Bipolar Affective Disorder

1. NURSING CARE AND MANAGEMENT OF PSYCHIATRIC
PATIENT WITH BIPOLAR AFFECTIVE DISORDER

Group Members :
 Viviana ak Incha
 Nur Ainina bt. Mohd Fadzil
 Lai siang Wei

Semester 5 / July 2011 Intake
Subject : Psychiatric in Nursing
Subject Code : NENS 5262
Lecturer’s Name : Madam Chin Nyuk Chin

2. CONTENT PAGE
Introduction
Definition
Causes
Sign and symptom
Patient’s Biodata
Patient’s Current History
Referral Source
Family History
Personal History
Social History
Premorbid Personality
Previous Medical History
Mental Status Examination
Mental Status Examination -reverse-
Management :
 Medication
 Divertional Therapy
 Psychoeducation

Nursing Care Plan
Conclusion
References
Appendix

3. INTRODUCTION

We choose Bipolar Disorder for our case study during attach at Hospital Sentosa. We
find out the case when first patient re-admitted at 12/8/13 in Male Acute 1.Brought by his
brother. Patient names Mr.A.R, 40 years old, Malay. His brother brought him to Sentosa
and request to admit plus the patient also wanted to admitted because apparently not well
at home (voluntary, under Borang 1).
His brother and others family member noticed that patient always hanging around with
village boys and lossy money.
Throughout our observed, during interview Mr. A.R, his was talkative, flight of ideas,
and non-stop singing.
We have chosen this case study because our patient able to talk relevantly. Besides
that, he was admitted to Male Acute 1 . So, it will be easier for us to interview. Other than
that, we can make this case study presentation as part of our revision.

4. Definition Of Bipolar Disorder

 is a chronic ,recurrent illness characterized by episod es of mania
(expansiveness,elation,agitation,hyper-activity) ,hypomania,depression ,and
concurrent mania & depression (mixed episodes) with periods of normal mood and
functioning in between the episodes.

(Mental Health Nursing,sulaigah baputty-sabtu hitam-sujata sethi,pg.176)

 is a mood disorder characterized by mood swings from (exaggerated feeling or well-
being ,stimulation and grandiosity in which a person can lose touch with reality)to
depression overwhelming worth,which can include suicidal though & suicide
attempts.

(www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001924/#asadam_000926.disease.causes.
)

 sometimes called manic-depressive disorder. Bipolar disorder is associated with
mood swings that range from the lows of depression to the highs of mania.

(http://www.mayoclinic.com/health/bipolar-disorder/DS00356)

5. Causes Of Bipolar Affective Disorder

 unknown
 but genetics do seem to be involved. Relatives of people with bipolar effective and
depression are more likely to be affected.
 abnormal brain structure & brain function.

6. GENERAL SIGNS & SYMPTOMS
MANIC DEPRESSED

 mood swings
 depression
 Manic episodes
 increase activity level
 talkactive,
 ideas that moves quickly from one
subject to the next
 (flight of ideas)
 excessive irritability ,aggresive
behaviour
 reckless sex,spend lot of money




 feeling of sadness or hopelessness
 lost of interest in pleasurable or
usual activities
 difficulty sleeping ,early-morning
awakening
 difficulty concentrating

7. BIODATA

 Name : Mr. A.R

 Age : 40 y.o

 Religion : Islam

 Race : Malay

 Address : No. 52 ,Kampung Gersak,Petra Jaya, Kuching

 Occupation : Unemployed

 Status : single

 Admission Status : Voluntary (Borang 1)

 No. Of Admission : 23 (19 July 2013)

 Diagnosis : Bipolar Affective Disorder (BAD)

8. PATIENT CURRENT HISTORY

History from brother :
 During Home Leave 19/7/13 until 11/8/13 ,the patient always hangout and
gambling with village boys until back home lately.

History from patient :
 Cannot sleep around 2-3 days (hyperactive)
 Feel hopeless because lost a lot of money because of gambling
 Increasing in smoking
 Not taking alcohol anymore

During our interview, the patient was talkative, flight of ideas and non-stop singing. The
patient also spoke relevantly. Sometimes patient not cooperative with activities been
conduct.

9. A. REFERRAL SOURCE :

Patient was brought to Male Acute 1 at Hospital Sentosa Kuching (HSK) by his
brother on 12
th
of August 2013. So, he was admitted
Chief complaint ; his brother claimed that patient was not well at home and like to
wonder around at night.
Patient’s history of present illness ; according to his brother patient was drank
alcohol brought by the village boys , scolding everyone at home , gambling and become
more aggressive. Upon losing money he likes to disturb people at home.
History from patient ; troughout our interview session on the 14
th
of August 2013,
the patient spoke Malay with us. Patient is also able to attend his activity of daily living
independently. His sleep pattern was not regular, he always sleeps late at night around
3am to 4am and woke up around 12nn to 1pm.
Patient’s appetite was good and normal. Patient claimed that every meal, he will
eat two plate of rice. Besides that , his toilet habits was perform well and oral hygiene is
poor.
Before admission , his family had brought him to see “Bomoh” at around 15 years
ago at Petra Jaya. Other than that , he also had “mandi air bunga dengan rempah” at
Kpg. Tupong Tengah in few years ago.
He was also admitted to Hospital Sentosa on 30
th
of January 2013 which the 22
nd

of admission ; the treatment given to patient are Tab. Clonazepam, Tab. Quetiapine, Tab.
Sodium Valporate, Tab. Amlodipine , Tab. Metformin and Tab. Simvastatin.

10. B. FAMILY HISTORY


According to case note, patient having moderate strong family history of mental
illness. His uncle from his mother’s side was positive history of mental illness. His uncle
ever admitted for the past few years ago but already discharged from Sentosa Hospital ;
being as a outpatient and still taking the medication as prescribed by the doctor.

11. Patient stays with parent and ten siblings. He is the 9
th
among his siblings. Patient
was stayed with mother and the 5
th
sister with his brother-in-law.
Patient’s father was dead few years ago due to stroke and asthma. His mother
was 75 years old and diagnosed Diabetes Mellitus under treatment.
Patient’s 1
st
brother ; 53 years old ; married ; work at the airport. Patient’s 2
nd

brother ; 51 years old ; married ; work at hospital as PPK. Patient’s 3
rd
brother ; 50 years
old ; married ; work as engineer. Patient’s 4
th
brother ; 49 years old ; married ; work as
personal assistant with a Dato’. Patient’s 5
th
sister ; 47 years old ; married ; work as
telekom officer. Patient’s 6
th
brother ; 46 years old ; married ; work as driver BERNAS.
Patient’s 7
th
sister ; 45 years old ; married ; work at the RHB Bank. Patient’s 8
th
brother ;
43 years old ; married ; work at Kompleks Belia & Sukan. Patient’s youngest sister ; 38
years old ; married ; work as Telekom officer.
There are no social standing in patient’s family ; economic status of the family is
moderate about RM2000/- ; from the brothers and sisters who supply to the mother every
month.

12. C. PERSONAL HISTORY

Mr. A.R was a Malay , born on 9
th
July 1973 at Sarawak General Hospital with
normal delivery. He has no neurotic problems since birth. He is healthy. He completed
secondary school at SMK Tun Abang Haji Openg for Form 1 till Form 5. On 1997 , he
pass with seven subjects in SPM. He was not active at school and like to do his own work
alone.
After Form 5 , patient did not work for a few years. Patient just stayed at home and
hang around with village boys. On 2002, patient doing part time job at Banquet as a waiter
for two years. Patient was earned around RM30-40 per day from the part time job.
On 2005, patient work at coffee shop for 3 to 4 years. Patient helped his cousin to
sell “Laksa Sarawak”. After that, patient quit again as he felt his salary is insufficient to
support his daily expenses. Patient was earned between RM 600 to RM 800 per month.
On 2012, patient was worked as a guard at condominium area. He only worked for
8 days because he engaged in a police case by history of stealing. Patient also was being
fired by his employer. After that, he worked at a hotel on and off for a few months. He quit
again and not doing any job until now.
Patient sexual experience was having reckless behavior. He claimed that , he was
done sex with many partner and also with the psycho people at the outside. He was
started sex experience since 14 years old and addicted with porno CD. He also often to
masturbate.

13. D. SOCIAL HISTORY

Recently, the patient present home was concrete double-storey house. That house
is not a rent house but their own house. Mr. AR’s friend are mostly the village boys. His
friends are likes gambling also. So, they’ll influence Mr. AR to gambling and lossy money.
During home leave on 5
th
to 11
th
August 2013, almost every night he went out play
‘Olo’ and cards. His religious affiliation , he’s Muslim but never practice it.
He also smoked since 14 years old. He smoked on demand because he will
smoked as long the cigarettes have in his hand.
Patient drank alcohol since 2005,such as Cap Apek but he took it on-off. On 2007,
he took “Royal + cola + ice” . Before the admitted into Male Acute 1 ward , patient had
took beer such as “Dexter (1 can) and Tsingtao (1can)” .

14. E. PREMORBID PERSONALITY

Before patient was sick , he was prefer more being alone and not socialize with
other people accept his family ; but its also limited. He only very closed with his 5
th
brother.
He also very kind and polite towards others as claimed by his brother upon our interview.


F. PREVIOUS MEDICAL HISTORY

Upon our interviewed and referral from the patient’s case note, below are the medical
history of patient ;

 Bipolar Disorder type 1
 Hypertension – diagnosed on 8/3/12
 Non Insulin Dependent Diabetis Mellitus (NIDDM) -8/3/12
 Hypercholesterolemia -8/3/12


Hypertension , Non Insulin Dependent Diabetes Mellitus and Hypercholesterolemia are
being diagnosed on the 8
th
of March 2012.

15. MENTAL STATUS EXAMINATION

General Appearance and Behavior :
During interview on 14
th
of August 2013 (Day 3 of admission) , we had done an
assessment on patient in Male Acute 1. Patient’s general appearance and behavior are
talkative, flight of ideas and tidy. Patient also attentive and aware to surrounding activity.
His physical appearance are tough, tall, dark skin and many freckles. Patient was
well dressed and clean. Patient also able to maintain eye contact during conversation.
His facial expression; smiling and happy but patient walk is unusual gait.
There were presence of poor manner because he just grab the things that he want
to take without any permission. He able to co-operate during interview session eventough
easily distracted occasionally.

Talk
Patient’s spoke Malay and sometime in English during interview session. The
volume is normal but in rapid rate. The speech is clear and relevance. He has no loose
or clang association.

Moods
Patient mood state is happy during interview. His affective response is appropriate
and having inconsistency of mood. He denied any suicidal thoughts.

Thought Content
There are present of delusion which patient says that he’s a “pengarang cerita”.
He denied any feelings of influence, passivity, depersonalization, repetitive dreams or
phobias.

16. MENTAL STATUS EXAMINATION –reverse-

Orientation
Place Patient able to tell us where he is now.
Q : Mr.AR, do you know the name of this place?
A : Of course, this is Hospital Sentosa.
Person Patient able to recognise us during our interview.
Q : Mr. AR, do you know who we are?
A : Ya, you are nurse from ICATS.
Date Patient able to state the date.
Q : Mr. AR, do you know what date is today?
A : Ya, it's 14th August 2013.

Memory
Remote Memory : Pt able to tell us where he’s secondary school.
Nurse : “kamu bersekolah di mana dulu?”
Patient : “kat Smk Tun Abg Hj Openg lah.”
Recent Memory : Good & able to remember our names in the second
time we meet on 16 August 2013.
Five Minute Memory
Test :
Patient able to recall 3 items out of 3 items after 5
minutes.
Items : nurse watch, name tag & note book.

17. Information and Vocabulary

In estimation of intelligence level, patient able to tell us what his medication is on;
able to explain or state the medication and time to be taken. He also had explain to us
the function of his medication and the effect if not taking it. Eventough its not proper well
said in medical term but he able to says it in his own words.

Abstraction
In proverb test, patient able to explain “bagai menatang minyak yang penuh” ;
where he explained it “seorang ibu akan menjaga anaknya dengan penuh kasih sayang.
Walau apa pun yang terjadi ibu tetap sayang dengan anaknya.”

Attention and Concentration
Patient able to concentrate well during interview. We’re perform some test with
patient which are;
Serial seven test : Patient’s being instructed to minus 7 from 100 and continuously minus 7 from
the answer.
Remarks : Patient able to give fast answer.
Digit span test : We instructed patient to count number in reverse that is 10 to 1 .
Remarks : Patient able to count number in reverse from 10 to 1.

18. Judgement
Patient able to make decision and conclusion when asked about his response if
confront with a serious situation.
Nurse : “ Mr. A.R,apa kamu akan buat jika kamu lihat kawan kamu tercedera dekat wad?”
Patient : “ Saya panggil misi lah.”

Insight
Patient is aware of his condition that is Bipolar Affective Disorder. He know the
consequences if he is not comply with his treatment. He just need a better understanding
of his illness.

19. CASE MANAGEMENT
Medication :
Name of Drug Group Route Indication Side Effect Nursing
Implications
Generic Name :
Clonazepam
(0.5mg – 6mg)

Trade Name :
Klonopin

Patient’s Dosage
:
2mg

Anti-
anxiety
Oral
(ON)
 Used to treat
seizures, panic
disorder and
anxiety.
 Used to treat
bipolar disorder.
 Drowsiness,
dizziness
 Loss of
appetite,
nausea
 Unusual risk-
taking
behavior
 Confusion,
hallucinations
 Involuntary
eye
movements
 Do not
drink
alcohol.
Generic Name :
Quetiapine
(150mg – 800mg)

Trade Name :
Seroquel

Patient’s Dosage
:
800mg
Anti-
Psychotics
Oral
(ON)
 Used for the
treatment of
schizophrenia,
bipolar disorder
and along with
antidepressant to
treat MDD (Major
Depressive
Disorder)
 Chills
 Cold sweats
 Confusion
 Dizziness
 Drowsiness
 Constipation
 Headache
 Avoid
getting up
too fast
from a
sitting or
lying
position.

20. Generic Name :
Sodium Valproate
(1000mg –
3000mg)

Trade Name :
Epilim

Patient’s Dosage :
1000mg
 Anti-
convulsant
 Mood
Stabilizers
Oral
(BD)
 Used in the
treatment of
epilepsy,
panic,
anxiety
disorder,
migraine and
bipolar
disorder
 Confusion
 Abnormal eye
movement
 Extrapyramid
al side effects
 Memory
problems
 Sleepiness
 Tremors
 Weight gain
 Headache
 Lethargy
 Advice
patient to
do
regular
exercise.
 Encourag
e patient
to label
the
picture of
family
members
.
Generic Name :
Amlodipine

Trade Name :
Norvasc

Patient’s Dosage :
5mg
Calcium
Channel
Blocker
Oral
(OD)
 Treats high
blood
pressure or
chest pain
(angina).
 Swelling of
ankles &
feets
 Dizziness
 Fast, irregular
heartbeat /
pulse
 Feeling of
warmth
 Shortness of
breath
 Tightness in
the chest.


21. Generic Name :
Metformin

Trade Name :
Glumetza

Patient’s Dosage :
1g
Biguanide Oral
(BD)
 Used with
diet and
exercise to
control blood
sugar in
patients with
type 2
diabetes.
 Decreased
appetite
 Diarrhea
 Lower back
or side pain
 Muscle pain
or cramping
 Painful or
difficult
urination
 Sleepiness

Generic Name :
Simvastatin

Trade Name :
Zocor

Patient’s Dosage :
20mg
Anti-
Hyperlipidemic
Agents
Oral
(ON)
 Used to treat
high
cholesterol
and
triglyceride
levels in the
blood
 Headache
 Constipation
 Insomnia
 Joint pain
 Mild muscle
pain
 Cold
symptoms
such as
sneezing,
sore throat.

22. Diversional Therapy :

 The activities that we have done with the patient are :

1. Play chess – At certain moments, our patient is in mania state, during this
time, we would ask him to sit down and play chess with him. He able to focus
in the game and won several times.

2. Singing – Patient loves to sing most of the times. Whenever he saw us, he
loves to sing. He has a good voice. Even though sometimes his voice makes
us feel annoying but he loves to make us feel entertaining.

3. Musical chair – We gathered 8 patients and 2 students to play together. Our
patient sometimes do feel restless, we would play musical chair with him in
order to let him focus on the music.










Psychoeducation :

23. 1. Understanding illness :
 First and foremost, we assess patient knowledge on his illness. Then, we explain
the definition, sign & symptoms of the illness.

2. Treatment :
 Then, we ask the patient about his medication. We ask him by the colour of the
medication and the name if the patient remember it. We also tell him the action and
side effects of the medication and ask him which side effects he experienced as
well as teach him how to cope with the side effects. We also remind him not to take
alcohol when taking medications.

3. Prevent relapse :
 In order to prevent the illness from reoccur, we advise the patient to maintain a
balance of rest and activities, regular check-up and compliance towards medication.
In addition, we also advise the patient to have balanced diet, regular exercise and
avoid alcohol. We also educate the patient of the early signs of relapse such as less
sleep, feels irritable and not feeling of taking medication.

24. 4. Crisis intervention :
a) Managing stress – when feeling stress, do some exercises. We also teach the
patient to do deep breathing exercise if he feel stress.
b) Problem solving skills
i. Identify the problem
ii. Find a better solution
c) Follow up treatment according to the appointment.

5. Healthy lifestyle :
 Avoid alcohol together with drugs that might increase the risk of relapse.
 Have a healthy balanced diet. Consume more vegetables and fruits.
 Exercise regularly because exercise can affect mood positively.
 Have enough rest. Go to bed at the same time every night.
 Regular follow-up and compliance with treatment.

25. Nursing Care Plan :
Nursing
Diagnosis
Goal Nursing
intervention
Rationale Evaluation
Risk for violence
related to the
patient’s
aggressive
behavior.

OD :
• Patient looks
irritable when
people keeps
bothering him.

SD :
• Patient
verbalize that
other patient
keeps taking
cigarette from
him which
makes him
angry.

Patient feels
less irritable
when get
along with
other people
within 1 week.

 Provide
diversional
therapy such as
playing chess.

 To divert
patient’s anger

After 1 weeks,
patient feel less
irritable when get
along with other
people.
 Encourage
patient to
express his
feelings
 To help the
patient to
relieve his
feelings and
anger.
 Avoid expose the
patient to
predictable high
situation.

 To avoid
patient
became out of
control.
 Administer
medication as
prescribed by
doctor such as
epilim.
 To calm the
patient.

26. Knowledge deficit
regarding to
illness.

OD :
• Patient facial
expression
seems
confused.

SD :
• Patient do not
understand his
disease upon
interviewing.


Patient
verbalize
understand
about his
illness /
disease within
1 weeks upon
interviewing.


 Assess patient
level of
understand
towards his
illness.


 To identify his
understanding
level.


After 1 weeks,
patient verbalize
understand about
his illness /
disease upon
interviewing.

 Explain to patient
regarding his
disease which
includes
treatment.


 To increase
patient’s
knowledge on
his illness /
disease.

 Educate patient
on his sign and
symptoms of his
illness / disease.


 To increase
patient’s
knowledge
and to prevent
relapse.

27. Sleep
disturbance
related to
hyperactive.

OD :
• Patient look
dozy in the
day.

SD :
• Patient
verbalize feel
wanted to do
something at
night.


Patient able to
sleep for 6
hours at night
after 1 week.


 Advice patient to
go to bed at the
same time every
day.


 To maintain
bedtime
routine.


After 1 week,
patient able to
sleep for 6
hours at night.

 Advice patient to
pass urine before
go to bed.
 To avoid
disturb during
sleep.

 Increase daytime
activity for patient
such as play
balls.

 So that patient
will feel tired at
night.

 Limit the amount
and length of
daytime sleeping
to half an hour.
 So that patient
able to sleep
at night.


 Administer
medication as
prescribed by
doctor such as
clonazepam.

 To reduce the
sleep
disturbance of
the patient.

28. Poor compliance
related to lack of
family support.

OD :
• Patient has
flight of ideas
upon returning
from home
leave.
• Patient look
hyperactive

SD :
• Patient
verbalizes
unable to
sleep well at
night.
• Patient’s
brother
verbalize
patient always
hang out at
night.


 Patient is
willing to
take
medication
by 1 week.

 Patient
verbalize
understand
the
importance
of
compliance
towards
treatment.


 Supervise the
patient’s
medication
intake.


 To ensure
patient take
the medication
as prescribed.


 After 1 week,
patient is willing
to take
medication
regularly.

 Patient also
verbalize
understand on
the importance
of compliance
towards
treatment.


 Explain the
illness and
importance of
treatment
towards the
patient.


 To increase
patient
knowledge
level on his
illness and
treatment.


 Encourage the
patient to take
treatment
unsupervised
and regularly.


 To allow
patient being
independently
after
discharge.

29. Conclusion :
Through this case study, we learned a lot about Bipolar Affective Disorder. We
improved our knowledge on the sign and symptoms such as distractibility, impaired
judgment and increased energy.
Besides collecting data from documentation of the staffs from Hospital Sentosa,
we also manage to gather some data from the patient through interview. During that
interview, we get to know more about him as well as his feelings.
Our patient is co-operative upon interviewing by answering the questions that we
asked him. He also sang song for us in order to entertain us.
This case study also encouraged us to read more on Bipolar Affective Disorder
(BAD). I believe this case study will help us in the future.

30. Refferences

 (Mental Health Nursing,sulaigah baputty-sabtu hitam-sujata sethi,pg.176)
 (www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001924/#asadam_000926.disease.c
auses.)
 (http://www.mayoclinic.com/health/bipolar-disorder/DS00356)