ERA COLLEGE OF NURSING, LUCKNOW

ADVANCED NURSING PRACTICE

CASE PRESENTATION ON
“BIPOLAR AFFECTIVE DISORDER”

SUBMITTED TO: SUBMITTED BY:

MISS. GODHULI GHOSH
ASST. PROFESSOR
DEPT.- MED. SURG. NSG.
NSG.
ERA COLLEGE OF NSG.
SARFARAZGANJ, LKO.
PIN. 226003
DEEPIKA SONI
M.Sc. NSG. 1ST YEAR
DEPT.- MENTAL HEALTH
ERA COLLEGE OF NSG
SARFARAZGANJ, LKO.
PIN. 226003
 HISTORY FORMAT IN PSYCHIATRIC NURSING
I. IDENTIFICATION DATA
Name: Mrs. Vandana Kumari
Age: 29 year
Sex: Female
Diagnosis: Bipolar Affective Disorder
Spouse: Mr. Ajay
Address: Sitapur
Education: Graduate
Occupation: Housewife
Income: nil
Marital Status: Married
Religion: Hindu
Date of Admission: 07/07/2021
Informant: Husband and Mother
Information: Relevant

II. PRESENTING CHIEF COMPLAINT

In patient own words: hum theek h ...hume kuch nhi hua h ...humko chutti de dijiye

In Informants’ words:
Bahut jayada bolti hai, nonstop
Ek jagah pr nhi baith pati h, aur gaali bhi deti hai.

III. HISTORY OF PRESENT ILLNESS

Duration: 2 years
Mode of Onset: Incidious.
Course: continuous
Intensity: same
Precipitating Factors: small fight with her sister-in-law in his in-law house, before occurrence of
manic episodes as per her mother.
Description of present illness:
According to the informant, patient was well before 2 years, well settled in her in-law house,
maintain her daily activity properly and taking care of responsibility, but her husband starts to notice
that she used to sleep more around 14-16 hours a day, not active like before, not taking proper meal,
leave her stove turned on and use to stay alone. Also, he notices that she blames herself for each and
everything and create issue for every small thing then she starts to complain about anxiety and
headache, so they seek to local physician but did not get relief.
She also went to her mothers’ home where her symptoms remain same. As per her mother when she
returns to her in law house, there was a small fight between her sister-in-law regarding property.
At night, patient woke up from her sleep in between and starts to shout, abuse and remove her
clothes and became hyperactive. Then her (patient’s) father took her back to home and came to seek
for treatment at Era Hospital on 07-07-2021, under the consultation of Dr. Kushagra.

TREATMENT HISTORY

Drug: She seek Dr. Kushagra with her condition of episodic headache and anxiety.
Cap. Betacap TR (40) OD
Tab. Nexitoplus OD
 Cap. Cocid DSR OD
Tab. Naxdon 250 SOS
Syp. Overyme 2tsf TDS×5 days

She also went to Noormanzil Psy. Hospital, Lucknow, 1.5 year ago where doctor prescribed
following drugs:
Tab. Lithosum 300 mg
Tab. Nexito
ECT: Not done
Psychotherapy: Not specified
Family Therapy: Not specified
Rehabilitation: Not specified

IV. PAST PSYCHIATRIC AND MENTAL HISTORY

Number of previous episodes/ hospitalizations: episode of depression 1.5 yrs. ago
Complete/ incomplete remission: incomplete
Duration of each episodes: 1 year for Depression and 15 days for Mania
Treatment outcome: Not satisfactory
Details of any precipitating factor: Fight with her sister-in-law in her in law house between
21/06/20201 – 28/06/2021

V. FAMILY HISTORY
S.no Name Age Gender Education Occupation Relation Health
with history
patient
1. Shyam 58 yr. Male 10th std Farming Father Had
cardiac
disease
2. Geeta 53 yr. Female Illiterate Housewife Mother well
3. Ajay 37 yr. Male Graduation Farming Husband Well
kumar
4. Arvind 38 yr. Male 12 Std Business Brother Well
5. Sudha 31 yr. Female 12 Std Housewife Sister Well
6. Vandana 29 yr. Female MA Housewife Patient Ill
7. Khushbu 6 yr. Female - - Daughter Well
8. Nitin 2.5 Male - - Son Well
yr.

VI. FAMILY TREE

29 37
Family tree key:
Male
Female
Female patient

VII. PERSONAL HISTORY

1. Perinatal History
Antenatal period: No any complication
Intranatal period: Normal
Birth: At term
Birth Cry: Immediate
Birth defect: Not present

2. Childhood History
Primary caregiver: Mother
Feeding: Breastfeeding
Age at weaning: at 9 months
Developmental milestones: Normal
Behaviour and emotional problems: no any specific problem was present
Illness during childhood: Not present

3. Education History
Age beginning of formal education: At 5 years
Academic performance: she was good at her studies as per her mother
Extracurricular achievement: use to participate in curriculum activities
Relationships with peers and teachers: good
School phobia: Not present
Conduct Disorder: Not present

4. Play History
Game played: with doll along with play mates
Relationship with playmates: was good and cheerful

5. Emotional problems during Adolescence: Absent

6. Puberty
Age at appearance of secondary sexual characteristic: 12 years
Anxiety related to puberty changes: not present
Age at menarche: 15years
Reaction to menarche: normal, was not anxious
Regularity of cycle, duration: had regular, 30 days cycle but irregular while taking medicine
since 2019
Abnormality: not present

7. Obstetrical History
LMP: 16/06/2021
Number of children: 2
 Any abnormality: absent

8. Sexual and Marital History

Type of marriage: Arrange
Duration of marriage: 7 years
Interpersonal and sexual relation: was satisfactory but decreased desire for 1.5 years.

9. Premorbid Personality
Interpersonal relationships: Extrovert
Family and social relationships: involve happily
Use of leisure time: doing household chores, knitting sweater etc
Predominant mood: cheerful
Usual reaction to stressful event: become anxious and sad
Attitude to self and other: happy with her achievements
Attitude to work and responsibility: patient taking responsibility very effectively
Religious beliefs and moral attitudes: have faith in god
Fantasy life: not specified
Eating pattern: regular
Elimination: regular
Sleep: less than normal (3 hours a day and half hour in afternoon)
Use of drugs, tobacco, alcohol: absent

MENTAL STATUS EXAMINATION

First MSE was conducted on 09/07/2021

A. GENERAL APPEARANCE AND BEHAVIOUR
Appearance: Looking one’s age
Facial expression: pleasant but sometimes anxious
Level of grooming: well groomed
Level of cleanliness: Adequate
Level of Consciousness: Fully conscious and alert
Mode of entry: persuaded
Behavior: over friendly and aggressive
Co-cooperativeness: less than so
Eye-to-eye contact: maintained
Psychomotor activity: increased
Rapport: spontaneous
Gesturing: exaggreated
Posturing: Normal
Other catatonic phenomena: Absent
Conversion and dissociative sign: Not specified
Compulsive acts or rituals or habits: Absent
Hallucinatory behavior: Complains for hearing cricket sound and sing songs spontaneously (Elementary
hallucination)

B. SPEECH
Initiation: spontaneous
Reaction time: shortened
Rate: Rapid
Productivity: pressure
Volume: increased
Tone: high pitch
Relevance: sometimes off target
Stream: flight of ideas, circumstantiality and tangentiality
Clang association: Absent
Coherence: loose association
Other: Echolalia
Sample
Question: Aaj kaisa lga raha hai aapko?
Answer: Acha lag raha h
Question: Aap samaaj ke liye kya krna chahti h?
Answer: Hum chai banyege sbke liye, hamare ghr me 20-liter chai banti h.

C. MOOD AND AFFECT

Question: Aaj aap kaisa mehsus kr rahi hai?
Subjective: Achha lag raha hai, mai bilkull theek hun, mujhe chutti de dijiye.
Objective: elated
Predominant mood state: aggressive and elated mood.

D. THOUGHT
Stream: pressure of thought and flight of ideas
Form: Understandable
Delusion: Grandeur
Ideas: Flight of Ideas
Thought alienation phenomena: Absent
Obsessional /compulsive phenomena: Absent
Phobias: not specified

E. PERCEPTION
Illusions: Absent
Hallucinations: patient complains for hearing sound of beetle (Cricket)
Somatic passivity: Not specified
Deja vu / jamais vu: Not present
Depersonalization / derealization: Present

F. COGNITIVE FUNCTION (NEUROPSYCHIATRIC ASSESSMENT)

1. Consciousness: Conscious
2. Orientation:
a. Time: Able to differentiate between day and night
b. Place: Aware of the place and name of hospital
c. Person: oriented
3. Attention: Aroused with difficulty, cannot sit at one place
Digit forward: able to recall
Digit backward: Found difficulty
4. Concentration:
Distractible

5. Memory:
 Difficult in recalling 3 objects (Hawa, pankha, paani)
 Unable to recall her breakfast meal fully.

6. Remote
Personal event: Aware about various hospitals she went for treatment previously.
Impersonal events:
Not specified
Illness- related events:
Not clearly defined
7. Intelligence
Question: Yahan ke mukhya mantri kon h?
Answer: Yogi ji
Arithmetic: Able to solve equation of sum, subtraction, multiplication and division too

8. Abstraction
Interpretation of proverb
Ankho ka tara: Bhaut pyara
9 do Gyarah ho jana: Bhaag jana, paisa lekar bhaag gya
Similarities between Object:
Kitab or copy: Could not tell
Difference: Kitab se padhte h, padhai ki jati h

9. Judgement
Person-
Question: Aap yahan se theek hokr jab ghr jayegi to kya krengi?
Answer: Hum Pdhenge, khana banayenge, kaam karenge, tehlenge,Vidhayak banege, achaar banayenge.
Inference: Impaired
Social-
Question: Aap samaaj ke liye kuch karna chahti h?
Answer: Chai banayenge sbke liye
Inference: Impaired

Test-
Question: Agr aapka exam ho, or koi aapse bahar ghumne jaane ke liye bole tb aap kya krengi?
Answer: Patient starts to shout
Inference: Impaired

G. INSIGHT
1 Complete denial of illness but sometimes her insight lies in Grade 2

Second MSE was conducted on 13/03/2021

Inference: Everything was same, only visual hallucination was prominently auditory hallucination
Patient’s word: Anju (Patient’s step sister, died) khadi h vahan, vahi hume pagal kr rakhi h, mere sar pr
chadh jati h.
PHYSICAL EXAMINATION

Past medical History:

There is no specific past medical history of patient is found like diabetes mellitus, hypertension, thyroid etc.
Past surgical History:
There is history of cesarian section delivery in her both pregnancies.
General Examination
Body Type- Endomorphic
Posture- Normal
Gait- Normal
Activity- Hyperactive
Vital Signs
Temperature- 98.6 ̊F
Pulse- 68 bt/min
Respiration- 28 br/min
Blood Pressure- 110/90 mmHg
Height- 152 cm
Weight- 62 kg
Integumentary-
Patient have normal color, texture, moisture and temperature. No any abnormality found.
Hair and Scalp-
Patient hair color is black with equal distribution, no any abnormality is found.
Head and Neck-
No any abnormality is found
Eye-
No any abnormality is present in patient’s visual acuity, lens pupil, only conjunctiva is little pale due to low
Hemoglobin level.
Ear-
Normal hearing acquity
Nose-
No abnormal discharge or other abnormality was present
Mouth-
Patient tongue remains white coated due to improper cleaning, no other abnormality is found.
Heart-
No any specific abnormality was found.
Respiratory-
Patient have normal respiratory rate.
Breast-
No lump or abnormal discharge was present.
Abdomen-
No lesion, scar, bowel sound, or thrill was present.
Musculoskeletal-
No any abnormality was present, only patient used to do more activity example continuous walking in ward.

INVESTIGATION DONE

1. Complete hemogram-

S. No Investigation Name Patient value Reference Value

1. Hemoglobin 11.1 12-15g/dl
2. WBC 7.27 4-10 Thousand/MicroLtr
3. Platelet Count 138 15-450 Thousand/MicroLtr
4. RBC count 3.67 3.8-4.8 Million/MicroL
8. MCHC 34.7 31.5-34.5g/dl
9. RDW CV 14.0 11.6-14%
10. Neutrophils 66.3 40-80%
11. Lymphocytes 25.0 20-40%
12. Monocytes 2.6 2-10%
13. Eosinophils 5.5 1-6%
14. Basophils 0.6 0-1%
15. Mean Platelets Volume 14.1 9.4- 12.3 fL
16. Platelet Distribution Width 21.8 10.0-17.9%

LIVER FUNCTION TEST

1. Total Bilirubin 0.36 0.3-1.2 mg/dl
2. Direct Bilirubin 0.11 <0.3 mg/d
3. Indirect Bilirubin 0.25 <1 mg/dl
4. ALT/SGPT 30.0 10-28 U/L
5. AST/SGOT 25.7 <31 U/L
6. ALP 65.9 30-90 U/L
7. Total Protein 6.72 6.4-8.3 g/dl
8. Albumin 3.99 3.4-4.8 g/dl
9. Globulin 2.73 2-3.5 g/dl
 10. A/G Ration 1.46 1.5-2.5 g/dl
KIDNEY FUNCTION TEST
1. Serum Urea 14.7 13-43 mg/dl
2. Creatinine 0.66 0.7-1.3 mg/dl
3. Uric Acid 5.03 3.5-7.2 mg/dl
4. Serum Calcium 9.25 8.6-10mg/dl
5. Phosphorus 3.03 2.7-4.5 mg/dl
6. Sodium 139.25 135-145meq/l
7. Potassium 4.26 3.5-5 meq/l
8. Chloride 106.58 98-107 meq/l
LIPID PROFILE SERUM
1. Total cholesterol 121.0 <200 mg/dl
2. Triglycerides 239.1 <150 mg/dl
3. HDL 33.2 40-60 mg/dl
4. VLDL 47.82 2-30 mg/dl
5. LDL 39.98 100-129 mg/dl
6. Cholesterol/HDL Ratio 3.64 <4.5 mg/dl
LITHIUM LEVEL
1. Lithium+ 0.79

1. FT3 5.26 3.5-6.5 pmol/L

2. FT4 17.5 11.5-22.7 pmol/L
3. TSH 2.54 0.35-5.5 IU/ml

YOUNG’S MANIA RATING SACLE

DATE SCORE INFERENCE
02/03/20201 45 Severe Mania
05/03/20201 42 Severe Mania
08/03/20201 32 Moderate mania
11/03/20201 28 Moderate mania

INTERPRETATION:
The YMRS total score ranges from 0 to 60 where higher scores indicate more severe mania, thus, a negative
change (or decrease) from baseline indicates a reduction (or improvement) in manic symptoms. Total score: 
≤12 indicates remission
13-19=minimal symptoms
20-25=mild mania
26-37=moderate mania
38-60=severe mania

TREATMENT
S. no. DRUG NAME DOSE FREQUENCY
1. Tab. Clonazepam 4mg OD
2. Tab. Olanzapine 25 mg BD
 3. Tab. Chlorpromazine 300 OD
4. Tab. Lithium 1200 mg OD
5. Tab. Valproate 100 mg BD
6. Inj. Haloperidol+ Inj. Phenergan 0.5 mg + 25 mg Stat

BIPOLAR AFFECTIVE DISORDER

BOOK PICTURE OF DISEASE CONDITION

HISTORICAL PRESPECTIVE
Documentation of the symptoms associated with bipolar disorder dates back to about the second century in
ancient Greece.
Aretaeus of Cappadocia, a Greek physician, is credited with associating these extremes of mood as part of
the same illness. He described patients who could at times laugh and play all night and day but at other times
appeared “torpid, dull and sorrowful”.
His view that these moods swings were part of the same illness did not gain acceptance until much later.
The modern concept of manic- depressive illness began to emerges in the 19th century. In 1854, Jules
Baillarger presented information to the French Imperial Academy of Medicine which he used the term Dual-
form insanity to describe the illness.
In the same year, Jean-Pierre Falret described the same disorder, one with alternating periods of Depression
and manic excitation, with the term circular insanity, who also noticed that this disorder appeared to have
genetic underpinnings, a belief that is adhered today.
Contemporary thinking about bipolar disorder has been shaped by the works of Emil Krapelin, who first
coined the term Manic-Depressive in 1913. He added that this disorder was characterized by acute episodes
followed by relatively symptom- free periods.
In 1980, The American Psychiatric Association adopted the term Bipolar disorder as the diagnostic category
for manic- depressive illness in the third edition of Diagnostic and statistical Manual of Mental Disorders.
This term identified a period of mood elevation and excitation as a defining characteristic of the disorder
that distinguishes it from other mood or psychotic disorders.

DEFINITION
“A disorder associated with episodes of mood swings ranging from depressive lows to manic highs.”
INCIDENCE
Bipolar disorder affects approximately 5.7 million American adults, or about 2.6 % of the US population
aged 18 and older in a given year.
Of these cases 82. 9 % are considered severe (National Institute of Mental Health, NIMH, 2015)
In terms of gender, the incidence of bipolar disorder is roughly equal, with a ratio of women to men of about
1.2 to 1.
The average age of onset for bipolar disorder is 25 years and following the first manic episode, the disorder
tends to be recurrent. Unlike depressive disorders, bipolar disorder appears to occur more frequently among
the higher socioeconomic classes.
Bipolar disorder is the sixth leading cause of disability in the middle- age group, but for those who respond
to lithium treatment (about 33% of those treated within lithium), bipolar disorder is completely treatable,
with no further episodes.

CLASSIFICATION

F31.0- Bipolar affective disorder, current episode hypomania

F31.1- Bipolar affective disorder, current episode mania without psychotic symptoms
F31.2- Bipolar affective disorder, current episode mania with psychotic symptoms
F31.3- Bipolar affective disorder, current episode mild or moderate depression-
F31.4- Bipolar affective disorder, current episode severe depression without psychotic symptoms
F31.5- Bipolar affective disorder, current episode severe depression with psychotic symptoms.

TYPES OF BIPOLAR DISORDER

A Bipolar disorder is characterized by mood swings from profound depression to extreme Euphoria (Mania),
with intervening periods of normalcy.
Delusion or Hallucination may or may not be part of clinical picture and onset of symptoms.
During a manic episode, the mood is elevated, expensive or irritable.
Disturbance is sufficiently severing to cause marked impairment in occupational functioning with others or
to require hospitalization to prevent harm to self or other.
Motor activity is excessive and frenzied.

A somewhat milder degree of this clinical symptoms picture is called Hypomania.

Hypomania is not severe enough to cause marked impairment in social or occupational functioning or to
require hospitalization and it does not include psychotic feature.

Bipolar Disorder I
It is diagnosis given to an individual who is experiencing a manic episode or has a history of one or more
manic episodes. The client may also have experienced of depression this diagnosis is further specified by the
current and most recent behavioral episodes experienced.
Bipolar Disorder II
It is characterized by recurrent bouts of major depression with episodic occurrence of Hypomania.
The individual who is assigned this diagnosis may present with symptoms of depression or hypomania. The
client has never experienced a full manic episode, and the symptoms are “not severe enough to cause
marked impairment in social or occupational functioning or to necessitate hospitalization”.
The diagnosis may specify whether the current or most recent episode is hypomanic, depressed or with
mixed features. If the current syndrome is a major depressive episode, psychotic or catatonic features may
be noted.

Cyclothymic Disorder
The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years duration,
involving numerous periods of elevated mood that do not meet the criteria for a hypomania episode and
numerous periods of depressed mood of insufficient severity or duration to meet the criteria for major
depressive episode.
The individual is never without the symptoms for more than 2 months.
Substance/ Medication – Induced bipolar Disorder
The disturbance of mood associated with this disorder is considered to be the direct result of physiological
effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse or a medication).
The mood disturbance may involve elevated, expansive or irritable mood with inflated self-esteem,
decreased need for sleep and distractibility. The disorder cause clinically significantly distresses or
impairment in social, occupational or other important areas of functioning.
Mood disturbances are associated with intoxication from substances such as alcohol, amphetamines,
cocaine, hallucinogens, inhalants, opioids, phencyclidine sedatives, hypnotics and anxiolytics. Symptoms
can also occur during withdrawal from substances such as alcohol, amphetamines, cocaine, sedative,
hypnotics and anxiolytics.
A number of medications have been known to evoke mood symptoms. Classification includes anesthetics,
analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian, agents, antiulcer agents,
cardiac medications, oral contraceptives, psychotropics medications, muscle relaxants, steroids and
sulfonamides. Some specific examples are included in the discussion of predisposing factors associated with
bipolar disorder.
Bipolar Disorder Due to Another Medical Condition
This disorder is characterized by and persistently elevated or irritable mood and excessive activity or energy
judged to be the direct psychological consequences of another medical condition.
The mood disturbance causes clinically significant distress or impairment in social, occupational or other
important areas of functioning. Types of physiological influences are included in the discussion of
predisposing factors associated with bipolar disorder.

ETIOLOGY
BOOK PICTURE1 PATIENT PICTURE
1. GENETIC -
Bipolar disorder strongly reflects an underlying
genetic vulnerability. It has been found that
schizophrenia and bipolar disorders had about 15 %
of genetic variation in common
2. TWIN STUDIES -
Bipolar disorder among monozygotic twins has
identical genes, compared to 10-20 % in dizygotic
twins
3. FAMILY DISORDER -
If one parent has a mood disorder, the risk that a
child will have a mood disorder is between 10-25
%, If both parents have the disorder, the risk is 2-3
times greater
4. OTHER GENETIC STUDIES -
 ANK3 protein, located on the first part of
the axon, is involved in making the
determination of whether a neuron will fire,
Its increase expression may cause mania
symptoms.
 CACNA1C protein regulates the influx and
outflow of calcium channel blockers
sometimes used in the treatment of Bipolar
Disorder
5. BIOGENIC AMINES -
 Functional Excess of norepinephrine and
dopamine is associated with Mania
 SSRI sometimes triggers the manic episodes
and rapid cycling of mood swings in client
with bipolar disorder
 Acetylcholine is another neurotransmitter
believed to be related to symptoms in
bipolar disorder]
 Excessive levels of Glumate, an excitatory
neurotransmitter, have been associated with
bipolar disorder
6. NEUROANATOMICAL FACTORS -
 Dysfunction in the prefrontal cortex, basal
ganglia, temporal and frontal lobes of the
forebrain and part of the limbic system
including the amygdala, thalamus and
striatum
 As per Sadock and associates report widely
replicated positive emission tomography
PET demonstrates decreased anterior brain
function on the left side in depression and
greater right-side reduction in brain activity
in mania.
7. MEDICATION SIDE EFFECT -
 Steroid’s medication used to treat chronic
illness such as multiple sclerosis and
systemic lupus erthematousus.
 Amphetamines, antidepressants and high
doses of anticonvulsant and narcotics also
have the potential for initiating a manic
episode

8. PSYCHOSOCIAL THEORIES As per informant (patient’s husband) patient had an

 A link between childhood trauma (Emotional, emotional stress of her step sister’s death with
physical and sexual abuse) and the development of whom she was close, patient also has visual
bipolar disorder. hallucination of her step sister.
AAS and associates identify that childhood trauma
interacts with genes along several different
pathways, which influence not only an increased
risk for Bipolar disorder but also earlier onset, more
severe symptoms, substance use and suicide risk.

9. THE TRANSACTIONAL MODEL OF STRESS Patient’s stress adaptation capabiltiy was also poor
AND ADAPTATION

CLINICAL MANIFESTATIONS

Symptoms of manic state can be described according to three stages: Hypomania, Mania and Delirious

BOOK PICTURE PATIENT PICTURE

Stage I: HYPOMANIA
At this stage, disturbance is not sufficiently severe Present
to cause marked impairment in social or
occupational functioning or to required
hospitalization
MOOD-
 Cheerful and expansive Present
 Irritability due to unfulfilled wishes Present
COGNITION AND PERCEPTION
  Perception of the self are exalted- the Present
individual has ideas of great worth and
ability.
 Flight of ideas. Present
 Easily distractibility by irrelevant stimuli Present
ACTIVITY AND BEHAVIOUR
 Increased motor activity. Present
 Exhibits Extroverted and sociable Present
 Lack depth of personality and warmth to Present
formulate close friendships.
Present
 Talk and laugh a great deal, usually lod and
often inappropriate
Present
 Increased libido
Present
 Anorexia and weight loss in some case Present
 Inappropriate Behaviour like phoning the
President of India etc
STAGE II ACUTE MANIA
Symptoms of acute mania may progress in
intensification from those experienced in
hypomania, or they may be manifested directly.
Most individuals experience marked impairment in
functioning and require hospitalization
MOOD-
 Euphoria and elation Present
 Patient appears continuous “high”
 Frequent changes in mood, irritability and
anger or even to sadness and crying
COGNITION AND PERCEPTION
 Cognition and Perception become
fragmented and often psychotic.
 Racing of thought, over connection of ideas
and flight of ideas.
 Pressure of speech
 Incoherent and disorganized speech.
Present
 Hallucination and delusion (usually
paranoid and grandiose) are common.
ACTIVITY AND BEHAVIOUR
 Excessive psychomotor activity
 Increased sexual interest
 Poor impulse control and low frustration
tolerance
 Individual typically has little insight into
his or her behaviour and
communication.
 Denying of problem
 Energy seems inexhaustible and the
need for sleep is diminished.
 Individual may go for many days
without sleep and still not feel tired.
 Hygiene and grooming may be
neglected.
 Dress may be disorganized, flamboyant
or bizarre and the use of excessive
 makeup or jewellery is common.

STAGE III DELIRIOUS MANIA

It is a grave form of the disorder characterized by
severe clouding of conciousness and an
intensification of the symptoms associated with
acute mania.
This condition has become relatively rare since the
availability of antipsychotic medication.
MOOD-
Mood of delirious person is very labile.
Patient may exhibit feelings of despair, quickly
converting to unrestrained merriment and ecstasy or
becoming irritable or totally indifferent to the
environment.
Panic- level anxiety may be evident.
COGNITION AND PERCEPTION
Clouding of consciousness, with accompanying
confusion, disorientation and sometimes stupor.
Religiosity, delusion of grandeur or persecution and
auditory or visual hallucinations.
Individual is extremely distractible and incoherent.
ACTIVITY AND BEHAVIOUR
Psychomotor activity is frenzied and characterized
by agitated, purposeless movements.
Exhaustion, injury to self or other, eventually death
could occur without intervention.

INVESTIGATIONS AND DIAGNOSES

BOOK PICTURE PATIENT PICTURE

1. Criteria for Bipolar Disorder Diagnostic and Conducted

Statistical Manual of Mental Disorders (DSM-5), Conducted
published by the American Psychiatric Association.
and CD 10 CRITERIA
2. Perform physical examination Conducted
3. Mood Charting: Ask about your moods and Conducted
behaviours for a psychological evaluation
4. Blood test, urine test, thyroid function test Conducted
5. Young Mania Rating Scale Conducted

TREATMENT

BOOK PICTURE PATIENT PICTURE

 Mood stabilizers. Patient will
typically need mood-stabilizing
medication to control manic or
hypomanic episodes. Examples of
mood stabilizers include lithium Tab. Lithium
 (Lithobid), valproic acid (Depakene), Tab. Vaporate
divalproex sodium (Depakote),
carbamazepine (Tegretol, Equetro,
others) and lamotrigine (Lamictal).

 Antipsychotics. If symptoms of
depression or mania persist in spite of
treatment with other medications,
adding an antipsychotic drug such as
Tab. Olanzapine
olanzapine (Zyprexa), risperidone
(Risperdal), quetiapine (Seroquel),
aripiprazole (Abilify), ziprasidone
(Geodon), lurasidone (Latuda) or
asenapine (Saphris) may help. These
medications alone or along with a
mood stabilizer.

 Antidepressants.  doctor may add an

antidepressant to help manage
depression. Because an antidepressant
can sometimes trigger a manic
episode, it's usually prescribed along
with a mood stabilizer or
antipsychotic.

 Antidepressant-antipsychotic. The
medication Symbyax combines the
antidepressant fluoxetine and the
antipsychotic olanzapine. It works as a
depression treatment and a mood
stabilizer.

 Anti-anxiety
medications. Benzodiazepines may
help with anxiety and improve sleep,
but are usually used on a short-term
basis.

NURSING MANAGEMENT
1.) Nursing Assessment
Assessment of a patient with bipolar disorder include:
HISTORY- Taking a history with a client in a manic phase often proves difficult; obtaining data in several
short sessions, as well as talking to family members, may be necessary.
GENERAL APPEARANCE AND MOTOR BEHAVIOUR- Client with mania experience psychomotor
agitation and seem to be in continuous motion; sitting still is difficult; this continual movement has many
consequences; clients can be exhausted or injure themselves.
MOOD AND AFFECT- Mania is reflected in periods of euphoria, exuberant activity, grandiosity, and false
sense of wellbeing.
THOUGHT PROCESS AND CONTENT- Cognitive ability or thinking is confused and jumbled with
thoughts racing one after another, which is often referred to as flight of ideas; clients cannot connect
concepts, and they jump from one subject to another.

2.) LIST OF NURSING DIAGNOSES

 Risk of Injury related to extreme hyperactivity/ physical agitation as evidence by uncontrolled and
purposeless movements
 Risk of self- and other-directed violence related to impulsivity and Manic excitement as evidence by
her violent behaviour toward staff and self.
 Altered nutritional pattern less than body requirement as evidenced by patient refusal to eat food
properly at proper time.
 Impaired social interaction related to delusion though process (grandeur and persecution) as
evidenced by inability of patient to develop satisfying relationship and manipulation of others for
won desire.
 Altered family process related manipulative behaviour of patient as evidenced by their anxiety level
and query regarding patient’s illness

NURSING CARE PLAN

 HEALTH EDUCATION

Client Education for Lithium

The client should:

 Take medication on a regular basis, even when feeling well. Discontinuation can result in return of
symptoms.
 Not derive or operate dangerous machinery until Lithium levels are stabilized. Drowsiness and
dizziness can occur.
 No ignorance of dietary sodium intake. He or she should eat a variety of healthy foods and avoid
“junk” foods. The client should drink six to eight large glasses of water each day and avoid excessive
use of beverages containing caffeine (Coffee, tea, colas), which promote increased urine output.
 Notify the physician if vomiting or diarrhoea occurs. These symptoms can result in sodium loss and
an increased risk of lithium toxicity.
 Carry a card or other identification noting that he or she is taking lithium.
 Be aware of appropriate diet should weight gain become a problem. Include adequate sodium and
other nutrients while decreasing number of calories.
 Be aware of risks of becoming pregnant while receiving lithium therapy. Use information furnished
by health -care providers regarding methods of contraception. Notify the physician as soon as
possible if pregnancy is suspected or planned.
 Be aware of side effects and symptoms associated with toxicity. Notify the physician if any of the
following symptoms occur: persistent nausea and vomiting, severe diarrhoea, ataxia, blurred vision,
tinnitus, excessive urine output, increasing tremors or mental confusion.
 Refer to written materials furnished by health care providers while receiving self- administered
maintenance therapy. Keep appointments for outpatient follow-up; have serum lithium level checked
every 1 to 2 months or as advised by physician.

Client and Family Education for Anticonvulsant Mood Stabilizer

The client should:

 Refrain from discontinuing the drug abruptly. Physician will administer orders for tapering the
drug when therapy is to be discontinued.
 Report the following symptoms to the physician immediately: skin rashes, unusual bleeding,
spontaneous brushing, sore throat, fever, malaise, dark urine and yellow skin and eyes.
 Not drive or operate dangerous machinery until reaction to the medication has been established.
 Avoid consuming alcoholic beverages.
 Carry a card at all times identifying the names of medications being taken.
Client and Family Education for calcium Channel Blocker
The Client should:
Take medication with meals if gastrointestinal upset occurs.
Use caution when driving or when operating dangerous machinery. Dizziness, drowsiness and blurred vision
can occur.
Refrain from discontinuing the drug abruptly. To do so may precipitate cardiovascular problems. Physician
will administer orders for tapering the drug when therapy is to be discontinued.
Report occurrence of any of the following symptoms to physician immediately: irregular heartbeat,
shortness of breath, swelling of the hands and feet, pronounced dizziness, chest pain, profound mood
swings, severe and persistent headache.
Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure.
Avoid taking other medication (Including over the counter medication) without physicians being taken.

Client and Family Education for Antipsychotic

The client should:
 Use caution when driving or operating machinery.
 Refrain from discontinuing the drug abrupt after long term use. To do so might produce withdrawal
symptoms such as nausea, vomiting, dizziness, gastritis, headache, tachycardia, insomnia and
tremulousness.
 Use sunblock lotion and wear protective clothing when spending time outdoors as skin burn can
occur within 30 minutes.
 Report the occurrence of any of the following symptoms to the physician immediately: sore throat,
fever, malaise etc.
 Rise slowly from sitting or lying position to prevent a sudden drop in blood pressure.
 Take frequent sips of water, chew sugarless gum, in case of dry mouth. Good oral care is performed.
 Dress warmly in cold weather and avoid extended exposure to very high or low temperature as body
temperature is harder to maintain with these medications.
 Avoid drinking alcohol or related drinks.
 Avoid taking other medication without physician approval.
 Be aware of possible risks of taking antipsychotic during pregnancy.
 Be aware of side effects of antipsychotic medications. Refers to written materials furnished by health
care providers for safe self- administration.
 Continue to take the medication even if feeling well. Symptoms may return if medication is
discontinued.
 Carry a card at all times describing medication being taken.

PROGNOSIS
Prognosis of patient is based on following factors:
Bipolar Disorder – Good and Poor prognostic Factors
Good prognostic Factors Poor prognostic Factors
 Abrupt or acute onset
 Severe depression
 Typical clinical features
 Well-adjusted premorbid personality
 Good response to treatment
 Double depression
 Comorbid physical disease, personality
disorder or alcohol dependence
 Chronic ongoing stress
 Poor drug compliance
 Marked hypochondriacal feature or mood
incongruent psychotic feature
My Patients Prognosis
Day 1: Patient was irritable, anxious and do not want to talk
Day 2: Try to maintain rapport with patient.
Day 3: Patient was expressive, her symptoms were at peak for example increased libido, high pitch, volume
speech, hyperactivity etc.
Day 4: Patient wants to be involved in activities like origami making, drawing but for a short period of time,
complains for visual delusion and delusion of persecution
Day 5: Due to increase excitement of patient and hyperactivity, patient was tended to be sedate. Patient
remains calm due to effect of drug.

SUMMARY:
In this case presentation, I discussed about condition Bipolar Affective Disorder, Patient’s history, mental
status examination, physical examination, Investigation, young mania rating scale which I applied to my
patient, Treatment, about disease condition, its historical perspective, definition, incident, classification,
type, aetiology, clinical manifestation, Investigation, treatment of my patient in comparison to book picture,
Nursing management and nursing care plan after formulating nursing diagnosis as per priority, health
education and prognosis.

CONCLUSION
With the help of this Case Prestation, I was able to understand Bipolar Affective Disorder properly. As is a
common psychiatric disorder characterized by affective instability and cognitive deficits, particularly during
mood episodes and Abnormalities within the ALN and related brain regions appear to be involved in the
neurophysiology of bipolar disorder, it is important to have knowledge and to educate family member so
that they could accept the symptoms of patient and can contribute in the treatment of patient.
 BIBLIOGRAPHY
1. Valfre Morrison, Foundations of Mental Health Care, 6 Edition, published by Elsevier, page no: 242-243
2. Boyd Ann Mary, Psychiatric Nursing contemporary practice, sixth edition, published by Wolters Kluwer,
page no: 407-415.
3. Stuart. W Gail, Principles and Practice of Psychiatric Nursing, 10 editions, published by Elsevier, page
no: 292-293
5. Sreevani R, A Guide to Mental Health and Psychiatric Nursing, 4 Edition, published by Jaypee Brothers,
page no,208-210
6. Townsend C Mary, Morgan I Karyn, Psychiatric Mental Health Nursing, Concepts of care in Evidence
Based Practice, 9th Edition, Published by Jaypee Brothers, Page no:542-557