NURS 6630 Case Study: An Asian American Woman with Bipolar Disorder

Sample Answer for NURS 6630 Case Study: An Asian American Woman with Bipolar Disorder Included After Question

NURS 6630 Case Study An Asian American Woman with Bipolar Disorder

 

Bipolar disorder is defined in the DSM V as a collection of mental diseases characterized by severe fluctuations in an individual’s mood, energy, and functioning. Bipolar disorder is characterized by periods of severe, protracted, and profound depression followed by periods of mania marked by an abnormally elevated or irritable mood (APA, 2013). A manic episode is a marked departure from normal behavior. At least three of the following symptoms are present: inflated self-esteem or grandiosity, increased talkativeness, decreased need for sleep, racing thoughts, easy distraction, increased goal-directed activity, and participating in activities with unfavorable consequences (APA, 2013). The purpose of this article is to examine a client who suffers from bipolar disorder and to explain the client’s treatment plan using a decision tree.

Overview of the Case Study

The case scenario represents a 26-year-old lady of Korean ancestry who is attending her first checkup following a 21-day stay in the hospital for acute mania. The client has been diagnosed with manic depression type I. She currently weighs 110 pounds and stands at a height of 5′ 5. She defines her mood as amazing and notes that she sleeps approximately five hours every night, although she despises sleep because it is unpleasant (Laureate Education, 2016). The client’s medical records indicate that she is in good health overall and that her lab results are within normal ranges. Genetic testing, however, reveals that she carries the CYP2D6*10 allele. The client confirms that she stopped taking Lithium two weeks ago after being released. On MSE, the client is vigilant and aware of his or her surroundings, including person, place, time, and event. Her attire is peculiar, and her discourse is quick, hurried, and tangential. Her mood, as described by herself, is euthymic, and her affect is broad. She denies visual or auditory hallucinations and freely admits to having no overt delusory or paranoid cognitive processes (Laureate Education, 2016). Although she lacks understanding, she rejects suicide or homicidal ideation. On the Young Mania Rating Scale, she receives a score of 22. (YMRS).

Decision Point One

NURS 6630 Case Study An Asian American Woman with Bipolar Disorder
NURS 6630 Case Study An Asian American Woman with Bipolar Disorder

Begin Lithium 300 mg orally BID.

Why I Selected This Decision

Lithium is a mood stabilizer recommended for treating Mania in Bipolar disorder and maintenance therapy of bipolar disorder in persons with a history of mania. I selected Lithium because it targets unstable mood, which is the major symptom of mania (Won & Kim, 2017). Besides, mania is recommended as first-line therapy for long-term prevention of Bipolar disorder, particularly for euphoric mania.

I did not select Seroquel because it has documented side effects of dry mouth, fatigue, constipation, and dizziness, contributing to

decreased medication compliance. Seroquel is also associated with increased appetite and weight and elevated triglycerides and total cholesterol levels (Shah et al., 2017). The side effects make it an inappropriate drug since the client is overweight.  I did not select Risperdal since the patient was positive for the CYP2D6*10 allele. According to Puangpetch et al. (2016), the CYP2D6*10 allele slows the drug’s clearance resulting in high levels of Risperdal in the blood, causing sedation.

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What I Was Hoping To Achieve By Making This Decision

I hoped that prescribing Lithium would stabilize the patient’s mood and reduce the severity of manic symptoms by at least 50% in the first four weeks of treatment. According to Won and Kim (2017), Lithium exerts mood-stabilizing effects by acting on cellular targets and exerting neuroprotective effects.

How Ethical Considerations May Impact the Treatment Plan and Communication with Patients

Ethical principles of nonmaleficence and beneficence may impact the treatment plan as the PMHNP has a duty to prevent harm and promote better patient outcomes. The PMHNP is obliged to assess a drug for its impact and potential side effects before prescribing it to ensure it will promote better outcomes and have no adverse consequences to the patient (Bipeta, 2019). In this case, the PMHNP assessed each drug’s potential side effects and selected the one associated with better outcomes and fewer adverse effects.

Decision Point Two

Assess rationale for non-compliance to elicit reason for non-compliance and educate the client on drug effects and pharmacology.

Why I Selected This Decision

I selected this decision because the client reported taking the medication “off and on” when she feels that she needs it. The decision aimed at understanding the primary cause for the patient not complying with the medication (Won & Kim, 2017). Besides, educating the patient on the possible side effects and pharmacology of Lithium would enlighten her on the drug’s impact in improving her health outcomes.

I did not increase Lithium to 450 mg because the non-compliance behavior would persist if the reasons for the behavior were not identified and addressed. Besides, it is crucial that the PMHNP assess a patient’s response to Lithium and associated side effects before increasing the dose (Won & Kim, 2017).  I did not switch treatment to Depakote because the patient’s response to Lithium had not been established. According to Shah et al. (2017), the evidence for Depakote efficacy in acute depression is not as robust as that for Lithium.

What I Was Hoping To Achieve By Making This Decision

I was hoping that assessing and eliciting reason for non-compliance would help in identifying a practical solution to increasing compliance and eventually improve the manic symptoms. I was hoping that educating the patient on Lithium’s drug effects and pharmacology would enable her to understand the importance of adhering to treatment and increase her medication compliance.

How Ethical Considerations May Impact the Treatment Plan and Communication with Patients

The ethical principle of autonomy, which means that patients have a right to make decisions about their lives without interference from others, may impact the treatment plan. The PMHNP must respect the patient’s decision regarding her care which may impact the treatment interventions (Bipeta, 2019). In this case, the PMHNP had to elicit the rationale for the patient not complying with treatment, which determined the next intervention.

Decision Point Three

Change Lithium to sustained release, preparation at the same dose and frequency.

Why I Selected This Decision

I changed Lithium to sustained release because the formulation is documented to prevent Lithium’s side effects, such as nausea and diarrhea, which were reported. The sustained release formulation suppresses the side effects while at the same time effecting its mood-stabilizing properties (Girardi et al., 2016).  I did not change therapy to Depakote because it is also associated with similar side effects as Lithium (Shah et al., 2017). Besides, the sustained Lithium formulation is a better option than Depakote. I did not select Trileptal because it is only recommended as a second-line agent in treating Bipolar disorder (Shah et al., 2017). It was not ideal at this step because there had been no adequate trials with Lithium.

What I Was Hoping To Achieve By Making This Decision

I hope that the sustained release formulation would alleviate the severity of side effects and that the patient would report fewer side effects. I also hoped that the patient’s treatment compliance would increase, and there would be improved manic symptoms. According to Girardi et al. (2016), Lithium’s sustained formulation has several advantages, including fewer adverse events, consistent serum lithium concentrations, and improved adherence to therapy.

How Ethical Considerations May Impact the Treatment Plan and Communication with Patients

The ethical principle of nonmaleficence may impact the treatment plan since the PMHNP may be forced to change treatment based on associated adverse effects to avoid harming the client (Bipeta, 2019).  In this case, the PMHNP changed Lithium from immediate to sustained formulation to reduce the drug’s side effects and improve the patient’s quality of life.

NURS 6630 Case Study: An Asian American Woman with Bipolar Disorder Conclusion

The client in the case study was diagnosed with Bipolar 1 Disorder, a manic-depressive disorder that can occur both with and without psychotic episodes.  She presented with manic symptoms, including excessive talking, reduced need for sleep, and distractibility. In the first decision step, I began treatment with Lithium 300 mg BD to target the manic symptoms and stabilize the patient’s mood. However, the drug did not have any impact since the patient was not compliant with treatment. I assessed the rationale for non-compliance to elicit the reason for non-compliance and educate the patient on Lithium effects and pharmacology. This aimed at establishing the causes of non-compliance and increasing the compliance to promote better outcomes.

The patient was still not compliant with the medication because of its associated side effects of nausea and diarrhea. I changed the Lithium from immediate to sustained-release preparation but at the same dose and frequency to reduce the side effects and increase compliance. Ethical principles that may impact the treatment plan include beneficence, nonmaleficence, and autonomy. In this case, the PMHNP upheld beneficence by selecting the medication associated with the best possible outcomes for patients with Bipolar disorder. Nonmaleficence was upheld by evaluating the medication’s side effects and changing the Lithium formulation due to the associated side effects. Besides, autonomy was promoted by addressing the patient’s concerns on treatment and identifying solutions to address these concerns.

 

 

NURS 6630 Case Study: An Asian American Woman with Bipolar Disorder References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Girardi, P., Brugnoli, R., Manfredi, G., & Sani, G. (2016). Lithium in Bipolar Disorder: Optimizing Therapy Using Prolonged-Release Formulations. Drugs in R&D16(4), 293–302. https://doi.org/10.1007/s40268-016-0139-7

Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author

Puangpetch, A., Vanwong, N., Nuntamool, N., Hongkaew, Y., Chamnanphon, M., & Sukasem, C. (2016). CYP2D6 polymorphisms and their influence on risperidone treatment. Pharmacogenomics and personalized medicine9, 131–147. https://doi.org/10.2147/PGPM.S107772

Shah, N., Grover, S., & Rao, G. P. (2017). Clinical Practice Guidelines for Management of Bipolar Disorder. Indian journal of psychiatry59(Suppl 1), S51–S66. https://doi.org/10.4103/0019-5545.196974

Won, E., & Kim, Y. K. (2017). An Oldie but Goodie: Lithium in the Treatment of Bipolar Disorder through Neuroprotective and Neurotrophic Mechanisms. International journal of molecular sciences18(12), 2679. https://doi.org/10.3390/ijms18122679

 

A Sample Answer For the Assignment: NURS 6630 Case Study: An Asian American Woman with Bipolar Disorder

Title: NURS 6630 Case Study: An Asian American Woman with Bipolar Disorder

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).

Expected Outcome

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.

Ethical Considerations

            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).

Expected Outcome

            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).

Ethical Considerations

            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).

Expected Outcome

            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.

Ethical Considerations

            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).

NURS 6630 Case Study: An Asian American Woman with Bipolar Disorder 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).

 

 

NURS 6630 Case Study: An Asian American Woman with Bipolar Disorder 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 disorders25(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 Psychiatry62(6), 680-700. https://doi.org/10.1111/jcpp.13305