BIPOLAR: CASE STUDY 1

Bipolar: Case Study

Conor Crogan

Nursing Department: Youngstown State University

BSN Program

Mental Health Nursing

Professor Teressa Peck

November 17th, 2022

BIPOLAR: CASE STUDY 2

Abstract

The following case study shows the process of a patient with Bipolar I Disorder. The main

subject of this study is G.S, which is the patients initials who is a 56 year old white male. G.S is

presented the psychiatric floor during a manic episode. Upon admission G.S was intoxicated and

is being treated for withdrawal symptoms from alcoholism. In this case study there are many

different types of references that give valuable information about the patient’s case and brings

credibility to another level. The searches were all on scholarly engines and a couple of the many

search engines used was World Wide Science, and Bielefeld Academic Search Engine (BASE).

This paper will emphasize the manifestations of Bipolar I disorder and the actions that can lead

to the progression and increase the intensity of the manic episodes.

BIPOLAR: CASE STUDY 3

Bipolar Disorder: Case Study

Objective Data

G.S. is a 56-year-old male patient admitted to the hospital a couple days ago and was just

transferred to the psychiatric unit from a medical surgical where he was detoxing from alcohol.

G.S. arrived on this unit on November 3rd, 2022, with a diagnosis of Bipolar Mania 1. G.S is well

groomed and dressed appropriate for the weather. Patient presents himself with adequate hygiene

and seems to have shaved recently.

During G.S. interview, the patient showed various actions and behaviors that correlate

with the patient’s diagnosis of Bipolar Mania 1. During the interview, G.S. is going through a

manic episode, others may refer it to as hypomanic. Starting off the interview G.S. denied ever

being sad or depressed and that it wasn’t him even though his family members said that he

couldn’t even speak or get out of his bed three months ago. Moving forward in the interview

G.S. is very eager to talk and feels pressured to speak. The patient is very anxious and has a very

high energy level as he is constantly moving his legs and using his arms and hands to talk during

the interview. The patient exhibits indications of racing thoughts and flights of ideas. The patient

stated that his thoughts are as fast as a “jet” or a “nuclear blast”, which shows that his mind is

constantly racing and moving from topic to topic. G.S. stated he has concerts in his head and

referred himself as Da Vinci because he always has projects he is working on.

During the interview, G.S. exhibits grandiose delusions stating that he, “feels wonderful”

and “everything is enormous” and that he is lucky he is this way. G.S. states that he taught

himself the violin and it only took him “2 months” to teach himself how to play. The patient

states that music is a passion of his and it helps him cope with stressors. G.S. stated that he is

fantastic at playing the violin and it was very easy to learn compared to others. G.S. states it’s
BIPOLAR: CASE STUDY 4

like “ripping music out of my stomach”. Patient states that he goes around and does concerts in

big cities like New York. Says that he loves doing it in the subway because when people get off

the subway, they are getting off to watch him play.

In addition to playing music the patient also states that he does art work for the museums

and that the material needs to be more modern. Patient states that he does not have enough time

to read and that there is too much out there to read. Patient states that he would rather do almost

anything else than read.

The patient showed poor manners and social skills by stating that when he was in

Indiana, he had to teach “the farmers how to farm”. G.S. stated that the farmers were very

embarrassed and that one of the farmers assaulted him by hitting him across the face. Another

example G.S. showed of poor social skills was that he said that the lobby at the hospital was in

terrible shape. He wrote down numerous things that needed work done and at the end of the

interview G.S stated that he is going to start working on “that lobby”.

The patient also talks about how he engages in sexual contact with strangers in multiple

different cities and describes how the sex is different from place to place. This showing an

excessive amount of sexual activity and poor, impulsive decision making.

When questioned about money and financial decisions G.S. stated that “money talks to

me.” He believes that “hearing voices is a gift.” Patient stated that money manages itself in its

own due time. G.S. gave an example that he holds an object up to his ear and listens, if it tells

him to buy it, he does. This is auditory hallucinations through pulses and vibrations with objects

and money. G.S. states that he is one with the earth and is more in tune with the world around

him. This means that he can hear everything around him and has more comfort and

understanding. Patient states that he is more advance than everyone else at this and is a “gift”.
BIPOLAR: CASE STUDY 5

Moving farther into the interview G.S. stated he is in perfect health and that he has no

operant medical condition. Patient states he takes Aspirin daily but it is not prescribed and his

doctor does not know about it. G.S. states that he eats a healthy diet with vegetables, vitamins,

and fiber so he gets all the nutrients he needs. G.S. stated that he hardly has to eat because the

alcohol makes him not hungry. G.S. states that he doesn’t drink during the week but drinks every

weekend. G.S. states that he loves the “euphoric” feeling of getting drunk. Patient states that he

has ringing in the ears when he drinks and the day after he drinks his thoughts slow down. G.S.

justifies that he believes drinking is good and that everyone should do it without being asked.

This shows that he is pushing off the strong affect alcohol has on his life and that he may have a

problem with drinking.

When asked about the use of marijuana, G.S. denied any use of the drug because of

paranoia. Not shortly after that statement G.S. talked about having a visual hallucination of a tree

branch coming out of his friend’s mouth after using a vape pen implying it was with marijuana.

When G.S. was asked if his alcohol consumption has any effect on his jobs and he stated that it is

responsible for losing many jobs and relationships. When asked about if he ever went to therapy

for the alcohol, G.S. stated yes but it was a “mistake”. He said it was his aunt’s and cousin’s idea

for him to go. His cousin already went to this “therapy.” G.S. went to the therapy alone and

hated it.

Laboratory Results

Lab Normal Results Why do we want to

Range know?

Potassium 3.4 – 5.0 3.4 Hypokalemia can cause

depression, psychosis,
hallucinations, and delirium
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Sodium 135-145 132 Monitor for malnutrition from

the alcohol and lithium therapy

Glucose/A1C 70-110 110 Poor glycemic regulation, can

mirror symptoms of irritability,
anxiety, and worry

Blood Urea 8-25 20 Important to assess because

some medications are
Nitrogen nephrotoxic, and we must make
sure the patient can excrete the
medication given
Creatinine 0.6-1.8 1.0 No toxic affect from lithium
therapy.

Red Blood Cells 4.0-5.9 NO LAB If low these can it can cause
agitation.

Hemoglobin Hemoglobin: 13-18 Hemoglobin: 16.4 If these are low it can cause
agitation.
&
Hematocrit Hematocrit: 37-49% Hematocrit: 44%

White Blood Cells 4.5-11 6.2 See if there is any sign of

infection, and was not affected
by the risperidone treatment

AST AST: 10-55 AST: 46 Must assess liver enzymes on a

patient taking antipsychotic,
due to risk of hepatoxicity
ALT ALT: 10-40 ALT: 59
Lithium/Depakote/ Lithium: 0.6-1.2 Lithium: 0.2 Monitor for lithium toxicity…
number one sign is diarrhea &
Tegretol Level Depakote: 50-125 N/V
Tegretol: Will see change in level of
LOC, seizures, confusion in
Depakote. Tegretol can
decrease WBC.
TSH/T4 0.5-5.0 WDL Thyroid disease & depression
and anxiety, share similar
symptoms. Must rule out
thyroid disorders prior to
diagnosing
Drug Toxicology All Negative + Marijuana Ordered to allow providers to
have a transparent
understanding of physical well-
being, and possible habits

UA. Alcohol Level <50 or 0.05% 0.25 Alcohol can alter behavior
and also has CNS effects

QTC/ECG 350-450 477 Antipsychotics are known to

cause a prolonged QTC
wave on a EKG
BIPOLAR: CASE STUDY 7

Psychiatric Medication

Medication: Dose: Route: Frequency: Classification: Reason

Pt on Rx:

Lithium 600mg Oral BID Antimanic Mania

Risperidone 2mg Oral Daily Antipsychotic Unusual thinking, &

inappropriate behaviors

Haldol 5mg Oral Q4 PRN Antipsychotic Agitation

Haldol 5mg IM Q4 PRN Antipsychotic Agitation

Ativan Per order Benzodiazepine Anxiety

--- --- of CIWA
Scale

Librium 10mg Oral Q6 Sedative Sedative, help sleep

Nico -Derm 14mg Patch Daily Smoking Helps pt. quit smoking or
Cessation to help with urge to smoke
Aid

Multivitamin Oral Daily Vitamin Provide supplemental

nutrition
BIPOLAR: CASE STUDY 8

Summary of Bipolar Diagnosis

Bipolar disorder is defined as, “is a chronic and complex mood disorder that is

characterized by an admixture of manic (bipolar mania), hypomanic and depressive (bipolar

depression) episodes” (Calabrese & McIntyre, 2019). Along with those signs, there are times

where the patient will show normal behavior and there can also be delusions or hallucinations. In

the case for G.S, he had hallucinations and delusions which inhibited his relationship with family

members and the people around him. There are various amounts of types of bipolar disorders.

Some patients may have depression or severe depression and little mania. Some patients may

have severe mania or hypomania meaning that the state of mania they go in isn’t as severe or

extreme. Those patients won’t have as intense depressive states. For Bipolar I it is stated that,

“requires the occurrence of at least one fully syndromal lifetime manic episode, although

depressive episodes are common” (Calabrese & McIntyre, 2019). Another thing to consider for

bipolar disorder is suicide. “Suicide occurs 14 times more often in patients with bipolar disorder

compared with the general population” (Bobo, 2017). There is another type of illness alongside

bipolar disorder which is called cyclothymic disorder. This disorder is based off of mood

disturbance that must last the length of 2 or more years with depression or exaggerated

excitability but isn’t considered a manic state.

Stressors and Behaviors that Precipitated Hospitalization

For the patient G.S., he had multiple stressors and actions that led prompted his stay in

the hospital. The patient stated he was binge drinking and smoking marijuana and also seemed to

stop taking his medications since his lithium levels were low at 0.2. Since the patient has been

having these signs of manic behavior and has been binge drinking, he has lost multiple jobs and
BIPOLAR: CASE STUDY 9

friendships. He most recently lost a job at Walmart which can be a major stressor in life. G.S.

brought up his aunt a lot during the interview and had nothing good to say. He got quite agitated

when asked about her. The aunt confirmed that he has been on edge more than usual and is

agitated a lot. These signs of agitation can come from poor diet and the lack of sleep as G.S.

stated that he sleeps around 3 hours a night.

Another big factor with the patient is the history of physical abuse from his father. G.S.

lost both of his parents as a young teenager at the age of 15 years old. During that time, he had

remorse for his mother because she didn’t do anything about it. In the article titled, Childhood

Adverse Life Events and Parental Psychopathology as Risk Factors for Bipolar Disorder

discusses the adverse events that are risk factors for later bipolar disorder in children under 15. It

shows direct correlation between abusive family relationships and having a traumatic childhood

is a major factor into the later development of bipolar disorder (Bergink & Larsen, 2016).

Patient and Family History of Mental Illness

In the interview with G.S. the patient does not say any of his family members had any

mental illnesses he was aware of, but he did describe them in ways that sound like certain mental

illnesses may have been present. First off, he brought up his cousin who had to go to rehab in

Florida for smoking marijuana. G.S. grew up with two alcoholics, stating that his father and half-

brother were both alcoholics. G.S. never stated his mother had a history of bipolar disorder but

he listed some characteristics that lean towards that. For example, he stated that she was

depressed all the time and would not intervene when his father beat him. He also stated that she

would “snap out of it” and buy them fancy toys. All these statements indicate that there is a

possibility in a history in alcoholism and bipolar.

BIPOLAR: CASE STUDY 10

Psychiatric Evidence Based Nursing Care

The two main treatments for bipolar disorder through medication is by Lithium and

Depakote (valproic acid). Usually only one is given because the two medicines have the same

effect for Bipolar patient; they just have different side effects. The patient usually cannot take

one because they are at risk for life threatening side effects if there is too much of that

medication in their system. G.S. is not on the medication Depakote because the lab value of his

QTC interval was already over the normal value of 440 at 477. Thus, meaning that if he was

given the Depakote, it can force him into “increased risk of torsade de pointes (TdP), that can

lead to ventricular fibrillation and sudden cardiac death (SCD) and it is considered a marker of

arrhythmia” (G. Guarnieri & G. Cammarata, 2022). Since G.S. cannot receive this treatment, he

will be getting Lithium, which has a very small therapeutic range since his Lithium lab values

are low. Toxicity is not as much of a concern since the dose will be calculated along with the

duration it is taken. Since Lithium has such a small therapeutic range, you have to get constant

blood work to check the ranges. G.S. is receiving Lithium and Risperidone as his treatment for

the manic episodes.

Another evidence based nursing care intervention that has taken place on the Psyche floor

is to provide a safe, relaxing, low stimulus environment for the patient. Thus, meaning that when

the patient is admitted to the floor all hazardous objects will be removed from any potential reach

of the patient along with anything they can tie something with like a string or cord. No sharp

objects or easily breakable material accessible to the patient. Along with keeping a low stimulus

environment we advised G.S to attend group therapy. G.S. was able to attend group therapy, the

first couple times the patient had to leave because of his inability to stay quiet but as he
BIPOLAR: CASE STUDY 11

progressed in his health the therapy sessions improved as well. G.S. hardly ever ate because it

takes too much time, therefore he had inadequate nutrition and imbalanced fluid and electrolytes.

G.S. would not sit down and eat a whole meal, but as he walked throughout the day on the floor

he was offered finger foods to increase the nutritional intake.

Ethical, Spiritual and Cultural Influences

G.S. is a 56-year-old white, Caucasian male and seems to have no religious beliefs. On

the other hand, G.S. has stated that he is very down to earth like the “Native Americans” during

his manic state. G.S. seems to enjoy traveling as he stated he has gone to multiple big cities

during his interview. The only family member G.S. seems to have a relationship with is his aunt,

there was no mention of his son or ex-wife when asked.

Evaluation of Patient Outcomes

The evaluation on the stay for G.S. on the psych unit has been progressing more and

more each day in the right direction. After a couple of days on the unit G.S. has been taking his

medications on schedule and has realized that he needs a long term medication routine. In

addition to proper medication treatment, the auditory and visual hallucinations are almost

nonexistent. When there are hallucinations, he is able to recognize they aren’t apart of reality and

stop them relatively quickly. G.S. is also sleeping a lot more going from only 3 hours of sleep to

6-9 hours of sleep. Alongside the sleep, the patient’s agitation has gone down and any signs of

harming himself or others. G.S. has shown initiative when it comes to more nutritional intake.

He has been prioritizing hydration and nutrition by eating over 75% of his food at each meal.

The patient attended group therapy sessions and was able to contain his thoughts and not distract

the group like prior sessions.

BIPOLAR: CASE STUDY 12

Summarized Plans for Discharge

G.S’s plan of discharge is to get him into a therapy routine so that he can recover from

his alcoholism and use of marijuana. After he finishes therapy, G.S. should attend AA meetings

during the weekdays and weekends to prevent drinking habits (5 times a week). G.S. will

continue his Lithium medication, which is 600mg orally, 2 times a day along with his

Risperidone 2mg orally, daily. Since G.S. is on Lithium medication he will have to have blood

work taken weekly to see therapeutic levels aren’t becoming toxic. Then over time it will

progress to months as those levels are sustained. Lithium can cause dehydration, so the patient

will have to drink around 8 to 10 cups of fluids a day and increase his salt intake with that.

Patient will need to be educated on side effects of medication. Since G.S. was recently fired at

Walmart, he should be looking for a new job when ready and creating therapeutic relationships

with others.

Prioritized List of Actual Nursing Diagnosis

1. Disturbed thought process related to bipolar diagnosis as evidence by visual auditory

hallucinations, and grandiose delusions.

2. Disturbed Sensory Proception related to malnutrition, no sleep, and alcoholism as

evidence by inappropriate communication skills, auditory and visual hallucinations.

3. Risk for self-harm related to manic episodes as evidence by extreme mood swings and

easily irritable when something goes the way he doesn’t want it to.

4. Disturbed sleep pattern related to manic episodes as evidence by patient states he gets 3

hours of sleep and racing thoughts.

5. Impaired social interaction related to manic episodes of bipolar diagnosis as evidence by

patient was struck by farmer because he told them how to do their job.
BIPOLAR: CASE STUDY 13

Potential Nursing Diagnosis

1. Risk for self-harm

2. Insufficient Individual Coping

3. Impaired Social Interaction

4. Total Self-Care Deficit

5. Malnutrition

6. Disturbed Thought Process

7. Disturbed Sensory Perception

8. Risk for Suicide

Conclusion

In conclusion, G.S. was a very unique patient and had a lot of information dissected for

this case study. In my opinion, if G.S. sticks to a strict medication routine and goes back to

therapy, he should have less exacerbations of these manic episodes. I think he will need a support

person there to help him stay to his routine even when he doesn’t want to. It should be his aunt

because she seems the most responsible between her and the cousin. The patient’s

communication skills should improve upon the medication routine if the patient makes the effort

to get better.
BIPOLAR: CASE STUDY 14

References

Bergink, V., Larsen, J. T., Hillegers, M. H. J., Dahl, S. K., Stevens, H., Mortensen, P. B.,

Petersen, L., & Munk-Olsen, T. (2016, October 25). Childhood adverse life events and

parental psychopathology as risk factors for bipolar disorder. Nature News. Retrieved

November 13, 2022, from [Link]

Bobo, W. V. (2017, October). Home Page: Mayo Clinic Proceedings. Retrieved November 13,

2022, from [Link]

Guarnieri, G., Battini, V., & Cammarata, G. (2022, January). Valproic acid and prolonged qt:

Highlights from the FDA ... - pharmadvances. Valproic acid and prolonged QT: highlights

from the FDA Adverse Event Reporting System (FAERS) database. Retrieved November

15, 2022, from [Link]

content/uploads/2022/03/Battini_PhAdv-[Link]

authors, A., & Roger S. McIntyre & Joseph R. Calabrese. (2019, July 16). Bipolar depression:

The clinical characteristics and unmet needs of a complex disorder. Taylor & Francis.

Retrieved November 13, 2022, from

[Link]
BIPOLAR: CASE STUDY 15

Case Study Comment Sheet 4842 (Turn in with Case Study)

Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

___________ Patient education required (based on symptoms, diagnosis, medications, labs,

safety, etc.)

___________ Priority patient needs (day of care and discharge)

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format