BIPOLAR/DEPRESSION CASE QUESTION AND ANSWER STUDY CASE

Luis Chaves is a 22-year-old who migrated to Miami at the age of 2 years with his parents. He is unemployed and lives with his sister. He is actively involved with an intercity gang and depressed. Today he intentionally overdosed with paroxetine, zolpidem, oxycodone and alcohol. He goes to his sister’s apartment to say goodbye after taking the drugs and alcohol and confesses to overdosing. His sister immediately calls 911 as be became unconscious. On the way to the emergency room Luis was treated with naloxone, which produces a rapid improvement in his level of consciousness. He becomes agitated and starts yelling that he “doesn’t want to live anymore.” This is the report from the emergency squad: We responded to the residence at 2204. Upon arrival we found a 22-year-old male unconscious. Sister reports that the client stated overdosing with paroxetine, zolpidem, oxycodone, ibuprofen and alcohol. Patent airway and breathing spontaneously at 8 resp. a minute, pulse 60 bpm, blood pressure 90/58 mmHg. Naloxone administered during transport and client’s level of consciousness increased. Began yelling “I don’t want to live anymore.” Respirations 20 breaths per minute, pulse 90 bpm, blood pressure 148/988. Handoff report given to emergency room nurse. Answer the following questions related to the above information: 1.You have received report from the emergency squad, what are your top three priority concerns? 1. Safety- pt tried to commit suicide and doesn’t want to live anymore, so suicide precautions. 2. Blood pressure- elevated 3. Respiratory because of relapse of decreased respirations after Narcan wears off. 2. As the nurse triaging Luis what is your priority focused assessment? 1. Cultural preferences 2. Respiratory status 3. Suicide risk 4. Substance abuse history 3. Luis responded to naloxone on the way to the emergency department. Which of the following substances would not react to naloxone? (Select all that apply) 1. Paroxetine (Paxil) 2. Zolpidem (Ambien) 3. Oxycodone 4. Ibuprofen 5. Alcohol Luis is stabilized in the emergency department. He reports feeling “desperate” over being estranged from his 4-year-old son and the negative consequences of his current life decisions. He goes on to discuss conflicts that he has with his mother, his inability to find a job, the recent deaths of several close friends murdered in gang violence, and feelings of helplessness, hopelessness, and depression and self- loathing. He shares that his biological father is an alcoholic and has a drug abuse problem. He denies that he has problems with alcohol because he “just doesn’t like the taste” and only drinks one or two times a month. He also states that he doesn’t take drugs because he doesn’t “like the way they make me feel”. Luis states that he has a family history of depression, schizophrenia and bipolar disorder. At age 14 he tried to commit suicide for the first time and has made three attempts since then and has been hospitalized for this. He says, “I wish I hadn’t gone to my sister and told her what I did; then this would be over.” He denies feeling suicidal currently. 5. What is the best predictor of a suicide attempt? 1. A family history of suicide attempts 2. Previous suicide attempts 3. Stating suicidal intent 4. Having a friend who had a suicide completion 6 You continue your assessment. What questions should you ask? (Select all that apply) 1. “What medications are you currently prescribed besides oxycodone?” 2. “Tell me more about any illicit drugs you have taken in the past.” 3. “How do you feel about your attempt being unsuccessful?” 4. “What is your relationship with your sister?” 5. “Tell me more about your family history of mental illness.” 6. “ How has your mood been lately?” 7 What are the criteria for a diagnosis of major depressive disorder? (Select all that apply) 1. Depressed mood 2. Lack of interest in activities that used to be enjoyable 3. Manic mood 4. Change in appetite 5. Fatigue or loss of energy 6. Feelings of elation 7. Feelings of worthlessness 8. Inability to concentrate 9. Thoughts of death 10. Increase in a goal-focused activity 8 You discover that Luis takes paroxetine for a major depressive disorder. Which statement is correct about this medication? 1. Paroxetine (Paxil) is a monoamine oxidase inhibitor that works by blocking the breakdown of tyramine, a precursor to dopamine 2. Paroxetine (Paxil) is a tricyclic antidepressant that works by altering norepinephrine and serotonin levels at the synapse 3. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor that works by helping serotonin get to the synapses where it is needed. 4. Paroxetine (Paxil) is a heterocyclic that works by inhibiting neuronal uptake of norepinephrine and dopamine. 9 Answer the following question after reviewing the following lab values from the Emergency Department lab Normal Resulted WBC 4,000-10,000 uL 5.6 Hemoglobin 12.0-17.0 g.dL 11.2 L Hematocrit (%) 36-51% 32 L RBC 4.2-5.9 cells/L 4.0 L Platelets 150,000-350,000 uL 156,000 Calcium 9-10.5 mg/dL 9.0 Chloride 98-106 mEq/L 103 Magnesium 1.5-2.4 mEq/L 1.4 L Phosphorus 3.0-4.5 mg/dL 4.5 H Potassium 3.5-5.0 mEq/L 3.4 L Sodium 136-145 m/eq/L 136 Glucose-fasting 70-100 mg/dL 104 H BUN 8-20 mg/dL 25 H Creatinine 0.7-1.3 mg/dL 1.3 CPK 30-170 U/L 6.3 LDH 60-100 U/L 156 H AST 0-35 U/L 38 H ALT 0-35 U/L 31 GGT 9-48 U/L 23 Thyroid Stimulating Hormone 0.5-5 mU/L 5.4 H Which of the labs above could be the cause of his current symptoms of depression? 1. Liver function 2. Kidney function 3. Metabolic function 4. Thyroid function 10 As the nurse you are concerned that Luis may have a bipolar disorder and you talk to the mental health provider about his current medications. Which medications might be prescribed for Luis in an effort to manage his bipolar disorder? (Select all that apply) 1. Valproate (Depakote) 2. Lamotrigine (Lamictal) 3. Clozapine (Clozaril) 4. Risperidone (Risperdal) 5. Aripiprazole (Abilify) 6. Lorazepam (Ativan) 11 The mental health care provider is also concerned that Luis may have bipolar disorder and wants to start him on lithium carbonate. Which statement made by the client indicates an understanding of the medication and its side effects? 1. “If I have fine hand tremors, I’ll just take the benztropine (Benadryl) as needed.” 2. “ I will have the blood levels drawn regularly.” 3. “ I will decrease my salt and fluid intake.” 4. “ If a skin rash appears, I’ll just stop taking my medications.” 12 You are getting ready to administer Luis’ morning dose of Lithium and you note a fine to coarse hand tremor. What is your priority action? 1. You should administer the morning dose as this is a normal side effect. 2. You should call the doctor immediately because this is a rare and fatal side effect of lithium. 3. The hand tremor is a sign of mild toxicity, and you should hold the dose until further assessment. 4. You will give the lithium, continue to monitor the hand tremor and call the physician when the lithium levels rise to 2.3 mEq/L. 13 The mental health provider decided to change Luis’s medication to lamotrigine (Lamictal). Which statement made by Luis would require immediate action? 1. “I am having difficulty falling asleep at night.” 2. “I noticed a weird rash on my chest that wasn’t there before.” 3. “I feel like my thoughts have improved.” 4. “ I sure hope I don’t get that hand tremor that I had with Lithium.” 14 Luis has been stabilized on his medication regimen and is discharged from the inpatient unit. As you are reviewing the discharge instructions with Luis, which statement(s) would require additional follow-up? (Select all that apply) 1. “When I start to feel better, I can stop taking my medication.” 2. “ I am glad that my attempt was unsuccessful, I have my children to think about, and so much else to live for.’ 3. “I am sure I will be back; these mood issues have been a problem for me for quite a while.” 4. “ I need to figure out how to get my GED and figure out how to take care of my kids.” 5. “ I am worried my prescription for oxycodone won’t hold me until my appointment, could you talk to the doctor to get me more?” 15. Luis is concerned about how to get away from the gang and get his life back on track. What suggestions should you as the nurse make? (Select all that apply) 1. Change your contact information so they cannot call or text you. 2. Spend more time with your family. 3. Find other interests in the community to fill your time. 4. Let them know that you want out. Don’t be available to them.