A.

INTRODUCTION

Psychiatric area is one area of exposure of the nursing students. Our group
was lucky enough to be assigned at the psychiatric area at BGHMC (Baguio General
Hospital and Medical Center). The group had encountered several common
psychiatric disorders like the different types of schizophrenia and bipolar disorders.
The group had chosen to study Bipolar Affective Disorder, current episode, manic
with psychotic disorder. The group had chosen this type of disorder for us to
understand and appreciate this type of psychiatric ailment.

Bipolar disorder or manic-depressive disorder which causes mood swings that

ranges from the lows of depression to the highs of mania. In some cases, bipolar
disorder causes symptoms of depression and mania at the same time. Bipolar
disorder causes serious shifts in mood, energy, thinking and behavior from the highs
of mania on one extreme to the lows depression on the other. More than just a
fleeting good or bad mood swings, the cycles of bipolar disorder last for days,
weeks, months or even a year. Unlike ordinary mood swings, the mood changes,
bipolar disorder is so intense that it interferes with your ability to function.

If the client is under mania, the common signs and symptoms includes feeling
that are unusually high, optimistic and very irritable, unrealistic, grandiose belief
about ones abilities or powers, sleeping less but feeling extremely energetic,
talking so rapidly, racing thoughts, jumping quickly from one idea to the next, highly
distractible, impaired judgement and impulsiveness, acting recklessly without
thinking about the consequences and lastly in severe cases, delusions and
hallucinations may appear.
If the client is under depressive, the common signs and symptoms are
decreased energy, easy fatigability, lethargic, has diminished activities, insomnia or
even hypersomnia, usually lost of interest in pleasurable activities and lastly social
withdrawal.

B. PATIENTS PROFILE
Name: Mr. I.E.R
Age: 56 years old
Birthday: July 4, 1953
Civil Status: Married
Address: Km8 Asin road, Tuba, Benguet
Religion: Roman Catholic
Nationality: Filipino
Date of Admission: June 11, 2010
Time of Admission: 7:35 PM

1
 Admitting Diagnosis: Bipolar Affective Disorder,
Current
Episode, Manic with Psychotic Disorder

C. ASSESSMENT
1. Psychiatric History/Developmental History
The patient is born via NSVD (normal spontaneous vaginal delivery), no
known complications and abortion attempts of the mother. According to
the patient he was both breastfed and bottlefed up to 1 years of age.
He was also toilet trained by his parents. He further claimed that he was
pampered by his parents with love and affection as well as with other
things like toys, books and clothing. Basically, he had a good childhood
experience as claimed.

During his school age, he remembered that he does not participate in

school activities and seldom mingle with his classmates. He further
claimed that he is respectful to elders especially to his parents and
grandparents. During his high school years, he experienced being
involved with fist fights with the bullies. He remembered he was never
separated from his family and was able to finish his degree in
mechanical engineering.

He was married at the age of 36 years old. After how many years, his
wife gave birth to a baby boy. They then decided that the husband will
go abroad in Saudi Arabia and work as a mechanical Engineer while his
wife is left with the son in the Philippines. After how many years, they
decided to switch, the husband was left with the baby and his wife went
abroad to Saudi to work as a nurse at a hospital. With this set up of a
long distance relationship which is too hard to handle. Being away from
your wife and being with your son for several years. His wife has only
quality time for them whenever she comes home for vacation. Whenever
his wife comes home for a vacation, he is usually very happy.

According to the patient, the most traumatic experience he had is the

death of his sister. It was during this time that he knew that his sister
died to an accident, due to financial matters he wasnt able to attend his
sisters burial. That is the time he feels very sad because he claimed
that he was really close to his sister. For his other siblings, he visits them
occasionally and whenever there was a problem with one of the member
of the family he and the others would lend their hands and intervene to
any problem to resolve it.

2
 He and his neighbor misunderstood each other, but not identified,
every now and then they are almost having an argument. The son saw
his change of reactions and behaviors 5 days prior to admission like
auditory hallucinations, illusions, mood swings, he keeps on digging at
their backyard and always saying that may ginto sa likod ng bahay
natin.

Now at his age of 56 years old, he was admitted because of the

presence of hallucinations, illusions and delusions. He claimed that he
was brought to the hospital because of his hypertension. Often times he
sits on his bed or lie down and sleep, he usually dont mingle with the
other patients but feels comfortable when talking to student nurses.
2. History of Present Illness

The patient could remember that his mother told him that when
he was sick with chickenpox and measles, he had high fever and
convulsion. Aside from this, patient claimed he was generally healthy as
a child.

During his school age, he claimed that he was shy. He does not
participate in school activities and seldom mingle with his classmates
but as he grows up, he further claimed that he feels more comfortable
with girls and so he has more female friends than boys. At the age of 15,
after he graduated from high school, he then have to be separated to his
family because he enrolled to one of the schools in Baguio to finish his
college degree. It was his first time to be separated from his family and
so he felt so sad.

During his college years, he learned to be independent and so he

was able to finish his chosen field of mechanical engineering. After
graduating, he decided to work abroad in Saudi to earn his own money.
He then met his wife who is a registered nurse in one of the Hospitals in
Saudi. They got married and blessed with a son. In order to sustain their
needs of the family, he continued to work abroad leaving his family in
Zamboanga. They decided that his wife will go abroad also leaving their
son with him. With this set up of a long distance relationship which is too
hard to handle. Being away from your wife and being with your son for
several years. His wife has only quality time for them whenever she
comes home for vacation. Whenever his wife comes home for a
vacation, he is usually very happy.

According to the patient, the most traumatic experience he had is the

death of his sister. It was during this time that he learned that his sister
died from an accident, due to financial matters he wasnt able to attend
his sisters burial. That is the time he feels very sad because he claimed
3
that he was really close to his sister. For his other siblings, he visits them
occasionally and whenever there was a problem with one of the member
of the family he and the others would lend their hands and intervene to
any problem to resolve it.

In the case of our patient there was no mental illness in the family.
However, he was only diagnosed with hypertension before admission at
the Psychiatric Hospital. The time he was firstly observed with
manifestations of the disorder the patient was into treasure hunting. He
claimed that he met an old woman that was dictating him what to do and
where to hunt. He claimed that the old woman manipulated him to do it.
Since then, the patient would dig around their backyard and was
preoccupied with doing unnecessary things, but the patient wouldnt
forget his position in the family and would do household chores and
would act accordingly. He was helpful with doing house chores but
noticed that he had lost his social life. His friends were not visiting him
anymore and vice versa. Soon after, the patients wife came home from
Saudi, and around that time he was observed to be normal again, the
patient stopped his treasure hunting activities and also claimed that he
stopped seeing the old woman. He was observed to be happy during
those times. The wife then went back to Saudi and after sometime the
patient resumed his usual activities of digging around their house. The
patient started to mumble, and would walk around the house to and fro
and he would utter incoherent words.

Five days prior to admission, the patient felt abnormally good, high,
excited, hyperactive and irritable. This was extreme since the patient lost
contact with reality and started to believe strange things. He had poor
judgment and behaved in harmful ways which was dangerous. This was
accompanied by an elevated mood and he had reduced sleep. He had
optimistic ideas and plans were expressed. The patient developed
symptoms of hallucination and delusion. One day prior to admission, the
patient kept on saying S.B, who was the patients relative who worked in
a mining company. After he went to Balatoc Mines, during the night when
his son was watching t.v. the patient came close to him saying, Sino
ka sino ka?... P.F. (their neighbor whom he always had an argument
with). So, the son introduced himself. Afterwards, the patient went to his
room shouting over and over again. Out of fear, the son called their
relatives and asked help from the nearby police station to get the patient.
The patient was seen half naked, praying on the road, kissing the ground
and saying that he is the savior. The patient had a bag of stones and
books saying he would go home to Zamboanga leaving the treasure to
4
 his son. He was held and brought to the institution hence the admission.
Hence patient I.R., 56 years old was admitted and diagnosed with bipolar
affective disorder, current episode, manic with psychotic symptoms.

3. Mental Status Examination

A. APPEARANCE
The client appears to be well groomed. Mr. I.R. has a noticeably
proper cut hair and is well combed. Mr. I.R. wears clothing appropriately
depending on his mood and with the weather. Mr. I.R. refers wearing long
sleeves but when it is hot, he wears the usual t-shirt along with his shorts
or any available pants he has. For 3 consecutive days of duty, it was
observed that he only took a bath on the third day then changed his
clothes; the patient is observed to brush his teeth before and after meals.
His nails are trimmed and his beard and mustache are neatly shaved. The
client appeared as the stated age of 56 years old with visibly white hair
and some noticeably wrinkles on his face.

B. BEHAVIOR
1. MANNER OF RELATING
Mr. I.R. is participative during discussion. He actively and openly
answers queries being asked to him by the student nurses. He
sometimes cracks jokes that make the conversation lively. He usually
prefers to talk with student nurses rather than to his co-patients inside
the ward.

2. PSYCHOMOTOR ACTIVITES
The patient has a good posture. However, he sometimes slouches
during conversation with his legs and arms crossed and sometimes
with his hands on his lap, swaying his feet while looking around the

5
 room. He usually stay on bed sitting or if not, sleeping. Patient has
good posture, gait and station. He was observed to walk straight. He
has mild hand tremors observed.

3. SPEECH/LANGUAGE
The client talks with normal rate, rhythm and intensity. He speaks
clearly and has good articulation of words. He elaborates his answers
to questions asked and sometimes, he shares some topics to be
discussed. It was also observed that he can easily find the right words
to use when lost during conversation. To explain further what are his
thoughts. Patient is able to talk in English, Tagalog and Ilokano fluently.

4. RELEVANCE/COHERENCE
The client was able to answer relevantly and coherently. He used
simple, concrete and easy to understand responses to the topics being
discussed during the NPI (Nurse-Patient-Interaction).

5. DEVIATIONS
There were no deviation like inventing, rhyming, stammering,
clanging of words, repetition of words and speeches in particular
questions being asked by the student nurses noted.

6. VOCABULARY
The patient uses appropriate terms to use when conversing. He
sometimes use terms related to his field of engineering such as the
different machineries and gadgets he encountered while he is still
studying and working abroad. Patient is able to adjust his choice of
words depending on whom he is talking to. He would use simple words
to his co-patient while he uses more complex vocabularies to the
health care providers.

C. MOOD and AFFECT

Mr. I.R. stated okay naman pero minsan nadedepress. It was
observed during the conversation that whenever the discussion deals
with his wife finding time visiting him, he feels very happy and is seen
smiling. However, when the topic is about the incident where he wasnt
able to visit his sister and dads burial, he becomes very sad with teary
eyes.

D. THINKING
During the conversation, Mr. I.R. was able to discuss topics
concerning religion, philosophy and history. He was able to discuss
recent events of the world and how these are predicted by previous
events. He also talks about his work and how was he as an employee
when he works abroad. He talks about his family often and mentioned
Yung asawa ko nagwork sa Saudi at may isa akong anak.. Maaga
nakapag asawa. May isa na akong apo. There was no paranoid
delusions observed from the client. However the patient was observe
to avoid topics which concern on the reasons why he was brought to

6
 the hospital. Mr. I.R. is oriented to person, place, time and self. He can
identify who brought him to the ward.

The patient is able to recall recent and past events in his

personal history. He can still recall up to now that hes 56 years old the
memorable experience he had when he was 6 years old which made his
parents got mad. He said May ilog kasi doon malapit sa bahay namin.
Naliligo kami ng walang paalam kaya pag-uwi namin, palagi kaming
nabubuking kaya napapalo kami.

When the patient was asked to tell the name of one of our co-
student nurse that was introduced to him for no longer than 15
minutes, he said Si Earl, oo yung mataba. Siya yung una kong nakita
nung pagpasok niyo. Malaking tao kasi..

E. ABSTRACTION
When the patient was asked of how did he understand the saying
A hard beginning maketh a good ending. He responded immediately
Parang ganito sa situation ko, para akong nakakulong ngayon pero
theres a purpose why I am here however taking that all into
consideration, I am positive that this turmoil is to make me and my
family stronger than before.

1. CALCULATION AND CONCENTRATION

The patient was able to compute simple mathematical equations

as fast as 5 to 10 seconds when asked to answer 9 x 23=___. He can
concentrate even if the ward seems so noisy.

2. INSIGHT

When he was asked how can he sees himself as a father to his

child, he simply said I have been a good father or a parent. In fact not
only that, I know I have been a good husband to my wife kasi ginawa
ko lahat para mabigyan sila ng magandang buhay sa pamamagitan ng
pagtatrabaho ko at pagtitiis ko sa Iran for income out of hard work.He
also claimed Hypertension talaga problema ko. Hindi naman ako
baliw. Wala akong nakikita o nakakausap o naririnig na gaya ng
naririnig at nakikita nung iba kong kasamahan dito.The patient
mentioned also Magbabakasyon muna ako sa Zamboanga
pagnakalabas ako dito para makapagpahinga na din. Kasama ko ang
asawa kong pupunta siguro.

7
 3. JUDGMENT

The client mentioned along with the discussion that he had

some fight with his neighbor and was asked of what he will do when he
sees his neighbor again and he said Makikipag ayos na ako. Siguro nga
talagang kailangan na ng peace-of-mind kaya makipag=ayos na.

F. SUPEREGO FUNCTIONING/IMPULSE CONTROL

The client stated that Noong hindi ko natulungan yung ate ko
financially at noong hindi ako nakapunta nung burol nya when he was
asked what he or makes him guilty or what he regrets the most.

G. SELF- CONCEPT
The patient has low self-esteem as he is shy and he doesnt
mingle or talk with the other patients in the ward. When conversing
with him he often focuses on his positive behavior like being a good
husband to his wife and father to his son, which indicates that he is
trying to elevate his self-esteem.

H. PHYSICAL COMPLAINTS/PROBLEMS
The client doesnt have any physical deformities. He is slow when
walking because of aging. He has tremors and claimed that Ganito to
kasi side effect ng gamot, which indicates a circulatory problem because
of HPN.

8
D. DIAGNOSTIC EXAMINATION

Date of Diagnostic Description Results Normal Values Significance

Procedure Procedure

June 12, 2010 Urinalysis This test detects ion Color: yellow Normal The specific gravity of
concentration of the urine. your urine is measured
Small amounts of protein Transparency: Slightly Normal by using a urinometer.
or ketoacidosis tend to Turbid Knowing the specific
Normal
elevate results of the gravity of your urine is
Reaction/pH: 6.0
specific gravity. Specific Concentrated urine very important
gravity is an expression of Specific Gravity: 1.020 because the number
the weight of a substance Normal indicates whether you
relative to the weight of an Protein: Neg are hydrated or
equal volume of water. Normal dehydrated.
WBC: None
Normal
Epithelial Cells: Rare
Normal
Bacteria: None

There is a presence of
Amorphous urates/PO4: amorphous urates
Occasional due to prolong
refrigeration.

9
 Date of Diagnostic Description Results Normal Values Significance
Procedure Procedure

June 17, 2010 CBC (Complete The CBC is used as a RBC - 4.32 x 1012/L 4.6 6.2 x 1012/L The significance of this
Blood Count) broad screening test laboratory procedure is to
to check for such WBC -10.4 x 109/L 4.5 11.0 x 109/L mainly includes the care and
disorders as anemia, treatment of patients with
Lymph # -2.7 x 109/L 0.8 4.0 x 109/L
infection, and many conditions that will result in
other diseases. It is Mid # -0.9 x 109/L 0.1 0.9 x 109/L increases or decreases in
actually a panel of the cell populations
tests that examines Gran # -6.8 x 109/L 2.0 7.0 x 109/L
different parts of the
blood. Lymph % -26.2 % 20.0 40.0 %

Mid % -8.2% 3.0 9.0 %

Gran % - 65.65 50.0 70.0 %

Hgb - 141 g/L 135 -180 g/L

HCT - 0.433/L 0.4 0.54/L

MCV - 99.8/L 78.0 - 100.0/L

MCH -32.4 pg 27.0 31.0 pg

MCHC -325 g/L 320 360 g/L

RDW-CV - 13.1 % 11.5 14.5 %

10
RDW-SD - 48.6/L 35 56/L

PLT - adequate

MPV - 6.8/L 7.0 11.0/L

PDW - 15.5/L 15.0 17.0/L

PCT - 0.184 % 0.108 0.282 %

11
 E. PSYCHOPATHOLOGY
1. Biological Cause
A. Neurotransmitter Alteration
A.1 Increase Dopamine
- Overproduction of dopamine causes the nerve circuits to
misfire and create a split state in the mind where delusions and
hallucinations make the reality of the outside world easier to
accept
A.2 Increase Serotonin level
- An increase in serotonin levels indicates Mania / Manic in
Bipolar Disorder. Because he has the three signs of mania which
are Auditory Hallucinations, delusions and paranoia
A.3 Decrease Serotonin Level
- A decrease in serotonin levels indicates depression. He has
the symptoms of depression like social withdrawal, low self-
esteem and persistent sadness
B. Genetic Predisposition
B.1 Being Shy
- He has the presence of the type A personality, which is
inherently acquired thus he has poor IPR to others
2. Psychosocial Causes
A. Development of Mistrust
- It is according to Freuds Psycho-social theory. Presented by poor
IPR to other people, unable to express feelings, lack of close
friends, isolates self, social withdrawal
B. Cultural Norms
- Because they have a close-knit family
C. Traumatic Experience
C.1 Separation from family members
- Being alone and independent in an area that is unfamiliar
C.2 Death of his Sister
- As presented by Long term depression
C.3 Living alone for several years
- As manifested by anxiety and fear
D. Use of Defense Mechanism
- Ineffective use of Denial as manifested by unrealistic perception
of the situation

12
 PSYCHODYNAMICS

Neurotransmitter Alteration Psychosocial Causes

Genetic
Predisposition
Serotoni Development Cultural
Dopamine n Being shy
vs. Mistrust norms
Over
Close-knit
production of Type A Poor IPR to family
dopamine personality other people
causes nerve
Increase Decrease
circuits to
misfire and -Unable to express feelings
create a split Manic Depressive
-Lack of close friends
state in the
Auditory Signs and Signs and -Isolates self
hallucinatio Symptoms: Symptoms:
-Social withdrawal
ns -Agitation -Insomnia
- -Persistent Traumatic Experience
Delusion Hyperactivity sadness
s -Racing -Social
Thoughts withdrawal
-Delusions of -Low self- Separation Death of his Living
Paranoia
Grandeur esteem from family sister alone for
-Illusions -Difficulty several
- Concentrating years

Chronic Low Self- Anxiety

esteem

Use of defense Long term

mechanism depression

Denial Stress

Activation of the SNS

Ineffective
(fight or flight response)

Unrealistic
Blood Pressure, pulse
perception of
Bipolar Affective Disorder, Current rate, respiration
the situation
Episode, Manic with Psychotic Disorder

Causing Altered
Risk for disturbed Hypertensio cardiovascu
injury visual field n lar status
and postural
Poor compliance Possible imbalance
to treatment separation to
regimen wife
-medicine

Risk for relapsed episode

13
 F. DRUG STUDY
Generic Classificatio Dosage Mechanism of Indication Side Effects Nursing
name n Start and Action Consideration
Completion
Trade name of
Medication

Amlodipine Calcium Dosage: Blocks the >Essential CNS: >Monitor the patients
besylate channel 10 mg 1 tab transport of hypertension, dizziness, BP, cardiac rhythm, and
blocker OD calcium into the or in light- output while adjusting
smooth muscle combination headedness, drug to therapeutic
Antianginal Date started: cells lining the with other headache, dose.
Norvasc drug 06/17/10 coronary arteries agents fatigue >instruct client to
and other CV: swallow the tablet
Antihyperten arteries of the peripheral whole with or without
sive body. Since edema, food as directed by the
calcium is arrhythmias physician.
important in DERMATOLO >Instruct client to take
muscle GIC: with meals if stomach
contraction, Flush, rash upset occurs.
blocking calcium GI: nausea, > tell the client to
transport relaxes abdominal report irregular
artery muscles discomfort. heartbeat, shortness of
and dilates breath, swelling of
coronary arteries hands and feet,
and other pronounced dizziness or
arteries of the constipation.
body. coronary
artery disease

14
 Generic Classificatio Dosage Mechanism of Indication Side Effects Nursing
name n Start and Action Consideration
Completion
Trade name of
Medication

15
Clonidine Antihyperten Dosage: 75 Stimulates CNS >For CNS: >monitor BP carefully,
hydrochloride sive mg. 1 tab SL alpha2 adrenergic hypertension drowsiness, when discontinuing
fo BP receptors, inhibits sedation, clonidine, hypertension
140/90 sympathetic dizziness usually returns within
Catapres cardioaccelerator CV: CHF, 48 hours.
Date started: and orthostatic >Take the drug exactly
06/14/10 vasoconstrictor hypotension, as prescribed. The drug
centres, and tachycardia, should be put under the
decreases palpitations tongue.
sympathetic GI: dry >Do not discontinue
outflow from mouth, drug unless so
CNS. constipation, instructed.
nausea > tell the patient that
GU: discontinuing abruptly,
impotence, life threatening adverse
decreased effects may occur.
sexual
activity,
diminished
libido

Generic Classificatio Dosage Mechanism of Indication Side Effects Nursing

name n Start and Action Consideration
Completion
16
Trade name of
Medication

Lithium Antimanic Dosage: Alters sodium Treatment of CNS: >Give drug with food or
carbonate drug 450 mg 1 tab transport in nerve manic lethargy, milk after meals.
BID and muscle cells, episodes of slurre d >Monitor clinical status
inhibits release of manic- speech, closely
Date started: norepinephrine depressive muscle >take this drug exactly
Carbolith 06/12/10 and dopamine, illness. weakness as prescribed, after
but not serotonin GI: nausea, meals or with food or
from stimulated vomiting, ,milk
neurons, slightly diarrhea >Instruct client to open
increases GU: pyloria mouth and lift tongue to
intraneural stone check for the drugs.
of
cathecolamines; >tell the patient to eat
decrease a normal diet with a
intraneuronal normal salt intake,
content of second maintain adequate fluid
messengers and intake.
may the by
selectively
modulate the
responsiveness of
hyperactive
neurons that
might contribute
to the manic
state.

17
 Generic Classificatio Dosage Mechanism of Indication Side Effects Nursing
name n Start and Action Consideration
Completion
Trade name of
Medication
Haloperidol antipsychotic Dosage: 10 Haloperidol Management CNS: >Take the drug with
mg deep IMx interferes with of drowsiness, food or exactly as
haldol 3 doses PRN the effects of manifestation insomnia, prescribed.
for severe neurotransmitter of psychotic headache >Do not dilute this with
psychotic s in the brain disorders. autonomic: coffee, tea, colas or
agitation. which are the drymouth, apple juice - the
chemical salivation, medication may lose
Date started: messengers that nasal effectiveness.
06/11/2010 nerves congestion >Do not stop taking this
manufacture and CV: drug suddenly without
release to hypotension consulting your doctor.
communicate hematologic >Instruct client to open
with one another. : mouth and lift tongue to
It blocks eosinophilia, check for the drugs.
receptors for the leukopenia >Instruct client to Avoid
neurotransmitter engaging in other
s (specifically the dangerous activities. If
dopamine and dizziness or drowsiness
serotonin type 2 or vision changes
receptors) on the occurs.
nerves. As a
result, the nerves
are not
"activated" by
18
 the
neurotransmitter
s released by
other nerves

Generic Classificati Dosage Mechanism of Indication Side Effects Nursing

name on Start and Action Consideration
Completion
Trade name of
Medication

diphenhydra Antihistamin Dosage: Competitively Parkinsonism CNS: >Administer with food

mine e 50 mg. IM q 1 blocks the effects (including drug drowsiness, if GI upset occurs.
Antiparkinso hr. x 3 doses of histamine at induced sedation, >Monitor patients
Benadryl nian PRN for H1-receptor sites, parkinsonism dizziness response.
severe Diphenhydramine and CV: >take as prescribed,
psychotic also blocks the extrapyramidal hypotension, avoid excessive
agitation with action of reactions), in palpitation, dosage
BP acetylcholine the elderly bradycardia >Instruct client to
precaution (anticholinergic tolerant of the GI: epigastric open mouth and lift
effect) and is more potent distress, tongue to check for
Date started: used as a agens, for anorexia, the drugs.
06/11/10 sedative because milder form of GU: urinary >tell the client to
it causes disorders in frequency, report difficulty of
drowsiness other age dysuria breathing, tremors,
groups, and in thrombocytope unusual bleeding or
combination of nia brusing, irregular
19
 centrally Hepatic: heart beat.
acting hemolytic
anticholinergic anemia
antiparkinsonia
n drugs.

Generic Classificati Dosage Mechanism of Indication Side Effects Nursing

name on Start and Action Consideration
Completion
Trade name of
Medication

Chlorpromazi Antipsychoti Dosage: Block dopamine Management CNS: >Assess mental status
ne cs 200 mg. receptors in the of neuroleptic prior to and
tab AM; 1 tab brain; also alter manifestation malignant periodically during
Thorazine in HS dopamine release of psychotic syndrome, therapy.
and turnover. disorders; sedation, >Monitor BP and pulse
Date Started: control of CV: prior to and frequently
06/12/10 manic phase of hypotension during the period of
manic EENT: blurred dosage adjustment.
depressive vision, >Observe patient
illness. GI: carefully when
constipation, administering
dry mouth, medication.
anorexia, >Instruct client to
GU: urinary open mouth and lift
retention tongue to check for

20
 Hematologic: the drugs.
leukopenia >Advice patient to
take medication as
missed doses as soon
as remembered, witih
remaining doses
evenly spaced
throughout the day.

Generic Classificatio Dosage Mechanism of Indication Side Effects Nursing

name n Start and Action Consideration
Completio
Trade name n of
Medication

antiparkinson Dosage: Anticholinergic Adjunct in the CNS: >Give with meals if GI

Biperiden ian 2 mg. 1 tab activity in the therapy of disorientation, upset occurs, give
OD CNS that is parkinsonism confusion, before meals for
akineton believed to (post memory loss, clients who have dry
helpnormalize encephalitic, hallucination mouth, give after
Date the hypothesized arterioschleroti CV: meals if drooling or
started: imbalance of c, and tachycardia, vomiting occurs.
cholinergic and idiopathic palpitations, >Take the drug as
06/12/10 dopaminergic types) hypotension prescribed.
neurotransmitter Dermatologic >Instruct client to
in the basal : rash, urticaria open mouth and lift
ganglia of the GI: dry mouth, tongue to check for
brain of a constipation, the drugs.
parkinsonism dilatation of > tell patient to report
21
patient. Reduces colon difficult or painful
severity of urination;
rigidity, and to constipation, rapid
lesser extent, pounding of the heart,
akinesia and confusion, eye pain or
tremor rash.
characterizing
parkinsonism.

22
G. PRIORITIZATION

RANKING NURSING DIAGNOSIS/ PROBLEMS JUSTIFICATION

Airway, breathing and circulation

concept states that circulation
Altered cardiovascular status
should always be the third to be
related to increase pressure
1 assessed. And if the heart
secondary to Hypertension
doesnt work normally, the other
systems and their functions will
be affected. The aorta is the
largest artery of the body that
extends from the left ventricle of
the heart to begin the
distribution of oxygenated blood
throughout the rest of the body,
narrowing and clogging of aorta
brought about by fatty deposits
causes a decrease in the blood
flow from the left ventricle into
the systemic circulation. This
obstruction creates a resistance
to ejection and increased
pressure in the left ventricle.

We ranked this as our second

priority because People with chronic
low self esteem issues often spend
Chronic low self-esteem more time worrying about the
2
related to impaired future, or dwelling on mistakes that
they've made in the past, that they
cognitive self-appraisal AEB
fail to enjoy the here and now
negative feedback about moments in life. Without the self
self esteem to believe they can
accomplish something new, fear
keeps the sufferer from asking for
that promotion; going on a date with
the person they're attracted to; or
even getting on that roller coaster
with their kids.

For most persons, everyday life

includes its share of stressors and
Ineffective denial related to demands, ranging from family,
inability to tolerate the work, and professional role
consequences of known responsibilities to major life events
disorder such as divorce, illness, and the
death of loved ones. How one
3 responds to such stressors depends
on the persons coping resources.
Such resources can include
optimistic beliefs, social support
networks, personal health and
energy, problem-solving skills, and
material resources. Socio-cultural
and religious factors may influence
how people view and handle their
23

Risk for injury related to
imbalanced between oxygen
supply and demand secondary to
hypertension
4
5 Risk for relapsed episode maybe
R/T poor medical treatment
regimen compliance
problems. Vulnerable populations
such as elderly patients, those in
adverse socioeconomic situations,
or those who find themselves
suddenly physically challenged may
not have the resources or skills to
cope with their acute or chronic
stressors.
Risk for injury is one of the most
common complications of
hypertension that is why it is the
prioritized potential problem.
Patients having hypertension are
prone to injury because of the
imbalance in their oxygen supply
and demand causing disturbed
visual field and postural imbalance.
If this potential problem is not given
immediate attention, this may cause
a more serious problem to the
patient.
We ranked this as the least priority
because the chances of having
relapse episode are about 40% is
needs are not satisfied, majority of
psychiatric clients are r/t poor
compliance to medical treatment
24
 H. NURSING CARE PLAN
NCP ACTUAL #1: ALTERED CARDIOVASCULAR STATUS R/T INCREASE PRESSURE SECONDARY TO HYPERTENSION
ASSESSMENT EXPLANATION OF GOALS AND NURSING INTERVENTION RATIONALE EVALUATION
THE PROBLEM OBJECTIVES

S> Problema Patient has a history STO: After 1 hour of Dx: >Monitored vital signs >Note response to STO: Goal met,
ko tong BP ko, of hypertension. health teaching, especially BP activities patient was able to
tumataas Bp- During admission until patient will be able to >Assessed contributory >To know the demonstrate
factors of increase BP appropriate
150/100 the third day patient demonstrate understanding and
intervention
has a fluctuating BP of understanding of Tx: >Assisted in getting up >Patient might be techniques to
O> Fluctuating 130/100 to 150/100, techniques and ways to prevent increase of
BP of 140/100 slowly from bed to bedside getting up of bed in
this was caused by prevent further or from supine to moderate the wrong way which BP
to 150/100
over excitement increase of blood high back rest may add up in the
>Feeling of when his wife came pressure like: >Assisted in going to the increase BP
dizziness like home from Saudi and comfort room or using the
when going to a. Waking up slowly commode if necessary >To provide safety
stress that causes
the comfort on bed and >Promoted adequate rest
sympathetic nervous by decreasing stimuli,
room resting before
system (that walking providing quiet >To maximize sleep
>Increase stimulates the fifgt or b. Proper Deep environment and periods that provide
respiratory rate flight response) over breathing scheduling activities good energy source
LTO: Goal met,
activity increasing exercises Edx: >Instructed to report
>Fast shortness of breath, chest >Immediate patients Bp was
breathing hearts contractility
pain or any discomfort interventions will be maintained at
over stress.
>Emphasized importance done 130/90
A> Altered
of diet low fat, low sodium
cardiovascular Source:
LTO: After 3 days of >Reiterated religious >To maintain normal
status related
Brunner and nursing intervention, taking of medication BP
to increase
the Blood pressure will >Encouraged rest periods
pressure Suddarths Medical-
be maintained at as necessary >To help regulate BP
secondary to Surgical Nursing 7th
Hypertension edition 130/90 from 150/100 >To prevent sudden
increase of BP

25
 NCP ACTUAL #2: CHRONIC LOW SELF-ESTEEM R/T IMPAIRED COGNITIVE SELF-APPRAISAL AEB NEGATIVE FEEDBACK ABOUT SELF
EXPLANATION OF THE GOALS AND
ASSESSMENT INTERVENTION RATIONALE EVALUATION
PROBLEM OBJECTIVES
S>ang asawa ko Mr. ICI wife is a nurse LTO: After 3 days of PDx > Established Individuals with low LTO: Goal met if
ang nagtratrabaho working in Saudi. She is the self-esteem are
nursing
para sa min, ako one whos working for their Rapport reluctant to discuss The client is able
interventions, the client
pa man din ang family, taking charge for all true feelings to verbalize
lalaki wala akong will be able to verbalize
their expenses, providing understanding of
magawa understanding of
support for their family and >Assessed presence individuals role in the
individuals role in the Re-enforcement of
taking already the seat as the society regardless of of negative attitude society regardless of
O> Feels guilty communicating
and shame when bread winner of their family. and or self talk and interacting their gender
their gender
talking about his Mr. ICI felt so bad with that with others could
wife who works for because he should be the one stimulate to
STO: After 8 hours of enhance self-
them whos doing all of that stuff. appropriate nursing
esteem
>Noted attitude of He felt shame and guilty to interventions, the client
his present situation. To STO: Goal met
shyness will be able to increase
compensate to his > Assessed existing Incongruences
> Unable to
self-esteem through: strengths and coping
shortcomings he made use between
communicate with himself by doing household abilities, and provide verbal/non-
a. Giving positive The client was
this co-patient opportunities for verbal
chores and becoming able to increase self-
feedback their expression and communications
> Took a bath on responsible in taking care of require
esteem through giving
recognition
the third day only his son but these were not b. Focusing topics clarification. positive feedback, was
enough to show that he is able to appreciate his
A> Chronic low such as on the clients >Noted
useful and not enough to To assist client to accomplishments in life
self-esteem related accomplishments in life non-verbal
show his worth as father. All develop internal and was able to
to impaired behavior
of the things that he did were sense of self-
cognitive self- c. Reinforcing the esteem identify his strengths
appraisal AEB in turn inadequate for him >Used
personal strengths and and positive perceptions
negative feedback which led him to have a positive perceptions
positive
about self chronic low self-esteem. messages Supporting a
that the client identifies
rather than
26
Source: praise. clients beliefs and
self-rejection and
Tx>Maintained helping them cope
therapeutic can affect self-
www.medscape.com/viewprog communication esteem
ram
> Rendered positive
feedback To facilitate trust
during interaction

>Focused on
accomplishments To increase self-
esteem
Edx> Encouraged
participation in group
To lift self-esteem
activities. Caregiver
may need to
accompany client at
first, until he or she Positive feedback
feels secure that the from group
group members will members will
be accepting, increase self-
esteem
regardless of
limitations in verbal
communication

>Encouraged client's
attempts to
communicate. If
verbalizations are not
The ability to
understandable,
communicate
express to client effectively with
27
what you think he or others may
she intended to say. enhance self-
It may be necessary esteem
to reorient client
frequently

>Reinforced the
personal strengths
and positive
perceptions that the
client identifies. Clients with low
self-esteem need
>Gave to have their
reinforcement existence and
value confirmed
for progress
noted.
Give
reinforcement
for progress
noted.

28
29
 ASSESMENT EXPLANATION OF THE GOALS AND INTERVENTIONS RATIONALE EXPECTED
PROBLEM OBJECTIVES OUTCOME

S> Hypertension P/Dx> Observed > Shows if the patient STO:

naman talaga ang One cause of bipolar disorder is STO: behavioral responses could interact and Goal met if the
problema ko. stressful life events these are After 1-2 hours of interested to patient was able
Hindi ako baliw. thought to be the main element in appropriate nursing therapeutic regimen to feelings
Wala naman the development of bipolar intervention the congruent with
akong nakikita o disorder. In our patients case one patient will verbalize >Assessed ability to behavior.
nakakausap o factor that could be seen is the feelings congruent respond or interpret > To explore hidden
naririnig na gaya loss of his job making his wife with behavior. questions. thoughts and feelings
ng naririnig at work for him and one more thing that the patient might LTO:
nakikita ng ibang is that he is left alone while his LTO: After 2-3 days of not show through his Goal met if
kasamahan ko wife is abroad. appropriate nursing facial expressions. patient meet
dito.
interventions the > Assessed triggering > knowing the trigger psychological
A symptom of bipolar that patient will meet factor that may stop factors could help you needs as
contributes for the patient to deny psychological needs your client from talking determine what to do evidence by
his known illness is exaggerated as evidence by to you. if the patient shows. appropriate
O> Does not self-esteem. appropriate > Client may expression of
mingle to other expression of Tx> Minimized misinterpret and feelings.
roommates. feelings. discussion of negative believe references are
personal problems to him.
>Always stays in Source: within clients hearing.
his bed. http://bipolar.about.com/cs/bpbasics/
> Showing interest
>Only interacts to a/what_causes_bp.htm
>Listened attentively while the patient talks
nurses, doctors, to what the patient boost his confidence
family members . says. to share more.
and student
nurses. > Positive
>Provided positive reinforcement will
A> Ineffective reinforcement. help the patient
denial related to change his mood like
inability to sadness, but
tolerate the
limitations should be
consequences of
known disorder. set so that you wont
be giving negative
result to the behavior
of the client.
Edx> Encouraged
patient to continue 30
verbalizing thoughts >help the client
and feelings. relieve stress and you
will be able to know
how to be therapeutic
 NCP POTENTIAL #1: RISK FOR INJURY R/T IMBALANCE BETWEEN OXYGEN SUPPLY AND DEMAND SECONDARY TO HYPERTENSION

Assessment Explanation of the Objectives Interventions Rationale of the Expected Outcome

Problem Interventions
Blood The client is then STO: Dx> Monitored and > this will serve as
pressure experiencing After 8 hours of recorded vital signs, baseline data Goal met if the
above normal hypertension that nursing intervetions, noting blood pressure patient is able to
parameters causes imbalance the patient will be > Noted treatment- > sometimes these verbalize
ranges from between the oxygen able to verbalize related factors, such are not recognized by understanding of
120/70 to supply and demand. understanding of as side effects or the clients, therefore individual factors that
150/100 This imbalance individual factors that interactions of increasing their contribute to
Intake of causes alteration in contribute to medications susceptibility to injury possibility of injury.
hypertensive the brain cell possibility of injury. > Noted clients > these affects
agents like functioning leading to age, gender, clients ability to
catapres and decreased perceptual developmental stage, protect self and/or
norvasc function as decision-making others and influences
Complains of manifested by ability, level of choice of
easy dizziness when cognition or interventions and/or
fatiguability standing suddenly, competence teachings
A> Risk for injury decreased > this helps the
related to concentration and Tx> Provided patient to control his
imbalanced easy fatigability LTO: information regarding condition, thus
between After 1 to 2 days disease or conditions preventing the risk for
oxygen supply Source: of nursing that may result in injury Goal met if the
and demand interventions, the increased risk of > to promote active patient is able to
secondary to Brunner and patient will be able to injury and positive view of demonstrate
hypertension. Suddarths Medical- demonstrate > Assisted client to self behaviors, lifestyle
Surgical Nursing 7th behaviors, lifestyle develop plan for changes to reduce
edition changes to reduce activity and exercises risk factors and
risk factors and within individual >participating in protect self from
protect self from ability pleasurable activities injury.
injury. > Provided can refocus energy
diversional activities, and diminish feelings
avoiding of unhappiness,
overstimulation and sluggishness and
31
understimulation worthlessnesss
> antihypertensive
agents usually causes
Edx> Cautioned the drowsiness which is
patient to avoid one of the most
activities requiring common cause of
alertness until the injury
effects of > to protect self from
medications are injury
known
> Instructed client > to prevent risk for
to request assistance injury and give
as needed prompt attention to
> Advised the side effects as
patient to report any necessary
adverse reactions or
side effects of the
medication taken

32
 NCP POTENTIAL #2: RISK FOR RELAPSED EPISODE MAYBE R/T POOR MEDICAL TREATMENT REGIMEN COMPLIANCE
Assessment Explanation of the Objectives Nursing Interventions Rationales Evaluation
Problem
O > Has interest in Worked as a farmer STO > After 6-8 Dx > Assessed clients > to determine STO > Patient was
treasure hunting with family early in hours of nursing perception of self causative factors able to
and going outside the morning to intervention patient and noted use of defense demonstrate
naked when the afternoon from is able to show mechanisms. coping mechanism
wife goes back to childhood to adult. signs coping > Assessed clients > to determine signs of as evidenced by
Iran. Completed his measures. coping relapse. relaxed posture
> Returns back education till college behaviors already > to determine and calm behavior.
to his usual self level and later got LTO > After 1-2 present. contributing factors.
when the wife is married and have hours of nursing > Reviewed > promotes sense of LTO > Patient was
back home. children. Went to Iran intervention patient laboratory and trust, allowing patient to able to understand
and worked abroad to is able to medication chart. discuss feelings openly. about his
A > Risk for help support his understand the Tx > Developed > to avoid reinforcing treatment by
relapsed episode family. Came back to importance of his therapeutic manipulative behavior. taking his
maybe r/t poor the Philippines and treatment and nurse-patient > offer emotional medications as
medical treatment continue working for verbalize his relationship. support and scheduled and
regimen compliance his family. Wife had feelings. understanding. informing any
gone back to Iran to > Maintained straight > builds trust, changes of
work, leaving the forward communication. enhancing therapeutic behaviors.
husband and son in > Listened to relationship.
Philippines. Then feelings that he
husband start acting expresses. > for positive
strange with interest > Being truthful distraction.
of treasure hunting when giving information
and going outside and dealing with patient. > encourages
naked. But returns > Invited client to do continuation of
normal when wife activities. treatment.

33
comes back home. > Gave positive
reinforcement for > decreases defense
clients response.
efforts.
> Maintained calm, > to prevent fatigue.
matter of fact,
nonjudgmental attitude. > to help to deal with
Edx > Encouraged client stress.
to get adequate sleep.
> Instructed client > to understand that it
to take is a long term treatment.
medication as
ordered.
> Explained to client > to make adjustments
symptoms improve in the treatment.
gradually and not
immediately. > to prevent relapse.
>Advised client to
report mood changes
immediately.
> Educated client to
not stop on medication
without physicians
order.

34
35
I. DISCHARGE PLAN

DIET AND NUTRITION ACTIVITY HEALTH TEACHINGS

Instructed client to eat frequent small
meals
Instructed to have high protein, high
carbohydrate diet for energy
Mental health professionals try to Teach client to take medications
steer people away from sedentary
regularly
activities such as TV where the mind
and body are not fully engaged. Instruct the wife that whenever she
Cleaning, reorganizing, reading, or
see signs and symptoms of Bipolar
raising goldfish could all be great
indoor activities. Disorder to refer him immediately
Teach the client on the side effects of
Creative activities like occupational
therapy, drawings his medicines when not taken
Advise the client to go back to the
Medications should be given regularly
everyday for a certain period of time institution after discharge for follow-up
check-up and consultation
Make client be more active and
cooperative in any activities given to
him

Instruct client to do activities that do

not require alertness because one side
effect of medication is drowsiness,
thus may cause injury to the client

36
J. CONCLUSIONS AND RECOMMENDATIONS

Bipolar disorder causes serious shifts in mood, energy, thinking and

behavior from the highs of mania on one extreme to the lows depression on
the other. More than just a fleeting good or bad mood swings, the cycles of
bipolar disorder last for days, weeks, months or even a year. Unlike ordinary
mood swings, the mood changes bipolar disorder is so intense that they
interfere with your ability to function. People experiencing a manic episode
often talk a mile a minute, sleep very little and are hyperactive.

Interaction with the patient for more than 3 days is not enough to
cover from his childhood up to now. We should interact with the patient more
and more to know about his history and different traumas that he
encountered. Well preparation to go on duty at the area should be done
before the actual duty by conducting self awareness test. We should also be
well knowledgeable to psychiatric disorders prior to duty to enhance more
our interventions and interactions.

Since the client has Bipolar Disorder, the group concluded that this
disorder has different symptoms as compared to the other psychiatric
disorders. Therefore, in the making of this case study and understanding how
this disorder affects a person through appreciating its pathophysiology. This
study makes us student nurses more competent and gained more confidence
in handling patients with Bipolar Disorder.

37