Case Conference: Mark A Study of Bipolar Disorder 4A Group 2

GENERAL OBJECTIVES This case conference aims to enhance the student nurses knowledge about bipolar disorder. This is designed to establish a channel in learning through group discussion and sharing of insights. SPECIFIC OBJECTIVES Each of the student nurses will be able to provide gathered information for group conference. The student nurses can engage in a dynamic group conference about the presented disorder. To describe the local referral pathways and support options managing a client with bipolar disorder. Identify opportunities for collaborative care between doctors, nurses, student nurses, social workers, occupational therapists and other mental health professionals. To supplement missed information through group conference related to current situation.

BACKGROUND AND RATIONALE This week we are assigned to carry out our psychiatric exposure in the VSMMC- Center for Behavioural Sciences. In our entire exposure weve come up to encounter several common Psychiatric Disorders akin to the different types of Schizophrenia and Bipolar Disorders. The group had chosen to study the case of a patient suffering from Bipolar Affective Disorder current episode manic. The group had selected this kind of disorder for us to have a chance to fully maximize our therapeutic skills in engaging with this kinds of patients by understand critically its full nature of illness. Bipolar affective disorder is characterized by repeated episodes in which the patients mood and activity levels are significantly disturbed, with on some occasions, an elevation of mood and increased energy and activity which is referred as mania or hypomania and on others a lowering of mood

and decreased energy and activity which we commonly recognized as depression. Episodes of both kinds often follow stressful life events or other mental trauma, but the presence of such stress is not essential for the diagnosis. The first episode may occur at any age from childhood to old age. The frequency of episodes and the pattern of remissions and relapses are both very variable, though remissions tend to get shorter as time goes on and depressions become commoner and longer lasting after middle age. The symptoms of mania include a decreased need for sleep, pressured speech, and increased libido, reckless behavior without regard for consequences, grandiosity, and severe thought disturbances, which may or may not include psychosis. If the client is under the depressive episode, 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. Between these highs and lows, patients usually experience periods of higher functionality and can lead a productive life.

Assessment and History M.S.D 17 yrs old male single catholic from Sudlon 2 Cebu City, 6 months prior to admission the patient's family observed change in the behavior of the patient, the patient often go out at night to hang out with friends, patient is also seen talking to himself, and patient does not help in the household chores. Patient is also irritable and changes mood easily, he throw stones in the neighborhood which make him end up being beaten by the people.. 3 days prior to admission the patient attempts to burn the house but was stopped by the relatives which decided to bring the patient to Sotto Medical Center for check up. Diagnostic Studies Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) Diagnostic Criteria for Bipolar Disorder The essential feature of Bipolar I Disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes or Mixed Episodes. The essential feature of Bipolar II Disorder is a clinical course that is characterized by the occurrence of one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Hypomanic A. Currently (or most recently) in a Hypomanic Episode. B. There has previously been at least one Manic Episode or Mixed Episode.

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Manic A. Currently (or most recently) in a Manic Episode. B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode. C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Mixed A. Currently (or most recently) in a Mixed Episode. B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode. C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Depressed A. Currently (or most recently) in a Major Depressive Episode. B. There has previously been at least one Manic Episode or Mixed Episode. C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Unspecified A. Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Episode. B. There has previously been at least one Manic Episode or Mixed Episode.

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Diagnostic criteria for Bipolar II Disorder A. Presence (or history) of one or more Major Depressive Episodes. B. Presence (or history) of at least one Hypomanic Episode. C. There has never been a Manic Episode or a Mixed Episode. D. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Laboratory There were no significant laboratory results. Psychopathology 1. Biological Cause

Neurotransmitter Alteration Bipolar disorder is partly caused by an underlying problem with the balance of brain chemicals called neurotransmitters. Overproduction of dopamine causes the nerve circuits to misfire and create a split state in the mind where delusions and hallucinations make the reality if the outside world easier to accept.

Increased Serotonin Level An increase in serotonin levels indicate mania/manic in bipolar disorder. The patient exhibits paranoia and delusions which are some of the symptoms exhibited by a person in a manic state. He also appears excited, hyper and irritable at times. Disruption of the Dopamine System Disruption to the dopamine system is connected to psychosis and schizophrenia, a severe mental disorder characterized by distortions in reality and illogical thought patterns and behaviors. The client has verbalized that he has powers and that he is all- knowing. Genetics The client has not reported that he has any other family that has any psychiatric problem. Moreover, he has reported that he was previously admitted to a Mental Hospital in Manila.

2. Psychosocial Causes

Traumatic Experience/Stressful Situations The patient reported that he was made fun of by his aunt (e.g. given rotten food to eat). The client also reports that he was previously admitted to a Mental Hospital in Manila.

Coping Mechanism

The patient acts all mighty in order to compensate for what is really happening to him; nevertheless, he verbalizes that he is aware that hes in the psych ward to be cured.

Nursing Diagnosis 1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar Disorder 2.) Self- care Deficit: Dressing and Grooming r/t Manic Excitement 3.) Disturbed Thought Process r/t Mood Alteration

4.) Imbalanced nutrition, less than body requirements r/t Refusal to Sit Still Long Enough to Eat Meals 5.) Defensive Coping r/t to Anxiety 6.) Ineffective Role Performance r/t Inadequate Support System 7.) Interrupted Family Process r/t Deterioration of Family Functioning 8.) Risk for other Directed Violence r/t Irritability and Impulsive Behaviour 9.) Risk for injury related to biochemical dysfunction, psychological (affective orientation) FDAR F>Disturbed Thought Process r/t Mood Alteration D>received client dancing, inaccurate interpretation of environment, inappropriate thinking, egocentricity noted, decreased ability to grasp ideas, disordered thought sequencing, decreased ability to use abstract reasoning A>Assessed attention span/distractibility and ability to make decision or problem solve, utilized safety measures, interacted with client on the basis of things in the environment, distracted client from his delusions by engaging in reality-based activities, gave simple directions using short words and simple sentence, encouraged to maintain self-care, reoriented client to time/place/person, presented reality concisely and briefly, reduced provocative stimuli and negative criticism, refrained from forcing activities and communication R>Client was able to maintained usual reality orientation

F>Defensive Coping r/t Anxiety D>received client watching television, decreased use of social support, poor concentration noted, rationalization of failures, superior attitude towards others, hostile laughter, grandiosity, denial of obvious problems A>Assessed and observe client regularly for signs of increasing anxiety and hostility, called client by name, listened and identified client perceptions of what is happening, used a non-judgemental respectful, and neutral approach with the client, was honest and consistent with client regarding expectations and enforcing rules, used clear and simple language when communicating, maintained low level of stimuli and enhanced a nonthreatening environment, encouraged verbalization of fears and

anxieties and expression of feelings of denial and anger, allowed client to react in own way without judgement by staff, provided and encouraged an atmosphere of realistic hope, provided support and diversion R>client was able to verbalize awareness of own coping abilities

F>Self- care Deficit: Dressing and grooming r/t Manic Excitement D>seen client siting on the chair with dirty clothes on, dirty nails, dirty feet, foul odor, profuse sweating and grimacing noted, A>planned time for listening to the clients feeling and concerns, assisted with necessary adaptations to accomplish ADLs, identified energy-saving behaviours, implemented bowel or bladder training program as indicated, assisted in developing self-care practices and goals that promote health, developed plan of care appropriate to individual situation, encouraged scheduling activities to conform to clients usual schedule, practiced and promoted short-term goal setting and achievement R>client was able to performed self-care activities within level of own ability

F> Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar disorder D>client is restless and irritable, inability to concentrate, slowed reaction noted, listlessness observed, A>determined presence of physical or psychological stressors including night-shift working hours and current or recent illness, determined clients usual sleep pattern and expectations, promoted adequate physical exercise activity during day, investigated anxious feelings, instructed in relaxation techniques, limited evening fluid intake if nocturia is present, provided calm and quiet environment, instructed client to get out of bed and engage in relaxing activities if unable to fall asleep and not return to bed until feeling sleepy R>client was able report improvement in sleep/ rest pattern

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 it has interfered with the patients ability to function. When experiencing a manic episode, the patient often talks a mile a minute, sleep very little and is hyperactive. Interaction with the patient for more than 3 days is not enough to cover from his childhood up to now. Before going on duty the student nurse should conduct a self- awareness test. We should also be well-versed about psychiatric disorders prior to duty so that we may know how to adjust our interactions with him. Since the client has Bipolar Disorder, it was challenge talking to him. There were flights of ideas and his perception of the boundaries of reality and fantasy has blurred to a point that he strongly believes in them. He sees himself as the hero in his fantasies. This study can help us gain more insight about patients with this disorder, understanding their needs and how to handle them as future nurses.