Bukidnon State University Malaybalay City, Bukidnon College of Nursing

In Partial Fulfillment of the Requirement on the Course NCM 105B Related Learning Experience
A case presentation on

Cannabis-Induced Bipolar Disorder with Psychotic Features

Presented by: Artana, Dionflor Berena, Rolando Borromeo, Seneca Jill Callao, Luiggi Mikael Casite, Neilmark Gayona, Emily Golda Gomez, Junfelm Hernandez, Aren Mae Jr. Jacutin, Sushmita Ann Lorca, Lyra Palado, Marcher Rellita, Jezza Ronolo, Ma. Vanessa Tortola, Loweelyn Villamor, Rachelle Suzzanne

Presented to: FATIMA C. TANZO, RN, MAN Lemeul T. Que, RN, MN

March 2014

Table of contents

I.

Introduction
Cannabis-Induced Bipolar Disorder with Psychotic Features The role of cannabis in psychiatric illnesses has been an area of interest. Epidemiological

studies have shown that as the frequency of cannabis abuse increases, so does the risk for a psychotic disorder such as schizophrenia. Studies have also shown that cannabis is the most commonly abused drug among those diagnosed with bipolar disorder. Cannabis intoxication can lead to acute psychosis in many individuals and can produce short-term exacerbations of pre-existing psychotic diseases. Cannabis use also causes symptoms of depersonalization, fear of dying, irrational panic, and paranoid ideas, which coincide with acute intoxication and remitted quickly. Based on research reviews, looking at the connection between cannabis and psychosis, two hypotheses have been developed. The first hypothesis is that cannabis use causes psychotic symptoms in an otherwise healthy individual that would not have occurred with abstinence. The second hypothesis is that cannabis use may precipitate psychosis in individuals who are predisposed to acquiring a psychotic disorder. Only two case studies have reported prolonged depersonalization after cessation of cannabis use. Symptoms experienced during drug-free periods are rarely reported. The role of cannabis in causing bipolar disorder is not well documented. Epidemiological studies have shown that bipolar disorder has the highest rate of substance abuse comorbidity of any axis I disorder. The study found that 41 percent of patients with bipolar disorder had a comorbid substance use with cannabis being the most frequently abused. Cannabis abuse prior to development of bipolar disorder has a significant effect on first-episode mania and on the course of the disease. Another study reported that using cannabis at baseline can significantly increase the risk for manic symptoms during follow up.

Recent advances in cannabinoid receptors and endogenous ligands have renewed interest in the mechanisms by which cannabis can cause major psychiatric disorders. It is now recognized that the endocannabinoid system represents a new signaling process in the nervous system that regulates neurotransmitter systems, energy metabolism, and immune function. Researchers now believe that cannabis consumption during critical phases of brain development can lead to a strong disturbance of the endocannabinoid system and ultimately cause an inappropriate hardwiring of the brain. We present a case of a young high school graduate, with a family history of a psychiatric illness, who presents with psychosis secondary to cannabis abuse. His psychosis persisted long after he stopped abusing cannabis, and he needed to be treated medically for new onset bipolar disorder with psychotic features. In the face of having a genetic predisposition, it is interesting that cannabis was one of the trigger for psychosis, which warrants further study into understanding the exact mechanism that cannabis affects the neurotransmission at various receptors.

II.

Objectives and Purpose

III.
I.

Anamnesis
Informants a. b. c. d. e. Name: Alfredo Ledesma Address: Barangay 4, Valencia City, Bukidnon Relationship to patient: Father Length of time known to patient: 18 years Apparent understanding of present illness of patient:

Sauna nasakpan ko mana siya nga nag-inom uban iyang mga barkada, pero kato nga time wala pa sa akong huna-huna nga sila ga gamit man diay ug droga. Niabot ra dayon ang panahon nga ang among mga silingan ug uban sa akong mga amigo ni ingon nga si ___ ga hithit daw ug marijuana. Didto na pud nag sugod nga nakapansin mi nga nay nag bag-o saiya. Para sa ako, naka apekto sad siguru saiya ang kawad-on ug kakulangon sa kwarta. Dili sa tanang panahon maihatag nako ang tanan nila gusto. Gusto man gud siya makahuman gyud ug iskwela, pero tungod lagi sa ka pobrehon, iyang pangandoy nawala. Basin isa pud ni sa nakahatag ug problema saiya ba. f. Other characteristics and attitude of informant: During the interview, the informant was crying. He was unhappy and down because of the health condition of his son. What added to his depression was that he was blaming himself because he was not able to give more attention and time to his son.

a. b. c. d. e.

Name: Rolly Ledesma Address: Barangay 4, Valencia City, Bukidnon Relationship to patient: Elder brother Length of time known to patient: 18 years Apparent understanding of present illness of patient:

Duha ra gyud tingali ang rason ngano naingon-ana siya. Una, mu tuo gyud ko nga tungod sa droga (marijuana). Sugod mana nga na amigo na niya si James, sila na permi ga uban. Ug ang ika duha, tungod sa mangga nga kahoy diha sa luyo sa balay sa una, kay naa lagi daw gapuyo diha nga dili ingon-nato. Wala man hinuon ko naka kita ug in-ana, pero mu tuo gyud ko nga naa gyuy mga dili parehas nato. Sa pinaka una gyud nga pag tukar saiyang pagka-buang, wala man gyud ko naka matyag ato ay tua man ko sa bukid. Paguli nako sa balay, si ___ mu yaw-yaw naman ug bisan unsa. Usahay dili siya paka-ila na ug tao. Mag sige na syag wally ug ga estorya permi mahitungod sa Ginoo. Sige pud na syag storya about sa mga kapre, ug bampira kay mao daw na iyang mga gakakita.

Sauna sa ayo pa na si ___, hilumon gyud kayo na siya. Dili na siya mu storya saiyang mga problema, isulat ra man na niya dayon saiyang diary. Hadlok na siya nga pagkatao kay hilom ra kayo, pero lawom kayo ug dulot inig masuko. Buotan man hinuon na siya nga pagkabata, ug seryoso gyud na siya saiyang pagskwela. Didto ra man gyud nag bago ang tanan katung nag-ila na sila ni James. f. Other characteristics and attitude of informant: Upon interview, the informant was very attentive. He was able to respond directly to the questions given by the interviewer. The informant was visibly sad about his brothers condition. He was very hopeful that his brother will be cured and will be returned into his normal state.

a. b. c. d. e.

Name: Analyn Address: Barangay 4, Valencia City, Bukidnon Relationship to patient: Wife of the patients elder brother Rolly Length of time known to patient: 6 years (2008-2014) Apparent understanding of present illness of patient:

Sa akong panan-aw, tungod sa droga na iyang sakit sa utok. Sauna buotan mana siya. Gatabang dinhi sa balay. Makigdula saiyang mga manghud. Pero atong 2012 na nitukar na siya, permi na gabii mu uli kay gikan daw siya ug simba sa Born Again. Naa pud tong ni ingon siya nga nag overnight test daw sila mao wala siya nakauli. Wala pud mi kabalo kung nag aha gyud siya. Naka amigo man gud na siya ug bugoy. Si James, pero wala pako kita ana saiya ug dili pud kaila niya. Pero sige na ko ug kadunggan kay __ iyang pangalan. Kana si James, nabagsak mana siya gikan sa Cagayan mao naka abot na siya dire. March 2012 man nagsugod iyang sakit. Gasinggitaay ra sya ug sigeg pamalikas dayon kalit ra pud dayon mukatawa. Dayon adtong Pebrero 2013, kahinumdom ko nag basketball siya diha sa ubos bisag perti ang ulan. Bisag unsa ang tawag saiya ni Rolly, di siya mu patuo kay kailangan gyud lagi daw niya e-shoot ang bola. Atong October 2013 dayon,atong sa wala pa mi kabalo nga sa utok diay ang iyang problema, gi-adto namo siya sa binisaya para mapatambalan. Ingon pa sa manambalay, gisakyan daw si ___ ug dili ingon-natu. Naa dayon gipa-inom saiya nga tabletas pampakalma daw. f. Other characteristics and attitude of informant: During the interview, the informant was obviously hurt about the situation their family was in right now. She maintained an eye contact with the interviewer and it seemed that she was able to give good informations about the patients present illness. In fact, she was able to remember and enumerate the significant dates when asked.

a. b. c. d. e.

Name: Miercel Fragata Address: Barangay 4, Valencia City Relationship to Patient: Neighbor Length of time known to patient: approximately 5 years Apparent understanding of present illness of patient:

Once, the informant noticed that the patient went outrageous. The patient was shouting and took a knife and attempted to hurt his family. After that incident, the informant has not seen the patient for a while and has not heard anything about him. One day, the informant saw the patient again and noticed that he gained weight and learned that the patient has been to a psychiatric institution for one year. The informant has no any idea why the patient was admitted to that institution. She was shocked because she has known the patient as a quiet and helpful person. f. Other characteristics and attitude of informant:

II.

Family History a. Maternal and Paternal Grand Lineages

There was no known maternal and paternal grand lineages history of nervous and mental diseases, alcoholism and drug addiction. b. Father The patients father was a very hard working and a responsible man. He worked at Villahermosa building as a utility for 18 years, and had an income of eight thousand pesos per month. When it comes to work, he was a man with perseverance. He was their familys provider and adviser. In terms of disciplining his children, he was a type of a father who cannot afford to hurt his child physically. So, he disciplined his children through confronting them and speaking to them. But unfortunately, because he was very busy with his work in order to gain extra money, his bonding with his family was deteriorated. The patients father was an elementary graduate and did not have the chance to proceed in school due to financial constraints. He and his family were active in their church and with their social status. He was a cigarette smoker since a very long time and said he cannot leave his vices alone. He was not fond of gambling and treated women respectably. c. Mother The mother is a 46 years old woman currently working at Valencia, Bukidnon City as a Vendor (banana cue, camote cue). She earns a living of 3,000 pesos a month (100 pesos/day) and gives it to her family to support her children needs. The mother is observed to be kind, patient, caring, and responsible. She disciplines her children by verbal reinforcement. She has a good relationship towards her children, relatives, and neighbors. d. Siblings The patient has 3 brothers and 1 half-sister. Her older sister (Cristine) is a 25 years old, single woman. She is working in Dubai for 2 years as a hospitality staff in a cruise ship. Her sister is not informed of her brother's current medical condition. His older brother (Rolly) is a 23 years old, married man and has 2 children. He works as a utility worker to Dr. Efren Villahermosa. He was diagnosed to have Hernia and was successfully operated last June 2013. He is the closest brother to the patient. His younger brother (Reniel) is 10 years old, and a grade 2 pupil. In his early age, he works as a watcher in a pay toilet at Villahermosa Supermarket. His youngest brother (Renjay) is 7 years old and a grade 2 pupil. All siblings have a good relationship towards each other and towards the other member of the family.

III.

Personality History a. Prenatal

Prenatal checkups were done at the Barangay Health Center. During the first month of pregnancy, patients mother was bitten by a dog. She was brought to a quack doctor to seek help. She was given a medicine. She forgot what the name of the medicine was but she can only remember the explanation of the quack doctor that if she will not take the medicine, she will be greatly affected and if she will take the medicine, she might terminate the pregnancy. The mother experienced abortion before she got pregnant with patient bampira. The aborted fetus was 1 month old. The mothers attitude towards her pregnancy was quite okay. She stopped taking her vitamins because she noticed that the color of her stool was dark and smells like rust. Her usual food during the pregnancy was vegetables such as okra and kamunggay. After giving birth, immunizations were started at Damulog Barangay Health Center but were not able to complete the immunization because they transferred to another address. She thought she was anemic because when she stands up, her vision starts to lose and she feels like shes going to faint. She has adequate sleep. She has a good appetite. She has a good relationship with his husband. b. Birth During labor, she felt pain. Pain that was not relieved by any medicines that she took and by any positions that she has tried that would alleviate the pain that she was experiencing. She gave birth at night. After that, she felt so weak that she could raise her body. She also experienced hypersensitivity like whenever she changes the lampin of her child, she feels pangingilo. She gave birth to a full term baby boy last May 2, 1994. The placenta was delivered an hour after the baby came out. She had a 4 hour labor. She gave birth at home (Damulog) with a midwife facilitating the delivery. c. Infancy and Childhood Characteristics She prefer to lay down when breastfeeding because they can get to sleep together. The baby has a good appetite and sucks milk very well and only cries when hungry. She usually places the baby on her right side when lying down even when sitting down. He was four years old then when her mother left for Manila to work as a cook. His mother left him in the supervision of a helper for one year. The helper was one of their neighbors. At 7 months, he started to stand. At 9 months, he started to walk. At one year old, his tooth started to grew. At 2 years old, he started talking and also started his toilet training. The first words that he has spoken was mama, papa, nini, tubig, and o-o. He has no history of enuresis; thumb sucking, night terrors, tantrums, stammering, and history of falls, infantile convulsions, and other childhood diseases.

d. Psychosexual/Psychosocial History Whenever he likes a girl, he would just simply smile. He had a short term relationship with a girl. Whenever his friends and family mentions about his girlfriend, he just stare and keep silent. He was known as a gentleman. He respects girls. He was very formal and regularly goes to church. e. Play Life

Bampira plays many games like sundalo, tarak-tarak, taklob sa coke himuon ug balaybalay ug himuon ug dalan para agihan sa iyang tarak2x. He prefers to play alone by himself. He is very secretive about the games he plays and after playing he cleans up and hides his toys so that no one else can play with them or see what he was playing with. His favorite game is to pretend that he is a soldier; he picked up sticks and put them in his pants to pretend that he is holstering a firearm. Bampira doesnt like to play with the opposite sex and hardly interacts with other kids. Bampira plays with people his age but occasionally plays games with his older brother. He is usually a follower, which is evident in how easily he can be influenced by the people around him. He doesnt like being away from home so he prefers to play most of the games he plays near home. Patient doesnt have much influence of sequel in habit -formation brought about by playmates because he doesnt have many playmates. He does not abandon home or school work for the sake of playing. f. School History Bampira was about 7 years old when he started school at the first grade level. He graduated the high school level at San Agustin Institute of Technology by the age of 12 years old. He was eager to learn and always look forward going to school. He attended school regularly for the first two years of high school but started missing and cutting school for the last two years which almost caused him from graduating. His teachers had no complains about his attitude towards school and his performance during his classes. He spends ample amount of time on his home works since he does them on his own and doesnt want any help from anyone else. He is very interested in his studies especially Filipino, Math and Sciences. He manages to pass every year and every semester. His grades were average and sometimes he excels in his favorite subjects such as Filipino. g. Religious and Social Adaptability Bampira has many friends but spends most of his time with 4 of his closest friends James, Paz and the two which he cannot remember or state the name. He also has girl friends that he claims to have spent lots of time with but cannot remember their names. Most of his friends are not of his socioeconomic level or status. However, their characters seem to fit and are like Bampiras. He is somewhat shy, but very friendly; this may be due to his kind and polite personality. He is responsible as his family would say and contrary to his shyness he is selfassertive. He is very interested in religion and enjoys attending church. He became most interested when his neighbors brought and converted him to the Born Again religion. He is proud of his success but doesnt boast about it. He likes it when his parents acknowledge his success. He handles failure easily by accepting it but tends to think deeply as to why he or his plans had failed.

h. Occupational History His current occupation was being a salesperson in their little sari-sari store that he managed. He was a hard worker because he used to work at Yem-Yem Eatery and would sometimes work overtime just to earn extra cash that he can save. He also worked at Villahermosas Pay Toilet as a watcher. He didnt last long with his part time jobs because he worked while he attended high school at San Agustin Institute of Technology. And even afterwards he didnt last long in between jobs due to his different interests that occupied him during his free time. He didnt have much reason as to why he changed jobs. He just took the jobs according to how they suited him at that moment, place, or time. Given the fact that he was a hard worker he cared very little as to what his job may be as long as it pays. He saves a lot which directly related to why he works; to save money for his future plans. However he is not selfish with his money because according to his father there has been countless times where his parents had to ask him if they can use his savings to buy food for the family or he would voluntarily give it freely for whatever reason his money was needed for. There was a time where his younger brother was admitted to the hospital having dengue fever and his savings of six thousand pesos helped pay for their familys medical expenses. He was a good worker according to his father since his employers report to his father about Bampiras work ethics.

B. Family Genogram
Lolo, 85, visual deficit Lola, 70, deceased Jojo, alive and well

Gloria, 50

Adrian, deceased

Lolita, HTN

Edita,
deceased

Roel, alive and well

Linda, 50

Doroy, deceased

Ligoy, HTN

Lotlot

Nestor, alive and well

Marjun, alive and well

Dario, 40+

Edgar, alive and well

Alex, alive and well

Dad, 49, alive and well

Mom, 45, alive

Halfsister, 23, alive and well

Kuya, 23 yo, alive and well

Patient

Bro, 11, alive and well

Bro, 10, alive and well

IV.

Mental Status Examination

Type of Assessment Observations about dress, hygiene, facial expressions, eye contact, pupil dilatation/constrictio n, general state of health, posture, gait and appearance Appearance versus stated age Normal Parameters Clean Nails trimmed Tidy/neatly dressed Hair is combed Dress/clothing intact appropriate for age, weather and situations Teeth/dentures in good repair No unusual odors No obvious marks or scars Appears as stated age Erect/upright Symmetrical extremities Comfortably positioned Alteration Form Normal Obvious marks and scars Flushed or pallid skin color Implications Obvious marks and scars may reflect patients history of violence Flushed or pallid skin color are seen with anxiety

Area of Assessment A. General Appearance

posture

Sits on the edge of the seat Stooped posture

Gait

Eye contact

Steady Movement is smooth and coordinate Maintains eye contact

Rigid movement Unsettled eye contact Dilated pupils

Sitting on the edge of the seat may reflect patients anxiety Stooped posture is often seen in patients with depression Side effects of antipsychotic medications May indicate anxiety Dilated pupils are sometimes

Facial expression

Calm Appropriate to words expressed Happy Observations about patients actions and reactions to health personnel. Cooperative Calm Attentive Alert Awake Relaxed No unusual movements or behaviors Warm Friendly

Irritable

associated with drug intoxication Irritability may suggest an anxiety disorder

B. Behavior

Often distracted Uncooperative Irritable Somnolent

Irritability may suggest an anxiety disorder Somnolent due to medication side effects

C. Motor activity

Observations about patients physical movement

Tremors Restless

D. Speech

Observations of patients speech quantity and quality

Humor Soft Appropriate Modulated voice/tone audible Clear Fluent

Excessively loud Stuttering Muttering Abundant Rapid pressure of speech

Excessive body movement may be associated with anxiety, mania or stimulant abuse Tremors may suggest medication side effects Changes in voice quality may indicate neurological problem Speech disturbances are often caused by

specific brain disturbances Style and vocabulary Formal Humor Appropriate No exaggeration Relevant Appropriate response Speak in Tagalog Claims to know the Latin and Spanish language Irrelevant Loose association: disorganized thinking that jumps from one idea to another with little or no relation between the thoughts Tangentiality: wandering off the topic and does not provide specific information pressured

Organization of talk

May be indicative of psychiatric disorders Disorganized speech are seen with schizophrenia

Stream of talking

Spontaneous Normal pace Pleasant tone Observation and assessment to the clients pervasive and enduring emotional state Happy Normal

E. Mood

Unpredictable Depressed Unpredictable Suicidal Anxious

pressured speech may indicative of psychiatric disorder Mixed: anxious and depressed are seen with depression Suicidal ideation is also common in patients with anxiety disorders and schizophrenia

F. Affect

Assessment of the outward expression of the clients emotional state of feelings

Appropriate to the situation and feelings verbalized

Inappropriate affect: displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances

Anxious is seen with anxiety Inappropriate affect is associated with schizophrenia

G. Perception

Hallucination

Delusions Illusion H. Thought content Suicidal/homicidal I. Orientation

Assesses the way a person experiences reality. Observe the patients statements about his/her environment and the behaviors expressed in association with those statements. Assesses false sensory Auditory perceptions or perceptual Hallucinations (+) experiences that do not vampires, anime really exist. characters, ingkanto, and aswang Fixed false belief not based in reality Misperception of a real external stimulus Assessment of what the patient is thinking Thoughts of harming self Suicidal/homicidal and others precaution Assessment of patients awareness of date, time and place

Auditory hallucinations may suggest schizophrenia

No delusions noted No illusions noted

Associated with depression, anxiety or schizophrenia Well oriented

J. Memory

K. Intellect

L. Insight

Assesses immediate recall of recent and remote memory Assessment of the patients information and intelligence Assessment on patients understanding of the nature or the problem or illness

Memory intact average Poor impaired poor and impaired insight is seen in psychosis

V.

Progress Notes and Other Observations on the Succeeding Interactions During the first day of interaction (February 13, 2014) client is very loud and uncooperative upon receiving him; he doesnt follow instructions of his assigned student nurse. His student nurse had difficulties in interacting with him. Patient has auditory hallucination of vampires; he is hesitant and suspicious upon answering to his student nurse. On the second day of interaction (February 14, 2014) patients starts to interact with his student nurse, he also cooperates in the activities. The patient had a deliberate stream of talk and incoherent with the questions asked by his student nurse. The 3rd day of interaction and observation (February 20, 2014) with the client hes still cooperating and answers when questioned but still very loud. During the fourth day (February 26, 2014) he is still cooperative but loud and joins activities on the fifth day, but during the sixth day our Culmination Program (February 28, 2014) he became moody and does not maintain eye contact.

VI.

Psychodynamics
Biological Factors

Genetics

Prenatal

Mother was bitten by a dog when Bampira was still a month old inside her womb. He was given an herbal medicine by a quack doctor to alleviate the pain. Mother is not sure if she was immunized during her childhood. Attitude of mother towards pregnancy this includes: increased appetite sleeps most of the time and has a good relationship with her husband. Bampira was being breastfed by her mother until the age of 4 months. Incomplete prenatal: failed in complying the last shot

Family members who has a history of having a mental problem: 1. Junior (Deceased) maternal side; episodes of mental disorder lasted for only a month. Believed to be treated by a quack doctor. Death was caused by a stabbed wound on his back during his early 50s. 2. Jack (Alive and well) maternal side; eldest son of Junior; believed to be a marijuana and shabu drug addict after working in Davao(2010) when he was still 21 years of age.

Socio-cultural Factors

External

Internal

Friends -since Bampira was a child, he is not fond of playing with other children his age. Yes, there are times wherein he plays with them but most of the time he preferred to be alone with his toys. When he reached adolescence particularly during his 3rd year where he is acquainted with James more often, he started to change his habits. He comes home late and would say excuses just so he can go out and hang with James. He had a love affair during his 4th year which lasted for not more than a week only.

His teachers were really proud of him. He is an average student who chose to be in school and learn. He likes the subject Filipino among others and is fond of learning Math as well. Teachers said he is a friendly classmate and student. But most of the time he sits and stays silent in a corner during classes.

His mother was with him since birth until she decided to be a kusinera in Manila when Bampira was 4 years old and left him under the care of a nanny, who lasted for a year only. His mother was always away for work. They bond only if she is at home. Even his stay in Happy Home Foundation, Inc., she left him under the care of another patients mother. She admits that she loves her son so much and that she is disappointed for what happened to him.

His father strives hard just to pursue his childs dream but feels that he has failed. He only scolded his children verbally and had not ever touched any of them just to show his authority. He feels he is to blame for Bampiras condition for he hadnt given him the support he needs emotionally and financially. He works as a Utility Man with a very low salary to suffice their needs. There are no complaints against his father from any of the informants.

Bampira has 4 siblings. He is closer to the 2nd eldest sibling, his older brother and his youngest brother. He talks to the second eldest sibling often but is secretive about his love life. He plays basketball with the youngest brother at a nearby plaza. He doesnt talk much to the 2nd to the last sibling for he questions his identity. The eldest, despite the issue of being their halfsister is close to Bampira and is said to be an understanding and supportive.

Psychosocial factors (Erik Eriksons Theory)

Infancy (Trust VS Mistrust)

Toddler (Autonomy VS Shame & Doubt)

Pre-school (Initiative VS Guilt)

School-age
(Inferiority VS Industry)

Adolescence (Identity VS Role Confusion)

Bampira does not cry most of the time and when he does it only means that he is either hungry or wet from peeing. His mom prefers to breastfeed him on the right side for this is the position which can stop Bampira from crying. He learned to stand on his own at 7months old and was able to walk without assistance during 9months of age. His first tooth came out during his first year of extra uterine life.

Mama was the first word which came out of Bampiras mouth and papa was the next during his 2nd year of life. Was able to determine his identity at 3 years of age for he prefers to play with boys toys specifically guns for he insists that he is a soldier. Do not have any serious illnesses. Has episodes of fever and coughs only during his toddler life and was remedied by a gi-laga na bulak sa santan na pula na laya. Bampira would say u-o if he wants to take a bowel and would say wee-wee an indication that he needs to empty his bladder.

Was a follower during times wherein he feels to play with others? Would follow and listens to what his playmates wanted to play for a while (510mns) and would rather play by himself wherein nobody would touch his toys. After playing with his toys, he would hide them within a box to prevent others from getting it. He is being scolded in a low-voiced manner and hasnt been beaten up as a disciplinary measure. He is sometimes caught of touching his reproductive part and is being told not to. He only smiles whenever reprimanded.

At 8 years of age, he had undergone circumcision in a Barangay Health Center. Parents were caught off-guard for he had a savings of P100 when he was still in Grade 1. And had 6,000 pesos hidden under his bed when he was still in Grade 3. They were happy and proud of him.

During his 1st year in Secondary school, he helped her mother in their Sari-sari Store and was able to save money for his nightlife schooling. At the 2nd year of high-school, he was able to suffice his needs. His parents wanted to ask him why he wasnt able to do this during his 3rd year in High School, for they noticed that he doesnt save money anymore and sometimes was caught stealing from his father. During this time also, his attendance in school is at stake and that is the time he met James.

VII.

Diagnosis Statistical Manual

a. Multi System of Diagnosis AXIS I AXIS II AXIS III AXIS IV Cannabis-Induced Bipolar Disorder with Psychotic Features Histrionic Personality None Trust vs. Mistrust Family Problems (Financial) AXIS V 61-70

b. Justification Axis I Bampira was at. Upon admission Bampira was noted to have increased severity of his attitudes. Saba kayo siya sige siya og wali gamit ang bible og hapit niya sumbaga iyang papa, daghan na iyang makit-an nga kapri og bampira according to his mother. He was restless, positive for decreased sleep. Axis II the client has a histrionic personality because he has manifested most of the signs and symptoms of his personality disorder. During childhood he was silent but he plays with other children. As time went by the manifested labile emotions and was reported alcoholism and using of drug (marijuana) during high school days (4th year high school). Axis III - he did not have any medical problem, but he was at risk for developing hypertension. Because of genetic factor (Both side History). Axis IV the family of the client constantly moves from one place to another. Those places were crowded, noisy and high risk for fire injury violence, and prone to communicate diseases. At present their home is made up of plywood and galvanizing iron, which is used to build their current house, their house is not clean and safe for living. Patient was not open about his feelings and problems towards his siblings and parents. During his childhood, he is a follower during playtime according to his brother. Axis V Bampira is scored 61/70 in global assessment functioning during our interview. The client indicates some mild symptoms demonstrating restless, positive for decreased sleep, but overall, he functions pretty well in the facility.

VIII. Drug Study

List of Drugs 1. Biperiden 2. Chlorpromazine 3. Diphenhydramine 4. Haloperidol DRUG #1 BIPERIDEN CLASSIFICATION: Anticholinergic DOSE/FREQUENCY/ROUTE: MECHANISM OF ACTION: Competitively antagonizing acetylcholine receptors in corpus striatum to restore neuromuscular balance.
Figure 1 sample image only

INDICATION: Control of extrapyramidal disorders (serious side effects of antipsychotic drugs) secondary to neuroleptic drug therapy. CONTRAINDICATIONS: ADVERSE EFFECTS: Unusual fever Fast or irregular heartbeat Anxiety Hallucinations Confusion Agitation Hyperactivity or loss of consciousness Seizures Eye pain NURSING PRECAUTION: Nurse Education Assess for Parkinsonism Assess for mental status Assess for tolerance over long term therapy, dosage may have to be increased or changed. Avoid activities that require alertness, may cause dizziness, drowsiness and blurring of vision. Patient and Family Education Explain that doses will be tapered gradually before stopping to avoid withdrawal reaction.

Advise patient that increasing fluid intake will help decrease dry mouth and constipation. Instruct patient to pay particular attention to dental hygiene because of problems associated with decreased salivation (e.g., increased risk of caries). Tell patient that stool softeners may be used if constipation occurs. Small doses of milk of magnesia may be helpful. Warn patient to drink plenty of fluids and take precautions against hyperthermia in hot weather.

DRUG #2 CHLORPROMAZINE CLASSIFICATION: Antipsychotic, Phenothiazine, Antiemetic DOSE/FREQUENCY/ROUTE: MECHANISM OF ACTION: Blocks postsynaptic dopamine receptors of the brain (antipsychotic) and Suppresses chemoreceptor trigger zone (antiemetic). INDICATION: Controls manic phase of manic-depressive illnesses. Management for Schizophrenia and to control excessive anxiety and agitation. CONTRAINDICATIONS: Hypersensitivity Withdrawal state from alcohol

Figure 2 sample image only

ADVERSE EFFECTS: Idiopathic edema Orthostatic hypotension Palpitation Dry mouth Drowsiness Blurred vision NURSING PRECAUTION: Nurse Education Establish baseline BP and pulse rate Monitor I&O ratio and pattern (Urinary retention due to mental depression and compromised renal function may occur. Be alert on complaints of diminished visual acuity

Patient and Family Education Take medications as prescribed May cause pink to red brown discoloration of urine Oral hygiene When drug is discontinued, dosage must be tapered off gradually over a period of several weeks

DRUG #3 DIPHENHYDRAMINE CLASSIFICATION: Centrally acting cholinergic antagonist, antihistamine, H1 receptor antagonist DOSE/FREQUENCY/ROUTE: MECHANISM OF ACTION: Figure 3 sample image only Diphenhydramine competes for H1 receptor cells on effector cells thus blocking histamine release. Suppresses central cholinergic activity and to prolong action of dopamine by inhibiting its reuptake and storage. INDICATION: Temporary symptomatic relief of allergic conditions Sedative-hypnotic Insomia CONTRAINDICATIONS: Hypersensitivity ADVERSE EFFECTS: Drowsiness Tachycardia Dry mouth NURSING PRECAUTION: Nurse Education Monitor cardiovascular Supervise ambulation Patient and Family Education Do not use alcohol Increase fluid intake since drug has drying effect which may cause difficulty in expectoration

DRUG #4 HALOPERIDOL CLASSIFICATION: Antipsychotic, Butyrophenone DOSE/FREQUENCY/ROUTE: MECHANISM OF ACTION: Blocks postsynaptic dopamine receptors in the limbic system of the brain. INDICATION: Management of manifestations of psychotic disorders. CONTRAINDICATIONS: Seizure disorder Severe neutropenia Alcoholism Severe mental depression ADVERSE EFFECTS: Dystonia Insomia Euphoria Agitation Fatigue Headache Hypersalivation NURSING PRECAUTION: Nurse Education Monitor for therapeutic effectiveness. Target symptoms expected to decrease with successful haloperidol treatment include hallucinations, insomnia, hostility, delusions Observe patients for rapid mood shift Patient and Family Education Avoid use of alcohol Discuss oral hygiene. Drink adequate fluids Avoid over exposure to sun since drug can cause photosensitivity
Figure 4 sample image only

IX.

Nursing Care Plan

DATA Cues Subjective: Masakit yung kamay ko maam.

NURSING DIAGNOSIS Acute pain related to physical injury

OBJECTIVES At the end of 2 weeks of nursing intervention, client will be able to cooperate, follow instructions and compliance medication as instructed by the nurse.

NURSING INTERVENTION Encouraged significant other for warm compress Instructed patient to and avoid doing risk for physical injuries Encouraged personal hygiene Give medication as indicated

RATIONALE Helps moving out waste and reducing inflammation To provide relaxation to the patient and prevents possible injuries To boost selfesteem

EVALUATION At the end of 2 weeks of nursing intervention, client shall cooperate; follow instructions and compliance of medication.

Objective: Swelling of one hand Redness pain upon palpation restless

DATA Feb. 14, 2014

NURSING DIAGNOSIS Disturbed sleep pattern related to inadequate sleep hygiene

OBJECTIVES At the end of 2 days of nursing intervention, client will be able to identify individually appropriate interventions to promote sleep and report increase sense of well-being and feeling rested.

NURSING INTERVENTION Encourage client to participate in regular exercise program during the day. Encourage S.O. for quiet environment and comfort measures like having mosquito net at bedtime and encourage client to rest early. Encourage the patient and significant other to limit fluid intake at night Recommend midmorning nap if one is required Advice s.o to arrange care and allowing client for longer periods of sleep at night if possible.

RATIONALE To aid in stress control/release of energy To establish optimal sleep or rest patterns To reduce need for night time elimination Napping especially in the afternoon can disrupt normal sleep patterns To provide uninterrupted periods for rest

EVALUATION At the end of 2 days of nursing intervention client shall identified individually appropriate interventions to promote sleep and report increased sense of well-being and feel rested

Wala kaayo ko katulog gabie maam, daghang lamok oy

Objective: Sleepy Look tired Falling asleep During activities hallucinating

DATA

NURSING DIAGNOSIS Disturbed thought process r/t disruption in cognition operations and activities

OBJECTIVES At the end of 2 weeks of nursing intervention, client will be free of injury And respond to reality

NURSING INTERVENTION Be sincere and honest when communicating the client and avoid vague or evasive remarks Be consistent in setting expectation enforcing rules Dont make promises that cannot keep

RATIONALE Evasive comments or hesitation reinforces mistrust or dilution Clear, consistent limits provide a secure structure of client Broken promises reinforce the clients mistrust others

EVALUATION At the end of 2 weeks of nursing intervention, client shall be free of injury and respond to reality

Objectives Thinking not base on reality Distractivity Restless Inappropriate social behavior

DATA

NURSING DIAGNOSIS Ineffective coping r/t situational crises

OBJECTIVES At the end of 2 weeks of nursing intervention, client will be able to develop adaptive and lasting coping skills

NURSING i

RATIONALE

EVALUATION At the end of 2 weeks of nursing intervention client shall developed adaptive and lasting coping skills.

Objectives Restless Raising thoughts Poor concentratio n Verbal manipulatio n

Establish The client must rapport and built trust the nurse trust with the before talking client about clients situation Using clients Call client by name enhances name ascertain sense of self and how client promotes prefers to be individuality/ addressed self-esteem. Expressing Encouraged feelings towards client to express the strategic feelings event, minimizes regarding the anxiety stressors

X.
Categories 1.Onset of illness

Prognosis and Recommendation

Poor Fair Good Interpretation The condition of the client appeared at the age of 15. Those who develop the illness early shows outcome than those who develop it later. Client was already in the 4th year of his mental illness. There is still possibility that client will have a good prognosis if there is minimized occurrence of positive symptoms beside the negative symptoms. It is seen that there are improvements with regards to the clients condition. The mood of the patient is unpredictable. Sometimes he keeps on mumbling, Taking about vampires and genitals. Sometimes hes easy to be with. He answers all the questions appropriately and cooperative. Prognosis is good. Because the clients parents was traced and were not diagnosed on having mental disorder. The environment is somehow helpful for the recovery of the patient. It is being cleaned daily still it lacks some facilities needed by the client such as bed linens, shampoo, toothbrush and other things in daily living. Health care in the said institution were very kind and showed their therapeutic care to the client in which a helpful way for clients socialization. It is seen that the client does not possess any depressive actions. But sometimes he verbalized that someone is going to get him. He also had religious delusion and auditory

2. Duration of illness

3. Mood and Affect

4. Genetic factor

5.Environmental and Psychosocial Factor

6. Any depressive feature

hallucinations. 7. Attitude and willingness to take medication With the encouragement and support of his family, the client has been able to comply his medications religiously. In Happy home, he is continuously monitored and given due medications as part of his mental problem treatment. The family shows concern towards the condition of the client. His mother was able to visit him as often as possible and provide some of the clients needs.

8. Family Support

COMPUTATION: Number of categories rated as POOR (1) + umber of categories rated as FAIR (2) + number of categories rated as GOOD (3) divided by total number of categories = Score. X = 4 (1) +2(2) +2(3) = 4+4+6 = 14/8 =2 Scoring for the prognosis: 1 1.7 = POOR 1.7 2.3 = FAIR 2.3 3.0 = GOOD PROGNOSIS INTERPRETATION: Based upon the data that have been tabulated, categorized and computed. It was found out that the prognosis of the clients condition was FAIR with the score of 1.875 or 1.9. This means that the client is improving and responsive with regards to the treatments that have been planned by the health care tea. Moreover, the client has a big responsibility to perform his task independently as a member of society. With proper treatment and good coping system the client can recover easily.

XI.

RESEARCH UPDATE

Bipolar disorder evolves differently in patients who also binge eat, a study by Mayo Clinic 0ctober 2, 2013. The Lindner Center of HOPE and the University of Minnesota found. Bipolar patients who binge eats are more likely to have other mental health issues such as suicidal thoughts, psychosis, anxiety disorders and substance abuse, the study found. People with bipolar disorder who are obese but do not binge eat are more likely to have serious physical problems such as arthritis, diabetes, high blood pressure and heart disease. It was more common for women than men with bipolar disorder to binge eat or to be obese, the study showed. "The illness is more complicated, and then by definition how you would conceptualize how best to individualize treatment is more complicated," Dr. Frye says. "It really underscores the importance of trying to stabilize mood, because we know when people are symptomatic of their bipolar illness their binge frequency is likely to increase. We want to work with treatments that can be helpful but not have weight gain as a significant side effect." The researchers used the Mayo Clinic Bipolar Biobank, a collaborative effort by Mayo Clinic, the Lindner Center of HOPE, University of Minnesota and Mayo Clinic Health System. More research is planned to see whether there is a genetic link to binge eating disorder in bipolar disease. "Patients with bipolar disorder and binge eating disorder appear to represent a more severely ill population of bipolar patients. Identification of this subgroup of patients will help determine the underlying causes of bipolar disorder and lead to more effective and personalized treatments," says co-author Susan McElroy, M.D., chief research officer at the Lindner Center of HOPE. Lithium, introduced in the late 1940's, was the first "wonder drug" in psychiatry. It was the first medication treatment for the manic and depressive episodes of bipolar disorder and it remains among one of the most effective treatments for this disorder. The identification of these molecular actions of lithium coincided with the discovery of regional brain volume deficits in imaging studies of people with bipolar disorder. In particular, a generation of research studies identified alterations, predominately reductions, in the size of brain regions involved in mood regulation. These studies also began to provide hints that some of the treatments for bipolar disorder would increase the volumes of these brain regions. In a massive research effort published in Biological Psychiatry, eleven international research groups collaborated to pool brain imaging data from adults with bipolar disorder. This allowed them to perform a mega-analysis to evaluate the differences in brain structure between individuals with bipolar disorder and healthy comparison subjects. They found that individuals with bipolar disorder had increased right lateral ventricular, left temporal lobe, and right putamen volumes. Individuals with bipolar disorder who were not

taking lithium had a reduction in cerebral and hippocampal volumes compared with healthy comparison subjects. Importantly, however, bipolar patients taking lithium displayed significantly increased hippocampal and amygdala volume compared with patients not treated with lithium and healthy comparison subjects. Cerebral volume reduction was also significantly associated with illness duration in bipolar individuals. "This important mega-analysis provides strong support for regional brain structural alterations associated with bipolar disorder, but also sends a signal of hope those treatments for this disorder may reduce some of these deficits," commented Dr. John Krystal, Editor of Biological Psychiatry.

XII.

Bibliography

XIII. Pictures

First Home Visit February 22, 2014 This is the first encounter of the group with our Clinical Instructor to Rodels family at Valencia City, Bukidnon.

All of the members of the group who visited Rodels family had a chance to interview the father, brother and sister in law of Rodel.

Second Home Visit March 1, 2014 The second home visit of the group with our Clinical Instructor to Rodels family at Valencia City, Bukidnon.

The group had a chance to interview Rodels father and neighbors.

XIV. Student Names And Signature

Artana, Dionflor Berena, Rolando Borromeo, Seneca Jill Callao, Luiggi Mikael Casite, Neilmark Gayona, Emily Golda Gomez, Junfelm Hernandez, Aren Mae Jr. Jacutin, Sushmita Ann Lorca, Lyra Palado, Marcher Rellita, Jezza Ronolo, Ma. Vanessa Tortola, Loweelyn Villamor, Rachelle Suzzanne

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