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I. INTRODUCTION

A client diagnosed with Bipolar I disorder, such as Mary Ann Garces,

intrigues and challenged the student nurses to applying onto the practical field, their

acquired knowledge, attitude and skills from preceding lessons in order to function as an

operative and effective member of the multidisciplinary team. The group members are

determined to broaden their knowledge concerning the disorder, particularly in the various

methods in which they are supposed to interact with the patient, utilizing the various

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appropriate therapeutic approaches, therefore rendering holistic caring care to the said

client. The group also aspires to gain a concrete and total exemplar of the treatment of the

disease condition, having only encountered such condition in texts. Also, the group feels

that and successful intervention is crucial during manifestations of signs and symptoms of

the Bipolar I disorder so as to ensure that the client will not have difficulties in functioning in

his daily life. If the students are to be efficient nurses, the student nurses should be

educated in such matters.

Bipolar disorder is a recurrent illness that involves long-term, drastic changes

in mood. A person with bipolar disorder experiences alternating highs (mania) and lows

(depression). A manic period can be brief, lasting from three to fourteen days, or longer,

lasting up to several weeks. The depressive periods may also last from days to weeks or

even six to nine months. The periods of mania and depression range from person to person

many people may only experience very brief periods of these intense moods, and may not

even be aware that they have bipolar disorder.

The “highs” or manic episodes are characterized by extreme happiness,

hyperactivity, little need for sleep and racing thoughts, which may lead to rapid speech.

Symptoms of the “lows” or depressive periods include extreme sadness, a lack of energy or

interest in things, an inability to enjoy normally pleasurable activities and feelings of

helplessness and hopelessness. On average, someone with bipolar disorder has three

years of normal mood between episodes of mania or depression.

Those with bipolar disorder often describe their experience as being on an

emotional roller coaster. Cycling up and down between strong emotions can keep a person

from functioning normally. The emotions, thoughts and behavior of a person with bipolar

disorder are beyond his control friends, co-workers and family must intervene to protect his 2

interests. This makes the condition exhausting not only for the sufferer, but for those in

contact with him as well.

Bipolar disorder can create many difficulties. Manic episodes can lead to

family conflict or financial problems, especially when the person with bipolar disorder

appears to behave erratically and irresponsibly. During the manic phase, people often

become impulsive and act aggressively. This can result in high-risk behavior, such as

repeated intoxication, extravagant spending and risky sexual behavior.

During severe manic or depressed episodes, people with bipolar disorder

may have symptoms that overwhelm their ability to deal with reality. This inability to

distinguish reality from unreality results in psychotic symptoms such as hearing voices,

paranoia, visual hallucinations, and false beliefs of special powers or identity. They may

have distressing periods of great sadness alternating with euphoric optimism (a “natural

high”) and/or rage that is not typical of the person during periods of wellness. These abrupt

shifts of mood interfere with reason, logic and perception to such a drastic degree that

those affected may be unaware of the need for help.

However, if left untreated, bipolar disorder can seriously affect every aspect

of a person’s life. Identifying the first episode of mania or depression and receiving early

treatment is essential to managing bipolar disorder. In most cases, a depressive episode

occurs before a manic episode, and many patients are treated initially as if they have major

depression. Usually, the first recognized episode of bipolar disorder is a manic episode.

Once a manic episode occurs, it becomes clearer that the person is suffering from an

illness characterized by alternating moods. Because of this difficulty with diagnosis, family

history of similar illness and/or episodes is particularly important. Patients who first seek

treatment as a result of a depressed episode may continue to be treated as someone with 3

unipolar depression until a manic episode develops. Ironically, treatment of depressed

bipolar patients with antidepressants can trigger a manic episode in some patients.

II. OBJECTIVES

Student-Nurse Centered:

At the end of this case study, the student nurse will be able to:

1. discuss about the personal, social and familial history of the patient

2. recall and review on the normal growth and development of an elderly

3. discuss bipolar disorder

4. trace the pathophysiology of bipolar disorder

5. cite the classical signs and symptoms of disorder

6. make use of the nursing process in caring for a patient with disorder

7. instruct health teaching to the patient with the disease condition

Patient/Significant-Others Centered:

At the end of this case study, the patient and his significant-others will be able to:

1. establish trust and rapport with the student nurse

2. express their feelings and concerns with the current condition

3. state the reason for her stay in the institution

4. utilize coping skills during her stay in the institution

5. exhibit positive attitude towards the therapeutic treatment regimen

6. carry out activities of daily living such as self-care4

III. NURSING ASSESSMENT

1. PERSONAL HISTORY

1.1 Patient’s Profile

Name: Mary Ann Garces

Age: 41 years old

Sex: Female

Civil Status: Single

Religion: Roman Catholic

Date of Admission:

Ward: Psychiatric Waling-Waling Ward

Impression/ Diagnosis: Bipolar I Disorder Manic Phase

Physician: Dr.

1.2 Family and Individual Information

The client originally came from Talisay City, Cebu. She has 2 sisters of whom

she claims are now in Manila. Prior to her stay in the institution, the client had been drinking

2 liters of Pepsi Cola. She had been admitted to the instituition by her mother to a

mischievious conduct of hers. Further examination in the instituon revealed that the patient

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had Bipolar Disorder I Manic Phase. During her stay in the Psychiatric Ward, the client had

received visits coming from her family. She have many friends in the instituition and had

known a lot of patients in their.

1.3 Level of Growth and Development

1.3.1 Normal Development (Elderly)

PHYSICAL DEVELOPMENT

Dramatic physical changes occurs among elder people. Their physical

appearance changes in a way which is obvious. Such changes include that of their skin

which has become dry and wrinkled and in some presence of age spots are seen. White

hair and hair loss are also evident among the elderly. The development of presbyopia and

presbycusis are also noted and such has resulted to difficulties of the elderly in maintaing

theie activites of daily living. As for the functions of the several systems in the body such as

the cradiovascular, neurological and gastrointestinal systems, their functional capability

decreases due to the efffect of the aging process. Such is evident in cases of dementia,

confusion, frequent constipation and cardiovascular problems occuring during the old age.

PSYCHOSOCIAL DEVELOPMENT

Eric Erikson

Acquiring a Sense of Integrity While Avoiding Despair (Old Age)

As the aging process creates physical and social losses, the adult may also

suffer loss of status and function, such as through retirement or illness. These external

struggles are also met with internal struggles such as the search for meaning of life.

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Meeting these challenges creates the potential for growth and wisdom. Many elders view

their lives with a sense of satisfaction even with the inevitable mistakes. Others see

themselves as failures with marked attempt and disgust.

MORAL DEVELOPMENT

Universal Ethical Principle Orientation

This stage defines “right” by the decision of conscience in accord with self-

chosen-ethical principles. These principles are abstract, like the golden rule and appeal to

logical comprehensiveness, universality and consistency. It also defines the principles by

which agreement will be most just.

COGNITIVE DEVELOPMENT

Period IV: Formal Operations

With the individual's thinking moves to abstract and theoritical subjects in the

formal operation period, thinking can venture into such subjects as achieving world peace,

finding justice and seeking meaning in life.

1.3.2 The ill person at particular stage of the client

Bipolar disorder causes dramatic mood swings—from overly "high" and/or

irritable to sad and hopeless, and then back again, often with periods of normal mood in

between. Severe changes in energy and behavior go along with these changes in mood.

The periods of highs and lows are called episodes of mania and depression.

1.3.3 Actual Ill Behavior

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Increased energy, activity, and restlessness

Excessively "high," overly good, euphoric mood

Extreme irritability

Racing thoughts and talking very fast, jumping from one idea to another

Distractibility, can't concentrate well

Little sleep needed

Unrealistic beliefs in one's abilities and powers

Poor judgment

Spending sprees

A lasting period of behavior that is different from usual

Abuse of drugs, particularly cocaine, alcohol, and sleeping medications

Provocative, intrusive, or aggressive behavior

Denial that anything is wrong

A manic episode is diagnosed if elevated mood occurs with three or more of

the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is

irritable, four additional symptoms must be present.

Signs and symptoms of depression (or a depressive episode) include:

Lasting sad, anxious, or empty mood

Feelings of hopelessness or pessimism

Feelings of guilt, worthlessness, or helplessness 8

Loss of interest or pleasure in activities once enjoyed, including sex

Decreased energy, a feeling of fatigue or of being "slowed down"

Difficulty concentrating, remembering, making decisions

Restlessness or irritability

Sleeping too much, or can't sleep

Change in appetite and/or unintended weight loss or gain

Chronic pain or other persistent bodily symptoms that are not caused by physical

illness or injury

Thoughts of death or suicide, or suicide attempts

A depressive episode is diagnosed if five or more of these symptoms last

most of the day, nearly every day, for a period of 2 weeks or longer.

A mild to moderate level of mania is called hypomania. Hypomania may feel

good to the person who experiences it and may even be associated with good functioning

and enhanced productivity. Thus even when family and friends learn to recognize the mood

swings as possible bipolar disorder, the person may deny that anything is wrong. Without

proper treatment, however, hypomania can become severe mania in some people or can

switch into depression.

DIAGNOSIS

A physician makes this diagnosis based on the patient's symptoms. Other

conditions that might also cause these symptoms will be considered and ruled out. The

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patient's medical history, including whether there have been previous episodes of mental

illness, will be evaluated. Family medical history, particularly of mood disorders, is important

information. Blood tests are not routine at present but are being researched as a future aid

in diagnosing.

CAUSES

There are several different pathways into the set of symptoms given the

diagnosis "Bipolar Affective Disorder". Among the explanations indicated by research and

generally accepted are the following:

1. Genetic abnormalities, Bipolar affective disorder has clearly been shown to run in

families. (Genetic abnormalities on chromosomes 18 and 21 are suspected.)

2. Chemical imbalance in the brain, particularly related to leaking membranes in the

pathways used for delivering messages within the brain.

3. A seizure disorder in the brain's frontal cortex. No convulsions occur with frontal

cortex seizures because there are no psycho-motor centers located in the frontal

cortex. Seizures occurring in this area affect mood and judgment.

3. Present profile of Functional Health Patterns

3.1 Health Perception/ Health Management Pattern

The client despite her current condition does not have any vitamins and only recieves a

monthly dose of an antipsychotic drugs monthly. She claims that she is not well and when

asked why she is in the institution, laughs and says that she does know.

3.2 Nutritional- Metabolic Pattern

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The client eats what the instituition has to offer, from breakfast to dinner. Occassionaly, she

ate foods given by student nurses. Unfortunately, such foods are not that nutricious to meet

her metabolic needs as evidenced by her pale color and her body built.

3.3 Elimination Pattern

The client normally defecates once every day. For her urination, she verbalized to urinate at

least 4 times a day.

3.4 Activity- Exercise Pattern

Her activity- exercise pattern greatly depends on her mood. During our time with her, there

are days when she actively join the activities prepared by the student nurses and enjoys

walking in the grounds. While in some days, the client all wants is to sit down in her place

and remains away from the company of others.

3.5 Cognitive Perceptual Pattern

The client cognitive and perceptual pattern is distorted, especially in cases mood swings.

She falsely believes that they are all artists and that they had a show. She also had

misperceptions of having a store in front of her which in reality is just a window. She's also

oriented to time and date.

3.6 Sleep-Rest Pattern

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As been claimed by the client, she doesn’t sleeps well during night which starts from around

10 pm - 5 am. During the afternoons, she naps a liittle bit.

3.7 Self-Perception Pattern

The client sees herself as a well individual and says that nothing is wrong. She oftenly says

that she speaks with the resident physician with regards to her stay in the institution.

3.8 Role-Relationship Pattern

There are problems with the client's relationship to others. This had been due to her

condition and the sign and symptoms accompanying it. During her stay in the institution,

there had been visits coming from her family. As to her relationship with fellow clients in the

instituition, she does have close friends.

3.9 Sexuality-Sexual Functioning

The client is an elder woman who long time had her menopausal. She is single and doesn't

have any children at all.

3.10 Coping-Stress Management Pattern

The client whenever provoked or when she hears unpleasant things, easily gets angry and

irritable. To cope up, she frequently shouts to the people around her and when she's happy,

she joins with the activities prepared by student-nurses.

3.11 Value-Belief System12

4. PATHOPHYSIOLOGY AND RATIONALE

4.1. Anatomy and Physiology of Organ/System affected

1. Nervous system

Three basic functions are performed by nervous systems:

1. Receive sensory input from internal and external environments

2. Integrate the input

3. Respond to stimuli

Sensory Input

Receptors are parts of the nervous system that sense changes in the internal or external

environments. Sensory input can be in many forms, including pressure, taste, sound, light,

blood pH, or hormone levels that are converted to a signal and sent to the brain or spinal

cord.

Integration and Output

In the sensory centers of the brain or in the spinal cord, the barrage of input is integrated

and a response is generated. The response, a motor output, is a signal transmitted to

organs than can convert the signal into some form of action, such as movement, changes in

heart rate, release of hormones, etc.

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Divisions of the Nervous System

The nervous system monitors and controls almost every organ system through a series of

positive and negative feedback loops. The Central Nervous System (CNS) includes the

brain and spinal cord. The Peripheral Nervous System (PNS) connects the CNS to other

parts of the body, and is composed of nerves (bundles of neurons).

Peripheral Nervous System

The peripheral nervous system consists of the nerves that branch out from the brain and

spinal cord. These nerves form the communication network between the CNS and the body

parts. The peripheral nervous system is further subdivided into the somatic nervous system

and the autonomic nervous system. The somatic nervous system consists of nerves that go

to the skin and muscles and is involved in conscious activities. The autonomic nervous

system consists of nerves that connect the CNS to the visceral organs such as the heart,

stomach, and intestines. It mediates unconscious activities.

Two main components of the PNS:

1. Sensory (afferent) pathways that provide input from the body into the CNS.

2. Motor (efferent) pathways that carry signals to muscles and glands (effectors).

Most sensory input carried in the PNS remains below the level of conscious awareness.

Input that does reach the conscious level contributes to perception of our external

environment.

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Autonomic nervous system

The autonomic nervous system is a visceral efferent system, which means it sends motor

impulses to the visceral organs. It functions automatically and continuously, without

conscious effort, to innervate smooth muscle, cardiac muscle, and glands. It is concerned

with heart rate, breathing rate, blood pressure, body temperature, and other visceral

activities that work together to maintain homeostasis.

The autonomic nervous system has two parts, the sympathetic division and the

parasympathetic division. Many visceral organs are supplied with fibers from both divisions.

In this case, one stimulates and the other inhibits. This antagonistic functional relationship

serves as a balance to help maintain homeostasis.

Somatic Nervous System

The Somatic Nervous System (SNS) includes all nerves controlling the muscular system

and external sensory receptors. External sense organs (including skin) are receptors.

Muscle fibers and gland cells are effectors. The reflex arc is an automatic, involuntary

reaction to a stimulus. When the doctor taps your knee with the rubber hammer, she/he is

testing your reflex (or knee-jerk). The reaction to the stimulus is involuntary, with the CNS

being informed but not consciously controlling the response. Examples of reflex arcs

include balance, the blinking reflex, and the stretch reflex.

Sensory input from the PNS is processed by the CNS and responses are sent by the PNS

from the CNS to the organs of the body.

Motor neurons of the somatic system are distinct from those of the autonomic system.

Inhibitory signals cannot be sent through the motor neurons of the somatic system.

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Central Nervous System

The Central Nervous System (CNS) is composed of the brain and spinal cord. The CNS is

surrounded by bone-skull and vertebrae. Fluid and tissue also insulate the brain and spinal

cord.

The brain is composed of three parts: the cerebrum (seat of consciousness), the

cerebellum, and the medulla oblongata (these latter two are "part of the unconscious

brain").

The medulla oblongata is closest to the spinal cord, and is involved with the regulation of

heartbeat, breathing, vasoconstriction (blood pressure), and reflex centers for vomiting,

coughing, sneezing, swallowing, and hiccuping. The hypothalamus regulates homeostasis.

It has regulatory areas for thirst, hunger, body temperature, water balance, and blood

pressure, and links the Nervous System to the Endocrine System. The midbrain and pons

are also part of the unconscious brain. The thalamus serves as a central relay point for

incoming nervous messages.

The cerebellum is the second largest part of the brain, after the cerebrum. It functions for

muscle coordination and maintains normal muscle tone and posture. The cerebellum

coordinates balance.

The conscious brain includes the cerebral hemispheres, which are are separated by the

corpus callosum. In reptiles, birds, and mammals, the cerebrum coordinates sensory data

and motor functions. The cerebrum governs intelligence and reasoning, learning and

memory. While the cause of memory is not yet definitely known, studies on slugs indicate

learning is accompanied by a synapse decrease. Within the cell, learning involves change

in gene regulation and increased ability to secrete transmitters.16

The Brain

Most brains exhibit a substantial distinction between the gray matter and white matter. Gray

matter consists primarily of the cell bodies of the neurons, while white matter is comprised

mostly of the fibers (axons) which connect neurons. The axons are surrounded by a fatty

insulating sheath called myelin (oligodendroglia cells), giving the white matter its distinctive

color. The outer layer of the brain is gray matter called cerebral cortex. Deep in the brain,

compartments of white matter (fasciculi, fiber tracts), gray matter (nuclei) and spaces filled

with cerebrospinal fluid (ventricles) are found.

The brain innervates the head through cranial nerves, and it communicates with the spinal

cord, which innervates the body through spinal nerves. Nervous fibers transmitting signals

from the brain are called efferent fibers. The fibers transmitting signals to the brain are

called afferent (or sensory) fibers. Nerves can be afferent, efferent or mixed (i.e., containing

both types of fibers).

The brain is the site of reason and intelligence, which include such components as

cognition, perception, attention, memory and emotion. The brain is also responsible for

control of posture and movements. It makes possible cognitive, motor and other forms of

learning. The brain can perform a variety of functions automatically, without the need for

conscious awareness, such as coordination of sensory systems (eg. sensory gating and

multisensory integration), walking, and homeostatic body functions such as heart rate,

blood pressure, fluid balance, and body temperature.

Many functions are controlled by coordinated activity of the brain and spinal cord.

Moreover, some behaviors such as simple reflexes and basic locomotion, can be executed

under spinal cord control alone.

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The brain undergoes transitions from wakefulness to sleep (and subtypes of these states).

These state transitions are crucially important for proper brain functioning. (For example, it

is believed that sleep is important for knowledge consolidation, as the neurons appear to

organize the day's stimuli during deep sleep by randomly firing off the most recently used

neuron pathways; additionally, without sleep, normal subjects are observed to develop

symptoms resembling mental illness, even auditory hallucinations). Every brain state is

associated with characteristic brain waves.

The Forebrain

The forebrain is the largest and most complex part of the brain. It consists of the cerebrum -

the area with all the folds and grooves typically seen in pictures of the brain - as well as

some other structures beneath it.

The cerebrum contains the information that essentially makes us who we are: our

intelligence, memory, personality, emotion, speech, and ability to feel and move. Specific

areas of the cerebrum are in charge of processing these different types of information.

These are called lobes, and there are four of them: the frontal, parietal, temporal, and

occipital.

The cerebrum has right and left halves, called hemispheres, which are connected in the

middle by a band of nerve fibers (the corpus collosum) that enables the two sides to

communicate. Though these halves may look like mirror images of each other, many

scientists believe they have different functions. The left side is considered the logical,

analytical, objective side. The right side is thought to be more intuitive, creative, and

subjective. So when you're balancing the checkbook, you're using the left side; when you're

listening to music, you're using the right side. It's believed that some people are more "right-

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brained" or "left-brained" while others are more "whole-brained," meaning they use both

halves of their brain to the same degree.

The outer layer of the cerebrum is called the cortex (also known as "gray matter").

Information collected by the five senses comes into the brain from the spinal cord to the

cortex. This information is then directed to other parts of the nervous system for further

processing. For example, when you touch the hot stove, not only does a message go out to

move your hand but one also goes to another part of the brain to help you remember not to

do that again.

In the inner part of the forebrain sits the thalamus, hypothalamus, and pituitary gland. The

thalamus carries messages from the sensory organs like the eyes, ears, nose, and fingers

to the cortex. The hypothalamus controls the pulse, thirst, appetite, sleep patterns, and

other processes in our bodies that happen automatically. It also controls the pituitary gland,

which makes the hormones that control our growth, metabolism, digestion, sexual maturity,

and response to stress.

The Midbrain

The midbrain, located underneath the middle of the forebrain, acts as a master coordinator

for all the messages going in and out of the brain to the spinal cord.

The Hindbrain

The hindbrain sits underneath the back end of the cerebrum, and it consists of the

cerebellum, pons, and medulla. The cerebellum - also called the "little brain" because it

looks like a small version of the cerebrum - is responsible for balance, movement, and

coordination.

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The pons and the medulla, along with the midbrain, are often called the brainstem. The

brainstem takes in, sends out, and coordinates all of the brain's messages. It is also

controls many of the body's automatic functions, like breathing, heart rate, blood pressure,

swallowing, digestion, and blinking.

The Spinal Cord

The spinal cord runs along the dorsal side of the body and links the brain to the rest of the

body. Vertebrates have their spinal cords encased in a series of (usually) bony vertebrae

that comprise the vertebral column.

The gray matter of the spinal cord consists mostly of cell bodies and dendrites. The

surrounding white matter is made up of bundles of interneuronal axons (tracts). Some tracts

are ascending (carrying messages to the brain), others are descending (carrying messages

from the brain). The spinal cord is also involved in reflexes that do not immediately involve

the brain.

The Brain and Drugs

Some neurotransmitters are excitory, such as acetylcholine, norepinephrine, serotonin, and

dopamine. Some are associated with relaxation, such as dopamine and serotonin.

Dopamine release seems related to sensations of pleasure. Endorphins are natural opioids

that produce elation and reduction of pain, as do artificial chemicals such as opium and

heroin. Neurological diseases, for example Parkinson's disease and Huntington's disease,

are due to imbalances of neurotransmitters. Parkinson's is due to a dopamine deficiency.

Huntington's disease is thought to be cause by malfunctioning of an inhibitory

neurotransmitter. Alzheimer's disease is associated with protein plaques in the brain.

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Drugs are stimulants or depressants that block or enhance certain neurotransmitters.

Dopamine is thought involved with all forms of pleasure. Cocaine interferes with uptake of

dopamine from the synaptic cleft. Alcohol causes a euphoric "high" followed by a

depression.

Marijuana, material from the Indian hemp plant (Cannabis sativa), has a potent chemical

THC (tetrahydracannibinol) that in low, concentrations causes a euphoric high (if inhaled,

the most common form of action is smoke inhalation). High dosages may cause severe

effects such as hallucinations, anxiety, depression, and psychotic symptoms.

Cocaine is derives from the plant Erthoxylon coca. Inhaled, smoked or injected. Cocaine

users report a "rush" of euphoria following use. Following the rush is a short (5-30 minute)

period of arousal followed by a depression. Repeated cycle of use terminate in a "crash"

when the cocaine is gone. Prolonged used causes production of less dopamine, causing

the user to need more of the drug.

Heroin is a derivative of morphine, which in turn is obtained from opium, the milky

secretions obtained from the opium poppy, Papaver somniferum. Heroin is usually injected

intravenously, although snorting and smoking serve as alternative delivery methods. Heroin

binds to opioid receptors in the brain, where the natural chemical endorphins are involved in

the cessation pain. Heroin is physically addictive, and prolonged use causes less endorphin

production. Once this happens, the euphoria is no longer felt, only dependence and delay

of withdrawal symptoms.

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Classical Symptom Clinical Symptom Rationale

22

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BIPOLAR DISORDER TYPE II

Precipitating Factors

stress social status

psychosocial

Predisposing Factors

genetics biogenic amines

cardiac dysfunction

PSYCHODYNAMICS

1. Sigmund Freud’s Psychoanalytical Theory

One of the leading psychoanalytical theories concerning depression was first

proposed by Sigmund Freud. Freud argued that at some point in early childhood, the

depressed patient suffered the loss, real or imagined, of someone with whom they were

very close. Moreover, the individual depended on that other person to maintain his/her self-

esteem. Unable to cope with the loss, the person then creates an internal representation of

the lost individual so that they can maintain the close relationship. Anger begins to develop

to develop towards the lost individual, but since this anger is not recognized and dealt with

on a conscious level and since the object is internalized, the person directs the feelings

toward him- or herself.

2. Beck’s Cognitive Model

Beck proposed that the depressed individual's tendency to express more

negativity than non-depressed individuals is derived from his or her cognitive distortions, or

erroneous ways, of thinking about the self. Negative and derogatory views of the self, the

world, and of the future are core features of the depressed individual. More specifically, a

depressed individual tends to attribute global, personalized reasons for failure, form

overarching principles of the self based on negative experiences, to exaggerate negative

events and dismiss positive events, and to selectively recall more negative events. One

could then say that these self-defeating biases lead to the development of a cognitive

schema that affects the way the individual interprets, perceives, and interacts with the

environment. This negative schema in turn increases the probability of the individual being

more negatively affected by stressful life events.

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3. Seligman’s Learned helplessness-Hopelessness Theory

Seligman suggested that depression was similar to the passive behavior

shown by animals that had been exposed to shock. Depressed individuals, then, like the

animals in the lab experiments, begin to believe that they are helpless--that they do not

have the power to control the events in their lives. They therefore fail to realize the

contingency between their actions and the outcome of events. Learned-helplessness

theory, in an attempt to answer some of the criticisms rose against it, such as the fact that

most people do not become depressed after experiencing a negative life event, was later

revised and described instead in terms of "hopelessness." L. Y. Abramson and his

colleagues proposed that individuals who are vulnerable to depression possess an

attribution style consisting of negative expectations concerning future events, regardless of

their own actions. After the occurrence of a negative life event, the causal attribution

(explanations and importance) that the person ascribes to the event is correlated with the

probability of then becoming depressed. This attribution style also consists of the tendency

to explain negative events as internal, stable, and global factors. This means that unlike

non-depressed individuals, a depressed person is more likely to think of negative events as

proof of their own inadequacies (internal), as having existed in the past and continuing to

persist in the future (stable), and responsible for his or her failure in other areas of life

(global).

4. Object Loss Theory

Is the idea that the alleged to be universal emotional states that are major

building blocks of the personality ego-self exists only in relation to other objects which may

be external or internal. Internal objects are internalized versions of external objects,

primarily formed from early interactions with the parents. According to object-relations 25

theory there are three fundamental "affects" that can exist between the self and the other -

attachment, frustration, and rejection. These affects are alleged to be universal emotional

states that are major building blocks of the personality.

5. Personality Organization Theory

Subtle differences in neurotransmitter availability and re-uptake vary the

sensitivity of individuals to cues about their environment that predict future resource

availability and external rewards and punishments. It is the way these cues are detected,

attended to, stored, and integrated with previous experiences that makes each individual

unique. Current work on the bases of individual differences is concerned with

understanding this delicate interplay of biological propensities with environmental

opportunities and constraints as they are ultimately represented in an individual’s

information processing system. With time we can expect to increase our taxonomic and

predictive power by using these causal bio-social theories of individual differences.

The Disease Process

Bipolar Disorder, formerly known as manic-depression, is a diagnosis in

psychiatry referring to mania (or hypomania or mixed states) alternating with clinical

depression (or depressed or euthymic mood) over a significant period of time. Unlike highs

and lows a normal person might experience, one with bipolar disorder experiences extreme

mood swings that can last for minutes to months. Mood changes of this nature are

associated with distress and disruption, and a relatively high risk of suicide. Bipolar

Disorder is commonly categorized as either Bipolar I or Type I, where an individual

experiences full-blown mania, or Bipolar II or Type II, in which the "highs" do not go beyond

hypomania (unless triggered in to mania by medication). The latter is much more difficult to

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diagnose, since the hypomanic episodes may simply appear as a period of successful high

productivity. Psychosis can occur, particularly in manic periods. There are also 'rapid

cycling' subtypes. Because there is so much variation in the severity and nature of mood-

related problems, the concept of a bipolar spectrum is often employed, which includes

cyclothymia. There is no consensus as to how many 'types' of bipolar disorder exist. Many

patients with bipolar disorder suffer from severe anxiety and panic when in a manic state,

while others are euphoric. Some do not experience full-blown mania, and will display milder

symptoms, known as hypomania. Depression medications are often contraindicated for

patients with bipolar disorder, as these medications may induce mania and worsen the

disorder. In addition, many patients with bipolar disorder are inaccurately diagnosed with

unipolar depression (clinical depression), further complicating diagnosis. In fact, it often

takes more than a decade before patients are accurately diagnosed and treated for their

bipolar disorder.

NURSING INTERVENTIONS

a. Care Guide of Clients with Bipolar II disorder

Depressive state

Try to sit beside and be in the person’s space – often people who are depressed do

not like to make demands on others but they appreciate company. Likewise, you will

need to do the talking rather than expecting the person to do so

Keep up good levels of communication even when not reciprocated eg Let the

person know where you are going even if there is no response.

Provide for the safety of the client and others.

27

Begin a therapeutic relationship by spending non-demanding time with the client.

Promote completion of activities of daily living by assisting the client only as

necessary

Establish adequate nutrition and hydration.

Promote sleep and rest.

Engage the client in activities.

Encourage the client to verbalize and describe the emotion.

Set realistic tasks and have realistic expectations.

Be aware of suicide risk. Ask the appropriate questions and communicate with

treating team about this issue. This issue may be a reason for hospitalization.

If the person expresses unexpected happiness and begins to give possessions

away, seek assistance immediately.

Avoid placing unrealistic demands on the person.

Be patient.

Manic state

Be calm.

Do not participate in the escalation of excitement.

Use simple, clear communications, and make sure the message has been

understood.

28

Make sure that you move away from potential conflictual situations. Use their distract

ability to come back again.

Do not make too many demands.

Reduce stimulation and loud noises.

Avoid conflict.

Keep the person’s real level of expertise in mind. Do not allow yourself to be overly

influenced by their persuasive presentation of advice.

This is very tiring so make sure that you get some space, which you will need to

regulate for yourself – the other person will not recognize your need.

When you want space, try to manage your emotional state as the individual will pick

up on your distress and you may have to defend yourself, as the person will not see

themselves as unreasonable.

Be genuine, try not to turn off. When something is funny enjoy it.

Be conscious of the safety factor. The danger of physical complications may be one

of the trigger factors to indicate the need for hospitalization.

Remember it is very easy for this person to end up with disturbed sleep patterns,

sleep late and spend half the evening ringing people. You may need to seek advice

about medication for sleep.

In hot weather, fluid replacement is important, particularly when the person is on

lithium. People can become so dehydrated that the blood concentration of lithium

29

increases to such an extent that the person can go into a hepatic coma. Lithium also

increases sensitivity to sun

Encourage the person to drink small amounts regularly. Consider what the person

likes to drink and make it easily available. Address nutrition in the same way,

thinking of high-energy food.

Encourage the person to have a bath or a shower

Some people suggest warm drinks, but not coffee or tea. This helps the person feel

looked after.

Be assertive about your own boundaries in a friendly manner

Reduce access to dangerous situations.

Patient: Mary Ann Garces Age: 42 years old

Complaint: Bipolar 1Disorder Sex: Female

NURSING CARE PLAN

Need/Problem/Cues

Nursing Diagnosis

Scientific BasisObjectives of

CareNursing

InterventionsRationale

I. Psychologic

A. Deficit

1. Inappropriate perception of stimuli

Objective cues:

Stopping in midsentences while

Sensory – Perceptual Alteration: Inapproriate Perception of Stimuli related to manic phase experienced.

Mania is reflected in periods of euphoria, exuberant activity, grandiosity and false sense of well-being. Some clients manifest mania with an aggressive

After 8- hours of holistic caring-care, the client will be able to:

1. recognize and restate correctly previously interpreted stimuli

Measures to minimize occurrence of sensory and perceptual misperceptions:

1. Observe client for signs of hallucinations, listening pose, laughing or talking to self and stopping in

Early interventions may prevent aggressive responses to command

30

conversing and not continiung statements previously constructed.

Talking to herself.

Mood swings from day to day.

Changes in usual response to a visual stimuli seen.

Subjective Cues:

Claims that the another patient who had just passed by is the famous actress Imelda Papin.

Disorientation to time and date .

“Lantawa ra gud nang nawonga, nawong bag tindera...” as

tone and are sarcastic and irritable especially when others set limits on their behavior.

Source: Psychiatric Mental Health

Nursing 2nd Ed. By Sheila L. Videbeckl p. 356.

midsentece.

2. Avoid touching the client before warning him or her that you are about to do so.

3. An attitude of acceptance will encourage the client to share the content of the hallucination with you.

4. Try to connect the times of the misperceptions to times of increased anxiety. Help client to understand this connection.

5. Do not reinforce the hallucinations.

6. Try not to distract the client away from the misperceptions

hallucinations.

Client may perceive touch as threatening and respond in an aggressive manner.

This is important to prevent possible injury to the client or others form command hallucinations.

If client can learn to interrupt the escalating anxiety, reality orientation may be maintained.

So patient realizes that hallucinations are unreal.

Involvement in interpersonal activities and exploration in the actual situation may

31

verbalized by the patient when another student nurse had pass by.

Source :

1. Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychiatric Medications

5thEd. By Mary Townsend. pp.198-200.

bring the client back to reality.

Source :

2. Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychiatric Medications

5thEd. By Mary Townsend. pp.198-200.

NURSING CARE PLAN

Need/Problem/Cues

Nursing Diagnosis

Scientific BasisObjectives of

CareNursing

InterventionsRationale

2. Flight of Ideas

Cues:

Easily distracted upon first interaction

Making statements which are not related to one another

Altered Thought Process: Flight of Ideas related to imbalance in biochemical processes.

Cognitive ability or thinking is confused and jumbled with thoughts racing one after another. Clients cannot connect concepts and jump from one subject to another.

2.differentiate between reality and unrealistic events or situations.

Measures to reorient client to reality:

1. Convey your acceptance of the client's need for the false belief while telling him or her that you do not share the delusion.

A positive response would convey to the client that you accept the delusion as reality.

32

Restlessness

Answering questions first correctly then suddenly saying things not within context.

Source: Psychiatric Mental Health

Nursing 2nd Ed. By Sheila Videbeck p. 356.

2. Do not argue or deny the belief.

3. Use the technique of consensual validation and seeking clarification when communication reflects alteration in thinking.

4. Use real situations ans events. Reinforce and focus on reality.

5. Give positive reinforcement as client is able to differentiate between reality-based and non-reality-based thinking.

Arguing with the client or denying the belief serves no purpose because delusional ideas are not eliminated by this approach and the development of a trusting relationship may be impeded.

These techniques reveal to the client how she or he is being perceived by others and the responsibility for not understanding is accepted by the nurse.

To divert client away from long, tendious, repetitive verbalizations of false ideas.

Positive reinforcements enhances self-esteem and encourages repetition of desirable behaviors

33

6.Teach client to intervene, using thought stopping techniques when irrational thoughts prevail.

7. Use touch cautiously, particularly if thoughts reveal ideas of premonition.

Source :

3. Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychiatric Medications

5thEd. By Mary Townsend. pp.197-198

This noise or command distracts the individual from the undesirable thinking which often precedes undesirable emotions or behaviors.

Clients who are suspicious may perceive touch as threatening and may respond with aggression.

Source :

4. Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychiatric Medications

5thEd. By Mary Townsend. pp.197-198

34

NURSING CARE PLAN

Need/Problem/Cues

Nursing Diagnosis

Scientific Basis Objectives of Care

Nursing Interventions

Rationale

II. Physiologic

A. Deficit

1. Inability to perform hygienic measures

Cues:

Presence of long nails in

Self-Care Deficit : Inability to perform hygienic measures related to alterations in sensory and thought processes.

Inattention to hygiene and grooming is common during psychotic episodes. The patient can become so preoccupied with delusions or other hallucinations that she fails to perform even the basic

3. perform self-care activities with little assistance from the student nurse.

Measures to promote self-care:

1. Promote client participation in problem identification and decision-making.

2. Plan time for listening

enhances commitment to plan, optimizing outcomes

To discover barriers

35

the feet and hands with dirt stuck on it.

Teeth not brushed well.

Bad-smelling breath.

Hair is shoulder length, not combed and not tied.

activities of daily living.

Source: Psychiatric Mental Health

Nursing 2nd ed. By Videbeck p.311

to the client.

3. Provide for communication among those who are involved in caring for the client.

4. Assist with the rehabilitation program.

5.Provide privacy during personal care activities.

6. Assist with necessary adaptations to accomplish ADLs. Begin with familiar, easily accomplished tasks.

Source ;

Nursing Diagnoses in Psychiatric Nursing Care

to participation

Enhances coordination and continuity of care

To enhance capabilities

To avoid embarassment.

To encourage client and build on successes.

Source ;

Nursing Diagnoses in Psychiatric Nursing Care Plans and

36

Plans and Psychiatric Medications

5th Ed. By Mary Townsend. pp.197-198

GEissler – Murr pp.

Psychiatric

Medications 5th Ed. By Mary Townsend. pp.197-198

HEALTH TEACHING PLAN

Objective Content Methodology Evaluation

General Objective

After 5 days of

nurse-client

interaction the client

will be able to gain

knowledge, attitude,

and skills in caring

for person with

Psychologic illness

After 45 minutes

37

of student nurse-

client interaction the

client will be able to:

1.state the

importance of having

proper hygiene

2.cite ways in

maintaining proper

hygiene

1.Importance of

having good hygiene

1.1 best defense

against diseases

1.2 pleasing to look

1.3 stress free

person is not irritable

1.4 proper blood

circulation

1.5 promotes

optimum level of

functioning

2. Ways in

maintaining proper

hygiene

2.1 taking a bath

2.2 brushing teeth

2.3 changing clothes

everyday

2.4 wearing slippers

Informal discussion

Informal discussion

Client looks clean

when we met her on

the next day.

Client is seen

brushing her teeth

and her fingernails

are already short.

38

3.enumerate ways

on how to cope with

loneliness

4.demonstrate

proper way in taking

a bath

2.5 keeping

fingernails short

3.Ways to cope with

loneliness

3.1 listening to music

3.2 watching

television

3.3 talking with other

people

3.4 playing ball

games

3.5 playing cards

with friends

4.Proper way in

taking a bath

4.1 wet your body

4.2 apply shampoo

and massage your

hair properly and

rinse

4.3 apply soap and

rinse

4.4 wipe your body

with a towel until dry

Informal discussion

Demonstration and return demonstration

Client talks to the

student nurses

around her.

Client looks clean on the next day we met.

39

4.5 change dirty

clothes with clean

one

EVALUATION

Ms. Mary Ann Garces, diagnosed of Bipolar I disorder, and based on the

client’s medical history and all other assessment data gathered, it was observed that the

client manifested and experienced certain signs and symptoms of the particular disorder

during the investigation and the student nurses conduct this case study.

The behavioral findings have proven that the client is mentally ill as

evidenced by altered behavior alternating from depression to mania when interacting with

the student nurse. She is aware of what is currently happening in her life.

RECOMMENDATION

40

The psychiatric home staff

The researchers recommend to the psychiatric staff that in the care of the

client, they should not only be able to provide the clients with their maintained medications

as prescribed by the physician, but also to provide the patients with the utmost care that

each client needs. The staff should also continue he therapies started by the student nurses

to further improve the client’s development.

Student nurses

The researchers would like to recommend to the present and future student

nurses to use proper therapeutic communication techniques in dealing with the psychiatric

clients. Also, the student nurses must always encourage the clients to actively participate in

the different therapies se in order to help them improve the client’s present condition such

as remotivation therapy, sensory stimulation therapy, psycho therapy, art therapy, music

therapy and dance therapy which aims to provide the relief of the clients aggravation and so

as to be able to divert the clients aggravated behavior into a more positive one.

VI. IMPLICATIONS OF CASE STUDY TO:

1. Nursing Practice

Through this case study , the researchers hope that present and future nurses

in the psychiatric filed of nursing practice will be guided in carrying out psychiatric-related

activities of such mentioned disorder and therefore be able to:

collect, report and record accurate Bipolar I disorder

offer bipolar I disorder information and resources

41

participate in ongoing management of patients with bipolar I disorder

evaluate and monitor the impact of bipolar I disorder and the treatment on the

individual and family

2. Nursing Education

This case study will hopefully improve the health care givers regarding

education to the significant others on how to manage these patients and protect them from

developing further complications. It provides a broader knowledge on the person’s normal

behavior, psychopathology, signs and symptoms, predisposing and precipitating factors,

medical and nursing management. It also allows a greater understanding of the patient’s

condition since it portrays the actual patient portraying the different signs and symptoms of

the disorder. Nurses will be equipped with actual clinical information regarding the

predictable outcomes of the disease and its medical nursing management.

3. Nursing Research

This case study will hopefully encourage nursing research on finding new

management which have a faster effect to this kind of condition and can serve as a tool

guide or basis for future research on studies concerning about psychosis, which may

acquire the researcher, added information about the case of the patient with psychosis. It

can hopefully serve as a foundation for present and future nurses in the psychiatric field of

nursing practice in rendering effective and holistic caring care to clients with bipolar I

disorder.

42

PROCESS RECORDING NO. 1

I. Objectives

General:

After 2 weeks of student nurse patient interaction, the patient will be able to establish rapport and make use of the different adaptive coping mechanisms in dealing stress or crisis.

Specific:

After 45 minutes of student nurse patient interaction, the patient will be able to:

1. introduce self to the student nurse

2. establish rapport to the student nurse

3. give information about herself with her past experiences

4. verbalize feelings about self with her past experiences

5. set contract with the client

43

II. Setting of Interaction

DATE: November 29, 2011

TIME: 7:55 AM – 8:15 AM

PLACE: Vicente Sotto Psychiatric Female Ward Room

APPEARANCE:

Ms. M.G was seen wearing a clean skinny jeans and a black and white stripes shirt. She

has a long curly hair, black uncombed hair. Ms. M.G is petite approximately five feet tall.

She is not always well groomed until told to do so. She has clean fingernails. Ms. M.G is

always wearing her rosary as a necklace. She enjoys singing religious songs that

everybody when talking. Nevertheless, she has short attention span when talking. Ms. M.G

displaces regression as she acts childish and dependent.

BEHAVIOR:

44

Ms. M.G was seen standing and singing with the other patient. She sometimes argues with

the other patient. Sometimes goes to bed acting like meditating. Moreover, she interrupt

other patients. She seems talkative and easily distracted. She usually have flight of ideas

and most of the time delucinating.

COMMUNICATION:

Ms. M.G speaks in a high-toned voice. She is responsive when ever asked but sometimes

answered the questions not related to the topic. She sing every time we talk. She talks

using English and Cebuano language during interaction. She speaks clear words and very

long phrases that is out of the topic.

IMPLICATION:

Ms. M.G talks too much, easily get mad when someone interrupts her. She is having

delusions and most of the time has flight of ideas.

EVALUATION:

The client Ms. M.G was feeling well during the interaction with the student- nurse but after

for a while she felt sleepy. During the interaction, Ms. M.G was able to establish rapport

with the student-nurse because she introduced herself, made an eye-to-eye contact and

she is aware of what is happening surrounding her and keeps on singing and shouting. She

is able to identify her own condition and asked the student nurse. The student nurse

regarding the contract, as to time, date, and place for the next interaction, reminded the

client.

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