Bipolar Depression/ Mania Week 1 Case Study

Bipolar Depression/ Man ia 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 History of Present Problem: Bipolar Depression/Mania 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: · Exacerbation of BD · Dangerous to self and others · Non-adherent to med regimen · Sleep deprived · Agitated · Reason why patient is admitted · Clinical staff is aware and can protect themselves and the patient if patient is dangerous · Evidence as to why the patient is behaving the way they are · Can administer medications that can help the patient get some rest · Can administer medication that can calm the patient down RELEVANT Data from Social History: Clinical Significance: · Diagnosed at 19 · Admitted 6 times due to non-adherence to medication regimen · Divorced with 3 year old son · Lives with mother · Gives you a picture of how long the patient has had this disorder · May need to improvise nursing care plan so patient will adhere to medication regimen · Possible reason for depression · Support system 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: · T: 99.1 · Low grade fever · P: 110 · R: 28 · Exacerbation of bipolar disorder, heart rate will increase · BP: 142/84 · Respirations are increased as well, can be associated with the mania the patient is experiencing · BP is high as well due to the feelings of anxiety the patient is feeling 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: · Disheveled, hasn’t showered in several days · Not oriented to time · Impaired ability to concentrate · Labile emotions · Has not slept in four days · All of these findings are expected with bipolar and depression and it is important to know so that the proper care can be given to this patient such as a safety environment, rest, assisting or giving reminders about hygiene, and listening and using a calm voice when interacting with the patient APPEARANCE: Is disheveled, and according to his mother he has not showered in several days. He has not shaved, 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 with winter boots on as well. 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/HOMICIDAL: 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: · Disheveled, hasn’t; showered in several days, wearing multiple layers and winter boots in 95 degree weather · Agitated, restless · Rapid speech, ecstatic, delusional · Lacks reason for hospitalization · Does not engage in lasting conversation · These finding are significant because they demonstrate bipolar 1 disorder that can result in manic episodes so the patient is often hyperverbal, does not eat, drink, or sleep, moods can be elevated and irritable. They should be known so staff can protect themselves as well as the patient, physical restraints if need be, one-to-one staff to minimize stimulation, relaxation techniques, and medications. 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. Anitmanic 2. Anticonvulsants · Lithium will Decrease incidence of mood swings, decrease incidence of acute manic episodes, and resolve symptoms of mania such as hyperactivity, pressured speech, poor judgment, and need for little sleep, and will prevent reoccurrence of mania, depression, and suicide · Depakote will decrease incidence of manic episodes, if lithium is not effective 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: