Bipolar Mania

Identify data, legal status

Data : 45 Year old male admitted for homicidal
ideations. Patient stated that after binging on
methamphetamine for one week, he began
hearing voices telling him to kill people. Patient
wanted help and was taken to hospital by a
friend. Patient has diagnosis of Bipolar Mania,
which he takes medications for.
Voluntary (MH-5) on Sunday, 1/17/2016
When an individual commits himself on his or her own
free will.

DSM Diagnosis

Axis I: Bipolar I Disorder, Mania

Axis II: None
Axis III: None
Axis IV: Sexual abuse as a child, Drug addicted
friends, inadequate social support
Axis V: GAF is 60-51
Moderate symptoms (flat affect and circumstantial
speech, occasional panic attacks), or moderate
difficulty in social, occupational, or school
functioning (few friends, conflicts with peers or
coworkers)

Patients symptoms compared to

DSM criteria
Patient
Inflated self-esteem or
grandiosity
Decreased need for sleep
More talkative than usual
Flight of ideas
Excessive involvement in
pleasurable activities that
have high potential for
painful consequences

DSM

Persistently elevated,
expansive, or irritable
mood lasting at least one
week
Inflated self-esteem or
grandiosity
Decreased need for sleep
More talkative than usual
or pressure to keep
talking
Flight of ideas
Distractibility
Increase in goal-directed
activity or psychomotor
agitation
Excessive involvement in
pleasurable activities that

Reason for admission

Pt. went on a binge of smoking
methamphetamine for one week,
then stated that he started feeling
urges to kill people.

Financial data/insurance
Cleans nightclubs and bars for
$15/hour
Pays $400 rent
HMSA Quest

Patients description of
problem
I blew it the moment I cocked that
bowl. I hit the rock for a whole week
and everything happened so fast. I
started feeling these urges to kill
people. I didnt like that feeling and
wanted help. My friend brought me
hospital to get better.

Ethnicty /religious /spiritual

concerns
Korean ethnicity
Goes to church sometimes with
friends
Believes in god and that he has a
plan for him

Patients Strengths &

Limitations

Objective

Subjective

Hard worker
Motivated
Able to do math
equations in head

Professional athlete
Can hustle anything
Good at money
management

Limited money to
supply daily needs
Overweight and short
Drug addiction

Not enough money to

invest in inventions
Friends who influence
him to do drugs
No business partner

Medications

Quetiapine (Seroquel) 400mg oral daily (medium dose)

Atypical antipsychotic, mood stabilizer
Usual dose: 400-800mg/day
SE: NMS, seizures, palpitations, edema, dry mouth

Divalproex sodium (Depakote) 5000mg oral BID (medium dose), Mood

stabilizer
Usual dose: 750mg/day divided doses initially. Titrated rapidly to
desired clinical effect
SE: Suicidal thoughts, Hepatotoxicity, Pancreatitis, vomiting, rash,
diarrhea

Lithium (Lithobid) 300mg TID (medium dose), Mood stabilizer

Usual dose: 300mg 3-4 times per day
SE: Seizures, arrhythmias, abdominal pain, diarrhea, polyuria

Medical issues, lab

CBC and BMP within normal limits
Urinalysis reveals positive THC and
methamphetamine

Mental status assessment

Appearance: Poor hygiene as evidence by uncombed hair, wrinkled
clothes, unwashed face. Appropriate dress.
Affect: Euphoric as evidence by smiling and answers questions
appropriately
Mood: Euphoric as evidence by stating how excited he is to be
discharged and start making money
Thought Process: Circumstantial
Thought Content: Patient verbalized multiple grandiose statements
Cognitive Exam: Alert and oriented x3, recalls events prior to
hospitalization, memory intact
Insight and judgment: Patient understands that his choice to smoke
meth was bad, and now that he got help, he wants to stay clean.
Level of Function: Patient is able to perform ADLs with no difficulty.
Psychotropic medications: Seroquel, Depakote, Lithium
Mild Anxiety as evidence by 11 on the Burns Anxiety Assessment

Hospital treatment plan

Ensure no suicidal or homicidal ideations
Medication management to maintain
stable mood
Encourage group therapy for improving
effective communication
Educate importance of follow up
appointments with PCP
Educate about adverse effects of
methamphetamine

Discharge plan/community
resources
Narcotics Anonymous 12 step meetings/
church
Stay away from illicit drugs
Keep up with PCP appointments
To Do List

3 highest priorities in order of acuity

with rationale

Safety from self harm and inflicting harm on others. The

well being of the patient, other patients, and the staff are
the highest priority.

Noncompliance with medications. Noncompliance can result

in exacerbation of manic episodes and failure to maintain
normal behavior patterns.

Ineffective health maintenance. Manic patients may not eat

or drink, putting physical health at risk.

Nursing Diagnosis:

Disturbed thought processes related

to ineffective processing and synthesis of stimuli (secondary
to brain chemistry changes in bipolar mania) and exaggerated
responses to psychosocial stressors (secondary to bipolar
mania) as evidenced by flight of ideas, grandiosity, initiating
multiple simultaneous projects, poor judgment and insight,
and intrusion in others lives.

P: Disturbed thought process and exaggerated response to

psychosocial stressors

E: Change in behavior pattern, change in problem-solving

abilities, change in sensory acuity, change in usual response
to stimuli, disorientation, impaired communication, irritability,
sensory distortion

S: Personal and environmental safety management, behavior

management, reality orientation, delusion management, mood
management, medication management

Short term goal: Patient will stay safe

in milieu and not be intrusive to other
patients.
Long term goal: Patient will be
educated about medication
management and maintain routine
appointments to PCP.

Intervention & Frequency

Rationale

Maintain a safe, harm free

environment through close
observations q 15 minutes to
minimize the patients risk of self
harm or violence.

Safety is the biggest concern for the

patient, patients in the milieu, and
hospital staff.

Assess the patients cognitive and

perceptual processes periodically
during shift to ascertain the
existence of hallucinations or
delusions that are troubling or
harmful to the patient.

The response of these altered

thinking and perceptual experiences
can be harmful to the patient or
others.

Administer scheduled and PRN

medications in a timely manner

Management of medications will

maintain stable mood for patient

Establish a low stimulus environment An environment with many stimuli

for patient to reduce sensory input
can promote the escalation of the
every shift
manic symptoms.

Nursing Diagnosis: Noncompliance related to

personal abilities and motivational forces (unable or
unwilling to comply secondary to biochemical
imbalance of mania) as evidenced by hyperactive and
disorganized behavior indicating failure to adhere to
medication regimen, evidence of exacerbation of
manic symptoms, failure to progress toward normal
behavior patterns, lack of family support in
medication regimen.

P: Noncompliance
E: Exacerbation of manic symptoms, change in
behavior,

S: Behavior modification, develop behavior contract,

medication education, decision making support

Short term goal: Patient will maintain

therapeutic level of medication in body
during hospitalization
Long term goal: Patient will verbalize
importance of adhering to medication
and keep up with routine appointments
with PCP

Intervention & Frequency

Rationale

Compliance
increases when there is
Intervention with
rationale
a trusting relationship and a

Develop therapeutic relationship

with patient and family every shift

consistent caregiver. Use of a skilled

interpreter is necessary for patients
who do not speak the dominant
language
Assess the patients individual
perceptions of health problems
every shift

A patients perceived susceptibility

to and perceived seriousness and
threat of disease, along with
perceived benefits from adhering to
treatment plan, after compliance.
Some patient may not understand
their disease.

Develop a behavioral contract

The contract will help the patient

understand and accept the role in
the care plan and clarifies what the
patient can expect from the health
care worker or system.

Develop a reward system with

patient after every successful
compliance.

Rewards provide positive

reinforcement for compliant
behavior. They may consist of verbal

Nursing Diagnosis: Imbalanced Nutrition: Less

than body requirements related to knowledge
deficit, unwillingness to eat, and increased
metabolic needs caused by disease process or
therapy

P: Imbalanced Nutrition: Less than body

requirements

E: Poor PO intake of meals, fatigue, altered mental

status not related to noncompliance, change in vital
signs, change in laboratory values,

S: Nutrition monitoring, nutrition therapy, nutrition

management, nutrition education

Short term goal: Maintain body weight

and have excellent PO intake during
hospitalization
Long term goal: Able to maintain body
weight and have excellent PO intake
when visiting PCP

Intervention & Frequency

Rationale

Intervention with rationale

Document weight every morning at
same time with same clothes

This will determine how well the

patient is responding to nutrition
education.

Provide finger foods and take out

cups for meals

Manic patients have difficulty sitting

still at a table. Providing something
that is easy to eat and carry with
them can help with maintaining
adequate nutrition.

Discourage beverages that are

caffeinated or carbonated

These beverages may decrease

appetite or act as a diuretic and put
the patient at risk for deficient fluid
volume.

Educate about balanced diets,

appropriate snacks, and scheduling
of meals

Patients may not understand what is

involved in a balanced diet. They are
better able to ask questions and
seek assistance when they know
basic information.

Current, evidences based journal

article supporting nursing intervention
With the recent attention to evidence-based medicine in psychiatry, a
number of treatment guidelines for bipolar disorders have been
published. This survey investigated prescribing patterns and
predictors for guideline disconcordance in the acute treatment of a
manic and mixed episode across mainland China.
The pharmacological treatments of 2828 patients with a recent
hypomanic/manic episode or mixed state were examined. Guidelines
disconcordance was determined by comparing the medication(s)
patients were prescribed with the recommendation(s) in the
guidelines of the Canadian Network for Mood and Anxiety
Treatments.
In mainland China, the disconcordance with treatment guidelines for
a most recent acute manic or mixed episode was modest under
naturalistic conditions. The higher risk for disconcordance in general
hospitals than in psychiatric hospitals suggests that special education
based on treatment guidelines to practitioners in general hospitals is

What does all this mean?!?!

Improvements
NO ILLICIT DRUGS
Medication education and
compliance
Nutritional education and compliance
Behavioral, Cognitive, Individual
therapies
Supportive groups (NA, church,)

References
Fortinash, K., Worret, P. (2012). Psychiatric Mental
Health Nursing, 5th Edition. St.
Louis, Missouri: Elsevier
Gulanick, M., Myers, J. (2011). Nursing Care Plans:
Diagnoses,

interventions, and outcomes. St.

Louis, Missouri: Elsevier