Eyalbert ACKNOWLEDGEMENT The group wishes to express their deepest gratitude and warmest appreciation to the following people,

who, in any way gave us the possibility making this case study a success: First of all, to the Almighty God, who never ceases in loving us unconditionally and for the continued guidance, protection, and blessings. To the groups clinical instructors for their guidance and support in the duration of the study and during the psychiatric nursing exposure, whose help, stimulating suggestions and encouragement helped us in all the time of making this case study. For their unlimited patience, guidance and being with us during our psychiatric nursing exposure, we sincerely thank them. Without their encouragement and constant guidance, our Psychiatric Nursing exposure would not have been a very meaningful learning experience. With special mention, we acknowledge Mr. Richard Cheng for the unending support and encouragement that he never-endingly gives us all throughout the Psychiatric exposure and throughout the making of this case study. The group also wishes to acknowledge the invaluable assistance and cooperation of the staff nurses of the Southern Philippines Medical Center Psychiatric Department, for allowing us to conduct this study, for essential assistance in reviewing the patient files and giving us the opportunity to care for the mentally-ill patients. Special appreciation is extended to the client subjected for this study and other informants for their selfless cooperation, time and entrusting personal information needed for this study. To the group, we would like to show our endless gratitude to each other; for the understanding, believing in each other, and for the teamwork. May we continue working hard for future studies. And lastly but not the least, we acknowledge our parents who have always been very understanding and supportive both financially and emotionally.

INTRODUCTION Bipolar disorder is a psychiatric disorder characterized by severe mood swings, from the highest of highs (manias) to the lowest of lows (depression). In its various forms, it affects about 4.5% of the population, or about 1 in every 22 persons. This rate breaks down into 1% for bipolar I disorder (at least one fully syndromal manic or mixed episode as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition [DSM-IV]), and 1.1% for bipolar II disorder (at least one major depressive episode and one hypomanic episode). The average age at onset for bipolar I disorder is 18.2 years, and for bipolar II disorder, 20.3 years. Between 50 and 67% of these patients develop bipolar disorder by age 18, and between 15 and 28% before age 13. Bipolar disorder is often quite debilitating, because patients usually have highly recurrent courses of illness. More than 90% of patients have recurrences of mania or depression over their lifetimes, with one study estimating that patients average three episodes and five hospitalizations over 10 years. Bipolar I patients (those with full manic or mixed episodes) change symptom status an average of six times per year, and switch from depression to mania (or mania to depression) an average of three or more times per year. (Miklowitz, David J., PhD, 2008. Bipolar Disorder. USA: The Guilford Press.) There are several notable differences between bipolar I and bipolar II disorders.A primary distinction is the absence of manic episodes with bipolar II. Only a lesser form of mania, known as hypomania, is present in bipolar II.While psychotic symptoms are sometimes noted with bipolar I disorder, their presence rules out bipolar II disorder. (http://organizedwisdom.com/Bipolar_I_vs._Bipolar_II. Retrieved on January 16, 2011.) In the Philippines (2008), Department of Health Secretary Francsico Duque III identified bipolar disorder as one of the ten leading causes of disability in the Philippines. There is a prevalence of approximately 1,034,900 people with bipolar disorder. Nowadays, causes of bipolar disorder are not yet clearly identified, but it often runs in families. 90 percent of people diagnosed with bipolar disorder have a relative who also suffer from either depression or bipolar disorder. Public awareness is low regarding the condition and stigma is high. (http://upiu.com/articles/conquering-a-lifetime-disorder. retrieved on January 16, 2011.)

Last January 3 15, 2011, the group 4 of BSN-3A was given an opportunity to have a psychiatric nursing exposure in Davao Mental Hospital. During the abovementioned dates, the group found a commendable case sensible to be presented as case presentation. Such case was, first of all, suggested by their clinical instructor, Mr. Richard A. Cheng, R.N. and was then agreed on by whole group. The patient, Max, not his real name, was one of the patients admitted to the Crisis Intervention Unit of Davao Mental Hospital due to Bipolar disorder I, Manic Phase with Psychotic Features. Maxs case has been chosen mainly because his case posed as a complex case requiring due understanding and knowledge. Making this case is a good avenue to broaden the proponents knowledge about the mental illness involved. In addition, ability to study such case will allow us, not only to understand its course, but also to identify ways on how to help those diagnosed with the same illness. The exposure in Davao Mental Hospital, the experience, and this study give us a logical insight and clear appreciation as to the nature and characteristics of the mental illnesses. Furthermore, these will help us student nurses to value the use of therapeutic communication and holistic approach and relate them in the health promotion towards the recipients of our care. By this, we widen our horizon by keeping abreast with the recent breakthroughs and innovations occurring through time and by learning more about psychiatric nursing in particular and in the nursing profession at large.

OBJECTIVES General Objective: At the end of our two-week Psychiatric Nursing Exposure at Davao Mental Hospital, our group aims to come up with a comprehensive case study which contains in depth information and detailed facts about the patient, including the factors which led to his present illness and to come up with effective nursing interventions and management to aid him on his recovery. Specific Objectives: +Cognitive: Obtain Pertinent data gathered from the client and his family State past and present health history of the patient Trace the family genogram Define the complete diagnosis of the patient Discuss the Anatomy and Physiology of the system and organs involved in the patients illness Explain the Etiology and Symptomatology of the disease Trace the history of the patient through the Psychodynamics Present the mental status examination of the patient Obtain the Doctors Order and rationalize each present the anamnesis by thorough gathering of the clients pertinent personal data, appropriate selection of informants, and familial history tracing Discuss the nature of the drugs given to the patient and explain why such drugs were administered Evaluate the difference stages of development of the client according to the theories of Orem, Orlando, and Henderson

+Psychomotor: Establish rapport to the patient and the patients significant others Provide health teachings to the client and the family Gather pertinent data about the client through detailed chart taking, and effective therapeutic communication and interaction with the client and his significant others; Render quality nursing care in line with the formulated nursing care plans; Assess clients mental status thoroughly during the orientation and termination phase as well as the Multi-Axial diagnosis; Trace the health history of the client and family illnesses (past and present) through a genogram; Present the medications given to the client, including their respective modes of action, indications, contraindications, side effects, adverse reactions, nursing responsibilities, and importance to the clients condition; +Affective: Establish a trusting nurse-patient relationship with the client and his significant others through provision of holistic care toward the client and use of appropriate verbal and non-verbal therapeutic communication skills with the client and significant others during the data gathering Formulate a specific, measurable, attainable, realistic and time-bounded nursing care plan for the client Outline recommendations based on the case studys findings

PATIENTS DATA PERSONAL DATA: CODE NAME: Max AGE: 29 years old SEX: Male BIRTHDAY: March 25, 1981 BIRTHPLACE: Davao Oriental ADDRESS: Block 66 Lot 8 Zone 1 San Antonio, Buhangin, Davao City ORDINAL RANK: 5th CIVIL STATUS: Single NATIONALITY: Filipino RELIGION: Catholic EDUCATIONAL ATTAINMENT: High School Graduate OCCUPATION: None NUMBER OF CHILDREN: 0 NUMBER OF BROTHERS: 2 NUMBER OF SISTERS: 6 MOTHER: Mama AGE: 58 EDUCATIONAL ATTAINEMNT: Elementary graduate OCCUPATION: Vendor FATHER:Papa

EDUCAIONAL ATTAINMENT: Elementary undergraduate OCCUPATION: Tuba gatherer

CLINICAL DATA: WARD/SERVICE: Crisis Intervention Unit/Psychiatry ADMITTING PHYSICIAN: Al Raymond D. Tupas, M.D. ADMITTING DIAGNOSIS: Bipolar 1 Manic Phase with PF PRINCIPAL DIAGNOSIS: Bipolar 1 Manic Phase with PF DATE OF AMISSION: January 5, 2011 DATE OF DISCHARGE: January 10, 2011 INSTITUTION: Southern Philippines Medical Center Psychiatric Department

Interpretation of the Genogram

On the paternal side, prominent family illnesses only concern some members having hypertension and arthritis. There was one case of liver cancer on this side. There was one case of Bipolar disorder which Papa Js uncle. Aside from the condition, no other illnesses run the family.

On the maternal line, prominent family illnesses only concern some members having hypertension, asthma and one case of arthritis and myocardial infarction. There is one case of Down syndrome. There is on case of Bipolar disorder which is Mama Rs cousin.

Papa J has arthritis while Mama R has no medical illness. The only medical illnesses that Maxs siblings have are Sister Us hypertension and Sister BBs asthma. Max was only the one who have bipolar disorder among his siblings.

A. ANAMNESIS Informant # 1: Mama R Age: 61 years old Address: Zone 1, San Antonio, Buhangin, Davao City Sex: Female Civil Status: Married Relationship with Client: Mother Length of time Known by the Patient: Since birth up to present (29 years) Apparent Understanding of the Present Illness of the Client: According to her, she believed that Maxs way of taking food was not normal. She stated that Max dreamt of becoming a boxer in order for their family to go out of poverty. She said that, maybe Max experienced pasmo. This pasmo might have gone up to Maxs brain and that it caused trouble in his thinking and caused his insanity or mental illness. Characteristics and Attitude of the Informant: Mama R was very open to the group during the interview and was very hospitable to us. She tried to accommodate the group by inviting us inside their house and giving us comfortable seats for the interview. She tried to recall all the important information regarding Maxs condition. She was very friendly and was not hesitant to share any information she knew about her son.

Informant #2: Papa J Age: 61 years old Sex: Male Civil Status: Married

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Relation to patient: Father Address: Zone 3, San Antonio, Buhangin, Davao City Length of time known to patient: Since birth up to present (29 years) Apparent understanding of the present illness of the patient: According to him, the reason behind Maxs condition was hes boxing career. He verbalized that tungod man na sa iyahang pagbawas ug timbang para makab-ot ang tama nga timbang para maka-apil siya sa boxing. Other characteristics and attitude of the informant: Papa J was a little bit quiet and brief in answering some of our questions. Although he was that type of person, he still let us go inside their house and answer some of our questions truthfully.

Informant #3: Abigail Age: 26 years old Sex: Female Civil Status: Married Relation to patient: Sister-in-law Address: Zone 3, San Antonio, Buhangin, Davao City Length of time known to patient: 6 Years Apparent understanding of the present illness of the patient: According to her, Max is really a normal type of person. Hes attitude only seems unusual when the patients illness strikes again. She verbalized that ako lang nahibalhan nga tungod na sa iyahang dili pagkaon ug tarong pero dili man siya ing-ana pag wala siya gi-atake sa iyahang sakit. Other characteristics and attitude of the informant:

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Abigail was very friendly and accommodating during the interaction. She was not hesitant to answer some of the information asked to her. She showed her interest in the conversation by always smiling and being cheerful.

Informant #4: Victoria Marilla Age: 37 years old Sex: Female Civil Status: Married Relation to patient: Neighbor Address: Zone 1, San Antonio, Buhangin, Davao City Length of time known to patient: 8 years Apparent understanding of the present illness of the patient: She does not really know what exactly caused the illness of the patient, but she just relied on hearsay from other neighbors. She said, Nag-adto siya sa usa ka haya, unya wala siya nagkaon. Napasmo siya ug nag-wild mao gihatod na siya sa hospital. She also said, Kana si Max kay buotan man na siya. Nagatrabaho na siya sa construction unya kadalasan dili na siya makakaon mao na mapasmohan. Other characteristics and attitude of the informant: Although she was willing to be interviewed, at first, she did not take the initiative in allowing the interviewers to come inside her store. Instead, the interviewers had to ask themselves to go inside. She was busy during the interview. However, she was not hesitant to answer our questions and remained cooperative.

Informant #5: Brenda Address: NHA Buhangin, Zone 1, Davao City Relation to Patient: Neighbor

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Length of time known to patient: 8 years Apparent understanding of the present illness of patient: Brenda believed that the patient became mentally challenged because of starving himself too much to hasten the duration of losing weight for his boxing fights. During the interview, Brenda said, Napasmuhan man yata to siya. Kada-buntag sauna, mupalit ra man to siyag pan ug energy drink kay baunon daw niya sa iyahang practice. Mao ra pud daw to iyahang ginakaon para dali lang daw siya mabawasan ug timbang. Brenda said that what she understood regarding the present illness of the patient was that the condition doesnt always last for long. Characteristics and Attitude of the Informant: During the interview, Brenda is very accommodating and cooperative. She is willing to answer every question asked to her, with regards to the patients condition. She was also very eager in clarifying the details that she shared.

Informant #6: Leticia Age: 54 years old Address: Zone 1, Blk. 3, Lot 5, San Antonio, Buhangin, Davao City Sex: Female Civil Status: Married Relationship to Client: Neighbor Length of time Known by the Patient: Since 2006 up to present (4 years) Apparent Understanding of the Present Illness of the Client: Leticia sees Maxs condition rooted from his hobby which is boxing. He knew that Max was taking small amounts of food in order to join the light weight division in boxing. She thought

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that maybe, his less consumption of food caused his mental illness. They thought that this term Pasmo went up from his stomach towards his brain. Characteristics and Attitude of the Informant: Leticia was at first hesitant to talk to us because she was very busy doing something in her store. Later on, she decided to talk with us and opened up what she knew about Max. She was very open and receptive to our group during the interview. She had shown effort to recollect and remember all the information she knew about Max.

Informant #7: Asuncion Sonza Age: 47 years old Sex: Female Address: Blk 66 Lot 9, Zone 3, NHA Buhangin, Davao City Civil Status: Married Relationship to the patient: Neighbor Lenth of time known he patient: 7 years Apparent Understanding of the patients illness: She verbalized Ok mana siya pag-abot nila diri. Nagaboksing-boksing man gud na siya unya mag sige ug diet. Diha daw to nagsugod. Natingala na lng mi ana niya kay kung mulakaw na siya, mura gani siyag robot. Unya mag sige ug shades bisan gabii kay isa ra lagi daw ang adlaw ug gabii. Mailhan pud na namo nga murag lain na gani siya kay matinahuron kaayo. Naa man gud na siyas pangarap day na mag boksingero. Sa diet- diet man daw niya. Luoy pud baya. Other characteristics and attitude of informant: Mrs. Asuncion Sonza was very hospitable and accommodating as she shared her views and ideas about the patients condition. She showed to us her willingness and cooperation as we ask her questions. Based on her gestures, we could see that she shows no discriminaton on the patient and his family. Mrs. Sonza was also concerned regarding patients situation.

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Informant #8: Fely Denuna Age: 39 years old Sex: Female Address: Blk 66 Lot 12, Zone 3, NHA Buhangin, Davao City Civil Status: Married Relationship to the patient: Neighbor Lenth of time known he patient: 7 years

Apparent Understanding of the patients illness: According Mrs. Denuna, the patients condition started when the patient started to go on a diet. She said that the patient had this dream of becoming a boxer, just like Manny Pacquiao. Mrs. Denuna stated that when the patient is in his normal behavior, he helps in house chores and assists his father in his work. She verbalizedMabal-an ra na nako kung lain na siya kay nurag robot gani maglakaw. Unya mahurot na ilang tinda tanan kay ipaghatag na niya sa mga bata. Nakahilak jud ko atong last niya pag adto sa hospital kay gitakluban iyang ulo ug habol kay dili man gd siya muuban. Naluoy ko niya kay but-an kaayo na pagkatao si titi.

Other characteristics and attitude of informant: During our interview, Mrs. Denuna was cooperative and was able to tell us her views regarding the patients condition. She felt sorry for the patient and his family. She didnt say any negative thing about the patient and sees the patient as a good and helpful neighbor.

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FAMILY HISTORY

1. Maternal and Paternal Grand Lineages On the paternal side, there is one relative who have been diagnosed with mental illness. It was Papa Js uncle, who was also diagnosed with Bipolar disorder. Seriousness, impatience, strictness and a great concern for discipline are some of the common attitudes of the paternal side. Papa J has good relationship with his siblings. Even though they do not always share feelings with each other, they have a harmonious relationship and rarely argue.

On the maternal side, there is one relative who have been diagnosed with mental illness. It was Mama Rs cousin, who was diagnosed with Bipolar disorder as well. Religiosity, kindness,cleanliness, order and leniency are some of the common attitudes of the maternal side. Mama and her siblings are close with each other. 2. Father Papa was born at Governor Genoroso on June 12, 1949. He was the fifth among the six children of Lola A and Lola B. During his childhood years, he was very playful and obedient to his parents. He wasnt able to finish his elementary years because of financial constraint and lack of interest in schooling. And so the only work he kept before until this day is to gather and make tuba. He said that he earns 300 per day with his work. He regularly goes home late at night because his work. Mama R also said that he is a very workaholic type of person. Papa J and Mama R met when Mama Rs family transferred at Governor Genoroso on the year 1974. Since then, Papa J started courting Mama R then eventually got married at the age of 25 after Mama R delivered their very first child. Papa verbalized that Gigusto man nako ang pagbuntis ng mrs. nako. Buotan man pud ko na tatay. Papa was very strict and serious in disciplining his children. Although he is not always at home, all of his children were scared of him because of his strictness. He and Mama R have a

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good relationship with each other. The only fight when it comes to Papa Js smoking and because of financial difficulties.

3. Mother Mama was born at Mati on October 18, 1956. She was the seventh among the nine children of Lola C and Lolo D. During her childhood years, she was very respectful and obedient to her parents. She always helps at the household chores at their home.She was only able to finish elementary because of financial difficulties. She sells cassava cake and candies. She earns 400-500 per day as vendor. She is very religious and lenient. She goes to church every Sunday. Mama Rs family transferred to Governor Generoso when she was only 17. She met Papa J there and eventually married him after giving birth to their first child at the age of 18. Her family agreed with their marriage because they dont want to see their grandchild without a father. Mama R is not also fond of punishing her children through pain. She prefers talking to them and telling them their wrongdoings. She has a good relationship with all her children and with Papa J. 4. Siblings Max has 8 siblings: 6 sisters and 2 brothers. He was the fifth among the nine children of Papa J and Mama R. All of them were born at Governor Genoroso. Almost all of his siblings were married except Max, Sister AA, and Sister BB. Most of them were only high school graduate except Sister Y and Brother Z who was able to finish college. Sister U was born on 1975 and was a housewife at Manila. Sister V was born on 1976 and was a cashier at SM City North Edsa in Quezon City. Sister W was born on 1978 and was a saleslady at Sony Centre in Manila. According to Mama R, the three inherited their fathers strictness and their mothers religiosity. Brother X was born on 1980 and was a construction worker at Buhangin. He inherited his fathers strictness. Sister Y was born on 1983 and was a

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call center agent at Quezon City. She was an AB Language graduate at the University of Southern Philippines. She was religious and lenient like her mother. Brother Z was born on 1985 and was a computer technician at Electroworld. He was a computer science graduate at the University of Southern Philippines. He inherited hes mothers religiousness and leniency. Sister AA was born on 1995 and was a 3rd year high school student at Davao City National High School. She was also religious like her mother. Sister BB, the youngest of them all, was born on 1998 and was currently residing with sister Y in Manila. She was a 1 st Year high school student at San Francisco High School. During childhood, the older children were the ones who often help around the house. The older sisters are particularly in-charge with taking care of the house chores while the eldest brother helped his father in harvesting tuba. Max was not very close to his siblings because of his attitude of wanting to spend time alone. Yet, he did sometimes play with them and even asked for his sisters assistance in school work. Presently, almost all of Maxs sisters, except Sister AA, are in Manila. They currently work there. They keep in touch with the family through weekly phone calls. They also help with the familys finances. Maxs brothers are currently in Davao.

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PERSONALITY HISTORY I. Prenatal Max is the 5th child in their family. Mama R conceived him at the age of 25. The mother unplanned the pregnancy but said that Max was not an unwanted child either. She was instead happy because she would be having another child. She verbalized that she drank tuba during the first two weeks of her pregnancy because she was unaware of her condition. She drank about two glasses every other day since his husband was a harvester of tuba at that time. Upon discovering that she was pregnant, she stopped drinking. Mama R was also a vendor of cassava cakes during this time and she continued to sell goods to neighbors even when she was pregnant. Her older children helped her around the house so she does not get too stressed out. During the course of her pregnancy, Mama R had adequate pre-natal check-ups. She verbalized that her diet mainly consisted of vegetables, "daghan man sa among lugar ug gulay, so makakaon jud ko ug daghang gulay halos kada adlaw." Sometimes, she eats fish when they have money to spend for it. Mama R also verbalized that her husband smoked tobacco during her pregnancy and this resulted to their petty fights. They also fought about their financial difficulties. II. Birth Max was born on March 25, 1981 via Normal Spontaneous Vaginal Delivery (NSVD) on full term. Mama R gave birth to Max in their house with the assistance of a hilot. According to her, she did not experience any unusual incidents during her pregnancy. However, she had a difficult labor but Max did not demonstrate any abnormalities either. Papa J was not present during the birth of Max because he was busy at work. Mama R breastfed Max immediately following birth. She cuddled him during breastfeeding and promptly responds to his cry. III. Infancy and Childhood Characteristics Max was breastfed by his mother from birth until 7 months. After which, Max lived with his uncle who was in Tibanban. As a result, Max switched to bottle feeding with Bona. After 2 months, Max was returned to his mother since his uncles wife has gotten pregnant. Max started walking at the age of 1 and began talking at the age of 2. Max was potty trained by his mother. Every time his mother went to the comfort room, Max was brought along

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to expel his wastes as well. Mama R was consistent in following this routine. She also does not scold the child when he expels his waste. She just tells him where to go if he wants to urinate or defecate. Mother verbalized that Max has complete immunizations. IV. Psychosexual History At the age of 6, Max was already aware of the difference between a girl and a boy. He was also often seen by his mother to play with his penis. Mama R scolded Max every time he did this. He was circumcised through pakang at the age of 7. V. Play Life Maxs only playmates were his siblings since houses at their area are located far away from each other and Max is not allowed to go very far. They usually play hide and seek. He also preferred to be a follower whenever they played. According to his mother, Max often preferred playing alone or with the animals such as the young goats. He is not very participative in cooperative play. He was very shy and untalkative. Thus, Max had very few friends. He said his friends during grade school were Warren and Darwin which befriended him. According to Mama R, during grade school, Max did not abandon school for the sake of playing. VI. School History Max began to go to school at 6 years old as a 1st grader in Governor Generoso Elementary School. Max got low grades even if he tried to work hard. He also did not have a lot of friends since he was shy and quiet. During the 3rd grade, Max stopped going to school because of financial difficulties. He resumed schooling during the 4th grade together with his younger sibling, Sister Y. At this point, Max was often compared to his sister and his sister gained the greater praise. During grade school, Maxs grades were mostly line of 8. Max was not participative in group activities. He would immediately go home from school and spend his time alone. During his 6th grade, Max had a conflict with his teacher. His teacher was scolding and hurting his friend because of misbehavior. Max soon became agitated and stood angrily in front of his teacher. He told his teacher that what she was doing was wrong. His teacher threatened to spank him if he did not go back to his chair but Max remained firm and stared furiously at his teacher. After a while, Max calmed down and sat on his chair. The mother reported that the teacher soon favored Max and gave him high grades. During high school, Max and his younger sibling moved to Tibanban to study. They both lived at their uncles house.

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VII. Religious and Social Adaptablity Max was described as shy, frank, introverted, and courteous towards other people. He, however, had difficulty in forming relationships with others. Max went with his mother to church when he was still a child. Max says that he goes to church but does not take interest in reading the Bible or joining church groups. He views failures and successes in life as part of being human which all people must learn to live with. VIII. Occupational History When Max arrived at Davao City on 1999, he first worked as a dishwasher in a carenderia near the Mandaya Hotel. He was paid 100 pHp every 15 days. Then he became a carwash boy. His last job was as a gasoline boy in a shell station in Lanang, Davao City on 2005. At this point, he had a conflict with his co worker. According to Max, his co worker was taking advantage of his kindness. The co worker ordered Max around and Max felt agitated by his attitude. Once, Max did not follow the orders of this co worker of his. As a result, Max got punched in the face. Max returned a heavy blow on his co workers face. He said, kung unsa ilang ihatag nako kay mao lang pud akong ibalik sa ilaha. Kung maayo sila sa ako kay maayo pud ko. Pero kung dili kay dili pud ko basta magpapildi. IX. Marital History Max did not have any relationships in the past. He said that whenever he liked a girl, he often just stood there in admiration and never made an effort to express his feelings. Until, one day, Max tried courting a girl who worked with him at the carenderia. Max eventually lost to his rival because, according to the girl, Max was too weird and quiet. Ever since, Max lost interest in women. He does not masturbate either. X. Onset of Present Illness The illness started when Max experienced hallucinations about seeing two tall persons wearing black and white. That time, he started to become restless and agitated. He started to gather the umbrellas in their house and held a knife on one hand. At this point, he also tried baking bread. His mother tried to stop him but he refused to stop or give the knife to her. He was then brought to Davao Mental Hospital by their neighbors on December 13, 2006. Max was admitted for 6 days. After 2 years, Max and his mother attended a wake and when it was time

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for them to go home, Max stayed by the side of the coffin and started mumbling words. He was saying that he can resurrect the dead just like Christ. He was then brought to the mental hospital again on 2008. Max was admitted for 5 days and again discharged. On November 2010, Max was not taking his medications anymore. He said that these medications were not made by God so he should not take them. By then, he started to walk on a circular path and does not want anything to go in his way. His mother tried to make him stop but Max refused and started to become agitated and irritable. One night, Max wore sunglasses. He said that the reason behind this was that night and day is the same in the eyes of God. During a rainy day, Max wielded a knife and started waving it everywhere. He believed that he could stop the rain through this action. He was brought to the mental hospital once again on November 22, 2010 and admitted for 2 days. During the latest admission, Max was admitted still due to noncompliance to his medications. He manifested delusions once again. This time, he believed that he was Christ himself. There was also an instance wherein Max was walking on a straight line. When an elf truck came his way, he did not move out of the way. He did not care even when the truck almost hit him. Next, Max began collecting shiny coins and gave them to children so that they could play video games. He also started giving away the ice candy they sold because he said that these blessings from God should be shared to other people. There were also instances in which he forced passers-by to take the ice candy he gave away. The mother also told us a story about when Max made two roosters fight. He was so fascinated with this that he killed one of the roosters. After a few days, Max brought again to the Davao mental Hospital by the 911 team on January 3, 2010 and admitted for five days.

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DEVELOPMENTAL DATA Developmental data contains records and analysis of an increase or stagnancy in the complexity of function and skill progression. It manifests the persons capability and skills in adapting to a dynamic environment. It begins in infancy stage and ends in the old age stage while attaining intelligence, developing problem-solving ability and coping and adapting to the environment in all aspects. Development is the behavioral aspect of growth such as persons ability to walk, talk, run and even feelings of sensation and emotion. It proceeds from simple to complex such as from single acts to integrated ones. Development becomes increasingly differentiated. Differentiated development begins with a generalized response and progresses to a skilled specific response.

Eriksons Stages of Psychosocial Development Eriksons theory proposes that life is a sequence of developmental stages or levels of achievement. Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial, or unsuccessful. Erikson believed that the more success an individual has at each developmental stage, the healthier the personality of the individual. Failure to complete any developmental stage influences the persons ability to progress to the next level. These developmental stages can be viewed as series of crises. Successful resolution of these crises supports healthy ego development. Failure to resolve the crises damages the ego. Erikson proposed that at each stage of development, special psychological tasks need to be achieved in order to overcome developmental challenges and allow development to proceed successfully. Successful accomplishment of these task results in adaptation and failure in maladaptation. Stage Trust versus Mistrust Infancy (Birth to 18 Description Trust Vs. Mistrust is the first of Erik Erikson's personality. warmth and eight stages Erikson's regularity theory and Result Justification Max was breastfed by his immediately responds to

of ACHIEVED mother for 7 months. Mama R Maxs cry and cuddles him every time she breastfeeds. When Max was 8 months, he

argues that following a life of protection from the outside world

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months)

while in the mother's womb, the infant is faced with a less secure world. According to Erikson, infants learn to trust when they are cared for in a "consistent and warm manner". If the infant is not cared for and not fed in such a manner, the infant is more likely to develop a sense of mistrust. If an infant's physical and emotional needs are met in a consistent and caring way, he learns that his mother or caregiver can be counted on and he develops an attitude of trust in people. If his needs are not met, an infant may become fearful and learns not to trust the people

lived Thus,

with Max

his

uncle

who being

resides a municipality away. stopped breastfed and started being bottlefed with formula milk which is Bona. Still, despite the distance, Max is well taken care of by his uncles family especially uncles his that favorite. he is After his 2 his

months, Max was returned to mother. However, mother did not resume with breastfeeding. Therefore, Max was bottlefed until he was 1 year old.

Autonomy versus Shame and Doubt Early Childhood to 3 years)

around him. Autonomy vs. shame and doubt (1- ACHIEVED Max was potty trained at the 3 yrs) refers to the 2nd stage of Erik Erikson's theory of Psychosocial development where the child begins to act on his or her own, often in ways that go against the parents' wishes. The child can this conflict either by establishing self-control (autonomy) or by punishing himself or herself with feelings of shame, doubt, and inadequacy. The toddler realizes that he is a separate person with his own desires and abilities. He wants to do things for himself age of 1; he began talking at the age of 2; he started to walk at the age of 1. Max was potty trained by his mother. Every time his mother went to the comfort room, Max was brought along to expel his wastes as well. Mama R was consistent in following this routine. She also does not scold the child when he expels his waste. She just tells him where to go if he wants to urinate or defecate. As a

(18 months resolve

24

without help or hindrance from other people. The toddler's favourite word "No" is a declaration of independence and a bid for increased autonomy. Initiative versus Guilt Late Childhood (3-5 years) In this third stage of development, Erikson believes the preschooler is entering a wider range of social interaction and is developing a more purposeful behavior in order to where deal with may challenging begin to responsibilities. This is a time children develop feelings of guilt and begin to feel anxious. During this stage, the healthily developing child learns: (1) to imagine, to broaden his skills through active play of all sorts, including fantasy (2) to cooperate with others (3) to lead as well as to follow. Immobilized by guilt, he is: (1) fearful (2) hangs on the fringes of groups (3) continues to depend unduly on adults and (4) is restricted both in the development of play skills and in imagination. Increased muscular, mental and language abilities set the stage for more activities and questions. There is a great curiosity and openness to learning. The favourite word of pre-schoolers is "why." FAILED

result, Max is able to cultivate control of himself by not being overly controlled and by being told what is right to do.

Maxs only playmates were his siblings since houses at their area are located far away from each other and Max is not allowed to go very far. He also preferred to be a follower whenever they played. According to his mother, Max often preferred playing alone or with the animals such as the small kids. He is not very participative untalkative. in cooperative play. He was very shy and

25

Parents who take time to answer their But preschoolers' parents who questions see their reinforce their intellectual initiative. children's questions as a nuisance may stifle their initiative and cause them to be too dependent on others and to be ashamed of themselves. Imaginative activity of play this is the basic The stage.

preschooler explores and reenacts the different roles and activities of people, both real (home life) and Industry versus Inferiority School Age (6-12 years) fictional (often based on television). Industry vs. inferiority (5-12 yrs) refers to the 4th stage of Erik Erikson's theory of Psychosocial development when the child become increasingly involved in situations where long, patient work is demanded of them. Those that rise to this challenge gain a sense of industry; those that do not feel inferior. Here the child learns to master the more formal skills of life: (1) relating with peers according to rules (2) progressing from free play to play that may be elaborately structured by rules and may demand formal teamwork, such as baseball and (3) mastering social studies, reading, arithmetic. Homework is a FAILED Max started to go to school at the age of 6. Max got low grades even if he tries to work hard. He also did not have a lot of friends since he was shy and quiet. During the 3rd grade, Max stopped going to school because of financial burden. He resumed schooling during the 4th grade together with his younger sibling, Sister Y. at this point, Max was often compared to his sister and his sister praise. Max was not participative in group activities. He would immediately go home from school and spend his time gained the greater

26

necessity, and the need for selfdiscipline increases yearly. The child who, because and of his successive successful

alone.

resolutions of earlier psychosocial crisis, is trusting, autonomous, and full of initiative will learn easily enough to be industrious. However, the mistrusting child will doubt the future. The shame - and guilt-filled child will experience defeat and inferiority. At the school-going stage, the child's world extends beyond the home to the school. The emphasis is on academic performance. There is a movement from play to work. Earlier the child could play at activities with little or no attention given to the quality of results. Now, he needs to perform and produce good win recognition and from peers results! parents, by being The child soon learns that he can teachers

proficient in his school work. The attitudes and opinions of others become important. The school plays a major role in the resolution of the developmental crisis of initiative versus inferiority. If children are praised for doing their best and encouraged to finish tasks then work enjoyment and

27

industry

may

result.

Children's

efforts to master school work help them to grow and form a positive self-concept ... a sense of who they are. Children who cannot master their school inferiority work may may consider arise. themselves a failure and feelings of A child may also feel a sense of shame if his parents unthinkingly share his "failures" with others. Shame stems from a sense of selfexposure, a feeling that one's deficiencies are exposed to others. LIFE STAGE INDICATORS OF POSITIVE RESOLUTION INDICATORS OF NEGATIVE RESOLUTIO Adolescence (13 to 19 years) Central Task: Identity vs. Role Confusion The adolescent is newly concerned with how they appear to others. The sense of central identity appears through sexual, Sense of self and plans to actualize ones abilities N Feelings of confusion, hesitancy, and possible antisocial behavior Role Confusio n At this stage the client is on his high school years. According to her sister Y who at the same time his classmate also, Max is really an introvert person all throughout his high school life. Maxs mother also shared that he and her sister had several conflicts and admits she was not there to guide the two. Max never tried to court a girl or engage in close relationships with his ASSESS MENT JUSTIFICATION

28

emotional, educational, ethnic, cultural, and vocational discovery. The adolescent person also develops coherent sense of self and plans to actualize ones abilities. The sense of self can be confused if a core identity does not solidify. Feelings of confusion, hesitancy, and possible antisocial behavior may also emerge. Early Adulthood (20 to 34 years) Central Task: Intimacy vs. Isolation Once people have established their identities, they are ready to make long-term commitments to Intimate relationship with another person and has a sense of commitment to work and relationships Avoidance of relationship, career or lifestyle commitments Isolation

sisters friends. There came a point wherein max would go home for a few days just to be relieve from being homesick and the stress of the new environment. There were many experiences of failures such as in academics and sports that for Max, discouraged him to be active once more.

At this stage, Max already finished high school and spent about 2 years in his hometown and transferred to Davao. He never had the chance of entering college due to financial constraints as reported by the mother. As mentioned above, Max failed to achieve ego identity in the previous stage. At this

29

others. They become capable of forming intimate, reciprocal relationships and willingly make the sacrifices and compromises that such relationships require. If people cannot form these intimate relationships--a sense of isolation may result.

stage it seems Max had a hard time forming close relationships with his family, co-workers and people in the community. This could be due to his siblings travelling to Manila and Davao while he is in his hometown and his father went to Davao for months to prepare them to transfer there. In his work also, he had conflict with his co-worker which fired him from his job and failed to handle the growing relationship with a girl working with him in the carenderia. Mama R just said there was another guy who became his rival and unfortunately he failed to have the girl whom he first courted.

30

Freuds Psychosexual Theories Sigmund Freud developed a theory of how our sexuality starts from a very young ages and develops through various fixations. If these stages are not psychologically completed and released, we can be trapped by them and they may lead to various defense mechanisms to avoid the anxiety produced from the conflict in and leaving of the stage. Stage Oral Stage Birth to 1 year Description The center of pleasure is the mouth; it is the major source of pleasure and satisfaction and exploration. The childs primary need is security or safety. Major conflict: weaning Feeding produces pleasure, a sense of comfort or ease and safety. Feeding it should should be be ACHIEVED Max was potty trained by his mother at the age of 1. Mama R was consistent in following a routine to train her child. Every time Mama R went to the comfort room, Max was brought along to expel his wastes as well. Mama R also did not scold the child when he accidentally expels his waste. She just tells him where to go if he wants to urinate or Phallic Stage 4 to 6 years The genitals are the center of gratification. Masturbation offer pleasure to the child. Other actions include fantasy, NOT defecate. Due to Maxs social withdrawal, relate with his peers well. Max continues to be closer to his pleasurable, Anal Stage 1 to 3 years Result Justification ACHIEVED Mama R breastfed Max for 7 months. She immediately responds to Maxs cry. Even when Max lived with his uncle for 2 months, he was continued to be bottlefed with formula milk which is Bona.

provided when necessary. The sources of pleasure are the anus and the bladder (sensual satisfaction, self control). Major conflict: toilet training. Controlling and expelling feces give pleasure and sense of comfort. Toilet training should be a pleasurable experience.

ACHIEVED he was not sufficiently able to

31

experimentation with peers, and questioning of adults about sexual issues or sexual matter. Major conflicts: the Oedipus Complex (refers to the male child's attraction for his mother and unfriendly attitudes towards his father) and Electra Complex (refers to the female's attraction for her father and sees her mother as her rival), which resolves when the child identifies when the child identifies with parent of same sex. The child determines together with the parent of the opposite sex and later takes on a love Latency Stage 6 years to Puberty relationship outside the family. Energy is heading for physical and intellectual activities. Sexual impulses tend to be repressed. Develop relationships between peers of the same sex. Encourage child with physical and intellectual sports pursuits. and other Encourage NOT

mother. His father was often at work and Max is not able to have good interaction with him.

Max started to go to school at are low. Max, due to his withdrawn attitude, is not fully able to engage himself in group activities and only has very few friends. He remains timid and silent.

ACHIEVED this stage. His grades in school

activities with same-sex peers.

32

LIFE STAGE Genital (puberty and after)

CHARACTERISTICS Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment.

IMPLICATIONS Encourage separation from parents, being independent and able to make right and good decisions

ASSESSMENT NOT ACHIEVED

JUSTIFICATION Max is not independent, until now , he still lives with his parents and being dependent to them, especially when it comes to his basic needs and as well as financial matters. He is not able to have stable job. Until now he is not able to have a partner or have close relationships. He courted a girl once but failed to develop their relationship.

33

JEAN PIAGETS STAGES OF COGNITIVE DEVELOPMENT Jean Piaget's stages of cognitive development describe the intellectual development of children from infancy to early adulthood. Piaget believed that children are not less intelligent than adults, they simply think differently. He also proposed a number of concepts to explain how children process information. Stage Sensorimotor Thought (birth-2years) Description In this stage, infants build world by coordinating Result Justification Max, being breastfed by his elicit a sucking reflex. He

an understanding of the ACHIEVED mother, is able to adequately sensory experiences (such as seeing and hearing) with physical, Infants motoric gain actions. moves his mouth to suck where the breast is, as verbalized by his mother. He also grasps an object placed on his palm.

knowledge of the world from the physical actions they infant perform on it. An from progresses

reflexive, instinctual action at birth to the beginning of symbolic thought toward the end of the stage. Thought derives from sensation and movement. The child learns that he is separated from his environment and that aspects of his environment continues to exist even they may be outside the Preoperational Thought (2-7 years) reach of his senses. Thinking is still egocentric: has difficulty taking the point of view of others. The children begin to Max is able to talk at the age of ACHIEVED 2 and has not manifested any abnormalities or difficulties in speech. He tells his mother

34

represent the world with images and words. Symbolic thought goes further than connections of sensory information and physical action. Objects are classified in simple ways, especially by significant feature; the child isnt able to conceptualize Concrete Operational Thought (7-12 years) abstractly. The child starts to think abstractly and conceptualize, forming logical structures that explains his or her physical experiences. Children can execute operations and logical reasoning replaces intuitive thought as long as reasoning can be applied to specific or concrete examples. Children show thinking is decentered -they consider multiple problem understanding aspects of the (e.g. the

what he wants. He is fond of pictures and often draws mountains and trees with his crayons as a child.

Max is knows the difference ACHIEVED between a girl and a boy. He also knows what death is. He knows how to count from high to low and is able to read and write.

significance of height and width). They focus on the dynamic problem. change And, in the most

importantly, they show the

35

reversibility of true mental Formal Operational Thought (12 years and above) operation. The person is capable of deductive and hypothetical reasoning. The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion. During this stage the young adult is able to understand such things as love, "shades of gray", logical proofs and values. During this stage the young adult begins to entertain possibilities for the future and is fascinated with what they can be. Judgment ACHIEVED Abstract thinking

36

ETIOLOGY Predisposing Factors Actual Rationale Present Patient has relatives who were identified by the mother to have the same condition: mothers cousin and fathers uncle. One or more genes that could contribute to as many as one in four cases of bipolar disorder may be located on a region of chromosome 18. Of the genes identified, one codes for a protein that plays a specific part in chemical sign reception; the other is involved in stress hormone production, a physiological function that has been shown to be hyperexcitable in both depression and bipolar disorder. Bipolar disorder is a highly heritable illness with concordance rates of 65% to 70 % and approximately 14% in mono- and dizygotic twins, respectively. The mode of inheritance of bipolar disorder is not clear. McMahon et al. (1995) found evidence of maternal transmission of the illness suggesting the effect of imprinted genes or mutations on mitochondrial DNA. Attempts to find mutations in the mitochondrial DNA of bipolar disorder patients have failed. However, by comparing polymorphisms in the mitochondrial DNA of bipolar patients and a control group, Kirk et al. (1999) were able to find suggestive evidence of selection against maternal lineages in bipolar disorder. Evidence of genomic imprinting on the transmission of bipolar disorder has been observed by several research groups. However, other studies have yielded negative results regarding the parent-of-origin effect on the transmission of bipolar disorder. Antai-Otong, Deborah. Psychiatric Nursing: biological and behavioural concepts. 2003. p. 242. USA: Delmar Learning. Factors Family Dynamics Precipitating Factors Actual Present Rationale

Factors Genetic Factor

Patient was left in the care of his uncle when he

37

was only 7 months old. He stayed with his familys uncle for 2 months before his mother took him back again. Developmental theorists have hypothesized that faulty family dynamics during early life are responsible for manic behaviours in later life. According to this view, the unnatural tension between dependence and independence, and the inherent ambivalence in this family environment, can be a causative factor in bipolar illness. Dysfunctional families are primarily a result of codependent adults, and may also be affected by addictions, such as substance abuse (alcohol, drugs, etc.). Other origins include untreated mental illness, and parents emulating or over-correcting their own dysfunctional parents. In some cases, a "child-like" parent will allow the dominant parent to abuse their children. It is also said that faulty family dynamics can result a person to have moderate to severe mental health issues, including possible depression, anxiety,[12] and suicidal thoughts. Keltner, Norman L., Schwecke, Lee Hilyard Bostrom, Carol E. Psychiatric Nursing. 1999. p. 409. St. Louis Missouri: Mosby, Inc. Patient has increased psychological stress and has frustrations with regards to his boxing career. Bipolar disorder is primarily a biological disorder that occurs in a specific area of the brain and is due to the dysfunction of certain neurotransmitters, or chemical messengers, in the brain. These chemicals may involve neurotransmitters like norepinephrine, serotonin and probably many others. As a biological disorder, it may lie dormant and be activated on its own or it may be triggered by external factors such as psychological stress and social circumstances. The synthesis of serotonin in neurons proceeds by biochemical steps that are analogous to those of the dopamine biosynthesis pathway. Like dopamine, serotonin is degraded by monoamine oxidases, preferentially MAO-A. Of the known 14 types of serotonin receptors, all but 5-HT3, which is a ligand-gated ion channel, are G-protein

Neurochemical factors

Present

38

coupled receptors. In neurons that synthesize the neurotransmitter norepinephrine, dopamine is transported into vesicles in where dopamine betahydroxylase catalyzes the hydroxylation of the ethylamine side chain of dopamine to form norepinephrine. The effects of serotonin and norepinephrine are transmitted via G-protein coupled receptors. It has been postulated that serotonin and norepinephrine deficits occur in parallel. This theory was supported by the observation that when depressed patients were treated with a combination of the serotonin and norepineprin uptake blockers fluoxetine and desipramine, respectively, a more rapid antidepressant response was achieved than with desipramine treatment alone. Furthermore, the administration of the norepinephrine precursor tyrosine potentiated the antidepressant effect of 5hydroxytryptophan, the precursor of. Mongeau et al. (1997) proposed that antidepressant treatment works, at least in the hippocampus, by increasing and decreasing serotonin and norepinephrin neurotransmission, respectively. Lithium has been shown to increase serotonergic transmission, possibly by producing a subsensitivity of presynaptic inhibitory 5-HT1A receptors, and thus increasing the net release of serotonin per impulse. The effect of lithium on signal transmission by norepinephrine is inconclusive. However, there is some evidence that lithium prevents neurotransmitter depletion induced supersensitivity of beta-adrenergic receptors. Keltner, Norman L., Schwecke, Lee Hilyard Bostrom, Carol E. Psychiatric Nursing. 1999. pp. 409-410. St. Louis Missouri: Mosby, Inc. Life Stress Present Prior to profound manifestations of mania, patient was training hard for boxing. Soon, he began to overlook proper rest and adequate sleep. Life stresses may precipitate manic-depressive illness. Sleep deprivation may sometimes trigger mania, and in some persons, symptoms seem to respond to restorative sleep. An errant enzyme linked to bipolar disorder, in the brains prefrontal cortex, impairs cognition under stress. The disturbed thinking, impaired judgment,

39

impulsivity, and distractibility seen in mania, a destructive phase of bipolar disorder, may be traceable to over activity of protein kinase C (PKC). Either direct or indirect activation of PKC dramatically impaired the cognitive functions of the prefrontal cortex, a higher brain region that allows us to appropriately guide our behavior, thoughts and emotions. PKC activation led to a reduction in memory-related cell firing, the code cells use to hold information in mind from moment-to-moment. Exposure to mild stress activated PKC and resulted in prefrontal dysfunction, while inhibiting PKC protected cognitive function. Frisch, Noreen Cavan & Frisch, Lawrence E. Psychiatric Mental Health Nursing. 2002. p. 287. USA: Thomson Learning Inc. Patient does not drink any alcoholic drinks. Symptoms of bipolar disorder may emerge during the course of chronic alcohol intoxication or withdrawal. Other studies have suggested that people with bipolar disorder may use alcohol during manic episodes in an attempt at self medication, either to prolong their pleasurable state or to sedate the agitation of mania. Finally, other researchers have suggested that alcohol use and withdrawal may affect the same brain chemicals involved in bipolar illness, thereby allowing one disorder to change the clinical course of the other. In other words, alcohol use or withdrawal may "prompt" bipolar disorder symptoms. According to Dr. Stephen Strakowski, professor of psychology and biomedical engineering at the University of Cincinnati Academic Health Center, alcohol can have a detrimental effect on the moods of people with bipolar disorder. Alcohol use can deepen the depression and even trigger mania. A normal person experiences chemical changes in his brain when he drinks, but when used in moderation, it does not cause any serious damage. However, since the brain of a person with bipolar disorder is different, his response to alcohol is more intense. Bipolar disorder and alcoholism commonly cooccur. Multiple explanations for the relationship between these conditions have been proposed,

Alcohol Abuse

Absent

40

but this relationship remains poorly understood. Some evidence suggests a genetic link. This comorbidity also has implications for diagnosis and treatment. Alcohol use may worsen the clinical course of bipolar disorder, making it harder to treat. There has been little research on the appropriate treatment for comorbid patients. Some studies have evaluated the effects of valproate, lithium, and naltrexone, as well as psychosocial interventions, in treating alcoholic bipolar patients, but further research is needed. Frisch, Noreen Cavan & Frisch, Lawrence E. Psychiatric Mental Health Nursing. 2002. pp. 287288. USA: Thomson Learning Inc.

41

SYMPTOMATOLOGY Symptoms Manifestations Present/Absent Rationale Justification

Abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week

Present

A neurotransmitter facilitates the transmission of messages from one brain region to another. Cells of neurotransmitters like serotonin are widely distributed, thus they are assumed to be capable of affecting psychological processes and physiological functions. Serotonin, which is an essential neurotransmitter responsible for regulating many body and brain activities, directly or indirectly influences most of the 40 million brain cells, such as those responsible for mood changes, sexual urge, sleep, memory, appetite, temperature regulation, cognition, and some social behavior. Two areas product serotonin: the intestines and the brain. Neurons produce serotonin in the brain. The serotonin in these two areas is distinct. That is, the serotonin from the intestine cannot go to the brain because of the blood-brain barrier, which the body uses to protect the brain from toxins. Serotonin in the brain regulates mood, appetite and sleep. Serotonin also creates a general "good" feeling. A serotonin deficiency can result in depression, anxiety, violent behavior and obesity. The fact that delusional disorder is more common in people who have family members with delusional disorder or schizophrenia suggests there might be a genetic factor involved. It is believed that, as with other mental disorders, a tendency to develop delusional disorder

Prior to admission, Mama R reported that Max exhibited irritable mood especially when instructed to eat his meals and take his medications. This was also the reason why Mama R called the 911 personnel to take Max to DMH.

Persistence of inflated self-esteem or grandiosity

Present

The patient insisted that Jesus Christ is in him and that he will be the one to save everyone from the devil.

42

might be passed on from parents to their children. Researchers are studying how abnormalities of certain areas of the brain might be involved in the development of delusional disorders. An imbalance of certain chemicals in the brain, called neurotransmitters, also has been linked to the formation of delusional symptoms. Neurotransmitters are substances that help nerve cells in the brain send messages to each other, such as dopamine and serotonin which can cause delusional disorders and hallucinations. An imbalance in these chemicals can interfere with the transmission of messages, leading to symptoms. An example of a neurotransmitter disorder is the serotonin deficiency. Evidence suggests that delusional disorder can be triggered by stress. Managing your stress is extremely important as stress can easily trigger "an episode." Alcohol and drug abuse also might contribute to the condition. People who tend to be isolated, such as immigrants or those with poor sight and hearing, appear to be more vulnerable to developing delusional disorder the relatively common occurrence of delusions in neurological illness has led investigators to speculate on the role of the limbic system, basal ganglia, and neocortical association areas. Hyperdopaminergic states have been implicated in the development of delusions. Recently, Morimoto et al14reported that 13 patients with delusional disorder were reported to have increased levels of plasma homovanillic acid (HVA) (a dopamine metabolite) compared with control subjects. Decreased need for sleep (e.g., feels rested after only 3 Present Mood disorders are characterized by sleep disturbance. Mania tends to be characterized by a decreased need for sleep. Sleep deprivation may precipitate mania in patients who are bipolar I and

He said he is the chosen one by God to lead the people here on earth.

Upon initial interview, the patient appeared sleepless,

43

hours of sleep)

temporarily relieve depression in those who are unipolar. Artificially induced sleep deprivation is known to precipitate mania in some patients with bipolar disorder (Grunze et al., 2002). Because a number of neurotransmitter and hormone levels follow circadian patterns, sleep disruption may lead to biochemical abnormalities that affect mood.

Waldinger, R. (2007) Psychiatry for Medical Students

drowsy, weak, and chewing his words while talking. Max verbalize that he shouldnt sleep because he still has a big mission to finish. Mama R reported that if Max gets really weak and too drowsy already, he just fell asleep. After 2 hours, Max will get up hurriedly to do his mission which is to clean our surroundings. The people around Max especially his family observed that Max is now more talkative and asks a lot of various questions. This is one notable symptom that made his family say theres a big difference in terms of his behavior.

More talkative than usual or pressure to keep talking

Present

Manic patients speak as if they are under pressure to get the words out. They speak loudly and rapidly and are usually difficult to interrupt. Their speech content may be normal, full of jokes and puns, or full of hostile accusations and angry tirades. Manic patients often have a theatrical style and can be quite entertaining. Associations and word choice may be based on sounds rather than ideas, resulting in clang associations (e.g., talk-tic-toc-whats up doc?)

Waldinger, R.; Psychiatry for Medical Students Flight of ideas or subjective experience that thoughts are racing Present Skipping from one idea to another in a continuous flow of accelerated speech is known as flight of ideas. The speaker makes associations that are comprehensible but based on puns, extraneous stimuli, or other chance factors. If flight of ideas is severe, it can make the manic persons speech impossible to follow.

Although talkative, the group noticed during interviews that Max always add more topics far from what we have been

44

Waldinger, R.; Psychiatry for Medical Students

discussing. He cannot stay long for one topic and have to jump to another introducing new idea. During interviews, the group observed Max often has poor eye contact and needs to be drawn to the topic discussed. He always observes people inside the ward walking, fixing their things, and janitor cleaning. Max is hyperactive and is focused on cleaning his surroundings such as comfort rooms. Mama R reported that he stays up late and wakes up too early that sometimes she wakes up to the sound of Max scrubbing the floor, arranging the furnitures and even doing carpentry. Max is preoccupied with his religious beliefs such as Jesus

Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

Present

Inattention and distractibility appear to be related to low levels of Norepinephrine. ADHD Children/Adults can't judge which things in their environment are important and which should be ignored. ADHD Children/Adults often feel the flight path of a fly in the room is as important as the teacher's algebra lesson. To the ADHD Child/Adult, everything on the desk is equally interesting and worthy of attention. Low levels of Norepinephrine also make it very difficult for ADHD Children/Adults to sustain their focus on a task, plan ahead, and understand such concepts as sequence and time.

Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

Present

Hyperactivity that includes motor restlessness and over-involvement in sexual, recreational, occupational, and other activities. Manic individuals will plan and enter into a variety of project, overcommitting themselves and using poor judgment. Along with poor judgment, manic patients commonly demonstrated expansiveness, grandiosity and unwarranted optimism, and these characteristics lead to many painful consequences.

Waldinger, R.; Psychiatry for Medical Students

Excessive involvement in pleasurable activities that

Present

Pathological gambling, a tendency to disrobe in public places, wearing clothing and jewelry of bright colors in unusual or outlandish combinations, and inattention to small details (e.g., forgetting to hang up

45

have a high potential for painful consequence s (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

the telephone) are also symptomatic of the disorder. Patients act impulsively and at the same time with a sense of conviction and purpose. They are often preoccupied by religious, political, financial, sexual, or persecutory ideas that can evolve into complex delusional systems. Occasionally, manic patients become regressed and play with their urine and feces.

Christ being inside of him and given him a mission. This consumes most of his time that he tend to forget socializing with his family and losses enough time for sleep.

Kaplan & Sadock (2007). Synopsis of Psychiatry Behavioral Sciences

46

47

INITIAL MENTAL STATUS

Name: Max Age: 29 years old Place of Interview: CIU

Diagnosis: Bipolar I Manic Phase with PF Physician: Al Raymond D. Tupas, M.D. Date of Examination: January 8, 2011

I.

PRESENTATION A. General Appearance During the interview that the group did, the patient was wearing a white shirt and white shorts. He was young-looking and looks exactly with his age; properly groomed and has a long mustache. His fingernails and toenails are trimmed. The patient was mesomorphic with average body built. Eye contact was present but somewhat sleepy during the interview.

B. General Mobility a. Posture and Gait The patient slouches when seated but holds himself erect when standing and walking. His mannerisms are present and evident throughout the interview, like playing with his tongue. b. Activity During the interview, the patient was able to sit straight and focus on answering the questions asked to him. There is no overactivity or underactivity nor impulsiveness noted. He was very calm and composed along the interview. c. Facial Expression The patient was able to exhibit appropriate facial expression towards a certain topic but appears very drowsy during the interview. C. Behavior/Attitude towards the examiner

48

The patient was accommodating to the group. The patient was seated on his bed and appears sleepy; the patient smiles to the examiner every time he answers a question. II. STREAM OF TALK A. Characteristic of Talk He speaks in a normal tone and his words were very clear to us. Blocking was still evident especially when we bring in the discussion about his illness. He maintained eye contact but a little bit sleepy but his attention was still in the conversation though. B. Organization of Talk Most of his statements were comprehensible. Circumstantiality and Tangentiality surfaced during the interview. He cooperates with the discussion and still, he tries to answer the questions we gave him. III. EMOTIONAL STATES AND REACTION A. Mood The patient was able to maintain a normal mood all through the interview. He was responding well to the conversation and his mood was appropriate for the discussion. B. Affect The patients affect was appropriate as well. His statements jived very well with his facial expressions and gestures. IV. THOUGHT CONTROL A. Perceptions Throughout the interview, the group did not observe any manifestations of illusions or hallucinations. He was very calm and composed. V. Delusion Religious delusion was present. He believes that God lives in him and that Christ is the only one who understands him and what is happening to him. When he was asked why did he say so, he answered, Nisulod man gud si kristo sa akong huna huna. Nagdamgo pud ko na gil;impyohan ni Kristo ang kalibutan unya sundun pud nako iyang ginabuhat. This is a manifestation of Religious delusion. VI. NEUROVEGETATIVE STATE A. Sleep The patient said that his sleep was not enough because according to him, he has lot of things to do. B. Appetite The patient had a good appetite. He was eating his meals unlike before. C. Diurnal Variation

49

It was around 8:30 am when we conducted the interview and so far, he was relaxed and comfortable. He just felt a little bit sleepy during the interview. VII. GENERAL SENSORIUM AND INTELLECTUAL STATUS A. Orientation The patient is well oriented of the time, place and person. He was aware of the persons around him. He is aware of the time and the place as well.

B. Memory The patient still remembers all the things he has been doing. When asked anything about his childhood he was still able to answer. As well as the things he has done in his previous birthdays and what he ate for breakfast. C. Calculation The patient was given again given mathematical equations. We started from 100 and asked to subtract 7 from it. He answered the first correctly. Then, there were times he answered it incorrectly and the others correctly. D. General Information The patient was asked who the current Philippine president was. He answered Noynoy Aquino. He was also asked who was the current Davao city mayor. He answered Inday Sara Duterte. E. Abstract Thinking, Judgement and Reasoning The patient was given another set of situations and questions to evaluate him. ABSTRACT THINKING He was asked to explain the saying: Try and try until you succeed. He answered, Kanang ayaw pag-undang sa imong paglaog. JUDGMENT: We gave a situation to the patient which says: kung makakita ka ug us aka kawatan na gikuha ang pitaka sa isa ka dalaga, unsa man imong buhaton?. The patient answered: Ako jud buyagon sir oi, maski magkaunsa man. This means that the patients judgement is good and his reaction was appropriate. He has a sense of righteousness.

50

REASONING: The patient was asked what will he do if he was left alone in an island. The patient answered: magsunog ug dahon para naay aso mahimo ug signal, sir. This means that the patients critical thinking skills are intact and appropriate.

VIII.

INSIGHTS He insists his false belief that God lives in him, and that his medications were made of fake powers made by the people here on earth and not made by God. Delusions were very evident during the interview. He also believe Nino, the quack doctors advice that he should not eat any form or kind of bread or any soft drinks except for rice and water. His reasoning and thinking abilities were intact and functioning well.

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FINAL MENTAL STATUS EXAM

Name: Max Age: 29 years old

Diagnosis: Bipolar I Manic Phase with PF Physician: Al Raymond D. Tupas, M.D.

Place of Interview: Zone 1 San Antonio, Buhangin, Davao City Date of Examination: January 15, 2011

IX.

PRESENTATION D. General Appearance During the home visit the group did, the patient was wearing a white shirt and blue jeans. He was young-looking; Properly groomed and looked like he had just taken a bath. His fingernails and toenails are trimmed. The patient was mesomorphic with average body built. Eye contact was present and he never loses eye contact during the conversation. During the interview, the patient was very warm and welcoming to us. He looked happy to see us again for the second time. E. General Mobility d. Posture and Gait The patient still slouches when seated but holds himself erect when standing and walking. His mannerisms are still present and evident throughout the interview, like playing with his tongue. e. Activity During the interview, the patient was able to sit straight and focus on answering the questions asked to him. There is no overactivity or underactivity nor impulsiveness noted. He was very calm and composed along the interview. f. Facial Expression The patient was able to exhibit appropriate facial expression towards a certain topic. He does not appear anxious, frightened nor angry during the course of the interview. F. Behavior/Attitude towards the examiner

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The patient was still accommodating to the group and we did not notice any hesitation during the interview. The patient was seated on a chair and appears calm; the patient smiles to the examiner everytime he answers a question. X. STREAM OF TALK C. Characteristic of Talk He speaks in a normal tone and his words were very clear to us. Blocking was still evident especially when we bring in the discussion about his illness. He maintained eye contact this time and prefers to look directly to the nurse while doing his mannerisms. His attention was still in the conversation though. D. Organization of Talk Most of his statements were comprehensible. Circumstantiality and Tangentiality surfaced during the interview. He cooperates with the discussion and still, he tries to answer the questions we gave him. XI. EMOTIONAL STATES AND REACTION C. Mood The patient was able to maintain a normal mood all through the home visit. He was responding well to the conversation and his mood was appropriate for the discussion. D. Affect The patients affect was appropriate as well. His statements jived very well with his facial expressions and gestures. XII. THOUGHT CONTROL B. Perceptions Throughout the interview, the group did not observe any manifestations of illusions or hallucinations. He was very calm and composed. C. Delusion Religious delusion was present. He believes that God lives in him and that Christ is the only one who understands him and what is happening to him. When he was asked why did he say so, he answered, Makasabot man ko maam nga ang panan-aw sa mga tao sa akoa buang, pero para sa ako, ang Ginoo lang gyud ang nakasabot sa akoa ug kabalo ko nga gihimo ni niya para akong iwale ang maayong balita sa Ginoo. This is a manifestation of Religious delusion. XIII. NEUROVEGETATIVE STATE D. Sleep

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The patient said that he had a good sleep the night before the interview. According to him, he slept at around 9pm and woke up at around 4am. He said that he did not have any difficulty sleeping at night. E. Appetite The patient had a good appetite. He was eating his breakfast well and was able to consume a moderate amount of rice and viand. F. Diurnal Variation It was around 9:00 am when we conducted the home visit and so far, he was relaxed and comfortable. He did not have any feeling of discomfort or uneasiness during the interview. XIV. GENERAL SENSORIUM AND INTELLECTUAL STATUS F. Orientation The patient is well oriented of the time, place and person. He was still able to recognize our group after one week of not seeing each other. He is aware of the time and the place as well. G. Memory Most of our questions to him were about his adolescent life and we can say that he has no difficulty remembering details. Long pauses before answering indicate that he was trying to retain information for him to come up with the answer. REMOTE MEMORY: The nurse asked: Kinsa sa una ang imong mga amigo kayo?, the patient answered: Si Mario ug si Warren ang akong mga suod kayo sa una, sa Gov. Generoso paman ko ato. Dugay na kayo to During this question and answer, the patient took a long time to answer because he tried to recall who his closest friends way back when he was still a child.

RECENT PAST MEMORY: The nurse asked: Nag-unsa mo atong imohang ika twenty-nine nga birthday?, the patient answered: Nagluto-luto lang ug ginagmay, kanang tama lang pud nga makalipay-lipay mi.

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The patient answered right away with this question. RECENT MEMORY: The nurse asked: Unsa inyong sud-an kaganinang buntag?, the patient answered: Kuan sir, bulad ug itlog, unya kan-on pud. IMMEDIATE MEMORY: The nurse asked: Kani si Maam Cara, Maam Jairah, ug Sir Jayvee kinsa gane to siya? (points at Cara). The patient answered si maam Cara. H. Calculation The patient was given again given mathematical equations. We started from 100 and asked to subtract 7 from it. At first, he answered it correctly but later on, he committed mistakes. I. General Information The patient was asked who the current Philippine president was. He answered Noynoy Aquino. He was also asked who was the current Davao city mayor. He answered Inday Sara Duterte. Lastly, the nurse asked him unsay bag-o nga mall ang ginatukod karon. He answered Ayala Mall sir. J. Abstract Thinking, Judgement and Reasoning The patient was given another set of situations and questions to evaluate him. ABSTRACT THINKING He was asked to explain the saying: Beauty is in the eyes of the beholder. He answered, Ang kanindot sa nawong sa usa ka tao, naa ra gyud sa nagatan-aw, ang nagatan-aw lang ang makaingon kung gwapa ba ang us aka tao o dili. JUDGMENT: We gave a situation to the patient which says: kung makakita ka ug us aka kawatan na gikuha ang pitaka sa isa ka dalaga, unsa man imong buhaton?. The patient answered: Ako jud buyagon sir oi, maski magkaunsa man. Naa gane atong isang adlaw katong naa pako sa mental, nanguha ug pitaka tong buang didto, ako gyud siyang gibuyag. iya man kong gikasab.an, ana siya na dili daw nako itug-an. Pero wala gyud ko nahadlok. This means that the patients judgement is good and his reaction was appropriate. He has a sense of righteousness. REASONING:

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The patient was asked what will he do if he was left alone in an island. The patient answered: mukaway ko sa mga barko nga muagi, sir. This means that the patients critical thinking skills are intact and appropriate. XV. INSIGHTS The patient still had the same understanding of his illness. He insists his false belief that God lives in him, and that his medications were made of fake powers made by the people here on earth and not made by God. Delusions were less evident. He still believe Nino, the quack doctors advice that he should not eat any form or kind of bread or any soft drinks except for rice and water. The patient acts normal and his delusions were not evident. His reasoning and thinking abilities were intact and functioning well.

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MULTIAXIAL ASSESSMENT Axis I Features The essential feature of Bipolar 1 disorder is a clinical course that is characterized by the occurrence of one or more manic episodes or mixed episodes. The most recent episode is Manic, which is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood. (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. (p. 382). Washington, DC. American Psychiatric Association, 2000.) Diagnostic Criteria for Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary). During the period of mood disturbance, three (or more) of the following symptoms have persisted, (four if the mood is only irritable), and have been present to a significant degree: B. Symptoms 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g. feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility ( i.e. attention too easily drawn to unimportant or irrelevant external stimuli) 6. Increase in goal-directed activity (either socially, at work or school, or sexually), or psychomotor agitation 7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business Present / / / / / / 296.44 Bipolar 1 Disorder, Most Recent Episode Manic, Severe with Psychotic

57

investments) C. The symptoms do not meet criteria for a mixed episode. D. The mood disturbance is sufficiently severe to cause marked impairment to occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition. Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment should not count toward a diagnosis of Bipolar I Disorder. The full diagnostic criteria are currently met for a manic episode. Specification of the current clinical status of the patient includes, Severe with Psychotic Features. This specifier indicates the presence of either delusions or hallucinations (typically auditory) during the current episode. Most commonly, the content of the delusions or hallucinations is inconsistent with the manic themes. For example, Gods voice may be heard explaining that the person has a special mission. (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. (p. 362). Washington, DC. American Psychiatric Association, 2000.) Axis II 301.20 Schizoid Personality Disorder

Lack of interest in social relationships, seeing no point is sharing time with others. Ever since the patient was younger, he was seen by other people as an aloof type of person. He rarely makes time to socialize with other people, and instead, chooses to take good care of the animals in their residence. When he grew older, this kind of personality became more evident. He has no close friends that he could consider his own barkada. He only has his

58

siblings as his close friends. He finds it hard to get along with other people because he has difficulty in giving in his trust to others. Thus, in conclusion, he is seen to have a schizoid personality disorder. Axis III - None Axis IV - Inability to go back to school, inadequate finances, stressful work schedule The patient was unable to finish his studies. He was only a high school graduate. The reason for stopping school was due to inadequate finances. Nevertheless, he wanted to become employed as a boxer so he had regular practices at Almendras Gym. He needed to come on time during his practices, and there was a need for him to lose weight whenever he has a fight. This prompted him to starve himself to lose weight hastily, and in addition, because of his practices, he comes home tired and drained of energy. Axis V Global Assessment of Functioning

a) Current Assessment (71-80) If symptoms are present, there are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning. (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. (p. 34). Washington, DC. American Psychiatric Association, 2000.) During the interview with the patient, that is, after being discharged from DMH, the patient is coherent all throughout the conversation. His medications allow him to become normal from his illness. He maintains a customary functioning with regards to his daily activities. It is only when he misses his maintenance medication (Chlorpromazine) that his illness strikes again, thus the symptoms arise. When the symptoms become present, the visible indications are the following: he always walks back and forth, he becomes more talkative than usual, he wears sunglasses even at night, and that he becomes more active in doing different things.

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NURSE-PATIENT INTERACTION Name: Max Diagnosis: Bipolar I, Manic Phase with Psychotic features Age: 29 years old Physician: Al Raymond Tupas, MD Date: January 10, 2011 FIRST NURSE-PATIENT INTERACTION

Ward: Crisis Intervention Unit

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Nurse verbal Maayong buntag! Mga student nurse diay mi sa Ateneo. Ako si maam Jairah tapos siya si maam Cara Naa lang mi pangutana sa imoha Ok lang ba nimu? Unsa man imong pangalan? Looks at the patient and smiles to establish good rapport. Maximo maam nonverbal Greets the patient with a smile and uses hand gestures to introduce other group members verbal Maayong

Patient nonverbal Looks at the nurse with a smile on his face

Interpretation N: gives the patient a warm greeting to create a positive atmosphere and establish a good rapport P: Greets back and acknowledges the nurses by smiling and shows interest

Analysis Greetings acknowledge client`s presence as well as creating a good start and knowing client`s disposition. Psychiatic-Mental Health Nursing by Johnson, B. p. 76

buntag pud. Ok ra.

Looks at the student nurse with a smile but appears to be sleepy.

N: Asks a question to seek information P: the smile on his face shows that his interested and he is being cooperative

Seeking information is used to know more about clients feelings, thoughts and ideas. It is also used to make clear that which is not meaningful or vague. Psychiatric-Mental Health Nursing by Keltner, N. p. 185

N: tries to open up Kumusta Looks at the Ok ra man Changes conversation by using

Broad openings make explicit that the client has the lead in the interaction. For 61

62

Final Nurse-Patient Interaction Place of Interview: Blk. 66, lot 8, San Antonio, Buhangin, Davao City Nurse Verbal Maayong buntag Max! kumusta naman ka? Kami diay tong taga Ateneo na mga student nurse. Nonverbal Greets patient with a smile Shakes pts hand, and uses hand gestures to introduce each member of the group. Patient Verbal Nonverbal Uy! Maayong buntag Looks at student sab. Maayo lang nurses and man ko maam. maintains eye contact. Shakes hand and smiles. Date: January 15, 2010 (9:30 am)

Interpretation Nurse: Gives the patient a warm greeting to create a positive atmosphere and re-establish rapport. Patient: Greets back and acknowledges the nurses greeting with a smile and shows interest and a positive outlook.

Analysis The nurse greets the patient upon seeing each other and uses broad openings to start their conversation. Broad openings lead or invite the client to explore thoughts or feelings. Openended questions specify only the topic to be discussed and invite answers that are longer than one or two words. Circumstantiality is when in a response to a direct question, the patient provides an excessive amount of irrelevant detail before finally answering the question. Kozier, B. Fundamentals of Nursing. Chapter 26,

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Kumusta naman ka, unsa man imong ginahimo atong wala ta nagkita?

Looks at patient in the eye and smiles at him. Holds back of the patient.

Maayo lang man kayo maam, medyo laay kay sige raman ko katulugon. Basin tungod ni sa tambal na akong gitumar. Ali mo maam, sir diri ta sa sulod sa balay para maka storya ta ug tarong.

Patient keeps on smiling and uses hand to guide us to go to their home. Patient took his cap off and scratches head.

Kinsa man imong kauban karon diri Max?

Looks at patient and looks around the house to find a family member.

Akoang mama ug akong manghod lang maam. Naa pud mga gagmay na bata, mga anak mani sa akong magulang. Unya ang naa sa tindahan karon kay akoang Papa lang.

Points his mother and the other family members present in the household and tries to point out his fathers house on the other block.

Max, kabalo baka sa imong sakit?

Looks directly in the patients eyes

Yes maam. Kabalo ko nga nabuang ko.

Touches legs and starts to move

Nurse: tries to open up a conversation by using questions that encourages patient to talk and share about what he did in the past few days. Patient: Patient answers appropriately. And tries to find a comfortable place (home) to conduct the interview. He took his cap off when we arrived in their house. Nurse: tries to ask questions to seek viable information and tries to evaluate patients sense of orientation with the place, and person around him. Patient: patient seems to know the persons present in the household and knows where the other members are residing. Nurse: Tries to evaluate patients

p. 469. Broad openings make explicit that the client has the lead in the interaction. For the client who is hesitant about talking, broad openings may stimulate him or her to take the initiative. Psychiatic-Mental Health Nursing by Johnson, B. p. 74

Seeking information is used to know more about clients feelings, thoughts and ideas. It is also used to make clear that which is not meaningful or vague. Psychiatric Mental Health Nursing by Keltner, N. p. 185

Since the patient has a bipolar disorder,

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and uses hand gestures while asking the patient

Wala man gud sila kasabot kung unsa ang nahitabo sa ako. Maong ila kong giadto sa hospital. Pero okay lang man sa ako kay mas nakabalo man gyud ang Ginoo kung naunsa ko.

knees very fast. he was not smiling, but not angry. He was very seious and maintains direct eye contact with the nurse.

Max, unsa imong bation kung sumpungon naka sa imong sakit?

Looks directly to patients eyes Uses hand gestures to explain in an appropriate manner which will not offend the patient.

Max, mag-Math ta

Smiles with the

Oo maam, kabalo kayo ko kung unsa na akong ginabuhat ana nga oras kung sumpungon na ko sa akong sakit sa ulo. Kabalo ko nga nagalakaw-lakaw ko, nagadala ug sundang, pero dili man ko manghilabot maam. Paminaw nako kay ang akong utok kay mao nay nagamandar kung unsa akong himuon. Kabalo ko unsa akong ginahimo pero dili nako makontrol akong lawas. Sige maam.

Changes sitting position, and continued to move knees. He nods while affirming his answer and bows down while answering the question and explaining.

Uses hand gestures while explaining and smiles at some point during his explanation. Nods head and

understanding about his condition or illness and how he feels about it. Patient: he seems to have delusions about his faith about God. He believes that God is the only person who understands him, and why is he experiencing this condition. Nurse: asks question and explore a certain topic. Evaluates patients knowledge and feelings during his course of being mentally ill. Patient: patient explained his thoughts and feelings thoroughly. He seemed to understand his experience very well and knows what he did when he was out of his control doing things cant manipulate. Nurse: tries to

he experiences delusions and grandiosity. Patient suffering from this tends to have false beliefs and think that they are on a special mission. Psychiatic-Mental Health Nursing by Johnson, B. p. 74 Patient who is suffering from bipolar disorder are experiencing delusions. People may feel out of control or unstoppable, or as if they have been "chosen" and are "on a special mission" or have other grandiose or delusional ideas. Kozier, B. Fundamentals of Nursing. Chapter 26, p. 470.

This was performed

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ha, iingon lang ang imong answer pagkahuman sa akong ihatag na mga numero. 100 minus 7?; 93 minus 7?; 86 minus 7?; 74 minus 7?; 63 minus 7?

patient and uses hand gestures to explain the procedure carefully.

smiles. 93; 86; 74 maam; 63 maam; 56 maam. Raises eyebrows and plays with tongue while thinking. Frequent changing of sitting position

evaluate the mathematical capability of the patient whether he has lost his sense of counting. Patient: seemed to have difficulty subtracting numbers by seven and was disturbed while thinking.

to test the abstract thinking of the patient. Abstract thinking is used to identify disturbances in concept formation. It was also performed to test the concentration ability of the patient if it is poor, fair or good. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter 7

Okay, sige Max, okay nato. Karon tagaan taka ug sitwasyon; kung naa ka sa us aka isla unya ikaw lang ang naa didto unya walay pagkaon, balay o maski unsa, unsa man imong buhaton?

Smiles at the patient and looks directly in the eye. Uses hand gestures to explain the situation thoroughly.

Kuna maam kanang, mukaway ko sa mga barko. Kundi mag himo ko ug Bangka.

Looks up while thinking and moves his feet side by side.

Nurse: tries to evaluate the logical thinking of the patient and good reasoning skills if in a specific situation. Patient: Patient has never lost his sense of critical thinking and was able to give an acceptable action in accordance to the given situation.

Encouraging evaluation asks for patients views of the meaning or importance of something. Circumstantiality is when in a response to a direct question, the patient provides an excessive amount of irrelevant detail before finally answering the question. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter

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Ah sige. Kani max: kung makakita ka ug us aka kawatan na nanguha ug pitaka sa is aka tao unsa man imong buhaton?

Looks seriously towards the patient and raises eyebrows

Ako jung kasab.an maam uy!

Appears surprised and serious.

Nurse: tries to evaluate the thinking skill of the pt when given a situation. Patient: has a sense of righteousness and justice and the reaction he has given was appropriate.

Unya Max, dili diay ka mahadlok na basi unsaon ka sa kawatan?

Smiles and looks at patient.

Dili jud ko mahadlok maam magkinaunsa pa! kay kabalo ko ang akong gihimo maayo. Ug mao ang tama nga buhaton ana si Kristo.

Appears surprised and aggressive.

Nurse: Further evaluates patients judgment from the given situation and how he would respond from it. Patient:

I explain daw ni nga kasabihan Max: Beauty is in the eye of the

Smiles and raises eyebrows.

Ang ka-anindot sa nawong sa usa ka tao, naa ra gyud sa nagatan-aw.

Smiles and scratches head.

Nurse: tries to evaluate the abstract thinking of the patient.

7, p. 93. Encouraging evaluation asks for patients views of the meaning or importance of something. Circumstantiality is when in a response to a direct question, the patient provides an excessive amount of irrelevant detail before finally answering the question. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter 7, p. 93. The nurse is trying to evaluate on the clients judgment further. Encouraging evaluation asks for patients views of the meaning or importance of something. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter 7, p. 93. Abstract thinking was tested to identify any disturbances in concept formation.

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Beholder

Patient:

Max, naga unsa man ka diri kada adlaw?

Smiles and leans forward to the patient.

Kuan maam, nagatulog lang. usahay mutabang kay papa maninda sa tindahan ug mga tuba.

Smiles and uses hand gestures while answering.

Nurse: tries to divert the topic into opening a new one. Patient: answered accordingly with the question and was not confused.

With this, we would know the manner on how patient conceptualize or handles ideas. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter 7, The nurse asks the patient a question in order to start a new topic. Questioning is using open-ended questions to achieve relevance and depth in discussion. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter 7, p. 119 The nurse is evaluating the patient if he still remembers such things. The nurse used questioning in order to achieve appropriate answers and ideas from the patient. Fortinash,K. Psychiatric Nurisng.p. 19

Nag-unsa mo diri atong pasko ug katong bag-ong tuig Max?

Smiles at the patient and raises eyebrows.

Nagkaon lang maam. Nagsabasaba lang mi kay bawal man ang pabuto diri sa Dabaw.

Smiles while trying to recall what happened during their celebration.

Nurse: tries to evaluate the memory of the patient if still intact. Patient: patient was happy recalling what they did during Chrostmas celebration and his memory is still intact.

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Ah. So mao ra to Max, daghan kaayong salamt sa imong oras ug panahon para mag interview mi.

Smiles and shakes hand with the patient

Uy sus! Okay lang kayo maam ug sir..salamat pud kayo sa pag anhi ug sa pagdala ug painit ug mainom. Unta magmalampuson mo sa inyong kurso. Godbless you.

Smiles and shakes hand happily with the nurse. Uses hand gestures while giving thanks.

Nurse: tries to terminate the interaction with the patient. And end the nurse patient relationship. Patient: Patient was very happy and thankful with the visit of the student nurses; he also gave advices and wishes for the group and proved that he was a good person

The nurse gives recognition in a nonjudgmental way. The nurse then terminates the interaction by thanking the client for his participation and cooperation during the whole interview. Psychiatic-Mental Health Nursing by Johnson, B. p. 81

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Definition of Complete Diagnosis BIPOLAR 1 MANIC PHASE WITH PF BIPOLAR Bipolar literally means two poles, implying that there are two basic poles or moods caused by the disorder. The opposite poles are severe depression or extreme mania or hypomania. While these two extremes may be present in the disorder, it is misleading to think of bipolar disorder in terms of extremes. Its more accurate to think of it as being a spectrum of disorders involving a wide range of moods. Bipolar disorder is a neurobiological disorder. It is a real physical condition involving the brain. It is not caused by a character flaw, or laziness, or stubbornness. Mountain, J. Bipolar Disorder: Insights for Recovery (p. 8). 2nd Edition (2008). USA: Chapter One Press Bipolar disorder is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, or mood with or without one or more depressive episodes. http://en.wikipedia.org/wiki/Bipolar_disorder Bipolar disorder has something to do with moods going up and down. However, normal moods go up and down in response to the things that happen in everyday life. In bipolar disorder, moods go beyond the ups and downs that come with everyday life. Bauer, M. Overcoming Bipolar Disorder (p. 8) California: New Harbinger Publications, Inc BIPOLAR I Bipolar 1 is the most serious form of all bipolar disorders. A person with bipolar 1 has manic episodes that are usually followed by periods of major depression. The symptoms last for at least a week. Some people with bipolar 1, however, may not have severe depression. Mixed episodes may also occur with bipolar 1. This means that the person has both manic and depressive moods in the same episode. Severe bipolar 1 always leads to hospitalization. They

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may become psychotic. This means they lose touch with reality. They also have higher risk for suicide. Peacock, J. Bipolar disorder: A roller coaster of emotions. (p. 16). Minnesota: Capstone Press. Bipolar I disorder is also known as manic-depressive disorder or manic depression is a form of mental illness. A person affected by bipolar I disorder has had at least one manic episode in his or her life. A manic episode is a period of abnormally elevated mood, accompanied by abnormal behavior that disrupts life. http://www.webmd.com/bipolar-disorder/guide/bipolar-1-disorder Bipolar I disorder is defined as being present if the person experiences one or more lifetime episodes of mania and usually episodes of depression. The severity and duration of episodes are often severe and may result in hospitalization. http://www.blackdoginstitute.org.au/healthprofessionals /bipolardisorderthegp/bipolaribipolarii.cfm MANIC PHASE In the manic phase of bipolar disorder, feelings of heightened energy, creativity, and euphoria are common. People experiencing a manic episode often talk a mile a minute, sleep very little, and are hyperactive. They may also feel like theyre all-powerful, invincible, or destined for greatness. But while mania feels good at first, it has a tendency to spiral out of control. People often behave recklessly during a manic episode: gambling away savings, engaging in inappropriate sexual activity, or making foolish business investments, for example. They may also become angry, irritable, and aggressivepicking fights, lashing out when others dont go along with their plans, and blaming anyone who criticizes their behavior. Some people even become delusional or start hearing voices. http://helpguide.org/mental/bipolar_disorder_symptoms_treatment.htm In the manic phase, there is a mood disturbance, which causes the person to have a severely elevated or irritable mood. Episodes of mania are generally associated with bipolar disorder. Besides the stereotypical euphoria of a manic episode, other symptoms of mania include extreme optimism, talkativeness and rapid speech, racing thoughts, agitation, poor

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judgment, recklessness, difficulty sleeping or decreased need for sleep, distractibility, and difficulty concentrating. http://www.manic-depression.net/mania/

The manic phase is the hallmark of bipolar disorder. To be more precise, mania is a cluster of symptoms that are associated with one aspect of bipolar disorder. An episode of mania can quickly spiral out of control, causing a great deal of disruption and mayhem for the individual and his or her loved ones. The patient may experience increased energy, speech disruptions, impaired judgments, changes in thought patterns and mood elevations. http://bipolar.about.com/od/maniahypomani1/a/mania.htm PF (PSYCHOTIC FEATURES) Psychotic features are often present during the manic phase of bipolar I disorder. Aspects of psychosis may also manifest during extreme episodes of depression. They are also present in schizophrenia and schizoaffective disorder. These features include delusions (false ideas about what is taking place or who one is) and hallucinations (seeing or hearing things which aren't there). http://bipolar.about.com/od/psychoticfeatures/ Psychotic_Features_of_Bipolar_Disorder.htm Being diagnosed with bipolar disorder with psychotic features almost always demands patient's hospitalization under the antipsychotic drugs though much of them could be having some serious side effects such as hypertension. And also you may count on periodic bipolar disorder relapses for it is very frequent, the bipolar disorder with psychotic features returns regularly. http://www.steadyhealth.com/bipolar_disorder_with _psychotic_features_t124249.html

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BIPOLAR 1 MANIC PHASE WITH PF

Bipolar I Disorder, considered the most severe form of this mental illness, is characterized by one or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes. In a major manic episode the patient may become delusional and even suffer from hallucinations. If this occurs, the condition is called Bipolar I with Psychotic Features. Only bipolar I disorder, by definition, can include such psychotic features. Bipolar I can seriously impair day-to-day functioning. http://www.manic-depression.net/bipolarI/

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DIFFERENTIAL DIGNOSIS

CRITERIA FOR MANIC EPISODES

A Manic Episode is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood

CRITERIA A. Distant period of abnormally and persistently elevated, expansive, or irritable mood, lasting for at least 1 week.

PRESENT /

ABSENT

B. During the period of mood disturbance, three (or more) of the following symptoms have persistent (four if the mood is only irritable and have been present to a significant degree.

a. Inflated self-esteem or grandiosity b. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

c. More talkative than usual or pressure to keep talking /

d. Flight of ideas or subjective experience that thoughts are racing

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e. Distractibility (e.g., attention too easily drawn to unimportant or irrelevant external stimuli)

f.

Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.

g. Excessive involvement in pleasurable activities that have a high potential for painful consequences

C. The symptoms do not meet criteria for a Mixed Episode

D.

The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

11/11= 1%x 100= 100% CONCLUSION: CRITERIA MET.

CRITERIA FOR MAJOR DEPRESSIVE EPISODE

A Major Depressive Episode is a period of at least two weeks duration in which there is either depressed mood or there is a loss of interest or pleasure in nearly all activities.

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CRITERIA A. Five (or more) of the following symptoms have been present during the same 2 week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure

PRESENT a. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).

ABSENT

b. Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day (as indicated by either subjective account or observation made by the other).

c. Significant weight loss when not dieting or weight gain d. Insomnia or hypersomnia e. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) /

f.

Feelings of worthlessness or inappropriate guilt nearly every day

excessive

or

g. Diminished ability to think or concentrate, or indecisiveness, nearly every day

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h. Recurrent thought of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The symptoms are not due to the direct physiological effects of a substance or a general medical condition

D. The symptoms are not better accounted for by bereavement, the symptoms persists for a longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms of psychomotor retardation. 3/12= 0 .25x 100= 25% CONCLUSION: CRITERIA NOT MET.

CRITERIA FOR MIXED EPISODE A mixed episode is characterized by a period of time (at least 1 week) in which the criteria are met both for a Manic Episode and for a Major Depressive Episode.

CRITERIA A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1 week period B. The mood disturbance is sufficiently severe to cause a marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization or prevent harm to self or to others, or there are psychotic features.

PRESENT

ABSENT

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C. The symptoms are not due to the direct physiological effects of a substance or a general medical condition 2/3= 0.67 x 100= 66.67% CONCLUSION: Criteria for Mixed Episode is not met

CRITERIA FOR HYPOMANIC EPISODE

A hypomanic episode is defined as a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood that lasts at least 4 days.

CRITERIA A. A distinct period of persistently elevated or irritable mood, lasting throughout at least 4 days, that is clearly different form the usual nondepressed mood.

PRESENT

ABSENT

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree.

1. inflated self-esteem or grandiosity 2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. more talkative than usual or pressure to keep talking 4. flight of ideas or subjective experience that thoughts are racing 5. distractibility

/ /

/ 6. increase in goal-directed activity or psychomotor agitation /

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7. excessive involvement in pleasurable activities that have a high potential for painful consequences

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person with schizophrenia when not symptomatic D. The disturbance in mood and the change in functioning are observable by others E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization, and there are no psychotic features F. The symptoms are not due to the direct physiological effects of a substance or a general medical condition 11/12=.91 %x 100= 91%

CONCLUSION: Criteria for Hypomanic Episode not met

BIPOLAR I DISORDER

Bipolar I Disorder is characterized by one or more Manic or mixed Episodes, usually accompanied by Major Depressive Episodes

296.0x Bipolar I Disorder, Single Manic Episode

CRITERIA A. Presence of only one Manic Episode and no past Major Depressive Episodes Note: Recurrence is defined as either a change in polarity form depression or an interval of at least 2 months without manic episodes

PRESENT

ABSENT

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B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed or Schizophrenia, Schizophreniform Disorder, or Psychotic Disorder Not Otherwise Specified. 1/2= 0.5 x 100= 50%

CONCLUSION: Criteria for 296.0x Bipolar I Disorder, Single Manic Episode not met.

296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

CRITERIA A. Currently (or most recently) in a hypomanic Episode B. There has previously been at least one Manic Episode or Mixed Episode C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The mood episodes in Criteria A and B are not better accounted for a Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, delusional Disorder, or Psychotic Disorder Not Otherwise Specified 3/4= 0.75 x 100= 75%

PRESENT

ABSENT

CONCLUSION: Criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic not met.

296.4x Bipolar I disorder, Most Recent Episode Manic

CRITERIA A. Currently (or most recently) in a Manic Episode B. There has previously been at least one Major Depressive Episode, Manic Episode or Mixed Episode

PRESENT / /

ABSENT

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C. The mood episodes in Criteria A and B are not better accounted for a Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, delusional Disorder, or Psychotic Disorder Not Otherwise Specified 3/3= 1 x 100= 100%

CONCLUSION: Criteria for 296.4x Bipolar I disorder, Most Recent Episode Manic was met.

296.6x Bipolar Disorder, Most Recent Episode Mixed

CRITERIA A. Currently (or most recently) in a Mixed Episode B. There has previously been at least one Major Depressive Episode, Manic Episode or Mixed Episode D. The mood episodes in Criteria A and B are not better accounted for a Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, delusional Disorder, or Psychotic Disorder Not Otherwise Specified 2/3= 0.67 x 100= 66.67%

PRESENT

ABSENT

CONCLUSION: Criteria for 296.6x Bipolar Disorder, Most Recent Episode Mixed not met.

296.5x Bipolar I Disorder, Most Recent Episode Depressed

CRITERIA A. Currently (or most recently) in a Depressed Episode B. There has previously been at least one Major Depressive Episode, Manic Episode or Mixed Episode C. The mood episodes in Criteria A and B are not better accounted for a Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder,

PRESENT

ABSENT

/ /

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delusional Disorder, or Psychotic Disorder Not Otherwise Specified 2/3= 0.67 x 100= 66.67% CONCLUSION: Criteria for 296.5x Bipolar I Disorder, Most Recent Episode Depressed not met.

296.7 Bipolar Disorder, Most Recent Episode Unspecified

CRITERIA A. Criteria Except for Duration, are currently (or most recently) met for a Manic, Hypomanic, Mixed Depressed Episode B. There has previously been at least one Manic Episode or Mixed Episode C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

PRESENT / /

ABSENT

D. The mood episodes in Criteria A and B are not better accounted for a Schizoaffective Disorder and are not / superimposed on Schizophrenia, Schizophreniform Disorder, delusional Disorder, or Psychotic Disorder Not Otherwise Specified E. The mood symptoms in Criteria A and B are not due to the / direct physiological effects of a substance or general medical condition. 5/5= 1 x 100= 100% CONCLUSION: Criteria for 296.5x Bipolar I Disorder, Most Recent Episode Unspecified met.

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ANATOMY AND PHYSIOLOGY THE FUNCTIONS OF THE BRAIN The human brain is a complex organ that allows us to think, move, feel, see, hear, taste, and smell. It controls our body, receives information, analyzes information, and stores information (our memories). The brain produces electrical signals, which, together with chemical reactions, let the parts of the body communicate. Nerves send these signals throughout the body. SIZE OF THE HUMAN BRAIN The average human brain weighs about 3 pounds (1300-1400 g). At birth, the human brain weighs less than a pound (0.78-0.88 pounds or 350-400 g). As a child grows, the number of cell remains relatively stable, but the cells grow in size and the number of connections increases. The human brain reaches its full size at about 6 years of age. COMPOSITION OF THE BRAIN The brain consists of gray matter (40%) and white matter (60%) contained within the skull. Brain cells include neurons and glial cells. The brain has three main parts: the cerebrum, the cerebellum, and the brain stem (medulla). NOURISHMENT OF THE BRAIN Although the brain is only 2% of the body's weight, it uses 20% of the oxygen supply and gets 20% of the blood flow. Blood vessels (arteries, capillaries, and veins) supply the brain with oxygen and nourishment, and take away wastes. If brain cells do not get oxygen for 3 to 5 minutes, they begin to die. Cerebrospinal fluid (CSF) surrounds the brain.

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THE NERVOUS SYSTEM The brain and spinal cord make up the central nervous system (CNS). The brain is connected to the spinal cord, which runs from the neck to the hip area. The spinal cord carries nerve messages between the brain and the body. The nerves that connect the CNS to the rest of the body are called the peripheral nervous system. The autonomic nervous system controls our life support systems that we don't consciously control, like breathing, digesting food, blood circulation, etc. PROTECTION The cells of the nervous system are quite fragile and need extensive protection from being crushed, being infected by disease organisms, and other harm. The brain and spinal cord are covered by a tough, translucent membrane, called the dura mater. Cerebrospinal fluid (CSF) is a clear, watery liquid that surrounds the brain and spinal cord, and is also found throughout the ventricle (brain cavities and tunnels). CSF cushions the brain and spinal cord from jolts. The cranium (the top of the skull) surrounds and protects the brain. The spinal cord is surrounded by vertebrae (hollow spinal bones). Also, some muscles serve to pad and support the spine. More subtly, the blood-brain barrier protects the brain from chemical intrusion from the rest of the body. Blood flowing into the brain is filtered so that many harmful chemicals cannot enter the brain.

The brain has three main parts, the cerebrum, the cerebellum, and the brain stem. The brain is divided into regions that control specific functions. THE CEREBRUM: Frontal Lobe

Behavior Abstract thought processes Problem solving

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Attention Creative thought Some emotion Intellect Reflection Judgment Initiative Inhibition Coordination of movements Generalized and mass movements Some eye movements Sense of smell Muscle movements Skilled movements Some motor skills Physical reaction Libido (sexual urges)

Occipital Lobe

Vision Reading

Parietal Lobe

Sense of touch (tactile senstation) Appreciation of form through touch (stereognosis) Response to internal stimuli (proprioception) Sensory combination and comprehension Some language and reading functions Some visual functions

Temporal Lobe

Auditory memories Some hearing

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Visual memories Some vision pathways Other memory Music Fear Some language Some speech Some behavior and emotions Sense of identity

Right Hemisphere (the representational hemisphere)

The right hemisphere controls the left side of the body Temporal and spatial relationships Analyzing nonverbal information Communicating emotion

Left Hemisphere (the categorical hemisphere)

The left hemisphere controls the right side of the body Produce and understand language

Corpus Callosum

Communication between the left and right side of the brain

THE CEREBELLUM

Balance Posture Cardiac, respiratory, and vasomotor centers

THE BRAIN STEM

Motor and sensory pathway to body and face Vital centers: cardiac, respiratory, vasomotor

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Hypothalamus

Moods and motivation Sexual maturation Temperature regulation Hormonal body processes

Optic Chiasm

Vision and the optic nerve

Pituitary Gland

Hormonal body processes Physical maturation Growth (height and form) Sexual maturation Sexual functioning

Spinal Cord

Conduit and source of sensation and movement

Pineal Body

Unknown

Ventricles and Cerebral Aqueduct

Contains the cerebrospinal fluid that bathes the brain and spinal cord

The brain and spinal cord are made up of many cells, including neurons and glial cells. Neurons are cells that send and receive electro-chemical signals to and from the brain and nervous system. There are about 100 billion neurons in the brain. There are many more glial cells; they provide support functions for the neurons, and are far more numerous than neurons.

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There are many type of neurons. They vary in size from 4 microns (.004 mm) to 100 microns (.1 mm) in diameter. Their length varies from a fraction of an inch to several feet.

Neurons are nerve cells that transmit nerve signals to and from the brain at up to 200 mph. The neuron consists of a cell body (or soma) with branching dendrites (signal receivers) and a projection called an axon, which conduct the nerve signal. At the other end of the axon, the axon terminals transmit the electro-chemical signal across a synapse (the gap between the axon terminal and the receiving cell). The word "neuron" was coined by the German scientist Heinrich Wilhelm Gottfried von Waldeyer-Hartz in 1891 (he also coined the term "chromosome"). The axon, a long extension of a nerve cell, and take infromation away from the cell body. Bundles of axons are known as nerves or, within the CNS (central nervous system), as nerve tracts or pathways. Dendrites bring information to the cell body. Myelin coats and insulates the axon (except for periodic breaks called nodes of Ranvier), increasing transmission speed along the axon. Myelin is manufactured by Schwann's cells, and consists of 70-80% lipids (fat) and 20-30% protein. The cell body (soma) contains the neuron's nucleus (with DNA and typical nuclear organelles). Dendrites branch from the cell body and receive messages.

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A typical neuron has about 1,000 to 10,000 synapses (that is, it communicates with 1,00010,000 other neurons, muscle cells, glands, etc.). DIFFERENT TYPES OF NEURONS There are different types of neurons. They all carry electro-chemical nerve signals, but differ in structure (the number of processes, or axons, emanating from the cell body) and are found in different parts of the body.

Sensory neurons or Bipolar neurons carry messages from the body's sense receptors (eyes, ears, etc.) to the CNS. These neurons have two processes. Sensory neuron account for 0.9% of all neurons. (Examples are retinal cells, olfactory epithelium cells.)

Motoneurons or Multipolar neurons carry signals from the CNS to the muscles and glands. These neurons have many processes originating from the cell body. Motoneurons account for 9% of all neurons. (Examples are spinal motor neurons, pyramidal neurons, Purkinje cells.)

Interneurons or Pseudopolare (Spelling) cells form all the neural wiring within the CNS. These have two axons (instead of an axon and a dendrite). One axon communicates with the spinal cord; one with either the skin or muscle. These neurons have two processes. (Examples are dorsal root ganglia cells.)

LIFE SPAN OF NEURONS Unlike most other cells, neurons cannot regrow after damage (except neurons from the hippocampus). Fortunately, there are about 100 billion neurons in the brain.

GLIAL CELLS Glial cells make up 90 percent of the brain's cells. Glial cells are nerve cells that don't carry nerve impulses. The various glial (meaning "glue") cells perform many important functions, including: digestion of parts of dead neurons, manufacturing myelin for neurons, providing physical and nutritional support for neurons, and more. Types of glial cells include Schwann's Cells, Satellite Cells, Microglia, Oligodendroglia, and Astroglia.

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Neuroglia (meaning nerve glue) is another type of brain cell. These cells guide neurons during fetal development.

The spinal cord is a bundle of nerves that connects the brain to other parts of the body. It is protected by a series of doughnut-shaped bones called vertebrae, which surround the spinal cord. The human spinal cord is about 43-45 cm long and approximately as wide as a human finger. There are 13,500,000 neurons that transmit electro-chemical signals in the spinal cord. The cord weighs approximately 35 grams. The vertebral column (bones) that supports it is about 70 cm long and has 31 segments and 31 pairs of spinal nerves. Spinal Cord Vertebrae

7 cervical (neck) segments

12 thoracic segments 5 lumbar segments 5 sacral segments 4 fused coccygeal segment

Neurotransmitter Neurotransmitters are endogenouschemicals which transmit signals from a neuron to a target cell across a synapse.[1] 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. Release of neurotransmitters usually follows arrival of an action potential at the synapse, but may also follow graded electrical potentials. Low level "baseline" release also occurs without electrical stimulation. Neurotransmitters are synthesized from plentiful and simple precursors,

90

such as amino acids, which are readily available from the diet and which require only a small number of biosynthetic steps to convert.

As explained above, the only direct action of a neurotransmitter is to activate a receptor. Therefore, the effects of a neurotransmitter system depend on the connections of the neurons that use the transmitter, and the chemical properties of the receptors that the transmitter binds to. Here are a few examples of important neurotransmitter actions:

Glutamate is used at the great majority of fast excitatory synapses in the brain and spinal cord. It is also used at most synapses that are "modifiable", i.e. capable of increasing or decreasing in strength. Modifiable synapses are thought to be the main memory-storage elements in the brain.

GABA is used at the great majority of fast inhibitory synapses in virtually every part of the brain. Many sedative/tranquilizing drugs act by enhancing the effects of GABA. Correspondingly glycine is the inhibitory transmitter in the spinal cord.

Acetylcholine is distinguished as the transmitter at the neuromuscular junction connecting motor nerves to muscles. The paralytic arrow-poison curare acts by blocking transmission at these synapses. Acetylcholine also operates in many regions of the brain, but using different types of receptors.

Dopamine has a number of important functions in the brain. It plays a critical role in the reward system, but dysfunction of the dopamine system is also implicated in Parkinson's disease and schizophrenia.

Serotonin is a monoamine neurotransmitter. Most is produced by and found in the intestine (approximately 90%), and the remainder in central nervous system neurons. It functions to regulate appetite, sleep, memory and learning, temperature, mood, behaviour, muscle contraction, and function of the cardiovascular system and endocrine system. It is speculated to have a role in depression, as some depressed patients are seen to have lower concentrations of metabolites of serotonin in their cerebrospinal fluid and brain tissue.[5]

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Substance P is an undecapeptide responsible for transmission of pain from certain sensory neurons to the central nervous system.

Neurons expressing certain types of neurotransmitters sometimes form distinct systems, where activation of the system affects large volumes of the brain, called volume transmission. Major neurotransmitter systems include the noradrenaline (norepinephrine) system, the dopamine system, the serotonin system and the cholinergic system. Drugs targeting the neurotransmitter of such systems affect the whole system; this fact explains the complexity of action of some drugs. Cocaine, for example, blocks the reuptake of dopamine back into the presynaptic neuron, leaving the neurotransmitter molecules in the synaptic gap longer. Since the dopamine remains in the synapse longer, the neurotransmitter continues to bind to the receptors on the postsynaptic neuron, eliciting a pleasurable emotional response. Physical addiction to cocaine may result from prolonged exposure to excess dopamine in the synapses, which leads to the downregulation of some postsynaptic receptors. After the effects of the drug wear off, one might feel depressed because of the decreased probability of the neurotransmitter binding to a receptor. Prozac is a selective serotonin reuptake inhibitor (SSRI), which blocks re-uptake of serotonin by the presynaptic cell. This increases the amount of serotonin present at the synapse and allows it to remain there longer, hence potentiating the effect of naturally released serotonin.[6]AMPT prevents the conversion of tyrosine to L-DOPA, the precursor to dopamine; reserpine prevents dopamine storage within vesicles; and deprenyl inhibits monoamine oxidase (MAO)-B and thus increases dopamine levels. Diseases may affect specific neurotransmitter systems. For example, Parkinson's disease is at least in part related to failure of dopaminergic cells in deep-brain nuclei, for example the substantia nigra. Treatments potentiating the effect of dopamine precursors have been proposed and effected, with moderate success.

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DOCTORS ORDER Date/Time 1/5/11 2:00 pm Doctors Order Please admit patient at CIU w/ watcher Rationale For close monitoring of the patient and proper management of his condition. The crisis intervention unit is a special unit operating on a 24hour basis, which serves as a receiving and action center for walk-in referred, and rescued individuals and families in crisis situation. Diet as tolerated by the body enables a regular intake that is enough for the person to consume. This is done to give appropriate and adequate nourishment to the patient. Vital signs are important for baseline assessment and to monitor patients condition which evaluates the whole treatment course, especially the medications he receives that could be a contributing factor in the variation results of the vital signs. Lithium carbonate is indicated in the treatment of manic episodes of manic-depressive illness. Maintenance therapy prevents or diminishes the intensity of subsequent episodes in those manic-depressive patients with a history of mania. Chlorpromazine is used to treat psychotic disorders such as schizophrenia or manicdepression, and severe behavioral problems. Chlorpromazine has strong alpha-adrenergic blocking activity and can cause orthostatic hypotension. Remarks Admitted

DAT

Done

Monitor VS q4 & record please

Taken and recorded.

Meds: Lithium Carbonate 450mg/tab 1 tablet BID

Done

Chlorpromazine 10 mg/tab 1 tablet BID with BP Precaution

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Biperiden HCl 20mg/tab 1 tablet BID prn for eps Homicidal/ Suicidal/ Escape precaution For 2 point restrain

Biperiden is used to control extrapyramidal disorders. This is ordered so that the patient will be monitored closely and to avoid the harming of patient's life or others. Psychiatric facilities often use medical interventions in the form of restraints to reduce safety risks posed by violent patients and to prevent patients from harming themselves and others. This may create a collaborative treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client. Haloperidol is an antipsychotic agent that aids in the management of aggressive and agitated behaviour. To promote the patient's wellbeing and to continuously control the symptoms. Chlorpromazine is used to treat psychotic disorders such as schizophrenia or manicdepression, and severe behavioral problems. Chlorpromazine has strong alpha-adrenergic blocking activity and can cause orthostatic hypotension. Done

Done

refer

Done

1/5/11 2:38 pm

Give Haloperidol 5mg/amp 1 amp IM now

1/6/11 7:00 am 1/7/11 7:00 am

Continue meds

Done

Chlorpromazine 20mg 1 tablet TID with BP precaution

Done

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DRUG STUDY

95

Generic Name: Brand Name: Classification: Ordered Dosage: Dosage Frequency:

haloperidol Haldol Antipsychotic, Dopaminergic blocker 5mg/amp 1 amp IM

It blocks postsynaptic dopamine receptors in the brain, depress the Mechanism of Action: RAS, including those parts of the brain involved in wakefulness and emesis. It also resembles the phenothiazines.

Management of manifestations of psychotic disorders Control of tics and vocalizations in Tourette syndrome in adults and children Behavioral problems in children with combative, explosive hyperexcitability provocation Indications: Short-term treatment of hyperactive children with excessive motor activity, mood lability Prolonged parenteral therapy of chronic schizophrenia Other uses: Control of nausea and vomiting Control acute of psychiatric situations (IV use) Treatment of intractable hiccoughs, agitation, that cannot be attributed to immediate

hyperkinesia, infantile autism. Hypersensitivity to typical antipsychotics, coma or severe CNS depression, bone marrow depression, blood dyscrasia, circulatory collapse, subcortical brain damage, Parkinsons disease, liver Contraindications: damage, cerebral arteriosclerosis, coronary disease, severe hypotension or hypertension Pregnancy, lactation, respiratory disorders, glaucoma, prostatic hypertrophy, epilepsy, tardive dyskinesia, breast cancer, peptic Side Effects: ulcer, decreased renal function. Dry mouth, urinary retention, constipation CNS: insomia, drowsiness, vertigo, headache, weakness, tremor, Ataxia, slurring, edea, exacerbation of psychotic syndrome, extrapyramidal symptoms CV: hypotension, orthostatic hypotension, tachycardia, cardiac 96

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Generic Name: Brand Name: Classification: Ordered Dosage: Dosage Frequency:

chlorpromazine Thalitone Antipsychotic, Antiemetics 10 mg/tab 1 tablet BID Chlorpromazine is a neuroleptic that acts by blocking the postsynaptic dopamine receptors in the mesolimbic dopaminergic system and inhibits the release of hypothaloamic and hypophyseal hormones. I has antiemetic, serotonin-blocking, and weak antihistaminic properties and light ganglion-blocking activity.

Mechanism of Action:

Management of manifestations of antipsychotic disorders Conrol of manic phase of manic depressive illness Relief of preoperative restlessness and aprehension Indications: Acute intermittent porphyria therapy Induced nausea and vomiting intractable hiccups Treatment of tetanus in combination with other drugs Hypersensitivity narrow-angle glaucoma Contraindications: Patients with CNS depression Coma Bone marrow suppression Lactation Drowsiness Side Effects: Dizziness Faintness

Pink or reddish brown urine CNS: drowsiness, vertigo,insomia, headache, weaknesss, edema, Seizures, extrapyramidal symptoms, tardive dyskinesia CV: hypotension, orthostatic hypotension, cardiac arrest, heart failure, cardiomegaly, pulmonary edema GI: dry mouth, dalivation, nauea, vomiting, anorexia, constipation Adverse Reactions: EENT: nasal congestion, glaucoma, photophobia, blurred vision GU: urinary retention, polyuria, incontinence, priapriam, ejaculation Inhibition, pink to red brown urine, HEMATOLOGIC: eosinophilia, leukopenia, leukocytosis, anemia, Thrombocytopenia, pancytopenia 98

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NURSING THEORIES SELF-CARE DEFICIT THEORY OF NURSING by Dorothea E. Orem Orem defined nursing as, the act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness. Orem's theory of nursing is guided by a patientcentered model that revolves around identifying self-care needs, deficiencies of self-care and appropriate interventions. Orem describes five different ways nurses can help their patients in developing greater selfcare: acting and doing for others, guiding, supporting, promoting personal development and teaching. The basic premise is that individuals can take responsibility for their health and the health of others. In a general sense, individuals have the capacity to care for themselves or their dependents. It is based upon the philosophy that all patients wish to care for themselves. Self care requisites are groups of needs or requirements that Orem identified. They are classified as: 1. Universal requisites are common to all people. They include maintaining intake and

elimination of air, water, and food; balancing rest, solitude, and social interaction; preventing hazards to life and well-being; and promoting normal human functioning. 2. 3. Developmental requisites result from maturation or are associated with conditions or Health deviation requisites result from illness, injury, or disease or its treatment. events, such as adjusting to a change in body image or to the loss of a spouse. They include actions such as seeking health care assistance, carrying out prescribed therapies, and learning to live with the effect of illness or treatment. When an individual is unable to meet his own self care requisites, a self care deficit occurs. It is the duty and obligation of the professional nurse to recognize and identify these deficits in order to define a support modality or intervention. Generally, we, as student nurses, should care for the patients and at the same time foster encouragement to enable patients to care for themselves and fulfill their needs. Through proper teaching and guidance, the patient will be able to find the essence in taking care of themselves

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thereby gaining confidence and independence. We fostered self-determination on the patient by teaching them proper care and also by explaining the purposes of such interventions. We also assisted the individual so as to be able to fulfill her self-care requisites. Proper assistance is necessary so as to promote teaching and wellness without creating a sense of dependence on the patient. Some of the nursing interventions we implemented on the patient are: Assisted with personal hygiene, appropriate dress, and grooming; Provided clean clothing/grooming supplies as needed; obtained the clients own clothing and supplies as quickly as possible; Established routine goals for self-care: comb hair every morning, wash clothes twice a week or more, if possible; Ensured that the client is clean and well-groomed; Gave simple step-by-step reminders for hygiene and dress.

ORLANDOS NURSING PROCESS THEORY Ida Jean Orlandos theory has developed observations she recorded between a nurse and a patient. From these observations, she formulated the deliberative nursing process. The nursing process is an interaction of three basic elements: 1. The behavior of the patient 2. The reaction of the nurse 3. The nursing actions which are designed for the patients benefit The role of the nurse is to find out and meet the patients immediate need for help. The patients presenting behavior may be a plea for help. However, the help needed may not be what it appears to be. Therefore, nurses need to use their perception, thoughts about perception, or the feeling engendered from their thoughts to explore with patients the meaning of their behavior. This process helps the nurse find out the nature of distress and what help the patient needs. The use of this theory keeps the nurses focus on the patient. Orlandos theory can increase the therapeutic effectiveness of nurses by the expression of empathy, warmth and genuineness especially in the light of addressing the immediate need of the patient for help.

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The assumption that patients can communicate verbally or nonverbally requires nurses to be very meticulous and critical of any form of patient behavior that may be his means to communicate his needs for help. Therefore, in order to identify appropriate interventions for the patient, it is essential that a student nurse goes through meticulous assessment of the patients condition and analysis of the presenting problems. In the case of our patient, we incorporated interventions that include assessment of: the patients current condition and response to the treatment regimen and hospitalization, the factors that may cause or contribute to the problem, the patients attitude towards wellness and other variables that may greatly affect the patient. Involved in the process is also the application of principles of investigating the problem and other contributing factors, observation and accurate interpretation and analysis on perceived data and monitoring of the progress of the problem and improvement of the patient. Altogether, these principles allowed us to come up with appropriate interventions and care which are specific to patients needs, apparent to change, and attainable within an allotted period of time. Examples of interventions which include thorough assessment are: Observe for destructive behavior toward self or others;Assess clients behavior frequently every (15 minutes) for signs of increased agitation and hyperactivity; Continue to assess the extent to which self-care deficits interfere with the clients functions.

VIRGINIA HENDERSONS NEED THEORY Virginia Hendersons theory states nursing asassisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge. It is the unique contribution of nursing to help the individual to be independent of such assistance as soon as possible. In her theory, individual care is her focus that she even stressed out assisting the individual with essential activities to maintain health, to recover or to have a peaceful death.

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She proposed the 14 components of basic nursing care. These components are the following: 1. breathe normally, 2. eat and drink adequately, 3. eliminate body wastes, 4. move and maintain posture, 5. sleep and rest, 6. suitable clothing, dress or undress, 7. maintain body temperature, 8. keep body clean and well-groomed, 9. avoid dangers in environment, 10. communicate, 11.worship according to ones faith, 12. work accomplishment, 13. recreation, 14. learn, discover, or satisfy curiosity. Nurses must identify the ability of one to meet needs with or without assistance. The objective of the student nurses was to assist the patient in meeting his needs due to his condition. Based on his condition wherein patients thinking is affected, Max is unable to keep his body clean and well groomed. With this, student nurses and significant other worked together in keeping the patient clean to prevent illness and diseases. Patients body temperature is maintained within normal range by adjusting clothing and modifying the environment. Patient was also assisted in eating and drinking because he experiences delusions that makes him refuse to eat. To prevent fatigue, patient was encouraged to rest and sleep. With these, Hendersons theory was manifested.

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Da te J A N U A R Y 8, 2 0 1 1 @ 10: 00 AM

Cues Subjective: Ni-ingon si Kristo sa ako na musulod siya sa akong lawas as verbalized by the patient. Objective: Inabili ty to distin guish betwe en real and unrea l stimul us Flight of ideas Press ured speec h Chan ges in eatin g habits Prese nce of

Need

Nursing Diagnosis Disturbed thought processes related to delusion of religiosity secondary to bipolar I disorder

Nursing Planning Care Plans At the end of 1 day of nursepatient contact, the patient will be able to: Manifest proper insight and orientation to self and others

Intervention 1. Listen actively to the clients conversation, focusing on key themes, meaning of content, feelings, and reality-oriented words or phrases. Active listening helps to build trust between the client and nurse, assist in comparing the clients content with the underlying meaning or intent, and identifies key themes that are important or disturbing to the client. It also encourages the client to relate to others, because many clients with thought disturbances resist becoming involved in a therapeutic alliance. 2. Assist the client to correct any misinterpretations about environment/self/ experiences by recalling events and problem solving. Exploring events with the client step-by-step encourages reality orientation. 3. Focus on the meaning/feeling/intent of the clients delusion rather than only the words or content. Focusing on intent and feelings versus content helps to better meet the clients needs, reinforces reality, and discourages false beliefs. 4. Avoid challenging the clients delusional system or arguing with the client. Arguing or challenging the client who is experiencing a delusion can diminish trust, provoke a volatile response, or force the client to cling

Evaluation Goal met January 9, 2011 @ 10:00 AM At the end of 1 day of nurse-patient contact, the patient: Manifested good insight and orientation regarding self and others

C O G N I T I V E P E R C E P T U A L P A T T E R N

Bipolar I is the designation for the classic variety of bipolar disorder, characterized by fullblown manic attacks and deep, paralyzing depression. In the early stages of mania, the mood state of affected persons begins gradually to move upward, and they find themselves filled with pleasant feelings of exuberance. Person suffering from this also experiences grandiosity and high self confidence. Grandiosity is a symptom of mania or hypomania in bipolar disorder.Grandiosity occurs when a person has an inflated selfesteem, believe they have special powers, spiritual connections, or religious relationships Changes in thinking accompany the changes in mood. The feeling that one is thinking more clearly and more rationally than usual is especially common in the

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DATE

CUES

NEED

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

J A N U A R Y 8, 2 0 1 1 @

SUBJECTIVE: Daghan pa ko ug kailangan buhaton kay nisulod si Kristo sa ako. Kailangan nako siya sundun mao ng di nako matulog, as verbalized by the patient. OBJECTIVE: - Baggy eyes Restlessne ss Frequent yawning Has a mission

S L E E P R E S T P A T T E R N

Disturbed sleep pattern related to frequent delusional sight R: Disturbed sleep is a typical part of Bipolar Disorder. During a manic episode you may feel very little need for sleep. However during a depressive episode you may have little energy and want to rest a lot. You may also have

At the end of 4 days of nursing care, the patient will be able to: - Verbalize improvement in sleep pattern Verbalize no delusional sight

8:00 AM -

1. Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth, length, positions, aids, and interfering agents. : Sleep patterns are unique to each individual. 2. Instruct patient to follow as consistent a daily schedule for retiring and arising as possible. : This promotes regulation of the circadian rhythm, and reduces the energy required for adaptation to changes. 3. Instruct to avoid heavy meals, alcohol, caffeine, or smoking before retiring. : Though hunger can also keep one awake, gastric digestion and stimulation from caffeine and nicotine can disturb sleep. 4. Encourage frequent rest periods during the day. : Lack of sleep can lead to exhaustion and death. 5. Keep client in areas of low stimulation. : Promotes relaxation and minimizes manic behavior. 6. At night, encourage soothing music. : Promotes relaxation, rest, and sleep.

GOAL NOT MET January 10, 2011 @ 8:00 AM At the end of 2 days of nursing care, the patient was not able to: - Verbalize improvement in sleep pattern Verbalize no delusional sight

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trouble getting to sleep and wake up very early. Bipolar Disorder can impair insight and judgment. Insufficient or poor sleep patterns can make this worse. . http://www.b ipolar.com.a u/living/slee p.cfm

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DA TE

CUES

NEED

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

J A N U A R Y 8, 2 0 1 1 @ 10: 00 AM

OBJECTI VE: Unkempt hair Unkempt clothing - Has unshaven facial hair

A C T I V I T Y E X E R C I S E P A T T E R N

Self-care deficit: dressing/groo ming related to lack of interest as evidenced by inability to maintain appearance at satisfactory, ageappropriate level R: The more severe the depression or mania is, the more important physical care becomes because the client loses interest in selfcare and may have difficulty making decisions. Assistance

At the end of 3 1. Continue to assess the extent to which self-care days of nursing deficits interfere with the clients functions. care, the : Ongoing assessment of the clients functional patient will be abilities helps to determine the clients able to: strengths, as well as areas that require assistance. Perform self2. Assist with personal hygiene, appropriate dress, care activities and grooming. within level of : Personal hygiene assistance helps to own ability as preserve the clients dignity and self-esteem evidenced by: 3. Make available only the clothing that the client will wear; add more clothing as the clients - Dressing judgment and attention span improve. appropriately : Reducing the number of choices minimizes the clients confusion and simplifies the - Grooming selection process. self 4. Provide clean clothing/grooming supplies as appropriately needed; obtain the clients own clothing and supplies as quickly as possible. : The client feels more comfortable and less confused if personal supplies are available. 5. Establish routine goals for self-care: comb hair every morning, wash clothes twice a week or more, if possible. : Routine and structure organize the clients chaotic world and promote success. 6. Initiate grooming and hygiene tasks when the client is best able to comply. : Clients with hyperactive behaviors are more attentive to self-care after taking medication. 7. Encourage the client to initiate the activity of grooming even when unwilling. : The act of grooming and its results can

GOAL MET January 11, 2011 @ 10:00 AM At the end of 3 days of nursing care, the patient was able to: Perform self-care activities within level of own ability as evidenced by: - Dressing appropriately - Grooming self appropriately

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with bathing, grooming, personal hygiene, and selection of appropriate clothing may be necessary. Shives, L.R. (2008). Basic concepts of psychiatricmental health nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

influence the clients attitude in a positive way. 8. Ensure that the client is clean and wellgroomed. : A neat appearance prevents the embarrassment and emotional/physical trauma that result from being an object of ridicule. 9. Praise the client for attempts at self-care and reach successfully completed task. : Positive reinforcement increases feelings of self-worth and promotes continuity of functional behaviors. 10. Teach the family the importance of promoting the clients self-care abilities. : Family involvement provides continuity between the hospital and home environment and ensures the clients progress while decreasing dependency. 11. Give simple step-by-step reminders for hygiene and dress. : Distractibility and poor concentration are countered by simple, concrete instructions.

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DATE

CUES

NEED

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

J A N U A R Y 8, 2 0 1 1 @ 9:00 AM

SUBJE CTIVE: Naay kausa nga nagbakt as na siya ug diretso, unya katong nakasug at na siya ug elf track, wala jud siya niliko o maski nilikay Hapid gyud maligsa n, as verbaliz ed by the patients mother. OBJEC TIVE:

H E A L T H P E R C E P T I O N H E A L T H M A N A G E M

Risk for injury directed to self related to poor judgment and delusions R: Because of the clients poor judgment, excessive and constant motor activity, probably dehydration, and difficulty evaluating reality, the client is at risk for injury. Varcarolis, E.M. (2004). Manual of psychiatric nursing care plans: Diagnoses, clinical tools, and psychopharmacol ogy. St. Louis, MO: Saunders.

At the end of 4 days of nursing care, the patient will be able to: -Be free of injury

1. Reduce or minimize environmental stimulation. : A soothing external environment helps to calm the clients internal state, reduces hyperactivity, and prevents accident or injury. 2. Remove furniture with sharp edges from the clients environment, and place furniture/obstructing objects as close to the wall as possible. : An open, uncluttered space is more likely to prevent accident or injury. 3. Praise the client for efforts made to use physical energy productively and avoid accident or injury. : Positive feedback reinforces safe, adaptive behaviors and increases the clients self-esteem. 4. Provide frequent rest periods. : Prevents exhaustion. 5. Redirect violent behavior. : Physical exercise can decrease tension and provide focus. 6. Protect client from giving away money and possessions. : Clients generosity is a manic defense that is consistent with irrational, grandiose thinking.

GOAL MET January 12, 2011 @ 9:00 AM At the end of 4 days of nursing care, the patient will be able to: -Be free of injury

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Grandio sity Restless ness Poor judg ment

E N T P A T T E R N

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Da te J A N U A R Y 8, 2 0 1 1 @ 8:0 0 AM

Cues

N ee d R

Nursing Diagnosis Risk for otherdirected violence related to manic behavior Manic individual alternates quickly between elation and irritability for a time, but usually an irritable, unpleasant mood becomes predominant. It is often this irritability that brings the patient to medical attention. As the manic state continues to develop, pressured, racing thoughts, increased energy level, and loss of inhibitions lead to more disorganized and disturbed thinking and behavior. Driven by greater pressure of activity, terror and excitement, the manic person becomes violent, attacks neighbor, begins to shout all kinds of accusations against his alleged persecutors. Distortions and misinterpretation s are now elaborated into delusions of persecution accompanied by violence and panic, the patient runs down the street nude, sets fire to the house,

Planning

Intervention

Evaluation

Objective: demonstrat es aggressive behavior -Presence of delusions -destruction of property -irritated facial expression restlessnes s

O L E R E L A T I O N S H I P

P A T T E R N

At the end of Goal met 1. Assess clients behavior 2 days of PROGNOSIS frequently every (15 minutes) for nurse-patient January 10, signs of increased agitation and contact, the 2011 @ hyperactivity. patient will be 8:00AM Early detection and intervention of able to: escalating mania might help prevent At the end of 2 harm to self or others, and decrease days of nurse Demo patient contact, need for seclusion. nstrat the patient was able to: 2. Build a trust relationship with the e client as soon as possible; ideally Demons reduct well in advance of aggressive trate ion of episodes. reductio violent Familiarity with and trust in the n of or staff members can decrease the violent aggre clients fears and facilitate or ssive communication. aggressi 3. Listen for verbal threats or hostile behav remarks directed toward self or ve ior others. behavior The clients verbal threats, Partici physical contact, and acting out may Participate pate be precursors or cues to impending in therapy in violence. for therap 4. Help the client manage angry, underlying y for inappropriate, or intrusive behaviors or underl in a therapeutic but firm, direct associated manner. ying psychiatric Helping the client manage anger, problems or inappropriate, or intrusive behaviors associ early in the escalation phase may ated prevent assault or violence. psychi 5. Reduce milieu noise and atric stimulation, or accompany client to a proble calmer, quieter environment at early signs of anger, agitation or ms frustration. A calm external environment often helps to promote a relaxed internal state within the client and may lessen agitation and prevent violence. 6. Praise the client for efforts made to control anger or hostility directed at self or others. Positive feedback reinforces repetition of positive, functional behaviors. 7. Allow the client freedom to move around unless you are trying to restrain him. Interfering with the clients mobility without the intent of restraint may increase the clients frustration, fears, or perception of threat. 112 8. Talk with the client in a low, calm

Precipitating factors

starve himself too much to lose weight, and he always gets very tired from his boxing practices. The proponents rated this area as poor since the patient is abusing his body with the way he practices his diet. Patient is lively and overt in participating

Mood and affect

with

conversations. with

He

expresses

his

feelings

appropriate

facial

expressions and verbalizations. The prognosis of the patients attitude and willingness Attitude Willingness take and treatment and to / medications robotic and to take medication and treatment is only fair. He dislikes taking sometimes slow in terms because of doing according to him, medications make him activities. On the other hand, there are also times that he is willing to take his medication and treatment because, according to him, he knew that something is wrong with him and that he needed medical attention so he sometimes follows his medication and treatment regimen. During the interview, the patient does not show any signs of depressive features. Any depressive / The patient knew that something is wrong with him and that he needed medical attention, but still, he is not depressed with this fact. Not getting the things he wants does not make him depressed, but instead manifests hostile tendencies. The patient has a good foundation of family support. His family encourages him Family support / to follow his medication and treatment regimen. The members of his family work features

medication

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hand in hand in providing him his needs with regards to his illness. Computation: TOTAL 4 1 2 Poor (4*1)/7 Fair (1*2)/7 =4/7 =2/7 =6/7 = 1.72 = POOR = FAIR = GOOD

Good (2*3)/7 TOTAL

GENERAL PROGNOSIS: 1-1.6 1.7-2.3 2.4-3.0 Rationale for FAIR PROGNOSIS: The patient has a fair prognosis therefore he has a small chance, according to the calculation, of recovering from his illness. The onset of illness was approximately more than four years ago. He was not immediately brought to the hospital, and the family waited for about a month before deciding to bring him to the hospital because of having hostile tendencies, on the morning prior to admission. The duration of illness is long since it was last December 13, 2006 that he was first diagnosed with brief psychotic disorder, and just this last January 05, 2011 that he was diagnosed with Bipolar 1 Manic Phase with PF. On the whole duration of his illness, the patient still continued the abusive process of his diet through starving himself too much and becoming too tired. In addition to that, his attitude in following his medication and treatment regimen is not continuous. It is only at some points in time that he submits himself for medication and treatment. Furthermore, during the interview, the patient has appropriate mood and affect. He also has a good family support as evidenced by how his family gives him provision in the duration of his condition. The family understood what he is experiencing, giving him the support he needs for his recovery. Lastly, the patient does not show any depressive features. The patient knew that something is wrong with him and that he needs medical attention only at some times.

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RECOMMENDATION The group 4 of section 3A would like to recommend the following: To the patient: As student nurses, it is our duty to make sure that the patient will be advised to take part in complying with the treatment; the medication and therapeutic regimen designed for his rehabilitation. Adequate rest, appreciation, and encouragement to the patient must be given importance, being aware of his condition. This will allow the patient to adapt to different stressors, and in turn may be helpful in dealing with his daily living. The patient should realize the importance of complying with his medication and the benefits this practice would bring to the improvement of his well-being. To the patients family: The role of the family is very important for the progress of the patients rehabilitation process. They are the primary provider of guidance and main support system of the patient. The family should make themselves physically present so that the patient would feel their support and they are encouraged to continue interacting with the patient so that possible ideas of violence towards self and others will be diverted. In addition, it is of prime importance that they are oriented and educated regarding the patients mental illness so that they will understand him even better and assist him in his daily activities. To the Davao Mental Hospital: The group recommends that they should improve their facilities in treating the mentally-ill patients, because still they deserve due treatment. The patients must be kept clean, well-fed, and have mattresses to sleep on. The hospital must provide a safe and therapeutic environment to the patients and staff, address the needs of each patient by first assessing the level of severity of the patients condition. Let every patient be submitted for history and physical examination and be evaluated by a psychiatrist, so that appropriate care is rendered to them. The proponents recommend that the psychiatric team would work together in order to provide mental health care service that promotes rehabilitation of the patient. Also they are recommended to know the latest trends in improving therapeutic communication between them and the patients.

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To the Ateneo de Davao University, College of Nursing: All the things we learned and achieved, all the concepts that have been inculcated in our minds, most of it we owe to the prestigious College of Nursing of the Ateneo de Davao University. The college has provided before us the necessary exposures for us to fully achieve what we are today. The faculty and staff are highly recognized for their noble effort and dedication in uplifting the standards of the Ateneo Nursing Curriculum thus providing us education of highest quality for the near future. We recommend that the faculty and staff, especially the clinical instructors, continue to give quality education to the student nurses in the Ateneo. The clinical instructors should be learned and confident in their teaching skills and are encouraged to be more patient and considerate with the students. Also, the College of Nursing should improve its facilities for the student to be well-equipped with their learning experience To the Student Nurses: Even if the nursing students find it difficult to establish therapeutic relationships with mentally-ill patients because of the relatively short time spend in the clinical area, we still have to render more amounts of effort to establish trust in every interaction we make with the patients. We should improve our therapeutic technique in caring for our patients, that we may play a part in the rehabilitation of these patients.

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SIGNIFICANCE OF THE STUDY

This study will be a significant undertaking in depth understanding the reason behind our subjects mental illness. This study will also be beneficial to the students and clinical instructors in College of Nursing in making use of different concepts taught inside the classroom related to psychiatric nursing.

This case study will give us better understanding regarding mentally-ill patients; provide recommendations on how to deal with them in the future. It will give us better grasp why certain people experience being mentally unstable by looking deeper into the history, physiology, brain chemistry; development of physical, emotional and cognitive; and social relations of the patient.

Some of the mentally ill patients remain undiagnosed and untreated because they never sought medical attention due to old stigmas and societal attitudes towards mental illness. Stigmas results in the social exclusion of people with a mental illness and is detrimental to the part of the family. Moreover, this study will be helpful to aid the family in caring their mentally-ill member; giving them more understanding, acceptance, and how to deal with the illness and issues concerning it.

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BIBLIOGRAPHY Broyles, Bonita E., Reiss, Barry S., Evans, Mary E. 2007. Pharmacological aspects of nursing care. 7th edition. Singapore: Thomson Learning Asia. Cohen, Barbara Janson, & Taylor, Jason James. Memmlers Structure and Function of the Human Body. (2009). 9th Edition. Philadelphia: Lippincott Williams & Wilkins. Deborah Antai- Otong, Psychiatric Nursing Biological and Behavioral Concepts Thomson Asian Ed., Delmar, Singapore, 2003. Doenges, Marilynn E., & Moorhouse, Mary Frances, & Murr, Alice C. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. Philadelphia: F.A. Davis Company. Doenges, Marilynn E., & Moorhouse, Mary Frances, & Murr, Alice C. (1997) Nursing Care Plans: Guidelines for Individualizing Patient Care. Philadelphia: F.A. Davis Company. DSM IV TR 4th edition by American Psychiatric Association 2004 Fortinash, K. and Holoday Worret, P, Psychiatric Nursing Care Plans 4th edition, Mosby Inc., Westline Industrial Drive, St. Louis, Missouri, 2003 Fundamentals of nursing 7th edition by Kozier, 2004 Keltner, Schwecke, Bostrom, Psychiatric Nursing 3rd Ed., Mosby Inc., Singapore , 1999. Late, P. (2009). Seeleys Principle of Anatomy and Physiology. (p. 616) McGraw Hill; New York, NY 10020 Mondimore, F. (2006). Bipolar disorder a guide for patients and families. Baltimore, MD: The John Hopkins University Press. Mosbys Pocket dictionary 4th edition2002 by Mosby Nurses Drug Handbook. (2010). 9th edition. USA: Jones and Bartlett Publishers. Nurses Pocket Guide edition 10, Doenges 2006 by F.A. Davis

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Psychiatric Mental Health Nursing 5th edition, Mary C.Townsend Sheila Videbeck, Psychiatric Mental Health Nursing 2nd Ed., Wolters Kluwer Company, Philadelphia,2004.

Shier, Butler, Lewis. Holes Human Anatomy and Physiology. 12th Edition. (p. 371). Mosby Elsevier Inc., 11830 West line Industrial Drive St Louis, Missouri 63146. Shives, L.R. (2008). Basic concepts of psychiatric-mental health nursing. Philadelphia, PA: Lippincott Williams & Wilkins. Spratto, George R. & Woods, Adrienne, L. (2005). Pdr nurses drug handbook. USA: Thomas Delmar Learning. Springhouse nurses drug guide. (2007). USA: Lippincott Williams & Wilkins. Tortora, G & Grabowski, S. Principles of Anatomy and Physiology. 9th edition. (p. 793). John Wiley and Sons, Inc VanPutte, Cinnamon, et. Al. Seeleys Essentials of Anatomy & Physiology. (2010). 7th Edition. New York: McGraw-Hill Varcarolis, E.M. (2004). Manual of psychiatric nursing care plans: Diagnoses, clinical tools, and psychopharmacology. St. Louis, MO: Saunders. Widmaier E., Raff, H., Strang, K. Vanders Human Physiology. The Mechanism of Body function. 2008 Edition. (p.449) McGraw Hill; New York, NY 10020.

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