3.

3 Level of Growth and Development

3.3.1 Normal development of a young adult (Potter and

Perry)
Young adulthood is the period between the late teens and the mid to
late 30s (Edelman and Mandle, 2010). In recent years young adults between
the ages of 18 and 29 have been referred to as part of the millennial generation.
In 2009 young adults made up approximately 33% of the population (U.S.
Census Bureau, 2009). According to the Pew Research Center (2010), todays
young adults are historys first always connected generation, with digital
technology and social media major aspects of their lives. They adapt well to
new experiences, are more ethnically and racially diverse than previous
generations, and are the least overtly religious American generation in modern
times. Young adults increasingly move away from their families of origin,
establish career goals, and decide whether to marry or remain single and
whether to begin families; however, often these goals may be delayed (e.g.,
because of the economic recession of recent years).

Physical Development
The young adult usually completes physical growth by the age of
20. An exception to this is the pregnant or lactating woman. The physical,
cognitive, and psychosocial changes and the health concerns of the pregnant
woman and the childbearing family are extensive. Young adults are usually quite
active, experience severe illnesses commonly than older age-groups, tend to
ignore physical symptoms, and often postpone seeking health care. Physical
characteristics of young adults begin to change as middle age approaches.
Unless patients have illnesses, assessment findings are generally
within normal limits.
 Psychosocial Development
The emotional health of the young adult is related to the individuals
ability to address and resolve personal and social tasks. The young adult is
often caught between wanting to prolong the irresponsibility of adolescence
and assume adult commitments. However, certain patterns or trends are
relatively predictable. Between the ages of 23 and 28, the person refines
self-perception and ability for intimacy. From 29 to 34 the person directs
enormous energy toward achievement and mastery of the surrounding
world. The years from 35 to 43 are a time of vigorous examination of life
goals and relationships. People make changes in personal, social, and
occupational areas. Often the stresses of this re-examination results in a
midlife crisis in which marital partner, lifestyle, and occupation change.

Cognitive Development
Critical thinking habits increase steadily through the young-
and middle-adult years. Formal and informal educational experiences,
general life experiences, and occupational opportunities dramatically
increase the individuals conceptual, problem-solving, and motor skills.
Identifying an occupational direction is a major task of young adults. When
people know their skills, talents, and personality characteristics, educational
preparation and occupational choices are easier and more satisfying. A
bachelors or associates degree is the most significant source of
postsecondary education for 12 of the 20 fastest-growing occupations. An
understanding of how adults learn helps you to develop patient education
plans. Adults enter the teaching learning situation with a background of
unique life experiences, including illness. Therefore always view adults as
individuals. Their adherence to regimens such as medications, treatments,
or lifestyle changes such as smoking cessation involves decision-making
processes. When determining the amount of information that an individual
needs to make decisions about the prescribed course of therapy, consider
factors that possibly affect the individuals adherence to the regimen,
including educational level, socioeconomic factors, and motivation and
desire to learn. Because young adults are continually evolving and adjusting
to changes in the home, workplace, and personal lives, their decision
making processes need to be flexible. The more secure young adults are in
their roles, the more flexible and open they are to change. Insecure persons
tend to be more rigid in making decisions.

Moral Development
Kohlberg stated that the stage of moral development at age
of 26 is at level of conventional, the stage in which the person is concerned
with maintaining expectations and rules of the family, group, nation, or
society. A sense of guilt has developed and affects behavior. The person
values conformity, loyalty, and active maintenance of social order and
control. Conformity means good behavior or what pleases or helps another
and is approved. He/she lives according to principles of law-and-order
orientation that the person wants established rules from authorities, and he
reason for decisions and behavior is that social and sexual rules and
traditions demand the purpose

Spiritual Development
According to Fowler, it is ideal that a person reach stage IV in
their early to mid-twenties, it is evident that many adults never reach it. If it
happens in the thirties or forties, Fowler says, it is much harder for the
person to adapt. It is called the Individuative-Reflective Stage.

This is the tough stage, often begun in young adulthood, when

people start seeing outside the box and realizing that there are other
"boxes". They begin to critically examine their beliefs on their own and often
become disillusioned with their former faith. Ironically, the Stage 3 people
usually think that Stage 4 people have become "backsliders" when in reality
they have actually moved forward.
3.3.2 The ill person at a particular stage of Patient
Many young adults remain healthy; however risk of
developing a health problem is lower than that of the middle adult. Health
risk factors for a young adult originate in the community, lifestyle patterns,
and family history. The lifestyle habits that activate the stress response
increase the risk of illness. Smoking is a well-documented risk factor for
pulmonary, cardiac, and vascular diseases in smokers and the individuals
who receive second-hand smoke. Inhaled cigarette pollutants increase the
risk of lung cancer, emphysema, and chronic bronchitis.
A family history of a disease puts a young adult at risk for
developing it in the middle or older adult years. For example, a young man
whose father and paternal grandfather had myocardial infarctions (heart
attacks) in their 50s has a risk for a future myocardial infarction. The
presence of certain chronic illnesses such as diabetes mellitus in the family
increases the family members risk of developing a disease. Regular
physical examinations and screening are necessary at this stage of
development.
As in all age-groups, personal hygiene habits in the young
adult are risk factors. Sharing eating utensils with a person who has a
contagious illness increases the risk of illness. Poor dental hygiene
increases the risk of periodontal disease. Individuals avoid gingivitis
(inflammation of the gums) and periodontitis (loss of tooth support) through
oral hygiene.
Violence is a common cause of mortality and morbidity in the
young-adult population. Factors that predispose individuals to violence,
injury, or death include poverty, family breakdown, child abuse and neglect,
drug involvement (dealing or illegal use), repeated exposure to violence,
and ready access to guns. It is important for the nurse to perform a thorough
psychosocial assessment, including such factors as behaviour patterns,
history of physical and substance abuse, education, work history, and social
support systems to detect personal and environmental risk factors for
violence. Death and injury occur from physical assaults, motor vehicle or
other accidents, and suicide attempts. In 2007, homicides occurred at a
higher rate among men and people ages 20 to 24 years than other violent
deaths (USDHHS, CDC, 2010)
4. Pathophysiology and Rationale
4.1 Anatomy and physiology of the organ / system affected

FIGURE 1. View of the external surface of the brain showing lobes, cerebellum,
and brain stem.
Source: Brunner and Suddarths Textbook of Medical-Surgical Nursing 10th Edition
 Anatomy of the Nervous System

Three basic functions are performed by nervous systems:

1. Receive sensory input from internal and external environments

2. Integrate the input
3. Respond to stimuli

Sensory Input

Receptors are parts of the nervous system that sense changes in the internal or
external environments. Sensory input can be in many forms, including pressure, taste,
sound, light, blood pH, or hormone levels that are converted to a signal and sent to the
brain or spinal cord.

Integration and Output

In the sensory centers of the brain or in the spinal cord, the barrage of input is
integrated and a response is generated. The response, a motor output, is a signal
transmitted to organs than can convert the signal into some form of action, such as
movement, changes in heart rate, release of hormones, etc.

Divisions of the Nervous System

The nervous system monitors and controls almost every organ system through a
series of positive and negative feedback loops. The Central Nervous System (CNS)
includes the brain and spinal cord. The Peripheral Nervous System (PNS) connects the
CNS to other parts of the body, and is composed of nerves (bundles of neurons).

CENTRAL NERVOUS SYSTEM

The brain is divided into three major areas: the cerebrum, the brain stem, and the
cerebellum. The cerebrum is composed of two hemispheres, the thalamus, the
hypothalamus, and the basal ganglia. Additionally, connections for the olfactory (cranial
nerve I) and optic (cranial nerve III) nerves are found in the cerebrum.
 The brain stem includes the midbrain, pons, medulla, and connections for cranial
nerves II and IV through XII. The cerebellum is located under the cerebrum and behind
the brain stem. The brain accounts for approximately 2% of the total body weight; it
weighs approximately 1,400 g in an average young adult (Hickey, 2003). In the elderly,
the average brain weighs approximately 1,200 g.

Cerebrum
The cerebrum consists of two hemispheres that are incompletely separated by the
great longitudinal fissure. This sulcus separates the cerebrum into the right and left
hemispheres. The two hemispheres are joined at the lower portion of the fissure by the
corpus callosum. The outside surface of the hemispheres has a wrinkled appearance that
is the result of many folded layers or convolutions called gyri, which increase the surface
area of the brain, accounting for the high level of activity carried out by such a small-
appearing organ. The external or outer portion of the cerebrum (the cerebral cortex) is
made up of gray matter approximately 2 to 5 mm in depth; it contains billions of
neurons/cell bodies, giving it a gray appearance. White matter makes up the innermost
layer and is composed of nerve fibers and neuroglia (support tissue) that form tracts or
pathways connecting various parts of the brain with one another (transverse and
association pathways) and the cortex to lower portions of the brain and spinal cord
(projection fibers). The cerebral hemispheres are divided into pairs of frontal, parietal,
temporal, and occipital lobes. The four lobes are as follows:

a. Frontalthe largest lobe. The major functions of this lobe are concentration,
abstract thought, information storage or memory, and motor function. It also
contains Brocas area, critical for motor control of speech. The frontal lobe is also
responsible in large part for an individuals affect, judgment, personality, and
inhibitions.
b. Parietala predominantly sensory lobe. The primary sensory cortex, which
analyzes sensory information and relays the interpretation of this information to the
thalamus and other cortical areas, is located in the parietal lobe. It is also essential
to an individuals awareness of the body in space, as well as orientation in space
and spatial relations.
 c. Temporalcontains the auditory receptive areas. Contains a vital area called the
interpretive area that provides integration of somatization, visual, and auditory
areas and plays the most dominant role of any area of the cortex in cerebration.
d. Occipitalthe posterior lobe of the cerebral hemisphere is responsible for visual
interpretation.

Corpus Callosum

The corpus callosum is a thick collection of nerve fibers that connects the two
hemispheres of the brain and is responsible for the transmission of information from one
side of the brain to the other. Information transferred includes sensation, memory, and
learned discrimination. Right-handed people and some left-handed people have cerebral
dominance on the left side of the brain for verbal, linguistic, arithmetical, calculating, and
analytic functions. The nondominant hemisphere is responsible for geometric, spatial,
visual, pattern, and musical functions.

Basal Ganglia
The basal ganglia are masses of nuclei located deep in the cerebral hemispheres
that are responsible for control of fine motor movements, including those of the hands
and lower extremities.

Thalamus
The thalamus lies on either side of the third ventricle and acts primarily as a relay
station for all sensation except smell. All memory, sensation, and pain impulses also pass
through this section of the brain.

Hypothalamus
The hypothalamus is located anterior and inferior to the thalamus. The
hypothalamus lies immediately beneath and lateral to the lower portion of the wall of the
third ventricle. It includes the optic chiasm (the point at which the two optic tracts cross)
and the mammillary bodies (involved in olfactory reflexes and emotional response to
odors). The infundibulum of the hypothalamus connects it to the posterior pituitary gland.
The hypothalamus plays an important role in the endocrine system because it regulates
the pituitary secretion of hormones that influence metabolism, reproduction, stress
response, and urine production. It works with the pituitary to maintain fluid balance and
maintains temperature regulation by promoting vasoconstriction or vasodilatation. The
hypothalamus is the site of the hunger center and is involved in appetite control. It
contains centers that regulate the sleepwake cycle, blood pressure, aggressive and
sexual behavior, and emotional responses (blushing, rage, depression, panic, and fear).
The hypothalamus also controls and regulates the autonomic nervous system.

Pituitary Gland
The pituitary gland is located in the sella turcica at the base of the brain and is
connected to the hypothalamus. The pituitary is a common site for brain tumors in adults;
frequently they are detected by physical signs and symptoms that can be traced to the
pituitary, such as hormonal imbalance or visual disturbances secondary to pressure on
the optic chiasm Nerve fibers from all portions of the cortex converge in each hemisphere
and exit in the form of a tight bundle of nerve fibers known as the internal capsule. Having
entered the pons and the medulla, each bundle crosses to the corresponding bundle from
the opposite side. Some of these axons make connections with axons from the
cerebellum, basal ganglia, thalamus, and hypothalamus; some connect with the cranial
nerve cells. Other fibers from the cortex and the subcortical centers are channeled
through the pons and the medulla into the spinal cord. Although the various cells in the
cerebral cortex are quite similar in appearance, their functions vary widely, depending on
location. The topography of the cortex in relation to certain of its functions. The posterior
portion of each hemisphere (the occipital lobe) is devoted to all aspects of visual
perception. The lateral region, or temporal lobe, incorporates the auditory center. The
mid-central zone, or parietal zone, posterior to the fissure of Rolando, is concerned with
sensation; the anterior portion is concerned with voluntary muscle movements. The large
area behind the forehead (ie, the frontal lobes) contains the association pathways that
determine emotional attitudes and responses and contribute to the formation of thought
processes. Damage to the frontal lobes as a result of trauma or disease is by no means
incapacitating from the standpoint of muscular control or coordination, but it affects a
persons personality, as reflected by basic attitudes, sense of humor and propriety, self-
restraint, and motivations.

Brain Stem

The brain stem consists of the midbrain, pons, and medulla oblongata The
midbrain connects the pons and the cerebellum with the cerebral hemispheres; it contains
sensory and motor pathways and serves as the center for auditory and visual reflexes.
Cranial nerves III and IV originate in the midbrain. The pons is situated in front of the
cerebellum between the midbrain and the medulla and is a bridge between the two halves
of the cerebellum, and between the medulla and the cerebrum. Cranial nerves V through
VIII connect to the brain in the pons. The pons contains motor and sensory pathways.
Portions of the pons also control the heart, respiration, and blood pressure. The medulla
oblongata contains motor fibers from the brain to the spinal cord and sensory fibers from
the spinal cord to the brain. Most of these fibers cross, or decussate, at this level. Cranial
nerves IX through XII connect to the brain in the medulla

Cerebellum

The cerebellum is separated from the cerebral hemispheres by a fold of dura

mater, the tentorium cerebelli. The cerebellum has both excitatory and inhibitory actions
and is largely responsible for coordination of movement. It also controls fine movement,
balance, position sense (awareness of where each part of the body is), and integration of
sensory input.
NEUROTRANSMITTERS

Neurotransmitters are chemicals which transmit signals from a neuron to a target

cell across a synapse. Neurotransmitters are packaged into synaptic vesicles clustered
beneath the membrane on the presynaptic side of a synapse, and are released into the
synaptic cleft, where they bind to receptors in the membrane on the postsynaptic side of
the synapse.
 ACETYLCHOLINE
Found in the brain, spinal cord and PNS.
Can be inhibitory and excitatory
Synthesized from dietary choline found in red meat and vegetables
Affects sleep- wake cycle and to signal muscles to become active

DOPAMINE

Essential to the functioning of CNS

Excitatory
Involved in emotions, moods and regulation of motor control.
Dopamine forms from a precursor molecule called dopa- manufactured
from liver from amino acid tyrosine.

NOREPINEPHRINE & EPINEPHRINE (ADRENALIN)

Most prevalent neurotransmitter in nervous system.

Excitatory
Has limited distribution in brain but controls fight or flight in PNS
Play a role in attention, learning & memory, sleep and wakefulness and
mood regulation.

SEROTONIN

Its function is mostly inhibitory that includes induction of sleep and

wakefulness, pain control, temperature regulation, control of mood,
memory, and sexual behavior.
Inhibitory
Serotonin is produced in brain from amino acid tryptophan- derived from
foods high in CHON.
HISTAMINE

Involved in emotions, regulation of body temperature and water balance.

Neuromodulators

GLUTAMATE

Excitatory amino acid that at high levels that can have major
neurotoxic effects.

GABA

Most abundant neurotransmitters within the CNS and in cerebral

cortex.

Largely responsible for such higher brain functions as thought and

interpreting sensations.

Major inhibitory neurotransmitter in the brain

4.2.1 Schematic diagram showing the Pathophysiology of the disease

Non-modifiable factors:
-Genetic (1000 % risk)
-Abnormalities in brain structure and of
Modifiable factors:
certain brain circuits
-Trauma and or abusive experiences
-Alterations to mitochondria and sodium
during childhood
ATPase pump
-Acquired Neuroendocrine disorders
-Hereditary Neuroendocrine disorders

Cause:

UNKNOWN and UNCLEAR

Abnormality in the brain and

regulation of neurotransmitters

Disturbed Neurotransmitter Level of:

-Norepinephrine
-Serotonin
-Dopamine
-Gamma Aminobutyric Acid
-Glutamate
-Acetylcholine

Depression as manifested as: Mania as manifested as:

-Depressed mood -Grandiosity
-Diminished behaviour -Decreased need for sleep
-Insomnia -Flight of Ideas
-Feeling of worthlessness -Easy distractibility
-Psychomotor agitation
-Auditory Hallucination
 4.2.2 Disease process and its effect to the organ system
involved

The exact psychopathology of this condition is yet to be determined but several

theories suggest that it arises from a complex interaction of genetic disposition,
neurochemical influences, anatomical variations, substance abuse, and stressful
perinatal and childhood experiences.

I. Biologic Theories:

Genetic theories

Genetic studies implicate the transmission of major depressive first-degree

relatives, who have twice the risk of developing depression compared with the general
population. First-degree relatives of people with bipolar disorder have a 3% to 8% risk of
developing bipolar disorder compared with a 1% risk in the general population. For all
mood disorders, monozygotic (identical twins have a concordance rate (both twins having
the disorder) two to four times higher than that of dizygotic (fraternal) twins. Although
heredity is a significant factor, the concordance rate for monozygotic twins is not 100%,
so genetics alone does not account for all mood disorders (kelsoe,2005)

Markowitz and Milrod (2005) discussed indications of a genetic overlap between

early-onset bipolar disorder and early onset-alcoholism. They noted that people with
cycling, poorer response to lithium, slower rate of recovery, and more hospital
admissions. Mania displayed by these clients involves more agitation than elation; clients
may respond better to anticonvulsants than to lithium.

II. Neurochemical Theories

Neurochemical influences of neurotransmitters (chemical messengers) focus on

serotonin and norepinephrine as the two major biogenic amines implicated in mood
disorders. Serotonin has many roles in behaviour: mood, activity, aggressiveness and
irritability, cognition, pain, biorhythms, and neuroendocrine process. Deficits of serotonin,
its precursor tryptophan, or a metabolite of serotonin found in the blood or cerebrospinal
fluid occurs in people with depression. Positron emission tomographies demonstrate
reduced metabolism in the prefrontal cortex, which may promote depression.

Norepinephrine levels may be deficient in depression and increased in mania. This

catecholamine energizes the body to mobilize during stress and inhibits kindling. Kindling
is the process by which seizure activity in a specific area of the brain is initially stimulated
by reaching a threshold of the cumulative effects of stress, low amounts of electric
impulses, or chemicals such as cocaine that sensitize nerve cells and pathways. These
highly sensitized pathways respond by no longer needing a stimulus to induce seizure
activity, which now occurs spontaneously. It is theorized that kindling may underlie the
cycling of mood disorders as well as addiction. Anticonvulsants inhibit kindling; This may
explain their efficacy in the treatment of bipolar disorder.

Dysregulation of acetylcholine and dopamine also are being studied in relation to

mood disorders. Cholinergic drugs alter mood, sleep, neuroendocrine function, and the
electroencephalographic pattern; therefore, acetylcholine seems to be implicated in
depression and mania. The neurotransmitter problem may not be as simple as
underproduction or depletion through overuse during stress. Changes in the sensitivity as
well as the number of receptors are being evaluated for their roles in mood disorders.

Neuroendocrine influences

Hormonal fluctuations are being studied in relation to depression. Mood

disturbances have been documented in people with endocrine disorders such as those
of thyroid, adrenal, parathyroid, and pituitary. Elevated glucocorticoid activity is
associated with the stress response, and evidence of increase cortisol secretion is
apparent in about 40% if clients with depression, with the highest rates found among older
clients
 4.3 Comparative Chart showing the classical and clinical signs and
symptoms of the disease and rationale

Classical Clinical Rationale

Inflated self-esteem Manifested
or grandiosity
Decreased need for Manifested
sleep
More talkative than Not
usual or pressure to Manifested
keep talking
Manic State
Clients with mania have exaggerated self-esteem. They
believe they can accomplish anything. They rarely
discuss their self-concept realistically
Clients with mania can go days without sleep or food
and not even realize they are hungry or tired.
Clients experiencing manic episode think move and talk
fast.

Flight of ideas Manifested Cognitive ability is confused and jumbled with thoughts
racing one after the other. Clients cannot connect
concepts and jump from one subject to another
Distractibility Manifested The ability to concentrate or pay attention is grossly
impaired because the persons attention span is brief
Psychomotor Manifested Clients with mania experience psychomotor agitation
agitation and seem to be in perpetual motion. Sitting still is
difficult.
Excessive Not Excessive involvement in pleasurable activities that
involvement in Manifested Have high potential for painful consequences
pleasurable
activities that
Have high potential
for painful
consequences
 Depressed State
Depressed mood Manifested Clients with depression describe themselves as
hopeless, helpless, down, or anxious

Diminished interest Manifested They experience anhedonia, losing any sense of

or pleasure in all or pleasure from activities they formerly enjoyed.
most activities

Significant weight Not Clients in the depressive phase manifest weight loss
loss Manifested from lack of appetite or disinterest in eating.

Insomnia Manifested Sleep disturbances are common: either clients cannot

sleep or the feel exhausted and unrefreshed no matter
how much time they spend in bed.
Fatigue Not Because of the lack of food and inactivity, clients feel
Manifested exhausted and unrefreshed.

Feeling of Manifested Clients with depression may describe themselves as

worthlessness hopeless, helpless, down, or anxious. They also may
say they are a burden on others or are a failure to life
Diminished ability to Not Clients with depression experience slowed thinking
think Manifested process. They may not respond verbally to questions

Recurring thoughts Not Often clients with depression have thoughts of dying or
of death Manifested committing suicide.
5. Nursing Intervention

5.1 Care Guide of patient with Bipolar 1 Disorder

Depressive state

Try to sit beside and be in the clients space often people who are
depressed do not like to make demands on others but they appreciate
company. Likewise, you will need to do the talking rather than expecting the
person to do so.
Keep up good levels of communication even when not reciprocated e.g. Let
the client know where you are going even if there is no response.
Provide for the safety of the client and others.
Begin a therapeutic relationship by spending non-demanding time with the
client.
Promote completion of activities of daily living by assisting the client only as
necessary
Establish adequate nutrition and hydration.
Promote sleep and rest.
Engage the client in activities.
Encourage the client to verbalize and describe the emotion.
Set realistic tasks and have realistic expectations.
Be aware of suicide risk. Ask the appropriate questions and communicate
with treating team about this issue. This issue may be a reason for
hospitalization.
If the client expresses unexpected happiness and begins to give
possessions away, seek assistance immediately.
Avoid placing unrealistic demands on the client.
Be patient.
Manic state

Be calm.
Do not participate in the escalation of excitement.
Use simple, clear communications, and make sure the message has been
understood.
Make sure that you move away from potential conflictual situations. Use
their distract ability to come back again.
Do not make too many demands.
Reduce stimulation and loud noises.
Avoid conflict.
Keep the clients real level of expertise in mind. Do not allow yourself to be
overly influenced by their persuasive presentation of advice.
This is very tiring so make sure that you get some space, which you will
need to regulate for yourself the other client may not recognize your need.
When you want space, try to manage your emotional state as the individual
will pick up on your distress and you may have to defend yourself, as the
client will not see themselves as unreasonable.
Be genuine, try not to turn off. When something is funny enjoy it.
Be conscious of the safety factor. The danger of physical complications may
be one of the trigger factors to indicate the need for hospitalization.
Remember it is very easy for this client to end up with disturbed sleep
patterns, sleep late and spend half the evening ringing people.
In hot weather, fluid replacement is important, particularly when the client is
on lithium. Clients can become so dehydrated that the blood concentration
of lithium increases to such an extent that the person can go into a hepatic
coma. Lithium also increases sensitivity to sun
Encourage the client to drink small amounts regularly. Consider what the
client likes to drink and make it easily available. Address nutrition in the
same way, thinking of high-energy food.
Encourage the client to have a bath or a shower
 Some client suggest warm drinks, but not coffee or tea. This helps the
person feel looked after.
Be assertive about your own boundaries in a friendly manner
Reduce access to dangerous situations.
 5.2.1 Nursing Care Plan

Cues Nursing Scientific Objectives Intervention Rationale Evaluation

Diagnosis basis
Subjective report of Ineffective coping Inability to form General :
worry related to impaired a valid After 5 days of holistic GOAL
mingaw na gud kung adaptive behaviour appraisal of the nursing care, the pt will UNMET: client
MAMA Bro ba. Wala stressors, be able to reach still unable to
syay kauban sa balay inadequate Optimum Level of assess current
as verbalized by the choices with Functioning situation
patient practiced Specific : accurately
responses, After 8 hrs of nurse-pt 1.Determined 1.to determine degree of
Objective- and/or inability interaction, the pt will be individual stressors impairment
Looks worried to use able to assess current 2. Evaluated ability to 2.to determine degree of
available situation accurately understand events impairment
resources. and provide realistic
Source : appraisal to the
Doenges, situaion
Moorhouse, 3. Ascertained clients 3. to assess coping abilities
Murr Nurses understanding of and skills
Pocket current situation and
Guide12th its impact on life
edition 4.Called client by 4. using clients name
name. Ascertain how enhances sense of self and
clients prefer to be promotes individuality and
addressed self-esteem
5. Used reality 5. to assist client deal with
orientation current situation
6. Assisted client in 6. to assist client deal with
use of diversion and current situation
recreation
techniques
7.Encouraged 7.to provide for meeting
verbalization of psychological needs
feelings and fears
8. administered 8.to aid pharmacologically
prescribed
medication
 Cues Nursing Scientific basis Objectives Intervention Rationale Evaluation
Diagnosis
Subjective - laay kaau ari Deficient Decreased General : GOAL MET:
oy. Maaug muinit kay diversional activity stimulation from After 5days of holistic the client
makagawas mi pero lay related lack of recreational or nursing care, the pt participated in
ghapun oy. environmental leisure activities. will be able to reach the activity/s
Objective: stimulation Optimum Level of intervened
-Disinterested in the Source : Functioning.
environment Doenges, Specific:
-lethargic noted Moorhouse, Murr After 8 hrs of nurse-pt
Nurses Pocket interaction, the pt will
Guide12th be able to engage in 1. Assessed clients 1. validates reality of
edition satisfying activities physical, cognitive, environmental deprivation
within personal emotional, and when it exists
limitations. environmental status 2. to establish therapeutic
2. Acknowledged the relationship and support
reality of situation and helpful emotions
feelings 3. to provide positive sensory
stimulation, reduce sense of
3. Provided change of boredom, improve sense of
scenery normalcy and control
4.Involved 4. to provide positive sensory
recreational, play, stimulation, reduce sense of
music therapy as boredom, improve sense of
appropriate normalcy and control
5. determined actual
ability to participate
and interest in 5. presence of acute illness,
available activities, depression or sensory
noting attention span, deprivation may interfere with
physical limitations desired activity
and tolerance, level of
interest or desire and
safety needs.
6. administered 6.to aid pharmacologically
prescribed medication
 Cues Nursing Scientific basis Objectives Intervention Rationale
Diagnosis Evaluation
Subjective - Risk for self- At risk for General :
directed violence behaviors in After 5 days of holistic GOAL MET:
Objective- and or other which an nursing care, the pt the client does
-psychiatric diagnosis of directed violence individual will be able to reach not
bipolar 1 disorder related to mental demonstrates Optimum Level of demonstrate
-living with people with health problem that he/she can Functioning any
co-mental health and be physically, Specific : 1. Determined the 1. to assess causative or violent
problems in an environmental risk emotionally, and After 8 hrs of nurse-pt underlying dynamics contributing factors behavior
environment which had or sexually interaction, the pt will of etiology 2. to assess causative or
risk for violent behaviors harmful to self be able to 2. Ascertainn clients contributing factors
-history of and or others demonstrate self- perception of self and
aggressiveness and control as evidenced situation
violence toward others In manic phase by nonviolent 3. Observed and 3.may indicate possibility of
A risk diagnosis negative, behaviors listened for early cues loss of control and to
is not evidenced uncontrolled of distress and or intervene at this point to
by signs and thoughts feeling increasing anxiety prevent a blow-up
symptoms, as the and behavior 4.Determine 4 to assess causative or
problem has not pose a threat or availability of contributing factors to prevent
occurred; rather danger to harm homicidal and or violence against self and or
nursing self or other. They suicidal means others
interventions are are aggressive, 5. Developed SN- 5.to promote sense of trust
directed at hostile and cleint relationship allowing to discuss feelings
prevention cannot evaluate openly
the consequence 6.remain calm and 6.to set boundaries on clients
of their behavior. state limits on behavior
inappropriate
behavior in a firm
manner
7.administered 7. to aid pharmacologically
prescribed medication Source :
-Doenges, Moorhouse, Murr
Nurses Pocket Guide12th
edition
-Sheila L. Videbeck 2011
Psychiatric-Mental Health
Nursing 5th Edtion
 5.2.1 Drug Therapeutic Record

Drug Classification/ Indication Contraindication / Side Effect Nursing Responsibility

Action
Name : Classification : -psychotic disorder Contraindication : Before
haloperidol Dopaminergic- -tourettes syndrome -hypersensitivity Educated for possible side effects.
Dose :20 mg blocking agent -behavioral problem -coma During
Route : PO Antipsychotic in children -severe CNS depression - Ensured that the patient took the
Frequency : once a -hyperactive -Parkinsons disease medicine
day Action: children -liver damage After
Mechanism not fully Avoided activities that require
understood, Side Effect: alertness
antipsychotic blocks -Dry mouth Avoided alcohol during treatment
post synaptic -nausea and vomiting Avoided prolonged exposure to
dopamine receptors in -seating sunlight
the brain, depress the -drowsiness Educated not to withdraw dug
RAS, including those -headache abruptly unless prescribed
parts of the brain that -vertigo Educated the importance of
are involved with -extrapyramidal syndrome compliance to therapeutic regimen
wakefulness and Monitored for signs and symptoms of
emesis. Side Effects

Source : Lippincott 2013 Nursing Drug Guide

12th edition
Drug Classification/ Action Indication Contraindication / Side Effect Nursing Responsibility

Name : Classification : - Schizophrenia Contraindication Before

olanzapine Therapeutic Class: - Manic Bipolar 1 - Hypersensitive to drug Educated for possible side effects
Dose :10 mg Antipsychotic disorder - Sedation incluiming coma Informed patient that he may gain
Route : PO Pharmacologic Class: - Agitation caused - Caution in patients with heart weight
Frequency : once a Dibenzapine by Schizophrenia disease, cerebrovascular During
day derivative and Bipolar 1 disease, conditions that - Ensured that the patient took the
disorder predispose patient to hypotension medicine
Action: - Depressive and hepatic impairment. After
May block dopamine episodes of Side Effect Avoided activities that require
and 5-HT2 receptors Bipolar 1 disorder - CNS: somnolence, insomnia, alertness
- Obsessive- parkinsonism, dizziness, Avoided alcohol during treatment
Compulsive neuroleptic malignant syndrome, Avoided prolonged exposure to
Disorder suicide attempt, abnormal gait, sunlight
- Tourette asthenia, personality disorder, Informed patient to rise slowly to
Syndrome akathisia, tremor, articulation avoid dizziness upon standing up
impaitment, tardive dyskinesia, quickly
fever Educated not to withdraw dug
- CV: orthostatic hypotension, abruptly unless prescribed
tachycardia, chest pain Educated the importance of
hypertension, ecchymosis, compliance to therapeutic regimen
peripheral edema, hypotension
Monitored for signs and symptoms of
- EENT: Amblyopia, rhinitis,
Side Effects
pharyngitis, conjuctivitis
- GI: constipation, dry mouth,
dyspepsia, increased
appetite,increased salivation
vomiting, thirst
- GU- hematuria, metrorrhagia,
urinary incontinence, UTI,
- Hematologic : leucopenia
- Metabolic: htperglycemia, weight
gain
- Musktal: joint pain extremity
pain, back pain, neck rigidity,
twitching hypertonia
- Respir: increased cough,
dyspnea
- Skin: sweating
Other: flulikesyndrome, injury.
Source : Lippincott 2013 Nursing Drug Guide
Overdose Signs and Symptoms: 12th edition
Agitation, aggressiveness,
dysarthria, tachycardia, EPS,
reduced level of consciousness,
CP arrest, cardiac arrhythmias,
delirium, NMS, respi depression,
seizures, HPN, hpn
Drug Classification/ Action Indication Contraindication / Side Effect Nursing Responsibility

Name : Classification : parkinsonism Contraindication Before

Biperidine Anticholinergic -relief of symptoms -use cautiously with tachycardia, Educated for possible side effects
Dose :2mg Action: of extrapyramidal pregnancy and lactation During
Route : PO Anticholinergic disorder -reduce dosage in hot weather - Ensured that the patient took the
Frequency : twice a Activity in the CNS that Contraindications: -discontinue or reduce dosage if dry medicine
day is believed to -hypersensitivity mouth makes speaking or swallowing After
normalize -close-angle difficult Avoided activities that require
The hypothesized glaucoma Side Effect alertness
imbalance of -peptic ulcers disorientation Avoided alcohol during treatment
cholinergic and -confusion Avoided prolonged exposure to
dopaminergic -nervousness sunlight
neurotransmission in -light headedness Informed patient to rise slowly to
the basal ganglia in the -dizziness avoid dizziness upon standing up
brain. -dry mouth quickly
. -blurred vision Educated not to withdraw dug
abruptly unless prescribed
Educated the importance of
compliance to therapeutic regimen
Monitored for signs and symptoms of
Side Effects

Source : Lippincott 2013 Nursing Drug Guide

12th edition
 5.2.3 Nursing Process Recording
Setting and Appearance of the Student Nurse Verbalization Patients Verbalization Students thoughts and Communication technique used and
patient feelings concerning the rationale
interaction
The patient is wearing a red musta naman ang imu paminaw okey raman I was quite nervous and Encouraging expression
colored jacket, shorts and Churchill fearful on what may asking the client to appraise the quality
slippers. The patient looks happen next of his or her experiences
interested for the conversation.
ako diay si Jack imung Student- ah. Di diay mo kadtong Giving information
Nurse. Gkan diay mi sa Leyte. Tga- tagaBOHOL? making available the facts that the client
Naval State University mi ug naa mi needs
kutob sa sabado, January 21, 2017.
Naa mi ari sugod alas sais (6) sa
buntag kutob alas 2 sa hapun
lahi man to sila nga school. Taga- ah Giving information
Bohol State University to cla ug making available the facts that the
kutob rato sila sa alas 10 sa buntag client needs
okey ra mangutana ko nimu okey ra man I was delighted that the Asking consent
C******l? patient accept my allows client to cooperate with his/her
invitation for my queries own will
taga-asa diay ka CHURCHILL? taga-Carcar man ko. Exploring
delving further into a subject or an idea
ah. Kahinumdum ka nganu miabut di man ko buang. Acceptingindicating reception
k ngari C******l? Nahadlok man gud akong Exploring
Mama maTOKHANG ko delving further into a subject or an idea
matokhang? Giunsa man nimu Gagamit man gud ko ug My nervousness was Seeking information
pagkasulti nga iTokHang ka bawal kadtong una pero replaced with interest seeking to make clear that which is not
C******l? dugay naman to kaau meaningful or that which is vague
 unsa man sad nga bawal imu sama gud sa droga, Seeking information
gigamit diay? rugby nya syrup pud seeking to make clear that which is not
meaningful or that which is vague
The patient looks sad and ah. Nahadlok imu mama? Giunsa hadlok man cla nga I was sad also but I Acceptingindicating reception
derpressed. man nimu pagkaingun nga nahadlok mapareha ko kanang sa didnt show it to the Encouraging expression
imu mama diay C*******l? TV gud. Kanang mapatay patient. I showed asking the client to appraise the quality
lag kalit ba. Mao na ilang empathy rather than of his or her experiences
kahadlokan. Mao gidala sympathy.
ko sa aku Mama ug
maguwang ari
cgue pa diay kag gamit atong bawal dugay na oy. Kadtu last I wasnt nervous Exploring
diay year pa. sugod sa anymore cause I sensed delving further into a subject or an idea
birthday naku. that the patient was not
violent as I think.
kanus-a man to imu Birthday oh gad. Dec 30, 1991 Exploring
C******l? kadumdum ka? delving further into a subject or an idea
The patient suddenly looks and ah. So pipila palang diay ka Kadto pa last year man. I was amazed how he Acceptingindicating reception
acts as energetic. kaadlaw diay gaundang Suwatan natog kanta imu shift suddenly from one Exploring
notebook bi. topic to another. delving further into a subject or an idea
kanta? Unsa man sad nga kanta bisaya ni. Ako ra Seeking information
imu isulat sad? nagsuwat ani ganue. Title seeking to make clear that which is not
ani kay tambag meaningful or that which is vague
wala man koy lapis ari C*****l kanang ballpen nalang

pagamiton tikag ballpen basta di ni oh gad, pagsuwat lang

gamiton para makipag-away hap! ang ballpen
Ang ballpen para pagsuwat
lamang.
 dia ra C******l oh. (he wrote the song he
mentioned above)
unsa mani nga kanta C*****l? puedi about na sa atoa. Cause Exploring
ko nimu sultian kung para asa mani we are all Son of GOD, in delving further into a subject or an idea
nga kanta? the name of Jesus Christ
cgue daw palhug ko ug kanta ani (he sang the song) I was amazed and
C******* mesmerize by his ability
to sing.
maayu man diay ka mukanta doctor mo bro? Giving recognition
C******l acknowledging, indicating awareness
student-nurses mi C*****l. ah. Nagskuwela man sad Giving information
nagskuwela mi ug nursing nga ko, 3rd year nko. making available the facts that the client
course needs
unsa man imu course C******l Bachelor of Arts in Exploring
diay? English ko. delving further into a subject or an idea
imu course kay Bachelor of Arts in Magprform mi anah. Im a Exploring
English? Mag-unsa man diay mo ana total performer, Im a delving further into a subject or an idea
C******l? judge and a performer.
You mean performer and judge ka? Gajudge man ko ug mga I didnt believe on what Seeking information
Giunsa man nimu pagsulti nga perormances nya kabalo he said instead I assume seeking to make clear that which is not
performer ug judge ka? sad ko mukanta ug it a feeling of grandiosity meaningful or that which is vague
maggitara, drums, baho. only. Exploring
delving further into a subject or an idea
Pedro approaches and shouts
1+1?
Mukanta? Puedi mngayug sample two, ayg samuk dha Bro. I assume it as a Seeking information
nimu C****l? May banda pa ganue ko manifestation of being seeking to make clear that which is not
(2) duha kabouk. easily distracted. meaningful or that which is vague

As he replied, he suddenly
looks sad and depressed.
All of the patients were called for
their lunch. Our conversation
ended.
Astiga gud anah C****l Unsa man
sad ngalan sa imu banda C****l?
Black Damp? Palhug daw ko ug
spell out C*****l?
Ah. Nya ung isa?
Ah. Musta naman imu Banda karun
C*****l?
Uyab nimu dati?
Puedi ko nimu sultian nganuj
gabulag mo C*******l?
Cgue-cgue
Black Damp ang isa nya Exploring
ang isa jelvaniers delving further into a subject or an idea
B L A C K nya space D A Seeking information
M P seeking to make clear that which is not
meaningful or that which is vague
J E L V A N I E R S, mao Acceptingindicating reception
na nag ako is aka banda Seeking information
seeking to make clear that which is not
meaningful or that which is vague
Exploring
delving further into a subject or an idea
Okey raman to, nay bag- I sensed that what he Acceptingindicating reception
o na cla lead singer. Ang claimed is true. Exploring
kadto asawa sa aku uyab delving further into a subject or an idea
dati.
OO, uyab mi ato six (6) Seeking information
years pero gibiyaan ko seeking to make clear that which is not
niya. Sakitan ko Bro oy meaningful or that which is vague
Okey raman mi ato nya Exploring
gisultian nlang ko saku delving further into a subject or an idea
kabanda sad nga gi-okoy
ang aku uyab ni Richie
sakitan ko Bro oy
Kaon sang ko Bro
Date: January 19, 2017 Time: 1:00 pm
The patient is wearing a black Musta naman ka C*****l?
colored jacket, shorts and
slippers.
As he replied, he suddenly looks Mingaw ka sa imu Mama? Kanus-a
sad and depressed. man diay sad to last gabisita nimu
C******l?
Bdaw nangita pato ug kwarta
C****l.
giunsa man nimu pag-ingun nga
buangun ang mga ayu ari C*****l?
Wala man ko kabalo ana C*******l
nganu gdala ka ari pero ang mga
Doktor man ang gakita nimu nya
may nakita sila nga dili maayu sa
imu karun. Di mana sila magdala ari
kung okey imu paminaw.
Okey raman, mingaw Encouraging expression
lague kong Mama Bro oy. asking the client to appraise the quality
Wala syay kauban sa of his or her experiences
balay?
Miari man to siya kadtong I felt sad as well but I Seeking information
Sabado pero gaingun man didnt show it. seeking to make clear that which is not
to sya nga mubalik sya meaningful or that which is vague
karun pero wala paman
mingaw na kaayu oi .
Mao lague sad pero di
man ko kailangan
presohon ari kay
presohan mani sa mga
buang. Di man ko buang.
Ang mga buang ayuhon,
ang mga ayu buangun.
Kitaa ra gud na cla. Naay Seeking information
gahubo, glakaw-lakaw seeking to make clear that which is not
nya gatuyok-tuyok. Kinsa meaningful or that which is vague
ba pud kaha di mabuang Exploring
ana kauban. delving further into a subject or an idea
Ganahan na kaayu ko
mugawas ba.

Date: January 21, 2017 Time: 1:30 pm
The patient was on the CMU. He
was holding the wall rails while
waiting for her mothers arrival.
He is wearing white polo shirt
with prints, shorts and slippers.
The patient looks just got wake
up and seems happy.
Ang imu mabuhat karun C*****l para Mao mana aku gbuhat.
mapadali imu paggawas kay Maminaw man ko niya di
mutumar ka sa imu mga tambal nimu sad pabalong.
ug tumanun ang mga tambag sa
mga Doktor, Nurse o bisan Student-
Nurse.
Musta naman imu paminaw Bro? Okey lang man Bro. Naa Encouraging expression
naman si Mama. asking the client to appraise the quality
of his or her experiences
Naa na imu Mama? Oo Bro, tua pa sa gawa. I was delighted and Seeking information
gapalit pa ug tinapay. happy. seeking to make clear that which is not
meaningful or that which is vague
Ahh, maayu. Kuan diay Bro, Aww, oo. Sabado man Acceptingindicating reception
manguli nami karun. Last day nani diay karun. Cgue Bro,
namu karun ayo-ayo. Tarung ug
skwela.
O gad Bro, kaw pud ari. Ganahan na sad ko mouli
Bro oy
Ganahan na kaau ka mouli? Mao lague Bro, kapoy ari
oy.
Basta tumanun nimu ubsa gisulti Lague sad
sa Doktor, sa Nurses unya dili
magsiaw-siaw.
Cgue-cgue Bro
 5.2.4 FDAR Charting
Date Focus Data Action Response
January Deficient Received patient -Assessed physical, cognitive, Patient
18, 2017 diversional lethargic and emotional and environmental participated in
activity disinterested in factors the morning
the environment -informed the importance of exercise and
diversional activity (morning verbalized the
exercise) importance its
-encouraged to participate into importance
diversional activity
-encouraged verbalization of
feelings
-change of scenery provided
January Deficient Received patient -Assessed physical, cognitive, Patient
19, 2017 diversional lethargic and emotional and environmental participated in
activity disinterested in factors the morning
the environment -informed the importance of exercise and
diversional activity (dance verbalized the
therapy) importance its
-encouraged to participate into importance
diversional activity
-encouraged verbalization of
feelings
-change of scenery provided
 5.2.5 Health Teaching Plan
Objective Content Methodology

General Objective

After 5 days of
student nurse-client
and significant others
interaction the client
will be able to gain
knowledge, attitude,
and skills.

After 45 minutes of
student nurse-client
interaction the client
will be able to:

1.state the
importance of having
proper hygiene

1.Importance of having good hygiene Discussion

1.1 best defense against diseases

1.2 pleasing to look

1.3 stress free person is not irritable

2.cite ways in 1.4 proper blood circulation

maintaining proper
1.5 promotes optimum level of functioning
hygiene
 2. Ways in maintaining proper hygiene Discussion

2.1 taking a bath

2.2 brushing teeth

2.3 changing clothes everyday

3.enumerate ways on 2.4 wearing slippers

how to cope with
2.5 keeping fingernails short
loneliness

3.Ways to cope with loneliness Discussion

3.1 listening to music

3.2 watching television

3.3 talking with other people

3.4 playing ball games

4.demonstrate proper
way in taking a bath 3.5 playing cards with friends

4.Proper way in taking a bath Demonstration

and return
4.1 wet your body
demonstration
4.2 apply shampoo and massage your hair
properly and rinse

4.3 apply soap and rinse

5.the family would be
able to discuss 4.4 wipe your body with a towel until dry

preventive measures 4.5 change dirty clothes with clean one

of relapse
5.Preventive measures to prevent relapse

5.1.Encourage family to provide a quiet ,calm,

atmosphere.
Discussion

5.2.Instruct the family members to set limits on

acting out behaviours of the client and learn ways to
express emotions in an acceptable manner.

5.3.Encourage restful environment where

possible .

5.4.Advise the family or S.O. to help the client in

setting limits on acting out behaviours and learn way to
express emotions in an acceptable manner.

5.5.Encourage structured or controlled increase

in physical activity.

5.6.Encourage client to avoid strenuous activity.

 6. Evaluation and Recommendation
6.1 Prognosis based on Nursing assessment and rationale
Clients often do not understand how their illness affects others. They may
stop taking medications because they like the euphoria and feel burdened by the
side effects, blood tests, and physicians visits needed to maintain treatment.
Bipolar I disorder is treatable with a lifetime regimen of psychotropic drugs in
combination with psychotherapy.

Based on the gathered data by the student-nurse, the prognosis of patient

is good for the reason that he had followed all the therapeutic regimen prescribed.
6.2Recommendation to promote early recovery and rehabilitation
Patient is recommended to follow therapeutic regimen accurately as
prescribed by physician, to participate in any of the activities within personal limits,
to maintain good personal hygiene and must avoid to engage in any violent
activities.
7 Evaluation and Implications to:
7.1 Nursing Education
The main purpose of this case study in nursing education is to develop
individuals, to broaden their knowledge related to the condition, enhance their
nursing attitude in rendering care to patient who has Bipolar 1 Disorder.
7.2 Nursing Practice
The study will help student nurses and individuals (health care provider) to
utilize the concepts learned in planning and implementing care to patients with
Bipolar 1 Disorder.
7.3 Nursing Research
The researchs aim is to help for the new researches to obtain factual datas
internationally, nationally and locally. Its target is to discover treatment to eliminate
existing problem, and to decrease the morbidity and mortality rate in our country
and in other countries.
8. Discharge Planning
Objectives:
After 30 minutes of discharge instructions, the patient will be able to:
1. Verbalize understanding about his present condition;
2. Identify methods that will provide relief of anxiety regarding
her condition; and
3. Repeat the instructions provided
Exercise / Activity:
Type of activity allowed/ to be continued: ROM exercises
Procedure or steps:
Proper Bathing
4.1wet your body

4.2 apply shampoo and massage your hair properly and rinse

4.3 apply soap and rinse

4.4 wipe your body with a towel until dry

4.5 change dirty clothes with clean one

Health Teachings
1. state the importance of having proper hygiene

2. enumerate ways on how to cope with loneliness

3. cite ways in maintaining proper hygiene
4. demonstrate proper way in taking a bath
5. preventive measures of relapse
6. state the importance of compliance to therapeutic regimen

Diet: Diet as tolerated

Restrictions: NONE

Follow-up: Not yet defined

9. Bibliography

Electronic Books:
Potter & Perry Fundamentals of Nursing 8th Edition
Kozier and Erbs Fundamentals of Nursing 10th edition
Martini, Ober, Bartholomew Visual Essentials of Anatomy & Physiology
Marrilyn E. Doenges Nurses Pocket Guide Diagnoses, Prioritized Interventions
and Rationales 12th Edition
Lippincott Manual of Nursing Practice Handbook 3rd Edition
Lippincott William and Wilkins Nursing 2013 Drug Handbook
Brunner and Suddarths Textbook of Medical-Surgical Nursing 10th Edition
A. Pillitteri Maternal and Child Health Nursing- Care of the Childbearing and
Childrearing Family 6th Edition
Lippincott William and Wilkins Medical-Surgical Nursing Made Incredibly Easy
3rd Edition
Kemp, Burns, and Browns The Big Picture Pathology
Sheila L Videbeck, 2011 Psychiatric Mental Health Nursing 5th Edition