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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: - Reason why patient was admitted on a 501 (involuntary inpatient - Exacerbation of Bipolar Disease admission) - Has been admitted previously - May have some relationship between staff, relapse - Dangerous to self, others, and police - Noncompliant with medication regimen - Pt is at risk to harm himself and others - Pt stopped taking lithium carbonate and divalproex, remission, - -Agitated, rapid speech and relapse - Has not slept for four days - Evidence why he is behaving this way - Pt may not be able to follow directions or have ability to listen - Pt cannot relax of sleep, symptom of mania, can make delusions worse

RELEVANT Data from Social History: -Diagnosed at 19 -Admitted six times in the past due to nonadherence to med regimen - Has a three-year-old son -Is divorced -Lives with mother, who is supportive

Clinical Significance: - Lets medical professionals how long pt has had disorder, how long mother has been supporting son - Previous admissions show relapse in illness - May need to change care plan based on nonadherence to medication regime - Pt has limited access to son, may be related to instability and safety of son - May be related to reasons of depression - Mother may be Pt. 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

Words: Intensity: Location: Duration:

© 2016 Keith Rischer/www.KeithRN.com

Patient denies

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: Pts BP is elevated - May be related to stress and agitation to how Pt is feeling 142/84 -Low grade fever -Temp is slightly elevated - Pulse is elevate, may be related to agitation, anxiety from how Pt is feeling 99.1 F - Respirations are increased as well, can be associated with the mania the patient is -Pulse- 110 experiencing -Resp: 28 -Increased HR may be from exacerbation from illness

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: -Pt is disheveled -Not showered in several days -Has not slept in four days -Impaired ability to concentrate, labile emotions -Pt resp. is raid and deep -Urine is clear and yellow -Denies both use/abuse of ETOH/street drugs

-These findings may be expected with Bipolar disease and depression, clinical significance is important to provide a safe environment for Pt - May need an EKG to see what cardiac function is at -Sign Pt may be hydrated since urine is clear and yellow -Need to do a urine test to see if patient has anything in system also before administering medications in case he does have something in his system for clearance

Mental Status Examination: APPEARANCE:

MOTOR BEHAVIOR:

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. Psychomotor agitation present, appears restless; he is unable to sit still

© 2016 Keith Rischer/www.KeithRN.com

SPEECH: MOOD/AFFECT: THOUGHT PROCESS: THOUGHT CONTENT:

Talking fast with pressured speech. Appears ecstatic, bright affect Delusional, flight of ideas/ jumping from one idea to another 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: -Pt is disheveled, has not showered in several days -Inappropriate clothing attire, wearing multiple layers in 95-degree weather -Pt is agitated and restless, unable to sit still -Rapid speech, ecstatic, bright mood affect -Delusional, believes CIA is controlling the nurse’s actions, must get to the CIA headquarters immediately -Lacks insight and reason for hospitalization -Conversations is not lasting when engaged

-Judgement is impaired, may be reason for low grade fever -He is a vulnerable adult that is unable to care for himself properly -Pt is unable to sit still jumps form one idea to another which distractibility is a hallmark symptom of mania -Pt mood doesn’t match; he has no reason to be ecstatic, nurse needs to set limits and must have back towards door and close for exit, because Pt may have sudden change in mood, leading to Pt acting out and becoming dangerous -He may not believe you’re a nurse, lack of insight current condition, -Grandiose delusions -Findings are significant because Pt is demonstrating a relapse and exacerbation of his disease Bipolar 1, can result in Pt not taking care of personal hygiene, eating properly, moods can be elevated, hyperverbal, etc. -Certain medications or techniques can be administered to provide safety to himself and to staff, and to minimize stimulation for Pt

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 Mood-stabilizer Lithium can help decrease 1. Lithium 600 mg PO BID incidences of mood swings, decrease episodes of mania, 2. Depakote and help treat episodes of Anticonvulsant 750 mg PO daily hyperactivity (Skidmore-Roth, 2018, p. 757) Depakote will decrease incidence of manic episodes if lithium isn’t effective in reducing symptoms of Bipolar © 2016 Keith Rischer/www.KeithRN.com

(Skidmore-Roth, 2018, p. 1254)

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: All labs are within normal limits

Pts labs doesn’t indicate infection or abnormal values Hgb levels are important to monitor to see levels of lithium if Pt is below or if values are above therapeutic levels since it has narrow therapeutic window

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)

Current: 142 4.0 102 1.0

High/Low/WNL?

WNL WNL WNL WNL

RELEVANT Lab(s):

Clinical Significance:

-Sodium

-Lithium can decrease reabsorption in the kidneys and can lead to sodium deficiency -Low sodium can lead to an increase in lithium levels in the blood, can lead to lithium toxicity -Continue to monitor K, and electrolytes for signs and symptoms of electrolyte disturbances, monitor K if causing cardiac issues -Important to see kidney function, renal clearance -Check thyroid levels to see if thyroid levels are WNR, lithium may cause hypothyroidism

-Potassium -Creatinine -Thyroid

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

Current: 0.2 mEq/L

High/Low/WNL? LOW

RELEVANT Lab(s):

Clinical Significance:

Lithium: 0.2 mEq/L

-Lithium levels are below therapeutic levels from medication nonadherence, can lead to exacerbation of disorder and mood swings for Pt -Continue to monitor Pt and levels that reach therapeutic levels, and monitor for signs and symptoms of toxicity -Low levels may indicate administering lithium could take a week or two till blood levels are in therapeutic range

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

Normal Value: 0.8-1.2 mEq/L

Clinical Significance: Low levels indicate

© 2016 Keith Rischer/www.KeithRN.com

Nursing Assessments/Interventions Required: -Administer lithium prescribed so pt can reach maintenance

that lithium is not at therapeutic levels which can cause Pt to have exacerbation of mania episodes

Lithium: 0.2

levels -Monitor serum lithium levels, thyroid, kidney and renal function, WBC, and electrolytes, monitor for lithium toxicity, assess MSE, monitor I’s and O’s and weight for Pt

Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Bipolar depression 2. What is the underlying cause/pathophysiology of this concern? No definitive cause, etiology isn’t quite understood. There is a

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

Rationale: - Pt will be in proper unit to monitor him, so he is safe from himself and others. Milieu can be when patient is in proper unit

Urine drug screen

Urine drug screen to make sure Pt isn’t on other substances that could interact with medications and to check function of kidneys, also to check electrolyte status

Expected Outcome: -Pt will not harm himself or others, pt will be in environment he can sleep, and have adequate fluids and food -

Pt will drink fluids and help if Pt is dehydrated, Pt will clear anything that shouldn’t be in system

Lithium 600 mg PO BID -Lithium will reduce symptoms of mania

Depakote 375 mg PO BID

-

Will help decrease manic episodes, combination if lithium isn’t effective

-Pt will have decrease mood swings and abnormal behavior from Bipolar -Pt will have a decrease in manic episode

To help with sleep, mild antidepressant effect

Trazodone 100 mg PO PRN sleep

-

Lorazepam 1 mg PO BID

-To help calm him and ease any anxiety

-

Pt hasn’t slept in four days and help some of that sleep deprivation psychosis, pt will obtain adequate sleep and have improved symptoms, sense of wellbeing

-

Pt will be able to calm down, and reduce thoughts contributing to anxiety

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Urine drug screen

Order of Priority: First priority- Admit to unit and engage patient in milieu

© 2016 Keith Rischer/www.KeithRN.com

Rationale: -First priority is to have patient in unit and so he is in a place that he is safe from hurting himself and others, and so he can sleep

Lithium 600 mg PO TID Depakote 375 mg PO BID

Second priority- Urine drug screen

Trazodone 400 mg PO PRN sleep

Third priority- Lithium 600 mg PO TID

Lorazepam 1 mg PO BID

Fourth priorityDepakote 375 mg PO BID

Admit to unit and engage patient in milieu

- Second priority I would do is urine screen test to see if he has other things in his system that could interact with drugs prescribed to him -Third priority is to administer Lithium so he can get on tract to have therapeutic levels in his bloodstream, the medication he was taking for his disorder

Fifth priority- Trazodone 400 mg PO PRN sleep

-Fourth priority would administer Depakote, medication he was previously taking that he stopped to have drug in his system to increase therapeutic levels

Sixth priority Lorazepam 1 mg PO BID

-Fifth priority is to administer Trazodone to help Pt fall asleep. He hasn’t slept in four days and lack of sleep can increase delusional thoughts and paranoia -Sixth priority is to give Pt lorazepam to help with his anxiety if he is still extremely agitated. This medication will help him relax, and can also help him fall asleep if his anxiety is keeping him up from paranoia

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 -Therapeutic relationship -Medication non-adherence -Disturbed sleeping pattern -Self-care deficit -Disturbed thought process -Alteration in nutrition -knowledge deficit -Coping skills 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: -Risk for injury Provide a safe environment for Pt by removing all possible hazards in the environment such as pen, razors, room clutter, matches, and anything the Pt may use to injure himself or others. Also, place Pt in a room next to the nurse’s station so Pt can be monitored closely by staff

-Therapeutic relationship Establish and enhance feelings of trust © 2016 Keith Rischer/www.KeithRN.com

when clients' safety culture is improved, there is a decrease in client adverse events. EBN: “A client-centered environment of care is not just the care provided at the client's side. It is seen throughout the facility” (Ackley, 2016, p. 536)

Pt will remain free of injuries to himself, staff, and other’s Pts for shift. Pt will demonstrate behaviors that decrease his risk for injuries throughout shift

Assess Pts current level of comfort as acceptable for

between Pt and nurse, as well as other healthcare staff to maintain an effective and therapeutic relationship between Pt

Trust between Pt and nurse relationship is an essential element in nurse-Pt care that happens through caring attitudes, availability, respect, empathy, sensitivity to Pt needs, competence, and for establishing good communication (Ackley, 2016, p. 223)

-Medication non-adherence Assess Pt with failing self-care for noncompliance with medication regimen, and administer medications prescribed to Pt

-Disturbed sleeping pattern Combine multiple interventions to create a sleep-promotion care plan such as keeping the environment quiet during sleep periods, masking hospital noises, dimming lights for Pt sleep periods, and administering prescribed medication for sleep -Promote rest periods, decrease environmental stimulation

-Self-care deficit Monitor Pt with acute/chronic mental illness for defining characteristics for selfneglect -Remind Pt of personal hygiene such as showering, oral hygiene Refer Pt with failing with self-care to © 2016 Keith Rischer/www.KeithRN.com

Individuals who exhibit self-neglect may demonstrate noncompliance with other therapeutic regimes (Ackley, 2016, p. 781)

Efforts to limit noise and bright lighting along with efforts to consolidate care could successfully be combined into a care bundle effective for limiting sleep fragmentation (Ackley, 2016, p. 818).

Psychiatric conditions underlie most cases of self-neglect, as demonstrated in studies of impaired older adults (Ackley, 2016, p. 781) Individuals with self-care deficits may need assistance from other health professionals

him and express the need to achieve a therapeutic relationship, identify strategies to enhance Pts level of comfort. Perform and modify appropriate interventions as needed for increasing therapeutic relationship and comfort for shift. Evaluate effectiveness of interventions for intervals and adjust if necessary. Maintain an enhanced level of comfort when possible for Pt throughout shift Pt will demonstrate improvement in mental health problems and demonstrate improved function of basic and instrumental ADLs throughout shift. Pt will demonstrate adherence to medication provided to get him back on track to adherence and medical appointments throughout shift

Pt will easily fall asleep without difficulty during shift and remain asleep through sleep period (4-6 hours minimum), while waking up naturally with feeling refreshed and less fatigued

-Pt will perform self-care activities throughout shift. Pt will take a shower or bathe during shift. Pt will perform oral hygiene during shift. -Pt will meet with therapist during shift for evaluation, therapy, or future appointment

appropriate specialists such as psychologist, psychiatrist, social worker

-Disturbed thought process Obtain accurate history and preform MSE medical history, cognition as evidence by level of consciousness, level of attention, behavior characteristics and level of psychomotor behavior, mood and affect, insight and judgement, memory, language, altered sleep wake cycle - Assess the client's behavior and cognition systematically and continually throughout the day and night -Administer antipsychotic medication or sedative prescribed as ordered, while monitoring medication s...