Case Presentation of Bipolar Affective Disorder, Current Episode, Manic with Psychotic Disorder
-
Upload
earl-natividad -
Category
Documents
-
view
6.411 -
download
1
description
Transcript of Case Presentation of Bipolar Affective Disorder, Current Episode, Manic with Psychotic Disorder
A. INTRODUCTION
Psychiatric area is one area of exposure of the nursing students. Our group was lucky enough to
be assigned at the psychiatric area at BGHMC (Baguio General Hospital and Medical Center). The group
had encountered several common psychiatric disorders like the different types of schizophrenia and
bipolar disorders. The group had chosen to study Bipolar Affective Disorder, current episode, manic
with psychotic disorder. The group had chosen this type of disorder for us to understand and appreciate
this type of psychiatric ailment.
Bipolar disorder or manic-depressive disorder which causes mood swings that ranges from the
lows of depression to the highs of mania. In some cases, bipolar disorder causes symptoms of
depression and mania at the same time. Bipolar disorder causes serious shifts in mood, energy, thinking
and behavior from the highs of mania on one extreme to the lows depression on the other. More than
just a fleeting good or bad mood swings, the cycles of bipolar disorder last for days, weeks, months or
even a year. Unlike ordinary mood swings, the mood changes, bipolar disorder is so intense that it
interferes with your ability to function.
If the client is under mania, the common signs and symptoms includes feeling that are unusually
high, optimistic and very irritable, unrealistic, grandiose belief about one’s abilities or powers, sleeping
less but feeling extremely energetic, talking so rapidly, racing thoughts, jumping quickly from one idea to
the next, highly distractible, impaired judgement and impulsiveness, acting recklessly without thinking
about the consequences and lastly in severe cases, delusions and hallucinations may appear.
If the client is under depressive, the common signs and symptoms are decreased energy, easy
fatigability, lethargic, has diminished activities, insomnia or even hypersomnia, usually lost of interest in
pleasurable activities and lastly social withdrawal.
B. PATIENT’S PROFILE
Name: Mr. I.E.R
Age: 56 years old
Birthday: July 4, 1953
Civil Status: Married
Address: Km8 Asin road, Tuba, Benguet
Religion: Roman Catholic
Nationality: Filipino
Date of Admission: June 11, 2010
Time of Admission: 7:35 PM
Admitting Diagnosis: Bipolar Affective Disorder, Current
Episode, Manic with Psychotic Disorder
1
C. ASSESSMENT
1. Psychiatric History/Developmental History
The patient is born via NSVD (normal spontaneous vaginal delivery), no known
complications and abortion attempts of the mother. According to the patient he was both
breastfed and bottlefed up to 1 ½ years of age. He was also toilet trained by his parents.
He further claimed that he was pampered by his parents with love and affection as well as
with other things like toys, books and clothing. Basically, he had a good childhood
experience as claimed.
During his school age, he remembered that he does not participate in school activities
and seldom mingle with his classmates. He further claimed that he is respectful to elders
especially to his parents and grandparents. During his high school years, he experienced
being involved with fist fights with the bullies. He remembered he was never separated
from his family and was able to finish his degree in mechanical engineering.
He was married at the age of 36 years old. After how many years, his wife gave birth to a
baby boy. They then decided that the husband will go abroad in Saudi Arabia and work as
a mechanical Engineer while his wife is left with the son in the Philippines. After how many
years, they decided to switch, the husband was left with the baby and his wife went
abroad to Saudi to work as a nurse at a hospital. With this set up of a long distance
relationship which is too hard to handle. Being away from your wife and being with your
son for several years. His wife has only quality time for them whenever she comes home
for vacation. Whenever his wife comes home for a vacation, he is usually very happy.
According to the patient, the most traumatic experience he had is the death of his
sister. It was during this time that he knew that his sister died to an accident, due to
financial matters he wasn’t able to attend his sister’s burial. That is the time he feels very
sad because he claimed that he was really close to his sister. For his other siblings, he
visits them occasionally and whenever there was a problem with one of the member of
the family he and the others would lend their hands and intervene to any problem to
resolve it.
He and his neighbor misunderstood each other, but not identified, every now and then
they are almost having an argument. The son saw his change of reactions and behaviors 5
days prior to admission like auditory hallucinations, illusions, mood swings, he keeps on
digging at their backyard and always saying that “may ginto sa likod ng bahay natin”.
Now at his age of 56 years old, he was admitted because of the presence of
hallucinations, illusions and delusions. He claimed that he was brought to the hospital
because of his hypertension. Often times he sits on his bed or lie down and sleep, he
2
usually don’t mingle with the other patients but feels comfortable when talking to student
nurses.
2. History of Present Illness
The patient could remember that his mother told him that when he was sick with chickenpox and measles, he had high fever and convulsion. Aside from this, patient claimed he was generally healthy as a child.
During his school age, he claimed that he was shy. He does not participate in
school activities and seldom mingle with his classmates but as he grows up, he further
claimed that he feels more comfortable with girls and so he has more female friends than
boys. At the age of 15, after he graduated from high school, he then have to be separated
to his family because he enrolled to one of the schools in Baguio to finish his college
degree. It was his first time to be separated from his family and so he felt so sad.
During his college years, he learned to be independent and so he was able to finish his
chosen field of mechanical engineering. After graduating, he decided to work abroad in
Saudi to earn his own money. He then met his wife who is a registered nurse in one of the
Hospitals in Saudi. They got married and blessed with a son. In order to sustain their needs
of the family, he continued to work abroad leaving his family in Zamboanga. They decided
that his wife will go abroad also leaving their son with him. With this set up of a long
distance relationship which is too hard to handle. Being away from your wife and being
with your son for several years. His wife has only quality time for them whenever she
comes home for vacation. Whenever his wife comes home for a vacation, he is usually
very happy.
According to the patient, the most traumatic experience he had is the death of his sister.
It was during this time that he learned that his sister died from an accident, due to
financial matters he wasn’t able to attend his sister’s burial. That is the time he feels very
sad because he claimed that he was really close to his sister. For his other siblings, he
visits them occasionally and whenever there was a problem with one of the member of
the family he and the others would lend their hands and intervene to any problem to
resolve it.
In the case of our patient there was no mental illness in the family. However, he was
only diagnosed with hypertension before admission at the Psychiatric Hospital. The time he
was firstly observed with manifestations of the disorder the patient was into treasure
hunting. He claimed that he met an old woman that was dictating him what to do and
where to hunt. He claimed that the old woman manipulated him to do it. Since then, the
patient would dig around their backyard and was preoccupied with doing unnecessary
things, but the patient wouldn’t forget his position in the family and would do household
chores and would act accordingly. He was helpful with doing house chores but noticed that
3
he had lost his social life. His friends were not visiting him anymore and vice versa. Soon
after, the patient’s wife came home from Saudi, and around that time he was observed to
be normal again, the patient stopped his treasure hunting activities and also claimed that
he stopped seeing the old woman. He was observed to be happy during those times. The
wife then went back to Saudi and after sometime the patient resumed his usual activities of
digging around their house. The patient started to mumble, and would walk around the
house to and fro and he would utter incoherent words.
Five days prior to admission, the patient felt abnormally good, high, excited, hyperactive
and irritable. This was extreme since the patient lost contact with reality and started to
believe strange things. He had poor judgment and behaved in harmful ways which was
dangerous. This was accompanied by an elevated mood and he had reduced sleep. He had
optimistic ideas and plans were expressed. The patient developed symptoms of
hallucination and delusion. One day prior to admission, the patient kept on saying S.B, who
was the patient’s relative who worked in a mining company. After he went to Balatoc
Mines, during the night when his son was watching t.v. the patient came close to him
saying, “Sino ka… sino ka?... P.F. (their neighbor whom he always had an argument with).
So, the son introduced himself. Afterwards, the patient went to his room shouting over and
over again. Out of fear, the son called their relatives and asked help from the nearby police
station to get the patient. The patient was seen half naked, praying on the road, kissing the
ground and saying that he is the savior. The patient had a bag of stones and books saying
he would go home to Zamboanga leaving the treasure to his son. He was held and brought
to the institution hence the admission. Hence patient I.R., 56 years old was admitted and
diagnosed with bipolar affective disorder, current episode, manic with psychotic
symptoms.
4
3. Mental Status Examination
A. APPEARANCE
The client appears to be well groomed. Mr. I.R. has a noticeably proper cut hair and
is well combed. Mr. I.R. wears clothing appropriately depending on his mood and with the
weather. Mr. I.R. refers wearing long sleeves but when it is hot, he wears the usual t-shirt
along with his shorts or any available pants he has. For 3 consecutive days of duty, it was
observed that he only took a bath on the third day then changed his clothes; the patient is
observed to brush his teeth before and after meals. His nails are trimmed and his beard and
mustache are neatly shaved. The client appeared as the stated age of 56 years old with
visibly white hair and some noticeably wrinkles on his face.
B. BEHAVIOR
1. MANNER OF RELATING
Mr. I.R. is participative during discussion. He actively and openly answers queries being asked to him by the student nurses. He sometimes cracks jokes that make the conversation lively. He usually prefers to talk with student nurses rather than to his co-patients inside the ward.
2. PSYCHOMOTOR ACTIVITES The patient has a good posture. However, he sometimes slouches during
conversation with his legs and arms crossed and sometimes with his hands on his lap, swaying his feet while looking around the room. He usually stay on bed sitting or if not, sleeping. Patient has good posture, gait and station. He was observed to walk straight. He has mild hand tremors observed.
3. SPEECH/LANGUAGEThe client talks with normal rate, rhythm and intensity. He speaks clearly and has
good articulation of words. He elaborates his answers to questions asked and sometimes, he shares some topics to be discussed. It was also observed that he can easily find the right words to use when lost during conversation. To explain further what are his thoughts. Patient is able to talk in English, Tagalog and Ilokano fluently.
4. RELEVANCE/COHERENCEThe client was able to answer relevantly and coherently. He used simple,
concrete and easy to understand responses to the topics being discussed during the NPI (Nurse-Patient-Interaction).
5. DEVIATIONSThere were no deviation like inventing, rhyming, stammering, clanging of words,
repetition of words and speeches in particular questions being asked by the student nurses noted.
6. VOCABULARYThe patient uses appropriate terms to use when conversing. He sometimes use
terms related to his field of engineering such as the different machineries and gadgets he encountered while he is still studying and working abroad. Patient is able to adjust his choice of words depending on whom he is talking to. He would use simple words to his co-patient while he uses more complex vocabularies to the health care providers.
5
C. MOOD and AFFECT
Mr. I.R. stated “okay naman pero minsan nadedepress”. It was observed during
the conversation that whenever the discussion deals with his wife finding time visiting
him, he feels very happy and is seen smiling. However, when the topic is about the
incident where he wasn’t able to visit his sister and dad’s burial, he becomes very sad
with teary eyes.
D. THINKING
During the conversation, Mr. I.R. was able to discuss topics concerning religion,
philosophy and history. He was able to discuss recent events of the world and how
these are predicted by previous events. He also talks about his work and how was he as
an employee when he works abroad. He talks about his family often and mentioned
“Yung asawa ko nagwork sa Saudi at may isa akong anak.. Maaga nakapag asawa. May
isa na akong apo.” There was no paranoid delusions observed from the client. However
the patient was observe to avoid topics which concern on the reasons why he was
brought to the hospital. Mr. I.R. is oriented to person, place, time and self. He can
identify who brought him to the ward.
The patient is able to recall recent and past events in his personal history. He can
still recall up to now that he’s 56 years old the memorable experience he had when he
was 6 years old which made his parents got mad. He said “May ilog kasi doon malapit sa
bahay namin. Naliligo kami ng walang paalam kaya pag-uwi namin, palagi kaming
nabubuking kaya napapalo kami”.
When the patient was asked to tell the name of one of our co-student nurse that
was introduced to him for no longer than 15 minutes, he said “ Si Earl, oo yung mataba.
Siya yung una kong nakita nung pagpasok niyo. Malaking tao kasi.”.
E. ABSTRACTION
When the patient was asked of how did he understand the saying “A hard
beginning maketh a good ending.” He responded immediately “ Parang ganito sa
situation ko, para akong nakakulong ngayon pero there’s a purpose why I am here
however taking that all into consideration, I am positive that this turmoil is to make me
and my family stronger than before”.
1. CALCULATION AND CONCENTRATION
The patient was able to compute simple mathematical equations as fast as 5 to
10 seconds when asked to answer “9 x 23=___”. He can concentrate even if the ward
seems so noisy.
6
2. INSIGHT
When he was asked how can he sees himself as a father to his child, he simply
said “ I have been a good father or a parent. In fact not only that, I know I have been a
good husband to my wife kasi ginawa ko lahat para mabigyan sila ng magandang buhay
sa pamamagitan ng pagtatrabaho ko at pagtitiis ko sa Iran for income out of hard
work.”He also claimed “Hypertension talaga problema ko. Hindi naman ako baliw. Wala
akong nakikita o nakakausap o naririnig na gaya ng naririnig at nakikita nung iba kong
kasamahan dito”.The patient mentioned also “ Magbabakasyon muna ako sa
Zamboanga pagnakalabas ako dito para makapagpahinga na din. Kasama ko ang asawa
kong pupunta siguro.”
3. JUDGMENT
The client mentioned along with the discussion that he had some fight with his neighbor and was asked of what he will do when he sees his neighbor again and he said “Makikipag ayos na ako. Siguro nga talagang kailangan na ng peace-of-mind kaya makipag=ayos na”.
F. SUPEREGO FUNCTIONING/IMPULSE CONTROLThe client stated that “Noong hindi ko natulungan yung ate ko financially at
noong hindi ako nakapunta nung burol nya” when he was asked what he or makes him guilty or what he regrets the most.
G. SELF- CONCEPTThe patient has low self-esteem as he is shy and he doesn’t mingle or talk with
the other patients in the ward. When conversing with him he often focuses on his positive behavior like being a good husband to his wife and father to his son, which indicates that he is trying to elevate his self-esteem.
H. PHYSICAL COMPLAINTS/PROBLEMSThe client doesn’t have any physical deformities. He is slow when walking because
of aging. He has tremors and claimed that “Ganito ‘to kasi side effect ng gamot”, which indicates a circulatory problem because of HPN.
7
D. DIAGNOSTIC EXAMINATION
Date of Procedure Diagnostic Procedure
Description Results Normal Values Significance
June 12, 2010 Urinalysis This test detects ion concentration of the urine. Small
amounts of protein or ketoacidosis tend to elevate results of the specific gravity.
Specific gravity is an expression of the weight of a substance
relative to the weight of an equal volume of water.
Color: yellow
Transparency: Slightly Turbid
Reaction/pH: 6.0
Specific Gravity: 1.020
Protein: Neg
WBC: None
Epithelial Cells: Rare
Bacteria: None
Amorphous urates/PO4: Occasional
Normal
Normal
Normal
Concentrated urine
Normal
Normal
Normal
Normal
There is a presence of amorphous urates due to
prolong refrigeration.
The specific gravity of your urine is measured by using a
urinometer. Knowing the specific gravity of your urine
is very important because the number indicates
whether you are hydrated or dehydrated.
8
Date of Procedure Diagnostic Procedure
Description Results Normal Values Significance
June 17, 2010 CBC (Complete Blood Count)
The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood.
RBC - 4.32 x 1012/L
WBC -10.4 x 109/L
Lymph # -2.7 x 109/L
Mid # -0.9 x 109/L
Gran # -6.8 x 109/L
Lymph % -26.2 %
Mid % -8.2%
Gran % - 65.65
Hgb - 141 g/L
HCT - 0.433/L
MCV - 99.8/L
MCH -32.4 pg
MCHC -325 g/L
4.6 – 6.2 x 1012/L
4.5 – 11.0 x 109/L
0.8 – 4.0 x 109/L
0.1 – 0.9 x 109/L
2.0 – 7.0 x 109/L
20.0 – 40.0 %
3.0 – 9.0 %
50.0 – 70.0 %
135 -180 g/L
0.4 – 0.54/L
78.0 - 100.0/L
27.0 – 31.0 pg
320 – 360 g/L
The significance of this laboratory procedure is to mainly includes the care and treatment of patients with conditions that will result in increases or decreases in the cell populations
9
RDW-CV - 13.1 %
RDW-SD - 48.6/L
PLT - adequate
MPV - 6.8/L
PDW - 15.5/L
PCT - 0.184 %
11.5 – 14.5 %
35 – 56/L
7.0 – 11.0/L
15.0 – 17.0/L
0.108 – 0.282 %
10
E. PSYCHOPATHOLOGY
1. Biological Cause
A. Neurotransmitter Alteration
A.1 Increase Dopamine
- Overproduction of dopamine causes the nerve circuits to misfire and create a
split state in the mind where delusions and hallucinations make the reality of the
outside world easier to accept
A.2 Increase Serotonin level
- An increase in serotonin levels indicates Mania / Manic in Bipolar Disorder.
Because he has the three signs of mania which are Auditory Hallucinations,
delusions and paranoia
A.3 Decrease Serotonin Level
- A decrease in serotonin levels indicates depression. He has the symptoms of
depression like social withdrawal, low self-esteem and persistent sadness
B. Genetic Predisposition
B.1 Being Shy
- He has the presence of the type A personality, which is inherently acquired
thus he has poor IPR to others
2. Psychosocial Causes
A. Development of Mistrust
- It is according to Freud’s Psycho-social theory. Presented by poor IPR to other
people, unable to express feelings, lack of close friends, isolates self, social
withdrawal
B. Cultural Norms
- Because they have a close-knit family
C. Traumatic Experience
C.1 Separation from family members
- Being alone and independent in an area that is unfamiliar
C.2 Death of his Sister
- As presented by Long term depression
C.3 Living alone for several years
- As manifested by anxiety and fear
D. Use of Defense Mechanism
- Ineffective use of Denial as manifested by unrealistic perception of the situation
11
PSYCHODYNAMICS
12
Neurotransmitter Alteration
Dopamine
Auditory hallucinations
Serotonin
Increase Decrease
Manic Depressive
Signs and Symptoms:
-Agitation-Hyperactivity-Racing Thoughts-Delusions of Grandeur-Illusions-Hallucinations
Signs and Symptoms:
-Insomnia-Persistent sadness-Social withdrawal-Low self-esteem-Difficulty Concentrating
Chronic Low Self-esteem
Genetic Predisposition
Type A personality
Psychosocial Causes
Development vs. Mistrust
Cultural norms
Poor IPR to other people
Close-knit family
-Unable to express feelings
-Lack of close friends
-Isolates self
-Social withdrawal
Traumatic Experience
Separation from family
Death of his sister
Living alone for several
years
Anxiety
Long term depression
Use of defense mechanism
Activation of the SNS (fight or flight response)
Stress
Blood Pressure, pulse rate, respiration
Altered cardiovascular
status
Ineffective
Unrealistic perception of the
situation
Risk for injury
Bipolar Affective Disorder, Current Episode, Manic with Psychotic Disorder
Denial
Over production of dopamine causes nerve circuits to misfire and create a split state in the mind
Delusions
Paranoia
Hypertension
Causing disturbed visual
field and postural
imbalancePoor compliance to treatment regimen
-medicine
Possible separation to wife
Risk for relapsed episode
Being shy
F. DRUG STUDY
Generic name
Trade name
Classification DosageStart and
Completion of Medication
Mechanism of Action Indication Side Effects Nursing Consideration
Amlodipine besylate
Norvasc
Calcium channel blocker
Antianginal drug
Antihypertensive
Dosage: 10 mg 1 tab OD
Date started:06/17/10
Blocks the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. coronary artery disease
>Essential hypertension, or in combination with other agents
CNS: dizziness, light-headedness, headache, fatigueCV: peripheral edema, arrhythmiasDERMATOLOGIC:Flush, rashGI: nausea, abdominal discomfort.
>Monitor the patient’s BP, cardiac rhythm, and output while adjusting drug to therapeutic dose.>instruct client to swallow the tablet whole with or without food as directed by the physician.>Instruct client to take with meals if stomach upset occurs.> tell the client to report irregular heartbeat, shortness of breath, swelling of hands and feet, pronounced dizziness or constipation.
13
Generic name
Trade name
Classification DosageStart and
Completion of Medication
Mechanism of Action Indication Side Effects Nursing Consideration
Clonidine hydrochloride
Catapres
Antihypertensive Dosage: 75 mg. 1 tab SL fo BP ≥ 140/90
Date started:06/14/10
Stimulates CNS alpha2
adrenergic receptors, inhibits sympathetic cardioaccelerator and vasoconstrictor centres, and decreases sympathetic outflow from CNS.
>For hypertension CNS: drowsiness, sedation, dizzinessCV: CHF, orthostatic hypotension, tachycardia, palpitationsGI: dry mouth, constipation, nauseaGU: impotence, decreased sexual activity, diminished libido
>monitor BP carefully, when discontinuing clonidine, hypertension usually returns within 48 hours.>Take the drug exactly as prescribed. The drug should be put under the tongue. >Do not discontinue drug unless so instructed.> tell the patient that discontinuing abruptly, life threatening adverse effects may occur.
14
Generic name
Trade name
Classification DosageStart and
Completion of Medication
Mechanism of Action Indication Side Effects Nursing Consideration
Lithium carbonate
Carbolith
Antimanic drug Dosage: 450 mg 1 tab BID
Date started: 06/12/10
Alters sodium transport in nerve and muscle cells, inhibits release of norepinephrine and dopamine, but not serotonin from stimulated neurons, slightly increases intraneural stone of cathecolamines; decrease intraneuronal content of second messengers and may the by selectively modulate the responsiveness of hyperactive neurons that might contribute to the manic state.
Treatment of manic episodes of manic-depressive illness.
CNS: lethargy, slurre d speech, muscle weaknessGI: nausea, vomiting, diarrheaGU: pyloria
>Give drug with food or milk after meals.>Monitor clinical status closely>take this drug exactly as prescribed, after meals or with food or ,milk>Instruct client to open mouth and lift tongue to check for the drugs.
>tell the patient to eat a normal diet with a normal salt intake, maintain adequate fluid intake.
15
Generic name
Trade name
Classification DosageStart and
Completion of Medication
Mechanism of Action Indication Side Effects Nursing Consideration
Haloperidol
haldol
antipsychotic Dosage: 10 mg deep IMx 3 doses PRN for severe psychotic agitation.
Date started: 06/11/2010
Haloperidol interferes with the effects of neurotransmitters in the brain which are the chemical messengers that nerves manufacture and release to communicate with one another. It blocks receptors for the neurotransmitters (specifically the dopamine and serotonin type 2 receptors) on the nerves. As a result, the nerves are not "activated" by the neurotransmitters released by other nerves
Management of manifestation of psychotic disorders.
CNS: drowsiness, insomnia, headacheautonomic: drymouth, salivation, nasal congestionCV: hypotensionhematologic: eosinophilia, leukopenia
>Take the drug with food or exactly as prescribed.>Do not dilute this with coffee, tea, colas or apple juice - the medication may lose effectiveness.>Do not stop taking this drug suddenly without consulting your doctor.>Instruct client to open mouth and lift tongue to check for the drugs.>Instruct client to Avoid engaging in other dangerous activities. If dizziness or drowsiness or vision changes occurs.
16
Generic name
Trade name
Classification DosageStart and
Completion of Medication
Mechanism of Action Indication Side Effects Nursing Consideration
diphenhydramine
Benadryl
AntihistamineAntiparkinsonian
Dosage: 50 mg. IM q 1 hr. x 3 doses PRN for severe psychotic agitation with BP precaution
Date started: 06/11/10
Competitively blocks the effects of histamine at H1-
receptor sites, Diphenhydramine also blocks the action of acetylcholine (anticholinergic effect) and is used as a sedative because it causes drowsiness
Parkinsonism (including drug induced parkinsonism and extrapyramidal reactions), in the elderly tolerant of the more potent agens, for milder form of disorders in other age groups, and in combination of centrally acting anticholinergic antiparkinsonian drugs.
CNS: drowsiness, sedation, dizzinessCV: hypotension, palpitation, bradycardiaGI: epigastric distress, anorexia, GU: urinary frequency, dysuria thrombocytopeniaHepatic: hemolytic anemia
>Administer with food if GI upset occurs.>Monitor patient’s response.>take as prescribed, avoid excessive dosage>Instruct client to open mouth and lift tongue to check for the drugs.>tell the client to report difficulty of breathing, tremors, unusual bleeding or brusing, irregular heart beat.
17
Generic name
Trade name
Classification DosageStart and
Completion of Medication
Mechanism of Action Indication Side Effects Nursing Consideration
Chlorpromazine
Thorazine
Antipsychotics Dosage: 200 mg. ½ tab AM; 1 tab in HS
Date Started: 06/12/10
Block dopamine receptors in the brain; also alter dopamine release and turnover.
Management of manifestation of psychotic disorders; control of manic phase of manic depressive illness.
CNS: neuroleptic malignant syndrome, sedation, CV: hypotension EENT: blurred vision, GI: constipation, dry mouth, anorexia, GU: urinary retentionHematologic: leukopenia
>Assess mental status prior to and periodically during therapy.>Monitor BP and pulse prior to and frequently during the period of dosage adjustment.>Observe patient carefully when administering medication.>Instruct client to open mouth and lift tongue to check for the drugs.>Advice patient to take medication as missed doses as soon as remembered, witih remaining doses evenly spaced throughout the day.
18
Generic name
Trade name
Classification DosageStart and
Completion of Medication
Mechanism of Action Indication Side Effects Nursing Consideration
Biperiden
akineton
antiparkinsonian Dosage:2 mg. 1 tab OD
Date started:
06/12/10
Anticholinergic activity in the CNS that is believed to helpnormalize the hypothesized imbalance of cholinergic and dopaminergic neurotransmitter in the basal ganglia of the brain of a parkinsonism patient. Reduces severity of rigidity, and to lesser extent, akinesia and tremor characterizing parkinsonism.
Adjunct in the therapy of parkinsonism (post encephalitic, arterioschlerotic, and idiopathic types)
CNS: disorientation, confusion, memory loss, hallucinationCV: tachycardia, palpitations, hypotensionDermatologic: rash, urticariaGI: dry mouth, constipation, dilatation of colon
>Give with meals if GI upset occurs, give before meals for clients who have dry mouth, give after meals if drooling or vomiting occurs.>Take the drug as prescribed.>Instruct client to open mouth and lift tongue to check for the drugs.> tell patient to report difficult or painful urination; constipation, rapid pounding of the heart, confusion, eye pain or rash.
19
G. PRIORITIZATION
RANKING NURSING DIAGNOSIS/ PROBLEMS JUSTIFICATION
1
Altered cardiovascular status related to increase pressure secondary to
Hypertension
Airway, breathing and circulation concept states that circulation should
always be the third to be assessed. And if the heart doesn’t work normally, the
other systems and their functions will be affected. The aorta is the largest artery of the body that extends from the left
ventricle of the heart to begin the distribution of oxygenated blood throughout the rest of the body,
narrowing and clogging of aorta brought about by fatty deposits causes a
decrease in the blood flow from the left ventricle into the systemic circulation. This obstruction creates a resistance to ejection and increased pressure in the
left ventricle.
2 Chronic low self-esteem related to impaired cognitive self-appraisal AEB negative feedback about self
We ranked this as our second priority because People with chronic low self esteem
issues often spend more time worrying about the future, or dwelling on mistakes
that they've made in the past, that they fail to enjoy the here and now moments in life. Without the self esteem to believe they can accomplish something new, fear keeps the
sufferer from asking for that promotion; going on a date with the person they're
attracted to; or even getting on that roller coaster with their kids.
3
Ineffective denial related to inability to tolerate the consequences of
known disorder
For most persons, everyday life includes its share of stressors and demands, ranging from family, work, and professional role
responsibilities to major life events such as divorce, illness, and the death of loved ones. How one responds to such stressors depends
on the person’s coping resources. Such resources can include optimistic beliefs,
social support networks, personal health and energy, problem-solving skills, and material
resources. Socio-cultural and religious factors may influence how people view and
handle their problems. Vulnerable populations such as elderly patients, those in adverse socioeconomic situations, or those
who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic
20
stressors.
4
Risk for injury related to imbalanced between oxygen supply and demand
secondary to hypertension
Risk for injury is one of the most common complications of hypertension that is why it
is the prioritized potential problem. Patient’s having hypertension are prone to injury
because of the imbalance in their oxygen supply and demand causing disturbed visual field and postural imbalance. If this potential
problem is not given immediate attention, this may cause a more serious problem to
the patient.
5 Risk for relapsed episode maybe R/T poor medical treatment regimen
compliance
We ranked this as the least priority because the chances of having relapse episode are
about 40% is needs are not satisfied, majority of psychiatric clients are r/t poor
compliance to medical treatment
21
H. NURSING CARE PLAN
NCP ACTUAL #1: ALTERED CARDIOVASCULAR STATUS R/T INCREASE PRESSURE SECONDARY TO HYPERTENSION
ASSESSMENT EXPLANATION OF THE PROBLEM
GOALS AND OBJECTIVES
NURSING INTERVENTION RATIONALE EVALUATION
S>” Problema ko tong BP ko, tumataas” Bp- 150/100
O> Fluctuating BP of 140/100 to 150/100
>Feeling of dizziness like when going to the comfort room
>Increase respiratory rate
>Fast breathing
A> Altered cardiovascular status related to increase pressure secondary to Hypertension
Patient has a history of hypertension. During admission until the third day patient has a fluctuating BP of 130/100 to 150/100, this was caused by over excitement when his wife came home from Saudi and stress that causes sympathetic nervous system (that stimulates the fifgt or flight response) over activity increasing hearts contractility over stress.
Source:
Brunner and Suddarth’s Medical-Surgical Nursing 7th
edition
STO: After 1 hour of health teaching, patient will be able to demonstrate understanding of techniques and ways to prevent further increase of blood pressure like:
a. Waking up slowly on bed and resting before walking
b. Proper Deep breathing exercises
LTO: After 3 days of nursing intervention, the Blood pressure will be maintained at 130/90 from 150/100
Dx: >Monitored vital signs especially BP>Assessed contributory factors of increase BP
Tx: >Assisted in getting up slowly from bed to bedside or from supine to moderate high back rest>Assisted in going to the comfort room or using the commode if necessary>Promoted adequate rest by decreasing stimuli, providing quiet environment and scheduling activitiesEdx: >Instructed to report shortness of breath, chest pain or any discomfort>Emphasized importance of diet low fat, low sodium >Reiterated religious taking of medication>Encouraged rest periods as necessary
>Note response to activities>To know the appropriate intervention>Patient might be getting up of bed in the wrong way which may add up in the increase BP
>To provide safety
>To maximize sleep periods that provide good energy source
>Immediate interventions will be done
>To maintain normal BP
>To help regulate BP
>To prevent sudden increase of BP
STO: Goal met, patient was able to demonstrate understanding and techniques to prevent increase of BP
LTO: Goal met, patient’s Bp was maintained at 130/90
22
NCP ACTUAL #2: CHRONIC LOW SELF-ESTEEM R/T IMPAIRED COGNITIVE SELF-APPRAISAL AEB NEGATIVE FEEDBACK ABOUT SELF
ASSESSMENT EXPLANATION OF THE PROBLEM GOALS AND OBJECTIVES INTERVENTION RATIONALE EVALUATION
S>“ang asawa ko ang nagtratrabaho para sa min, ako pa man din ang lalaki wala akong magawa”
O> Feels guilty and shame when talking about his wife who works for them
>Noted attitude of shyness
> Unable to communicate with this co-patient
> Took a bath on the third day only
A> Chronic low self-esteem related to impaired cognitive self-appraisal AEB negative feedback about self
Mr. ICI wife is a nurse working in Saudi. She is the one who’s working for their family, taking charge for all their expenses, providing support for their family and taking already the seat as the bread winner of their family. Mr. ICI felt so bad with that because he should be the one who’s doing all of that stuff. He felt shame and guilty to his present situation. To compensate to his shortcomings he made use himself by doing household chores and becoming responsible in taking care of his son but these were not enough to show that he is useful and not enough to show his worth as father. All of the things that he did were in turn inadequate for him which led him to have a chronic low self-esteem.
Source:
LTO: After 3 days of nursinginterventions, the client will be able to verbalize understanding of individual’s role in the society regardless of their gender
STO: After 8 hours of appropriate nursing interventions, the client will be able to increase self-esteem through:
a. Giving positive feedback
b. Focusing topics such as on the client’s accomplishments in life
c. Reinforcing the personal strengths and positive perceptions that the client identifies
PDx > Established
Rapport
>Assessed presence of negative attitude and or self talk
> Assessed existing strengths and coping abilities, and provide opportunities for their expression and recognition
>Notednon-verbalbehavior
>Usedpositivemessages
Individuals with low self-esteem are reluctant to discuss true feelings
Re-enforcement of communicating and interacting with others could stimulate to enhance self-esteem
Incongruence’sbetweenverbal/non-verbalcommunications requireclarification.
To assist client to develop internal sense of self-esteem
Supporting a client’s beliefs and self-rejection and helping them cope can affect self-esteem
LTO: Goal met if
The client is able to verbalize understanding of individual’s role in the society regardless of their gender
STO: Goal met
The client was able to increase self-esteem through giving positive feedback, was able to appreciate his accomplishments in life and was able to
identify his strengths and positive perceptions
23
www.medscape.com/viewprogram rather thanpraise.
Tx>Maintained therapeutic communication
> Rendered positive feedback
>Focused on accomplishments
Edx> Encouraged participation in group activities. Caregiver may need to accompany client at first, until he or she feels secure that the group members will be accepting, regardless of limitations in verbal communication
>Encouraged client's attempts to communicate. If verbalizations are not understandable,
To facilitate trust during interaction
To increase self-esteem
To lift self-esteem
Positive feedback from group members will increase self-esteem
The ability to communicate effectively with others may enhance self-esteem
24
express to client what you think he or she intended to say. It may be necessary to reorient client frequently
>Reinforced the personal strengths and positive perceptions that the client identifies.
>Gavereinforcementfor progressnoted.
Clients with low self-esteem need to have their existence and value confirmed
Givereinforcementfor progressnoted.
25
ASSESMENT
S>” Hypertension naman talaga ang problema ko. Hindi ako baliw. Wala naman akong nakikita o nakakausap o naririnig na gaya ng naririnig at nakikita ng ibang kasamahan ko dito.”
O> Does not mingle to other roommates.
>Always stays in his bed.
>Only interacts to nurses, doctors, family members and student nurses.
A> Ineffective denial related to inability to tolerate the
EXPLANATION OF THE PROBLEM
One cause of bipolar disorder is stressful life events these are thought to be the main element in the development of bipolar disorder. In our patients case one factor that could be seen is the loss of his job making his wife work for him and one more thing is that he is left alone while his wife is abroad.
A symptom of bipolar that contributes for the patient to deny his known illness is exaggerated self-esteem.
Source: http://bipolar.about.com/cs/bpbasics/a/what
_causes_bp.htm
.
GOALS AND OBJECTIVES
STO:After 1-2 hours of appropriate nursing intervention the patient will verbalize feelings congruent with behavior.
LTO: After 2-3 days of appropriate nursing interventions the patient will meet psychological needs as evidence by appropriate expression of feelings.
INTERVENTIONS
P/Dx> Observed behavioral responses
>Assessed ability to respond or interpret questions.
> Assessed triggering factor that may stop your client from talking to you.
Tx> Minimized discussion of negative personal problems within clients hearing.
>Listened attentively to what the patient says.
>Provided positive reinforcement.
RATIONALE
> Shows if the patient could interact and interested to therapeutic regimen
> To explore hidden thoughts and feelings that the patient might not show through his facial expressions.> knowing the trigger factors could help you determine what to do if the patient shows.> Client may misinterpret and believe references are to him.
> Showing interest while the patient talks boost his confidence to share more.
> Positive reinforcement will help the patient change his mood like sadness, but
EXPECTED OUTCOME
STO:Goal met if the patient was able to feelings congruent with behavior.
LTO:Goal met if patient meet psychological needs as evidence by appropriate expression of feelings.
26
NCP ACTUAL #3: INEFFECTIVE DENIAL R/T INABILITY TO TOLERATE THE CONSEQUENCES OF KNOWN DISORDER
consequences of known disorder.
Edx> Encouraged patient to continue verbalizing thoughts and feelings.
>Encouraged SO to talk and touch client frequently.
limitations should be set so that you won’t be giving negative result to the behavior of the client.
>help the client relieve stress and you will be able to know how to be therapeutic towards him.
>Helps on faster recovery of the patient.
NCP POTENTIAL #1: RISK FOR INJURY R/T IMBALANCE BETWEEN OXYGEN SUPPLY AND DEMAND SECONDARY TO HYPERTENSION
Assessment Explanation of the Problem Objectives Interventions Rationale of the Interventions
Expected Outcome
Blood pressure above normal parameters ranges from 120/70 to 150/100
Intake of hypertensive agents like catapres and norvasc
Complains of easy fatiguability
A> Risk for injury
The client is then experiencing hypertension
that causes imbalance between the oxygen
supply and demand. This imbalance causes
alteration in the brain cell functioning leading to decreased perceptual
function as manifested by dizziness when standing
suddenly, decreased concentration and easy
fatigability
STO: After 8 hours of nursing intervetions, the patient will be able to verbalize understanding of individual factors that contribute to possibility of injury.
Dx> Monitored and recorded vital signs, noting blood pressure > Noted treatment-related factors, such as side effects or interactions of medications > Noted client’s age, gender, developmental stage, decision-making ability, level of cognition or competence
Tx> Provided information
> this will serve as baseline data
> sometimes these are not recognized by the clients, therefore increasing their susceptibility to injury> these affects clients ability to protect self and/or others and influences choice of interventions and/or teachings> this helps the patient to
Goal met if the patient is able to verbalize understanding of individual factors that contribute to possibility of injury.
27
related to imbalanced between oxygen supply and demand secondary to hypertension.
Source:
Brunner and Suddarth’s Medical-Surgical Nursing
7th edition
LTO: After 1 to 2 days of nursing interventions, the patient will be able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
regarding disease or conditions that may result in increased risk of injury > Assisted client to develop plan for activity and exercises within individual ability > Provided diversional activities, avoiding overstimulation and understimulation
Edx> Cautioned the patient to avoid activities requiring alertness until the effects of medications are known > Instructed client to request assistance as needed > Advised the patient to report any adverse reactions or side effects of the medication taken
control his condition, thus preventing the risk for injury> to promote active and positive view of self
>participating in pleasurable activities can refocus energy and diminish feelings of unhappiness, sluggishness and worthlessnesss> antihypertensive agents usually causes drowsiness which is one of the most common cause of injury> to protect self from injury
> to prevent risk for injury and give prompt attention to side effects as necessary
Goal met if the patient is able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
28
NCP POTENTIAL #2: RISK FOR RELAPSED EPISODE MAYBE R/T POOR MEDICAL TREATMENT REGIMEN COMPLIANCE
Assessment Explanation of the Problem Objectives Nursing Interventions Rationales EvaluationO > Has interest in treasure hunting and going outside naked when the wife goes back to Iran. > Returns back to his usual self when the wife is back home.
A > Risk for relapsed episode maybe r/t poor medical treatment regimen compliance
Worked as a farmer with family early in the morning to afternoon from childhood to adult. Completed his education till college level and later got married and have children. Went to Iran and worked abroad to help support his family. Came back to the Philippines and continue working for his family. Wife had gone back to Iran to work, leaving the husband and son in Philippines. Then husband
STO > After 6-8 hours of nursing intervention patient is able to show signs coping measures.
LTO > After 1-2 hours of nursing intervention patient is able to understand the importance of his treatment and verbalize his feelings.
Dx > Assessed client’s perception of self and noted use of defense mechanisms. > Assessed clients coping behaviors already present. > Reviewed laboratory and medication chart.Tx > Developed therapeutic nurse-patient relationship. > Maintained straight forward communication. > Listened to feelings that he expresses. > Being truthful when giving
> to determine causative factors
> to determine signs of relapse.> to determine contributing factors.> promotes sense of trust, allowing patient to discuss feelings openly.> to avoid reinforcing manipulative behavior.> offer emotional support and understanding.> builds trust, enhancing
STO > Patient was able to demonstrate coping mechanism as evidenced by relaxed posture and calm behavior.
LTO > Patient was able to understand about his treatment by taking his medications as scheduled and informing any changes of behaviors.
29
start acting strange with interest of treasure hunting and going outside naked. But returns normal when wife comes back home.
information and dealing with patient. > Invited client to do activities. > Gave positive reinforcement for client’s efforts. > Maintained calm, matter of fact, nonjudgmental attitude.Edx > Encouraged client to get adequate sleep. > Instructed client to take medication as ordered. > Explained to client symptoms improve gradually and not immediately. >Advised client to report mood changes immediately. > Educated client to not stop on medication without physician’s order.
therapeutic relationship.
> for positive distraction.
> encourages continuation of treatment.
> decreases defense response.
> to prevent fatigue.
> to help to deal with stress.
> to understand that it is a long term treatment.
> to make adjustments in the treatment.
> to prevent relapse.
30
31
I. DISCHARGE PLAN
DIET AND NUTRITION ACTIVITY HEALTH TEACHINGS
Instructed client to eat frequent small meals
Instructed to have high protein, high
carbohydrate diet for energy
Mental health professionals try to steer people away from sedentary activities such as TV where the mind and body are not fully engaged. Cleaning, reorganizing, reading, or raising goldfish could all be great indoor activities.
Creative activities like occupational therapy, drawings
Medications should be given regularly everyday for a certain period of time
Make client be more active and cooperative in any activities given to him
Instruct client to do activities that do not require alertness because one side effect of medication is drowsiness, thus may cause injury to the client
Teach client to take medications regularly
Instruct the wife that whenever she see signs
and symptoms of Bipolar Disorder to refer him
immediately
Teach the client on the side effects of his
medicines when not taken
Advise the client to go back to the institution
after discharge for follow-up check-up and
consultation
32
J. CONCLUSIONS AND RECOMMENDATIONS
Bipolar disorder causes serious shifts in mood, energy, thinking and behavior from the
highs of mania on one extreme to the lows depression on the other. More than just a fleeting
good or bad mood swings, the cycles of bipolar disorder last for days, weeks, months or even a
year. Unlike ordinary mood swings, the mood changes bipolar disorder is so intense that they
interfere with your ability to function. People experiencing a manic episode often talk a mile a
minute, sleep very little and are hyperactive.
Interaction with the patient for more than 3 days is not enough to cover from his
childhood up to now. We should interact with the patient more and more to know about his
history and different traumas that he encountered. Well preparation to go on duty at the area
should be done before the actual duty by conducting self awareness test. We should also be
well knowledgeable to psychiatric disorders prior to duty to enhance more our interventions
and interactions.
Since the client has Bipolar Disorder, the group concluded that this disorder has
different symptoms as compared to the other psychiatric disorders. Therefore, in the making of
this case study and understanding how this disorder affects a person through appreciating it’s
pathophysiology. This study makes us student nurses more competent and gained more
confidence in handling patients with Bipolar Disorder.
33