Running head: BIPOLAR DISORDER 1

Bipolar Disorder and Pregnancy

Tricia Hoskin

Youngstown State University

BIPOLAR DISORDER 2

Abstract

My patient was a thirty-two year old Caucasian female that is seven months pregnant. Her

clinical diagnosis on the DSM-IV-TR is listed as bipolar disorder and psychotic disorder. On the

date of care my patient stayed in her room in the PICU therefore my review and evaluation is

based on her patient records. Typical behaviors of those diagnosed with bipolar disorder and

psychotic disorder are discussed. Psychiatric medications and and the reason they are prescribed

are listed. Safety and security measures that were implemented for the patient, staff, and the

other patients located on 3 south are included. The patients history of mental illness, current

medical conditions, and precipitating factors leading up to hospitalization are reviewed. Long

and short term goals, behavioral outcomes that are to expected of the patient, and discharge

planning are also discussed.

Keywords: bipolar disorder, pregnancy, precipitating factors.

Objective Data
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My patient is a thirty-two year old, Caucasian, female that is seven months pregnant. Her

date of admission was 10/15/2016 and the date of care is 10/18/2016. She was involuntarily

admitted to the psychiatric intensive care unit to prevent harm to herself or to others.

On date of admission paramedics picked up the patient outside of her motel room where

the patient was screaming that she was going to get killed and buried alive. She also had random

nonsense talking. The paramedics then transported her to the emergency department. The

patient was pink slipped by the emergency department where she was acting delusional and

paranoid. She stated that her prenatal vitamins were poisoned with down syndrome. Patient was

unable to care for self, unaware of surroundings, paranoid, felt that others were trying to harm

her. Her alcohol and drug screen were negative. Limitations listed on her initial assessment

were; no identified support system, difficulty communicating thoughts and feelings, no insight to

illness, difficulty making decisions, negative attitude, poor concentration, poor judgement, and

financial difficulties.

Using the DSM IV-TR, Axes I through V, the psychiatric diagnosis of the patient is as

follows: Axis I identifies the patients clinical disorder. Her axis I is bi-polar disorder and

psychotic disorder with unspecified psychosis not due to a substance or known psychological

condition. Comments in these sections are to rule out drug-related versus schizo-affective. Axis

II describes any personality disorder or if there is any evidence that the patient has mental

retardation. The patients axis II is listed as personality disorder unspecified. Axis III is the

patients general medical conditions that they are affected by. My patient is seven months

pregnant. Axis IV describes any environmental or psychosocial problems. My patient has two

listed. The first one is listed as severe that states that the patient is seven months pregnant and

acutely psychotic. The second one is listed as moderate and it states that the client has limited
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support. Axis V is The Global Assessment of Functioning Scale which gives a number that

indicates the degree of occupational, psychological, and social functioning a patient is capable

of. Axis V is not listed for my patient.

Behaviors observed on admission and up to date of care. According to the history and

physical on date of admission the patient was actively hallucinating by yelling and screaming at

unseen others. Patient was displaying destructive behavior by turning over furniture and

throwing her belongings. She was labile and being verbally aggressive and threatening staff. On

date of care patient stayed in her room for my shift. She only came out to get her breakfast tray.

She did not say anything but she had an unkempt appearance.

Medical Conditions and Treatments

My patient is currently seven months pregnant. For her pregnancy she takes prenatal

vitamins and folic acid. She takes polyethylene glycol for constipation and hydrocortisone-

pramoxine for her hemorrhoids.

Safety and Security Measures Maintained

Patient was put into the psychiatric intensive care unit to prevent harm to herself and to

others. In the PICU the patient is more secluded and monitored more closely. Once the patient

was placed in the PICU, she reacted by screaming loudly, pounding on the door, and throwing

around her furniture. The staff then removed all furniture from her room with the exception of

the bed to prevent her from harming herself or others. Vital signs performed on patient daily and

PRN. Conduct patient checks and document every 15 minutes or as otherwise ordered. Physical

assessment and search for contraband upon admission and PRN. Have the patient report any
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safety concerns that they may have to the staff. Patient is pregnant therefore precautions need to

be taken with medication administration and ensuring she does not harm herself or the fetus.

Prescribed Psychiatric Medications and Reason for Taking

Latuda (lurasidone) 40 milligrams given once daily is an antipsychotic medication that is

given for bipolar disorder. Benadryl (diphenhydramine) 25 milligrams intra-muscular every

eight hours PRN is an antihistamine that is given to help decrease anxiety or agitation. Patient

has limited choices for psychiatric medications due to her pregnancy.

Psychiatric Diagnoses and Common Behaviors

Bipolar disorder is, characterized by mood swings from profound depression to extreme

euphoria (mania), with intervening periods of normalcy. Psychotic symptoms may or may not be

present (Townsend, 2015, p.899). Symptoms of the disorder may include, aggressiveness,

impulsivity, compromised memory, psychotic incidents, personality changes, and severe episodes

of depression and mania that included extreme hyperactivity and intense feelings of sorrow,

sadness, and anxiety (Granek, Danan, Bersudsky, & Osher, 2016, p. 193). From my patients

chart, she displayed many of these symptoms. She presented with destructive behavior, throwing

furniture and her belongings, verbally aggressive and threatening towards staff. My patient was

actively hallucinating by arguing and yelling at unseen others. At times she had cognitive

impairment and was not able to understand directions and she displays impulsivity with her

history of drug abuse. In the severe manic phase, the symptoms are extremely pronounced: the

person sleeps no more than 3-4 h, is in constant activity, is out of control and has feeling of being

invincible. The condition can be associated with severe anxiety, but the person can also be
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threatening, aggressive, and explosive (Larsen, Damkier, Pedersen, FengerGron, Mikkelsen,

Nielsen, Linde, Knudsen, Skaarup, & Videbech, 2015, p13). My patient did not sleep for very

long periods at a time. One of her long term goals was to sleep at least seven hours a night for

three consecutive nights.

Bipolar disorder is a severe, chronic psychiatric condition that affects 2-3% of the

population (Granek, Danan, Bersudsky, & Osher, 2016, p. 192). Research on bipolar disorder

has indicated that divorce and separation are two to three times more likely than in the general

United States population and the risk of suicide in patients is high, estimated to be close to 20%

(Granek, Danan, Bersudsky, & Osher, 2016, p. 192). My patient recently broke-up with her

boyfriend but denies any suicidal ideations and denies any suicide attempts in the past.

My patient is pregnant and that makes managing her condition even more challenging.

Severe and persistent mental illness can arise at first onset of pregnancy or can be

exacerbated as a result of the significant physiologic and psychosocial changes

occurring during pregnancy. The dramatic hormonal changes that occur in the perinatal

period and the abrupt and frequent discontinuation of pharmacotherapeutic regimens in

women with severe and persistent mental illness create increased challenges for

clinicians and pregnant women. (McKeever, Alderman, Luff, & DeJesus, 2016, p. 486)

My patient was noncompliant with her medication regimen but the reason for it is uncertain.

There could be many factors contributing to this; drug addiction, homelessness, impaired

cognitive understanding, no transportation, or possible teratogenic affect on fetus.

Paschetta et al. (2014) reported that, historically, obstetricians rarely had the experience

in managing pregnant women with severe and persistent mental illness, because these

women were viewed as psychologically impaired for childbearing and parenting and
BIPOLAR DISORDER 7

were advised by their psychiatric providers to not seek pregnancy. As a result,

maternal-child health care providers have received minimal training in caring for

pregnant women with severe and persistent mental illness. (McKeever, Alderman,

Luff, & DeJesus, 2016, p. 486)

My patient is homeless and has no support system and it is very unlikely that she has regular

prenatal care. The psychiatric doctor treating my patient had limited medicinal options to offer

the patient. She was having psychotic episodes and the only medications they were

administering were Latuda and Benadryl which were only slightly effective. Drugs should only

be used if the benefits for the pregnant woman (and her unborn child) outweigh the potential side

effects

(Larsen, Damkier, Pedersen, FengerGron, Mikkelsen, Nielsen, Linde, Knudsen, Skaarup, &

Videbech, 2015, p. 8). Therefore the physician has to make the best decision for both the mother

and fetus.

Relapse in bipolar disorder in pregnancy is common. The risk of relapse of depression or

mania seems to be highest in month 4-9 of the pregnancy. Some studies find that approximately

35% experience relapse despite medical treatment, whereas 85% experience relapse without

drugs, primarily in the shape of depressive episodes or mixed episodes with both manic and

depressive symptoms at the same time. If the mother is not treated, the fetus can risk being

exposed to larger concentration of stress hormone (Larsen, Damkier, Pedersen, FengerGron,

Mikkelsen, Nielsen, Linde, Knudsen, Skaarup, & Videbech, 2015, p. 13). It is a very high

relapse rate even if the mother is medication compliant. It is important to find something that

works to regulate the mother with as little danger to the fetus as possible because the fetus being

exposed to stress hormones over a period of time is not good for the fetus either.
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Precipitating Behaviors and Stressors

My patient is seven months pregnant, single, and homeless with bipolar disorder with

psychotic features. She recently separated from her boyfriend. She has a history of cocaine

(rock, crack, and powder) abuse and is currently on probation. The patient has a felony with a

history of drug trafficking and domestic violence. She was previously incarcerated at Marysville

prison in November 2015. The patient has no family, no support system, and is currently on SSI.

Previously she had juvenile court involvement and the client gave up her daughter for adoption.

The patient was also noncompliant with her medications.

Patient and Family History of Mental Illness

Patient has had multiple prior psychiatric hospitalizations. She has previously been

hospitalized at St. Elizabeths in Youngstown and Trumbull Memorial Hospital from 05/01/2016

through 5/10/2016 for depression. She was also hospitalized in the psychiatric unit in Marysville

prison for five months. The patient also has a past history of hospitalizations at state and local

levels. Patient has no family to list history of mental illness.

Psychiatric Nursing Care

The psychiatric nursing care provided to my patient includes medication administration

at specific times to ensure she was receiving the medication as prescribed to help control her

mental illness. The nursing staff constantly monitored the patient to make sure she wasnt

harming herself or others. The patient was in the PICU where the environment was calm and

quiet to prevent further irritation to the patient. The staff monitored the patient for side effects
BIPOLAR DISORDER 9

and effectiveness of medications every waking shift. Staff spends time with the patient on a 1:1

basis to establish trust and identify needs at least three times a day. With each encounter the

nurses assess signs and symptoms of delusional thinking and they will reorient patient to time,

place, and person whenever delusional symptoms interfere with reality. The staff monitor and

document any factors contributing to disorientation or precipitants to delusions.

Analysis of Ethnic, Spiritual, and Cultural Influences

In the patients chart it states that she denies any cultural or ethical issues and also denies

any religion or spirituality.

Evaluation of Patient Outcomes

A short term goal listed for my patient is to maintain good personal hygiene. Long term

goals included, by the time of discharge patient will verbalize understanding of illness and the

need to comply with treatment. Patient will be able to perform activities of daily routine without

interference of delusional thoughts. Patient will not allow paranoia to interfere with eating,

sleeping, and taking medications as demonstrated by compliance with each activity of daily

living for a period of three days. Patient will verbalize or demonstrate a decrease in fear and

suspicion of others by the time of discharge. Another long term goal is patient will sleep at least

seven hours a night for at least three days. The last long term goal listed is that patient will

experience three or less episodes of agitation or aggression related to delusional thoughts in three

days. On my date of care the patient was not able to meet any of her short term or long term

goals.
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Discharge Planning

The only order listed for the patient to be discharged is that she needs to have consistent

stabilization of mood. I imagine that another condition could be upon discharge the patient will

take prescribed medications, in the correct dosage, at the right time. Also the patient will not be

a harm to herself or to others and will seek help if condition worsens.

Prioritized List of Actual Diagnoses

1. Aggressive behavior related to psychosis as manifested by patient throwing furniture and

threatening staff.

2. Ineffective health maintenance related to not taking medications as prescribed as evidenced by

exacerbation of symptoms.

3. Impaired social interaction related to absence of significant others as evidenced by no family

or support system.

4. Ineffective coping related to situational crisis as manifested by history of cocaine addiction

5. Impaired verbal communications mental illness as evidenced by arguing and screaming at

unseen others.

6. Sleep deprivation related to emotional instability and hyper agitated state as evidenced by

sleeping less than five hours a night.

7. Adult failure to thrive related to mental illness as evidenced by inability to perform self care

List of Potential Nursing Diagnosis

At risk for self directed violence related to altered thought process.

At risk for others directed violence related to history of violence.

BIPOLAR DISORDER 11

At risk for loneliness related to no family or support system

At risk for grieving related to loss of a child through adoption

At risk for anxiety related to unmet security and safety needs

At risk for suicide related to psychiatric disorder

At risk for disturbed maternal/fetal dyad related to substance abuse

At risk for constipation related to decreased intestinal motility

At risk for fatigue related to hormonal, metabolic and body changes

At risk for injury related to drug effects and hallucinations

At risk for ineffective childbearing process related to substance abuse

At risk for impaired parenting related to emotional instability

At risk for disturbed personal identity related to manic state

At risk for fear related to imagined threat to own well being

References

Ackley, B.J., Ladwig, G.B. (2014). Nursing Diagnosis Handbook (10th ed.).

Maryland Heights, MO: Elsevier.

Granek, E., Danan, D., Bersudsky, Y., & Osher, Y. (2016). Living with Bipolar

Disorder: The Impact on Patients, Spouses, and Their Marital Relationship.

Bipolar Disorders, 18(2), 192-199.

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Larsen, E., Damkier, P., Pedersen, L., Fenger-Gron, J., Mikkelsen, R., Nielsen, R.,

Linde, V., Knudsen, H., Skaarup, L., & Videbech, P. (2015). Use of Psy-

chotropic Drugs During Pregnancy and Breastfeeding. Acta Psychiatrica

Scandinavica, 132(S445), 1-28.

McKeever, A., Alderman, S., Luff, S., & DeJesus, B. (2016). Assessment and Care

of Childbearing Women With Severe and Persistent Mental Illness. Nursing

for Womens Health, 20(5), 486-499.

Townsend, Mary. (2015). Psychiatric Mental Health Nursing (8th ed.).

Philadelphia, PA: F. A. Davis.