Question

Case study #5: Bipolar disorder

S: Janet, is a 25-year old, brought to the Psych ED yesterday by the Crisis Team who responded to a “deranged and violent” person destroying property at a local bar. She has been admitted to the psychiatric unit with a diagnosis of Bipolar I Disorder, Manic Episode. She was started on Olanzapine, 15 mg. She remains somewhat irritable and expressing delusions of grandeur – saying, her “home that she shares with her husband is a mansion, soon her husband will be taking her to vacation on the island that they own.

B: Janet was engaged for a year when her boyfriend abruptly announced that he did not want to get married and took a job in Japan. That was three months ago. Her roommate reports that Janet was hysterical at first, then depressed, and finally was accepting the situation and moving on. She changed her hairstyle and bought new clothes. She then began going out several nights a week for what she called “action.” She also started exercising excessively and was sleeping very little, as reported by her roommate.

A: Vital signs are stable, Janet is afebrile. She weighs 109 lbs, and looks very thin for her 5’7’’ height. She slept only 1- hour last night, refused breakfast and was seen doing jumping jacks in her room.

R: A care plan needs to be developed for Janet. Medication teaching, and psychotherapy will probably begin today if Janet is determined to be stable.

#1 nursing diagnosis of “Risk for Injury”

a. Identify the contributing evidence for this diagnosis.

b. Determine a goal or expected outcome for Janet

c. List 3 – 5 appropriate nursing interventions that the you, the nurse will do, to help Janet reach her goal or expected outcome.

d. Create a med card for Lithium and one other “mood stabilizer” medication.

Be prepared to share med cards with clinical instructor and participate in discussion.

#2 Nursing diagnosis: Risk for self- or other - directed violence

a. Identify the contributing evidence for this diagnosis.

b. Determine a goal or expected outcome for Janet

c. List 3 – 5 appropriate nursing interventions that the you, the nurse will do, to help Janet reach her goal or expected outcome.

#3 Nursing diagnosis: Imbalanced nutrition: less than body requirements

a. Identify the contributing evidence for this diagnosis.

b. Determine a goal or expected outcome for Janet

c. List 3 – 5 appropriate nursing interventions that the you, the nurse will do, to help Janet reach her goal or expected outcome.

Answer 1

Janet had broken relationship her boy her boy friend. Then she started to show characteristics of abnormal behavior such as less sleep, more exercise, buying new cloths and going outing at nigh time. She was brought to emergency department after she showed violent behavior and destroying property in a local bar.

Nursing care plan:

1. Risk for injury related to extreme hyperactivity as evidenced by the jumping jacks in her room

a. Contributing evidence : she is doing jumping racks in her room as a result of manic expressions

b. Goal is patient will stop doing hyperactivity behavior with the help of medication and nursing procedures

. Nursing intervention

· Asses the patient conditions of the patient and her motor behavior in order to make a plan of care

· Provide a safe environment for her in order to reduce injury

· Ensure the environment that are free from external stimuli such as bright light, loud noise can enhance brain activity

· Ensure the floor that should not be slipperybecause it cause injury by falling while doing jumping

· Administer sedative medication to control her behavior

d. Mood stabilizer medication lithium and valproic acid

sno	Medication	Dose	action	Side effects	Contraindications	Nurses responsibility
1.	Lithium	300mg 3-4 times /day	it change cation in nerve and muscle	Gastrointestinal symptoms: Nausea, loss of appetite, diarrhea, abdominal pain CNS: headache, tremors, fatigue, loss of memory Cardiovascular : changes in ECG Genito urinary: increased urination ENDO: hypothyroidism	Hypersensitivity, dehydrated patients, cardiovascular and renal problems	Monitor sodium levels because it cause lithium toxicity Monitor intake and output daily. Because it causes toxicity in case of dehydartion Monitor for signs and symptoms of lithium toxicity Monitor ECG in case of irregular pulse
2	Valproic acids	250mg	It rises level of gamma amino butyric acid in the CNS	Nausea, vomiting, indigestion, rashes, paresthesia, drowsiness, sedation, headache, visual disturbances	Hypersensitivity, liver impairment	Administer medication after foods Avoid administer medication after consuming milk in order to avoid early absorption Monitor for dizziness and any side effects

c

2. Risk for self or other related to hyperactivity, restlessness   as evidenced by showing violent behavior and damaging property at local bar

a. Contributing evidence is showing deranged and violent behavior and damaging behavior

b. Goal: patient will show the normal behavior with the help of medication and nursing care

c. Interventions

· Assess the client for aggressive behavior

· Avoid arguments with the patients. argument increase violent behavior

· Maintain safe environment for the patient to avoid injury to the patient

· Maintain a calm talking with the patient after winning confidence from patient.

· Educate to show her feelings in a written form, that helps to ventilate her feelings

· Provide her a punching bag to show her feeling that helps to remove her emotional feelings

· Provide her separate room. Because she endangers other patient in her room

· Ensure the environment is free from stimuli and remove any harmful substances and things from her room. Because she sometimes causes injury herself because of bipolar disorder

3. Imbalanced balanced nutrition less than body requirement

a. Contributing evidence: she refused to eat. Her Body mass index is 17

b. Goal is her body mass index is improved

c. Intervention

· Assess the nutritional status of the patient to plan a care

· Provide her food in a safe and environment free environment. Because stimuli can distract her mind

· Provide her simple and frequent feeds   to helps in digestion

· Explain in a clear and calm manner in order to build the relationship with the patient

· Explain importance of foods and its benefits on her that helps to motivate to consume foods

· Motivate her by telling about this diet cannot decrease her beauty and can maintain health beauty skin

· Monitor   her weight in order to monitor her weight improvement

Nursing diagnosis	evidence	goal	Nursing intervention and rationale
Risk for injury related to extreme hyperactivity as evidenced by the jumping jacks in her room	she is doing jumping racks in her room as a result of manic expressions	patient will stop doing hyperactivity behavior with the help of medication and nursing procedures	.Asses the patient conditions of the patient and her motor behavior in order to make a plan of care Provide a safe environment for her in order to reduce injury Ensure the environment that are free from external stimuli such as bright light, loud noise can enhance brain activity Ensure the floor that should not be slippery Administer sedative medication to control her behavior
Risk for self or other related to hyperactivity, restlessness   as evidenced by showing violent behavior and damaging property at local bar	showing deranged and violent behavior and damaging behavior	patient will show the normal behavior with the help of medication and nursing care	Assess the client for aggressive behavior Avoid arguments with the patients. argument increase violent behavior Maintain safe environment for the patient to avoid injury to the patient Maintain a calm talking with the patient after winning confidence from patient. Educate to show her feelings in a written form, that helps to ventilate her feelings Provide her a punching bag to show her feeling that helps to remove her emotional feelings Provide her separate room. Because she endangers other patient in her room Ensure the environment is free from stimuli and remove any harmful substances and things from her room. Because she sometimes causes injury herself because of bipolar disorder
Imbalanced balanced nutrition less than body requirement related to psychological impairment as evidenced by she refused to eat. Her Body mass index is 17	she refused to eat. Her Body mass index is 17	her body mass index is improved she begins to consume food	Assess the nutritional status of the patient to plan a care Provide her food in a safe and environment free environment. Because stimuli can distract her mind Provide her simple and frequent feeds   to helps in digestion Explain in a clear and calm manner in order to build the relationship with the patient Explain importance of foods and its benefits on her that helps to motivate to consume foods Motivate her by telling about this diet cannot decrease her beauty and can maintain health beauty skin Monitor   her weight in order to monitor her weight improvement