L. F.

Gonzales College of Science and Technology Institute Maharlika Highway, San Leonardo, Nueva Ecija

Submitted by: Balajadia, Enrick D. Feliciano, Geruel D. Garcia, Patria Rose Anne Oberez, James Dohn G. Reyes, Glaiza M.

Submitted to: Florida Sarmiento RN, MAN, PhD Dean, College of Nursing

TABLE OF CONTENTS
I. Introduction II. Objectives III.Nursing Process
A. Assessment

1. General Data
Name: Address: Date Admitted: Diagnosis: Age: Civil Status: Chief Complaint: Informant:

2. Reason for hospitalization 3. Family history of mental illness 4. History of present illness 5. Related events/situations to present health condition 6. Pre-morbid personality assessment 7. Course in the ward 8. Personal/educational/occupational/marital history and significant person to patient 9. Mental status examination
a) General description

(1) Appearance (2) Behavior and psychomotor activity (3) Attitude toward examiner

b) Psychopathophysiology and Psychodynamics B. Planning C. Nursing management Process recoding D. Evaluation and learning derived E. Conclusion / recommendation

IV.Drug study
A. Generic name B. Brand name C. Classification D. Mechanism of action E. Patient dosage F. Contraindications G. Adverse effect H. Nursing interventions

Bipolar disorder
The illness tends to be highly genetic, but there are clearly environmental factors that influences whether the illness is occur in a particular child. Bipolar disorder can skip generations and take different in different individuals. The small group of studies that have been done vary in the estimate of the risk to a given individual. For the general population a conservative estimate individuals risk of having full-bloom bipolar disorder one percent. Disorder in the bipolar spectrum may affect 4-6%, who one parent has bipolar disorder, the risk to each child is 15-30%, when both parents have bipolar disorder, the risk increases to 50-75%. The risk in siblings and fraternal twins is 15-25%, and the risk of identical twins is approximately 70%. Bipolar disorder is classified into two, the bipolar I and the bipolar II. The bipolar I disorder in which individual may experience one or more manic episodes or mixed episodes. During a manic episode must be present to a significant degree. Impairment in various of functioning, psychotic symptoms, and the possibility of self-harm exist. Bipolar II disorder is characterized by recurrent major depressive episodes with hypomanic (a mood between euphoria and excessive elation) episodes. It is believe to occur frequently in women than in men.

This case study aims to: Know the definition and the history of the development of bipolar manic disorder. Identify the facts that may contribute in acquiring bipolar manic disorder. Formulate appropriate diagnosis on which to base the necessary psychiatric nursing interventions. Implement interventions and psychodynamic approach. Evaluate the actions done to clients and its effectivity.

A. Assessment
1. General Data
Name: Age: Address: Civil Status: Date Admitted: Chief complaint: Nestor 42 Nueva Ecija Married August 5, 2007 1. Pananakit 2. Poor sleep 3. Nambabato ng bahay 4. Nagbabasag ng gamit Wife

Informant:

2. Reason for Hospitalization

Her wife brings him here at Mariveles Mental Hospital, August 5, 2007 11:05 in the morning. She said that his husband Nestor is not in normal mental state again. He refused to take his medicine, he had sleep disturbance and the last time he forced his daughter to get money to her and bought him cigarettes. And before that day, his husband threw a stone at his neighbors house.

3. Family History of Mental Illness

According to his wife, he is the only one in the family having this mental illness. His parents and relatives have the normal state. His family work and do their daily tasks like any individual and possess good intention of living except him.

4. History of Present Illness

The patient is previously confined in Mariveles Mental hospital last March 2001, the client flow up until October 2003. The last admission was August 5, 2007 (with relatives). According to his wife, when they got home after the first exclusion, his husband was able to help in their financial needs. He work as a tricycle driver but still the money that they earned is not enough to continue and support his medication that is why they decided to stop taking his medicine. After a few weeks, he started to have signs and symptoms of relapses. He became destructive Nagbabasag ng kasangkapan at Nambabato ng kapitbahay. He always walks and kept panic. When his mother seen his situation, she brought him medicines but the patient refuses to take it because he thinks it was a poison. She heard their neighbor said Papatayin na lang namin yan. Therefore, she decided to take him here in this mental institution again.

5. Related Events/Situations to Present Health Condition

According to the medical doctor, Mr. Nestor has mental illness because of trauma he experienced. One day, he said that he saw his father stabbed by his fathers friend and after that incident, he never forget that. He also said that they have financial problem and he thinks that their younger 11-year-old son was not his son. He think that his wife having an affair with another man. However, he never confronted his wife about it in afraid that his wife got angry.

6. Pre-Morbid Personality Assessment

During our interaction with the patient, he seems to be kind to us and eager to answer our question. He does not hesitate to answer although we ask about his personal life. We also noticed his kindness during the session. We almost think that we are talking to a normal person. In addition, he possesses silence quite some time as he is thinking something that we do not ask.

7. Course in the Ward

From August 2007 until now, according to Mr. Nestor, he only got one trouble inside the hospital. The reason of that commotion is a stick of cigarette. From then on, he never do that again because he wants to go home and return to his normal life.

8. Personal/Educational/Occupational/Marital History and Significant Person to the Patient

The client is a high school graduate, a farmer and tricycle driver in occupation. Sometimes, he is also a balut vendor at night to sustain their financial needs. He has a doubt on his wife that she is having an affair. They have seven children; his sister adopts two of them. He never tried to have an affair to other woman because he only wants to have a simple and happy family. His two daughters are the special person in his life.

9. Mental Status Examination

a) General Description

(1) Appearance
Seen this adult male in blue MMH uniform with short hair and nails, poorly kept with body odor. With no slippers, like any body inside the hospital. Not so nourished, and slim in built.

(2) Behavior and Psychomotor Activity

He is not harmful as we first thought about him. He responds in every question that we gave. He also participates in exercise, games, drawings, or any program or activities that we planned for them. He won in the pinoy henyo game.

(3) Attitude toward Examiner

He is sitting straight in front of us. He just staring to us at first, but in few moments, he answers our questions. He respects our presence in excusing himself every time he will go to the comfort room or when he wants to walk for a while.

b) Psychopathophysiology Modifiable Factors Substance abuse Sleep deprivation Stress Non-Modifiable Factors Genetic factors

Imbalance Serotonin and Norephinephrine level

Increase in Serotonin and Norephinephrine

Chemical changes in the brain

Kindling

Spontaneous seizure activity in the brain

Hyperactivity Signs and Symptoms Walking aimlessly Decreased sleep Increased involvement in pleasure seeking activity Hallucinations Agitation Delusions Signs and Symptoms (Book based) Abnormal and persistent elevation of mood Agitative Gradiosity Decreased need for sleep Increase involvement in goal directed activity Hallucinations

Psychodynamics Balance between physiological safety needs (low Socio-economic) Abraham Maslow Hierarchy of Needs

Orally fixated (smoking and drinking) (Oral stage Jean Piaget)

Disturbed Psychological Aspects (Chained by his wife) (Maslow Hierarchy of Needs)

Fear (auditory hallucination) (Collective unconscious Carl Jungs Theory)

Family constellation Alfred Adler

Intimidate (High School graduate only) (Cognitive Impairment Jean Piaget)

Anxiety Self-searching, unproductive (unable to sustain the family needs) (Generatively versus stagnation Eric Erikson)

Frustration and self-deficit (Dorothea Orem)

Bipolar manic

B. Planning
NURSING CARE PLAN CUES Subjective: puro mga sinungaling ang andito, as verbalized by the patient. NURSING DIAGNOSIS Disturbed thought process related to inability to trust as evidenced by suspiciousness of others, resulting in alteration in societal participation. GOAL/OBJECTIVES INTERVENTIONS
Prioritize safety of the client.

RATIONALE
Client may harm self or others in disoriented, confused state.

EVALUATION

Short-Term Goal Within 1 week, client will start to recognize and verbalize when thinking is non-reality based. Long-Term Goal Client will experience no delusional thinking by discharge from treatment.

Frequently orient client to reality and surroundings.

Disorientation may

Try to redirect violent behavior with physical outlets for the client's anxiety.

endanger client safety if he or she unknowingly wanders away from safe environment.

Goal met. After a week of intervention, the client able to recognize and verbalize when thinking is nonreality based.

Physical exercise is a safe and effective way of relieving pent-up tension. Verbalizing feelings with a trusted individual may help client work through unresolved issues.

Encourage the client to verbalize true feelings. The nurse should avoid becoming defensive when angry feelings are direct at him.

C. Nursing management
Process recording Client initials: Sex: Age: Date of birth: Address: Nationality: Physical appearance: Description of the environment: Tentative diagnosis: Goals of intervention/Objective: Student question Ako po ay si Patria. Kayo po ba, pwede ko po ba malaman ang inyong pangalan? Nestor Male 42 years old March 26, 1967 Jaen, Nueva Ecija Filipino In blue MMH uniform, short hair, short nails, poorly kept and no slippers. Sunny day, clear environment and good atmosphere under the big mango tree. Bipolar manic with psychotic features To help the client to express thought and feeling. Patient response Ako si Nestor. Therapeutic communication Giving information Rationale/Defense mechanism Informing the client of facts increases his knowledge about a topic or let the client know what to expect. The nurse is functioning as a resource person. Giving information also builds trust with the client. Accepting response indicates that the client has heard and followed the train of thoughts.

Maari po ba kayong makinig at sumagot sa mga bagaybagay na itatanong ko sa inyo?

Sige.

Accepting

 Ano po ba ang trabaho ninyo bago kayo mapunta dito?

Dati akong tricycle driver tapos nagtitinda din ako ng mais kasama ang asawa ko.

Exploring

When client deals with topic superficially, exploring can help them examine the issue more fully. Make explicit that the client has the lead in the interaction. For the client who is hesitate about talking, broad opening may stimulates him or her to take the initiative. To understand the client. The nurse must see things from his perspective. Encouraging the client to describe the ideas fully may relieve the tension the client is feeling, and he might not be less likely to take action or ideas that are harmful or frightening.

Kuya, mayroon po ba kayong gustong ikuwento o sabihin sa Wala. Magtanung ka na lang. akin?

Broad openings

Ano ang ginagawa mo kapag nalulungkot ka?

Nakikipagkwentuhan ako sa kaibigan ko na si Inggo.

Encouraging description of perception

D.Evaluation and learning derived

1. The client physical appearance improved from poor to good hygiene. 2. The students had learned how to interact and understand the emotions and coping mechanism. 3. The client showed interest in each therapy. 4. The client was able to express his/her own feelings and thoughts during nurse-client interaction.

E. Conclusion / Recommendation As a conclusion, bipolar is a serious mental disorder that could lead to serious of harmful situation or even complications that they could be manic or depressed. According to the stimuli, that they encounter this disorder needs careful handling and attentive support emotionally, because they could be lacking from emotional support or attention from immediate family. Like our client with the help also of other mental personnel. These mental institution patient can be managed well and be free from the said disorder. We recommend careful management and careful attention plus support to those affected by the disorder and for those with symptoms of said disorder, kindly report immediately into different or nearest mental institution.

Generic name Lithium carbonate

Brand name Priadel

Classification Antimanic drug

Mechanism of Action Thought to disrupt sodium exchange and transport in nerves and muscles and control reuptake of neurotransmitters.

Patient Dosage 600mg BID

Contraindications (none)

Adverse Effect

Nursing Interventions

CNS: Dizziness, Advise patient to take drowsiness, headache, with food or milk to tremor, ataxia, slurred minimize G.I. upset. speech, hallucination Advise to limit foods CV: bradycardia, and beverages hypotension containing caffeine. Tell patient to maintain adequate fluid intake. Emphasize importance of having regular blood tests to help detect and prevent serious adverse reactions. Dry mouth Advise the client to avoid dry, bulky, and irritating foods and fluids such as tobacco and alcohol. Advise client to talking too much if not necessary.

Biperiden

Akineton Antiparkinsonian

Biperiden has an antropine-like blocking effect on all peripheral structures that are parasympathetic innervated.

2mg OD

Caution should be observed in patient with manifest glaucoma thought no prohibitive rise in intraocular pressure has been noted following either oral or parenteral administration. Patient with prostatism epilepsy or cardiac arrhythmia should be given this drug with caution.

Generic name
Diphenhyramine

Brand name

Classification

Mechanism of Action

Patient Dosage

Contraindications
Hypersensitivity to drug Alcohol intolerance Acute asthma attack MAO inhibitor use within 14 days Breastfeeding Neonates, premature infants

Adverse Effect

Nursing Interventions

Benadryl Antihistamine , antitussive, antiemetic, antivertigo agent, antidyskinetic

Interferes with 25mg PO histamine effect at HS histamine receptor sites; prevents but does not reverse histamine-mediated response. Also possesses CNS depressant and anticholinergic properties. May block postsynaptic dopamine receptors in brain and depress areas involved in wakefulness and emesis. Also possesses anticholinergic, antihistaminic, and adrenergic-blocking properties. 10mg BID

CNS: drowsiness, Advise patient to avoid headache, paradoxical alcohol and other stimulation depressant such as sedatives. CV: hypotension, tachycardia, Caution patient to palpitations avoid driving and other hazardous activities EENT: blurred vision, until he knows how tinnitus drug affects GI: diarrhea, concentration and constipation, dry alertness. mouth CNS: sedation, drowsiness, extrapyramidal reaction, tardive dyskinesia, pseudoparkinsonism, seizure CV: tachycardia, hypotension EENT: blurred vision, dry eyes, lens opacities, nasal congestion GI: constipation, ileus, anorexia, dry mouth Hepatic: jaundice, hepatitis Tell patient to take capsule or tablets with a full glass of water, with or without food. Instruct patient not to crush sustained-release capsules. Tell patient to mix oral concentrate in juice, soda, applesauce, or pudding. Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.

Chlorpromazine hydrochloride

Antipsychotic , anxiolytic, antiemetic

Hypersensitivity to drug Angle-closure glaucoma Bone marrow depression Severe hepatic or cardiovascular disease