COLLEGE OF NURSING

ATTENTION DEFICIT HYPERACTIVITY DISORDER

May 4, 2021

Tuesday

Level 3 Section B

Florita, Niño John S.

Gabiana, Audrey Nicole C.

Gabisay, Ayrcel Maye O.

Gargar, Franz Diane Shae R.

Lagahit, Cleiza Cake V.

Lozano, Princess Lyn P.

Melencion, Christian Van Joseph M.

Moliño, Niña Ley M.

Dr. Adriel Arman V. Pizarra, DCHM, MAN, RN

Clinical Instructor

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 TABLE OF CONTENTS

INTRODUCTION

GOALS

OBJECTIVES

SIGNIFICANCE OF THE STUDY

DEFINITION OF TERMS

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

CEPHALO CAUDAL ASSESSMENT

LABORATORY & DIAGNOSTIC

STUDIES
INTRODUCTION
5 NURSING PROBLEM LISTS

DRUG STUDY According to American

LITHIUM CARBONATE Psychiatric association bipolar

disorder is a brain disorder
RISPERIDONE
which causes to change
CARBAMAZEPINE
someone's mood, energy, and ability
LAMOTRIGINE
to function.  People with bipolar
VALPROIC ACID
disorder experience severe emotional
NURSING CARE PLAN
states known as mood episodes
NCP #1 which are manic/hypomanic
NCP #2 (abnormally cheerful or irritable
DISCHARGED PLAN mood) and depressed mood (sad

LEARNING OUTCOMES mood). People with bipolar disorder

CONCLUSION also experience periods of neutral

mood, which occur over a span of
RECOMMENDATION
days to weeks.
REFERENCES

APPENDICES Bipolar has several types which

are the bipolar I disorder, bipolar II
disorder, cyclothymic disorder and
the mixed features. To further understand the given topic, which is bipolar II
to be specific, this disorder will exhibit at least one major depressive episode
and at least 1 hypomanic episode but never had a manic episode.

During the occurrence of the disorder the person may manifest the
following signs and symptoms which categorizes into two episodes.

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 Both a manic and a hypomanic episode include three or more of
these symptoms:

 Abnormally upbeat, jumpy or wired- This isn’t just a normal good

mood. You can imagine when you have this kind of energy surge, you
feel reactive. Picture electricity zooming through your body.

 Increased activity, energy or agitation- You have all these ideas and
energy and start taking on a lot of new projects.

 High sex drive- constantly thinking about and wanting sex.

 Cranky and/or impatient- feel like no one can keep up with you, and
it’s frustrating.

 Poor decision-making- emotions are skewed, and your sense of

consequence and danger are dulled.

 Racing thoughts- it’s hard to keep track of everything swirling around

in your brain you have all kinds of ideas, plans, and opinions.

 Distractibility- with all this internal racing going on, it’s nearly
impossible to focus.

 Abnormally talkative- want to express all thoughts, so you’re extra

chatty and may jump from topic to topic.

Major Depressive episode- an episode includes five or more of these

symptoms:

 Depressed mood, such as feeling sad, empty, hopeless or tearful (in

children and teens, depressed mood can appear as irritability)

 Marked loss of interest or feeling no pleasure in all or almost all

activities

 Either restlessness or slowed behavior- This is the kind of behavior

drain that makes you just want to lay on the couch or under the covers
all day.

 Fatigue or loss of energy- feel so tired and just want to sleep (Though
insomnia is also a symptom)

 Indecisiveness- Maybe it’s because you feel hopeless or ambivalent

about everything, but you really can’t make your mind up, even about
small things.

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  Decreased ability to think or concentrate, or indecisiveness- loses
focus.

 Thinking about, planning or attempting suicide- because of feeling of

hopelessness.

This affects about 6 million individuals in the United States, or around

2.5 percent of the population. While the prevalence rate of bipolar in the
Philippines is 0.2% (0.2% females, 5.0% males). Once bipolar disorder
symptoms first appear, most people are in their teens or early twenties.
Bipolar II disorder affects almost all before they reach the age of 50. Women
is more at risk than in men.

The precipitating factor for this disorder are:

 Genetic factor- this connection may be due to certain genes. Adults

who have relatives with the disorder have an average tenfold increase
in risk of developing the disorder.

 Structural features in the brain- the subgenual portion of the anterior

cingulate cortex was reduced in volume in patients with bipolar
disorder with a family history of affective disorder.

The predisposing factor for this disorder are:

 Environmental factors- Life events, such as abuse, mental stress, a

“significant loss,” or another traumatic event, may trigger an initial
episode in a susceptible person.

 Stress- stress gives negative effect as it involves dramatic shifts in

mood, energy level, and behavior.

 Traumatic events- factors such as sexual or physical abuse, neglect,

the death of a parent can increase the risk of bipolar disorder later in
life.

According to Lijffijt, et al. (2019). With the study entitled Interactions of

immediate and long-term action regulation in the course and
complications of bipolar disorder stated that with potentially severe
complication impulsivity is increased in affective disorders, substance-use
disorders (SUD), severe aggression and suicide or other premature death
may result.

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Enable to manage the disorder and prevent the further complications
the following prevention must be applied; pay attention to warning signs;
avoid drugs and alcohol, take your medications exactly as directed.

Therapy that are helpful may include: Cognitive-behavioral therapy- learn

how to change negative thinking patterns and behaviors into more positive
ways; Interpersonal and social rhythm therapy- focuses on current
relationship issues and helps you improve the way you relate to the
important people in your life. Social rhythm therapy focuses on stabilizing
social rhythms such as sleeping, eating, and exercising; Family-focused
therapy- addresses these issues and works to restore a healthy and
supportive home environment.

 Treatments/medications for this are the following: Mood

Stabilizers (e.g., lithium, carbamazepine, lamotrigen); Antipsychotic
(e.g., aripiprazole, asenapine, cariprazine); Benzodiazepines (e.g.,
alprazolam, diazepam, and lorazepam); Antidepressant (e.g., fluoxetine,
paroxetine, and sertraline)

This study is important for the nursing students to have the ability and gain
widen knowledge to significantly impact the successful care of the patients
by recognizing and assessing bipolar disorder, managing treatment with
appropriate mood stabilizers and therapies, and educating patients and their
families.

GOALS:

The goal of this case study is to describe the case of the client, identify
underlying causes of Bipolar 2 Disorder and analyze the case study. This
case will cover up to the client’s final diagnosis of Bipolar 2 Disorder. To
identify and discuss the Anatomy and Physiology, Pathophysiology,
Laboratory and Diagnostic Studies as well as identifying 5 nursing problem
lists for the client’s condition.

GENERAL OBJECTIVES:

After 3 – 4 days’ exposure at Vicente Sotto Memorial Medical Center: Center

for Behavioral Sciences (Psychiatric and Psychological Services), being aided

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with the concept of, Care of Clients with Maladaptive Patterns of Behavior,
Acute and Chronic, we will be able to demonstrate competencies in
knowledge, skills, and attitudes of an effective clinician in evaluating and
caring for patients with Bipolar 2 Disorder and other mental disorders in the
health care setting. We will be able to learn the need to study for Bipolar
Disorder in school, for professors, and students. Lastly, to be able to present
data about Bipolar 2 Disorder. 

SPECIFIC OBJECTIVES:

After 4-6 hours exposure at Vicente Sotto Memorial Medical Center: Center
for Behavioral Sciences (Psychiatric and Psychological Services), the nurse
will be able to:

1. Identify the individual factors in experiencing the Bipolar 2 Disorder.

2. To be able to present the signs and symptoms of Bipolar 2 Disorder.

3. Apply the practice guidelines for the treatment of patients with Bipolar 2
Disorder.

4. Recognize the importance of effective detection and treatment of Bipolar 2

Disorder in adults/children.

5. Formulate management plans for the longitudinal care of patients with

Bipolar 2 Disorder.

6. Develop prevention plans, including health education and behavioral

change strategies, for patients with Bipolar 2 Disorder.

6. Discuss behaviors with patients, in an empathic, respectful and non-

judgmental manner.

7. Use information technology to access patient and family education

resources on Bipolar 2 Disorder.

8. Critically review the medical literature regarding new evidence based

clinical trials and its implication on current treatment guidelines of Bipolar 2
Disorder and other mental disorders. 

 9. Improve patient care outcomes through effective communication with

other health care professionals, partnerships through community resources,
and government agencies.

10. To be able to tackle the medications related and is applicable to Bipolar 2

mental disorder.

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SIGNIFICANCE OF THE STUDY

The aim of the study includes understand this kind of disorder specifically to
the promotion of health prevention of complication and treating or managing
the symptoms of bipolar; know the challenges people with bipolar disorder
(BD) experience; examine what these challenges imply for health care; and
making us ready to reencounter bipolar disorder and other psychiatric
disorders in that we will be able to provide effective and holistic nursing
care.

This study is deemed beneficial to the following:

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Family: This study can help the family to try their best to get that person
the help that they need. Change the habits and relationships in ways that
affect the whole family, not just the individual with the disease and educate
them about the importance of early diagnosis and care. In addition, raising a
person with bipolar disorder presents a challenge in terms of assisting with a
major task, which is parenting.

Educators: This study can develop strategies to aid students with the
learning about bipolar disorder in focusing and learning to their full potential
through appropriate accommodations and interventions.

Society: This study enables them to give emotional support, understanding,

patience, and encouragement. As well as, raising awareness to them about
the disorder.

Healthcare Professionals: This study help clients be more successful in

their daily lives and to reduce the degree to which untreated bipolar disorder
interferes with getting things done and recover from their disorder.

School: This will serve as an output that they can use in the future studies
regarding bipolar disorder.

DEFINITION OF TERMS

Anxiety: is an emotion characterized by feelings of tension, worried

thoughts and physical changes like increased blood pressure. People
with anxiety disorders usually have recurring intrusive thoughts or concerns.
They may avoid certain situations out of worry.

Bipolar Disorder: also known as manic depression, is a mental illness that

brings severe high and low moods and changes in sleep, energy, thinking,
and behavior. People who have bipolar disorder can have periods in which

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they feel overly happy and energized and other periods of feeling very sad,
hopeless, and sluggish.

Bipolar 1 Disorder: This involves manic episodes lasting 7 days or more, or

severe mania that requires hospitalization. The person may also experience
a major depressive episode that lasts 2 weeks or more. A person does not
have to experience this type of episode to receive a bipolar I diagnosis.

Bipolar 2 Disorder: involves a major depressive episode lasting at least

two weeks and at least one hypomanic episode (a period that’s less severe
than a full-blown manic episode). People with bipolar 2 typically don’t
experience manic episodes intense enough to require hospitalization.

Cyclothymic disorder: Also known as cyclothymia, this type includes

symptoms of hypomania and depression that last for 2 years or more in
adults or 1 year in children. These symptoms do not fit the criteria for wholly
manic or depressive episodes.

Depression: is a mood disorder that causes a persistent feeling of sadness

and loss of interest and can interfere with your daily functioning.

Euphoria: is an overwhelming feeling of happiness, joy, and well-being.

People experiencing euphoria may feel carefree, safe, and free of stress. This
emotion can be either a normal reaction to happy events or a symptom of
substance abuse and certain mental health conditions.

Hypomania: is a period of mania that’s less severe than a full-blown manic

episode. Though less severe than a manic episode, a hypomanic phase is
still an event in which your behavior differs from your normal state.

Mania: is a period of extreme high energy or mood associated with bipolar

disorder. Everyone's moods and energy levels change throughout the day
and over time. But mania is a serious change from the way a person
normally thinks or behaves, and it can last for weeks or even months.

Mental Health:  refers to cognitive, behavioral, and emotional well-being. It

is all about how people think, feel, and behave.

Mental Illness: also called mental health disorders, refers to a wide

range of mental health conditions — disorders that affect your mood,
thinking and behavior. Examples of mental illness include depression,
anxiety disorders, schizophrenia, eating disorders and addictive behaviors.

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Other types: People with these disorders experience symptoms that do not
fall into the above categories. The symptoms may stem from drug or alcohol
use or medical conditions, for example.

Psychosis: is a condition that affects the way your brain processes

information. It causes you to lose touch with reality. You might see, hear, or
believe things that aren't real. Psychosis is a symptom, not an illness. A
mental or physical illness, substance abuse, or extreme stress or trauma can
cause it.

Psychotherapy: or talk therapy, is a way to help people with a broad

variety of mental illnesses and emotional difficulties. Psychotherapy can
help eliminate or control troubling symptoms so a person can function better
and can increase well-being and healing.

Rapid Cycling: This means that they have had at least 4 episodes in the
previous year, with occasional periods of remission for at least 2 months or a
shift to the opposite mood, such as from mania to depression.

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ANATOMY AND PHYSIOLOGY

PREFRONTAL CORTEX: helps people set and achieve goals. It receives

input from multiple regions of the brain to process information and adapts
accordingly. The prefrontal cortex contributes to a wide variety of executive
functions, including: Focusing one's attention. In bipolar disorder, MRI shows
abnormalities in the brain structure. Cognitive function is clearly disrupted
like attention.

AMYGDALA: thought to play important roles in emotion and behavior. There

are deficits in emotional processing.

HIPPOCAMPUS: major role in learning and memory. A part of the brain

involved in memory and emotion, has identified specific regions that are
diminished in size in people with bipolar disorder.

BRAIN STEM: includes the midbrain, the pons, and the medulla. It controls
fundamental body functions such as breathing, eye movements, blood
pressure, heartbeat, and swallowing. There are abnormal findings in the
brain stem when you have bipolar disorder.

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CEREBELLUM: is to coordinate muscle movements, maintain posture, and
balance. An area of the brain responsible for coordinating movement and
perhaps even some forms of learning. Cerebellar abnormalities are found
when you have bipolar disorder.

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PATHOPHYSIOLOGY

 GENETICS  ENVIRONMENT
 AGE (early 20s/adolescence)  TRAUMATIC EXPERIENCE
 GENDER (male/female)  STRESS
 ANTIDEPRESSANTS

Neurotransmitter Alterations

Increase Serotonin
Over production of Decease Serotonin
Dopamine

Decrease inhibitory control of

emotions

 Bipolar
Disorder Disruption of emotional homeostasis
DSM-5
 MRI Major depressive episode
 Thyroid
Function Mood is low
Test
 CBC Fluctuation between moods of Sleep disturbance
hypomania and major Low energy
depressive episode
Hypomanic Episode Difficulty in concentrating

Loss of interest

Increased activity, Suicidality

energy or agitation

Talkativeness

Decrease need for sleep  Disturbed thought

process
Racing thoughts  Risk for self-
directed violence
Increased Confidence
 Spiritual distress
Impulsivity BIPOLAR 2 DISORDER
Irritability

Inflated self-esteem or Mood Stabilizers

grandiosity
Lithium - 300 mg, P.O.

Headache
 Risk for Injury
Dizziness
 Risk for Violence
 Impaired social Risk for committing Nausea or vomiting
interaction suicide
Diarrhea

Hand Tremor

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LEGENDS:

PREDISPOSING FACTORS

PRECEPITATING FACTORS

MECHANISM

DIAGNOSTIC TEST

SIGNS & SYMPTOMS

NURSING DIAGNOSIS

MEDICATION

COMPLICATIONS

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CEPHALO-CAUDAL ASSESSMENT

Skin: The client’s skin is evenly light brown color and no edema. No
excoriations noted, has presence of foul odor. He has a good skin turgor
when held and released, skin snaps rapidly back to its normal position.
Skin’s temperature is warm to touch. Nailbeds are pink without clubbing.
When nails pressed between the fingers nails return to usual color in less
than 4 seconds. Nails are soiled and untrimmed.

Scalp and Hair: Skull is generally round, there are no nodules or masses
and depressions when palpated. The hair of the client is thick, silky hair is
evenly distributed. There are also no signs of infestation observed.

Head and Face: Head symmetrically round, hard, and smooth without
lesions or bumps.  Face oval, smooth, symmetrical, and no observed
drooping of the face on both sides.

Eyes: The client’s eyebrows are symmetrically aligned. Evelids in normal

position with no abnormal widening or ptosis.  No redness, discharge, or
crusting noted on lid margins.  Conjunctiva and sclera appear moist and
smooth.  Sclera white with no lesions or redness.  Cornea is transparent,
smooth, and moist with no opacities, lens is free of opacities. Presence of
periorbital puffiness. Irises are round, flat, and evenly colored.  Pupils are
equal in size and reactive to light and accommodation. 

Ear: Ears are equal in size bilaterally.  Auricles are aligned with the corner of
each eye.  Skin smooth, no lumps, lesions, nodules.  No discharge. 
Nontender on palpation.  Small amount of moist yellow cerumen in external
canal.  Whisper test: can repeat 2 syllable words.

Nose: Nose somewhat large but smooth and symmetric.  Able to sniff
through nostrils. No purulent drainage noted.  Frontal and maxillary sinuses 
are not tender to palpation and percussion. No nasal flaring noted.

Mouth and Throat: Lips pink, smooth, and moist without lesions.  Buccal
mucosa pink, moist, and without exudates. Broken teeth and dental carries
noted. Uvula is in midline, pinkish, with no sweeling or lesions noted. The
uvula move up when saying “ahh” and the patient can swallow with ease
and has no hoarseness when talking.

Upper Extremities: Absence of deformities. No swelling and redness.

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Neck: Trachea is in midline with no presence of mass or lumps. The neck is
straight, symmetrical. No swell lymph nodes noted. Jugular vein not
distended upon palpation.

Chest: Chest expansion symmetric.  No retraction or bulging of interspaces. 

No pain or tenderness on palpation.  Tactile fremitus symmetric.  Percussion
tones resonant over all lung fields.  Vesicular breath sounds auscultated over
lung fields.  No adventitious sounds present.

Back: Patient’s back is symmetrical. No tenderness is noted on palpation of

the spinous processes. Spinous processes are midline. Cervical, thoracic, and
lumbar paraspinal muscles are not tender and are without spasm. No
lesions, bruises, deformities and edema noted.

Abdomen: Skin of abdomen is free of striae, scars, lesions, or rashes. 

Umbilicus is midline and recessed with no bulging.  Abdomen is flat and
symmetric with no bulges or lumps. No tenderness or guarding in any
quadrant with light palpation.

Lower Extremeties: Both extremeties are equal in size and no edema.

Presence of scars on the knee. Temperature is warm and even to touch.

Genitals: Male- Circumcised penis is free of rashes, lesions, and lumps and
is soft, flaccid and nontender on palpation. No masses or swelling noted in
scrotum and left side hangs slightly lower than right side. Female- Labia
majora pink, smooth, and free of lesions, excoriation, and swelling.  Labia
minora dark pink, moist, and free of lesions, excoriation, swelling or
discharge.  No discharge from urethral opening.  No malodorous discharge
noted from vagina. 

Mental Status: Clients may be oriented to person and place but rarely to
time. Ability to concentrate or to pay attention is grossly impaired.

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LABORATORY AND DIAGNOSTIC STUDIES

Diagnostic and Statistical Manual (DSM)-5 is that it includes the extent of activity, energy and emotions. With DSM-5, hopelessness has been
added to the mood criteria. The DSM-5 pinpoints a hypomania episode as the existence of a single or greater number of depressive events
(see list below) and a minimum of one hypomania episode, which has continued for a greater part of the day for a minimum of 96 hours.

For a diagnosis of bipolar 2 disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following
criteria for a current or past major depressive episode:

 Criteria have been met for at least one hypomanic episode and at least one major depressive episode
 There has never been a manic episode
 The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other
psychotic disorder.
 The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania
causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the criteria for
a current or past major depressive episode.

Hypomanic Episode:

 A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased
activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

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  During the period of mood disturbance and increased energy and activity, 3 (or more) of the above symptoms (4 if the mood is only
irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree.
 The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
 The disturbance in mood and the change in functioning are observable by others.
 The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If
there are psychotic features, the episode is, by definition, manic.

The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment).

Diagnostic Procedure Indication or Purpose Result and/or Possible Normal Values Nursing Responsibilities

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 Result (Before, During and After)
Thyroid function test A thyroid function test is a -reading above 2.0 mIU/L, -T4 and TSH normal values BEFORE
blood test that measures you’re at risk for progressing are 0.4 to 4.0 mIU/L. 1. Ask for consent.
how well your thyroid gland to hypothyroidism.
functions. The thyroid 2. Inform the patient this test can assist in
produces and secretes -Reading above 220 ng/Dl -normal Total T3 level in evaluating thyroid function.
hormones that help regulate levels most commonly adults ranges from 1000-200 3. Explain that a blood sample is needed for
many bodily functions. If indicate a condition ng/dL.
your body doesn’t receive called Grave’s disease. This is the test.
enough of the thyroid an autoimmune disorder DURING
hormone, known associated with 4. Inform the client that when the needle is
as hypothyroidism, your hyperthyroidism. inserted to draw blood, may feel moderate
brain may not function
properly. As a result, you pain, or only a prick or stinging sensation.
may have problems with AFTER
depressive symptoms or 5. Apply manual pressure and dressings over
develop a mood disorder. puncture site on removal of dinner.

6. Document findings.
7. Test results are reported to the patient's
doctor, specialists and others in need of the
information by nurses.
MRI MRI scan is therefore Normal brain structure, not Before:
Significant and widespread
sometimes ordered in smaller nor with alterations in 1. Remove any metal devices
pattern of reduced cortical
patients who have had a the shape. 2. The staff may ask you to wear a hospital
thickness associated with
sudden change in thinking, gown or clothing that doesn’t contain metal
Bipolar Disorder with the
mood, or behavior to assure fasteners.
largest effects in the left
that a neurological disease is 3. You can’t have electronic devices in the
pars opercula is, left
not the underlying cause. MRI room.
fusiform gyrus and left
4. Tell the medical staff if you’re pregnant.
rostral middle frontal
An MRI’s magnetic field affects unborn
cortex.
children in a way that isn’t yet fully
understood.

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During:
5. Stay still to obtain clear image.
6. You will lie down on a table that slides
into the MRI machine.
7. You may have a plastic coil placed around
your head.
8. After the table slides into the machine, a
technician will take several pictures of your
brain, each of which will take a few minutes.
9. There will be a microphone in the machine
that allows you to communicate with staff.
After:
10. you can get dressed and leave the
testing facility
11. A radiologist will analyze your MRI
images and provide your doctor with the
results.

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THERAPIES INDICATION
COGNITIVE BEHAVIORAL A type of psychotherapy that can be used to help
THERAPY manage bipolar disorder.
Involve a one-on-one interaction with a therapist. It
may also involve group sessions that include the
therapist and other people with similar issues.
Although there are many approaches, they all
involve helping patients manage their thoughts,
perceptions, and behavior. Psychotherapy is also a
resource for finding healthy ways to deal with
problems.
INTERPERSONAL AND Based on the observations that bipolar disorders are
NURSING RESPONSIBILITIES
BEFORE:
1. Establish rapport with the client.
2. Discuss why therapy is needed and how does it work.
3. Encourage client to ask questions and verbalize questions or anything that he/she
feels in the session.
DURING:
4. Determine the problem that’s bothering the client.
5. Examine thoughts, behaviors and emotions associated to the problem.
6. Spot negative or inaccurate thoughts, behaviors and emotions that can actually
worsen the problem.
7. Change the client’s reaction to positive or constructive ones.
AFTER:
8. Determine which reactions are unhealthy and replace healthier alternatives.
9. Document the findings
10. Make sure client has gain a new outlook on his/her situation.
BEFORE:
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SOCIAL RHYTHM THERAPY essentially body rhythm disturbances, and that
altered body rhythms (e.g., circadian rhythms,
seasonal rhythms, and social/occupational rhythms)
can lead to mood disturbances.
FAMILY FOCUSED A combination of two forms of psychotherapy. First,
THERAPY it is a variety of psychoeducation, which is a type of
therapy whose main goal is to teach patients and
their families about the nature of their illness. It is
also a type of family therapy.
Family therapy sessions dig into the details of the
interactions between family members as a core part
1. Establish rapport with the client..
2. Discuss why therapy is needed and how does it work.
3. Encourage client to ask questions and verbalize questions or anything that he/she
feels in the session.
DURING:
4. Encourage client to track their mood states and their daily activities and body
rhythms.
5. Instruct client to record when they eat, sleep and go to work on a social rhythm
metric chart.
6. Instruct client to complete an interpersonal inventory where they make note of
social interactions, such as conflicts and stresses that have an effect on their daily
body rhythms and on their bipolar mood disorder.
AFTER:
7. This chart becomes an important tool for raising awareness of the relationship
between body rhythms and mood.
8. Help patients to set up and maintain steady and stable routines such as taking
bipolar medication consistently and going to sleep and getting up at regular times
every day.
9. Also help patients with bipolar disorder to recognize the sorts of activities and
interactions that cause their body rhythms to become disturbed so that these
situations can be avoided.
10. For some patients, this self-monitoring and problem-solving type of bipolar
therapy is effective in helping prevent recurring mood episodes.
BEFORE:
1. Establish rapport with the client..
2. Discuss why therapy is needed and how does it work.
3. Encourage client to ask questions and verbalize questions or anything that he/she
feels in the session.
DURING:
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 of treatment. It looks at the role of the person with
bipolar disorder in the overall psychological well-
being of the family, as well as the role of the family
in creating bipolar symptoms. Family therapy aims
to identify and then change destructive relationship
patterns that may be contributing to the system's
difficulties.
ELECTROCONVULSIVE Is often an option for people whose bipolar disorder
THERAPY has proven resistant to drug treatment or is causing
severe episodes.
4. Identify the problem.
5. Educate all family members about the nature of bipolar disorder, bipolar
treatment, and ways that family members can best support their affected
member.
6. Provide training to support the family's development of communication and
problem solving skills.
7. Re-channel any anger that may be present, promote re-engagement of family
members who have checked out.
AFTER:
8. Identify and then change destructive relationship patterns that may be
contributing to the system's difficulties.
9. Promote a balanced blend of acceptance of the patient's limitations, as well as the
need for the patient to take age-appropriate responsibility for his or her own well-
being.
10. Document findings.
BEFORE:
1. A muscle relaxant is given to prevent injury.
2. An anesthetic will also be given to be temporarily unconscious.
DURING:
3. Nurse will place electrode pads on the head.
4. When asleep and muscles are relaxed, a doctor will send a small amount of
electricity through the brain.
5. Seizure will occur but this seizure activity improves the symptoms through
mechanism of action that reboots or restarts the brain to normal function.
AFTER:
6. Check for side effects like memory loss, nausea, vomiting, headache, jaw pain,
muscle ache and muscle spasms.
7. Document findings.
23
24
5 NURSING PROBLEM LISTS

1. Risk for Injury R/T Extreme hyperactivity as evidenced by Lack of

control over purposeless and potentially injurious movements
2. Risk for Violence: Self Directed and Others related to manic phase as
evidenced by verbal threats against self and others
3. Impaired Social Interaction R/T disturbance in thought processes
Secondary to Bipolar 2 Disorder
4. Ineffective Individual Coping R/T Inadequate level of perception of
control as evidenced by Changes in usual communication patterns
5. Total Self-Care Deficit related to Racing Thoughts and Poor Attention
Span Secondary to Bipolar 2 Disorder.

25
DRUG STUDIES

Name of the Drug Mechanism Of Action Indication/s Side Effects Nursing Responsibilities

Generic Name: Multiple actions of lithium Control and prophylaxis of CNS: headache, dizziness or BEFORE:
Lithium Carbonate
are critical for its acute mania and the acute drowsiness
Brand Name:
Eskalith therapeutic effect, and manic phase of mixed bipolar GI: nausea or vomiting, 1. Lab test: Periodic lithium levels
Classification: (draw blood sample prior to next
that these complex effects disorder. diarrhea, changes in appetite,
CENTRAL NERVOUS SYSTEM
(CNS) stabilize neuronal dry mouth, increased thirst dose or 8–12 h after last dose);
AGENT; PSYCHOTHERAPEUTIC periodic thyroid & kidney function
activities, support neural MUSKULOSKELETAL: hand
AGENT; MOOD STABILIZER
Pregnancy Category: plasticity, and provide tremors tests.
D 2. Weigh patient daily; check ankles,
neuroprotection. Three URINARY SYSTEM: increased
Dosage:
600 mg interacting systems appear urination tibiae, and wrists for edema.
Route: Report changes in I&O ratio,
most critical. (i) SKIN: acne-like rash, thinning
PO
Frequency: Modulation of of hair or hair loss sudden weight gain, or edema.
TID 3. History: Hypersensitivity to
neurotransmitters by
Timing:
8-1-6 lithium likely readjusts tartrazine; significant renal or CV

balances between disease; severe debilitation,

excitatory and inhibitory dehydration; sodium depletion,

activities, and decreased patients on diuretics; protracted

CONTRAINDICATIONS ADVERSE EFFETCS sweating, diarrhea; suicidal or
glutamatergic activity may
contribute to Significant cardiovascular or CNS: lethargy, fatigue, slurred impulsive patients; infection with

neuroprotection. (ii) kidney disease, brain damage, speech, psychomotor fever; pregnancy; lactation

Lithium modulates signals severe debilitation, retardation, giddiness,

DURING:
impacting on the dehydration or sodium incontinence, restlessness,

cytoskeleton, a dynamic depletion; patients on low-salt seizures, confusion, blackout

4. Give drug with food or milk or after

26
system contributing to diet or receiving diuretics; spells, disorientation, recent meals.
neural plasticity, at pregnancy, especially first memory loss, stupor, coma, 5. Monitor for S&S of lithium toxicity
multiple levels, including trimester (category D), EEG changes.  (e.g., vomiting, diarrhea, lack of
glycogen synthase kinase- lactation, children <12 y. CV: Arrhythmias, hypotension, coordination, drowsiness, muscular
3β, cyclic AMP-dependent vasculitis, peripheral circulatory weakness, slurred speech when
kinase, and protein kinase collapse, ECG changes.  level is 1.5–2.0 mEq/L; ataxia,
C, which may be critical for Special Senses: Impaired blurred vision, giddiness, tinnitus,
the neural plasticity vision, transient scotomas, muscle twitching, coarse tremors,
involved in mood recovery tinnitus.  polyuria when >2.0 mEq/L).
and stabilization. (iii) Endocrine: Diffuse thyroid Withhold one dose and call
Lithium adjusts signaling enlargement, physician. Drug should not be
activities regulating second hypothyroidism, nephrogenic stopped abruptly.
messengers, transcription diabetes insipidus, transient 6. Monitor older adults carefully to
factors, and gene hyperglycemia, glycosuria, prevent toxicity, which may occur
expression. hyponatremia.  at serum levels ordinarily tolerated
The outcome of these GI: anorexia, abdominal pain, by other patients.
effects appears likely to diarrhea, metallic taste.  7. Be alert to and report symptoms of
result in limiting the Musculoskeletal: Fine hand hypothyroidism.
magnitudes of fluctuations tremors, coarse tremors, 8. Report early signs of
in activities, contributing choreoathetotic movements; extrapyramidal reactions promptly
to a stabilizing influence fasciculations, clonic to physician.
induced by lithium, and movements, incoordination
neuroprotective effects including ataxia, muscle AFTER:

may be derived from its weakness, hyperreflexia,

9. Be alert to increased output of
modulation of gene encephalopathic syndrome
dilute urine and persistent thirst.

27
expression. (weakness, lethargy, fever,
tremors, confusion, Dose reduction may be indicated.

extrapyramidal symptoms).  10. Advise to contact physician if

Skin: Thought to be toxicity diarrhea or fever develops. Avoid

rather than allergy: Pruritus, practices that may encourage

maculopapular rash, dehydration: hot environment,

hyperkeratosis, chronic excessive caffeine beverages

folliculitis, transient acneiform (diuresis).

papules (face, neck, 11. Advise to drink plenty of liquids (2–

intertriginous areas), anesthesia 3 L/d) during stabilization period

of skin, cutaneous ulcers, drying and at least 1–1½ L/d during

and thinning of hair, allergic ongoing therapy.

vasculitis.  12. Advise to avoid self-prescribed low-

Hematologic: Reversible salt regimen, self-dosing with

leukocytosis (14,000 to antacids containing sodium, and

18,000/mm3).  high-sodium foods (e.g., prepared

Urogenital: Albuminuria, meats and diet soda).

oliguria, urinary incontinence, 13. Advise to not drive or engage in

polyuria, polydipsia, increased other potentially hazardous

uric acid excretion.  activities until response to drug is

Body as a Whole: Edema, known. Lithium may impair both

weight gain (common) or loss, physical and mental ability.

exacerbation of psoriasis; flu- 14. Educate about the use effective

like symptoms. contraceptive measures during

lithium therapy. If therapy is
continued during pregnancy, serum

28
 lithium levels must be closely
monitored to prevent toxicity.
15. Advise to not breast feed while
taking this drug.

Name of the Drug Mechanism Of Action Indication/s Side Effects Nursing Responsibilities

Generic Name: Reduction or elimination of GI: nausea, vomiting, diarrhea, BEFORE:

Risperidone is a second-
psychotic symptoms in constipation, heartburn, dry
Risperidone  generation antipsychotic 1. Check medication tickets and
schizophrenia and related mouth, increased saliva,
(SGA) medication used in check medication for leak and
psychoses; treatment of increased appetite
Brand Name:  the treatment of a number expiration.
bipolar disorder. Seems to
of mood and mental health 2. Establish rapport. 
Risperdal  improve negative symptoms
conditions including 3. Assess for allergy of the drugs.
such as apathy, blunted affect,

29
 schizophrenia and bipolar 4. Assess degree of cognitive and
Classification:  and emotional withdrawal.
disorder. It is one of the motor impairment, and assess
most widely used for environmental hazards.
CENTRAL NERVOUS
SGAs. Paliperidone, another
SYSTEM (CNS) AGENT; CONTRAINDICATIONS ADVERSE EFFETCS DURING:
commonly used SGA, is the
ANTIPSYCHOTIC;
primary active metabolite of
ATYPICAL  Hypersensitivity to risperidone; Body as a Whole: Orthostatic 5. Monitor diabetics for loss of
risperidone (i.e. 9-
elderly with dementia-related hypotension with initial doses, glycemic control.
Pregnancy Category: hydroxyrisperidone).
psychosis; QT prolongation, sweating, weakness, fatigue.  6. Monitor closely the neurologic
Schizophrenia and various
C Reye's syndrome, brain tumor, status of older adults.
mood disorders are thought CNS: Sedation, drowsiness,
severe CNS depression, head 7. Monitor cardiovascular status
Dosage:  to be caused by an excess headache, transient blurred
trauma; suicidal ideation, closely; assess for orthostatic
of dopaminergic D2 and vision, insomnia, disinhibition,
tardive dyskinesia; sunlight hypotension, especially during
2-3 mg serotonergic 5-HT2A agitation, anxiety, increased
(UV) exposure, tanning beds; initial dosage titration.
activity, resulting in dream activity, dizziness,
Route:  pregnancy (category C), 8. Monitor closely those at risk for
overactivity of central catatonia, extrapyramidal
lactation, children <15 y. seizures.
PO mesolimbic pathways and symptoms (akathisia, dystonia,
mesocortical pathways, pseudoparkinsonism), especially AFTER:
Frequency: respectively. Risperidone is with doses >10 mg/d,
9. Carefully monitor blood glucose
thought to reduce this neuroleptic malignant syndrome
 OD  levels if diabetic.
overactivity through (rare), increased risk of stroke in
10. Advise patients or SO to not
Timing:  inhibition of dopaminergic elderly. CV: Prolonged QTc
engage in potentially hazardous
D2 receptors and interval, tachycardia. 
8 AM activities until the response to
serotonergic 5-HT2A
GI: Dry mouth, dyspepsia, drug is known.
receptors in the brain.
nausea, vomiting, diarrhea, 11. Be aware of the risk of
Risperidone binds with a
constipation, abdominal pain, orthostatic hypotension.

30
very high affinity to 5-HT2A 12. Learn adverse effects and report
elevated liver function tests
receptors, approximately to physicians those that are
(AST, ALT). 
10-20 fold greater than the bothersome.
drug's binding affinity to D2 13. Advise patients or SO to wear
Endocrine: Galactorrhea. 
receptors, and carries sunscreen and protective
lesser activity at several Metabolic: Hyperglycemia, clothing to avoid
off-targets which may diabetes mellitus.  photosensitivity.
responsible for some of its 14. Encourage patients to notify
Respiratory: Rhinitis, cough,
undesirable effects. physicians if they intend to or
dyspnea. 
become pregnant.

Skin: Photosensitivity. 
15. Inform to not breastfeed while
taking this drug.
Urogenital: Urinary retention,
menorrhagia, decreased sexual
desire, erectile dysfunction,
sexual dysfunction male and
female.

31
 Name of the Drug Mechanism Of Action Indication/s Side Effects Nursing Responsibilities

GENERIC NAME Structurally related to Carbamazepine is indicated for GI: nausea, vomiting, diarrhea, BEFORE:
Carbamazepine 1. Assess for history of psychosis,
tricyclic antidepressants epilepsy, trigeminal neuralgia, constipation, heartburn, dry
BRAND NAME drug may activate symptoms.
(TCAs) but lacks and acute manic and mixed mouth, increased saliva,
Tegretol, Teril
2. Assess for CBC baseline.
antidepressant properties. episodes in bipolar I disorder. increased appetit
CLASSIFICATION
3. Do not mix suspension with
Anticonvulsants, Central Anticonvulsant actions Indications for epilepsy are GI: Nausea, vomiting, anorexia,
other medications or elements
Nervous System Agent, appear qualitatively similar specifically for partial seizures abdominal pain, diarrhea,
(e.g., liquid chlorpromazine or
Tricyclic to those of phenytoin. Like with complex symptomatology constipation.
thioridazine) precipitation may
PREGNANCY CATEGORY: phenytoin, provides relief in (psychomotor, temporal lobe), CNS: Dizziness, vertigo,
D occur.
trigeminal neuralgia by generalized tonic seizures drowsiness, disturbances of
DOSAGE
DURING:
200mg reducing synaptic (grand mal), and mixed coordination, ataxia, confusion,
4. Give drug with meal to increase
ROUTE transmission within seizure patterns. headache, fatigue, listlessness,
PO drug absorption and avoid GI
trigeminal nucleus. Also has Carbamazepine is not indicated speech difficulty.

32
FREQUENCY sedative, anticholinergic, for absence seizures. Skin: Skin rashes, urticaria, upset.
BID
antidepressant, and muscle Carbamazepine is FDA petechiae 5. Confusion and agitation may
TIMING
relaxant (by inhibition of indicated as first-line Special Senses: Abnormal be aggravated in the older
8am-6pm
neuromuscular treatment trigeminal neuralgia hearing acuity, scotomas, adult; therefore, side rails
transmission) effects and or tic douloureux (cranial conjunctivitis, blurred vision,
and supervision of ambulation
slight analgesic actions. nerve V). A systemic review nystagmus.
may be indicated.
shows the efficacy of Urogenital: Urinary frequency
6. Instruct not to take grape fruit
Chemically related to carbamazepine extended- or retention, oliguria, impotence
juice while taking this drug
tricyclic antidepressants release in bipolar I mania in
because it increases the level of
(TCAs). Anticonvulsant patients with acute manic or
drugs in the body instead of
action may result from mixed episodes.
being absorb.
reduction in polysynaptic
7. Ensure not to give MAO within
responses and blocking of
14 days (MAO also interact with
post-tetanic potentiation. CONTRAINDICATIONS ADVERSE EFFETCS
seizure medications like
Hypersensitivity to CNS: Development of minor
carbamazepine, thus it can
carbamazepine and to TCAs; motor seizures, hyperreflexia,
increase the occurrence of side
history of myelosuppression or akathisia, involuntary
effects).
hematologic reaction to other movements, tremors, visual
8. Monitor for fluid intake and
drugs; increased IOP; SLE; hallucinations, activation of
output it may cause fluid
cardiac, hepatic, or renal latent psychosis, aggression;
retention.
disease; coronary artery agitation, respiratory
AFTER:
disease; hypertension. depression.
9. Advise patient to avoid excessive
Endocrine: Hypothyroidism,
sun exposure and to wear
SIADH.
protective clothing and
CV: Edema, syncope,
sunscreen (drug may cause skin

33
arrhythmias, heart block. rash, itching, redness or other
GI: Dry mouth and pharynx, discoloration of the skin, or a
hepatitis. severe sunburn).
Hematologic: Aplastic anemia, 10. If the patient is using
leukocytosis, agranulocytosis, contraceptives, advise to use
eosinophilia, thrombocytopenia. alternative birth control method
(e.g., withdrawal method)
because drug may decrease the
effectiveness of contraceptive.
11. Monitor for CBC result because it
may cause bone marrow
depression.

12. Monitor for the following

reactions, which commonly occur
during early therapy:
drowsiness, dizziness, light-
headedness, ataxia, gastric
upset. If these symptoms do not
subside within a few days, report
to the physician, dosage
adjustments may be needed.

34
NAME OF DRUG MECHANISM OF ACTION INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES

GENERIC NAME: One proposed mechanism of Indicated for the maintenance Cardiovascular: Palpitation BEFORE:
Lamotrigine action of Lamotrigine, the treatment of bipolar I disorder
1. Instruct patient to take medication
BRAND NAME: relevance of which remains to delay the time to Respiratory:
Lamictal to be established in humans, occurrence of mood episodes exactly as directed.
CLASSIFICATION: involves an effect on sodium (depression, mania, Infrequent: Yawn. 2. Caution patient to wear sunscreen
anticonvulsants or channels. In vitro hypomania, mixed episodes)
antiepileptic drugs (AEDs) pharmacological studies in patients treated for acute and protective clothing to prevent
suggest that lamotrigine mood episodes with standard
photosensitivity reactions.
inhibits voltage-sensitive therapy
sodium channels, thereby CONTRANDICATION: ADVERSE EFFECT: 3. Instruct patient to notify health care
stabilizing neuronal
professional of medication regimen
membranes and
Hypersensitivity. Urogenital System
consequently modulating prior to treatment or surgery.
Impaired cardiac function. Infrequent: Abnormal
presynaptic transmitter
PREGNANCY CATEGORY: ejaculation, hematuria 4. Advice patient to carry identification
release of excitatory amino
C Gastrointestinal: Esophagitis
acids (e.g., glutamate and at all times describing disease
Hepatobiliary Tract and
aspartate).
Pancreas: Pancreatitis process and medication regimen.
Immunologic:
DURING:
DOSAGE: Hypogammaglobulinemia, lupus-
25mg like reaction, vasculitis. 5. Advise patient to notify health care
ROUTE:
professional immediately if skin rash
PO
occurs or if frequency of seizures
FREQUENCY:
increases. May cause dizziness,
BID
TIMING: drowsiness, and blurred vision.

35
8AM-6PM 6. Caution patient to avoid driving or
activities requiring alertness until
response to medication is known.
7. All forms of this drug can be taken
with or without food.
AFTER:
8. Take missed doses as soon as
possible unless almost time for next
dose. Do not double doses
9. Do not discontinue abruptly; may
cause increase in frequency of
seizures.
10. Do not resume driving until
physician gives clearance based on
control of seizure disorder.
11. Don’t store these drugs in moist or
damp areas, such as bathrooms.
12. Keep these drugs away from light.

36
 NAME OF DRUG MECHANISM OF ACTION INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
GENERIC NAME: Directly increases Treatment of simple and CNS: Epilepsy, tremors, BEFORE
Valproic acid concentration of inhibitory complex absence (petit mal) drowsiness, dizziness, 1.Baseline assessment
BRAND NAME: neurotransmitter gamma- seizures (monotherapy headache, Asthenia 2. Assess B/P, pulse, respirations
Depakene aminobutyric acid (GABA). preferred due to unpredictable GI: Abdominal pain, diarrhea, immediately before administration.
CLASSIFICATION: Therapeutic Effect: interactions, increased risk of nausea, vomiting, Constipation, 3. Review history of seizure disorder
Anticonvulsant, antimanic, Produces anticonvulsant hepatotoxicity). Adjunctive dyspepsia (intensity, frequency, duration, level of
antimigraine effect, stabilizes mood, therapy of multiple seizures GU: irregular consciousness).
PREGNANCY CATEGORY: prevents migraine headache. (Stavzor). menses, 4. Assess behavior, appearance,
D Treatment of manic episodes SKIN: skin rash, emotional status, response to
DOSAGE: with bipolar disorders, environment, speech pattern, thought
25 mg/kg complex partial seizures. content.
ROUTE: Prophylaxis of migraine DURING
PO headaches. OFFLABEL: 5. Monitor serum hepatic function tests,
FREQUENCY: Status epilepticus. bilirubin, ammonia, CBC, platelets.
OD 6. Monitor for clinical improvement
TIMING: (Decrease in intensity/frequency of
8 seizures).
7. Assess for therapeutic response
(Interest in surroundings, increased
CONTRAINDICATION ADVERSE EFFECTS
ability to concentrate, relaxed facial

37
 expression).
Active hepatic disease, urea OTHER: Hepatotoxicity may
cycle disorders. Cautions: occur, particularly in first 6 mos. AFTER
History of hepatic disease, of therapy. May be preceded by 8. • Report if seizure control worsens,
bleeding abnormalities, pts at loss of seizure control, malaise,
high risk for suicide. weakness, lethargy, anorexia, suicidal ideation (depression, unusual
vomiting rather than abnormal changes in behavior, suicidal thoughts)
serum hepatic function test
results. Blood dyscrasias may occurs.
occur. 9. Avoid tasks that require alertness,
motor skills until response to drug is
established.
10. Inform physician if nausea,
vomiting, lethargy, altered mental
status, weakness, loss of appetite,
abdominal pain, yellowing of skin,
unusual bruising/ bleeding occurs.

38
NCP #1

DEFINING DIAGNOSIS SCIENTIFIC GOAL OF CARE INTERVENTION RATIONALE EVALUATION

CHARACTERISTIC ANALYSIS
S
Subjective: Total Self- care Clients with bipolr Short term: Short term:
“Ambot, dili ko ka disorder can go days After 8 hours of After 8 hours of
deficit related to
focus, walay gana I without sleep or food nursing nursing
lihok” as verbalized racing thoughts and not even realize intervention patient will intervention pt. was
by patient. they are hungry or be able to: Independent: able to:
and poor attention
tired. They may be on A. Verbalize how his 1. Let the patient A. Verbalize how his
1. To identify basis of
Objective: span secondary to the brink of physical condition affect his condition affect his
exhaustion but are self-care need. verbalize possible reason the care to be self-care need.
*Weight loss(from bipolar 2 disorder.
60kg on the first unwilling to stop or of deficient self-care provided. -Goal met
week, 56.5kg on the unable to rest or B. Propose B. Propose
sleep. They often such as inability to realistic goal for him
third or current realistic goal for him or
week) ignore personal herself concentrate, inability or herself
*Unpleasant odor hygiene as “boring” -Goal met
when they have making decision
*Drowsiness 2. To assess
“more important 2. Encourage patient to
things” to do. They readiness and
verbalize expectations or
tend to ignore or be
motivation for
unaware of health expected result such as
needs that can treatment.
improved sleep pattern,
worsen. C. Comply to
C. Comply to
pharmacologic and increased focus, well pharacologic and
People with bipolar non-pharmacologic non-pharmacologic
groomed and weight
disorder intervention. intervention.
experience mood gain. 3. To identify -Goal met
swings, they go from 3. Let the patient patient’s response to
episodes of very high
energy to extreme verbalize what are his treatment.
lows of depression. actions to meet goal D. Establish support
When depressed, D. Establish support system from family
people often do not system including family such as following
and friends
concentrate as well. and friends instructions for the -Goal met.
They may have

39
trouble thinking and treatment religiously. 4. Atleast to lessen
making decisions.
Dependent: daydreamng and
Almost anything can Long term goal:
become a distraction 4. Teach patient other unwanted After 3-4 days of
when they are down. nursing intervention
Long term goal: divertional activities thoughts.
Being unable to patient was able to:
concentrate can be a After 3-4 days of such as reading, 5. Pharmacologic
nursing intervention E. Perform effective
problem because it self- care such as
patient will be able to: listening to music, intervention is an
makes it hard for improved sleep
people E. Perform effective watching movies. effective treatment.
self- care such as pattern, improved
with bipolar disorder grooming and
improved sleep 5. Administer medication
to perform tasks  improved eating
pattern, improved as prescribed such as 6. May reduce anxiety habits.
Activities of daily grooming and
improved eating Lithium, 600 mg, oral, and increase -Goal partially met
living or ADLs are since the patient is
defined as “the stuff habits. BID. motivation. under observation if
we regularly do such Collaborative: he or she can
as feeding ourselves, maintain the
bathing, dressing, 6. Encourge family
activities.
grooming, work, members to support for
homemaking, and
leisure. However, better coping by giving
there are some that time for family and
might have difficulties
in performing self- friends to visit.
care. Self-care refers
to those activities an
individual performs
independently
throughout life to
promote and maintain
personal well-being.  Independent: 7. Lack of sleep can
Sleep Pattern: lead to exhaustion
Self-Care Deficit is the
inability of an and death.
individual to perform 7. Encourage the client
self-care. The deficit
may be the effect of to follow a routine of

40
temporary limitations, sleeping at night by 8. Talking with the
such as those one
offering daily sleeping client during night
might experience
while recovering diary. hours will interfere
from surgery, or the
8. Limit interaction with with sleep by
result of gradual
deterioration that the client at night and stimulating the client
erodes the individual’s
allow only a short nap and giving attention
ability or willingness
to perform the during the day by for not sleeping.
activities required to
restricting visitors at Sleeping excessively
care for himself or
herself. Also, patients night and to limit during the day may
who are suffering
morning nap to 30 mins- decrease the client’s
from depression may
not have the interest 1hr. ability to sleep at
to engage in self-care
night.
activities.
9. Limiting stimuli will
help encourage rest
9. Decrease stimuli F. Modify behavior
and sleep
F. Modify behavior before bedtime (dim through referral to
psychologist or
through referral to lights, turn off psychiatrist.
psychologist or television). -Goal partially met,

psychiatrist. Nutrition: 10. The client is since obervation

10. Frequently remind unaware of bodily takes time.

the client to eat by needs and is easily

always telling him/ her distracted. Needs
to eat on time and watch supervision to eat.
over until he finished
eating.
11. Constant fluid

41
11. Encourage frequent and calorie
high-calorie protein replacement are
drinks and finger foods needed. Client might
(e.g., sandwiches, fruit, be too active to sit at
milkshakes). meals. Fingers foods
allow “eating on the
run”.

Bowel Elimination:
12. Monitor bowel
habits; offer fluids and 12. Prevents fecal
foods rich in fiber. impaction resulting
Evaluate the need for from dehydration and
a laxative. Encourage decreased peristalsis.
client to go to the
bathroom.
Dressing/Grooming:
13. Lessens the
13. If warranted,
potential for
supervise choice of
inappropriate
clothes; minimize
attention, which can
flamboyant and bizarre
increase the level of
dress, and sexually
mania, or ridicule,
suggestive dress, such
which lowers self-
as bikini tops and
esteem and increases
bottoms.
the need for manic
defense. Assists client

42
 in maintaining
dignity.
14. Distractability and
poor concentration

14. Give simple step-by- are countered by

step reminders for simple, concrete

hygiene and dress instructions.

(e.g.,”Here is your
toothbrush. Put the
toothpaste on the 15. Treatment mut
brush”). inlcude referral for
Collaborative: proper diagnosis and
15. Refer patient to proper interventions.
psychologist for proper
treatment such as
psychotherapy.

43
NCP #2

DEFINING NURSING SCIENTIFIC GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS ANALYSIS
CHARACTERISTICS
OF CARE INTERVENTIONS

SUBJECTIVE: Risk for Violence: Bipolar disorders are SHORT TERM: SHORT TERM:
Self Directed and mood disorders that
“Gusto nako Others related to comprises of one or After 8 hours of nursing After 8 hours of nursing
mamatay. Ay mog manic phase as more manic or intervention the client intervention the client
duol nako, mapatay evidenced by hypomanic episodes will be able to: will be able to:
ta mo” as verbalized verbal threats and usually one or INDEPENDENT:
by the patient. against self and more depressive
others episodes with periods A. Understand and 1. Redirect agitation and 1. To relieve pent-up A. Understand and
of relatively normal repeat health teachings potentially violent hostility and relieve repeat health teachings
OBJECTIVE: functioning in regarding self-control behaviors with physical muscle tension. regarding self-control
between. They are and anger outlets in an area of low and anger
- Loud, threatening, said to be linked to management. stimulation (e.g., management. (goal was
profane speech biochemical punching bag). met)
imbalances in the
- Provocative brain and it is said
behaviors that the disease is
genetically 2. Teach the client and
2. To equip the client
- Verbal threats transferred. Bipolar II the family to recognize
family effectively with
against others disorder involves early signs and symptoms
resources and
periods of depression of escalating agitation or

44
- Verbal threats and periods of hypomanic behaviors interventions when
against self elevated mood, called (e.g., yelling cursing, client’s behaviors
hypomania. threatening, pacing, threatens the safety
intrusiveness, of self or others and
suspiciousness) that can the integrity of the
lead to full blown mania, environment.
Violent behaviour is
self-harm, assault or
relatively common in
violence.
bipolar disorder and
usually occurs during
acute manic episodes.
The relationship 3. To prevent
3. Help the client manage
between violence and escalation of early
angry, inappropriate or
psychotic symptoms phase of assault or
intrusive behaviors in a
has been widely violence
therapeutic but firm direct
described. This is manner.
consistent with other
psychiatric conditions
in which psychotic B. Adopt control of B. Adopt control of
symptoms are also feelings and not injure 4. Intervene immediately 4. To prevent harm or
feelings and not injure
correlated with an self or others. if the client demonstrates injury to self and
self or others. (goal was
increased risk of aggressive behavior others.
met)
violence. Some studies toward self or others.
have focused on the
presence of mood
congruent/incongruent 5. To help with
5. Remind the client to negative feelings
psychotic symptoms in continue seeking staff from
mania. It has been reaching to
when first experiencing destructive levels.
observed that manic frustration, anger,
patients with hostility or suspiciousness
incongruent psychotic rather than waiting until
symptoms score the negative thoughts and
higher for agitated, feelings are out of control,
aggressive behaviour. which can lead to
violence.

45
Behaviors in which an
individual
demonstrates that can 6. Involve client in activity 6. To keep the mind
be physical, emotional therapies (e.g., music relaxed and help
or sexual harmful to therapy, re motivational express feelings. Also
self or others. People therapy and bibliotherapy. to retreat unhealthy
with bipolar disorder defense of the client.
may be more of a
threat to themselves
than anyone else in
their lives. Innocent
bystanders may be
worrying unnecessarily 7. Motivate the patient to
C. Demonstrates C. Demonstrates
about their own safety express feelings and 7. To reduce
awareness of awareness of aggressive
when the reality is perceptions of problems. physiological distress.
aggressive and violent and violent behaviors by
that bipolar disorder
behaviors by expression of feelings.
can lead to a lot more
expression of feelings. (goal was met)
damage to the person
living with it.
8. Listen for verbal threats 8. To rule out verbal
or hostile remarks threats, physical
towards self or others. contact and acting
out may be
precursors or cues to
impending violence.

9. Praise the clients

efforts made to control 9. To reinforce
anger or hostility to self repetition of positive
and others. function behaviors.
LONG TERM: LONG TERM:

After 4 days of nursing After 4 days of nursing

intervention, the client intervention, the client
will be able to: will be able to:

46
 DEPENDENT:

D. Apply response to 1. Administer 1. To increase D. Apply response to

external controls (e.g., receptor sensitivity to external controls (e.g.,
medications) when antipsychotic drug, lithium serotonin. medications) when
potential or actual loss as ordered. potential or actual loss
of control occurs. of control occurs. (goal
was met)

COLLABORATIVE:
E. Practice refraining
E. Practice refraining 1. To control
1. Consult and provide a symptoms, from verbal threats and
from verbal threats and include
referral to a psychiatrist. loud, profane language
loud, profane language education and
toward others.
toward others. support groups.
(goal was met)

F. Evaluate display of
F. Evaluate display of 2. Associate together with 2. To ensure that nonviolent behavior
nonviolent behavior the family or SO to stay someone will look towards self and others.
towards self and with client. after the client and
(partially met)
others. help observe the
attempt of violence to
self and others.

47
DISCHARGE PLAN

DISCHARGE PLANNING
Subjective Data “Okay na ko. Ma-control na nako ako emotions and behavior.
Maka focus na ko sa mga buhatunon nako. Kabalo nako sa ako
buhaton if ever mutukar nasad ako sakit,” as verbalized by the
patient.
Objective Data  Able to control behavior and emotions
 Happy
 Effective decision making
 Absence of restlessness and fatigue
 Able to focus on certain tasks
Interventions:
Analysis From being hyperactive, euphoric, unusual talkativeness, easily
distracted, poor decision making, feeling sad, no interest,
restless, and feelings of worthlessness and hopelessness, the
patient is now happy, has good decision making, has interest in
almost all activities, and can control his/her behavior and
emotions. Patient was taught ways to relax, such as deep
breathing, to manage stress. Patient’s SO understands what
Bipolar 2 Disorder is and is doing the best to guide and look after
the patient’s welfare.
Planning After 15-30 minutes of patient teaching, the patient and his/her
family were encouraged to do these:
 Be safe with medicines.
 Take medicines on schedule to keep moods even.
 Go to counselling sessions.
 Get at least 30 minutes of activity on most days of the
week. 
 Get enough sleep.
 Eat a healthy diet.
 Try to lower stress.
 Do not use alcohol, cannabis, or illegal drugs.
 Learn the early signs of mood changes (e.g. increase
energy, decreased need for sleep, irritable, etc.). 
 Ask for help from friends and family when needed.
Activity Instructed patient to encourage him or her to join a physical
activity that he or she likes as this can foster interaction with
other people (e.g. walking, running, swimming, cycling, etc.);
encouraged him or her to exert his or her energy productively
but do not let him or her get over fatigued, too; physical activity
helps in getting good sleep but over fatigue might as well make
him/her uneasy and irritable. Encouraged the patient and family
to make his or her routine predictable and something like
ritualistic so that it will only be easy for him or her to grasp for
his/her independent functioning (e.g. making a morning
schedule for him/her to do once he/she wakes up).
Medications Educated the patient and SO with the purpose of each drugs and
its side effects; instructed not to take other medications without

48
 consulting with the physician to prevent harmful drug-drug
interactions; and instructed patient and SO to comply strictly
with the following prescribed medications:

1. Lithium, 600 mg, three times a day (8 am, 1 pm, and 6

pm);

2. Carbamazipine, 200 mg, two times a day (8am and 6

pm);

3. Lamotrigine, 25 mg, twice a day (8am and 6pm);

4. Valproate, 25 mg/kg, once a day (8 am);

5. 5. Risperidone, 2-3 mg, once a day (8 am).

Environment Encouraged the patient and the family to make sure that the
environment is clean and must be a good place to stay.
Homemaking services and emotional and economic support
systems are in place. Encouraged the patient and family to
involve his or her daily activities in a quiet and non-stimulating
area (e.g. free from arguments, drugs, alcohol, noise, etc.) to
prevent him or her from interruptions in sleeping patterns,
becoming easily distracted, or hyperactive.
Treatment Advised patient and family to follow instructions on the patient’s
treatments (e.g. medications, counseling, etc.). Advised patient
and family to report immediately by any changes in symptoms.
Emphasized importance of compliance to home medications
prescribed by the physician.
Health Teaching The patient and the family were taught how to administer
drugs and treatments when necessary. Instructed the family to
monitor the patient’s behavior all the time. Encouraged patient
to take medicines on schedule to keep moods even. When
he/she feel good, he/she may think that he/she do not need
medicines. But it is important to keep taking them. Encouraged
patient and family to go to counselling sessions. Call and talk
with the counsellor if they can't go to a session or if they don't
think the sessions are helping. Do not just stop going.
Encouraged patient to get enough sleep. Keep the room dark
and quiet and try to go to bed at the same time every night.
Advised patient and family to try to lower the stress. Manage the
patient’s time, build a strong support system, and lead a healthy
lifestyle. To lower the stress, try physical activity, slow deep
breathing, or getting a massage. Encouraged the patient and
family to learn the early signs of mood changes (e.g.
hyperactive, extremely restless, easily distracted, feeling overly
happy, etc.). They can then take steps to help the patient feel
better. Encouraged patient to ask for help from friends and
family when he/she need it. He/she may need help with daily

49
 chores when he/she is depressed. When patient is manic, he/she
may need support to control your high energy levels.
Outpatient Referral  The patient and family were instructed to have available
telephone numbers of referred physicians and agencies. A
written discharge will be provided. It will be reviewed and
explained to the family.
 Instructed the patient and family to strictly comply with
the follow-up checkups which is important to check the
overall results from the given medications and health
teachings.
 Follow-up care in Vicente Sotto Memorial Medical Center:
Center for Behavioral Sciences (Psychiatric and
Psychological Services) on 05/04/2020 by Dr. Wendell
with all repeat laboratory results will be arranged. The
family will know the time, date, and location of
appointments given by the physician.

Diet The patient and family were taught foods that patient should
avoid (e.g. caffeine, alcohol, sugar, salt, and fat). Emphasized
eating a balance of protective, nutrient-dense foods. These foods
include fresh fruits, vegetables, legumes, whole grains, lean meats,
cold-water fish, eggs, low-fat dairy, soy products, and nuts and
seeds. These foods provide the levels of nutrients necessary to
maintain good health and prevent disease, in general. Encouraged
patient to watch caloric intake and exercising regularly to maintain
a healthy weight. 
Spiritual Encouraged the patient and family to go to church and attend
mass every Sunday. And pray for the betterment of the patient’s
condition.
Evaluation The goals were met. The patient exhibits improvement in
his/her condition and the family knows what to do to when
hypomanic episodes and depression occur. Records are
completed. Labs and Diagnostic Tests were already transcribed.

LEARNING OUTCOMES

1. Identified the etiology and disorder’s process.

2. Assessed the history, onset and prognosis of the disorder.
3. Recognized the prevalence of occurrence in adults and school age with
ADHD.
4. Explained the anatomy and physiology affected with the disorder.
50
 5. Recognized the signs and symptoms associated with the disorder.
6. Properly selected and study the licensed medication used to treat
ADHD.
7. Identified the nursing problems with regards to the given condition.
8. Formulated strategies and proper management on how to properly
handle person with ADHD.
9. Practiced therapeutic communication between nurse and patient
relationship.
10. Assessed the patient’s level of cognitive and behavioral function.

CONCLUSION

Bipolar disorder is a life-long illness that has far-reaching, often devastating,

consequences to both people afflicted with the illness and health care
professionals. It is common among primary care patients presenting with
depression; it is often treated exclusively in primary care. Ranked among the
leading causes of worldwide disability. Bipolar II disorder requires the
occurrence of at least one hypomanic episode and one major depressive
episode; it is no longer considered a milder form of bipolar disorder as it is
associated with considerable time spent depressed and with functional
impairment that accompanies mood instability. Between episodes, the
person’s mood may be stable for months or years, especially if they are
following a treatment plan. Treatment enables many people with bipolar
disorder to work, study, and live a full and productive life. However, when
treatment helps a person feel better, they may stop taking their medication.
Then, the symptoms can return.

Some aspects of bipolar disorder can make a person feel good. During an
elevated mood, they may find they are more sociable, talkative, and
creative. However, an elevated mood is unlikely to persist. Even if it does, it
may be hard to sustain attention or follow through with plans. This can make
it difficult to follow a project through to the end.

RECOMMENDATION

Recommendation for patient with bipolar 2 disorder is to managed mood

episodes with an emphasis on safety first, with medical consultation included
as early as possible, and with an evidence-based procedure that can be
extended into the maintenance process. Long-term care focuses on

51
preserving euthymia, necessitates continuing treatment, and can benefit
from adjunctive psychotherapy. Psychotherapy, also known as "talk"
therapy, is an integral component of bipolar 2 disorder care. They would talk
about patients’ emotions, opinions, and habits that are causing the issues in
therapy. Talk therapy will assist the patient in understanding and, ideally,
mastering any issues that are interfering with the ability to work effectively
with the life and career. Nurses should caution patient against making
drastic changes in their salt intake because increased salt intake can result
in lower serum lithium levels and effectiveness, whereas decreased intake
can result in higher levels and toxicity. Patients who are depressed are
encouraged to exercise; these individuals should try to establish a regular
daily schedule of major activities, especially at times when they are not
feeling well. Families and patients are advised to identify the signs and
symptoms of bipolar disorder, establish strategies for intervening early with
new episodes, and maintain medication regimen adherence as part of family
therapies for bipolar disorder.

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