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SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING

Baguio City

CASE ANALYSIS
Case 3:
Bipolar Disorder

Submitted to:
Sir Jay Ablog

Submitted by:
BABAY, Leanlexoz Valiant
MERCADO, Ismael
CASTRO, Alyssa Jean
CABRITO, Carla Cassandra
DEL ROSARIO, Katrina
GOMEZ, Charlene Dec
MATEO, Lynn Dinah
MIRALLES, Sharmayne
OTEYZA, Darianne
PINLAC, Paula Jane
BSN 3D1

PROFILE:

Marina

20 years old, sophomore, college


Goes without any sleep, spent time in a heightened state of activity
Describe herself as OUT OF CONTROL
behavior is strange and grandiose ideas on a mystical/sexual tone

(recently proclaimed to a group of friends that she did not menstruate


because, she was a of a third sex, a gender above the human sexes
explained that she is superwoman can avoid human sexuality an still give
birth.

Believes that she had switched souls with that senior senator from her
state states that it would make her particularly well suited for a high
position in government; perhaps even the presidency.

Worries that she will forget some of her thoughts begun writing notes
everywhere (notebook, computer, even on the walls of her dormitory.

Family & friends known her for being extremely tidy and organized
room is disarray with frantic and incoherent messages written all over
the walls and furniture. (messages reflect her disorganized, grandiose
thinking about spiritual and sexual themes)

Experienced two previous episodes of wild and bizarre behavior


ALTERNATED WITH PERIODS OF INTENSE DEPRESSION.

When depress doesnt attend classes, school activities, insomnia,


poor appetite difficulty in concentrating
Contemplated suicide

Family History

Grew up in a TRADITIONAL FILIPINO HOME

With overprotective and demanding parents

5 siblings the only one who always obeyed her parents and played
the role of the GOOD GIRL in the family she describes as Little Miss
Perfect

Quite dependent on her parents

Describes her siblings as rebellious her older sister told her parents
that she was sexually active in high school

Parents are strict with sexual matters never discussed issues r/t to
sex except to make it clear that their children were to remain virgins
until they were married
Mother forbade her to wear makeup.

Shocked and frightened when she began menstruating distressed


and loss of control

Never dated high in high school and has never had a steady boyfriend

With history of mood disorders Maternal grandfather (depression),


her fathers aunt (depression when she went through menopause)

BIPOLAR DISODER
ACCORDING TO DSM 5
Bipolar disorder is a mental health condition that is characterized by periods
of both MANIA and DEPRESSION; the criteria for bipolar requires at least one
depressive episode and one mania episode.

BIPOLAR DISORDER I (Marinas Case)


It involves one or more manic episodes or mixed (mania and depression) episodes.
The episodes are not due to medical condition or substance abuse.

Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased goal-directed activity or energy,
lasting at least 1 week and present most of the day, nearly every day (or any
duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a
significant degree and represent a noticeable change from usual behavior:
1
2
3
4
5
6
7

Inflated self-esteem or grandiosity


Decreased need for sleep
Pressure of speech
Flight of ideas
Easily distracted
Excess pursuit of goal-directed activities or psychomotor agitation (pacing ,
hand wringing and etc.)
Excess pursuit of pleasure with high risk of danger

C. The mood disturbance is sufficiently severe to cause marked impairment in social


or occupational functioning or to necessitate hospitalization to prevent harm to self
or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication, other treatment) or to another medical condition.

Major Depressive Episode


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
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report
2. Markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day
.3. Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in appetite
nearly every day
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate, or indecisiveness, nearly every
day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal


ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide.
B The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
C. The episode is not attributable to the physiological effects of a substance or
another medical condition.

BIPOLAR DISORDER II ( addition)


For a diagnosis of bipolar II disorder, it is necessary to meet the following
criteria for a current or past hypomanic episode and the following criteria for a
current or past major depressive episode:

Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased activity or energy, lasting at least
4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three
(or more) of the following symptoms have persisted (four if the mood is only
irritable), represent a noticeable change from usual behavior, 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 (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or obsen/ed.
6. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual 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. If there are psychotic
features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication or other treatment).

* characterized by a clinical course of recurring mood episodes consisting of one or


more major depressive episodes (Criteria A-C under "Major Depressive Episode")
and at least one hypomanic episode

Major Depressive Episode


A. Five (or more) of the following symptoms have been present during the same 2week 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
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report
2. Markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day
. 3. Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in appetite
nearly every day
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate, or indecisiveness, nearly every
day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide.

BIPOLAR 1

BIPOLAR 2

Mania

Hypomania

Full blown mania


Mania may include
psychotic symptoms delusions or hallucinations.
Mood is extremely
abnormal combined with:
increased activity or
energy that is also
abnormal.

Mild Mania
Hypomania does not have psychotic
symptoms.
Sustained mood :
elevated (heightened),
expansive (grand, superior) or
irritabl
e.

*A note on psychosis and bipolar II disorder:

someone with bipolar II MAY experience hallucinations or delusions during


depressive episodes without the diagnosis changing to bipolar I.

OTHER TYPES

Rapid Cycling

-diagnosed when a person experiences four or more manic, hypomanic, or


depressive episodes in any 12-month period.

-----may be a temporary condition for some people.

"Mixed features

-occurrence of simultaneous symptoms of opposite mood polarities during


manic, hypomanic or depressive episodes.
-It's marked by high energy, sleeplessness, and racing thoughts. At the same
time, the person may feel hopeless, despairing, irritable, and suicidal.

RISKS AN DIAGNOSTIC FACTOR

ENVIRONMENTAL - More common in high income than low income


countries.

GENETIC AND PHYSIOLOGIC- Family history of Bipolar is the strongest and


most consistent risk.

GENDER RELATED Female are more likely to experience rapid cycling and
mixed states

MEDICATIONS/TREATMENTS
LITHIUM (first drug of choice)

Mood stabilizing drugs are used to treat bipolar disorder by stabilizing the
clients mood, preventing or minimizing the highs and lows that characterize
bipolar illness, and treating acute episodes of mania.

Mechanism of action poorly understood

Normalizes the reuptake of certain neurotransmitters such as serotonin,


norepinephrine, acetylcholine, and dopamine.

It also reduces the release of norepinephrine through competition with


calcium

The effective dosage of lithium is determined by monitoring serum lithium


levels and assessing the clients clinical response to the drug.

Daily dosages generally range from 900 to 3,600 mg - serum lithium level
should be about 1.0 mEq/L.

Serum lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels
of more than 1.5 mEq/L are usually considered toxic.

********!!!!!!!WARNING: Lithium
Toxicity is closely related to serum lithium levels and can occur at therapeutic
doses. Facilities for serum lithium determinations are required to monitor
therapy
Toxic effects of lithium are:
Severe diarrhea

Vomiting,

Drowsiness
Lack of coordination.
Muscle weakness
*if untreated, these symptoms worsen and can lead to
Renal failure
Coma, and death.
*When toxic signs occur, the drug should be discontinued immediately.
If lithium levels exceed 3.0 mEq/L, dialysis maybe indicated.

1. BIPOLAR AND ANTICONVULSANTS

recognized as mood stabilizers to treat or prevent mood episodes

calms hyperactivity in the brain

prescribed for people who have rapid cycling- four or more episodes of
mania and depression in a year

Depakote, Depakene (divalproex


sodium, valrpoic acid, or avalproate
sodium
Lamictal (lamotrigine)
Tegretol (carbamazepine)

2. ANTIPSYCHOTIC DRUGS

Side Effects:

Dizziness
Drowsiness
Fatigue
Nausea
FOR BIPOLAR
Tremor
Rash,
control psychotic
symptoms
Weight
gain

short-term treatment to
such as
hallucinations, delusions or mania symptoms (occur during acute
mania or severe depression; some also treat bipolar depression and
several have demonstrated long-term value in preventing future
episodes of mania or depression)
Abilify (aripiprazole)
Side Effects:
Clozaril (clozapine)
Geodon (ziprasidone)
Weight gain
Latuda (lurasidone)
High cholesterol levels
Saphris (asenapine)
Increase risk of diabetes
Seroquel (quetiapine)
Blurred vision
Zyprexa (olanzapine)
Dry mouth
Drowsiness

3. BENZODIAZEPINES
-help control certain manic symptoms (restlesness, agitation or
insomnia) ; slow the activity of brain--help treat mania, anxiety, panic
disorder and seizures

Side Effects:

Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Xanax (alrazolam)

WARNING:

can be habit-forming and addictive;


dangerous to combine them with alcohol; may suffer
withdrawal symptoms if stopped suddenly

Drowsiness
Lightheadedness
Fatigue
Blurred vision
Slurred speech
Memory loss
Muscle weakness

4. MAOI ANTIDEPRESSANTS AND BIPOLAR DISORDER


-should be used for bipolar depression only in combination with a mood
stabilizer such as lithium or valproate, to minimize risk of inducing mania

Side Effects:
Nardil (phenelzine)
Parnate
Difficulty getting to sleep
ELECTROCONVULSIVE
THERAPY
FOR BIPOLAR (ECT)
(tranylcypromine)
Dizziness
Marplan
(isocarboxazid)
short-term
treatment
for severe manic or depressive episodes, (particularly
when symptoms involve serious suicidal or psychotic symptoms or when
Dry mouth
medicines seem to be ineffective. It can be effective in nearly 75% of
patients)

Hypertension

an electric current is passed through the scalp to cause a brief seizure in the
Weight gain
brain.

fastest ways to relieve symptoms in people


whotwitching
suffer from mania or severe
Muscle
depression

PROCEDURES
Prior to ECT , a person is given a muscle relaxant and put under general
anesthesia.
-

Electrodes are placed on the patient's scalp, and an electric current is applied
that causes a brief seizure. Because the muscles are relaxed, the seizure will
usually be limited to slight movement of the hands and feet.

The patient is carefully monitored during the treatment.

The patient awakens minutes later, does not remember the treatment or
events surrounding the treatment, and may be briefly confused

usually given up to three times a week for 2-4 weeks

short term memory loss is a common side effect, although this usually goes
away 1-2 weeks after treatment, and can be minimized based on how the
electrodes are placed on the scalp and other technical aspects

Side Effects:

Mild nausea

Diarrhea

Anorexia

Fine hand tremor

Polydipsia

Therapies
applied

that could be

1. PSYCHOTHERAPY
"talk" therapy:

- behavioral therapy

- cognitive therapy

- interpersonal therapy

- social rhythm therapy

or

Polyuria

A metallic taste in the mouth

Fatigue or lethargy

Weight gain

Acne

2. SUPPORT GROUPS

- Establish routines : sleep, eat,


activity
- Do not use alcohol or drugs

3. EDUCATION
4.
MANAGEMENT

LIFESTYLE

Activities for Bipolar Disorder


Exercise

Boost endorphins during low periods and help


those with bipolar disorder feel more balanced. Outdoor
activities like hiking, mountain climbing, trail jogging and
skiing can be helpful since being in nature can have a
calming effect.
Stress-Reducing Activities

Can help some people with bipolar disorder relax after a


hard day. Deep-breathing exercises, yoga, meditation and
visualization can all help reduce stress. Doing such activities a
few hours before bedtime can also be helpful during hypomanic
periods, when energy levels are higher and restlessness sets in.
Social Activities

Meeting with close friends and family to talk or simply


spend time can benefit people with bipolar disorder.
Domestic Activities

Sedentary activities like watching TV can trigger


depression or anxiety because they are not fully stimulating,
according to Jay Miklowitz, author of "The Bipolar Disorder
Survival Guide." Replace them with domestic activities like
cleaning, doing laundry, washing dishes, vacuuming or giving a
pet a bath.
Volunteering

Can help those with bipolar disorder fill time and give
back to those in need, which can help them feel more
balanced. Involve yourself in charitable activities based on
personal interests or hobbies.

LIST OF NURSING DIAGNOSES

1. Altered sensory perception r/t endogenous chemical alteration

2. Alteration in thought processes related to biochemical alteration

3. Disturbed sleep pattern r/t psychological stress

4. Imbalanced nutrition: less than body requirements r/t poor appetite

5. Interrupted family processes r/t situational crisis

6. Ineffective individual coping

7. Impaired social interaction r/t state of depression

8. Risk for self-directed or other directed behavior r/t wild and bizarre
behavior

Be

First Prioritized Nursing Diagnosis:


INTERVENTIONS
DISTURBED
PROCESS
sincere
and
honest THOUGHT
when Engage
the client in one-to-one activities

communicating with the client. Avoid at first, then activities in small groups,
vague or evasive remarks.

and gradually activities in larger groups.

Be consistent in setting expectations,

Recognize

enforcing rules, and so forth.

accomplishments (projects

Do not make promises that you cannot

responsibilities

keep.

initiated).

Encourage the client to talk with you, but

Show empathy regarding the clients

do not pry for information.

feelings; reassure the client of your

Give positive feedback for the clients

presence and acceptance.

successes.

Do not be judgmental or belittle or joke

Recognize the clients delusions as the

about the clients beliefs.

and

support
fulfilled,

the

clients

completed,
inter-actions

clients perception of the environment.

Directly

Initially, do not argue with the client or

delusions as soon as the client seems

try to convince the client that the

ready to accept this (e.g., I find that

delusions are false or unreal.

hard to believe.). Do not argue but

Never convey to the client that you

present a factual account of the situation

accept the delusions as reality.

as you see it.

Interact with the client on the basis of

Ask the client if he or she can see that

real

the delusions interfere with or cause

things;

do

not

dwell

on

the

interject

doubt

regarding

problems in his or her life.

delusional material.

Second Prioritized Nursing Diagnosis:


DISTURBED SLEEP PATTERN

INTERVENTIONS
Provide a quiet environment, with a low
level of stimulation.
Monitor
sleep
patterns.
Provide
structured schedule of activities that
includes established times for naps or
rest.
Before
bedtime,
provide
nursing
measures that promote sleep, such as
back rub; warm bath; warm, non
stimulating drinks; soft music; and
relaxation exercises

Administer sedative medications, as


ordered, to assist client achieve sleep
until normal sleep pattern is restored.
Assess clients activity level. Client may
ignore or be unaware of feelings of
fatigue. Observe for signs such as
increasing restlessness, fi ne tremors,
slurred speech, and puffy, dark circles
under eyes.
Prohibit intake of caffeinated drinks, such
as tea, coffee, and colas.

JOURNALS
Managements for Patients with Bipolar Disorder

1. Cognitive behavioral therapy-based treatment comprising three


modules:

-Nutrition teaches appropriate serving sizes and balanced diet;


-Exercise emphasizes increasing weekly physical activity;
-Wellness focuses on skills for healthy decision-making.

2. Psychoeducation is a simple approach to support prevention of future


episodes by delivering behavioural training to improve illness insight, early
symptom identification and development of coping strategies.

3. Enhancing patient self-management skills with group psychoeducation;

-Providing clinician decision support with simplified practice guidelines


-Improving access to care, continuity of care, and information flow via nurse
care coordinators
-Nursing interventions can help by educating the caregivers of the disorder
and informing them of treatments, encouraging the use of support systems,
and collaborating with multiple healthcare and community resources.


4. Psychological interventions should form the foundation of therapy for
adolescents and children, as medicines used in bipolar disorder can have a
damaging effect on childrens growth and development.

5. Nurses are in a position to build rapport and counsel that bipolar patient on
effective techniques for managing the disorder and maintaining a good state
of physical health. Interventions for the patient experiencing mania include
encouraging patients to eat high-calorie finger foods to help
maintain nutrition during states where the patient may not want to
sit down to consume a meal(Follin, et al., 2006). It is also important to
encourage and provide a quiet non-stimulating environment and
quiet activities for the patient to do. During periods of depression,
patients should be encouraged to participate in group therapy. It is also
helpful to encourage patients to use a journal to write down their feelings
when they are having difficulties talking about them.

REFERENCES:

American Psychiatric Association. (2013). Diagnostic and statistical


manual of mental disorders

(5th ed.). Arlington,VA: American Psychiatric Publishing.

Medications. 8th Edition. Philadelphia : F.A. Davis Company.

Schultz D.P. & Schultz S.E. (2005). Theories of Personality. Belmont, CA:
Thomson Wadsworth

Company

Townsend, M. (2011). Nursing Diagnoses in Psychiatric Nursing: Care


Plans and Psychotropic

Videbeck, S. (2008). Psychiatric-mental health nursing (4th ed.).


Philadelphia, PA: Lippincott Williams & Wilkins.