A psychiatric nursing case study

INSIDE
THE MIND

A Day with a Bipolar Patient

“Behind every diagnosis is a human story. Explore the patient’s experience, understand the clinical presentation, and discover the nurse’s role in providing safe, compassionate care.”

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Confidentiality notice: this website is an educational nursing case presentation. The patient is identified only by the case code HA.

01 · Introduction

One patient. One admission. One story.

HA is a 28-year-old husband and father of four, admitted to Al-Fuheis Psychiatric Hospital on 10 October 2026 with a documented diagnosis of bipolar disorder. This presentation follows his assessment on 13 October 2026 and the nursing care that follows from it.
Documented data

Facts from the hospital record and patient report.

Clinical interpretation

Nursing reasoning based on those facts.

Hypothetical

Examples for teaching — never real outcomes.

02 · Background

Understanding Bipolar Disorder

Definition

A mental health condition with episodes of significant change in mood, energy, activity, and functioning — including manic or hypomanic episodes and often depressive episodes.

Diagnostic limitation

The hospital record documents bipolar disorder but does not specify Bipolar I or II. No subtype is assigned here, and full diagnostic criteria have not been verified.

03 · Patient History

Clinical Case File — HA

Patient record

Documented
Patient code
HA
Age
28 years
Gender
Male
Marital status
Married
Children
Four — three daughters, one son
Education
Did not complete Tawjihi
Previous occupations
Coffee shop, factory, company work
Hospital
Al-Fuheis Psychiatric Hospital
Admission date
10 October 2026
Assessment date
13 October 2026
Admission history
First admission to this hospital
Documented diagnosis
Bipolar disorder (subtype not specified)
Usual weight
78 kg
Allergies
No drug or other allergies reported
Chief complaint — patient’s reported statement
“I have been feeling overwhelmed by my marital and financial problems, and I have suicidal thoughts. I am afraid I might act on them.”

History of present illness · reported timeline

  • Increasing psychological distress
  • Marital conflicts and financial difficulties
  • Irritability and difficulty controlling emotions
  • Recurrent suicidal thoughts

Timeline is patient/family reported. Exact onset dates and prior episodes are not established.

Reported exacerbating factors

  • Marital conflict
  • Financial difficulties
  • Stressful situations
  • Upsetting comments from other people
  • Interpersonal conflict

Relieving / protective factors

  • Withdrawal from others when angry
  • His children
  • Willingness to seek help
  • Hope that circumstances may improve
  • Family support

Note: withdrawal has not reliably relieved his distress.

Complete psychiatric history

Previous psychiatric history
  • No previous psychiatric diagnoses reported
  • No previous psychiatric hospitalization reported
  • No previous outpatient psychiatric treatment reported
  • No previous psychiatric medication use reported
Self-harm and suicide historySafety

HA has a history of previous suicide attempts, including taking rat poison and stepping into traffic. He currently reports recurrent suicidal thoughts due to severe marital and financial problems. In bipolar disorder these dangerous behaviors can be driven by high impulsivity and poor emotional control. Although his children are a protective factor, he fears he might act on his thoughts.

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Substance use history
  • Current alcohol use: reports he has stopped drinking
  • Previous: approximately one bottle or can once weekly, as documented
  • Attempted to reduce and eventually stop
  • No morning alcohol use reported
  • No current or previous drug use reported; no IV use or shared needles

Family and social history
  • Lives with his wife and four children
  • Trusts his wife most; depends on family during crisis
  • Shares financial responsibilities and decisions with his wife
  • Family concerned about his distress, irritability, reduced sleep and behavior changes
  • Family encourages psychiatric treatment
  • No known family psychiatric history reported
Developmental history
  • Unstable family environment during childhood
  • History of being bullied; nightmares reported
  • No learning difficulties or repeated/skipped grades reported
  • Childhood cruelty to animals documented — no diagnosis is inferred
  • Social difficulties reported
  • Worked in a café; married approximately 10 years ago
  • No imprisonment or legal problems reported
Current medications3 documented

Depakine

Once daily

Sodium valproate + valproic acid · Anticonvulsant, mood stabilizer

Trade: Depakine Chrono, Epilim, Depakote

Side effects: Nausea, vomiting, drowsiness, tremor, weight gain, hair loss.

Serious: Liver toxicity, pancreatitis, thrombocytopenia, hyperammonemia, birth defects.

Contraindications: Liver disease, POLG-related mitochondrial disorders, urea cycle disorders, hypersensitivity.

Nursing care

  • Monitor liver function, platelets, ammonia when indicated, and serum level (50–100 mcg/mL).
  • Report abdominal pain, jaundice, unusual bleeding, or persistent vomiting.
  • Swallow tablet whole; do not crush or chew.
  • Educate about pregnancy risks and contraception.
  • Do not stop suddenly.
  • Give with food if needed; prevent falls due to drowsiness.

Prexal

Once daily

Olanzapine · Atypical antipsychotic

Trade: Zyprexa, Prexal

Uses: Schizophrenia and bipolar disorder, especially mania.

Side effects: Drowsiness, weight gain, increased blood glucose, increased lipids, dizziness, dry mouth.

Nursing care

  • Monitor weight, blood glucose, and lipid profile.
  • Assess sedation and fall risk.
  • Monitor blood pressure, especially orthostatic hypotension.
  • Educate about healthy diet and physical activity.
  • Teach not to stop without medical advice.

Metformin

Three times a day

Metformin hydrochloride · Antidiabetic, biguanide

Trade: Glucophage

Side effects: Diarrhea, nausea, abdominal pain, metallic taste, vitamin B12 deficiency.

Serious: Lactic acidosis.

Contraindications: Severe renal impairment (eGFR below 30), metabolic acidosis, hypersensitivity.

Nursing care

  • Give with or after meals.
  • Monitor blood glucose, HbA1c, and renal function.
  • Report rapid breathing, muscle pain, or severe weakness.
  • Avoid excessive alcohol intake.
  • Monitor vitamin B12 during long-term use.
  • Hold around contrast imaging when ordered.
  • Hypoglycemia is uncommon when used alone.

Physical assessment and investigations
Usual weight78 kg
Recent weight change1.82 cm
Sleep≈ 3–4 h per night
EEGNot performed
Height / BMI23
Vital signsNot provided
LFTs, platelets, valproate levelTo be assessed
Glucose, HbA1c, lipidsTo be assessed
Renal function, B12To be assessed
ECGNot performed 

04 · Presentation

Signs and Symptoms

Increased energy
Reduced need for sleep
Rapid, pressured speech
Racing thoughts
Increased activity and restlessness
Irritability
Impulsive behavior
Excessive spending
Distractibility
Flight of ideas

These findings may be consistent with manic-spectrum symptoms. Full episode criteria, duration, impairment, exclusion of substance/medical causes, and subtype require clinical confirmation.

05 · Assessment

Mental Status Examination

Select a category to reveal the documented findings.

Requires immediate clinical attention

Suicidal ideation + impulsivity + reduced sleep + increased energy demand immediate attention and ongoing reassessment. No numerical score can predict or rule out suicide.
Appearance and behavior
  • Appears stated age of 28
  • Clothing appropriate for weather
  • Fair personal hygiene
  • Animated facial expressions
  • Sits upright, frequently changes position
  • Increased psychomotor activity; difficulty remaining seated
  • Frequent and intense eye contact
  • Generally cooperative and talkative
  • Easily distracted; occasionally requires redirection
  • Restless and impulsive behavior documented

Discrepancy preserved: facial expressions are documented as animated, while affect is documented elsewhere as restricted.

Speech
  • Rapid rate, loud volume
  • Excited and irritable tone at times
  • Pressured, increased amount of speech
  • Minimal response latency
  • Generally relevant, but frequently shifts between topics
  • Fluent, understandable articulation
Consciousness and orientation
  • Alert, awake, responsive
  • Oriented to person, place, and time
  • Immediate, recent, and remote memory described as intact
  • Attention and concentration mildly impaired due to distractibility
Mood and affect
  • Reports feeling stressed and worried about marital and financial problems
  • Reports feeling calmer since receiving treatment
  • Occasional irritability remains
  • Mood: irritable and mildly dysphoric — rated 4/10
  • Affect: restricted; congruent with stated mood and thought content
Thought process
  • Circumstantiality present — takes a long, detailed route but eventually reaches the point
  • Flight of ideas present — rapid jumps between loosely connected topics
  • Not observed: loose associations, tangentiality, word salad, neologisms
Thought content
  • No grandiose delusions reported
  • Ideas of reference reported by history: believes two people are talking about him
  • Excessive thinking about his wife interferes with sleep
  • Fear of being harmed while sleeping
  • No delusions of control or somatic delusions reported

These are reported beliefs and assessment findings — not confirmed psychotic symptoms.

Perception
  • Auditory hallucinations not reported
  • Visual hallucinations not reported
  • No response to internal stimuli observed
  • No illusions, depersonalization, or derealization reported
Insight and judgment
  • Insight: Requires further assessment.
  • Judgment: Requires further assessment.

Suicide and violence riskRisk
  • Passive suicidal thoughts reported intermittently
  • Active suicidal ideation reported in the history
  • No specific plan reported in supplied assessment
  • Current intent requires direct, ongoing assessment
  • Hopelessness rated 7/10
  • Protective: children, hope for improvement
  • Current homicidal thoughts denied; no violent plan or target reported
  • History of irritability and anger

06 · Nursing Care Plan

Prioritized nursing care

Suicide safety is the first priority. All outcomes are pending actual implementation.

Nursing diagnosis

Risk for injury

Related / risk factors

  • Recurrent suicidal thoughts and fear of acting on them
  • Psychosocial stressors: marital conflict, financial difficulty
  • Impulsivity, irritability, difficulty controlling emotions
  • Hopelessness rated 7/10
  • Reduced need for sleep with increased energy
  • History of previous suicide attempts (see flagged history)

Supporting evidence

  • Related to suicidal ideation and impulsivity.

Short-term SMART goals

  • Within 24 hours, HA will remain free from self-harm while receiving appropriate clinical safety precautions.
  • Within 24 hours, HA will communicate any increase in suicidal thoughts or intent to nursing staff.
  • Within 48 hours, HA will identify at least two coping strategies and one way to seek immediate help when thoughts intensify.

Long-term SMART goal

  • Before discharge, HA will participate in completing a written safety plan listing warning signs, coping strategies, support people, and emergency contacts.
Independent interventions + rationales

Establish a calm, therapeutic, nonjudgmental relationship.

Rationale: Trust increases honest disclosure of suicidal thoughts.

Directly assess thoughts, intent, plan, access to means, recent behavior, and changes in risk.

Rationale: Asking directly does not increase risk and identifies the level of precaution needed.

Reassess promptly when mood, agitation, sleep, or behavior changes.

Rationale: Risk is dynamic; activation and poor sleep can raise it quickly.

Implement observation and environmental precautions per assessed risk and hospital policy.

Rationale: Reduces opportunity for impulsive self-harm using the least restrictive safe approach.

Encourage HA to communicate escalating distress.

Rationale: Early reporting allows early intervention.

Collaboratively identify warning signs, coping strategies, and support people.

Rationale: Forms the basis of an individualized safety plan.

Document findings and communicate significant changes promptly.

Rationale: Ensures continuity and timely team response.

Collaborative interventions + rationales

Notify the treating psychiatric team about active or worsening ideation.

Rationale: Medical review may change observation level or treatment.

Participate in multidisciplinary safety planning.

Rationale: Shared plans are more consistent across shifts.

Coordinate psychiatric assessment and treatment.

Rationale: Treating mood symptoms addresses a driver of risk.

Involve family when appropriate, with attention to consent and confidentiality.

Rationale: Family is a documented support and can help monitor warning signs.

Review access to harmful means and support restriction as part of the plan.

Rationale: Means restriction is one of the most effective suicide-prevention measures.

EvaluationEvaluation pending actual implementation
Self-harm during evaluation periodPending
Willingness to report worsening thoughtsPending
Suicide-risk reassessment completedPending
Coping strategies identifiedPending
Safety plan completed and reviewedPending

Hypothetical example “Goal met if, after 24 h, HA has had no self-harm and has approached staff when thoughts increased.” This is a teaching example — not a real outcome.

Nursing intervention library

IndependentIn care plan

Structured suicide-risk assessment each shift and on change

Why: Risk fluctuates

Finding: Recurrent suicidal thoughts, fear of acting

CollaborativeIn care plan

Remove or restrict access to harmful means

Why: Prevents impulsive acts

Finding: Impulsivity; past attempts

07 · Nursing Simulation

You are the nurse. What would you do?

Scenario 1 of 3

Score: 0 / 3

Immediate suicide safety

HA reports suicidal thoughts and says he is afraid he might act on them. He has been sleeping only 3–4 hours per night and shows impulsive behavior.

What is the nurse’s most appropriate immediate priority?

08 · Therapeutic Communication

Choose your words

HA says
“I cannot stop thinking about my problems, and I feel like everything is getting out of control.”

Therapeutic

  • Open-ended questions
  • Active listening
  • Reflection and clarification
  • Validation of emotions
  • Direct, nonjudgmental safety assessment
  • Respect for autonomy and dignity

Nontherapeutic

  • False reassurance
  • Minimizing distress
  • Judgmental responses
  • Arguing about beliefs (e.g. that two people talk about him)
  • Giving premature advice
  • Avoiding necessary suicide-risk questions

Patient-centered care

A diagnosis does not define the whole person.

A father of fourA husband under marital and financial stressA worker facing occupational difficultyA patient who sought treatmentHolds onto his children and hope as reasons to stay safe

His strengths matter — but family responsibility alone does not make him safe. Care must preserve dignity and confidentiality, avoid stigma, listen to his perspective, support shared decisions, and stay individualized and evidence-informed.

09 · Film

WATCH THE FILM

“A visual exploration of the patient’s experience.”
Replace the film

“Treat the person, not just the diagnosis.”

  1. 1

    Patient safety comes first, particularly when suicidal thoughts and impulsivity are present.

  2. 2

    Therapeutic communication builds trust and encourages honest disclosure.

  3. 3

    Nursing interventions must be individualized to the patient’s actual assessment findings.

  4. 4

    Sleep, mood, behavior, and risk require ongoing monitoring.

  5. 5

    Recovery-focused care should preserve dignity, involve appropriate support, and reduce stigma.

What is the most important nursing priority in this case, and why?

10 · References

References

  1. Townsend, M. C., & Morgan, K. I. Davis Advantage for Psychiatric Mental Health Nursing (10th ed.). F.A. Davis.

Educational nursing case presentation. Done by Mohammed batran, saleh alspakhi, omar omush, rayan zouid, tamer almashaqba

11 · Summary Video

Summary video