CASE PRESENTATION1.pdf bipolar disorder in which both mania and depression happen.

MODERN NURSING COLLEGE ANNANDALE SHIMLA-03
MENTAL HEALTH (PSYCHIATRIC)NURSING
CASE PRESENTATION- 1
ON
BIPOLAR AFFECTIVE DISORDER WITH CLUSTER B TRAITS
SUBMITTED TO: SUBMITTED BY:
MRS. RITU RILTA SEEMRAN THAKUR
ASSISTANT PROFESSOR M.Sc. NURSING 1ST
YEAR
MENTAL HEALTH (PSYCHIATRIC) NURSING ROLL NO, 06
SUBMITTED ON:16/08/2024

I. IDENTIFICATION DATA
Name : Mrs. Chander Rekha
Age (in years) : 26 years
Sex : Female
Bed no. : 28
Name of Ward : Psychiatry ward
Date of admission (with time) : 23/ 02/ 24
CR. No. : 202111201454
Identification mark : not significant
Language : Hindi, Pahadi
Educational status : Graduation
Urban/ Rural : Rural
Dietary habits : Non- vegetarian (egg, meat etc.)
Marital status : Married

Religion : Hindu
Nationality : Indian
Occupation : Unemployed
Socio- economic status : 15,000/- per annum
Informant : Patient herself
: Father- Jay Dev, 50 year, 8th
pass, occupation- field worker,
currently staying with patient for 1 year
Information : Adequate and reliable
Address :Village Kothari, P.O. Ghasani Tehsil Rohru, District Shimla (H.P).
MSE done on :2,3,4 march 2024
Final diagnose : F31.6 with cluster- B traits with Z63.0 with Vit. D3 deficiency
II. PRESENTING CHIEF COMPLAINTS:
According to patient:
 Mn udaas h.X 1 month

According to informant:
 Ghussa krti h X 1 month 7 days
 Ajeeb awajen nikalti h X 1 month 7 days
 Khana nahi khana chahti h X 1 month 7 days
III. HISTORY OF PRESENT ILLNESS:
 Mode of onset: Chronic
 Course: Episodic
 Total duration of illness: 1 month 7 days for current episode
 Precipitating factor: Not known, IPR issues
 Predisposing factor: Not present.
 Facilitating factor: Not present
DESCRIPTION OF PRESENT ILLNESS:
Patient is a known case of F31.6 with cluster B- traits one episode of illness and admission in past with symptoms of irritability, disturbed
sleep, decreased appetite, and was on medication Tab. Diva (750 mg), Tab. Olanzapine (5mg), Tab. Lorazepam (1.5 mg)till 19 August
2022 when she visited OPD in IGMC. After consultation on returning home she stopped all medication and when asked by her family
members she would say that she will not take the medication because these medication will harm her body, and she would also refuse
food sometimes. The client discontinued the medications till 15 January 2023 but her overall behavior was normal.

Suddenly on 15 January 2023 she started shouting on her family members and according to her father she would undress herself in his
house, make weired noises loudly when her family members tried to stop her. She would become angry and she would start running to
nearby houses and would enter others houses in villages, whenever her family tried to stop her she would say, “ Tum mere raaste se hut
jao.”, “ Mujhe jahan jane ka man h jaane do.” She would make angry faces whenever family members tried to stop her from roaming
purposelessly. She would refuse food whenever asked about her changing behavior, gradually over time in next 2 weeks her irritability
and anger increased, even on small matters. In between these episodes the client would sometime remain sad for whole day and refuse
food. This pattern of irritability, anger, loss of appetite, decreased sleep, abnormal talks continued for next 3 weeks, after which she was
brought to IGMC- OPD and admitted in psychiatry ward.
IV. HISTORY OF PAST ILLNESS:
 Past medical history: There is no past history of diabetes, hypertension, or any other medical condition.
 Past Surgical history: Patients does not have any history of surgical procedure done on her like appendectomy etc.
 Allergy: Not known
 Obstetric history: Information not available.
V. FAMILY HISTORY OF ILLNESS:
 History of medical illness in family: There is no significant history of chronic illness in family like asthma, hypertension, or any
hereditary disease.
 Surgery history: Patient’s family is not having history of any surgery like appendectomy, etc.
 Psychiatric history: There is history of psychiatric illness in mother, was on medication but no document are available.
 Alcohol/ drug dependence/ suicidal ideation: History of substance use- Tobacco, smoking in father.

FAMILY TREE:
Jay Dev,
50 year, Male
8th
pass
Santosh Kumari,
47 year, Female
No formal education
Mukesh Bisht,
30 year, Male
10+2, Farmer
Chander Rekha
26 year, Female
Graduation
Sunny Chauhan,
24 year, Male
BA, LLB
Hazel
11/2
year, Fch
KEY USED:
Male
Female
Patient on
whom case
is presented

SOCIO-ECONOMIC STATUS:
 Type of family: Nuclear family
 Income per month: 15,000 per annum
VI. PERSONAL HISTORY:
a) Prenatal history:
1. Antenatal period:
Registered or not :
Immunization :
Antenatal checkups :
Diet during pregnancy :
Family environment :
Wanted child or not :
2. Intranatal period:
Delivery
Birth
Birth cry
Birth defect
APGAR score
Breast feeding
3. Postnatal complications:
In mother:
No significant evidence available.
Accurate information cannot be inquired.
PPH (Post partum hemorrhage)
Puerperal sepsis

In baby:
Cyanosis
Convulsions
Jaundice
Respiratory distress syndromes
Any genetic defect
b.) Infancy and early childhood (birth through age 3)
Middle childhood (3 years- 11 years)
Pre- school and school experience
 Play history:
 Relationship with playmates:
Accurate information cannot be acquired.
Lochia
Involution of uterus
Anemia
Postnatal depression
Postnatal psychosis
Bonding with child
Late childhood (adolescent 12- 19 years)
Emotional problems during adolescence
:
Puberty:
Age at appearance of secondary sexual
characteristics
:

d
Occupational history
Activities/ household chores
Attitude towards work
Relationship with family members
e) Premorbid personality
Interpersonal relationship : Trusting
Family & social relationships : Client was ambitious, adjustable, independent
Use of leisure time/ Hobbies/ Interest : Dancing, Singing
Usual reaction to stressful events : Adjustable and flexible
Attitude to self and others : Works in harmony and had a good attitude towards self and others.
Attitude to work & responsibilities : Welcomes responsibility, flexible, determined
Religious beliefs & moral attitudes : Normal
Fantasy life : Day dreaming was absent
Anxiety related to puberty changes :
Behavior and emotional problem
)Young adulthood (19- 24 years)
:

Eating pattern : Client is vegetarian
Bowel and bladder habit : Regular bowel
Sleep : Good sleeping pattern before the illness (as said by the attendant.)
Use of drugs, tobacco, alcohol : Client has no history of substance use.
PROBLEMS IDENTIFIED:
- Patient is having disturbed sleeping pattern.
- Reduced food intake.
- Self -initiation is absent.
VII. MENTAL STATUS EXAMINATION
GENERAL APPEARANCE AND BEHAVIOUR
Appearance : looks apparent to her age
Facial expression : Anxious, no facial expression change as evidenced on conversating with the client
Level of grooming : Normal (Hair combed, brushed teeth and bathing done every day)
Level of cleanliness : Adequate
Level of consciousness : Fully consciousness
Mode of entry : On OPD basis, by her family
Co-cooperativeness : Cooperative (client performs activities on request or when asked to do so)
Eye to eye contact : Maintained
Psychomotor activity : Normal

Rapport : Only when conversating with others or asked by others/ self- initiation is not present
Gesturing : Normal as evidenced when conversating with the client
Posturing : Normal; attains comfortable position to self as observed when conversating with client
Other movement : Normal
INFERENCE: - In general appearance and behavior patient looks apparent to her age, level grooming is normal, and having adequate
cleanliness and fully conscious, psychomotor activity, gesturing, posturing is normal but facial expression patient looks anxious, and
not much change in facial expression is seen while conversating with the client, mode of entry was on OPD basis, brought in by her
family members. Overall attitude of patient was co-operative, rapport established easily, eye- to- eye contact was maintained.
MOTOR DISTURBANCE:
OVERACTIVITY OR HYPERACTIVITY: patient was nor overactive neither hyperactive. She was involved in activities like
prayer, playing games etc. when asked to do so.
INFERENCE: overactivity is not present as evidenced by observation of the client during prayer and lunch.
UNDERACTIVITY OR MOTOR RETARDATION: client does not show any underactivity or motor retardation. Patient didn’t
show any sign of motor retardation, patient carrying her daily activities with normal way.
INFERENCE: underactivity is not present as evidenced by observation of the client during prayer and lunch
STUPOR: patient did not show any progressive and severe retardation and is not motionless.
Patient was fully conscious and kept on changing position during interaction.
INFERENCE: stupor is absent.
STEREOTYPE: patient does not show constant repetition of speech, movements, nor was involved in writing a particular words
phrase by own.
INFERENCE: stereotype is absent.
COMPULSIVE MOVEMENTS OR COMPULSION: patient did not have compulsive movements or repeated activities like hand
washing, checking locks etc.
INFERENCE: compulsion is not present as evidenced by observing the behavior of client during exercise and prayer
ECHOPREXIA: patient did not have any pathological repetition by imitation of the movements of another person

INFERENCE: echopraxia is absent.
NEGATIVISM: Patient was cooperative. She didn’t refuse any simple requests without apparent reasons. She obeyed my commands,
as I said can I talk with you for sometime, patient accepted my request and maintained a conversation.
INFERENCE: negativism is absent.
AUTOMATIC OBEDIENCE: Automatic obedience was not present in the patient, as evidenced by patient did not show a pathological
degree of compliance.
INFERENCE: automatic obedience is absent.
THERE ARE THREE ASPECTS OF DISORDER:
 Disorder of form of thought
 Disorder of content of thought
 Disorder in rate of speech
DISORDER OF FORM OF THOUGHT
a) CIRCUMSTATIALITY: patient was not including unnecessary details and explanations while giving answer to my question.
Student nurse: Chander Rekha g, kese ho aap?
Patient: Thik hun!
Student nurse: Aaj apka mn kesa h?
Patient: Mn thik h.
INFERENCE: No circumstantiality was present as evidenced by conversation with patient.
b) TANGENTIAL THINKING: patient did not give unnecessary detail and explanation and reached at the goal finally.
Student nurse: Apne gaon k baare m btayenge?
Patient: Mera gaon kuthari h, mei wahn ki rehne wali hun. Mere gaon k log ache h, mere aspass k log bhi ache h. mujhe apne gaon mei
rehna bahot acha lgta h.
INFERENCE: No tangential thinking was present as evidenced by conversation with patient.
c) INCOHERENCE: patient’s speech was cleared and sense can be extracted from her speech.
INFERENCE: No incoherence was present in patient as evidenced by above conversation with patient.

d) IRRELEVANT: patient was giving appropriately reply to questions being asked. No irrelevant talks were present.
INFERENCE: No irrelevant talk was present in the patients speech as evidenced by conversation with client.
e) NEOLOGISM: patient did not coin or invented own language and words which has special meaning to the patient.
INFERENCE: neologism was not present in the patient evidenced by above conversation.
a) Word salad
Word salad and preservation was not present as observed during conversation
b) Persevation
Student nurse: Apne subh nashte mei kya khaya?
Patient: Dudh, daliya, bread.
INFERENCE: Persevation was not present in the patient as she was giving correct answer to asked question as evidenced by
conversation with her.
f) Ambivalence and ambivalence ideas
Student nurse: Chander Rekha ji, apko kesa lag rha h?
Patient: Thik hun
INFERENCE: Ambivalence was not present as enquired during conversation with the patient, the attendants information, and doctors
notes.
EVALUATION OF SPEECH
a) Intensity: Patient’s voice was normally audible as observed during conversation with patient.50-70 (decibels) but have to go a little
closer to the client to hear clearly and appropriately.
b) Pitch: Her voice is monotonous, she showing no variation in her speech as evidenced during conversation with the client.
c) Speed: Rate of speech was slowed as evidenced by conversations with patient. (responding only to the asked question if she feels to
respond)
d) Spontaneous: Patient respond after a 5- 8 sec gap of when question was put to her as evident by conversation with her
e) Manner: Patient’s manner is relaxed evident by conversation
f) Reaction time: Reaction time of patient is increased as observed during the time of conversation with her.

DISORDER OF THE CONTENT OF THOUGHT
a. Delusion
i. Persecutory Delusion
Student nurse: Chander Rekha ji, kya apko pka vishwaas h ki koi apko marna chahta h ya nuksaan pohchana chahta h?
Patient: Nahi, esa toh kuch nhi h.
Inference: Persecutory delusion was not present as evidenced by conversation with the patient.
ii. Delusion of reference
Student nurse: kya aapko aisa pka vishwaas hai ki aapke aas- paas k log hmesha aapke bare me hee baat krrhe hain ?
Patient: Nhi, esa kyun hoga?
Inference: Delusion of reference is not present as enquired during conversation with patient
iii. Delusion of influence or passivity
Student nurse: Kya aapko aisaa pka vishwaas hai ki jo aap bolrhe ho yakr rhe ho wo koi or aapse krwa rha hai?
Patient: Nhi ji
Inference: Delusion of influence / passivity was not present in patient as evidenced by enquiring during conversation with patient.
iv. Delusion of sin and guilt
Student nurse: kya apko pkaa vishwaas h ki jo kuch b galat ho rha h usme apki glti h?
Patient: Nahi esa kuch b nhi h.
Inference: Delusion of sin and guilt was not present in patient as enquired by asking question during conversation and on confirming
with the attendant.
v. Hypochondrical delusion
Student nurse: Kya apko pka vishwaas h ki apko koi bohot badi bimari ho gyi hai jiski wajh se apko baar baar doctor k pass jana pdta
h?
Patient: Nhi
Inference: Hypochondrial delusion was not present as inquired during conversation with client, family members.
vi. Delusion of grandeur

Student nurse: Kya apko pka vishwaas h ki aap ek mahan insan ho or apme bohot si shaktiyaan h?
Patient: Nhi.
Inference: Delusion of grandeur was not present as evidenced by conversation with patient and on attendents information, doctors notes.
vii. Nihlistic delusion
Student nurse: kya apka pkaa vishwaas h ki apke aas paas ki saari cheezeisn khtm ho chuki hain ya khtm ho rhi h?
Patient: Nahi, esa kuch nhi h
Inference: Nihlistic delusion was not present as evidenced by on inquiring with the client, doctors notes, information given by the
attendant.
 Derealization: Derealization not present in patient as evident by conversation with patient.
Student nurse: Kya apka pka vishwas h ki apke aas- pass ki duniya badl gayi h ya nasht ho chuki h?
Patient: Esa kyun hoga
Inference: Derealization not present in the patient.
 Depersonalization: Depersonalization was not present in patient as evident during conversation.
Student nurse: Kya apka pka vishwas h ki apke shareer ka koi ang nsht ho chuka h?
Patient: Nhi esa nhi h ,pr paer m drd h.
Inference: Depersonalization not present in the patient as per conversation and observation done.
viii. Disorders of the possession of thought or control of thinking:
 Thought alienation
Student nurse: Kya apko esa lgta h ki koi apke dimaag se khayal nikalata hai?
Patient: Nhi
Inference: Thought alienation not present in client as inquired by the client and on viewing the doctors notes.
 Thought insertion
Student nurse: Kya apko esa lgta h ki koi apke dimaag mei khayal dalta h jo apke mn se na aye ho?
Patient: Nhi, esa kyun hoga.

Inference: Thought insertion not present in the client as inquired during the conversation, and information received by the attendant.
 Thought deprivation (withdrawal)
Student nurse: Kya apko esa lgta h ki koi apke dimag se khayal nikal leta h?
Patient: Nahi
Inference: Thought deprivation not present in the client as inquired by the client and doctors notes.
 Thought broadcasting
Student nurse: Kya apko esa lgta h ki apke vichar or khayal apke bina btaye sbko pta lg jaten h?
Patient: Nahi
Inference: Thought broadcasting not present in patient as evidenced by doctors notes, information given by attendants and on inquiring
the client.
b. Obsession
Student nurse: kya apke mn mei ek hi vichar baar- baar aaten h jiski vjh se aap kisi aur cheez pr dhyan nhi de pate?
Patient: Nhi
Inference: Obsession not present in client as seen after inquiring with the client and doctors’ notes in the file.
c. Compulsion
Student nurse: kya apke mnn mei ek hi kaam karne ka khayal baar-baar aata h?
Patient: Nhi
Inference: Compulsion was not present in the client as inquired during conversation and on observing the clients daily routine.
d. Phobias
Student nurse: kya apko bina kisi spsht karn ke kisi cheez se dar lgta hai?
Patient: Nhi, dar toh nhi lgta.
Inference: Phobia was not present in the client as inquired during conversation and on observing the clients daily routine.

e. Phantasy/fantasy
Student nurse: yahan se jane k baad aap kya karoge?
Patient: Kuch ni, ghr jake apni beti ka dhyan rakhungi..
Inference: Phantasy was not present in the patient as evidenced after inquiring with the client.
i. Creative: Creative thinking was not present as enquired during conversation.
ii. Day dreaming: Day dreaming was not present in patient as enquired during conversation.
D) DISORDER OF RATE OF SPEECH
a. Pressure of speech: Pressure of speech was normal as evidenced by conversation with patient.
b. Flight of idea: Flight of idea was not present in patient as evidenced by conversation with patient.
c. Retardation: Slowness in speech was absent as evidenced during conversation with patient.
d. Mutism: Mutism was not present in patient as evident during conversation.
e. Aphonia: Aphonia was not present as evident during conversation.
f. Thought Block: Thought block was not present as evident during conversation.
g. Clang association: Clang association was not present as evidenced during conversation with patient.
E) DISORDER OF PERCEPTION
a. Illusion
Student nurse: Wo kya h (pointing towards exhaust fan)
Patient: Pankha h
Inference: Illusion was not present in patient as inquired by the client and observed the client activity.
b. Hallucination

i. Auditory hallucination
Student nurse: Kya jb aap akele hote ho tbh apko koi awazein sunayi deti h, aur apke aas paas koi ni hota?
Patient: Nhi, esa kuch nhi sunai deta.
Inference: Auditory hallucination was not present in patient as inquired during conversation and observed her activity.
ii. Visual hallucination
Student nurse: jb aap akele hote ho or apke aas- paas koi nhi hota to apko kuch dikhayi toh nhi deta jo asal m wahan maujud nhi hota?
Patient: Nhi, esa kuch nhi h.
Inference: Visual hallucinations were not present as inquired during the conversation and on observing the client and information taken
from the attendant.
iii. Olfactory hallucination
Student nurse: Kya apko apnea aspass se alag trh ki smell ati h jo kisi aur ko na aa rhi ho?
Patient: Nhi
Inference: Olfactory hallucination was not present as inquired from the client.
iv. Gustatory hallucination
Student nurse: Kya apko es alga ho ki jb aap khana kha rhe ho to khane ka swaad bdl rha ho ya sb khane se ek hi swaad aa rha ho?
Patient: Nhi
Inference: Gustatory hallucination was not present in the client as inquired during the conversation.
v. Tactile hallucination
Student nurse: Kya apko kbhi es alga ho ki apke sharer pr keede raing rhe h?
Patient: Nhi, esa kuch nhi h
Inference: Tactile hallucination was not present in the patient as inquired during conversation and no evidence present in doctors notes.
vi. Hypnogogic hallucination
Student nurse: jb aap sone lgte ho kya apko koi awaazein sunayi ya kuch dikhayi deta h?

Patient: Nhi, kuch b ni
Inference: Hypnogogic hallucination was absent in the client as evidenced by inquiring the client and as per the information gathered
through the attendant’s and doctors’ notes.
vii. Hypnopepnic hallucination
Student nurse: Kya jb aap soo k uthte ho toh apko koi awazen sunai deti h aur apke ass pass koi na ho?
Patient: Nhi
Inference: Hypnopepnic hallucination was absent in the client as evidenced through inquiring during conversation and as per doctors
notes.
viii. Lilliputian hallucination
Student nurse: kya apko apke samne rakhi cheezien kbhi bohot hi choti dikh rhi ho ya apse duur ja rhi ho?
Patient: Nhi
Inference: Lilliputian hallucination not present in the patient as inquired during the conversation.
ix. Kinesthetic hallucination
Student nurse: Apko kbhi aisa lga ki shreer ka koi hissa, mood gya ho, ya apke shreer k hisse m koi hlchl ho rhi ho?
Patient: Nhi aisaa nhi lgta.
Inference: Kinesthetic hallucination was not present as inquired during conversation.
x. Macropsia
Student nurse: Kya apko kbhi esa laga ki apke samne rkhi cheez ya koi insaan bada ho gya h?
Patient: Nhi
Inference: It was not present as inquired during conversation.
xi. Micropsia
Student nurse: kya apko kbhi ais alga ki apke samne rkhi cheez, aakar m chota ho gya h?

Patient: Nhi
Inference: Micropsia was not present in the client as inquired during conversation and doctors notes.
F) DISTURBANCE IN AFFECT
a. Inappropriate or incongruent affect
The facial expression of the client was appropriate, not having incongruent affect.
b. Pleasurable affect
i. Euphoria
Student nurse: apka mn abhi kesa h?
Patient: Thik h.
Inference: Euphoria was not present in the client as inquired during the conversation, and on observing the client’s daily activity, doctors
notes.
ii. Elation: Elation, exaltation, ecstacy was not present in patient as evidenced by above conversation
iii. Exaltation: Exaltation and ecstacy was not present in patient as evidenced by above Conversation and by observing patient’s behavior.
iv. Ecstacy
c. Unpleasurable affect
i. Depression – Depression was present in patient as evidenced by observation and inquired during conversation, the information gathered
through the patients file and doctors notes.
Student nurse: aj apka mn kesa h?
Patient: Thik h
Student nurse: mn m kese vichar aate h?
Patient: mn m toh filhal kuch bhi vichar nahi h. Apni beti ko padhana likhana chahti hun. Jisse ki vo apne paon pr khade ho sake. Jb
purani baaten yaad ati h toh marne k bhi vichar aate h. mene ekbaar marne ki koshish bhi ki thi, apne sasural mei, phir baache ka khayal
aya, devi- devta ka khayal aya toh 2-3 dawayi ki patiyan toh pani m dho rakhi thi, wo aadha hi piya, baki fek di. Iske baad toh lagta h ki
apne baccho k liye hi jeena chahiye.

Inference: Client was worried about her relationship with her husband, and seemed worried about her child and had ideas of self harm
as per above conversation, information gathered from her father and as per the patients file
ii. Grief or mourning – Not present in patient as evidenced by above conversation.
d. Other affect
i. Anxiety
Student nurse: Kya apko bina kisi spsht karn ke choti si baat pe ghabrahat hoti h?
Patient: Nhi
Inference: Anxiety was not present in the patient as evidenced by conversation with patient.
ii. Fear
Student nurse: Kya apko kisi cheez se dar lgta h?
Patient: Nhi
Inference: Fear was not seen in patient.
iii. Agitation: Patient was not agitated at the time of conversation.
iv. Panic: Patient was not panic as observed during conversation.
v. Free floating anxiety
Student nurse: kya apko bina kisi karn k dar lgta h?
Patient: Nhi
Inference: Free floating anxiety not present in the client as per inquired during conversation, doctors notes, information gathered from
attendant.
vi. Apathy: Not present in patient.
vii. Aggression: Aggression was absent in patient.
viii. Mood swings: Mood swing was not present in patient.
ix. Emotional liability: Emotional liability not present in the patient.

G) DISORDER OF MEMORY
Memory
a. Immediate memory
Student nurse: main aapko abhi 5 cheezon k naam btaungi. 5 minute k baad aapse puchungi aapko jitna yaad hoga aap bol k bta skte ho
ya agr likhna chaho to aap likh bhi skte ho. Pen, Scale, chappal, chashma, notebook.
After 5 minute student nurse: Mainne aapko 5cheezon k naam btaaye the kya aap mujhe bta skte ho?
Patient: Pen, scale, chappal, chasma, notebook
Inference: Immediate memory was intact as enquired by asking question.
b. Recent memory
Student nurse: Chander Rekha ji aapne kl dinner me kya khaya tha?
Patient: Dal, chappati, sbji
Student nurse: Dal konsi thi?
Patient: Rajma
Inference: Recent memory was intact to some extent as enquired by asking question.
c. Remote memory
Student nurse: aap bta skte ho ki aapka janam din kb aata hai?
Patient: 15 july
Inference: Remote memory of patient was completely intact as confirmed with patient’s file.
i. Amnesia
Student nurse: aap ko apne bachapan k dosto k nam yad ha?
Patient: Priyanka, Chandni
Inference: Amnesia was not present as inquired and cross- checked with patient’s file.
ii. Paramnesia
Student nurse: aapki padaie kaha tak hue ha?
Patient: Mene graduation kri h, uske baad shadi ho gyi

Inference: Patient not having paramnesia as evidenced after inquiring the client as cross- checked with patient’s file.
iii. Anterograde amnesia (patient is able to recall the recent event)
Student nurse: aapko hospital me aaye huye kitne din ho gye?
Patient: hafta ho gya h
Inference: Anterograde amnesia was not present in patient as inquired and confirmed from the attendant.
iv. Retrograde amnesia: (patient is able to recall past event)
Student nurse: Kya apko apne bchpn ke doston k naam yaad h?
Patient: Nhi.
Inference: Though the client was not able to remember the name of her childhood friends, the client is not having retrograde amnesia as
per inquired during the conversation.
v. Déjà vu
Student Nurse: kya aapko kbhi aisaa lgta ya aisaa mehsoos hota hai ki jo aapke sath ho rha hai wo pehle bhi ho chuka hai ?
Patient: Nhi esa kuch nahi h?
Inferences: Déjà vu was not present in patient as evidenced by inquiring after conversation.
vi. Jamaes vu
Student nurse: Saapko kbhi aisaa lgta hai ki jinko pehle se jante ho, ya jo aapki life me pehle ho chukka hai wo pehli baar ho rha hai ?
Patient: Nhi
Inferences: Jamaes vu was not present in patient as inquired during conversation, patients file.
vii. Hypermnesia
Student nurse: aapko apane bachapan ki koe ghatana yad ho?
Patient: Yaad ni
Inferences: Hypersomnia was not present in patient as enquired by asking question.
Orientation
a. Time
Student nurse: abhi kya time hua hai (pointing toward clock)?

Patient: 11 bj gye honge
Student nurse: aaj kaun see taarik hai?
Patient: 3 march
Student nurse: abhi kaun sa maheena chl rha hai?
Patient: march.
Student nurse: abhi kaun sa saal chl rha hai ?
Patient: 2023
Student nurse: kya aap bta skte ho kaun sa mosum chl rha hai ?
Patient: grmiyan ane wali h
Inferences: Patient completely oriented to time as evidenced after inquiring through conversation.
b. Place
Student nurse: ky aapko pta h aap abhi kahaan pr ho?
Patient: Shimla
Student nurse: kya aap bta skte ho ki baahr mausam kaisa hai ?
Patient: Dhoop lagi h.
Inferences: Patient was oriented to place.
c. Person
Student nurse: nmste m kon hun kya apko yaad h?
Patient: Shivani
Student nurse: aapke samne jo khade ha vo kon ha( pointing toward the father)
Patient: Mere father h.
Inferences: Patient was oriented to person.
Insight
Student nurse: aap hospital kis wajah se aaye ho?
Patient: Pehle bhi ese bimar thi tbh bhi Hospital ayi thi.
Student nurse: Aap apni bimari k bare me jante ho?

Patient: Choti choti baton p ghussa aajata tha, dwai bhi lena bnd kr liya tha
Inferences: Insight (Grade 5 i.e., intellectual insight)
ATTENTION & CONCENTRATION:
CONCENTRATION: -
Student nurse: abhi mai apko kuch number dungi, apko unhe minus karna hai 100-7 kitne hote hai?
Patient: 93
Student nurse: 93-7 to kitne bchte h?
Patient: 86
Student nurse: 86- 7 to kitne bchte h?
Patient: 79
Inferences: Patient concentration is good.
Student nurse: kya aap mujhe mahino k nam bata sokte ho, jiase January ,February
Patient: January, February, March, April, May, June, July
Inference: Client concentration is normally sustained.
ATTENTION:
Student nurse: me kuch bolugi aap phir aap bhi vasa hi repeat karna ?
Patient: Thik h
Series forward Student nurse Patient
1 Pen, scale, chappal pen, scale, chappal
Student nurse: ab jasa me bolugi vase hi aapne use ulta bolana ha
Patient: Thik ha ji
Start karen
Series backward student nurse patient
10-9-8-7-6-5 5- 6-7-8-9-10
Inference: Attention is present as evidence doing backward and forward counting client is able to do so.

Abstract thinking
Student nurse: kya aap bta skte ho ball or orange me kya smanta hai ?
Patient: Dono gol h
Student nurse: kya aap bta skte ho ball or santre me kya frk hai?
Patient: Santra khane k liye hota h.
Proverb testing: nach na jane aagan tedha ka kya mtlb hota h?
Patient:
Inference: Abstract thinking is normal.
Personal
Student nurse: yhan se jane k baad aap kya kroge ?
Patient: Ghr jaungi.
Social
Student nurse: jab aap kahi ghumane phiarane jaooge ya apni beti k sath jaooge to kase kapade pahan kar jaooge?
Patient: tayar hoti hun, aur apni beti ko b tyar krungi
Student nurse: agr aapko raaste me letter mil jata hai jo sealed h, jiss pr pta likha ho to aap kya kroge?
Patient: Agr m pta janti hun toh unko de dungi
Student nurse: agar aapko khana bnate bnate cut lag jaye to aap kaya karoge?
Patient: Pani se saaf.
Inferences: Patient judgement was good as evidenced by asking question during conversation.
Intelligence
Student nurse: hmare desh k pradhanmantri kaun hain?
Patient: Sh. Narender Modi g
Student nurse: Himachal ki rajdhani kya hai?

Patient: Shimla
Student nurse: Aapke jila ka kaya nam ha?
Patient: Solan
Inference: Intelligence of patient is average as evidenced by asking question, doctors notes.
Sleep
a) Observe pattern of sleep
i. Temporary insomnia
Student nurse: jb aap sonne lgtte ho to neend aane me kitna samay lg jata hai?
Patient: Pta nhi khane k baad so jati hun.
Inference: Temporary insomnia was present as evidenced by attendents information and cross- checking the file.
ii. Persistent insomnia
Student nurse: hospital me aane se pehle bhi aapko neend aane me samay lg jata tha?
Patient: Hmm.. (non- verbal response), on inquiring with the patient.
Inferences: Persistent insomnia not present in the patient.
iii. Temporary hypersomnia: Not present
iv. Persistent hypersomnia: Not present
v. Non organic sleep wake cycle disturbances
Student nurse: kya aap raat ko neend se baar bar jagte ho?
Patient: Hmm.. kabhi- kabhi
Inference: There is slight disturbance in patient’s sleep wake cycle.
E.M.A: Early morning awakening
Student nurse: aap subah kitne bje uthte hain?
Patient: 5 bje tk uth jati hun

Inference: Early morning awakening was present as confirmed by night duty staff and attendents.
b) Episodic disturbances
Any attack or fit of
i. Epilepsy Any attack of epilepsy, hysterical, impulsive, destructive
ii. Hysterical was not present in patient as confirmed by on duty staff, ward
iii. Impulsive attendant and observed behavior during my shift.
iv. Aggressive Client often gets angry on small things.
v. Destructive
PROBLEM IDENTIFIED AFTER MENTAL STATUS EXAMINATION
 Client is in mixed state of bipolar affective disorder.
 Replies to asked questions only.
 No initiation of talk or any activity.
 Has reduced appetite.
 Has decreased sleep.
NEUROLOGICAL EXAMINATION
A. Level of Consciousness
B. Mental Status Examination
C. Special cerebral functions
Agnosia : absent in the patient i.e. lack of ability to identify people or objects. Patient is able to identify his attendants and objects.
Aproxia : absent
Aphasia : absent in the patient i.e. inability to communicate
Optic nerve: Inspection of eye
Visual acquity : Normal
Visual field examination: Normal
Color vision : Normal

Oculomotor trochlear and abducent nerves
Pupillary reaction to light : Normal
Pupillary size : Normal
Eye movement in six direction: Normally done
Nystagmus : Absent
Diplopia : Absent
Trigeminal nerve:
Corneal reflex : Present
Facial sensory response : Present
Mandibular strength : Present/Normal
Facial nerve:
Facial expression : Appropriate to conversation
Taste sensation : Normal
Vestibulo cochlear nerve:
Auditory acquity test : Normal
Glossopharyngeal and Vagus nerve:
Gag reflex : Present
Swallowing reflex : Present
Position and movement of uvula and palate : Normal
Sensation of taste : Normal
Spinal accessory nerve:
Sternocleidomastoid muscle strength : A little weak but normal according to age
Elevation of shoulder : Normal

Turning of head : Normal
MOTOR FUNCTION ASSESSMENT
Muscle size : normal
Muscle strength : normal
Muscle tone : normal
Muscle co-ordination : present
Gait : normal
Gait : Normal
Movement of all the joints: normal
Deformities: Absent
Abnormal movement : Absent
SENSORY FUNCTION ASSESSMENT
Pain sensation : Present
Temperature sensation : Present
Touch sensation : Present
Vibration sensation : Present
ASSESSMENT OF CEREBELLAR FUNCTION
Finger to finger test : Normally done
Finger to nose test : Normally done
Romberg test : Not possible to assess in client
Tandem walking test : Not assessible
ASSESSMENT OF REFLEXES
Superficial reflexes : Not assessed
Deep tendon reflexes : Not assessed

Biceps : Not able to assess
Triceps : Not able to assess
Brachioradial : Not able to assessed
Patellar : Not assessed
Achilles : Not assessed
Any abnormal reflexes : Absent
PROBLEM IDENTIFIED IN PHYSICAL EXAMINATION AND NEUROLOGICAL EXAMINATION
No such deformity or physical disturbances are present in the client but sometimes complains of stomachache the reason being as a
occurrence of somatic symptoms in relation to the present psychiatric illness.
No such medical condition has been ruled out for her stomachache .

MINI- MENTAL STATUS EXAMINATION
S.NO. CONTENT POINTS PATIENT SCORE
1. ORIENTATION (Total Score= 10)
What is the year?
Season?
Date?
Day?
Month?
Which is our state?
Country?
Town or City?
Hospital?
Floor?
(10)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2. ATTENTION AND CALCULATION (Total Score= 5)
Spell “world” backwards
D
L
R
O
W
Ask to count backwards from 100 in blocks of 7
100-7= 93
93- 7= 86
86-7= 79
79- 7= 72
72- 7= 65
(5)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

3. REGISTRATION (Total Score=3)
Name three objects
- apple
- table
- pen
Ask the patient to repeat the names of all three objects
Repeat the objects names until all three are learned
(3)
1
1
1
1
1
1
4. RECALL (Total Score= 3)
Ask to repeat the three objects
- apple
- table
- pen
(3)
1
1
1
1
1
1
5. LANGUAGE (Total Score= 7)
Point to any object and ask to name the object
Do the same again with a different object
Ask the patient to repeat any proverb. “No ‘ifs and/ or ‘buts’”
Allow only one trial
Give patient a blank paper and ask to follow a three-stage command
Take a paper in your right hand
Fold it in half
Put it on the floor
Write “CLOSE YOUR EYES” and show it to the patient. Ask him or her to read
the message and do what it says.
(7)
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Ask the patient to write a sentence of their choice on a blank piece of paper,
sentence should make sense.
Show the patient a drawing of two pentagons which intersect to form a
quadrangle. Ask to copy the design exactly as it is.
1
1
1
1
TOTAL SCORE 30 30
DESCRIPTION OF THE CASE BIPOLAR AFFECTIVE DISORDER
Bipolar disorder, formerly manic depression, is a mental disorder with periods of depression and periods of elevated mood. The elevated
mood is significant and is known as mania or hypomania, depending on its severity, or whether symptoms of psychosis are present. During
mania an individual behaves or feels abnormally energetic, happy or irritable. During periods of depression there may be crying, a negative
outlook on life, and poor eye contact with others.

DEFINITION:
Affective disorders are characterized by a sever disturbance of mood manifested as elation or excitement and depression. These are
accompanied by one or both of the following: -
 Delusions
 Perplexity (a form of confusion in which the patient is bewildered and uncertain about his thoughts)
 Disturbed attitude towards self
 Disorder of perception and behavior
These symptoms appear according to the mood of the patient. In DSM III these disorders include major affective disorders (manic
episodes, major depressive episode, bipolar disorders). So it can be defined as- “affective disorders are illness in which mood
change is primary and dominant feature. Mood change is relatively persistent and is associated with characteristics changes in thinking,
attitude and behavior.
INCIDENCE :- the incidence of bipolar disorder is roughly equal, with a ratio of women to men of about 1.2 to 1. The average age of
onset for bipolar disorder is the early twenties, and following the first manic episode, the disorder tends to be recurrent. As with depression,
bipolar disorder appears to be more common in unmarried than in married person.
COURSE: Bipolar mood disorder has an earlier age of onset (third decade) than recurrent depressive (uni polar) disorder. Unipolar
depression, on the other hand, is common in two age groups: late third decade and fifth to sixth decades.
An average manic episode lasts for 3-4 months while a depressive episode lasts from 4-6 months. Unipolar depression usually lastslonger
than bipolar depression. With rapid institution of treatment, the major symptoms of mania are controlled within 2 weeks and of depression
within 6-8 weeks.
CLASSIFICATIONAcc. To ICD 10-
F31.0 Bipolar affective disorder current episode mania
F31.1 Bipolar affective disorder current episode mania without psychotic symptom
F31.2 Bipolar affective disorder current episode mania with psychotic symptom
F31.3 Bipolar affective disorder current episode mild or moderate depression

F31.4 Bipolar affective disorder current episode severe depression without psychotic symptoms.
F31.5 Bipolar affective disorder current episode Severe depression with psychotic symptoms.
Acc. To DSM IV –
Bipolar 1
Bipolar 11
ETIOLOGICAL FACTORS:
BOOK PICTURE PATIENT PICTURE
Genetic predisposition: - There is increasing evidence that genetic plays a strong role in predisposition.
Approximately 15% of the brothers, sisters, parents and children of BPAD were also suffering from
these ailments.
Not present
Neurophysiological factors: - Researchers have found the possibility that imbalance in excitatory and
inhibitory processes may predispose BPAD.
Present
Biochemical factors: - findings reveal the possibility of metabolic changes in the brain pathology with
these disorders, particularly the catecholamine imbalance. Increased or decreased catecholamine may
cause mania or depression respectively.
Present
Psychological or interpersonal / predisposing family and personality factors: - Mood swings in the
parents will leads to maladaptive learning in the children. These children may develop a typical premorbid
personality pattern.
Not present
Severe stress: - Patients who have experienced severe stress in their life-time may be more prone. present

PHYSIOLOGICAL INFLUENCES
Right-sided lesions in the limbic system, temporo- basal areas, basal ganglia, and thalamus have been show
to induce secondary mania. Magnetic resonance imaging studies have revealed enlarged third ventricles an
subcortical white matter and periventricular hyperintensities in clients with bipolar disorder
Not present
TYPES OF BIPOLAR DISORDER
BIPOLAR I DISORDER: - Bipolar I disorder is the diagnosis given to an individual who is experiencing, or has experienced, a full
syndrome of manic or mixed symptoms. The client may also have experienced episodes of depression. This diagnosis is further
specified by the current or most recent behavioral episode experienced. For example, the specifier might be “single manic episode” (to
describe individuals having a first episode of mania). For individuals who have had recurrent mood episodes, the current (or most
recent) episode may be identified as manic, hypomanic, mixed, or depressed.
BIPOLAR II DISORDER: - The bipolar II disorder diagnostic category is characterized by recurrent bouts of major depression with
episodic occurrence of hypomania. The individual who is assigned this diagnosis may present with symptoms (or history) of
depression or hypomania. The client has never experienced an episode that meets the full criteria for mania or mixed symptomatology.
OTHER BIPOLAR DISORDERS
BIPOLAR DISORDER DUE TO A GENERAL MEDICAL CONDITION: This disorder is characterized by a prominent and
persistent disturbance in mood that is judged to be the result of direct physiological effects of a general medical condition (American

Psychiatric Association [APA], 2000). The mood disturbance may involve depression or elevated, expansive, or irritable mood, and
causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Types of
physiological influences are included in the discussion of etiological implications for bipolar disorders.
SUBSTANCE-INDUCED BIPOLAR DISORDER: The disturbance of mood associated with this disorder is considered to be the
direct result of physiological effects of a substance (e.g., a drug of abuse, a medication, or toxin exposure). The mood disturbance may
involve depression or elevated, expansive, or irritable mood, and causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning Mood disturbances are associated with intoxication from substances such as
alcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedatives, hypnotics, and anxiolytics
CLINICAL MANIFESTATION
MANIC PHASE DEPRESSIVE PHASE
Expensive, grandiose, or hyperirritable mood √ Low self esteem -
Increased psychomotor activity such as agitation pacingor hand
wringing
- Overwhelming inertia -
Excessive social extroversion - Feeling of Hopelessness, Apathy, self reproach -
Rapid speech with frequent topic changes - Difficulty concentrating, intellectualimpairment -
Decreased need for sleep and food √ Psychomotor Retardation -
Impulsivity - Anhedonia -
Impaired judgement - Suicidal Ideation √

DIAGNOSTIC CRITERIA FOR BIPOLAR AFFECTIVE DISORDER
BOOK PICTURE PATIENT PICTURE
 History taking √
 Mental Status Examination √
 Mini Mental Status Examination √
According to ICD 10
F31 BIPOLAR AFFECTIVE DISORDER
F31.0 Bipolar affective disorder, current episode hypomanic
A. The current episode meets the criteria for hypomania (F30.0).
B. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode (F30.-),
depressive episode (F32. or mixed affective episode (F38.00).
F31.1 Bipolar affective disorder, current episode manic without psychotic symptoms
A. The current episode meets the criteria for mania without psychotic symptoms
B. There has been at least one other affective episiode in the past, meeting the criteria for hypomanic or manic episode (F30.-),
depressive episode (F32.) or mixed affective episode (F38.00).
F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms
A. The current episode meets the criteria for mania with psychotic symptoms (F30.2).
B. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode (F30.-),
depressive episode (F32.-) or mixed affective episode (F38.00).

F31.3 Bipolar affective disorder, current episode moderate or mild depression
A. The current episode meets the criteria for a depressive episode of either mild (F32.0) or moderate severity (F32.1).
B. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode (F30.-), ormixed
affective episode (F38.00).
F31.4 Bipolar affective disorder, current episode severe depression without psychotic symptoms
A. The current episode meets the criteria for a severe depressive episode without psychotic symptoms (F32.2).
B. There has been at least one well authenticated hypomanic or manic episode (F30.-) or mixed affective episode (F38.00) in the past.
F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms
A. The current episode meets the criteria for a severe depressive episode with psychotic symptoms (F32.3)
B. There has been at least one well authenticated hypomanic or manic episode (F30.-) or mixed affective episode (F38.00) in the past.
F31.6 Bipolar affective disorder, current episode mixed
A. The current episode is characterized by either a mixture or a rapid alternation (i.e. within a few hours) of hypomanic, manic and
depressive symptoms.
B. Both manic and depressive symptoms must be prominent most of the time during a period of at least two weeks.
C. There has been at least one well authenticated hypomanic or manic episode (F30.-), depressive (F32.-) or mixed affective episode
(F38.00) in the past.
My client is suffering from F31.6 Bipolar affective disorder, current episode mixed with cluster B- traits

MANAGEMENT:
TREATMENT MODALITIES: - The specific goals of treatment are to decrease the frequency, severity & psychosocialconsequences
of episodes & to improve psychosocial functioning between episodes.
A. Psychiatric Management: -
The general goals of management are to assess & treat acute exacerbation prevent recurrence improve inter episode functioning &provide
assistance, insight & support to patient & family.
The specific goals of psychiatric management include establishing & maintaining a therapeutic alliances, monitoring the patient’s
psychiatric status, providing education regarding their illness, prognosis & treatment, enhancing treatment compliance. Promoting regular
patterns of activity & wakefulness, promoting understanding of an adaptaion to the psychosocial effects of bipolar disorder, identifying
new episodes early & reducing the morbidity & sequelae of bipolar disorder.
B. Pharmacological Treatment:-
Three mood stabilizer currently available are lithium, valproate & carbamazepine; lithium has been the primary pharmacological
treatment of patient with bipolar disorder.
The combination of cabamazepine & lithium may be particularly effective for some patients, although it appears to increase their riskof
developing an acute, confusional state
-T. lithium: 900 – 2100mg/day
-Carbamazepine: 600 – 1800 mg/day
-Sodium Valproate: 600 -2600 mg/day
-Clonazepam.
In My Patient:-

T. Divalproex Sodium
T. Olanzapine
250 mg
5mg
TDS
BD
T. IFA HS
T. Lorazepam 1mg BD
NON-PHARMOCOTHERAPY-
ECT- ECT is useful for certain patients, particularly for those who cannot take or have respond to number of antidepressants, have
severe depression and high risk for suicide.
C. PSYCHOTHERAPIES
 Interpersonal psychotherapy:- Interpersonal therapy, developed by Gerald Klerman, focuses on one or two of a patient's current
interpersonal problems. This therapy is based on two assumptions. First, current interpersonal problems are likely tohave their roots in
early dysfunctional relationships. Second, current interpersonal problems are likely to be involved in precipitating or perpetuating the
current depressive symptoms. Controlled trials have indicated that interpersonal therapy is effective in the treatment of major depressive
disorder and, not surprisingly, may be specifically helpful in addressing interpersonal problems. Some studies indicate that interpersonal
therapy may be the most effective method for severe majordepressive episodes when the treatment choice is psychotherapy alone.
 Behavior therapy:- Behavior therapy is based on the hypothesis that maladaptive behavioral patterns result in a person's receiving
little positive feedback and perhaps outright rejection from society. By addressing maladaptive behaviors in therapy, patients learn to
function in the world in such a way that they receive positive reinforcement. Behavior therapy for major depressive disorder has not yet
been the subject of many controlled studies. The limited data indicate that it is an effective treatment for major depressive disorder.
 Family therapy and marital therapy:- The ultimate objectives in working with families of clients with mood disorders are toresolve
the symptoms and initiate or restore adaptive family functioning. As with group therapy, the most effective approach appears to be with

a combination of psychotherapeutic and pharmacotherapeutic treatments. Some studies with bipolar disorder have shown that behavioral
family treatment combined with medication substantially reduces relapse rate compared with medication therapy alone.
 Group therapy:- Once an acute phase of the illness is passed, groups can provide an atmosphere in which individuals may discuss
issues in their lives that cause, maintain, or arise out of having a serious affective disorder. The element of peer supportmay provide a
feeling of security as troublesome or embarrassing issues are discussed and resolved. Some groups have other specific purposes, such as
helping to monitor medication-related issues or serving as an avenue for promoting education relatedto the affective disorder and its
treatment.
 Cognitive behavior therapy:- In cognitive therapy, the individual is taught to control thought distortions that are considered to be a
factor in the development and maintenance of mood disorders. In the cognitive model, depression is characterized by atriad of negative
distortions related to expectations of the environment, self, and future. The environment and activities withinit are viewed as unsatisfying,
the self is unrealistically devalued, and the future is perceived as hopeless.
 Supportive psychotherapy
 Psychodynamic psychotherapy.

NURSING MANAGEMENT
ASSESSMENT
 Assess the biological history, current symptoms and family history.
 Assess the person’s current mood and thought content.
 Assess the person nutritional status.
 Assess the person hygiene level.
NURSING DIAGNOSIS
1. Risk for violence directed to self and others related to impaired cognitive process as evidenced by physical abuse on his family.
2. Disturbed sleep pattern, related to hyperactive abusive and assaultive behavior evidenced by difficulty in falling asleep.
3. Impaired verbal communication process related to less interest in talking with others as well as abusive and assaultivebehavior.
4. Imbalanced nutrition Less than body requirements related to loss of appetite and excessive physical agitation, evidenced byloss of
weight.
5. Ineffective individual coping related to anxiety as evidenced by lack of positive feedback and unmet dependency needs.
6. Deficit Knowledge of family members regarding the disease condition, its prognosis and management as evidenced by family
members asking doubts regarding the disease condition.

NURSING DIAGNOSIS
ASSESSMENT NURSING
DIAGNOSIS
GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjectivedata:
Clients says that
she use to feel
anger and gets
irritated easily
and is having self
harming
behaviour.
Objective data:
Her father said
that she gets
irritable on
smallest of matter
and have
previously
attempted to harm
self.
Risk for
violence
directed to
self and others
related to
impaired
cognitive
process as
evidenced by
physical
abuse on his
family.
Short-Term
Goal: Client will
not harm self or
others during
hospitalization.
Long-Term
Goal: Agitation
and hyperactivity
will be
maintained by
administrationof
tranquilizing
medication.
-Assess the client’srisk
for harming self.
-Closely monitor the
client’s behavior.
-ensure that all sharp
objects, glass or
mirrored Items, belts,
ties, have been removed
from clientenvironment.
-redirect violent
behavior with physical
outlets.
-offer transquilizing
medication as per
treating physician’s
prescription.
-Assessed the client’slevel
of anger and the reason for
anger which isat risk for
harming others.
-Closely monitored the
client for any violent
behaviors like hurting
others and the using
abusive language.
-Ensured that all sharp
objects, glass or mirrored
items, belts, ties,smoking
materials have been
removed from client’s
environment.
-Involved client in exercise
and other activities like
relaxationand diversion
therapy.
-Administered Tab
lorazepam wheneverthe
patient got agitated as
prescribed by physician.
-To preventing the client
and the otherfamily
members from getting
injury.
-To Risk for hurting
family is being reduced
by monitoring client.
-To Prevent the client
injury whichcan also
leads to suicide.
-To help in divertingthe
mind and help the client
for relaxation.
-To help the clientfor
controlling his
aggressive behaviour
when client got agitated
Client remained free from
the risk for violence
directed to others.Her
irritability andanger
outburst is reduced to some
extent.

ASSESSMENT NURSING
DIAGNOSIS
Subjective
data:
Patient says,
“She is
feeling
restlessness.’
Objective data:
Her father said
that she didn’t
sleep properly
at last night and
client looks
dull.
Disturb sleep
pattern, related
to hyperactive
abusive and
assaultive
behavior
evidenced by
difficulty in
falling asleep.
Short term
goal: To
provide
adequate
resting
hours to the
patient.
Long term
goal: Get
adequate
sleep at
night
-Assess the level of
sleeping pattern of the
client.
-Planning daytime
activities according to
the patient’s interests.
-Ensure a quiet and
peaceful environment
when the patient is
preparing for sleep.
-Do not allow the patient
to sleep for long time
during the day.
-Assessed the sleeping
pattern of the client. The
client is not able to sleep
he use to sleep for 1-2
hours in a day.
-A time schedule was
prepared for the patient.
And in that schedule,
some activities are given
to the patient according to
his interest like- drawing,
playing games.
-Provided him quiet and
peaceful environment
when he want to sleep by
keeping distracting thing
away from client like
mobile phone.
-Avoided his excessive
day time sleep by
engaging the client in
doing some task like
drawing and playing
ludoo
-To improve the
sleeping pattern of the
client.
-To engaging the
client in daily
activities and
diverting the mind as
client gets frustrated
and shows anger.
-To help the client to
have adequate resting
time and sleeping
hours when needed.
-To help the client to
engaged in some task
which is provided to
client which will
avoid the clients day
time sleep.
The sleeping pattern
of the client was
improved as theclient
is now taking
adequate rest i.e upto
8 hours sleep.
-Teach the family to give
some hot drink to client.
-Mother is taught to give
hot drink to client like
milk for drinking. Which
can induce sleep.
-To induce the sleep
of the client.

CASE PRESENTATION1.pdf bipolar disorder in which both mania and depression happen.

ASSESSMENT NURSING
DIAGNOSIS
Subjective
data:- patient
family member
verbalize that
patient is not
taking food at
proper time and
adequately.
Objective
data:- I
observed this by
doing physical
examination.
Imbalanced
nutrition Less
than body
requirements
related to lack
of appetite and
excessive
physical
agitation,
evidenced by
loss of weight.
Short-Term
Goal: Client
will consume
sufficient
foods and meal
snacks to meet
recommended
daily
allowances of
nutrients.
Long-Term
Goal:
Client will
begin to regain
weight
and exhibit no
signs or
symptoms of
malnutrition.
-Consult dietitian to
determine appropriate
diet for Client to
restore nutrition and
gain weight.
-Ensure that his diet
includes foods that
he particularly likes.
-Maintain an accurate
record of intake,
output, and calorie
count. Obtain daily
weights.
-Administer vitamin
supplement, as
ordered by physician.
Sit with Client during
mealtime
-Diet chart of the patient
was prepared by the
nurse to improve the
nutrition level and
maintain the weight of
the client.
-Diet chart was prepared
particularly according to
patient likes and dislikes.
-Recording and reporting
of the client intake,
output, and about calorie
count is recorded timely.
-Medicine like vitamin A
and D supplement is
given to the client to
maintain vitamin level
and during meal time
checked the client for
proper food and
medicine.
-To help the client
to restore nutrition
and gain weight.
-To help the client
to take food in time
with interest.
-To maintain and
check the client
input and output and
to obtain calorie
level and revised the
diet plan for the
client.
-To help to increase
the clients vitamin
level.
The client nutrition level
is being maintainedto
some extent and the
clients weight is gained
i.e. 54 previouslythat
was 52.

PSYCHOEDUCATION
SEMI- STRUCTURED
SCHEDULE:
A semi- structured schedule was given and explained to the client as well as the family members to be followed at home to
maintain the routine day activities.
MEDICATION: I advised patient to take medicine as prescribed by Psychiatrist.
I also advised the patient to not skip any medicine and complete the course.
Patient has been advised related to the safe use of medicine as per patient’s level of understanding.
I advised the patient to report any side effect of medicine like constipation, GI upset, Nausea, photosensitivity etc.
Patient has been advised to take plenty of water as patient was complaining for constipation and advised to take prescribed
medication for constipation.
I advised the patient related to the ill effect of medicine left in between the course.
DIET: Unfortunately, there's no specific diet that's been proven to relieve depression. Still, while certain eating plans or foods may not
ease symptoms or put client instantly in a better mood, a healthy diet may help as part of overall treatment.
Antioxidants Prevent Cell Damage
Beta-carotene: apricots, broccoli, cantaloupe, carrots, collards, peaches, pumpkin, spinach, sweet potato
Vitamin C: blueberries, broccoli, grapefruit, kiwi, oranges, peppers, potatoes, strawberries, tomato
Vitamin E: margarine, nuts and seeds, vegetable oils, wheat germ
"Smart" Carbs Can Have a Calming Effect
Carbohydrates are linked to the mood-boosting brain chemical, serotonin. Experts aren't sure, but carb cravings sometimes may
be related to low serotonin activity. Limit sugary foods and opt for smart or “complex” carbs (such as whole grains) rather than
simple carbs (such as cakes and cookies). Fruits, vegetables, and legumes also have healthy carbs and fiber.
Protein-Rich Foods Boost Alertness
Foods like turkey, tuna, and chicken have an amino acid called tryptophan, which may help you make serotonin. Try to eat
something with protein several times a day, especially when you need to clear your mind and boost your energy. Good sources
of healthy proteins include beans and peas, lean beef, low-fat cheese, fish, milk, poultry, soy products, and yogurt.

EXERCISES: Depression symptoms often improve with exercise.
Regular exercise may help ease depression by:
Releasing feel-good endorphins, natural cannabis-like brain chemicals (endogenous cannabinoids) and other natural brain
chemicals that can enhance your sense of well-being
Taking your mind off worries so you can get away from the cycle of negative thoughts that feed depression and anxiety
Regular exercise has many psychological and emotional benefits, too. It can help:
Gain confidence. Meeting exercise goals or challenges, even small ones, can boost your self-confidence. Getting in shape
can also make you feel better about your appearance.
Get more social interaction. Exercise and physical activity may give you the chance to meet or socialize with others. Just
exchanging a friendly smile or greeting as you walk around your neighbourhood can help your mood.
Cope in a healthy way. Doing something positive to manage depression is a healthy coping strategy. Trying to feel better
by drinking alcohol, dwelling on how you feel, or hoping depression or anxiety will go away on its own can lead to
worsening symptoms.
Doing 30 minutes or more of exercise a day for three to five days a week may significantly improve depression symptoms.
But smaller amounts of physical activity — as little as 10 to 15 minutes at a time — may make a difference. It may take less
time exercising to improve mood when one does more-vigorous activities, such as running or bicycling.
FOLLOW- UP: I advised the patient for the regular follow up after discharge.
Patient has been Educated about the importance of regular follow up whenever she will be discharged.
I advised the patient related to any symptom that may relapse after hospital discharge and advised her to come immediately
to hospital if any relapsing symptom will reoccur.
I gave her instruction and education related to her doctor in charge Dr. Ravi Sharma that she can any time contact to her
doctor if any problem will occur after discharge. Information is provided to the family member about the OPD days of Dr.
Ravi Sharma.
I advised client’s family to look for the client patiently and closely observe her as there were chances for suicidal risk in the
client.
Prognosis: Improved (good prognosis).
Social worker: Mrs. Payal Chauhan
Voluntary organizations: Moksha, Sunrise Rebirth Foundation, New born foundation.

S.no. Drugs Dose Frequency Route Action Side- effects
1. Tab. Pan- D 40mg OD P/O Antacid Watery stools, Nausea or Vomiting, Unusual tiredness and weakness, Skin
rash, Loss of appetite, Muscle pain, Dizziness
2. Tab. Olanzapine 5mg BD P/O Atypical
antipsychotics
Drowsiness, dizziness, lightheadedness, stomach upset, dry
mouth, constipation, increased appetite, or weight gain
Rarely cause a condition known as tardive dyskinesia develop
unusual/uncontrolled movements (especially of the face, lips, mouth, tongue,
arms or legs).
For females, this increase in prolactin may result in unwanted breast milk,
missed/stopped periods, or difficulty becoming pregnant.
For males, it may result in decreased sexual ability, inability to produce sperm,
or enlarged breasts.
Serious side effects, including: difficulty swallowing, shaking (tremor), slow
heartbeat, fainting, mental/mood changes (such as confusion, restlessness),
numbness/tingling of arms/legs, yellowing eyes/skin,
Severe stomach/abdominal pain, trouble urinating, interrupted breathing
during sleep, blood sugar rise, which can cause or worsen diabetes, seizures,
neuroleptic malignant syndrome (NMS) following symptoms: fever, muscle
stiffness/pain/tenderness/weakness, severe tiredness, severe
confusion, sweating, fast/irregular heartbeat, dark urine, signs
of kidney problems (such as change in the amount of urine).
Allergic reaction including: fever, swollen lymph nodes, rash, itching/swelling
(especially of the face/tongue/throat), severe dizziness, trouble breathing.

3. Tab. Diva- OD 250mg TDS P/O Anticonvulsant
(or anti-
epileptic)
Headache, Dizziness, Blurred vision, Weakness, Abdominal pain,
Infection, Nausea, Vomiting, Sleepiness, Hair loss, Weight gain, Double
vision, Diarrhea, Tremors, Weight loss, Flu-like symptoms
4. Tab. Lorazepam 1mg BD P/O Benzodiazepin
es
Drowsiness, dizziness, tiredness, weakness, dry mouth, diarrhea, nausea,
changes in appetite, restlessness or excitement, constipation, difficulty
urinating, frequent urination, blurred vision
5. Tab. IFA - BD P/O Iron
Supplement
Constipation, diarrhea, stomach cramps, or upset stomach
allergic reaction, including: rash, itching/swelling (especially of the
face/tongue/throat), severe dizziness, trouble breathing.

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