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1. CASE STUDY
BIPOLAR DISORDER
General objective:
To provide knowledge about bipolar in relation to the condition of the client including
history, assessment, treatment and management.
Specific objectives:
 To define bipolar disorder and identify the course of the disease process
 To show concepts/ theories of nursing
 To identify the anatomy and physiology of the brain emphasizing nuerotransmitters
 To understand the pharmacological treatment
 To analyze the altered physiology of the nuerotransmitters and the like
 To examine and correlate actual assessment findings to the assessment of the patient
with bipolar disorder
 To appreciate nursing interventions to put into practice in rendering care to the elderly
I. INTRODUCTION
Background of the Study
When broadly defined, 4% of people experience bipolar at some point in their
life. The lifetime prevalence of bipolar disorder type I, which includes at least a lifetime
manic episode, has generally been estimated at 2%.A reanalysis of data from the
National Epidemiological Catchment Area survey in the United States, however,
suggested that 0.8 percent experience a manic episode at least once (the diagnostic
threshold for bipolar I) and 0.5 a hypomanic episode (the diagnostic threshold for
bipolar II or cyclothymia). Including sub-threshold diagnostic criteria, such as one or two
symptoms over a short time-period, an additional 5.1 percent of the population, adding
up to a total of 6.4 percent, were classed as having a bipolar spectrum disorder b. A
more recent analysis of data from a second US National Comorbidity Survey found that
1% met lifetime prevalence criteria for bipolar 1, 1.1% for bipolar II, and 2.4% for
subthreshold symptoms.
• On a strictly biological level, a person's ethnicity does not play a role in their risk of
developing a bipolar disorder. Skin color does not mean a person is more or less likely to
develop a condition or disease. However, racial stereotypes may play a role in the
diagnoses of bipolar disorder.
• The onset of bipolar disorder tends to occur later in women than men, and women
more often have a seasonal pattern of the mood disturbance. Women experience
depressive episodes, mixed mania, and rapid cycling more often than men. Bipolar II

2. disorder, which is predominated by depressive episodes, also appears to be more
common in women than men.
Rationale for Choosing the Case
Bipolar disorder is a very interesting case to analyze. Since this is the first time to
encounter the disorder, we decided to study this case to prepare ourselves in dealing and
handling psychiatric patients.
Significance of the Study
The significance of our study is to know and understand this kind of disorder (bipolar)
specifically to the promotion of health, prevention of complication and treating or managing
the disorder symptoms. In addition, the importance of this study is to make ourselves ready to
reencounter bipolar disorder and other psychiatric disorders in succeeding clinical exposures so
that we can able to provide effective and holistic nursing care.
Scope and Limitation
The study focuses on the nursing interventions and pharmacological interventions in
managing the disorder. Some data are not explicitly identified due to limited sources of the
institution and its policy of strict confidentiality.
Conceptual Theory
This case corresponds to Dorothea Orem’s Self Care Model
because it allows the individual and their families to maintain
control of their healthcare. Self-care is ongoing through out the
continuum of life and is forever evolving. A patient with bipolar
disorder can affect the function of self-care; therefore, these
patients need care from the nurses or care provider to fulfill
their self-care duty.
Orem believes there are three components to the Self-care
nursing model, the compensatory system, the partial
compensatory systemand the educative-developmental system.
1) Compensatory system -is when the nurse provides total care for the patient. This patient
cannot do anything for themselves including but not limited to activities of daily living and
ambulation. This patient is totally dependent of the nurse for survival, such as an acute Stroke
patient.
2) Partial Compensatory - The nurse must assist in the care of the patient but the patient and
family can assist as well. A pneumonia patient, who is very short of breath, may require the

3. nurse to monitor vital signs, oxygen saturations, assist in ADL’s and ambulation. The patient will
be able to resume their own care when they are better but need the assistance and education a
nurse can provide at this time.
3) Educative-developmental system -The patient has primary control over their health; the
nurse assists with education and promoting safe health practices. The patient who has high
cholesterol may fit into this category, diet, exercise regimen and medication is important
education for this patient. The nurse would teach the patient how to properly maintain good
health practices.
Related Literature
• Bipolar disorder, or manic-depressive disorder, is a mood disorder in which people
experience alternating episodes of mania and major depression. Mania is characterized
by elation, irritability, excitability, racing thought and speech, and hyperactivity. Major
depression is characterized by sadness, withdrawal, despair, and suicidal thoughts.
• In the early 1900s, the German psychiatrist Emil Kraeplin was the first to formally
describe bipolar disorder. He used the term "manic depressive" to explain how mania
and depression both affect the patient. His work in the early 20th century led to
advancements in classifying, treating, and predicting the course of mental illness, which
ushered in the formal discipline of psychiatry.
• Bipolar disorder has two distinct classifications:
Bipolar I: history of major depression and at least one episode of mania
Bipolar II: history of major depression and much less severe episodes of mania
(hypomania)
Bipolar I
• An onset before the age of 30 usually results in frequent, severe episodes. Psychosis is
more common in this group and symptoms tend to linger between episodes. An onset
after the age of 40 has a better prognosis. Generally, short episodes, late onset, the
absence of other medical or psychiatric conditions, and early treatment have a better
prognosis.
• Most people are symptom free for months or even years between episodes of
depression and mania. Approximately 25% of people never fully recover from an
episode. Nearly 33% of people have great difficulty functioning at work and in social
settings.
• Three-fourths of manic episodes occur before or right after a major depressive episode.
After the first manic episode, there's a 90% chance that a second one will occur.
Typically, a greater number of manic episodes are experienced over a lifetime.
Approximately 40% of people with bipolar disorder have an average of one episode
every 2 1/2 years, or four in every 10 years.

4. Bipolar II
• People with bipolar II disorder experience major depressive episodes that alternate with
hypomania (milder manic episodes). During hypomanic episodes, patients may become
more productive or noticeably goal driven, but their ability to function well in their
normal daily activities is not impaired.
• About 10% of people who experience hypomanic episodes eventually have manic
episodes
II. CLINICAL SUMMARY
General Data Profile
Name: patient A
Sex: female
Age: 85 y/o
Birth date: April 15, 1925
Birth place: Calauag, Quezon
Citizenship: Filipino
Civil Status: Widowed
Religion: Roman Catholic
GROWTH AND DEVELOPMENT THEORIES
Arnold Gesell
(BIOPHYSICAL THEORY)
STAGE AGE SIGNIFICANT
CHARACTERISTICS
NURSING
IMPLICATION
Old-old 85 and over Increased
physiological
Assist client with self-
care as required, and

5. problems may
develop.
with maintaining as
much independence
as possible.
According to Arnold Gesell theories describe the development of the physical
body how it grows and changes. These changes are compared against established norms. In the
situation of the patient, an elder has the tendency to develop increased physiological problems
or diseases like osteoporosis, arthritis, cardio and pulmonary diseases because of the changes
on the whole systems of the body. It is necessary to assist the patient in ADL while empowering
and promoting their autonomy or independence.
PSYCHOSOCIAL THEORIES
Sigmund Freud
STAGES AGE CHARACTERISTIC NURSING
IMPLICATION
GENITAL Puberty and after Energy is directed
toward full sexual
maturity and
functional and
development of skills
needed to cope with
the environment.
Help patient to cope
properly to
separation anxiety.
Encourage the patient
to deal with the
environment and
relationships.
Psychosocial development refers to the development of personality, a complex concept
that is difficult to define, can be considered as the outward (interpersonal) expression of the
inner (intrapersonal) self. It encompasses a person’s temperament, feelings, character traits,
independence, self-esteem, self-concept, behavior, ability to interact with others, and ability to
adapt life changes.
This theory of Sigmund Freud was said that energy is directed toward full sexual
maturity and functioning and development of skills needed to adopt with the environment.
People in this stage want to have a joyful and fulfilling family life. In the case of our patient, she

6. is included in this stage that deals with separation and death. She loosed her spouse and her
son left her in the home for the aged. The nurse or caregiver should help the patient in dealing
with the environment and relationships to the other residents of the health home for the aged.
Erik Erikson
STAGES AGE CENTRAL TASK INDICATORS OF
POSITIVE
RESOLUTION
INDICATORS
NEGATIVE
RESOLUTION
MATURITY 65 years to
death
Integrity vs.
despair
Acceptance of
worth and
uniqueness of
one’s own life
Acceptance of
death
Sense of loss,
contempt for
others.
This theory of Erik Erickson proposes that life is a sequence of developmental stages or
levels of achievement. In maturity stage shows that integrity vs. despair happened. It describes
the physical, emotional and psychological stages of development and relates specific issues, or
developmental work or tasks, to each stage. Review life accomplishments, deals with loss and
preparation for death. The person best able to undergo psychoanalysis is someone who, no
matter how incapacitated at the time, is basically, or potentially, a sturdy individual. This
person may have already achieved important satisfactions—with friends, in marriage, in work,
or through special interests and hobbies—but is nonetheless significantly impaired by long-
standing symptoms: depression or anxiety, sexual incapacities, or physical symptoms without
any demonstrable underlying physical cause. One person may be plagued by private rituals or
compulsions or repetitive thoughts of which no one else is aware. Another may live a
constricted life of isolation and loneliness, incapable of feeling close to anyone. Some people
come to analysis because of repeated failures in work or in love, brought about not by chance
but by self-destructive patterns of behavior. Others need analysis because the way they are—
their character—substantially limits their choices and their pleasures. The patient experienced
loss and grief when his husband died and she was abandoned by her son.

7. Environmental living condition
The client’s environment in the area of Lucban, Quezon has the spirit of peace and
humility as observed. As a high altitude place, it has a very cold surrounding that is suitable for
the living process of the client. We also observed that the environment was clean and well
ventilated which contributed to their health aspect. Silence of the place also observed and it is
one factor that our client need in a way that elderly should have a peace of mind and be free
from noise pollution.
PHYSICAL ASSESSMENT
Parameters Normal
Findings
Actual Findings Interpretation
1. Integumentary
 SKIN
 HAIR
Increased skin
dryness
Increased skin
pallor
Increased skin
fragility
Progressive
wrinkling and
sagging of the
skin
Brown “age
spots” (lentigo
senilis) on
exposed body
parts (e.g., face,
hands, arms)
Decreased
perspiration
Thinning and
graying of scalp,
pubic, and
axillary hair
Slower nail
growth and
Dry skin
Pale skin
Skin becomes fragile
Saggy skin
Brownish spot
Reduced sweating
With white hair evenly
distributed and thinning
of the scalp, pubic and
axillary hair.
Normal because as we grow
old our subcutaneous gland
activity and tissue fluid
decreases.
Normal: because of
decreasing vascularity
Normal : Reduced thickness
and vascularity of the
dermis; loss of subcutaneous
fat
Normal: because of loss of
skin elasticity, increased
dryness, and decreased
subcutaneous fat
Normal: because of the
Clustering of melanocytes
(pigment-producing cells)
Normal: Reduced number
and function of sweat glands
Normal: Progressive loss of
pigment cells from the hair
bulbs
Inadequate self-care
Increased calciumdeposition

8.  NAILS
2. Neuromuscular
3.Sensory
/Perceptual
increased
thickening with
ridges
Decreased
speed and
power of
skeletal muscle
contractions
Slowed reaction
time
Loss of height
(stature)
Loss of bone
mass
Joint stiffness
Impaired
balance
Greater
difficulty in
complex
learning and
abstraction
Decreased
visual acuity
Progressive loss
of hearing
(presbycusis)
Decreased
sense of taste,
Nails slightly dirty but
smooth, firm and not
brittle
No clubbing of nails
Slow movement with
decrease ROM
Slow reaction
Not in proper stature
Decrease ROM with
slow movement
Cannot demonstrate
flexion of knees
Cannot perform ADL
without assistance.
Delayed understanding
on situations and
cannot verbalize clearly
her statements
Blurred vision
Poor hearing function
Normal: Because of
decreased muscle fibers
Normal: Diminished
conduction speed of nerve
fibers and decreased muscle
tone
Normal: Because of atrophy
of intervertebral discs,
increased flexion at hips and
knees
Normal: Because the bone
reabsorption outpaces bone
reformation
Normal: Drying and loss of
elasticity in joint cartilage
Normal: Because of
decreased muscle strength,
reaction time, and
coordination, change in
center of gravity
Normal: because of fewer
cells in cerebral cortex
Normal: because of
Degeneration leading on
lens opacity (cataracts),
thickening and inelasticity
(presbyopia)
Normal: Because of the
changes in the structures
and nerve tissues in the
inner ear
Normal: Decreased number
of taste buds in the tongue
because of tongue atrophy

9. 4. Pulmonary
5. Cardiovascular
especially the
sweet
sensations at
the tip of the
tongue
Decreased
ability to expel
foreign or
accumulated
matter
Decreased lung
expansion, less
effective
exhalation,
reduced vital
capacity, and
increased
residual volume
Difficult short,
heavy, rapid
breathing
(dyspnea)
following
intense exercise
Reduced cardiac
output and
stroke volume,
particularly
during
increased
activity or
unusual
demands; may
result in
shortness of
breath on
exertion and
pooling of blood
in the
extremities
Reduced
elasticity and
increased
rigidity of
arteries
Cannot clearly identify
different kinds of taste.
Decreased ability to
expel secretions
RR – 23bpm
-Respiratory patterns-
eupnea
-Lung clear sound
Easy fatigability
PR – 88bpm
Normal: Decreased elasticity
and ciliary activity
Normal:
Weakened thoracic muscles;
calcification of costal
cartilage, making the rib
cage more rigid with
increased anterior-posterior
diameter dilation from
inelasticity of alveoli
Normal: Diminished delivery
and diffusion of oxygen to
the tissues to repay the
normal oxygen debt because
of exertion or changes in the
both respiratory and
vascular tissues
Normal: Increased rigidity
and thickness of heart valves
(hence decreased
filling/emptying abilities);
decreased contractile
strength
Normal: Increased calcium
deposits in the muscular
layer

10. 6. Gastrointestinal
7. Urinary
8.Immunological
Increased in
diastolic and
systolic blood
pressure
Orthostatic
hypertension
Delayed
swallowing time
Increased
tendency for
constipation
Reduced
filtering ability
of the kidney
and impaired
renal function
Urinary urgency
and urinary
frequency
Tendency for
nocturnal
frequency and
retention of
residual urine
Decreased
immune
response;
lowered
resistance to
infections
Poor response
to immunization
Decreased
stress response
BP – 150/80mmHg
Slow movement when
eating
No sign of constipation
With poor bladder
control especially at
night
With increased voiding
frequency but less
amount of urine.
With poor bladder
control especially at
night
Susceptible to disease
due to weak body
resistance
Normal: Inelasticity of
systemic arteries and
increased peripheral
resistance
Normal: Reduced sensitivity
of the blood pressure-
regulating baroreceptors
Normal: Alteration in the
swallowing mechanism
Decreased muscle tone of
the intestines; decreased
peristalsis; decreased free
body fluid
Normal: Decreased number
of functioning nephrons
(basic functional units of the
kidney) and arteriosclerosis
changes in blood flow
Normal: Decreased tubular
function
Normal: weakened muscles
supporting the bladder or
weakness of the urinary
sphincter in women
Normal: Decreased bladder
capacity and tone
Normal: T cells less
responsive to antigen; B cells
produce fewer antibodies
immune systemchanges
may participate insulin
resistance

11. PATTERNS OF FUNCTIONING
FUNCTIONAL HEALTH
PATTERN
DURING RESIDENCY INTERPRETATION/
IMPLICATION
Health Management Pattern Patient has clean
environment, inside and
outside the facility.
The patient demonstrated
poor hygiene such as voiding
on her bed during night. She is
sometimes reluctant to take a
bath.
Patient’s environment is
important for the patient’s
wellness. Safety should be
maintained and assist or
supervise the patient during
self- care.
Nutritional/Metabolic Patient eats rice, fruits and
vegetables, fish, chicken,
meat and bread. During meal,
1 cup of rice is enough for her.
She drinks 4-5 glasses of
water daily.
Fewer calories are needed by
the elderly because of their
lower metabolic rate and
decreased in physical activity.
The patient should continue
to comply adequate
hydration.
Elimination Patient urinates 4- 5 times a
day and defecates once a day,
semi- formed to formed stool
in consistency.
Fewer amounts urinated due
to insufficient water intake.
An estimated 30% of
nephrons are loss by age 80
and renal blood flow decrease
because of vascular changes.
Activity and Exercise Patient’s exercise is walking
and some mild ROM exercise
provided by the student
nurses. The patient is willing
to participate and cooperate
to the activities.
Exercise helps in diverting and
preventing the patient’s mood
swings. It also provides
strength for muscles and
bones.
Roles and Relationship The patient has a slightly good
relationship with other
patients. When the patient
hears other patients saying
something about her that
makes her mood to change
easily. The client
demonstrated hostile reaction
when she gets mad to the
other elders.
The patient is sometimes hard
to deal with, which depends
on her mood. The patient is
easily to make laugh and cry.
Values and Belief The patient prays, believes
and has faith in GOD.
The patient has good religious
beliefs. She is also willing to
cooperate and participate in
bible studies. Elderly has high
spiritual beliefs.

12. IMPRESSION/ DIAGNOSIS:
Bipolar disorder
Clinical Discussion of Disease
A. Anatomy & Physiology
4 PARTS OF THE BRAIN
• Cerebrum
• Cerebellum
• Brain stem
• Limbic system
CEREBRUM
• Most high level brain function takes place
• Divided into 2 hemisphere: right & left hemisphere
• Right hemisphere is responsible for music & art awareness, insight and controls the left
part of the body
Cognitive/Perceptual She is oriented in time, place
but sometimes her responses
are not appropriate to the
questions being asked.
Sometimes, her answers are
no consistent with the same
question. She is also has
hearing and very mild speech
difficulties.
Normal changes in aging often
result in varying degrees of
impairment in sensory
perception of the sense of
hearing, vision, smell taste
and touch. Because of the
disease process might be
affecting her cognitive
functioning.
Self-Perception She views herself positively
but views on some things
negatively depend on her
moods.
The disease process and the
aging process greatly affect
the self- perception of the
client.

13. • Left hemisphere is responsible for mathematical skills, language, reading, writing and
controls the right part of the body
• Have 4 lobes: frontal, temporal, parietal and occipital lobe.
• Covers 85% of the brain’s weight
CEREBELLUM
• “little brain”
• Located at lower back of brain beneath the occipital lobe
• Center for coordination of movement and postural adjustment
CEREBELLUM...
• Receives & integrates information from all areas of body such as: muscles, joints, organs
& other components of CNS
• Inhibited the transmission of dopamine in this area.
BRAIN STEM
• Connects spinal cord to the rest of the brain
• Composed of the following:
-MEDULLA- located at top of spinal cord, contains vital centers for respirations &
cardiovascular function.
-PONS- bridges the gap both structurally & functionally serving as primary motor
pathway.
-MIDBRAIN- connects pons & cerebellum with the cerebrum.
-LOCUS CERULEUS- a small group of norepinephrine- producing neurons in brain stem.
LIMBIC SYSTEM
• “Emotional brain”- emotional responses such as; anger, fear, anxiety, pleasure, sorrow
& sexual feelings generated in limbic systembut interpreted in frontal lobe.
• Parts of the limbic system:
-THALAMUS- regulates activity, sensation & emotion.

14. -HYPOTHALAMUS- involved in temperature regulation, appetite control, endocrine
function, sexual drive & impulsiveness behavior associated with feelings of anger, rage
& excitement.
-HIPPOCAMPUS & AMYGDALA- involved in emotional arousal & memory.
STRESS HYPOTHALAMUS- PITUITARY- ADRENAL AXIS

15. NEUROTRANSMITTERS
Neurotransmitters are chemicals which transmit signals from a neuron to a target cell
across a synapse. Neurotransmitters are packaged into synaptic vesicles clustered
beneath the membrane on the presynaptic side of a synapse, and are released into the
synaptic cleft, where they bind to receptors in the membrane on the postsynaptic side
of the synapse.
ACETYLCHOLINE
• Found in the brain, spinal cord and PNS.
• Can be inhibitory and excitatory
• Synthesized from dietary choline found in red meat and vegetables
• Affects sleep- wake cycle and to signal muscles to become active
DOPAMINE
• Essential to the functioning of CNS
• Excitatory
• Involved in emotions, moods and regulation of motor control.
• Dopamine forms from a precursor molecule called dopa- manufactured from liver from
amino acid tyrosine.

16. NOREPINEPHRINE & EPINEPHRINE (ADRENALIN)
• Most prevalent neurotransmitter in nervous system.
• Excitatory
• Has limited distribution in brain but controls fight or flight in PNS
• Play a role in attention, learning & memory, sleep and wakefulness and mood
regulation.
SEROTONIN
• Its function is mostly inhibitory that includes induction of sleep and wakefulness, pain
control, temperature regulation, control of mood, memory, and sexual behavior.
• Inhibitory
• Serotonin is produced in brain from amino acid tryptophan- derived from foods high in
CHON.
HISTAMINE
• Involved in emotions, regulation of body temperature and water balance.
• Neuromodulators
GLUTAMATE
• Excitatory amino acid that at high levels that can have major neurotoxic effects.
GABA
• Most abundant neurotransmitters within the CNS and in cerebral cortex.
• Largely responsible for such higher brain functions as thought and interpreting
sensations.
• Major inhibitory neurotransmitter in the brain
Interpretation:
In the pathophysiology of Bipolar Disorder there is no known cause. An idiopathic
disease where in there is only risk factors.
Clients with:
 Genetic history of Bipolar Disorder
• Biochemical Malfunction in the brain
• Neuroanatomic Circuits Problem
• Childhood Precursors refers to the way the parents raised a child
• Life Events and Experiences which are traumatic for the client may have higher risk for
having Bipolar Disorder. In our interpretation our client had experienced life events and
experiences which triggered the onset of Bipolar disorder.

17. The client would first experience abnormalities in the structure and/or function of a
certain brain circuit where in the brain malfunction and would have problems in releasing or
controlling the neurotransmitters in the brain. There would be imbalance in
neurotransmitters in the brain:
 Acetylcholine- affects the sleep and wake pattern on the client this happens on the
onset of the disorder where in the client experiences difficulty in her sleep.
 Dopamine- affects the elevation of moods and emotions, during the manic and
depressive episodes Dopamine is involved
 Norepinephrine and Epinephrine (Adrenalin) - play a role in attention, learning &
memory, sleep and wakefulness and mood regulation.
 Serotonin- Its function is mostly inhibitory that includes induction of sleep and
wakefulness, pain control, temperature regulation, control of mood, memory, and
sexual behavior.
The client would also experience shifting to extreme moods during the manic episodes of the
client she may experience elevation of moods, irritability, excitability, racing thought and
speech and hyperactivity. And in her depressive episodes she may experience extreme sadness,
withdrawal, despair and suicidal thoughts. This would lead to the altered functioning of her
daily living activities and relationships to others. She may experience violence to others and to
herself also may lead to suicide.
The complications are just perceived scenarios that may happen if the disorder is not
properly managed.
PATHOPHYSIOLOGY of Bipolar Disorder:
NeurobiologicPerspective (Book-based)
ACUTE MANIA DEPRESSION
Interactive among
neurotransmitters
(Serotonin,Dopamine,
Norepinephrine,GABA) or
certainchemicalsinthe
brainthat regulate mood
Drugs: Cocaine,MAOIs,
Trycyclin,
Antidepressants,
Steroids,Levadopa
Interactive among
neurotransmitters
(Serotonin,Dopamine,
Norepinephrine,GABA) or
certainchemicalsinthe
brainthat regulate mood
Alcohol,Drugs:Sedative-
hypnotics,amphetamine
withdrawal,
glucocorticoids,
propanolol,resperine,&
steroidal contraceptives
Physical Illness:Stroke,
Cushing’sdisease&some
Endocrine disorders
Increasedlevel
of
norepinephrine,
dopamine &
serotonin
ACUTE MANIA DEPRESSION
Decreasedlevel
of
norepinephrine,
dopamine &
serotonin

18. MANIC/ DEPRESSIVE BEHAVIOR
(BIPOLAR)
PATHOPHYSIOLOGY of Bipolar Disorder:
NeurobiologicPerspective (Patient-based)
ACUTE MANIA DEPRESSION
Elevatedorirritable
mood(1 week):
Grandiosity,insomnia,verbosity,
flightof ideas,distractibility,
increasedingoal- directed
behaviororpsychomotor
agitation,excessiveinvolvement
inpleasurable activitieswithout
regardfor consequences
Impairmentin
occupational or social
activities&inrelationship
Extreme activity(requires
hospitalization)
Impairmentin
functioning
Prime Symptoms:
Depressedmoodorlossof
interestorpleasure (2
weeks)
Change inlevel of functioning
or five ormore of the ff:
Change inweight,insomnia,
psychomotoragitation,fatigue,
worthlessfeelings,inappropriate
guilt,concentrationdifficulties,death
thoughts,suicidal ideation,and
suicidal attempts
Sex drive decreased
Constipationandurinary
retention
Interactive among
neurotransmitters
(Serotonin, Dopamine,
Norepinephrine,GABA) or
certainchemicalsinthe
brainthat regulate mood
Interactive among
neurotransmitters
(Serotonin,Dopamine,
Norepinephrine,GABA) or
certainchemicalsinthe
brainthat regulate mood
Physical Illness:
MildStroke secondary
to Hypertension
Increasedlevel
of
norepinephrine,
dopamine &
serotonin
ACUTE MANIA DEPRESSION
Decreasedlevel
of
norepinephrine,
dopamine &
serotonin

19. MANIC/ DEPRESSIVE BEHAVIOR
(BIPOLAR)
DRUG STUDY
DRUG NAME DOSAGE ACTION INDICATION ADVERSE
REACTION
NURSING
CONSIDERATION
Haldol
(Haloperidol)
1 tab prn • Alters the
effects of
dopamine in
the CNS
• Also has
anticholinergic
and alpha-
adrenergic
blocking
activity.
• Diminished
signs and
symptom of
psychoses
•Organic
Psychoses
• acute
psychotic
symptoms
• Relieve
hallucinations,
delusions,
disorganized
thinking
• severe
anxiety
•CNS:
extrapyramidal
symptom such
as muscle
rigidity or
spasm, shuffling
gait, posture
leaning forward,
drooling,
masklike facial
appearance,
dysphagia,
akathisia, tardive
dyskinesia,
headache,
seizures.
•CV:
tachycardia,
arrhythmias,
hypertension,
orthostatic
hypertension.
•EENT: blurred
vision, glaucoma
• GI: dry mouth,
• Assess mental
status prior to and
periodically during
therapy.
• Monitor BP and
pulse prior to and
frequently during
the period of
dosage
adjustment. May
cause QT interval
changes on ECG.
• Observe patient
carefully when
administering
medication, to
ensure that
medication is
actually taken and
not hoarded.
•Monitor I&O
ratios and daily
eight. Assess
patient for signs
and symptoms of
Elevatedor
irritable mood
Grandiosity,insomnia,
verbosity,flightof ideas,
distractibility,
psychomotoragitation,
excessiveinvolvement in
pleasurable activities
withoutregardfor
consequences
Impairmentin
occupational or
social activities
& in relationship
Impairmentin
functioning
Prime Symptoms:
Depressedmoodorlossof
interestorpleasure
Change inlevel of
functioning:
Change inweight,insomnia,
psychomotoragitation,fatigue,
worthlessfeelings,concentration
difficulties,death thoughts,has
tendencytocommitphysical violence
to others
Constipationandurinary
retention

20. anorexia,
nausea,
vomiting,
constipation,
diarrhea, weight
gain.
• GU: urinary
frequency, urine
retention,
impotence,
enuresis,
amenorrhea,
gynecomastia
• Hematologic:
anemia,
leucopenia,
agranulocytosis
• Skin: rash,
dermatitis,
phtosensitivity
dehydration.
• Monitor for
development of
neuroleptic
malignant
syndrome (fever,
respiratory
distress,
tachycardia,
seizures,
diaphoresis,
hypertension or
hypotension,
pallor, tiredness,
severe muscle
stiffness, loss of
bladder control.
Report symptoms
immediately. May
also cause
leukocytosis,
elevated liver
function tests,
elevated CPK.
• Advise patient to
take medication as
directed.
Multivitamins 1 cap od Prevention of
deficiency or
replacement in
patients whose
nutritional
status is
questionable.
Treatment and
prevention of
vitamin
deficiencies.
Allergic
reactions to
preservatives,
additives, or
colorants.
1. Assess patient
for signs of
nutrition
deficiency prior to
and throughout
therapy.
2. Instruct to
notify side effects
of medications to
physician.
3. Encourage to
comply on
medications.
4. Encourage
patient to comply
with physicians’
recommendations.
Explain that the
best source of
vitamins is a well
balanced diet with
foods from the 4
basic food groups.

21. NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
“ Mga walang hiya
yang mga yan! Lagi na
lang aq
pinagtsitsismisan!” as
verbalized by the
patient.
Objective:
- With rigid
posture
- With clenching
of fists
- With annoyed
facial
expression
- Pacing
- Hyperactive
- Attempted to
throw hot
coffee to
others
- Has the
tendency to
verbally
threatened
others
Risk for
other-
directed
violence
related to
irritability,
impulsive
behavior
and manic
excitement
with
possible
indicators
of overt
and
aggressive
acts.
Within the
shift, the
patient will
demonstrate
self-control.
Assess client’s
perception of
self and
situation.
Note use of
defense
mechanism.
Observe/
listen for early
cues of
distress/
increasing
anxiety.
Ask directly if
the person is
thinking of
acting on
thoughts/
feelings.
Develop and
maintain
therapeutic
nurse-client
relationship.
Make time to
listen to
expressions of
feelings.
Acknowledge
reality of
client’s
feelings.
Approach in
positive
manner,
acting as if
the client has
control and is
responsible
To assess
causative/
contributing
factors.
May indicate
possibility of
loss of
control and
intervention
at this point
can prevent
a blow up.
To
determine
violent
intent.
Promotes
person’s
sense of
trust,
allowing
client to
discuss
feelings
openly.
To assist
client to
accept
responsibility
for impulsive
behaviour
and
potential for
violence.
To assist
client in
controlling
behavior.
The client
demonstrated
self- control
as evidenced
by relaxed
posture, non-
violent
behavior.
Goal met.

22. for own
behavior.
Give positive
reinforcement
for client’s
efforts.
Maintain
calm, matter-
of-fact, non-
judgemental
attitude.
Provide a
safe/ quiet
environment
and remove
items from
the client’s
environment
that could be
use to inflict
harm to
others.
Encourage
walking or
exercise as
activities that
may diffuse
aggression
To
encourage
continuation
of desired
behaviors.
Decreases
defensive
response.
To promote
safety in
event of
violent
behavior.
To promote
wellness
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
“Huwag na
magpalit ng panty,
hayaan nang
mamaho,” as
verbalized by the
patient.
Objective:
- Inability to
prepare
foods
- Inability to
wash body
and access
to
Self- care
deficit
related to
as
perceptual/
cognitive
impairment
as
evidenced
by inability
to perform
self-care
task.
Within the
shift, the
patient
will
participate
in self-
care
activities.
Note
concomitant
medical and
psychological
problem that
may be factors
for care.
Identify degree
of individual
impairment or
functional level.
Perform/ assist
with meeting
To identify
causative /
contributing
factors.
To assess
degree of
disability.
To assist in
The client
participated
in self-care
activities like
in nutrition
and personal
hygiene.
The patients
demonstrated
initiative in
self-care
activities.
Goal met.

23. bathroom
- Inability to
maintain
appearance
at a
satisfactory
level
client’s needs
when she is
unable to meet
own needs.
Develop plan of
care
appropriate to
individual
situation.
Plan time for
listening to the
client’s
concerns.
Provide for
communication
among those
who are
involved in
caring.
Provide privacy
and equipment
within easy
reach during
personal care
activities.
Support client
in making
health related
decisions and
assist in
developing self-
care practices
that promote
health.
Impart health
teachings about
self-care and
emphasize the
importance of
it.
dealing with
situation.
To conform
to clients
usual
schedule.
To discover
barriers to
participation
in regimen
and to work
on problem
solution.
Enhances
coordination
and
continuity of
care.
To assist in
dealing with
situation.
To promote
wellness

24. Health Teaching
• Eat a balanced diet
• Exercise daily.
• Get approximately the same number of hours of sleep every night.
• Reduce stress at home through variety of stress management techniques
• Limit caffeine and nicotine during manic episodes.
Exercise is an important part of promotion of health and prevention of other illnesses related to
aging. It is important to strengthen bones and muscles, to gain weight and maintain well-being.
During group exercise in the nursing home, they tend to socialize with other residents, thus,
improving their socialization skills.
Sleep Management. Good sleep hygiene is particularly important for patients. Techniques used
to enforce healthy sleep may help reduce mood cycling and promote wellness.
Diet. A healthy diet low in saturated fats and rich in whole grains, fresh fruits, and vegetables is
important for anyone. People with bipolar disorder should be sure to maintain a regular healthy
diet. They may need to restrict calories if they are on medications that increase weight.
Psychotherapy and Lifestyle Changes
Psychotherapy is an important addition to medication. Many approaches are proving to be very
useful. Trained mental health professionals can:
Educate patients about bipolar disorder and its treatments
Teach patients to recognize and manage early warning symptoms of imminent manic or
depressive episodes
Help them comply with drug regimens
Monitor the patient's on-going status
Intervene early in manic and depressive episodes to reduce the severity of the attack
Psychotherapy adjusts to the reality of the illness and understands the negative consequences
of mania -- particularly important for patients who consider their mania to be positive, creative,
and exhilarating
Cope with feelings of guilt and remorse that occur after manic episodes
Deal with feelings of imperfection and despair.
While no cure exists for bipolar disorder, effective management of this illness can enable most
people to lead highly functioning, healthy lives. Managing bipolar disorder is complex and may
include psychotherapy, medication and lifestyle changes. The support of loved ones and a
strong commitment to your own wellness are key elements to disease management as well.

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