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 NURSING

CHARACTERISTICS IMPLICATION
Old-old 85 and over Increased Assist client with self-
physiological care as required, and
problems may with maintaining as
develop. 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 Help patient to cope
toward full sexual properly to
maturity and separation anxiety.
functional and Encourage the patient
development of skills to deal with the
needed to cope with environment and
the environment. 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 INDICATORS

POSITIVE NEGATIVE
RESOLUTION RESOLUTION
MATURITY 65 years to Integrity vs. Acceptance of Sense of loss,
death despair worth and contempt for
uniqueness of others.
one’s own life

Acceptance of
death

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 Actual Findings Interpretation
Findings
Increased skin Dry skin Normal because as we grow
1. Integumentary dryness old our subcutaneous gland
 SKIN activity and tissue fluid
decreases.

Normal: because of
Increased skin Pale skin decreasing vascularity
pallor

Normal : Reduced thickness

Increased skin Skin becomes fragile and vascularity of the
fragility dermis; loss of subcutaneous
fat

Normal: because of loss of

Progressive Saggy skin skin elasticity, increased
wrinkling and dryness, and decreased
sagging of the subcutaneous fat
skin
Normal: because of the
Clustering of melanocytes
Brown “age Brownish spot (pigment-producing cells)
spots” (lentigo
senilis) on
exposed body
parts (e.g., face,
hands, arms)
Normal: Reduced number
Decreased and function of sweat glands
perspiration Reduced sweating
Normal: Progressive loss of
pigment cells from the hair
Thinning and bulbs
graying of scalp, With white hair evenly
 HAIR pubic, and distributed and thinning
axillary hair of the scalp, pubic and
 axillary hair. Inadequate self-care
Slower nail Increased calcium deposition
growth and
increased Nails slightly dirty but
 NAILS thickening with smooth, firm and not
ridges brittle Normal: Because of
No clubbing of nails decreased muscle fibers
Decreased
speed and
2. Neuromuscular power of Slow movement with
skeletal muscle decrease ROM
contractions
Normal: Diminished
Slowed reaction conduction speed of nerve
time fibers and decreased muscle
tone
Slow reaction
Normal: Because of atrophy
Loss of height of intervertebral discs,
(stature) increased flexion at hips and
knees
Not in proper stature
Normal: Because the bone
Loss of bone reabsorption outpaces bone
mass reformation

Decrease ROM with Normal: Drying and loss of

Joint stiffness slow movement elasticity in joint cartilage

Normal: Because of
Impaired Cannot demonstrate decreased muscle strength,
balance flexion of knees reaction time, and
coordination, change in
Cannot perform ADL center of gravity
without assistance.
Normal: because of fewer
Greater cells in cerebral cortex
difficulty in
complex Delayed understanding
3.Sensory learning and on situations and
/Perceptual abstraction cannot verbalize clearly
her statements Normal: because of
Decreased Degeneration leading on
visual acuity lens opacity (cataracts),
Blurred vision thickening and inelasticity
(presbyopia)

Normal: Because of the

Progressive loss changes in the structures
of hearing and nerve tissues in the
(presbycusis) Poor hearing function inner ear
 Normal: Decreased number
Decreased of taste buds in the tongue
sense of taste, because of tongue atrophy
especially the Cannot clearly identify
sweet different kinds of taste.
sensations at
the tip of the
tongue
Normal: Decreased elasticity
and ciliary activity
Decreased
ability to expel Decreased ability to
foreign or expel secretions
accumulated Normal:
4. Pulmonary matter Weakened thoracic muscles;
calcification of costal
Decreased lung cartilage, making the rib
expansion, less cage more rigid with
effective RR – 23bpm increased anterior-posterior
exhalation, diameter dilation from
reduced vital -Respiratory patterns- inelasticity of alveoli
capacity, and eupnea
increased -Lung clear sound
residual volume Normal: Diminished delivery
and diffusion of oxygen to
Difficult short, the tissues to repay the
heavy, rapid normal oxygen debt because
breathing of exertion or changes in the
(dyspnea) Easy fatigability both respiratory and
following vascular tissues
intense exercise

Normal: Increased rigidity

Reduced cardiac and thickness of heart valves
output and (hence decreased
stroke volume, filling/emptying abilities);
particularly decreased contractile
during PR – 88bpm strength
increased
5. Cardiovascular activity or
unusual
demands; may
result in
shortness of
breath on
exertion and
pooling of blood
in the
extremities

Reduced Normal: Increased calcium

elasticity and deposits in the muscular
 increased layer
rigidity of
arteries

Increased in Normal: Inelasticity of

diastolic and systemic arteries and
systolic blood increased peripheral
pressure resistance

BP – 150/80mmHg
Orthostatic Normal: Reduced sensitivity
hypertension of the blood pressure-
regulating baroreceptors

Normal: Alteration in the

Delayed swallowing mechanism
swallowing time

Increased Decreased muscle tone of

tendency for the intestines; decreased
constipation Slow movement when peristalsis; decreased free
eating body fluid
6. Gastrointestinal
Reduced Normal: Decreased number
filtering ability No sign of constipation of functioning nephrons
of the kidney (basic functional units of the
and impaired kidney) and arteriosclerosis
renal function changes in blood flow
With poor bladder
control especially at Normal: Decreased tubular
Urinary urgency night function
7. Urinary and urinary
frequency

Tendency for Normal: weakened muscles

nocturnal With increased voiding supporting the bladder or
frequency and frequency but less weakness of the urinary
retention of amount of urine. sphincter in women
residual urine
Normal: Decreased bladder
capacity and tone
With poor bladder
control especially at Normal: T cells less
Decreased night responsive to antigen; B cells
immune produce fewer antibodies
response; immune system changes
lowered may participate insulin
resistance to resistance
infections
Susceptible to disease
Poor response due to weak body
to immunization resistance
8.Immunological Decreased
stress response
PATTERNS OF FUNCTIONING
FUNCTIONAL HEALTH
PATTERN
Health Management Pattern
Nutritional/Metabolic
Elimination
Activity and Exercise
Roles and Relationship
Values and Belief
DURING RESIDENCY
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 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.
 
Patient urinates 4- 5 times a
day and defecates once a day,
semi- formed to formed stool
in consistency.
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.
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 prays, believes
and has faith in GOD.
INTERPRETATION/
IMPLICATION
Patient’s environment is
important for the patient’s
wellness. Safety should be
maintained and assist or
supervise the patient during
self- care.
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.
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.
Exercise helps in diverting and
preventing the patient’s mood
swings. It also provides
strength for muscles and
bones.
The patient is sometimes hard
to deal with, which depends
on her mood. The patient is
easily to make laugh and cry.
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 Normal changes in aging often

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.
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 The disease process and the
but views on some things aging process greatly affect
negatively depend on her the self- perception of the
moods. 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

 NEUROTRANSMITTERS
Neurotransmitters 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
Interactive among Drugs: Cocaine, MAOIs,
neurotransmitters Trycyclin,
(Serotonin, Dopamine, Antidepressants,
Norepinephrine, GABA) or Steroids, Levadopa
certain chemicals in the
brain that regulate mood
Increased level
of
norepinephrine,
dopamine &
serotonin
ACUTE MANIA
MANIC/ DEPRESSIVE BEHAVIOR
(BIPOLAR)
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
relationship
Extreme activity(requires
hospitalization)
Impairment in
PATHOPHYSIOLOGY of Bipolar Disorder:
Neurobiologic Perspective (Patient-based)
ACUTE MANIA
Interactive among
neurotransmitters
(Serotonin, Dopamine,
Norepinephrine, GABA) or
certain chemicals in the
brain that regulate mood
DEPRESSION
Interactive among
neurotransmitters
(Serotonin, Dopamine,
Norepinephrine, GABA) or
certain chemicals in the
brain that regulate mood
Alcohol, Drugs: Sedative-
hypnotics, amphetamine
Decreased level withdrawal,
of glucocorticoids,
norepinephrine, propanolol, resperine, &
dopamine & steroidal contraceptives
serotonin
Physical Illness: Stroke,
Cushing’s disease & some
Endocrine disorders
DEPRESSION
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 decreased
Constipation and urinary
retention
DEPRESSION
Interactive among
neurotransmitters
(Serotonin, Dopamine,
Norepinephrine, GABA) or
certain chemicals in the
brain that regulate mood
 Physical Illness:

Decreased level Mild Stroke secondary

Increased level
of to Hypertension
of
norepinephrine, norepinephrine,
dopamine & dopamine &
serotonin serotonin

ACUTE MANIA DEPRESSION

MANIC/ DEPRESSIVE BEHAVIOR

(BIPOLAR)
Elevated or Prime Symptoms:
irritable mood
Depressed mood or loss of
Grandiosity, insomnia, interest or pleasure
verbosity, flight of ideas, Change in level of
distractibility, functioning:
psychomotor agitation,
Change in weight, insomnia,
excessive involvement in
pleasurable activities psychomotor agitation, fatigue,
worthless feelings, concentration
without regard for
consequences difficulties, death thoughts, has
tendency to commit physical
Impairment in violence to others
occupational or
Constipation and urinary
social activities
& in relationship retention
Impairment in
functioning

DRUG STUDY

DRUG NAME DOSAGE ACTION INDICATION ADVERSE NURSING

REACTION CONSIDERATION
Haldol 1 tab prn • Alters the •Organic •CNS: • Assess mental
(Haloperidol) effects of Psychoses extrapyramidal status prior to and
dopamine in • acute symptom such periodically during
the CNS psychotic as muscle therapy.
• Also has symptoms rigidity or • Monitor BP and
 anticholinergic • Relieve spasm, shuffling pulse prior to and
and alpha- hallucinations, gait, posture frequently during
adrenergic delusions, leaning forward, the period of
blocking disorganized drooling, dosage
activity. thinking masklike facial adjustment. May
• Diminished • severe appearance, cause QT interval
signs and anxiety dysphagia, changes on ECG.
symptom of akathisia, tardive • Observe patient
psychoses dyskinesia, carefully when
headache, administering
seizures. medication, to
•CV: ensure that
tachycardia, medication is
arrhythmias, actually taken and
hypertension, not hoarded.
orthostatic •Monitor I&O
hypertension. ratios and daily
•EENT: blurred eight. Assess
vision, glaucoma patient for signs
• GI: dry mouth, and symptoms of
anorexia, dehydration.
nausea, • Monitor for
vomiting, development of
constipation, neuroleptic
diarrhea, weight malignant
gain. syndrome (fever,
• GU: urinary respiratory
frequency, urine distress,
retention, tachycardia,
impotence, seizures,
enuresis, diaphoresis,
amenorrhea, hypertension or
gynecomastia hypotension,
• Hematologic: pallor, tiredness,
anemia, severe muscle
leucopenia, stiffness, loss of
agranulocytosis bladder control.
• Skin: rash, Report symptoms
dermatitis, immediately. May
phtosensitivity also cause
leukocytosis,
elevated liver
function tests,
elevated CPK.
• Advise patient to
take medication as
directed.
Multivitamins 1 cap od Prevention of Treatment and Allergic 1. Assess patient
deficiency or prevention of reactions to for signs of
replacement in vitamin preservatives, nutrition
patients whose deficiencies. additives, or deficiency prior to
nutritional colorants. and throughout
status is 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: Risk for Within the Assess To assess The client
“ Mga walang hiya other- shift, the client’s causative/ demonstrate
yang mga yan! Lagi directed patient will perception of contributing d self-
na lang aq violence demonstrat self and factors. control as
pinagtsitsismisan!” as related to e self- situation. evidenced by
verbalized by the irritability, control. Note use of relaxed
patient. impulsive defense posture, non-
Objective: behavior mechanism. violent
- With rigid and manic behavior.
posture excitemen Observe/ May Goal met.
- With t with listen for indicate
clenching of possible early cues of possibility of
fists indicators distress/ loss of
- With annoyed of overt increasing control and
facial and anxiety. intervention
expression aggressive at this point
- Pacing acts. can prevent
- Hyperactive a blow up.
- Attempted to Ask directly if
throw hot the person is To
coffee to thinking of determine
others acting on violent
- Has the thoughts/ intent.
tendency to feelings.
verbally
threatened Develop and
others maintain Promotes
therapeutic person’s
nurse-client sense of
relationship. trust,
allowing
client to
discuss
feelings
openly.
Make time to
listen to To assist
expressions client to
of feelings. accept
Acknowledge responsibilit
reality of y for
client’s impulsive
feelings. behaviour
and
Approach in potential for
positive violence.
manner,
acting as if To assist
the client has client in
control and is controlling
responsible behavior.
for own
behavior.

Give positive
reinforcemen
t for client’s
efforts. To
encourage
continuation
Maintain of desired
calm, matter- behaviors.
of-fact, non-
judgemental Decreases
attitude. defensive
response.
Provide a
safe/ quiet
environment
and remove To promote
items from safety in
the client’s event of
environment violent
that could be behavior.
use to inflict
harm to
others.

Encourage
walking or
exercise as
activities that To promote
 may diffuse wellness
aggression

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Self- care Within the Note To identify The client
“Huwag na deficit shift, the concomitant causative / participated
magpalit ng panty, related to patient medical and contributing in self-care
hayaan nang as will psychological factors. activities like
mamaho,” as perceptual/ participate problem that in nutrition
verbalized by the cognitive in self- may be factors and personal
patient. impairment care for care. hygiene.
Objective: as activities. The patients
- Inability to evidenced Identify degree To assess demonstrated
prepare by inability of individual degree of initiative in
foods to perform impairment or disability. self-care
- Inability to self-care functional level. activities.
wash body task. Goal met.
and access Perform/ assist
to with meeting To assist in
bathroom client’s needs dealing with
- Inability to when she is situation.
maintain unable to meet
appearance own needs.
at a
satisfactory Develop plan of
level care To conform
appropriate to to clients
individual usual
situation. schedule.

Plan time for

listening to the To discover
client’s barriers to
concerns. participation
in regimen
and to work
on problem
solution.
Provide for
communication Enhances
among those coordination
who are and
involved in continuity of
caring. care.

Provide privacy
and equipment To assist in
within easy dealing with
reach during situation.
personal care
 activities.

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

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

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.