Sample Answer for NURS 6630 Bipolar Therapy Client of Korean Descent or Ancestry Included After Question
BACKGROUND INFORMATION
The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.
Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”
She weights 110 lbs. and is 5’ 5”
SUBJECTIVE
Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”
You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.
Genetic testing reveals that she is positive for CYP2D6*10 allele.
Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.
MENTAL STATUS EXAM
The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.
The Young Mania Rating Scale (YMRS) score is 22
RESOURCES
- Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6
Decision Point One
Select what you should do:
Begin Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 100 mg orally at HS
Decision Point One
Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client informs you that she has been taking her drug “off and on” only when she “feels like she needs it”
- Today’s presentation is similar to the first day you met her
Decision Point Two
Select what you should do next:
Increase Lithium to 450 mg orally BID
Switch to Depakote ER 500 mg orally at HS
Decision Point One
Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client informs you that she has been taking her drug “off and on” only when she “feels like she needs it”
- Today’s presentation is similar to the first day you met her
Decision Point Two
Increase Lithium to 450 mg orally BID
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client returns reports that she is still taking the medication when she feels that she needs it
- She remains quite manic and reports that her family is getting really upset because she likes to play her new guitar at night
Decision Point Three
Select what you should do next:
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NURS 6630 Bipolar Therapy Client of Korean Descent or Ancestry
Assess for rationale for non-compliance and educate client
Change to abilify 10 mg orally at HS
Decision Point One
Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client informs you that she has been taking her drug “off and on” only when she “feels like she needs it”
- Today’s presentation is similar to the first day you met her
Decision Point Two
Increase Lithium to 450 mg orally BID
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client returns reports that she is still taking the medication when she feels that she needs it
- She remains quite manic and reports that her family is getting really upset because she likes to play her new guitar at night
Decision Point Three
Assess for rationale for non-compliance and educate client
Guidance to Student
You should further assess for dangerousness to self or others. The client should be assessed for self-care, to including hygiene, eating, sleeping, etc. Hospitalization may be indicated if the client remains non-compliant and is a danger to self. If the client is not a danger to self, and hospitalization is not indicated, you needs to assess for rationale for non-compliance. Many clients enjoy mania as it is a nice feeling to be consistently happy. When clients are successfully treated for mania, they often describe themselves as feeling ‘down’ or ‘flat.’ You need to assess for depression at this point as opposed to normalization of mood. Abilify is also FDA approved as monotherapy for mania and mixed presentations, but at a dose of 15 mg. day., so although you may be tempted to begin Abilify- be certain to use correct dose. Also, because it can be “activating” you need to dose this drug in the morning. However, the client is non-compliant and therefore, eliciting reasons for non-compliance is essential to the care of this client.
Decision Point One
Begin Risperdal 1 mg orally BID
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic
- Client’s mother explains that “she has been like this since about a week after the last office visit”
Decision Point Two
Discontinue Risperdal and start Lithium sustained release 300 mg orally BID
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client no longer lethargic after the end of the first week
- Client has a slight decrease in her Young Mania Rating Scale (from 22 to 19)
- Client reports that her sleep is again decreasing, but that overall, she is happy
Decision Point Three
Increase Lithium SR to 450 mg orally BID
Guidance to Student
Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may be demonstrating slower clearance of Risperdal from her system, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The client responded well to the discontinuation of Risperdal and after about a week of drug cessation, she was no longer lethargic/sedate. However, in the following 3 weeks, she had experienced increased symptoms, although a slight improvement in YMSR score was noted. You could make no changes at this time and allow the lithium to remain at its current dose for an additional 4 weeks and reassess. Conversely, you can increase the lithium to 450 mg orally BID and then reassess in 4. The additional milligrams may hasten mood stabilization. Risperdal 0.5 mg orally BID may be appropriate if the clients’ symptoms are worsening, however, you would need to have the client return to the office sooner than 4 weeks for an interim visit to assess effects of drug and presence of somnolence/lethargy.
Decision Point One
Begin Seroquel XR 100 mg orally at HS
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client is reporting that she sleeps a bit more at bedtime
- Client states that she has gained about 2 or 3 pounds, which she does not like
- Client also reports that she has been constipated since starting this medication
- Client is also complaining of dry mouth which she does not like.
- Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18
- Client is reporting really good mood, but is asking for a different medication because of the weight gain
Decision Point Two
Increase Seroquel XR to 300 mg orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client reports that her constipation is worse and that she has now gained a total of 7 pounds since starting this drug
- Client feels that you are not listening to her concerns and is very upset
- Client’s Young Mania Rating Scale has decreased from 18 to 14
Decision Point Three
Increase Seroquel XR to 400 mg orally daily
Guidance to Student
The client is becoming frustrated and feels that you do not hear her concerns about weight gain and constipation, which can be causing a rupture in the therapeutic relationship. In addition, after 8 weeks, the client still has significant manic symptoms despite the fact that they have decreased, they are still present.
You could discontinue the Seroquel XR and begin Geodon. This may be an appropriate choice as Geodon is cleared by approximately one third through the CYP-3A4,1A2 alleles and the remaining two-thirds of the drug are cleared through aldehyde oxidase, which means that it should not cause the same adverse effects as Seroquel. Although this drug is metabolized through 2D6, you need to remember that this is a minor pathway for metabolism and 3A4 is the major pathway through which this drug is metabolized. Geodon must be administered with a 500 calorie meal in order to assure adequate absorption.
In this case, the Seroquel is causing side effects through the muscarinic 1 receptors. You should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.
Decreasing Seroquel as suggested in the third choice may result in a decrease in side effects, but addition of Depakote can also result in weight gain- which is one of the side effects that the client has found objectionable.
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A Sample Answer For the Assignment: NURS 6630 Bipolar Therapy Client of Korean Descent or Ancestry
Title: NURS 6630 Bipolar Therapy Client of Korean Descent or Ancestry
Bipolar disorder is one of the most common mental illnesses characterized by drastic shifts in the patient’s mood, activity, and energy levels, affecting their ability to conduct daily tasks (Marzani, & Neff, 2021). Such drastic changes in the patient’s energy levels and mood are more severe, unlike the normal ups and downs experienced by most people. The National Institute of Mental Health (NIH) reported that approximately 2.8% of adults in the United States were diagnosed with bipolar disorder last year (Citrome, 2020). Bipolar disorders are associated with severe morbidity and mortality rates. However, through evidence-based practice, several treatment options have been proposed with proven effectiveness in the management of patients with bipolar disorder. In this discussion, the choices of medication used to manage a young Asian adult diagnosed with bipolar type 1 have been discussed in addition to the reasons behind the choice of psychotropic agent and the expected outcome and legal and ethical considerations encountered by the PMHNP. The choices of medications used are based on both pharmacodynamic and pharmacokinetic factors.
The case study provided described a 26 years old Asian woman who presented to the clinic with a primary diagnosis of bipolar type 1. The patient was previously hospitalized for 21 days as a result of the onset of acute mania. The patient is in good health with a stable mood at the moment but claims to hate sleeping. She is however underweight with a BMI of 18.3. Genetic testing reveals that the patient is positive for the CYP2D6*10 allele. She has been taking lithium to manage her mental condition during the hospitalization period, which she stopped talking when she was discharged. Mental examination results reveal that the patient is oddly groomed, but displays perfect orientation in person, time, and place. She is however rapid and pressured. Upon administration of the Young Mania Rating Scale (YMRS), the patient revealed a score of 22, which indicated mild mania. She however denies suicidal ideation and auditory or visual hallucination.
Decision #1
Begin Seroquel XR 100 mg orally at HS
Reason Behind Decision 1:
Seroquel (Quetiapine) is recommended by most study guidelines for the management of bipolar disorder as monotherapy. The mood-stabilizing effects of Seroquel are associated with its antagonistic effect at the 5-HT2A and D2 receptors (Citrome, 2020). Studies have revealed great effectiveness of the drug and long-term adherence among patients on extended-release (XR) quetiapine which is administered once daily. The drug also exhibits a desirable safety profile with mild side effects which can be managed non-pharmacologically such as changes in weight. The drug is metabolized in the liver by cytochrome P450 (CYP) 3A4, which is low among patients with CYP2D6*10 allele such as Asians. This promotes slow metabolism, hence prolonged duration of action.
The use of lithium is not appropriate given that the patient stopped taking the drug immediately, which is discouraged as a result of increased risks of relapse and non-compliance. Lithium is also associated with undesirable side effects such as weight gain and GI disturbances especially when administered in higher doses like 300mg (Lin et al., 2020).
Risperdal is also not a good alternative for the patient as monotherapy. The drug displays great effectiveness when administered in combination with lithium (Marzani, & Neff, 2021). Consequently, the recommended starting dose with Risperdal is 2 to 3mg once daily, which makes the 1mg dose undesirable.
Expected Outcome
Within the next 4 weeks, the patient is expected to exhibit at least 50% remission of manic symptoms (Citrome, 2020). Her compliance level is also expected to improve, with good sleeping patterns. Her agitation is also expected to reduce. Upon administration of the Young Mania Rating Scale (YMRS), the patient should record a score of less than 12.
Ethical Considerations Impact on Treatment Plan
According to the legal and ethical guidelines, the PMHNP must take into account the patient’s race and ethnicity in formulating the most effective treatment plan (Lin et al., 2020). Consequently, given that the patient is an adult, the nurse needs to involve the patient in making decisions concerning the medication choice to promote satisfaction.
Decision 2:
Discontinue using Seroquel and Start 40mg Geodon 40 mg orally BID.
Reason Behind Decision 2:
The initial intervention revealed minimal effectiveness in controlling the patient’s manic episodes. Consequently, undesired side effects were exhibited by the patient such as constipation, weight gain, and dry mouth which made the patient uncomfortable with the drug. As such it is necessary to discontinue the drug and initiate Geodon which is FDA approved for the management of manic episodes among patients diagnosed with bipolar 1 disorder (Marzani, & Neff, 2021). The drug exhibits a desirable safety profile, unlike Seroquel. Consequently, studies show that Geodon has great bioavailability, and hence must be administered with a 500 calorie intake. The patient also disliked the weight gain side effect associated with the initial drug which will not be the case with Geodon.
Increasing the dose of Seroquel is not appropriate as this will only worsen the side effects already exhibited by the patient (Rhee et al., 2020). The patient also suggested the drug changes, and ignoring her request would only promote non-compliance and affects their therapeutic relationship with the nurse.
Continuing the same dose of the medication is also against the patient’s will as this will lead to a further increase in the patient’s body weight (Lin et al., 2020). Consequently, the drug displayed minimal effectiveness which is below the desired therapeutic threshold in the management of bipolar.
Expected Outcome
The patient is expected to display at least 50% remission of symptoms within the next four weeks. Her sleeping pattern and agitation levels are expected to improve significantly (Rhee et al., 2020). Consequently, the initial side effects such as dry mouth, constipation, and weight gain are expected to resolve once Seroquel has been discontinued.
Ethical Considerations Impact on Treatment Plan
The legal and ethical requirements give the patient the right of making decisions concerning her health (Marzani, & Neff, 2021). As such, the PMHNP must respect the patient’s decision and make appropriate interventions as desired by the patient to promote satisfaction which intern builds on a positive therapeutic relationship with the patient.
Decision 3:
Continue the same dose and reassess in 4 weeks.
Reason Behind Decision 1:
The patient displayed great tolerance and adherence to the previous intervention with 50% remission of symptoms. Consequently, the undesired side effects were resolved within this time, promoting patient compliance. Studies show that despite the goal of attaining 100% remission of symptoms with psychotropic agents, a 50% management of symptoms is still desirable. Consequently, Geodon takes up to 8 to 12 weeks to completely managed maniac symptoms among patients with bipolar disorder (Mazza et al., 2020). As such, it is necessary to continue the same dose to promote further management of the patient’s symptoms, with no side effects. The treatment outcome must however be evaluated after four weeks, given that the treatment regimen was changed just after the first intervention failed.
Increasing the dose of Geodon is not necessary given the great tolerance and effectiveness displayed by the patient (Mazza et al., 2020). Consequently, studies show that increased plasma concentrations of the drug are associated with severe side effects such as weight gain which resulted in to change of regimen in the first place.
Augmenting Geodon with lithium is desirable, but at low doses to avoid side effects (Mazza et al., 2020). Consequently, this intervention could only be considered among patients who are not lithium defaulters as this will only compromise the patient’s compliance levels.
Expected Outcome
The patient is expected to display complete remission of symptoms within the next four weeks. She should be able to sleep well, with significantly reduced agitation levels (Rhee et al., 2020). Her scores upon administration of the Young Mania Rating Scale should also display a reading of less than 8.
Ethical Considerations Impact on Treatment Plan
According to the nursing code of ethics, it is the obligation of the PMHNP to promote the patient’s health and prevent harm. Consequently, holistic care requires the nurse to promote patient-centered care to attain positive treatment outcomes (Rhee et al., 2020). As such, listening to the patient and involving them in making decisions concerning which intervention is appropriate for their health is necessary.
Conclusion
Bipolar disorder is one of the most common mental illnesses across the world with increased morbidity and mortality rates. However, with early detection, studies show that patients can greatly benefit from the available treatment options with improved quality of life. Clinicians must also consider pharmacodynamic and pharmacokinetic factors when deciding on which medication to use for a given patient (Citrome, 2020). In the provided case study, the first intervention was to initiate the patient on Seroquel which is FDA approved for the management of bipolar among adults. However, the drug displayed undesired side effects such as weight gain, which made the patient uncomfortable with taking the medication (Lin et al., 2020). Consequently, the drug displayed minimal effectiveness, which led to changing the treatment regimen is the second decision. Geodon, is also FDA approved for the management of manic episodes among bipolar patients, hence considered as the best replacement for Seroquel (Mazza et al., 2020). The patient displayed great adherence and tolerance to this medication with 50% remission of symptoms. Consequently, the initial side effects were resolved.
As a result, it was necessary to maintain the dose of this medication for the third intervention to avoid additional side effects and promote further remission of the patient’s symptoms. several legal and ethical considerations were encountered with the PMHNP in the management of this patient (Marzani, & Neff, 2021). For instance, the patient being an adult gives her the right of making decisions concerning her health. As such, the nurse needed to change the patient’s regimen when she was not comfortable with the weight to gain side effects as a result of Seroquel (Rhee et al., 2020). General, the nurse has the obligation of promoting the patient health and preventing harm.
References
Citrome, L. (2020). Food and Drug Administration–Approved Treatments for Acute Bipolar Depression: What We Have and What We Need. Journal of Clinical Psychopharmacology, 40(4), 334-338. DOI: 10.1097/JCP.0000000000001227
Lin, Y., Mojtabai, R., Goes, F. S., & Zandi, P. P. (2020). Trends in prescriptions of lithium and other medications for patients with bipolar disorder in office-based practices in the United States: 1996–2015. Journal of Affective Disorders, 276, 883-889. https://doi.org/10.1016/j.jad.2020.07.063
Marzani, G., & Neff, A. P. (2021). Bipolar Disorders: Evaluation and Treatment. American Family Physician, 103(4), 227-239. PMID: 33587568.
Mazza, M., Marano, G., Giuseppin, G., & Janiri, L. (2020). Ziprasidone in treating bipolar child and adolescent patients: More research is warranted. Bipolar disorders, 22(3), 311-312. https://doi.org/10.1111/bdi.12911
Rhee, T. G., Olfson, M., Nierenberg, A. A., & Wilkinson, S. T. (2020). 20-year trends in the pharmacologic treatment of bipolar disorder by psychiatrists in outpatient care settings. American Journal of Psychiatry, 177(8), 706-715. https://doi.org/10.1176/appi.ajp.2020.19091000