I.

INTRODUCTION

A. OVERVIEW
Bipolar I Disorder is one of the most severe forms of mental illness and is characterized by recurrent episodes of mania and (more often) depression. The condition has a high rate of recurrence and if untreated, it has an approximately 15% risk of death by suicide. It is the third leading cause of death among people aged 15-24 years, and is the 6th leading cause of disability (lost years of healthy life) for people aged 15-44 years in the developed world. Bipolar I Disorder is a life-long disease and runs in families but has a complex mode of inheritance. Family, twin and adoption studies suggest genetic factors. The concordance rate for monozygotic (identical) twins is 43%; whereas it is only 6% for dizygotic (nonidentical) twins. About half of all patients with Bipolar I Disorder have one parent who also has a mood disorder, usually Major Depressive Disorder. If one parent has Bipolar I Disorder, the child will have a 25% chance of developing a mood disorder (about half of these will have Bipolar I or II Disorder, while the other half will have Major Depressive Disorder). If both parents have Bipolar I Disorder, the child has a 50%-75% chance of developing a mood disorder. First-degree biological relatives of individuals with Bipolar I Disorder have elevated rates of Bipolar I Disorder (4%-24%), Bipolar II Disorder (1%-5%), and Major Depressive Disorder (4%-24%). The finding that the concordance rate for monozygotic twins isn't 100% suggests that environmental or psychological factors likely play a role in causation. Certain environmental factors (e.g., antidepressant medication, antipsychotic medication, electroconvulsive therapy, stimulants) or certain illnesses (e.g., multiple sclerosis, brain tumor, hyperthyroidism) can trigger mania. Mania can be triggered by giving birth, sleep deprivation, and major stressful life events. In adults, mania is usually episodic with an elevation of mood and increased energy and activity. In children, mania is commonly chronic rather than episodic, and usually presents in mixed states with irritability, anxiety and depression. In adults and children, during depression there is lowering of mood and decreased energy and activity. During a mixed episode both mania and depression can occur on the same day.

Comorbidity is the rule, not the exception, in bipolar disorder. The most common mental disorders that co-occur with bipolar disorder are anxiety, substance use, and conduct disorders. Disorders of eating, sexual behavior, attention-deficit/hyperactivity, and impulse control, as well as autism spectrum disorders and Tourette's disorder, cooccur with bipolar disorder. The most common general medical comorbidities are migraine, thyroid illness, obesity, type II diabetes, and cardiovascular disease. Bipolar I Disorder is often associated with: alcoholism, drug addiction, Anorexia Nervosa, Bulimia Nervosa, Attention-Deficit Hyperactivity Disorder, Panic Disorder, and Social Phobia. Bipolar I Disorder affects both sexes equally in all age groups and its worldwide prevalence is approximately 3-5%. It can even present inpreschoolers. There are no significant differences among racial groups in the prevalence of this disorder. The first episode may occur at any age from childhood to old age. The average age at onset is 21. More than 90% of individuals who have a single Manic Episode go on to have future episodes. Untreated patients with Bipolar I Disorder typically have 8 to 10 episodes of mania and depression in their lifetime. Often 5 years or more may elapse between the first and second episode, but thereafter the episodes become more frequent and more severe. There is significant symptom reduction between episodes, but 25% of patients continue to display mood instability or mild depression. As many as 60% of patients experience chronic interpersonal or occupational difficulties between acute episodes. Bipolar I Disorder may develop psychotic symptoms. The psychotic symptoms in Bipolar I Disorder only occur during severe manic, mixed or depressive episodes. In contrast, the psychotic symptoms in Schizophrenia can occur when there is no mania or depression. Poor recovery is more common after psychosis. Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months (median duration about 4 months). Depressive episodes tend to last longer (median length about 6 months), though rarely for more than a year, except in the elderly.

B. OBJECTIVE AND PURPOSE OF THE STUDY

This study generally aims to investigate a mentally ill patient particularly we drive to: Know the History of the client and the family Track down the developmental stages of the client Trace the incident that precipitated the mental illness of client Describe the symptoms manifested by the client Build Nurse-client relationship Anticipate the needs pertaining to the client illness Provide nursing interventions Develop positive coping mechanism Encourage verbalization of feelings of the client Provide opportunities for the client to practice new behavior Promote positive self concept Evaluate progress and redefine goals as appropriate The purpose of the study is to gather significant data broaden our understanding and knowledge in psychiatric nursing and to improve our abilities in determining and/or differentiating the distinct mental disorders. Moreover, the activity will develop our skills in managing the mentally ill person. Bipolar

disorder. As healthcare providers, we sought to investigate, plan and implement as

A. SCOPE AND LIMITATION

The study was conducted at SPMC psychiatric section Crisis Intervention unit . It covers the patients mental condition and focused on the diagnosis formulated by the patients psychiatrist. The information was gathered through the groups observations on the behaviors manifested by the client. An interview with the clients family

members, relatives, friends, and neighbors was also conducted to gain more information that would add to the understanding of the patients present condition. The care of the patient is good for 5 days, 4 days care at the hospital and 1 day follow-up care / home visit. Five days of visitation is still not enough to gain progress in the clients mental ability and doesnt give the group a chance to explore the case further and more intensively. Furthermore, the limitation of the study lies on providing financial support and short-term nursing goals were drawn on due to time limitation.

: Mr. RO : 31 years old Gender : Male The estimated timeSingle Marital statu : of travel is about 30 t 45 minutes from SPMC. The distance Nationality : Filipino cover is almost 35 kilometers. Yu can ride in a jeepney going to Tugbok, the loading Address : Santo Nino, Tugbok, Davao City and Birth date area is on: the Acasia street, the fare is 60 pesos. unloading October 10, 1980 Birthplace of the highway Bohol pass by, on the NCCC mall. Then you will turn : Clarin, you will On the right side Religion : Roman Catholic left. Educational Attainment by on the bridge, from there the road will be straight. Then After that you will pass

B. SPOT MAP Age

Name

after that,Elementaryby on the intersection. You will right turn, because this is the you will pass Clarin, Bohol road going to Brgy. Santo Nino. You will pass by on Matina, and you can see on the Los Amigos right side High School building of DAR. Then after covering few kilometers. You will of the road the College : University of Mindanao see a road, on the left side, the road going to Barangay Santo Nino. You will take several turns to reach our patients house. In there you will pass by on the Barangay Arrest, Court States Probation : Yes Hall,Vital Signs: then turn left, and you will see the Santo Nino National Highschool. Turn left, then straight the road. You will see a basketball court, turn right, then straight the road. Our Blood Pressure 120/80 mmHg patients house is lacated at the end part of the road. If you see a house selling Temperature 37.1 c Respiratory Rate our patients house. 18cpm vegetables on their porch, thats Pulse Rate 73bpm Food and drug allergy: Use of street drugs: Use of street alcohol: (-) (+) (+)

C. PATIENTS PROFILE

II. ANAMNESIS
1. INFORMANTS

e st..Tugbok ,Davao City or t: 7 years s illness: syun kay ma-o ... mangisog siya sa mga tao peru dili mana siya mang hilabot gyud...mag yaw-yaw siya dayun ma

aay panahon nga ga wild na siya peru di na siya manakit pag dili unhan. Most of the time jud ga lingkod-lingkod na

her

nimalay...iyang gina problema kini ug diha siya ma gu-ol, ilabi na kanang matang sa kwarta...duda naku na depres

A ars old urok 11-3rd batch Molave st..Tugbok ,Davao City p to client: neighbor ime known to client: 21 years nderstanding to the clients illness:

tch Molave st..Tugbok ,Davao City Relationship to client: Neighbor own to client: 14 years to the clients illness: na siya ug kalit,pag naa siya sa gawas...mag shagit2x dayun naa pud na siyay igsn na ingana...ug sa akng na obs

Molave st..Tugbok ,Davao City Relationship to client: Neighbor o client: 18 years he clients illness: n rana siya na baylente nga bata...kay gapanakit siya . naa gali na siyaay na kulatahan tungd kay gi hagit man siya

ve st..Tugbok ,Davao City Relationship to client: Neighbor ient: 22 years ients illness: ngon.isog kaayu, mukalit lang siya muhangad sa adlaw ug mag storya2x...mura na siya siguro ug patol na mukalit l

nt 8 ame: Mr.R ge: 41 years old ddress: Purok 11-3rd batch Molave st..Tugbok ,Davao City Relationship to client: Neighbor Length of time known to client: 6 years pparent Understanding to the clients illness: a akong pag sabot sa iyang kundisyun...murag naa na siyaay deperensha sa pangutok,pag balhin man gud naku d

A. MATERNAL AND PATERNAL LINEAGE Patients cousin on the father side had a history of mental illness as claimed by the patients mother. Also, patients uncle on the mothers side had a history of Mental retardation. 1. FATHER Mr. U is a garbage collector, he is just earning a small amount of salary in this paid job. He engaged himself in smoking and drinks occasionally. His father involved in gambling, called majong infrequently. In terms of disciplinary matter, he rarely hit his children as a form of discipline. This notion remains until his children reaches adulthood.

2. MOTHER Mrs. U is a simple housewife that manages their own little vegetable store in front of their house. She do all the household chores and takes care of her children. Based on our observations, she is a good mother to her children, very supportive and understanding in terms of caring patient Rey. This relationship continued until her children reaches adulthood. Infact Mrs. U strives hard and does everything just to do her duty as a mother. 3. SIBLINGS The client has 2 brothers and 1 sister. He is the 3 rd child in the family. It was also noted that his 2nd elder brother do have Mental Retardation. There was miscarriage happen before their youngest sibling was born, this abortion happened upon reaching 2 months of pregnancy due to stress. B. PERSONAL HISTORY 1. PRENATAL CHECK-UP

The mother of pt.RO recalled that during her pregnancy she had completed her prenatal visit to the nearest Health Centre. Also mother claimed that she wasnt able to complete patients RO immunization. 2. BIRTH

Patient RO was full term upon delivery and the mother claimed that there were no unusual incidents that happened after giving birth. According to the patients mother, she had no difficulty while on labor. The patient was delivered through Normal Spontaneous Vaginal Delivery (NSVD), at the known hospital in Candahik, Bohol on October 10, 1980.

3.

INFANCY AND CHILDHOOD CHARACTERISTICS

The patient received bottle milk feeding and lasted up to 2 years old. Teething started at 8 months old and talking started when he was 9 months old while walking started at 1 year old. As a toddler, he had undergone proper toilet-training. He had history of tantrums. Also, accidents such as falls were experienced by the patient during this age. As a child cough and colds are commonly experience. By the time patient reaches 4 years of age, her mother left him under the care of a yaya.Thumb sucking departed until 7 years old. 4. PSYCHOSEXUAL FACTOR

Patient RO is aware of his sex and gender at an early age. And he had his circumcision at the age 5 years old. At the age of 12 years of age patient involved himself to masturbation, since his friends are getting into with this sexual curiosity. 5. PLAY LIFE

According to the mother of the patient, patient RO played games like basketball and traditional street games such as patintero and tumba lata with the same gender friends. He did his homework every night but not at the period during class hours. 6. SCHOOL HISTORY

The patient entered school at the age of six as a grade 1 pupil. In fact, His academic performance was average from elementary up to the tertiary level. Unfortunately, he only reached til second year college because of financial problem. 7. RELIGIONS AND SOCIAL ADAPTABILITY Patient RO wasnt really a church goer, according to his mother; he goes to church once a year. Patient Rey is sociable in fact he have a circle of friends during his early age. By the time he reaches college he affiliated himself in fraternity. 8. OCCUPATIONAL HISTORY The patient had several works applied after he stop going in college. He experiences working as a kargador, motorela driver, farmer and a hardware salesman. By the time he receives his salary he seldom gives money to his parents because of the reason that he is not obliged to furnish.

9.

MARITAL HISTORY The patient had no marital relationships.

10.

ONSET OF ILLNESS

According to the patients mother, these symptoms were observed when patient RO was talking to himself. And he was able to look at the sun directly for several minutes in the middle of the afternoon and started to walk around. Then he will get mad if her mother cannot provide him money for his material consumption. One instance ensues when somebody provoked patient RO to have a man to man fight, because of undefined issue. This leads to trouble, the issue then blown out beyond the

corners of 3rd batch Molave street, Purok 11, Tugbok Davao City, where patient is currently residing.

I. COURSE IN THE HOSPITAL

A. MENTAL STATUS EXAMINATION D1 Date of Visit D2 D3 March 10, 2011 D4 March 11, 2011 D5 March 13, 2011

March March 8, 2011 9, 2011 A. SPEECH Soft Loud Hesitant Slurred Superior Humor Frightened B. Does her style & vocabulary convey: Coyness Suspiciousness Arrogance Secrecy Superiority Humor Fear C. Stream of Talk Spontaneous Deliberate Pressured D. Organization of Talk Relevant Irrelevant Incoherent Loose Association Flight of Ideas Tangentiality Circumstantiality Perseveration Clang Association Neologism Echolalia Echopraxia

E. Mood and Affect 1. Mood Euthymic Depressed Euphoric 2. Affect Flat Blunt Angry Elated Anxious Fearful 3. Range of Affective Expression Consistent Labile Anhedonic Appropriate to the situation & feelings verbalized

D1 F. Perception Hallucination Auditory Visual Olfactory Gustatory Tactile Delusion Grandeur Persecutory Reference Illusion Derealization Depersonalization Identification Thought Broadcasting Dj vu Jamais vu

D2

D3

D4

D5

G. Orientation and Memory 1. Identifies date correctly 2. Estimates time of the day

Yes Yes

Yes Yes

Yes Yes

Yes Yes

3. Knows where he is 4. Knows the examiner 5. Recalls events prior to admission 6. Recalls activities done within 24 hours 7. Recalls activities done within 1 week H. Neuro-vegetative Functioning Sleep & Rest Pattern Normal sleep Early morning awakening Middle night awakening Hyper insomnia Difficulty falling asleep Interrupted sleep I. Elimination Bowel Bladder J. Abstract Thinking Ability K. Judgment

Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes

1 4 Good Good

1 3 Good Good 1 3 Good Good 1 3 Good Good

A. PROGRESS NOTES
General Objectives: At the end of 5 days visit, the NCM 105 Group C3 students of Liceo de Cagayan University will be able to assess and identify the most important patients concern that contributes to her mental status and to implement interventions designed to address the patients needs. Day 1: March 8, 2011

Specific Objectives: At the end of 1 hour visit to the client, the group will be able to: a. b. family c. d. e. f. Conduct information related to his present condition and the history of present Orient the patient and his family with our purpose Assess his current mental status Make a nursing interventions designed to address the clients needs. mental illness Ask permission to him and his family to allow us to make him to be the subject of Established rapport, gain trust and cooperation from the patient and immediate the groups case study.

This was our first day of visit in our client, he was admitted at SPMC, Crisis Intervention Unit. Our patient is Mr. R.O a 31 years old. First we asked the patient and his mother to allow us to visit the patient, to care, and to interview for our care study about him and to the family, stating the duration of the relationship, the purpose, and the parameters of subsequent condition. During the initial interaction, we were able to set contract with the patient meetings. We also set clarifications of some expectations. We specified the boundaries, the time, date, place, the length of session, and the confidentiality of any information that will be gathered. After stating the contract and purposes we then started to gather important data by having an interview to the client and to his mother. During our few minutes of interview, we observed that our patient is manifesting being grandeur and tends to talk in a angry manner. Some of the patients present health related problems were already identified. But before we end up our conversation and interaction that day, we emphasized to them that we will visit them in the hospital for 4 consecutive days and the last day for the 5th visit will be a home visit. And the patient and his mother immediately agreed in the said contract which could also indicates that they are willing to entertain us.

Day 4: March 11, 2011

Specific Objectives: At the end of 1 hour visit, the group will be able to do the following: a. Conduct Mental Status Exam of the patient. b. Identify again the most important clients concern at the moment. b. Obtain information on the present situation. c. Perform nurse-patient interaction. d. Implement nursing interventions and health teachings. e. Evaluate progress and redefining goals as appropriate. f. Inform again the client and his significant others for the up coming home visit. Today is our 4th day of visit in our patient, and also our last visit on his confinement in this institutuion because he is about to discharge. Still we continued with our goal in helping the client in his recovery, the nursing care plans we made was being implemented and so with the health teachings to the client and significant others were emphasized. As part of our contineous assessment we still filled up his mental status exam. As we observed there were only few changes of the client we identified, these includes; his facial expression seems to be more calmed today compared in our previews visit were in he looks angry not knowing for some reasons, he also said that he was now able to sleep well. We also do updated his doctors order and copy his home medications which is also important so we could give an appropraite health teachings with regards to proper intake of medications. Lastly, we reminded the patient and his mother that we will be going to visit them this Sunday, this would be our 5th and last visit and interaction with the client and his family. Day5: March 13, 2011

Specific Objectives: At the end of 2 hours of psychiatric visit to the client, the student nurses will be able to; 1.

During our fifth visit, we went to our patients house which is located at Brgy. Sto. Nino, Tugbok Davao City with our clinical instructor. Along the way we dont have any idea on where this place located we just look for the landmark they gave which is the Phillipine Science High School. As we arrived in the given address we kept on asking the residents on where Mr. R.Os residence located. Successfully we arrived in the area safely. Unfortunately our patient was not at home, only his mother, sister and elder brother was at home during our visit. Because of this we were not able to filled up our Mental Status exam for the fifth day. We dont have a choice so we conducted another interview with her mother and sister for additional data with regards to our patients attitude and manner at home. They stated several experiences with Mr. R.O as a son and brother. Some of the group members also conducted an interview in their neighborhood. A lot of data were also gathered from them. The group decided to empart health teachings to the mother since our client wasnt there.

3-7-11 8:55 pm

DOCTORS ORDER RATIONALE Please admit patient To render proper medical management to CIU and treatment of condition. Secure consent to The right to refuse medical intervention is care DAT well established. This particular diet was given when client can tolerate any food he desires that is nutritious, if this will not lead to any complications and if the client needs Monitor vital signs Meds: Haloperidol 5 mg 1 further monitoring for lab test. To monitor patients physiological state.

amp IM Biperiden EPS Escape, homicidal, precaution 3-8-11 1:45 pm for 4 point restraint Give 20 mg 1 amp IM Hold Haloperidol IM Shift to Haloperidol 20 mg/tab tab BID Continue meds For therapeutic regimen. HCL 20 mg/tab BID PRN for suicidal,

3-9-11 3:55 pm 3-10-11 + appetite Good sleep Racing thought Visual Hallucination 3-11-11 + sleep appetite Non hostile + hallucination good and

Start Carbonate

Lithium

Continue meds MGH

For therapeutic regimen. Patients condition was having a progress.

Home meds: Haloperidol tab tab BID Biperiden HCL 20 5 mg

mg 1 tab BID Flu Follow-up check up 1 week after discharge @ OPD

I. PSYCHODYNAMICS A. Tabular Presentation of the Predisposing Factors and Rationale Factors Predisposing a. Hereditary The mother claims that the patients cousin in paternal side had a history of mental illness; also the patients uncle in maternal side had a history of mental retardation. Current theories and studies shows that several psychiatric disorders may be linked to a specific gene or combination of genes: although nongenetic factor is also an important factor. Studies have tried to compare whether it is a more common among first degree relatives than more distant relatives (NIH 2007) Present Rationale

b. Psychosocial

Prenatal His mother carried herself well and didnt experience any bumps, falls and other accidents during pregnancy. She had her prenatal check-ups every month. She never experienced any sickness

MISTRUST (0-18 months)

during her pregnancy to R.O.. She had normal pregnancy. She was provided well, with all the vitamins and immunizations. Ray was delivered through normal spontaneous delivery. According to Kendra Van Wagner, caregivers who are inconsistent and emotionally unavailable, contribute to feelings of mistrust in the children they care for.

SHAME AND DOUBT (18months-3yrs)

Because parents both have to work in their business the patient was left under the care of yaya. The only time given to the patient was at As said by Tara Kuther, if parents nighttime. and caregivers provide for physical and emotional needs, the infant will develop a basic sense of trust in their caregivers and the world. Like Freud, Erikson believed that toilet training was a vital part of this process. However, Erikson's reasoning was quite different than that of Freud's. Erikson believe that learning to control ones body functions leads to a feeling of control and a sense of independence. As stated by Kendra Van Wagners statement, during the preschool years, children begin to assert their power and control over the world through directing play and other social interaction. Those who fail to acquire these skills are left with a sense of guilt, self-doubt, and lack of initiative.

GUILT (3-5)

No proper toilet training. Patient does not recieve punishments from both his parents during toddler years. Patient had a history of fall from stairs (2 years old)

INFERIORITY (6-12)

Follower during playtimes. He had also a history of hospitalization due to hit and run and lasted 2 days at the hospital.

At the age of 12 years old, According to Erikson, if a person

ROLE CONFUSION (12-18)

their business drop and all doesnt develop confidence in of a sudden their family own abilities, inferiority tends to decided to move in Davao develop because of shame. R.O. was depressed at this time and was inferior with others who stayed rich.

ISOLATION (18-45)

Patient stopped his school days because of financial restraints. According to his mother he was so depressed at this time since all he wanted is to become a police officer

Research also suggests that social isolation and poor social relations are indicators of high levels of social stress and anxiety in the child.

d. Environmental

e. Socioeconomic Status

Had no relationships w/ woman ever since his As said by Davis, successful disorder appeared. completion can lead to At the age of 23 years old, comfortable relationships and a the patient had his first sense of commitment, safety, episode of mania. They and care within a relationship. would seek medical Unsuccessful relationships can advice at SPMC two times lead to isolation, loneliness, and a year. He is depressed depression. whenever they dont have money Living in poor environmental sanitation and community. Joins and shares with his barkadas, but doesnt really had a close-relationship with the neighbors

f. Age

According to Videbeck, the client should have a sense of community access to adequate resources in tolerance to violence and support of diversity among people.

Patient socioeconomic Ostrove (1999) stated that people brought him to stop who live in poverty are at risk for schooling and go working, threats to health and psychiatric

yet still unable to met disorders. needs in self and fulfill dreams According to Videbeck, the peak The onset of the patients age for persons to usually symptoms occurred at develop this sickness is at the age 23 years old. age of early 20s.

B. SCHEMATIC DIAGRAM BIOLOGICAL

GENETIC The mother claims that the patients cousin in paternal side had a history of mental illness; also the patients uncle in maternal side had a history of mental retardation.

BIOCHEMICAL Decreased serotonin (depression) and increased in norepinephrine (mania)

INCREASE VULNERABILITY TO MENTAL DISORDER

PSYCHOSOCIAL

INFANCY Because parents both have to work in their business the patient was left under the care of yaya. The only time given to the patient was at nighttime.

TODDLER No proper toilet training. Patient does not recieve punishments from both his parents during toddler years. Patient had a history of fall from stairs (2 years old)

PRESCHOOL Follower during playtimes.

SCHOOLER At the age of 12 years old, their business drop and all of a sudden their family decided to move in Davao because of shame. R.O. was depressed at this time and was inferior with others who stayed rich

YOUNG ADULT. Had no relationships w/ woman ever since.At the age of 23 years old, the patient had his first episode of mania. They would seek medical advice at SPMC two times a year. He is depressed whenever they dont have money

Mistrust was developed

Shame and Doubt was developed

Guilt was developed

Inferiority was developed

Isolation was developed PREMORBID TRAIT (Labile, violent, hostile, insomnia, auditory and visual hallucinations_)

Weakened ego Low self-esteem Isolation denial Use of defense mechanism Precipitating factors Displacement Isolation Denial Use of exaggerated defense mechanism Failure of Coping Maladaptive Behaviours Thought Process DELUSION: Grandiose FLIGHT OF IDEAS Impaired Perception HALLUCINATION: Auditory Visual Other Behaviours BIPOLAR I Labile Pressured speech Insomnia Increased energy level Agitated mood Appearance Drowsy eyes First manifestations occurred around 23 years old due to: Doesnt have girlfriend since then his disorder occurred Unable to continue educations Unfulfilled dreams Financial problems

ENVIRONMENTAL FACTOR

INTERNAL FATHER Doesnt have a close relationship with his father. MOTHER The only person in the family he shares with SIBLINGS Doesnt have close relationship with his siblings because of many factors ENVIRONMENT Living in poor and environmental sanitation.

EXTERNAL SOCIAL NETWORKS Has a small group of friends (barkadas) and do not had a closerelationships with the neighbours Neglect from lovers SOCIOCULTURAL Poor socioeconomic status Unfulfilled dreams Stopped schooling Drinks alcoholic beverages. CHEMICAL

DEPRESSION

A. Analogy The scripture once relates a metamorphosis of a butterfly; from an egg to a larva (caterpillar), pupa then to a beautiful butterfly that flies in the garden. This narration brings the metaphor between how a man could be liken to a butterfly, yet the conclusion will not be as pleasant as many factors may occur that disrupts the beauty and development of a butterfly. This is the story of our patient. The butterfly egg is covered with a protective layer called chorion. This functions as preventing the egg from drying out before the larva has had to fully develop. If the chorion is soft because of a defective gene, then many conditions may develop. This implies the genetic predisposition in the family. Female butterflies usually lay their eggs on or near plants suitable for the young to eat. As the egg hatch (two or three days to a month) and becomes a larva, it will then find healthy leaves to eat. Lack of care and careless laying of eggs in unhealthy leaves results to mistrust to its caregivers. And so the egg hatched and becomes a larva. The larva finds leaves that can be eaten for its development. Since the egg is hatched at the unhealthy leaves, deprivation of food may result. Larva form mutual associations with ants, they communicate with the ants using vibrations that are transmitted through the substrate as well as using chemical signals. The ants provide some degree of protection to these larva and they in turn gather honeydew secretions. These are considered the support groups of R.O. He doesnt had many support groups, only his family and his few barkadas. They considered R.O. as shy type boy (low self-esteem). So the story continues. When the larva is fully grown, the larva stops feeding and begins "wandering" in the quest of a suitable pupation site, often the underside of a leaf. The larva transforms into a pupa by anchoring itself to a substrate and moulting for the last time. This time development of behaviours, attitudes and characteristics are being moulded by him. Environmental, social and many factors may lead to each individuals characteristics.

In life of a pupa, came the long periods of warm summer where the sun shine so brightly in the sky making the surrounding trees and flowers bloom, well shortly after every after long sunrise comes heavy rain and strong winds blew. The pupa was being blew to and fro, and its foundation was then unstable. The sunshine comprises of the time of the patients life where he had live normally, we always consider the suns warm as something that is good such as having his support groups. Now the storm is always seen as disastrous. The greatest storm could only be is when they are forced to move from their current place because of the drop of their business (shame) and when he had stopped schooling because of financial restraints and lastly when he experienced no relationships with opposite sex ever since his disorder appeared which left our patient deserted and depressed. The pupal transformation into a butterfly through metamorphosis has held great appeal to mankind. To transform from the miniature wings visible on the outside of the pupa into large structures usable for flight. But since many problems and factors that occurred in the life of the butterfly, the wings are formed weak and fragile. Then there were times where-in the butterfly becomes manic, combative and hostile after periods of depression. And so what is left to do is to conclude what happened with the butterfly or rather to the patient.

I. LABORATORY EXAM NO LABORATORY EXAM/TEST/RESUHED TO THE PATIENTS CHART

II. DIAGNOSIS
BIPOLAR 1 MANIC PHASE WITH PSYCHOTIC FEATURES Bipolar disorder or manic-depressive disorder, also referred to

as bipolar affective disorder or manic depression, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or more depressive episodes. The elevated moods are clinically referred to as mania or, if milder, hypomania. Individuals who experience manic pisodes also commonly experience depressive episodes, or symptoms, or mixed episodes in which features of both mania and depression are present at the same time. These episodes are usually separated by periods of "normal" mood; but, in some individuals, depression and mania may rapidly alternate, which is known as rapid cycling. Extreme manic episodes can sometimes lead to such psychotic symptoms as delusions and hallucination. Bipolar I is one or more manic episodes. Subcategories specify whether there has been more than one episode, and the type of the most recent episode. A depressive or hypomanic episode is not required for diagnosis, but it frequently psychotic features are often present during the manic phase of bipolar I disorder. Aspects of psychosis may also manifest during extreme episodes of depression. These features include delusions (false ideas about what is taking place or who one is) and hallucinations (seeing or hearing things which aren't there).

III. MULTIAXIAL DIAGNOSIS

AXIS Axis I. CLINICAL DISODERS

CLASSIFICATION
Patient R.O has Bipolar I Manic phase with psychotic features. In which he has feeling of euphoria, racing thoughts, impulsive behavior, decreased judgment, overly high self-esteem, and extreme optimism. He had also verbalized that the stars and comet appears on him, this statement shows that he is having visual hallucination. Patient R.O no known personality disorder such as the Histrionic personality disorder ,Dependent Personality Disorder, Obsessive-Compulsive Personality Disorder, or mental retardation. Patient R.O has no known physical or medical disorder such as the hyperthyroidism and Mitral valve prolapse. Patient R.O psychiatric disorder is triggered by environmental factors such as, poor nutritional status and stressful environment where she lives brought about by low socio-economic status. Based on Global Assessment of Functioning (GAF) scale, a scale of 71-80 is given which symptoms are present, there are transient and expectable reactions to psycho-social stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). .Patient has good judgement but he has difficulty in dealing with others because he always insist that he is always right in every conversation he had especially in his family.

Axis II. PERSONALITY DISORDERS AND MENTAL RETARDATION

Axis III. GENERAL MEDICAL CONDITION Axis IV. PSYCHOSOCIAL AND ENVIRONMENTAL FACT (Stressors) Axis V. GLOBAL ASSESSMENT AND FUCTIONING

IV. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT Diagnosis: Disturbed thought process related to physiologic causes. INTERVENTION RATIONALE 1. Give short, simple explanation to - to avoid confusion and aid successful task completion. client each time you do - rest periods help prevent sensory something. overload. 2. Schedule nursing care to provide - client may unable to consider her quite times. safety needs or risk. 3. Use appropriate safety measures - this reduces confusion and frustration to protect client from any injury. and aids task completion. - enhances clients self-esteem and helps prevent complications of 4. Speak slow and clearly. Allow ample time for client to respond. inactivity. 5. Encourage client to perform activity. Diagnosis: Disturbed sensory perception related to hallucinations. INTERVENTION RATIONALE 1. Identify and reduced as many - these measures decrease clients stressors as possible. Be honest anxiety. and consistent in al interactions with client. - reacting verbally forces client to focus on you rather than on internal stimuli. 2. When speaking to the client. Use directive statements such - to distract client from internal stimuli. as look at me and listen, try not to pay attention to the - such responses foster a sense of control voices right now. and help distract the client, thereby reducing frequency and duration of 3. Provide regular physical hallucinations. activity that requires use of - to increase clients level of functioning. concentration and large muscles. 4. Teach patient to intervene in a hallucinatory experience. Encourage client to speak out

against the hallucination, using statements such as go away; you arent real. 5. As clients anxiety level decreases encourage participation in group oriented activities and involvement in the community.

Diagnosis: Risk for Violence directed at others related to angry response when wishes are refused. INTERVENTION RATIONALE 1. Decrease environmental Client may be unable to focus stimuli, avoiding exposure to attention on only relevant stimuli and will be reacting/responding to all areas or situations of environmental stimuli. predictable high stimulation and removing stimulation Facilitates early intervention and from area if client becomes assists client to manage situation agitated. independently if possible. 2. Continually reevaluate clients ability to tolerate frustration and/or individual situations. 3. Provide safe environment, removing objects and rearranging room to prevent accidental/purposeful injury to self or others 4. Intervene when agitation begins to develop, with strategies such as being verbally direct, prompting more effective behavior, redirecting or removing from the provoking situation, voluntary Time out in room or a quiet place, physical Provide safe environment, removing objects and rearranging room to prevent accidental/purposeful injury to self or others Intervention at earliest sign of agitation can assist client in regaining control, preventing escalation to violence and allowing treatment in least restrictive manner.

Questions regarding prevention increase frustration because agitation decreases ability to analyze situation. In hyperactive state, client does not tolerate waiting or deal well with abstractions, and unnecessary delay

control (e.g., holding). 5. Defer problem-solving regarding prevention of violence and information collection about precipitating or provoking stimuli until agitation/irritability is diminished (e.g., no why, analytical questions). 6. Avoid unnecessary delay of gratification. Give concrete and nonjudgmental rationale if refusal is necessary. 7. Antimanic drugs, e.g., lithium carbonate (Lithobid, Eskalith);

can trigger aggressive behavior. Lithium is the drug of choice for mania. It is indicated for alleviation of hyperactive symptoms.

Diagnosis: Impaired Social Interaction related to impulsivity. INTERVENTION RATIONALE 1. Observe for, gently confront Grandiose behavior may be inappropriately used with client manipulative behaviors (e.g., becoming demanding and overbearing, not taking responsibility for interfering with relationships with own actions, getting others to others. Clients who are manic are do things they normally would attuned to sources of conflict and may not do). consciously or unconsciously escalate the conflict to refocus attention from self, thus putting others on the defensive. 2. Discuss consequences of Client needs to accept responsibility for clients behavior and ways in own behavior before adaptive change which client attempts to can occur. attribute them to Avoids triggering agitated/angry 3. Redirect or suggest more response. Helps reduce and control appropriate behavior using low- exaggerated/unrealistic thinking and behaviors. key, matter-of-fact, When the client believes staff responses nonjudgmental style. have reasons, refusals will provoke less agitation.

4. Ask client to wait until a specified time and give rationale if gratification of a request is not possible. 5. Maintain a nondefensive response to criticism or suggestions regarding better ways to run things, such as the unit. Use suggestions when appropriate.

A low-key response can reduce the volatility of the situation. (This may be frustrating when the client is either outrageous or partly correct.)

Diagnosis: Disturbed sleep pattern related to internal factors. INTERVENTION 1. Allow client to discuss any concerns that may be preventing sleep. 2. Create quite time conducive to sleep like close curtains and close door. 3. Ask client to describe in specific terms each morning the quality of sleep during previous night. 4. Educate client in such relaxation techniques as guided imagery.
5. Administer medication that promote normal sleep pattern as ordered.

RATIONALE - active listening helps you determine causes of difficulty of sleep. - these measures promotes sleep - these helps detect sleep-related behavioral symptoms. -purposeful relaxation efforts usually help promote sleep. - this enhances the clients self esteem and helps prevent complications of inactivity.

Diagnosis: Interrupted Family Processes, disabled Family Coping INTERVENTION RATIONALE 1. Determine individual situation Living with a family member with bipolar illness engenders a multitude of and feelings of individual feelings and problems that can affect family members (e.g., guilt, interpersonal relationships/functioning anger, powerlessness, despair, and may result in dysfunctional alienation). responses/family disintegration. Provides clues to degree of problem

2. Observe patterns of communication (e.g., Are feelings expressed freely? Who makes decisions? What is the interaction between family members?). 3. Determine patterns of behavior displayed by client in relationships with others (e.g., manipulation of self-esteem of others, perceptiveness to vulnerability and conflict, projection of responsibility, progressive limit-testing, alienation of family members).

being experienced by individual family members and coping skills being used to handle crisis of illness. These behaviors are typically used by the manic individual to manipulate others. These clients are sensitive to others vulnerability and can intentionally escalate conflict, shifting responsibility from self to others and putting the other person on the defensive. Family members assume blame and continually try to keep peace at any cost. The client will test limits, constantly getting concessions from others and creating feelings of guilt and ambivalence. The result of these behaviors is alienation and high rate of divorce. When the role of the ill person is not filled, dissonance and family disintegration can occur. The spouse and children of the manic individual may not understand what is happening and react in an adversarial manner, escalating the conflicts that exist. Provides support for family members who may feel helpless to change the client and/or what is happening in her or his life. Family may be afraid to discuss the behavior because of the clients volatile temper. Confrontation can promote insight into the dynamics of the illness and bring about a positive resolution of the family situation

4. Assess role of client in family (e.g., nurturer, provider) and how illness affects the roles of other members.

5. Acknowledge difficulties observed while reinforcing that some degree of conflict is to be expected and can be used to promote growth. 6. Encourage family members to confront clients behavior.

A. ACTUAL NURSING MANAGEMENT S , as verbalized by the mother

Family members have difficulty in coping effectively with clients maladaptive behaviors. Interrupted Family Processes, disabled Family Coping Long Term: At the end of 5 visits, the family will express feelings appropriately, honestly, and openly. Demonstrate individual involvement in problem-solving processes directed at appropriate solutions. Verbalize understanding of illness, treatment regimen, and prognosis. 1. Determined individual situation and feelings of individual family members e.g., guilt, anger, powerlessness, despair 2. Observed patterns of communication

A P

3. Provided opportunity for family members to discuss feelings, impact of disorder on family, and individual concerns. 4. Assessed role of client in family and how illness affects the roles of other members. 5. Provided honest information about the nature and seriousness of the disorder, treatment, what to expect and how to respond to inappropriate behavior. Enlist cooperation of family members to help client to remain in the community 6. Established and encouraged ongoing open communication within the family.

After 5 meetings, the family demonstrated improvement in communications, problem-solving, behavior control, and affective spheres of family functioning. kanang adlaw makita nako na siya nga dli ko sulawan, nakakita napud ko og hangin as verbalized by the client. Visual hallucination Bizarre thinking disoriented

S O

Disturbed sensory perception (visual) related to biochemical imbalance.

Long term: At the end 5 days visit, the client will be able to orient himself to reality. Short term: At the end of 1 hour, the client will be able to distinguish fantasy from reality. 1. Built patient rapport

2. Applied the use of therapeutic communication 3. Encouraged the patient to share what he had experienced and to verbalize feelings 4. Used directive statements such as look at me and listen 5. Encouraged the client to strictly follow the medication regimen.

At the end of 5 days visit, the client was able to orient himself to reality.

S O

Magsige ko ug mata-mata labi na ug gabii. As verbalized by the patient Weary look Frequent yawning Appeared weak and drowsy

A P

Sleep pattern disturbance related to amplified sensory perception. Long term: At the end of 5 meetings, the client will be able to identify ways to improve rest and sleep pattern.

1. Encouraged the significant others to provide quite environment for the patient when sleeping. I 2. Provided structured scheduled of activities that includes establish times for naps or rest. 3. Before bedtime, encouraged significant others to provide comfort measures to promote sleep such as back rub. 4. Instructed significant others to restrict client from intake of caffeinated

drinks, such as coffee, colas and tea. 5. Instructed the significant others to offer small snack/warm milk at bedtime or when awake during the night. 6. Encouraged engaging in physical activities/exercise during morning and afternoon. Restrict activity in the evening prior to bedtime. E After 5 meeting of the patient and the mother of the patient, they were able to identify ways to improve rest and sleep pattern.

I. MEDICAL MANAGEMENT

A. Doctors Order
3-7-11 8:55 pm DOCTORS ORDER Please admit patient to CIU Secure consent to care DAT RATIONALE
To render proper medical management and treatment of condition. The right to refuse medical intervention is well established. This particular diet was given when client can tolerate any food he desires that is nutritious, if this will not lead to any complications and if the client needs further monitoring for lab test. To monitor patients physiological state. An antipsychotic drug use to manage manifestation of psychotic disorder An anticholinergic drug use to relief symptoms of extrapyramidal disorders that accompany phenothiazine therapy. Precaution for possible hostility and violence.

Monitor vital signs Meds: Haloperidol 5 mg 1 amp IM Biperiden HCL 20 mg/tab BID PRN for EPS Escape, suicidal, homicidal, precaution for 4 point restraint Give flupentixol 20 mg 1 amp IM Hold Haloperidol IM Shift to Haloperidol 20 mg/tab tab BID

3-8-11 1:45 pm

A typical antipsychotic drug use to manage manifestation of psychotic disorder Because patient can now able to intake per orem medications. An antipsychotic drug use to manage manifestation of psychotic disorder

3-9-11 3:55 pm 3-10-11 + appetite Good sleep Racing thought Visual Hallucinatio n

Continue meds Start Lithium Carbonate

For therapeutic regimen. Lithium is commonly used to treat mania and bipolar depression (manicdepression or bipolar disorder ). Less commonly, lithium is used to aggressive behavior and emotional instability in adults and children. Rarely is lithium taken to treat depression in the absence of mania. When this is the case, it is usually taken in addition to other antidepressant medications. For therapeutic regimen. Patients condition was having a progress.

3-11-11 + good sleep and appetite Non hostile + hallucinatio n

Continue meds MGH

Home meds: Haloperidol 5 mg tab tab BID Biperiden HCL 20 mg 1 tab BID Flu Follow-up check up 1 week after discharge @ OPD

An antipsychotic drug use to manage manifestation of psychotic disorder An anticholinergic drug use to relief symptoms of extrapyramidal disorders that accompany phenothiazine therapy. For evaluation of progress.

A. Drug Study Biperiden Hydrochloride

Date Ordered: March 7, 2011 Classification: Anticholinergic drug Dose/ Frequency/Route: 20 mg, BID, PO
SPECIFIC
INDICATION

MECHANISM OF ACTION

CONTRAINDIC ATION

SIDE EFFECTS

NURSING PRECAUTION

Relief symptoms of extrapyrami dal disorders that accompany phenothiazin e therapy.

the mechanism of action of centrally active anticholinergic drugs, such as biperiden, is considered to relate to competitive antagonism of acetylcholine at the cholinergic receptors in the corpus striatum, which restores the balance. Similarly, biperiden has been shown to antagonize the Parkinson-like effects of agents with central cholinergic properties.

Narrow angle glaucom a Bowel obstructi on or megacol on. hypersen sitivity to biperide n or any ingredie nt in the formulati on

Atropine-like side effects such as dry mouth; blurred vision; drowsiness; euphoria or disorientation; urinary retention; postural hypotension; constipation; agitation; disturbed behavior may be seen

Take this drug exactly as prescribed . Avoid the use of alcohol, sedative, and over the counter drug.
Maintain adequate fluid intake and exercise regularly. Report difficult or painful urination; constipation , rapid or pounding heartbeat; confusion, eye pain, or rash.

Haloperidol
Date Ordered: March 7, 2011 Classification: Antipsychotic Dose/ Frequency/Route: 5mg; 1 ampule, OD, IM Specific Indication Management of manifestation of psychotic disorder Mechanism Contraindication of Action It can bind to Contraindicated in dopamine D1 patient and D2, 5hypersensitive to HT2, histamine H1 drug and in those and 2 with parkinsonism, adrenergic coma or CNS receptors in depression. the brain.
The efficacy of neuroleptics is thought to be due to antagonism

Side effects Seizure, nueroleptic malignant syndrome, dry mouth, constipation, jaundice,leucopenia and tardive dyskinesia.

Nursing Precaution
Monitor patient for tardive dyskinesia; which may occur after prolonged use. Protect drug from light, slight yellowing of injection.

of dopamine receptors in the mesolimbic and mesofrontal systems.

Flupentixol
Date Ordered: March 8, 2011 Classification: Typical Antipsychotic Dose/ Frequency/Route: 20mg; 1 ampule, OD, IM Specific Indication Management of manifestation of psychotic disorder MECHANIS M OF ACTION
Flupentixol acts as an antagonist at various dopamin e (D1-D5), seroto nin (5-HT2), adre naline (1), and histamine (H [7] wit 1) receptors, hout affecting the muscarinic acetylcholine receptors

Contraindication Side effects Contraindicated in patient hypersensitive to drug and its formation.
extrapyramida l symptoms of akathisia, m uscle tremors, and rigidity an d antihistamin e effects like sedation a nd somnolenc e.

Nursing Precaution Take this drug exactly as prescribed. Avoid the use of alcohol, sedative, and over the counter drug. Maintain adequate fluid intake and exercise regularly. Report difficult or painful urination; constipation, rapid or pounding heartbeat; confusion, eye pain, or rash.

I. PROGNOSIS AND RECCOMMENDATION

A. Prognosis

PROGNOSTIC INDICATORS A. Onset of illness

POOR

GOOD

B. Duration of illness

C. Attitude & willingness to take medications

D. Mood &Affect

E. Precipitating factors

F. Depressive features

G. Family support

B. Recommendations/Health Teachings COMMUNITY It is suggested that the client be a part of social gathering and community activities to achieve feeling of belongingness and dismiss from his thought that he is an outcast or the troublemaker. It is advised that the client must be kept accompanied most of the time in order for the client to express his thoughts and

emotions and to let him feel and know that the people care for him. Respect must be given and she should be treated with dignity. FAMILY The members of the family must be more understanding and supportive in order for them to regain the clients trust and confidence which is imperative for the recovery of the client. The family was encouraged to extend their support and avoid inflicting harm to the client. The family was given proper instructions regarding her home medications with the common side effects were also discussed and its interventions. It is also recommended to consult Dr. Giola Fe D. Dinglasan to monitor the progress or if there are any complications persisted.

II. DOCUMENTATIONS