General Objective:

To enhance understanding on the nature and effective management of Bipolar Affective

Disorder (Bipolar 1)

Specific Objectives

● To define the Bipolar affective disorder

● To trace the disease process by the psychopathology of Bipolar affective disorder
● To illustrate the clinical signs and symptoms of Bipolar affective disorder
● To present the laboratory and diagnostic procedure and their importance
● To show the application of the Domains of mental status examination
● To determine the action of psychopharmacological intervention for Bipolar affective
disorder
● To formulate and provide an appropriate and effective nursing care plan for patients
with Bipolar affective disorder.

Overview

Bipolar disorders are brain disorders that cause changes in a person's mood, energy, and ability
to function. People with bipolar disorder experience intense emotional states that typically occur
during distinct periods of days to weeks, called mood episodes. These mood episodes are
categorized as manic (abnormally happy or irritable mood) or depressive (sad mood). People
with bipolar disorder generally have periods of neutral mood as well.

Bipolar disorder is a category that includes three different diagnoses: bipolar I (manic), bipolar II
(depressive), and cyclothymic (hypomanic and depressive) disorder.

Bipolar I disorder is diagnosed when a person experiences a manic episode. During a manic
episode, people with bipolar I disorder experience an extreme increase in energy and may feel
on top of the world or uncomfortably irritable in mood. Some people experiencing manic
episodes also experience disorganized thinking, false beliefs, and/or hallucinations, known as
psychotic features.

Bipolar disorder symptoms commonly improve with treatment. Medication is the cornerstone of
bipolar disorder treatment, though talk therapy (psychotherapy) can help many patients learn
about their illness and adhere to medications, preventing future mood episodes.

Patient’s Profile

Name: L. B.
Address: #109, Barangay Carsadang Bago 1, Imus, Cavite

Birthday: January 18, 1978

Age: 45 y/o

Place of Birth: Imus, Cavite

Religion: Roman Catholic

Status: Single

Case: Non-Court Case

Admission Date: October 03,2023

Admission Time: 9:45pm

Admitting Diagnosis: Undifferentiated Schizophrenia

Attending Physician: Dra. M.L Pang

Final Diagnosis: Bipolar Affective Disorder, Manic w/ Psychotic Symptoms

Past Medical History

History of Present Illness

The patient was apparently well until 2001 when he disembarked from a cargo ship and found
out that his girlfriend got married to someone else and was pregnant. Since then, he was noted
to talk to self, frequently stated Bible verses, and shouted at people unprovoked. No
consultation was done but he took herbal medicine and other alternative medications.
Symptoms were allegedly resolved and he was semi-functional, able to feed and care for
himself but without work, with tolerable relapses talking by himself and shouting at other people.

Three years prior to complaints, the patient was noticed to talk to himself and began preaching
on the streets. He continued being semi-functional and was tolerated. No consultation done.

Four days prior to complaints, he punched his niece and pointed a mop handle towards his
sister. Three days prior to admission, he hit his niece with a steel pipe. Few hours prior to
complaints, he wandered around the subdivision, shouting Bible verses and disturbing others in
their neighborhood, hence consulting and subsequent admission.

Socio-economic History

The patient lives with his older sister together with his brother-in-law and two nephews.
They lived in a two storey house that is concrete and well ventilated, located at 109 Brgy.
Carsadang Bago I, Cavite. Water for consumption was district water supply. His former job was
a seafarer for almost 5 years. The patient prefers to eat meat rather than vegetables.

Familial History

Disease Paternal Side Maternal Side

Bipolar Affective Disorder - -

Asthma + -

Anatomy & Physiology

The prefrontal cortex, which contains dorsolateral, ventromedial, and orbitofrontal circuits that
are thought to form a common anatomical structure in mood disorders, is one of the key regions
regulated by mood. The prefrontal cortex is the place where internal, external, conscious and
unconscious information from all sources is stored as memory, and information from organ
centers is organized and combined to determine behavior.
The Cingulate gyrus lies on the medial aspect of the cerebral hemisphere. It forms a major part
of the limbic system which has functions in emotion and behaviour. The cingulate gyrus is an
arch-shaped convolution situated just above the corpus callosum. The frontal portion is termed
the anterior cingulate gyrus (or cortex).

The hippocampus is one of several brain regions that together comprise the hippocampal
formation. The hippocampal formation is a prominent C-shaped structure bulging in the floor of
the temporal horn of the lateral ventricle. It is one of the important parts of the memory system,
is a part of the forebrain and located in the medial temporal lobe. A large number of afferent
fibers related to all senses enter directly or indirectly in the hippocampus. The hippocampus is
defined as the link region between perception and memory systems. The hippocampus is a part
of the fronto-limbic circuit associated with memory and it regulates mood together with
parahippocampal cortex and amygdala.

The lateral ventricles are paired C-shaped structures comprising a body and atrium along with 3
projections into the frontal, temporal, and occipital lobes, termed “horns.” The lateral ventricles
communicate with the third ventricle through the interventricular foramina of Monro. Each lateral
ventricle has an estimated capacity of 7–10 mL.

Psychopathology

Psychodynamics
 FRAMEWORK PSYCHODYNAMICS

TRUST VS. MISTRUST According to the patient, he is the youngest

INFANCY among 3 siblings of his parents.
(Birth -12 months)

to develop a basic trust in the mothering

figure & to generalize it to others.

AUTONOMY VS.SHAME & DOUBT

Toddler
(1-3 years old)

to gain some self-control and independence

within the environment.

INITIATIVE VS. GUILT

Late Childhood
(3-6 years old)
to develop a sense of purpose and ability to
initiate and direct one’s own activities.

INDUSTRY VS. INFERIORITY

School Age
(6-12 years old)
to achieve a sense of self-confidence.

IDENTITY VS. ROLE CONFUSION

Adolescence
(12-18 years old)
to integrate the tasks mastered in the
previous stages into a secure sense of self.

INTIMACY VS. ISOLATION

Young Adulthood
(18-40 years old)
to form an intense, lasting relationship or a
commitment to another person, a cause, an
institution, or a creative effort.

GENERATIVITY VS. SELF ABSORPTION

OR STAGNATION
Middle Adulthood
(40-65 years)
to achieve the life goals established for
oneself while considering the welfare of future
generations.
 Psychopharmacology

Name of Dose/ Mechanism Indication Contraindication Side effect Nursing

Drugs Route/ of actions Consideration
Frequency

Generic Dose: 2mg Blocks Acute ● Hypersen ● Head ❖ Obtain

Name: Route: per dopamine, 5- manic sitivity ache baselin
Risperidone orem HT2, alpha1 episodes ● Opioids ● dizzin e BP
Brand name: Frequency: and alpha2 of should ess measur
Risperdal OD PRN adrenergic, bipolar, only be ● Inso ement
Classificatio and H1 acute prescribe mnia before
n: histaminergi mixed d with ● Agitat starting
Anticholiner c receptors episodes benzodiaz ion therapy
gic in the of bipolar epines or ● Depre and
brain. disorder other CNS ssion monitor
depressan ● Hallu BP
ts to cinati regularl
patients on y.
for whom ● Mania Watch
alternative ● Abno for
treatment rmal orthost
options thinki atic
are ng hypote
inadequat and nsion,
e. drea especia
ming lly
during
first
dosage
adjustm
ent.

Generic Dose: Used for Acute Contraindicated Nervousnes Closely

Name: 500mg simple mania in patients with s monitor all the
Divalproex Route: per absence and Bipolar hypersensitivity Depression patients taking
Brand Name: orem mixed prophyla to drugs and in Palpitation or starting anti
Depakote Frequency: seizures, xis those with urea Abdominal epileptic drugs
Classificatio BID migraine, cycle disorder. pain forchanges in
n: prophylaxis, Dysuria behavior
Anticonvulsa and mania. indicating and
nt worsening of
suicidal
thoughts or
depression.

Generic Dose: 2mg Acts as reduces Narrow-angle hyperthermi

Name: Route: per antagonist the glaucoma, a,blurred
Biperiden Orem of effects of megacolon, vision,
Frequency: muscarinic certain bowel constipation
Brand Name: OD receptor naturally obstruction, ,
Akineton activated by occurring paralytic ileus. xerostomia,
acetylcholin chemical urinary
Classificatio e s in your retention
n: Anti- body that CNS
cholinergic may depression;
become confusion,
unbalanc hallucinatio
ed as a ns, delirium,
result of anxiety,
disease amnesia
(such as (usually at
Parkinso higher
n's doses).
disease), Cardiac
drug disorders:
therapy, Bradycardia.
or other Nervous
causes. system
disorders:
Drowsiness.

Mental Status Examination

9 Domains Nurse’s Observation Initial Nurse’s Observation Final

(January 9, 2024) (January 10, 2024)

Appearance Average built and stature. Close
to scalp haircut with beard.
Appears clean and well-kempt.
Clothing is clean and tidy. No
abnormal motor activity.
Average built and stature. Close
to scalp haircut with beard.
Appears clean and well-kempt.
Clothing is clean and tidy. No
abnormal motor activity.

Behavior Slightly slouched but relaxed. Slightly slouched but relaxed.

Cooperative and active. Cooperative and active.
Maintains eye contact. Maintains eye contact.

Mood and Affect Euthymic. Appropriate affect. Euthymic. Appropriate affect;

not too restricted and not too
lively; responsive and consistent
with his facial expressions.

Speech No dysarthria. Overly talkative, No dysarthria. Overly talkative,

spontaneous with loud volume. spontaneous with loud volume.

Cognition Alert and oriented to person and Alert and oriented to person and
 time. time. Listen attentively.

Thoughts He has grandiose delusion; He has grandiose delusion;

thoughts are appropriate with thoughts are appropriate with
our topic but he has thought our topic but he has thought
insertion. No suicidal ideation insertion. No suicidal ideation
noted. noted.

Perception Auditory hallucination noted. Auditory hallucination noted.

Insight Good. He has both intellectual Good. He has both intellectual

and emotional awareness of his and emotional awareness of his
illness. He is also aware about illness. He is also aware about
the surroundings and the surroundings and
happenings. happenings.

Judgement Good judgement. Good judgement.

Laboratory and diagnosis

LABORATORY DESCRIPTION RESULT REFERENCES/ INFERENCE

TEST RANGES

● HEMOGLOBI 142g/L 140-180g/L Normal

N Hemoglobin is
a protein in
your red blood
cells that
carries oxygen
to your body’s
organs and
tissues and
transports
carbon dioxide
from your
organs and
tissues back to
your lungs.

● HEMATOCRI 0.41 L 0.40-0.54 L Normal

T Hematocrit is
the percentage
by volume of
red cells in
 your blood.

● WHITE 6.7 x 10^9/L 4.5-11.5 x Normal

BLOOD A WBC count 10^9/L
CELLS is a blood test
measuring the
number of
white blood
cells (WBC) in
the blood.

4.47 X 10^12/L 4.60-6.00 X Due to specific

● RED BLOOD A RBC count 10^12/L medication
CELLS is a blood cell (risperidone),
that measures unhealthy
how many red lifestyle
blood cells specifically
(RBC) you lack of sleep
have. and with a
history of
presumptive
tuberculosis
that may cause
decreased
levels in red
blood cells.

● MEAN 92.4 f/L 80-90 f/L Due to

CORPUSCUL Measures the presumptive
AR VOLUME average size tuberculosis is
of your red directly known
blood cells. to cause the
An MCV blood body to
test can help decrease mean
your corpuscular
healthcare volume that
provider may lead to
determine if anemia.
you have
anemia, liver
disease or
other
conditions.

● MEAN 31.8 pg 26-32 pg normal

CORPUSCUL A
 AR
HEMOGLOBI measurement
N of the average
amount of
hemoglobin in
each red
blood cell.
Hemoglobin is
a protein in
red blood
cells that
carries
oxygen from
your lungs to
organs and
tissues of
your body

● MEAN 34 g/dL 32-36 g/dL normal

CORPUSCUL Measures the
AR average
HEMOGLOBI hemoglobin
N concentration
CONCENTRA in a given
TION volume of red
blood cells.An
MCHC blood
test may be
used as a
preliminary
check for
anemia and is
part of a
complete
blood count
(CBC) test.

● RBC 11.5% 11.5-14.5% Normal

DISTRIBUTIO Measures how
N WIDTH varied your
red blood
cells are in
size and
volume. Your
red blood
cells carry
oxygen from
 your lungs to
organs and
tissues
throughout
your body.
The oxygen
fuels your
body's cells
so that they
can produce
energy.

● ACTUAL 173 x 10^9/L 150-450 x norrmal

PLATELET To measure 10^9/L
COUNT how many
platelets you
have in your
blood.
Platelets are
parts of the
blood that
help the blood
clot. They are
smaller than
red or white
blood cells.

DIFFERENTIAL COUNT

● NEUTROPHILS 6.7 x 10^9 x 10/L 2.0-8.0 x 10^9/L NORMAL

●LYMPHOCYTES 0.09 0.18-0.42 Due to presumptive

tuberculosis that
causes infection
that decreases
lymphocytes.

● MONOCYTES 0.11 0.02-0.11 NORMAL

 ● EOSINOPHILS 0.01 0.01-0.03 NORMAL

● BASOPHILS 0.01 0.00-0.02 NORMAL

ROUTINE CHEMISTRY

TEST DESCRIPTION RESULT REFERENCES INFERENCE

RANGE

● BLOOD URIC A waste 370.30 3.6-7.7mg/dL NORMAL

ACID (BUA) product that is umol/L (214.15-458.03
created when umol/L)
your body
breaks down
chemicals
called purine
in food and
drinks. Most
uric acid
dissolves in
your blood,
passes
through your
kidneys and
leaves your
body in your
 urine.

● BLOOD UREA The BUN test 6.23 <23 mg/dL Normal

NITROGEN measures the mmol/L (<8.21mmol/L)
(BUN) amount of
urea nitrogen
in your blood.
Urea nitrogen
is a waste
product that
your kidneys
remove from
your blood.

● CREATININE a chemical 81.10 0.7-1.2mg/L Normal

waste product umol/L (61.88-106.08
of creatine. umol/L)
Creatine is a
chemical
made by the
body and is
used to supply
energy mainly
to muscles.
This test is
done to see
how well your
kidneys work.

ELECTROLYTES

TEST DESCRIPTION CONVENTIONA REFERENCES IMPLICATION

L RANGE

● SODIUM measures the 140.10mEq/L 135-145mEq/L Normal

amount of (135-145
sodium in your mmol/L)
blood. Sodium
is a type of
 electrolyte.
Electrolytes
are electrically
charged
minerals. They
help control
the amount of
fluid and the
balance of
acids and
bases (pH
balance) in
your body.

● POTASSIUM Potassium is 3.84mEq/L 3.60- NORMAL

an essential 5.50mEq/L
mineral that is (3.60-
needed by all 5.50mmol/L)
tissues in the
body. It is
sometimes
referred to as
an electrolyte
because it
carries a small
electrical
charge that
activates
various cell
and nerve
functions.

● IONIZED calcium in 1.12mEq/L 1.10- Normal

CALCIUM your blood 1.40mEq/L
that is not (1.10-
attached to 1.40mmol/L)
proteins. All
cells need
calcium in
order to work.
Calcium helps
build strong
bones and
teeth. It is
important for
 heart function.

● MAGNESIUM measures the 1.20mEq/L 1.80- Normal

amount of 3.00mEq/L
magnesium in (0.74-
your blood. 1.23mmol/L)
Magnesium is
a type of
electrolyte.
Electrolytes
are electrically
charged
minerals that
are
responsible for
many
important
functions and
processes in
your body.
Your body
needs
magnesium to
help your
muscles,
nerves, and
heart work
properly.

ROUTINE CHEMISTRY

TEST DESCRIPTION CONVENTIONAL REFERENCES IMPLICATION

RANGE

● FASTING common blood 3.46mmol/L 70-99 mg/dL Normal

BLOOD test to (3.89-5.49
SUGAR diagnose mmol/L)
prediabetes,
diabetes or
gestational
 diabetes.

CHOLESTEROL cholesterol 223 mg/dL Low risk levels It indicates that

looks at the (desirable): the patient has
levels of an unhealthy
cholesterol and <200 mg/dL dietary
other fats in (5.18-6.19 lifestyle.
your blood. mmol/L)

Moderate risk
levels
(borderline):

200-239 mg/dL
(5.18-6.19
mmol/L)

High risk
levels:

= 240 mg/dL
(>/=6.20
mmol/L)

LOW DENSITY Triglycerides 198 mg/dL Normal: It indicates that

LIPOPROTEIN are a type of the patient has
(LDL) fat, called lipid, <150 mg/dL an unhealthy
that circulate in (<1.69 mmol/L) lifestyle.
your blood.
Borderline
high:

150-199 mg/dL
(1.69-2.24
mmol/L)

High:

200-499 mg/dL
(2.25-5.63
mmol/L)

Very High:

>/=500 mg/dL
(>/=5.64
 mmol/L)

HIGH DENSITY HDL (high- 41 Low NORMAL

LIPOPROTEIN density (undesirable,
(HDL) lipoprotein) high risk):
cholesterol,
sometimes <40 mg/dL
called “good” (<1.03 mmol/L)
cholesterol,
absorbs High
cholesterol in (desirable, low
the blood and risk):
carries it back
to the liver. The >/=60 mg/dL
liver then (>/=1.55
flushes it from mmol/L)
the body. High
levels of HDL
cholesterol can
lower your risk
for heart
disease and
stroke.
Medical Management

Name of Dose/ Mechanis Indication Contraindi Side Nursing

Drug Route/ m of cation effects Considera
Frequency Action tion

Ascorbic Dose: Ascorbic To provide Patient -weight -dietary

Acid 500mg/tab acid, a vitamins with gain modificati
water- that are diabetes -dizziness on
Route:P.O soluble not taken mellitus, -
vitamin through G6PD adjustmen
Frequency that acts diet. deficiency t in daily
: OD as a , living
cofactor haemochr activities
and as an omatosis, -advice
history of increase
antioxida
renal fluid
nt. It is
stones intake
essential (e.g.
for oxalate
connectiv kidney
e tissue stones),
synthesis, predisposi
and Fe tion to
absorptio recurrent
n and renal
storage. calculi.
Additional Renal
ly, it is an impairmen
electron t. Children
donor (<2 years
used for of age)
collagen and
hydroxyla elderly.
tion, Pregnancy
carnitine and
biosynthe lactation.
sis, and
hormone
or amino
acid
synthesis.

Multivitam Dose: The To provide - -Stomach -providing

ins 500mg/tab mechanis vitamins Hemochro upset fluids
m of that are matosis, a -
 Route: P.O action for not taken condition encouragi
multivitam through in which ng eating
Frequency in is to diet. excess
:OD increase iron builds
nutrient up in the
intakes body.
and help
people
obtain -Do not
recommen administer
ded adult
amounts multivitam
of in
vitamins preparatio
and ns to
minerals children;
when they may
do not contain
meet iron at
these amounts
needs not
from food suitable
alone. for
children
and can
cause
severe
iron
toxicity .

-Patient
with
severe
impairmen
t of kidney
or liver
failure

Rosuvasta Dose: Rosuvasta For Active -joint pain -

tin 5mg/tab tin patient’s liver enhancing
selectively high disease, physical
Route: P.O and cholestero including mobility
competitiv l level and unexplain
Frequency ely hyperlipid ed,
: OD inhibits 3- emia. persistent
hydroxy-3- elevations
methylglut of serum
aryl transamin
coenzyme ases;
A (HMG- myopathy.
 CoA) Severe
reductase, renal
the rate- impairmen
limiting t (CrC| <30
enzyme in mL/min).
cholestero Pregnancy
l and
synthesis. lactation.
It
increases
the
number of
hepatic
LDL
receptors
on the cell
surface,
thereby
enhancing
the uptake
and
catabolis
m of LDL.
It also
decreases
apolopopr
otein HDL
concentrat
ion.

Nursing Care Plan

Process Recording

ORIENTATION PHASE

Student’s Name: Tricia F. Cuevo Date: January 9, 2024

Patient’s Initial: L.B. Time Alloted: 15 mins

Diagnosis: Bipolar Affective Disorder, Manic with Psychotic Symptoms

Nurse’s Dialogue Client’s Response Inference/Analysis Nurse’s Thoughts

and Feelings
Magandang araw po! Magandang umaga
Ako po si Tricia sayo.
Cuevo, student nurse
level 4 sa College of
the Immaculate
Conception,
Cabanatuan City.
Maaari ko po bang L***. Ako si L***
malaman ang B*******.
pangalan mo?

Okay po. Kamusta po Mabuti. Ayos naman

kayo? ako dahil
binabantayan ako ng
Diyos.

Mabuti naman po Ay ako? 45 years old

kung ganun. Maaari na ako.
ko po bang malaman
kung ilang taon na po
kayo?

Kailan po ang January 18, 1978

birthday niyo?

Taga-saan po kayo? Ako ay tubo sa

Saan po kayo lalawigan ng Cavite.
nakatira?