CASE STUDY

BIPOLAR DISORDER

General objective:

To provide knowledge about bipolar in relation to the condition of the client including history, assessment, treatment and management.

Specific objectives:

To define bipolar disorder and identify the course of the disease process To show concepts/ theories of nursing To identify the anatomy and physiology of the brain emphasizing nuerotransmitters To understand the pharmacological treatment To analyze the altered physiology of the nuerotransmitters and the like To examine and correlate actual assessment findings to the assessment of the patient

with bipolar disorder To appreciate nursing interventions to put into practice in rendering care to the elderly

I. INTRODUCTION

Background of the Study

When broadly defined, 4% of people experience bipolar at some point in their life. The lifetime prevalence of bipolar disorder type I, which includes at least a lifetime manic episode, has generally been estimated at 2%.A reanalysis of data from the National Epidemiological Catchment Area survey in the United States, however, suggested that 0.8 percent experience a manic episode at least once (the diagnostic threshold for bipolar I) and 0.5 a hypomanic episode (the diagnostic threshold for bipolar II or cyclothymia). Including sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, an additional 5.1 percent of the population, adding up to a total of 6.4 percent, were classed as having a bipolar spectrum disorder b. A more recent analysis of data from a second US National Comorbidity Survey found that 1% met lifetime prevalence criteria for bipolar 1, 1.1% for bipolar II, and 2.4% for subthreshold symptoms.

• On a strictly biological level, a person's ethnicity does not play a role in their risk of developing a bipolar disorder. Skin color does not mean a person is more or less likely to develop a condition or disease. However, racial stereotypes may play a role in the diagnoses of bipolar disorder.

• The onset of bipolar disorder tends to occur later in women than men, and women more often have a seasonal pattern of the mood disturbance. Women experience depressive episodes, mixed mania, and rapid cycling more often than men. Bipolar II

disorder, which is predominated by depressive episodes, also appears to be more common in women than men.

Rationale for Choosing the Case

Bipolar disorder is a very interesting case to analyze. Since this is the first time to encounter the disorder, we decided to study this case to prepare ourselves in dealing and handling psychiatric patients.

Significance of the Study

The significance of our study is to know and understand this kind of disorder (bipolar) specifically to the promotion of health, prevention of complication and treating or managing the disorder symptoms. In addition, the importance of this study is to make ourselves ready to reencounter bipolar disorder and other psychiatric disorders in succeeding clinical exposures so that we can able to provide effective and holistic nursing care.

Scope and Limitation

The study focuses on the nursing interventions and pharmacological interventions in managing the disorder. Some data are not explicitly identified due to limited sources of the institution and its policy of strict confidentiality.

Conceptual Theory

This case corresponds to Dorothea Orem’s Self Care Model because it allows the individual and their families to maintain control of their healthcare. Self-care is ongoing through out the continuum of life and is forever evolving. A patient with bipolar disorder can affect the function of self-care; therefore, these patients need care from the nurses or care provider to fulfill their self-care duty.

Orem believes there are three components to the Self-care nursing model, the compensatory system, the partial compensatory system and the educative-developmental system.

1) Compensatory system -is when the nurse provides total care for the patient. This patient cannot do anything for themselves including but not limited to activities of daily living and ambulation. This patient is totally dependent of the nurse for survival, such as an acute Stroke patient.

2) Partial Compensatory - The nurse must assist in the care of the patient but the patient and

family can assist as well. A pneumonia patient, who is very short of breath, may require the nurse to monitor vital signs, oxygen saturations, assist in ADL’s and ambulation. The patient will be able to resume their own care when they are better but need the assistance and education a nurse can provide at this time.

3) Educative-developmental system -The patient has primary control over their health; the nurse assists with education and promoting safe health practices. The patient who has high cholesterol may fit into this category, diet, exercise regimen and medication is important education for this patient. The nurse would teach the patient how to properly maintain good health practices.

Related Literature

• Bipolar disorder, or manic-depressive disorder, is a mood disorder in which people experience alternating episodes of mania and major depression. Mania is characterized by elation, irritability, excitability, racing thought and speech, and hyperactivity. Major depression is characterized by sadness, withdrawal, despair, and suicidal thoughts.

• In the early 1900s, the German psychiatrist Emil Kraeplin was the first to formally describe bipolar disorder. He used the term "manic depressive" to explain how mania and depression both affect the patient. His work in the early 20th century led to advancements in classifying, treating, and predicting the course of mental illness, which ushered in the formal discipline of psychiatry.

• Bipolar disorder has two distinct classifications:

Bipolar I: history of major depression and at least one episode of mania

Bipolar II: history of major depression and much less severe episodes of mania (hypomania)

Bipolar I

• An onset before the age of 30 usually results in frequent, severe episodes. Psychosis is more common in this group and symptoms tend to linger between episodes. An onset after the age of 40 has a better prognosis. Generally, short episodes, late onset, the absence of other medical or psychiatric conditions, and early treatment have a better prognosis.

• Most people are symptom free for months or even years between episodes of depression and mania. Approximately 25% of people never fully recover from an episode. Nearly 33% of people have great difficulty functioning at work and in social settings.

• Three-fourths of manic episodes occur before or right after a major depressive episode. After the first manic episode, there's a 90% chance that a second one will occur. Typically, a greater number of manic episodes are experienced over a lifetime. Approximately 40% of people with bipolar disorder have an average of one episode every 2 1/2 years, or four in every 10 years.

Bipolar II

• People with bipolar II disorder experience major depressive episodes that alternate with hypomania (milder manic episodes). During hypomanic episodes, patients may become more productive or noticeably goal driven, but their ability to function well in their normal daily activities is not impaired.

• About 10% of people who experience hypomanic episodes eventually have manic episodes

II. CLINICAL SUMMARY

General Data Profile

Name: patient A Sex: female Age: 85 y/o Birth date: April 15, 1925 Birth place: Calauag, Quezon Citizenship: Filipino Civil Status: Widowed Religion: Roman Catholic

GROWTH AND DEVELOPMENT THEORIES

Arnold Gesell

(BIOPHYSICAL THEORY)

STAGE AGE SIGNIFICANT CHARACTERISTICS

NURSING IMPLICATION

Old-old 85 and over Increased physiological problems may develop.

Assist client with self-care as required, and with maintaining as much independence as possible.

According to Arnold Gesell theories describe the development of the physical body how it grows and changes. These changes are compared against established norms. In the situation of the patient, an elder has the tendency to develop increased physiological problems or diseases like osteoporosis, arthritis, cardio and pulmonary diseases because of the changes on the whole systems of the body. It is necessary to assist the patient in ADL while empowering and promoting their autonomy or independence.

PSYCHOSOCIAL THEORIES

Sigmund Freud

STAGES AGE CHARACTERISTIC NURSING IMPLICATION

GENITAL Puberty and after Energy is directed toward full sexual maturity and functional and development of skills needed to cope with the environment.

Help patient to cope properly to separation anxiety. Encourage the patient to deal with the environment and relationships.

Psychosocial development refers to the development of personality, a complex concept that is difficult to define, can be considered as the outward (interpersonal) expression of the inner (intrapersonal) self. It encompasses a person’s temperament, feelings, character traits, independence, self-esteem, self-concept, behavior, ability to interact with others, and ability to adapt life changes.

This theory of Sigmund Freud was said that energy is directed toward full sexual maturity and functioning and development of skills needed to adopt with the environment. People in this stage want to have a joyful and fulfilling family life. In the case of our patient, she is included in this stage that deals with separation and death. She loosed her spouse and her son left her in the home for the aged. The nurse or caregiver should help the patient in dealing with the environment and relationships to the other residents of the health home for the aged.

Erik Erikson

STAGES AGE CENTRAL TASK INDICATORS OF POSITIVE RESOLUTION

INDICATORS NEGATIVE RESOLUTION

MATURITY 65 years to death

Integrity vs. despair

Acceptance of worth and uniqueness of one’s own life

Acceptance of death

Sense of loss, contempt for others.

This theory of Erik Erickson proposes that life is a sequence of developmental stages or levels of achievement. In maturity stage shows that integrity vs. despair happened. It describes the physical, emotional and psychological stages of development and relates specific issues, or developmental work or tasks, to each stage. Review life accomplishments, deals with loss and preparation for death. The person best able to undergo psychoanalysis is someone who, no matter how incapacitated at the time, is basically, or potentially, a sturdy individual. This person may have already achieved important satisfactions—with friends, in marriage, in work, or through special interests and hobbies—but is nonetheless significantly impaired by long-standing symptoms: depression or anxiety, sexual incapacities, or physical symptoms without any demonstrable underlying physical cause. One person may be plagued by private rituals or compulsions or repetitive thoughts of which no one else is aware. Another may live a constricted life of isolation and loneliness, incapable of feeling close to anyone. Some people come to analysis because of repeated failures in work or in love, brought about not by chance

but by self-destructive patterns of behavior. Others need analysis because the way they are—their character—substantially limits their choices and their pleasures. The patient experienced loss and grief when his husband died and she was abandoned by her son.

Environmental living condition

The client’s environment in the area of Lucban, Quezon has the spirit of peace and humility as observed. As a high altitude place, it has a very cold surrounding that is suitable for the living process of the client. We also observed that the environment was clean and well ventilated which contributed to their health aspect. Silence of the place also observed and it is one factor that our client need in a way that elderly should have a peace of mind and be free from noise pollution.

PHYSICAL ASSESSMENT Parameters Normal

FindingsActual Findings Interpretation

1. Integumentary SKIN

HAIR

Increased skin dryness

Increased skin pallor

Increased skin fragility

Progressive wrinkling and sagging of the skin

Brown “age spots” (lentigo senilis) on exposed body parts (e.g., face, hands, arms)

Decreased perspiration

Thinning and graying of scalp, pubic, and

Dry skin

Pale skin

Skin becomes fragile

Saggy skin

Brownish spot

Reduced sweating

With white hair evenly distributed and thinning

Normal because as we grow old our subcutaneous gland activity and tissue fluid decreases.

Normal: because of decreasing vascularity

Normal : Reduced thickness and vascularity of the dermis; loss of subcutaneous fat

Normal: because of loss of skin elasticity, increased dryness, and decreased subcutaneous fat

Normal: because of the Clustering of melanocytes (pigment-producing cells)

Normal: Reduced number and function of sweat glands

Normal: Progressive loss of pigment cells from the hair bulbs

NAILS

2. Neuromuscular

3.Sensory /Perceptual

axillary hair

Slower nail growth and increased thickening with ridges

Decreased speed and power of skeletal muscle contractions

Slowed reaction time

Loss of height (stature)

Loss of bone mass

Joint stiffness

Impaired balance

Greater difficulty in complex learning and abstraction

Decreased visual acuity

Progressive loss of hearing (presbycusis)

of the scalp, pubic and axillary hair.

Nails slightly dirty but smooth, firm and not

brittleNo clubbing of nails

Slow movement with decrease ROM

Slow reaction

Not in proper stature

Decrease ROM with slow movement

Cannot demonstrate flexion of knees

Cannot perform ADL without assistance.

Delayed understanding on situations and

cannot verbalize clearly her statements

Blurred vision

Poor hearing function

Inadequate self-careIncreased calcium deposition

Normal: Because of decreased muscle fibers

Normal: Diminished conduction speed of nerve fibers and decreased muscle tone

Normal: Because of atrophy of intervertebral discs, increased flexion at hips and knees

Normal: Because the bone reabsorption outpaces bone reformation

Normal: Drying and loss of elasticity in joint cartilage

Normal: Because of decreased muscle strength, reaction time, and coordination, change in center of gravity

Normal: because of fewer cells in cerebral cortex

Normal: because of Degeneration leading on lens opacity (cataracts), thickening and inelasticity (presbyopia)

Normal: Because of the changes in the structures and nerve tissues in the inner ear

4. Pulmonary

5. Cardiovascular

Decreased sense of taste, especially the sweet sensations at the tip of the tongue

Decreased ability to expel foreign or accumulated matter

Decreased lung expansion, less effective exhalation, reduced vital capacity, and increased residual volume

Difficult short, heavy, rapid breathing (dyspnea) following intense exercise

Reduced cardiac output and stroke volume, particularly during increased activity or unusual demands; may result in shortness of breath on exertion and pooling of blood in the extremities

Reduced

Cannot clearly identify different kinds of taste.

Decreased ability to expel secretions

RR – 23bpm

-Respiratory patterns- eupnea

-Lung clear sound

Easy fatigability

PR – 88bpm

Normal: Decreased number of taste buds in the tongue because of tongue atrophy

Normal: Decreased elasticity and ciliary activity

Normal: Weakened thoracic muscles; calcification of costal cartilage, making the rib cage more rigid with increased anterior-posterior diameter dilation from inelasticity of alveoli

Normal: Diminished delivery and diffusion of oxygen to the tissues to repay the normal oxygen debt because of exertion or changes in the both respiratory and vascular tissues

Normal: Increased rigidity and thickness of heart valves (hence decreased filling/emptying abilities); decreased contractile strength

Normal: Increased calcium

6. Gastrointestinal

7. Urinary

elasticity and increased rigidity of arteries

Increased in diastolic and systolic blood pressure

Orthostatic hypertension

Delayed swallowing time

Increased tendency for constipation

Reduced filtering ability of the kidney and impaired renal function

Urinary urgency and urinary frequency

Tendency for nocturnal frequency and retention of residual urine

Decreased immune response; lowered resistance to infections

Poor response to immunization

BP – 150/80mmHg

Slow movement when eating

No sign of constipation

With poor bladder control especially at

night

With increased voiding frequency but less amount of urine.

With poor bladder control especially at

night

Susceptible to disease due to weak body

resistance

deposits in the muscular layer

Normal: Inelasticity of systemic arteries and increased peripheral resistance

Normal: Reduced sensitivity of the blood pressure-regulating baroreceptors

Normal: Alteration in the swallowing mechanism

Decreased muscle tone of the intestines; decreased peristalsis; decreased free body fluid

Normal: Decreased number of functioning nephrons (basic functional units of the kidney) and arteriosclerosis changes in blood flow

Normal: Decreased tubular function

Normal: weakened muscles supporting the bladder or weakness of the urinary sphincter in women

Normal: Decreased bladder capacity and tone

Normal: T cells less responsive to antigen; B cells produce fewer antibodies immune system changes may participate insulin resistance

8.Immunological Decreased stress response

PATTERNS OF FUNCTIONINGFUNCTIONAL HEALTH PATTERN

DURING RESIDENCY INTERPRETATION/ IMPLICATION

Health Management Pattern Patient has clean environment, inside and outside the facility. The patient demonstrated poor hygiene such as voiding on her bed during night. She is sometimes reluctant to take a bath.

Patient’s environment is important for the patient’s wellness. Safety should be maintained and assist or supervise the patient during self- care.

Nutritional/Metabolic Patient eats rice, fruits and vegetables, fish, chicken, meat and bread. During meal, 1 cup of rice is enough for her. She drinks 4-5 glasses of water daily.

Fewer calories are needed by the elderly because of their lower metabolic rate and decreased in physical activity. The patient should continue to comply adequate hydration.

Elimination Patient urinates 4- 5 times a day and defecates once a day, semi- formed to formed stool in consistency.

Fewer amounts urinated due to insufficient water intake. An estimated 30% of nephrons are loss by age 80 and renal blood flow decrease because of vascular changes.

Activity and Exercise Patient’s exercise is walking and some mild ROM exercise provided by the student nurses. The patient is willing to participate and cooperate to the activities.

Exercise helps in diverting and preventing the patient’s mood swings. It also provides strength for muscles and bones.

Roles and Relationship The patient has a slightly good relationship with other patients. When the patient hears other patients saying something about her that makes her mood to change easily. The client demonstrated hostile reaction when she gets mad to the other elders.

The patient is sometimes hard to deal with, which depends on her mood. The patient is easily to make laugh and cry.

Values and Belief The patient prays, believes and has faith in GOD.

The patient has good religious beliefs. She is also willing to

cooperate and participate in bible studies. Elderly has high spiritual beliefs.

Cognitive/Perceptual She is oriented in time, place but sometimes her responses are not appropriate to the questions being asked. Sometimes, her answers are no consistent with the same question. She is also has hearing and very mild speech difficulties.

Normal changes in aging often result in varying degrees of impairment in sensory perception of the sense of hearing, vision, smell taste and touch. Because of the disease process might be affecting her cognitive functioning.

Self-Perception She views herself positively but views on some things negatively depend on her moods.

The disease process and the aging process greatly affect the self- perception of the client.

IMPRESSION/ DIAGNOSIS: Bipolar disorder

Clinical Discussion of Disease

A. Anatomy & Physiology

4 PARTS OF THE BRAIN

• Cerebrum

• Cerebellum

• Brain stem

• Limbic system

CEREBRUM

• Most high level brain function takes place

• Divided into 2 hemisphere: right & left hemisphere

• Right hemisphere is responsible for music & art awareness, insight and controls the left part of the body

• Left hemisphere is responsible for mathematical skills, language, reading, writing and controls the right part of the body

• Have 4 lobes: frontal, temporal, parietal and occipital lobe.

• Covers 85% of the brain’s weight

CEREBELLUM

• “little brain”

• Located at lower back of brain beneath the occipital lobe

• Center for coordination of movement and postural adjustment

CEREBELLUM...

• Receives & integrates information from all areas of body such as: muscles, joints, organs & other components of CNS

• Inhibited the transmission of dopamine in this area.

BRAIN STEM

• Connects spinal cord to the rest of the brain

• Composed of the following:

-MEDULLA- located at top of spinal cord, contains vital centers for respirations & cardiovascular function.

-PONS- bridges the gap both structurally & functionally serving as primary motor pathway.

-MIDBRAIN- connects pons & cerebellum with the cerebrum.

-LOCUS CERULEUS- a small group of norepinephrine- producing neurons in brain stem.

LIMBIC SYSTEM

• “Emotional brain”- emotional responses such as; anger, fear, anxiety, pleasure, sorrow & sexual feelings generated in limbic system but interpreted in frontal lobe.

• Parts of the limbic system:

-THALAMUS- regulates activity, sensation & emotion.

-HYPOTHALAMUS- involved in temperature regulation, appetite control, endocrine function, sexual drive & impulsiveness behavior associated with feelings of anger, rage & excitement.

-HIPPOCAMPUS & AMYGDALA- involved in emotional arousal & memory.

STRESS HYPOTHALAMUS- PITUITARY- ADRENAL AXIS

STRESS HYPOTHALAMUS

CRFPITUITARY GLADSTRESS

ACTH ADRENAL CORTEX CORTISOL

STRESS HPA AXIS

NEUROTRANSMITTERSNeurotransmitters are chemicals which transmit signals from a neuron to a target cell across a synapse. Neurotransmitters are packaged into synaptic vesicles clustered beneath the membrane on the presynaptic side of a synapse, and are released into the synaptic cleft, where they bind to receptors in the membrane on the postsynaptic side of the synapse.

ACETYLCHOLINE• Found in the brain, spinal cord and PNS.• Can be inhibitory and excitatory• Synthesized from dietary choline found in red meat and vegetables• Affects sleep- wake cycle and to signal muscles to become active

DOPAMINE

• Essential to the functioning of CNS• Excitatory • Involved in emotions, moods and regulation of motor control.• Dopamine forms from a precursor molecule called dopa- manufactured from liver from

amino acid tyrosine.

NOREPINEPHRINE & EPINEPHRINE (ADRENALIN)

• Most prevalent neurotransmitter in nervous system.• Excitatory• Has limited distribution in brain but controls fight or flight in PNS• Play a role in attention, learning & memory, sleep and wakefulness and mood

regulation.

SEROTONIN

• Its function is mostly inhibitory that includes induction of sleep and wakefulness, pain control, temperature regulation, control of mood, memory, and sexual behavior.

• Inhibitory• Serotonin is produced in brain from amino acid tryptophan- derived from foods high in

CHON.

HISTAMINE

• Involved in emotions, regulation of body temperature and water balance.• Neuromodulators

GLUTAMATE

• Excitatory amino acid that at high levels that can have major neurotoxic effects.

GABA

• Most abundant neurotransmitters within the CNS and in cerebral cortex.

• Largely responsible for such higher brain functions as thought and interpreting sensations.

• Major inhibitory neurotransmitter in the brain

Interpretation:

In the pathophysiology of Bipolar Disorder there is no known cause. An idiopathic disease where in there is only risk factors.

Clients with:

Genetic history of Bipolar Disorder

• Biochemical Malfunction in the brain

• Neuroanatomic Circuits Problem

• Childhood Precursors refers to the way the parents raised a child

• Life Events and Experiences which are traumatic for the client may have higher risk for having Bipolar Disorder. In our interpretation our client had experienced life events and experiences which triggered the onset of Bipolar disorder.

The client would first experience abnormalities in the structure and/or function of a certain brain circuit where in the brain malfunction and would have problems in releasing or controlling the neurotransmitters in the brain. There would be imbalance in neurotransmitters in the brain: Acetylcholine- affects the sleep and wake pattern on the client this happens on the

onset of the disorder where in the client experiences difficulty in her sleep. Dopamine- affects the elevation of moods and emotions, during the manic and

depressive episodes Dopamine is involved Norepinephrine and Epinephrine (Adrenalin) - play a role in attention, learning &

memory, sleep and wakefulness and mood regulation. Serotonin- Its function is mostly inhibitory that includes induction of sleep and

wakefulness, pain control, temperature regulation, control of mood, memory, and sexual behavior.

The client would also experience shifting to extreme moods during the manic episodes of the client she may experience elevation of moods, irritability, excitability, racing thought and speech and hyperactivity. And in her depressive episodes she may experience extreme sadness, withdrawal, despair and suicidal thoughts. This would lead to the altered functioning of her daily living activities and relationships to others. She may experience violence to others and to herself also may lead to suicide.

The complications are just perceived scenarios that may happen if the disorder is not properly managed.

PATHOPHYSIOLOGY of Bipolar Disorder:

Neurobiologic Perspective (Book-based)

ACUTE MANIA DEPRESSION

MANIC/ DEPRESSIVE BEHAVIOR

(BIPOLAR)

PATHOPHYSIOLOGY of Bipolar Disorder:

Neurobiologic Perspective (Patient-based)

ACUTE MANIA DEPRESSION

Interactive among neurotransmitters (Serotonin, Dopamine, Norepinephrine, GABA) or certain chemicals in the brain that regulate mood

Drugs: Cocaine, MAOIs, Trycyclin, Antidepressants, Steroids, Levadopa

Interactive among neurotransmitters (Serotonin, Dopamine, Norepinephrine, GABA) or certain chemicals in the brain that regulate mood

Alcohol, Drugs: Sedative- hypnotics, amphetamine withdrawal, glucocorticoids, propanolol, resperine, & steroidal contraceptives

Physical Illness: Stroke, Cushing’s disease & some Endocrine disorders

Increased level of norepinephrine, dopamine & serotonin

ACUTE MANIA

Elevated or irritable mood (1 week):

Grandiosity, insomnia, verbosity, flight of ideas, distractibility, increased in goal- directed behavior or psychomotor agitation, excessive involvement in pleasurable activities without regard for consequences

Impairment in occupational or social activities & in relationshipExtreme activity(requires hospitalization)Impairment in

DEPRESSION

Decreased level of norepinephrine, dopamine & serotonin

Prime Symptoms:

Depressed mood or loss of interest or pleasure (2 weeks)Change in level of functioning or five or more of the ff:

Change in weight, insomnia, psychomotor agitation, fatigue, worthless feelings, inappropriate guilt, concentration difficulties, death thoughts, suicidal ideation, and suicidal attempts

Sex drive decreasedConstipation and urinary retention

Interactive among neurotransmitters (Serotonin, Dopamine, Norepinephrine, GABA) or certain chemicals in the

Interactive among neurotransmitters (Serotonin, Dopamine, Norepinephrine, GABA) or certain chemicals in the brain that regulate mood

MANIC/ DEPRESSIVE BEHAVIOR

(BIPOLAR)

DRUG STUDY

DRUG NAME DOSAGE ACTION INDICATION ADVERSE REACTION

NURSING CONSIDERATION

Haldol (Haloperidol)

1 tab prn • Alters the effects of dopamine in the CNS• Also has

•Organic Psychoses• acute psychotic symptoms

•CNS: extrapyramidal symptom such as muscle rigidity or

• Assess mental status prior to and periodically during therapy.• Monitor BP and

Interactive among neurotransmitters (Serotonin, Dopamine, Norepinephrine, GABA) or certain chemicals in the

Interactive among neurotransmitters (Serotonin, Dopamine, Norepinephrine, GABA) or certain chemicals in the brain that regulate mood

Physical Illness:

Mild Stroke secondary to Hypertension

Increased level of norepinephrine, dopamine & serotonin

ACUTE MANIA

Elevated or irritable mood

Grandiosity, insomnia, verbosity, flight of ideas, distractibility, psychomotor agitation, excessive involvement in pleasurable activities without regard for consequences

Impairment in occupational or social activities & in relationshipImpairment in functioning

DEPRESSION

Decreased level of norepinephrine, dopamine & serotonin

Prime Symptoms:

Depressed mood or loss of interest or pleasureChange in level of functioning:

Change in weight, insomnia, psychomotor agitation, fatigue, worthless feelings, concentration difficulties, death thoughts, has tendency to commit physical violence to others

Constipation and urinary retention

anticholinergic and alpha-adrenergic blocking activity.• Diminished signs and symptom of psychoses

• Relieve hallucinations, delusions, disorganized thinking• severe anxiety

spasm, shuffling gait, posture leaning forward, drooling, masklike facial appearance, dysphagia, akathisia, tardive dyskinesia, headache, seizures.•CV: tachycardia, arrhythmias, hypertension, orthostatic hypertension.•EENT: blurred vision, glaucoma• GI: dry mouth, anorexia, nausea, vomiting, constipation, diarrhea, weight gain.• GU: urinary frequency, urine retention, impotence, enuresis, amenorrhea, gynecomastia• Hematologic: anemia, leucopenia, agranulocytosis• Skin: rash, dermatitis, phtosensitivity

pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG.• Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded.•Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration.• Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK.• Advise patient to take medication as directed.

Multivitamins 1 cap od Prevention of deficiency or replacement in patients whose nutritional status is

Treatment and prevention of vitamin deficiencies.

Allergic reactions to preservatives, additives, or colorants.

1. Assess patient for signs of nutrition deficiency prior to and throughout therapy.

questionable. 2. Instruct to notify side effects of medications to physician. 3. Encourage to comply on medications. 4. Encourage patient to comply with physicians’ recommendations. Explain that the best source of vitamins is a well balanced diet with foods from the 4 basic food groups.

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:“ Mga walang hiya yang mga yan! Lagi na lang aq pinagtsitsismisan!” as verbalized by the patient.Objective:- With rigid

posture- With

clenching of fists

- With annoyed facial expression

- Pacing- Hyperactive- Attempted to

throw hot coffee to others

- Has the tendency to verbally threatened others

Risk for other-directed violence related to irritability, impulsive behavior and manic excitement with possible indicators of overt and aggressive acts.

Within the shift, the patient will demonstrate self-control.

Assess client’s perception of self and situation. Note use of defense mechanism.

Observe/ listen for early cues of distress/ increasing anxiety.

Ask directly if the person is thinking of acting on thoughts/ feelings.

Develop and maintain therapeutic nurse-client relationship.

Make time to listen to expressions of feelings. Acknowledge reality of client’s feelings.

Approach in positive manner, acting as if the client has control and is responsible for own behavior.

To assess causative/ contributing factors.

May indicate possibility of loss of control and intervention at this point can prevent a blow up.

To determine violent intent.

Promotes person’s sense of trust, allowing client to discuss feelings openly.

To assist client to accept responsibility for impulsive behaviour and potential for violence.

To assist client in controlling behavior.

The client demonstrated self- control as evidenced by relaxed posture, non- violent behavior. Goal met.

Give positive reinforcement for client’s efforts.

Maintain calm, matter- of-fact, non- judgemental attitude.

Provide a safe/ quiet environment and remove items from the client’s environment that could be use to inflict harm to others.

Encourage walking or exercise as activities that may diffuse aggression

To encourage continuation of desired behaviors.

Decreases defensive response.

To promote safety in event of violent behavior.

To promote wellness

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:“Huwag na magpalit ng panty, hayaan nang mamaho,” as verbalized by the patient.Objective:- Inability to

prepare foods

- Inability to wash body and access to bathroom

- Inability to

Self- care deficit related to as perceptual/ cognitive impairment as evidenced by inability to perform self-care task.

Within the shift, the patient will participate in self- care activities.

Note concomitant medical and psychological problem that may be factors for care.

Identify degree of individual impairment or functional level.

Perform/ assist with meeting client’s needs when she is

To identify causative / contributing factors.

To assess degree of disability.

To assist in dealing with situation.

The client participated in self-care activities like in nutrition and personal hygiene.The patients demonstrated initiative in self-care activities.Goal met.

maintain appearance at a satisfactory level

unable to meet own needs.

Develop plan of care appropriate to individual situation.

Plan time for listening to the client’s concerns.

Provide for communication among those who are involved in caring.

Provide privacy and equipment within easy reach during personal care activities.

Support client in making health related decisions and assist in developing self- care practices that promote health.

Impart health teachings about self-care and emphasize the importance of it.

To conform to clients usual schedule.

To discover barriers to participation in regimen and to work on problem solution.

Enhances coordination and continuity of care.

To assist in dealing with situation.

To promote wellness

Health Teaching

• Eat a balanced diet

• Exercise daily.

• Get approximately the same number of hours of sleep every night.

• Reduce stress at home through variety of stress management techniques

• Limit caffeine and nicotine during manic episodes.

Exercise is an important part of promotion of health and prevention of other illnesses related to aging. It is important to strengthen bones and muscles, to gain weight and maintain well-being. During group exercise in the nursing home, they tend to socialize with other residents, thus, improving their socialization skills.

Sleep Management. Good sleep hygiene is particularly important for patients. Techniques used to enforce healthy sleep may help reduce mood cycling and promote wellness.

Diet. A healthy diet low in saturated fats and rich in whole grains, fresh fruits, and vegetables is important for anyone. People with bipolar disorder should be sure to maintain a regular healthy diet. They may need to restrict calories if they are on medications that increase weight.

Psychotherapy and Lifestyle Changes

Psychotherapy is an important addition to medication. Many approaches are proving to be very useful. Trained mental health professionals can:

Educate patients about bipolar disorder and its treatments

Teach patients to recognize and manage early warning symptoms of imminent manic or depressive episodes

Help them comply with drug regimens

Monitor the patient's on-going status

Intervene early in manic and depressive episodes to reduce the severity of the attack

Psychotherapy adjusts to the reality of the illness and understands the negative consequences of mania -- particularly important for patients who consider their mania to be positive, creative, and exhilarating

Cope with feelings of guilt and remorse that occur after manic episodes

Deal with feelings of imperfection and despair.

While no cure exists for bipolar disorder, effective management of this illness can enable most people to lead highly functioning, healthy lives. Managing bipolar disorder is complex and may include psychotherapy, medication and lifestyle changes. The support of loved ones and a strong commitment to your own wellness are key elements to disease management as well.

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