Bipolar Case Study PDF

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Case Study 143 Bipolar Disorder Difficulty: Beginning Setting: Outpatient clinic Index Words: bipolar disorder, mania, hypomania, depression, lithium, drug levels, patient education Giddens Concepts: Care Coordination, Mood and affect, Patient education HESI Concepts: assessment, Care Coordination, Mood & affect, Patient education

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Scenario

You are the registered nurse case manager in an outpatient mental health clinic. S.T. is here today for her outpatient mental health appointment. she has a diagnosis of bipolar disorder and has been stable for the past year. Her last episode was one of mania that required hospitalization. she is 29 years old, married, with two children aged 2 and 4. she reports that her mood is better than it has been in a long time and she has lots of energy. When asked whether she thinks this is a recurrence of mania, she says no, she thinks that things are just finally getting better.

1. It is common for patients with bipolar illness to deny the onset of

mania because it feels good. What other information would be important to ask S.T.? How many hours is she sleeping at night? Are her thoughts racing? What kinds of activities is she involved in? Have other people made any comments about her behavior?

2. What other information would help determine whether S.T. is

experiencing the onset of a manic or hypomanic episode? Obtain collaborating information from S.T.'s husband. Be cautious about violating the Health Insurance Portability and Accountability Act (HIPAA); you can obtain information from the husband only if he is present during the interview or if you receive the patient's permission to talk to her husband regarding her care. Check your facility policy, state laws, health advocacy laws, power of attorney laws, and durable power of attorney laws. Assess body language, eye movements, and nonverbal communication. Have her keep a 24-hour food diary.

3. Bipolar disorder is a disorder of mood, characterized by episodes of

depression, mania, or hypomania. What symptoms might you see if S.T. is experiencing mania or hypomania? Flight of ideas or reported racing thoughts Distractibility Increase in goal-directed activity Agitation, excessive moodiness, or irritability Decreased need for sleep 4. How is hypomania different from mania?

Hypomania is a less severe form of mania. It actually may feel pretty good because your mood is up and you have more energy than usual, but it's not out of control. For someone with bipolar disorder, hypomania can evolve into mania. Or it can switch to serious depression.

CASE STUDY PROGRESS Lithium (Eskalith) is commonly used to treat bipolar disorder. S.T. has been taking lithium for several years.

5. When S.T. first started taking lithium, she would have been cautioned to

report side effects. Which are common side effects of lithium? Select all that apply. a. Thirst b. Nausea c. Constipation d. Tremor e. Dizziness

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6. Lithium toxicity can occur in patients taking lithium. What are the

symptoms of early lithium toxicity? Select all that apply. a. Vomiting b. Insomnia c. Dyspnea d. Diarrhea e. Lethargy 7. S.T.'s maintenance lithium level results are reported as 1.0 mEq/L. Interpret these

results.

Maintenance blood levels for lithium should range from 0.4 to 1.3 mEq/L. Her level is within normal limits. 8. What other laboratory examinations should be routinely performed

while S.T. is taking lithium? Thyroid function tests—Hypothyroidism is a risk of long-term lithium therapy. Creatinine and blood urea nitrogen (BUN)—Impairment of renal function is a risk of long-term lithium therapy. Sodium levels—Dehydration can contribute to lithium toxicity. 9. What instructions should have been given to S.T. when she began lithium therapy?

Maintain adequate hydration at all times, but especially when perspiring heavily or losing fluids as a result of vomiting or diarrhea. Know the symptoms of toxicity. Hold the next dose of lithium and notify your physician immediately if symptoms of toxicity occur.

10. Aside from lithium, what other medications are used to treat bipolar disorder?

Certain antiseizure medications are often used to treat bipolar disorder. These include valproate (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal). Both valproate and carbamazepine require blood level monitoring. Valproate requires monitoring of liver function and platelet levels. Carbamazepine requires routine monitoring of the complete blood count, platelets, and liver function study results. Two of the atypical antipsychotics, risperidone (Risperdal) and olanzapine (Zyprexa), have been used to treat bipolar disorder.

teaching about drug therapy with S.T. Which statement by S.T. reveals a need for further education? a. "I will call my doctor if I have severe vomiting or diarrhea." b. "I need to be careful because lithium is addictive." c. "I take the lithium tablets with meals." d. I will keep my appointments to have my drug levels checked."

12. Given her history of bipolar disorder, what should you teach S.T. to minimize mood

swings? • Avoid stressful situations. • Maintain a regular schedule for sleep and exercise.

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11. Even though she has been taking lithium for a year, you review some

• Eat a healthy diet. • Avoid intake of caffeine, alcohol, drugs of abuse, and over-the-counter drugs; these might cause a relapse, even in small amounts. • Take medications consistently, the same time every day. • Keep the appointments for group or individual psychotherapy support sessions.

CASE STUDY OUTCOMES S.T. is told that her lithium level is within normal limits, and states, "I feel better than I've felt in ages!" she expresses hope that this will last a long time....