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Transcript of Mental Case Study
A case study on BPAD with Mania 2010
TABLE OF CONTENTS
Background of the study 1
Objective of the study 2
History Taking 3
Family Tree 8
Examination of Patient 9
Physical Examination 9
Mental Status Examination 9
Disease Condition 14
Mood Disorders 14
Classification 14
Bipolar Affective Disorders (BPAD) 14
Definition 15
Classification 15
Etiology 15
Mania (Manic Episode) 16
Epidemiology 16
Classification 17
Sign and Symptoms 17
Diagnosis 19
Treatment 20
Drug bank 23
Theory application 28
Nursing care paln 33
Discharge Teaching 38
Summary 40
References 41
BACKGROUND OF THE STUDY1
A case study on BPAD with Mania 2010
As a part of the requirement for Post Basic Bachelor in Nursing (PBBN) Curriculum of
Purbanchal University (PU) under Mental Health Nursing (Practicum), we were required to
do practical in Mental Hospital, Lagankhel for 2 weeks. Here we were expected to do a
detailed study of one case.
After having a glance in all cases, I selected a case of Bipolar Affective Disorder
(BPAD) with Mania. This case study was done in order to gain comprehensive knowledge
about the disease and provide holistic care to the patient as well as family. I selected this
case since BPAD, Mania is a mood disorder. And the prevalence rate of mood disorders is
1.5 percent, and it is uniform throughout the world i.e. it is equal in developed or
developing country.
This case study includes all the information about the patient, his disease and
management done for his disease.
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A case study on BPAD with Mania 2010
OBJECTIVES OF THE STUDY
The main goal of this study is to gain comprehensive knowledge about a specific case
and be able provide holistic nursing care and management to the patients using appropriate
scientific rationales. The specific objectives of this case study in particular are as given
below:
To provide holistic nursing care to the patient with mania.
To apply knowledge from basic science and nursing theory in planning the
comprehensive care to the patient.
To communicate in helpful manner with patient and his problems and also to involve
them in resolving problem.
To involve the patient and family members and health team members in the discharge
planning.
To minimize the stress of the patient and his family by appropriate diversional therapy
according to age.
To give health education to the patient and his family members to promote and
maintain health.
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A case study on BPAD with Mania 2010
HISTORY TAKING
A. PRELIMINARY IDENTIFICATION OF PATIENT
Name: Sahara Rai
Age: 27 Years
Sex: Female
Ward: Female Ward
Bed No.: 18
Marital Status: Married
Educational Level: S.L.C. Failed
Occupation: House Wife
Religion: Hindu
Address: Saptari, Phattepur-2
Date of Admission: 2067.03.10
Diagnosis: BPAD (Bipolar Affective Disorder) with Mania
Source of Referral: BPKIHS, Dharan
Attending Doctor / Unit: Dr. MRS / Unit II
ABOUT INFORMANT
Name: Mahima Rai
Age: 36 Years
Education: S.L.C. Passed
Occupation: Work in Christian Office
Relationship with patient: Elder Sister
Reliability of Information: Reliable
Adequacy of Information: Adequate
Date of Interview: 2067.03.11
B. PRESENTING COMPLAINTS (WITH DURATION)
According to patient According to informant
PSn} xfF:g], ?g] cfˆgf] / aRrfsf] care gug]{
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A case study on BPAD with Mania 2010
vfgf gvfPsf] / toilet gu/]sf] @)
lbg eof]
cgfjZos s'/f dfq ug]{
lgb|f gkg]{ aflx/ aflx/ lx8\g]
/fd|f] 7fpFdf hfg vf]Hg]
/fd|f] /fd|f] n'uf dfq nufpg vf]Hg]
Ps} 7fpFdf w]/} a]/ a:g g;Sg]
c?;Fu l/;fpg]
C. HISTORY OF PRESENT ILLNESS
Onset: Gradual
Duration: 20 days
Precipitating Factors: Separation from husband
Suspicious nature of her husband and in-laws
Course of Illness: The illness is episodic. This is the second time. After dispute with her
husband in phone, she stopped taking medicines. It was followed by sleep disturbances,
not taking food, excessive not relevant talk, always being angry with others, not caring
own children, doing unnecessary things whole day. Then she was brought to mental
hospital, Lagankhel for the further treatment.
Biological Symptoms and Consequences of Illness
Sleep: Decrease than normal
Appetite: Loss of appetite
Weight Loss: Not significant
Libido: Normal
Personal Care: Decrease interest in personal care and child care
Work Performance: Nowadays hindrance
Bowel Habit: Normal
Bladder Habit: Normal
Inter-personal Relationship: Good IPR within family and friends but gets angry easily
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A case study on BPAD with Mania 2010
Personal Hygiene: Maintained
Patient was under treatment with Tab. Oleanz, Tab. Trepex and Tab. Lithocade.
D. PAST HISTORY
Psychiatric History: When she gave birth to her second daughter, she had problems
like not caring and feeding the baby properly because she had the desire of having male
baby. So she had mental illness from 10 years but taking medicine since last 2 years only.
She developed 2nd episode of attack this time after discontinuing medication.
Medical and Surgical History: She had not any history of medical and surgical
disorders. No history of previous hospitalization due to any other illnesses.
E. FAMILY HISTORY
She had a nuclear family. It includes 5 members, her husband, three daughters and she
herself. But now her husband is abroad i.e. Malaysia for work. She belongs to middle-
class background. The main source of income in her family is her husband. He sends
money regularly from Malaysia for them, which is financially sufficient for them. There is
no any history of similar or other type of psychiatric illness, alcohol or drug dependence,
suicide and major medical illness in her family of origin as well as her family of
procreation.
F. PERSONAL HISTORY
Birth: Home delivery
Event during pregnancy: Not significant
Birth weight: Exact weight not known
Event after birth: Crying – good, breathing – normal, not any cyanosis, icterus, high
temperature, convulsion, or any other abnormalities.
Milestones: Normal
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A case study on BPAD with Mania 2010
Presence of neurotic symptoms: no thumb sucking and bed wetting but there was
presence of temper tantrums.
Marital History: She was married at 15 years of age with love marriage.
Sexual History: Good relationship with husband
Work history: Housewife
Personal Habit: No history of drinking and smoking
Menstrual History: Menarche occurred at 13 years of age. Regular menstrual flow
Obstetric History: She had three children. They all were born in hospital. There were not
any obstetric problems. There is no history of abortion.
G. PRE-MORBID HISTORY
Important Habits: Not significant
General Mood: Angry and stubborn
Attitude towards work: She used to do all house hold activities by self.
Relationship with family, friends, relatives and colleagues: Good
Religiosity: Belief in god and religion
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A case study on BPAD with Mania 2010
FAMILY TREE
EXAMINATION OF PATIENT
PHYSICAL EXAMINATION
General: Not any abnormalities
8
74 Yrs 60 yrs
42 Yrs 40 Yrs 36 Yrs 35 Yrs 31 Yrs34 Yrs
MALE
23Yrs29 yrs 25 Yrs
6 Yrs10 Yrs11 Yrs
27 Yrs
INDEX
FEMALE PATIENT
22 Yrs
A case study on BPAD with Mania 2010
Systemic: Not any abnormalities
Vital signs and other measurements
Pulse: 82/min
Respiration: 20/min
Blood Pressure: 120/80 mmHg
Temperature: 98.6°F
Height: 5 Feet
Weight: 61 Kg
MENTAL STATUS EXAMINATION
1. GENERAL APPEARANCE AND BEHAVIOUR
Built: Looks physically healthy
Facial Expression: Happy
Age Group: Young Adulthood
Hygiene: Maintained
Grooming: Well groomed and well dressed up according to season
Level of consciousness: Fully conscious
Level of co-operation: Co-operative
Level of communication: normal
Posture: Normal gait
Psychomotor Activity: Increased
Overall behavior during interview: Sometimes shows anger and sometimes be very
friendly. Moves here and there while talking also.
2. TALK AND SPEECH
Spontaneous
Reaction to time: Immediate
Rate of speech: Normal
Rhythm: Monotonous
Tone: Audible
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A case study on BPAD with Mania 2010
Pitch: Normal
Volume: Normal but sometimes increases while she is angry
Language: Nepali
Content: Understandable
3. MOOD
Subjective:
Question: tkfFO}sf] dg s:tf] 5 <
Answer: v';L 5. afaf cfPkl5 c´} v';L.
Objective: She looks happy and cheerful.
Outcome: Appropriate affect
4. THOUGHT
Form and Production:
Question: tkfFO{sf] 3/df sf] sf] x'g'x'G5<
Answer: d / ltg6f 5f]/L, afaf aflx/ uPsf] 5
Outcome: Relevant answer to the question, no circumstantialities and thought
impairment, no word salad.
Progression of thought:
Question: tkfFO{ clxn] sxfF x'g'x'G5<
Answer: c:ktfndf
Outcome: No flight of ideas, no thought block, no incoherence.
Content of thought:
Question: tkfFO{sf] n'uf t s:tf] /fd|f].
Answer: dx+uf] 5. lbbLnfO{ klg p:t} lslglbPsf] 5'
Outcome: patient gave inappropriate answer, so patient has delusion of grandiose
5. PERCEPTION
Auditory Hallucination:
Question: s] tkf‘O{ PSn} ePsf] a]nfdf s;}n] sfgdf s]xL eg] h:tf] nfU5<
Answer: nfUb}g
Outcome: No auditory hallucination
Visual Hallucination:
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A case study on BPAD with Mania 2010
Question: s] tkf‘O{ PSn} ePsf] a]nfdf c?n] gb]v]sf] s'/f b]Vg'x'G5<
Answer: b]lVbg
Outcome: No visual hallucination
Illusion:
Question: s] tkf‘O{ 8f]/LnfO{ ;k{ bVg'x'G5<
Answer: cx‘ blVbg
Outcome: No illusions present
6. ATTENTION AND CONCENTRATION
Question: @) af6 # 36fpb} nfg'
Answer: @)–#Ö!&, !&–#Ö!$, !$–#Ö!!, !!–#Ö*
Question: xKtfsf] af/x? k5f8Laf6 eGb} hfg'
Answer: cfOtaf/, zlgaf/, z'qmaf/, laxLaf/, a'waf/, dËnaf/, ;f]daf/
Outcome: Good attention and concentration capacity
7. MEMORY
Immediate Memory:
Question:
d tkfFO{nfO{ b'O{j6f a:t'sf] gfd eG5' / % ldg]6kl5 km]/L Tof] a:t'sf]
gfd ;f]W5' eGg' n
sfkL / snd
Answer: sfkL / snd
Outcome: Immediate memory is intact
Recent Memory:
Question: tkfFOn] lxhf] laxfg s] t/sf/L vfg'eof]<
Answer: d"nf / cfn'
Outcome: Recent memory is intact
Remote Memory:
Question: tkfFO{sf] lax] slt ;fndf ePsf]<
Answer @)%$ ;fndf
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A case study on BPAD with Mania 2010
Outcome: Remote memory is also intact
8. ORIENTATION
Time:
Question: clxn] stL aHof]<
Answer laxfgsf] ( aHof]
Outcome: oriented to time
Place:
Question: tkfFO{ clxn] sFxf x'g'x'G5<
Answer dfgl;s c:ktfndf
Outcome: Oriented to place
Person:
Question: tkfFO{ ;Fu sf] x'g'x'G5<
Answer lbbL
Outcome: Oriented to person
9. INTELLIGENCE
She had ability to tackle perfectly in her household activities. Average intelligence level.
10.JUDGEMENT
Question: tkfFO{ cfˆgf] cuf8L ;k{ b]Vg'eof] eg] s] ug'{x'G5<
Answer: efU5' . lgbf]{;nfO{ dfg'{ x'‘b}g .
Question: tkfFO{sf] l5d]sdf cfuf] nfUof] eg] s] ug'{x'G5<
Answer: kfgL nu]/ cfuf] lgefp5'
Outcome: Good judgment capacity
11.GRASP OF GENERAL KNOWLEDGE
Question: g]kfndf clxn] /fhf 5 ls 5}g<
Answer: 5}g
Question: g]kfnsf] k|wfgdGqLsf] gfd s] xf]<
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A case study on BPAD with Mania 2010
Answer: dfwjs'df/ g]kfn
Outcome: Well grasp of general knowledge is observed
12. INSIGHT
Question: tkfFO{nfO{ s] ePsf] 5<
Answer: s]lx klg ePsf] 5}g .
Outcome: Insight is absent
13. ABSTRACTION
Question: :ofp / ;'Gtnfdf s] s'/f Pp6} 5<
Answer: b'O{6} kmnkm"n xf] .
Outcome: Normal capacity of abstract thinking.
Part II
DISEASE CONDITION
MOOD DISORDERS
Mood disorders are characterized by a disturbance of mood accompanied
by a full or partial manic or depressive syndrome, which is not due to any other
physical or mental disorder. The prevalence rate of mood disorder is 1.5
percent, and it is uniform throughout the world.
CLASSIFICATION
Manic Episodes
Depressive Episodes
Bipolar Mood (Affective) Disorder
Recurrent Depressive Disorder
Persistent Mood (Affective) Disorder
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A case study on BPAD with Mania 2010
Other Mood (Affective) Disorder
Unspecified Mood (Affective) Disorder
BIPOLAR AFFECTIVE DISORDER (BPAD)
This disorder, earlier known as manic depressive psychosis which is
characterized by repeated (at least two) episodes in which the patient’s mood
and activity levels are significantly disturbed, this disturbance consisting on
some occasions of an elevation of mood and increased energy and activity
(mania or hypomania), and or other of a lowering of mood and decreased
energy and activity (depression). Characteristically, recovery is usually
complete between episode, and the incidence in the two sexes is more nearly
equal than in other mood disorder. These episodes can occur in any sequence.
Patients with recurrent episodes of mania (unipolar mania) are also classified
here as they are rare and often resemble the bipolar patients in their clinical
features.
DEFINITION
“Recurrent attacks of both mania and depression, in the same patient at
different times or this disorders characterized by mood disturbance (in
appropriate depression or elation). It is usually accompanied by abnormalities in
thinking and pe4rception arising out of mood disturbance.”
CLASSIFICATION
1. Bipolar Affective Disorder: Recurring attacks of both mania and
depression.
2. Unipolar Affective Disorder: Recurring attacks depression only.
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A case study on BPAD with Mania 2010
3. Mixed Affective Disorder: Cases where manic and depressive symptoms
occur simultaneously.
ETIOLOGY
The etiology of mood disorders is currently unknown. However, several factors
have been propounded, these include;
1. Biological Factors
Genetic: The life-time risk for the first degree relatives of bipolar mood
disorder patients is 25% and of recurrent depressive disorder patient is
20%. The life-time risk for the children of one parent with mood disorder
is 27% and both parents with mood disorder is 74%. The concordance
rate in bipolar disorder for monozygotic twins is 65% and for dizygotic
twins is 20%. Therefore, genetic factors are very important in making an
individual vulnerable to mood disorders.
Biochemical Factors: A deficiency of norepinephrine and serotonin has
been found in depressed patient and they are elevated in mania.
Dopamine GABA and acetylcholine are also presumably involved.
2. Psychosocial Factors
Increased stressful life events (e.g. death of loved person, marriage,
financial loss) before the onset or relapse probably have a formative
rather than a precipitating effect.
Early childhood experiences: Maternal deprivation, prolonged absence
of a parent.
MANIA AND MANIC EPISODE
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A case study on BPAD with Mania 2010
Mania (from Greek word meaning "to rage, to be furious") is a severe
medical condition characterized by extremely elevated mood, energy, unusual
thought patterns and sometimes psychosis.
A manic episode is not a disorder in and of itself, but rather is a part of a
type of bipolar disorder.
A manic episode is characterized by period of time where an elevated,
expansive or notably irritable mood is present, lasting for at least one week.
These feelings must be sufficiently severe to cause difficulty or impairment in
occupational, social, educational or other important functioning and can not be
better explained by a mixed episode.
EPIDEMIOLOGY
According to Book In Patient
Incidence 0.6 to 1% adults will have mania during
their lifetime.
Age Onset is most common in late adolescence
or early adulthood.
Early adulthood.
Sex Bipolar affective disorders equally common
among men and women. But all depressive
disorders is twice as common in women.
Female
Social Class Occurs among people in high social class
comparatively.
Middle-class
family
Marital
Status
Unmarried, widow, divorce and separation
from husband have increase episodes.
Separation from
husband since 3
yrs
Professionals It occurs 4 times more in professionals than
in non professionals.
N0n-professional
Length The average length of manic episodes is
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A case study on BPAD with Mania 2010
about 6 months.
Recurrence At least 90% of patients with mania
experience further episodes of mood
disturbance. On average bipolar patient
experience about 10 further episodes of
mood disturbances.
CLASSIFICATION OF MANIA
1. Hypomania: It is a mild form of mania.
2. Acute Mania: The signs and symptoms are moderately increased and
leads towards severity.
3. Delirious Mania: The patient is out of contact, speech is inconvenient
and is constantly and purposelessly active. The patient may be
hallucinating, delusional and extremely dangerous without treatment. The
patient may die of exhaustion.
SIGN AND SYMPTOMS OF MANIA OR A MANIC EPISODE
ACCORDING TO BOOK IN
PATIENT
Increased energy, activity, and restlessness √
Excessively "high," overly good, euphoric mood √
Extreme irritability √
Distractibility, can't concentrate well
Little sleep needed (e.g., one feels rested after only 3 hours of
sleep)
√
Unrealistic beliefs in one's abilities and powers √
Poor judgment
Spending sprees
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A case study on BPAD with Mania 2010
A lasting period of behavior that is different from usual √
Increased sexual drive
Abuse of drugs, particularly cocaine, alcohol, and sleeping
medications
Provocative, intrusive, or aggressive behavior √
Denial that anything is wrong √
Racing thoughts and talking very fast (pressure to keep
talking), jumping from one idea to another
√
Psychomotor agitation √
Marked impairment in occupational functioning, in social
activities or relationships with others.
√
Excessive involvement in pleasurable activity
Engage in impulsive activities such as spending money √
Inflated self-esteem or grandiosity √
DIAGNOSIS
Proper history taking
Mental status examination (positive criteria of mania)
Episodes should last for at least a week
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A case study on BPAD with Mania 2010
TREATMENT
1. Pharmacotherapy.
SN According to Book In Patient
1. Antipsychotic drugs: The commonly used
drugs are haloperidol, chlorpromazine,
risperidone, olanzapine. The drugs are used
along with mood stabilizers for the first few
weeks before their effect appears.
Tab. Oleanz Repitas 5
mg PO BD
Inj Serenac 5 mg + Inj
phenargan 25 mg IM
SOS
2. Lithium (Li) is the drug of choice for
treatment of manic episode. (acute phase) as
well as for prevention of further episodes in
bipolar mood disorder.
Tab. Lithocade 300 mg
PO TDS.
3. Other mood stabilizers:
Sodium Valporate: for acute treatment of
mania and prevention of bipolar mood
disorder. Particularly useful in those patients
who are refractory to lithium.
Carebamazepines and oxycarbazepine for
acute treatment of mania and prevention of
bipolar mood disorder. Particularly useful in
those patients who are refractory to lithium
and valporate.
4. Benzodiazepines: like lorazepam may be
added to control agitation for initial 5 to 7
days.
lorazepam
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A case study on BPAD with Mania 2010
2. ECT (Electroconvulsive therapy): ECT can also be used for acute
mania excitement if it is not adequately responding to antipsychotic and
lithium.
3. Psychosocial treatment: Although somatic treatment is the primary
mode of management in major mood disorders, psychosocial treatment
may be indicated in certain cases. Family and marital therapy is used to
decrease interfamilial and interpersonal difficulties and to reduce or
modify stressors.
NURSING INTERVENTIONS
1. Keep environmental stimuli to a minimum, assign single room, and keep
lighting and noise level low.
2. Remove hazardous objects (glass, belts, ties, ropes, knife, and match
boxes) and substances when there is possibility of an accident.
3. Assess patient’s personality and cultural background.
4. Establish trusting relationship with patient.
5. Administer medications in time, as prescribed by physician.
6. Assist patient to engage in activities, such as writing, drawing and other
physical exercise.
7. Observe patient’s behavior closely and protected from suicidal act.
8. Accept client while rejecting objectional behavior.
9. Permitted expression of hostility and ambivalence without reinforcement
of guilt feelings.
10.Encourage verbal expression of feelings.
11.Provide high protein, high calorie, nutritious foods and drinks (6-8 glass
of fluid per day) and provide favorite foods.
12.Maintain accurate record of Intake / Output.
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A case study on BPAD with Mania 2010
13.Weight the patient regularly.
14.Do not argue with patients and ignore attempts by patient to argue.
15.Identify client’s social support system to minimize isolation.
16.Engage self care activities in times when client may have more energy to
increase activity tolerance and minimize fatigue.
17.Advice all care givers to approach client in a consistent manner.
18.Give short, simple and direct answer when the patient asked questions.
19.Give clear instruction regarding taking medication. Explain about side
effects of medication and how to deal with it.
PROGNOSIS
At least 90% of patients with mania experience further episode of mood
disturbance. Nearly all bipolar patients recover from acute episode but the long
term prognosis is rather poor. Less than 20% of bipolar patients recover from
administer a period of five years clinical stability with good social and
occupational performance. Usually the prognosis depends upon the various
factors such as, compliance of treatment, regular follow up, home environment,
family support, coping mechanisms, stress and factors etc.
Drugs Bank21
A case study on BPAD with Mania 2010
INJ SERENACDrug Class Description:
Butyrophenones (antipsychotics).
Generic Name:
Haloperidol
Drug description:
1.5mg white tablets; 5 mg, 10 mg, 20 mg pink tablets.
Indications :
Schizophrenia, mania and hypomania, organic psychoses, agitation in psychotic illness. Childhood behaviour disorders. Adjunct to short-term management of anxiety.
Adult Dose :
Serenace Tablets and Serenace Liquid: Initially 1 .5 - 20 mg daily, increasing as required for control, then decreasing for maintenance, usually 3 - 10 mg daily. Maximum 200 mg daily.
Serenace Injection: Emergency control, 5 - 10 mg, infrequently up to 30 mg, by intramuscular or intravenous injection 6 - 12 hourly, followed by oral therapy..
Child Dose :
Serenace Tablets and Serenace Liquid: Initially 0 .025 - 0.05 mg/kg daily. Usual maximum Serenace Injection: Not recommended. Serenace Capsules: 0 .025 - 0.05 mg/kg daily to maximum 10 mg daily. Some adolescents may require up to 60 mg daily.
Contra Indications:
Comatose states, Parkinsonism, nursing mothers.
Special Precautions:
Epilepsy, hyperthyroidism. Liver or renal failure. Pregnancy. Severe cardiovascular disorders.
Interactions :
CNS depressants, alcohol, analgesics, antihypertensives, antidepressants, anticonvulsants, antidiabetics, levodopa.
Adverse Reactions :
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A case study on BPAD with Mania 2010
Acute dystonias (spasms of eye, face, neck and back muscles), akathisia (motor restlessness), parkinsonism-like syndrome (rigidity and tremor), and tardive dyskinesia, dry mouth, nasal stuffiness, difficulty in micturition, tachycardia, constipation, blurring of vision, hypotension, weight gain, impotence, galactorrhoea, hypothermia (a problem in the elderly), gynaecomastia, amenorrhoea, benign obstructive jaundice, blood dyscrasias and dermatitis, ECG irregularities, drowsiness, lethargy, fatigue, epileptiform seizures.
PHENERGANDrug Class Description :
Antihistamines (sedating) (phenothiazine type).
Generic Name :Promethazine Drug description :
Phenergan Tablets: 10mg blue f- c tablets marked PN10; 25 mg blue f-c tablets marked PN25. Elixir: clear golden syrupy liquid. Phenergan Injection: ampoules.
Indications : Allergic conditions. Sedation, nausea and vomiting. Adult Dosage :
Phenergan Tablets and Phenergan Elixir: Allergies, 10 - 25 mg two or three times daily. Anti- emetic, 20 - 25mg to be taken the night before journey and repeated after 6 - 8 hours if necessary. Sedation, 20 - 50mg as a single nightime dose.
Phenergan Injection: 25 - 50 mg by deep intramuscular injection or, in an emergency, by slow intravenous injection after dilution.
Child Dosage:
Phenergan Tablets and Phenergan Elixir: Allergies, under 2 years, not recommended; 2 - 5 years, 5 - 10 - 25 mg. If two doses in 24 hours are required, use lower amount stated. Anti-emetic, under 2 years, not recommended; 2 - 5 years, 5 mg (use elixir); 5 - 10 years, 10 mg; over 10 years, 25 mg. To be taken the night before journey and repeated after 6 - 8 hours if necessary. Sedation, under 2 years, not recommended; 2 - 5 years, 15 - 20 mg (use elixir); 5 - 10 years, 20 - 25 mg. Each as a single dose at night. Phenergan Injection: Under 5 years, not recommended; over 5 years, 6 - 12.5 mg by deep intramuscular injection.
Interactions :
Alcohol, CNS depressants, MAOIs.
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A case study on BPAD with Mania 2010
Adverse Reactions :
Drowsiness, impaired reactions. Dizziness, disorientation, photosensitivity. Extrapyramidal reactions, anticholinergic effects.
Lorazepam Drug Class Description :
Intermediate-acting benzodiazepines (anxiolytics).
Presentation :
Tablets, lorazepam 1mg , 2.5mg .
Indications :
Moderate to severe anxiety.
Adult Dosage :
1 - 4 mg daily in divided doses.
Child Dosage :Not recommended. Elderly Dosage : 0.5 - 2 mg daily. Contra Indications :
Acute pulmonary insufficiency, respiratory depression, phobic or obsessional states, chronic psychosis, myasthenia gravis. Pregnancy, labour and lactation.
Special Precautions :
Chronic pulmonary insufficiency, chronic renal or hepatic disease.
The elderly. Judgement and dexterity may be impaired, patients should be warned of these effects. Do not use alone to treat depression or anxiety associated with depression. In cases of bereavement, psychological adjustment may be impaired. Avoid long-term use; withdraw gradually.
Interactions :
Alcohol and other CNS depressants, anticonvulsants, narcotic analgesics, cimetidine, rifampicin.
Adverse Reactions :
Drowsiness, light-headedness, muscle weakness, ataxia, confusion, vertigo, GI upset, hypotension, visual disturbances, and dexterity. Urinary retention, changes in libido. Rarely blood disorders and jaundice. Abnormal psychological reactions, Risk of dependence increases the higher the dose and the longer the treatment.
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A case study on BPAD with Mania 2010
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A case study on BPAD with Mania 2010
Application of Nursing Theory
Nursing theory differentiate nursing from other discipline and activities
in that it solves the purpose of describing, explaining, predicting or controlling
events or controlling desired outcome of nursing practice. There are numerous
nursing theories developed till date but regarding the applicability, some
theories are important. i.e.:
1. Florence Nightingale’s Environmental Theory
2. Dorothea E. Orem’s General Theory of Nursing
3. Virginia Henderson’s Independent Theory
4. Faye Glenn Abdellah’s Typology of Nursing Problems
5. Sister Callista Roy’s Adaptation Model
Among these 5 Theories, I had applied 2 of them in providing nursing care
to my patient. They are Henderson’s Independent Theory and Orem’s Theory
of Nursing System. I had applied these theories in the following way:
1. Henderson’s Independent Theory
I had applied the Henderson’s Independent Theory by relating the 14
components of this theory with the Maslow’s Hierarchy of Needs and its 5
components. The nurse serves as a substitute for whatever patient lacks in
order to make him or her “complete” or “whole” or independent depending
his or her physical strength, will or knowledge to attain good health. So, I had
provided nursing care from the basic needs to the higher needs according to
the patient’s needs as shown in the following figure:
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A case study on BPAD with Mania 2010
Fig: Henderson’s Independent Theory in relation with Maslow’s Hierarchy of needs
COMPONENTS ASSESSMENT ACTION
Physiological Needs
Breathing She was breathing normally. Respiratory rate was also normal i.e. 20-24 breaths per minute.
Eating and Drinking
She forget and ignore drinking.
I encouraged her to drink adequate fluids. I also
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A case study on BPAD with Mania 2010
advised her and her family to take food in frequent intervals but in small quantity.
Elimination There was not any
problem in
elimination. She
was having urine
and stool regularly.
Moving She was conscious
and over active
I advice her to take some
rest an try to keep involve
her in indoor game which
decrease her activities
Sleeping and
resting
Her sleeping was
disturbed.
I provided her medicine on
time
Safety and
Security
Dressing and
undressing
appropriately
She was capable of
dressing and
undressing by
herself.
Maintaining
body
temperature
Her temperature is
maintained
Keeping clean
and protecting
skin
She was looking
dirty as she can care
her self but ignore
do self care.
I encourage her to take
bath and arrange for that. I
cut her nails. I also assist
her to comb hair
Avoiding She is over active I advised visitor to go to
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A case study on BPAD with Mania 2010
dangers and
injuries
and moving here
and there so has
high risk of injuries
toilet with her. I also
advice her to wear slippers
while moving in order to
prevent any cuts.
Love and
Belongingness
Communicating Not appropriate
sometimes talkative
but both sense and
non sense.
I advised her visitor to
speak to her in order to
relieve her boredom. I also
communicated with her
with positive attitude as
well as to divert her mind.
Self-Esteem Worshipping She in lord . I allowed her and
encouraged her for
worshipping god according
to her belief and her
religion.
Self-
Actualization
Working She was thinking
that she cannot do
any thing.
I encouraged her for
working for her self eg. her
self care so that she will
have sense of self
accomplishment.
Playing I encourage her in indoor
game. Which will decrease
her activities.
Learning I teach her new games
with appropriate rules
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A case study on BPAD with Mania 2010
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A case study on BPAD with Mania 2010
Nursing Care Plan
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A case study on BPAD with Mania 2010
SN
ASSESSMENT NURSING. DIAGNOSIS
NURSING GOAL
PLANNING IMPLEMMENTATION RATIONALE EVALUATION
1. Subjective Data: Patient said, “I cannot sleep at night.” “I wake up frequently.”“Many things come repeatedly in mind.”Informant said that patient wakes up many times at night.
Objective Data:I observed patient’s eyes were drowsy and red.
Altered sleep pattern related to disease condition.
Patient’s sleep pattern will be improved with in the period of hospitalization.
1. Assess patients sleeping pattern.
2. Encourage patient to involve in day time activities according to interest.
3. Provide calm and comfortable environment with minimal stimulation.
4. Provide comfortable measures (back rub) at the time of sleeping.
1. Assessed sleeping pattern of patient by asking with informant.
2. Encouraged patient to involve in day time activities like watching television and playing games like Chinese checker, carom board, chess etc.
3. Encouraged informant to maintain a quite and peaceful environment with minimal stimulation.
4. Adviced informant for back rubs at the time of sleeping.
1. Helps to identify information which in turn helps for prompt intervention.
2. It helps to make busy in day time and in turn helps to achieve peaceful sleep at night.
3. Calm and comfortable environment helps for sound sleep.
4. Provide relaxation and facilitate for sleep.
Goal was fully achieved as patient had achieved sound sleep.
S ASSESSMENT NURSING. NURSING PLANNING IMPLEMMENTATION RATIONALE EVALUATION
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A case study on BPAD with Mania 2010
N DIAGNOSIS GOAL2. Subjective
Data: Informant said that patient does not stay in one place for long time.
Objective Data:I observed that patient is not staying in one place. Walking here and there.
High risk for injury related to extreme hyperactivity.
Risk for injury will be decreasedDuring the period of hospitalization.
1. Maintain minimal level of environmental stimuli.
2. Remove hazardous objects from patient side.
3. Encourage patient to engage in activities.
4. Close observation of patient.
5. Administer medication as prescription.
1. Maintained minimum level of environmental stimuli.
2. Removed hazardous objects like knife, glass, rope like clothes from patient side.
3. Encouraged patient to engage in activities like writing, drawing and playing.
4. Close observation of patient was done.
5. Administered medications as prescribed.
1. Helps to reduce risk of injury to patient.
2. Decreases stimuli and chances of injury.
3. Helps to engage the patient in one place and reduce the risk of injury.
4. Helps to prevent from injury.
5. Helps to reduce symptoms of hyperactivity.
Goal was fully achieved as t6here was no injury to patient during the period of hospitalization.
SN
ASSESSMENT NURSING. DIAGNOSIS
NURSING GOAL
PLANNING IMPLEMMENTATION RATIONALE EVALUATION
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A case study on BPAD with Mania 2010
3. Subjective Data: Patient said, “Do not ask more questions to me. Ask to my sister.”
Objective Data:I observed that patient does not want to give answers to more questions in a period of time. (Certain time)
Impaired social interaction related to irritability and hyperactivity.
Social interaction will be increased with in the period of hospitalization.
1. Assess patient’s level of social interaction.
2. Assist person in managing and maintaining social interaction on to other patients, visitors by sharing feelings, thoughts.
3. Encourage to involve in group activity like play.
4. Give positive reinforcement for manipulative behavior.
1. Assessed the level of patient’s social interaction.
2. Assist person in maintaining social interaction on the other patient and visitors by sharing feeling, thoughts.
3. Encouraged to involve in group activity like.
4. Gave positive reinforcement for manipulative behavior.
1. Helps in further nursing intervention.
2. Helps to facilitate social interaction.
3. Helps to increase social interaction.
4. Enhance self-esteem and promote repetition of desirable behavior.
Goal was fully achieved as the social interaction of patient was increased during the period of hospitalization.
SN
ASSESSMENT NURSING. DIAGNOSIS
NURSING GOAL
PLANNING IMPLEMMENTATION RATIONALE EVALUATION
4. Subjective Data: Informant said
Risk for relapsing the
The informant will be
1. Assess the risk causes for relapsing the
1. Assessed the risk causes for relapsing the
1. Provide further adequate intervention.
Goal was fully achieved as
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A case study on BPAD with Mania 2010
that the symptoms were severed because of discontinuation of medicine after dispute with her husband in phone.
Objective Data:I find out that she was staying alone with her 3 daughters. Her husband was abroad and no mature person is there to care patient.
symptoms related to discontinuation of medicine.
made aware about the disease condition and importance of regular medication.
symptoms.
2. Explain to the informant about medications (dose, route, side effects).
3. Explain the informant about importance of medicines.
4. Explain the patient about the importance of regular taking medication.
5. Explain informant to consult psychiatric doctor if any complication arise.
symptoms.
2. Explained to the informant about medications (dose, route, side effects).
3. Explained the informant about importance of medicines.
4. Explained the patient about the importance of regular taking medication.
5. Explained informant to consult psychiatric doctor if any complication arise.
2. Helps to reduce chances of discontinuation of medicines.
3. Reduce chances of discontinuation of medicines.
4. Encourage to take regular medications.
5. Helps in immediate management of complication
the informant was made aware about the disease condition and importance of regular medication.
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A case study on BPAD with Mania 2010
DISCHARGE TEACHINGDischarge teaching is very important part of nursing care. It is necessary not only for
patients but also for family and caregivers in order to enhance prompt recovery, prevent the
reoccurrence of disease and maintenance of health through out life.
Our patient was discharged on 24.03.2066 after 6 days of admission. So, we gave
discharge teaching to the patient and family as given below;
1. Drug Compliance:
Close observation should be done to monitor the side effects of the drugs. If major side
effects are observed, immediately consult with psychiatrist.
Monitor closely whether the patient is taking medicines or not.
Do not stop medicine.
Give medicines regularly. Medicines should be given regularly otherwise reoccurrence
may occur and it is very dangerous.
2. Nutrition:
Provide foods rich in vitamins and minerals.
Avoid allergic foods and junk foods.
Provide food according to availability. It is not necessary to provide animal products if
you cannot afford.
Avoid food stuffs like alcohol, caffeine and fried foods.
Provide finger foods. Provide plenty of liquids.
3. Rest and Sleep:
Provide adequate rest and sleep to the patient.
Set a regular bedtime and wake up time.
Avoid caffeine, excessive fluid intake, stimulating drugs and alcohol in the evening and
before bed.
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A case study on BPAD with Mania 2010
Make the patient to get out of bed and engage in other activities if not able to fall
asleep.
4. Others:
Provide good family support.
Avoid stress factors to her as it precipitates the further episodes.
Monitor patient closely to recognize early sign of manic episode as well as prevent from
self injury and injury to others.
Patient should not be involved in hazardous activities like driving and swimming.
Regular follow up should be done.
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A case study on BPAD with Mania 2010
SUMMARY
According to our nursing curriculum under Mental Health Nursing (Practicum), we were
posted in Mental Hospital, Lagankhel for 2 weeks. During this period, we got an opportunity to
be exposed with psychiatric patients. We found different kinds of cases here. Among them we
chose a lady with Bipolar Affective Disorder with Mania for our case study.
Ms. Sahara Rai was 27 years old lady from Phattepur, Salyan. She belongs to middle
class family. She was brought to mental hospital by her sister with the complaint of being
aggressive, not caring self and her children as well, sleeping disturbances and walking here and
there. She was admitted in female psychiatric ward. She was treated with antipsychotics and
lithium. Her general condition was improving. So she was discharged after 6 days of
hospitalization.
During hospitalization, we provided holistic care to the patient considering physical,
mental, socio-cultural, spiritual and economic aspects.
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A case study on BPAD with Mania 2010
REFERENCE
1. Subedi D. 2008. Mental Health and Psychiatric Nursing. First Edition. Kathmandu. Makalu
Publication House. PP: 74-80.
2. Neeraja KP. 2008. Essentials of Mental Health and Psychiatric Nursing: Vol II. First Edition.
New Delhi. Jaypee Brothers Medical Publishers (P) Ltd. PP: 401-410.
3. Sreevani R. 2007. A Guide to Mental Health and Psychiatric Nursing. Second Edition. New
Delhi. Jaypee Brothers Medical Publishers (P) Ltd. PP: 88-96.
4. http://www.medicinenet.com/bipolar_disorder/page2.htm
5. http://en.wikipedia.org/wiki/Mania#Symptoms
6. http://psychcentral.com/disorders/sx9.htm
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