bipolar and depression case study for clinical PDF

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bipolar and depression case study for mental health practicum and lecture...

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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

© 2016 Keith Rischer/www.KeithRN.com

Bipolar Depression/Mania History of Present Problem: 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: - 35 year old male; admitted into crisis intervention unit for exacerbation of bipolar disorder - admitted involuntarily d/t mother fearing for his safety - has not slept in 4 days d/t racing thoughts - patient believes he is the head of CIA - patient stopped taking his medications because he feared his mother was posoning him

- experiencing manic disorder (decreased desire to sleep and rapid speech) - patient is a danger to himself and others - racing thoughs and delusions can be related to medication noncompliance

RELEVANT Data from Social History:

Clinical Significance:

- diagnosed with bipolar I at 19 - divorced with a 3 year old sone - lives with supportive mother - 6 previous admissions d/t non-

- limited support system

Current VS:

WILDA Pain Assessment (5th VS):

T: 99.1 F/37.3 C (oral) P: 110 (regular) R: 28 (regular) BP: 142/84 O2 sat: 99% room air

Words: Patient denies Intensity: Location: Duration: 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 R: 28 BP: 142/86

- Elevated T, RR, and BP are all d/t manic state and delusion

© 2016 Keith Rischer/www.KeithRN.com

Current Assessment: GENERAL APPEARANCE: NEURO: RESP: CARDIAC: GI: GU: SKIN: CHEMICAL USE:

Is disheveled, and according to his mother, he has not showered in several days. Oriented to person and place but not to time, impaired ability to concentrate, labile emotions, has not slept for four days Breath sounds clear however, patient is breathing rapidly and deeply Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants, has adequate appetite. Voiding without difficulty, urine clear/yellow Skin integrity intact 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, has not showered in several days - disoriented to time, impaired ability to concentrate; liable emotions; no sleep for 4 days - breathing rapidly and deeply

- patient not taking care of personal hygiene d/t current condition - lack of sleep can cause disorientation and/or mania d/t inability to differentiate reality

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/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: - lack of hygiene, inappropriate dress - psychomotor agitation, restless - rapid speech - bright effect - delusional - lack of insight into current condition - lack of remote memory, not oriented to time - cannot engage in lasting conversation

© 2016 Keith Rischer/www.KeithRN.com

- patient unable to meet/take care of personal needs - manic episodes cause bright affect, rapid speech

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 mood stabilizer 1. decrease incidence 2. Depakote 750 mg PO daily

antivonculsant

of acute manic episode 2. decrease manic epi

Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Complete Blood Count (CBC:) WBC (4.5–11.0 mm 3) Hgb (12–16 g/dL) Platelets (150-450 x103/µl) Neutrophil % (42–72) WNL

Current: 8.9 12.9 325 70

High/Low/WNL? WNL WNL WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: N/A No lab abnormalities

Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Glucose (70–110 mg/dL) Creatinine (0.6–1.2 mg/dL)

RELEVANT Lab(s): N/A

Therapeutic Blood Levels: Lithium ( 0.8 to 1.2 mEq/L)

RELEVANT Lab(s): Lithium: 0.2 mEq/L

Current: 142 4.0 102 1.0

High/Low/WNL? WNL WNL WNL WNL

Clinical Significance: No imbalances

Current: 0.2 mEq/L

High/Low/WNL? Low

Clinical Significance: Low therapeutic range, decreases functioning of medication Low levels could be related from patient being non-compliant with medication for several days

© 2016 Keith Rischer/www.KeithRN.com

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab:

Normal Value:

0.8 - 1.2

Lithium: 0.2

Clinical Significance:

Nursing Assessments/Interventions Required:

Not in range for medication to work, therefore manic episodes

administer lithium monitor for s/s of lithium toxicity obtain lithium blood levels after administration

Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? The primary problem the patient is most likely presenting is bipolar depression, due to non-adherance to prescribed medications

2. What is the underlying cause/pathophysiology of this concern?

No known cause; possibly related to genetics and/or changes that occur within the brain

Collaborative Care: Medical Management Care Provider Orders: Admit to unit and engage patient in milieu

Rationale:

Expected Outcome:

Recive treatment/medications and be closely monitored

Patient will not harm himself/others

Ensure no other drugs, substances or alcohol

No toxicity/interactions with medications administered

Lithium 600 mg PO BID

mood stabilizer

decreased incidence of mania

Depakote 375 mg PO BID

inhibit neurotransmitters within CNS

Trazodone 100 mg PO PRN slee

antidepressant and combat insomnia

Urine drug screen

decreased maniac episodes

avoid sleep deprivation

Lorazepam 1 mg PO BID

sedation

© 2016 Keith Rischer/www.KeithRN.com

decreased anxiety and increase calmness and rest

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Urine drug screen Lithium 600 mg PO TID Depakote 375 mg PO BID Trazodone 400 mg PO PRN sleep

Order of Priority:

Rationale:

1. Admit to unit and engage patient milieu 2. urine drug screen 3. lithium 600 mg PO 4. depakote 375 mg PO 5. trazodone 400 mg PO 6. lorazepam 1 mg PO

1. provide safe environment, monitoring and avoid harm to himself/others 2. determine subtances that could possibly interact with medications ordered 3. increase therapeutic range 4. decrease severity of manic episode being experienced 5. help the patient sleep and decrease delusions 6. decrease agitation and anxiety

Lorazepam 1 mg PO BID Admit to unit and engage patient in milieu

Collaborative Care: Nursing 3. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)

Risk for injury, disturbed sleeping pattern, disturbed thought process

4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: 1. Risk for injury - provide patient a safe environment: remove all possible hazard monitor patient closely: placing him close to nurse’s station or 1:1 to avoid selfharm or harm to others 2. Disturbed sleeping patterns - create a sleep promoting plan of care: quiet and calm environment, dimming lights, administer prescribed medications to aid in sleep, encourage rest periods and decrease environmental stimulation 3. Distubed though process - perform MSE: assess behavior, cognition, administer prescribed medications to decrease alterations

1. creating a safe environment for the patient to be in 2. creating sleep promotion plan can be effective for sleep deprivation and decreasing manic episode 3. establishing baseline to recognize improvement or decline of condition

Expected Outcome: 1. maintain harm free environment for himself and others 2. patient will fall asleep without difficulty 3. demonstrate improved cognition, baseline and thought-process

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

Neurological 6. What is the most likely complication/problem that the nurse should anticipate?

Delirious Mania 7. What nursing assessments will identify this complication EARLY if it develops?

MSE, mood labile, cognition and perception become severly clouded 8. What nursing interventions will you initiate if this complication develops? © 2016 Keith Rischer/www.KeithRN.com

observe patient’s behaviors frequently; intervene at first sign of anxiety, agitation, aggression; maintain calm attitude

Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Two hours later… The nurse observes the patient yelling and banging on the door of the unit. They need to let him out because he has to get to CIA headquarters to stop a terrorist attack. The staff tries to reorient him and the more they talk with him, the more agitated he becomes. Current Assessment: GENERAL Agitated, and delusional. Is restless and agitated. APPEARANCE: 1. Has the status improved or not as expected to this point?

The patient's status has not improved, rather has worsened as evidenced by yelling, banging on door of the unit and stating he needs to get to CIA headquarters to stop 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

Previous plan of care may have to be modified in order to help the patient deescalate the situation by the use of least restrictive to most restrictive interventions .

3. Based on your current evaluation, what are your nursing priorities and plan of care?

Top priority is patient/staff/other safety. Trial of deescalation by therapeutic communication, possible medication and/or restriction/seclution

Nurse to Physician SBAR for Change in Status:

Situation: 35 year old male; admitted on a 501 d/t exacerbation of bipolar disorder. Patient has been noncompliant with medications, has not slept in 4 days, had rapid and pressured speech. Patient has elevated BP and HR. Patient is yelling and banging on unit door.

Background: Patient was diagnosed at 19, noncompliance to medications, divorced and father to a 3 year old; visitations have been reduced recently. Patient has had 6 previous admissions d/t non-adherence. Patient lives with his mother, and was

Assessment: VS: T 99.1; P: 110 (regular); R: 28 (regular); BP 142/84 (elevated) Patient is delusional, and becomes more agitated as staff tries to reorient and talk with him

Recommendation: Providing patient with calm, quiet environment away from stimuli to decrease agitation © 2016 Keith Rischer/www.KeithRN.com

Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will discuss with Brenden about his medical condition to prevent future readmission with the same problem?

The discharge/education priority to discuss with the patient is medication adherence in order to avoid/decrease signs and symptoms of mental illness and prevent relapse

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

Have Brenden state the importance of medication adherence and recognize signs and symptoms in order for those to not worsen

Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation?

The patient is probably confused, agitated, misunderstood, exhausted. Although the patient has been in the hospital multiple times; he can still feel scared of being there and not having anyone understand what he is going through

2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person?

I think it is important to not feed into patient's delusions but in a therapeutic and caring way, I would want to deescalate the situation but sit down with the patient when he has a clear mind and talk about the effects of not not taking his medications, how his lack of sleep also feeds into those s/s and allow him to share his feelings about his current situation with his divorce and son's visitation; making him feel cared for and heard.

Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario?

Without medication adherence, the patient most likely will always be in that constant cycle of reentering the hospital and coming out. I also noted the effect external factors play on a patient's mental health and take them into consideration when caring for them and planning care. It is possible that in this scenario, Brenden also did not want to comply with medications due to his current lack of visitation rights, and only having his mother as support system; therefore it is important to holistically treat a patient in order to best provide for them and their needs

2. How can I use what has been learned from this scenario to improve patient care in the future?

From this scenario I learn how to modify care and implement safety when treating a patient who is bipolar and is having an episode that just continues to escalate.

© 2016 Keith Rischer/www.KeithRN.com...