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

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

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.

Definition Of Bipolar Disorder

is a chronic ,recurrent illness characterized by episodes 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)

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.

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

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)

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.

A. REFERRAL SOURCE :

Patient was brought to Male Acute 1 at Hospital Sentosa Kuching (HSK) by his

brother on 12th 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 14th 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 30th of January 2013 which the 22nd

of admission ; the treatment given to patient are Tab. Clonazepam, Tab. Quetiapine, Tab.

Sodium Valporate, Tab. Amlodipine , Tab. Metformin and Tab. Simvastatin.

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.

Patient stays with parent and ten siblings. He is the 9th among his siblings. Patient

was stayed with mother and the 5th 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 1st brother ; 53 years old ; married ; work at the airport. Patient’s 2nd

brother ; 51 years old ; married ; work at hospital as PPK. Patient’s 3rd brother ; 50 years

old ; married ; work as engineer. Patient’s 4th brother ; 49 years old ; married ; work as

personal assistant with a Dato’. Patient’s 5th sister ; 47 years old ; married ; work as

telekom officer. Patient’s 6th brother ; 46 years old ; married ; work as driver BERNAS.

Patient’s 7th sister ; 45 years old ; married ; work at the RHB Bank. Patient’s 8th 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.

C. PERSONAL HISTORY

Mr. A.R was a Malay , born on 9th 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.

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 5th to 11th 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)” .

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 5th 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 8th of March 2012.

MENTAL STATUS EXAMINATION

General Appearance and Behavior :

During interview on 14th 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.

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.

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.

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.

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.

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.

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.

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 :

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.

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.

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.

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.

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.

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.

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.

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)