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Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C
Introduction to the Case Study
Bipolar disorder is one of the most prevalent mental health conditions worldwide. Bipolar disorder is defined by bouts of neuropsychological deficits, mood disorders, physiological alterations, immunological inadequacies, and impairments in daily functioning. Bipolar disorder has long been regarded as a primary cause of impairment on a global scale. Additionally, the disease contributes to premature mortality as a result of medical complications and suicide (Rowland & Marwaha, 2018). Genetics has been widely assumed to be a major factor in the development of bipolar disorder. Genetics has a role in the increased risk of developing bipolar illness in those born into families with a history of the disorder. Additionally, environmental factors have been implicated in the development of bipolar disorder.
For example, infectious agents such as Epstein-Barr virus and varicella zoster virus have been demonstrated to enhance the risk of bipolar disorder during the perinatal period. Additional risk factors for the development of bipolar illness include childhood maltreatment, psychological stressors, substance addiction, and medical comorbidities (Ferrari et al., 2016). As such, this paper will analyze the treatment decisions that should be made for a client who has bipolar illness. The client is a 26-year-old Korean woman with a bipolar I disease diagnosis. The client stated that she was in a terrific mood and despised sleep. The client was found to carry the CYP2D6*10 allele. She stopped taking lithium two weeks after being prescribed it. The client’s mental status evaluation revealed that he was alert, dressed strangely, spoke rapidly, and was in a euthymic mood. Additionally, the customer received a rating of 22 on the Young Mania Rating Scale. These results contribute to the patient’s diagnosis of bipolar I illness.
The first decision that I will adopt for treating this patient is the use of Risperdal 1 mg orally BID. The fact that Risperdal is an effective antipsychotic agent used in the treatment of bipolar disorders informed the decision to prescribe the patient this drug, orally BID.
Risperdal has been shown to exert its effect in bipolar disorders by balancing the levels of dopamine and serotonin. The balancing of these hormones result in good conduct as well as moods (Wu et al., 2016). The patient in the case study exhibited symptoms of bipolar confusion such as disorderly dressed, fantastic mood, hating sleep, and disbelief in having bipolar disorder. As a result, the use of Risperdal is an effective treatment that will restore the mood and behavior of the client (Chan et al., 2016).
The other two treatment options for the client were not selected due to a number of reasons. Firstly, lithium was not selected because the client has poor history of adherence to lithium. Accordingly, the client was prescribed lithium two weeks ago, which she stopped taking. It therefore implies that the risk of non-adherence is high if the patient is prescribed lithium (Severus et al., 2018). The decision not to prescribe the patient Seroquel was because of the adverse and side effects associated with this drug. Studies have shown that the use of Seroquel as the first line of drug in bipolar disorder increases the risk of weight gain in patients (Joas et al., 2017). Consequently, Risperdal is an effective alternative from the given medications. Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C
One of the expected outcomes with the above decision is the reduction in the symptoms of bipolar disorder that the client is experiencing. The client should be able to engage in her activities of the daily living with minimal difficulties. The patient should also be able to make informed decisions about her behavior and minimize engagement in self-destructive practices.
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Expectations vs. Outcomes
The client came to the clinic after four weeks accompanied by her mother. The client looked very lethargic and sedated. The client’s mother reported that the client has been experiencing the symptoms for the last three weeks. The symptoms were expected because of the presence of CYP2D6*10 allele, which lowers the clearance of Risperdal from the system. As a result, the medication remains long in circulation, leading to the symptoms that the client presented with to the clinic. An effective decision would therefore involve lowering the dosage of Risperdal to increase serum clearance and levels of circulating Risperdal (Wu et al., 2016). Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C
The selected decision in this step is decreasing the dosage of Risperdal to 1 mg at HS. As noted in the above analysis, the patient came back after four weeks with evidence of increased side effects of Risperdal. The use of Risperdal was however effective in managing the symptoms of bipolar I disorder as evidenced by symptom improvement in the first week followed by the increased effect of the side effects of the medication. The best decision would therefore be lowering the dosage of Risperdal to reduce the side effects of the drug on the patient. Reducing the dosage would also increase the rate of drug clearance in the system, leading to lowered or eliminated incidence of side effects with the treatment (Chan et al., 2016). The other options of treatment were not adopted because of some reasons. Firstly, the patient has poor adherence to lithium. The poor adherence makes it not the best option for treating the client. Changing Risperdal to 2 mg at HS would increase the risk of side effects of the medications, hence, not an appropriate decision at this time.
One of the expected outcomes with the treatment is the reduction in the side effects of Risperdal in the patient. It is expected that the client will report less incidences of lethargy and sedation. The other expected outcome is the improved social and occupational functioning. The patient should also report a reduction in self-destructive behaviors with the current treatment.
Outcomes vs. Expectations
The client came to the clinic after four weeks. The client was less sedated, less lethargic with evidence of symptom improvement. The score of the client was 16 from 22, which translated into more than 25% decrease in symptoms. Therefore, the expectations were moderately achieved with the reduction of the dosage of Risperdal for managing the bipolar disorder. Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C
The decision to be adopted at this point is continuing with the same dose of Risperdal and reassess the client in four weeks. The client has demonstrated significant improvement in symptoms. The reduction in the dosage of Risperdal led to improvements that included reduced rate of sedation and lethargy and improvement in symptoms. The reduction of the dosage of Risperdal also led to significant decline in the score of the Young Mania Rating Scale from 22 to 16. Therefore, there is no indication for the need to change the current dosage of medication.
The other options were not selected for the client because of a number of reasons. The decision to increase Risperdal back to 1 mg orally BID was not selected because of the increased risk of side effects of Risperdal such as sedation and lethargy. The adoption of this option would imply that the symptoms of the client would not improve. The decision to change the medication to Latuda 40 mg orally daily was not selected because there is moderate achievement of the set treatment outcomes (Wu et al., 2016). Changing the treatment plan to a new drug would also increase the risk of adverse events in the management process. Consequently, sustaining the current dosage and treatment plan is the most effective decision for management.
The expected outcomes with the adoption of the above decision is that the patient will reported a further improvement in her symptoms. The patient will also reported a further reduction in sedation and lethargy. Therefore, the treatment outcomes would have been achieved.
Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C Conclusion
In conclusion, the treatment of bipolar I disorder should take into consideration the ethical issues affecting the practice of psychiatric mental health nurse practitioner. PMHNP should ensure that the treatments selected for patients with bipolar I disorder are safe. The selected options should have optimum benefits and minimal side effects or harm to the patients. The patients should also be informed about the treatment options for them to make an informed decision on the methods that should be used to manage their health problems. Patients should also be assured of the integrity of their information through the promotion of privacy and confidentiality of their data. Therefore, the consideration of these ethical aspects promote the provision of high quality mental health care to patients suffering from bipolar disorders.
Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C References
Chan, H.-W., Huang, C.-Y., Feng, W.-J., & Yen, Y.-C. (2016). Clinical outcomes of long-acting injectable risperidone in patients with bipolar I disorder: A 1-year retrospective cohort study. Journal of Affective Disorders, 205, 360–364. https://doi.org/10.1016/j.jad.2016.08.023
Ferrari, A. J., Stockings, E., Khoo, J.-P., Erskine, H. E., Degenhardt, L., Vos, T., & Whiteford, H. A. (2016). The prevalence and burden of bipolar disorder: Findings from the Global Burden of Disease Study 2013. Bipolar Disorders, 18(5), 440–450. https://doi.org/10.1111/bdi.12423
Joas, E., Karanti, A., Song, J., Goodwin, G. M., Lichtenstein, P., & Landén, M. (2017). Pharmacological treatment and risk of psychiatric hospital admission in bipolar disorder. The British Journal of Psychiatry, 210(3), 197–202. https://doi.org/10.1192/bjp.bp.116.187989
Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235
Severus, E., Bauer, M., & Geddes, J. (2018). Efficacy and effectiveness of lithium in the long-term treatment of bipolar disorders: An Update 2018. Pharmacopsychiatry, 51(5), 173–176. https://doi.org/10.1055/a-0627-7489
Wu, C.-S., Hsieh, M. H., Tang, C.-H., & Chang, C.-J. (2016). Comparative effectiveness of long-acting injectable risperidone vs. Long-acting injectable first-generation antipsychotics in bipolar disorder. Journal of Affective Disorders, 197, 189–195. https://doi.org/10.1016/j.jad.2016.03.043
A Sample Answer For the Assignment: Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C
Title: Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C
In the provided case study, the 8-year-old Caucasian female patient came to the clinic accompanied by her parents for psychiatric evaluation. The patient’s teacher suggested that the patient might be having attention deficit hyperactivity disorder (ADHD). Their family physician also suggested that the patient should see a psychiatrist for further evaluation of her mental disorder. The patient parents came with a completed Conner’s Teacher Rating Scale-Revised screening tool, which revealed that the patient is easily distracted at school, and with a short attention span. The patient also displayed poor arithmetic, spelling, and reading skills in addition to being inattentive and forgetful most of the time. Her teacher claims that the patient even failing to complete her homework will lack interest in school activities. She also fails to follow instructions at times. Despite the patient’s parents being in denial that their daughter has ADHD, mental status examination results proved otherwise together with the Conner’s Teacher Rating Scale-Revised screening tool completed by the teacher, supporting the diagnosis of attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.
Developing a treatment plan for pediatric patients with mental disorders is quite challenging given the safety issues associated with this age group. However, appropriate prescriptive practice will involve considering patient-specific factors that might affect the pharmacokinetic and pharmacodynamic processes. Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. The purpose of this discussion is thus to demonstrate the appropriate decision-making process in the selection of the most appropriate intervention in the treatment of the 8-year-old attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.
Decision Point One
Selected Decision and Rationale
From the listed options, initiating Ritalin (methylphenidate) 10mg chewable tablets taken every morning was decided on as the initial intervention. Ritalin is recommended by most clinical guidelines as the first-line medication for the management of ADHD among both children and adults (Rodrigues et al., 2021). Despite the psychostimulant not being approved by the FDA, it has displayed great effectiveness in the management of ADHD with a desirable safety profile in most children from ages 6 to 15 years (American Psychiatric Association, 2013; Castells et al., 2021)). It has demonstrated a substantial impact in managing ADHD symptoms such as inattention, forgetfulness, impulsivity, diminished interest, and hyperactivity among children (Hodgkins et al., 2012). The chewable formulation is considered the best option for children with sweeteners to mask the bitter taste of the drug (Breaux et al., 2022). Consequently, the drug has a short onset of action of between 1 to 2 hours with a long duration of action of between 7.5 to 10.5 hours after oral administration (Mechler et al., 2021). This helps in the management of the patient’s symptoms all day long (Coghill et al., 2021).
Bupropion is associated with increased risks of seizures among children below the age of 10 years, hence not an appropriate decision (Coghill et al., 2021). Intuniv on the other hand is associated with cardiovascular side effects, hence should only be considered in case there is no other safer and more effective drug for use in the pediatric population (Rodrigues et al., 2021).
The patient will experience improved symptoms of ADHD in the next four weeks (Coghill et al., 2021). She should be able to improve her spelling, arithmetic, and language skills, in addition to being more attentive and able to concentrate on school work (Hodgkins et al., 2012). Her school performance will improve significantly within this period.
The patient is 8 years of age, which gives the parents legal responsibility of making decisions concerning the health of their child (American Psychiatric Association, 2013). As such, the PMHNP must educate them adequately regarding the patient’s diagnosis and potential treatment options, to promote sound decision-making in promoting the health of their child (Rodrigues et al., 2021).
Decision Point Two
Selected Decision and Rationale
The second decision was to change the treatment regimen to long-acting Ritalin 20mg administered orally in the morning. Based on the treatment outcome, Ritalin displayed potential effectiveness given that the patient’s ADHD symptoms improved evidenced by her improved school performance (Breaux et al., 2022). However, since the medication was not able to manage the patient’s symptoms throughout the entire day, it was necessary to introduce a long-acting formulation to prolong the duration of action of the drug (American Psychiatric Association, 2013). Studies show that long-acting Ritalin lasts for between 8 to 12 hours hence, helps in managing the patient’s symptoms throughout the day (Castells et al., 2021). It is also administered once daily which is more convenient and much easier. The patient also reported a side effect of elevated pulse, which is a common self-limiting side effect of Ritalin that is expected to diminish with time (Coghill et al., 2021).
Continuing with the same drug at the same dosage was inappropriate as the patient would still exhibit ADHD symptoms later in the day, once the drug wears off from the body system (Mechler et al., 2021). Replacing Ritalin with Adderall is also inappropriate as Adderall is associated with increased incidences of suicidal events when used among children (Hodgkins et al., 2012).
The long-acting formulation is expected to manage the patient’s symptoms all day long within the following four weeks (Breaux et al., 2022). The patient’s school performance will improve even further. The side effect of elevated heart rate will resolve completely within this time (Coghill et al., 2021).
In making this decision, the PMHNP had to consider several ethical principles including justice, beneficence, nonmaleficence, and respect for the patient’s autonomy (Breaux et al., 2022). The patient was quite comfortable with how the drug was working, but only concerned with the side effect, and effectiveness of the medication later in the day (Rodrigues et al., 2021). As such, it was necessary to respect the patient and display clinical judgment in making decisions that will promote the patient’s mental health.
Decision Point Three
Selected Decision and Rationale
Maintaining the patient on the current medication and reevaluating after four weeks, seemed to be the most appropriate decision for the third intervention. The patient reported great effectiveness and tolerance to the medication, with resolved side effects of an elevated pulse (Mechler et al., 2021). Previous evidence shows that once the optimal dose of Ritalin has been attained, it can take between 8 to 12 weeks to completely manage the patient’s symptoms of ADHD (American Psychiatric Association, 2013; Castells et al., 2021). Consequently, at safe doses, long-term use of the drug has been associated with limited possibilities of side effects, hence the need to reevaluate the patient within 4 weeks (Hodgkins et al., 2012). Studies also show that long-term use of Ritalin normally reduces the risks of side effects as the patient will display further tolerance to the drug, enhancing its safety profile (Breaux et al., 2022).
Increasing the dose of Ritalin to 30mg was not necessary at this point, as studies suggest that low effective doses are safer to use to promote positive outcomes, with reduced risks of side effects (Mechler et al., 2021). Consequently, obtaining EKG at this point was not necessary given that the patient’s pulse had already resolved back to normal for her age, with a recording of 92 during the current visit (Rodrigues et al., 2021).
With great compliance to the treatment regimen, the patient will report even further management of the ADHD symptoms over the following two weeks (Breaux et al., 2022). Her academic performance is also expected to improve (American Psychiatric Association, 2013). No side effects are expected.
The nurse’s main objective is to promote the health of the patient and not harm. At this point, the patient was satisfied with the treatment outcome (Hodgkins et al., 2012). It was thus necessary to respect the patient’s autonomy and maintain the dose for further evaluation of the treatment outcome (Mechler et al., 2021).
Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C Conclusion
The 8-year-old patient in the case study presented with symptoms of ADHD. Formulating a treatment plan for the patient involved consideration of certain patient-specific factors which affect her pharmacokinetic and pharmacodynamic processes (American Psychiatric Association, 2013). Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. Based on these factors, the first decision was to initiate a 10mg Ritalin chewable table once daily as recommended by most clinical guidelines given its effectiveness in the management of ADHD and safety for pediatric use (Coghill et al., 2021). Intuniv and bupropion were neglected because of their increased risks of side effects among children as reported by most studies (Mechler et al., 2021). After 4 weeks, the patient came back to the clinic reporting improved symptoms but with side effects of increased pulse rate. The second decision was thus to change the treatment regimen to long-acting Ritalin 20mg once daily in the morning, to prolong the duration of action of the medication throughout the day (Castells et al., 2021). Maintaining the dose would still lead to ineffectiveness, while Adderall display increased risks of suicidality hence neglected (Breaux et al., 2022).
The patient reported further improvement in ADHD symptoms all day long, with resolved side effects of elevated pulse, which led to the final decision of maintaining the treatment regimen and reevaluating the patient after 4 weeks. Obtaining EKG and increasing the dose of Ritalin was not necessarily due to safety issues (Hodgkins et al., 2012). Finally, the PMHNP encountered several ethical considerations in each decision process with the observation of ethical principles such as justice, respect for patient autonomy, not harm, and beneficence (Rodrigues et al., 2021).
Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630C References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Breaux, R., Dunn, N. C., Swanson, C. S., Larkin, E., Waxmonsky, J., & Baweja, M. D. (2022). A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD. Frontiers in Psychiatry, 151. https://doi.org/10.3389/fpsyt.2022.794044
Castells, X., Ramon, M., Cunill, R., Olivé, C., & Serrano, D. (2021). Relationship between treatment duration and efficacy of pharmacological treatment for ADHD: a meta-analysis and meta-regression of 87 randomized controlled clinical trials. Journal of attention disorders, 25(10), 1352-1361. https://doi.org/10.1177/1087054720903372
Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., … & Simonoff, E. (2021). The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). European Child & Adolescent Psychiatry, 1-25. https://doi.org/10.1007/s00787-021-01871-x
Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. https://doi.org/10.2165/11599630-000000000-00000
Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2021). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940
Rodrigues, R., Lai, M. C., Beswick, A., Gorman, D. A., Anagnostou, E., Szatmari, P., … & Ameis, S. H. (2021). Practitioner Review: Pharmacological treatment of attention‐deficit/hyperactivity disorder symptoms in children and youth with autism spectrum disorder: a systematic review and meta‐analysis. Journal of Child Psychology and Psychiatry, 62(6), 680-700. https://doi.org/10.1111/jcpp.13305