PSYCH 209 Bipolar case study week 2- Kendall Harrison

Kendall Harrison Schizophrenia Case Study Mental Health Clinical Rosalyne Reynolds Week 2 Bipolar Depression/Mania UNFOLDING Reasoning Brenden Manahan, 35 years old Primary Concept Mood and Affect Interrelated Concepts (In order of emphasis) 1. Psychosis 2. Clinical Judgment 3. Patient Education 4. Communication Brenden Manahan is a 35-year-old male, who has been admitted to the crisis intervention unit for exacerbation of his bipolar disorder. He was admitted on a 501 (involuntary inpatient admission, patient has been deemed either dangerous to self or others) and brought to the hospital by police because his mother feared for his safety. In the past few weeks he stopped taking his medication because he feared that his mother was poisoning him. Brenden has not slept in the past four days due to racing thoughts. He believes that he is the head of the CIA and told his mother that he needed her car to go to CIA headquarters in McLean, Virginia, and fire everyone. When the police arrived, they noted that Brenden was speaking at a very rapid rate and pace and was becoming increasingly agitated. He began yelling that the police where there to poison him and prevent him from returning to his job. He has been admitted to the locked mental health unit for evaluation of his mental capacity and stabilization. Brenden will participate in the following education groups: medication education, and bipolar illness education. The goal is to resume lithium carbonate and divalproex sodium. Personal/Social History: Brenden was diagnosed at 19 with bipolar I, and subsequently has been admitted six times due to non-adherence to the medication regimen. Brenden is divorced and has a 3-year-old son who lives with his mother. He was recently in court to have his visitations reduced to one supervised visit a week. He lives with his mother, who is supportive. What data from the histories is important and RELEVANT and has clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: -Patient has been admitted to the crisis intervention unit on a 501 (involuntary inpatient admission because he is deemed a danger to self to others) related to an acute exacerbation go his bipolar disorder. He was also brought by the police. -Patient has stopped taking his medication in the past few weeks because he fears his mother has poisoned them -Patient has not slept in the last 4 days due to racing thoughts - Believes he is the head of the CIA and claims he needs to drive to the headquarters to fire everyone -When the police arrived, Brenden was speaking at a rapid rate and pace while becoming increasingly agitated and then began yelling at the policies saying they were only there to poison him and keep him from returning to work. - Patient is at risk for harming self or others. Being admitted to an inpatient program will allow him to be in a monitored safe environment and allow for staff to get patient back on appropriate medication (Professor Reynolds, 2020). -Patient seems to be experiencing a persecutory delusion and believes that someone is trying to harm him. This kind of delusions are common during the manic phase of bipolar disorder. The patient is having trouble adhering to his medication regimen and this needs to be evaluated with the MD. The mother’s safety is at jeopardy because the patient lived with her and is fearful that she is poisoning his medication (Professor Reynolds, 2020). - Patients lack of sleep is also an indicator of being in the manic phase of bipolar disorder. Patient in manic phases can die from their lack of sleep (Halter, 2018). -Grandiose delusions are also common during manic episodes of bipolar disorder (Halter, 2018). -Pressured speech is also a common characteristic of being in the manic phase of bipolar disorder. It is important to avoid getting in any power struggles with the patient, until his mania is under control he may not be cooperative. It takes time to build trust with this patient (Halter, 2018) RELEVANT Data from Social History: Clinical Significance: -Brendan was diagnosed at 19 with Bipolar 1, and has been admitted 6 times due to -This is known as “revolving door,” and may be a result to only short stays in the hospital. Patient is having issues adhering to his non-adherence to medication -Divorced with a 3yr old son, and recently went to court to have his visitation reduced to one supervised visit a week medication regimen and it should be evaluated with the HCP for whether or not the patient may need different medication, patient may also not have a strong enough support system that can assist him when her is starting to go into a manic phase (Halter, 2018). -This is a psychosocial stressor that may have led to the patients relapses and exacerbation of bipolar disorder manic phase (Halter, 2018). Current VS: WILDA Pain Assessment (5th VS): T: 99.1 F/37.3 C (oral) Words: Patient denies P: 110 (regular) Intensity: R: 28 (regular) Location: BP: 142/84 Duration: O2 sat: 99% room air Aggravate: Alleviate: Patient Care Begins: What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: P: 110 (regular) R: 28 (regular) BP: 142/84 -Physiological RED FLAG- his physiological metabolic demands are increased (Professor Reynolds, 2020). -Needs continually assessment, this accompanies with rapid speech can lead to hyperventilation (Professor Reynolds, 2020). -Elevated BP is related to increased respiration’s and heart rates as a result of his manic state. Needs to be closely monitored (Professor Reynolds, 2020). Current Assessment: GENERAL APPEARANCE: Is disheveled, and according to his mother, he has not showered in several days. NEURO: Oriented to person and place but not to time, impaired ability to concentrate, labile emotions, has not slept for four days RESP: Breath sounds clear however, patient is breathing rapidly and deeply CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants, has adequate appetite. GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact CHEMICAL USE: Denies both use/abuse of ETOH or other street drugs What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: - Appears disheveled and according to his mother he has not showered in several days - Oriented to person and place but not time, impaired ability to concentrate, labeled emotions, and has not slept for 4 days - Patient is breathing rapidly - Has no adequate appetite - According to the DSM5 from the American Psychiatric Association (2013), all of these behaviors and characteristics are congruent with mania (P. 168). His appearance and not sleeping, he is not caring for himself adequately. Patient is at risk for dehydration due to inadequate appetite and fluid intake. Mental Status Examination: APPEARANCE: Is disheveled, and according to his mother he has not showered in several days. He is unshaven, and has a significant odor coming from his body and or clothes. His clothes are not consistent with the weather, it is 95 degrees and is wearing multiple layers of clothing and has winter boots on. MOTOR BEHAVIOR: Psychomotor agitation present, appears restless; he is unable to sit still SPEECH: Talking fast with pressured speech. MOOD/AFFECT: Appears ecstatic, bright affect THOUGHT PROCESS: Delusional, flight of ideas/ jumping from one idea to another THOUGHT CONTENT: Believes that the CIA is controlling the nurses’ actions and following him and that he must get to the CIA headquarters immediately. PERCEPTION: Denies hallucinations INSIGHT/JUDGMENT: Has lack of insight into current condition and reason for inpatient hospitalization COGNITION: Oriented to person and place but not to time, his immediate and recall were intact but remote memory is not. INTERACTION: Approaches others, but does not engage in lasting conversation SUICIDAL/HOMICIDA L: Denies homicidal/suicidal ideation What MSE assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: -Is disheveled, and according to his mother he has not showered in several days. He is unshaven, and has a significant odor coming from his body and or clothes. His clothes are not consistent with the weather, it is 95 degrees and is wearing multiple layers of clothing and has winter boots on. -Psychomotor agitation present appears restless, and is unable to sit still, talking fast - Patient seems to be unable to take care of himself, as a result of his mental status. He is vulnerable to his disorder, and is a potential harm to himself and the fact that he cannot take care of his basic needs (Professor Reynolds, 2020). - Patient is clearly in a manic state, is experiencing an elevation in with pressured speech, bright affect and appears ecstatic, delusional, flight of ideas. -Believes that the CIA is controlling the nurses and telling them to follow him around and that he must go to the CIA headquarters immediately, denies hallucinations, has lack of insight into current condition, and denies suicidal or homicidal ideations -Only oriented to person and place but not time his mood as compared to his agitation earlier. He is grandiose, has a decreased need for sleep, and is reckless related to his impaired insight and judgment (Professor Reynolds, 2020). - Patient is currently experiencing delusions and is paranoid which means that in his current manic state that he is unpredictable. This puts him at an increased harm risk to himself and others. Patient needs to be closely watched so that he does not try to escape the facility, or harm any staff members he feels are being “controlled by the CIA”. Need to continue to follow up asking about hallucinations (Professor Reynolds, 2020). - Patient needs to be reminded of where he is, and why he is there. As the nurse we need to continuously reorient him to our name, our position and that we are there to help (Professor Reynolds, 2020). What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: Bipolar depression 1. Lithium 600 mg PO BID 2. Depakote 750 mg PO daily 1. Psychotropic agent-antimanic (lithium salt) 2. Antiepileptic 1. This drug is used to reduce the patient’s symptoms of mania 2. This drug is being used currently to stabilize the patient’s mood (Skidmore-Roth, 2019, p. 757 & p. 1254). Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Complete Blood Count (CBC:) Current: High/Low/WNL? WBC (4.5–11.0 mm 3) 8.9 WNL Hgb (12–16 g/dL) 12.9 WNL Platelets (150-450 x103/µl) 325 WNL Neutrophil % (42–72) 70 WNL What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: -CBC lab All labs values are within normal limits but will continue to monitor. WBC test is done to evaluate for possible infection or inflammation (Potter et al., 2017) Neutrophil test is also done to evaluate for infection. These are the cells that are the first responders to signs of bacterial infection (Potter et al., 2017) Hemoglobin test is done to evaluate for anemic conditions, bleeding, or if elevated, polycythemia (Halter, 2018) Platelet test is done to evaluate for wither decreased or increased risk for clotting (Potter et al., 2017) Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Sodium (135–145 mEq/L) 142 WNL Potassium (3.5–5.0 mEq/L) 4.0 WNL Glucose (70–110 mg/dL) 102 WNL Creatinine (0.6–1.2 mg/dL) 1.0 WNL RELEVANT Lab(s): Clinical Significance: -BMP labs Sodium is an essential electrolyte for fluids and electrolyte balance and to maintain overall health and function of body systems (Potter et al., 2017). Potassium is an important electrolyte associated with muscle contractions and importantly cardiac functioning. Potassium needs to always be monitored closely (Potter et al., 2017). Glucose is a molecule used as an energy source for the whole body. Elevated or decreased levels can indicate comorbidity of diabetes, elevated levels can also indicate activation of the sympathetic nervous system in response to anxiety and agitation (Potter et al., 2017). Creatinine monitors functionality of kidney. The renal system functioning properly is important for all body systems (Potter et al., 2017). Therapeutic Blood Levels: Current: High/Low/WNL? Lithium ( 0.8 to 1.2 mEq/L) 0.2 mEq/L LOW RELEVANT Lab(s): Clinical Significance: Lithium: 0.2 mEq/L -Levels are much lower than therapeutic limits and can be an indication that patient has not been reviewing his medication. In order to improve patients’ levels, he needs to be started on medication immediately because onset of action can take up to 10-21 days. While this is taking its time to work, we will need to get him some other medication to help with his current symptoms of mania (Halter, 2018). Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Lithium: 0.2 Normal value is 0.8-1.2 mEq/L Adverse effects are seen when levels are 1.5 mEq/L Early signs of toxicity are seen at 1.5-2.0 mEq/L Advanced signs of toxicity are seen at 2.0-2.5 mEq/L Severe toxicity is seen at 2.5 mEq/L (Halter, 2018). The mechanism of action for Lithium is “May alter sodium, potassium ion transport across cell membrane in nerve, muscle cells; may balance biogenic amines of norepinephrine, serotonin in CNS areas involved in emotional responses” (Skidmore- Roth, 2019, p. 757) The specific mechanism of action in mania is unknown. If patient’s levels are too high or too low outside of normal limits, serious adverse reactions can occur. - Because patient’s value is low and sub therapeutic, the physician should be notified, patient should be evaluated for whether or not lithium therapy she be started (Halter, 2018). - If lithium therapy is started, mental status must first be assessed for manic symptoms, mood, behavior before and during treatment (Halter, 2018). - Physiological status related to mania and physical exhaustion (Halter, 2018). - Once therapy has been started patient needs to be monitored for any adverse effects of lithium such as; vomiting, diarrhea, poor coordination, fine motor tremors, weakness, lassitude; major toxicity: coarse tremors, severe thirst, tinnitus, diluted urine, seizures, slurred speech, restlessness, fatigue, confusion, and memory loss (Halter, 2018). - Ensure the patient receives other medication that promotes rest such as Trazadone and Lorazepam (Skidmore-Roth, 2019).