BIPOLAR CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Julia Hum

September 29, 2023

Dr. Teresa Peck & Mrs. Phyllis Jean Defiore-Golden

NURS: 4842L Mental Health Nursing Laboratory

Youngstown State University

BIPOLAR CASE STUDY

Abstract

The following case study discusses the disease process of a patient diagnosed with Bipolar

Disorder 1. The patient being discussed is R.B, a 42 year old caucasian male that presented to the

emergency department due to suicidal ideation and an attempt to overdose using medication. R.B

main diagnosis is Bipolar Disorder 1 and in congruence is diagnosed with Major Depressive

Disorder, Anxiety, and Schizophrenia. Many journal articles were researched and used to put

together the following case study, by using supportive evidence and factual information.
BIPOLAR CASE STUDY

Objective Data

Patient Identifier R.B

Age 42

Sex Male

Date of Admission September 25, 2023

Date of Care September 29, 2023

Psychiatric Diagnosis Bipolar Disorder 1

Other Diagnoses: Major Depressive Disorder, Anxiety, Schizophrenia

Behaviors on Admission

RB was brought into the emergency department by ambulance and appeared very

lethargic, combative, and non-compliant. He was alert and oriented x2. RB was pink slipped due

to suicidal ideation and was combative with the nurse in the emergency department. It was found

that patient had became suicidal and ingested fifteen 300 mg seroquel and 14 tablets of Lybalvi,

which were both old medications that patient is no longer prescribed. Patient stated upon arrival

that his roommate stabbed him, but upon assessment no stab wounds were found, which

indicated hallucinations as a side effect of overdosing. Some of the behaviors of the patient

included kicking, hitting, confusion, yelling at staff, lethargy, and pulling at tubing and IV sites.

Behaviors on Day of Care

RB was very pleasant to speak to from the beginning to end of the day. The social worker

approached and asked the patient if he was willing and comfortable talking to a nursing student,

and he agreed very easily. He was open, honest, and willing to discuss his behaviors and feelings

with me. RB was asked to start his mental health story from the beginning and he was very
BIPOLAR CASE STUDY

compliant. RB did appear very depressed and had a flat affect during certain times of care or

when others around him were talking about depression. He teared up during the group activity

but remained compliant and interactive during the group session, even though he was slightly

quiet compared to other patients. He had small side conversations with other patients on the unit

and tried his best to maintain social interaction.

Patient has a history of very bad social anxiety. The patient did appear extremely anxious,

especially when talking about himself. Some physical signs of anxiety that he displayed was

needing to take deep breaths in between sentences, fidgeting with fingers and clothes, taking

multiple sips of water and playing with the cup while talking, failure to maintain eye contact, and

tapping his feet and legs continuously. Patient stated that his anxiety was a 4/10 but his behaviors

were very indicative of severe anxiety.

Safety and Security Measures: As stated above, patient was brought into the emergency

department due to suicidal ideation. Upon admission to the emergency department, he was pink

slipped during triage in order to maintain his safety and ensure he did not hurt himself or others

around him. During his initial stay in the emergency department a safety companion was with

him at all times to ensure the patient did not harm himself or others.

Once RB was admitted to the mental health floor of the hospital, there were many safety

precautions that were put into place for the entire unit in order to ensure safety of all patients and

staff. This includes no long wires, no pens, metal utensils, phones, jewelry, vapes, or other

personal belongings with the patient. These measures also include heavy chairs and tables so that

they are not able to be picked up and thrown, no locks on doors to rooms or bathrooms, and no

full doors on the bathroom stalls. As for security, the entire unit is considered a “locked unit”

meaning that in order to open any door on the unit there is a key needed that only staff are
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permitted to use to unlock doors. There are no openings on the windows of the floor and there

are police officers within the hospital as well, in case they are needed. Each nurse and staff have

a panic button that they keep on at all times and are able to press in times that their safety or the

safety of a patient is put at risk.

Laboratory Results:

Lab Value Result

Potassium 3.7

Sodium 139

Glucose/A1C 108

BUN 6

H&H 14.2 / 41.4

Creatinine 0.8

RBC 4.66

WBC 7.4

BUN 9

Urine Drug Negative for all

Screen

Ethanol 97

Acetaminophen <5

Salicylate LVI <0.3

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Psychiatric Medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

Divalproex Depakote Anticonvulsant 500 mg Q12 Mood swings

Sodium hours daily and aggressive
outbursts

Folic Acid Folvite Vitamin 1 mg daily Low folvite

levels; anemia

Olanzapine Zyprexa Atypical 10 mg daily Manic episodes

antipsychotic

Docusate Senokot Stool Softener 8.6 mg daily Constipation

Vitamin B1 Thiamine Vitamin 250 mg daily Tingling in

numbness and
feet

Acetaminophen Tylenol analgesic 650 mg Q6 Mild pain and

hours PRN headaches

Nicotine Patch Nicoderm Nicotine 21 mg patch Smoking

replacement daily cessation
therapies

Summarize the psychiatric diagnoses

Bipolar Disorder 1 is a mental illness that causes unusual shifts in a person's mood,

energy, behaviors, etc. The moods that these patients can go through vary greatly and change

multiple times throughout their life. The 'highs' being mania, and the ‘lows’, being depression,

can last anywhere from several days to several months long. Treatment involves

pharmacotherapy and psychosocial interventions, but relapse of moods occurs often, particularly

with depression. Reevaluation and frequent treatments are usually required for patients with

long-term bipolar. Patients who have bipolar disorder often go undiagnosed because of the fact
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that symptoms of bipolar overlap as symptoms of other psychiatric illnesses. Prompt diagnosis of

this disease is very important in assuring that patients get the right treatment as early in their life

as possible. (Jann, 2014)

In order to be diagnosed with Bipolar Disorder 1, a patient must have experienced at least

one episode of mania. When a patient is in mania, they will often feel very happy, overjoyed,

have euphoria, heightened energy, be very hyperactive, have difficulty sleeping at night and often

go days without sleep, have an inflated self-image, excessive spending, hypersexuality, and be

very talkative at a high paced speed and volume. On the contrary, patients with Bipolar Disorder

1 will also become depressed. During this time the patient often feels sad, hopeless, empty,

tearful, loss of interest, and feeling no pleasure in things that usually bring them joy. (Hilty et al.,

1999)

Experiencing four or more episodes of mania or depression within 1 year is called “rapid

cycling.” However, people with bipolar disorder aren’t always in a hypomanic/manic or

depressive state. They also experience periods of normal mood, known as euthymia. The exact

cause of Bipolar Disorder is unknown, but appears to be due to an interaction of genetic,

epigenetic, neurochemical, and environmental factors. (Miola et al., 2023)

Identify the stressors and behaviors

Stressors to this particular patient are something that we discussed with a lot of detail.

Some of these patients' stressors appeared much different than things that others are “normally”

stressed about. The patient stated that he has been taking classes and just recently passed his

CDL trucking exam the morning of his suicide attempt. RB stated that he got “overly excited”

that he passed his exam, sending him into a manic episode due to his Bipolar Disorder 1

diagnosis. He became very energetic, compulsive, irrational, overly excited, etc. He stated that he
BIPOLAR CASE STUDY

realized he was in a manic episode, so in order to calm himself down he started drinking. RB

states he has 8-10 beers and became very depressed. He stated that he felt like his life “had no

meaning” and that is when he ingested the pills.

Patient also discussed that he just recently got news earlier in the week that one of his

friends since highschool committed suicide and died. He stated that this death happened a few

weeks ago and he just now found out, which he also seemed to be angry and upset about. He

stated that he grew up with this friend since middle school but grew apart when RB moved away

to North Carolina. He stated that this caused him to be very depressed. Another stressor that the

patient brought up is that in the past year he just moved back home to Ohio from North Carolina

from a “bad relationship”, which included his girlfriend who was verbally abusive to him. He

stated how stressful the relationship and move was for him. He said that moving back to Ohio

was good for him in the long run for his mental health.

Discuss the patient and family history of mental illness

When RB was asked if mental illness is a family issue he expressed a lot of feelings and

emotion towards this idea. He expressed that his mother was diagnosed with bipolar disorder 1

when he was growing up. It was very hard for him to get a stable and comforting relationship

from his mother when he was younger because of her diagnosis. His dad also suffers from

depression and anxiety which he stated he believes had an affect on his mental health growing

up. In addition to this he stated that his grandparents on his mothers side, both his grandpa and

grandma also suffered from Bipolar Disorder 1. He stated that while it was extremely hard to

have been raised surrounded by people struggling with mental illness, it felt good for him to be

surrounded by people that “understood” his diagnosis. RB stated that he also has a sister but they

never had a stable relationship. When asked about having kids or a family of his own, RB stated
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that he does not have any children and does not plan to try to seek relationships at this point in

his life.

Describe the psychiatric evidence based nursing care provided

During the patient's stay on the psychiatric nursing floor, he received care from a lot of

different healthcare professionals. The primary care doctor and the nurse practitioner are the ones

that prescribe the patient's medications. During his stay he was put on Depakote rather than the

seroquel he was previously on, and he stated this has helped him tremendously. The nurse's role

for this patient included monitoring his safety and mental health daily. RB stated he had a very

respectable relationship with the nurses on the floor. The nurses provide education about his

diagnosis and help him with ways to try and manage it. They are also there to provide emotional

support and guidance. The nurses make nursing diagnoses of the medical and emotional status of

the patient and recommend treatment options. Social workers are also there on the unit and

available to work one on one with patients and also in groups to help with coping and give

emotional guidance to patients. Psychotherapy is another resource that occurs on the unit. This is

led by a social worker, but really the patients are the ones who take charge and lead the

discussion. A lot of patients struggling with mental health issues can benefit greatly from talking

and listening to others who go through some of the same struggles they do.

Analyze ethnic, spiritual and cultural influences

RB is a caucasian, single man from a lower class family. He resides at home with his

parents and has lived with them on and off since growing up and moving away to North

Carolina. RB stated that he depended on his parents for financial needs before moving away. He

stated that he qualifies for food stamps and uses those for the majority of his expenses. Since
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coming back, he has been taking CDL classes to become a truck driver so he can financially

support himself.

The patient met with the chaplain twice during his admission to the unit. The note stated

that the topic they discussed was spiritual health and wellness. They talked about meaningfulness

in his life and said that RB expressed that he grew up in a catholic household when he was

younger, but has not practiced this religion in “a while”. The note also stated that RB was an

active listener during the session and was alert and cooperative. It stated that RB struggles a lot

with finding purpose in his life.

Evaluate the patient outcomes

Some of the outcomes that are desired for RB, as an individual with bipolar living out in

society are that that patient will not harm themselves or others during a manic episode, he will

demonstrate a calm demeanor before discharge, maintain a stable and self-sufficient job,

maintain healthy relationships with family and friends around them, know what to do and where

to call if any suicidal ideations occur, and have a stable living environment. RB expressed that he

knows where to call and what to do if he is in a manic episode and has suicidal ideation.

The patient also stated that he will still have his truck driving job that was lined up prior

to his admission to the unit once he is discharged, and emphasized that he thinks this will be

good for him. He stated that it was hard to maintain jobs prior to admission because of his social

anxiety, and states that being “alone on the road” while driving a truck will be very beneficial to

him. He stated that both his depression and anxiety range from about 3-4 out of 10 on a day to

day basis, which is extremely lower than it was upon admission, which was an 8/10 for anxiety

and a 9/10 for depression. He states he feels much better on his new prescribed medication and
BIPOLAR CASE STUDY

said that he thinks his admission was due solely from not being on the correct medication for his

diagnosis.

Summarize the plans for discharge

The plans for discharge with this patient are that he gets discharged on Monday, October

2nd if he meets all required criteria to be able to be discharged and the physician decides that it is

safe for the patient and the people around him. The plan is to discharge the patient to his parents

house, where he was previously living before his admission to the hospital after he got home

from North Carolina. RB stated that he plans to live with his parents until he starts working and

saves enough money to get an apartment in Youngstown. He says that he will be getting a job

driving truck once he gets discharged since he passed his CDL exam.

Prioritized list of all actual diagnoses

The following are prioritized nursing diagnoses for RB:

1. Disturbed thought process related to psychosis as evidenced by manic episodes.

2. Risk for suicide related to suicidal ideation evidenced by previous suicide attempts and

current suicidal ideations.

3. Disturbed sensory perception related to sleep deprivation as evidenced by impaired

insight.

4. Ineffective coping skills related to drinking as evidenced by consuming alcohol in

response to depression.

5. Anxiety related to discharge as evidenced by patient sharing concern about needing to get

home to care for animals.

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List of potential nursing diagnoses

The following are prioritized potential nursing diagnoses for RB:

1. Risk for injury related to hyperactivity.

2. Risk for imbalanced nutrition related to depressive state.

3. Risk for violence related to irritability.

4. Risk for self harm related to suicidal ideation.

5. Risk for poor decision making related to manic episodes.

Conclusion paragraph

Bipolar Disorder is a very complex disease. It is important to get a prompt diagnosis as

early in life as possible in order to ensure adequate and effective treatment to maintain the best

outcomes for the patient. Bipolar Disorder 1 can appear in many different ways; depressive,

manic, or euthymia. The direct cause of bipolar disorder is unknown, but it is known to be highly

attributed to hereditary factors. Trauma, stressful life events, altered brain chemistry, medication,

drugs, and alcohol are also possible causes of the disease.

R.B was newly diagnosed with bipolar disorder upon this admission to the unit. R.B

seemed to be in good spirits about his new diagnosis because now he is able to get the help and

treatment that is correct for his diagnosis. Medication changes were made to R.B care plan and

he attended group therapy sessions, interacted with patients, and talked openly about his

diagnosis in order to maintain good emotional health.

BIPOLAR CASE STUDY

References

Hilty, D. M., Brady, K. T., & Hales, R. E. (1999). A review of bipolar disorder among adults.

Psychiatric Services, 50(2), 201–213. https://doi.org/10.1176/ps.50.2.201

Jann MW. Diagnosis and treatment of bipolar disorders in adults: a review of the evidence on

pharmacologic treatments. Am Health Drug Benefits. 2014;7(9):489-499.

Miola, A., Tondo, L., Pinna, M., Contu, M., & Baldessarini, R. J. (2023). Characteristics of rapid

cycling in 1261 bipolar disorder patients. International Journal of Bipolar Disorders,

11(1). https://doi.org/10.1186/s40345-023-00300-z