INTRODUCTION

Bipolar disorder, also known as manic-depressive illness, is a brain

disorder that causes unusual shifts in mood, energy, activity levels, and the

ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe.

They are different from the normal ups and downs that everyone goes through

from time to time. Bipolar disorder symptoms can result in damaged

relationships, poor job or school performance, and even suicide. But bipolar

disorder can be treated, and people with this illness can lead full and

productive lives.

Bipolar disorder often develops in a person's late teens or early adult

years. At least half of all cases start before age 25. Some people have their

first symptoms during childhood, while others may develop symptoms late in

life. It occurs almost equally among men and women. It is more common in

highly educated people. Because some people with bipolar illness deny their

mania prevalence rates may actually be higher than expected.

Bipolar 1 disorder is classified under axis 1 by Diagnostic and

Statistical Manual of Mental Disorders (DSM-IV). It has a diagnostic code of

2960 according to the US Census Bureau, Population Estimated of 2004;

bipolar 1 disorder has an Extrapolated prevalence of 1,034,900 and

Population Estimated Use of 86,241,697 in the Philippines.

People with bipolar 1 disorder experience unusually intense emotional

states that occur in distinct periods called "mood episodes." An overly joyful or

overexcited state is called a manic episode, and an extremely sad or hopeless

state is called a depressive episode. Sometimes, a mood episode includes

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symptoms of both mania and depression. This is called a mixed state. People

with bipolar disorder also may be explosive and irritable during a mood

episode.

A person may be having an episode of bipolar disorder if he or she has

a number of manic or depressive symptoms for most of the day, nearly every

day, for at least one or two weeks. Sometimes symptoms are so severe that

the person cannot function normally at work, school, or home.

Sometimes, a person with severe episodes of mania or depression has

psychotic symptoms too, such as hallucinations or delusions. The psychotic

symptoms tend to reflect the person's extreme mood. For example, psychotic

symptoms for a person having a manic episode may include believing he or

she is famous, has a lot of money, or has special powers. In the same way, a

person having a depressive episode may believe he or she is ruined or has

committed a crime. As a result, people with bipolar disorder who have

psychotic symptoms are sometimes wrongly diagnosed as having

schizophrenia, another severe mental illness that is linked with hallucinations

and delusions.

Bipolar disorder tends to run in families, so researchers are looking for

genes that may increase a person's chance of developing the illness. Genes

are the "building blocks" of heredity. They help control how the body and brain

work and grow. Genes are contained inside a person's cells that are passed

down from parents to children. Children with a parent or sibling who has

bipolar disorder are four to six times more likely to develop the illness,

compared with children who do not have a family history of bipolar disorder.

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However, most children with a family history of bipolar disorder will not

develop the illness.

Genetic research on bipolar disorder is being helped by advances in

technology. This type of research is now much quicker and more far-reaching

than in the past. One example is the launch of the Bipolar 1 Disorder

Phenome Database, funded in part by National Institute of Mental Health.

Using the database, scientists will be able to link visible signs of the disorder

with the genes that may influence them. So far, researchers using this

database found that most people with bipolar disorder had:

• Missed work because of their illness

• Other illnesses at the same time, especially alcohol and/or substance

abuse and panic disorders

• Been treated or hospitalized for bipolar disorder.

The researchers also identified certain traits that appeared to run in families,

including:

• History of psychiatric hospitalization

• Co-occurring obsessive-compulsive disorder (OCD)

• Age at first manic episode

• Number and frequency of manic episodes.

Scientists continue to study these traits, which may help them find the genes

that cause bipolar disorder some day.

But genes are not the only risk factor for bipolar disorder. Studies of

identical twins have shown that the twin of a person with bipolar illness does

not always develop the disorder. This is important because identical twins

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share all of the same genes. The study results suggest factors besides genes

are also at work. Rather, it is likely that many different genes and a person's

environment are involved. However, scientists do not yet fully understand how

these factors interact to cause bipolar disorder.

To date, there is no cure for bipolar disorder. But proper treatment

helps most people with bipolar disorder gain better control of their mood

swings and related symptoms. This is also true for people with the most

severe forms of the illness.

Because bipolar disorder is a lifelong and recurrent illness, people with

the disorder need long-term treatment to maintain control of bipolar

symptoms. An effective maintenance treatment plan includes medication and

psychotherapy for preventing relapse and reducing symptom severity.

Proper diagnosis and treatment helps people with bipolar disorder lead

healthy and productive lives. In most cases, treatment can help reduce the

frequency and severity of episodes.

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Scope and Delimitation

The patient was admitted at St. Mary Frances of Five Wounds Psychiatric

Home Care on November 16, 2009.The patient was handled by student

nurse, Miss Janil Angeline S. Silvestre last February 1- 4, 2010 (0700H-

1500H). The case study focuses on bipolar affective 1 and this is based on

the condition presented by the patient. The patient’s chart was read last

February 1, 2010.The physical assessment and interviews was conducted on

February 12, 2010, at 1200H, but records from Millview Hospital and Rolling

Garden Hospital in England were not gathered due to technical problems.

Primary information came from the patient and the patient’s chart, but since

she has a problem psychologically, we also gathered some information from

her daughter, information gathered was consented with utmost confidentiality.

The patient has no laboratory exams done. The daughter was interviewed last

February 15, 2010, at 1700H. The patient was discharged last February 17,

2010, at 1330H. We were not able to record the daily appraisal beyond the

duty days due to conflict of schedules.

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2
REVIEW OF ANATOMY AND PHYSIOLOGY OF THE BRAIN

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 The central nervous system has three major divisions; the brain,

spinal cord and the nerves. When talking about psychological problems the

major affected part is the brain. The anatomy of the brain is complex due its

intricate structure and function. This amazing organ acts as a control center

by receiving, interpreting, and directing sensory information throughout the

body. There are three major divisions of the brain; they are the forebrain

(cerebrum), the midbrain (cerebellum), and the hindbrain (brainstem).

The cerebrum is the largest part of the brain. In general terms it

is well understood that the left hemisphere controls linguistic consciousness,

the right half of the body, talking, reading, writing, spelling, speech

communication, verbal intelligence and memories, and information processing

in the areas of math, typing, grammar, logic, analytic reasoning, and

perception of details. The right hemisphere is associated with 'unconscious'

awareness (in the sense it is not linguistically based), perception of faces and

patterns, comprehension of body language and social cues, creativity and

insight, intuitive reasoning, visual-spatial processing, and holistic

comprehension. Communication between the two hemispheres takes place

through the corpus callosum, which, by the way, is more fully developed in

women than men- likely giving rise to women's intuition. The parietal,

temporal, and occipital lobes are specialized for perception. Within the

parietal lobe is the primary somatosensory cortex which receives information

pertaining to the senses of the body: touch, pressure, temperature, and pain.

Visual information is received by the primary visual cortex located within the

occipital lobe. Hearing is processed in the primary auditory cortex within the

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temporal lobe. Their anterior and posterior portion are referred to as the

“psychic cortex”, and are associated with function such as abstract thought

and judgment. Most of the temporal lobe is separated from the rest of the

cerebrum by the lateral fissure. This part is the most affected when there is a

psychological disorder. The limbic system is a collection of brain structures

involved with emotion, motivation, multifaceted behavior, and memory storage

and recall. The hippocampus and the amygdale; along with portions of the

hypothalamus, thalamus, caudate nuclei, and septum function together to

form the limbic system.

Two primary parts comprise the midbrain : the tectum and the tegmentum.

The primary structure of the tectum include the superior colliculi and the

inferior colliculi. The superior colliculi form part of the visual system. The

inferior colliculi are part of the auditory system. The structures appear as four

small bumps located on the brain stem. Function in mammals relates to

visual reflexes and reaction to moving stimuli. The tegmentum is situated

below the tectum. The reticular formation, periaqueductal gray matter, and

the red nucleus and substantia nigra are part of the tegmentum. The reticular

formation is comprised of more than 90 nuclei and an interconnected neural

network located at the core of the brain stem. It receives sensory information

and is involved with attention, sleep and arousal, muscle tonus, movement,

and various vital reflexes. The periaqueductal gray matter consists of neural

circuits that control sequences of movements constituting species-typical

behavior. The red nucleus and substantia nigra are parts of the motor

system. The red nucleus serves as one of two major fiber systems bringing

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motor information from the brain to the spinal cord. The substantia nigra

affects the caudate nucleus via dopamine-secreting neurons.

Cerebellum’s (little brain) primary function involves control of

bodily movements. It serves as a reflex center for the coordination and

precise maintenance of equilibrium. Voluntary and involuntary bodily

movements are controlled by the cerebellum. Visual, auditory, vestibular, and

somatosensory information is received by the cerebellum, as is information on

the movements of individual muscles. Processing of this information results in

the cerebellum's ability to guide bodily movements in a smooth and

coordinated fashion. The pons appear as a large bulge in the brain stem

between the mesencephalon and the medulla oblongata. The pons contain a

portion of the reticular formation as well as nuclei believed important in the

role of sleep and arousal.

The myelencephalon is comprised of one structure: the medulla

oblongata (oblong marrow). It is the origin of the reticular formation and

consists of nuclei which control vital bodily functions. The medulla oblongata

is the control center for cardiac, vasoconstrictor, and respiratory functions.

Reflex activities, including vomiting, are controlled by this structure of the

hindbrain. Appearing as a pyramid-shaped enlargement of the spinal

Although neurotransmitters have two types of effects, depolarization or

hyperpolarization, many of them are not hard-wired. Many transmitters do not

always have the same effect. The nature of the ion channels that are

controlled by the postsynaptic can determine the effects of some transmitters.

Neurotransmitters are also involved or affected when there is a psychological

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disorder. Neurotransmitters are chemical substances that transfer an impulse

from one neuron to another at the synapse. This excites stimulates action in

the cells (excitatory) or inhibits and stops actions (inhibitory) to fill into the

specific receptor cells. Sudden increase or decrease in the level of the

neurotransmitters can lead to psychiatric disorders.

An action potential is a short-lasting event in which the electrical

membrane potential of a cell rapidly rises and falls, following a stereotyped

trajectory. Action potentials occur in several types of excitable cells, including

neurons. ction potentials are generated by special types of voltage-gated ion

channels embedded in a cell's plasma membrane. These channels are shut

when the membrane potential is near the resting potential of the cell, but

rapidly begin to open if the membrane potential increases to a precisely

defined threshold value. When the channels open, they allow an inward flow

of electrical current, which produces a further rise in the membrane potential.

This then causes more channels to open, producing a greater electrical

current, etc. The process proceeds explosively until all of the available ion

channels are open, resulting in a large upswing in the membrane potential,

often to the extent of briefly reversing its polarity. The ion channels then

rapidly inactivate, allowing the membrane potential to drop back to its baseline

level, sometimes speeded by other types of voltage-gated ion channels which

are active specifically during the falling phase of an action potential.

In animal cells there are two primary types of action potentials, one

type generated by voltage-gated sodium channels, the other by voltage-gated

calcium channels. Sodium-based action potentials usually last for less than

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one millisecond, whereas calcium-based action potentials may last for 100

milliseconds or longer. In some types of neurons, slow calcium spikes provide

the driving force for a long burst of rapidly-emitted sodium spikes. In cardiac

muscle cells, on the other hand, an initial fast sodium spike provides a

"primer" to provoke the rapid onset of a calcium spike, which then produces

muscle contraction.

Action potentials are most commonly initiated by excitatory postsynaptic

potentials from a presynaptic neuron. Typically, neurotransmitter molecules

are released by the presynaptic neuron. These neurotransmitters then bind to

receptors on the postsynaptic cell. This binding opens various types of ion

channels. This opening has the further effect of changing the local

permeability of the cell membrane and thus the membrane potential. If the

binding increases the voltage (depolarizes the membrane), the synapse is

excitatory. If, however, the binding decreases the voltage (hyperpolarizes the

membrane), it is inhibitory. Whether the voltage is decreased or increased,

the change propagates passively to nearby regions of the membrane (as

described by the cable equation and its refinements). Typically, the voltage

stimulus decays exponentially with the distance from the synapse and with

time from the binding of the neurotransmitter. Some fraction of an excitatory

voltage may reach the axon hillock and may (in rare cases) depolarize the

membrane enough to provoke a new action potential. More typically, the

excitatory potentials from several synapses must work together at nearly the

same time to provoke a new action potential. Their joint efforts can be

thwarted, however, by the counter-acting inhibitory postsynaptic potentials.

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Neurotransmission can also occur through electrical synapses. Due to the

direct connection between excitable cells in the form of gap junctions, an

action potential can be transmitted directly from one cell to the next. The free

flow of ions between cells enables rapid non-chemical mediated transmission.

Rectifying channels ensure that action potentials move only in one direction

through an electrical synapse. In the human nervous system this type of

synapse is uncommon however.

All-or-noneprinciple. The amplitude of an action potential is independent of

the amount of current that produced it. In other words, larger currents do not

create larger action potentials. Therefore action potentials are said to be all-

or-none (or boolean), since they either occur fully or they do not occur at all.

Instead, the frequency of action potentials is what encodes for the intensity of

a stimulus. This is in contrast to receptor potentials, whose amplitudes are

dependent on the intensity of a stimulus.

• Neuron – is the cell or the functional unit of the nervous

system.

• Synapse – the junctions between the neurons.

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Neurotransmitter Functions Related disorders
Acetylcholine Excitatory on the Decreased level
skeletal muscles. That causes Alzheimer’s
is also involved with disease.
learning and recall, as
well as in controlling
the stage of sleep
during which dreams
occur.
Dopamine Activates cells involved Hyperactivity leads to
in motivation and schizophrenia and
pleasure. mania.
Integration of thoughts
and emotions. Hypo-activity leads to
Abstract thinking, depression and
decision making. Parkinson’s disease.
Gamma Amino-butyric Inhibits brain activity Anxiety state of those
Acid (GABA) and has a sedating with low levels of
effect. As it induces GABA or fewer GABA
calmness, receptors.
contentedness and
reduction of
aggression.
Glutamate The “workhorse” Brain damage and
chemical that keeps Alzheimer’s disease.
the brain ticking over.
Nor-adrenaline Induces physical and Mood disorders
mental arousal and
heightens mood, for Anxiety disorders
“flight or fight”
response
Serotonin The “feel-good” Anxiety disorder
chemical. It produces
feelings of wellbeing Mood disorders
and regulates sleep,
appetite and blood Personality disorders
pressure.
Delusions

Hallucinations

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2
Genetic factors

Data derived from virtually every methodologies strategy in human

genetics strongly suggest significant genetic influences in the major affective

disorders, but as yet the mode of genetic transmission has not been

established. The degree of genetic expression varies considerably from

patient to patient and in some patients marked and predictable genetic factors

are present; in others genetic expression appears to be significantly less

influential. The twin studies have been one of the major research strategies

used by psychiatric geneticists to attempt to quantify genetic loading in

various psychiatric diseases. Twin studies in affective disorders have reported

concordance rates among monozygotic (MZ) twins ranging from 33.3 to 75

percent, with an average of 65 percent. In contrast, the concordance rates for

dizygotic (DZ) twins range from 9 to 23 percent, averaging 15 percent. The

difference in concordance rates between MZ and DZ twins strongly suggests

inherited genetic vulnerability. Further, there is evidence that even the polarity

of the disorder may be genetically controlled, since there is an 80 percent

concordance for bipolar and 59 percent concordance for unipolar disorders in

MZ twins. In an attempt to separate the “nature” and “nurture” contributions to

the development of affective disorders, the adoption study strategy has also

been used. Unfortunately, because of muthodologie problems and the paucity

of subjects studied, no definitive answers are available. There is, however, a

trend indicating that adoptees with affective disorders have a greater

incidence of affective illness in their biologic parents than in their adopted

parents. A large number of family studies have been conducted in the

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affective disorders. The standard paradigm is to make independent and blind

diagnoses in the first-degree relatives of affective disorder patients,

anticipating that if genetic components are present, the consanguineous

relatives will manifest an increased risk for affective illness. First-degree

relatives of bipolar patients have a morbidity risk for bipolar disorder ranging

from 2.8 to 17.7 percent and a risk of 0 to 22.4 percent for unipolar

depression. The first-degree relatives of unipolar patients have a risk of 6.4 to

17 percent for unipolar depression and of 0.3 to 29 percent for bipolar

disorder. Thus, bipolar patients have both unipolar and bipolar disorders

among their blood relatives, whereas unipolar patients have increased

incidence for unipolar, but not bipolar, disorders in their relatives. Modern

studies of genetic transmission combine careful family pedigree studies with

molecular genetics in an attempt to identify the linkage between the specific

gene markers and manifestation of major affective disorder in an afflicted or

informative family. At present, no clear dominant or recessive inheritance

pattern has been identified. It appears that genetic heterogeneity is present,

which suggests a multiple threshold model in order to account for the varying

degrees of genetic variability in the affective disorders. Genetic marker

surveys in informative families have been conducted, including studies which

have used genetically regulated markers that are etiologically significant in

affective illness, such as the concentrations of dopamine B-hydroxylase,

monoamine oxidase A, monoamine oxidase B, and lithium red blood cell

(RBQ/plasma ratio. No marker has yet been found which segregates to the

presence of affective disorder. There is however, a small subgroup of bipolar

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patients who do manifest a linkage of protan-deutan (red-green) color

blindness and the Xg blood group with the presence of bipolar disorder.

Unfortunately this very interesting genetic linkage pattern has not been

present in other families similarly afflicted with major affective disorder.

In summary, the genetic studies strongly indicate the inheritance of a

vulnerability to affective illness, but the genetic expression is heterogeneous

and the degree of vulnerability varies significantly. There is evidence that the

genetic factors are stronger in bipolar disorder than in unipolar depression.

There are currently several large-scale surveys combining molecular and

pedigree methodologies which are either in progress or in the final stages of

implementation, and it is possible that the gene(s) coding for affective

disorders will be identified and cloned in the foreseeable future.

Neurotransmitter systems

The most consistent search for etiologic mechanisms in the affective

disorders has involved studies of the various neurotransmitter systems in the

brain. The original biogenic amine hypothesis focused primarily on the central

nervous system (CNS) neurotransmitters norepinephrine, serotonin, and

dopamine, attributing depression and mania, respectively, to the deficiency or

excess of these neurotransmitters at important synaptic sites in the brain. This

hypothesis has stimulated and directed research in the field for many years,

and data consistent with the hypothesis continue to emerge. Urinary and

cerebrospinal fluid (CSF) studies of Norepinephrine, its metabolite 3-methoxy-

4-hydroxyphenethyleneglycol (MHPG), and the catalytic enzyme dopamine B-

hydroxylase have been consistently reported as being increased or decreased

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in the predictable direction during depressed and manic episodes. More

recently, increases in norepinephrine have been described in both mania and

depression. Alterations in serotonin and its metabolites have also been

identified in patients during depressive episodes. In addition, 5-hydroxyindole

acetic acid (5HIAA), a serotonin metabolite, has been found to be reduced in

the CSF of depressed patients who make frequent and aggressive suicide

attempts. Deficits in other neurotransmitters such as dopamine and gamma-

aminobutyric acid (GABA) have also been identified in some patients with

major depression. Finally, another neurotransmitter hypothesis which has

directed research in the affective disorders is the cholinergic hypothesis,

which postulates increased central cholinergic tone in depression, decreased,

cholinergic tone in mania, and an imbalance between the cholinergic and

adrenergic neurotransmitter systems as being a central pathophysiologic

mechanism in affective disorders.

Within the last 5 years, there has been a shift of research focus from the

neurotransmitter biosynthetic, storage, and release mechanisms in the

presynaptic neuron to the study of receptors on postsynaptic neurons. There

is growing evidence that postsynaptic receptor kinetics and activity are

predictibly and consistently altered during affective episodes and by the

psychotropic medications known to ameliorate these disorders. Future

research in the pathophysiology of the affective disorders will be concentrated

on the role of postsynaptic receptor systems and the cascade of intraneuronal

biochemical events in the postsynaptic neuron which follow the binding of the

neurotransmitter to the receptor.

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 In summary, there is a general agreement in the large number of

studies which have been conducted to date that the relative paucity of a

neurotransmitter or the inactivation or down-regulation of postsynaptic

receptors has often been correlated with depressive episodes, but the

reciprocal changes which one would predict have not been consistently

identified in manic episodes.

Environmental factors

There is little systematic data available indicating what role

environmental stresses and untoward life events play or what types of

stressors might be etiologically significant in the development of major

affective episodes. Attempts have been made, for example, to relate early

childhood loss and parental separation as predisposing factors for the future

development of an affective illness, but the data are inconsistent. In general,

studies have shown an overall temporal relationship between stressful and

negative life events and the subsequent appearance of affective episodes.

Research attempting to characterize qualitative differences in the impact of

life stress have been disappointing, although serious life events such as the

death of a child or a spouse, job loss, marked changes in social status, and

even severe assaults on self-esteem have been linked to affective episodes.

While the relationship between environmental stresses and the appearance of

affective episodes has not always been demonstrated, generally speaking

most experts agree that a single severe or multiple severe adverse events in

life can interact with the constitutional predisposition of a patient and result in

the triggering of an affective episode.

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In further support of the influence of environmental events are the studies

which have been conducted in higher primates. In these studies, phenomena

which resemble or are analogous to the depressive states in humans are

seen in monkeys following both mother/infant and peer separation paradigms.

Furthermore, the monkey’s “despair” response to the separation paradigms

can be predictably enhanced by drugs known to specifically alter central

concentrations and metabolism of various relevant CNS neurotransmitters

(e.g., norepinephrine, dopamine).

Biologic rhythms

The marked tendency of major affective disorders to periodic

manifestation and possibly to seasonal variations has stimulated hypotheses

which suggest that the dysregulation of biologic rhythms may be centrally

involved in the pathophysiology of affective disorders. There are reports of

dysynchronization of circadian rhythms in some bipolar patients in which

these patients manifested both rapid free-running circadian rhythms (e.g., 23-

versus 24-hour rhythms) and a phase delay in their rhythms. There is also a

specific subgroup of patients with major depression in which the depressive

episodes are manifested seasonally during the wintertime. These patients,

while residing in more northern latitudes, experience major depressive

episodes during the winter when days are significantly shorter and periods of

darkness more prolonged; they do not experience depression of this type

when residing in latitudes where the environmental light/ dark cycle is not as

extreme.

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ASSESSMENT

Patient’s Profile:

Name: Ms. Flower

Sex: Female

Age: 42

Nationality: Filipino

Religion: Catholic

Date of Birth: December 24, 1967

Place of Birth: Makati

Educational Attainment: Highschool - undergraduate

Occupation: None

Address: Novaliches, Quezon City

Date of Admission: November 16, 2009

Time of Admission: 0515h

Chief Complaint: Hyperactive Behavior, as verbalized “Nagwawala kasi siya.

Hindi niya nakilala ako na anak niya kaya dinadala po namin siya dito”.

Admitting Diagnosis: Bipolar 1 Affective Disorder

Attending Medical Doctor: Dr. Cruzada

Contact Person/ Informant: Ms Petal, Daughter

Percentage Reliability: 90%

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GENOGRAM

MALE

FEMALE
HYPERTEN
SION

ALIVE AND
WELL

HEPATIC
CANCER

DECEASE
D

PATIENT

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 Demographic data

Summary of client’s Family of orientation

Family Position Age Sex Civil Status Occupation Religion Educational

Member Attainment
Mr. Root father 45 male Deceased Roman
Catholic
Mrs. Soil mother 33 female Deceased Roman
Catholic
Mr. Trunk 1st child 46 Male Married Roman
Catholic
Mr. Branch 2nd Child 45 Male Married Roman
Catholic
Ms. Flower 3rd child 42 Female Separated Roman
(Patient) Catholic
Mrs. Leaves 4th Child 38 Female Married Roman
Catholic
Mrs. Fruit Youngest 37 Female Married Roman
child Catholic

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Family of Procreation

Family Position Age Sex Civil Status Occupation Religion Educational

member Attainment
Ms. Flower Mother 42 Female Separated Roman
(Patient) Catholic
Ms. Petal Eldest child 23 Female Single Roman
(1st husband) Catholic
Ms. Bud Youngest 9 Female Single Roman
Child (2nd Catholic
husband)

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Family Background

Ms. Flower, a 42 years old High School graduate, is the 3rd child among

5 children of Mr. Root and Mrs. Soil. In year 1978, Mrs. Soil died at the age of

33 years old because of vehicular accident, eleven years after; Mr. Root

experienced untreated depression because of the sudden death of his wife.

To escape from reality, he became alcoholic that cause hepatic cancer which

led him to death at the age of 45 (1989). Mr. Trunk a college graduate and

now a businessman, was the eldest child in the family. Mr. Branch was the 2 nd

child in the family. Mrs. Leaf and Mrs. Fruit was the 4th and 5th child in the

family. Their ages are 38 and 37 years old. All of the family members were

High School graduate. They were all Roman Catholics.

Ms. Flower marries 2 times and all of her husbands are alive. She had

her 1st daughter on her 1st husband. She had her 2nd child on her 2nd husband.

Family Health History

Ms. Flower’s mother died because of vehicular accident, and Mr. Root

became dent alcohol dependent which leads him to death because of hepatic

cancer.

Ms Flower has no history of hypertension and nor cancer. Her eldest

brother Mr. Trunk has been diagnosed with hypertension. Her remaining

siblings have no history of hypertension or other diseases; therefore we

conclude they are all alive and well.

Ms. Flower’s 2 children have no known history of diseases.

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Past Medical History

Ms. Flower had experienced illnesses like chickenpox, mumps and

measles. She verbalized “Oo, nagkabulutong na ako noon. Pati nga tigdas at

beke eh”.

Patient has no known allergies to either foods or medication.

Whenever client experiences fever, cough or colds she used to buy

over the counter drugs like Paracetamol and Neozep. She has no history of

hospitalization except for giving birth to her 2 children.

Ms. Flower said that she has been given immunization shots but could

not remember if she had been fully immunized.

Present Medical History

She worked at England for six years straight and felt homesick and

severely stressed because of money. She met her second husband a British

man, whom she lived with for 2 years, on February 2001 she got pregnant, so

they decided to go back to the Philippines to introduce his husband to her

relatives last 2001 of May. After giving birth on November 24, 2001 to her

second daughter, Ms. Bud, she went back to Europe on July of 2002. After

many months of living with the British man; they decided to separate because

of their frequent misunderstandings.

She had no job for almost two years and begun to exhibit hyperactive

behaviors. She was then sent to Millview Hospital at January of 2004 and was

first diagnosed of having Bipolar I she was discharged after 8 months later.

She had not carry on her medication thinking that she had been cure.

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 On 2004-2006 She went out looking for work but instead she met her

third Italian partner and decided to settle with him. She then decided to go

home to the Philippines with her live-in-partner at December of 2006 for the

Christmas Season and to introduce him to her daughter. She and her partner

started to have misunderstandings because her partner cannot acknowledge

her daughters, Ms. Petal and Ms. Bud. They went back to Europe the next

year of January 2007 and separated June of that year. Her symptom

regurgitated and was admitted on July 2007 to Rolling Garden Hospital with

the same diagnosis and was discharged on August 2008.

November that same year, she opted to return to Philippines. She was

admitted on November 16, 2009, at 0515H at St. Mary Frances of the Five

Wounds Psyche and Custodial Care, due to uncontrolled hyperactive

behavior as Ms. Petal verbalized “Nagwawala kasi siya. Hindi niya nakilala

ako na anak niya kaya dinadala po namin siya dito”.

She was given Lithium 450 mg. and Chlorpromazine 5mg. She had

undergone several therapies with the custodial care. She experienced various

depressions and has been having difficulty with sleeping for quite some time

because she felt threaten and unease. She felt troubled because of her

infirmary charges and repeatedly demands that she must be sent home

because she does not feel sick and claims to feel fine.

She was discharged last February 17, 2010.

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Ob-gyne History

Ms. Flower’s menarche was at 15 years old. She was 18 years old at

her first pregnancy and had completed her prenatal check-ups. She gave birth

to a healthy baby girl last October 18, 1986 through normal delivery at Makati.

She was 34 years old when she gave birth to her second baby girl last

November 24, 2001 via normal delivery at Manila. She was not able to

complete her prenatal check-ups because of money matters.

She is still having her monthly menstrual period.

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DEVELOPMENTAL DATA

Erik Erikson
Generativity vs. Stagnation (40-60 years old)

Basic Virtue or Qualities: Productivity and ability to Care for others

Erickson refers to generativity as an adult’s ability to look outside

oneself and care for others. It is a concern for the next generation.

Generativity is a love that is given regardless of whether it is reciprocated.

The most obvious example of generativity would be parenting. Erikson stated

that adults need children as much as children need adults and that this stage

reflects the innate need to recreate a living legacy. Stagnation is the exact

opposite. It is caring for no one and being self-absorbed.

Analysis:

Ms. Flower did not achieve the developmental task because she was

unable to perform well as part of her family. She was unable to teach and care

for her children because of her present condition, as a result, stagnation is

developed.

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Developmental Ms.Flower Analysis
Task
Physical Ms. Flower’s development belongs Task partially met
Development to a young/middle adult stage. She Ms.Flower
weighs 55 kg, and stands 5 feet, 4 considered herself
inches tall. By merely looking at the as a well fitted and is
patient’s physicality, she was not conscious about
actually “voluptuous” in her present illness
appearance. She usually spends
most of her days inside the ward or
participating in the activities made
by the student nurses.
In terms of perception of health
functioning, Ms. Flower considered
herself as a well fitted and is not
conscious of her present disease.
Psychosocial Ms. Flower was playful and has a Task partially met
Development good camaraderie during her Before illness, Ms.
childhood. According to the Flower has
daughter, “nakuwento saamin dati harmonious
na nung bata pa daw siya ay relationship with her
marami naman daw siyang kalaro fellow employees
noon, di naman siya pala away, and boss but due to
tapos kasundo naman niya ang her illness, she
mga kapatid niya, pero minsan di cannot socialize well
naman maiwasan na because of her
magkatampuhan sila”. manic-depressive
In terms of family relationships, as attacks.
the daughter can recall Ms. Flower
was close to her youngest sister
Ms. Petal, the daughter verbalized,
“silang dalawa yung magkasundo,
siguro kasi pareho silang babae
tapos magkalapit pa sila ng edad”.
She worked as a manicurist in the
Philippines for two years and in
England for seven years before her
confinement at mental institution.
She had a harmonious relationship
with her fellow employees and
boss.
She had two husbands and a live-
in-partner, for her previous
relationship didn’t work out because

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 he couldn’t accept that Ms. Flower
already had daughters

Cognitive Ms. Flower was an elementary Task partially met

Development graduate, after which she did not Based from the
have the chance to continue her experiences of Ms.
studies due to her family’s financial Flower and the
constraints. As the daughter added information by
verbalized “hindi na daw siya her daughter, it can
nakapag-highschool kasi kapos sila be presumed that
sa pera para matustusan ang her personality
pagaaral nilang magkakapatid, ang feature was molded
trabaho lang daw naman ni lola during the time
noon ay labandera at si lolo naman before her
tricycle driver lang”. The daughter confinement. She
also added that Ms. Flower was a was focused on that
good student during her elementary part of her life and
days. She was always doing her she developed every
homework and an active student. virtues and attitudes
According to Ms. Flower, the most in that part of her life
significant years for her were during but due to her
working years. She was very eager mental illness, there
and motivated to work for her is seen change in
family. As the daughter added, her mental status as
“masipag ang nanay ko, she is unaware of
nagtrabaho pa sa ibang bansa pra her place and
matulungan kami”. condition
Moral Ms. Flower grew up with discipline Task partially met
Development and obeyed all of the things that her The patient was
parents said to her. She was raised raised with discipline
together with her siblings by their and obeyed her
parents by punishing them when parents, but due to
they make mistakes, they were her condition she
scolded and “pinapalo” by their had manic attacks
parents. As the daughter verbalized and showed
“kapag nagaaway sila unnecessary
pinapagalitan namin tapos pinapalo behaviors like
lalo na kapag nagkakasakitan na speaking bad words
sila, pinapangaralan naming sila and throwing things
pra lumaki silang maayos”. that she can reach.

Spiritual The patient is a Roman Catholic. Task not met

Development She is not an active church The patient is not an
member but she believes in God. active church
The patient verbalized, “Catholic member and has
ako, hindi lang ako aktibo disturbed values and
pagdating sa pagsisismba pero beliefs.

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 naniniwala naman ako sa Diyos”.

Havighurst Developmental Task

Middle Age
Developmental Ms. Flower Analysis
Task
Achieving Adult The patient is a former manicurist; Task Partially Met
and Social she participates in the chores of the The patient had
Responsibility institution, like laundry and washing worked for her family
dishes. She also participates in the for several years.
daily activities that the students She also participates
prepare for them. in the daily activities
that the students
prepared for them.
Establishing and The patient has provided the Task Partially Met
Maintaining an essential needs and gave her Before her present
Economic children a good quality of condition she is able
Standard of education. The patient verbalized. to provide essential
Living “nakagraduate na yung pangnay needs and gave her
ko, yung bunso nal ang ang nag- children a good
aaral”. But due to her present quality education. But
illness she was unable to work due to her present
anymore. condition, she is
unable to provide for
her youngest
daughter.
Assisting Ms. Flower has a teenage child, but Task Not Met
Teenaged due to her present illness she is As a responsible
Children to unable to guide her into becoming a adult during this age,
become responsible adult. an individual tend to
Responsible practice Generativity
and Happy as they try to provide
Adults insight and advices to
the future generation.
Being experienced
they tend to guide
and support them in
the way of life, and
assisting them into
making right
decisions.

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 Task Not Met
One of the task of a
middle adult that
Developing She doesn’t smoke nor drink
brings satisfaction is
Adult Leisure alcoholic drinks, she enjoys being
to see her self as a
Time Activities with her friends, family and
valuable member of
relatives. Bonding moments usually
society, where
on their free time. The patient
people around her
verbalized “Masaya naman kami,
appreciate and give
kadalasan naguusap usap kami
her worth, without
kapag break time”. She was not a
these, this could
member of any association in her
result to self
community.
absorption of the
individual and she is
able to develop
feelings of adequacy.
Relating One’s The patient is divorced as she Task Not Met
Self in One’s verbalized “hiwalay na kami ng The patient cannot
Spouse as a asawa ko, di niya kasi tanggap na relate herself to her
Person may anak na ako.” spouse because of
being divorced.
Accepting and Before her present illness, Ms. Task Partially Met
Adjusting in the Flower is aware that she is not At first, she is able to
Physiologic getting any younger and everyone, adjust to the changes
Change of the even she will grow old. She is also of a middle adult, but
Middle Age aware of her responsibilities being due to her present
an adult. But due to her present condition her outlook
condition, her awareness of the on life changed.
environment changed drastically.
Adjusting to Her mother died when she was only Task Not Met
Aging Parents 11 y/o and her father became an The patient cannot
alcoholic and died after 11 years relate in adjusting to
due to hepatic cancer. aging parents
because her mother
died at the age of 33
and her father at 45.

PATTERNS OF FUNCTIONING

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 Before Illness: 2001 – January 2004 (start of manic episodes)

Before Hospitalization: November 2008 – November 16, 2009

During Hospitalization: November 16, 2009 – February 4, 2010

Health Perception – Health Management Pattern

Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
Client was Client shows being “Hindi ko alam There is a big
healthy. hyperactive on her kung bakit dinala difference
She stays calm behavior. As Ms. ako dito. Ang alam between her
and performs Petal verbalized, ko lang gagamutin health
her activities of “Nagwawala kasi daw ako. “Client perception
daily living in a siya. Hindi niya does not know the before and
normal nakilala ako na anak reason why she during her
condition. niya kaya dinadala was brought at the illness. The
po namin siya dito” institution. client was not
She views herself able to
as well fitted but is recognize her
not conscious of daily activities
her present and was not
condition. aware of the
things that are
happening
around her
when she had
started to
became
hyperactive.

Nutritional – Metabolic Pattern

Before Illness During Illness Analysis

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 Before During
Hospitalization Hospitalization

Breakfast: Breakfast: (0600H- Full diet except There was a

(0600H -varies) varies) foods that contains change in the
Consumes 2 cup of caffeine like coffee, client’s diet
Consumes 2
rice, egg and 1 sodas, chocolates, after she had
cup of rice, egg
piece of hotdog and and tea. been admitted
and 1 piece of
a glass of hot at St. Mary
hotdog and a
chocolate Frances
glass of warm
Mental Health
milk
Lunch:(1200H- time Center due to
varies) her condition,
Lunch: (1200H-
Consumes 1 ½ cup Bipolar 1.
time varies)
rice , 1-2 servings of Since she had
Consumes 1
meat (pork chop, been
cup rice, 1-2
beef or chicken) and diagnosed
servings of meat
a glass of juice. with the said
(pork chop, beef
illness, she
or chicken) and
Snacks:1500H had been
a glass of water.
Banana cue and avoided to the
soda foods that
Snacks: 1500H
contain
“Turon” and
Dinner: (1900H- caffeine like
soda
1930H) sodas, coffee
Consumes 1 cup and tea as it
Dinner: (1900H
rice, fried tilapia and may trigger
– 1930H)
1 medium size the effects of
Consumes 1 ½
banana with 2 ½ the
cup rice, fried
glasses of water medications
tilapia and 1
given to her.
medium size
banana with 2
glasses of water

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Elimination Pattern
Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
Bowel habits Bowel habits Bowel habits Her bowel
Frequency: Frequency: 1- 2 Frequency: 1-2 habits remains
1- 2 days days days normal during
Consistency: Consistency: Consistency: the
Formed Formed Formed hospitalization.
Color: Brown Color: Brown Color: Brown There were no
Odor: Odor: Aromatic Odor: Aromatic significant
Aromatic changes
noted.
Bladder Habits Bladder Habits
Frequency: Bladder Habits Frequency: 8x
6x per day Frequency: 6x per per day Her bladder
Color: day Color: Yellowish habits
Yellowish Color: Yellowish Amount: changes prior
Amount: Amount: Moderate to
moderate Moderate hospitalization
as the amount
of and urge to
urinate
increases
because of the
side effect of
the Lithium
medication
she is taking.

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Drinking Pattern
Before Illness During Illness Analysis
Before During
hospitalization Hospitalization
Consumes 5-6 Consumes 5-6 Consumes 10-12 The drinking
glasses of water glasses of water per glasses of water pattern of the
per day day (Approximately per day client
(Approximately 1050ml/day) (approximately increases
1050ml/day) 2520ml/day) during
hospitalization.
Fluid intake
had been
increased due
to the side
effects of the
medication
given to her
like Lithium
that causes
polydypsia or
excessive
thirst.

Activity – Exercise Pattern

Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
Hygiene: every Hygiene: every day Hygiene: Everyday Client’s activity
day she takes a she takes a bath takes a bath, exercise
bath Good posture and however is untidy in pattern has
Good posture has good grooming. appearance. been changed
and has good She easily gets tired Posture: Sloppy due to the
grooming in performing mild to unawareness
strenuous activities. of her
condition.

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Sexuality – Reproduction Pattern
Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
The client’s The client’s Decreased libido Client has
menarche menarche started at and she still has decreased
started at the the age of 15 and menstruation. libido due to
age of 15 and last for about 5 the side
last for about 5 days. effects of the
days. Gravida 2 Para 2 Lithium
Gravida 2 Para and has no history medication
2 and has no of abortion. given to her.
history of
abortion.

Sleep- Rest Pattern

Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
Client usually Client experiences Client sleeps at Her illness
sleeps around difficulty in sleeping 2000H however, marked her
2100H. and remaining she was disturbed sleep pattern
asleep. Interruption due to the things disturbance.
She usually of sleep is that she was
wakes up at experienced. thinking. She
around 0600H. experiences
difficulty in falling
asleep and remain
asleep. Interruption
of sleep is being
experienced. “baka
kasi may manakit o
huliin ako pag
natutulog na ako,
kaya minsan konti
lang ang tulog ko”,
as verbalized by
the patient.
She usually wakes
up at around
0600H.

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Sensory – Perceptual Pattern
Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
Vision: good Vision: difficulty in Vision: has difficulty Client’s
eye sight reading small fonts, in reading small sensory and
Good hearing range unknown. fonts, range perceptual
Does not have Good hearing unknown and with pattern
any Does not have any good hearing. changed prior
hallucinations hallucinations and to admission
and illusions illusion. because she
experiences
hallucinations.
Her vision
does not
change before
and during
hospitalization.

Cognitive Pattern
Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
She is well She was still well Client does not Client’s
coordinated and coordinated, but understand the cognitive
has good now behaves illness and does not pattern
understanding, differently with understand the became less
with a positive increased anxiety treatments. functioning as
outlook in life. and confusion that She was able to she was not
affects cognitive express herself on able to
abilities. what she wanted to determine her
say. “wala naman illness and the
akong sakit bakit pa treatment
ako nandito, sayang
rendered to
lang ang ang
her. She is
binabayaran naming
always
ditto, baka mahal
na”, as verbalized by disturbed
the patient. when trying to
She has difficulty recall and
recalling and remote things
remoting. on her life.

Role- Relationship Pattern

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 Analysis

During Illness
Before During
Hospitalization Hospitalization

She has 2 She has 2 children She has 2 children Her role was
children and she and somewhat able but she was not not performed
was able to do to do her role as a able to perform her prior to the
her role as a mother however role as a mother. hospitalization
mother. Worked with some Her role and as she
as manicurist to limitations. responsibility was became
sustain her disturbed. She has hyperactive in
family. sometimes family her behavior.
visits. “nakakahiya
kasi nadito ako
ngayon, gastos pa
ako imbes na ako
yung nagta-trabaho
para sa mga anak
ko”, as verbalized
by the patient.

Self Perception Pattern

Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
She is friendly, She became irritable Identity: Silent She became
approachable and disturbed. person as she only silent as she
and easy to deal talks when wanted to
with. someone think the
approaches her. things that run
She has a healthy on her mind.
body image and She is
can perform her experiencing
activities well disturbed
however with the thought
slow movement. process as
“natatakot akong also with the
sabihin ang mga effects of the
nararamdaman ko medications.
kasi iniisip lang nila
na sira ang utak
ko,” as verbalized
by the patient.

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Value – Belief Pattern
Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
She was not an She was not an She has disturbed Her belief was
active church active church values yet was able changed as
member but member but to participate in prayer has
believes that believes that there is prayers during the been practiced
there is a God. a God. activities rendered on the
by the nurses. different
activities given
to her.

Level of Competencies

Before Illness: 2001 – January 2004 (start of manic episodes)

Before Hospitalization: November 2008 – November 16, 2009

During Hospitalization: November 16, 2009 – February 4, 2010

A. Physical
Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
The client’s She was not able to She was not able to There is a
physical do her job as do her job as a change in her
activities is manicurist due to manicurist, yet she physical
directed in doing her hyper active helps in performing activity due to
her job as behavior. household chores her hyper
manicurist, do in the institution like active
the house hold sweeping the behavior yet
chores and ground, cleaning has been
used to the table, make disciplined by
socialize with things orderly and the
different people. wash her clothes. management
She usually stays in helping
on her room and doing the
goes out when it’s household
time to eat. chores.

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B. Mental Physical
Before Illness During Illness Analysis
Before During
hospitalization Hospitalization
The mental She was somewhat She can answer all There is a
capacity of the disturbed and the questions change in her
client is within unaware of the however she is mental status
the average place, date and oriented to place upon her
range recent person. and person but hospitalization
and remote cannot understand as she was
memories are why she was oriented to
intact. She was brought to the time, place
oriented as to institution. “hindi ko and person
time, place and alam kung bakit but she was
person. ako nagkakaganito, unaware of
hindi ko narin her condition.
maintindihan ang
mga
nararamdaman ko.
Magulo lang kasi,
ang alam ko hindi
ako dapat nandito”,
as verbalized by
the patient.

C. Emotional
Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
Client was Mood swings was She has low There is a
emotionally observed as she positive views in change in her
competent. She became hyperactive life however she emotional
is an in her behavior as thinks that she capacity as
affectionate verbalized by her should go home she became
person who daughter, because she is in hyperactive
shows her care “Nagwawala kasi her good and has mood
to her daughter siya. Hindi niya condition. swings.
by means of nakilala ako na anak
making her niya kaya dinadala
daughter feel po namin siya dito”.
that Ms.
Flower’s

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presence is
there even
though she is
far from Ms.
Petal.
D. Social
Before Illness During Illness Analysis
Before During illness
Hospitalization
She is a friendly She is disturbed and She used to There was a
type of person wanted to be alone. participate in the change in her
and has a good therapies rendered social status
relationship with to her. as she
her colleagues She still wanted to manifests low
in her work at be on her own. self esteem by
the hotel. She wanting
has very strong herself to be
connection with on her own.
her family
especially to her
daughter.

E. Spiritual
Before Illness During Illness Analysis
Before During
Hospitalization Hospitalization
She is not an She is not an active She participates in There is a
active church church member praying before change in her
member however she doing the spiritual
however she believes that there is therapies. outlooks
believes that God, moreover, she during her
there is God. is disturbed with her hospitalization
beliefs. because she
was trained to
pray.

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REVIEW OF THE SYSTEMS

Systems Interaction
Integumentary Nurse: “May makati po ba sa braso niyo?”

Patient: “Wala naman”

Nurse: “Eh, ano po iyang kinakamot niyo?”

Patient: “Hindi ko alam, basta lang”

Nurse: “Napipigilan niyo po ba ‘yang ginagawa niyo?”

Patient: “Hindi ko napapansin”

Musculoskeleta Nurse: “May masakit po bas a kasu-kasuan niyo?”

l Patient: “Wala namang sumasakit”

Nurse: “Nahihirapan po ba kayo gumalaw?”

Patient: “Hindi naman ako nahihirapan gumalaw”

Respiratory Nurse: “Nahihirapan po ba kayo huminga?”

Patient:”Hindi naman ako nahihirapan huminga, maayos

naman iyong paghinga ko.”

Nurse: “Mabilis po ba kayong hingalin?”

Patient: “Hindi, dahan-dahan lang naman kasi ako

maglakad.”

Nurse: “Kapag sumasali po kayo sa mga activities, hindi

po ba kayo napapagod o hinihingal?”

Patient: “Medyo lang naman, pero masaya naman ako

kapag sumasali.”

Digestive Nurse: “Sumasakit po ba ang tiyan niyo?”

Patient:”Wala namang sumasakit, kumakain naman ako

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 sa oras.”

Nurse: “Madami po ba kayo kumain?”

Patient: “Oo, madami.”

Nurse: “Nitong mga nakaraang araw, nakaranas po ba

kayo ng pagsusuka o pagtatae?”

Patient: “Hindi naman ako nagsusuka at nagtatae.”

Nurse: “Mga ilang beses po kayo dumumi sa isang araw?”

Patient: “Minsan isang beses, minsan dalawa“

Nurse: “Ano po ang itsura ng dumi niyo?”

Patient: “Buo-buo naman tapos kulay brown pa. “

Nurse: “Bakit po nakahawak kayo sa pisngi niyo?”

Patient: “Ahh.. masakit kasi namamaga ang gilagid ko.”

Nurse: “Kelan po nagsimulang sumakit iyong gilagid mo?”

Patient: “Mga tatlong araw nang sumasakit’”

Lymphatic Nurse: “Nagkaroon nap o ba kayo ng bulutong, beke,

tigdas at iba pang sakit noong kabataan niyo?”

Patient: “Oo, Nagkabulutong na ako noon, pati nga tigdas

at beke eh. “

Nurse: “May allergy po ba kayo sa pagkain, gamot o kahit

ano pa?”

Patient: “Wala naman akong allergy sa kahit ano.“

Nurse: “Kumpleto po ba kayo sa bakuna?”

Patient: “Nabigyan na ako ng bakuna pero hindi ko

maalala kung kumpleto.”

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 Nurse: “Mabilis po ba kayo magkasakit, katulad po ng

ubo, lagnat o sipon?”

Patient: “Hindi naman, minsan lang.”

Nurse: ”Ahh.. Ganun po ba. Kapag nagkakasakit po kayo,

kumukunsulta po ba agad kayo sa doctor o bumibili na

agad ng gamot sa botika?”

Patient: “Bumubili lang kami sa botika.”

Nurse: “Ahh. Bumubili po pala agad kayo sa botika,

katulad po ng anong mga gamot?

Patient: “Neozep at paracetamol”

Cardiovascular Nurse: “Meron po ba kayo ng lahi na may sakit sa puso?”

Patient: “Wala naman, pero ‘yong nanay ko high blood”

Nurse: “Pag nagagalit po kayo, sumasakit po ba ang

dibdib niyo?”
Endocrine Nurse: “Pawisin po ba kayo”

Patient: “Hindi naman kapag sumasali lang sa activities”

Nurse: “Kapag pinagpawisan po kayo sobra po bang

dami?

Patient: “ Hindi naman medyo lang”

Urinary Nurse: “Mga ilang beses po kayo umiihi sa isang araw?”

Patient: “Madalas ako umihi, mga 8-10 beses”

Nurse: “Mga gaano po karami kada ihi niyo?”

Patient: “Medyo madami naman”

Nurse: “Ano pong kulay”

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 Patient: “Medyo madilaw?”
Reproductive Nurse: “Nireregla pa po ba kayo?”

Patient: “Oo, naman”

Nurse: “Malakas po ba?”

Patient: “Tama lang naman”

Nurse: “Nakaka-ilang napkin po kayo sa isang araw”

Patient: “Mga dalawa”

Nervous Nurse: “Alam niyo po ba kung bakit kayo dinala dito?

Patient: ”Hindi ko alm kung bakit ako dinala dito, ang alam

ko lang gagamutin daw ako”

Nurse: “Mga anong oras po ang pagtulog at gising niyo?”

Patient: “8 pm ako natutulog tapos 6 am ako nagigising,

pero pautol-putol ang tulog ko baka kasi may manakit o

hulihin ako pag natutulog ako, kaya minsan konti lang ang

tulog ko”

Nurse: “Ano po ang nararamdaman niyo kapag nagagalit

kayo?

Patient: “Natatakot ako sabihin ang nararamdaman ko

kasi iniisip nila may sira ang utak ko”

Nurse: “Alam niyo po ba talaga yung sakit niyo?”

Patient: “Wala naman akong sakit bakit pa ako nandito,

syang lang ang binabayaran naman dito, baka mhal n.”

Nurse: “Ano po ang naiisip niyo bakit niyo po nasabi yon?”

Patient: “Hindi ko alam kung bakit ako nagkakaganito,

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 hindi ko na rin maintindihan and mga nararamdaman ko,

magulo lang kasi, ang alam ko hindi ako dapat nandito.”

Nurse: “Magkasma pa po ba kayong asawa niyo.”

Patient: “Hiwalay na kami ng asawa ko, di niya kasi

tanggap na may anak ako.”

Nurse: “Noong minsan po nabanggit inyong nahihiya kayo

sa anak niyo ano pobang meron?”

Patient: “Nakakahiya kasi nandito ako ngayon, gastos pa

ako imbes na ako yung nagtratrabaho para sa nag anak

ko.”

Nurse: “Nahihirapan po ba kayo matulog sa gabi?”

Patient: “Nahihirapan ako matulog sa gabi naiisip ko nya

anak ko gusto ko na lumalabas para nakasama ko nasila.”

Nurse: “Ano na po ba ang naramdaman niyo ngayon?”

Patient: “Wala ng silbi buhay ko hindi na dapat ako

nabubuhay pa hindi ko alam kung para san pa na buhay

pa rin ako.”

PHYSICAL ASSESSMENT:

General Appearance

As we conducted our interview in SMF last February 14, 2010 at

1200H, the patient was in proper grooming and was in a stable and good

mood. She was cooperative while we are asking some questions and doing

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physical assessment. Overall, the patient was normal during the entire

procedure.

Vital Signs:
Temp. = 37.4º C
BP= 100/70 mmHg
RR= 17 bpm
PR= 76 bpm
CR= 78 bpm

BODY TECHNIQUES NORMAL ACTUAL ANALYSIS

PART
Skin Inspection Light to deep Fair in Normal
brown complexion no
complexion, presence of
no lesions or lesions or
abrasions abrasions

Palpation Smooth and Smooth and Normal

soft skin soft skin

Head Inspection Rounded Rounded Normal

(Normocephali (Normocephali
c& c&
Symmetrical Symmetrical
with frontal, with frontal,
parietal, & parietal, &
occipital occipital
prominences) prominences)

Scalp and Inspection Black in color, Black hair with Normal

Hair clean and some white
silky, free from hairs, equally
masses, distributed but
lumps, scars, decreased
lice, dandruff, density in
and lesion some parts,
clean, free
from masses,

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 lumps, scars,
lice, dandruff,
and lesion

Face Inspection Absence of Symmetrical Normal

any lesions, with no
scars, and no lesions or
defect masses seen,
with normal
facial
movements
Eyes Inspection Normal vision Has a poor Abnormal,
20/20 vision) due to work
and side-
effects of
drugs
(Chlorprom
azine)

Pupils Inspection Pupil size is 3- Pupil size is 3- Normal

5 mm in 5 mm in
diameter, react diameter,
briskly to light, react briskly to
and both light, and both
pupils constrict pupils
consensually constrict
consensually

Eye Inspection Eye is moving Eye is moving Normal

Movement accordingly accordingly

Visual Inspection Has 20/20 Has difficulty Abnormal,

Acuity vision or at 20 in reading eye strains
meter distance letters with due to her
at which Arial 12 fonts, past work
normal eye range as a
can read unknown manicurist.
Ears Inspection Equal in shape Equally in Normal
and size, shape, pinna
pinna aligned properly
to the cantus aligned, clean
of the eyes,
clean with
some cerumen
and cilia

2
Ear Canal Normal

Inspection Pinkish, clean Clean with

with scanty scanty amount
amount of of cerumen
cerumen and and cilia, no
few cilia masses seen.
Hearing Inspection Hearing the Hearing the Normal
Acuity gentle rubbing gentle rubbing
of the of the
examiner's examiner's
fingers fingers
approximately
3-4 inches
away from his
right and left
ear
Nose Inspection Symmetrical Symmetrical Normal
and straight, and straight,
no discharge; no discharge;
air moves air moves
freely as freely as
breath through breath through
the nose the nose
Mouth Inspection Absence of Absence of Normal
sores, gum sores, gum
bleeding, and bleeding, and
lesions lesions
Lips Inspection Pink, moist, Moist and Normal
and smooth smooth
Teeth Inspection 32 permanent Inflamed Abnormal,
teeth, well gums at the due to poor
aligned, free second left hygiene
from caries mandible
and halitosis molar
Buccal Inspection Moist, smooth, Moist, smooth, Normal
Mucosa and pink and pink
Neck Inspection Normal in size, Normal in Normal
normal in size, normal in
swallowing swallowing
Palpation Nodes are No nodes Normal
generally no palpated
palpable (if
palpable it
should be
small, mobile
and not
tender)
Thorax Inspection Chest Chest Normal

2
and Lungs

symmetry, symmetry,
spine vertically spine
aligned and vertically
effortless aligned, and
respiration effortless
Normal
respiration

Auscultation Normal breath Normal breath

sounds, quiet, sounds quiet,
and rhythmic, rhythmic,
Breast Inspection No masses No masses Normal
Palpation and and Normal
Non - tender Non - tender
Heart Auscultation Include s1 to Include s1 to Normal
be louder at be louder at
the tricuspid the tricuspid
and apical and apical
areas. With s2 areas. With s2
louder at the louder at the
aortic and aortic and
pulmonic pulmonic
areas. There areas. There
should not should not
include any include any
extra heart extra heart
sounds at any sounds at any
of the cardiac of the cardiac
landmarks, landmarks,
and abnormal and abnormal
rate or rhythm. rate or rhythm.
Abdomen Inspection Rounded or Rounded and Normal
flat, symmetrical,
symmetrical,u unblemished,
nblemished with some skin
skin folds

Auscultation Audible bowel Bowel sounds Normal

sounds, can be heard
absence of
friction rubs

Percussion Generalized Tympanic of Normal

tympanic on all all four
four quadrants quadrants

Palpation Soft, smooth, Soft, without Normal

consistent tenderness

2
 tension;
without
tenderness
Upper
Extremities

Arms Inspection, Can move With IVF D5W Abnormal

Palpation freely without at left hand due to
any discomfort With presence of
hematoma at hematoma
right upper and
arm and abrasions
abrasions

Palm and Inspection, Slightly visible Slightly visible Normal

dorsal Palpation veins with veins with findings
surface smooth palmar smooth
surface palmar
surface

Fingernails Inspection, Trimmed and Trimmed and Normal

Palpation normal normal findings
capillary refill capillary refill
noted back in noted back in
2 sec. as
2 sec. as
pressure is
applied pressure is
applied

Lower
Extremities

Legs and Inspection, Normal flexion Normal flexion Normal

toes Palpation and extension, and extension, findings
symmetrical, symmetrical,
no lesions and no lesions and
no edema no edema

PHYCHIATRIC ASSESSMENT

Level of consciousness: the patient is oriented to person, place, and time

and date.

2
 This examination was done to assess the patient’s orientation to

person, place, time and date, her capacity to recall; her cognitive abilities, and

her ability to perform a command.

Findings Analysis
Affect
The patient manifested - With the manifestations of different reactions
many reactions and and emotions, the patient was concluded with
emotions ranging from broad affect, with different moods manifesting
happy to sad and agitated signs and symptoms of Bipolar disorder.
and anxious.

Memory
During the interview the - The patient experiences some difficulty
patient had some difficulty remembering some of her past memories. It is
remembering some past concluded that the patient is having retrograde
memories, especially amnesia and/or repression or suppression.
some of her stressing
experiences, including
about his past husbands.

Motor
Mild hand tremors and - Hand tremors and decreasing movements
some decreased are the first signs of the side effect of her
movements are seen in medication (Chlorpromazine).
the patient through out the
interaction.

The patient was also - The agitation and anxiety was an impending
agitated during the sign of manic stage.
interview with mild anxiety.

Perception
“Wala naman akong sakit
bakit pa ako nandito,
sayang lang mga
binabayaran sakin, baka
mahal na.” as verbalized
by the patient.
- The patient has altered perception about her
health and self depending on her state. With
manifestations of low self-concept during a
depressive state, and moderate anxiety during
a manic sate.

“hindi ko alam bakit ako

nagkakaganto, hindi ko
narin maintindihan
nararamdaman ko.

2
Magulo lang kasi ang
alam ko hindi ako dapat
nandito,”verbalized by the
patient.

“Wala na akong
nagawang tama sa buhay
ko. Lahat nalang nangyari
sa buhay ko mali.
Nakakahiya kasi nandito
ako ngayon, gastos pa
ako imbes na ako yung
nag-tratrabaho para sa
mga anak ko” as
verbalized by the patient.

“wala ng silbi buhay ko,

hindi na dapat ako
nabubuhay pa. hindi ko
alam kung para saan pa
kung buhay parin ako” as
verbalized by the patient.

Thinking
“May mga time na - The patient has delusion of persecution. She
pakiramdam ko talaga always thinks that someone will put her in jail.
may mananakit sa akin, And she shows agitation throughout the
sumusunod lang sila sakin interaction
lage.” as verbalized by the
patient.

Pakiramdam ko kasi may

mananakit sa kin pag
natutulog ako eh kaya
hindi ako makatulog sa
gabi. Konting tunog lang
nagigising ako agad.” as
verbalized by the patient.

ON-GOING APPRAISAL

February 2, 2010, Tuesday

2
 Activity

0700H- 0735H The activity started with the daily routine of taking blood
pressure of the patients before giving their medications.
After the daily routine, it proceeded to the activity that was
started with a prayer for guidance all throughout the
activity. The acknowledgement of the patient was first
done then the student nurses introduced themselves. Miss
Flower stood up to introduce herself but seemed restless
but smiling. Next, the exercise was done to make them
awaken and help their body to function well.

0735H- 0800H In the dance therapy, the patients practice a dance that will
be performed on the “Grand Socialization Day”. Miss
Flower cannot follow easily on the choreography. The
patient showed lack of eagerness towards the dance
because her face seemed so unhappy and her action
seemed so tired.

0800H- 0830H After the finishing the dance therapy, the student nurse
facilitate a nurse patient interaction to establish trust and
empathy. She was being interviewed about her thoughts
and feelings through her life, family, and social interaction
on the people on her external environment. The student
nurse establishes rapport to the patient that she easily
open the problems encountered by the patient outside the
institution including her life and family. But noticing to the
feelings of the patient, she was unhappy inside the
institution because she wanted her family to see.

0830H- 0850H In the play therapy, the patient participated on the activity
but there still a lack of eagerness and excitement towards
the games. It was noticed that she’s just doing her part on
the group but you will not see the enjoyment on what she

2
 was doing.

0850H- 1020H In the music and arts therapy, the patient actively listened
to the music then does her part by drawing what the music
processes on her mind. She clearly explained the art that
she thinks while listening to the music.

February 3, 2010, Wednesday

Date Activity

0700H- 0735H The morning starts with the blood pressure taking of the
patients and giving their medications. After the routine, the
program starts with a prayer lead by one of the student
nurse. Then the exercise was done.

0735H- 0800H In the dance therapy, the patients continue practicing their
dance steps for their performance on the “Grand
Socialization Day”. While practicing the dance steps, the
assigned student nurse teaches her patient to easily cope
with the steps. She seemed so happy whenever she got
on successfully on the steps being taught by her student
nurse.

0800H- 0830H In the nurse- patient interaction, the patient continues

expressing her feelings towards her life inside and outside
the institution. She was much open expressing her feelings
on the student nurse. While interviewing the patient, there
were blockings made because she didn’t remember some
events or ideas that she wanted to say.

0830H- 0850H In the biblio-therapy, a play was presented called “Ang

Kuneho at Ang Pagong” through puppets for the patient to
be entertained. The patient listened well on the story by
giving her thoughts regarding the moral value of the story
after it was presented. Her answer fitted to the moral value

2
 of the story.

0850H- 1020H In the play therapy, the patient is excited on the new
games that we offer to them. You will see to her face the
happiness on performing the activity. She tried to be more
active participating on the team.

1020H- 1040H In the cooking therapy, there some cupcakes and sweet
decorative like marshmallows, chockies, and stick- o were
prepared. The goal of the therapy is much likely compared
to music and art therapy but instead of drawing, they will
design cupcakes according to the music played. The
patients felt so eager and excited decorating those
cupcakes. Miss Flower showed her creativity constructing
a colorful decoration towards the cupcakes through
listening to the music.

February 4, 2010, Thursday

Date Activity

0800H- On the last day of our duty, a “Grand Socialization Day”

1100H was organized wherein it may give a chance to the patients
to have more time to enjoy and made them happy on the
last day of duty. As usual, a prayer was done and
promoting body function through exercise.

After that, the program was started with the dance therapy
that the patient practiced on the days of duty. The patient
gave her best to follow the steps and you will see on her
face that she was happy on what she was doing.

Next, a dance presentation is performed in front of the

patients by the student nurses. On the part of dancing
presentation, the patients stand up and Miss Flower is
being happy while she following the dance even if she

2
 didn’t know the steps. Then we do our farewell song. The
patient was awarded as “Best in Smile” and makes her best
smile in front of the camera with her student nurse.

In our last day to make the play therapy, the patient being
observed that she was being happy all throughout the play.

DIAGNOSTIC TEST
Diagnosis is based on the self-reported experiences of an

individual as well as abnormalities in behavior reported by family members,

friends or co-workers, followed by secondary signs observed by a psychiatrist,

nurse, social worker, clinical psychologist or other clinician in a clinical

assessment. There are lists of criteria for someone to be so diagnosed. These

depend on both the presence and duration of certain signs and symptoms.

2
 Assessment is usually done on an outpatient basis; admission to an inpatient

facility is considered if there is a risk to oneself or others. The most widely

used criteria for diagnosing bipolar disorder is the American Psychiatric

Association's Diagnostic and Statistical Manual of Mental Disorders, the

current version being DSM-IV-TR and used by health professionals that

describes mental disorders according diagnostic criteria.

• Axis I: Clinical disorders, including major mental disorders, and learning

disorders

• Axis II: Personality disorders and mental retardation (although developmental

disorders, such as Autism, were coded on Axis II in the previous edition, these

disorders are now included on Axis I)

• Axis III: Acute medical conditions and physical disorders

• Axis IV: Psychosocial and environmental factors contributing to the disorder

• Axis V: Global Assessment of Functioning or Children's Global Assessment

Scale for children and teens under the age of 18

MANAGEMENTS

Nursing Management

A. Nurse- Patient Relationship

Client with mania have a short attention span, so the nurse uses clear, simple

sentences when communicating. They may not be able to handle a lot of

2
 information at once. The nurse breaks information into may small segments.

It helps to ask clients to repeat brief messages to ensure they have heard and

incorporated them.

o Matter of Fact Tone. A matter fact tone minimizes the need for the patient to

respond defensively and avoids power struggles. By providing emotional

support and responding to patients in a matter of fact manner, the nurse

conveys both control of the situation and empathy.

o Reinforcement of Reality. Manic patients also experiences disturbances in

perception. The intervention strategies outlined for other patients with

disturbed perceptions are recommended for manic patients as well.

o Respond to Legitimate Complaints. Although many frivolous complaints arise,

the nurse must respond to legitimate complains to defuse irritability and

develop trust.

o Redirect Patient’s into More Healthy Activity. The bipolar patient’s

distractibility serves as an intervention tool when the patient engages in non-

productive behavior.

B. Diet

Dietary regulation depends on the severity of the disease. Therapeutic

diets involve modification of food intake to supplement the needs of the body.

The eating pattern of the patient is prepared by the nutritional complements

necessitated by a client’s disease state or nutritional status or to prepared

clients for a procedure.

2
o Diet as tolerated (DAT). An individual can eat according to her preference

without enables her to take sufficient sources of energy.

o Avoid caffeine, sugar, chocolate, and carbonated beverages

C. Psychological Management

o Play Therapy- an individualized intervention that offers an individual a

symbolic way to express feelings, anxiety, aggressions, and doubt.

Analysis:

The activity will help the patient to relieve stress and boredom, and

something that promotes not only emotional health but physical health as well

as the other three domains of health; cognitive, spiritual and social. It can

improve communication skills and self-esteem. On this activity, the patient

had willingness to participate by showing positive attitude towards on it.

o Dance therapy, or dance movement therapy- uses of movement and

dance for emotional, cognitive, social, behavioral and physical conditions. The

ultimate purpose of the dance movement therapy is to find a healthy balance

and sense of wholeness.

Analysis:

2
The activity will strengthen the body and mind connection through body

movements of the patient to improve both the mental and physical well-being.

The patient followed every steps of the choreography of the student nurses.

On her presentation with the other patient, she had fun on the dancing activity

that she remembers the dance steps that the student nurses taught.

o Music and Arts therapy- allow an individual to express her or himself in

these disciplines and can be effective with those who have difficulty

communicating with others.

Analysis:

The activity will help the patient to discover what underlying thoughts

and feelings are being communicated in the artwork and what it means to

them. The patient listened attentively to the music while processing the

feelings that should be interpreted on her drawing. She explains clearly the

meaning of her drawing on her co- patient.

o Bibliotherapy- the use of selected reading materials as therapeutic

adjuvants in medicine and in psychiatry.

Analysis:

2
 The activity will provide the patient good moral values that will help

them in functioning well mentally. The patient actively listening to the short

story that the student nurses prepared. She was being cooperative by sharing

her thoughts on the moral value of the story.

o Cooking Therapy- a therapy that will enhance the creativity of an individual

in food presentation accompanied by music.

Analysis:

The activity will enhance the creativity of the patient. It was

accompanied by music that will show the emotion of the patient through food

presentation. The patient listened carefully on the music then started

decorating the cupcakes with the colorful chocolates and marshmallows. She

explained her decorated cupcakes that were suited on the feelings given by

the music.

MEDICAL MANEGEMENT

Drug Study

2
Generic Name: Lithium Carbonate

Dosage: 450 mg, OD PO

Classification: Mood Stabilizing Drug

Indication: To prevent or control mania

Action: Normalizes the reuptake of certain neurotransmitters and reduces the

release of norepinephrine

Side Effects: fatigue, lethargy, vomiting, anorexia, diarrhea, thirst, polyuria,

muscle weakness

Nursing Considerations:

o Take drug with plenty of water and after meals to minimize GI upset.

o Regular blood tests to determine drug levels; slightly high values can be

dangerous.

o Expect transient nausea, large amounts of urine, thirst, and discomfort

during first few days of therapy and to watch for evidence of toxicity (diarrhea,

vomiting, tremor, drowsiness, muscle weakness, uncoordinated movements).

Withhold one dose and call physician if signs and symptoms appear, but not

to stop drug abruptly.

o Avoid hazardous activities that require alertness and good psychomotor

coordination until CNS effects of drug are known.

o Regular monitoring of serum lithium level, (0.5-1.5 meq/L)

Generic Name: Chlorpromazine Hydrochloride

2
 Dosage: 5 mg, ODHS PO

Classification: Antipsychotic Drug

Indication: Psychosis, Mania

Side Effects: extrapyramidal reactions, sedation, tardive dyskinesia,

pseudoparkinsonism, orthostatic hypotension,dry mouth, constipation, urine

retention, mild photosensitivity reactions

Action: Blocks postsynaptic dopamine receptors in the brain

Nursing Considerations:

o Avoid activities that require alertness or good coordination until effects of drug

are known. Drowsiness and dizziness usually subside after first few weeks.

o Have patient report signs of urine retention or constipation.

o Relieve dry mouth with sugarless gum or hard candy.

10 Identified Problems

2
1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar

Disorder

2.) Self- care Deficit: Dressing and Grooming r/t Depression

3.) Disturbed Thought Process r/t Mood Alteration

4.) Risk for Suicide r/t Mood Alteration Secondary to Bipolar Disorder

5.) Chronic Low Self- Esteem r/t Anxiety

6.) Hopelessness r/t Feeling of Abandonment

7.) Defensive Coping r/t to Anxiety

8.) Risk for other Directed Violence r/t Bipolar Disorder

9.) Interrupted Family Process r/t Deterioration of Family Functioning

10.) Disturbed Energy Field r/t Bipolar Disorder

5 Prioritized Problems

1.) Disturbed Sleep Pattern r/t Episodes of Delusion Secondary to Bipolar

Disorder

2.) Self- care Deficit: Dressing and Grooming r/t Depression

3.) Disturbed Thought Process r/t Mood Alteration

4.) Risk for Suicide r/t Mood Alteration Secondary to Bipolar Disorder

5.) Chronic Low Self- Esteem r/t Anxiety

2
 Cues Nursing Rationale Nursing Interventions Rationale Evaluation
Diagnosis Objectives
Subjective: Problem: During the Short Term: Independent: Short Term:
Disturbed depressed phase
“Pakiramdam Sleep Pattern of the bipolar After 1-2 days 1. Arrange care 1. A silent After 2 days of
ko kasi may disorder, it's of nursing to provide for and clam nursing
mananakit sa Etiology: common to intervention the uninterrupted environment intervention,
kin pag Related to experience patient will periods of rest, during sleep the patient had
natutulog ako Episodes of insomnia, indentify especially will help to indentified
eh kaya hindi Delusion characterized by individually allowing for lengthen the individually
ako Secondary to difficulty falling appropriate longer periods of range of appropriate
makatulog sa Bipolar asleep, staying interventions to sleep at night sleep. interventions
gabi. Konting Disorder asleep, or promote sleep. when possible. to promote
tunog lang waking up too sleep.
nagigising As evidenced early. Bipolar Long Term: 2. Encourage 2. Rituals GOAL MET
ako agad.” as by: depressed client to establish and routines
verbalized by patients are also After 3-4 Days a bedtime routine induce
the patient. Subjective: particularly of Nursing to facilitate comfort, Long Term:
sensitive to Intervention the transition from relaxation,
“Pakiramdam “Pakiramdam hypersomnia -- patient will wakefulness to and sleep. After 3 days of
ko paggising ko kasi may characterized by report sleep. nursing
ko sa umaga mananakit sa too much sleep, improvements intervention,
parang pagod kin pag sometimes up to in quality of 3. Encourage 3. Stress the patient
na pagod natutulog ako 18 hours per sleep pattern client to eliminate interferes reported
parin ako.” as eh kaya hindi day, and daytime as evidenced stressful with a improvements
verbalized by ako fatigue. What's by: situations before person’s in quality of
the patient. makatulog sa especially • Verbaliz bedtime. ability to sleep pattern
gabi. Konting problematic with ation of feeling relax, rest, as evidenced
tunog lang bipolar patients of satisfaction and sleep. by:
nagigising is that after waking • “Mas
ako agad.” as sometimes up in the masarap

2
 verbalized by yung tulog ko
Objective: the patient. kagabi kesa
• Weakn noong isang
deprivation of morning.
ess “Pakiramdam 1. Has a gabi.” as
ko paggising
sleep for any • No Dependent:
therapeutic verbalized by
• Restles reason -- such
ko sa umaga feeling of effect of patient.
sness as caffeine 1. Adm
fatigue after
• Dark parang sedation that • No
consumption -- waking up. inister
circles pagod na may induce feeling of
could lead to a • Not Chlorpromaz
under the pagod parin sleep. fatigue after
switch into mania restless and ine as
eyes ako.” as waking up.
-- which could be weak, no ordered.
• Dissati verbalized by • Not
a big problem. frequent
sfaction the patient. restless and
yawning and
with sleep weak, no
Objective: dark eyes.
• Freque Reference: frequent
nt yawning • Weakn yawning and
Psychiatric
ess dark eyes.
Nursing Care
• Restle Plans 5th Edition, GOAL
ssness Fortinash, PARTIALLY
• Dark Holoday Worret MET
circles page 185-202
under the
eyes
• Dissati
sfaction
with sleep
• Frequ
ent
yawning

Cues Nursing Rationale Objective Intervention Rationale Evaluation

2
 Diagnosis
Subjective: Problem: Short Term:
“wala akong Self Care
Hygienic care Short Term: Independent:
ganang mag- Deficit: 1. Monitor the After 8 hours
promotes
ayos sa sarili Dressing and client’s of nursing
cleanliness, After 1- 2 hours 1. Monitor
ko,hindi ko Grooming functional intervention,
provides of nursing continually the
naman talaga abilities in the patient
relaxation, intervention the extent to which
malaman Etiology: an ongoing improved
improves self- patient will self care
kung minsan Related to way helps to hygienic care
image, and verbalized deficits interfere
bakit ako Depressed determine with a
promote healthy ways how to with the client’s
biglang Mood the client’s verbalization
skin. Client improve function
nagwawala,ta secondary to strength and of “alam ko na
hygiene is an hygienic care/
pos minsan Bipolar areas ngayon na
extension of self care
sobrang Disorder needing importanteng
providing client
lungkot ko assistance bigyan ko ng
safety and Long Term:
naman…” as As pansin ang
protecting the
verbalized by manifested 2. Routine pag-aayos ko
client’s defense After 2- 3 days
the patient. by: and sa’kin sarili…”
mechanisms. of nursing 2. Establish
structure GOAL MET.
Body image is intervention the routine goals
”lagi yaan Subjective: organize the
associated with patient will for self care
ang suot niya, “wala akong client’s Long Term:
the client’s consistently
(pointing to ganang mag- chaotic
emotion, mood, performs self
her red turtle ayos sa sarili world and After 3 days of
attitude, and care activities
neck ko,hindi ko promote nursing
values. A client’s and consistent
sleeveless naman talaga success intervention
body image with
blouse) paag malaman the patient
directly affects developmental
tinatanong kung minsan was able to
the type of stage as
naman bakit ako perform self
personal hygiene evidenced by
naming siya biglang care activities.
practiced; this being
hindi naman nagwawala,t GOAL
may change if dependent in
niya masagot apos minsan 3. Depressed PARTIALLY
the client body providing self
kung bakit…” sobrang clients have MET.
image is altered care 3. Initiate
as verbalized lungkot ko more
because of grooming and

2
by the nurse naman…” as brighter
in charge. verbalized by affect later
the patient. in the day;
illness. hygiene tasks
Objective: and client
when the client
• Repeatedly ”lagi yaan with anxiety
is best able to
used of ang suot and
comply
clothing niya,(pointing hyperactive
to her red behaviors
• Demonstrat turtle neck are more
e infrequent sleeveless attentive to
bathing blouse) paag self care
tinatanong after taking
• Displays naman medication
inadequate naming siya
personal hindi naman 4. Providing
hygiene: niya masagot as much as
foul odor kung bakit…” privacy as
as verbalized possible
4. Provide privacy
• Gingivitis by the nurse helps to
for self care
in charge. preserve the
without
client’s
comprising
Objective: dignity
client’s safety
• Repeatedly
used of
clothing 5. Positive
reinforceme
• Demonstrat nt increases
e infrequent feelings of
5. Praise the
bathing self worth
client for
and
attempts at self
• Displays promotes
care and each
inadequate continuity of
successfully
personal functional
completed task

2
 hygiene: behavior
foul odor

• Gingivitis 1. Normalizes
the reuptake
of certain
neuro-
Dependent:
Transmitters
and reduces
1. Administer
release of
mood stabilizing
norepinephri
drug: Lithium
ne
Carbonate 450
mg OD
2. May bloclk
pst synaptic
dopamine
receptors in
the brain.
2. Administer
antipsychotic
drug:
Chlorpromazine
Hydrochloride 5
mg ODHS

Cues Nursing Rationale Objective Nursing Rationale Evaluation

Diagnosis Intervention

2
Subjective: Problem: Short term:
Disturbed
“Nagwawala Thought 1. These steps After 1 hr. of
kasi siya Bipolar disorder Short term: Independent: nursing
Process help reinforce
noon, hindi or manic- intervention, the
After 30 mins.- reality and
naming siya Etiology: depressive 1. Orient client patient
1 hr of nursing provide cues
mapigilan. Related to disorder (also and call client responded
intervention, that maintain
Maraming Mood referred to a by name, coherently to
the patient will orientation.
beses na rin Alteration bipolarism or introduce self simple, concrete
manic responds on each
naulit un statements as
As manifested depression) is a coherently to contact;
kaya nag- evidenced by:
by: psychiatric simple, frequently
decide na rin
diagnosis that concrete mention time, • Demonstr
kaming 2. Validation
Subjective: describes a statements as date, and place. ated orientation
ipadala siya seeks to help
category of evidenced by: to person, place
doon.” as “Nagwawala the caregiver,
verbalized by kasi siya noon, mood disorders 2. Provide and time.
• Exhibiti encouraging
the relative hindi naming defined by the validation of
ng judgment, empathy. • Exhibiting
of the patient siya mapigilan. presence of one thoughts and
insights, judgment,
Maraming or more feelings of
coping skills, 3. Acceptance insights, coping
“May mga episodes of client.
beses na rin and problem promotes trust.
time na abnormally skills, and
naulit un kaya solving
pakiramdam elevated mood 3. Do not problem solving
nag-decide na abilities.
ko talaga clinically attempt to abilities.
rin kaming
may referred to as • Client’s argue or
ipadala siya 4. To verify that GOAL
mananakit mania or, if expresses change the
doon.” as client is PARTIALLY
sa akin, milder, logical, goal- client’s belief.
verbalized by swallowing the MET
sumusunod hypomania. oriented
the relative of tablets or
lang sila Individuals who thoughts with 4. Check mouth Long Term:
the patient capsules.
sakin lage.” experience absence of if hoarding
5. The
as verbalized “May mga time manic episodes delusion. medicines. After 3 days of
suspicious
by the na also commonly nursing
client does not
patient. pakiramdam experience • Demon intervention the
have the
ko talaga may depressive strates 5. An assertive, patient
capacity to
mananakit sa episodes or socially matter- of- fact, established

2
 akin, relate to an reality
sumusunod overly friendly, orientation as
Objective: lang sila sakin overly cheerful evidenced by:
symptoms, or appropriate yet genuine
lage.” as attitude.
• Distra mixed episodes for age and approach is the • Appropria
verbalized by
ctibilit in which status. least teness of
the patient.
y features of both threatening to interactions and
• Social mania and • Demon the suspicious
1. May block willingness to
Withdr depression are strates person.
postsynaptic participate in
awal Objective: present at the orientation to
dopamine the therapeutic
• Depre same time. person, place
receptors in the community.
• Distracti These episodes and time. Dependent:
ssion brain.
bility are usually GOAL
• Blocki
• Social separated by 1. Administer PARTIALLY
ng 2. Normalizes
Withdra periods of anti- psychotic MET
• Fear Long Term: the reuptake of
wal “normal” mood, drug:
• Anxiet certain
• Depress but in some After 1- 3 days Chlorpromazine
y neurotransmitte
ion individuals, of nursing Hydrochloride
rs and reduces
• Blocking depression and intervention,
the release of
• Fear mania may the patient will
norepinephrine.
• Anxiety rapidly alternate maintain 2. Administer
known as rapid reality mood stabilizing
1. Prevent
cycling. orientation as drug: Lithium
anxiety from
evidenced by: Carbonate
escalating to
• Approp unmanageable
Reference: riateness of levels.
Collaborative
Keltner, interactions 1. Continue to
Norman L., and support and
Scwecke Lee willingness to monitor
Hilyard, participate in psychosocial
Bostron, Carole. the treatment plans.
Psychiatric therapeutic
Nursing. Fifth

2
 Edition. Mosby. community.
Pg. 396- 398
• Solves
problems and
makes
decisions
appropriate
for age and
status.

• Maintai
n residual
sensory-
perceptual
functions.

CUES NURSING RATIONALE NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES

2
Subjective: Problem: Short term:
Risk for
“Wala na Suicide 1 The nurse After 2 days of
Clients who Short term: Independent:
akong first priority is nursing
express feeling
nagawang Etiology: providing for intervention,
of After 1-2 days 1. Check the
tama sa buhay Related to the client’s the patient
worthlessness, of nursing client’s room for
ko. Lahat Mood safety and demonstrated
helplessness, intervention, potentially
nalang Alteration protects the consistent,
hopelessness, the patient will destructive
nangyari sa Secondary to client from self- optimistic, and
and other demonstrate implements:
buhay ko mali. Bipolar inflicted life hopeful
feelings absence of sharp objects,
Nakakahiya Disorder threatening attitude by
associated with suicidal belt, chemicals,
kasi nandito injury or death. showing
depressive attempts, and hoarded
ako ngayon, As manifested brighter affect,
states are at display medications; and
gastos pa ako by: smiling, and
increased risk consistent, take steps to
imbes na ako upon
for suicide. optimistic, and protect client
yung nag- Subjective: conversation
Depressed hopeful through
tratrabaho she focuses
person see attitude. appropriate
para sa mga “Wala na on present
suicide as a therapeutic
anak ko” as akong 2. Allowing the activities.
means of Long term: interventions.
verbalized by nagawang client to GOAL
escaping from
the patient. tama sa buhay verbalize helps PARTALLY
anxiety After 3-4 days 2. Listen actively
ko. Lahat the client MET
provoking and of nursing to the client’s
“wala ng silbi nalang relieve pent-up
intensely intervention, story regarding
buhay ko, hindi nangyari sa thoughts, Long term:
frightening the patients will how the client
na dapat ako buhay ko mali. feelings and
situations. expresses came to the point
nabubuhay pa. Nakakahiya emotions After 4 days of
They are desire to live. of suicide, using
hindi ko alam kasi nandito related to nursing
frightened by Display therapeutic skills
kung para ako ngayon, suicide and is intervention,
their consistent, such as reflection,
saan pa kung gastos pa ako in itself the patient
overwhelming optimistic, and clarification, and
buhay parin imbes na ako therapeutic. It expressed a
anxiety, hopeful validation, and
ako” as yung nag- also gives the desire to live,
isolation, attitude. indicate
verbalized by tratrabaho nurse display
hopelessness, acceptance of the
the patient. para sa mga information consistent,
and client’s thought

2
 anak ko” as about the optimistic, and
Objective: verbalized by critical events hopeful
• frequently the patient. that influenced attitude
helplessness. and feelings.
agitated the client’s towards
Clients
• impaired “wala ng silbi story promotes betterment of
considering
grooming buhay ko, hindi trust and instill own life.
suicide may
na dapat ako hope. GOAL
also
nabubuhay pa. PARTIALLY
experience
hindi ko alam 3. Constant MET.
feelings of
kung para staff support
excessive guilt,
saan pa kung and protection
self blame, and
buhay parin reduce the
frustration.
ako” as client’s fear of
Suicidal clients 3. Tell the client
verbalized by suicidal
often to come to staff
the patient. impulses and
experience whenever the
offer hope for
severe anger. client experiences
Objective: survival.
such thoughts or
• frequently Reference: feelings.
agitated 4. Educating
Mental Health
• impaired the client about
Psychiatric
grooming the temporary
Nursing, by
nature/
Norris,
experience of
Connell, 4. Help the client
suicide and
Stockard, to see that suicide
depression
Ehrhart, is not an
promotes the
Newton. P.772 alternative to life’s
client’s insight
problems but is
about the
rather a
threatability of
temporary
the disease
experience often
process and
brought by an
offers hope for
actual illness and
the future.
exacerbated by

2
 1. To stabilize
life stressors.
the mood of
the patient.
1. Prevent
anxiety from
escalating to
Dependent:
unmanageab
1. Administer
le levels.
Lithium as
ordered.

Collaborative:
1. Continue to
support and
monitor
psychosocial
treatment plans.

Cues Nursing Rationale Nursing Interventions Rationale Evaluation

2
 Diagnosis

Objectives
Subjective: Problem: Depression is a Short Term: Independent: Short Term:
Chronic Low feeling 1. Note non- 1. Incongruenc
“Dati Self-esteem involving an After 1-2 days verbal e’s between After 2 days of
masiyahin siya element of of nursing behavior. verbal/non- nursing
at may tapang Etiology: sadness and intervention the verbal intervention the
ng loob sa mga Related to helplessness. patient will: communicatio patient
ginagawa niya, Anxiety There is little • Client n require demonstrated
pero ngayon drive for demonstrate clarification. self-care
naging as evidenced socialization or self-care appropriate for
withdrawn na by: communication appropriate for 2. Use positive 2. To assist age and
siya,” as , although age and status messages client to status,used
verbalized by Subjective: depression is • Uses rather than develop techniques to
the patient’s the techniques to praise. internal sense decrease
relative. “Dati predominant, decrease of self-esteem. anxiety and
masiyahin siya outward feeling anxiety. had a
“wala na akong at may tapang shown, the 3. Give 3. Positive verbalization of
nagawang ng loob sa mga fear, anger and reinforcement words of “nalaman ko na
tama sa buhay ginagawa niya, guilt for progress encourageme importanteng
ko, lahat pero ngayon components of Long Term: noted. nt promote alagaan ko
nalang ng naging anxiety are continuation of sarili ko, hindi
nangyare sa withdrawn na internalized or After 3-4 days efforts, lang para sa
buhay ko siya,” as turned inward of nursing supporting sarili ko kundi
mali…” as verbalized by upon the self. intervention the development para rin sa
verbalized by the patient’s The fear of patient will: of coping mga taong
the patient relative. unleashing • Verbaliz behaviors. importante
anger or e increased sakin…”
“nakakahiya “wala na akong hostility or of sense of self- GOAL MET
kasi nandito nagawang exposing guilt- worth in
ako ngayon, tama sa buhay producing relation to
gastos pa ako ko, lahat unacceptable current 4. Encourage 4. Adaptation Long Term:

2
imbes na ako nalang ng to change in
ung nangyare sa self-concept After 4 days of
nagtatrabaho buhay ko depends on its nursing
thoughts and situation. client to
para sa mga mali…” as significance to intervention the
anak ko…” as verbalized by
wishes to • Demons progress at
individual, patient had
others trate behaviors own rate.
verbalized by the patient disruption to verbalized
reinforces the and/or lifestyle
the patient. lifestyle, length increased
learning of changes to
“nakakahiya of sense of self-
internalization promote
Objective: kasi nandito illness/debilitat worth in
of anxiety. The positive self
ako ngayon, ion. relation to
individual has image.
• Social gastos pa ako current
learned during
Withdrawal imbes na ako 5. To situation.
the
• Depression ung decrease GOAL
socialization
• Fails to nagtatrabaho anxiety level. PARTIALLY
process to 5. Encourage
attend to para sa mga MET
anticipate techniques
hygiene anak ko…” as
rejection, such as deep
• Demonstrates verbalized by disapproval breathing.
difficulty the patient. 1. Used to
and loss of love
communicatin balance
leading to Dependent:
g or Objective: biogenic
disruption in
interacting 1. Administer amines of
interpersonal
with others: • Social Lithium as norepinephrin
relations.
poor eye Withdrawal ordered. e and
contact and • Depression serotonin in
Reference:
soft voice • Fails to CNS area
Page 127,
attend to involved in
Psychiatric
hygiene emotional
Nursing by
• Demonstrates response.
Manfreda &
difficulty Krampitz, 10
communicatin Edition
g or 2. Depress
interacting cerebral
with others: 2. Administer cortex,

2
poor eye hypothalamus,
contact and and limbic
soft voice systems which
Chlorpromazin
control activity
e as ordered.
an aggression;
blocks
neurotransmis
sion produced
by dopamine
and synapse.

1. To help the
patient
establish
Collaborative sense of
worth.
1. Continue to
support and
monitor
psychosocial
treatment
plans.

2
DISCHARGE PLAN

• Meeting Physiologic Needs

o Decreasing environmental stimulation may assist the client to relax by

providing a quiet environment without noise, television or other distraction.

o Establish a bedtime routine, such as a tepid bath, may help clients to calm

down enough to rest.

o Nutrition is another area of concern. Manic clients may be too “busy” to sit

down and eat, or they may have such poor concentration that they fail to

stay interested in food for very long time. “Finger foods” or things client

can eat while moving around are the best options to improve nutrition.

Such foods also should be as high in calories and protein as possible.

o Monitor food and fluid intake and hours of sleep until client routine meet

these needs without difficulty.

• Medication

Bipolar Affective 1 is treated by:

o Lithium Carbonate that may normalizes the reuptake of certain

neurotransmitters and reduces the release of norepinephrine.

o Chlorpromazine Hydrochloride that may block postsynaptic dopamine

receptors in the brain.

2
• Providing Client and Family Teaching

o Education about the cause of bipolar disorder, medication management,

ways to deal with behaviors, and potential problems that manic people can

encounter is important for family members.

o Education reduces the guilt, blame, and shame that accompany mental

illness, increases client’s safety, enlarges the support system for client

and the family members, and promotes compliance.

o Education takes the “mystery” out of treatment for mental illness by

providing proactive view: this is what we know, this is what can be done,

and this is what you can do to help.

o Client should learn to adhere to the established dosage of lithium and not

to omit doses or change dosage intervals; not prescribed dosage

alterations interfere

o Periodic monitoring of serum lithium levels is necessary to ensure the

safety and adequacy of the treatment regimen.

2
REFERRENCES

Book

1. Page 127, Psychiatric Nursing by Manfreda & Krampitz, 10 Edition

2. Nursing 5th Ed pp120-121, by Keltner, Schwecke, Bostrom

3. Psychiatric Nursing Care Plans 5th Edition, Fortinash, Holoday Worret page 185-202

4. Keltner, Norman L., Scwecke Lee Hilyard, Bostron, Carole. Psychiatric Nursing. Fifth

Edition. Mosby. Pg. 396- 398

5. Page 149, Psychiatric Nursing by Manfreda & Krampitz, 10 Edition

6. Fundamentals of Nursing by Kozier

7. Nurse’s Pocket Guide 11th Ed by Doenges, Moorhouse, & Murr

8. Nursing Diagnosis Handbook 7th Ed. By Ackley, Ladwig, & Gail

9. Fundamental of Nursing by Deleune

10. Nurse’s Handbook in Health Assessment by Webber

11. Bipolar by Mc Burnie

Internet

1. Nursingcrib.com

2. MIMs.com