Running head: CASE STUDY 1

Bipolar Disorder: Case Study

Alissa Sipus

Centofanti School of Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

Professor Teresa Peck

November 10, 2022

CASE STUDY 2

Abstract

The patient of this study is L.S, a 28-year-old Caucasian female who was admitted to the

inpatient psychiatric unit due to a manic episode that involved the police. The following case

study describes the disease process of a patient with Bipolar 1 disorder, mixed along with the

treatments, influences, outcomes, reviews of actual and potential nursing diagnoses and the care

provided for the patient. Multiple nursing research articles and textbook were utilized to further

enhance all that Bipolar 1 Disorder, mixed entails, and call attention to the disorder.
CASE STUDY 3

Bipolar Disorder: Case Study

Objective Data

Patient Identifier L.S

Age 28 years old

Gender Female

Marital Status Single

Children None

Career unemployed, on medical leave last worked April 2022.

ADL’s Independent

Legal status Voluntary

Erikson’s Developmental stage Young adulthood (Intimacy vs isolation)

Date of admission November 2, 2022

Date of care November 8, 2022

Psychiatric diagnosis Bipolar 1 disorder, mixed and amphetamine abuse

Behaviors on admission L.S was hyperactive, hyperverbal, labile and evasive upon arrival to

the TRM emergency department which she was transferred to from University Hospitals for a

psychiatric evaluation. She was initially pink slipped by the police because she appeared to be in

a manic state, and she told them she was paranoid that people were following her and that her

electronic were bugged. The police found knives and razors in her car, and she stated that her

friend gave them to her.

Behaviors on day of care While interviewing L.S I examined her general appearance. She was

wearing sweatpants and a hoodie and looked slightly disheveled, her hygiene seemed to be fair

because she did mention that she doesn’t get to shower and clean up like she does at home. Her
CASE STUDY 4

hair was brown and curly, and I didn’t see any tattoos within view. She maintained eye contact

for most of the interview and was calm but did experiences periods of sad and lability. L.S would

be crying when we were talking about stressors but then would start laughing when talking about

friends and cannabis. She did seem restless in her seat she would fidget with her legs and move

them around a lot. L.S had a congruent mood and affect that was appropriate. L.S was overall

cooperative, friendly and a little suspicious of other patients listening to our conversation. When

it came to her content of thought she did talk about how someone bugged her electronics and

phone and that someone also broke into her apartment. Which shows that she is having

persecutory delusions and paranoia. Her level of alertness/ consciousness was times 4, she is also

aware of her circumstances. When talking about things such as stressors, past history she did

well in recalling the events which tells me she has both good recent and remote memory. Her

ability to control impulses were good.

Medical Conditions L.S has a medical history of Chron’s disease which she stated she has been

dealing with and is the reason she was on leave from her job. She is taking Mesalamine for it.

She also has a history of irritable bowel syndrome that she also struggles with on a daily.

Safety and Security measures Throughout L. S’s stay there were many measures to ensure

safety which included 15 min checkups of what she was doing and where she was. L.S is also on

suicide precautions and Elopement precautions. Some other safety measures include ligature

management for the doors and handles they are unable to hold or give enough support to hang

anything. They are only aloud certain items in their rooms to prevent harm to themselves or

others. All the room furniture is screwed down and they have a single padded mattress. When it

comes to showers, they are limited in time, they don’t get to be alone, and the mirror isn’t made

of glass. The psychiatric floor also has a locked unit where they can place patients that are a risk
CASE STUDY 5

to others and within that locked unit that have a locked room in which they can put very

aggressive/ harmful/ combative patients and watch them to ensure safety.

Laboratory results

Lab value Results

Potassium 4.3
Sodium 142
Glucose/A1C 87/5.1
Blood Urea Nitrogen 7
Creatinine 0.59
RBC 4.31
Hbg/Hct 13.5/40.5
WBC 5.6
AST/ALT 8/16
Lithium/Depakote/Tegretol level 42.1
TSH/T4 0.35/1.0
Drug toxicity Positive amphetamines
UA alcohol level Negative
QTC/ECG 456/Normal sinus rhythm
From interrupting the results of the lab values and the normal levels we can see that all

the lab results are within normal range except the AST, Depakote and TSH. ASTs normal range is

10-37 her lab results showed a level of 8 which is just below the normal range. The Depakote

levels normal range is 50.0-100.0 but her lab result showed that it was at a level of 42.1, which

indicates she hasn’t been taking her medications. The last lab value that was abnormal was the

TSH which was .35 when the normal range is 0.36-3.74. It is just below the normal range, but

this is an important lab to keep an eye on because with thyroid issues we can see that the

symptoms are similar to those of depression with hypothyroidism and mania with

hyperthyroidism.

Psychiatric medications

Generic Name Trade Name Class/Category Dose/ Freq. Reason

sodium Depakote Anticonvulsant 500mg/BID Mood
valproate stabilizer
hydroxyzine Atarax Anxiolytics/ 50mg/ Q6H Anxiety,
HCL antihistamine PRN calms CNS
CASE STUDY 6

mesalamine Pentasa Anticonvulsants 500mg/ QID Chron’s

disease
trazodone Desyrel Antidepressants 50mg/QHS sleep
HCL PRN
aripiprazole Abilify Antipsychotic 10mg/Daily Paranoid,
mood
stabilizer

Summary of Psychiatric Diagnosis

Bipolar Disorder is a chronic illness associated with very debilitating symptoms that

effects not only the patient but the people around them. It will usually start in adolescence or

early adulthood and effects all aspects of their live, including mentally, physically educationally

and occupationally. It can and will also affect the ability to form relationship or current

relationships whether that be with friends or significant others. Patients with bipolar disorder to

also tend to have other psychiatric illnesses in addition to other medical co morbidities

(McCormick et al., 2015).

When diagnosing bipolar disorder, you may see the patient present in a manic episode

which usually makes the diagnosis definitive. On the other hand, you have a patient that presents

with major depression which then must be differentiated between a diagnosis of Major

depressive disorder or bipolar disorder. You start with a bipolar screening tool to help diagnosis

then will need to be confirmed by clinical staff. Some screening stool used include The Mood

Disorder Questionnaire and the Composite International Diagnostic Interview version 3.0.

Although screening tools are used as a supplement in the diagnosis of the disorder the actual

diagnosis is decided after the clinical interview (McCormick et al., 2015).

Bipolar disorder is a mental illness that is an umbrella over the different sub diagnosis of

types that fall under neath that. The first type is Bipolar mixed which is when the patient

alternates between periods of mania, normal mood, depression back to normal mood and then the
CASE STUDY 7

cycle continues to repeat. The second type is bipolar type 1 which occurs when the patient has at

least one episode of depression, but more manic episodes occur. The last type is Bipolar type 2

which is when the patient has multiple depressive episodes with at least one hypomanic episode

(Videbeck, 2020). L.S primary diagnosis was bipolar disorder type 1, mixed because this current

admission was due to her cycle of mania, she presented the floor in a manic episode, but it is

mixed because she does and has also had episodes of depression and cycles through both.

There are two moods that are apart of bipolar disorder, which include mania and

depression. The symptoms that occur during the manic phase includes euphoria, grandiose,

energetic and sleeplessness, exaggerated self-esteem, pressured sleep, flight of ideas, and sex

with strangers, they typically have an abrupt onset with rapid escalation and last normally about

one week. Major depressive episodes last at least 2 week and includes depressed mood, loss in

pleasure in almost all activities, changes in eating habits, hypersomnia or insomnia, impaired

concentration, feeling of worthlessness, guilt, despair, thoughts of death and or suicide.

(Videbeck, 2020). You can see both set of these symptoms when a patient is diagnosed with

bipolar disorder, the amount of which see depends on whether you have mixed, type 1 or type 2.

Identify the stressors and behaviors precipitating current hospitalization

Prior to L. S’s admission she had stopped talking her medications as scheduled and was

only taking them intermittently because she didn’t like the way they made her feel, she

specifically mentioned the medication Depakote and abilify. We can see that she wasn’t taking

her medication because when they checked her Depakote level it was 42.1 which is not within

the normal therapeutic range of 50.0-100.0. Another stressor for L.S was her PTSD from her rape

in 2003, she had mention ed it during her interview but didn’t want to mention any details. Her

chron’s disease was another stressor for her, she stated that the gets very overwhelmed by this
CASE STUDY 8

disease is ashamed of it and what it all entails. Another stressor that she stated caused this recent

exacerbation was her mom and sister. Due to L. S’s sister doing drugs she stole her mother’s car

and took it for a couple days; L. S’s mother made her go looking for it and her sister. Once she

did finally find her, L.S stated that she was jumped by her sister and her friend and that brought

up even more PTSD to the patient. The last stressor that the patient stated was her neighbors, she

doesn’t feel safe around them and they stress her out because they have random people coming

in and out of their apartment which is right across form hers. She stated that she believes they

sell drugs, and she believes that they are the ones responsible for breaking into her apartment. All

these stressors played a role in her current manic episode, and she is aware that she needs to

change/control some of the stressors she can and learn to find appropriate coping skills.

Patient and family history of mental illness

L.S didn’t mention when exactly she was diagnosed with bipolar disorder but from her

interview, she made a lot of indications that she has been dealing with her mental illness for a

quite a while. She was admitted to the psychiatric floor in July of 2020 which was due to a crisis

state and then again in November of that same year because she was experiencing a major

depressive episode and polysubstance abuse. There is also a question of a possible rape in 2003

and there was investigation done and the patient stated that she does feel emotion abused by her

family. The only recorded family history of mental illness is on the patient’s paternal side. Her

father also had a history of bipolar disorder ad passed away in 2013 of a sudden stroke. Although

there was no mention of the patient’s mother having an history of mental illness in the chart, L.S

did state that her sister had brought her mom to the hospital, and she got admitted to the

psychiatric floor in the past. L.S also stated that her sister has a history of substance abuse that

weighs very heavily on their family.

CASE STUDY 9

Psychiatric evidence-based nursing care provided

Throughout her stay on the psychiatric unit at the hospital L.S recived mulitiple

psychiatric eveidence based care along with milieu activites. She was first assgined a physican

and also nurses that ensure she has a safe enviorment by taking all harmful items upon her arrival

to the floor. Items that would/ may have been taken are shoe laces, belts, string, anything that is

sharp including mirriors. They are also repsonsible for administering her perscribed medication

and encouragring her to praticiapte in all activites that improve her managament of her illness.

Accroding to Crowe, et al (2010), “Several studies have demonstarted that including

group psych-education as an adjunct to psychopharmacology is effective in reducing the number

of relasped patients and the number of recurrences per patient, and increasing the time to

depressive, hypomanic and mixed recuuences” (p.898). L.S was also provided group therapy

when on psychiatirc floor. They psychiatric floor would have group readily avaible for the

patients to attend and they would review, eudcate and discuss mental illnesses and patient can

then share as much as they wanted about their experince. This an important nursing care that is

provided to the patient to ensure they have the “tools” acessible to have control of their mental

ilness.

Milie activites that were provided by the nursing staff was ensuring that has the

avalibility to bath, eat and wake up/ get out of bed. They provided scheulde that is listed in the

day room for all patietns to see and read. This allows the patient to have a structured day and

have eveything in order for them. They have scheulded meal time, snack times, TV times, group

times, hygenie care, and cell phone/ visitor time. There are also certain times when the social

workers, nurses and psychiatrist comminicated and enage with the patient.
CASE STUDY 10

Although family for L.S hasn’t been the best there is evidenced based practice that shows

the importance and the impact that family has on the stabilization of bipolar disorder according

to Crowe, et al (2010),

The results of these studies identified good effects. Miklowitz et al. (2000) found that

patients assigned to family-focused psycho-education had fewer relapses and longer

delays before relapse during study year. They showed greater improvements in

depressive (but not manic) symptoms. During follow-up, this group had fewer relapses

and longer survival intervals and showed greater reductions in mood disorder symptoms

and better medication adherence. (p. 903)

We do see the inpatient psychiatric floor try to include family in the care of the patients and L.S

has stated that her mother has been to see her and brought her clothes, but she would like her to

be more of a support system for her. If we can get her mom and possibly friends more included

and supportive, we may see improvements in her overall care of her bipolar disorder and better

mediation compliance.

Ethnic, spirtitual and clutural influnces

L.S is a caucasian, single female that has no children. She is currently unemployed and

does recive fincial support from the government. Her socioecomonic statues was not stated but

she did mention that where her apartment is located in East Lake Cleveland Ohio is not the best

or safest area which makes me believe that she is of the lower socioeconmic status. She also

stated that she believes that her neighbors are selling drugs out of the apartment building. L.S

also did mention that her cultural background included greek and palestinain but she doesn’t

spend much time with her family. Although family is usally of up most importance to both greek
CASE STUDY 11

culture and palestinain culutre, she said that she doesn’t talk to her extended or close fmaily

much because she feels like the black sheep. She did state that she does belive in god and that he

has a plan for everything and it will all work out but didn’t state a specific religion. L.S did

mention that she leans into her faith to help her when she is struggling with her mental illness.

Evaluation of patient outcomes

Outcomes that are wanted for a patient with bipolar disorder is the ability function daily

without the interfernce of their mental ilness which focuses on the absence of manic episodes or

depressive epsiodes. With L.S we have to watch for both set of symptoms because she was

diagnosed with bipolar disorder type 1, mixed. We also want them to have reality based thinking

that doesn’t include delusions or hallucinations. On the day of her care and interview I was able

to see that L.S ability to problem solve was fair, for example she doesn’t trust her neighbors,

when mentioning if she would consider moving she said she shouldn’t have to run away. L.S’s

ability to make decisions regarding her illness is fair because she does make excuses for a lot of

missteps. For example she stated she knew she was suppose to be taking her meds but would

only take intermittently because she didn’t like the way they made her feel. When assesing her

self awareness, I can tell she is very aware of her illness, consequences and limitions but she

dose continue to make excuses and to also engage in acitvity she states is not good for her or her

mental illness such as maladaptive coping skills. Some maladaptive skills she metioned were

cannibus and alcohol abuse. Which she states that she has been clean from for months. Some

adaptive coping strategies she has established she is going to use are reading, drawing, and any

type of art in general. Throughout her interview I was able to see that she wasn’t in themanic

state she was in upon admission and she also said that she that her anxiety and depression were
CASE STUDY 12

very low and she knew that was from medcation compliance. L.S has imporved since admission

and she stated that she wants to continue to.

Summary of the plans for discharge

When L.S is discharged, she plans to return to her apartment in East Lake Cleveland,

where she resides alone in an apartment. Staff on the psychiatric floor reviewed and discussed

alternative treatments including community health services with L.S and she was agreeable to the

plans. L.S also plans to get her work release form signed and wants to return to work at the

Cleveland Clinic as an EKG technician. She also stated that she will take her medication as

scheduled which include Depakote, mesalamine, and abilify. L.S stated she will continue to not

smoke cannabis or drink alcohol. L.S also mentioned she wants to return to school and further

her education in the future. She plans to gain support for her bipolar disorder from her friends

and possibly her mom.

Prioritized list of actual nursing diagnosis

The following are prioritized nursing diagnosis for L.S:

1. Risk for Violence: self-directed or other directed

2. Ineffective Health maintenance

3. Impaired social interaction

4. Chronic low Self-esteem

5. Total Self-care deficit

Potential nursing diagnosis

1. Ineffective individual coping related to biochemical/neurologic changes in the brain

as evidence by non-medication compliance.

CASE STUDY 13

2. Distrusted thought process related to sleep deprivation as evidence by L.S being

suspicious of other patients.

3. Imbalanced nutrition: less than body requirements related to refusal as evidence by

L.S worrying about what others have to say about her eating a lot.

Conclusion

Bipolar disorder is a multiplex disorder than has so many different variables including

periods of remission and exacerbations which includes manic and depressive episodes. This case

study of L.S let us see and learn about all what bipolar disorder type 1, mixed entails. Overall,

we need to focus on the medication compliance and the importance of continuing mental health

services in the community, as well as have good and appropriate coping strategies when the

patient experiences stressors. With all these steps L.S can maintain control of her disorder and

function daily without interferences of bipolar disorder.

CASE STUDY 14

References

Crowe, M., Whitehead, L., Wilson, L., Carlyle, D., O’Brien, A., Inder, M., & Joyce, P. (2010).

Disorder-specific psychosocial interventions for bipolar disorder- A systematic review of

the evidence for mental health nursing practice. International Journal of Nursing Studies,

47(7), 896-908. [Link]

McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with

bipolar disorder: A review for advanced practice nurses. American Association of Nurse

Practitioners, 27(9), 503-542. [Link]

Videbeck, S. L. (2020). Psychiatric-mental health nursing (8th edition). Wolters Kluwer.