I.

IDENTIFICATION DATA
Name of the patient ;-Swapna rani Barik
D/O:-Late HimanshuBarik
Age:-35 years
Sex :-Female
At:-Lukapada
Ps:-Menda
Dist:-Balangir
Bed no : -6
Regd no:-144/10.7.19
Marrital status :-Unmarried
Religion :-Hindu
Education :-10th
Occupation :-Dependant
Diagnosis :-BPAD
Date of admission:-10/7/19
Name of the informant :-Sister
Duration of stay :-5 years
Reliabillity:-Reliability
II.Present chief complaint:
According to patient :-Patient told that he has feel loss of appetite
According to informant :-Patient has loss of appetite , decrease sleep , she feel depressed and suicidal
attempt .
III. History of Present illness:-
Miss SwarnalataBarik was before 15 days apparently alright and 15 day back her grandfather was
expired then develop depression irritability , loss of appetite, , disturbances of sleep, suicidal attempt
Duration :-She is having history of these psychotic symptoms last 3 year
Mode of Onset She is having history of irritability decrease sleep and food intake
Course :-Episodic
Intensity : Increased
Precipitating factor :
IV. Treatment history –
Injection Serenac 2.5 mg IM BD
Injection Promethazine 25 Mg IM BD
Injection Lopez 4mg IM BD
Tab Imipramin 100 mg BD
ECT : No ECT
Psycho therapy : Individual psycho therapy
Family therapy :Family therapy has given to the family members
V. PAST PSYCHIATRIC HISTORY
 Numbers of previous episodes/ hospitalization with onset and course :
This is the 3rdepisode of psychiatric illness
 Complete or incomplete Remission : There is incomplete remission
 Duration of each episode :- 10 days
 Treatment details and its side effect if any :Treatment taken .
 Treatment out come : She has discontinue medication so develop 3rd episode of psychiatric illness.
 Details of any precipitating factor if present : Stress And family problem
VI. PAST MEDICAL HISTORY OF PATIENT :
She has no past medical history of illness.
VII. PAST SURGICAL HISTORY OF PATIENT :
There is no significant past surgical history
VIII. FAMILY HISTORY OF PATIENT
She is having no history of medical disorder like TBHypertesion and DM and no history of psychiatric
illness in family.

FAMILY TREE KEY :

- Male

- Female

-Death

-case

VIII. PERSONAL HISTORY

A. Perinatal History
: No co ordination
B. Child hood History
: No co ordination
C. Educational History
: She has discontinued her study after 7th class due to family problem
D. Play History
: Shelike to play her friend
E. Occupational History
:
F. Puberty
: She is having the maturity at the age 15 years. She is having regular menstrual cycle

G. Obstetric History
: She is unmarried
H. Sexual and Marital History
: She is unmarried.
I. Premorbid personality
Inter personal relation ship
: Her interpersonal relationship with her friend was satisfactory
Family and social relation ship
 :Her relationship with her family member is goo and the social relationship neighbour and peer is good.
Use of leisure time
:She uses her leisure time with stitching
Predominant Mood
:Her predominant mood is depressed
Usual Reaction to stressful event
:She becomes worried in any stressful situation.
Attitude to self and others
: Her attitude towards self and also to other is good.
Attitude to work and responsibility
:Her attitude towards work is so good in her family
Religious beliefs and moral attitudes
: Religion beliefs and moral attitude is present.
Herbelief on god “Shiva”
Fantasy Life
:Nothing suggestive
Habits:
Eating pattern:Irregular
Elimination: Regular
Sleep:irregular
Use of drugs, tobacco alcohol:Nothing
PHYSICAL EXAMINATION

Genera Appearance:She looks anxious and worried

Temperature:98.6 F
Pulse:80 bt/ min
Respiration: 20 bt/ min
Blood Pressure:110/80 mmHg
Height:5 feet
Weight:55 kg
Head &scalp:Clear & healthy scalp, no dandruff, no lesion
Eye /ENT: No abnormal discharge
Mouth:No dental carries, Teeth and gum are healthy
Neck: No enlargement of lymph node and glands
Chest: Chest is bilaterally symmetrical, no abnormal sound present
Abdomen: No splenomegaly and hepatomegaly, bowel sound is present
Extremities: No abnormality is present
Foot and nail:Healthy
MENTAL STATUS EXAMINATION
A. GENERAL APPEARANCE AND BEHAVIOR :
 Appearance :Looking ones age
 Facial expression :Anxious
 Level of grooming : Adequate
 Level of cleanliness : Adequate
 Mode of entry :Came willing
 Behaviour : Normal
 Co cooperativeness : Less than so
 Eye to eye contact :Maintain
 Psychomotor activity :Normal
 Rapport : Not established
 Gesturing : Normal
 Posturing :Normal posture
 Other movement :Not established
 Other catatonic phenomena : Not established
 Hallucinatory behaviour : Absent
B. SPEECH
 Initiation : Speaks when spoken to
 Reaction time :Delay
 Rate : Normal
 Productivity :Monosyllabic
 Volume : Normal
 Tone : Normal variation :Fully relevant
 Stream : Normal
 Coherence :Fully coherent
 Sample of speech : Nurse: why are you coming here?
Patient:She having loss of appetite
C. MOOD AND AFFECT
 Subjective : Nurse: What are doing?
Patient:Iam sleeping
 Objective :Patient look worried
 Predominant mood state :Depressed
D. THOUGHT
 Stream (flow of thought ) :Normal
 Form(formal thought disorder ) :Normal
 Content :Hopelessness, death wishes (suicidal ideation)
E. PERCEPTION
 Illusion : Absent
 Hallucination :Absent
 Somatic passivity :Headache
F. COGNITIVE FUNCTION (NEUROPSYCHIATRIC ASSESSMENT )
 Consciousness :Conscious
 Orientation:
Time: Nurse: What is time now?
Patient: It is about 11.30 am
Inference: oriented to time
Place: Nurse: Which place is this?
Patient: This is Burla hospital
Inference: Oriented to place
Person: Nurse: Who is she (Pointing to her elder sister)
Patient: She is my elder sister
Inference: Oriented to person
 Attention:
Nurse: Count the digit 1, 2, 3, .in forward direction and 10, 9, 8, in backward
direction.
Patient: Count 1, 2, 3, and 10, 9, 8…2, 1
Inference Concentration is intact
 Concentration:
 Nurse: Subtract 50-5
Patient: 45
Inference: Concentration is intact

 Memory:
Immediate memory: Nurse: What have you taken breakfast?
Patient: Samosa Bara
Inference: Immediate memory is intact
Recent memory: Nurse: When come to this hospital
Patient: 2 to 3 days
Inference: Remote memory is intact
Remote memory:
Nurse: Can you tellme 2 name of your best friend from school?
Patient: Forget my friends name
Nurse: What is your date birth?
Patient:Forget my date of birth
Inference: Remote memory is impaired
Intelligence: Nurse: Who is your sarapanch ?
Patient: MR. GopalSahu
Inference: Intelligence is intact
Abstraction: Nurse: What is difference between salt and sugar?
Patient:Salt andsugar colour are white but sugar is sweet.
Inference: Abstraction is intact
Judgement:
Personal: Nurse:- What is future plan?
Patient:- When I got discharge from here and will do stitching
Social judgement:-
Nurse:- If you saw person drowning in water what will you do?
Patient:-I go to the person and shouting for help and bring the person back
from the water.
Test:-
Nurse:- If your going on the way and suddenly see that a person is lay down
on the road, then what u will do?
Patient:- i will go to the person and shrink the water on his face and finally
bring him to hospital.
Inference: he is judgement is intact.
Provisional diagnosis is BPAD
Final Diagnosis –BPAD (Depressive episode)
BIPOLAR AFFECTIVE DISORDER
INTRODUCTION:
Bipolar disorder ( Manic Depression) is mental disorder that is characterized by constantly changing moods
between depression and mania .The mood swing are significant and the experiences of the highs of mania
and the lows of depression are usually extreme.
DEFINITION
 Bipolar disorder is a cyclical mood disorder characterised by abnormally elevated mood or irritability
which alternate with depressed mood.
 It is an episodic potentially lifelong disabling disorder that can be difficult to diagnose.
CLASSIFICATION
1. Bipolar mood disorder is classified in to
A. Bipolar-1 : Characterised by episodes of sever mania and severe depression.
B. Bipolar-II: Characterised byepisodes of hypomania that alternate with period of with severe depression.
C. Cyclothymic disorder: Period of hypomanic symptoms alternating with brief periods of depressive
symptoms that are not as extensive as long lasting as seen in full hypomanic episodes or full depressive
episode.
D. Mixed features: Simultaneous symptoms of opposite mood polarities during manic, hypomanic or
depressive episodes. It marked by high energy sleepless and racing thoughts.
ICD 10 CLASSIFICATION OF AFFECTIVE (MOOD DISORDER)
F31.0: Bipolar affective disorder, current episode hypomania.
F31.1: Bipolar affective disorder, current episode mania without psychiatric symptoms
F31.2: Bipolar affective disorder, current episode mania with psychotic symptoms
F31.3: Bipolar affective disorder, current episode mild or moderate depression
F31.4: Bipolar affective disorder, current episode severe depression without psychotic symptoms.
F31.5: Bipolar affective disorder, current episode severe depression with psychotic symptoms
F31.6: Bipolar affective disorder, current episode mixed.
ETIOLOGY
INBOOK IN PATIENT
1) Precise cause unknown Stress full event due to death of her grand father
2) Genetic biochemical and psychological
factors may play role
3) May be triggered by stress full event anti
depressant use
4) Sleep deprivation and hypothyroidism

SIGN AND SYMPTOMS OF BIPOLAR DISORDER

IN BOOK IN PATIENT
MANIC PHASE
1) Expansive grandiose or hyperirritable mood.
2) Increased psychomotor activity such ass ,
agitation, pacing or hands wringing
3) Excessive social extroversion
4) Rapid speech with frequent topic changes
5) Decreased need for sleep and food.
6) Impulsivity
7) Impaired judgement

IN BOOK IN PATIENT
DEPRSSIVE PHASE  Feeling of hope less
1) Low self esteem  Suicidal ideatinonz
2) Over whelming inertia.
3) Feeling of hopeless apathy or self reproach
4) Difficulty concentrating or thinking clearly
5) Psychomotor retardation
6) Anhedonia
7) Suicidal ideation

DIAGNOSIS
IN BOOK IN PATIENT
 Based on sign and symptoms  History collection done
 ICD 10 criteria  Mental status examination done
 Blood test done

MANAGEMENT
IN BOOK IN PATIENT
SOMATIC TREATMENT Tab Imipramin 100 BD
1) ANTIDEPRESANT : The usual starting dose Injection serenac 2.5 mg BD IM
is about 75-150 mg of imipramin equivalent Injection Phenargon 25mgIM BD
2) Lithium :Treatment of manic episode Injection Lopez 4 mg IM BD
3) Antipsychotic : Treatment of mood disorder
4) Mood stabilizer
PSYCHOSOCIAL TREATMENT
1) Cognitive behaviour therapy
2) Interpersonal therapy
3) Psychoanalytic psychotherapy
4) Behaviour therapy
5) Group therapy
6) Family therapy

NURSING MANAGEMENT
ASSESSMENT
 Assessed the patient by collecting individual and family data.
 Severity of the disease should be assessed by patient behaviour.
 Assessed her sleeping pattern.
 Assessed her insight and judgement ability
 Assessed the behaviour attention, family process self esteem and anxiety level.
 Collect history about diet pattern
 Assessed social interaction level of the patient.
 Pattern of the verbal speech should be noted.
NURSING DIAGNOSIS
1) High risk of self- directed violence related to depressed mood, feeding of worthlessness and anger
directed in ward on the self.
2) Dysfunctional grieving related to real or perceived loss bereavement , evidenced by denial of loss ,
inappropriate expression of anger, inability to carry out activates of daily living
3) Power lessens related to dysfunctional grieving process, life style of helplessness,evidenced by feeling
of lack of control over life situations, over-dependence on others to fulfil needs
4) Self esteem disturbance related to learned helplessness, impaired cognition, negative view of self,
evidenced by expression of worth-lessens, sensitivity to criticism, negative and pessimistic outlook.
5) Impaired communication process related to depressive cognition, evidenced by being unable to
interact with others, withdrawn, expressing fear of failure or rejection.
6) Disturbed sleep pattern and rest related to depressed mood and depressive cognitions evidenced by
difficulty in failing a sleep, early morning awakening, and verbal complaints of not feeling well-rest.
7) Imbalanced nutrition less than body requirement related to depressed mood, lack of appetite or lack of
interest in food.
8) Self-care deficit related to depressed mood, feeling of worthlessness, evidenced by poor personal
hygiene and grooming.
PROGRESS NOTE
Day .1 Injection Serenac 2.5 mg IM
BP-110/80 mmHg Injection Phenargon25 mg IM
Pulse-72/min Injection Lopez 4 mg IM
Resp-20/min Tab Imipramin 100 mg
Temp-98.4 F Nursing intervention
Sleeping pattern disturbed  Provide comfortable
Decreased appetite  Provide calm and quite environment
 Monitor vital sign
 Provide medication according to physician
advice

Day -2
BP-110/80 MmHg Injection Serenac 2.5 mg IM
Pulse- 74/min Injection Phenargon25 mg IM
Resp-20/min Injection Lopez 4 mg IM
Temp- 98.6 F Tab Imipramin 100 mg
Decreased appetite Nursing intervention
Memory Decreased  Monitored vital signs
 Psychological support and re assurance to
the patient
 Perform mental status examination and
process recording

Day-3
BP-110/80 MmHg Injection Serenac 2.5 mg IM
Pulse- 74/min Injection Phenargon25 mg IM
Resp-24/min Injection Lopez 4 mg IM
Temp- 98.6 F Tab Imipramin 100 mg
No dehydration Nursing intervention
Stabilized mood  Monitored vital signs
 Provide medication as per the physician
advice

Day-4
BP-120/80 MmHg Injection Serenac 2.5 mg IM
Pulse- 72/min Injection Phenargon25 mg IM
Resp-24/min Injection Lopez 4 mg IM
Temp- 98.6 F Tab Imipramin 100 mg
No dehydration Nursing intervention
Normal appetite  Monitored vital signs
 Provided medication to the patient as
advised by physician
 Advise the adequate diet and regular
medication to patient.
DISCHARGE PLAN
My client suryakantiMeher was admitted in the VIMSAR Burla on dt 10.7.19 . She was taking medication
regularly his condition is well now. She feels good and sleep adequately. She is able to perform her daily
activities . Ther fore planned for discharge tomorrow on dt.14.7.19.
HEALTH EDUCATION
I explained him and her relatives to do following :
1) Teach about the illness of depression learning about the beginning symptoms of relapse may assist
patients to seek treatment early and avoid a lengthy recurrence.
2) Discuss the importance of support groups and assist in locating resources.
3) Teach the action, side effects and special , instructions regarding medications.
4) Discuss methods to manage side effects of medication.
5) Tell the family to offer the patient some house hold responsibilities, within the patient’s level of
capability to promote self –esteem.
6) Teach the family to recognize symptoms of suicidal ideation and how to conduct a suicidal assessment.
7) Emphasize that antidepressants can cause constipation, which may be prevented with a good bowel
regimen , adding fiber to the diet and drinking water.
8) Avoid making life changes while the patient is experiencing or recovering from depression.
9) Help the patient and family identify community resources such as suicidal hotlines.
SUMMARY
Summarizing my case study by identification data of the patient, socioeconomic status, present chief
complain, present and past illness, family history, person history , mental status examination, physical
examination, definition of BPAD, classification, etiology, sign and symptom, management ,nursing care
plan, progress note, health education, I assessed the client for perform mental status examination and
physical examination . I had collected all history .The informant her elder sister is co operative
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