Running head: BIPOLAR DISORDER 1

Psychiatric Comprehensive Case Study of the Characteristics of Bipolar Disorder

Alissa Romain

YSU Nursing

October 17, 2016

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Abstract

This case study focuses on a twenty-six-year-old, Caucasian, male, whose diagnosis is

bipolar disorder. An observation has been documented and evaluated based on my date of care

with the patient to when he was first admitted onto the psychiatric unit a few days prior.

Common behaviors seen in patients with bipolar disorder is summarized. Caring for a patient

with this diagnosis will be discussed in depth including their family history of mental illness,

predisposing stressors that possibly led to hospitalization, spiritual and cultural influences that

make an impact, and nursing care that took part in the patients treatment. Short-term and long-

term goals were created and prioritized. Also listed is an evaluation of the patients condition

before discharge.
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Objective Data

The patient is a 26-year-old single Caucasian male. He was admitted on 10/18/16 and the

date of care was 10/25/16. The patients psychiatric diagnosis using the DSM IV-TR, Axes I

through V is as follows: His Axis I is affective mood disorder and uncomplicated cannabis abuse.

Axis II is labeled as deferred. Axis III states type I diabetes mellitus. Axis IV is moderate

psychosocial and environmental problems, currently the patient has moved back and forth from

an apartment to living back at home with his family. Also, he has experienced a loss of a relative

and a separation from a girlfriend. Lastly, Axis V, the Global Assessment of Functioning Scale.

The patient received a 25 on the scale which indicates difficulties in functioning.

According to the history and physical, the patient was transported by ambulance to the

emergency room after a suicidal incidence at home where he is currently living with his mom,

dad, and three brothers. In the emergency room, the patient displayed impulsive behaviors and

believed he did not need treatment. It was stated that he was noncompliant with his medication.

It was reported that the patient was saying to his family he was going to shoot himself with a gun

he has and use a bottle of lighter fluid to light himself on fire. When talking to the patient on the

day of care, he says he has no recall of doing such, he only remembers riding in the ambulance to

the hospital. From the report, four police officers had to get him under control and use the assist

of a Taser. He was involuntarily admitted to the Trumbull Memorial psychiatric unit.

On the day of care, 10/25/16, the patient was calm, content, and easily approachable. He

politely agreed to sit down and have a conversation with me. He was very attentive during our

conversation and had no problem answering any questions. During my observation, he seemed to

be very interested in his plan of care and wanted to know more information about his
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medications. For example, the doctor had mentioned to him about prescribing a mood-stabilizer

for him so he wanted to know more about them before agreeing to take the medication. He

presented himself with animated facial expressions, relaxed posture, and dressed appropriately.

He denied any thoughts of suicide or homicide and contracted a plan for safety. He has plans for

when he is able to be discharged, such as visiting his grandma and spending time with his

brothers. He displayed feelings of happiness when sharing his plans. The client is diagnosed with

mood disorder, type I diabetes mellitus, hypertension, and sensory perceptual alteration.

The patient is on the current medications: diazepam (Valium), insulin aspart (NovoLog),

insulin detemir (Levemir), lisinopril (Zestril), sertraline (Zoloft), acetaminophen (Tylenol),

bisacodyl (Dulcolax), diphenhydramine (Benadryl), glucagon (GlucaGen), haloperidol (Haldol),

ibuprofen, magnesium hydroxide (Milk of Magnesia), trazodone (Oleptro). The patient is

prescribed a five milligram tablet of Valium, an anxiolytic, to be taken three times a day for his

anxiety. NovoLog, a fast acting insulin injection, to be taken daily subcutaneously before meals

and at bedtime for type I diabetes. Thirty units of Levemir, a long acting insulin, to be taken

daily subcutaneously, and twenty units subcutaneously at bedtime. A ten milligram tablet of

lisinopril, an angiotensin-converting-enzyme inhibitor, to be taken daily for a medical history of

hypertension. One-hundred milligram tablet of Zoloft, an antidepressant, to be taken daily for his

depression. A six-hundred and fifty milligram tablet of Tylenol, an analgesic, taken as needed if

he is experiencing any pain or fever. Ten milligrams of bisacodyl, a laxative, taken as needed for

constipation related to the side effects of psychiatric medications. As needed, he receives a

twenty-five milligram intramuscular injection of Benadryl, which is an antihistamine, to decrease

extrapyramidal symptoms when taking Haldol. He receives five milligrams of Haldol

intramuscularly as needed, which is an antipsychotic for agitation and anxiety that he may be
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experiencing. As needed, he takes four-hundred milligrams of ibuprofen, a non-steroidal anti-

inflammatory, every eight hours for headaches. One thousand two hundred milligrams of Milk of

Magnesia, an antacid, taken as needed for constipation related to the side effect of psychiatric

medications. Fifty milligrams of trazodone, an antidepressant, as needed for his depression.

Psychiatric Diagnoses and Common Behaviors

Goossens, Van Achterberg, & Knoppert-van der Klein (2007), characterized bipolar

disorder as, the alternating occurrence of manic, hypomanic, depressive, and possibly mixed

episodes. These patients have a high use in alcohol and drugs, specifically benzodiazepines

(Ward, 2011). This patient has a history of abuse with cannabis dependence and benzodiazepines.

They also have a significantly higher risk of suicide than any other psychiatric disorder

(Goossens et all). A persons mood can be looked at on a spectrum with the two outermost ends

being linked to bipolar disorder. The manic phase on the spectrum is when the patient

experiences racing thoughts, tons of ideas, rapid speaking, and increased motor activity (Mason,

Brown, & Croarkin, 2016). This type of mood was found in the patients report when he

displayed impulsive behaviors and racing thoughts of committing suicide. Meanwhile, with

depression, the patient displays symptoms of uneasiness, stupor, and apprehension (Mason et

all).

The patient has been dealing with type I diabetes mellitus at a young age. He stated he

has many times where his sugar will get out of control. A study done on the relationship of

diabetes mellitus and suicide risk found that men and those who have a lower glycemic control

are at a higher chance of committing suicide (Sarkar & Singh, 2014). Diabetic patients that

experience depression are also at a higher risk of committing suicide. These factors are displayed

with this patient.

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Identification of Stressors and Behaviors

According to the patients history and physical, there were multiple stressors listed that

could have precipitated his current hospitalization. The client has a history of depression. He

stated his depression comes and goes but he has been experiencing constant depression since his

girlfriend left him in December. His anxiety and depression become out of control when his

blood sugar level is not stable. Another stressor could be the fact that his aunt had died a couple

weeks prior to admission. Also, he stated that he has flashbacks to when he was diagnosed at the

age of four with type I diabetes. Whether the flashbacks relate to his noncompliance with

diabetes management is unclear. In 2011, Wards study interviewed clients with bipolar disorder

and substance abuse disorder. These clients expressed that living with physical health problems

such as hypertension, diabetes, hepatitis C, and HIV makes it harder to live on a daily basis and

attend to basic needs while dealing with a mental illness. Being around negative people puts a lot

of stress on him. He has moved back and forth from an apartment to living with his family.

Currently he has no income and is unemployed.

Patient and Family History of Mental Illness

The client does not have a family history of mental illness. He has had suicidal ideations

and threats in the past but there have been no reports of any previous hospitalizations. However,

with his current admission, his suicidal plan was specific and accessible due to the fact he had

access to a gun making the attempt highly lethal.

Evidenced Based Nursing Care and Milieu Activities

When admitted onto the floor, the nurse conducts a detailed assessment of the patient.

The nurse should obtain a detailed history of mood instability and mood swings, stress factors,
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life events, alcohol and drug use, money-spending patterns, and promiscuous behavior

(Goossens et all, 2007). During hospitalization, the client receives medication therapy to monitor

the therapeutic effects of the medication and adjust the dosages as needed depending on how he

responds to treatment. Milieu therapy is a very important component of care on the psychiatric

unit. The clients environment is controlled to display a calm and relaxing therapeutic place. For

example, the room is designed for patients to interact with one another, watch television, and

play board games. Therapeutic groups are held in a certain room that the client is expected to

attend and learn adaptive coping and skills. The group topics can range from expressing

emotions to discussing how the client should deal with negative relationships. The display of

lights on the unit are set to a certain brightness and the music is played quietly to maintain a calm

environment. This is especially important for this patient in regards to his impulsive behaviors

and mood disorders, especially when he is to experience signs of mania. The clients schedule for

the day is structured with certain times the client is to eat, attend different groups, visiting hours,

and activities they can attend. Also, there are certain times a day when the client can go outside

on the unit for fresh air. It is extremely important for the nurse to set clear and consistent limits.

A beneficial technique for modifying patient behavior would be the token economy system

(Goossens et all, 2007). The nurse provided care to the patient by administering medication,

such as his NovoLog during breakfast, to maintain a stable blood sugar. The nurse answered any

questions the client had about the medications and conversed with the patient to gain a brief

psychological assessment. On the unit, the client is always monitored and the nurse documents

fifteen minute checks based on the clients activity and behaviors. The doctor meets with him in

the mornings to discuss possible discharge, medications, and whether or not to adjust any

dosages.
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Analysis of Patients Ethnic, Cultural, and Spiritual Influences

It was stated that the patient goes to church. During the day of care with the patient, he

did not express any spiritual concerns and did not seem to be in any spiritual distress. He has

many protective factors that have an influence on his well-being. For example, he stated he has a

good support system with his friend. Also, he states his relationship is good with his mother,

father, and three brothers.

Evaluation of Patient Outcomes

Some of the short term goals that were created for the patient included not wanting to

harm himself for two days, alerting staff if he has active suicidal thoughts, verbalizing alternating

ways of coping, and not verbalizing suicidal plans for a period of three days. The long-term goals

included verbalizing an ability to recognize, accept, and cope with symptoms of depression, and

verbalizing knowledge on how to access help if he experiences symptoms of depression. On my

day of care, it has been the patients seventh day on the unit so I definitely seen a lot of progress

based on the patients history. He stated he was not having any suicidal plans or thoughts and that

he has felt a lot better in the past few days. I observed him comfortably watching television and

coloring. During our conversation he never expressed any negative thoughts. He was excited to

go home and carve pumpkins with his brothers and go out to eat with his grandma. He was

optimistic about going back to school in the future to work on computer software. His behavior

was controlled, he was compliant with his medications, and did not appear irritated.

Discharge Planning

Plans for discharge include medication compliance and increased knowledge of medication

regimen. The patient needs to be at no harm to himself or others and be able to reach out for
MOOD DISORDER 9

safety if these thoughts were to occur. The patient will demonstrate increased thought process

and show increased signs of a stabilized mood.

Prioritized List of Nursing Diagnoses

- Death anxiety related to stress as evidenced by expressed concerns due to change in life

events
- Noncompliance with medication related to individuals value system as evidenced by

exacerbation of hypoglycemic symptoms

- Ineffective coping related to inadequate available resources as evidenced by abuse of

chemical agents
- Disturbed thought process related to depressed mood as evidenced by decreased problem-

solving abilities
- Grieving related to death of significant other as evidenced by psychological distress
- Interrupted family processes related to situational crises as evidenced by changes in

availability for affective responsiveness

- Powerlessness related to substance addiction as evidenced by ineffective recovery

attempts
- Constipation related to antidepressants as evidenced by generalized fatigue, change in

bowel pattern.

Potential Nursing Diagnoses

- Risk for suicide related to impulsiveness and loss of an important relationship

- Risk for self-directed violence related to altered thought process
- Risk for loneliness related to separation from girlfriend
- Risk for unstable blood glucose related to lack of adherence to diabetes management

- Risk for decreased cardiac output related to increased vascular resistance

- Risk for falls related to ACE inhibitor

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References

Ackely, B.J., Ladwig, G.B. (2014). Nursing Diagnosis Handbook (10th ed.). Maryland Heights,

MO: Elsevier.

Goossens, P. J., van Achterberg, T., & Knoppert-van der Klein, E. M. (2007). Nursing processes
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used in the treatment of patients with bipolar disorder. International Journal Of Mental

Health Nursing, 16(3), 168-177. doi:10.1111/j.1447-0349.2007.00464.x

Mason, B. L., Brown, E. S., & Croarkin, P. E. (2016). Historical Underpinnings of Bipolar

Disorder Diagnostic Criteria. Behavioral Sciences (2076-328X), 6(3), 1-19.

doi:10.3390/bs6030014

Sarkar, S., & Singh Balhara, Y. P. (2014). Diabetes mellitus and suicide. Indian Journal Of

Endocrinology & Metabolism, 18(4), 468-474. doi:10.4103/2230-8210.137487

Ward, T. D. (2011). The Lived Experience of Adults with Bipolar Disorder and Comorbid

Substance Use Disorder. Issues In Mental Health Nursing, 32(1), 20-27.

doi:10.3109/01612840.2010.521620