1

BIPOLAR DISORDER: A CASE STUDY

A Case Presented
to the Faculty of School of Health Sciences
University of Saint Louis
Tuguegarao City, Cagayan Valley

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

By:
ANGELIE ROSE B. BAYAUA
KREIZZTEL ANGELLI F. BIGGAYAN
SHERYLINE C. LATTAO
PAULINE KAYE B. MANGADA
ANABELLE LEE I. UDDIPA

July, 2016
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ABSTRACT

The research study aims to familiarize students on adolescent bipolar disorder and the
efficacy of adjunct psychotherapy, medical management, and nursing intervention. The
research study also elucidates its benefits to the nursing profession, and in the
community as regards the symptomatic management of bipolar disorder. the
researchers utilized a descriptive interview method identifying and verifying the
psychopathological origin of bipolar disorder, which involves the patient, his significant
others, other support system, and the members of the healthcare team. With the advent
of this case study endeavor, the researchers focused on one patient confined within a
mental health institution in Tuguegarao City. Result of the study revealed that the
general support system and the milieu of the patient diagnosed with bipolar disorder
have significant influence on the general well-being of the patient; thus, the researchers
conclude that the family of the patient must be in constant communication and
interaction with him, aside from regular members of the healthcare team assigned.

Keywords: bipolar, adolescent, psychopathophysiology, nursing, nursing care plan,

general plan of care, outcome of care
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TABLE OF CONTENTS

Title Page
Title Page .. 1
Abstract .. 2
Table of Contents .. 3
List of Table .. 4
List of Figure .. 4

THE BACKGROUND OF THE STUDY

Subjective Background .. 5
Objective Background .. 14
Review of Related Literature .. 15

GENERAL PLAN OF CARE

Course in the Ward .. 23
Nursing Care Plan .. 25
Drug Study .. 62

OUTCOME OF CARE
Testimonials ...... 62
Patient Status .. 63

Discussion .. 63
Conclusion .. 63
Recommendation .. 64

REFERENCES .. 64

APPENDICES
A. Literature Matrix .. 68
B. Letter to the Clinical Instructor .. 89
C. Letter to the Informed Consent to the Patient .. 91
D. Physical Assessment .. 95
E. Course in the Ward .. 103
F. Drug Study .. 111
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LIST OF TABLE
Table No. Title Page

1 Nurse Patient Interaction 9

2 2012 Local Statistics of Bipolar Affective Disorder 16
3 2013 Local Statistics of Bipolar Affective Disorder 17
4 2014 Local Statistics of Bipolar Affective Disorder 17
5 International Statistics of Bipolar Disorder 18
6 Nursing Care Plan on Knowledge Deficit 25
7 Nursing Care Plan on Self-care Deficit 29
8 Nursing Care Plan Disturbed Sleep Pattern 33
9 Nursing Care Plan on Impaired Social Interaction 38
10 Nursing Care Plan on Ineffective Role Performance 44
11 Nursing Care Plan on Situational Low Self-esteem 48
12 Hopelessness 52
13 Risk for Suicide 57

LIST OF FIGURE
Figure No. Title Page

1 Psychopathopysiology 20
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THE BACKGROUND OF THE STUDY

Subjective background

I. Patients profile

Patient B.D is a seventeen years old male. July 22, 2013, he came to Cagayan
Valley Medical Center with the following complaints of impaired sleep pattern, poor
appetite and irrelevant speech. He was diagnosed with Bipolar Disorder by Dr. Paggadu.
B.D was born September 29, 1997 at Manaring, Isabela. His religion is Roman Catholic
while his civil status is single. He recalled his educational attainment in highschool level
only.

II. Mental Status Evaluation

i. History

Family History

Patient B.D is an only child. He is seventeen years old and can remember the
age of his parents. His mother died at the age of 39 years old due to fibrous myoma. He
was eleven years old at that time. His father is 54 years old and described his health as
Okay naman siya, maam. And when we asked if his father has vices, he verbalized
Manginginom dati si Papa pero huminto noong dinala niya ako dito. His father has no
history of mental disorder. His grandfather on his father side died at the age of 86 due to
hypertension while his grandmother died at the age of 85 due to lung disease. Also, his
grandparents on his mother side are still alive and dont have any history of hereditary
diseases.

Health History

Patient B.D completed his vaccination. He was first hospitalized last August 22,
2014 at Cagayan Valley Medical Center due to persistent vomiting and epigastric pain.
He was diagnosed with Peptic Ulcer Disease and stayed there for two weeks with
regards to his admission at Cagayan Valley Medical Center Psychiatry Ward, he was
first admitted last September 1, 2011 because of the following symptoms; keeps on
running and talking to self with irrelevant speech, destroys things, impaired sleep pattern
and poor appetite. These symptoms occur four days prior to admission. He was
discharged after six days and was readmitted four more times. The second admission
was on September 7, 2011, third admission was on June 28, 2012, fourth admission was
on June 20, 2013 and fifth admission was on July 22, 2013 which is now the current
confinement. All admissions are due to remission of symptoms similar to those observed
in his first admission. His fifth admission was triggered by an argument with his cousin
who he claims to be confidential. His father decided to readmit him at Cagayan Valley
Medical Center Psychiatry Ward since he exhibited behaviors the same as the one
previous mentioned. He rated his health as 7/10 before hospitalization because he can
do what he wants such as playing with his playmates and can do his vices (he learned
his vices when he was institutionalized) such as smoking consuming pack of cigarette
each day and drinking alcohol during occasions but during hospitalization he rated his
health as 6/10 because he exhibited symptoms of scabies and he felt untidy about it. For
 6

him, being clean is part of being healthy. But the patient sometimes admits that he
neglect his personal hygiene. He can still do his vices such as smoking consuming
pack of cigarette each day and drinking alcohol as written in his past medical records,
during his first out-patient consultation.

Growth and Development

Patient B.D verbalized Mahilig akong maglaro noon maam. Noong nagsimula
akong pumasok sa primary school lagi akong nakikipaglaro sa mga classmates ko,
palakaibigan po kasi ako. Saka lang po akong tumigil sa paglalaro kapag yung favorite
subject ko na yung inaaral namin. Noong pumasok ako sa secondary school, ang
daming nagbago maam. Isa na dun yung pakiramdam ko ayaw ako ng mga classmates
ko kaya hindi ko sila nilalapitan. He was circumcised when he was in Grade 5. His
coitarche happened when he was thirteen years old.

Beliefs

He is a Roman Catholic, believes in God, attends mass and prays every day. He
prays for his family (especially for his father) and also for his self to be given safety and
blessings. He also believes in superstitious beliefs such as Bawal magwalis kapag
gabi, bawal magnail cutter kapag gabi and bawal maglaba tuwing may patay. His
beliefs didnt change even during hospitalization.

ii. Activities of Daily Living

Diet and Elimination

Before hospitalization, he stated that he drinks approximately 8-10 glasses of

water per day and eat 3 times a day with snacks in between meals but there are days
that he only eats whenever they have food. He claimed that he has good appetite. His
food preferences are meat, vegetables and fruits. He doesnt have any food allergies. He
doesnt have any difficulty in chewing and swallowing. He defecates two times a day;
stool is brown in color and is well-formed. He voids whenever he felt like doing so; urine
is yellow in color and aromatic. Both elimination patterns are normal. Normal defined as
experiencing no pain and difficulty while doing it.

During hospitalization, he stated that they are given food daily but sometimes he
refused to eat them because he said that the food werent palatable enough or that he
does not have the appetite. He drinks whatever is offered by the institution (water,
snack) whenever he feels thirsty but doesnt pay attention to the amount, even the
approximation since he used different container. He verbalized that he usually defecates
two times a day; stool is yellow in color and is well-formed. He voids whenever he felt
like doing so; urine is yellow in color and aromatic. Again, both elimination patterns are
normal.

Exercise and Activity

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Before hospitalization, he stated that Puro laro naman po yung ginagawa ko

maam. Minsan tinutulungan ko si Papa sa gawaing bahay tulad ng paglalaba at
pagwawalis ng bahay. Pero madalas pa rin yung laro. Yun ung exercise ko,
maam.During hospitalization, he stated that Wala po akong exercise ngayon maliban
lang kung nilalabas niyo kami at nagpapaactivity kayo, maam.

Sleep and Rest Pattern

Before hospitalization, he said that he sleeps at around 8 pm with duration of

approximately 9 hours. Rest periods involve watching television and sometimes a nap in
the afternoon. During hospitalization, he said that he sleeps for approximately 4-5 hours
only because of the environment which is Mabaho po tsaka siksikan as verbalized and
his co-patients who are noisy. According to him Maingay kasi yung mga iba sa loob. Di
po ako makatulog ng maayos. He also said that sometimes he can go days without
sleep.

iii. General Appearance

Appearance/Speech/Motor activity

The patient and from the data taken from the chart, it is stated that hes 17 years
old and is appropriate to his age. He wears clothes that is brightly colored and is
appropriately for his age and weather. He maintains eye contact but sometimes not.
Sometimes he speaks rapidly and often loud speech without pauses. He doesnt have
any abnormal motor activity. He is malodorous and has dead tissues (libag). His nails
are dirty. He has scars on his arms and feet due to scabies. He is cooperative, friendly,
polite, alert, open and candid.

iv. Emotional State

He displays euphoric mood but he feels sad when we asked about his past
experiences. He said that he dont want that to happened again. He also verbalized that
Kapag nakalabas ako dito, maam. Mag-aaral po ulit ako. Para kahit papaano
matulungan ko si Papa kahit vocational course lang.

v. Experiences

He said that his experience being bullied greatly affected him. Even his
performance at school and relationship with his father got affected. On his first week
being a first year high school, hes always being picked by the seniors and abuses him
emotionally (verbal abuse) and sometimes physically (being slapped). He also said that
he got depressed when the wealth of his parents went down. All their source of living
went down. He believed that their relatives were the cause spreading stories that werent
true about their family. Inside the institution, he experienced being in petty fights with his
fellow patients especially when he wants something that the other patient has.
Sometimes he is being picked even if he does not start or even if hes not involved in
someones squabble.

vi. Thinking
 8

Patients thought process is clear and understandable. His thought content

makes sense and his ideas are related and flows logically from one to the next.

vii. Sensorium and Cognition

Level of Consciousness

Patient B.D is oriented with time, date, and place but dont know about the
current news because they dont have television inside the institution.

Memory

The patients immediate memory is good because he remembered what he did

upon waking up in the morning. He also has a good recent memory because he can
recall the topics we talked about which is one week ago (date of MSE: February 7,
2015). His remote memory isnt that clear because he vaguely remember some during
his childhood.

Level of Concentration and Calculation

The patients ability to concentrate and calculate is good too. He was able to
spell the word WORLD backward and can repeat the days of the week backwards. His
calculations are good too.

Information and Intelligence

The patients abstract thinking is concrete when we asked him an idiomatic

expression such as Anong naintindihan mo sa salawikain na aanhin mo pa ang damo
kung patay na ang kabayo? he answered us with Itapon mo na yung damo. Patay na
kasi yung kabayo.

Judgment

The patients judgment is good. When we asked him Anong gagawin mo kapag
may nakita kang sulat sa harap ng pintuan mo? he answered us with Titignanko muna
kung para kanino yon.

Insight

Patient B.D. verbalized that Ayaw yata ako ng iba kong kapamilya ganun din
noong nagsimula akong pumasok sa secondary school. Pakiramdam ko di nila ako
gusto. Kaya di ko na lang sila nilalapitan.

Self-concept

Patient B.D describes him as shy type. He also said that he has difficulties
interacting with others. These are the weakness that he plans to change.

Coping Strategies
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According to the patient whenever he has problems he usually shared it to his

father. Sometimes he seeks advice from him for it to be solved. But sometimes when his
father is not around, he usually burst out and destroys things (breaking and throwing
things). When he does this somehow the weight bearing in his chest diminishes.

Role Relationship

The patient verbalized Pakiramdam ko hindi ako nakakatulong kay Papa dahil
sa kondisyon ko. It greatly affected him and his relationship with his father. There was
no satisfaction since hes staying inside the institution but he does his best helping his
father by doing simple things such as washing their clothes.

Table 1. Nurse-Patient Interaction

Nurses Patients Therapeutic Remarks

Question/statement response communication
Good morning Benedict, Good morning din Giving The patient smiles
ako si Sheryline Lattao, maam! recognition and maintains eye
student nurse kami from Giving contact.
Saint Louis information
Kumusta ka naman? Okay lang naman Giving The patient
maam. recognition smiles.

Dati ka na bang ino- Opo maam. Exploring The patient smiles

OT? So alam mo na and maintains eye
yung mga ginagawa contact.
kapag may activity?
May mga tatanungin Syempre naman Suggesting The patient
lang ako sayo, willing ka maam collaboaration seems excited
bang makicooperate? about the
meeting.
Wag kang mag-alala Sige po maam. Giving The patient
kahit anong oras mo information maintains eye
maisipang umayaw sa contact.
usapan pwede mo agad
sabihin. Magtatagal tayo
depende sa flow ng
usapan natin at kung
paano ka
makikicooperate sa
amin.
Saan mo gustong Hindi ko alam Broad opening The patient looks
umpisahan maam. Siguro Exploring away for a
? kung bakit ako moment then
dinala ni Papa. looks back. The
patient drums his
fingers on his
seat.
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Sa tingin mo ano yung May sakit daw ako Exploring The patient shift
dahilan ng pagdala niya maam. position but
sayo dito? maintains eye
contact.

Anong klaseng sakit? Bipolar daw ako Exploring The patient looks
maam. Hindi ko away then looks
naman alam kung back and shift
ano yun. position.
Sa tingin mo ba Oo naman maam. Exploring The patient shifts
nakatutulong yung Pero gusto ko ng position but
pagdala niya sa iyo umuwi. Ang hirap maintain eye
dito? kasi dito. contact.
Paano mo nasabing Hindi ko kasi Focusing The patient
mahirap dito? magawa yung maintains eye
gusto ko maam. contact but
Boring dito. sometimes he
looks away then
looks back.
Binibisita ka ba ng iba Hindi maam. Exploring The patient looks
mong kamag-anak? Pakiramdam ko down for a while
ayaw nila sa akin. then looks back.
Paano mo nasabing Eh kung ano ano Encouraging The patient looks
ayaw nila sa iyo? kasi yung mga expression down then looks
sinasabi nila back.
tungkol sa akin.
May nagbago ba sa Hindi naman ako Exploring The patient still
pakikitungo nila sa iyo? binibisita ng iba maintains eye
kong kamag-anak. contact. Voice
Ang dami kasing rose.
nangyaring di
maganda sa
pamilya namin. Si
Papa na lang yung
andito.
Si Papa na lang? Patay na kasi si Focusing The patients
Mama. voice went down.
There was silence
in the part of the
interviewee.
Napansin kong parang Hindi maam. Miss Making The patient shifts
naiiyak ka. ko lang kasi si Observation position then
Mama. Bata pa looks back.
kasi ako nung
namatay po siya.
Ilang taon ka ba noon? Onse pa lang ako Focusing The patient
noon maam. maintains eye
contact.
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Mukhang di ka . Making The patient looks

komportableng pag- observation down while telling
usapan yung tungkol sa his reply.
pamilya mo.
Kumusta si Papa mo? Okay naman siya Focusing The patient looks
maam. Pero back and
umuwi muna siya. maintains eye
Kumuha kasi siya contact.
ng pera.
May nagbago ba sa Wala naman Encouraging The patient still
pakikisama niya sa iyo? maam. Ganun pa expression remains an eye
rin pero minsan Exploring contact.
nag-aaway kami sa
konting bagay.
Ano ung mga konting Sa akin na lang Exploring The patient
bagay na yon? yon maam. remains eye
Nakakahiya kasi. contact and
Haha. Pero sige smiles.
maam sabihin ko
na. Tamad daw
kasi ako. Hindi ko
daw kasi siya
tinutulungan. Eh
siya naman yung
tamad hindi kaya
ako!
Tamad? Sa anong Gawain pang- Focusing The patient
paraan? bahay maam. remains eye
Paglalaba ng damit contact and
ganun. Naiipon speaks with
kasi yung damit gestures.
namin dito. Ang
tagal ko na kasi
rito. Pabalik balik
kasi ako rito
maam.
Pabalik balik? Ilang Maraming beses Focusing The patient
beses na ba? na maam. Pang Exploring speaks with hand
lima ko na ito. gestures.
Ano nga bang dahilan Baliw daw ako Exploring Patients voice
pag balik balik mo rito? maam. went down.

Baliw ka raw? Oo maam. Kasi Restating The patient

takbo ako ng takbo. maintains eye
Tsaka kung ano contact.
ano pinagsasabi
ko.
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May nangyari ba bago Opo maam. Exploring The patient looks

mo maranasan ang mga down and speaks
yon? with gestures.

Okay lang ba na pag- .. Making The patient looks

usapan natin? observation away for a
Silence moment then
looks back.
Silence on the
part of the
interviewee.
Mukhang hindi ka . Making The patient looks
komportableng pag- observation down for a while
usapan yung tungkol sa and silence in the
past mo. part of the
interviewee.

May problema kasi Silence The patient looks

ako noon maam. down while
Pakiramdam ko answering.
kasi ayaw sa akin Silence in the part
ng mga classmates of interviewee
ko. Tapos palagi before proceding.
akong
pinagtritripan noon.
Sinasabihan pa
ako ng masasakit
na salita.
Tumatahimik lang
ako that time
maam. Pero sa
totoo lang ang sakit
sakit sa loob.
Dagdag mo pa
pagkawala ni
Mama.
May ginawa ka ba noon Meron maam. Exploring The patient
para mawala yung Naglalaro ako ng maintains eye
sama ng loob mo? computer games contact.
ung GTA. Dun ko
na lang nilalabas
lahat. Kasi maam
sinosolo ko lang
yung problema ko.
Pero maam simula
nung dinala ako
dito medyo okay na
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ako.

Paano mo nasabing Habang nandito Exploring The patients

okay ka na? kasi ako sa loob voice went louder
maam may and speaks with
kumakausap na sa gestures.
akin. Ang dami ko
ng kaibigan diyan
sa loob pero
minsan may
nakakaalitan din.
Tsaka maam kahit
papano
nababawasan ung
pagkamahiyain ko
kasi may nakikinig
na sa akin kapag
may problema ako.
Yung ginawa mo ba Nakikipag-usap na Consensual The patients
noon inaapply mo pa rin ako sa iba maam. validation voice is loud and
hanggang ngayon Yun ang iba kong Encouraging he still speaks
kapag may problema paraan. comparison with gestures.
ka? O may iba ka pang Tinatanggal ko lang
ginawa? yung
pagkamahiyain ko
tsaka yung pag-
iisip ko na ayaw
ako ng ibang tao.
Sa oras na malagay ka Papalakasin ko na Exploring The patient
ulit sa sitwasyon noon. lang yung loob ko maintains eye
Anong gagawin mo? maam nang sa contact and
ganon hindi na ako smiles while
gaano answering.
maapektuhan ng
pinagsasabi ng iba.
May kapamilya ka bang Wala naman Exploring The patient
may ganiyan ding maam. Ako lang maintains eye
kalagayan, yung parang naman ang may contact.
sayo? ganito.
Naospital ka na ba dati? Opo maam last Exploring The patient
Or naaksidente? year lang po. maintains eye
Sumaking kasi ung contact.
tiyan tapos
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nagtatae din po
ako.

Saan? At ilang days? Dito din maam. Exploring The patient

Hindi ko maalala Consensual maintains eye
maam. Siguro mga Validation contact and often
two weeks. Placing event in shifts position.
time
After two weeks ba hindi Opo maam Consensual The patient
ka na ulit nagsuka at Validation maintains eye
nagtae? Exploring contact.

May bisyo ka ba? Meron maam. Exploring The patient

Natutunan ko lang maintains eye
diyan sa loob. contact but
Tinuruan nila ako. speaks in a low
tone of voice and
with gestures
Ginagawa mo rin ba yan Opo maam pero Exploring The patient
noong lumabas ka? patago tsaka speaks in a low
minsan kapag may tone of voice.
problema ako.
Natatanggal niya
kasi yung
pagkakabado ko.
Kung susubukan mong 7 po maam kasi Exploring The patient
bigyan ng grado ang mahirap sabihin na seems relaxed
kalagayan mo ngayon, okay na okay while answering.
sampu bilang talaga ako.
pinakamataas at zero
bilang pinakamababa
ano ibibigay mo?
Sa kalagayan mo Naniniwala ako sa Exploring The patient
ngayon sino ang Panginoon maam. maintains eye
nagpapalakas ng loob Pagsubok lang ito. contact and he
mo? Makakaya ko rin seems relaxed
ito. Tsaka kapag while answering.
may problema po
ako. Dinadalangin
ko na lang.
May one week na lang Thank you rin Accepting The patient
tayo para activity na ito. Maam sa pakikinig smiles.
Salamat sa pagiging sa akin.
open mo sa amin.

The aim of the study is to explore the development of bipolar disorder to the
nursed, his lived experiences with his family and relationship to significant others and
 15

other people around him, effectiveness of nursing plan of care made by the health care
providers and other medical treatments also the alternative solutions for the disorder.

Objective Background

Physical Assessment

The skin area is assessed for presence of lesions through inspection and found
that there are presence of scars on his upper and lower extremities specifically on his
both hands and feet due to scabies. Also, due to tooth removal the patient has an
incomplete set of teeth.

Review of Related Literature

Anatomy and physiology

The Central Nervous System as part of the nervous system functions to

generate applicable response to sensory signals from the internal and external
body (Brunner & Suddarth, pp. 1831; Marieb, pp. 229).It is composed of the brain
and spinal cord (Brunner et al, p. 1831;Marieb, pp. 229). The brain is composed
of the brain stem, cerebellum, diencephalon and cerebrum. (Marieb, pp. 242-
249). The brain stem contains the midbrain, pons and medulla oblongata and
they function on the different reflex action of the body (Brunner et al,p
1833;Marieb,pp 247-248). The cerebellum is concerned with the motor functions
of the body (Marieb, p. 248). The diencephalon has two important structures, the
thalamus and hypothalamus. They act as sensory relay center and maintaining
homeostasis (Marieb, pp. 247-247). The cerebrum as the largest and most
prominent are divided into two hemispheres, the left and right hemispheres
(Brunner et et al, Marieb, pp. 242-245). It governs higher mental process such as
intellect, reason, memory and language skills. The cerebrum is divided also into
four lobes: the frontal, parietal, occipital and temporal lobe (Brunner et al,pp
1831-1832;Marieb, pp. 242-245).

The neuron is the basic functional unit of the nervous system(Marieb,232-

242; Videveck,p19). It transmits information to another by sending electrical
messages which is called neurotransmission (Videbeck, p. 19). A chemical
substance manufactured in the neuron called neurotransmitters aids in the
transmission of information throughout the body. Neurotransmitters also work to
stimulate or inhibit an action in the cells (Videbeck,p. 19). They have receptors
which they lack into it when they fit together. They released into the synapse and
relay message to the receptor cells, they are either transported back to the
synapse then to the axon for reuptake or metabolized and inactivated by
enzymes (Videveck, pp 19). The major excitatory neurotransmitters include
dopamine, norepinephrine and epinephrine. They control complex movements,
attention changes, flight and fight response and emotional response. The major
inhibitory neurotransmitters include serotonin and GABA. They control food
intake, sleep and wakefulness, temperature regulation and pain control. (Brunner
&.suddart,,p 1832; Videveck, pp 19-21)
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I. Disease

Bipolar disorder is a mental disorder that makes a patient experience alternating

moods of mania and depression. It is also known as bipolar affective disorder, manic-
depressive disorder or manic depression. In manic phase, patients are euphoric,
energetic, sleepless, grandiose delusion, poor judgment and rapid thought, actions, and
speech. In depressed phase, patients are feeling hopeless, irritable, loss of energy,
inability to experience pleasure, poor appetite, sleep problems, concentration and
memory problems and have suicidal ideation (Videbeck, 2011). In between episodes of
mania and depression; bipolar patient might experience euthymic mood or normal mood.
The potential factors that may cause an individual to develop bipolar disorder are familial
history and genetics; age; gender; environmental factors and lifestyle modifications
(Chen, Huang, Zhao, Zhou,Yang, Zheng, &Xie, 2014; Grande, Magalhes, Chendo,
Stertz, Panizutti, Colpo, &Vieta, 2014; Paaren, Bohman, von Knorring, Olsson, von
Knorring, &Jonsson, 2014; Zaane, Ven, Draisma, Smit, Nolen, & Brink2014). Although,
the cause varies between individuals, the exact process of the disorder remains
unknown. Patients with bipolar disorder often have accompanying psychiatric disorder
such as anxiety disorder, attention deficit hyperactivity disorder (Silva, Rovaris,
Guimares-da-Silva, Victor, Salgado, Vitola, &Bau, 2014) and substance abuse (Tyler,
Jones, Black, Carter & Barrowclough, 2015). The shifting of moods affects the
individuals ability to function in ordinary life. However, application of nursing
management in each phase can avoid the patient from self-harm. There is various
treatments on bipolar disorder but it does not mean that it cures the disorder because it
is already a lifetime illness. Pharmacologic treatment includes the use of anticonvulsant
drugs (Carbamazepine, Depakote) and antimanic drugs like lithium (Sylvia, Reilly-
Harrington, Leon, Kansky, Calabrese, Bowden, & Nierenberg, 2014). Psychotherapeutic
methods. The use of Psychotherapy includes Cognitive Behavioral Therapy wherein it
helps the patient develop strategies to cope with their symptoms, change negative
thinking and behavior, monitor their mood to try to prevent a relapse. Interpersonal and
social rhythm therapy is new treatment that is combined with CBT. This newer treatment
focuses on circadian rhythms to help patients establish and maintain routines and build
healthier relationships. Psycho education is also under Psychotherapy that teaches
individuals about their disorder and treatment and gives them the tools to manage it and
anticipate mood swings. It is also valuable for family members. Once diagnosed with
bipolar disorder, the patient will undergo such procedures like Magnetic Resonance
imaging in which it measures the brain activity. Another is the electroencephalogram
where in it measures and records electrical activity in the brain over time and CT scan
which it rules other disorders before a diagnosis of bipolar disorder can be made.
Complete blood count is also use to indicate underlying medical conditions. For the most
common diagnostic examination, commonly used by specialist are psychological
evaluation and mood charting, where in the mental health provider fill out psychological
assessment or questionnaires.

II. Statistics

Table 2. Local Statistics of Bipolar Affective Disorder Cagayan Valley Medical Center

2012

1-4 5-9 10-14 15-19 20-44 45-64 65 TOTAL

 17

M F M F M F M F M F M F M F M F

JAN 13 10 14 10 1 8 37 28 65
0

FEB 4 5 10 9 6 8 20 22 42

MAR 24 34 58

APR 32 40 72

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC 4 2 22 10 1 5 43 17 43 17 60
7

Total 156 141 297

Table 3. Local Statistics of Bipolar Affective Disorder Cagayan Valley Medical Center

2013(Quarterly report)

1-4 5-9 10-14 15-19 20-44 45-64 65

Total
M F M F M F M F M F M F M F M F

JAN 1 1 1 2 1 1 4 45 88
FEB 0 5 5 0 8 0 3
MAR
APR
MAY
JUNE
JULY 1 1 4 3 3 2 8 80 163
AUG 3 3 0 9 0 8 3
SEP
OCT 3 1 6 5 2 9 8 17
NOV
DEC
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268
Total

Table 4: 2014 Local Statistics of Bipolar Affective Disorder Cagayan Valley Medical
Center (Annually Report)
Total
admission
JANUARY-DECEMBER 236

INTERPRETATION

The tables show a higher incidence of bipolar I in males at ages ranging from 20-
44

Analysis

The tables show there were reported cases of bipolar disorder in the said
institution only starting in the ages 15-19. This could be because in those age, an
individual starts to face life problems and/or transitions (peer school), situations that are
usually emotion-evoking and/or are involved in circumstances that presents
environmental/societal stress (family, societal)

Table 5. International Statistics of Bipolar Disorder

Statistic Verification
Source: DBS Alliance, Bipolarism, Bipolar lifestyle
Bipolar disorder statistics
Total number of adults with bipolar 5.7 million
Total percent of people that suffer from bipolar disorder 5%
Average age of bipolar onset 25 years old
Percent child will get bipolar when 1 parent has it 23%
Percent child will get bipolar when both parents are diagnosed 66%
Average reduced life span from bipolar 9.2%
Percent of diagnosed bipolar who commit suicide 20%
Percent of people who receive correct diagnosed within 3 years 25%
Percent of people with bipolar who are obese 35%
Percentage of curing bipolar with lithium 77%
Percent of people with bipolar who will receive 1 misdiagnosis 70%
(DBS Alliance, Bipolar ism, Bipolar Lifestyles. 2014)

About 2.4% of people around the world have had diagnosis of bipolar disorder at
some point in their lifetime, according to the first comprehensive international figures on
the topic. The United States has the highest lifetime rate of bipolar disorder at 4.4%, and
India the lowest, with 0.1% (Amanda Gardner, 2014)

Analysis

It could be genetics; it could be environmental. It also could be the way

individuals in different cultures are willing to respond to this kind of an inquiry, Sarah
 19

Bodner, M.D Cultural awareness plays a very big role in psychiatry. Some cultures
have a huge reluctance to speak about psychiatric things. In the US, people with
bipolar symptoms may be more likely to be diagnosed with the condition. Were pretty
aware of [bipolar disorder], Merikangas. Awareness dovetails closely with stigma. With
lower awareness in lower-income nation comes higher levels of stigma. That means
fewer people may be willing to talk about or get treatment for symptoms, which can lead
to lower perceived rate of bipolar disorder. (Amanda Gardner, 2011)

Statistics for the Prevalence of Bipolar Disorder: The prevalence rate for bipolar
is approximately 1.1% of the population over the age (NIMH) or, in other words, at any
time as many as 51 million people worldwide suffer from bipolar disorder.

III. Psychopathophysiology

The cause of bipolar disorder is unknown but there are two factors that lead to
this kind of disorder, the predisposing and the precipitating. The predisposing factors are
the following: genetics, age, family history, and gender. The precipitating factors are:
environmental factors which include loss of love ones and lack of social support, and
lifestyle which involves abuse of substance.

There are two theories involved the biological and the developmental theory. In
the biological theory, the parts of the brain are involved. First, the larger basal ganglia
which may have abnormalities may cause difficulty initiating movements of the body
called dyskinesia. The smaller pre frontal atrophies which lead to loss of self- control as
one of the sign and symptoms of the patient. Another part of the brain is the white matter
which enlarges causing increased synaptic activity. Due to the increased synaptic
activity, the frontotemporal lobe blood flow will also increase leading to the destruction of
frontotemporal lobe and increased glucose metabolism resulting in impulsive delusion. If
theres alteration in arousal and memory, it causes memory retention leading also to
impulsive delusion.

Changes in the neurotransmitters also give signs and symptoms. The second
biological theory involves the neurotransmitters. There are four neurotransmitters
involves in bipolar disorder, the dopamine, serotonin, norepinephrine and GABA. If there
is an increased in dopamine, neurons may become hypoactive or hyperactive. There is
idea of reference, delusions, and hallucinations when neurons are hyperactive. An
increase in serotonin level may cause over activity in its function and inhibits dopamine
synthesis causing hypo dopaminergic process, fever, agitation, aggressiveness, and
seizure. A decrease in norepinephrine increases dopamine activity causing loss of
alertness and poor memory. A decrease in GABA which is an inhibitory neurotransmitter
blocks communication process causing emotion anxiety.

In the developmental theory, theory of growth and development is used to

evaluate if their behavior and actions are accurate with their age. We used Erick
Ericksons psychosocial theory and Sigmund Freuds psychosexual and
psychoanalytical theory. In our patient, between his id, ego, and superego, his id
dominated bringing him into naughty behavior. In the psychosexual theory, at genital
stage he had already engaged in sexual relationship. In the Erick Ericson growth and
development theory at adolescent stage, he had lose his mother bringing him to become
confused, hallucinating, suicidal ideation and acting out behavior.
20
21
 22

Figure 1. Psychopathophysiology of Bipolar Disorder.

 23

General Plan of Care

A. Course in the Ward

On July 17, 2014 at 8:50 am, the doctors orders are omeprazole 20 mg thrice a
day for 1 week and Metoclopromide 10 mg per orem now then every 8 hours if vomiting
persists. Advised patient to avoid activities that require alertness for two hours after
doses and not to drink alcohol during therapy.

At 8:45 in the morning, July 25, 2014 the doctor ordered medications for the
patient for one month such Clozapine 50 mg twice a day, Olanzapine 10 mg tablet
before sleeping, Valproic 500 mg tablet twice a day, Lanoxin 0.25 mg tablet once a day,
and Biperiden 2 mg tablet per day. The doctor also gave an order for suicide homicide
escape precaution. The patient was instructed that clozapine drug may be taken with or
without food. The patient was also monitored for abnormal body temperature, digitalis
toxicity and advised to avoid alcohol and increase intake of potassium-rich food. Also,
safety of the patient was ensured.

On August 22, 2014 at exactly 6:15 pm, the patient was referred to Pedia ER due
to hematemesis and Hypovolemic shock secondary to upper GI bleeding probably
secondary to bleeding peptic ulcer disease. As the patient was rushed to pedia ER, his
safety was ensured and it was referred accordingly with other health care team.

September 1, 2014 at 8:45 in the morning when the patient was transferred to
Psychiatry-male Ward. The doctor order for medication for a month were 10 mg of
Olanzapine once a day before hours of sleep, Valproic 500 mg tablet twice a day,
Lanoxin 0.25 mg tablet once a day, Biperiden 2 mg tablet per day. Suicide homicide
esacpe precaution was also ordered. Patient was assessed by taking vital signs and
level of consciousness when he was transferred back to psychiatry male ward. He was
instructed to take the valproic drug with food or milk to reduce adverse GI effect. The
patient was also encouraged for dental hygiene to prevent dental carries associated with
decrease salivation. Safety was ensured and all orders was referred accordingly.

September 3, 2014 at 9:00 am, the patient was rush to Pedia and notes were
given as follows: (1) recently admitted due to hypovolemic shock; (2) compression of
Omeprazole for eight days; (3) for abdominal pain; (4) still for EGD once with funds.
Safety was the priority when the patient was rushed to pedia and all pedia notes were
referred accordingly.

September 29, 2014 at 10:10 in the morning, patient was admitted to Pedia ward.
Ensured safety of the patient as the chief complaint was identified and as the patient
was assessed for vital signs regulations and level of consciousness.

October 1, 2014, November 7, 2014 at 9:05 am, and December 9, 2014, still the
Physician ordered the same medication and precaution for the patient. All the medication
and other orders were referred accordingly.

December 15, 2014 at 8:45 in the morning, Olanzapine 10 mg once a day before
hours of sleep and ordered the patient to apply Kwell lotion to affected areas twice a
day. Instructed patient to wait at least an hour after bathing, before using lindane lotion
and avoid activities that requires alertness when drug was taken. Other orders were
referred accordingly.
 24

January 8, 2015 at 8:50 am, the same medications were ordered such as
Olanzapine, Valproic, Lanoxin, Biperiden HCL, and a precaution for Suicide homicide
was included. All ordered medications were administered while observing the 10 Rs as
the medication was taken by the patient. Safety was ensured.

January 27, 2015 at 2:35 pm, 625 mg of Co-Amoxiclav was ordered twice a day
for seven days , and an increase for Olanzapine 5-10 mg twice a day. Instructed to take
meals before taking the medicine, monitored for normal body temperature, and
avoidance to alcohol.

February 9, 2015 at 8:40 am, Olanzapine medication was to its original time and
number of administration. His other medications are ordered the same. The patient may
involve in occupational therapy activities but a suicide homicide escape precaution was
ordered. The entire doctors orders are referred accordingly. Observed 10 Rs in giving
medications, watch out for stimuli that may trigger manic and depressive episode and
ensured safety of the patient.