Bipolar Affective Disorder


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Bipolar Affective Disorder

  1. 1. NURSING CARE AND MANAGEMENT OF PSYCHIATRIC PATIENT WITH BIPOLAR AFFECTIVE DISORDER Group Members :  Viviana ak Incha  Nur Ainina bt. Mohd Fadzil  Lai siang Wei Semester 5 / July 2011 Intake Subject : Psychiatric in Nursing Subject Code : NENS 5262 Lecturer’s Name : Madam Chin Nyuk Chin
  2. 2. CONTENT Introduction Definition Causes Sign and symptom Patient’s Biodata Patient’s Current History Referral Source Family History Personal History Social History Premorbid Personality Previous Medical History Mental Status Examination Mental Status Examination -reverseManagement :  Medication  Divertional Therapy  Psychoeducation Nursing Care Plan Conclusion References Appendix PAGE
  3. 3. INTRODUCTION We choose Bipolar Disorder for our case study during attach at Hospital Sentosa. We find out the case when first patient re-admitted at 12/8/13 in Male Acute 1.Brought by his brother. Patient names Mr.A.R, 40 years old, Malay. His brother brought him to Sentosa and request to admit plus the patient also wanted to admitted because apparently not well at home (voluntary, under Borang 1). His brother and others family member noticed that patient always hanging around with village boys and lossy money. Throughout our observed, during interview Mr. A.R, his was talkative, flight of ideas, and non-stop singing. We have chosen this case study because our patient able to talk relevantly. Besides that, he was admitted to Male Acute 1 . So, it will be easier for us to interview. Other than that, we can make this case study presentation as part of our revision.
  4. 4. Definition Of Bipolar Disorder  is a chronic ,recurrent illness characterized (expansiveness,elation,agitation,hyper-activity) by episodes of mania ,hypomania,depression ,and concurrent mania & depression (mixed episodes) with periods of normal mood and functioning in between the episodes. (Mental Health Nursing,sulaigah baputty-sabtu hitam-sujata sethi,pg.176)  is a mood disorder characterized by mood swings from (exaggerated feeling or wellbeing ,stimulation and grandiosity in which a person can lose touch with reality)to depression overwhelming worth,which can include suicidal though & suicide attempts. ( )  sometimes called manic-depressive disorder. Bipolar disorder is associated with mood swings that range from the lows of depression to the highs of mania. (
  5. 5. Causes Of Bipolar Affective Disorder  unknown  but genetics do seem to be involved. Relatives of people with bipolar effective and depression are more likely to be affected.  abnormal brain structure & brain function.
  6. 6. GENERAL SIGNS & SYMPTOMS MANIC DEPRESSED  mood swings  feeling of sadness or hopelessness  depression  lost of interest in pleasurable or  Manic episodes  increase activity level  talkactive,  ideas that moves quickly from one subject to the next  (flight of ideas)  excessive irritability ,aggresive behaviour  reckless sex,spend lot of money usual activities  difficulty sleeping ,early-morning awakening  difficulty concentrating
  7. 7. BIODATA  Name : Mr. A.R  Age : 40 y.o  Religion : Islam  Race : Malay  Address : No. 52 ,Kampung Gersak,Petra Jaya, Kuching  Occupation : Unemployed  Status : single  Admission Status : Voluntary (Borang 1)  No. Of Admission : 23 (19 July 2013)  Diagnosis : Bipolar Affective Disorder (BAD)
  8. 8. PATIENT CURRENT HISTORY History from brother :  During Home Leave 19/7/13 until 11/8/13 ,the patient always hangout and gambling with village boys until back home lately. History from patient :  Cannot sleep around 2-3 days (hyperactive)  Feel hopeless because lost a lot of money because of gambling  Increasing in smoking  Not taking alcohol anymore During our interview, the patient was talkative, flight of ideas and non-stop singing. The patient also spoke relevantly. Sometimes patient not cooperative with activities been conduct.
  9. 9. A. REFERRAL SOURCE : Patient was brought to Male Acute 1 at Hospital Sentosa Kuching (HSK) by his brother on 12th of August 2013. So, he was admitted Chief complaint ; his brother claimed that patient was not well at home and like to wonder around at night. Patient’s history of present illness ; according to his brother patient was drank alcohol brought by the village boys , scolding everyone at home , gambling and become more aggressive. Upon losing money he likes to disturb people at home. History from patient ; troughout our interview session on the 14 th of August 2013, the patient spoke Malay with us. Patient is also able to attend his activity of daily living independently. His sleep pattern was not regular, he always sleeps late at night around 3am to 4am and woke up around 12nn to 1pm. Patient’s appetite was good and normal. Patient claimed that every meal, he will eat two plate of rice. Besides that , his toilet habits was perform well and oral hygiene is poor. Before admission , his family had brought him to see “Bomoh” at around 15 years ago at Petra Jaya. Other than that , he also had “mandi air bunga dengan rempah” at Kpg. Tupong Tengah in few years ago. He was also admitted to Hospital Sentosa on 30th of January 2013 which the 22nd of admission ; the treatment given to patient are Tab. Clonazepam, Tab. Quetiapine, Tab. Sodium Valporate, Tab. Amlodipine , Tab. Metformin and Tab. Simvastatin.
  10. 10. B. FAMILY HISTORY According to case note, patient having moderate strong family history of mental illness. His uncle from his mother’s side was positive history of mental illness. His uncle ever admitted for the past few years ago but already discharged from Sentosa Hospital ; being as a outpatient and still taking the medication as prescribed by the doctor.
  11. 11. Patient stays with parent and ten siblings. He is the 9th among his siblings. Patient was stayed with mother and the 5th sister with his brother-in-law. Patient’s father was dead few years ago due to stroke and asthma. His mother was 75 years old and diagnosed Diabetes Mellitus under treatment. Patient’s 1st brother ; 53 years old ; married ; work at the airport. Patient’s 2 nd brother ; 51 years old ; married ; work at hospital as PPK. Patient’s 3rd brother ; 50 years old ; married ; work as engineer. Patient’s 4th brother ; 49 years old ; married ; work as personal assistant with a Dato’. Patient’s 5th sister ; 47 years old ; married ; work as telekom officer. Patient’s 6th brother ; 46 years old ; married ; work as driver BERNAS. Patient’s 7th sister ; 45 years old ; married ; work at the RHB Bank. Patient’s 8th brother ; 43 years old ; married ; work at Kompleks Belia & Sukan. Patient’s youngest sister ; 38 years old ; married ; work as Telekom officer. There are no social standing in patient’s family ; economic status of the family is moderate about RM2000/- ; from the brothers and sisters who supply to the mother every month.
  12. 12. C. PERSONAL HISTORY Mr. A.R was a Malay , born on 9th July 1973 at Sarawak General Hospital with normal delivery. He has no neurotic problems since birth. He is healthy. He completed secondary school at SMK Tun Abang Haji Openg for Form 1 till Form 5. On 1997 , he pass with seven subjects in SPM. He was not active at school and like to do his own work alone. After Form 5 , patient did not work for a few years. Patient just stayed at home and hang around with village boys. On 2002, patient doing part time job at Banquet as a waiter for two years. Patient was earned around RM30-40 per day from the part time job. On 2005, patient work at coffee shop for 3 to 4 years. Patient helped his cousin to sell “Laksa Sarawak”. After that, patient quit again as he felt his salary is insufficient to support his daily expenses. Patient was earned between RM 600 to RM 800 per month. On 2012, patient was worked as a guard at condominium area. He only worked for 8 days because he engaged in a police case by history of stealing. Patient also was being fired by his employer. After that, he worked at a hotel on and off for a few months. He quit again and not doing any job until now. Patient sexual experience was having reckless behavior. He claimed that , he was done sex with many partner and also with the psycho people at the outside. He was started sex experience since 14 years old and addicted with porno CD. He also often to masturbate.
  13. 13. D. SOCIAL HISTORY Recently, the patient present home was concrete double-storey house. That house is not a rent house but their own house. Mr. AR’s friend are mostly the village boys. His friends are likes gambling also. So, they’ll influence Mr. AR to gambling and lossy money. During home leave on 5th to 11th August 2013, almost every night he went out play ‘Olo’ and cards. His religious affiliation , he’s Muslim but never practice it. He also smoked since 14 years old. He smoked on demand because he will smoked as long the cigarettes have in his hand. Patient drank alcohol since 2005,such as Cap Apek but he took it on-off. On 2007, he took “Royal + cola + ice” . Before the admitted into Male Acute 1 ward , patient had took beer such as “Dexter (1 can) and Tsingtao (1can)” .
  14. 14. E. PREMORBID PERSONALITY Before patient was sick , he was prefer more being alone and not socialize with other people accept his family ; but its also limited. He only very closed with his 5 th brother. He also very kind and polite towards others as claimed by his brother upon our interview. F. PREVIOUS MEDICAL HISTORY Upon our interviewed and referral from the patient’s case note, below are the medical history of patient ;  Bipolar Disorder type 1  Hypertension – diagnosed on 8/3/12  Non Insulin Dependent Diabetis Mellitus (NIDDM) -8/3/12  Hypercholesterolemia -8/3/12 Hypertension , Non Insulin Dependent Diabetes Mellitus and Hypercholesterolemia are being diagnosed on the 8th of March 2012.
  15. 15. MENTAL STATUS EXAMINATION General Appearance and Behavior : During interview on 14th of August 2013 (Day 3 of admission) , we had done an assessment on patient in Male Acute 1. Patient’s general appearance and behavior are talkative, flight of ideas and tidy. Patient also attentive and aware to surrounding activity. His physical appearance are tough, tall, dark skin and many freckles. Patient was well dressed and clean. Patient also able to maintain eye contact during conversation. His facial expression; smiling and happy but patient walk is unusual gait. There were presence of poor manner because he just grab the things that he want to take without any permission. He able to co-operate during interview session eventough easily distracted occasionally. Talk Patient’s spoke Malay and sometime in English during interview session. The volume is normal but in rapid rate. The speech is clear and relevance. He has no loose or clang association. Moods Patient mood state is happy during interview. His affective response is appropriate and having inconsistency of mood. He denied any suicidal thoughts. Thought Content There are present of delusion which patient says that he’s a “pengarang cerita”. He denied any feelings of influence, passivity, depersonalization, repetitive dreams or phobias.
  16. 16. MENTAL STATUS EXAMINATION –reverse- Orientation Place Patient able to tell us where he is now. Q : Mr.AR, do you know the name of this place? A : Of course, this is Hospital Sentosa. Person Patient able to recognise us during our interview. Q : Mr. AR, do you know who we are? A : Ya, you are nurse from ICATS. Date Patient able to state the date. Q : Mr. AR, do you know what date is today? A : Ya, it's 14th August 2013. Memory Remote Memory : Pt able to tell us where he’s secondary school. Nurse : “kamu bersekolah di mana dulu?” Patient : “kat Smk Tun Abg Hj Openg lah.” Recent Memory : Good & able to remember our names in the second time we meet on 16 August 2013. Five Minute Memory Test : Patient able to recall 3 items out of 3 items after 5 minutes. Items : nurse watch, name tag & note book.
  17. 17. Information and Vocabulary In estimation of intelligence level, patient able to tell us what his medication is on; able to explain or state the medication and time to be taken. He also had explain to us the function of his medication and the effect if not taking it. Eventough its not proper well said in medical term but he able to says it in his own words. Abstraction In proverb test, patient able to explain “bagai menatang minyak yang penuh” ; where he explained it “seorang ibu akan menjaga anaknya dengan penuh kasih sayang. Walau apa pun yang terjadi ibu tetap sayang dengan anaknya.” Attention and Concentration Patient able to concentrate well during interview. We’re perform some test with patient which are; Serial seven test : Patient’s being instructed to minus 7 from 100 and continuously minus 7 from the answer. Remarks : Patient able to give fast answer. Digit span test : We instructed patient to count number in reverse that is 10 to 1 . Remarks : Patient able to count number in reverse from 10 to 1.
  18. 18. Judgement Patient able to make decision and conclusion when asked about his response if confront with a serious situation. Nurse : “ Mr. A.R,apa kamu akan buat jika kamu lihat kawan kamu tercedera dekat wad?” Patient : “ Saya panggil misi lah.” Insight Patient is aware of his condition that is Bipolar Affective Disorder. He know the consequences if he is not comply with his treatment. He just need a better understanding of his illness.
  19. 19. CASE MANAGEMENT Medication : Name of Drug Group Route Indication Side Effect Nursing Implications Generic Name : Anti- Oral Clonazepam anxiety (ON) (0.5mg – 6mg)  Used to treat seizures, panic disorder and anxiety.  Used to treat Trade Name : Klonopin bipolar disorder.  Drowsiness, dizziness  Loss of  Do not drink alcohol. appetite, nausea  Unusual risktaking Patient’s Dosage behavior  Confusion, : 2mg hallucinations  Involuntary eye movements Generic Name : Anti- Oral  Used for the Quetiapine Psychotics (ON) treatment of  Cold sweats getting up schizophrenia,  Confusion too fast bipolar disorder  Dizziness from a and along with  Drowsiness sitting or antidepressant to  Constipation lying treat MDD (Major  Headache position. (150mg – 800mg) Trade Name : Seroquel Patient’s Dosage : 800mg Depressive Disorder)  Chills  Avoid
  20. 20. Generic Name : Sodium Valproate (1000mg – 3000mg)  Anticonvulsant Oral  Used in the (BD) treatment of  Mood epilepsy, panic, Stabilizers anxiety Trade Name : disorder, Epilim migraine and  Confusion  Advice  Abnormal eye patient to movement do  Extrapyramid regular al side effects  Memory exercise.  Encourag problems e patient bipolar to label disorder  Tremors the  Weight gain picture of  Headache family  Lethargy Patient’s Dosage :  Sleepiness members 1000mg . Generic Name : Calcium Oral Amlodipine Channel (OD) Blocker Trade Name : Norvasc  Treats high  Swelling of blood ankles & pressure or feets chest pain  Dizziness (angina).  Fast, irregular heartbeat / Patient’s Dosage : pulse 5mg  Feeling of warmth  Shortness of breath  Tightness in the chest. 
  21. 21. Generic Name : Metformin Oral  Used with  Decreased (BD) Biguanide diet and appetite exercise to control blood Trade Name : Glumetza  Diarrhea  Lower back sugar in patients with Patient’s Dosage : type 2 1g diabetes. or side pain  Muscle pain or cramping  Painful or difficult urination  Sleepiness Generic Name : Anti- Oral Simvastatin Hyperlipidemic (ON) Agents Trade Name : Zocor  Used to treat high  Constipation cholesterol  Insomnia and  Joint pain triglyceride  Mild muscle levels in the Patient’s Dosage : 20mg  Headache blood pain  Cold symptoms such as sneezing, sore throat.
  22. 22. Diversional Therapy :  The activities that we have done with the patient are : 1. Play chess – At certain moments, our patient is in mania state, during this time, we would ask him to sit down and play chess with him. He able to focus in the game and won several times. 2. Singing – Patient loves to sing most of the times. Whenever he saw us, he loves to sing. He has a good voice. Even though sometimes his voice makes us feel annoying but he loves to make us feel entertaining. 3. Musical chair – We gathered 8 patients and 2 students to play together. Our patient sometimes do feel restless, we would play musical chair with him in order to let him focus on the music. Psychoeducation :
  23. 23. 1. Understanding illness :  First and foremost, we assess patient knowledge on his illness. Then, we explain the definition, sign & symptoms of the illness. 2. Treatment :  Then, we ask the patient about his medication. We ask him by the colour of the medication and the name if the patient remember it. We also tell him the action and side effects of the medication and ask him which side effects he experienced as well as teach him how to cope with the side effects. We also remind him not to take alcohol when taking medications. 3. Prevent relapse :  In order to prevent the illness from reoccur, we advise the patient to maintain a balance of rest and activities, regular check-up and compliance towards medication. In addition, we also advise the patient to have balanced diet, regular exercise and avoid alcohol. We also educate the patient of the early signs of relapse such as less sleep, feels irritable and not feeling of taking medication.
  24. 24. 4. Crisis intervention : a) Managing stress – when feeling stress, do some exercises. We also teach the patient to do deep breathing exercise if he feel stress. b) Problem solving skills i. Identify the problem ii. Find a better solution c) Follow up treatment according to the appointment. 5. Healthy lifestyle :  Avoid alcohol together with drugs that might increase the risk of relapse.  Have a healthy balanced diet. Consume more vegetables and fruits.  Exercise regularly because exercise can affect mood positively.  Have enough rest. Go to bed at the same time every night.  Regular follow-up and compliance with treatment.
  25. 25. Nursing Care Plan : Nursing Goal Diagnosis Nursing Rationale Evaluation intervention  Provide  To divert Risk for violence Patient feels related to the less irritable diversional patient’s when get therapy such as irritable when get aggressive along with playing chess. along with other behavior. other people patient’s anger  To help the OD : patient to patient to • Patient looks express his relieve his feelings feelings and irritable when people keeps bothering him. anger.  Avoid expose the  To avoid patient to patient SD : predictable high became out of • Patient situation. control. verbalize that other patient  Administer keeps taking medication as cigarette from prescribed by him which doctor such as makes him epilim. angry. patient feel less people.  Encourage within 1 week. After 1 weeks,  To calm the patient.
  26. 26.  Assess patient  To identify his Knowledge deficit Patient regarding to verbalize level of understanding patient verbalize illness. understand understand level. understand about about his towards his his illness / OD : illness / illness. disease upon • Patient facial disease within expression 1 weeks upon seems interviewing. interviewing.  Explain to patient  To increase regarding his patient’s disease which knowledge on SD : includes his illness / • Patient do not treatment. disease. confused. understand his disease upon interviewing. After 1 weeks,  Educate patient  To increase on his sign and patient’s symptoms of his knowledge illness / disease. and to prevent relapse.
  27. 27.  To maintain After 1 week, go to bed at the bedtime patient able to hours at night same time every routine. sleep for 6 after 1 week. day. Sleep Patient able to disturbance sleep for 6 related to hyperactive. OD : • Patient look dozy in the  Advice patient to  Advice patient to hours at night.  To avoid pass urine before disturb during go to bed. sleep. day.  Increase daytime  So that patient SD : activity for patient will feel tired at • Patient such as play night. verbalize feel balls. wanted to do something at night.  Limit the amount  So that patient and length of able to sleep daytime sleeping at night. to half an hour.  Administer  To reduce the medication as sleep prescribed by disturbance of doctor such as the patient. clonazepam.
  28. 28.  Patient is related to lack of willing to patient’s patient take patient is willing family support. take medication the medication to take medication intake. as prescribed. medication OD :  Supervise the  To ensure Poor compliance by 1 week.  After 1 week, regularly. • Patient has flight of ideas  Patient  Explain the  To increase  Patient also upon returning verbalize illness and patient verbalize from home understand importance of knowledge understand on leave. the treatment level on his the importance importance towards the illness and of compliance of patient. treatment. towards • Patient look hyperactive compliance SD : towards • Patient treatment. treatment.  Encourage the  To allow verbalizes patient to take patient being unable to treatment independently sleep well at unsupervised after night. and regularly. discharge. • Patient’s brother verbalize patient always hang out at night.
  29. 29. Conclusion : Through this case study, we learned a lot about Bipolar Affective Disorder. We improved our knowledge on the sign and symptoms such as distractibility, impaired judgment and increased energy. Besides collecting data from documentation of the staffs from Hospital Sentosa, we also manage to gather some data from the patient through interview. During that interview, we get to know more about him as well as his feelings. Our patient is co-operative upon interviewing by answering the questions that we asked him. He also sang song for us in order to entertain us. This case study also encouraged us to read more on Bipolar Affective Disorder (BAD). I believe this case study will help us in the future.
  30. 30. Refferences  (Mental Health Nursing,sulaigah baputty-sabtu hitam-sujata sethi,pg.176)  ( auses.)  (