RUNNING HEAD: Mental Health Case Study: Bipolar Disorder 1

Mental Health Case Study: Bipolar Disorder

Madison Bokros

Youngstown State University

NURS 4842: Mental Health Nursing

Professor Teresa Peck

December 1, 2020
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER
Abstract

Bipolar disorder is something that effects many lives throughout the world, making the lives of

many much more difficult to manage on a daily basis. Bipolar disorder is similar to depression

in a way that it can cause withdrawal from social settings, periods of major depression, and lack

of motivation. However, bipolar disorder differs from depression when it comes to the manic

aspects of the disorder. These manic characteristics can show in different forms, and it divided

into two types. Bipolar I disorder and bipolar 2 disorder are different in terms of how severe the

episodes may be. Bipolar I disorder will experience full manic episodes, which include a loss of

reality during exacerbations that can even lead to death due to exhaustion in very severe

situations, whereas bipolar 2 disorder will experience only hypomanic episodes, which are

considered less severe than a full manic episode that is seen within bipolar I disorder.

Throughout this paper, it will discuss the struggles an individual faces with bipolar I disorder. It

can be expected to read the characteristics of this patient’s behavior, the discussion of bipolar

disorder, how to evaluate this information, and how it is applicable to nursing. It will discuss the

importance of treating a patient with bipolar disorder due to the complications it brings forth in

his or her life.

Key words: Bipolar, Disorder, Manic, Diagnoses, Depression, Behaviors

Objective Data:

While caring for this patient, there was much evidence of bipolar I disorder. The patient

is a 56 year old male, who will be referred to as “G.S.” throughout this paper, and had no other

known diagnoses other than bipolar I disorder. He had one previous hospital admission for

psychiatric reasons, however the date was not listed. He has no known drug allergies and no

other medical diagnoses. It was apparent throughout the interviews, that G.S. was experiencing a

manic episode, but more specifically, he was in stage II of mania. Stage II mania is expected to

see certain characteristics such as loss of judgment, euphoria, grandiose, paranoid, irritable,

hyperactive, ideas of reference, pressured, manipulative, demanding, and/or hyper-religious.

G.S. projected most of these characteristics throughout the interviews. For example, he

showed loss of judgment while describing his drinking habits and various sexual partners. He

admitted to visual hallucinations while being intoxicated by alcohol and marijuana. G.S.

portrayed euphoria throughout most of his interview, when asked how things were going, he said

things were great, and that they have always been great. He then went on to sing Frank Sinatra

songs in order to show how happy he truly felt. G.S. then began describing that he was the best

violin player after just practicing for two months, but he was not surprised that it only took him

two short months to learn the instrument, which was very clearly grandiosity. He also

demonstrated grandiosity when telling a story about how he told farmers how to farm. He

ridiculed them and accused them of having no idea what they were doing. He then could not

understand why the farmers were angry with him. G.S. further suggested that he was a genius,

which also exemplified grandiose behavior.

G.S. became slightly irritable and paranoid when asked about his aunt, who he does not

seem to get along with. He feels as though she is forcing him into treatment that he does not
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER
need. He gets specifically irritable when the interviewer asks him if money truly does speak to

him. G.S. also shows paranoia and accuses the interviewer of not believing him, because he

questioned the idea that money was actually speaking to him. His perception of money speaking

to him also demonstrated ideas of reference, because he was taking something completely

irrelevant to his life, and using it as a sign that is convincing him to act a certain way. In this

instance, the money was speaking to him in order to get him to spend his money on things that

are not necessary. From the very beginning of the interview until the very end, he was extremely

hyperactive. This is very obvious through certain tendencies he carried with him throughout the

interview such as rapid hand gestures, rapid speech patterns, and speaking in a loud and agitated

tone. G.S. perceives moments of pressure because he feels as though he does not need help, but

is pressured by his aunt to make the right decision. He becomes demanding during this time, and

even manipulative, because he tries to explain that he does not need help, and that he is in a great

place mentally. He tries to manipulate the interviewer as well by stating he was only in rehab

because it was a mistake, and continued to be manipulative in an effort to make it seem like he

was in a good place mentally. As for being hyper-religious, G.S. does not seem to fit this

category, but does mention that he follows “Mother Earth” and feels connected to the universe.

Medically, he appeared to be healthy, with all of his labs in good condition. The labs that

were ran during his stay, which began on October 27th, 2020, were TSH and T4, which were

within normal range. His Lithium level was also 0.2 mEq/L, which was considered low, being

that the normal range should be 0.6-1.2, which may indicate lack of medication compliance, and

could explain his manic episode that he is currently having. He was prescribed Lithium 600 mg

daily, which should make his Lithium levels well within range if he is practicing medication

compliance. The rest of his labs appeared to be in good conditions, other than his ALT and AST
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER

values being slightly elevated, with his ALT at 59 units/L and his AST at 46 units/L. G.S. also

tested positive for marijuana upon admission, and his blood alcohol content was 0.25 upon

admission, which is over three times the legal limit, proving him to be very intoxicated.

Discussion of Mental Illness:

To summarize bipolar I disorder, it is a disorder that can be characterized by extreme

mood changes and major depressive symptoms, while also potentially leading to a state of

euphoria, which is then considered the manic state, then returning back to normalcy. In the

article, “Diagnosis and Treatment of Patient with Bipolar Disorder: A Review for Advanced

Practice Nurses” it explains that this all happens within a few months, therefore; it is not

something that appears one time in a person’s life, then expires when the person goes back to

their version of normal (Ursula McCormick MSN, RN, PMHCNS-BC, et. al 2015). Bipolar I

disorder includes stages of mania, with the first stage being hypomania. Hypomania is known as

have manic symptoms, but in a mild form that does not necessarily prevent the person from

activities of daily living, or negatively affect their social life. During this stage, it is normal to

see behaviors such as a happier mood with different ideas coming to mind, the person may seem

to be setting much larger goals. They also present signs of impulsivity, which include spending

too much money, making rash decisions, and in some cases loss of judgment. It is expected that

this person will have a heightened desire to interact with others, along with an increase in libido,

and creating superficial relationships. During this time, the person may not sleep any more than

four to five hours a night, claiming they feel too good and energized to need sleep. After these

feelings of euphoria subside, it is likely that the person will fall into a major depressive state. It

is common to see this phase when a person stops taking their medication, until they reach a point

of acute mania.
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Acute mania is stage two of the bipolar disorder stages, it is during this stage is when the

person will lose functioning, and need to seek medical attention. During this phase it is expected

that the person will present characteristics such as flight of ideas, increased speech patterns,

talking in a louder tone, psychomotor activity, pacing or fidgeting, unable to sit still, self-

medication, little to no sleep, increased sexual and social behaviors, tendencies of grandiosity,

and increased anxiety and irritability with a potential to become aggressive. During this stage,

the person may also experience delusions or hallucinations, but these are not necessary for a

bipolar diagnosis. This means that a person may still be diagnosed with bipolar disorder and

considered manic, without ever having delusions or hallucinations. Often times with people who

are experiencing acute mania, their version of self-medication may include illegal substances like

alcohol, marijuana, opiates, or other recreational street drugs. At this point, it is crucial that the

person seeks medical attention in order to prevent them from dwindling into delirious mania.

The third, and final, stage of bipolar disorder is stage three, which is known as delirious

mania, or psychotic mania. At this point, the person has lost all touch of reality, and is

experiencing the acute mania symptoms to the absolute fullest extent. During this time it is

normal to see behaviors such as a loss of reality, hallucinations or delusions, a labile mood or

panic and anxiety, constant psychomotor movements, and eventually reach a point of exhaustion.

Once the exhaustion phase takes over, the person will have gone so long without sleep that it

actually puts them at a risk for death due to exhaustion. It is the most severe stage in bipolar

disorder, and it is not uncommon to see this stage become fatal to a person. In most cases, this

stage is avoidable due to intervention taking place during the acute manic stage. However, there

are instances in which acute mania goes ignored, one of them being that the person is too

paranoid to seek help because they feel as though everyone is out to get them. It is important for
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER

people with bipolar disorder to have a support system that will be able to acknowledge when

they are reaching a point of needing mental health help, because it could potentially be the

difference between life or death.

Identify Stressors and Behaviors:

G.S. had many stressors and presented lots of behaviors in his life that could have

potentially led him to his point of acute mania. G.S. had a father who walked out on his family

when he was only ten years old, and his mother passed away from cancer when G.S. was only

fifteen years old, which prompted him to move into his aunt’s house, who he has been living

with ever since. Since living with his aunt, G.S. has not enjoyed it much because although he

states he loves her, he believes that she does not understand him. As of now, his aunt is the one

who is responsible for his finances, which could be a point of frustration for G.S. because he

would like to spend his money as he pleases. G.S. does not currently have a driver’s license, and

will borrow his aunt’s car from time to time, which could also be a potential for tension because

he may not have access to the car as much as he pleases.

Recently, his behavior within all aspects of his life has not appeared to be normal for him.

He had just lost his job as a shelf-stocker at Walmart and got into a fight with his best friend,

who he has not spoken since. G.S. states he also been fighting with his aunt more than usual,

and has been using marijuana and alcohol to help himself cope with these stressors. Patient also

states he has been experience hallucinations and showed signs of delusional thinking. These

thoughts may have all started due to the fact that he admitted to stopping his medications,

Lithium and Risperidone, which could lead to the mania that he is experiencing. He was recently

admitted into the hospital for three days in order to go through alcohol detoxification. The
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER
hallucinations and detox could have been very stressful for him, adding more stressors to his life

that may reflect on his recent behaviors.

Discuss Patient and Family History of Mental Illness:

The patient has a history of divorce, and has one son who is in his thirties, but he does not

maintain contact with him. G.S. never finished high school, but did receive a GED when he was

twenty years old. When G.S. was growing up, he did not have the best examples in his life. For

instance, he described his father as a “mean alcoholic” that left the family when he was only ten

years old. He also mentions that his father physically abused him, while his mother did not

intervene and allowed this to happen. He described his mother as being depressed most of the

time, but would “snap out of it” and do fun things with him like taking him shopping to buy lots

of expensive gifts.

This may indicate that his mother also had bipolar disorder, considering she appeared to

switch back and forth between depressive states and stages of euphoria. This could be a large

reason as to why G.S. ended up with his bipolar disorder diagnosis, since it is known that bipolar

disorder does run in the family. In the article “The Substance-Abusing Family: Consideration

for Nursing Research”, it states, “system, role, and family theories provide a framework for

understanding the influence of substance abuse on all family members” (Jane Hopkins Walsh,

MS, RNC, PNP, 1991). However, the mother’s diagnosis was never mentioned by the patient, so

it is unknown if that is the case. G.S. may have also inherited his alcohol abuse tendencies from

his father, who he described as an alcoholic. This also seems much more likely considering G.S.

verbalized that he had a half-brother, who he shared his dad with, that was also an alcoholic. It is

known that alcoholism is familial, which would make G.S. more susceptible to alcohol abuse in
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER

his life, which he has presented in his recent behaviors, and has been hospitalized over in the

past.

Describe Psychiatric Evidence Based Nursing Care Provided:

After evaluation of the patient’s current state, orders were given in an effort to help him

get back to where he needs to be in terms of his mental health. For now, G.S. is prescribed

Lithium, 600 mg twice daily by mouth, Risperidone, 2 mg daily by mouth, Haldol, 5 mg every

four hours or as needed, and can be given orally or as an intramuscular injection. If his CIWA

scale is a certain score, he may also take Ativan based on his score. Lastly, he is on a NicoDerm

QC patch that is applied daily, a multivitamin daily, and folic acid, 500 mcg daily due to promote

a better response to Lithium. All of these medications are necessary based on the data collected

during the interview.

There are also other orders such as activity as tolerated, meaning he can participate in any

activities going on, or do person activities himself like watch television, read a book, or draw or

write something to keep himself occupied. G.S. has been placed on unit restrictions and suicide

precautions, meaning all of his belongings must be searched upon admission, and anything that is

potentially dangerous will be taken away. G.S. will be kept on a locked psychiatric unit and will

not have access to his cell phone, but will be permitted to use the phone on the floor after asking

permission from the nurse. His Lithium levels will be reassessed in the morning to ensure that

his Lithium levels are rising into the expected range of someone who is prescribed Lithium for

bipolar disorder treatment. G.S. has been placed on regular diet, meaning he can eat whatever he

chooses as far as the hospital’s menu. However, the food will be served on a safety tray,

meaning the silverware must be plastic, and there can be no straws, or anything else that could be
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER
potentially used as a weapon. Lastly, G.S. will be assessed on a CIWA scale pertaining to his

alcohol abuse, and will be given Ativan per orders of the CIWA scale scores.

Analyze Ethnic, Spiritual, and Cultural Influences:

G.S. did not describe much in terms of his ethnic background, however, he did seem to be

attracted to those who indulge in his alcoholic behaviors ever since he started presenting his

acute mania symptoms. His spiritual influence is a figure he describes as “Mother Earth”, while

he also states that he feels very close to rocks and the universe. Although it is a good sign that he

uses some sort of spiritual being to look towards, the connection he feels with rocks and the

universe may indicate reasons behind his delusional thinking, and potentially his hallucinations.

As for cultural influences, G.S. has been sticking to the party culture lately, meaning he is taking

advantage of his access to alcohol, and abusing it as a result. He explained that he never used to

like the way marijuana made him feel, but when offered it by a friend, he gave into that influence

and decided to smoke it. This led to him continuing to abuse marijuana, even though it is

something he does not particularly like. Although G.S. did not go into much detail about his

ethnic, spiritual, and cultural influences, it is clear he is easily influenced by his thoughts and

those around him who may be promoting unhealthy behaviors.

Evaluate Patient Outcomes:

Expected outcomes that are to be seen in G.S. vary depending on his current orders. As

of now, an ideal outcome would be to lower his CIWA scale score, meaning he is less reliant on

the Ativan to get him through his detoxification process. Another outcome would be to increase

Lithium levels and promote medication compliance with his Lithium and Risperidone. G.S.

must willingly take his medications without being asked to in order to prove medication

compliance. Other expected outcomes include increase in appetite and intake, increase in sleep,
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER

while developing better sleeping habits, and participating in group activities while giving others

a chance to answer questions, and limit his loud outbursts. It is also essential for him to try to

minimize his psychomotor activities as an outcome. Lastly, important outcomes would be to

develop better coping skills other than substance abuse and develop communication skills in

order to avoid confrontation with others, specifically set goals to mend the relationship with his

aunt and his best friend. All of these outcomes are necessary for proof of improvements in order

for G.S. to be considered for discharge.

Summarize Plans for Discharge:

There is much thought and consideration taken into account from the entire care team

when planning for discharge. G.S. will be eligible for discharge when he shows improvements

on his outcomes. Once this is accomplished, he will be ready to take the next steps towards

getting his mental health back to where it needs to be. It will be crucial in his discharge planning

to include the importance of medication compliance. In the article, “Medication Compliance

Among Patients with Bipolar Disorder and Substance Use Disorder” it constructs a study that

includes people who were compliant with their medications for bipolar disorder, versus people

who were noncompliant with their medications. The study concluded that those who were

prescribed Lithium were less likely to be compliant due to side effects, but they had a much

larger chance for a relapse of mania (Roger D. Weiss, et. al 2020). It must be made very clear to

G.S. that abruptly stopping his medication is likely what led him to this point, and in order to

keep his mind at ease, he must be compliant with his medication. Lithium and Risperidone are

two medications that are very necessary to be accommodating with in order to see the best

treatment results. The patient must report any sort of adverse effects he may be experiencing

since resuming the medications, and he will be advised to call his health care provider before
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MENTAL HEALTH CASE STUDY: BIPOLAR DISORDER
stopping the medications. G.S. will also be referred to outpatient treatment centers that will

include individual therapy, along with group therapy and family therapy. This will be helpful to

him in order to pinpoint his strengths and weaknesses and work on them individually, and

collectively within a group. Family therapy will be necessary so that he and his aunt can learn to

be on the same page and avoid tension while living together. It will be a priority for G.S. to talk

about his relationships and how his decisions may be affecting them.

Prioritized list of NANDA Diagnoses:

 Deficient Knowledge related to poor medication compliance as evidenced by stopping his

medication without realizing the repercussions.

 Disturbed Sleep Pattern related to restlessness as evidenced by sleeping approximately

three hours per night.

 Disturbed Thought Processes related to delusions and hallucinations as evidenced by

claiming he saw a branch come out of his friend’s head while speaking with him.

 Ineffective Individual Coping related to grandiose schemes, plans, or stated self-image as

evidenced by claiming to be the best violin player out there, and telling farmers how to

do their job, although he is not a farmer himself.

 Interrupted Family Processes related to hostile behavior as evidenced by starting

arguments with his aunt and his best friend.

 Total Self-Care Deficit related to poor judgment as evidenced by substance abuse and

multiple sexual partners.

List of Potential Nursing Diagnoses:

 Suicidal ideas or behavior

 Slow mental processes

 Disordered thoughts

 Feelings of despair, hopelessness, and worthlessness

 Guilt

 Anhedonia

 Fear of intensity of feelings

Psychiatric-Mental Health Nursing (Sheila L. Videbeck, 2019)

Conclusion:

Bipolar disorder is something to be taken very seriously, and can be truly detrimental in

someone’s life. It is easy to allow this disorder to run one’s life, however, with the correct

treatment and assessments, it is a manageable disorder. In order to properly treat bipolar

disorder, it is important to first properly diagnose the disorder. It is essential to be able to

recognize the symptoms of mania, and the stages of the disorder in order to gauge the person’s

behaviors and match them with the criteria needed for the diagnosis. G.S. took the initial steps

needed in order to correct his mania that he had recently been experiencing. Through patient

interviews and medication reviews, it became clear that G.S. showed behaviors that placed him

in the manic stage of bipolar disorder. In order to correct this, the treatment team developed

outcomes that were necessary for his success, and allowed him to return back to his regular

medication regimen. This will all contribute to a safe discharge, where the patient will be able to

seek further outpatient treatment in order to maintain a healthy mental status.

Hopkins Walsh, J., MS, RNC, PNP. (1991, February 1). The Substance-Abusing Family:

Consideration for Nursing Research. Retrieved November 26, 2020, from

https://www.pediatricnursing.org/article/0882-5963(91)90091-7/pdf

McCormick, U., MSN, RN, PMHCNS-BC, Murray, B., PhD, RN, PMHCNS-BC, & McNew, B.,

MSN, RN, PMHCNS-BC. (2015, July 14). Diagnosis and Treatment of Patient with

Bipolar Disorder: A Review for Advanced Practice Nurses. Retrieved November 26, 2020,

from https://onlinelibrary.wiley.com/doi/full/10.1002/2327-6924.12275

Videbeck, S. L. (2019). Chapter 17: Mood Disorders and Suicide. In Psychiatric-Mental Health

Nursing (8th ed., p. 297). Lippincott Williams & Wilkins.

Weiss, R. D., Greenfield, S. F., Najavits, L. M., Soto, J. A., Wyner, D., Tohen, M., & Griffin, M.

L. (2020). Medication Compliance Among Patients with Bipolar Disorder and Substance

Use Disorder. Retrieved November 26, 2020, from

https://www.psychiatrist.com/JCP/article/Pages/medication-compliance-among-patients-

bipolar-disorder.aspx