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Manic Bipolar Disorder 1: Case Study

Ava Burcsak

Nursing Department, Youngstown State University

NURS 4842: Mental Health Nursing

Elizabeth Sanford

February 17, 2022

Objective Data:

A.L. is an 18-year-old female patient admitted to the Psyche floor, on February 17, 2022,

with a diagnosis of Manic Bipolar Disorder 1 with psychotic behavior. A.L. was involuntarily

admitted to the Emergency Department a couple days prior by her aunt and siblings, who stated

she has not slept in 3 days and is possessing manic behavior.

On the unit, A.L. felt energetic despite having significantly less sleep than usual. She

stated that she felt like she was sleep deprived but continued to wander around and act restless. I

assisted her to her room where she stated she needed to go to the restroom because she was

having extreme pain in her abdomen. Her hair was dyed blue and it was tangled and unkempt.

Her bed sheets were all disheveled and her bedside table had what appeared to be old cups and

bags. She constantly came to the nurses station with a flight of ideas and word salad. When her

anxiety grew, she began to speak more rapidly and asked several times if she was having a panic

attack or if she was colorblind. A.L. had been experiencing visual hallucinations in the ED days

prior, claiming she was seeing pink and blue. These are all common indications and symptoms of

someone experiencing a manic episode. These behaviors will be out of character for the person,

resulting in daily tasks being affected. Psychotic traits include disorganized thinking, false

beliefs, and/or hallucinations in people who are undergoing manic episodes (Howland &

Sehamy, 2021).

A.L. participated in a group therapy session that was set up by some of the YSU nursing

students in my clinical. Everyone who participated went around to share an experience that made

them feel honored, and those who listened noted down important strengths about that specific

person. When I asked A.L. to tell me a story she was proud of, she began to think in a
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disorganized manner. She mentioned that she used to play volleyball as a kid and that she was in

the Transitional Adjustment Program (TAP) in high school. TAP's is a transitional education

program for those experiencing phobias, anxiety disorders, persistent depression, or psychosis.

Labs were monitored throughout A.L.’s stay, her THC result came back as positive which

possibly played a role in her behaviors. Her electrolytes were all within normal range along with

her red blood cells, hemoglobin, hematocrit, creatinine, and BUN. However, her white blood

cells were slightly elevated (14.4). She stated she smoked cigarettes for about a year and has quit

for 6 months and is now vaping. A.L. was ordered a Nicoderm patch 21 mg/ 24 hours daily to

help reduce nicotine cravings due to inability to smoke on the unit.

On day of care, A.L. received Haldol 5 mg PO PRN and Vistaril 50 mg PO. Haldol

(Haloperidol) is an antipsychotic medication used to treat mood disorders. Haloperidol increases

dopamine to improve mood, thinking, and behavior (National Alliance on Mental Health, 2019).

This medication is intended to help A.L.’s visual and auditory delusions along with her

disorganized thinking. Vistaril is a prescription drug taken to decrease symptoms of anxiety. My

patient was very nervous, and it worsened as the night progressed. She questioned whether she

was having a panic attack. Every 5 minutes, she reiterated the same concerns, eventually

becoming irritated with herself and the staff as no one could assist her with what she wanted.

Visatril also belongs to the drug class of Antihistamines. Since the patient's white blood cell

count was elevated, vistaril can treat any inflammatory response that is going on in the body.

Safety and security measures were put into place to protect A.L. to minimize injuries.

Her bed, for example, was lowered to the lowest position in case she developed orthostatic

hypotension as a result of the antipsychotics' side effects. The call light was always within reach,
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as were the side rails and adequate lighting, which could be a trigger for her because she

screamed when the lights flickered.

Psychiatric Diagnosis

While interviewing the patient, A.L exhibited behaviors that are congruent with her

medical diagnosis. Bipolar I disorder is diagnosed when one goes through a manic episode.

During this episode patients experience an intense surge in energy and may feel on top of the

world or may feel tremendously angry. They may also feel depressed and experience hypomanic

episodes along with periods of neutral moods. Typically, an episode will only last for a few

hours at a time (Howland & Sehamy, 2021).

Anxiety disorders, substance abuse, and/or attention deficit hyperactivity disorder are all

common among people diagnosed with bipolar 1 disorder. A.L.'s health history revealed that she

suffers from all of the illnesses mentioned above. She claimed to have relapsed on heroin six

months ago, but there is no evidence that she was on the substance.

People with bipolar 1 disorder have a higher risk of suicide ideation (Howland &

Sehamy, 2021). A.L. had suicidal thoughts days before being admitted to the unit, but did not

attempt to her harmself. As a nurse, behavioral monitoring and mood changes are critical nursing

judgments utilized for this specific patient.

Stressors and Behaviors that Precipitated Hospitalization

There were multiple stressors and behaviors that led to A.L.’s hospitalization. She came

to the ED involuntarily, her family was worried she was going to harm herself. When the patient

was consulting with the provider in the ED she was experiencing auditory hallucinations, stating

that the voices inside her head are telling her to kill herself. She states, “I want to end my life”
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and “ I want to cut myself till I bleed”. She also did not sleep for 3 days which worried her

family, for that is a sign of a manic episode and symptoms of sleep deprivation.

During my time on the psyche unit, A.L. came to the nurses station several times,

claiming to be pregnant despite the fact that her pregnancy test had come back negative. She was

suffering from somatic delusions, which led her to assume she was pregnant. She stated "Who is

my baby daddy?" before adding, "I couldn't be pregnant". A.L. experienced severe abdominal

pain which led her to believe she was pregnant. She believed something was abnormal and

wrong with her body, experiencing physical sensations that resemble pregnancy.

Patient and Family History of Mental Illness

A.L. was born with a cleft lip and cleft palate. According to the Center for Disease

Control and Prevention, common causes of the disorders come from either genetics or from the

mother eating a poor diet, smoking, or drinking. Per the patient's notes, A.L. stated that her

parents took Methamphetamine and died from it and that she too was using the stimulant. The

healthcare team, on the other hand, confirmed that she was not abusing the drug. Developmental

delays and anxiety disorders are very common among children with a cleft lip and palate.

Because of the cleft palate and cleft lip, A.L.'s speech is altered, finding it challenging to

understand her at times, especially when she is having mood swings and is flustered.

A.L. was diagnosed with ADHD (Attention Deficit/ Hyperactivity Disorder) as a child.

Her speech was rapid when I spoke to her, and she could not keep track of what she had been

saying. Days before in the emergency department, the provider voiced that A.L. could not stop

talking and was unable to respond appropriately to questions. She displayed a labile mood,

claiming that she was fine one minute and then experiencing discomfort in her abdomen,
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screaming and falling to the ground the next. Her emotions were extremely heightened and

exaggerated, and she displayed it in an inappropriate way at times.

As previously stated, A.L. was hyper-fixated on the fact that she believed she was

pregnant; it became a known source of concern for her because she would continue to ask despite

being told she was not. Preservative behavior is defined as recurrent and continuous behavior

that occurs as a result of a change in memory or attention span. A.L., who has been diagnosed

with ADHD and bipolar 1 disorder, has difficult listening skills since her attention span is

heavily reduced. As a result, once the health care team assured her she was not pregnant and that

she needed to rest, she settled down and went back to bed. However, moments later she would

get up and voice the same concerns.

There was little information given about A.L.'s family or their relationship to her. Her

chart, on the other hand, revealed a long history of sexual, physical, and emotional abuse. Sexual

abuse as a child may have played a significant role in A.L.'s belief that she was pregnant. She

would periodically voice her confusion as to why she was pregnant because she had done

nothing wrong, and she was also concerned that she had a sexually transmitted infection.

Milieu Therapy and Evidenced Base Nursing Care

Evidence-based nursing practices were used to optimize A.L.’s recovery. A milieu

environment was provided for the patient, preventing violence and harm to herself and others.

Any potentially hazardous items, such as shoelaces, gloves, belts, and sharp objects, were

removed from A.L.'s room. The patient did not have a roommate since she was a nervous, high-

strung individual who behaved manically at times. A.L. tried engaging in a group therapy

session, but progressively felt overwhelmed and anxious. As a result, I accompanied her to her

room, where she began to relax for the time being.

For A.L., an Integrated Treatment for co-occurring disorders was implemented. This dual

approach is promoted by the US Department of Human Services' Drug Abuse and Mental Health

Services Administration (SAMHSA), for patients with behavioral and substance abuse disorders.

A.L.'s long-term recovery will be improved by the combination of the two treatments. According

to SAMHSA, the framework strives to give outside opportunities such as treatment, case

management, and employment assistance to people who are most at risk for relapse. As said

earlier, the patient stated she relapsed on drugs approximately 6 months ago, and because she is

so young, it is vital to offer her opportunities and connections as soon as possible so later she can

learn to cope with her abuse/disorders.

Ethnic, Spiritual and Cultural Influences

A.L. is an 18-year-old Caucasian female who does not specify her religion. When I

interviewed her she kept indicating that she was a female, not a boy. She had been having visual

hallucinations in the ED several days before and was linking them to genders. She said, "I see

blue, I see pink, I am a boy, I am transgender". A.L. might be experiencing an ongoing conflict

about how she wants to be labeled. There were no mentions of friendships, significant others, or

even family members, and when asked about them, she would gravitate towards other topics that

interested her more.

Evaluation of Patient Outcomes

Since it was A.L.’s first night on the unit, she was getting used to the other patients, the

healthcare team, and her environment. It appeared that the sleepier she was, the more restless and

confused she became. She showed no signs of aggression or harm towards the others on the

floor, but she was personable and approached several of them. On the other hand, seemed to be

agitating a few patents since she was invading personal space.

The healthcare team did not have much experience with A.L. to know when she is going

into a manic episode or not because a patient can appear neutral, depressed, or elated. Treatment

modalities and education consisted of calming A.L. down and reorienting her. Whenever she

expressed her anxious feelings and asked if she was sleep deprived, we told her to get some rest

and take deep breaths. Since the patient is on Aripiprazole, Clonidine, and Escitalopram it is

essential to watch for signs of depression and suicidal ideations. She has a history of “cheeking

medications”, therefore when she is discharged the family or caretaker need to watch her take her

medications and to be educated on the medications she is taking and what side effects to expect

from them, so they can provide the proper care to A.L.

Despite the fact that A.L. had indicators of a possible manic episode, she was surrounded

by a team of nurses and patients who provided her with the reassurance she needed. The nurses

were there to offer her support and stabilizing measures whenever she came to the nurses station

with anxiety. Some of the patients even spoke to A.L. to help her calm down. Something I feel

A.L. did not have when she was at home with her family days preceding her admission.

Following the administration of her medications, the client was monitored adequately and

continuously.

Plans for Discharge

A.L. was scheduled to be discharged in four days. The staff was unsure of A.L.’s baseline

status based on her compliance to therapy because she had only been admitted to the unit that

day. However, the goal for A.L. was for her to follow her medications as prescribed, attend

therapy group sessions, and seek help from the staff if she feels "overwhelmed."
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When it comes to discharge planning, the staff will stay updated on the patients' moods,

behaviors, and medication reactions. Considering A.L. lives with her aunt and siblings, the

family will need to be educated on the patient's medication, diagnosis, and treatment plan if the

patient's anxiety levels increase. Teaching the family how to communicate with A.L. will be very

beneficial to them and to her. Using precise, calm, and short sentences appeared to ease A.L.’s

anxious concerns.

Prioritized List of Actual Nursing Diagnosis

Risk for Suicide as evidenced by auditory hallucinations telling patient to harm herself.

Risk for Injury as evidenced by the combination use of antipsychotics, antidepressants, and

consumption of marijuana.

Disturbed Sensory Perception related to substance use, sleep deprivation, and biochemical

changes in the brain as evidenced by visual and auditory hallucinations, inability to problem

solve and answer questions appropriately.

Self Care Deficit related to racing thoughts and decreased attention span as evidenced

by observation of inability to groom self and bathe adequately.

Ineffective Individual Coping related to biochemical/neurologic changes in the brain as

evidenced by exaggerated emotional responses, inappropriates responses, and presence of

delusions.

Impaired Social Interactions related to biochemical imbalances and disturbed thought processes

as evidenced by poor attention span and difficulty focusing on one thing at a time.
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Potential Nursing Diagnosis

Caregiver Role Strain (Mother) Risk for Interrupted Family Process

Ineffective Health Maintenance Imbalanced Nutrition: Less than Body Requirements

Ineffective Impulse Control Risk for Chronic Low Self Esteem

Risk for Spiritual Distress

Conclusion

In conclusion, A.L. was an interesting, complex patient to work with for my case study.

At the end of the day she is only a child, and the inappropriate behaviors she exhibited on the

unit not only come from her medical diagnoses but from the lack of guidance and support A.L.

needs to grow. I believe she will comply with her medication regimen and with the right support

system and coping mechanisms A.L. will be able to overcome the boundaries that are preventing

her from perspiring.

References

Centers for Disease Control and Prevention. (2020, December 28). Facts about cleft lip and cleft

palate. Centers for Disease Control and Prevention. Retrieved February 23, 2022,

from https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Howland, M., & Sehamy, A. E. (2021, January). What is bipolar disorder? What Are Bipolar

Disorders? Retrieved February 22, 2022, from

https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-

bipolar-disorders

Plumptre, E. (2022, February 13). What are the symptoms of somatic delusions? Verywell Mind.

Retrieved February 22, 2022, from https://www.verywellmind.com/somatic-delusions-

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TRUMBULL COUNTY EDUCATIONAL SERVICE CENTER'S TRANSITIONAL ADJUSTMENT

PROGRAM (TAP): AN OVERVIEW. Tap. (2022). Retrieved February 22, 2022, from

https://www.trumbullesc.org/TAP.aspx

WebMD. (n.d.). Haldol oral: Uses, side effects, interactions, pictures, warnings & dosing.

WebMD. Retrieved February 22, 2022, from https://www.webmd.com/drugs/2/drug-

5419/haldol-oral/details

7 mental health evidence-based practices in nursing. Regis College Online. (2021,

November 2). Retrieved February 23, 2022, from https://online.regiscollege.edu/blog/7-

mental-health-evidence-based-practices-nursing/
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