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

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

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.

NURS 6630 Case Study An Asian American Woman with Bipolar Disorder

NURS 6630 Case Study An Asian American Woman with Bipolar Disorder

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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.

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.

 

 

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

Name:  Discussion Rubric

  Excellent

90–100

Good

80–89

Fair

70–79

Poor

0–69

Main Posting:

Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

40 (40%) – 44 (44%)

Thoroughly responds to the Discussion question(s).

Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

No less than 75% of post has exceptional depth and breadth.

Supported by at least three current credible sources.

35 (35%) – 39 (39%)

Responds to most of the Discussion question(s).

Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module.

50% of the post has exceptional depth and breadth.

Supported by at least three credible references.

31 (31%) – 34 (34%)

Responds to some of the Discussion question(s).

One to two criteria are not addressed or are superficially addressed.

Is somewhat lacking reflection and critical analysis and synthesis.

Somewhat represents knowledge gained from the course readings for the module.

Cited with fewer than two credible references.

0 (0%) – 30 (30%)

Does not respond to the Discussion question(s).

Lacks depth or superficially addresses criteria.

Lacks reflection and critical analysis and synthesis.

Does not represent knowledge gained from the course readings for the module.

Contains only one or no credible references.

Main Posting:

Writing

6 (6%) – 6 (6%)

Written clearly and concisely.

Contains no grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

5 (5%) – 5 (5%)

Written concisely.

May contain one to two grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

4 (4%) – 4 (4%)

Written somewhat concisely.

May contain more than two spelling or grammatical errors.

Contains some APA formatting errors.

0 (0%) – 3 (3%)

Not written clearly or concisely.

Contains more than two spelling or grammatical errors.

Does not adhere to current APA manual writing rules and style.

Main Posting:

Timely and full participation

9 (9%) – 10 (10%)

Meets requirements for timely, full, and active participation.

Posts main Discussion by due date.

8 (8%) – 8 (8%)

Meets requirements for full participation.

Posts main Discussion by due date.

7 (7%) – 7 (7%)

Posts main Discussion by due date.

0 (0%) – 6 (6%)

Does not meet requirements for full participation.

Does not post main Discussion by due date.

First Response:

Post to colleague’s main post that is reflective and justified with credible sources.

9 (9%) – 9 (9%)

Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

8 (8%) – 8 (8%)

Response has some depth and may exhibit critical thinking or application to practice setting.

7 (7%) – 7 (7%)

Response is on topic and may have some depth.

0 (0%) – 6 (6%)

Response may not be on topic and lacks depth.

First Response:

Writing

6 (6%) – 6 (6%)

Communication is professional and respectful to colleagues.

Response to faculty questions are fully answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

5 (5%) – 5 (5%)

Communication is mostly professional and respectful to colleagues.

Response to faculty questions are mostly answered, if posed.

Provides opinions and ideas that are supported by few credible sources.

Response is written in standard, edited English.

4 (4%) – 4 (4%)

Response posed in the Discussion may lack effective professional communication.

Response to faculty questions are somewhat answered, if posed.

Few or no credible sources are cited.

0 (0%) – 3 (3%)

Responses posted in the Discussion lack effective communication.

Response to faculty questions are missing.

No credible sources are cited.

First Response:

Timely and full participation

5 (5%) – 5 (5%)

Meets requirements for timely, full, and active participation.

Posts by due date.

4 (4%) – 4 (4%)

Meets requirements for full participation.

Posts by due date.

3 (3%) – 3 (3%)

Posts by due date.

0 (0%) – 2 (2%)

Does not meet requirements for full participation.

Does not post by due date.

Second Response:
Post to colleague’s main post that is reflective and justified with credible sources.
9 (9%) – 9 (9%)

Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

8 (8%) – 8 (8%)

Response has some depth and may exhibit critical thinking or application to practice setting.

7 (7%) – 7 (7%)

Response is on topic and may have some depth.

0 (0%) – 6 (6%)

Response may not be on topic and lacks depth.

Second Response:
Writing
6 (6%) – 6 (6%)

Communication is professional and respectful to colleagues.

Response to faculty questions are fully answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

5 (5%) – 5 (5%)

Communication is mostly professional and respectful to colleagues.

Response to faculty questions are mostly answered, if posed.

Provides opinions and ideas that are supported by few credible sources.

Response is written in standard, edited English.

4 (4%) – 4 (4%)

Response posed in the Discussion may lack effective professional communication.

Response to faculty questions are somewhat answered, if posed.

Few or no credible sources are cited.

0 (0%) – 3 (3%)

Responses posted in the Discussion lack effective communication.

Response to faculty questions are missing.

No credible sources are cited.

Second Response:
Timely and full participation
5 (5%) – 5 (5%)

Meets requirements for timely, full, and active participation.

Posts by due date.

4 (4%) – 4 (4%)

Meets requirements for full participation.

Posts by due date.

3 (3%) – 3 (3%)

Posts by due date.

0 (0%) – 2 (2%)

Does not meet requirements for full participation.

Does not post by due date.

Total Points: 100

Name:  Discussion Rubric

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