Capstone Mental

Health:
Bipolar I Disorder
Darren Marzan
N360

65 y.o. Female
Reason for Admission: Bizarre behavior, acutely manic
I dont have any illness. God tells me to choose, either him or the medicine, and I choose him!
Income: Retired, Husband
Legal Status: MH4 -> 90 days court order. Expiration Date: N/A
DSM Diagnosis:
I

Bipolar type 1 (dx 1990)

II

Deferred

III

Hypertension, Hyperlipidemia

IV

Family conflict

42

Patients Symptoms compared to DSM

A Manic episode
B 1 Grandiosity / inflated-self esteem
2 Decreased need for sleep
3 Pressured speech
4 Flight of ideas, extremely circumstantial flow of thought
5 Distractibility
6 Increase in goal-directed activity
7 Excessive involvement in pleasurable activities that have potential for
painful consequences

Ethnicity/religious/spiritual concerns
God guides the patients values, beliefs, and decisions

Patients Strengths & Limitations:

Patients Strengths: Cooperative, engaging and eager to talk

Patients Limitations: Acts impulsively and erratically, talks to self, hyperreligious

Medications
Order: Divalproex ER (Depakote ER) 500mg PO QHS
Drug class: Mood Stabilizer Pts target sx: Acute mania, prevent return of mania
Order: Lithium citrate (8 mEq/5mL = 300mg lithium) syrup 5mL PO BID
Drug class: Mood Stabilizer Pts target sx: Acute mania, prevent return of mania
Order: Amlodipine tab 5 mg PO BID
Drug class: Calcium channel blocker Pts target sx: Hypertension
Order: Atorvastatin tab 20 mg PO QHS
Drug class: Statin Pts target sx: Hyperlipidemia
Order: Haloperidol Inj 5mg IM Q4H PRN / Haloperidol tab 5mg PO Q4H PRN
Drug class: Typical Antipsychotic
Order: Lorazepam tab 1 mg PO Q2H PRN / Lorazepam syrg 2 mg IM Q4H PRN
Drug class: Anxiolytic

Medical issues, labs

1. Hypertension - Dietary Approach to Stop Hypertension diet, daily exercise, stress management techniques.
2. Hyperlipidemia - same as above, follow a low-carb / low-fat diet to reduce saturated & trans fat intake.

Mental status assessment

Behavior: Hyperactive and erratic as evidenced by: impulsive with outbursts, silly, apathetic, cooperative.
Affect: Labile
Sensorium: Oriented to person, place, time, and situation
Imagery: None
Cognition: Inability to concentrate on specific topic, normal recent/remote memory, average fund of knowledge.
Interpersonal relationships: Poor relationship with husband, He only visited me for 10 minutes! He doesnt care about
me. Daughters live on the mainland and they Do not call me. Cousins live in Hawaii.
Developmental level: Eriksons Psychosocial Stages Middle Adulthood (40-65yr) Generativity vs Stagnation

Standardized Assessment Tools

Goldbergs Mania Scale - 59 (Severely Manic)
Coppersmith Self-Esteem Assessment Tool

Hospital Treatment & Discharge Plan

Problems Identified In Hospitals Master Treatment Plan:
1.

Non-medication compliance

2.

Disruptive behavior

3.

Family concern

Current Discharge Plan: Patient will adhere to scheduled medication orders and be discharged back to home.

Prioritized Patient Care Needs

1. P: Non-medication compliance
E: Pt refuses to take ordered medications
S: Patient education on medications, promote medication compliance.
2. P: Safety - fall precautions
E: Pt has a history of two falls since admission
S: Patient education on preventing falls, ask for assistance from PAs and nurses
3.
P: Sleep dysregulation
E: Pt gets <4 hr of sleep a day, hyperinsomnia
S: Patient education on sleep hygiene
4.
P: Sedentary Lifestyle / Obesity
E: BMI of 41 kg/m^2
S: Promote diet and exercise

#1 Medication Noncompliance
P: Medication noncompliance r/t religious beliefs
E: Pt refuses to take ordered medication
S: Patient education on medications, promote medication compliance.
LT goal: Patient will adhere to 100% of medications by discharge.
ST goal: Patient will adhere to at least 50% of medications by end of shift.
Interventions

Provide patient education on medications, the patient will verbalize understanding by stating benefits and risks to adhering regiment.
Assess the patients religious beliefs or practices that affect health and disease management.
Include the patient in planning the treatment regiment.
If negative side effects of prescribed treatment are a problem, explain that many side effects can be controlled or eliminated.

Gulanick, M. (2014). Nursing Care Plans: Diagnoses, Interventions, and Outcomes (8th ed.). Philadelphia, PA: Elsivier Mosby
Steinkuller, A., & Rheineck, J. (2009). A Review of Evidence-Based Therapeutic Interventions for Bipolar Disorder. Journal of
Mental Health Counseling, 31(4), 338-350.