side. This can put the patient at risk for dysrhythmias

and any heart problems. Sodium was 132 which GS being on lithium can lower sodium levels due

to overworking the kidneys. BUN and Creatinine were normal, indicating no renal impairment.

Glucose was elevated due to being on an antipsychotic, Risperidone. AST/ALT were elevated due

to liver damage from alcohol. GS’s alcohol toxic screen was 0.25 which is way above the legal

limit. GS also had an ECG done and was compared to one taken a year ago. A year ago, his QTC

was 431 and now it is 477. This elevation is because of the antipsychotic medication which can

prolong the QTC interval.

The patient is order unit restriction and suicide precautions. Safety measures are taken to

ensure a safe environment including removal of all sharp objects as well as any strings, laces, or

belts that could cause harm. The patient is ordered vital signs every 4 hours or as needed. His

vitals on day of care were BP - 140/90, P - 98, RR - 18, and temp 97.9. For nutrition, the patient

ate 50 % of his breakfast and lunch. He continued pacing after eating. Education was also
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provided to the patient regarding a well-balanced meal. He was also encouraged to attend two

therapy sessions. In these sessions, GS loudly answered every question and talked nonstop about

a symphony he was going to perform later. Part way through the group, GS got up and walked out

the room to continue pacing in the hallways. He was seen talking to himself as well.

Summary of Bipolar 1 Diagnosis:

According to the National Institute of Mental Health (NIMH), bipolar 1 disorder is

defined by, “manic episodes that last for at least 7 days (nearly every day for most of the day) or

by manic symptoms that are so severe that the person needs immediate medical care. Usually,

depressive episodes occur as well, typically lasting at least 2 weeks” (NIMH, 2022). Bipolar can

be diagnosed during adolescence or early adulthood. The severity of symptoms can vary but this

disorder requires life-long treatment. In the text Psychiatric-Mental Health Nursing, the manic

phase is where clients are euphoric, grandiose, energetic, and sleepless. There may be poor

judgment and rapid thoughts or speech. The text suggests the depressed phase is when the mood,

behaviors, and thoughts are like someone diagnosed with depression (Videbeck, 2016). The

NIMH suggests that bipolar patients can have either manic episodes or depressed episodes or a

mix of both types combined. These can happen at the same time or independently where these

episodes can last every day or for longer periods such as weeks or days (NIMH, 2022).

Other behaviors that can be seen with these individuals in the manic phase are

sleeplessness, pressured speech, flight of ideas, increased activities with increased energy, high

risk activities with poor judgment such as sex with strangers, impulsiveness, or spending sprees.

These individuals may not understand how their illness affects others and may stop taking their

medication because they like the euphoria and hate the side effects of the medications (Videbeck,

2016). GS is shown to have some of these manic symptoms such as the need for less sleep since
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he states he only needs three hours. He also has the poor judgment aspect since he sleeps with

strangers. He has the pressured speech, flight of ideas, along with the increased energy.

Multiple types of Bipolar exist and each have different criteria for their diagnosis and

manifestation of symptoms. Bipolar 1 criteria is the need to meet at least one of the criteria for a

manic episode which are: a period of abnormal and persistent elevated, expansive or irritable

mood and increased activity or energy, lasting one week and present most of day; period mood

disturbance and increased energy or activity, three or more symptoms are present; cause marked

impairment in social or occupational functioning; and the episode is not attributable to the

physiological effects of a substance or other medical condition (Videbeck, 2016). Another

criterion is that the manic phase is followed by hypomanic or major depressive episodes.

Stressors and Behaviors that Precipitated Current Hospitalization:

In GS’s case, multiple stressors and behaviors led to his current hospitalization. The

important stressor is that GS was reported to be stopping his medications. This was suspected by

his lithium levels being decreased at 0.2. Therefore, his medication is not being effective enough

to help stabilize his mood. He was reported to be a binge drinker while smoking marijuana.

Throughout the interview, he stated that he lost his job as a Walmart stocker along with losing his

friend because of a fight they had so they no longer speak to each other. GS explains that he does

not sleep for no more than three hours. His aunt also takes care of his finances, so he does not

have money especially because of the loss of his job. GS’s father also left him when he was 10

years old and states he “hit him around and his mom just sat there.” GS stated that his mother died

when he was fifteen from cancer which can put stress into his life at a young age.

In a research article titled, “Family History in Patients with Bipolar Disorder”, the authors

discuss a study done that shows whether there is a genetic link between bipolar disorder and the
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patient’s family history. The researchers compare the tendency of developing bipolar from the

maternal and paternal side of the patient with a diagnosis of bipolar in the family history through

files or hospital records. As a result, they were able to figure out there is a significant relationship

between the kinship and the heritability of the disease, and that the effect of either the maternal or

paternal side and genetic susceptibility are similar (Atli et al., 2016). In relation to GS’s case, this

gives an insight as to why he was at a much higher risk due to having a family history from his

mother of bipolar disorder.

Patient and Family History of Mental Illness:

GS states that he does not have any history of mental illness. He practically denies that he

has any at the current moment during the interview. He denied any history of depression even

though three months ago he was going through symptoms of depression. Although any family

history was not directly stated, there is evidence to indicate possible bipolar history and substance

abuse. Patient admits that his father was “a mean” alcoholic and a half-brother on his dad’s side

who was also an alcoholic. When asked about his mom, he states that she can be considered

“moody” and often depressed and just sat around. GS mentioned she would “snap out of it” and

be fun-loving, caring, and would take them shopping. This indicates his mom having a history of

bipolar going on since it matches the symptoms.

Milieu Therapy and Evidence Based Nursing Care:

Throughout the patient’s day of care on the Psych floor different evidence-based nursing

care was provided along with a milieu environment for the therapeutic aspect of care. Primarily

care was directed towards eliminating hazardous objects that could be used on the patient or

others such as belts, shoelaces, or glass objects like mirrors to provide safety. Staff was also

trained to de-escalate conflict safely and effectively between patients on the unit. GS was
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encouraged to attend two group therapy sessions to help identify healthy ways of coping as well

as identifying previous coping mechanisms that were unhealthy. GS was seen to attend these

group therapy sessions but was seen to monopolize the group with talks about a symphony. The

patient was also encouraged to eat a healthy meal and that when he paces, he can try to consume

snacks or “finger-foods” to get more nutritional value daily. Both pharmacological and

nonpharmacological measures were taken during the day of care. Nonpharmacological measures

were provided by therapeutic communication and setting a strict schedule with the patient. A calm

environment was also established to reduce any agitation and anxiety GS may develop.

Lithium and Risperidone were administered to help stabilize his emotions during his

manic episodes. In an article, “Pharmacological Treatment of Bipolar Depression: What are the

Current and Emerging Options?” the authors discuss that previous medications have been used for

the symptoms of bipolar depression such as antidepressants, but they do not work the same as

someone with unipolar depression. Some treatment options such as quetiapine, olanzapine,

lithium, lurasidone, and valproate are considered first-line of treatment for bipolar depression.

The treatments that may be used currently are to not only manage the patient’s symptoms but

ensure their physical health is not compromised. According to the authors, in a randomized study

lithium “was significantly less effective than extended-release quetiapine in treating depressive

symptoms and improving sleep quality in patients with bipolar depression” (Yalin & Young,

2020). However, lithium has been the first line of treatment for these patients. This has allowed

more options to be available such as atypical antipsychotics to effectively manage bipolar

symptoms without long-term physical compromise.

Ethnic, Spiritual, and Cultural Influences:

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GS is a 56-year-old Caucasian male who does not specifically state being affiliated with

any religion. He does claim that he believes to follow mother earth and has a connection to the

universe. Socioeconomic status is not specified but his aunt takes care of his finances with whom

he travels with as well which could indicate being somewhat above poverty. GS often seems to be

driven by traveling experiences and recalls them mostly in his manic state. There is no mention of

any cultural or religious beliefs or any person who influences his daily activities from the patient

during the interview. GS had a wedding ring on but did not mention anything about a wife.

Evaluation of Patient Outcomes:

Throughout GS’s course of treatment on the Psych Unit, he was shown to have positive

outcomes related to his care. GS remained safe and free of injury during his stay. GS showed an

improvement in his sleep pattern whereas he got about 6-8 hours of sleep instead of only three

hours. He was also able to stay asleep during those hours. When observing his nutritional status,

he began to eat more than 50% of his meals and was able to explain what adequate nutrition and

hydration in relation to himself is. GS has been compliant with his medications while receiving

care, and patient teaching was still enforced to prevent noncompliance from happening again. GS

is still successful at attending group sessions and was able to not be so talkative during them.

Manic symptoms have decreased but delusions and hallucinations persist. The patient can tell they

are not real thoughts but are still experiencing them.

Summarized Plans for Discharge:

Upon discharge, GS is planned to return to his aunt’s house. A primary goal for discharge

is to have appropriate housing and continuation of GS in taking his medications as ordered. He is

to take Lithium 600 mg twice a day and Risperidone 2 mg daily. Education on medications will

be provided prior to discharge. Teaching will include adverse effects of the medications along
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with symptoms to report. This information will provide adherence due to the patient

understanding the possible side effects but the importance of taking his medications. Along with

taking his medication, he is advised to stay away from any substances such as alcohol and

marijuana. He was ordered to go to an AA meeting every week to help with his substance use. In

addition, GS is expected to follow-up with his psychiatrist to evaluate his compliance with

medications and the AA meetings as well as their effectiveness. GS and his aunt are encouraged

to attend family therapy to learn to cope with the disease, deal with the stressors in a healthy

manner, and how to communicate effectively with one another.

Prioritized List of Actual Diagnoses:

Disturbed Through Processes related to biochemical imbalances in the brain by evidence by

delusions of grandeur, auditory and visual hallucinations

Insomnia related hyperactivity with evidenced by the need of only three hours of sleep

Disturbed Sensory Perception related to substance use and sleep deprivation is evidenced by

emotional responses and inappropriate behaviors.

Impaired Social Interaction related to egocentric behavior as evidenced by being assaulted when

stating he was “a genius”

Imbalanced Nutrition related to inability to sit still long enough as evidenced by electrolyte

imbalance and weight loss

List of Potential Nursing Diagnoses:

Risk for Suicide

Spiritual Distress

Risk for Injury

Risk for Loneliness

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Ineffective Impulse Control

Self-Care Deficit

Caregiver Role Strain (Aunt)

Conclusion:

Through a multi-disciplinary approach, it is possible for GS to be able to function within

his day-to-day life. With the right environment and social support, GS will be able to maintain his

medication regimen to decrease the possibility of encountering a relapse of a manic or depressive

episode and keep his symptoms at a minimum level. GS will need ongoing family support and

encouragement for him to get treatment to ensure he gets the care needed to function at his

highest level. Overall, GS was a very interesting patient to observe for this case study since he

exhibited many different psych symptoms.

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References

Özdemir, O., Coşkun, S., Aktan Mutlu, E., Özdemir, P. G., Atli, A., Yilmaz, E., & Keskin, S.

(2016). Family history in patients with bipolar disorder. Noro psikiyatri Ars.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5378218/

U.S. Department of Health and Human Services. (n.d.). Bipolar disorder. National Institute of

Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder

Videbeck, S. (2022). Chapter 17: Bipolar Disorder. Psychiatric-Mental Health Nursing (pp.

306-315). Lippincott Williams & Wilkins.

Yalin, N., & Young, A. H. (2020). Pharmacological treatment of bipolar depression: What are

the current and emerging options? Neuropsychiatric disease and treatment.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294105/
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Case Study Comment Sheet 4842 (Turn in with Case Study)

Student Name Stacey Pezzenti

Pt Identifier GS

Date(s) of Care October 17, 2023

__________ Objective Data presentation the patient, treatments, medications

__________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

___________ Patient education required (based on symptoms, diagnosis, medications, labs,

safety, etc.)

___________ Priority patient needs (day of care and discharge)

__________ Summarize discharge plans and community care

__________ Actual nursing diagnosis, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format