Bipolar I Disorder most recent

episode (MRE) Manic with

Psychotic Features (PF)
 introduction
Bipolar I disorder, formerly termed manic-depressive illness, is defined by
at least one lifetime manic or mixed episode (Am. Psychiatr. Assoc. 2000).
Diagnostic criteria specify that mania must last at least one week or require
hospitalization. Manic symptoms include irritability or euphoria along with
symptoms such as decreased need for sleep, grandiose ideas, impulsive
behavior, increased talkativeness, racing thoughts, flight of ideas, increased
activity, and distractibility. Mixed episodes include manic symptoms and
simultaneous depressive symptoms lasting for at least one week. Most, but
certainly not all, people with BD I experience periods of depression. (Miklowitz
& Johnson, 2006)
 introduction
Characterized by wild, unpredictable rollercoaster shifts of emotion in the
extreme, and states of despair and exhaustion alternating with periods of hard work and
very effective functioning in milder cases, bipolar disorder is a mood disorder that
afflicts 0.4% to 1.2% of the U.S. adult population, equally among females and males
(American Psychiatric Association 19871, with a suicide mortality rate of 15% - an
extremely high risk, the highest among mental illnesses (Fieve 1989). Philippine data is
almost impossible to recover at the present time. Together with unipolar recurrent
depression, the other mood disorder classified by the American Psychiatric Association
which has the same biochemical nature and treatment, bipolar disorder is the single
most frequently encountered mental health problem in the U.S. (Fieve 1989).
(Encarnacion, 2013)
Patient’s Profile
Name: Pawai Q
Age: 52 years old
Gender: Female
Address: Sitio, Lower Sea
Lion, Inawayan,
Cebu City, Cebu
Religion: Roman Catholic
 Patient’s Profile
✘ Date of Admission: 03/12/2018
✘ Time of Admission: 6:40 pm
✘ Chief Complaints:
“Manapat ug manakit na siya ug
mga bata,” as verbalized by her aunt
✘ Admitting Diagnosis:
Bipolar I Disoder MRE Manic
with PF
✘ Admitting Physician:
Dr. Gian Alchris P. Villas
 Patient Health History
A. Present Health History

One week prior to consultation, patient hit her aunt because “Giiingnaan man
ko niya galirigon ko niya.” Patient misheard the statement made by her aunt. Her
aunt was answering questions from her customer asking “Unsa’y tinda niyo
Ma’am?” Her aunt suffered from a head injury. No consultation was done. Patient
had also several complaints from her neighbours. Patient had also delusions stating
“Ingnan kog bahog buto sa akong silingan.” Patient was sent to VSSMC
Psychiatric Ward because “Nagpetition na ang barangay ani niya ug dili na siya
muinom ug tambal,” according to her aunt. Thus, she was consulted.
Patient was in and out of the mental institution from Mandaluyog until she
came back to Cebu. She was then bought to this institution & was managed as a
case of Schizoaffective Disorder.
 Patient Health History
B. Past Health History

Patient is non-hypertensive, non-diabetic and non-

asthmatic. She has no food or drug allergies. Patient has
no prior psychiatric hospitalizations nor surgeries. She
is not also taking any maintenance.
 Patient Health History
C. Family Health History

Patient claimed of heredo-familial disease including

hypertension on both sides. Her father died of cardiac
arrest. Patient and informant stated no known history of
mental illness on the family.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Appearance

On the day of the assessment, patient is sitting on a bench at

the sleeping quarters of the female ward. She was well-groomed
and dressed. She was wearing a grey t-shirt & printed leggings
with a pair of violet slippers. Client had eye contact when
conversing.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Attitude

Patient is cooperative sometimes but she easily loses interest

on things.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Behavior

Patient NP shows interest on talking to anyone. She is

talkative and speaks in a clear, loud voice.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Speech

The patient speaks in a normal pace and tone, but sometimes

she talks fast when in good mood and she keeps on stating made
up words like “Pawai Q” and other things.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Affect

Patient has no consistency of her mood. She will smile when

greeted will become irritated later on and talk with herself.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Mood

Patient has no fluctuating mood that is sometimes difficult to

detect. She sometimes smiles when discussing about her interest
but with later on she becomes irritated. She will maintain eye
contact but look away after and move to another place.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Thought Process

The patient has flight of ideas, associative looseness,

circumstantial thinking, neologisms, clang associations, word
salad, and echolalia when talking about a certain topic. Although
sometimes she has concrete thinking and has selective attention
on topics.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Thought Content

Patient has grandiosity delusion. She stated that she was born
outside the planet. Sometimes, she was reported to be aggressive.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Perception

The patient exhibits abnormal perception. Symptoms such as

illusions & hallucinations were elicited.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Orientation

The patient is oriented to time, place, person, & certain

circumstances like what therapy are the therapists are conducting
for that certain day.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Memory Concentration

The patient is able to remember the recent days that passed

but is having a hard time remembering the remote occurrences.
Sometimes she fills in memory gaps with experiences that have
no basis in fact like she is saying she’s from another planet when
she was born. She has difficulty deciphering proverbs correctly.
 (Date Performed:
Mental Status Exam May 25, 2018 at 8:30 am)

Insight/Judgment

The patient has the ability to judge objects according to her

perception, and she can name things such as watch, pencil &
notebook.
 Significant Physical Assessment Findings

Grey & white streaks of hair

22 pieces of teeth & dental

carries on the molars

Pacing back & forth

 Diagnostic Results
Diagnostic
Date Normal Values Patient’s Result Significance
Result
Hemotology Section
5/11/2018
(CBC):

WBC 4.5 – 11.5 10^9/L 5.17 Normal

RBC 4 – 5.4 10^12/L 4.24 Normal

Hgb 120 – 150 g/L 129 Normal

Hct 0.35 – 0.49 L/L 0.377 Normal

RDW - CV 11.5 – 14.5 % 11.9 Normal

RDW - CD 39 – 46 % 38.6 Slightly decreased

 Diagnostic
Date Normal Values Patient’s Result Significance
Result

MCH 26 – 32 g/L 30.4 Normal

MCHC 320 – 360 g/L 342 Normal

MCV 80 – 100 L/L 88.9 Normal

Platelet 150 – 450 10^9/L 384 Normal

(Differential Count):

Neutrophil 50 – 70 % 56.6 Normal

Eosinophils 1 -3 % 2.1 Normal

Basophils 0–2% 0.8 Normal

 Diagnostic
Date Normal Values Patient’s Result Significance
Result

Chemistry Result:      

Na 135 – 145 mmol/L 138 Normal

K 3.5 – 5.5 mmol/L 3.66 Normal

Cl 98 – 108 mmol/L 103.5 Normal

BUN 7.87 – 20.25mg/dL 8.3 Normal

SGOT (AST) 0 – 31 U/L 13.3 Normal

SGPT (ALT) 0 – 34 U/L 14.59 Normal

 DRUG THERAPEUTIC RECORD
PO
> Olanzapine 10 mg 1 tab OD @HS
DRUG/DOSE/FREQUENCY CLASSIFICATION/ INDICATION/ SIDE EFFECTS/
NURSING RESPONSIBILITIES
/TIME/ROUTE MECHANISM OF ACTION CONTRAINDICATION ADVERSE EFFECTS
Brand Name: Classification: Indication: CNS: Abnormal gait, agitation, akathisia, Before
Chemical class: To treat psychosis altered thermoregulation, amnesia, 1. Obtain baseline LFT, serum glucose,
 To treat manic phase of acute anxiety, asthenia, dizziness, euphoria, weight, lipid profile before initiating
  Thienobenzodiazepine
bipolar disorder fatigue, fever, headache, hypertonia, treatment.
Generic Name: derivative insomnia, nervousness, neuroleptic 2. Assess behavior, appearance, emotional
 As adjunct to treat acute
Olanzapine Therapeutic class: Antipsychotic bipolar disorder malignant syndrome, restlessness, status, and response to environment,
     To treat agitation associated somnolence, stuttering, suicidal ideation, speech pattern, thought content.
Dose: Mechanism of Action: with schizophrenia and tardive dyskinesia, tremor During
10 mg Antagonizes alpha1-adrenergic, bipolar I mania CV: Chest pain, hyperlipidemia, 3. Monitor B/P, serum glucose, lipids, LFT.
  dopamine, histamine, muscarinic, hypertension, hypotension, orthostatic 4. Assess for tremors, changes in gait,
serotonin receptors. Produces Contraindication: hypotension, peripheral edema, abnormal muscular movements, behavior.
Frequency:
anticholinergic, histaminic, CNS tachycardia 5. Supervise suicidal-risk pt closely during
OD Contraindications: None known.
depressant effects. Therapeutic Cautions: Disorders where CNS EENT: Amblyopia, dry mouth, increased early therapy (as depression lessens,
  Effect: Diminishes psychotic salivation, pharyngitis, rhinitis energy level improves, increasing suicide
depression is prominent; cardiac
Time: symptoms. ENDO: Hyperglycemia, prolactin potential).
disease, hemodynamic instability,
8 am   elevation 6. Assess for therapeutic response (interest
prior MI, ischemic heart disease;
  GI: Abdominal pain, constipation, in surroundings, improvement in self-care,
hyperlipidemia, pts at risk for
Route: dysphagia, hepatitis, increased appetite, increased ability to concentrate, relaxed
aspiration pneumonia, decreased GI
PO nausea, thirst, vomiting facial expression).
motility, urinary retention, BPH,
GU: Urinary incontinence, UTI 7. Assist with ambulation if dizziness occurs.
narrow angle glaucoma, diabetes,
HEME: Agranulocytosis, leukopenia, 8. Assess sleep pattern.
elderly, pts at risk for suicide.
neutropenia After
MS: Arthralgia; back, joint, or limb pain; 9. Advise patient to avoid alcohol and
muscle spasms and twitching smoking during olanzapine therapy.
RESP: Cough SKIN: Ecchymosis, 10. Notify physician if extrapyramidal
photosensitivity, pruritus, urticaria symptoms (EPS) occur.
Other: Anaphylaxis, angioedema, flulike 11. Instruct patient to change position slowly to
symptoms, weight gain minimize effects of orthostatic
  hypotension.
 DRUG THERAPEUTIC RECORD
PO
> Divalproex Na 500mg 1 tab BID
DRUG/DOSE/FREQUENCY CLASSIFICATION/ INDICATION/ SIDE EFFECTS/
NURSING RESPONSIBILITIES
/TIME/ROUTE MECHANISM OF ACTION CONTRAINDICATION ADVERSE EFFECTS
Brand Name: Classification: Indication: SIDE EFFECTS Before
Chemical class: Carboxylic acid  To treat simple or complex Frequent: Epilepsy: Abdominal pain, 1. Antimanic: Assess behavior, appearance,
irregular menses, diarrhea, transient emotional status, and response to environment,
  derivative absence seizures, complex speech pattern, thought content.
Therapeutic class: Anticonvulsant partial seizures, myoclonic alopecia, indigestion, nausea, vomiting, During
Generic Name: tremors, fluctuations in body weight.
  seizures, and generalized 2. Antimanic: Question for suicidal ideation.
Divalproex Na Mania (22%– 19%): Nausea,
Mechanism of Action: tonicclonic seizures as 3. Assess for therapeutic response (interest in
  monotherapy drowsiness. Occasional: Epilepsy: surroundings, increased ability to concentrate,
Directly increases concentration
Dose:  As adjunct to treat simple or Constipation, dizziness, drowsiness, relaxed facial expression).
of inhibitory neurotransmitter 4. Give oral valproic acid or divalproex with food to
500 mg/tab complex absence seizures, headache, skin rash, unusual
gamma-aminobutyric acid minimize GI irritation, if needed.
  (GABA). Therapeutic Effect: complex partial seizures, excitement, restlessness. Mania (12%– 5. Don’t break or let patient chew delayed release
Frequency: Produces anticonvulsant effect, myoclonic seizures, and 6%): Asthenia, abdominal pain, tablets.
BID stabilizes mood, prevents generalized tonic-clonic dyspepsia, rash. Rare: Epilepsy: Mood 6. Monitor liver function test results, as ordered.
migraine headache. seizures changes, diplopia, nystagmus, spots Assess for signs and symptoms of hepatotoxicity
  during first 6 months of treatment, especially in
   To treat acute manic phase before eyes, unusual bleeding/bruising.
Time:   children under age 2. Notify prescriber
8 am – 8 pm of bipolar disorder immediately if you suspect hepatotoxicity.
ADVERSE EFFECTS/
  7. Monitor platelet count, as ordered, for signs of
  TOXIC REACTIONS thrombocytopenia, and notify prescriber if they
Route: Contraindication: Hepatotoxicity may occur, particularly in appear.
PO Contraindications: Active hepatic first 6 mos of therapy. May be preceded After
disease, urea cycle disorders, known by loss of seizure control, malaise, 8. Instruct patient to swallow capsules whole to
mitocondrial disorders; migraine weakness, lethargy, anorexia, vomiting prevent irritation to mouth and throat.
prevention in pregnant women. rather than abnormal serum hepatic 9. Advise patient to avoid hazardous activities during
Cautions: History of hepatic therapy because drug may affect mental and
function test results. Blood dyscrasias motor performance.
impairment, bleeding abnormalities, may occur. 10. Urge patient to avoid alcohol during therapy.
pts at high risk for suicide, elderly.   11. Advise patient to notify prescriber if tremor
  develops during therapy; it may be dose-related.
 
 Prognosis based on Nursing Assessment and Rationale:

Bipolar I disorder is classified by episodes of severe mania lasting at least

seven days and often requiring hospitalization due to their severity. Manic
episodes are characterized by periods of high energy, elevated moods, or
irritability. Sometimes these episodes also include psychotic breaks with
reality. A patient may display psychotic symptoms such as delusions of
grandeur or hallucinations. It always requires medication for effective
management as it can greatly reduce the frequency and severity of Bipolar
Type1 episodes.
During our interaction, the prognosis of patient is good for the reason that
she had a great social relationship to other, she followed her medication
regimen as well as therapy and exercise and also her diet.
 Recommendation to Promote Early Recovery And
Rehabilitation:
With proper treatment, bipolar disorder can be managed, and individuals can go
on to lead happy and healthy lives. Bipolar disorder is most commonly treated with
evidence-based care, including group and individual therapy, which works to teach
patients life skills and coping mechanisms. Cognitive behavioral therapy is a useful
tool to help someone suffering from bipolar disorder to pinpoint what may trigger a
manic or depressive episode and to help them learn to cope with or avoid these
specific triggers.
A healthy lifestyle, including a structured routine, can help as well. Those
suffering from bipolar disorder are often highly sensitive to change. As a result, a
specific routine with scheduled sleeping and waking times as well as a nutritious diet
and a healthy dose of exercise can be vital to managing symptoms.