Mental Case Study

A case study on BPAD with Mania 2010

TABLE OF CONTENTS

Background of the study 1

Objective of the study 2

History Taking 3

Family Tree 8

Examination of Patient 9

Physical Examination 9

Mental Status Examination 9

Disease Condition 14

Mood Disorders 14

Classification 14

Bipolar Affective Disorders (BPAD) 14

Definition 15

Classification 15

Etiology 15

Mania (Manic Episode) 16

Epidemiology 16

Classification 17

Sign and Symptoms 17

Diagnosis 19

Treatment 20

Drug bank 23

Theory application 28

Nursing care paln 33

Discharge Teaching 38

Summary 40

References 41

BACKGROUND OF THE STUDY1


As a part of the requirement for Post Basic Bachelor in Nursing (PBBN) Curriculum of

Purbanchal University (PU) under Mental Health Nursing (Practicum), we were required to

do practical in Mental Hospital, Lagankhel for 2 weeks. Here we were expected to do a

detailed study of one case.

After having a glance in all cases, I selected a case of Bipolar Affective Disorder

(BPAD) with Mania. This case study was done in order to gain comprehensive knowledge

about the disease and provide holistic care to the patient as well as family. I selected this

case since BPAD, Mania is a mood disorder. And the prevalence rate of mood disorders is

1.5 percent, and it is uniform throughout the world i.e. it is equal in developed or

developing country.

This case study includes all the information about the patient, his disease and

management done for his disease.

2


OBJECTIVES OF THE STUDY

The main goal of this study is to gain comprehensive knowledge about a specific case

and be able provide holistic nursing care and management to the patients using appropriate

scientific rationales. The specific objectives of this case study in particular are as given

below:

To provide holistic nursing care to the patient with mania.

To apply knowledge from basic science and nursing theory in planning the

comprehensive care to the patient.

To communicate in helpful manner with patient and his problems and also to involve

them in resolving problem.

To involve the patient and family members and health team members in the discharge

planning.

To minimize the stress of the patient and his family by appropriate diversional therapy

according to age.

To give health education to the patient and his family members to promote and

maintain health.

3


HISTORY TAKING

A. PRELIMINARY IDENTIFICATION OF PATIENT

Name: Sahara Rai

Age: 27 Years

Sex: Female

Ward: Female Ward

Bed No.: 18

Marital Status: Married

Educational Level: S.L.C. Failed

Occupation: House Wife

Religion: Hindu

Address: Saptari, Phattepur-2

Date of Admission: 2067.03.10

Diagnosis: BPAD (Bipolar Affective Disorder) with Mania

Source of Referral: BPKIHS, Dharan

Attending Doctor / Unit: Dr. MRS / Unit II

ABOUT INFORMANT

Name: Mahima Rai

Age: 36 Years

Education: S.L.C. Passed

Occupation: Work in Christian Office

Relationship with patient: Elder Sister

Reliability of Information: Reliable

Adequacy of Information: Adequate

Date of Interview: 2067.03.11

B. PRESENTING COMPLAINTS (WITH DURATION)

According to patient According to informant

PSn} xfF:g], ?g] cfˆgf] / aRrfsf] care gug]{

4


vfgf gvfPsf] / toilet gu/]sf] @)

lbg eof]

cgfjZos s'/f dfq ug]{

lgb|f gkg]{ aflx/ aflx/ lx8\g]

/fd|f] 7fpFdf hfg vf]Hg]

/fd|f] /fd|f] n'uf dfq nufpg vf]Hg]

Ps} 7fpFdf w]/} a]/ a:g g;Sg]

c?;Fu l/;fpg]

C. HISTORY OF PRESENT ILLNESS

Onset: Gradual

Duration: 20 days

Precipitating Factors: Separation from husband

Suspicious nature of her husband and in-laws

Course of Illness: The illness is episodic. This is the second time. After dispute with her

husband in phone, she stopped taking medicines. It was followed by sleep disturbances,

not taking food, excessive not relevant talk, always being angry with others, not caring

own children, doing unnecessary things whole day. Then she was brought to mental

hospital, Lagankhel for the further treatment.

Biological Symptoms and Consequences of Illness

Sleep: Decrease than normal

Appetite: Loss of appetite

Weight Loss: Not significant

Libido: Normal

Personal Care: Decrease interest in personal care and child care

Work Performance: Nowadays hindrance

Bowel Habit: Normal

Bladder Habit: Normal

Inter-personal Relationship: Good IPR within family and friends but gets angry easily

5


Personal Hygiene: Maintained

Patient was under treatment with Tab. Oleanz, Tab. Trepex and Tab. Lithocade.

D. PAST HISTORY

Psychiatric History: When she gave birth to her second daughter, she had problems

like not caring and feeding the baby properly because she had the desire of having male

baby. So she had mental illness from 10 years but taking medicine since last 2 years only.

She developed 2nd episode of attack this time after discontinuing medication.

Medical and Surgical History: She had not any history of medical and surgical

disorders. No history of previous hospitalization due to any other illnesses.

E. FAMILY HISTORY

She had a nuclear family. It includes 5 members, her husband, three daughters and she

herself. But now her husband is abroad i.e. Malaysia for work. She belongs to middle-

class background. The main source of income in her family is her husband. He sends

money regularly from Malaysia for them, which is financially sufficient for them. There is

no any history of similar or other type of psychiatric illness, alcohol or drug dependence,

suicide and major medical illness in her family of origin as well as her family of

procreation.

F. PERSONAL HISTORY

Birth: Home delivery

Event during pregnancy: Not significant

Birth weight: Exact weight not known

Event after birth: Crying – good, breathing – normal, not any cyanosis, icterus, high

temperature, convulsion, or any other abnormalities.

Milestones: Normal

6


Presence of neurotic symptoms: no thumb sucking and bed wetting but there was

presence of temper tantrums.

Marital History: She was married at 15 years of age with love marriage.

Sexual History: Good relationship with husband

Work history: Housewife

Personal Habit: No history of drinking and smoking

Menstrual History: Menarche occurred at 13 years of age. Regular menstrual flow

Obstetric History: She had three children. They all were born in hospital. There were not

any obstetric problems. There is no history of abortion.

G. PRE-MORBID HISTORY

Important Habits: Not significant

General Mood: Angry and stubborn

Attitude towards work: She used to do all house hold activities by self.

Relationship with family, friends, relatives and colleagues: Good

Religiosity: Belief in god and religion

7


FAMILY TREE

EXAMINATION OF PATIENT

PHYSICAL EXAMINATION

General: Not any abnormalities

8

74 Yrs 60 yrs

42 Yrs 40 Yrs 36 Yrs 35 Yrs 31 Yrs34 Yrs

MALE

23Yrs29 yrs 25 Yrs

6 Yrs10 Yrs11 Yrs

27 Yrs

INDEX

FEMALE PATIENT

22 Yrs


Systemic: Not any abnormalities

Vital signs and other measurements

Pulse: 82/min

Respiration: 20/min

Blood Pressure: 120/80 mmHg

Temperature: 98.6°F

Height: 5 Feet

Weight: 61 Kg

MENTAL STATUS EXAMINATION

1. GENERAL APPEARANCE AND BEHAVIOUR

Built: Looks physically healthy

Facial Expression: Happy

Age Group: Young Adulthood

Hygiene: Maintained

Grooming: Well groomed and well dressed up according to season

Level of consciousness: Fully conscious

Level of co-operation: Co-operative

Level of communication: normal

Posture: Normal gait

Psychomotor Activity: Increased

Overall behavior during interview: Sometimes shows anger and sometimes be very

friendly. Moves here and there while talking also.

2. TALK AND SPEECH

Spontaneous

Reaction to time: Immediate

Rate of speech: Normal

Rhythm: Monotonous

Tone: Audible

9


Pitch: Normal

Volume: Normal but sometimes increases while she is angry

Language: Nepali

Content: Understandable

3. MOOD

Subjective:

Question: tkfFO}sf] dg s:tf] 5 <

Answer: v';L 5. afaf cfPkl5 c´} v';L.

Objective: She looks happy and cheerful.

Outcome: Appropriate affect

4. THOUGHT

Form and Production:

Question: tkfFO{sf] 3/df sf] sf] x'g'x'G5<

Answer: d / ltg6f 5f]/L, afaf aflx/ uPsf] 5

Outcome: Relevant answer to the question, no circumstantialities and thought

impairment, no word salad.

Progression of thought:

Question: tkfFO{ clxn] sxfF x'g'x'G5<

Answer: c:ktfndf

Outcome: No flight of ideas, no thought block, no incoherence.

Content of thought:

Question: tkfFO{sf] n'uf t s:tf] /fd|f].

Answer: dx+uf] 5. lbbLnfO{ klg p:t} lslglbPsf] 5'

Outcome: patient gave inappropriate answer, so patient has delusion of grandiose

5. PERCEPTION

Auditory Hallucination:

Question: s] tkf‘O{ PSn} ePsf] a]nfdf s;}n] sfgdf s]xL eg] h:tf] nfU5<

Answer: nfUb}g

Outcome: No auditory hallucination

Visual Hallucination:

10


Question: s] tkf‘O{ PSn} ePsf] a]nfdf c?n] gb]v]sf] s'/f b]Vg'x'G5<

Answer: b]lVbg

Outcome: No visual hallucination

Illusion:

Question: s] tkf‘O{ 8f]/LnfO{ ;k{ bVg'x'G5<

Answer: cx‘ blVbg

Outcome: No illusions present

6. ATTENTION AND CONCENTRATION

Question: @) af6 # 36fpb} nfg'

Answer: @)–#Ö!&, !&–#Ö!$, !$–#Ö!!, !!–#Ö*

Question: xKtfsf] af/x? k5f8Laf6 eGb} hfg'

Answer: cfOtaf/, zlgaf/, z'qmaf/, laxLaf/, a'waf/, dËnaf/, ;f]daf/

Outcome: Good attention and concentration capacity

7. MEMORY

Immediate Memory:

Question:

d tkfFO{nfO{ b'O{j6f a:t'sf] gfd eG5' / % ldg]6kl5 km]/L Tof] a:t'sf]

gfd ;f]W5' eGg' n

sfkL / snd

Answer: sfkL / snd

Outcome: Immediate memory is intact

Recent Memory:

Question: tkfFOn] lxhf] laxfg s] t/sf/L vfg'eof]<

Answer: d"nf / cfn'

Outcome: Recent memory is intact

Remote Memory:

Question: tkfFO{sf] lax] slt ;fndf ePsf]<

Answer @)%$ ;fndf

11


Outcome: Remote memory is also intact

8. ORIENTATION

Time:

Question: clxn] stL aHof]<

Answer laxfgsf] ( aHof]

Outcome: oriented to time

Place:

Question: tkfFO{ clxn] sFxf x'g'x'G5<

Answer dfgl;s c:ktfndf

Outcome: Oriented to place

Person:

Question: tkfFO{ ;Fu sf] x'g'x'G5<

Answer lbbL

Outcome: Oriented to person

9. INTELLIGENCE

She had ability to tackle perfectly in her household activities. Average intelligence level.

10.JUDGEMENT

Question: tkfFO{ cfˆgf] cuf8L ;k{ b]Vg'eof] eg] s] ug'{x'G5<

Answer: efU5' . lgbf]{;nfO{ dfg'{ x'‘b}g .

Question: tkfFO{sf] l5d]sdf cfuf] nfUof] eg] s] ug'{x'G5<

Answer: kfgL nu]/ cfuf] lgefp5'

Outcome: Good judgment capacity

11.GRASP OF GENERAL KNOWLEDGE

Question: g]kfndf clxn] /fhf 5 ls 5}g<

Answer: 5}g

Question: g]kfnsf] k|wfgdGqLsf] gfd s] xf]<

12


Answer: dfwjs'df/ g]kfn

Outcome: Well grasp of general knowledge is observed

12. INSIGHT

Question: tkfFO{nfO{ s] ePsf] 5<

Answer: s]lx klg ePsf] 5}g .

Outcome: Insight is absent

13. ABSTRACTION

Question: :ofp / ;'Gtnfdf s] s'/f Pp6} 5<

Answer: b'O{6} kmnkm"n xf] .

Outcome: Normal capacity of abstract thinking.

Part II

DISEASE CONDITION

MOOD DISORDERS

Mood disorders are characterized by a disturbance of mood accompanied

by a full or partial manic or depressive syndrome, which is not due to any other

physical or mental disorder. The prevalence rate of mood disorder is 1.5

percent, and it is uniform throughout the world.

CLASSIFICATION

Manic Episodes

Depressive Episodes

Bipolar Mood (Affective) Disorder

Recurrent Depressive Disorder

Persistent Mood (Affective) Disorder

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Other Mood (Affective) Disorder

Unspecified Mood (Affective) Disorder

BIPOLAR AFFECTIVE DISORDER (BPAD)

This disorder, earlier known as manic depressive psychosis which is

characterized by repeated (at least two) episodes in which the patient’s mood

and activity levels are significantly disturbed, this disturbance consisting on

some occasions of an elevation of mood and increased energy and activity

(mania or hypomania), and or other of a lowering of mood and decreased

energy and activity (depression). Characteristically, recovery is usually

complete between episode, and the incidence in the two sexes is more nearly

equal than in other mood disorder. These episodes can occur in any sequence.

Patients with recurrent episodes of mania (unipolar mania) are also classified

here as they are rare and often resemble the bipolar patients in their clinical

features.

DEFINITION

“Recurrent attacks of both mania and depression, in the same patient at

different times or this disorders characterized by mood disturbance (in

appropriate depression or elation). It is usually accompanied by abnormalities in

thinking and pe4rception arising out of mood disturbance.”

CLASSIFICATION

1. Bipolar Affective Disorder: Recurring attacks of both mania and

depression.

2. Unipolar Affective Disorder: Recurring attacks depression only.

14


3. Mixed Affective Disorder: Cases where manic and depressive symptoms

occur simultaneously.

ETIOLOGY

The etiology of mood disorders is currently unknown. However, several factors

have been propounded, these include;

1. Biological Factors

Genetic: The life-time risk for the first degree relatives of bipolar mood

disorder patients is 25% and of recurrent depressive disorder patient is

20%. The life-time risk for the children of one parent with mood disorder

is 27% and both parents with mood disorder is 74%. The concordance

rate in bipolar disorder for monozygotic twins is 65% and for dizygotic

twins is 20%. Therefore, genetic factors are very important in making an

individual vulnerable to mood disorders.

Biochemical Factors: A deficiency of norepinephrine and serotonin has

been found in depressed patient and they are elevated in mania.

Dopamine GABA and acetylcholine are also presumably involved.

2. Psychosocial Factors

Increased stressful life events (e.g. death of loved person, marriage,

financial loss) before the onset or relapse probably have a formative

rather than a precipitating effect.

Early childhood experiences: Maternal deprivation, prolonged absence

of a parent.

MANIA AND MANIC EPISODE

15


Mania (from Greek word meaning "to rage, to be furious") is a severe

medical condition characterized by extremely elevated mood, energy, unusual

thought patterns and sometimes psychosis.

A manic episode is not a disorder in and of itself, but rather is a part of a

type of bipolar disorder.

A manic episode is characterized by period of time where an elevated,

expansive or notably irritable mood is present, lasting for at least one week.

These feelings must be sufficiently severe to cause difficulty or impairment in

occupational, social, educational or other important functioning and can not be

better explained by a mixed episode.

EPIDEMIOLOGY

According to Book In Patient

Incidence 0.6 to 1% adults will have mania during

their lifetime.

Age Onset is most common in late adolescence

or early adulthood.

Early adulthood.

Sex Bipolar affective disorders equally common

among men and women. But all depressive

disorders is twice as common in women.

Female

Social Class Occurs among people in high social class

comparatively.

Middle-class

family

Marital

Status

Unmarried, widow, divorce and separation

from husband have increase episodes.

Separation from

husband since 3

yrs

Professionals It occurs 4 times more in professionals than

in non professionals.

N0n-professional

Length The average length of manic episodes is

16

http://psychcentral.com/disorders/sx19.htm



http://en.wikipedia.org/wiki/Psychosis

http://en.wikipedia.org/wiki/Mood

http://en.wikipedia.org/wiki/Greek_language


about 6 months.

Recurrence At least 90% of patients with mania

experience further episodes of mood

disturbance. On average bipolar patient

experience about 10 further episodes of

mood disturbances.

CLASSIFICATION OF MANIA

1. Hypomania: It is a mild form of mania.

2. Acute Mania: The signs and symptoms are moderately increased and

leads towards severity.

3. Delirious Mania: The patient is out of contact, speech is inconvenient

and is constantly and purposelessly active. The patient may be

hallucinating, delusional and extremely dangerous without treatment. The

patient may die of exhaustion.

SIGN AND SYMPTOMS OF MANIA OR A MANIC EPISODE

ACCORDING TO BOOK IN

PATIENT

Increased energy, activity, and restlessness √

Excessively "high," overly good, euphoric mood √

Extreme irritability √

Distractibility, can't concentrate well

Little sleep needed (e.g., one feels rested after only 3 hours of

sleep)

√

Unrealistic beliefs in one's abilities and powers √

Poor judgment

Spending sprees

17


A lasting period of behavior that is different from usual √

Increased sexual drive

Abuse of drugs, particularly cocaine, alcohol, and sleeping

medications

Provocative, intrusive, or aggressive behavior √

Denial that anything is wrong √

Racing thoughts and talking very fast (pressure to keep

talking), jumping from one idea to another

√

Psychomotor agitation √

Marked impairment in occupational functioning, in social

activities or relationships with others.

√

Excessive involvement in pleasurable activity

Engage in impulsive activities such as spending money √

Inflated self-esteem or grandiosity √

DIAGNOSIS

Proper history taking

Mental status examination (positive criteria of mania)

Episodes should last for at least a week

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TREATMENT

1. Pharmacotherapy.

SN According to Book In Patient

1. Antipsychotic drugs: The commonly used

drugs are haloperidol, chlorpromazine,

risperidone, olanzapine. The drugs are used

along with mood stabilizers for the first few

weeks before their effect appears.

Tab. Oleanz Repitas 5

mg PO BD

Inj Serenac 5 mg + Inj

phenargan 25 mg IM

SOS

2. Lithium (Li) is the drug of choice for

treatment of manic episode. (acute phase) as

well as for prevention of further episodes in

bipolar mood disorder.

Tab. Lithocade 300 mg

PO TDS.

3. Other mood stabilizers:

Sodium Valporate: for acute treatment of

mania and prevention of bipolar mood

disorder. Particularly useful in those patients

who are refractory to lithium.

Carebamazepines and oxycarbazepine for

acute treatment of mania and prevention of

bipolar mood disorder. Particularly useful in

those patients who are refractory to lithium

and valporate.

4. Benzodiazepines: like lorazepam may be

added to control agitation for initial 5 to 7

days.

lorazepam

19


2. ECT (Electroconvulsive therapy): ECT can also be used for acute

mania excitement if it is not adequately responding to antipsychotic and

lithium.

3. Psychosocial treatment: Although somatic treatment is the primary

mode of management in major mood disorders, psychosocial treatment

may be indicated in certain cases. Family and marital therapy is used to

decrease interfamilial and interpersonal difficulties and to reduce or

modify stressors.

NURSING INTERVENTIONS

1. Keep environmental stimuli to a minimum, assign single room, and keep

lighting and noise level low.

2. Remove hazardous objects (glass, belts, ties, ropes, knife, and match

boxes) and substances when there is possibility of an accident.

3. Assess patient’s personality and cultural background.

4. Establish trusting relationship with patient.

5. Administer medications in time, as prescribed by physician.

6. Assist patient to engage in activities, such as writing, drawing and other

physical exercise.

7. Observe patient’s behavior closely and protected from suicidal act.

8. Accept client while rejecting objectional behavior.

9. Permitted expression of hostility and ambivalence without reinforcement

of guilt feelings.

10.Encourage verbal expression of feelings.

11.Provide high protein, high calorie, nutritious foods and drinks (6-8 glass

of fluid per day) and provide favorite foods.

12.Maintain accurate record of Intake / Output.

20


13.Weight the patient regularly.

14.Do not argue with patients and ignore attempts by patient to argue.

15.Identify client’s social support system to minimize isolation.

16.Engage self care activities in times when client may have more energy to

increase activity tolerance and minimize fatigue.

17.Advice all care givers to approach client in a consistent manner.

18.Give short, simple and direct answer when the patient asked questions.

19.Give clear instruction regarding taking medication. Explain about side

effects of medication and how to deal with it.

PROGNOSIS

At least 90% of patients with mania experience further episode of mood

disturbance. Nearly all bipolar patients recover from acute episode but the long

term prognosis is rather poor. Less than 20% of bipolar patients recover from

administer a period of five years clinical stability with good social and

occupational performance. Usually the prognosis depends upon the various

factors such as, compliance of treatment, regular follow up, home environment,

family support, coping mechanisms, stress and factors etc.

Drugs Bank21


INJ SERENACDrug Class Description:

Butyrophenones (antipsychotics).

Generic Name:

Haloperidol

Drug description:

1.5mg white tablets; 5 mg, 10 mg, 20 mg pink tablets.

Indications :

Schizophrenia, mania and hypomania, organic psychoses, agitation in psychotic illness. Childhood behaviour disorders. Adjunct to short-term management of anxiety.

Adult Dose :

Serenace Tablets and Serenace Liquid: Initially 1 .5 - 20 mg daily, increasing as required for control, then decreasing for maintenance, usually 3 - 10 mg daily. Maximum 200 mg daily.

Serenace Injection: Emergency control, 5 - 10 mg, infrequently up to 30 mg, by intramuscular or intravenous injection 6 - 12 hourly, followed by oral therapy..

Child Dose :

Serenace Tablets and Serenace Liquid: Initially 0 .025 - 0.05 mg/kg daily. Usual maximum Serenace Injection: Not recommended. Serenace Capsules: 0 .025 - 0.05 mg/kg daily to maximum 10 mg daily. Some adolescents may require up to 60 mg daily.

Contra Indications:

Comatose states, Parkinsonism, nursing mothers.

Special Precautions:

Epilepsy, hyperthyroidism. Liver or renal failure. Pregnancy. Severe cardiovascular disorders.

Interactions :

CNS depressants, alcohol, analgesics, antihypertensives, antidepressants, anticonvulsants, antidiabetics, levodopa.

Adverse Reactions :

22


Acute dystonias (spasms of eye, face, neck and back muscles), akathisia (motor restlessness), parkinsonism-like syndrome (rigidity and tremor), and tardive dyskinesia, dry mouth, nasal stuffiness, difficulty in micturition, tachycardia, constipation, blurring of vision, hypotension, weight gain, impotence, galactorrhoea, hypothermia (a problem in the elderly), gynaecomastia, amenorrhoea, benign obstructive jaundice, blood dyscrasias and dermatitis, ECG irregularities, drowsiness, lethargy, fatigue, epileptiform seizures.

PHENERGANDrug Class Description :

Antihistamines (sedating) (phenothiazine type).

Generic Name :Promethazine Drug description :

Phenergan Tablets: 10mg blue f- c tablets marked PN10; 25 mg blue f-c tablets marked PN25. Elixir: clear golden syrupy liquid. Phenergan Injection: ampoules.

Indications : Allergic conditions. Sedation, nausea and vomiting. Adult Dosage :

Phenergan Tablets and Phenergan Elixir: Allergies, 10 - 25 mg two or three times daily. Anti- emetic, 20 - 25mg to be taken the night before journey and repeated after 6 - 8 hours if necessary. Sedation, 20 - 50mg as a single nightime dose.

Phenergan Injection: 25 - 50 mg by deep intramuscular injection or, in an emergency, by slow intravenous injection after dilution.

Child Dosage:

Phenergan Tablets and Phenergan Elixir: Allergies, under 2 years, not recommended; 2 - 5 years, 5 - 10 - 25 mg. If two doses in 24 hours are required, use lower amount stated. Anti-emetic, under 2 years, not recommended; 2 - 5 years, 5 mg (use elixir); 5 - 10 years, 10 mg; over 10 years, 25 mg. To be taken the night before journey and repeated after 6 - 8 hours if necessary. Sedation, under 2 years, not recommended; 2 - 5 years, 15 - 20 mg (use elixir); 5 - 10 years, 20 - 25 mg. Each as a single dose at night. Phenergan Injection: Under 5 years, not recommended; over 5 years, 6 - 12.5 mg by deep intramuscular injection.

Interactions :

Alcohol, CNS depressants, MAOIs.

23


Adverse Reactions :

Drowsiness, impaired reactions. Dizziness, disorientation, photosensitivity. Extrapyramidal reactions, anticholinergic effects.

Lorazepam Drug Class Description :

Intermediate-acting benzodiazepines (anxiolytics).

Presentation :

Tablets, lorazepam 1mg , 2.5mg .

Indications :

Moderate to severe anxiety.

Adult Dosage :

1 - 4 mg daily in divided doses.

Child Dosage :Not recommended. Elderly Dosage : 0.5 - 2 mg daily. Contra Indications :

Acute pulmonary insufficiency, respiratory depression, phobic or obsessional states, chronic psychosis, myasthenia gravis. Pregnancy, labour and lactation.

Special Precautions :

Chronic pulmonary insufficiency, chronic renal or hepatic disease.

The elderly. Judgement and dexterity may be impaired, patients should be warned of these effects. Do not use alone to treat depression or anxiety associated with depression. In cases of bereavement, psychological adjustment may be impaired. Avoid long-term use; withdraw gradually.

Interactions :

Alcohol and other CNS depressants, anticonvulsants, narcotic analgesics, cimetidine, rifampicin.

Adverse Reactions :

Drowsiness, light-headedness, muscle weakness, ataxia, confusion, vertigo, GI upset, hypotension, visual disturbances, and dexterity. Urinary retention, changes in libido. Rarely blood disorders and jaundice. Abnormal psychological reactions, Risk of dependence increases the higher the dose and the longer the treatment.

24


25


Application of Nursing Theory

Nursing theory differentiate nursing from other discipline and activities

in that it solves the purpose of describing, explaining, predicting or controlling

events or controlling desired outcome of nursing practice. There are numerous

nursing theories developed till date but regarding the applicability, some

theories are important. i.e.:

1. Florence Nightingale’s Environmental Theory

2. Dorothea E. Orem’s General Theory of Nursing

3. Virginia Henderson’s Independent Theory

4. Faye Glenn Abdellah’s Typology of Nursing Problems

5. Sister Callista Roy’s Adaptation Model

Among these 5 Theories, I had applied 2 of them in providing nursing care

to my patient. They are Henderson’s Independent Theory and Orem’s Theory

of Nursing System. I had applied these theories in the following way:

1. Henderson’s Independent Theory

I had applied the Henderson’s Independent Theory by relating the 14

components of this theory with the Maslow’s Hierarchy of Needs and its 5

components. The nurse serves as a substitute for whatever patient lacks in

order to make him or her “complete” or “whole” or independent depending

his or her physical strength, will or knowledge to attain good health. So, I had

provided nursing care from the basic needs to the higher needs according to

the patient’s needs as shown in the following figure:

26


Fig: Henderson’s Independent Theory in relation with Maslow’s Hierarchy of needs

COMPONENTS ASSESSMENT ACTION

Physiological Needs

Breathing She was breathing normally. Respiratory rate was also normal i.e. 20-24 breaths per minute.

Eating and Drinking

She forget and ignore drinking.

I encouraged her to drink adequate fluids. I also

27


advised her and her family to take food in frequent intervals but in small quantity.

Elimination There was not any

problem in

elimination. She

was having urine

and stool regularly.

Moving She was conscious

and over active

I advice her to take some

rest an try to keep involve

her in indoor game which

decrease her activities

Sleeping and

resting

Her sleeping was

disturbed.

I provided her medicine on

time

Safety and

Security

Dressing and

undressing

appropriately

She was capable of

dressing and

undressing by

herself.

Maintaining

body

temperature

Her temperature is

maintained

Keeping clean

and protecting

skin

She was looking

dirty as she can care

her self but ignore

do self care.

I encourage her to take

bath and arrange for that. I

cut her nails. I also assist

her to comb hair

Avoiding She is over active I advised visitor to go to

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dangers and

injuries

and moving here

and there so has

high risk of injuries

toilet with her. I also

advice her to wear slippers

while moving in order to

prevent any cuts.

Love and

Belongingness

Communicating Not appropriate

sometimes talkative

but both sense and

non sense.

I advised her visitor to

speak to her in order to

relieve her boredom. I also

communicated with her

with positive attitude as

well as to divert her mind.

Self-Esteem Worshipping She in lord . I allowed her and

encouraged her for

worshipping god according

to her belief and her

religion.

Self-

Actualization

Working She was thinking

that she cannot do

any thing.

I encouraged her for

working for her self eg. her

self care so that she will

have sense of self

accomplishment.

Playing I encourage her in indoor

game. Which will decrease

her activities.

Learning I teach her new games

with appropriate rules

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30


Nursing Care Plan

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SN

ASSESSMENT NURSING. DIAGNOSIS

NURSING GOAL

PLANNING IMPLEMMENTATION RATIONALE EVALUATION

1. Subjective Data: Patient said, “I cannot sleep at night.” “I wake up frequently.”“Many things come repeatedly in mind.”Informant said that patient wakes up many times at night.

Objective Data:I observed patient’s eyes were drowsy and red.

Altered sleep pattern related to disease condition.

Patient’s sleep pattern will be improved with in the period of hospitalization.

1. Assess patients sleeping pattern.

2. Encourage patient to involve in day time activities according to interest.

3. Provide calm and comfortable environment with minimal stimulation.

4. Provide comfortable measures (back rub) at the time of sleeping.

1. Assessed sleeping pattern of patient by asking with informant.

2. Encouraged patient to involve in day time activities like watching television and playing games like Chinese checker, carom board, chess etc.

3. Encouraged informant to maintain a quite and peaceful environment with minimal stimulation.

4. Adviced informant for back rubs at the time of sleeping.

1. Helps to identify information which in turn helps for prompt intervention.

2. It helps to make busy in day time and in turn helps to achieve peaceful sleep at night.

3. Calm and comfortable environment helps for sound sleep.

4. Provide relaxation and facilitate for sleep.

Goal was fully achieved as patient had achieved sound sleep.

S ASSESSMENT NURSING. NURSING PLANNING IMPLEMMENTATION RATIONALE EVALUATION

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N DIAGNOSIS GOAL2. Subjective

Data: Informant said that patient does not stay in one place for long time.

Objective Data:I observed that patient is not staying in one place. Walking here and there.

High risk for injury related to extreme hyperactivity.

Risk for injury will be decreasedDuring the period of hospitalization.

1. Maintain minimal level of environmental stimuli.

2. Remove hazardous objects from patient side.

3. Encourage patient to engage in activities.

4. Close observation of patient.

5. Administer medication as prescription.

1. Maintained minimum level of environmental stimuli.

2. Removed hazardous objects like knife, glass, rope like clothes from patient side.

3. Encouraged patient to engage in activities like writing, drawing and playing.

4. Close observation of patient was done.

5. Administered medications as prescribed.

1. Helps to reduce risk of injury to patient.

2. Decreases stimuli and chances of injury.

3. Helps to engage the patient in one place and reduce the risk of injury.

4. Helps to prevent from injury.

5. Helps to reduce symptoms of hyperactivity.

Goal was fully achieved as t6here was no injury to patient during the period of hospitalization.

SN


NURSING GOAL


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3. Subjective Data: Patient said, “Do not ask more questions to me. Ask to my sister.”

Objective Data:I observed that patient does not want to give answers to more questions in a period of time. (Certain time)

Impaired social interaction related to irritability and hyperactivity.

Social interaction will be increased with in the period of hospitalization.

1. Assess patient’s level of social interaction.

2. Assist person in managing and maintaining social interaction on to other patients, visitors by sharing feelings, thoughts.

3. Encourage to involve in group activity like play.

4. Give positive reinforcement for manipulative behavior.

1. Assessed the level of patient’s social interaction.

2. Assist person in maintaining social interaction on the other patient and visitors by sharing feeling, thoughts.

3. Encouraged to involve in group activity like.

4. Gave positive reinforcement for manipulative behavior.

1. Helps in further nursing intervention.

2. Helps to facilitate social interaction.

3. Helps to increase social interaction.

4. Enhance self-esteem and promote repetition of desirable behavior.

Goal was fully achieved as the social interaction of patient was increased during the period of hospitalization.

SN


NURSING GOAL


4. Subjective Data: Informant said

Risk for relapsing the

The informant will be

1. Assess the risk causes for relapsing the

1. Assessed the risk causes for relapsing the

1. Provide further adequate intervention.

Goal was fully achieved as

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that the symptoms were severed because of discontinuation of medicine after dispute with her husband in phone.

Objective Data:I find out that she was staying alone with her 3 daughters. Her husband was abroad and no mature person is there to care patient.

symptoms related to discontinuation of medicine.

made aware about the disease condition and importance of regular medication.

symptoms.

2. Explain to the informant about medications (dose, route, side effects).

3. Explain the informant about importance of medicines.

4. Explain the patient about the importance of regular taking medication.

5. Explain informant to consult psychiatric doctor if any complication arise.

symptoms.

2. Explained to the informant about medications (dose, route, side effects).

3. Explained the informant about importance of medicines.

4. Explained the patient about the importance of regular taking medication.

5. Explained informant to consult psychiatric doctor if any complication arise.

2. Helps to reduce chances of discontinuation of medicines.

3. Reduce chances of discontinuation of medicines.

4. Encourage to take regular medications.

5. Helps in immediate management of complication

the informant was made aware about the disease condition and importance of regular medication.

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DISCHARGE TEACHINGDischarge teaching is very important part of nursing care. It is necessary not only for

patients but also for family and caregivers in order to enhance prompt recovery, prevent the

reoccurrence of disease and maintenance of health through out life.

Our patient was discharged on 24.03.2066 after 6 days of admission. So, we gave

discharge teaching to the patient and family as given below;

1. Drug Compliance:

Close observation should be done to monitor the side effects of the drugs. If major side

effects are observed, immediately consult with psychiatrist.

Monitor closely whether the patient is taking medicines or not.

Do not stop medicine.

Give medicines regularly. Medicines should be given regularly otherwise reoccurrence

may occur and it is very dangerous.

2. Nutrition:

Provide foods rich in vitamins and minerals.

Avoid allergic foods and junk foods.

Provide food according to availability. It is not necessary to provide animal products if

you cannot afford.

Avoid food stuffs like alcohol, caffeine and fried foods.

Provide finger foods. Provide plenty of liquids.

3. Rest and Sleep:

Provide adequate rest and sleep to the patient.

Set a regular bedtime and wake up time.

Avoid caffeine, excessive fluid intake, stimulating drugs and alcohol in the evening and

before bed.

36


Make the patient to get out of bed and engage in other activities if not able to fall

asleep.

4. Others:

Provide good family support.

Avoid stress factors to her as it precipitates the further episodes.

Monitor patient closely to recognize early sign of manic episode as well as prevent from

self injury and injury to others.

Patient should not be involved in hazardous activities like driving and swimming.

Regular follow up should be done.

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SUMMARY

According to our nursing curriculum under Mental Health Nursing (Practicum), we were

posted in Mental Hospital, Lagankhel for 2 weeks. During this period, we got an opportunity to

be exposed with psychiatric patients. We found different kinds of cases here. Among them we

chose a lady with Bipolar Affective Disorder with Mania for our case study.

Ms. Sahara Rai was 27 years old lady from Phattepur, Salyan. She belongs to middle

class family. She was brought to mental hospital by her sister with the complaint of being

aggressive, not caring self and her children as well, sleeping disturbances and walking here and

there. She was admitted in female psychiatric ward. She was treated with antipsychotics and

lithium. Her general condition was improving. So she was discharged after 6 days of

hospitalization.

During hospitalization, we provided holistic care to the patient considering physical,

mental, socio-cultural, spiritual and economic aspects.

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REFERENCE

1. Subedi D. 2008. Mental Health and Psychiatric Nursing. First Edition. Kathmandu. Makalu

Publication House. PP: 74-80.

2. Neeraja KP. 2008. Essentials of Mental Health and Psychiatric Nursing: Vol II. First Edition.

New Delhi. Jaypee Brothers Medical Publishers (P) Ltd. PP: 401-410.

3. Sreevani R. 2007. A Guide to Mental Health and Psychiatric Nursing. Second Edition. New

Delhi. Jaypee Brothers Medical Publishers (P) Ltd. PP: 88-96.

4. http://www.medicinenet.com/bipolar_disorder/page2.htm

5. http://en.wikipedia.org/wiki/Mania#Symptoms

6. http://psychcentral.com/disorders/sx9.htm

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http://en.wikipedia.org/wiki/Mania#Symptoms

http://www.medicinenet.com/bipolar_disorder/page2.htm

Documents

Mental Case Study