Sociodemographic Data

NAME Sumit Nath

AGE 29 years
SEX Female
WARD NO Pavilion 2 ward
EDUCATION 10+2
OCCUPATION unemployed

MARITAL STATUS Unmarried

RELIGION hindu
LANGUAGE Hindi, kanadar
ADDRESS Bangalore

HOSPITAL REG NO P.4678/6

DATE OF ADMISSION 21-07-2010

FINAL DIAGNOSE BPAD(Mania)

I. Complaints

INFORMANT : relatives, ward sister,patient

CHIEF COMPLAINTS :
- Abusive and aggressive
- Big talk
- Self muttering & smiling
- Poor personal hygiene
- altered sleep

II. History of present illness:

DURATION: Since last 3 months he is having the above said complaints.

MODE OF ONSET: onset of the problem is insidious.
COURSE: Course of the illness is episodic
INTENSITY: Intensity of the illness is decreasing
Patient brought to the hospital having auditory hallucination, delusion of grandiosity.some time patient
become aggressive and hyperactive most of the time she remain calm in the ward she was having abusive
and aggressive behavior, self muttering from last three months. Her sleep was decreased, becomes restless
and doesn’t maintain his self hygiene.

III. Treatment History:

 S.NO MEDICATION DOSE FREQUENCY ACTION
1 T.Haloperidol 5mg TDS(1-1-2) Antipsychotics

2 T. Lozazepam 2mg TDS(1-1-1) Antianxiety

3 T.Trihexyphenidy 2mg BD(1-1-0) Anticholinergic

l

IV. Past psychiatric and Medical History:

MEDICAL HISTORY: Patient has no history of any medical illness like cardiac disease, renal disease,
etc.

PSYCHIATRIC PAST HISORY: There is no any history of past psychiatric illness. She was never
hospitalized due to any illness like depression etc.
SURGICAL PROCEDURE: No any relevant surgical history

V. Family history
FAMILY HISTORY OF ILLNESS :No history of Mental retardation
No history of epilepsy
No history of mental and neurological illness
CONSANGUINITY AMONG PARENTS: No consanguinity of marriage is present in the parents

GENETIC DIAGRAM :

husband patient
tailor house wife

son, healthy son,healthy

CURRENT LIVING ARRANGEMENT

Living in a nuclear family .Cordial atmosphere in the house

VI. Personal History

(A) PERINATAL HISTORY:

Antenatal history:
 No history of any nutritional deficiency, exposure to any medication, infections
 No history of 1st and 2nd trimester bleeding, threatened abortion, Rh incompatibility, impaired fetal
movements
 No history of any maternal disease like diarrhea, anaemia, pre-eclampsia, hypothyroidism, or
premature placental separation

Intranatal history:
 Type of delivery: Full term normal vaginal delivery
 Any complication: no complication during the child birth

Birth: Baby was born at Full term and birth weight was 3.2 kg
Birth cry: Birth cry was immediate and normal
Birth defects: No birth defect is present
Postnatal complications: no history of any complications like cyanosis, convulsions, jaundice,
neonatal infections

(B) CHILDHOOD HISTORY:

Primary caregiver: Mother and father

Feeding: Breast feeding was given till the age of 1 year
Age of weaning: weaning was started at the age of 7 months
Developmental milestones: Normal developmental milestones
Behavior and emotional problems: No history of behavioral and emotional problems like thumb
sucking, excessive tempertantrums, head-hanging, nail biting, enuresis, night terrors, etc
Illness during childhood: No any history of CNS infections, epilepsy, neurotic disorders, malnutrition

(C) EDUCATIONAL HISTORY:

Age of beginning of formal education: Schooling was started at the age of 4 years
Academic performance: he was an average student
Relationship with peers and teachers: he had good relationship with peers and
 teachers
School phobia: No any history school phobia is present
Conduct disorder: No any history of conduct disorders
(D) PLAY HISTORY:
Games played (at what stage and with whom): he engages in plays with peer groups
Relationship with playmates: He had healthy relationship with playmates.
(E) EMOTIONAL PROBLEMS DURING ADOLESCENCE:
Running away from home/delinquency/smoking/drug taking/any other: No any history of
delinquency, smoking, drug taking is present.
(F) PUBERTY:
Age at appearance of secondary sexual characteristic: Secondary sexual characters appeared at the
age of 15 years.
(G)SEXUAL AND MARITAL HISTORY
she is married and having healthy relationship with his husband.
PREMORBID PERSONALITY:
Interpersonal relationships: She is an introvert.
Family and social relationships: she has healthy relationship with his family.
Use of leisure time: she spend his leisure time by watching TV and listening songs
Predominant mood: optimistic
Usual reaction to stressful events: She has ability to tolerate frustrations
Attitude to self and others: He has ability to trust others.
Attitude to work and responsibility: She is a responsible toward her work.
Fantasy like: daydreams & frequency and content: there is no nay fantasy or day dreamsing.
Habits:
 Eating pattern: regular
 Elimination: regular
 Sleep: regular
 Use of drugs, tobacco, alcohol: No consumption of any drugs, tobacco or alcohol

DIAGNOSIS:
 1. Risk for injury related to extreme hyperactivity evidenced by lack of control over
purposeless movements.
2. Imbalanced nutrition: less than body requirement related to inability to sit still long
enough to eat evidenced by weight loss.
3. Self care deficit related to ability to sit enough at place evidenced by difficulty carrying
out tasks associated with hygiene, dressing, grooming, eating, toileting.
4. Inability to sleep R/T worry guilt, restlessness and agitation.

GOALS:
The client will be able to:
1. Be free of self inflicted harm
2. Establish or maintain adequate nutrition.
3. Establish and maintain adequate sleep and activity.
4. Establish and maintain adequate personal hygiene.
5. Communicate with other & participate in activities.
6. Feeling both verbally and non-verbally.
7. Experience decrease hallucination, delusion.

NURSING CARE PLAN

NURSING OBJECTIVES INTERVENTION RATIONALE
DIAGNOSIS
1.Risk for injury To prevent the -Reduce environmental -Client is extremely
related to extreme client from any stimuli-keeping lighting and distractible & responses to
hyperactivity evidenced injury. noise level low. even the slightest stimuli
by lack of control over
purposeless movements -Client may harm self
-Removing the hazardous inadvertently.
objects & substances.
-Nurse’s presence may
-Stay with the client who is offer support & provide
hyperactive. feeling of security for the
client.

-Provide physical activities. -These will relieve pent-up

tension.

-Administer tranquilizing -Are very effective for

medication as ordered by providing rapid relief from
physician the symptoms of
hyperactivity.
2. Imbalanced nutrition To help the -Provide high protein, high Client has difficulty sitting
: Less than body patient to calorie, nutritious finger foods still long enough to eat a
requirement related to improve his & drinks that can be meal.
inability to sit still long intake of food.
consumed “on the run”.
enough to eat These are important
evidenced by weight -Give plenty of water. nutritional assessment data.
loss. -Maintain accurate record of
intake, output, calorie count,
weight. Monitor daily
laboratory values.
-Provide favorite foods. -Encourages eating.
-Improves nutritional
-Supplement diet with
status.
vitamins & minerals.
-Walk/ sit with the client -Nurse’s presence offers
while he/she eats. support & encouragement
to the client to eat food that
will maintain physical
wellness.

3. Self care deficit To develop a -Encourage the patient to -Make patient dependent
related to ability to sit sense of attend to personal hygiene
enough at place wellbeing. with minimum assistance.
evidenced by difficulty -Provide him with clothing &
carrying out tasks -Due to disturbed thought
toilet articles because the
associated with process patient may have
hygiene, dressing, patient might have given given away.
grooming, eating, away his clothes.
toileting. -Help the patient to select
clothings according to
weather.
-Ensure that the patient
attends to minimum care of
brushing, bathing, changing
clothes, combing in the
morning. Makes him feels fresh &
-Encourage the patient to comfortable.
spend time in the toilet to
develop regular bowel habits.

-Decreaced withdrawan
behaviour.

-Be gentle but firm in setting

 limits for time spend in bed. -To prevent constipation.

4.Inability to sleep R/T Promote an - Client’s activity is

worry guilt, adequate impaired.
restlessness and balance of -Client may need physical
agitation. rest, sleep & assistant. -Specific limits let the
activity. -Provide a night time routine client know what is
or comfort measures. expected of him.
-The client expects to
-Don’t allow the client to sleep.
sleep long time in day time.
-Sleeping during day time
-Give medication as indicated. reduce sleep at night.
-Prevent the client from
harming himself.

- Medication will helpful

in facilitating sleep.