BIPOLAR I DISORDER

Maria Josefa Recio Therapeutic Center SOUTHWESTERN UNIVERSITY College of Nursing

GENERAL OBJECTIVE
After an hour of case presentation, the student nurses will be able to identify the various clinical manifestations of the disease process through the data obtained in a comprehensive nursing health history documentation, evaluate and develop appropriate critical thinking skills in rendering specific nursing interventions, and maintain positive attitude in enhancing their ability to offer nursing care management, observing strict confidentiality toward patients with Bipolar I Disorder.

SPECIFIC OBJECTIVES
After an hour of case presentation, the student nurses will be able to: Assess and accurately determine the diagnosis and type of mental disorder of the guest. Describe the true nature and magnitude of Bipolar I disorder. Completely and thoroughly understand the personality, character and attitude of the guest. Enumerate the signs and symptoms of Bipolar I disorder highlighting the ones manifested and observed by and from the guest.

 Understand completely the disease process relating it to the guests past health history. Enhance and develop skills focusing on effective and appropriate handling of individuals with maladaptive pattern of behavior. Observe strict confidentiality of personal data and information obtained. Maintain optimism throughout the case presentation. Improve attitude and understanding towards guests with mental disorder Accept constructive criticisms and additional information given by the participating audience.

NURSING HEALTH HISTORY

DEMOGRAPHIC DATA
Name: RRT Address: San Carlos Heights, Quiot Sex: Female Age: 26 Civil Status: Single Education: College Level - Nursing Aide Occupation: Sales Agent Birthplace: Pangantukan, Bukidnon Birth date: October 22, 1986 Nationality: Filipino Attending Physician: Dr. Costas Impression: Bipolar I Disorder, Manic

CHIEF COMPLAINT

Behavioural changes

CURRENT HEALTH STATUS

Admitting a case of guest RT, 26 years old, female, currently residing at Palo, Leyte and working as a sales clerk at Forbes Lux International. Last 2012, she attempted to commit suicide after a breakup with her boyfriend. She thought of jumping from the terrace of which the height is unknown. She admitted to have auditory hallucinations during that time. She further explained that the voices she heard from her left ear provoked her to jump. However, an opposing voice on her right ear prevented her from doing so by inducing guilt when she thought of her mother.

On December 2012, guest RTs dad died and just a few weeks ago she had a big argument with her workmates and she believed that she had been possessed by Joan of Arc-a warrior. This triggered her to have episodes of what appears to be manicinsomnia, irritability, anger, talkativeness, and hyperactivity.

Her friends in the company decided to have her admitted at Palo Psych Unit. She was brought to Cebu by a guardian and was admitted here at MJRTC for the first time due to behavioural changes such as bizarre behaviour, posing a threat to self and others.

PAST HEALTH HISTORY

Pt. RT experienced chicken pox, mumps, sore throats, and fever during her childhood life. She was also hospitalized last 2010 due to Urinary Tract Infection (UTI) at Gatchalian Hospital in Ormoc City, Leyte and the following year at Naval Hospital for the same reason. She never had undergone surgical procedures nor serious injuries. Pt RT received immunizations but cant recall all of them.

She also has no known allergies to any medication or food. Pt RT doesnt take any vitamins but takes OTC drugs such as Paracetamol, and Neozep. Her recent travel was during her transport from Leyte to Cebu last April 22, 2013.

FAMILY HEALTH HISTORY

Ms. RT is the only daughter of the family. On the fathers side, her grandfather died because of cardiovascular attack while her grandmother died because of complications obtained from kidney stones and urinary tract infection. But unfortunately she couldnt remember at what age they died. Her father had six siblings and is the fifth son. He died at the age of 57 but Ms. RT had no idea as to the exact reason why he died because they were abandoned by her father when she was still young.

Her grandfather on her mothers side of the family is dead, however, the guest could not identify the reason of his death. According to the guest, her grandmother died because of depression as what her mom told her. Her mother have four siblings. She is the second daughter in their family.

PSYCHOSOCIAL HEALTH HISTORY

Guest RT is a sales clerk in Forbes Lux International Company. According to Ms. RT she didnt finish college but she took nursing aid for one year. She worked as a sales clerk at Forbes company for four years in Leyte specifically in Biliran. She is very talkative and her hobby is to play scrabble. She loves to buy clothes and gadgets. Miss RT admits that she has difficulties in handling and coping with daily stressors involving her occupation, relationship, and personal life. When asked about her strategies to handle stress, the guest stated that her outlet is shopping - purchasing clothes and other items for both herself and her boyfriend.

When asked about the status of her relationship with the people in her environment one statement by the guest stood out. She verbalized Dili ma saligan ang mga tao, ako amiga saona, gi libak man ko dili na mi amiga karon. Mo daot man og isig ka tao."

Miss RT, at the age of 26 years old, in Erik Eriksons psychosocial stages of development belongs to the basic psychosocial conflict of Intimacy VS Isolation. As a young adult, the primary and the most important focus is the establishment of a relationship. According to Erik Erikson, Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.

The guest has had her fair share in love. When asked about boys, the guest stated that boys are toys when asked to explain further she said gi duwaan man kog lalaki before, ako nasad ang mo duwa og lalaki ron. Having relationship as the focus of her current stage in Erik Eriksons theory, the guests current relationship status was assessed. She said she is currently dating her workmate from Forbes International. She expressed her fear that he might find someone new and leave her. However, after expressing her concern, she immediately stated that if he did find some other girls, she will go back to online dating.

Miss RT has tried online dating before. According to her there were many foreigners who wanted to be with her, however she refused to personally meet them because she thinks that they are bastos and selfish. During the conversation, the guest stated that if she would marry someone, she would want him to share his wealth to her family. According to her, even a small degree of help for the family is enough. She feels that marrying a foreigner who is selfish would not conform to this request. This shows that family plays an important in Miss RTs life.

HUMAN ANATOMY AND PHYSIOLOGY

NORMAL

LIMBIC SYSTEM: Is a complex set of brain structures that lies on both sides of the thalamus, right under the cerebrum. It is not a separate system, but a collection of structures from the telencephalon, diencephalon, and mesencephalon. The limbic system includes the hippocapmus, amvgdalae, anterior thalamic nuclei, septum, limbic cortex and fornix. It supports a variety of functions, including emotion, behavior, motivation, long-term memory, olfaction. It appears to be primarily responsible for our emotional life, and has a great deal to do with the formation of memories.

AMYGDALA: perform a primary role in the processing of memory and emotional reactions HIPPOCAMPUS: is a major component of the brains of humans and other vertebrates. It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation. CINGULATE GYRUS: The cingulate cortex is a part of the brain situated in the medial aspect of the cerebral cortex. It includes the cortex of the cingulate gyrus, which lies immediately above the corpus callosum, and the continuation of this in the cingulate sulcus. The cingulate cortex is usually considered part of the limbic lobe.

GREY MATTER: Grey matter is a major component of the central nervous system, consisting of neuronalcell bodies, neuropil (dendrites and unmyelinated axons), glial cells (astroglia and oligodendrocytes) and capillaries. Grey matter contains neural cell bodies, in contrast to white matter, which does not and mostly contains myelinated axon tracts. The color difference arises mainly from the whiteness of myelin. In living tissue, grey matter actually has a grey-brown color, which comes from capilary blood vessels and neuronal cell bodies.

Neurotransmitters: Electrical impulses and chemical signals carrying messages across different parts of the brain and between the brain and the rest of the nervous system Serotonin: helps control many functions, such as mood, appetite, and sleep. Research shows that people with depression often have lower than normal levels of serotonin. The types of medications most commonly prescribed to treat depression act by blocking the recycling, or reuptake, of serotonin by the sending neuron. As a result, more serotonin stays in the synapse for the receiving neuron to bind onto, leading to more normal mood functioning.

Dopamine: mainly involved in controlling movement and aiding the flow of information to the front of the brain, which is linked to thought and emotion. Norepinephrine: is similar to adrenaline. It works by constricting (narrowing) the blood vessels and increasing blood pressure and blood glucose (sugar) levels

ABNORMAL In bipolar disorder studies there were consistent regional gray matter reductions in paralimbic regions (anterior cingulate and insula) implicated in emotional processing. Gray matter reductions in schizophrenia studies were more extensive and involved limbic and neocortical structures as well as the paralimbic regions affected in bipolar disorder.

Lori Altshuler, director of the UCLA Mood Disorders Research Program, found that the amygdala seems to be significantly enlarged in patients with bipolar illness, along with enlarged ventricles. Bipolar disorder may result from a chemical imbalance within the brain. The brain's functions are controlled by chemicals called neurotransmitters. An imbalance in the levels of one of these neurotransmitters, such as norepinephrine, may cause bipolar disorder. When levels of this chemical are too high, mania occurs. When levels of norepinephrine drop below normal levels, a person may experience depression. Levels of other neurotransmitters, such as serotonin and dopamine, are also believed to play a role.

PATHOPHYSIOLOGY

DRUG STUDY

NURSING CARE PLAN

TREATMENT
Manic episodes in bipolar I disorder require treatment with drugs, such as mood stabilizers and antipsychotics, and sometimes sedativehypnotics (e.g., benzodiazepines such as Ativan or Klonopin). Mood Stabilizers Lithium: This simple metal in pill form is especially effective at controlling mania that involves classical euphoria rather than mixtures of mania and depression simultaneously. Lithium has been used for more than 60 years to treat bipolar disorder. Lithium can take weeks to work fully, making it better for maintenance treatment than for sudden manic episodes. Blood levels of lithium as well as tests to measure kidney functioning must be monitored to avoid side effects.

 Depakote: This antiseizure medication also works to level out moods. It has a more rapid onset of action, often making it more effective for an acute episode of mania than lithium. It is also often used "off label" for prevention of new episodes. Only mood stabilizers that can be used with the loading dose method -beginning at a very high dose -- allow the possibility of significant improvement in mood as early as four to five days. Some other anti-seizure drugs, notably Tegretol, and Lamictal, can have value in treating or preventing manias or depressions. Other antiseizure medicines that are less well-established for the treatment of bipolar disorder, include Trileptal, Neurontin, and Topamax.

 Antipsychotics For severe manic episodes, traditional antipsychotics (such as Haldol or Thorazine) as well as newer antipsychotic drugs -- also called atypical antipsychotics -- may be necessary. Abilify, Risperdal, Saphris, Seroquel, Geodon, and Zyprexa are often used, and many other drugs are available. Antipsychotic medicines are also sometimes used for preventive treatment. Benzodiazepines This class of drugs includes Xanax, Ativan, and Valium and is commonly referred to as tranquilizers. They are sometimes used for short-term control of acute symptoms associated with mania such as agitation or insomnia, but they do not treat core mood symptoms such as euphoria or depression.

 Antidepressants People with bipolar I disorder (mania or depression) have a high risk for recurrences and usually are advised to take medicines on a continuous basis for prevention. Electroconvulsive Therapy (ECT) Despite its scary reputation, electroconvulsive therapy (ECT) is an effective treatment for manic symptoms. ECT is seldom used to treat bipolar I disorder, but can be helpful if medicines fail or can't be used.

 Cognitive-behavioral therapy In cognitive-behavioral therapy, you examine how your thoughts affect your emotions. You also learn how to change negative thinking patterns and behaviors into more positive ways of responding. Family-focused therapy Family-focused therapy addresses these issues and works to restore a healthy and supportive home environment. Educating family members about the disease and how to cope with its symptoms is a major component of treatment.

 Interpersonal and social rhythm therapy

Interpersonal therapy focuses on current relationship issues and helps you improve the way you relate to the important people in your life. By addressing and solving interpersonal problems, this type of therapy reduces stress in your life. For bipolar disorder, interpersonal therapy is often combined with social rhythm therapy. People with bipolar disorder are believed to have overly sensitive biological clocks, the internal timekeepers that regulate circadian rhythms. This clock is easily thrown off by disruptions in your daily pattern of activity, also known as your social rhythms.

PROGNOSIS
Manic Depression Course of the Illness: Bipolar disorder can be severe and long-term, or it can be mild with infrequent episodes. Patients with the disease may experience symptoms in very different ways. A typical bipolar disorder patient averages 8 - 10 manic or depressive episodes over a lifetime. However, some people experience more and some fewer episodes. Medical evidence has shown that patients with bipolar disorder have higher death rates from suicide, heart problems, and death from all causes than those in the general population. Patients who get treatment, however, experience great improvement in survival rates, including deaths from suicide.

Typical Bipolar Cycles. In most cases of bipolar disorder, the depressive phases far outnumber manic phases, and the cycles of mania and depression are neither regular nor predictable. Many patients experience mixed mania, or a mixed state, in which both mania and depression coexist for at least 7 days. Rapid Cycling. About 15% of patients with the disorder have a temporary, complicated phase known as rapid cycling. With this phase the manic and depressive episodes alternate at least four times a year and, in severe cases, can even progress to several cycles a day. Rapid cycling tends to occur more often in women and in those with bipolar II. Typically, rapid cycling starts in the depressive phase, and frequent and severe episodes of depression may be the hallmark of this event. This phase is difficult to treat, particularly since antidepressants can trigger the switch to mania and set up a cyclical pattern.

Differences Between Children and Adults. Research suggests that symptoms of bipolar disorder in children and adolescents differ from those of adults. While adults with bipolar disorder usually have distinct and persistent periods of mania and depression, children with bipolar disorder fluctuate rapidly in their mood and behavior. Mania in children is characterized by irritability and belligerence whereas adults tend to experience euphoria. Children with bipolar depression are frequently angry and restless, and may have additional mood and behavioral disorders such as anxiety, attention deficit hyperactivity disorder, conduct disorder, and substance abuse problems.

It is not yet clear how frequently childhood bipolar disorder persists into adulthood or if treating childhood bipolar disorder can help prevent future illness.

THANK YOU.