COLLEGE OF THE HOLY SPIRIT MANILA COLLEGE OF NURSING 163 E. Mendiola, St.

Manila

Case Study on

BIPOLAR AFFECTIVE DISORDER MANIC EPISODE WITH PSYCHOTIC SYMPTOMS

Submitted by: BSN 3 Batch 2013

February 2012

Introduction: Bipolar disorder involves extreme mood swings from episodes of mania to episodes of depression. Bipolar disorder was formerly known as manic-depressive illness. During manic phases, clients are euphoric, grandiose, energetic and sleepless. They have poor judgment and rapid thoughts, actions and speech. During depressed phases, mood, behavior and thought are the same as in people diagnosed with major depression. In fact, if a persons first episode of bipolar illness is a depressed phase, he or she might be diagnosed with major depression; a diagnosis of bipolar disorder may not be made until the person experiences a manic episode. To increase awareness about bipolar disorder, health care professionals can use tools such as the Mood Disorder Questionnaire. Bipolar disorder ranks secondly only to major depression as a cause of worldwide disability. The lifetime risk for bipolar disorder is at least 1.2%, with a risk of completed suicide for 15%. Young men early in the course of their illness are at highest risk for suicide, especially those with a history of suicide attempts or alcohol abuse as well as those recently discharged from the hospital (Rihmer & Angst, 2005) Whereas a person with major depression slowly slides into depression that can last for 6 months to 2 years, the person with bipolar disorder cycles between depression and normal behavior (bipolar depressed) or mania and normal behavior (bipolar manic). A person with bipolar mixed episodes alternates between major depressive and manic episodes interspersed with periods of normal behavior. Each mood may last for weeks for or months before the pattern begins to descend or ascend once again. The three categories of bipolar cycles are; Bipolar mixed cycles alternate

between periods of mania, normal mood, depression, normal mood, mania and so forth. Bipolar type I Manic episodes with at least one depressive episode. Bipolar type II recurrent depressive episodes with at least one hypomanic episode.

Bipolar disorder occurs almost equally among men and women. It is more common in highly educated people. Because some people with bipolar illness deny their mania, prevalence rates may actually be higher than reported. Psychiatric -Mental Health Nursing 4th edition, p.317 by Sheila L. Videbeck

A. NURSING HEALTH HISTORY Personal Data NAME: Patient M.A.D. SEX: Female AGE: 34 y/o CIVIL STATUS: Single NATIONALITY: Filipino RELIGION: Catholic ADDRESS: Las Pinas City BIRTHDATE: June 30, 1977 BIRTHPLACE: Las Pinas City EDUCATIONAL BACKGROUND: High School Graduate OCCUPATION: None LANGUAGE SPOKEN: Filipino and English DIALECT SPOKEN: Tagalog Time and Date of Admission: December 30, 2011 at 12:44AM Hospitalization Plan: Admit to ACIS 3 with companion Admitting Diagnosis: F20.3 Undifferentiated Schizophrenia Presenting Complaint Patient M.A.D. verbalizes Inlove ako (Im inlove) and Gusto ko nang mamatay. (I wanna die). Informant: Patient Reliability of Resources: Poor Onset: 2001 History of Present Illness The patient has been mentally ill since 2001 with several prior admissions in National Center for Mental Health (NCMH). In 2001, she was only admitted for 2 weeks and was able to live normally again for about 7 years. She was re-admitted last 2008

and stayed at NCMH for 6 months at Pavilion 6. Her medication was Haloperidol 10mg/tab twice a day. She came in NCMH-Emergency Room last December 30, 2012 by herself and was noted to be restless and slightly irrelevant. She then subsequently admitted to ACIS 3 for observation 5-10 days and was given Risperidone and Biperiden for Extrapyramidal side effects (EPS) induced by neuroleptics such as Haloperidol. During observation period, she was restrained due to assaultive behaviour. After 5 days, she was transferred to Pavilion 3, the pavilion for Acute female and was given Risperidone, Biperiden, Haloperidol and Lithium Bicarbonate. Past Medical History Patient has a hypertension but has no drug maintenance. 1982, she was confined because she was hit by a taxi. In 1994, she delivered her eldest son; then followed by her middle child, a boy, in 1998; and the last one is a girl in 2008 via Normal Spotaneous Delivery (NSD). Family Health History The patient verbalized that her mother has hypertension and diabetis mellitus. Her mother died due to breast cancer. She also claimed that she has an asthma. Patient: Yung mommy ko at ate ko high blood at diabetic. At yung uncle ko naputulan ng paa. Sabi ako daw may hika. Lahi din namin ang breast cancer. Student Nurse: Ano naman kinamatay ng mommy mo? Patient: Breast Cancer Social History She was not able to establish a good relationship with her parents because she is a battered child by her mom and her father left for work abroad when she was 2 years old. She built a good relationship with her siblings (her youngest brother and oldest sister), but when her older sister went to Bahrain, she started to withdraw from school. After a year, she was again motivated and from then on, she built friendships with her classmates and begins to join school activities such as rondalla and dance club (muslim dance). She started to build an intimate relationship with the opposite sex when she was in her second year high school and became pregnant when she was in fourth year. She also claimed that she had a church wedding at the Bamboo Organ Church in Las Pinas when shes 19 years old after giving birth to her eldest son. She stopped her schooling after high school and focuses on parenting. She lived with her partner in his house. In the morning, she stays in her mothers house and went back to her partners house when her partner goes home from school. She again got pregnant when she was 21 years old, she delivered her second son. Her relationship with her partner lasted for 7 years, she was brought back to her mother and her children were left to her partner for some reason. At some point, after the relationship has ended, she felt depressed. She was admitted to NCMH last 2001. After two weeks, she was discharged and was able to live in a normal society. She again had a relationship; they had a daughter but she was

again left by her partner when he knew that she was pregnant. It again triggers her depression and was brought back to NCMH. It was her 5th month of pregnancy when she was re-admitted. It really causes her anxiety because her mother died during her stay at NCMH. She started to think a lot that she even cannot sleep for the rest of the night. She was then discharged after 6 months and was re-admitted last December 30, 2011 by herself. She was admitted to Pavilion 3 due to assaultive behaviour. She doesnt have any communication with her children; her auntie is the only one who used to visit her at NCMH and her sister used to call her from abroad Smoking, Alcohol and Substance History According to the patient, she started smoking when she was 13 years old, half pack (10 sticks) a day and occasionally drinks alcohol. She also stated that she didnt take any substance (drugs).

B. ASSESSMENT (B.1) PHYSICAL ASSESSMENT

Area assessed General assessment: Physical development Actual findings At par with age Evaluation Development is symmetrical to chronological age and gender. Answers question accordingly

Behavior

Cooperative and friendly

Mood and affect

Euthymic mood and appropriate affect Properly dressed

Portrays normal range of emotions Wears appropriate dress while keeping it clean The patient has proper balance.

Dress Gait Coordinated even through walking or running

Body build Psychomotor activity

Average body build Good impulse control, no psychomotor retardation

Body is well built. Patient can freely move or restrain her movements

Spoke spontaneously w/ relevance Speech No flight of ideas, looseness of association or delusions Thought Process Denies any hallucination Oriented to time, place and person. Can perform basic operations Light brown w/ scars but no lesions Lesions are present Skin: Color and pigmentation

Can have conversations with and maintains relevance. Consistently associate with someone. No deviations in perception Has self awareness and recognizes things around her

Perceptual disturbances

Cognition

Skin color is healthy Scars are present due to previous wound/accidents Presence of lesions because of skin disease/scabies

Lesions

Head: Size

Head is round and medium sized without any deviations to its size

It is proportional to her neck and body

Hair: Color Texture

Black Straight if combed put the presentation is messy. . Hair is correlated according to age. Hair is not properly taken care of

Presence of lice

Lice were present

Patient exhibits improper hygeine. Symmetrical to the color of the skin and varies with every person.

Face: Skin Color

Light brown w/ no flushing present.

Upper and Lower Extremities: Light brown wherein its the Size, symmetry ,skin color and same as head and skin, hair distribution symmetric in terms of size and shape. Lesions Lesions are present

Body development is adequate and normal.

Poor hygiene and due to scabies

(B.2) MENTAL STATUS EXAM (MSE): First MSE ( December 30, 2011 @ ER) Appearance : The clients hair was tied in ponytail, dark complexion, average built and height, clad in stripe blouse and mos green shorts, fairly groomed and kept. Behavior: 1.Manner of Relating - The patient was cooperative with poor eye contact and most of the time dysphoric. Latest MSE (Chart) Appearance : The client was fairly kempt and groomed in hospital uniform, tall stature and medium built Behavior: 1.Manner of Relating The patient was cooperative and friendly with fair eye contact. Observations during N.P.I (Nurse-Patient Interaction) Appearance : The patient is dressed with the hospitals uniform, hair is well combed and nails were trimmed. She has an eye bags and a little pale. Behavior: 1.Manner of Relating- The patient was nice, friendly and cooperative and with eye contact. She is active in all the activities given to them.She also has a smiling face especially when she is about to answer our questions. She

loves getting attention. 2. Psychomotor Activities The patient lied as if she was restrained. She slouches on the chair but when she was asked to stand and walk, she has a good posture and gait. 2. Psychomotor Activities- The patient has no psychomotor retardation and muscle rigidity. 2. Psychomotor Activities Patient has good posture and gait. However, she sometimes slouches during conversation with her legs and arms crossed and sometimes her hands on her lap. 3. Speech/ Language The patient is talkative. She speaks spontaneously. She has lot of stories to tell. She has a clear voice and has normoproductive speech. She uses Tagalaog in communicating with us. 4. Relevance/Coherence Patient can answer our questions about her life. She answered the questions confidently and without reluctance. 5. Thought Processes The patient never verbalized to us during NPI things like suicidal, homicidal, delusions and hallucinations. 6 . Thought Content- During NPI, patient M.A.D just shared her life stories, how the people around her contributed to her condition. She has good ideas and insights in some matters about life.(Patient: Ayoko Makita ako ng mga anak ko na nandito ako sa loob, dahil ayoko masakatan sila. Pero alam nila ang kondisyon ko ngayon at hinihiling ko n asana

3. Speech/ Language- Speech of the client was normo-productive speech , spontaneous in a clear but childish voice.

3. Speech/ Language The patient spoke spontaneously, relevantly and normoproductively with a clear voice.

4. Relevance/Coherence The client answered queries somewhat irrelevantly and incoherently. She just voiced out that she wanted to die 5. Thought Processes- N/A

4. Relevance/Coherence - The patient answered all the questions asked from her. 5. Thought Processes - The patient has no flight of ideas, looseness of association and has no delusions 6. Thought Content The patient denied suicidal, homicidal thoughts.

6 Thought Content N/A

wag nila ako ikahiya). She didnt mention any signs of hopelessness, delusions and hallucinations. Also, the patient denied committing homicide and suicide. 7. Mood/Affect The patient has appropriate affect and mood. 7. Mood/Affect - Mood was erythymic with appropriate affect / 7. Mood/Affect All most all of the observations to Patient M.A.D during NPI was appropriate. Whenever she was given a task to do and questions being asked, she participated well. She was euthymic sometimes and get easily distracted especially with the people around her but she can regain her full attention to us right away. 8. Abstraction One of the activities done to our patient was the music and art therapy. While she listened to the music, she was able to come up with a drawing and the drawing has a meaning. She can also do simple operations and can understand simple instructions. During the occupational therapy, she came up with a nice picture frame. The designs were placed in the proper place (lace/strings. Flower designs) 9. Super ego functioning/ Impulse control The client has good impulse control since whenever she is questioned about her life stories, she can answer it without too much effect in her mental health. 10. Perceptual Disturbances There was no incidence in our NPI wherein the patient verbalized that she has

8. Abstraction- N/A

8. Abstraction- N/A

9. Super ego functioning/ Impulse control The patient has poor impulse control

9. Super ego functioning Impulse control - The patient has good impulse control

10. Perceptual DisturbancesN/A

10. Perceptual Disturbances- The patient denied any hallucinations and

delusions. 11. Sensorium Disturbances N/A 11. Sensorium Disturbances- Patient is awake, excited to time,place and person. She can perform single addition and subtraction. She can read the word mundo. Recent memory was intact.

delusions or hallucinations. 11.Sensorium Disturbances Patient knew whats going around her. She was oriented with time, place and person.

C. THEORIES (C.1) SULLIVAN'S INTERPERSONAL THEORY Stage 1. Infancy (birth to 1 year) Theory based From birth to about age one, the child begins the process of developing, but Sullivan did not emphasize the younger years to near the importance as Freud. Primary need for bodily contact and tenderness. Prototaxic mode dominates (no relation between experiences). Primary zones are oral and anal. If needs are met infant has sense of well-being. Unmet needs lead to dread and anxiety. The development of speech and improved communication is key in this stage of development. Parents viewed as source of praise and acceptance. Shift to parataxic mode (experiences are connected in sequence to each other). Primary zone is anal. Gratification leads to positive self-esteem. Moderately anxiety leads to uncertainity and insecurity; severe anxiety results in self-defeating Patient based Interpretation

The patient cant No recall what interpretation happened during her infancy stage.

2. Childhood (Ages 1 to 5)

The patient cant recall what happened during her childhood stage.

No interpretation

patterns of behavior. 3. Juvenile (Ages 6 to 8) The main focus as a juvenile is the need for playmates and the beginning of healthy socialization. There is a shifting from parataxic mode to synaxic mode begins (thinking about self and others and based on analysis of experiences in a variety of situations) opportunities for approval and acceptance of others. The child learns to negotiate for his/her own needs. Severe anxiety may result in a need to control or an restrictive, prejudicial attitude The patient verbalized that her relationship with her classmates was good and she was even a top student. She is friendly and nice. Since elementary, she was already an active student. She is naughty sometimes, reason why her mother always scolded her and was physically abused. (Patient: Okay lang pero hindi masyadong okay. Grabe siya mambugbog.) The patient verbalized that she was an active student in a way that she joined rondalla club and muslim dance. She also said that she was friendly back then and had many friends. During this stage, the patient During this stage, it shows that the patient met this stages needs which lead her to feel accepted and approved. She also learned to negotiate for her needs but at this point of her life, she already experienced being a battered child by her mother.

4. Preadolescenc e (Ages 9 to 12)

During this stage, the child's ability to form a close relationship with a peer is the major focus. This relationship will later assist the child in feeling worthy and likable. Without this ability, forming the intimate relationships in late adolescence and adulthood will be difficult.

It shows that the patient was able to meet the needs of this stage. She became close to her schoolmates and band mates through extra curricular activities. It was also the

experiences sexual abused by her stepfather. (Patient: Hindi maganda kasi child abuse ako. Tinuruan niya ako kung paano magblow job.) 5. Early Adolescence (Ages 13 to 17) The onset of puberty changes this need for friendship to a need for sexual expression. Self worth will often become synonymous with sexual attractiveness and acceptance by opposite sex peers. The patient verbalized that she got pregnant at the age of 17. she also said that her relationship with her partner was not that good because her husband and her has a misunderstanding in a way that the guy lives his life as if hes not taken/married .

stage of her life where a traumatic experienced happened, sexual abuse by her step father. The patient met the needs of this stage and she even got involved in a relationship. She became attracted to opposite sex but she had a hard time trusting guys probably because of the incident in which her step father harasses her which gave her anxiety. It shows that in this stage the patient met the need for friendship and need for sexual expression. She also had a long term

6. Late Adolescence (Ages 18 to 22 or 23)

The need for friendship and need for sexual expression get combined during late adolescence. In this stage a long term relationship becomes the primary focus. Conflicts between parental control and self-expression are commonplace and the

The patient verbalized that she got married at the age of 17/18 with her band mate at Bamboo Organ Church. Her relationship with her husband/

overuse of selective inattention in previous stages can result in a skewed perception of the self and the world.

partner lasted for 7 years. But before getting married, she had conflicts with her mom because at an early age she got pregnant. The patient was left by her partner who causes her a lot of stress. She again brought up another relationship and had a daughter. She was again left by her live-in partner after he knew that she was pregnant. Her mother also died when she was 30 years old. It again increases her anxiety.

relationship which further proves she met the needs of this stage.

7. Adolescence The struggles of adulthood include (puberty to financial security, career, adulthod) and family. With success during previous stages, especially those in the adolescent years, adult relationships and much needed socialization become easier to attain. Without a solid background, interpersonal conflicts that result in anxiety become more common place. Lust is added to intrapersonal equation. There is a need for special sharing relationship shifts to the opposite sex. There are new opportunities for social experimentation lead to the consolidation of self-esteem or selfridicule. If the self-system is intact, areas of concern expand to include values, ideas, decisions and social concerns.

It shows that the patient had many experiences in this stage which made her stressed and triggered her illness.

(C.2) FREUD PSYCHOSEXUAL THEORY Stages Theory Patient Interpretation

Oral Stage (birth to 1 years) Early Infancy

It focused on oral pleasures (biting and sucking) activities. Personality which is evidenced by a preoccupation with oral activities. This type of personality may have a stronger tendency to smoke, drink alcohol, over eat, or bite his or her nails. On the other hand, they may also fight these urges and develop pessimism and aggression toward others.

The patient verbalized that when she was in high school her peers influenced her to drink alcohol and to smoke cigarettes.

According to this stage if an individual wasnt able to satisfied this stage the outcome will be the following: smoking drinking of alcohol According to Freud that if a baby gets too much or too little oral stimulation, the baby might be permanently affected. As an adult, the individual may act like a baby: dependent, pleasure-oriented, gullible, child-like, easily led astray. The person may become obese, or smoke, or chew gum a lot. This person is trying to recapture a lost paradise or perhaps making up for deficiencies -

in gratification during this stage.

Anal Stage (1 - 3 years) Late Infancy

The childs focus of pleasure in this stage is on eliminating and retaining feces. Through societys pressure, mainly via parents, the child has to learn to control anal stimulation. In terms of personality, after effects of an anal fixation during this stage can result in an obsession with cleanliness, perfection, and control (anal retentive). On the opposite end of the spectrum, they may become messy and disorganized (anal expulsive).

The patient has proper hygiene before; when she enters to the mental hospital she already had scabies in her both legs and had a lice and cooties in the hair.

Freud believed some children used their newfound bowel control against parents in a struggle of wills. If a parent tried to force toilet training, the child might deliberately hold back in rebellion, or else go at an inappropriate time. If fixated at the anal stage, Freud believed, the child who "holds back" might become an anal-retentive personality as an adult, fastidious and neat, while the child who goes at an inappropriate time may become an anal-expulsive personality, chronically messy.

Phallic Stage

The pleasure zone Patient verbalized switches to the that her step

At a young age the patient was

(3 to 6 years) Early Childhood

genitals. Genital focus of interest, stimulation and excitement. Penis is organ interest for both sexes. Masturbation is common. Penis envy (wish to possess penis) seen in girls; oedipal complex (wish to marry opposite sex parent and be rid of the sex parent) seen in boys and girls.

father taught her how to blow job and whenever she hesitate, her father will put ice pick in her neck.

exposed to sexual abuse of her step father. The patient became exposed to the opposite sex and became conscious about the sex.

Latency Stage (6 - 18 years) Middle and Late Childhood

Its during this stage that sexual urges remain repressed and children interact and play mostly with same sex peers. Sexual drive channeled into socially appropriate activities such as school work and sports.

During her middle childhood the patient verbalized that her relationship with her peers was great she was friendly. She joined playing rondalla and she was a member of the band before.

According to this stage the patient was active in extra curricular activity. According to Freud the child learns from its social environment, from family and friends, and school how to channel its sexual feelings into socially acceptable forms of

behavior.

Genital Stage (above 18 years) Puberty to Adulthood

It begins at the start of puberty when sexual urges are once again awakened. Through the lessons learned during the previous stages, adolescents direct their sexual urge onto opposite sex peers with the primary focus of pleasure is the genitals.

The patient verbalized that when she was 17 years old she became pregnant with her boyfriend. She got married when she was 19.

When she was young she was a buttered child and child abuse. According to Freud those feelings for the opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all her past.

Life (C.3) ERIKSONS PSYCHOSOCIAL THEORY psychosocial stage / relationships / issues crisis stages (syntonic v dystonic) 1. Trust v infant / mother / feeding and Mistrust being comforted, teething, 0-18 months sleeping old 2. Autonomy v toddler / parents / bodily Shame & functions, toilet training, Doubt muscular control, walking (18months-3 y/o) 3. Initiative v preschool / family / exploration Guilt and discovery, adventure and (3-5 y/o) play

Patient M.A.D.

Not recalled

Basic virtue and second named strength (potential positive outcomes from each crisis) Hope and Drive

Maladaptation / malignancy( potential negative outcome one or the other - from unhelpful experience during each crisis) Sensory Distortion / Withdrawal Impulsivity / Compulsion

Not Recalled

Willpower and SelfControl

4. Industry v Inferiority (5-13 y/o)

schoolchild / school, teachers, friends, neighbourhood / achievement and accomplishment

5. Identity v Role Confusion (13-21 y/o)

adolescent / peers, groups, influences / resolving identity and direction, becoming a grown-up

She entered school as a kinder student. As far as she can remember, she was a nice and friendly pupil. She was an honor student and active in participating school activities. The patient also stated that when she was in Gr.1 she already experienced being a battered child by her mother. The reason for this is her naughtiness. She was hit by a jeepney then because her mother didnt fetch her. Shes very active in school, joined some activities like rondalla and dance club. She excels in the class but in some time, when she was in grade 2, she withdrew schooling when her sister left for work in abroad. After a year, she was motivated and made it to the top again. She graduated elementary. She started smoking when she was 13 y/o and occasionally drinks alcohol. She had her first relationship

Purpose and Direction

Ruthlessness / Inhibition

Competence and Method

Narrow Virtuosity / Inertia

Fidelity and Devotion

Fanaticism / Repudiation

I. DRUG STUDY Generic Brand Name Name Haloperidol Haldol Classification Antipsychotics Dosage 5 mg 1 tab/BID Mechanism of action Alters the effects of dopamine in the CNS Also has anticholinergic and alphaadrenergic blocking activity. Diminished signs and symptoms of psychoses Indication Contraindication Organic Psychose s acute psychotic symptoms Relieve hallucinati ons, delusions, disorganiz ed thinking severe anxiety seizures seizure disorder glaucoma elderly clients Adverse Nursing Reaction Responsibilities CNS: 1.) Assess extrapyramidal mental status symptom such prior to and as muscle periodically rigidity or during therapy. spasm, shuffling gait, 2.) Monitor BP posture leaning and pulse prior forward, to and drooling, frequently masklike facial during the appearance, period of dysphagia, dosage akathisia, adjustment. May tardive cause QT dyskinesia, interval changes headache, on ECG. seizures. CV: 3.) Observe tachycardia, patient carefully arrhythmias, when hypertension, administering orthostatic medication, to hypertension. ensure that EENT: blurred medication is vision, actually taken glaucoma and not

 GI: dry mouth, anorexia, nausea, vomiting, constipation, diarrhea, weight gain. GU: urinary frequency, urine retention, impotence, enuresis, amenorrhea, gynecomastia Hematologic: anemia, leucopenia, agranulocytosis Skin: rash, dermatitis, phtosensitivity

hoarded. 4.) Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration. 5.) Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. 1.) Observe client for signs and symptoms of depression: mood changes, insomnia, apathy, or lack of interest in activities. 2.) Record

Lithium Carbonate

Eskalith

Antimanic

450 mg 1 tab/BID

Alteration of ion transport in muscle and nerve cells; increased receptor sensitivity to serotonin.

To treat Bipolar manicdepressiv e psychosis, manic episodes.

Liver and renal disease Pregnancy Lactation Severe cardiovascular disease Severe dehydration Brain tumor damage

Headache Lethargy Drowsiness Dizziness Tremors Slurred speech Dry mouth Anorexia Vomiting Diarrhea

 Sodium depletion

Polyuria Hypotension

clients vital signs. 3.) Monitor client for suicidal tendencies when marked depression is present. 4.) Evaluate clients urine output and body weight. Fluid volume deficit may occur as a result of polyuria. 5.) Observe client for fine and gross motor tremors and presence of slurred speech, which are signs of adverse reaction.

Beperiden

Akineton Anticholinergic

2 mg/PRN

Reduction of rigidity and tremors.

Adjunctive treatment of all forms of Parkinson s Disease, including

Hypersensitivity Narrow angle glaucoma Bowel obstruction

Dry eyes Blurred vision Constipation Dry mouth Urinary retention

1.) Assess bowel function daily. Monitor for constipation, abdominal pain, distention, or the absence of

drug induced extrapyra midal effect and acute dystonic reactions.

bowel sounds. 2.) Monitor intake and output ratios and assess patient for urinary retention. 3.) Withhold drug and notify physician or other health care provider if significant behavioral changes occur. 4.) Administer with food or immediately after meals to minimize gastric irritation. 5.) Advise patient to make position changes slowly to minimize orthostatic hypotension.

H. NURSING CARE PLANS Assessment Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation

Subjective Data: Hindi ako gaanong makapagisip at makatapos ng mga gawain ng mabuti as verbalized by the patient. Objective Data: - Disorientation to persons, place, time. -Impaired ability to make decisions, solve problems - Changes in behaviour, irritability -Memory deficit, altered attention span, dec. ability to grasp ideas.

Disturbed thought processes in relation to psychological conflicts, emotional changes and mental disorders as evidenced by memory deficit, altered attention span.

Disruption in cognitive operations and activities

Short term: In 7-8 hours, the patient will be able to demonstrate behaviour changes to prevent/minimize changes in mentation. Long term: In 3-4 days, the patient will maintain usual orientation in reality.

Independent: Determine if there are other contributing factors such as alcohol/drug use. Assess attention span and ability to make decisions Reorient to time/place/person As needed Schedule structured activities and rest periods. Maintain a pleasant, quiet environment and approach client in a slow, calm manner.

Drugs can have different side effects on the brain that may impair sensory/ health perception Determines the ability to participate and plan care. To prevent deterioration

Short term: Goal met, the patient has demonstrated behavioral changes that minimized mentation. Long term: Goal met, the patient has maintained his orientation with reality.

Provides stimulation

To prevent overstimulation.

Assessment Subjective:

Nursing Diagnosis Anxiety

Scientific Explanation Bipolar disorder is

Planning After 8 hours

Intervention Independent:

Rationale

Evaluation After 8 hours

Minsan gulonggulo ang isisp ko, Isip ako ng isip ng mga bagay bagay na nakakapagpabag abag sakin lalo na sa gabi.

related to situational crisis

Cognitive/Objectiv e: Inability to concentrate, Lack of awareness of surroundings, forgetfulness, blocking of thoughts, hyper attentiveness,

characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated or irritable mood known as mania. The symptoms of mania include a decreased need for sleep, pressured speech, increased libido, reckless behavior without regard for consequences, grandiosity, and severe thought disturbances, which may or may not include psychosis. Between these highs and lows, patients usually experience periods of higher functionality and can lead a productive life.

of nursing intervention the patient will br able to recognize signs of anxiety, and demonstrates positive coping mechanisms, and reduction in the level of anxiety experienced.

Assess patients level of anxiety Determine how the patient copes with anxiety Acknowledge awareness of the patients anxiety Reassure the patient that she is safe. Establish a working relationship with the patient through continuity of care. Encourage the patient to seek assistance from health care provider when anxious feelings become difficulty

To enhance the patient awareness and ability to identify and solve problems. To help determine the effectiveness of coping strategies currently used by the patient To acknowledge the patients feelings validates the feelings and communicates acceptance of those feelings The presence of a trusted person may be helpful during an anxiety attack To establish a basis for comfort in communicating anxious feelings

of nursing intervention the patient is able to recognize signs of anxiety, and demonstrates positive coping mechanisms, and reduction in the level of anxiety experienced.

Encourage the patient to talk about anxious feelings and examine anxietyprovoking situations To help the patient if they are perceive the situation in identifiable. Assist a less threatening

To be able to reinforce the feelings of security of the patient

patient in assessing the situation. Assist the patient in developing anxietyreducing skills.

manner.

To enhance the patients sense of personal mastery and confidence.

Assist the patient in developing problemsolving abilities To resolve that problem helps the patient cope Collaborative: Refer the patient for psychiatric management of anxiety that becomes disabling for an extended period. Additional, long term professional care may be needed when anxiety becomes severe and interferes with daily functioning

Assessment Subjective:

Diagnosis

Disturbed sleep Ilang araw na pattern r/t akong walang excessive tulog. Yung stimuli, mommy ko lagi noise, ko naiisip as ambient, verbalized by the temperature patient. , humility and noxious odor Objective: -restlessness noted -dark circles under eyes -irritability noted -frequent changes mood noted .

Scientific Explanation Bipolar disorder Involves periods of excitability (mania) Alternating with periods of depression. The mood swings between mania and depression can be very abrupt. Mania is the signature characteristics of bipolar disorder and, depending on its severity is how the disorder is classified. People commonly experience an increase in energy and a decreased need for sleep.

Planning Short term: After 8 hours of nursing intervention the client will verbalize of feeling rested. Long Term: After 1 week of nursing intervention, patient achieves optimal amounts of sleep as evidenced by rested appearance, verbalization of feeling rested and improvement in sleep pattern.

Interventions Independent -Assess past patterns of sleep in normal environment amount, bedtime, rituals, depth, length, positions, aids, and interesting agents. -Documents of nursing caregiver observations of sleeping and wakeful behaviors. Record number of sleep hours. Note physical (e.g. noise, pain, discomfort urinary frequency,) and or psychological (e.g. fear anxiety) circumstances that interrupt sleep. -instruct patient to follow consistent a daily schedule for retiring and arising as possible.

Rationale

Evaluation Short Term: PARTIALLY MET Long term: PARTIALLY MET

-sleep patterns are unique to each individual.

-often the patients perception the problem may differ from objective evaluation.

-this promotes regulations of the circadian rhythm, and reduces the energy required for adaption to changes. -Gastric digestion and stimulation from caffeine and nicotine can disturb sleep. Promotes sleep.

-Avoid including in the meal alcohol or caffeine as well as heavy meal Physical activities

-To promote sleep

G. PRIORITIZATION OF PROBLEMS

RANK 1

NURSING DIAGNOSIS Anxiety r/t situational crisis

JUSTIFICATION Anxiety is a vague feeling of apprehension and uneasiness from a stressful event. If not treated it can cause severe physiologic and psychological problems. We ranked this as our third priority because sleep helps the brain commit new information to memory through a process called memory consolidation and it may also alters immune function, including the activity of the bodys killer cells. Keeping up with sleep may also help fight diseases When going through a recovery process in mental health, his/her thought process must also be considered as a priority. Possible cognitive disruptions such as inability to concentrate may hamper his/her recovery towards reality. One must set ones mind to focus and it is usually remedied by solving the psychological conflicts that a patient has. We ranked this as our last priority because it doesnt bring the patient back to reality. A

Disturbed sleep pattern related to excessive stimuli, noise, ambient , temperature, humidity and noxious odor

Disturbed thought processes in relation to psychological conflicts, emotional changes and mental disorders

Ineffective role performance related to mental health

disruption in the way the patient perceives her role performance may change her physical capacity to resume role and may decrease sense of responsibility. It may also cause the delay of her recovery. 5 Interrupted family process r/t transition and crisis (role as a mother) Evidenced by Difficulty adapting to change or dealing with traumatic experience constructively Patient not meeting needs of its members Difficulty accepting or receiving help appropriately Inability to express or to accept feelings of hurt and love

J. INTERVIEW WITH PATIENT M.A.D

QUESTIONS 1. Kamusta tulog mo? 2. 3. 4. 5. Ilang taon ka na? Kailan birthday mo? Ilan kayong magkakapatid? Kamusta relasyon nyong magkakapatid? 6. Ano ibig sabihin ng spoiled? 7. May asawa na ba ate mo? 8. Kamusta relasyon niyo ng nanay mo? 9. Ano ang dahilan ng pambubugbog niyga sayo? 10. Maaari ba naming malaman ibig sabihin mo ng matigas ang ulo? 11. Kamusta naman relasyon mo sa tatay mo? 12. Ilan naging stepfather mo? 13. Ilang taon ka nung simula mong makasama stepdad mo? 14. Kamusta relasyon mo sa kanya? 15. Ilang taon ka nung tinuruan ka ng stepdad mo na magblow job? 16. Sino lang ang nakakaalam ng pangyayaring yan o pinagsasabihan mo? 17. Ano reaksyon o sinasabi nila? 18. Ano ang nararamdaman mo sa mga oras na yun? 19. Kailan mo siya huling nakita?

PATIENTS ANSWER okay lang dinalaw ako ng tita ko kaya okay lang. 34 June 13, 1977 Tatlo kaming magkakapatid. Si ate mabait sa akin, spoiled ako kay ate. Sunod lahat ng gusto ko. Oo. Meron siyang british na asawa. Dalawa anak ng ate ko. Nakilala ko kaya lang di kami close. Okay lang pero hindi masyadong okay. Grabe siya mambugbog. Matigas kasi ulo ko nung nag-aaral ako. Nung Grade I. Yung kapatid kong bunso, binubugbog din. Okay lang kasi matigas din ang ulo ko. Yung pinagsasabihan kami, hindi kami nakikinig. Dalawang taon pa lang ako, hindi ko na nakita papa ko. Bago ako pumasok dito pinapadalhan niya ako pero hindi monthly. Isa lang ang stepfather ko. 8-9 years old po. Hindi maganda kasi child abuse ako. Tinuruan niya ako kung paano magblow job. Mga 11y/o po ako nun. Yung mga kapitbahay naming. Nagulat sila. Natatakot po ako. Matagal na po. Siguro nung may anak na po ako. Namatay na po yun. Grade 2 pa lang ako nung nakasama ko na siya.Siguro po mg 9y/o. Parang siya po yung dahlian.

20. Sa tingin mo ba isa ito sa dahilan kung bakit nagkasakit ka? 21. Nasabi mo ba sa mommy mo yung ginagawa sayo ng stepdad mo?

Nag-away nga po kami dati kasi parang ang sama sama niya. Nasa harap ko kasi siya parang ang sama sama niya. Nasa harap kasi siya nung ginagawa sa akin yun. Siya dapat magpapasok nun sa akin. 22. Ilang taon ka nung naghiwalay yung Nung hiniwalayan niya stepdad ko, mga mommy mo at stepfather mo? 12y/o ako. 23. Sa pamilya mo, sino ang mayroong Yung mommy ko at ate ko high blood at history ng sakit? diabetic. At yung uncle ko naputulan ng paa. Sabi ako da w may hika. Lahi din naming ang breast cancer.

D.

ANATOMY & PHYSIOLOGY

4 PARTS OF THE BRAIN 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 brains weight

CEREBELLUM little brain Located at lower back of brain beneath the occipital lobe Center for coordination of movement and postural adjustment 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: o MEDULLA- located at top of spinal cord, contains vital centers for respirations & cardiovascular function. o PONS- bridges the gap both structurally & functionally serving as primary motor pathway. o MIDBRAIN- connects pons & cerebellum with the cerebrum. o 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: o THALAMUS- regulates activity, sensation & emotion. o HYPOTHALAMUS- involved in temperature regulation, appetite control, endocrine function, sexual drive & impulsiveness behavior associated with feelings of anger, rage & excitement. o 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

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.

E. PYSCHOPATHOPHSIOLOGY

TEST Hemoglobin Hematocrit RBC count

RESULT 138 0.40 4.40

NORMAL VALUE 120.00-160.00 g/L 0.36-0.48 L 4.00-6.00 x 10^12/L

WBC count

10.2

5.00-10.00 x 10^9g/L

Differential -Neutrophil - Lymphocytes -Monocyte 0.70 0.45-0.65 0.30-0.35 0.2-0. 06

G. LABORATORY AND DIAGNOSTIC FINDINGS: Hematology: Result 01/14/12

Hematology: Result 01/02/12

TEST Hemoglobin Hematocrit RBC count

RESULT 134 0.39 4.27

NORMAL VALUE 120.00-160.00 g/L 0.36-0.48 L 4.00-6.00 x 10^12/L

WBC count

9.1

5.00-10.00 x 10^9g/L

Differential -Neutrophil - Lymphocytes -Monocyte 0.54 0.44 0.02 0.45-0.65 0.30-0.35 0.2-0. 06

DANILO M. ANAHAW/ DR.GO JAN 19 DR.ROMANO STOOL EXAM 01-14 DR.PASCUAL Gross Examination Color: Brownish Consistency: Watery Microscopic Findings BLOOD CHEMISTRY BUN Creatinine RESULT 2.45 78.90 NORMAL VALUE 2.10-7.10 umo 53.00-97.00 umo

Positive for Entamoeba hystolytica cyst WBC: Moderate RBC: Moderate

BLOOD CHEMISTRY BUN Creatinine

RESULT 2.45 78.90

NORMAL VALUE 2.10-7.10 umo 53.00-97.00 umo

BLOOD CHEMISTRY BUN Creatinine

RESULT 2.45 78.90

NORMAL VALUE 2.10-7.10 umo 53.00-97.00 umo

F. PSYCHOPATHOLOGY: Bipolar Affective Disorder, Manic Episode with Psychotic Symptoms