SGRD COLLEGE OF NURSING VALLAH

AMRITSAR

NCP
on
BPAD
(Bipolar Affective Disorder )
[Client -Mr. Surinder singh]

SUBMITTED TO: DR.RAJESH KONNUR

H.O.D PSYCHIATRIC DEPT
SGRD CON VALLAH,ASR

SUBMITTED BY: MONIKA JOSPEH

M.SC (N) 1ST YEAR
SPECIALITY-PSYCHIATRIC NURSING
ROLL NO: 1118
SGRD CON VALLAH ASR

SUBMITTED ON 10/05/2012

This nursing care plan is made on the client Mr.Surinder singh diagnosed as BPAD in family unit of
Dr.Vidya sagar institute of mental health.
 History taking

Identification data:
Name: Mr. Surinder Singh
Age/Sex: 39 y/male
Address: Gali no: 5, h.no: 7, civil lines,
phillaur.
Education: Matriculation
Occupation: Farmer
Income: 1,500/month
Marital Status: married
Religion: Sikhism
Ward: Family unit
Diagnosis: BPAD
Hospital: Dr. Vidya sagar institute of mental health

Informant: Patient and his mother, is reliable and adequate .

Mother (Mrs.Harjant kaur) is staying with the client from last 39 years. She is worried
about client’s health and concerned about client’s condition. The information
provided by his mother is adequate and reliable.

Chief complaints:
Increased talkativeness
Decreased sleep since 20 days
Wandering behaviour
Sadness

History of Present Illness:

Mode of onset is insidious and is continuous in nature
Patient was apparently normal 20 days back when his wife observed that he stated praying to god
excessively, history of increased energy since 20 days, patient would hit strangers without any reason,
history of demanding behaviour, asks for new clothes, money etc.
History of decreased sleep, would wake up easily in morning wander aimlessly, history of
elevated mood, aggressive behaviour since 20 days. Patient is on irregular treatment since 10 years.
Patient used to get episodic similar illness, once in 3-4 months and he is on and off treatment.
His biological functions are disturbed due to illness- lack of personal hygiene, decreased sleep,
 Social and occupational functions are also disturbed due to illness – not going for work, and
disturbed social relations.

Treatment:
He is presently receiving drugs like;
Tab. Resperidon 4 mg 1-O-1
Tab.THP 2 mg 1-0-1
Tab. Lithium 600 mg 1-0-1

Past Psychiatric and Medical History:

He is having history of same illness since 10 years and for this he is taking treatment. No other
history of physical illnesses and hospitalization in the past.

Family History:
Patient is staying with one brother and two sisters. Family history of psychiatric illness is
present, his father was having history of BPAD and died by committing suicide. No other members of
the family are having the psychiatric illnesses. Family is maintaining good relationship with neighbours
and society. Economic condition of the family is satisfactory and are able to meet their basic needs.

Lt.Mrs Kulwant kaur, died at

Lt.Mr.Ajit singh,Died at the age the age of 75 years due to the
of 80 years with heart attack natural dealth

Lt.Mr Davinder singh, died at

the age of 52 years due to the
BPAD. Client commited suicide .Mrs Harjant kaur, age 60 years, illiterate,
housewife

Mrs. Amandeep, age

34 years, housewife
Ms. Ranjit kaur,23
years 12th passed

Mr. Surinder singh,

age 39 years, BA
passed,farmer
Mr. Amrik singh, illiterate farmer

Ms. Raman, age 25

years, doing BA

Personal History:
Perinatal history:
Antenatal period – uneventful
Mode of delivery – normal
Any complications – nil

Childhood history:
Feeding - Breast fed
Weaning – at the age of 4 months
He had normal developmental milestones during childhood
Educational history:
He started his education at the age of 6 years. He was dull average student of the school. He
maintained good relationship with teachers and peers. He studied up to SSLC, he terminated his studies
because of loss of interest in the studies and started working in the field.
Play history:
He played games like cricket, Kabaddi etc. his relationship with friends was good. No history of
abnormal behaviour during adolescence.
Occupational history:
His occupation is agriculture; he started working in the field after terminating the study. But now
days he is not going for work because of illness
Sexual history:
Appearances of secondary sexual characters are at the age of 13 years. No abnormalities
associated with puberty.
Marital history: married
Premorbid personality:
He was an extrovert in nature. He maintained good relationship with his family members and his
friends. He uses to spend his leisure time with friends, watching TV and playing games. He believes in
god and other religious activities.
Habits: appetite – decreased
Normal bowel and bladder movements

Mental status examination

 General appearance and Behaviour
 Mr. Surinder singh 39 years old male looks appropriate to his age; he is moderately built and under
nourished. Patient is conscious, well kempt and oriented to place, person and time. He looks restless and
is uncooperative, difficulty to establish eye to eye contact and rapport. Psychomotor activities are
increased. He is maintaining normal posture and gesture. No abnormal movements and extra pyramidal
symptoms, tremors are present. No catatonic phenomena.

 Speech:
Initiation of speech is spontaneous, reaction time is shortened, rate of speech is rapid,
productivity is elaborate reply and volume is increased. Speaks in monotonous tone and is irrelevant.
Stream is normal and coherent. No speech disorder.
Mood:
Subjective: patient tells is I am alright and nothing happened to me
Objective: patient is happy
Predominant mood state is labile with extreme happiness to anxious.
 Thought:
Stream of thought is racy and content is inadequate, and No thought disorders like aliniation;
thought withdrawal and thought broadcast are present.

 Perception: no any perceptual disorders present.

 Cognitive functions:
Consciousness – conscious
Orientation – oriented to time, place and person
Attention – arousal is normal but not able to sustain, able to do calculations like 20-1, and he recalls the
names of week days and months of the years.
Memory:
His immediate, recent and remote memory is intact.
Intelligence;
His general information is poor and arithmetic ability is good, not able to interpret the
abstraction.
Insight:
He is aware of his abnormal behaviour and willing to take treatment.
Judgement:
Personal and social judgements are intact.

Diagnostic formulation:
Bipolar affective disorder with current episode mixed

Physical examination:
General appearance:
Mr. Surinder singh is conscious, moderately built and under nourished.
VITAL SIGNS:
S. No. Vital Sign Normal Value Patient’s Value Inference
1. Temperature 98.60 F 97.40 F Normal
2. Pulse 72-90 /M. 74 /min Normal
Respiration 14-20/M. 16 /min Normal
3.
4. Blood Pressure 120/80 mm of Hg 130/80mm of Hg Normal

SUBJECTIVE DATA OBJECTIVE DATA

Vision Eye lashes are equally distributed

Patient said that “I can see you properly” Eye brows are normal
Pupils are equally reacting to light
No discharges from the eyes

Hearing Ears are equal in size and shape

Patient said “I can hear you properly” No colour change present
Renni’s test and Weber’s test are positive
No discharges from the ears
Not using any hearing aids

Speech and orientation

Patient say’s that “I don’t have any difficulty He is able to talk
while speaking” He is oriented to time, place and person
Respiratory system
“I don’t have any breathing difficulty” Inspection :
Respiratory rate :24/min
Chest normal symmetry and shape
No marks or scars over the chest
No pallor, cyanosis or nodules

Palpation :
Trachea is centrally placed
Respiratory movements are normal
Tactile fremitus is normal on both sides
Chest expansion – 2.5 cm
Percussion:
Resonance sound throughout lung field.
Auscultation;
Normal breath sounds heard
Circulatory system
Patient say’s that “I don’t have chest pain” Temperature : 37` c
 Pulse : 78/min
BP: 130/80 mm of Hg
Inspection :
No cyanosis on lips and extremities
No clubbing of fingers
Palpation:
Peripheral pulses are palpable
Auscultation:
S1 and S2 heard, no murmurs
Lymphatic system
Patient reported that “I am not having any enlarged
gland’s” Lymph nodes are not palpable and not enlarged
No enlargement of Thyroid glands
Gastrointestinal system
Patient says that “I not have pain in abdomen, my Inspection:
appetite and elimination pattern are normal” Patient is moderately built and under nourished
Weight 58 Kg
Height : 169 cm
Dental hygiene : yellowish discolouration of
teeth’s
No tonsil enlargement
Tongue is coated
No abdominal enlargement, no scars or marks on
abdomen,
Auscultation:
Bowel sounds heard on auscultation
Percussion:
Tympanic sounds on stomach and dull sounds on
liver and spleen heard on percussion.
Palpation:
No tenderness, organomegally found on palpation

Urinary system
“Patient reported that I don’t have painful
micturation” Urine colour is pale yellow, normal specific
gravity, no signs of urinary tract infections and
bladder distention.

Musculoskeletal system
Patient says that “ I don’t have any muscle pain” Inspection:
No scoliosis, kyphosis, lordosis
No swelling on joints
No abrasions
he is able to walk
Gait is normal
Palpation:
No swelling, ROM is normal
Muscle strength is normal
cranial nerves are intact
Percussion:
sensory and motor system is having adequate
function
all reflexes are normal, no use of supportive
Integumentary system devices
Patient says that “I am not having any rashes on
my body” Rashes, Pustules, ulcers are absent
skin is normal, adequate warmth is present
nails are in normal shape and size
Rest and sleep
Patient says that “I am not sleeping adequately” Drooping of eyelids present
The patient is having the disturbances in sleep,
Reproductive system sleeping duration is 5 to 6 hrs/day
Patient says “I am not having any problem in the
genital area”
No abnormalities found on examination

Psychosocial aspect
Patient says that I will go to home after completion
He is interacting with health team members in an
of the treatment
acceptable way. Relatives and neighbours are
visiting him. Sometimes he is uncooperative with
them and health team members.

Investigation:
Investigation Patient value Normal value remarks
Haemoglobin 11 gm/dl 13-17 mg/dl Normal
Total Leukocyte count 5,500 c/cmm 4,000-11,000 c/cmm Normal
Differentiate leukocyte
count
Neutrophils 55% 40-70% Normal
Lymphocytes 25% 20-40% Normal
Monocytes 04% 2-10% Normal
Eosinophils 04% 1-6% Normal
Basophil 01% 0-6% Normal
 Drug Dose, route Action Indication Contraindication Side effects Nursing action
and frequency
4 mg Antipsychotic drug  Short term  Hypersensitivit CNS:  Monitor BP regularly
Tab. Risperidon
Oral It blocks dopamine therapy for y Neuroleptic  Watch for Tardive dyskinesia
1-0-1 and serotonin in schizophrenia  Cardio vascular malignant  Monitor for symptoms of
receptors as well as  syndrome,
delaying response disease hyperglycemia
hallucinations,
alpha, alpha 2, H1 in long term  Cerebro  Advise to take plenty of
parkinson’s
receptor in CNS, therapy for vascular fluids
syndrome, tremors,
relives signs and schizophrenia diseases  Avoid activities that require
fatigue, pain,
symptoms of  monotherapy or  Dehydration, altertness
CVS: tachycardia,
psychosis. combination with hypovolemia, chest pain,  Wear protective clothing in
Lithium or seizures othostatic sunlight
valporate for hypotension  Monitor weight
short term ENT: rhinitis,
treatment sinusitis.

600 mg Anti manic drug  To prevent or  hypersensitivity  CNS- tremors,  Monitor lithium blood levels
Interferes with ionic control mania drowsiness, 8-12 hours after first dose,
Tab. Lithium
carbonate pump mechanism in  Major depression headache, two three times weekly in
brain cells and may  BPAD confusion, first month, then weekly to
complete with restlessness, monthly during maintenance
sodium ions seizures therapy
 Tinnitus and  Be alert for adverse reactions
lured vision and drug interactions.
 Dry mouth,  Warn patient to avoid
 metallic taste hazardous activities until the
nausea, drugs CNS effects are
vomiting, known.
anorexia,  Tell patient to drink alcohol
diarrhoea or smoke during therapy
 Polyuria,  Give with plenty of water
glycosuria, and after meals to minimize
 Prutitus, rash, GI reactions
dimisnished
sensations
Tab. THP 2 mg Anti Parkinson agent  Prevention of  Patients with Dry mouth,  Monitor liver, kidney and
0-0-1 Mechanism of action drug induced closed angle blurring of vision, haematopoietic function
Oral is, it inhibits the extra pyramidal glaucoma, constipation, studies periodically in patient
effects of symptoms chronic urinary retention, receiving repeated or
acetylcholine at the pulmonary glaucoma, prolonged therapy
autonomic effector disease, sick confusion, cardiac  Be alert for adverse reactions
sites innervated by sinus syndrome, failure and drug interactions.
parasympathetic thyrotoxicosis.  Warn patient to avoid
nerves. It also brings hazardous activities until the
about direct and drugs CNS effects are known
indirect  Tell patient to drink alcohol
antispasmodic action or smoke during therapy
on smooth muscle
 Process Recording

Aims and objectives of interview:

Patient point of view:

 To help the patient to come out of his problems
 To help the patient to conceptualize his problem
 To help the patient to choose alternatives and try them out
 To help the patient to communicate
 To help the patient to socialize
 To help the patient to change his attitude towards family members and life
 To help the patient to develop insight

Students point of view:

 To gain the patients confidence and get his co-operation
 To establish rapport with patient
 To know about the patient illness
 To identify the role of socio cultural background of patient’s behaviour
 To gain skill in the taking interview
 To practice various communication techniques

Interview:
Date: 21/09/2009
Time: 10.30am, Duration - 15 min

Specific objectives:
 To gain the confidence of the patient
 To assess the condition of the patient

Participants Conversation Inference

Verbal Non-verbal
Nurse : Good morning, Mr. Surinder singh Smile Maintains eye to eye
Patient : Good morning madam Observing contact

Nurse: Did you have breakfast? Leaning forward Initiation of speech

Patient: Yes, I had Maintained eye to is delayed
eye contact
Nurse: What you had?
Patient: I Bread and milk Flat affect Immediate memory
is intact
Nurse: How do you feeling now? Lean forward
Patient: Smile toward patient
Nodding the head

Nurse: What is the problem now?

Patient: I don’t have any problem Nodding the head

Nurse: What is the time now?

Patient: May be morning 9 or 10 o clock Maintains eye to Oriented to time
eye contact
 Nurse: Where are you now? Oriented to place
Patient: In hospital Smile

Nurse: Which is your district? General information

Patient: I don’t know Seing towards is poor
window
Nurse: Where you are taking medication
regularly? Nodding the head
Patient : Yes

Nurse: Thank you for answering for my

questions? Smile
Patient: Thank you

Summary and Conclusion:

Mr. Surinder singh is cooperative, less communicative, he established eye to eye contact and
maintained. His immediate and recent memory is intact, his personnel and social judgement are intact.
He is oriented to time, place and person. His initiation of speech is spontaneous and he has thoughts like
helplessness and guilt.

Introspection:
I was able to assess the condition of the patient. While interacting, I gained confidence. The
problem which I was identified was poor insight. Loss or recent and remote memory.

Interview technique used:

 Observing
 Listening
 Direct questioning
 Non verbal communication

Problem identified:
 Violent behaviour
 Sleeping disturbances
 Less social interaction
 Low self esteem
 Impaired family process
 Less communication
 Knowledge deficit
Nursing diagnosis:
1. Risk for injury related to hyperactivity as evidenced by increased agitation and lack of control over
purposeless and potentially injurious movements

2. Risk for imbalanced nutrition less than body requirements related to inability to sit still long enough
to eat as evidenced by weight loss

3. Impaired social interaction related to egocentric and narcissistic behaviour as evidenced by inability
to develop satisfying relationships and manipulation of others for own desires

4. Disturbed sleep pattern related to mood changes

5. Disturbed family coping related to highly ambivalent family relationship as evidenced by neglectful
care of the client in regard to basic human basis

6. Disturbed thought processes related to biochemical alterations in the brain evidenced by delusions of
grandeur and persecution

7. Anxiety related to hospitalization

 Assessment Diagnosis Plan of action Intervention Implementation Evaluation
Objective data; “High risk for Client will not harm  Maintain low level of Maintained low level of After providing all the
violence self or self and others as stimuli in patient’s stimuli in physical care patient violent
Patient behaviour more directed at others evidenced by environment. Provide environment provide behaviour reduced for
violent and aggressive related to excessive control over unchallenging environment unchallenging some extent
motor activity” behaviour. environment
 Observe patients behaviour Observed the patients
at least every 15 minutes behaviour

 Ensure that all sharp object Ensured that all sharp

glass or mirror items, belts, objects, glass etc have
match box have been been removed from
removed from patients patients environment
environment.
 Administer tranquiliziong Administered
medications tranquilizers
medications
Subjective data: “impaired social ‘client will interact  Recognize that manipulative  Recognized that After providing care
Patient says ‘I don’t like interaction related to with others in an behaviour helps to decreases manipulative patient starts and
to interact with people egocentric and appropriate manner feelings of insecurity by behaviour interact with people.
narcissistic as evidenced by increasing feelings of power
Objective data: behaviour” ability to develop and control.  Ignored attempts by
 Not talking with satisfying  Ignore attempts by patients patient to argue or
others relationship’ to argue or bargain his way bargain his way out
 Sitting alone out of time of the limit of the limit of
setting setting
 Give positive reinforcement  Given positive
for non manipulative reinforcement for
behaviour nonmanipulative
 Helps patient to identify behaviour
positive aspects about self  Helped patient
recognize accomplishment identify the aspects
and feels good about them about self recognize
accomplishment
Subjective data: ‘Anxiety related to Patient gets relief  Reassess the level of anxiety Reassessed the level of Clients anxiety level is
Patient says ‘ I don’t management of from anxiety as to get the base line data anxiety decreased to some
know what happened to disease’ evidenced by facial extent
me’ expression and  Explain about the disease Explained about the
verbalization’ management and disease disease management
Objective data; condition. It helps to reduce and disease condition.
Patient is asking so the anxiety and improve the
much doubts knowledge
Pulse rate increased
Palpitations  Develop good IPR with the Developed good IPR
sweating client it helps to achieve the with the client by
cooperation of the patient talking with him.

 Encourage the patient to ask Encouraged the patient

his doubts to reduce the to ask his doubts.
level of anxiety
 Provide psychological Provided psychological
support to get relaxation support to the client

 Provide relaxation Provided relaxation

techniques to reduce the techniques.
anxiety.

Subjective data: ‘Risk for Client will not  Assess the clients nutritional Clients nutritional status Clients nutritional status
Client says ‘I will not imbalanced develop status is assessed is improved to some
eat properly’ nutrition: less than signs/symptoms of  Consult dietitian. Determine extent
body requirements malnutrition the number of calories
related inability to required based on body size
Objective data: sit still long enough and level of activity. Intake and output record
Client looks, to eat as evidenced  Document intake, output in maintained
Weak by weight loss and calorie count, and
Less weight compare to weigh client daily. Client is told to take
height  Ask client to take small and small and frequent diet
frequent diet
 Provide the food according
 to like of the client
 Supplement nutritious meals
with multiple vitamin and
mineral tablet
Subjective data: ‘Disturbed sleep ‘Client maintains  Reassess the sleep pattern to Reassessed the sleep Client’s sleep pattern is
Patient says ‘I didn’t pattern related to adequate sleep get the base line data pattern improved to some
slept during night’ depressed mood and pattern during night extent
fears evidenced by as evidenced by  Encourage the patient to Encouraged the patient Sleep hrs-8-9 hrs
Objective data: difficulty falling a facial expression avoid the day time sleep to to avoid the day time
Droopy eyes sleep’ and verbalization’ promote night sleep sleep
Facial expression
Sleeping hrs – 5-6  Encourage the patient to Encouraged him to
hrs/day engage in some activities engage in some
before sleep to promote the activities before sleep
sleep
 Provide calm and quiet Provided calm and quiet
environment to promote the environment
sleep
 Provide a glass of warm Advised the family
milk before going for sleep. members regarding the
Tryptophan in milk induces same.
sleep
8.
 Application of Roy adaption theory:

The core The cure

Mr.Surinder singh Tab: Risperidon 4 mg
Age: 39 years Tab-THP
Sex: male Lithium 600 mg
Marital status: single
c/o: Increased talkativeness
Decreased sleep
Wandering behaviour
Sadness

The care
 Provided safe environment
 Established and maintained good
rapport
 Assisted in personal hygiene care
 Passive exercise provided
 Medication advinistration
 Educated client about nutrition and
hygiene

Health Education:
Health education regarding the nutrition and its importance, personal hygiene and measures
taken to maintain personal care and about the treatment and adherence to treatment is explained to client
and family members.
Regarding illness and medications
 Explained regarding the nature of illness, also the fact that this is a long term disorder and that
maintenance treatment therefore will require one or more medication may have be taken for
long time.
 Educated him regarding the medication, proper dose and time of administration.
 Explained regarding the expected side-effects and toxic effects of the prescribed medications as
well as where to go in care of severe side effects.
 Enlisted the signs and symptoms of relapse that may came, also explained the role of family
members and others in preventing relapse.
 Advised not to take any pother medication with out the advise not to stop drug abruptly with out
psychiatric advise
Personal hygiene
 Educated the client the importance of bathing daily, brushing teeth daily, grooming, weaning
clean clothes, combing hair, cutting nails.

Nutrition
 Educated regarding importance of balanced diet. Regarding maintenance of adequate weight.
Educated the intake of 3-4 liters of water per day. Educated the importance of fibers in diet.
Physical activities which interest him. Regular weighing.

Coping with illness

 Educated the patient and family members regarding how to cope up with illness
 Advised them to avoid situations which causes anxiety to client and provide calm and peaceful
environment.
 Encouraged client to take responsibilities.
 Educated family members to encourage and appreciate even small tasks.
 Explained the importance of follow up. Advised to abstain from alcohol and smoking.

Summary and Conclusion:

Mr.Surinder singh admitted to the hospital with complaints of increased talkativeness, Decreased
sleep, Wandering behaviour, Sadness since 20 days. After all the medical and nursing management to
the client his condition is improved to some extent.

Self evaluation:
After taking this case for providing nursing care I understood about this psychiatric disorder
and also how to care a patient with Bipolar affective disorder.