SWAMI RAMA HIMALAYAN UNIVERSITY

HIMALAYAN COLLEGE OF NURSING

NURSING CARE PLAN ON BPAD

SUBMITTED TO:
SUBMITTED BY:

Dr Grace M.Singh Ruchi Sharma

Associate Professor Msc Nursing Second Year

HCN,SRHU HCN,SRHU

SUBMITTED ON:

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 PSYCHIATRIC HISTORY

IDENTIFICATION DATA:

NAME OF PATIENT: Mr. Rahul

AGE 29 years

EDUCATIONAL STATUS :Graduate

RELIGION :Hindu

OCCUPATION :Unemployed

ADDRESS :balrampur near Maqbool masid

MARITAL STATUS : Married

DATE OF ADMISSION :17th Jan 2023

DIAGNOSIS : F-31 (Bipolar affective disorder).

DOCTOR INCHARGE: Dr. Naidu

INFORMANT:

NAME : Mrs. Madhvi shrama

RELATION : Mother

RELIABLITY : Reliable

Informant lives with patient since 29 years and he is reliable for the patient’s history

CHIEF COMPLAINTS:(according to patient):

 Mere kuch bhi karane ni mann ni karda aur baat baat par gussa aa jaata aur Meri neend puri nhi
hoti h. Mera pura sareer dard krta rhta h and Mera ghr me rhne ka mann ni krta.

CHIEF COMPLAINTS (according to Informant):

 Isse kisse cheez mn mann nhi lgta aur kuch kaam bhi nhi krta aur ghr se jane k baat krta hn.

HISTORY OF PRESENT ILLNESS:

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 PRESENT MEDICAL ILLNESS:

Patient is having no medical illness presently.

HISTORY OF PRESENT PSYCHIATRIC ILLNESS:

 Duration of present illness : 3 Years

 Mode of onset : Gradual onset.

 Course :Episodic Course.

 Precipitating Factor : Death of brother

On 1nd, December, 2016, patient’s brother had been lost from home. He was found dead in a an
accident. He was brought to the hospital but he died.. At the time of death of his brother he is 25
years old. Patient left alone in his house after death of his brother. So, at that time, in grieving
period, he started wandering here and there. His mother and father brought her to hospital for
treatment. And he was diagnosed with bipolar affective disorder in hospital.

PAST HISTORY

PAST MEDICAL HISTORY:

Patient is having past medical history of typhoid fever. Patient is not having history of diabetes,

hypertension or other medical conditions.

PAST SURGICAL HISTORY:

There is no past surgical history.

PAST PSYCHIATRIC HISTORY:

Patient is having no psychiatric history in past.

FAMILY HISTORY:

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Type of family : Nuclear family.

Total number of family members : 2 members.

FAMILY TREE:

KEYS:

 : Male : Dead Emotional

attachment

: Female : Patient.

FAMILY CHART:

SR. NAME OF RELATION AGE BEHAVIOUR ANY MENTAL

NO. PERSON WITH WITH ILLNESS
PATIENT PATIENT

1. Mr. Rijjo Grand-Father Death in 2010 --- ---

2. Mrs. Chinna Grand-Mother Death in 2013 --- ---

3. Mrs. Rincy Aunty 65 Years Healthy and No mental illness

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 good relations reported

4. Mr. Uncle 69 years Healthy and No mental illness

Mukeshappa good relations reported

5. Mrs. Madvi Mother 59 years Healthy and No mental illness

Good relations. reported

6. Mr. Jatesh Father 61 years Healthy No mental illness

Relations. reported

7. Mr. Rahul Patient 29 years Not healthy BPAD

relations

8. Mr. Dinna Uncle 59 years Healthy and No mental illness

good relations reported

9. Mrs. Aunty 56 years Healthy and No mental illness

Bhartamma good relations reported

RELATION WITH FAMILY MEMBERS:

 Patient is having healthy relations with all family members.

 There is no history of any aggression or fight with family members
VITAL SIGNS:

SR. VITAL NORMAL PATIENT’S READINGS REMARKS

NO. SIGNS VALUE

1. TEMPER 98.6oF 98.1oF 98.2oF 97.7oF Temperature is normal.

ATURE

2. PULSE 72-80/min 98/min 72/min 88/min Pulse is normal.

3. RESPIRA 18-22/min 22/min 20/min 22/min Respiration is normal.

TION

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4. BLOOD 120/80mmhg 100/70 100/70 110/70 Blood pressure is low.
PRESSUR
mmhg mmhg mmhg
E

TREATMENT:

SR NAME OF CHEMICAL DOSE FREQ- ROUTE ACTION

MEDICINES NAME UENCY
NO.

1. Tab. Librium Chlordiazpxide 200 mg BD Oral Anti-Anxiety

2. Tab. Lithium Lithium 300 mg BD Oral Anti-Manic

2. Tab. Serenace Haloperidol 0.25 mg TDS Oral Typical

antipsychotic
(Butyrphenones)

3. Tab.Aciloc Rantidine 150 mg BD Oral Antacid

4. Tab. Multi- Multi- vitamin 10 mg BD Oral Vitamin

vitamin Supplement.

5. Tab. Divax Sodium 500mg BF Oral Anti-Convulsant/

Valporate Mood stabilizer.

6. Tab. Bupron Bupiernon 150mg BD Oral Antidepressants

7. Inj Thaimine Multi-vitamin 50 mg OD Intra- Vitamin

muscular Supplement.

PERSONAL HISTORY

BIRTH HISTORY:

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  Patient is having normal birth history.

 Patient is born with normal vaginal delivery.

 There is no history of any birth anomaly or birth defects.

 Patient is breast fed for 1 year of age then he started bottle fed.

 Other information regarding patient’s birth is not known to informant and patient itself.

CHILDHOOD HISTORY OR EARLY DEVEOLPMENT:

 All milestones are achieved at accurate time.

 Patient explained that he is having nightmares during childhood period. He got scared
of all that scary things.

CHILDHOOD BEHAVIOURAL PROBLEMS:

Neurotic traits like thumb sucking, bed wetting are not present in the patient. More history
related to patient’s childhood is not known to informant and patient self.

PLAY HISTORY:There is no significant history about patient’s play characters.

 Type of play : Patient always plays in group.

 Behaviour during play : Patient is cooperative and adjustive during play.

 Relationship with playmates : Patient is friendly with his playmates.

 Personality during play : Patient is cooperative and helping during play.

SCHOOL HISTORY:

 Age of beginning school : Patient started school at the age of 5 years.

 Behaviour in school : Patient is cheerful and adaptive in school.

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 Relation with schoolmates : He is having friendly relation with the Classmates. He is
always participating with Classmates in school activities.

 Relation with teachers : Patient is having satisfactory relation with teachers. He is

always obedient to teachers and follows their commands.

ADOLESCENT HISTORY:

Relationship with peers: Patient was having good relations with peers. He explained that he
got very good friends during his adolescent period.

PUBERTY:

 Age of appearance of secondary sexual characters : 13 Years.

 Reaction towards puberty: During appearance of secondary sexual characters, he got anxious but
later on he understood the facts and his anxiety goes down to normal.

 Patient is having normal changes in behavior after puberty begins. He is not much anxious.

OCCUPATIONALHISTORY:

 Age of starting job : At the age of 18 years.

 Type of job : Patient is a painter.

 behavior at workplace : Patient’s behavior is satisfactory at his Workplace.

 Relation with workmates : Patient is having healthy relation with Workmates. He

remains cheerful and friend with them.

 There is no history of leaving the job and starting the new.

Patient is having a good work record. He remained happy during her job hours.

MARRITAL AND SEXUAL HISTORY:

 Type of marriage : not significant.

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  Age at marriage : not significant.

 Time of marriage : not significant.

 Behaviour with partner : not significant.

 Total years of marriage : not significant.

 Use of contraceptives : not significant.

 Number of children : not significant.

PRE-MORBID PERSONALITY:

This is the personality and behaviour of patient before his illness.

1. SOCIAL RELATIONS:

Patient was having satisfactory relations with his family members, friends and workmates.

2. HOBBIES:

Patient likes to play cricket in his free time. He love to watch old Bollywood movies

3. PERSONALITY CHARACTERICTIS:

Patient was loving, kind, optimistic, determined and cooperative. He loves and cares for his
child.

4. TEMPERAMENT:

Patient was cheerful and happy before illness.

5. ADDICTION AND HABBITS:

Patient was having addiction of smoking.

HABBITS:

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  Eating pattern : Regular eating pattern

 Sleep Pattern : Regular sleep pattern before having illness.

MASLOW`S HIERARCHY OF NEEDS:

NEEDS OF THE PATIENT

1. Family relationship and disturbed

2. Lacks confidence

SELF ACTUALIZATION

SELF ESTEEM

LACKS CONFIDENCE
LOVE AND BELONGING

FAMILY RELATIONSHIP
SAFETY ARE DISTURBED

PHYSIOLOGICAL
NO NEED

MENTAL STATUS EXAMINATION (MSE)

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A. GENRAL APPERANCE

 FACIAL EXPRESSION: Facial expressions of patient are appropriate to and

consistent with the subject. Patient is having blank and vacant gaze during
conversation.

 POSTURE: Posture of patient was normally relaxed.

 MANNERISMS: Patient was not having repeated small movements of habitual

kind under stress.

 DRESS: The patient is having dress with normal neatness. He is wearing dress
according to season and occasion.

 HYGIENE: Patient was clean, his hair combed and finger nail were cut.

 PHYSICAL FEATURES:

Her features are:

 He is having normal weight.

 He looks according to his age.

 He is not having any physical deformity.

B. MOTOR DISTURBANCES

a) OVERACTIVITY OR HYPERACTIVITY: Patient was having restlessness

and hyperactivity during conversation.

b) UNDERACTIVITY: Patient was not having slowing down of activity and

functions during conversation.

c) STUPOR: Patient was not motionless at all during talk.

d) STEROTYPY: It is of two types:

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  STEROTYPY ACTION: Patient was not having any repetition of
physical activity.

 STEROTYPY SPEECH: Patient was not having any repetition of

speech.

e) COMPULSIVE MOVEMENTS OR COMPULSIONS:

QUE: Aapko koi kaam baar baar krne ka mann krta hai jisko baar baar krne ki
jarrurat nhi hoti?

ANS:Nhi mujhe ese koi khyal nhi aate h.

OUTCOME: Compulsive movements were absent in patient.

f) ECHOPRAXIA:Patient was not having any pathological repetition by imitation

of movement of another person.

g) NEGTIVISM:

QUE: Kya aap apne bed se uthoge?

ANS: Haan, main uth jaata hu.

QUE: Kya aap aapne haath upper uthaoge?

ANS: Haan, main utha deta hu.

OUTCOME: Negativism is absent in the patient.

h) AUTOMATIC OBEDIENCE:Automatic obedience was absent in the patient.

i) WAXY FLEXIBLITY:Waxy flexibility is absent in the patient.

C. DISORDER OF THOUGHT:

There are three aspects of disorders:

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a) Disorder of form of thought.

b) Disorder of content of thought.

c) Disorder of progression of thought.

d) Disorder of speech.

a) DISORDER OF FORM OF THOUGHT:

i. Circumstantiality:

QUE: Aapne aaj subh kya khaya tha?

ANS:Mene parantha aur daliya khaya tha.

OUTCOME: Circumstantiality was absent in the patient.

ii. Incoherence:

QUE: Aapke ghr me total kitne log rhte hai?

ANS:Mere ghr m mujhe milakr ke pue 2 log rhte hai.

OUTCOME: Incoherence was absent in the patient. Patient’s speech

was not having any disorganization.

iii. Irrelevent:

QUE: Aap kya kaam krte ho?

ANS: Main kuch ni krta hu.

OUTCOME: Irrelevence was absent in the patient.

iv. Neologism:Patient was not having neologism. She was not coining the
new words or language.

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 v. Tangential thinking:Tangential thinking was absent in the patient. She
was giving reply appropriately.

vi. Word salad:Word salad was not present in the patient. His sentences
and words are connected and are not mixed- up.

vii. Perseveration:Perseveration was not present in the patient. Patient was

not having any involuntary and morbid repetition of word or idea.

viii. Ambivalence or ambivalent ideas:

Ambivalence ideas were absent in the patient.

EVALUTION OF SPEECH:

 Intensity:Patient’s voice was normally audible.

 Pitch: Pitch was appropriate to the content and doesn’t show any much
change.

 Speed:Patient spoke at higher rate of speed.

 Spontaneity:Patient answers are spontaneous.

 Manner: Patient’s manner of speaking was relaxed.

 Reaction time:Patient’s reaction time was appropriate. He answers the

questions at appropriate time.

b) DISORDER OF CONTENT OF THOUGHT:

i. DELUSIONS:

o Persecutory delusions:

QUE: Aapko esa lagta h ki koi aapko maarne ki kosish kr rha h?

ANS: Haan, mujhe koi maarne ki kosis kr ra h.

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 OUTCOME: Persecutory delusions were present in the patient.

o Delusion of reference:

QUE: Aapko kabhi esa lagta hai ki log aapke bare m baat kr rhe h?

ANS: Haan, log hmesha mere bare hi baate krte hain.

OUTCOME: Delusion of reference was present in the patient.

o Delusion of influence or passivity:

QUE: Apko esa lgta hai ki koi sakti aapko vash me krke rkhi hai aur
aapke dimag aur sareer ko control kr rhi h?

ANS:nhi, mujhe esa nhi lagta.

OUTCOME: Delusion of influence was absent in the patient.

o Delusion of sin or guilt:

QUE: Aapko esa lagta hai ki aapne bhut bda gunah kiya h jiski saja ab
aapko mil rhi h?

ANS:Nhi, mene koi gunaah nhi kiya h.

OUTCOME: Delusion of sin or guilt was absent in the patient.

o Hypochondrical delusion:

QUE: Kya aapko esa lagta hai aapko esi bimari hai jo kabhi thik nhi ho
skti?

ANS:Mujhe koi esi bimari nhi h. Main bilkul thik hun.

OUTCOME: Hypochondrical delusions were absent in patient.

o Delusion of grandeur:

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 QUE: Kya aapko esa lagta hai ki aap bhut balwaan aur saktishaali hai aur
aapke paas bhut paisa hai?

ANS:Nhi mere pas koi skti nhi h aur na hi jyada paisa hai.

OUTCOME: Delusion of grandeur was absent in the patient.

o Nihilistic delusion:

a. Depersonalization:

QUE: Kya aapko esa lagta hai ki aap badal gye ho aur aap ho hi nhi?

ANS:Nhi, esa kuch nhi h.

OUTCOME: Depersonalization was absent in patient.

b. Derealization:

QUE: Kya aapko esa lagta hai ki aapke aas pas ki dunia khtm ho gyi hai
ya sab kuch badal gya hai?

ANS:Nhi ese nhi hai.

ii. OBSESSIONS:

QUE: Koi ese khyal jo aapko baar baar mann mein me aate ho aur jinko
pura krne ke liye mann bechain hota hai?

ANS:Nhi khyal merko baar baar nhi aate hai.

OUTCOME: Obsessions are absent in the patient.

iii. PHOBIA:

QUE: Kya aapke man me kisi cheez ka esa darr h jiske bare mein
sochne se bhi aapko pareshani hoti h?

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 ANS:Nhi mujhe koi esa darr hi hai.

iv. PREOCCUPATION:

Preoccupation was absent in the patient.

v. FANTASY:

o Creative:

QUE: Aap hospital se discharge hone ke baad kya karoge?

ANS: Main ghar jaunga aur phle jaise hi rhungi

QUE: Kuch kaam suru kroge ?

ANS: Mujhe paint ka kaam aata hai. Main whi suru krunga.

OUTCOME: Creative fantasy was absent.

o Day dreaming:

QUE: Kya aapko esa lagta hai ki aap sawarg mein hain aur aapke pas
bhut costly cheezen hain?

ANS:Nhi, mere paas to kuch ha hi ni.

c) DISORDER OF PROGRESSION OF THOUGHT:

i. Pressure of speech: Pressure of speech was absent in the patient.

ii. Flight of ideas: Flight of ideas was not present in the patient.

iii. Retardation: Retardation of speech was present in the patient during

conversation.

iv. Mutism: Mutism was absent in the patient.

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 v. Aphonia: Aphonia was absent in the patient. Patient speaks in audible
manner.

vi. Thought block: Thought block was absent in the patient.

vii. Clang association: Clang association was absent in the patient. Patient
replies in simple sentences.

D) DISORDER OF PERCEPTION:

a) Illusion:

QUE: ye kya hai( pointing towards pencil.)

ANS: ye pencil hai.

OUTCOME: Illusion was absent in the patient.

b) Hallucinations:

o Auditory hallucination:

QUE: Kya aapko koi esi aawazein sunai deti hai jo aapko kuch krne ko bolti hai?

ANS: Hain mujhe bhuto ki aawanzein sunai deti hain. Par mujhe wo aawazen saaf
pta ni chlti ki wo bol kya rhi h.

OUTCOME:Auditory hallucinations are present.

o Visual hallucination:

QUE: Kya aapko kabhi esa lagta hai akele kamre me aapke alawa bhi koi aur hai?

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 ANS: Haan, mujhe esa lagta hai mere bhai ki saas mere sath kamre m hi rhti h.
par wo mujhe kabhi kabhi hi dikhti hai.

OUTCOME: Visual hallucinations are present in the patient.

o Olfactory hallucination:

QUE: Kya aapko koi esi smell aati hai jo whan kisi aur ko nhi aarhi hoti ya koi
esi khushboo ya badboo aati ho?

ANS:Nhi esi koi smell nhi aati.

OUTCOME: Olfactory hallucinations are absent.

o Gustatory hallucination:

QUE: Kya aapko kabhi kabhi kuch alag sa taste muh me aata tha jab aapne kuch
ni khaya hota tha?

ANS:Nhi.

OUTCOME:Gustatory hallucinations are absent.

o Tactile hallucination:

QUE: Kya kabhi aapko esa lagta hai ki aapke body par kuch chl rha hai ya reng
rha hai?

ANS:Nhi mujhe esa nhi lagta.

OUTCOME: Tactile hallucinations are absent.

o Lilliputian hallucination:

QUE: Is pen ka size kitna hai?

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 ANS: Ye pen to bhut 10 c.m. hoga.

OUTCOME: Lilliputian hallucination was absent.

E) DISTURBANCES IN AFFECT

 INAPPROPRIATE OR INCONGRUENT AFFECT:

a) MOOD: Patient was having mood according to the situation. Patient was happy at the
time of conversation.

b) AFFECT: Patient was having smile at the time of conversation. She was responding
according to the conversation.

 PLEASUREABLE EFFECT:

a) EUPHORIA: Euphoria was absent in the patient.

b) ELATION: Elation was absent in the patient.

c) EXLATATION: Exlatation was absebt in patient.

d) ECTASY: Ectasy was absent.in the patient.

 UNPLEASUREABLE EFFECT:

a) DEPRESSION: Patient was not depressed during conversation.

b) GRIEF OR MOURNING: Patient was not in grief state.

 OTHER AFFECTS:

Patient was not having any other afeect like anxiety, fear, agitation, apathy, aggression or mood
swings.

F) DISORDER OF MEMORY:

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 a) IMMEDIATE MEMORY:

QUE: main aapko 5 chizo ke naam bta rhi hu.(santra, kamiz, pencil, bed, mug).

Aap in chizo ko dohrao?

ANS: Santra, kamiz, bed pencil.

OUTCOME: Immediate memory was partially good.

b) RECENT MEMORY:

QUE: Kal raat ko aapne kya khana khyaya tha?

ANS: Mene kal raat ko kaddu ki sabzi aur chappati khaya tha.

OUTCOME: Recent memory was good.

c) REMOTE MEMORY:

QUE: Aap ki janamdin kab hota hai?

ANS: Mera janam din 15 January ko aata h.

QUE: Aapke papa ki death kb hui thi?

ANS: Unki death 5 saal phle hui thi.

OUTCOME: Remote memory was good.

DISORDERS OF MEMORY:

a) Amnesia: Amnesia was not present in patient.

b) Paramnesia: Paramnesia was not present in the patient.

c) Antegrade amnesia: Antegrade amnesia was absent in the patient.

d) Retrograde amnesia: Retrograde amnesia was not present in the patient.

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 e) Dija vu:

QUE: Kya aapko kabhi esa lagta hai ki kisi chiz ya kisi aadmi ko jisko aap phlli baar mil rhe h,
unko aapne phle kabhi dekha hai?

ANS: Esa kuch nhi hota mujhe.

OUTCOME: Dija vu was absent in the patient.

f) James vu:

QUE: Kya aapko kabhi kisi sthithi me esa lgta ha ki aap ne esa phle kabhi nhi mahsoos kiya par
asal me aapke sath wo sab kuch hua hota ha?

ANS:Nhi mujhe esa nhi lagta.

OUTCOME: James vu was absent in the patient.

g) Hyperamnesia: Hyperamnesia was absent in the patient.

G) ORIENTATION

TIME:

QUE: Aaj kon sa din hai?

ANS: Aaj sanibaar hai.

QUE: Aaj date kon si hai?

ANS: Aaj 18 jan tarik hai.

QUE: Abhi kon sa year aur mahina chal rha hai?

ANS: April mahina aur 2023 saal chal rha hai.

OUTCOME: Patient was fully oriented to time.

PLACE:

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QUE:Aap khan rhte ho?

ANS: Main balrampur se hu.

QUE:Wha se yha aane me kitna tym lgta hai?

ANS: Karib 40 minutes lag jaate hai?

QUE:Aap balrampur se yha kese aaye the?

ANS: Mein bike par bhai ke sath aayai hu.

OUTCOME: Patient was fully oriented to place.

PERSON:

QUE: Kal apse milne kon aaya tha?

ANS: Mujse milne meri bhabhi aur bhai aaye the.

QUE: Aapke sath abhi hospital me kon hai?

ANS: Meri mmi hai.

OUTCOME: Patient was fully oriented to person.

H) INSIGHT:

QUE: Aap hospital kyu aaye ho?

ANS: Mujhe mera bhai le aaya. mujhe kuch nhi hua hai. Main ek dum thik hu.

QUE:Aap bimar kese hue ho?

ANS: Mujhe nhi pta.

QUE: Aapko lgta hai ki aap thk ho jaoge?

ANS: hain, main thk ho jaunga.

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 QUE: Aapko yha kya kya treatment mil rhi hai?

ANS: mujhe dwai aur injections milte hai ro. Subh aur shaam ko.

OUTCOME: Insight of the patient was partially poor.

I) CONCENTRATION:

QUE:100 me se 7 ghtao aur ese hi 6 ghtate jao?

ANS: 93..phr, 86, 79, 67, 60.

OUTCOME: Concentration of patient was poor. He was not able to concentrate

properly on problem.

J) ABSTRACT THINKING:

QUE: Table aur chair me kya smanta aur difference hai?

ANS: Dono par baithte hai

QUE: Santra aur ball me kya smanta aur difference hai?

ANS: Dono gol hote hai. Par ball se hum khlte hai aur sntra khane k liye hota hai.

QUE: “Door ke dhol shuwane” is muhware ka matlb btaye?

ANS: door se kuch mousm shuana hai. Main thodi der baad btati hu.

OUTCOME: Abstract thinking of the patient was not completely concrete and
specific thinking was not appropriate.

K)JUDGEMENT:

1. PERSONAL JUDGEMENT:

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 QUE: Aap discharge hone ke baad kya karoge?

ANS: Kuch ni krungi main. Ghr me hi rhunga.

OUTCOME: Personal judgement was poor in the patient.

2. SOCIAL JUDGEMENT:

QUE: Agr aapko khin par ek chitti milti hai jisme address likha ho to aap kya kroge?

ANS: Address pr bhej dungi.

QUE: Agr abhi yha aag lag jaayegi to aap kya kroge?

ANS: Main aag bhujane lagungi aur fire brigade walo ko bula dungi.

OUTCOME: Social judgement was good in the patient.

L) INTELLIGENCE:

QUE: India ke prime minster kon hai?

ANS: Modi ji.

QUE: India ki rajdhani kon si h?

ANS: Delhi.

QUE: 850 me se 700 minus krke kitne rhenge?

ANS: 500 rhenge.

QUE: Jo main bolungi use ulta dohrana 9-8-7-6-5.?

ANS: 9-7-6-5.

OUTCOME: Patient’s intelligence level was good.

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 LI) SLEEP:

Patient was not having insomnia. She is having proper sleep at night.

M) GENRAL OBSERVATIONS:

Patient wakes up at 7 o’clock in morning. Then she is having daily morning activity including
brushing of teeth etc. she takes his medicine at 9:30 a.m. before that she offers prayer to the God
and some exercises. At afternoon around, 1:30 pm she took his lunch. Then she took some rest in
evening. In evening she do some walk in ward only for some time. Then she took her dinner at
9:00 p.m. then, she took his night medicines and go to sleep at 10:00 p.m.

Patient is observed for the fits, epilepsy, impulsiveness, aggressiveness and hysteria. He was not
having such kind of activities or any other associated conditions.

PHYSICAL EXAMINATION

A. GENERAL APPEARANCE-
 Nourishment - poorly nourished
 Body build - obese
 Health - unhealthy
 Weight - 87 kg
 Height - 5 ft 7 inches

B. MENTAL STATUS
 Consciousness - conscious
 Orientation - oriented to time, place and person
 Look - anxious
C. POSTURE
 Body Curve - Normal
 Lordosis - Not present (Absent)
 Kyphosis - Not present (Absent)

HEAD TO TOE EXAMINATION

1. SKIN
 Colour - Wheatish complexion of skin

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  Texture - soft and wrinkled skin
 Temperature - 101.2ͦ F
 Scars/Lesions - Not present (Absent)

2. HEAD to FACE
 Shape of Skull - Norm cephalic
 Dandruff - No any observed
 Hair colour - grey and white

3. EYES
 Symmetry - Symmetrical
 Cornea - Normal i.e. Transparent
 Abnormal discharge - No discharge
 Double Vision - Absent
 Pupils - Normal and responds to light
 Papillary Reflex - Change in size of pupil (constriction and dilation) seen
in response to light
 Irritation - Absent
 Vision - Loss

4. EARS
 Symmetry - Symmetrical
 External ears - Normal
 Pinna - Normally placed
 Discharge formation - No any discharge or signs of infection or impacted wax
 Hearing Power - Normal

5. NOSE
 Symmetry - Symmetrical
 External nares - Normal

6. NECK
 Carotid Pulse - Palpable
 Range of Motion - Possible (normal extension, flexion and rotation of
neck)

7. CHEST

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  Chest symmetry - Normal, Symmetrical
 Respiratory rate - 28 breaths/ minute
 Breathing pattern - Abnormal (laboured breathing and breathlessness)

8. ABDOMEN
 Rashes - Absent
 Ascites - Absent
 Bowel Sounds - Normal 30/ minute

9. EXTREMITIES
 Range of Motion - Normally possible
 Radial and Femoral pulse -Palpable
 Fracture - No any

SYSTEMIC EXAMINATION

1. CARDIOVASCULAR SYSTEM
 Blood Pressure - 130/60 mm Hg
 Pulse - 102 beats/ minute

Inspection –
 Cyanosis - Present over the Finger tips and toes
 Juglar vein distension - No distension seen
Palpation –
 Area of pain - Pain in chest region during respiration
 Tenderness - Present
Auscultation
 Pulse - 100 beats/minute
 Heart Sounds - Normal

2. RESPIRATORY SYSTEM
 Use of accessory muscles - Present
 Any chest deformity - No any present
 Respiratory rate - 28 breaths/ minute
 Rhythm - Disturbed as the patient is having difficulty in

28
 breathing and breathlessness
 Breath Sounds - Normal sounds are heard when patient breaths

3. CENTRAL NERVOUS SYSTEM

Inspection –
 Patient is conscious and oriented to time, place and person
 Level of attentiveness - Alert and anxious
Palpation –
 Spinal deformity - No spinal deformities
 Superficial sensation - Normal
4. G.I. SYSTEM
Inspection –
 Colour & texture of lips - dry and brownish
 Oral Hygiene - Coated tongue
Palpation –
 Pain & tenderness - No
 Enlargement - No any enlargement
Percussion –
 Presence of air or fluid - No ascites
Auscultation – Bowel Sounds- Normal

5. GENITOURINARY SYSTEM
Inspection –
 Discharge - No abnormal discharge reported by the patient
 Redness, if any - No

Percussion–
 Bowel Distension - Normal bowel movements and no bowel distension

6. MUSCULOSKELETAL SYSTEM
Inspection –
 Symmetry of 2 sides of body - Symmetrical
 Spinal deformity - No spinal deformity (like lordosis,
Scoliosis, kyphosis etc.)
 Bone deformity - No fracture or another bone deformity
Observed e.g. bow legs, knocked knees

29
  Gait - Normal gait
 Posture - Normal posture
Palpation –
 Fracture - No any bone fracture
 Discoloration - Cyanosis of finger tips and toes
 Muscle tone -

7. INTEGUMENTARY SYSTEM
Inspection –
 Texture - Soft and wrinkled skin
 Elasticity - Decreased due to aging
 Complexion/Colour - Wheatish complexion
 Oedema on face - No edema on the face
Palpation –
 Oedema - No
 Tenderness - No
Percussion
 Lump or Mass formation in any region (if any) - No any

8. SENSORY SYSTEM
 Color of the eyes - Black
 Vision - Loss
 Pupils - Normal
 External Ear (any discharge or infection) - Normal and responds to light
 Hearing - Normal
 Nostrils - Normal

CONCLUSION:

Mr. Rahul, 29 years, male patient admitted in h.i.h.t with chief complaints of irritability, loss of
appetite and decreased appetite. Patient is diagnosed with BPAD. Presently, patient is on Tab. Sernac,
Tab. Divax, Tab. Multivitamin, Tab. Librium, Syp. Liver tonic, Tab. Fluxetine and Inj. Thiamine.
The condition of patient is recovering after the date of admission.

30
 NURSING CARE PLAN

NURSING ASSESSMENT:

 Assess the affective, cognitive and psychomotor factors of the patient.

 Assess for biochemical and neurological imbalances.

 Assess for rage reactions.

 Assess for the risk of injury in the patient.

 Assess for the fluid status in the client.

 Assess the condition of patient at different times.

 Assess the level of orientation in patient.

 Assess for the lack of control over purposeless and potentially injurious movements.

 Assess for hyperactivity in the patient.

 Assess for the abrasions, bruises, cuts from running/falling from objects.

 Assess for excessive physical agitation in patients.

 Asses for the rest periods in client’s routine.

NURSING DIAGNOSIS:

1. Ineffective Coping related to slowed mental processes as evidenced by

inappropriate response and poor concentration.

2. Impaired Social Interaction related to low self-esteem and unsatisfactory or

inadequate interpersonal relationships as evidenced by observation and mental
status examination of patient.

31
 3. Chronic Low Self-Esteem related to feelings of inferiority and lack of
involvement as evidenced by inappropriate response and poor concentration.

4. High risk for self-directed violence related to depressed mood feeling of

worthlessness of anger directed inward on self .

GOALS:

LONG TERM GOALS:

1. Express feelings directly with congruent verbal and nonverbal messages

2. Initiate interactions with others, for example, approach a staff member to talk at least
once per shift.

3. Demonstrate behaviour consistent with increased self-esteem, for example, make eye
contact, initiate conversation or activity with staff or other clients

4. Make plans for the future consistent with personal strengths.

SHORT TERM GOALS:

The client will

1. Be free from self-inflicted harm throughout hospitalization.

2. Be oriented to person, place, and time within 48 to 72 hours

3. Express anger or hostility outwardly in a safe manner, for example, talking with staff
members within 5 to 7 days.

4. Communicate with others, for example, respond verbally to question(s) asked by staff
within 24 to 48 hours
5. Participate in activities within 48 to 72 hours

6. Verbalize increased feelings of self-worth within 2 to 5 days

7. Express feelings directly and openly with nursing facilitation within 2 to 4 days

32
 Virginia Henderson’s Contribution to Nursing Theory: Nursing Need Theory

1. Breathe normally. – patient able to breath properly .theres no any oxygen administration.
2. Eat and drink adequately.- patient is able to eat and drink adequately but sometimes
complaining about loss of appetite.
3. Eliminate body wastes – patient is able to eliminate and able to go washroom .
4. Move and maintain desirable postures – patient is able to move and make diserable
postures.
5. Sleep and rest- patient was not able to sleep properly due to her problem.
6. Select suitable clothes-dress and undress.- able to wear her clothes properly.
7. Maintain body temperature within normal range by adjusting clothing and modifying
environment- patient is able to maintain her body temperature according to atmosphere.
8. Keep the body clean and well groomed and protect the integument- her family members
were helping her to maintaining her hygiene.
9. Avoid dangers in the environment and avoid injuring others- patient is not able to avoid
dangers.
10. Communicate with others in expressing emotions, needs, fears, or opinions- patient is not
communicating with others.

11. Worship according to one’s faith- patient is not doing her daily prayer.

12. Work in such a way that there is a sense of accomplishment- patient is not working or
doing activities such a way that there is a sense of accomplishment.

13. Play or participate in various forms of recreation- patient is not participating in recreation
activities.

14. Learn, discover, or satisfy the curiosity that leads to normal development and health
and use the available health facilities.

33
 NURSING EXPECTED PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS OUTCOME

 To provide  Provide a safe  Physical safety of Coping skills of the

Immediate
Ineffective the secure environment for the the client is a patient was
Coping related The client will client. priority. Many
environment improved up to the
to slowed • Be free from . common items may
limit the patient
mental self-inflicted be used in a self-
processes as destructive manner. should have for the
harm throughout
evidenced by improved mental
hospitalization.  Continually assess
inappropriate processes.
• Be oriented to the client’s
response and
person, place, potential for
poor
and time within suicide. Remain
concentration. aware of this
48 to 72 hours
suicide potential at
• Express anger or
all times.
hostility
outwardly in a  We must be aware
safe manner, for of the client’s
example, talking  Assess the activities at all
client’s times when there is
with staff  Continually assess the
potential a potential for
members within client’s potential for
suicidal suicide or self-
5 to 7 days. attempts. suicide. Remain aware injury. Risk of
Stabilization of this suicide potential suicide increases as
at all times. the client’s energy
The client will level is increased
 Plan to
• Express feelings by medication,
observe the
directly with  Observe the client when the client’s
patient after
congruent verbal closely, especially under time is
different unstructured, and
and nonverbal the following

34
 conditions. circumstances: when observation
messages
of the client
• After antidepressant
decreases. These
medication begins to raise the
client’s mood. changes may
indicate that the
• During unstructured time on
client has come to a
the unit or times when the
decision to commit
number of staff on the unit is
limited. suicide.
• After any dramatic behavioral  Repeated
change (sudden cheerfulness, presentation of
relief, or giving away reality is concrete
personal belongings). reinforcement for
the client.

 Expressing feelings
may help relieve
despair,
hopelessness, and
so forth. Feelings
 Reorient the client to are not inherently
person, place, and time good or bad. You
as indicated (call the must remain
client by name, tell the nonjudgmental
client your name, tell about the client’s
the client where he or feelings and
she is, etc.).
express this to the
 Encourage the client to client.
ventilate feelings in
whatever way is
comfortable—verbal

35
 and nonverbal. Let the
client know you will
listen and accept what
is being expressed.

 Plan to
reorient the
client for
person, place
and time

 To
encourage
the client to
ventilate his
feelings with
family
members.

36
 NURSING EXPECTED PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS OUTCOME

Impaired Social 1. Introduce the  Client is  Gradually Social isolation

Immediate
Interaction client to other introduced to the increasing the and depressive
The client will clients in the scope of the
related to low small group behaviour of the
• Communicate milieu and through client’s social
self-esteem client was
with others, for facilitate their interactions
recreational and improved up to
and interactions on a will help the
example, respond group therapies.
unsatisfactory one client to one client build the extent the
verbally to
or inadequate client basis. confidence in client can
question(s) asked
Gradually social skills. converse with
interpersonal by staff within 24 facilitate social other s.
relationships as to 48 hours interactions
evidenced by • Participate in between the client
 Sharing views
observation activities within and small groups,
 Interpersonal provides an
and mental 48 to 72 hours then larger groups.
opportunity
relations are
status Stabilization 2. Talk with the for the client
maintained with
examination of client about his or to express his
The client will the client.
her interactions or her
patient. • Initiate and observations feelings.
interactions with of interpersonal
others, for dynamics.
example,  The client
approach a staff  Client is may have
member to talk at encouraged to been
3. Encourage the

37
 client to identify interact with depressed and
least once per
relationships, family members withdrawn for
shift
social, or and other some time
• Assume recreational and have lost
responsibility for
relatives and
situations that interest in
told them
dealing with have been positive people or
remain positive
feelings in the past. activities that
in every provided
situations. pleasure in
the past.

 The client
4. Teach the client  Client is taught may lack
social skills, such about the social skills
as approaching approaching the and
another person for other persons confidence in
an interaction, and interacting social
appropriate with them. interactions;
conversation this may
topics, and active contribute to
listening. the client’s
depression
and social
isolation.

5. Encourage client
to identify  Client is  To re-
supportive people educated about establishing
outside the interacting with past
hospital and to

38
develop these the other people relationships
relationships. to build up the increasing the
interpersonal establishing
relations. new
relationships
may help
decrease
future
depression.

39
 NURSING EXPECTED PLANNING IMPLEMENTATION RATIONALE EVALUATI
DIAGNOSIS OUTCOME ON

Chronic Low Self- Immediate  Encourage the  Client is  When the client
client to become encouraged can focus on
Esteem related to The client will
involved with about the other people or
feelings of • Verbalize involvement
staff and other interactions,
inferiority and increased clients in the with staff and cyclic, negative
lack of feelings of milieu through other client. thoughts are
involvement as self-worth interactions and interrupted.
evidenced by within 2 to 5 activities.
inappropriate days  Client is
• Express  Give the client
response and positive positively  Positive feedback
feelings reinforced for
poor feedback for increases the
directly and completing the
concentration. completing likelihood that the
openly with responsibility of
responsibilities client will
nursing art and craft
and interacting continue the
facilitation work given.
with others. behaviour and
within 2 to 4
begin to
days
internalize
positive feelings.
Stabilization

40
The client will  Explore with the  Client is keen
• Demonstrate client his or her interested in
personal strengths. doing art and  The client needs
behavior
craft and poems. to identify them
consistent
He was but may benefit
with increased
encouraged for from your
self-esteem,
the same. supportive
for example,
 Involve the expectation that
make eye
client in he or she will do
contact,
activities that are so.
initiate  Client was
pleasant or
conversation involved in the
recreational as a
or activity activities of the
break from self-  The client needs
with staff or ward.
examination. to experience
other clients
• Make plans
pleasurable
activities that are
for the future
 Give the client not related to self
consistent
honest praise for and problems.
with personal
strengths. accomplishing
small
responsibilities
 Client was given
by
honest praise for
acknowledging
completing the
how difficult it
responsibility  Positive feedback
can be for the
given. provides
client to perform
reinforcement for
these tasks.
the client’s
growth and can

41
 enhance self-
esteem.

NURSING EXPECTED NURSING IMPLEMENTATION RATIONAL EVALUATION

DIAGNOSIS OUTCOME INTERVENTIONS
High risk for To reduce Assess the condition of Condition of the patient is It help to give baseline data Self-violence of
self-directed the self- the patient assessed by observation and of the patient. patient is
violence directed verbalization. Patient mood is reduced by
sad.
related to violence. diverting the
depressed To create a safe mind.
Patient’s safety is maintained It helps to know the risk of
mood feeling environment for the
by removing sharp objects suicide and maintain safety
of patient.
from patient’s surrounding that
worthlessness is knife, cutter, etc.
Of anger
directed Assess the patient for Patient is assessed for suicidal It helps to know the risk of
inward on self suicidal attempts. attempts by verbalization and suicidal in patient.
history.

42
To properly observe the Patient is observed properly It helps to get clear data that
patient during daily during daily activities i.e whether patient is carrying

activities. patient never show interest in out any suicidal plans.

any work.

43
HEALTH EDUCATION

 MEDICATION: Advice the patient to take medicines properly and well in time. i.e.
antibiotics and other elated medications. It will soon improve the signs and symptoms
of the disease. Advice the patient no to skip the medicine.

 HYGIENE: Advice the patient to maintain personal hygiene. Personal hygiene is

the major part of health because some diseases will arise due to lack of maintenance
of proper personal hygiene.

 DIET: Meals play an important for body functioning. Advice the patient to take
proper meals low in fats.

 EXERCISE:Advice the patient for morning walk as it improves physical endurance. .

 EDUCATION: Educate the patient regarding disease condition and their arising
symptoms. Advice the patient to avoid intake of alcohol and cigarette smoking.
Advice the patient to avoid recurrent exposure to respiratory irritants that leads to
breathing difficulty.

 FOLLOW-UP: Educate the patient for proper follow-up.

44
REFERENCES

 Velden AM, Piet J, Moller AB, Fjorback. Mindfulness-based cognitive therapy is

efficient in the treatment of recurrent depression. Ugeskr Laeger. 2017 Jan

23;179(4):V04160291.

 R. Sreevani. A Guide to Mental Health and psychiatric Nursing. 3 rd Edition. Delhi:

Jaypee Brothers Medical Publishers (P) Ltd; 2010.

 Niraj Ahuja. A Short textbook of psychiatry. 7 th Edition. New Delhi: Jaypee

Brothers Medical Publishers (P) Ltd; 2010.

 Allen Tasman, Jeffery Kay, Michael B. First, Mario Maj. Psychiatry. 3 rd Edition.

USA: John Wiley & Sons, Ltd; 2008.

 Townsend M C. Psychiatric Mental Health Nursing. 5th Edition. New Delhi:

Published by Jaypee;2002.

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