NURSING CARE PLAN ON

BIPOLAR AFFECTIVE DISORDER

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 BIO-DATA OF THE PATIENT

NAME : Deepak

AGE : 22 Yrs.

SEX : Male

BED NO. : 19

MARITAL STATUS : Unmarried

RELIGION : Hindu

EDUCATION : Doing graduation

OCCUPATION : Student

LANGUAGE : Hindi, English

D.O.A. : 12/2/20

DIAGNOSIS : Bipolar Affective Disorder (currently mania)

INFORMANT: Mother and Sister.

Reliability of informant: Information reliable. As it is given by mother and sister and patient
lives with his mother and Sister from birth.
CHIEF COMPLAINTS: - Patient is admitted in the hospital with following chief
complaints:

ACCORDING TO THE PATIENT:

Mujhe gussa bahut aata tha.

Mujhe neend achi tarah se nahi aati

Mere pass bahut sari shaktiyan hai

Gharewale ladte the mujhe se

ACCORDING TO INFORMANT:

Patient was brought to the hospital with C/O:

Aggressive behavior/violence

Abusive language

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 Overtalktiveness

Decreased sleep × 20 days

Big talks(delusion of grandiosity)

HISTORY OF PRESENT ILLNESS: -

ONSET: Chronic

COURSE OF ILLNESS: Continuous with exacerbation.

Patient was brought to Psychiatric Hospital by his parents. Patient showed aggressive
behavior and even used to beat the family members. Patient considered himself as a
millionaire. He was wandering in the streets whole day.

PAST HISTORY OF ILLNESS: -

MEDICAL: Patient did not have any history of medical illness.

SURGICAL: nothing significant

PSYCHIATRIC:

Patient suffered from Bipolar Affective Disorder from last 4 years and associated symptoms
were violent behavior, alteration in daily life activities, inability to focus or concentration on
his work or domestic task.

The patient was continuously taking the medicine from Ashoka-Neuro Psychiatric Hospital
from the onset of the disorder.

From last one month he had stopped to take medicine at his own risk without any knowledge
of family members and he had shown the symptoms of affective disorder as irritable
behavior, hyperactivity, decreased appetite and irrelevant talk.

FAMILY HISTORY

Patient lives with his parents and sister. No psychiatric history is present

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♂ ♀

Grandfather Grandmother

Father ♂ ♀ Mother
54 years 52 years
Unhealthy Healthy
Irrigation deptt. Home maker

♀ ♀ ♂
Sister Sister Patient
28 years 26 years 22 years
Healthy Healthy Unhealthy
Private school teacher Private school teacher

FAMILY TREE

PERSONAL HISTORY: -

1. BIRTH AND EARLY DEVELOPMENT HISTORY: -

Antenatal history:

No history of any nutritional deficiency, exposure to any medication, infections

No history of 1st and 2nd trimester bleeding, threatened abortion, Rh

incompatibility, impaired fetal movements

No history of any maternal disease like diarrhea, anaemia, pre-eclampsia,

hypothyroidism, or premature placental separation

Intranatal history:
Date of Birth : 9th feb, 1996

Type of delivery: Full term normal vaginal delivery

Any complication: no complication during the child birth

Birth: Baby was born at Full term and birth weight was 3.2 kg

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 Birth cry: Birth cry was immediate and normal

Birth defects: No birth defect is present

Postnatal complications: no history of any complications like cyanosis, convulsions,

jaundice, neonatal infections

Childhood History:

Primary caregiver: Mother and father

Feeding: Breast feeding was given till the age of 1 year

Age of weaning: weaning was started at the age of 7 months

Developmental milestones: Normal developmental milestones

Behavior and emotional problems: No history of behavioral and emotional

problems like thumb sucking, excessive temper tantrums, head-hanging, nail
biting, enuresis, night terrors, etc

Illness during childhood: No any history of CNS infections, epilepsy, neurotic

disorders, malnutrition

Physical illness during childhood: Patient did not have any psychiatric illness
during his childhood

2. SCHOOL HISTORY: -

Age of beginning of formal education: Schooling was started at the age of 4

years

Academic performance: he was an average student

Relationship with peers and teachers: he had good relationship with peers and
teachers

School phobia: No any history school phobia is present

Conduct disorder: No any history of conduct disorders

3. OCCUPATION:

Patient was not involved in any type of occupation.

4. SEXUAL HISTORY:

Patient is unmarried and is attracted towards opposite sex.

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 No H/O any sexual disorder.

5. MARITAL HISTORY:

Patient is unmarried.

PREVIOUS PERSONALITY: -

1. SOCIAL RELATIONS:

Patient had good relationship with his parents and other family members. He was very
shy and conservative in nature.

2. INTELLECTUAL ACTIVITIES:

Patient was average in studies and had a history of fair academics.

He had more interest in play activities than study activities.

3. MOOD:

Patient’s mood was stable and used to behave in normal pattern.

4. HABITS:

No any H/O of addiction of alcohol and any other drug.

VITAL SIGNS:

Date: 26/02/14 Time: 11:00AM

Sr. No. Vital signs Patient value Normal value Remarks

1. Temperature 98.40 F(Axillary Route) 97-990F Normal

2. Pulse 78/min. 60-100/ min. Normal

3. Respiration 18/ min. 16-24 / min. Normal

4. Blood pressure 120-180 mm/Hg 110/70-130/90 mmHg Normal

5. SPO2 98% 99-100% Normal

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LAB INVESTIGATIONS:

Date:

S. No. Test Name Patient Value Normal value Remarks

1. Hb 14.0 gm/dl 12-16 gm/dl Normal

2. TLC 9400/ cumm 4000-11000 /cumm Normal

3. Neutrophils 68% 40-75% Normal

4. Lymphocytes 29% 20-45% Normal

5. Monocytes 02% 2-8% Normal

6. Eosinophils 02% 1-6% Normal

7. RBS 98 mg/dl 110-140 mg/dl Decrease

8. Blood Urea 26.0 mg/dl 15-45 mg/dl Normal

9. S. Creatinine 1.0 mg/dl 0.8-1.8 mg/dl Normal

10. Sodium 139 mg/L 132-148 mEq/L Normal

11. Potassium 4.2 meq/L 3.5-5.5 mEq/L Normal

12. Serum albumin 4.28 mg% 3.5-5.0 mg/L Normal

13. Direct Bilirubin 0.2 mg% 00-04 mg% Normal

14. Total Bilirubin 0.6 mg% 01-12 mg/ Normal

15. SGOT 38 u/L 0-400 u/L Normal

16. SGPT 46 u/L 0-400 u/L Normal

MEDICATION:

Sr. No. Medicine Dose Route Frequency Action

1. Lithium Carbonate 900 mg Oral BD Mood Stabilizer

2. Haloperidol 10 mg Oral BD Typical

Antipsychotic

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 (Butyrophenones)
Antiparkinsonism
3. Promethazine 25 mg Oral BD
& Antihistamine
Antianxiety
4. Lorazepam 2mg IM BD
(Benzodiazepines)
Antianxiety
5. Clonazepam 6 mg Oral TDS
(Benzodiazepines)

MENTAL STATUS EXAMINATION

BIO-DATA OF THE PATIENT

NAME : Deepak

AGE : 22 Yrs.

SEX : Male

CR.NO./FILE NO : 60956

BED NO. : 19

MARITAL STATUS : Unmarried

RELIGION : Hindu

EDUCATION : doing graduation

OCCUPATION : student

LANGUAGE : Hindi, English

D.O.A. : 12/2/20

DIAGNOSIS : F31.2 Bipolar Affective Disorder (currently mania)

1. GENERAL APPEARANCE: -
a. Facial expression: Patient’s facial expressions are not according to situation and he is
smiling without any specific reason.

b. Posture: Patient is having an open posture. He is sitting upright on bed.

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 c. Mannerism: Mannerism is present in my patient as the patient node his head while
talking.

d. Grooming and Dress: - Patient is wearing appropriate dress which is according to

the place and season. Hair was not combed.

e. Hygiene: -Hygienic condition of the patient is fair. Patient takes bath everyday and
also changes his clothes. His clothes are clean. Nails are also cut properly and are
clean.

f. Physique: -Patient is having average built, no any physical deformity.

g. Level of Eye Contact: -Patient sometimes maintained eye-to-eye contact throughout

the conversation.

RAPPORT
N: namste! Ajay
P: Hello!
N: Main M.Sc Psychiatric Nursing ki student hoon. Mein aapse kuch baatein jana
chahata hoon, jo ki aapke ilaaj mein meri sahayata karenge.
P: Ji haan! puchiye
Inference: A good rapport is maintained with the patient. He took part in the conversation
well and responded to all the questions asked to him.

2. MOTOR DISTURBANCES: -

a) Over activity or Hyperactivity: Patient some time show restless behaviour and
started roaming here and there.

b) Under activity or motor retardation: - Patient does not show shows motor
retardation.

c) Stereotypy: it is absent in my patient.

d) Negativism : It is absent in my patient

N: Ajay bed se uth kar bahar jao aur fir wapis bed pe ao.
P: Patients follow the commands.
Outcome: Negativism absent.

3. SPEECH AND THOUGHT DISORDERS: -

A. DISORDER OF FORM OF THOUGHT:

I. Circumstantiality : when I ask the Q: -

N: Aap kis vajah se yahan par admit hue?

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 P: Main apne dost ke saath bahar ghumne gaya tha, mera us se ladai ho gayi,gusse
mein aa kar ghar aake apni sister ko maraa tha, fir main ghar se bahar chala gya.
N: Fir kya hua?
P: fir main bahar ghumne laga aur ghar nah ata tha. Muje jalebi bohat pasand hai
main wo khane gya tha.
N: Apne yeh nahi bataya k kis vajah se yahan par admit hue?
P: muje pta nahi hai sabi jabardasti muje yahan shod gaye hain. Shayad main gusa
karta hoon isliye muje yahan shod gaye hain.

Inference: It is present in my patient. Patient reaches at goal after some irrelevant talking.

II. Irrelevant: Patient does not answer the question appropriately.

Q: What do you like in eating?
Ans.: Muje mithai achi lagti hai.
Inference: It is absent in my patient. Patient doesn’t speak in irrelevant manner.

III. Speech: Patient speaks at rapid that one have to wait for asking something to him till
his talking is completed. Interruption is difficult in his talking.

IV. Neologism: Patient answered question appropriately and not invent his own language
and new word for describing his sentence.

V. Tangential thinking: Patient answer appropriately of every question and goal is

achieved.

VI. Perservation: Patient had no involuntary and morbid repetition of specific word or
idea which persist inspite of patient’s efforts to move on to new idea.

VII. Patient has no contradictory ideas

EVALUATION OF SPEECH:

Intensity: patient voice is audible and not exceeding loud.

Pitch: pith of the patient voice is high.

Speed: patient speaks at usually high rate of speech.

Spontaneity: patient normally responds to questions but some time refuse to give answers.

Reaction time: Reaction time is normal and answered appropriately most of the time.

B. DISORDER OF CONTENT OF THOUGHT:

DELUSIONS: Delusions are false beliefs are irrational not shared by persons of same age,
race and standard of education, which is held by conviction and which cannot be altered by
arguments and are persistent.

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1. Delusion of Grandiosity: Patient belief that he has lots of money and having some
supreme power.
N: Kya aapko kabhi aisa lagta hai ki log aapke bare mein baat kar rahe hain yaan
aapko marna chahte hain.
P: (Smiling) Ji nahi aisa nahi hota
N: Kya aapko kisi cheez se dar lagta hai.
P: Nahi main nahi darta.
N; apko kya aise lagta hai k ap me koi shakti hai
P; wo to hai mujme, lekin mai kam e pta lagne deta hu, sab ko control kar sakta hu
mai, is liye to dar nai lagta kisi se
Inference: Delusions of grandiose is present. Phobia is not present.

2. Persecutory delusions:

N: Kabi apko yeh to nahi laga k koi apko nuksan pohchana chahta hai ja marna chahta hai.

P: nahi

Inference: Persecutory Delusion is absent.

3. Delusion of influence or passivity:

N: Kya apko kabi esa lagta hai k job hi ap kar rahe ho wo apse koi aur karwa raha hai

P: Nahi

Inference: Delusions of influence or passivity is absent.

4. Nlihilistic delusions:

N: apko kabi esa laga k duniya khatam ho gai hai?

P: Nahi muje esa ku lagega.

Inference: Nlihilistic Delusions is absent.

PROGRESSION LEVEL:

OBESSIONN: kya apko kabi esa laga k koi vicah apke man main bar bar aa raha hai jo apko
khud ko pta ho k yeh nahi anna chahiye aur jo apko tension de raha ho?

P: Nahi.

Inference: Patient himself does not recognize to be abnormal ideas.

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C. DISORDER OF RATE OF SPEECH:

Pressure of speech: Pressure of speech is that much that it is difficult for the listener to
interrupt.
Flight of idea: - it is present in my patient as the patient shifted his ideas from one to
another during conversation.
Q. Ajay tum apne college k bare mein btao?
Ans. Sir collge bohat acha hai. Achi to meri mom bhi hai, wo ayi nahi mujse milne,
milne to mujse kal dad aye the, ape dad kya karte hain.
Inference: It is present in my patient. Patient shifted his ideas from one to another during
conversation.

Rate and quantity of speech: -

Patient give spontaneous response to everyone questions
Rate of speech is fast.

4. DISORDER OF PERCEPTION: -

Hallucinations: May be defined as a sensory experience in the absence of a stimulus or an

object.

N: Woh jo udhar bed ke saath pada hai, who kya hai (pointing toward chair)?
P: Woh toh chair hai.
N: Kya aapko kabhi koi ajeeb aawazein sunai deti hain, jo koi aur nahi sun sakta?
P: haan.
N: Kya kabhi aisa lagta hai ki aapko koi cheez dikhayi deti hai, jo koi aur nahi dekh
sakta.
P: Nahi aisa kuch nahi hota.
Inference: Patient is not having any illusions and 1 st person auditory hallucinations are
present. Perception in patient is altered.

5. DISTURBANCES IN AFFECT: -

a) Pleasurable affect: - patient is in elation stage as the patient smiling while giving
answers and having increased psychomotor activity.

b) Un-pleasurable affect: -
i. Depression: - sometime patient looked depressed and talk about his grandparents
who was died few years back.
ii. Grief: - patient was in grief related to death of his grandparents.

c) Aggression: Patient shows aggression when he was as said to sit down on bed or take
medicine

d) Mood swing: present as the patient is diagnosed Bipolar Affective disorder.

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6. DISORDER OF MEMORY: -

Memory: Function by which information stored in the brain is later recalled to consciousness

a) Immediate memory
N: Main jo 5 cheejo ke nam boluga usse dhyan se sunna aur phir batana: pen, tea,
mobile, table, shirt.
P: pen, tea, mobile, table, shirt.
Inference: Immediate memory of the patient is intact.

b) Recent memory

N: Aap hospital mein kab admit hue thehue?

P: 25/02/2014 ko mere papa mujhe admit karva ke gaye the.
Inference: Patient’s recent memory is also intact.

c) Remote memory

N: Aapki janam tarikh kya hai?

P: 09 February 1992
Inference: Patient’s remote memory is intact.

7. ORIENTATION: -

It is the ability to recognize the surroundings.

Time:
Q. What is the day today?
Ans.: Wednesday
Outcome: Oriented to time

Place:
Q: Where are you at present?
Ans: Hospital (but not able to say name)
Outcome: oriented to place.

Persons:
Q.: yeh kon hai (pointing toward his mother)?
Ans: yeh mere mom hai.
Outcome: Oriented to person.
Inference: Patient is fully oriented with person, place and time.

8. INSIGHT: -

N: Aapko kya lagta hai ki aapko koi mansik ya sharirik bimari hai?

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 P: hanji hai thodi, Thoda gussa ata hai bas, who bhi logo ki wajah se aata hai.logo ke
karan mera mann thoda kharab sa ho jata hai
Inference: Patient is having grade III insight as he is aware of is illness but blaming it on
other people.

9. CONCENTRATION AND ATTENTION: -

N: Ek sawal hai isse solve karo: 100-7 =?

P: 93
N: ab 93 mein se 7 minus karo aur jitna bhi answer aega usme se fir se 7 minus krna.
P: 86, 79, 72, 65, 61, 57, 48.
Inference: Patient is having average concentration and attention.

10.ABSTRACT THINKING: -

N: “behti ganga mein haath dhona” se aap kya samajhte hain?

P: Iska matlab hai apna faida karna.
N. what is the similarity between apple and orange?
P. dono ki shape round hai.
Inference: Abstract thinking of the patient is good.

11.JUDGMENT: -

N: Aagar aapke aas-pados mein kabhi aag lag jaye toh aap kya karoge?
P: pani se aag bujhane ki koshish karounga.
Inference: Patient has logical judgment.

12.INTELLIGENCE: -

N: India ka prime-minister kaun hain?

P: Narendra Modi
N: India ki capital kya hai?
P: Nai delhi
Inference: Patient is intelligent and is having good general information.

13.SLEEP: -

Patient takes good sleep at night but sometimes have disturbed sleeping pattern because of
hyperactivity.

14.GENERAL OBSERVATION: -

N: Aaj subah nashta kiya aapne?

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 P: Haan kiya tha.
N: Bukh theekh se lagti hai?
P: thik thaak lagti hai, yahan par khana acha nai lagta.
N: Neend theek se aati hai?
P: kabi kabi rat neend khul jati hai.
N: pait main koi gadbar to nahi hai?
P: nahi sab theek hai
N: Kya aapne kabhi kahi naukri ki hai?
P: Nahi ki, main college mein padta hun.
N: app ko kya karna acha lagta hai?
P: Sports pasand hai, puja path kar leta hu, khelna dosto se acha lagta hai lekin koi koi
dost hi acha hai, unse milna h acha lagta hai

Inference: Patient’s appetite, bowel, bladder is normal and no kind of disturbance is present.
But his sleeping pattern is altered. Patient has not done job as he is a student. His social
interactions are not normal, he like some limited people and he believes in God and perform
daily spiritual activity as per their home routine.

ETIOLOGICAL FACTORS: -

Book Picture Patient picture

 HEREDITY
Genetic predisposition is common; lifetime risk is
noticed in first degree relative of clients. If one No heredity factor.
patient suffers, 25% chance for children to have the
disorder and if both the parents are suffering then 50-
75% chances to occur in children.
 BIOCHEMICAL FACTORS
 Imbalances in catecholamine ( Norepinephrine,
dopamine) levels or its functions results in
Bipolar disorders Not known
 Deficiency in serotonin levels may predispose
to depression
 Deficiency in GABA, acetylcholine levels
contributes to occurrence of mania.
 SLEEP ABNORMALITIES:
Problems with sleeping initial and terminal insomnia
or hypersomnia are common and classic symptoms
of depression and perceived decreased need for sleep
is classic symptom of mania.

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  SOCIAL FACTORS Patient is suffering insomnia
 Stressful life events, traumatic or disturbing life from past 20 days.
experiences
 Social pressures
 Rejection of children by parents
 Loss of loved one
 Unemployment , poor job opportunities
 Failure in life
 Environmental stress
 Maladaptive comparison
 PRE MORBID PERSONALITY PATTERN
 Ambitious , energetic , social
Both of the grandparents of
 Will not express hostile feelings, endomorphic
patient were dead.
in their built
 Uncontrollable impulsive behaviour
 Break down under stress, introversion,
insecurity

Uncontrollable anger is there

as told by his mother.

CLINICAL FEATURES: -

(I) DEPRESSIVE EPISODES

Depression is characterized by triad symptoms:

 Decreased Psychomotor Activity

 Poverty of speech and ideas
 Depressed mood

Book Picture Patient Picture

 Depressed Mood
 The most important feature is the Not present in patient presently.
sadness of mood or loss of interest in
almost all activities, sadness is present

36
 throughout day

 The loss of interest results in social

withdrawal, decrease ability to function
in occupational and interpersonal areas
 DEPRESSION IDEATION Not present in patient presently.

Sadness of mood is associated with following

depressive ideas:
 Hopelessness
 Helplessness Not present in patient presently.
 Worthlessness
 PSYCHOMOTOR ACTIVITY

In younger patients (less than 40 years of age)

retardation is more common which is
characterized by slowed thinking and activity, Not present in patient presently.
decreased energy and monotonous voice.

In older patients agitation is common with

marked anxiety and restlessness.

 PHYSICAL SYMPTOMS Not present in patient presently.

 Hypersomnia
 Weight Gain
 Loss of appetite
 Heaviness of head
 Vague bodyaches
 SUICIDAL IDEAS
 Suicidal ideas if expressed by
depressive patients should be taken
seriously.
 The risk is greater in the presence of
following features: Presence of marked
hopelessness, males age greater than 40
years of age, unmarried, divorced,
widowed , written or verbal
communication of suicidal intent

(II) MANIC EPISODES

Mania is a psychotic mood disorder characterized by triad symptoms: mood elevation, increased
psychomotor activities and speech and thought.

Book Picture Patient Picture

36
  ELEVATED, EXPANSIVE OR
IRRITABLE MOOD
Euphoria : mild elevation of mood Patient always say that he has lot of
Elation :moderate elevation of mood money and he can do any type of work,
with a feeling of confidence and with his supernatural powers.
enjoyment along with increased
psychomotor activity
Exaltation : intense elation with
delusion of grandeur
Esctasy: intense elevation of mood
 INCREASED PSYCHOMOTOR
ACTIVITY: ranging from over activeness
and restlessness to manic excitement that
patient is on toe and on the go.
 SPEECH AND THOUGHT Patient some time show restless
More talkative than usual behaviour and started roaming here and
Develops pressure of speech
there but do not want to perform any
Uses playful language
Speaks loudly activity.
Flight of ideas
Delusion of persecution develop Patient speaks loudly with pressure of
secondary to delusion of grandeur speech in his talks.
 OTHER FEATURES
Decreased need for sleep
Decreased food intake
Insight is absent Flight of ideas is present.

Patient is having delusion of

grandiosity as he says that he has some
supernatural powers.

Insomnia is present.

Grade III insight is present in patient

MEDICAL MANAGEMENT: -

Book Picture Patient Picture

36
 (i) Mood Stabilizers
 Lithium

Lithium has traditionally been drug of choice for

treatment of manic episode (acute phase) as well as for Lithium is given to patient
prevention of further episodes in bipolar disorder.
Dose: 900 mg/day
The usual therapeutic dose range is 900-1500mg/day

 Carbamezapine
Not given to patient
For acute treatment of mania and prevention of bipolar
mood disorder. Dose of carbamezapine is
600-1600mg/day

 Benzodiazepines
Lorazepam 2 mg/day and
Lorazepam and clonazepam are used for treatment of clonazepam 6mg/day is given to
manic episodes, these drugs have been used often as patient
adjuvants to antipsychotics

 Antipsychotics
Haloperidol is given to patient
For acute manic episode
Dose: 10 mg/day
Along with mood stabilizers for the first few weeks ,
before the effect of mood stabilizers like olanzapine

For Bipolar depression

Quetiapine has anti depressant in bipolar depression

For maintenance or prophylactic treatment in bipolar

disorder

Recent evidences shows that several atypical

antipsychotics such as olanzapine ,quetiapine and
aripiprazole can be successfully used in the maintenance
treatment of bipolar disorder

PSYCHOSOCIAL TREATMENT: -

Book Picture Patient Picture

36
  Individual Psychotherapy Individual psychotherapy is
given to patient
For depressive patients interpersonal therapy attempts to
recognize and explore interpersonal stressors, role
disputes ,social skill deficits which are acting as precipitants
for depression

For manic clients, these patients establish therapeutic

relationship because they are eager to please the therapist

 Group Therapy
Group therapy is not given
Once acute phase is passed then group therapy can be used by to patient
patients to discuss issues in their lives that cause this serious
affective disorder

 Family Therapy
Family therapy is given to
The ultimate aim in working with families of clients with patient’s family
mood disorders is to synthesize the available data to formulate
a therapeutic plan with 2 main goals, resolution of symptoms
and restoration or creation of adaptive family function

 Behaviour therapy
Behaviour therapy is not
This includes the various short term modalities such as social given to patient
skill training , self control therapy, activity scheduling and
decision making techniques

THEORY IMPLICATION
PAPLAU’S INTERPERSONAL RELATIONS THEORY

Patient named Ajay aged 22 years male is suffering from Bipolar Affective Disorder and is
not able to maintain Interpersonal relationship. As a nurse I have to improve patient’s
interpersonal relationship so I implemented Hildegard Paplau Model.

Phases of interpersonal relationship

Identified four sequential phases in the interpersonal relationship:

1. Orientation
2. Identification
3. Exploitation 
4. Resolution
Interpersonal theory and nursing process

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Both are sequential and focus on therapeutic relationship.

Both use problem solving techniques for the nurse and patient to collaborate on, with the end
purpose of meeting the patient’s needs.

Both use observation communication and recording as basic tools utilized by nursing.

NURSING PROCESS INTERPERSONAL THEORY

Assessment Orientation
Data collection and analysis [continuous] Non continuous data collection 
May not be a felt need Felt need 
Define needs
Nursing diagnosis  Identification
Planning Interdependent goal setting
Mutually set goals 
Implementation Exploitation
Plans initiated towards achievement of Patient actively seeking and drawing help 
mutually set goals Patient initiated
May be accomplished by patient , nurse or
family
Evaluation Resolution
Based on mutually expected behaviors  Occurs after other phases are completed
May led to termination and initiation of new successfully 
plans   Leads to termination a

Hildegard Paplau model:-

RESOLUTION

TERMINATION OF VISIT ON LAST

DAY BY TELLING TO THE PATIENT
AND ALL THE DISCHARGE CRITERIA
EXPLAINED TO PATIENT.

EXPLOITATION

INDIVIDUAL THERAPY, FAMILY THERAPY,

RECREATIONAL THERAPY, MEDICATION,
PSYCHOEDUCATION, COMPLAINCE.
IDENTIFICATION

CHIEF COMPLAINTS: - IRRITABLE, DECREASED APPETITE AND

SLEEP, AGGRESSIVE, INCREASED PSYCHOMOTOR ACTIVITY 36

PATIENT IDENTIFIED FOR CHIEF COMPLAINTS AND OTHER

HEALTH NEEDS.
 ORIENTATION

NAME: - AJAY, AGE: - 22 YEARS SEX: - MALE,

DIAGNOSIS: - BIPOLAR AFFECTIVE DISORDER

IPR MAINTAINED WITH PATIENT FOR A TRUSTWORTHY RELATIONSHIP WITH

PATIENT.

NURSING MANAGEMENT
NURSING ASSESSMENT: -

1. Patient is assessed for the behavioural changes like aggressive behaviour and
restlessness
2. Patient vital signs are assessed.
3. Patient is assessed for his general appearance and eating and sleeping habits that
indicate insomnia in patient.
4. Mental status examination is also conducted which indicates that pressure of speech is
present, along with delusion of grandiosity.
5. Patient level of insight is grade III and abstract thinking is intact.

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NURSING DIAGNOSES: -
1. Impaired social interaction related to egocentric and self muttering behavior
evidenced inability to develop satisfying relationships and observation.
2. Risk for injury related to extreme hyperactivity as evidence by agitation and lack of
control over purposeless and potentially injurious movements.
3. Risk for violence self directed related to manic excitement as evidenced by
observation.
4. Imbalanced nutrition less than body requirements related to inability to sit still long
enough to eat evidenced by weight loss.
5. Self care deficit related to cognitive impairment as evidenced by difficulty carrying
out tasks associated with hygiene.
6. Altered health maintenance related to disease condition i.e. mania cognitive
disturbance as evidenced by difficulties with activities of daily living.
7. Altered sleeping pattern related to hyperactivity, aggression and less eating as
evidenced by verbal communication and patient.
8. Ineffective family coping related to highly ambivalent family relationships, impaired
family communication, evidenced by neglectful care of the patient, extreme denial or
prolonged over-concern regarding his illness.

SHORT TERM GOALS: -

1. To establish adequate nutrition pattern, hydration and elimination

2. To prevent patient from self inflicted injury or harm to others
3. To improve thought process of patient
4. To encourage patient to develop trustful relationship with others.
5. To maintain an adequate balance of rest, sleep and activity

LONG TERM GOALS: -

1. To develop trusting relationship with patient.

2. To provide psychological support to patient.
3. To rehabilitate the patient.

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4. To prevent further complication due to medication side effects.

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 NURSING CARE PLAN

Nursing Diagnose Objective Planning Implementation Rationale Evaluation

Impaired social To improve the Recognize the Behavior is Understanding the Social interaction of
interaction related to social interaction of manipulative recognized. motivation behind the client is
egocentric and self the patient. behavior. the behavior may improved to some
muttering behavior facilitate greater extent.
evidenced inability acceptance of the
to develop satisfying Expected behavior is individual.
relationships and Explain the patient explained to the
observation. what is expected and patient. Consequences for
the consequences if violation of limits
limits are violent. must be consistently
Client is not argued
administered or
at any point.
Ignore attempts by behavior will not be
the client to anger, eliminated.
bargain her or his Positive Lack of feedback
way out of the limit reinforcement is may decrease these
setting. provided to the behaviours.
Give positive client.
reinforcement for It enhances self
non manipulative esteem and promotes
behaviours. repetition of
desirable behavior.

Nursing Diagnose Objective Planning Implementation Rationale Evaluation

Risk for injury To reduce the Reduce Quiet unit is Client is extremely Risk of injury is
related to extreme environmental provided to the distractible and reduced to some

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hyperactivity as chance of injury. stimuli. patient. response to even the extent by diverting
evidence by agitation slightest stimuli is the mind of client
and lack of control exaggerated. and kept him busy in
over purposeless and Remove hazardous Hazardous objects other physical
potentially injurious objects and are kept away from Rationality is activities.
movements. substances. the patient reach. impaired and client
may harm self
Stay with the client One person always inadvertently.
because of stays with the client. Presence of someone
hyperactivity and may offer support
agitated behavior. and provide feeling
Client kept busy in of security to the
Provide physical bed making and client.
activity to the client some other activities. Physical activities
help to relieve
Administer Lorazepam (2 mg) is tension.
tranquilizing provided to the Antipsychotic are
medication as ordered patient. common and are
by physician. very effective for
providing rapid relief
from symptoms of
hyperactivity.

Nursing Diagnose Objective Planning Implementation Rationale Evaluation

Risk for violence self To reduce the violent Maintain low level of Stimuli are removed This will minimize Risk of violence will
directed related to nature of the patient. stimuli in client’s near to the client anxiety, agitation and be reduced to some
manic excitement as environment. environment. suspiciousness. extent.
evidenced by
observation. Observe client’s Behavior is observed This is important so
behavior at last every every 15 min. that intervention can
15 minute. do if required to

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 ensure client’s safety.
Ensure that all sharp All items are away
objects, glass or mirror from the reach of These objects must be
item, belts, ties and client. removed so that client
smoking materials cannot use them to
have been removed harm self or others.
from client’s
environment. Lorazepam (2mg) is
provided to the client. These are effective in
Offer tranquilizing providing relief to the
medications. client.

Nursing Diagnose Objective Planning Implementation Rationale Evaluation

Imbalanced nutrition To improve the Provide high protein, Bread jams and Client has difficulty Nutritional status is
less than body nutritional status of high calorie, snacks are given to sitting still long improved to some
requirements related the patient/client. nutrition finger foods the patient. enough to eat a meal. extent.
to inability to sit still and drinks that can
long enough to eat be consumed “on the
evidenced by weight run.” Juice and snacks are Nutritious intake is
loss. Have a juice and available in the unit. required on a regular
snacks on the unit at basis to compensate
all times. for increased caloric
requirements as a
Intake and output is result of
maintained and is hyperactivity.

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Maintain accurate also monitored that These are important
report on intake, is 51 kg. nutritional
output, calorie count Favorite food i.e. assessment data.
and weight. apple is given to the
Provide favorite food patient. This encouraged
to the patient. Nurse remains with eating.
client while eating.
Walk or sit with The presence of
client while he eats. nurse offer support
and encouragement
to the client to eat
food.

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 HEALTH EDUCATION
1) PERSONAL HYGIENE:
 Patient is taught about importance of personal hygiene.
 Patient is advised to take the help of attended whenever needed in performing care.
 Patient is advised to change the cloths.
 Patient is advised to wash hands before and after the meal.

2) DIET:
 Client’s family is taught about the finger food that they should provide finger feed to
the client that can be consumed “on the run”.
 Family is educating to other favorites food to the client like apple.
 Client family is advised to provide to high protein, high caloric and nutritious diet to
the client because the client waste his energy/caloric in drug purposeless activities.
 Patient is taught about the importance of balanced diet.
 Client’s family is taught about foods that are contraindicated during taking particular
medications.

3) EXERCISES:
 Patient is taught about the importance of exercise.
 Patient is advised to perform relaxation exercises to overcome aggressive behavior.

4) ENVIRONMENT:-
 Patient is advised to perform his work in cool and calm environment.

5) MEDICATIONS:-

 Patient is taught about the importance of medication in treating psychiatric disorders.

 Client’s family is taught about medicine administration that dose should not be
skipped.
 Client’s family is advised to inform to physician whenever any side effect appears.
 Patient is advised not to stop medication by himself own.

SUMMARY:-

During my posting in psychiatric ward. I have taken patient named Ajay, chief
complain of anorexia, more talkative, aggressive behavior, insomnia. Now patient is taking
medication from Asohka-Neuro Psychiatric Hospital. I have observed the patient carefully
and collect the complete history. I assist the patient in social interaction, in maintaining
personal hygiene, psychoeducation given, teaching about medication and disease condition to
family member also.

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CONCLUSION:-

Client name Ajay, was diagnosed with bipolar disorder with chief complaint of
anorexia, insomnia, aggressive behavior, more talkative Nursing care provided according to
need of client. Psychoeducation provided as per need of individual, teach about the disease
condition, its outcome and treatment regimen. There was progress in the condition of client.

BIBLIOGRAPHY:

BOOKS:
1. Bhatia MS. Essentials of Psychiatry. 5th edition. New Delhi: CBS Publishers and
Distributors; 2000.
2. Neerja KP. Essentials of Mental Health Nursing. 1 st edition. New Delhi: Jaypee
Brothers Medical Publishers (P) Ltd; 2008.
3. Sadock BJ. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins;
2003.
4. Sharma Pawan. Essentials of Mental Health Nursing. 1st edition. Haryana: Jaypee
Brothers Medical Publishers (P) Ltd; 2003.
5. Sreevani R. A Guide to Mental Health and Psychiatric Nursing. 3 rd edition. New Delhi:
Jaypee Brothers Medical Publishers (P) Ltd; 2010.
6. Stuart Gail w. Principles and Practice of Psychiatric Nursing. 9th edition. Noida: Elsvier;
2009.
7. Townsend Mary C. Psychiatry Mental Health Nursing Concepts of Care. 4 th edition.
Philadelphia: F. A. Davis Publishers; 2003.

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