CASE STUDY OF A 30 YEARS OLD

MAN WITH THE DIAGNOSIS OF

BIOPLAR AFFECTIVE DISORDER

By
Group 1
ORIENTATION STUDENTS FROM OLABISI ONABANJO
UNIVERSITY AGO IWOYE OGUN STATE

PRESENTED TO
OLABISI ONABANJO UNIVERSITY
DEPARTMENT OF NURSING SCIENCE
 CERTIFICATION
This is to certify that this care study was carried
out by Group 1 orientation students of OLABISI
ONABANJO UNIVERSITY
Group members name
ADEBAKIN ZAINAB KOFOWOROLA
ADEGOKE ADEWALE SEGUN
ADEJARE SULIYAT ADEOLA
ADEKANMI KEHINDE OLUWAFEMI
ADEKUNLE RAHMAT ADENIKE
ADELEYE BRIDGET BOSE
ADETAYO EBUNOLUWA JUSTIN
ADETILEWA OLAWUNMI TEMILOLA
DEDICATION
This study is specially dedicated to God Almighty, the one
who has been good and faithful to us through this stage in the
course of our training

CHAPTER ONE
INTRODUCTION
BACKGROUND OF THE STUDY

Master O.I a 30 year old male who was admitted on the 9th of
January,2018 into the male ward 1 of Neuropsychiatric Hospital
Aro, Abeokuta with history of restlessness, talkativeness,
suicidal attempt, suicidal ideation, poor sleep, hears strange
voices in clear consciousness, weeping spell, feels unworthy,
believes he is been talked about on television. Series of
examination and laboratory investigations were carried out and
he was diagnosed of BIPOLAR AFFECTIVE DISORDER.
Bipolar disorder, previously known as manic depression, is a
mood disorder characterized by periods of depression and
periods of abnormally-elevated happiness that last from days to
weeks each.If the elevated mood is severe or associated with
psychosis, it is called mania; if it is less severe, it is called
hypomania.During mania, an individual behaves or feels
abnormally energetic, happy or irritable,and they often make
impulsive decisions with little regard for the
consequences.There is usually also a reduced need for sleep
during manic phases.During periods of depression, the
individual may experience crying and have a negative outlook
on life and poor eye contact with others.The risk of suicide is
high; over a period of 20 years, 6% of those with bipolar
disorder died by suicide, while 30–40% engaged in self-
harm.Other mental health issues, such as anxiety disorders and
substance use disorders, are commonly associated with bipolar
disorder.
While the causes of bipolar disorder are not clearly understood,
both genetic and environmental factors are thought to play a
role.Many genes, each with small effects, may contribute to the
development of the disorder.Genetic factors account for about
70–90% of the risk of developing bipolar
disorder.Environmental risk factors include a history of
childhood abuse and long-term stress.
The condition is classified as bipolar I disorder if there has been
at least one manic episode, with or without depressive
episodes, and as bipolar II disorder if there has been at least
one hypomanic episode (but no full manic episodes) and one
major depressive episode.If these symptoms are due to drugs
or medical problems, they are not diagnosed as bipolar
disorder.Other conditions that have overlapping symptoms
with bipolar disorder include attention deficit hyperactivity
disorder, personality disorders, schizophrenia, and substance
use disorder as well as many other medical conditions.Medical
testing is not required for a diagnosis, though blood tests or
medical imaging can rule out other problems.
Factors that may increase the risk of developing bipolar
disorder or act as a trigger for the first episode include:
 Having a first-degree relative, such as a parent or sibling,
with bipolar disorder.
 Periods of high stress, such as the death of a loved one or
other traumatic event.
 Drug or alcohol abuse.
People with bipolar affective disorders are at an increase risk
of:
 Suicidal attempt or suicidal thoughts
 Poverty and homelessness
 Family and interpersonal conflicts
 Unemployment
 Social isolation
Treatment typically involves ;
Mood stabilizers—lithium and certain anticonvulsants such as
valproate and carbamazepine as well as atypical antipsychotics
such as aripiprazole—are the mainstay of long-term
pharmacologic relapse prevention.Antipsychotics are
additionally given during acute manic episodes as well as in
cases where mood stabilizers are poorly tolerated or
ineffective. In patients where compliance is of concern, long-
acting injectable formulations are available.There is some
evidence that psychotherapy improves the course of this
disorder.The use of antidepressants in depressive episodes is
controversial: they can be effective but have been implicated in
triggering manic episodes.The treatment of depressive
episodes, therefore, is often difficult.Electroconvulsive therapy
(ECT) is effective in acute manic and depressive episodes,
especially with psychosis or catatonia.Admission to a
psychiatric hospital may be required if a person is a risk to
themselves or others; involuntary treatment is sometimes
necessary if the affected person refuses treatment.

Purpose of the study

 To identify the causes,signs and symptoms, predisposing
factors, precipitating factors of bipolar affective disorders
 To have adequate knowledge regarding the system
affected
 Describe and educate the patient on the prevention and
management of immediate and delayed complications of
bipolar affective disorders
 To use the nursing process As a frame work for therapeutic
care of the patient with bipolar affective disorders
 To use the nursing care plan to administer medical and
nursing management
  To describe the rehabilitation needs of the patient with
bipolar affective disorders
SIGNIFICANCE OF THE STUDY

 To organise the classification of bipolar affective disorders

 To serve as a relevant source of information for
future readers in promotion of mental health.

CHAPTER TWO
REVIEW OF THE LITERATURE ANATOMY
AND PHYSIOLOGY OF THE BRAIN
The brain is a complex organ that controls thought, memory,
emotion, touch, motor skills, vision, breathing, temperature,
hunger and every process that regulates our body. Together,
the brain and spinal cord that extends from it make up the
central nervous system, or CNS.
What is the brain made of?
Weighing about 3 pounds in the average adult, the brain is
about 60% fat. The remaining 40% is a combination of water,
protein, carbohydrates and salts. The brain itself is a not a
muscle. It contains blood vessels and nerves, including neurons
and glial cells.
What is the gray matter and white matter?
Gray and white matter are two different regions of the central
nervous system. In the brain, gray matter refers to the darker,
outer portion, while white matter describes the lighter, inner
section underneath. In the spinal cord, this order is reversed:
The white matter is on the outside, and the gray matter sits
within.
Gray matter is primarily composed of neuron somas (the round
central cell bodies), and white matter is mostly made of axons
(the long stems that connects neurons together) wrapped in
myelin (a protective coating). The different composition of
neuron parts is why the two appear as separate shades on
certain scans.
Each region serves a different role. Gray matter is primarily
responsible for processing and interpreting information, while
white matter transmits that information to other parts of the
nervous system.
How does the brain work?
The brain sends and receives chemical and electrical signals
throughout the body. Different signals control different
processes, and your brain interprets each. Some make you feel
tired, for example, while others make you feel pain.
Some messages are kept within the brain, while others are
relayed through the spine and across the body’s vast network
of nerves to distant extremities. To do this, the central nervous
system relies on billions of neurons (nerve cells).

Main Parts of the Brain and Their

Functions
Cerebrum
The cerebrum (front of brain) comprises gray matter (the
cerebral cortex) and white matter at its center. The largest part
of the brain, the cerebrum initiates and coordinates movement
and regulates temperature. Other areas of the cerebrum
enable speech, judgment, thinking and reasoning, problem-
solving, emotions and learning. Other functions relate to vision,
hearing, touch and other senses.

Cerebral Cortex
Cortex is Latin for “bark,” and describes the outer gray matter
covering of the cerebrum. The cortex has a large surface area
due to its folds, and comprises about half of the brain’s weight.
The cerebral cortex is divided into two halves, or hemispheres.
It is covered with ridges (gyri) and folds (sulci). The two halves
join at a large, deep sulcus (the interhemispheric fissure, AKA
the medial longitudinal fissure) that runs from the front of the
head to the back. The right hemisphere controls the left side of
the body, and the left half controls the right side of the body.
The two halves communicate with one another through a large,
C-shaped structure of white matter and nerve pathways called
the corpus callosum. The corpus callosum is in the center of the
cerebrum.

Brainstem
The brainstem (middle of brain) connects the cerebrum with
the spinal cord. The brainstem includes the midbrain, the pons
and the medulla.

Midbrain.
The midbrain (or mesencephalon) is a very complex structure
with a range of different neuron clusters (nuclei and colliculi),
neural pathways and other structures. These features facilitate
various functions, from hearing and movement to calculating
responses and environmental changes. The midbrain also
contains the substantia nigra, an area affected by Parkinson’s
disease that is rich in dopamine neurons and part of the basal
ganglia, which enables movement and coordination.

Pons.
The pons is the origin for four of the 12 cranial nerves, which
enable a range of activities such as tear production, chewing,
blinking, focusing vision, balance, hearing and facial expression.
Named for the Latin word for “bridge,” the pons is the
connection between the midbrain and the medulla.

Medulla.
At the bottom of the brainstem, the medulla is where the brain
meets the spinal cord. The medulla is essential to survival.
Functions of the medulla regulate many bodily activities,
including heart rhythm, breathing, blood flow, and oxygen and
carbon dioxide levels. The medulla produces reflexive activities
such as sneezing, vomiting, coughing and swallowing.

Cerebellum
The cerebellum (“little brain”) is a fist-sized portion of the brain
located at the back of the head, below the temporal and
occipital lobes and above the brainstem. Like the cerebral
cortex, it has two hemispheres. The outer portion contains
neurons, and the inner area communicates with the cerebral
cortex. Its function is to coordinate voluntary muscle
movements and to maintain posture, balance and equilibrium.
New studies are exploring the cerebellum’s roles in thought,
emotions and social behavior, as well as its possible
involvement in addiction, autism and schizophrenia.

Brain Coverings: Meninges

Three layers of protective covering called meninges surround
the brain and the spinal cord.
The outermost layer, the dura mater, is thick and tough. It
includes two layers: The periosteal layer of the dura mater lines
the inner dome of the skull (cranium) and the meningeal layer
is below that. Spaces between the layers allow for the passage
of veins and arteries that supply blood flow to the brain.
The arachnoid mater is a thin, weblike layer of connective
tissue that does not contain nerves or blood vessels. Below the
arachnoid mater is the cerebrospinal fluid, or CSF. This fluid
cushions the entire central nervous system (brain and spinal
cord) and continually circulates around these structures to
remove impurities.
The pia mater is a thin membrane that hugs the surface of the
brain and follows its contours. The pia mater is rich with veins
and arteries.

Lobes of the Brain and What They Control

Each brain hemisphere (parts of the cerebrum) has four
sections, called lobes: frontal, parietal, temporal and occipital.
Each lobe controls specific functions.

Frontal lobe
The largest lobe of the brain, located in the front of the head,
the frontal lobe is involved in personality characteristics,
decision-making and movement. Recognition of smell usually
involves parts of the frontal lobe. The frontal lobe contains
Broca’s area, which is associated with speech ability.

Parietal lobe.
The middle part of the brain, the parietal lobe helps a person
identify objects and understand spatial relationships (where
one’s body is compared with objects around the person). The
parietal lobe is also involved in interpreting pain and touch in
the body. The parietal lobe houses Wernicke’s area, which
helps the brain understand spoken language.

Occipital lobe.
The occipital lobe is the back part of the brain that is involved
with vision.

Temporal lobe
The sides of the brain, temporal lobes are involved in short-
term memory, speech, musical rhythm and some degree of
smell recognition.

Deeper Structures Within the Brain

Pituitary Gland
Sometimes called the “master gland,” the pituitary gland is a
pea-sized structure found deep in the brain behind the bridge
of the nose. The pituitary gland governs the function of other
glands in the body, regulating the flow of hormones from the
thyroid, adrenals, ovaries and testicles. It receives chemical
signals from the hypothalamus through its stalk and blood
supply.

Hypothalamus
The hypothalamus is located above the pituitary gland and
sends it chemical messages that control its function. It
regulates body temperature, synchronizes sleep patterns,
controls hunger and thirst and also plays a role in some aspects
of memory and emotion.

Amygdala
Small, almond-shaped structures, an amygdala is located under
each half (hemisphere) of the brain. Included in the limbic
system, the amygdalae regulate emotion and memory and are
associated with the brain’s reward system, stress, and the
“fight or flight” response when someone perceives a threat.

Hippocampus
A curved seahorse-shaped organ on the underside of each
temporal lobe, the hippocampus is part of a larger structure
called the hippocampal formation. It supports memory,
learning, navigation and perception of space. It receives
information from the cerebral cortex and may play a role in
Alzheimer’s disease.

Pineal Gland
The pineal gland is located deep in the brain and attached by a
stalk to the top of the third ventricle. The pineal gland responds
to light and dark and secretes melatonin, which regulates
circadian rhythms and the sleep-wake cycle.

Blood Supply to the Brain

Two sets of blood vessels supply blood and oxygen to the brain:
the vertebral arteries and the carotid arteries.
The external carotid arteries extend up the sides of your neck,
and are where you can feel your pulse when you touch the area
with your fingertips. The internal carotid arteries branch into
the skull and circulate blood to the front part of the brain.
The vertebral arteries follow the spinal column into the skull,
where they join together at the brainstem and form the basilar
artery, which supplies blood to the rear portions of the brain.
The circle of Willis, a loop of blood vessels near the bottom of
the brain that connects major arteries, circulates blood from
the front of the brain to the back and helps the arterial systems
communicate with one another.

Cranial Nerves
Inside the cranium (the dome of the skull), there are 12 nerves,
called cranial nerves:

Cranial nerve 1: The first is the olfactory nerve, which

allows for your sense of smell.

Cranial nerve 2: The optic nerve governs eyesight.

Cranial nerve 3: The oculomotor nerve controls pupil
response and other motions of the eye, and branches out from
the area in the brainstem where the midbrain meets the pons.

Cranial nerve 4: The trochlear nerve controls muscles in the

eye. It emerges from the back of the midbrain part of the
brainstem.

Cranial nerve 5: The trigeminal nerve is the largest and

most complex of the cranial nerves, with both sensory andion.
It originates from the pons and conveys sensation from the
scalp, teeth, jaw, sinuses, parts of the mouth and face to the
brain, allows thwiching muscles, and much more.
Cranial nerve 6: The abducens nerve innervates some of the
muscles in the eye.

Cranial nerve 7: The facial nerve supports face movement,

taste, glandular and other functions.

Cranial nerve 8: The vestibulocochlear nerve facilitates

balance and hearing.

Cranial nerve 9: The glossopharyngeal nerve allows taste,

ear and throat movement, and has many more functions.

Cranial nerve 10: The vagus nerve allows sensation around

the ear and the digestive system and controls motor activity in
the heart, throat and digestive system.

Cranial nerve 11: The accessory nerve innervates specific

muscles in the head, neck and shoulder.

Cranial nerve 12: The hypoglossal nerve supplies motor

activity to the tongue. The first two nerves originate in the
cerebrum, and the remaining 10 cranial nerves emerge from
the brainstem, which has three parts: the midbrain, the pons
and the medulla.
GENERAL MANAGEMENT OF MR O. DURING THE
PROCESS OF HOSPITAL INCLUDE:

1. ADMISSION: PATIENT AND RELATIVE WERE WELCOMED INTO

THE WARD THROUGH THE ASSESSMENT UNIT WITH THR
DIAGNOSIS OF BIPOLAR AFFECTIVE PATIENTS WAS
INTRODUCED TO THE WARD AND WARD ROUTINES WERE
EXPLANED TO his understanding.

2. Observations: vital signs at admission was T=37.6C,

P=150b/min, R=30c/min, WT=54kg, . He was observed to have
insight to his mental illness.

3. Nutrition: he was health educated on the importance of

taking good, healthy meals and timely also.
4. Psychological therapy: his emotional needs were identified
and he was advised to interact with other patients to promote
his mental well begin.
5. Physical care: he was health-educated in the importance of
good hygiene such as cleaning his environment, cutting his nails
etc. Attend to his dressing, grooming and hygiene care both the
environmental and personal
6. Medication: Due drugs were served as at when due and we'll
tolerated and the possible side effects were explained to him.
He was also asked to report to the nurses if he experience any
side effects. And also to be compliance with drugs.
7. Suicidal caution: He was counselled and suicidal caution chart
was also opened for him.
8. Occupational therapy: He was advised to engage in
occupational therapy and the importance to keep him of his
depressive mood and also provide divertional therapy for him.
Medical management
1. Tab cabamazepine
2. Tab olanzapine
3. Fluoretine
4. To be reviewed by a clinical psychologist
5. Undergo occupational therapy.

Diagnostic investigation
1. Electrocardiography
2. Urine drug test
3. Electrolyte, urea and creatine
4. Full blood count
5. Thyroid hormones

Nursing Diagnosis
1. Disturbed sleep pattern related to mental dysfunction and
evidenced by inability to fall asleep
2. Disturbed thought processes related to psychotic process as
evidenced by incoherent speech
3. Risk for injury related to thought insertion

PHARMACOLOGICAL REVIEW
S/N Drug Group/dosage Mechanism Indication Contra- Side- Nursing
of action indications effect management

1. Caba Anti-convulsant Enhancing Seizure 1.hepatic 1.low 1. Check

maze 400mg b.d the activity disorders failure grade patients
pine of the panic fever, weight daily
inhibitory attacks, 2.renal 2.drow
neurotrans maniac impairment siness, 2. Patients
mitter 3.verti should not
GABA. go, engage in
4.ataxi activities that
a, requires
5.diplo mental
pia, awareness
6.blurr 3. It should
ed not be taken
vision, on empty
 7.naus stomach.
ea,

2. Olanz Antipsychotic The atypical 1. Manic 1.Extra 1. Monitor

apine (atypical) 20mg drugs are 2.schizoph pyrami vital signs
dopamine renia dal
and sympt 2.observe for
histamin oms any extra
antagonists. pyramidal
They inhibit effect
the 2.Tardi
ve 3. Weigh the
reception of patient
these two dyskin
esia regularly
neurotrans
mitters, 3. 4. Educate the
dopamine Consti patient on the
and pation side effects of
serotonin, at and drugs
specific dry 5. Encourage
post- mouth high fibre
synaptic 4.Nasa intake to
sites. l reduce
conges constipation
tion
5.Blurr
ed
vision
and
mydria
sis

3 Fluor Selective Fluoxetine 1.unipolar 1.

etine serotonin exerts its
40mg reuptake effects by 2. Organic
inhibitors blocking the mood
reuptake of disorders
serotonin 3.
into Schizoaffe
presynaptic ctive
serotonin disorder
neurons by
blocking the 4. Panic
 reuptake disorder
transporter
protein
located in
the
presynaptic
terminal.

S/N DATE/ Nursing Nursin Nursing Rationale Nursing

g interve Evaluation
time diagnosis
objecti ntion
ves
Disturbed The 1) To obtain After 20
thought patien Access baseline days of
process t’s patient’ data. nursing
related to speec s intervention
psychotic h will speech. the patient’s
process as be
evidence more 2) 2) To speech
by coher Introdu relieve become
incoherent ent ce patient’s clear,
speech within patient level of concise and
14-21 to the anxiety. coherent
days environ
of ment.
nursin 3)To make
3)Provi
g them
de
interv more
comfor
ention relaxed
tability
and put
4)Place them at
import ease.
ant
4) To
objects
maximize
within
patient’s.
reach.
sense of
5)Learn independe
patient’ nce.
s need
5)To
and
reduce the
pay
time care
attenti
measures
on to
take whe
non-
there is
verbal
presence
cues.
of a
6) commuica
 Clarify tion
your deficit.
underst
6)Feedbac
anding
k from
of the
patient
patient’
allows the
s
nurse to
commu
assess the
icatio
effectiven
with
ess of the
the
nursing
patient.
interventi
on.
2 Disturbed 1)Asses 1)To
sleep s obtain
pattern patient baseline
related to sleepin data and
mental g help
dysfunctio pattern develop a
n . sleeping
evidenced plan .
2)Provi
by inability
de 2) To place
to fall
dark, the
asleep
quiet,c patient in
omfort a
able comfortab
atmosp le position
here. and
environme
nt for
sleep to
occur
naturally.
3)To know
3)The
the
nurse
importanc
will
e of
educat
sleeping
e the
and ways
patient
to fall
on
asleep
techniq
indepently
ues on
.
how to
fall
asleep
and
stay
asleep.
 4)

3 Risk for
injury
related to
thought
insertion.