Assessing and Treating Clients with With Bipolar Disorder
Assessing and Treating Clients with With Bipolar Disorder
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
Begin Lithium 300 mg oDrally BID
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client informs the PMHNP 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
The PMHNP 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, the PMHNP 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.’ The PMHNP needs 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.
Assignment
Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1
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Which decision did you select?
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Why did you select this decision? Support your response with evidence and references to the Learning Resources.
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What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
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Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
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Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
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Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
NOTE
1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).
2. look at the “assignment” section of the assignment in the classroom.
3. Answer those questions based on your decisions in the decision tree.
4. Write a paper addressing all section listed based on the decision tree
