Psych Final Contents

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features INTRODUCTION
2011
Bipolar Disorder is a mood disorder that is characterized by at least one manic or mixed episode. There may be episodes of hypomania or major depression as well. It is a subdiagnosis of bipolar disorder, and conforms to the classic concept of manic-depressive illness. Bipolar disorder, also known by its older name manic depression, is a mental disorder that is characterized by constantly changing moods. A person with bipolar disorder experiences alternating highs (what clinicians call mania) and lows (also known as depression). Both the manic and depressive periods can be brief, from just a few hours to a few days, or longer, lasting up to several weeks or even months. The periods of mania and depression vary from person to person many people may only experience very brief periods of these intense moods, and may not even be aware that they have bipolar disorder. A manic episode is characterized by extreme happiness, hyperactivity, little need for sleep and racing thoughts, which may lead to rapid speech. A depressive episode is characterized by extreme sadness, a lack of energy or interest in things, an inability to enjoy normally pleasurable activities and feelings of helplessness and hopelessness. On average, someone with bipolar disorder may have up to three years of normal mood between episodes of mania or depression. Bipolar disorder is recurrent, meaning that more than 90% of the individuals who have a single manic episode will go on to experience future episodes. Roughly 70% of manic episodes in bipolar disorder occur immediately before or after a depressive episode. Treatment seeks to reduce the feelings of mania and depression associated with the disorder, and restore balance to the persons mood. Those with bipolar disorder often describe their experience as being on an emotional roller coaster. Cycling up and down between strong emotions can keep a person from having
Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features
2011
anything approaching a normal life. The emotions, thoughts and behavior of a person with bipolar disorder are often experienced as beyond ones control. Friends, co-workers and family may sometimes intervene to try and help protect their interests and health. This makes the condition exhausting not only for the sufferer, but for those in contact with her or him as well. Bipolar cycling can either be rapid, or more slowly over time. Those who experience rapid cycling can go between depression and mania as often as a few times a week (some even cycle within the same day). Most people with bipolar disorder are of the slow cycling type they experience long periods of being up (high or manic phase) and of being down (low or depressive phase). Researchers do not yet understand why some people cycle more quickly than others.
Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features OBJECTIVES
2011
General Objective The main goal of the group is to be able to present the case study of our chosen client that would provide a comprehensive discussion of the pathological mechanism of the disease to yield significant information for the case study.
Specific Objectives In order to meet the general objective, the group aims to: - Establish rapport to the patient - Interpret the pertinent data gathered from the patient and her significant others, - State past and present health history of the patient, - Trace the family Genogram - Present the Mental Status Exam obtained from the patient, - Identify the Factors affecting the current condition of the patient - Discuss the nature of the drugs given to the patient, - Present a specific, measurable, attainable, realistic and time-bound nursing care plans for the client, - Justify the clients prognosis according to the different criteria,
Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features DEMOGRAPHIC PROFILE
2011
Name: Chai Age: 23 Nationality: Filipino Birth date: November 05, 1987 Birth Place: Davao City
Address: Bagobo vill. Calinan (Pob.) Davao city Religion: Catholic Ward/Room/Bed/Service number: CIU/Psychiatry Date of Admission: October 28, 2011 Time: 7:30pm Total number of days: 41 days Admitting physician: Al-Raymond D. Tupas, MD Type of Admission: Old Address of informant: Bagobo vill. Calinan (Pob.) Davao city Admission diagnosis: Bipolar I, Manic Phase with psychotic features Source of Information: Patient herself, Patients Family and the Neighboors
Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features GENOGRAM Maternal Side
Lola L Lolo B [x] Nephew [+] like Chai
2011
Paternal Side
Lolo M [x] Lolo D [x]
Beb
Ner & Nit
Mommy V [+] *
MJ
Rau [+]
Jun
Jer
Eli
Marce [+]
Mr T
Rey
Ton
Tin
Tom
Tere
Chai [+]
Bro V [+]
Interpretation of the Genogram: Legend: Both sides of Chai have mental disorders and as mentioned during the interview her brother also has the same condition and it is clear, that genetics plays a big part in her condition
[x] Deceased [+] Positive with Mental Disorder * Goiter Patient FEMALE MALE

FAMILY HISTORY
2011
Both parties of Chai has a history of mental disorder, Chais mother actually has a mental disorder, Mommy V had been admitted to DMH before but now she resides in their residence due to lack of financial factors, because the family cant support both mother and daughter to be admitted at the same time, for at that time the family suffered financial crisis which led them to sell their lot near Lola L, as mentioned by Lola L her Husband Lolo B also had a nephew which posses the same condition as Chai, apart from that Bro V, Chais Brother was previously admitted to DMH because of Substance Abuse, specifically Katchubong.

Informant: Mr. T
2011
Relationship to the client: Father
Address: Bagobo Village Poblacion Calinan, Davao City Length of time know the Client: Since Birth Apparent understanding of present illness of the patient: According to Mr. T, his daughter is a friendly, sweet and a loving daughter though sometimes can be sensitive and moody especially when she is under her mood disorders. Since from that time she had the bicycle accident when chai was 16 years old, after that his daughters attitude had changed. Chai became stubborn, loves to be with friends for outings and be back at home for 3 days or a week later, had difficulties in studying her lessons, and at home her daughter is fond of listening to loud music and sometimes screaming and shouting. There are also times that Chai made a scene in a resort that scandalous in public. Sometimes when her disorder arises, she is violent towards her mother, hurting her mother physically and emotionally. These factors led to Mr. Ts decision to admit her daughter Davao Mental Hospital. Upon interview, Mr. T told us that it is not the 1st time that Chai is admitted to the said institution but it is the 6th times of bringing his daughter in DMH for the said reasons above. He also added that his daughter got depressed from the time that Chai and Mr. N broke up. Because of this, his daughter attempted to commit suicide once. He also expressed that he is aware of what happened to Chai for there is a history of mental disorder to both of familial sides. He added, Even my wife is mentally disturbed Hes also responsible for enforcing discipline in his children and took good care of them especially Chai.

Informant: Mommy V
2011
Relationship to client: Mother
Address: Bagobo village calinan Davao city Length of time known the client: Since birth Apparent understanding of present illness of the patient: According to the mother of Chai her daughter has a problem with her brain, everything is good and normal during her pregnancy although there was no regular prenatal checkup, She mentioned during that during her pregnancy with chai her husband at that time gave her carbazspam without her husbands knowledge that she was already pregnant. During chais child hood stages she was a normal, happy, intelligent kid she earned honors and have good grades and later on her high school stage awarded batang pinoy awardee for athletics. Her peer time before wasnt that bona fide , gradually things got worst on her peer, actions, manners in relation to her family, she have been places like bars (hubo-hubo), beach resorts , have done prostitution and drugs.Regular guidance and advices where given to her by both mother and father regarding to mother chai, sad to say it didnt made or have an effect on chai. She also mentioned that chai have an accident that resulted to head trauma, her mother repeatedly emphasized that it was the reason why chai have mental problems and in addition chai has peer problems with alcoholic and drug problems. Also mentioned chais love affairs and her live in partner, she also mentioned chai likes to have pen pals in fact she has a pen pal named Mr. A who just got out of jail, chai has censorious habits regarding her health, she doesnt sleep well, eat properly, and has a very poor hygiene this started when she began showing signs of mental problems. Description of informant: Mommy V has present mental problems as we research further, although she is very cooperative her answers sometimes goes out of topic and her statement goes around in circle in addition she insert topics not related to what we previously are talking, the first site of us students she is already weary of what are our intensions.
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Informant: Lola L. Address: Mandaguit Compound
2011
Relationship to patient: Grandmother Length of time known the client: Since birth She is the grandmother of Chai in the mother side. She had 8 children and now is widowed. She stayed in her house with her daughter. According to her, chai was a very loving, sweet granddaughter, and a funny girl. And she states that Ms. Chai was close to her father than to her mother. Based on the statement that we gathered from the informant Ms.Chai stayed in to their house when she was in high school.she is very studious,but when she had an accident.Ms.chai told her grandmother as quoted If mag study daw siya di nadaw musulod sa ulo iya gi studyhanAccording to Lola L.Ms.Chai was very friendly and love to hang out with her friends. She also stayed that that ms.Chai had an accident,and she told as that after an accident ms.Chai started to change her attitude, at that time Lola noticed that Ms.Chai was very vulgar to her words and became violent. We asked Lola if they had a history of mental illnesses to their family and she stated that only virgie was the one who had the problem, and she quote that murag nabughat man gud to si Virgie maong nabuang- buang, but she mentioned that in her husbands side there is a history of mental disorder. But upon our interviewed to Lola L, we noticed that she is a little bit doubtful to us and she only stated few words as we explained to her our purpose but still there is a boundary between both parties.

Informant: Mr.& Mrs. Neighbor Relationship to the patient: Neighbor Length of time known to patient: since birth/26 years. Address: Mandaguit Compound
2011
Based in our survey, we have talked on their long time neighbor since the time that Chais parents are not yet married. Chai is a friendly person, shy and she never do anything that can harm to anyone. During 4th year high school,16 years of age, Chai started to get drunk and she often went out with her friends and will go home home after 3 days. After she graduated in high school, she applied as a sales lady in Tiwak store in Calinan but it only last for a week. She was been very stubborn daughter since the time that she is mentally ill. Taking considerations only to her decisions and not listening what her parents are trying to say to her. Her mother has mental disorder also. Her father is the one who supports and took care of them. He has his own pedicab started from year 2000 and sold it out last 2008 to support the condition of his daughter. She graduated in Terzo Elem.School in Calinan Davao City and also she is finished in Virgie High school. Continue to a vocational course of school in Tesda-Wangan 1st yearr college. Chais family was not financially stable for they sold out their properties just to sustain the maintenance needed for her medication.
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Religious and Social Adaptability
2011
In the community, Chai is friendly, talkative and hyperactive especially when she is happy. According to her, she had a group of friends during high school named F4 and they were famous in school. Though she is the only girl in the group but they are close to one another for they share common interests because Chai has a boyish-like type of personality. She likes going out with her peers. Whenever she goes to church, she wants to be with her friends also, however, she does it often. Chai admits to researchers that she attempted to commit suicide when she is on her depressed state but she never thought of committing homicide for she knows that killing is a sin. Environmental Status Last December 10, 2011, we conducted our survey in their place at Bagobo Village Poblacion Calinan, Davao City. Based on our observation, the place where they lived is a rural slum area because the houses are very near to each other. Some people living there are quite mentally challenged according to Chai and seconded by her father. Psychosocial History Chai started studying at 6 years old, she is very friendly, talented, athletic and an honor student. According to her she is very close to her teachers and she havent encounter any trouble in her school. She attended her class regularly and she spent more time on her lessons and homework but since the time that she experienced a bicycle accident when she was 16 years old, she has difficulty on her studies, however she still passed all her subjects. At the age of 14 her menarche started, and according to her it is regular and last for 7 days.
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Marital History
2011
Chai started having a relationship at the age of 14,According to her she has multiple relationship, but inform us more about Mr.N and guy E.Mr.N was her second boyfriend, and he is the one who took her virginity.She also shared to us that Mr.N is having a relationship now the other girl,and she really feels sad and depressed when Mr.N leaved her.After that incidence she started to go with her friends if they invite chai to joined their hang out, and chais back to her home after 3 days or a week. Chai also mentioned that she has a relationship with Mr.A now,,who is currently her penpal,,but currently on a jail ,and based on her mothers statement that guy is still in a jail now,with a case of substance abuse. She also states that she was one pregnant for she was delayed her menstrual period but her father denied it.
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STI College-Davao J.P. Laurel Ave., Davao City
2011
MENTAL STATUS EXAM FORM

PATIENT S NAME: CHAI AGE: 23 y.o. SEX: Female CIVIL STATUS: Single EXAMINED BY: Francis Peter Lahora, SN
DATE OF EXAMINATION: December 08, 2011 I. PRESENTATION
A. GENERAL APPEARANCE: Patient was awake and ambulatory, wore dark blue jersey s, also wearing a blue bandana, well groomed and [-] Audio/Visual Hallucination, Non-Hostile B. GENERAL MOBILITY y y Posture & Gait Activity ( ) Normal ( ) Normoactive ( ) Hyperactive Facial Expression ( ) Smiling ( ) Angry ( ) Tearful ( ) Frightened C. BEHAVIOR: Appropriate II. STREAM OF TALK A. CHARACTER OF TALK ( ) Spontaneous ( ) Deliberate ( ) Irrelevant ( ) Tangential ( ) Flight of Ideas ( ) Circumstantial ( ) Others 13 ( ) Appropriate ( ) Psychomotor ( ) Agitated ( ) Worried ( ) Ecstatic ( ) Suspicious ( ) Distant ( ) Sad ( ) Tense ( ) Happy ( ) Inappropriate
B. ORGANIZATION OF TALK ( ) Relevant ( ) Incoherent
( ) Looseness of Association

C. ACCESSIBILITY ( ) Good ( ) Mute ( ) Defensive III. EMOTIONAL STATE AND REACTION A. MOOD ( ) Euthymic ( ) Elated B. AFFECT ( ) Appropriate ( ) Hostile ( ) Histrionic C. DEPERSONALIZATION AND DEREALIZATION D. SUICIDAL ATTTEMP E. IV. HOMICIDAL ATTEMP ( ) Present ( ) Present ( ) Present ( ) Depressed ( ) Others ( ) Flat ( ) Inappropriate ( ) Blunted ( ) Labile ( ) Euphoric ( ) Fair ( ) Self-Absorbed ( ) Poor
2011
( ) Inaccessible
( ) Absent ( ) Absent ( ) Absent
CONTROL OF THOUGHT A. PERCEPTIONS ( ) Present Type:___________________________ B. C. DELUSIONS IDEAS PREFERENCE ( ) Present ( ) Present ( ) Present ( ) Present ( ) Absent ( ) Absent ( ) Absent ( ) Absent ( ) Absent
D. PREOCCUPATION AND RUMINATION E. DJ VU AND JAMAIS VU VII. NEUROVEGETATIVE DYSFUNCTION A. SLEEP ( ) Normal
( ) Hypersomnia
( ) Late Insomnia
( ) Mixed Insomnia B. APPETITE C. Weight D. Diurnal Variation :8 hrs 14 ( ) Normal ( ) Increased ( ) Increased ( ) Decreased
( ) Decreased

E. Libido: ________________________________________ F. Attention Span: VIII. ( ) Good ( ) Fair ( ) Poor
2011
GENERAL SENSORIUM AND INTELLECTUAL STATUS A. ORIENTATION: TIME PLACE PERSON SITUATION B. MEMORY IMMEDIATE RECENT REMOTE ( ) Unimpaired ( ) Unimpaired ( ) Unimpaired ( ) Impaired ( ) Impaired ( ) Impaired ( ) Unimpaired ( ) Unimpaired ( ) Unimpaired ( ) Unimpaired ( ) Impaired ( ) Impaired ( ) Impaired ( ) Impaired
C. CALCULATIONS Progressive subtraction of 9 s from 100 ( ) Good D. GENERAL THINKING ABILITY E. ABSTRACT THINKING ABILITY ( ) Unimpaired ( ) Unimpaired ( ) Fair ( ) Impaired ( ) Impaired ( ) Impaired ( ) Poor
F. JUDGMENTAL AND REASONING ( ) Unimpaired XI. INSIGHT ( ) Unimpaired ( ) Impaired
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X. SUMMARY OF MENTAL STATUS EXAM
2011
A. Disturbance in ( ) Mood and Affect ( ) Stream of Talk ( ( ) Neurovegetative Dysfunction ( ) General Sensorium and Intellectual status
) Emotional State and Reaction ( ) Insight ( ) Positive signs of organicity
( ) Thought control B. DIAGNOSTIC CATEGORY ( ) Functional ( ) Organic
( ) Psychic ( ) Non-Psychic
( ) Both functional and Organic C. DSM-IV DIAGNOSIS Axis I: Bipolar I Manic Phase with Psychotic Features Axis II: _____________________________________ Axis III: ____________________________________ Axis IV: ____________________________________ Axis V: _____________________________________
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STI College-Davao J.P. Laurel Ave., Davao City
2011
MENTAL STATUS EXAM FORM

PATIENT S NAME: CHAI AGE: 23 y.o. SEX: Female CIVIL STATUS: Single EXAMINED BY: Francis Peter Lahora, SN
DATE OF EXAMINATION: December 13, 2011 V. PRESENTATION
D. GENERAL APPEARANCE: Patient was awake and ambulatory, wearing patients dress, also wearing a blue bandana, fairly groomed and [-] Audio/Visual Hallucination, Non-Hostile E. GENERAL MOBILITY y y Posture & Gait Activity ( ) Normal ( ) Normoactive ( ) Hyperactive Facial Expression ( ) Smiling ( ) Angry ( ) Tearful ( ) Frightened F. BEHAVIOR: Appropriate VI. STREAM OF TALK D. CHARACTER OF TALK ( ) Spontaneous ( ) Deliberate ( ) Irrelevant ( ) Tangential ( ) Flight of Ideas ( ) Circumstantial ( ) Others 17 ( ) Appropriate ( ) Psychomotor ( ) Agitated ( ) Worried ( ) Ecstatic ( ) Suspicious ( ) Distant ( ) Sad ( ) Tense ( ) Happy ( ) Inappropriate
E. ORGANIZATION OF TALK ( ) Relevant ( ) Incoherent
( ) Looseness of Association

F. ACCESSIBILITY ( ) Good ( ) Mute ( ) Defensive VII. EMOTIONAL STATE AND REACTION F. MOOD ( ) Euthymic ( ) Elated G. AFFECT ( ) Appropriate ( ) Hostile ( ) Histrionic H. DEPERSONALIZATION AND DEREALIZATION I. J. VIII. SUICIDAL ATTTEMP HOMICIDAL ATTEMP ( ) Present ( ) Present ( ) Present ( ) Depressed ( ) Others ( ) Flat ( ) Inappropriate ( ) Blunted ( ) Labile ( ) Euphoric ( ) Fair ( ) Self-Absorbed ( ) Poor
2011
( ) Inaccessible
( ) Absent ( ) Absent ( ) Absent
CONTROL OF THOUGHT F. PERCEPTIONS ( ) Present Type:___________________________ G. DELUSIONS H. I. J. IDEAS PREFERENCE PREOCCUPATION AND RUMINATION DJ VU AND JAMAIS VU ( ) Present ( ) Present ( ) Present ( ) Present ( ) Absent ( ) Absent ( ) Absent ( ) Absent ( ) Absent
VII.
NEUROVEGETATIVE DYSFUNCTION G. SLEEP ( ) Normal ( ) Hypersomnia ( ) Late Insomnia
( ) Mixed Insomnia H. APPETITE I. J. Weight Diurnal Variation :6 hrs 18 ( ) Normal ( ) Increased ( ) Increased ( ) Decreased
( ) Decreased

K. Libido: ________________________________________ L. Attention Span: VIII. ( ) Good ( ) Fair ( ) Poor
2011
GENERAL SENSORIUM AND INTELLECTUAL STATUS G. ORIENTATION: TIME PLACE PERSON SITUATION H. MEMORY IMMEDIATE RECENT REMOTE ( ) Unimpaired ( ) Unimpaired ( ) Unimpaired ( ) Impaired ( ) Impaired ( ) Impaired ( ) Unimpaired ( ) Unimpaired ( ) Unimpaired ( ) Unimpaired ( ) Impaired ( ) Impaired ( ) Impaired ( ) Impaired
I.
CALCULATIONS Progressive subtraction of 9 s from 100 ( ) Good ( ) Fair ( ) Impaired ( ) Impaired ( ) Impaired ( ) Poor
J.
GENERAL THINKING ABILITY
( ) Unimpaired ( ) Unimpaired
K. ABSTRACT THINKING ABILITY
L. JUDGMENTAL AND REASONING ( ) Unimpaired
XI.
INSIGHT
( ) Unimpaired
( ) Impaired
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2011
X.
SUMMARY OF MENTAL STATUS EXAM
D. Disturbance in ( ) Mood and Affect ( ) Stream of Talk ( ( ) Neurovegetative Dysfunction ( ) General Sensorium and Intellectual status
) Emotional State and Reaction ( ) Insight ( ) Positive signs of organicity
( ) Thought control E. DIAGNOSTIC CATEGORY ( ) Functional ( ) Organic
( ) Psychic ( ) Non-Psychic
( ) Both functional and Organic F. DSM-IV DIAGNOSIS Axis I: Bipolar I Manic Phase with Psychotic Features Axis II: _____________________________________ Axis III: ____________________________________ Axis IV: ____________________________________ Axis V: _____________________________________
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Doctors Order 10/28/11 y y y y Please admit pt. CIV with watcher DAT Vital sign Q4 Medication Haloperidol 500mg Flupentixol 200mg Chlorpromazine 200mg 1 tab BID Lithium Carbonate 450g/tab 1 BID Biperiden HCL mg 1 tab BID 4 point restrain Homicidal/ Suicidal escape precaution. 10/29/11 y Carbamazepine 200mg 1 tab TID Nurses Progress Notes 10/28/11 y y y Awake, fairly ground Restless, always singing Good eye contact
2011
10/29/11 y y y Awake, fairly ground Restless, always singing Good sleep and appetite
10/30/11 y y y Awake, fairly ground Conversant, good eye contact Good sleep and appetite
11/01/11 y y y y y Good appetite Poor sleep Fairly groomed Conversant and good eye contact Hostile Episodes
10/30/11 y Continue meds.
11/02/11 y y y Awake conversant Good eye contact Fairly groomed
10/31/11 y y y Diphenhydromine 500g Haloperidol Cynithamine
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11/01/11 y Continue Meds. y y Always singing Hostile Episodes
2011
11/02/11 y Continue Meds.
11/03/11 y y y y Awake conversant Good eye contact Hostile Episodes Still poor sleep and always singing
11/03/11 y y Continue Meds. Hold carbomasepine
11/04/11 y y y y Awake Poor sleep Poor appetite Hostile Episodes
11/05/11 y Awake conscious, alert very much talkative y y y y Good sleep Poor appetite Fairly groomed Good eye contact
11/08/11 y y Continue Meds. Still for Flupentixol
11/09/11 y y Continue Meds. 4 points restrain
11/06/11 y y Awake, conscious alert Very much talkative(always shouting)
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11/11/11 y Continue Meds. y y y y y (-)Hallucination Good sleep Good appetite Fairly groomed Good eye contact
2011
11/12/11 y y Continue Meds. For hair cutting
11/13/11 y Continue Meds
11/07/11 y y y y Good sleep Conscious Talkative Fairly groomed
11/08/11 y y y y Good sleep Talkative Oriented to time and place Fairly groomed
11/17/11 y Carbamazepine 200mg BID
11/09/11 y y y y Good sleeping Still very much talkative Good appetite Fairly groomed
11/10/11 y y Poorly Groomed Poor appetite
11/22/11
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y Chlorpromazine 200mg 1 tab OD 2 tabs HS y Continue Meds. y y y With 4 point restriction Talkative Not cooperative
2011
11/11/11 y y y y Asleep (+) hostile episodes are claimed Poor sleep and appetite Good compliance to meds
11/12/11 y y Asleep, good appetite No hostile consider are claimed
11/13/11 y y y Awake, responsive Good sleep, good appetite No hostile episodes as claimed
11/14/11 y y y Awake Talkative Hyperactive
12/01/11 y y Preg.test Continue Meds.
11/15/11 y y y Awake Good eye contact Talkative ( speak a lot of English )
12/02/11
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y Continue Meds. y y (-) hostile
2011
12/03/11 y y Continue Meds. ff.up pregnancy test
Reported by father to keep walking up at night and sleep
Strict 4 point restrain
11/16/11 y y y y Awake, good eye contact Wearing her bra Less talkative Better sleep
12/05/11 y y Continue Meds. Hold pregnancy test
11/17/11 12/06/11 y Continue Meds. y y y Asleep Poor sleep Hostile episode w/ another patient
11/18/11 y y y Lethargic Still played w/ water earlier Was able get herself free and roam around gathering flowers y (-) hostile
12/13/11 y Continue meds.
12/15/11 1:20pm y Transfer from CIU, transfer per ambulatory, accompanied by NOD, VS checked and recorded. Transferred to masikap ward. ENDORSED.
11/19/11 y y y Asleep Still plays with water sometimes Was able to roam the grounds
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lastnight y (-) hostile episodes
2011
11/20/11 y Looks sleepy but she reported murag akong mata katulugon pero ako utok dili y Kept walking around and playing with water last night y (-) hostile episodes
11/21/11 y y Awake, angry looking Father reported she tried to escape by attempting to climb the wall 11/22/11 y y Lethargic Denied trying to escape
11/23/11 y y y y y Lethargic Eating Less talkative Poor eye contact Claimed had long sleep
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11/24/11 y y y y y y Awake Good eye contact
2011
Oriented to person, time and place Talkative (-) AV hallucination (-) hostile
11/25/11 y y y Awake Good eye contact Good appetite
11/26/11 y y y y y y Lethargic Good eye contact Oriented to time, place and person Good attention Good appetite (-) hostile
11/27/11 y y y y Awake Good eye contact Oriented to time place and person Good attention
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y y Good appetite (-) hostile episode
2011
11/28/11 y y y y Awake Good eye contact Good appetite (-) hostile
11/29/11 y y y y y Awake Good sleep and appetite Oriented to time, place and person Poor eye contact (-) hostile
11/30/11 y y y y Asleep but woke up later Good eye contact Oriented to time, place and person Good affect and congruent
12/01/11 y y y y Awake Conversant with good eye contact Good sleep Good appetite
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12/02/11 y y y y y Awake
2011
Conversant with good eye contact Good sleep Good appetite Mood affect
12/04/11 y y y y y y Awake Conversant with good eye contact Good sleep Good appetite Good compliance to meds. (-) AV hallucination
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y y Good compliance to meds. (-) AV hallucination
2011
12/06/11 y y y y y y y y Conversant with good eye contact Enough sleep Good appetite Good compliance to meds. (-) AV hallucination Non hostile Well groomed Euphoric mood with appropriate affect 12/07/11 y y y y y y y y Awake Well groomed Conversant with good eye contact Good sleep Good appetite Good compliance to meds. (-) AV hallucination Non-hostile
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12/08/11 y y y y y y y Awake
2011
Conversant with good eye contact Good sleep Good appetite Good compliance to meds. (-) AV hallucination Non-hostile
12/13/11 y y y y y y Awake, alert, conversant Good appetite Good sleep (-) AV hallucinations Good compliance to meds. Non-hostile
12/14/11 y y y y y Pt. found asleep, drowsy Poor sleep Poor appetite (-) AV hallucinations Non-hostile
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12/15/11 y Prior to be placed with Masikap patient being searched for any objects and removed. y
2011
Grooming was checked patient was instructed not t0o harm herself and others.
Provide the important for good grooming and in taking the medications regularly.
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Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features Psychodynamics
PREDISPOSING FACTOR PRESENT Rationale
2011
genetic/Hereditary
Both sides chais parentshave a family history her mother was admitted before at DMH Her uncle (mother side is also mentally ill. Chais Aunt (fathers side has mentally disease after giving birth when the time that her husband leaved her.
Hereditary plays a major role in the etiology of the disease. :according to statistics that if a member in the family has a mental disorder then other member of familial lineage are most likely to have a disorder about 50%-70%(National Institute of Mental Health 2005,shives 2008)
Gender
Female
Studies shows that 6.5% of women suffers from major depression disorder than in man(3.3%) (NIMH,2005 &NARSAD,2005)
Age
The onset of the 4 signs & symptoms of bipolar 1 disorder to chais is at the age of 16.
Most common to adolescents.and onsent of bipolar 1 disorder ranges from age 18-20(basis concepts of PsychiatricMental)
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Biochemical Chai has an attitude of being moody there are laso times that she is sexually pre occupied
2011
Bogenic amines or chemical compounds known as the Norepineprhine & serotonin have been shown to regulate mood & to control drive such as hunger, sex and thirst. Increase amounts of these neurotransmitters at receptors site & in the brain cause an elevated in the mood where as decreased amounts can lead to depression(sadock& sadock,2003)
Precipitating Factors Life Events Chai had a bicycle accident which results to head injury when she was 16 years old at Mount. Apo resort. During this age she also experienced her first sexual affair with Mr.N which lead her to too much depression after the guy broke up with her. Complex etiology based on interacting contributions from life events the environment may ultimately result in clinical symptoms of depression. Dramatic changes in ones life can trigger depressive episodes.
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Financial Chais family experiences financial crisis due to her condition plus her mother and brothers situation,her father couldnt sustain all that they need especially now that her father is jobless.
2011
Financial aspects really affect a persons life for it provides the basic needs of people. Lack of sustainability to it can lead to the onset of problem.
Environmental & Peers
They lived in a rural slum area. Some people living in that area are also experiencing mental problems according to Chai & her father.
Environment & Peers contribute much influence in ones own perception towards things that might be helpful or not to her personal growth and development.
Her peers have a big influenced to Chai because of them, she involves in using the prohibited drugs once according to chai. Because of them, she involves in using the prohibited drugs but only once according to chai.
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Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features SCHEMATIC PRESENTATION
Prenatal
2011
IDEAL: The mother should comply with monthly and weekly (at 9 months AOG) check up, the mother should deliver the baby at the hospital to ensure safety and wellness of the mother and the neonate.
ACTUAL: The mother was not able to comply, she only does her check up seldom, and gave birth with an aide from her neighbor at home
ORAL Stage: 0-1 year old IDEAL: the infant's primary source of interaction occurs through the mouth, so the rooting and sucking reflex is especially important. The mouth is vital for eating, and the infant derives pleasure from oral stimulation through gratifying activities such as tasting and sucking. Because the infant is entirely dependent upon caretakers (who are responsible for feeding the child), the infant also develops a sense of trust and comfort through this oral stimulation.
ACTUAL: Chai was breastfed until she was 1 year and 4 months old, at the same time she was also fed with cerelac, Chai also sleeps in side lying position, she also was under the care of both parents, Chai had her first teeth to erupt when she was 1 year old and at the same time also was her first time to walk and talk short words.
ANAL Stage: 1-3 years old IDEAL: During the anal stage, Freud believed that the primary focus of the libido was on controlling bladder and bowel movements. The major conflict at this stage is toilet training--the child has to learn to control his or her bodily needs. Developing this control leads to a sense of accomplishment and independence.
36
2011
According to Freud, success at this stage is dependent upon the way in which parents approach toilet training. Parents who utilize praise and rewards for using the toilet at the appropriate time encourage positive outcomes and help children feel capable and productive. Freud believed that positive experiences during this stage served as the basis for people to become competent, productive and creative adults.
ACTUAL: From 1-2 years of age she had a history of enuresis, luckily she had no childhood history of diseases.
PHALLIC Stage: 3-6 years old IDEAL: During the phallic stage, the primary focus of the libido is on the genitals. At this age, children also begin to discover the differences between males and females. Freud also believed that boys begin to view their fathers as a rival for the mothers affections. The Oedipus complex describes these feelings of wanting to possess the mother and the desire to replace the father. However, the child also fears that he will be punished by the father for these feelings, a fear Freud termed castration anxiety. The term Electra complex has been used to described a similar set of feelings experienced by young girls. Freud, however, believed that girls instead experience penis envy.
ACTUAL: Chai and V are close to their father, because their father was the only person left at their home. While their mother was admitted @ DMH.
LATENT Period: 6-Puberty IDEAL: During the latent period, the libido interests are suppressed. The development of the ego and superego contribute to this period of calm. The stage begins around the time that children enter into school and become more concerned with peer relationships, hobbies and other interests.
37
2011
The latent period is a time of exploration in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence.
ACTUAL: Chais first menstruation period was when she was 14 years old, it is regular as mentioned by her and also quoted that it would last for 7 days, she then elaborated to us how she lost her virginity when she was still 16 years old, a few more discussions passed she mentioned to have multiple relationships
GENITAL Stage: Puberty to death IDEAL: the individual develops a strong sexual interest in the opposite sex. This stage begins during puberty but last throughout the rest of a person's life.
Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas.
ACTUAL: Chai mentioned to us that after all she experienced, she will be focusing on her current long distance relationship with a pen pal,
38

Onset of illness
2011
Chai had 6 admissions including her present condition in the SPMC Psychiatric Department. The patient was observed to be restless, doesnt sleep well and have a poor appetite. There are times that Chai goes out with her friends and comes back home 3 days after or maybe a week later. There was a time when she argued with her father and intentionally hurts her mother, at that point her father decided to Re-Admit Chai back to the Institution.
Present Illness Patients condition recurred 1 week prior to admission and patient was noted to tell funny things (Nagpakatok), she would try to undress and sleep on the banig outside the sand. People come around her because of her behavior. Was restless and had difficulty in maintaining her sleep. She would come home late, would only sleep for about an hour and would leave their house again. Persistence of the above signs and symptoms prompted this.
Past Illness Previous admission in SPMC Psychiatric Department due to some condition
Personal: Uncooperative
39

Generic name C H L O R P R O M A Z I N E Brand name Classification Dopamenergic blocking drug Antipsychotic Dosage 200 mg BiD Mechanism of Action Antipsychotic drugs block postsynaptic dopamine receptors in the brain;depres s those parts of the brain involved with wakefulness and emesis; Indication Contraindication
2011
Adverse effect CNS; drowsiness. insomnia, excerbation of psychotic symptoms. GI;dry mouth, salivation. nausea Nursing intervention Do not change brand names of oral dosage. Protect oral concentrate from lights. Avoid skin contact with oral concentrates and parenteral drugs solutions due to to possible contact dermatitis. Patient or guardian should be advised about a possibility of tardive dyskinesias.
Management Contraindicated of with allergy to manifestation chlorpromazine, of psychotic disorders; control of manic phase of manic depressive illness. Therapy for combativeness hyperactivity
40

Generic name L I T H I U M C A R B O N A T E Brand name Classification Dosage Mechanism of action Alters sodium transport in nerve and muscle cells,inhibits release of norepineprine and dopamine,but not serotonin,from stimulated neurons,slightly increases intraneuronal content of second messenger ang may thereby selectively modulate the responsiveness of hyperactive neurons that might contribute to the manic person. Indication Contraindication
2011
Adverse effect Reactions are related to serum lithium levels (toxic lithium levels are close to therapeutic levels) Weight gain ,eye irritation Nursing intervention Give with caution and daily monitoring of serum lithium levels to the patients with life threatening psychiatric disorders. Decrease dosage after the acute manic episode is controlled;lithium tolerance is greater during the acute manic,phase and decreased when manic symptoms subside Increase fluid intake.
Anti-manic drug
450 mg tab
Treatment of manic episodes of manic depressive illness; maintainance therapy to prevent or diminish frequency and intensity of subsequent manic episodes.
Use cautiously with protracted sweating and diarrhea; suicidal or impulsive patients; infection with fever,
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Cues Subjective/objective Nursing Diagnosis Nsg.Background Planning Nsg.intervention
2011
Rationale Evaluation
Katulogon ko pero nagadagan akong hunahuna
Disturbed sleep Pattern related to Psychological
Time limited disruption of sleep (natural periodic suspension of conscious) amount and quality
Within 1hour span of care the patient will be able to : Report improvement in sleep/rest pattern. Verbalize increase sense of well being and
>Established rapport
>to gain trust and cooperation
Within 1hour span of care patient able to:
>Hyperactivity >Restlessness >wakes up 4am in the morning >sleep discomfort >poor sleep >drowsy noted
stress
>Ascertain usual sleep habits and changes that are occurring
>to determines need for action and helps identify appropriate intervention >Increase
Reported of improvement in sleep pattern Verbalized increase of well being and feeling rested
>Provide comfortable
comfort for sleep as well as physiologic support
feeling rested bedding
42
2011
>Helps to
>Instruct in relaxation measures
induce sleep
>to provide >Reduce noise and light conducive to sleep
>Restrict intake of caffeine containing foods/ fluids >Promote bedtime comfort regime >Established new sleep routine in cooperating old pattern and new environment
>Caffeine may delay patient falling asleep
>promotes a relaxing effect
>when new routine
43
2011
contains as many aspects of old habits as possible stress and related anxiety
>encourage position of comfort
maybe reduced
>Repositioning alters areas of pressures and promotes
44

Cues Nursing Diagnosis Naka try naman ko ug hikog sa CR pero wala ko namatay as verbalized by the patient. Risk for selfdirected and other directed violence r/t Psychological distress. Acknowledge realities of the Seeking to be alone. Poorly groomed. Had poor sleep. Inappropriate response asked. when (At risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally or sexually harmful to self.) situation. Verbalize understanding of why occurs. Demonstrate self-control evidenced as by Help client identify more appropriate solutions/beha behavior Within two weeks span of care, our patient will be able to: Develop therapeutic nurse-client relationship, provide consistent caregiver when possible. Maintain straightforward communicatio n. Objective Interventions
2011
Rationale Evaluation
Promote sense of trust, allowing client to discuss feelings openly.
Seemed to be cooperative during actual interview. No physical harm and injury happened throughout the
To avoid reinforcing manipulative communication . To lessen sense of anxiety and associated
interview.
relaxed posture, non behavior. violent
45

vior.
2011
physical manifestations.
Be truthful when giving information and dealing with client.
Build trust, enhancing therapeutic relationship.
Give positive reinforcement for clients effort.
Encourages continuation of desired behaviors.
Ask directly if the person is thinking of acting on thoughts/feelin gs.
To determine violent intent.
46

PROGNOSIS Criteria for Prognosis Good 3 Fair 2 Poor 1
2011
Justification
She doesn t belong 1.) Onset of Illness to the age bracket of onset of bipolar discover which is 18 years in men and 20 years in women, on the other hand her mental illness was also triggered by her head injury. She was admitted at 2.) Duration of Illness Davao Mental Hospital 6 times already. She has sad 3.) Precipitating Factors depressing experiences that made her think she is a failure and can t do things for her to succeed. For example love and relationship in addition they have
47

a very poor socioeconomic level.
2011
During the course of 4.) Mood and Affect our interview patient suddenly cried and minutes later she laugh. She is willing to 5.) Attitude/ willingness to treat medication take Medication but they have difficulty to comply medication because of the financial aspects.
Her family was 6.) Family support exhausted of her condition due to lack of financial aspects
COMPUTATION: 0-6 = Poor 8-13 = Fair 14-18 = Good
ANALYSIS: Based on the result, the patient got 9 out of 18% rates, equivalent to a Fair prognosis. One factor that contributes most is the genetic influence since her mother have history of mental illnesses 48

Recommendations CLIENT Encourage to have her proper hygiene. Encourage to minimize negative mannerisms like offensive jokes and gestures. Encourage to do recreational activities such as having regular exercise. Encourage to write down her feelings just in case she has trouble in expressing it. Instruct her to have enough rest and sleep. Provide safe environment for client and others.
2011
FAMILY Encourage the family to listen attentively and respectfully to what the client talks about. Understand her mood disorder and make her feel that shes not rejected. Increase emotional, physical,financial and spiritual support for the client.
COMMUNITY Provide understanding to the community by the patients disorder and make her feel that shes not rejected. Refrain from discriminating a person like her who has mood disorder. Support the client so that she may easily cope up with her present condition by letting her join in community activities.
49
2011
Evaluation
Chai doctor already gave the order for the transfer of Chai into the masikap ward, during the nurse patient interaction signs problem was already present, she has no limits on what information she gave us and she goes out of the topic most of the time, these are times that she was seen on her under wave only, She began to play physical jokes on her fellow patient, until this very day she began walking around naked, shouts loudly and spits on the nurse the economic status gradually went down nearing the point at being broke because her father is now jobless and their tricycle was forced to be sold because of badly needed cash.
50
2011
Summary
Chai was diagnose with Bipolar 1 Manic Phase with Psychotic feature, she manifest major depression, restlessness this manifestation of order belongs to axis 1 she was diagnosed with bipolar1 because her brother and mother has history of mental illness. Aside from this predisposition she went on countless trial, failures and heartbreak which led to her depression. We realized that family support is very kind crucial at this point of time with this of mental problems because her emotional and psychological stability is very low, despite of this condition her family has high hopes and very supportive to Chai. Our results is fair prognosis for the reason that this disorder was still present and the family has difficulty finding financial support for Chai medication
51

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Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features INTRODUCTION

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

Ner & Nit

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

Relationship to the client: Father

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

Relationship to client: Mother

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

MENTAL STATUS EXAM FORM

DATE OF EXAMINATION: December 08, 2011 I. PRESENTATION

B. ORGANIZATION OF TALK ( ) Relevant ( ) Incoherent

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

( ) Absent ( ) Absent ( ) Absent

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

F. JUDGMENTAL AND REASONING ( ) Unimpaired XI. INSIGHT ( ) Unimpaired ( ) Impaired

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

) Emotional State and Reaction ( ) Insight ( ) Positive signs of organicity

( ) Thought control B. DIAGNOSTIC CATEGORY ( ) Functional ( ) Organic

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

MENTAL STATUS EXAM FORM

DATE OF EXAMINATION: December 13, 2011 V. PRESENTATION

E. ORGANIZATION OF TALK ( ) Relevant ( ) Incoherent

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

( ) Absent ( ) Absent ( ) Absent

NEUROVEGETATIVE DYSFUNCTION G. SLEEP ( ) Normal ( ) Hypersomnia ( ) Late Insomnia

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

GENERAL THINKING ABILITY

K. ABSTRACT THINKING ABILITY

L. JUDGMENTAL AND REASONING ( ) Unimpaired

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

SUMMARY OF MENTAL STATUS EXAM

) Emotional State and Reaction ( ) Insight ( ) Positive signs of organicity

( ) Thought control E. DIAGNOSTIC CATEGORY ( ) Functional ( ) Organic

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

10/30/11 y Continue meds.

11/02/11 y y y Awake conversant Good eye contact Fairly groomed

10/31/11 y y y Diphenhydromine 500g Haloperidol Cynithamine

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

11/02/11 y Continue Meds.

11/03/11 y y Continue Meds. Hold carbomasepine

11/04/11 y Continue Meds.

11/04/11 y y y y Awake Poor sleep Poor appetite Hostile Episodes

11/05/11 y Continue Meds.

11/06/11 y Continue Meds.

11/07/11 y Continue Meds.

11/08/11 y y Continue Meds. Still for Flupentixol

11/09/11 y y Continue Meds. 4 points restrain

11/06/11 y y Awake, conscious alert Very much talkative(always shouting)

11/10/11 y Continue Meds.

Case Study on Bipolar 1 Disorder Manic Phase with Psychotic Features

11/12/11 y y Continue Meds. For hair cutting

11/13/11 y Continue Meds

11/07/11 y y y y Good sleep Conscious Talkative Fairly groomed

11/14/11 y Continue Meds.

11/15/11 y Continue Meds.

11/16/11 y Continue Meds.

11/17/11 y Carbamazepine 200mg BID

11/18/11 y Continue Meds.