Running head: A CASE STUDY OF THE CLIENT WITH BIPOLAR TYPE I DISORDER

A Case Study of the Client with Bipolar Type I Disorder

Natalie Noday

Youngstown State University

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Abstract

This paper will in depth describe and explain a patient to student nurse interaction with a

client that is diagnosed with Bipolar Type I Disorder. This case study will go into detail about

the patient’s mental health background, diagnosis using the DSM IV-TR, precipitating factors

leading up to admission, and the patient’s coping mechanisms of daily stressors. The student

nurse will use the data obtained from the day of the interaction, the patient’s medical chart, as

well as three different scholarly articles found online that reflect this patient’s specific diagnosis

and behaviors. These will help to develop a plan of care and implement treatment. In order to

promote healing and to provide a safe, therapeutic environment for the patient, the student nurse

will also include: the subjective data, objective data, expected behaviors of the illness, stressors

in the patient’s life, and the patient’s family history of mental illness.

It is important when conducting a case study to include the psychiatric evidence- based

nursing care that can be provided in discharge planning. It is also important to utilize Milieu’s

activities and keep record of those attended to adjust treatment, the patient’s plan of care, and

ability for self- growth. This paper will also include: spiritual and cultural influences on the

patient’s evaluation of outcomes, and some actual and potential NANDA nursing diagnoses for

the patient. The time spent together was therapeutic in nature and a relationship of trust and

rapport was developed between the client and the student nurse. This study will reflect the steps

leading up to this.
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Objective data

The patient that will be used for this case study is a 52-year-old female client with an

extensive psychiatric history. The patient was admitted to St. Elizabeth’s Inpatient Behavioral

Health Unit on February 14th, 2018 following a psychotic and delusional episode taking place at

the patient’s current group home residence. A one- time interaction occurred with this patient on

February 15th, 2018 along with another peer. The patient has a psychiatric diagnosis using the

DSM IV- TR, Axes I through V of Severe Manic Bipolar I Disorder, accompanied with

psychotic features, known as Psychosis. The patient admitted to the unit with severe agitation

and became angry upon assessment questions. The patient communicated in a disorganized

manner with a flight of ideas and racing thoughts that were irrelevant and had very lengthy,

extensive explanations. The patient was constantly re- directed to stay on task, but became

irritable on approach, anxious in speech, and expelled periods of sobbing loudly. The patient

stated that she currently does not seek any outpatient care.

The day of the interview, the client had a fixed and sad/depressed facial expression, with

an extremely flat affect. The patient was careless in appearance and was very tense; slouching

throughout the entire session. The patient represented akathisia, an extreme urgent need to move,

along with repetitive behaviors, such as; constant, deep picking and scratching of the skin and

ears. The client also showed tardive dyskinesia, an excessive movement of the mouth, and had

acute dystonic reactions throughout the session (ocular- gyric eye movements). The patient had a

friendly approach towards the student nurse and was cooperative with care throughout the

interaction.

On the other hand, the client also demonstrated unpleasant affects throughout the session,

including (dysphoria): anxiety, depression, anhedonia, fear, ambivalence, aggression, and mood
A CASE STUDY OF THE CLIENT WITH BIPOLAR TYPE I DISORDER 4

swings, which are all incongruent behaviors. When asked what the patient’s mood had been like

lately, she responded, “bad.” The student nurse then asked, “Are your moods more emotional

than usual?” The patient stated, “I have been emotional. I have parasites and fungus growing out

of the top of my head, the walls, the shower, everywhere!” The student nurse was able to observe

that the patient was demonstrating disturbed sensory impairment and perceptual disturbances

through tactile and visual hallucinations due to her behavior. The patient seemed to also have

disturbances in her thought processes, content, and mood. The patient demonstrated a

preoccupation of obsessions and phobias with bugs. She stated, “I am fearful that the scabies are

eating me alive! They are eating my bones and my brain!” When the student nurse asked if she

had any distraction methods or coping strategies, she said that she uses natural oils and puts them

inside of her body to cure the fluid from the fungus growing inside of her. This is also a

delusional thought. She states she has also smoked a half a pack of cigarettes daily for ten years.

During the time of this interaction, the patient was not expressing appropriate judgments

or valid conclusions regarding her current hospitalization. The patient stated, “I can not function

or do anything because the discharge gets everywhere and contaminates everything.” When re-

directing reality to the patient and explaining that the student nurse did not see bugs, the patient

was in denial of the hallucinations. To dig deeper into the hallucinations and ineffective denial,

evidence showed that there was a history of marijuana use in the patient’s chart and THC levels

found in her blood prior to admission to the hospital. The patient’s chart also listed a history of

opioid and cocaine abuse, which may greatly contribute to these irrational thoughts.

Her psychiatric diagnoses, also known as the Axis 1, were Psychosis and Bipolar Type I

Disorder mixed with severe psychotic behavior. Axis II showed proof of a history of tactile and

visual hallucinations, along with paranoia. Axis III was the patient’s medical history, and her
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chart did show a few medical problems. Those included: Chronic lower back pain, PTSD,

Scabies, and ADHD. Axis IV showed precipitating factors that lead up to the patient needing in-

patient admission to the Mental Health Unit. Those included the severe psychotic hallucinations

of bugs and fungus crawling out of her ears, causing the client to do severe harm to her skin and

body. The skin serves as a major reservoir to the rest of the body systems and the patient had

been previously hospitalized due to skin infections from excessive picking and breaking of the

skin. The patient also had outbursts of anger at her group home regarding these hallucinations.

Axis IV also includes that the patient is unemployed and was living with her husband,

until he passed away two weeks ago, due to a “suicide”, but she says she believes it was

“murder”. Pt. states she had been living with a male friend after the passing, but the friend abuses

her, so she brought herself to Serenity, where the staff noticed she was hallucinating and

showing psychotic behaviors by screaming at the walls and shower curtain. The patient states

that she hopes to be living in a group home upon discharge. The client also said that she has no

support system, that all of her relationships have failed, she does not speak to her children, and

she has to pick up and start all over again. When asking the patient if she was suicidal, she stated

that she has thought of it once, but has never carried out an action plan of doing so. She stated

that being in the hospital was helping her tremendously and improving her mood to “start over”.

The client is initiating getting help and is compliant, which is something very positive in her

treatment plan. She also states that she will be attending group therapy.

The patient was taking four different psychiatric medications at the time of the

interaction. The patient did state that she has experienced substance abuse in the past due to a

back surgery. She stated that once she could no longer receive her pain medication from the

surgery, she needed to somehow get relief of the back pain. The patient states she has only been
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in trouble with the law once and the encounterment was several years ago. To help with the

opioid addiction, the patient is taking Suboxone 2 mg PO b.i.d. as directed by her physician. The

other three medications prescribed by the psychiatrist include: Abilify 5 mg PO b.i.d, which is an

antipsychotic used to help with acute treatment of manic and mixed episodes associated with

Bipolar I Disorder, Ativan 1 mg PO t.i.d, which is a Benzodiazepine utilized to treat anxiety, and

lastly, Trintellix 5 mg PO daily, which is an anti-depressant, used to treat Major Depressive

Disorder. The patient was able to demonstrate understanding of importance of compliance with

the medications, side effects, and things to look out for. The patient was also able to verbalize all

of her current medication dosages and frequencies. The patient is under the hospital policy’s

safety measures regarding her symptoms and diagnoses.

Summarize

This specific patient was diagnosed with Bipolar Disorder Type I with severe psychotic

behavior as evidenced above. Bipolar disorder (BD), previously known as Manic-Depressive

Disorder, is defined as being associated with episodes of mood swings that can range from

depressive lows to manic highs. According to The National Institute of Mental Health, “Bipolar

Disorder in general is a brain disorder that affects mood, energy, ability to carry out day to day

tasks, and activity levels. Bipolar Disorder Type I is defined as having one or more manic

episodes that last at least four days accompanied by a period of an abnormal level of an elevated

mood and high energy” (NIMH Publication No. 15-3561). These patterns also exhibit abnormal

behavior and functioning. This may include but is not limited to: irritable moods, pressured

speech, inflated self-esteem or grandiosity, and a decreased need for sleep. Sometimes these
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symptoms can be so severe, especially if left untreated, that these individuals cannot live

functioning, healthy lives.

The major difference between Bipolar Disorder Type I and Bipolar Disorder Type II, is

that with Type II, people do not experience a full manic episode that occurs with Type I. This is

said, even though most people diagnosed with Type II do experience at least one

hypomanic/manic episode at some point in their life. Type I’s manic behaviors can be so

explosive, that the outbursts require immediate hospitalization to adjust therapies and stabilize

the patient and their mood. Statistics from the World Health Organization (WHO) state that,

“Bipolar Disorder is the sixth leading cause of disability in the world and two thirds of those that

are diagnosed have at least one relative with a mental disorder” (NIH). The predisposing factors

of Bipolar include: a family history, biochemical imbalances, or substance/ medication induced

behaviors, but the exact cause remains unknown.

If an episode of mania goes without treatment it can last from days to even months. In

some cases, clients can cycle back and forth from hypomania/mania to depression and others will

experience longer periods in between episodes. Some symptoms of a manic episode occurring

include: feeling very high up or elated, having a large burst of energy, talking very fast about a

cluster or multiple things, racing thoughts, believing many things can be done at one time, and

having the urge to have risky behaviors. The client exhibited these signs on admission and has

continued with the symptoms over night and into the day of interaction.

On the other hand, symptoms of a depressive episode include: feeling very down or “in

the dumps”, having minimal energy, insomnia, not enjoying things that the client previously did,

eating too much or too little, and having suicidal thoughts” (Townsend, 2015). With bipolar

disorders, you can have psychotic or catatonic features. This client’s behavior represents a loss of
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contact with reality. “While in a period of psychosis, the person’s own thoughts or perceptions

are disturbed and the individual has trouble sorting through what is real and what is not real.

Some symptoms of psychosis include: delusions, hallucinations, and incoherent speech”

(Townsend, 2015). This patient does posses severe psychotic features, such as the tactile and

visual hallucinations of the bugs and fungus.

Identify

This patient does have stressors in her life that exacerbated her outbursts, leading her to

another admission into the Psychiatric Unit. These stressors include: environmental stress, family

stress, financial stress, and also substance abuse. The patient’s chart proves that she has been

abusing marijuana lately. This patient stated that she has been feeling very depressed and has

been trying to find a way to make herself feel happy. Therefore, the student nurse can identify

that she was currently, on February 15th, 2018 in her depressive state of Bipolar Disorder. But,

when the patient went to Serenity to receive supportive and mental help due to her current abuse

at home, the staff found her in her mania state of Bipolar since she was experiencing severe

psychotic symptoms at that time. This supports that individuals with Type I can experience mood

swings very quickly.

The patient said that she was experiencing extreme stress due to the loss of her husband,

lacking a support system, recurrent abuse, losing her job, not having anymore pain medication

and “living in fungus”. The patient also said that her children’s lives are ruined and they will not

speak to her. When the student nurse asked if she has reached out to them, the patient said, “no

because their uncle molested them”. The student nurse was able to identify the family

dysfunction and stressors that led to the precipitation of this event. The patient engaged in
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negative coping skills, such as, turning towards substance abuse, “but that is very commonly

seen in Bipolar Disorder patients” according to the NIH.

Discuss

This patient has a history of mental illness starting back in 2011, according to the medical

chart. Although, through the interaction, the patient discussed otherwise. She stated that she used

to love getting into fights with other girls by her locker in high school and was an “angry”

person. She also stated a concern of not receiving her central nervous stimulant, Vyvanse

anymore due to this current hospitalization. The patient stated she is unable to concentrate, and

has been unable to since high school and is becoming very frustrated without her “focus” pill.

She stated she should have received mental help back then. Due to her mental illness, diagnosed

roughly seven years ago, she has been on a various trial of different medications. The patient

states she is usually compliant with her medication, unless she is very depressed. She stated that

she does not want to take her medication while in the hospital because she would like to try and

be “natural”. She has no history of attempted suicide or homicide, but has grown up with a

constant lack of family support and has tried to seek a support system through negative

mechanisms. The patient stated abuse from her parents and this trauma is a major contributor to

the patient’s mental illness. There is an extensive family history of depression stated in her

medical chart. The patient said she was scared at the thought of returning home, back to her

abusive friend and stated she wanted to live in a group home.

Describe
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“Milieu’s therapy is described as a type of psychotherapy in which the patient’s social

environment is controlled or manipulated with the idea in mind to prevent self-destructive

behavior” (Shattell, Thomas, and Martin pp. 99-107). These group therapies are not mandatory,

but are very much encouraged by the staff for the patient to make a healing recovery. The

purpose of the psychotherapy groups allows the patient to describe their current mood, thoughts,

and situations with those who are experiencing similar emotional and life distresses. The patients

are also taught many therapeutic coping strategies and share their positive experiences to learn

from one another. “A study with those going through cognitive therapy and group therapies

concluded that the milieu therapy interventions were very successful in teaching communication

skills and coping strategies” (Shattell, Thomas, and Martin pp. 99-107). The student nurse

exemplified that this therapy could be that support system the client currently needs.

Each morning, the patient has to decide a goal they would like to achieve for that day and

a goal for group therapy sessions. The patient’s goal for the day of the interaction was to be able

to express her anger through her body. She stated this with a large smile on her face and said that

she “knows her husband was murdered and must find a way to cope without hurting herself or

anyone else”. She had an appropriate verbalization and healthy physical outlets as well, such as

utilizing the workout equipment on the unit. In the chart, a mental health nurse made a note that

in a previous hospitalization the patient was aggressive and attempted to destroy property so she

was taken to the seclusion room. It also stated in the patient’s chart that the patient was only

going to about half of the group therapy sessions and actively participating when she went. She

was also not interacting with many of the patients on the unit the last admission.

But this admission, she has been attending the majority of group therapies offered and

has been interacting with a few other patients on the unit. When asked if this therapy strategy
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was helping, she said yes because she does love to socialize with others. The patient seemed

aware of consequences for aggressive behavior taught by the staff on the unit and the group

therapies were giving the patient different opportunities and ideas to cope with the daily stressors

of life.

There are a lot of differences on the Mental Health Unit than a regular hospital unit.

These are locked units and are made to be as secure as possible. There are many self-harm

precautions taken, such as: no glass mirrors, nothing that one can possibly hang themselves with,

no locks on doors, and many more. These are to protect the clients from harming themselves and/

or others in their mentally ill state through psychiatric evidence -based nursing care.

Analyze

The patient said she graduated from Chaney High School and enjoys going to church

every Sunday and praying to God. Having a regular religious practice can be linked to good

outcomes for patients. In an article by the American Psychological Association, it states that,

“Groups dealing with major life stressors such as: natural disasters, physical illness, loss of loved

ones, divorce, and serious mental illness show that religion and spirituality are helpful for people

in coping, especially the people with the fewest resources facing the most uncontrollable of

problems (Pargament K, 2013). The patient did not show any signs of significant cultural, ethnic,

or spiritual influences during the interaction.

Evaluate

The patient had many goals from the start of admission to prepare for discharge.

Goals for this group therapy are to teach problem solving strategies and positive coping
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mechanisms. The patient has showed positive outcomes in improvement since admission

and has had a significant decrease in her auditory hallucinations. Outcomes for the patient

should be patient specific, measurable, and time sensitive. The outcomes related to this

patient’s care include the following: Patient will seek help when experiencing manic

impulses. Patient will have satisfaction with social circumstances and achievements of life

goals. Patient will identify at least two to three people she can seek out for support and

emotional guidance when she is feeling majorly depressed before discharge. Patient will

not inflict any harm to self or others. Patient will start working on constructive plans for

the future. Patient will demonstrate compliance with any medication or treatment plan

within the next two weeks, since she is trying to be “natural” throughout this hospital stay;

even though she verbalizes compliance. Patient will demonstrate alternative ways of

dealing with negative feelings and emotional stress. The patient will decrease

hallucinations and will demonstrate use of appropriate interaction skills as evidenced by

lack of, or marked decrease in, manipulation of others to fulfill own desires. For example,

verbalizing her understanding of compliance with her medications, and behaving

otherwise proves this goal and intervention is necessary. The student nurse provided

positive reinforcement throughout the session for non-manipulative behaviors. The

student nurse also helped the patient to explore feelings and help the client seek more

appropriate ways to dealing with them. The rationale of this intervention will enhance self-

esteem and promote repetition of desired behaviors.

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Summarize

In conclusion, this patient is an involuntary admit, but is acceptable to treatment.

Since admission to St. E’s, the client will go see a psychiatrist weekly upon her discharge

and stated that she will continue to take her prescribed medications. She will be living in a

group home after being discharged. Patient was taught all of the available resources out

there and if needed, she will utilize them. Milieu’s activities and therapies also influenced

the patient’s thinking and cognition to develop positive social interactions and decisions

upon discharge. The patient also stated she will try to start using positive coping strategies.

Prioritize

1. Disturbed sensory perception related to visual, auditory, and tactile hallucinations.

2. Disturbed thought processes related to delusions and an inaccurate interpretation of the

environment as evidenced by hallucinations.

3. Ineffective coping related to inadequate support system as evidenced by mania and

aggression.

4. Chronic low self-esteem related to ineffective or inadequate coping skills as evidenced by

feelings of helplessness.

5. Social isolation related to maladaptive social behavior and inadequate resources as

evidenced by feelings of rejection, sad and dull affect.

6. Disturbed sleep pattern related to depression and manic episodes as evidenced by

insomnia.

7. Anxiety related to unconscious conflict about essential values and goals of life as

evidenced by feelings of discomfort, apprehension, or helplessness.

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List of Potential Nursing Diagnosis

1. Risk for loneliness related to lack of support system.

2. Risk for extrapyramidal symptoms of prescribed antipsychotic medications related

to the side effects.

3. Risk for self-destruction related to auditory, visual, and tactile hallucinations.

4. Risk for injury related to extreme hyperactivity and mania.

5. Risk for violence: Self- directed or other- directed related to manic excitement,

delusional thinking, hallucinations, and impulsivity.

6. Stress overload related to chronic mental illness.

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References

American Psychological Association (2013). What Role do Religion and Spirituality Play in

Mental Health? Publication manual of the American Psychological Association (6th

ed.). Washington, DC: Paragament, K.

Mary, T. (2014). Psychiatric Mental Health Nursing: Concepts of Care in Evidence Based

Practice. F.A Davis Company.

NIMH » Bipolar Disorder". Nimh.nih.gov. N.p., 2018. Web. 18 Feb. 2018.

Shattell, M. Thomas, S. and Martin, T. (2002). What’s Therapeutic About the Therapeutic

Milieu? Journal of Psychiatric Nursing, 16 (3), 99-107.

Townsend, M. Psychiatric Mental Health Nursing. 2015. 8th edition. Pgs. 419-435.
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