Table of contents

Contents Page no.

Part one
1) Background
2) Bio-data of the patient
3) Presenting complains
4) History of present illness
5) Past history
6) Personal history
7) Family history
8) premobid personality
9) Legal history
10) Hobbies
11) Examination of patient
12) Mental state examination
Part two (mania)
1) Introduction
2) Classification
3) Epidemiology
4) Etiology
5) Signs and symptoms
6) Diagnostic criteria
7) Diagnostic procedure
8) Treatment
9) Nursing management
10) Discharge teaching
11) Complication
12) Prognosis
13) Nursing care plan
14) Summary and Conclusion
15) Reference
 Acknowledgement

This case study on “mania” is prepared during our ‘two weeks’ clinical assignment at TUTH. This
report is prepared as a partial fulfilment of “BN curriculum” for hospital nursing minor in
psychiatric.

We remain very much greatful to madam “Chandra kala Sharma” and “Durga subedi” for her
continuous supervision, guidance, support, direction, encouragement and sedulous leadership
throughout the case study. We would like to express our sincere gratitude to the entire Doctor’s
team and the psychiatric ward sister incharge “Bimala Tamang” along with all the staffs concerned
with the care of my patient for their help and co-operation.

Our special thanks goes to my patient “Nirmala Koirala” and her husband for granting us
permission to conduct this case study, providing valuable information, time and co-operation that
allowed us to complete this case study successfully and finally we would like to express our
sincere gratitude to all the seen and unseen members who helped directly and indirectly on
making this case study.

Yours sincerely

Nirmala paudel

Parbati lamichhane

Background
This case study is prepared as a patient fulfilment of hospital nursing practicum (minor in
psychiatric) of 1st year BN which was carried out during the two weeks of clinical posting at TUTH,
Maharajgunj.

As per BN curriculum, we were assigned to various responsibilities in psychiatric and D. Addiction

ward. We had to conduct a case study during the two weeks of posting. We had selected a case
of “mania” in TUTH for our case study.

Mental health is a major aspect of health. Health cannot be defined without mental health.
Mentally ill person are increasing day by day in our society because of different contributing
factors 15-25% of patient presenting to general population in Nepal have neurotic condition , 2%
of the population estimated to be totally dysfunction due to their mental disorder. In Nepal there
are very few psychiatrics as compared to total population.

In Nepal, there is less concern from government for mental illness. In order to decrease and to
treat mental illness, government and Nepalese people should show adequate awareness for this
side.

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Bio-data of the patient
Name – Nirmala koirala

Age – 27yrs

Sex – female

Diagnosis – Mania

Ward – psychiatry

Bed no. – 10

I.P. no. – 417886/068

Marital status – married

Education status – IA (educated)

Occupation – Housewife

Religion – Hindu

Caste - Brahamin

Residence – Naubise, Dhading

Date of admission – 068-1-14

Date of discharge – 068-2-7

Hospital admitted days – 25 days

Attending doctor – Dr. Vidya Dev Sharma

Source of Referral
Informant:

Name – Deepak koirala

Age – 29 yrs
Relationship – Husband

Intimacy – close relationship staying together from the date of marriage

Reliability of information – reliable

Adequacy of information – adequate

5
Presenting complaints

Patient (when taking history on 068-2-3)

 Drowsiness and feeling sad

 Headache
 Constipation
 Pain abdomen from today morning

Visitors

According to her husband, her condition is more improving and she is almost normal now (on
date 068-2-3). He said that patient was admitted on psychiatric ward on 068-1-14 as patient
shows following behaviours.

 Grandiose talk
 Over talking
 Increased cheerfulness , alternating with increased irritability
 Singing and dancing
 Self muttering
 Hallucinating behaviour and delusional behaviour.
 On and off fearfulness
 No sleep at all
 Spitting to other

6
History of presenting illness
The patient is 27 yrs old female with the provisional diagnosis “mania”. The patient was
apparently Wright 3days back when patient partly noticed marked change in patient’s
behaviour. According to her husband, they had a mild dispute at home but had already
settled. It was at 12am in morning when suddenly patient started weeping continuously
for 5-10mins. She reported being very fearful And immediately than after started shouting
loudly. She became very talkative and cheerful at the same time. She started making
grandiose talking like She would talk on and on. When stop talking, she would spit to
others. She also became aggressive and started biting family member. She did not allow
other to talk and started becoming irritable. She also was seen responding to voice not
heard by others. She also scolded people around saying they are compiring against her.
She would go to each person’s place and would say and so on. So delusion of perception
and reference. She would seem to be self muttering (not undustable) with other delusion
and hallucinating behaviours like and on and off.
As patient showed these types of behaviours, she was brought to Kathmandu at TUTH,
emergency ward. Inj loree 4mg IV stat given and admitted to psychiatric ward TUTH.After
getting treatment for 9 days, she became oriented, intact insight, aggressive behaviour
comes to normal. She started to perform her daily routine i.e. morning care, maintaining
personal hygiene, normal appetite, normal sleeping pattern and had normal response. In
conclusion after treatment she was improving much. She was stable during our clinical
posting. Her behaviour was manageable but on date 068-2-3, she complained abdomen
pain. So surgical consultation was done. Doctor prescribed tab meftal 500mg TDS. Now
she has no pain.

Past history
The patient has no any history of other medical and surgical problems but she had similar
symptoms 8yrs back. So she was admitted in TUTH, psychiatric ward for one and half
months. She took medicine only for 2 months than stopped.

Personal history
The patient was born at home at term. The details of her childhood period could not be
verified but was apparently normal. She cried immediately after birth. There is no history
of cyanosis, persistent jaundice, fever, seizure, or any abnormalities at birth. No exact
normal weight was found, according to visitor (her aunt), she seemed as normal as other
newborn baby. There was no any prenatal and postnatal complication.The patient grew up
in Kathmandu valley. Normal milestone of development in infancy and childhood. No any
neurotic symptoms like thumb suckling bed wetting, temper tantrums etc proper social
relationship.
She passed her scholar from Bishow Niketan Tripureshwor and
completed IA from padmakanya campus, bagbazar. But she stopped her study after
marriage two years back. She loves music and used to spend her leisure time listening to
music and watching TV.
Her age of menarche is 13yrs and no any abnormal reaction.
 Her menstrual cycle was irregular. Her last menstrual period is 2 weeks ago.
She got married before two yrs. She has a normal relationship with her husband. She had
mild dispute with other members of family. She has one child of seven months. No
history of other sexual partner except with her husband.
Family history
Patient has joint family. At present there are 5 members in her family i.e. family in law,
mother in law, her husband, patient and her daughter.
Family history is negative for psychiatric disorders, medical disease (chronic), dementia,
addiction (alcohol drugs), suicidal attempts and violence.
Premobid personality
According to her husband, she had no any bad habits like smoking, drinking etc but is
ambitious and has habit of spending more money. It is very difficult to change this habit.
She used to become easily irritated. She has no any specific traits
Legal history
She was not involved in any kind of criminal activities and does not have any history with
legal problems.
Hobbies
Watching TV and singing songs

Examination of patient
General physical examination
General appearance.
- General condition hair
- Good personal hygiene
- Well grooming / dressing according to season
- No pale but looks sad
- Good posture and gait

Vital signs

- Bp- 100/80 mm of Hg
- Pulse- 96 b/m
- Respiration- 22 br/m
- Temperature- 36.4 degree c
- Weight- 53 kg
- Height-5ft

Systemic examination

Head and neck--On examination of patient’s neck, face, revealed no any

Neurological
 abnormalities.

Chest --Normal shaped, adequate air entry, bilaterally no wheezing and crepitus

sound. No any murmur sound of heart.

Abdomen

Abdomen was soft, no organomegaly. No tenderness, bowel sound present.

Extremities

Normal motor activities, no any abnormalities found.

No any abnormalities

Anaemia – not present

Jaundice – not present

Mental state examination (done on 068-2-5)

1) General appearance and behaviour

Built- average
Appearance- wears kutas surbal (suitable to season)
Personal hygiene- well maintained
Groomimg – well grooming
Level of co-operation- co-operative
Level of communication- good
Psychomotor activity- normal
Overall behaviour- normal during interview.
No catanotic features or abnormal movement.

2) Talk or speech
Spontaneous speech
Reaction time –normal
Tone, pitch, volume: normal
Language- Nepali, understandable
Speech was relevant and good directed.

3) mood
Objectively-patient looks sad
Outcome- her emotional expression is liable of full range and appropriate to content.
4) Thought
- Forms and production
Production level is intact
 Goal directed talk, immediately after question
-Progression of thought
-no thought blocks, losing of association mutism
-no flight of ideas
-circumstantialities present
-content on thought
Outcome: There is no idea of suicide, abessessional idea are not present, no any abnormal
ideas present.(during interview time)
5) Perception

Outcome: No illusion and visual hallucination. No any other perceptual abnormalities

(during interview)

6) Attention and concentration

Outcome: she gave right answer in time so her attention and concentration is intact.
7) Memory
Immediate-

Recent –

Remote-

Outcome: Her immediate and recent memories are intact but remote memory is not
intact.

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8) Orientation
Time

Person
 Place

Outcome: She is oriented to the time place and person.

9) Intelligence
After assessing her education level we asked her

Outcome: Her intelligence is normal

10) Judgement
Social
During our interview session, patient sat comfortably, proper response to others and
had attentive and average concentration. Patient stay still during interview.
Test

Outcome: Her judgement is intact

11) Grasp on general knowledge

14
Outcome: Her general knowledge is average.
12) Insight

Outcome: Her insight is present.

 15

Mania

Introduction:

Mania is a mood disorder. It is the name given for the illness when the patient is excessively
happy and energetic. Usually manic occurs as a part of bipolar disorders i. e. Mania and
depression occurs in cycles (manic depressive psychosis) very rarely patients get only recurrent
attacks of mania alone without any history of depressive episode. Mania is now considered either
primary or secondary in nature. Primary mania is an attective or mood disorder. Secondary mania
occurs to a variety of organic disorders e.g. drug intact, infection, neoplasm, epilepsy or metabolic
disturbances.

Definition –

Mania is defined as “an abnormally and persistently elevated, expansive or irritable mood”

It is a psychiatric medical condition in which client manifests a clinical syndrome

characterised by extremely elevated mood, energy, hyperactivity unusual thought process with
flight of ideas and acceleration in speaking process.

Classification of mania (ICD 10)

 F 30.0 - Hypomania
 F 30.1 - Mania without psychotic symptoms
  F 30.2 - Mania with psychotic symptoms
 F 30.9 - Manic episode unspecified

Hypomania:

Hypomania is a lesser degree of mania in which abnormalities of most and behaviour are too
persistent but are not accompanied by hallucination or delusion. There is persistent mild elevation
of mood, increased energy and activity and usually marked feelings at well being and both
physical and mental efficiency. Increased sociality, talkativeness, over familiarity, increased sexual
energy and a decreased need for sleep are often present but not to extent that they lead to
severe disruption of work or result in social rejection.

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Mania without psychotic symptoms:

Mood is elevated out of keeping with the individual’s circumstances and may vary from carefree
joviality to almost uncontrollable excitement. Elation is accompanied by increased energy,
resulting in over activity, pressure of speech and a decreased need for sleep. Normal social
inhabitation are lost, attention cannot be sustained and there is often marked distractibility. Self
esteem is inflated and grandiose are freely expressed.

Mania with psychotic symptoms:

The episode meets the criteria for mania without psychotic symptoms and hallucination or
delusion. The commonest examples are those with grandiose, self referential or persecutory
content.

Classification according to DSM IV

 Hypo manic episode

 Manic episode
- Mild
- Moderate
- Severe
- Severe with psychosis

Epidemiology of mania

According to book,

 0.6 – 1 % adults will have mania during their life time.

 Onset is most common in late adolescence or early adulthood
 Incidence is more in
 Unmarried, separated or divorced cases
 Urban, upper socioeconomic groups
  Positive family history, monozygotic twins
 Drug induced manic disturbances.

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 Male : Female ratio 1:1 (bipolar disorders : males tend to have manic episode
first, cycling with depressive episode : females tend to have depressive episode
first circle with mania later)

Epidemiology of mania

(In TUTH Maharajgunj Hospital) in psychiatric ward

 Total patient of mania – 26 (from 2068-2-1) to 2068-1-31)

 Male – 12
 Female – 14
 Average age of onset –
 Religion – buddist
Hindu

Etiology – according to book

 Genetic or hereditary factors

 Interference in neurotransmitter functioning and regulation
 Stressful life events, for example bereavement, secondary mania can occur due to a
variety of –
 Neurological conditions, e.g.- multiple sclerosis, brain tumours, epilepsy, brain
functioning.
 Drug induced: corticosteroids, adrenergic steroids, l-dopa, antidepressants, and
stimulants.
 Co-morbid illness adversely affects the outlook for mania e.g. Alcoholism and substance
abuse.

Etiological factors in our patient

May be: - stress resulting from adjustment problems in the family. Conflict arised among family
members and relapse.

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Signs and symptoms of mania.(according to book)

 Behaviour associated with mania

1) Affective
 Elation or euphoria
 Expansiveness
 Humorousness
 Inflated self esteem
 Intolerance of criticism
 Lack of shame or guilt
2) Physiological
 Dehydration
 Inadequate nutrition
 Little need of sleep
 Weight loss
3) cognitive
 ambitiousness
 denial of realistic danger
 Easily distracted
 Has flight of ideas
 Thoughts of grandiosity
 Has illusions
 Lack of judgement
 Loose associations
4) Behavioural
 Aggressiveness
 Excessive spending
 Grandiose acts
 Hyperactivity
 Increased motor activity
 Irresponsibility or argumentiveness
 Poor personal grooming
 Provecativeness, Sexual over activity
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Signs and symptoms (in our patient)

Before treatment following signs and symptoms are seen:-

 Lack of shame or guilt

 Inadequate nutrition(disturbed appetite)
 No sleep at all
 Ambitiousness
 Thought of grandiosity
 Has delusional and hallucinatory behaviours
 Lack of judgement
 Loose association
 Aggressiveness
 Grandiose acts
 Hyperactivity
 Poor personal grooming
 Sad mood

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 Diagnostic criteria

At least three of the following must be present to a significant degree for at least 1 week.

 Grandiosity
 Decreased need for sleep
 Pressured speech
 Flight of ideas
 Distractibility
 Psychomotor agitation
 Excessive involvement in pleasurable activities without regard for negative consequences

Diagnostic procedure

According to book

 Interview technique
 History taking
 Mental status examination
 Physical investigation
I. Routine : general screening, e.g. haemoglobin, urinalysis (additional investigations
may be ordered in special populations)
II. Routine specific
 Based on diagnostic ,e.g. - liver function test in alcoholics
 Based on treatment e.g. – pre lithium, pre ECT work up investigations
 Based on ongoing management e.g.- blood counts in patients receiving
closepine.
III. Non routine : based on need and index of suspicion
IV. Common neuropsychiatry investigation:
 Electroencephalogram (EEG)
 Computed tomographic scanning
 Magnetic resonance imagine (MRI)
 Psychological assessment

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Diagnostic procedures in our patient

 Interview technique
 History taking
 Mental status examination
 Investigation
 Haematology
Hb = 14.9 gm%
 WBC = 10700 / cmm
Neutrophils = 61%
Lymphocytes = 36%
Monocytes = 02%
Eosinophils = 01
 Biochemistry
Blood sugar(R) = 4.4 m mol/ L

Urea = 4.7 m mol/ L

Creatinine = 87 m mol /L

Sodium = 142 m eq / L
Potassium = 4 m eq / L
SGPT (ALT) = 29 U/L
SGOT (AST) = 26 U/L
 Urine Re/ME
Colour – yellow
Reaction – acidic
Albumin – nill
Sugar – nill
WBC – 1-2 HPF
RBC – nill
Epithelial cells – 5-6 HPF
Cast, crystals – nill
 ECG

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Treatment according to book

A. Pharmacotherapy
I. Antipsychotic drugs
Antipsychotics block the post synaptic dopamine receptors in the basal ganglia,
limbic system. It is used to control agitation and psychotic features e.g.
Haloperidol, olanzapine, chlorpromazine.
II. Anti anxiety drugs
May be used for short term to control agitation and associated sleep disorder
E.g. Lorazepam, diazepam or alprazolam, clonazepam etc.
III. Calcium channel blockers
For e.g. . Verapamil; if lithium must be discontinued, gradual reduction over a few
weeks is associated with a lower risk of relapse than abrupt discontinuation .
IV. Anti manic agents
Anti manic called mood stabilizers are used for the treatment of bipolar disorders.
Commonly used lithium is considered a treatment of choice for the manic phase
 of the bipolar disorders other commonly used mood stabilizers are
carbamazepine, sodium valporate etc
V. Anti parkisonian drugs :
To present extra pyramidal side effects. Also be used in depending on the dose of
antipsychotic e.g.- trihexypheonidyl.
B. Electroconvulsive therapy
If the client is not responding to antipsychotic medications (when client is having acute mania
symptoms) or in early pregnancy to avoid the risk of birth defects due to drugs; ECT may be given
C. Psychotherapy
Marital therapy, behaviour therapy, family therapy and cognitive therapy certainly useful as
adjunctive therapies. To enhance interpersonal relations, family cohesion, ensures continuation of
treatment and adequate drug compliance, restores self esteem, adapts a new range of emotions
and workout to overcome to prevent relapses.

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Treatment in our patient.

A. Pharmacotherapy
i. Anti psychotic drugs
a. Tab olenz – RT 10 mg po x-x-3 (HS)
b. Tab chlorpromazine – 10 mg po 2tab (sos)

Mechanism of action:-

The exact mechanism of action is not known. These drugs are believed to work by blocking dopamine
receptors in the dopamine pathways of brain. This means that dopamine released in these pathways has less
effect. It may also be related to the inhibition of dopamine mediated transmission of neural impulses as the
synapses. Sedation is caused by alpha adrenergic blockade anti dopaminergic action on basal ganglia are
responsible for causing EPS.

Doses:-

a. Chlorpromazine – 300-1500 mg/day

b. Oleanz-RT – 10-20 mg/day

Indications

 Functional disorder
 Organic psychiatric disorder – such as delirium, dementia, drug induced psychosis etc
 Mood disorder – such as mania, major depression with psychotic symptoms
 Childhood disorder- such as autism, enuresis, conduct disorder etc
 Neurotic and other physical disorders
 Medical disorder like intractable hic cough ,nausea and vomiting etc
Contraindications

Hypersensitivity to phenothiazine derivatives, withdrawal states from alcohol, barbiturates and other non
barbiturates sedatives, comatose states, bone marrow depression, myasthenia gravis etc

Side effects

Dry mouth, blurred vision, constipation, urinary retention, sedation, orthostatic hypotension, tachycardia,
arrhythmias, photosensitivity, hypertensive crisis, weight gain.

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II. Antianxiety drugs

Inj loree 4 mg IV stat

Tab loree 2mg (sos)

Mechanism of action

The exact mechanism of action of benzodiazepines is not clear. These drugs are believed to work by bind to
specific sites on the GABA receptors and increases GABA level. Since GABA (Gamma – Amino – Butyric –
Acid) is an inhibitory neurotrasmitte, it has a calming effect on the central nervous system, thus reducing
anxiety.

Doses:-2-9 po/IM or IV

Indications

 Generalized anxiety disorder

 Adjustment disorder with anxious mood
 Panic disorder
 Agoraphobia and school phobia
 Sleep disorder
 Treatment of alcohol and drug withdrawal syndrome
 Acute mania
 Psychosomatic management
 Emergency management of acute psychosis
 Preoperative sedation
 Anticonvulsant use

Contraindications

 Hypersensitivity to any of the anxiolytic drug

 They should not be taken in combination with other CNS depressants.
 May make it dangerous to drive or operate some machinery
 Pregnancy and lactation
 Narrow angle glaucoma
 Shock and coma

Side effects
 Drowsiness, confusion, lethargy, orthostatic hypotension, paradoxical excitement, dry mouth, blood
dyscrasias etc

III. Antimanic agents

a) Tab valprol- CR 500 mg po 1-x-1

Mechanism of action:-

The specific biochemical mechanism of action of antimanic agents is unclear. It alters sodium metabolism
within nerve and muscle cell and enhances the reuptake of biogenic amines (nor epinephrine and serotonin)
in the brain, lowering levels in the body and resulting in decreased hypersensitivity. It may block
development of sensitive dopamine receptors in the CNS of manic patients.

Doses:- initially 15 mg/kg p.o. daily divided b.i.d or t.i.d ; then may increase by 5 to 10 mg/kg daily at
weekly intervals upto maximum at 30mg/kg daily, divided, b.i.d or t.i.d.

Indications: - Manic phase of bipolar disorder

Contraindications:-

 Individuals with hypersensitivity to the drug.

 Severe cardiovascular or renal diseases
 Severe dehydration
 Sodium depletion or receiving diuretics
 Brain damage
 During first trimester of pregnancy and lactation

Side effects:-

Drowsiness, dizziness, headache, dry mouth, thirst, gastrointestinal upset nausea/vomiting, fine hand
tremors, hypotension, pulse irregularities, arrhythmias, polyuria, dehydration, thirst .

V. antiparkisonian

Tab trihexypheonidyl 2mg po 1-x-1

Mechanism of action:-

Synthetic tertiary amine anticholinergic agents with actions, contraindications, precautions and adverse
reactions similar to those atropine (qv). Thought to act by blocking acetylcholine at certain cerebral synaptic
sites relaxes smooth muscle bye direct effects and by atropine like blocking action on parasympathetic
nervous system. Antispasmodic action appears to be on half that of atropine and side effects are usually less
frequent and less severe.

Doses:-

Initially 1mg ; increased by 2mg increments at 3 to 5 day intervals upto 6 to 10 my daily in 3 or more
divided doses. Some patients may require 12 to 15 mg daily, sustained- release capsule (5mg each) : 1 or 2
capsule daily in single or divided doses (maximum 4 capsule daily)
Indications:-

Encephalitic Used in symptomatic treatment of all forms of Parkinsonism (arteriosclerosis, idiopathic, post).
Also used to prevent or control drug induced extra pyramidal disorders.

Contraindications:-

Hypersensitivity to trihexyphenidyl, narrow angle glaucoma, cardiac diseases, renal or hepatic disorders etc

Adverse reactions-

Dry mouth, dizziness, blurred vision, photophobia, nausea, nervousness, insomnia, constipation,
drowsiness etc.

Nursing responsibility in administration of drugs

 Instruct the patient to take sips of water frequently to relieve dryness of mouth. Frequent
mouth wash, use of chewing gum, applying glycerine on the lips are also helpful.
 Advice the patient to get up from the bed or chair very slowly. Patient should sit on the
edge of the bed for one full minutes dangling her feet, before standing up. check BP
before and after medication. This is an important measure to prevent falls and other
complication resulting from orthostatic hypotension.
 A high fiber diet increased fluid intake and laxative if needed, help to reduce constipation.
 Administer medicine with food to minimize gastric irritation.
 While giving anti parkinsonian agents, assess for parkisonian and extrapyramidal symptoms.
Medicine should be tappered gradually.
 Explain about adverse effects and advice her to avoid activities that require alertness.

Nursing Management
We reviewed the patient’s history, observed her behaviour and interacation with her surrounding
including her relatives and her care taker. We did her physical examination as well as her mental
status examination. After assessing the condition,the following nursing care are provided to our
patient.

 Keep environmental stimuli to a minimum, assign single room, limited interaction with others, keep
lighting and noise level low.
 Remove hazardous objects (glass,belts,ties,matchboxes) and substances when there is possibility of
an accident.
 Assist patient to engage in activities, such as writing , drawing, and other physical exercise.
 Administer medication as prescribed by physician.
 Observe patient’s behaviour at least every 15 minutes
 Establish a trusting relationship to facilitate patient willingness to communicate thought and
feelings.
 Encourage verbal expression of feelings
 Provide high protein, high calorie, nutritious food and drinks (6 to 8 glasses of fluid per day) and
provide favourite foods.
 Maintain accurate record of intake and output.
 Weight the patient regularly
 Do not argue with patient and ingnore attempts by patient to argue.
 Give positive reinforcement for no manipulative behaviours.
 Identify clients social support system to minimize isolation.
 Engage selfcare activities in time when client may have more energy to increase activity tolerance
and minimize fatigue.
 Give clear instruction regarding taking medicine. Explain about side effects of medicine and how to
deal with it.

Health education (discharge teaching)

 Regarding the disease

Educate the patient with the following guidelines-
 Mania is an abnormally and persistently elevated, expansive or irritable mood.
 It can be caused by genetic, biochemical, stressors, medications and socio
cultural factors.
 Disease can be distinguished by various features such as elevated or irritable
mood increase, psychomotor activity , more talkative , flight of ideas etc
 Treatment of mania includes individual, groups, family, cognitive therapies,
psychopharmacology and electroconvulsive therapy.
 Regarding drugs
 Medicine should be taken on regular basis carefully as doses advised by doctor.
 Explain about the side effects of medication such as drowsiness, dizziness,
headache, confusion etc
 Advice the patient to avoid alcohol or alcohol containing medicines.
 Advice to have medicine after meal to minimize gastrointestinal distress .
 Consult doctor if side effects of medicine are seen
 Encourage to have plenty of fluids and roughage diet
 Regarding the patient condition
 encourage patient to ventilate feelings
 assess the patient behavioural activities closely for injury, suicidal ideas etc
 give reassurance to patient and family members
 explain patient and patient party about the condition, prognosis and treatment.
 Complications

 drug abuse
 suicidal thought
 mood swing
 withdrawal behaviours

Prognosis

80 to 90% recovers, recurrent occur over time in 50% relapse.

Sn Nursing Nursing Implementation Rational Evaluation

no. diagnosis goal

1 Prone for Patient will -Provided peaceful, safe >It helps to minimized goal was
violence be and low stimuli anxiety and completely
resulting prevented environment in the ward. suspiciousness. met as
causing from patient
harm to causing -observed the patient’s >It helps to detect her didn’t harm
herself or to harm to self behaviour regularly (every abnormal behaviour in self or
other or to other 15 minutes) time. others.
related to during
manic hospitalizati -ensured that all sharp >patient cannot use this
excitement on. objects, glass or mirror items to harm self or
and items, belts, ties, match box others.
perceptual have been removed from
disturbance patients environment

-warned the visitors about >It helps to protect her

possible attack when the care givers and also to
patient becomes aggressive. patient herself.

-accepted the clients >It helps to reduce

feelings be with her and anxiety and also makes
show positive attitude to the client to ventilate the
the patient. emotion.

-administered the drugs as -drugs help to improve

per order and explain to condition of patient and
the patient and his relatives brings change in her
its importance. behaviours.

-provided physical restraint It helps patient not to

to patient. harm herself and others.
Nursing care plan
 sn. Nursing Nursing implementation Rational Evaluation
no diagnosis goal
2 Disturbed The -Provided calm and >It prevents from Goal was
sleeping patient’s soothing environment. unnecessary met as
pattern sleeping stimulation to patient. patient
could sleep
related to pattern will -Observe the patient for >it helps to identifies
well.
anxiety. be any interruption of sleep pattern and causes of
improved . sleep disturbance.
after our -Be with the patient >It provides
nursing don’t leave alone psychological support
intervention. and helps to feel
-Give a glass of hot milk secure.
> it helps to promote
-Corrected nutritional sleep.
deficiencies by well >it decrease signs and
balanced diet symptoms associated
with nutritional
-Rub the patient’s back deficiency
to make comfortable > It provides relaxation
and comforts.
-Administer antianxiety
medicine as prescribed. >It inhibits
neurotransmiting
action and reduce
anxiety

Sn. no Nursing Nursing goal Implementation Rational Evaluation

Diagnosis
4 Knowledge Patient and -Assess the selfcare >It helps to know Goal was
deficit visitors will abilities, interaction about patient’s self fully met
related to gain pattern, care and as patient
follow up knowledge communication communication and
continuity of regarding abilities, family abilities, family visitors
 care and follow up support, situational support, situational knew
treatment continuity of guidance etc guidance etc about
care and -Send the client for >It helps to know follow up,
treatment trial visit to family how patient cope with continuity
after our environment family environment of care
nursing -Educate the client >It helps the patient
intervention and her family and visitors to gain
members regarding knowledge about
follow up visit follow up care and
continuation of medicine to be
medicine, care at continue
home and warning
signs of new mood
episode.

Sn.n Nursing Nursing goal Implementation Rational Evaluation

o diagnosis
3 Self care Patient will -Involved the patient >It helps the Goal was
deficit maintain self in self care such as patient to continue made as
related to care during brushing, bathing, self care. patient
disease the period of combing and maintain self
condition hospitalization. changing cloths. care during
-gave health the period of
education regarding >It helps to hospitalization
personal hygiene increase awareness
and its importance. of self.
-provided clean
environment to
patient >It helps to
motivate the patient
-made routine to in doing self care
the daily activities. by seeing good
environment.
>It helps the
patient to know the
self care activities to
be done during the
day.
Summary of progress of patient’s during hospital stay
Nirmala koirala 27 years married female admitted in the psychiatric ward of TUTH Maharajgunj on the date
of 14th baisakh 068 with diagnosis of Mania. She presented appetite, poor concentration, increase violence in
response to physical restraint. With biopsycho-social treatment her condition is improving. Symptoms of
hallucination, insomnia, and loss of appetite, big talk, and violent behaviour were reduced. Now she is stable.
She reacts appropriately and behaves normally with her family members, staffs and other persons. After
getting long treatment she was discharged on 068-2-7 at 1 pm with oral medications.

Conclusion

Comprehensive case study involved through work up of a patient suffering from a Mania. It gives
opportunity to learn about etiology, predispositing factors, its manifestations and holistic management of the
patient. The patient psychosocial and spiritual background in the patients cares to provide pragmatic and
individualised care.
Ms Nirmala koirala 27 yrs female diagnosis of mania was admitted on 068-1-14, bed no. 9 in psychiatric
ward of TUTH. We selected Ms Nirmala koirala because she was suffering from a common mental disorder
“Mania”.

During the case study we review her history; we also did physical examination and mental state examination.

We also provided her daily nursing care, health education to her and her care takers and taught stress
reducing technique which has positive impact in her health. At the beginning of hospital days, she seemed
to be over talkative, on and off, fearfulness, showed hallucinationatery behaviour etc. After few days of
treatment, her condition improved more than before during the case study, we were able to revise the
etiology, clinical feature, medical management and implementation of mania.

References
 Barbara S.j 1986, Psychiatric Mental health Nursing , J.B. Lippincott Company, page no. 280-99
 Keltner. N.L, Schwecke L.H and Bostrom C.E (1999), psychiatric nursing (4 th edition), Catherine
Albright Jackson.
 Neeraja, KP (2008), essential of mental health and psychiatric Nursing, Jaypee brothers medical (p)
Ltd, page n.o 401-5
 Sreevani, R (2004), A guide to Mental Health and Psychiatric nursing (1 st edition), Jitendarprij jaypee
brothers Medical, page no 49-52.
 Subedi D(2010), Mental Health and Psychiatric nursing (1st edition), Makalu house publication,
Page no 102-5
 Ahuja , N(2002), A short text book of psychiatry (5th edition).
 TRIBHUVAN UNIVERSITY

MEDICINE INSTITUTE OF

NURSING CAMPUS; POKHARA

POST BASIC BACHLOR NURSING PROGRAM

A case study report of Mania.

Submitted to submitted by;

Respected mam, Parbati Lamichhane

Chandra Kala Sharma Nirmala paudel