Bipolar Depression Unfolding Reasoning 1 PDF

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Bipolar Depression/Mania UNFOLDING Reasoning ANSWER KEY

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

UNFOLDING Case Study: ANSWER KEY

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: Relapses and exacerbation of bipolar episodes can be a progressive Brenden has been admitted for exacerbation pattern of this disorder which leads to remission and relapse. There is a of his bipolar disorder. repeating course of symptoms of mania, depression, hypomanic, or a mixture of depressive and manic features. He has been admitted 6 times due to nonadherence to medication.

There is a revolving door issue when working with clients who have mental illness. Revolving door describes mentally ill patients who are frequently readmitted to psychiatric units. Revolving door syndrome has been linked to hospital stays that are too short, medication nonadherence, and or patients with inadequate psychiatric follow-up.

In the past few weeks he stopped taking his medication, fearing that his mother was poisoning him.

The patient is experiencing a delusion (a fixed false belief) that is not uncommon with the manic phase of bipolar disorder.

Brenden has not slept in the past 4 days due to racing thoughts.

The lack of sleep is a clinical RED FLAG for the manic phase of bipolar disorder.

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.

The patient is experiencing a delusion (a fixed false belief) that is not uncommon with the manic phase of bipolar disorder.

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. RELEVANT Data from Social History: He was recently in court to have his visitations reduced to 1 supervised visit a

Clients who present with pressured speech may be difficult to work with because they can be hard to understand. First, do not get into a power struggle with the patient. Their brain is moving at a very rapid rate and until the patients mania is controlled, it may be difficult to manage this phase of their illness. Be willing to spend time with the patient to build trust. Clinical Significance: Psychosocial stressors in relationships can exacerbate bipolar disorder. In this case, the failure of his marriage and legal issues associated with

© 2016 Keith Rischer/www.KeithRN.com

custody of his child may be precipitating factors in his manic episode.

week

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: Tachycardia is a clinical RED FLAG that represents his physiologic metabolic demands are P:110 increased as a result of his manic episode. R: 28

Tachypnea is a clinical RED FLAG that represents his physiologic metabolic demands are increased as a result of his manic episode. This level of tachypnea can lead to hyperventilation due to rapid talking and breathing very fast. This needs to be assessed by the nurse. When patients hyperventilate, this can lead to respiratory alkalosis. To distinguish tachypnea from hyperventilation, patients who are hyperventilating breathe very deeply or very rapidly over a period of time. Symptoms of hyperventilation include: x x x x x

BP: 142/84

Lightheadedness Dizziness Shortness of breath Heart palpitations Numbness

Though not significantly elevated, knowing that Brenden is in a manic episode and that his HR and RR are elevated, the BP must be closely trended and is relevant in this scenario.

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: Data clearly suggests that he has been unable to care for himself due to his GENERAL APPEARANCE: Is deteriorating mental status. disheveled, and according to his mother © 2016 Keith Rischer/www.KeithRN.com

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

Clustered together this clinical data is consistent with manic behavior

GU: Urine clear/yellow

Because of his high basal metabolism rate due to mania, Brenden is at risk for dehydration. His urine is yellow and not concentrated a darker yellow/amber. This suggests that he is currently hydrated. Despite the obvious mental health priorities, the nurse must continue to provide holistic care and address the physiologic implications of his manic episode.

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: Beliee ha he CIA i cllig he e aci ad fllig him ad ha he m 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: Clustered together, this data clearly suggests that he has been unable to care APPEARANCE: Is disheveled, and for himself due to his deteriorating mental status. Combined with his according to his mother he has not inappropriate clothing, it is obvious that Brenden is a vulnerable adult and a showered in several days. He is danger to himself. 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 © 2016 Keith Rischer/www.KeithRN.com

This data clustered together from his mental status exam confirms his manic state. The patient is actively delusional and paranoid. His speech is rapid and highly pressured. Patient is experiencing a period of mood elevation, irritation behavior with grandiose behavior, decreased need of sleep, talkativeness, flight of ideas, and recklessness. Clinical RED FLAG: Patients who are paranoid and or manic can become unpredictable. They can unintentionally hurt themselves or others. Make sure there are no items in the patient exam room that could cause him to harm himself and/or healthcare providers. Make sure that when you are in

THOUGHT CONTENT: Believes that he CIA i cllig he e aci 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.

the room with the patient that you have your back to the door in case you need to exit rapidly. Due to the patients delusion, he may not believe that he is in a real hospital, and that the nurse is not truly a nurse but a member of the CIA.

What is the RELATIONSHIP of or patients past medical histor (PMH) and crrent meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: 1. Lithium 600 mg PO BID Bipolar depression 1. Lithium salt 1. Reduction in manic symptoms 2. Antiepileptic 2. Stabilize patient mood 2. Depakote 750 mg PO daily

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)

Current: 8.9 12.9 325 70

High/Low/WNL? WNL WNL WNL WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: These labs are ALWAYS RELEVANT; therefore, they must be intentionally noted by the nurse! WBC: 8.9

ALWAYS RELEVANT based on its correlation to the presence of inflammation or infection. Will usually be increased if infection present, though it may be decreased in the elderly or peds...