Case+Study+Unit+III

Case Study Unit III: Please have case study completed by 2/3/10.
A 38 year old, three times divorced female is brought to the ER by police after being found at 2300 hours walking in the middle of the road against traffic. There are no signs of a struggle or evidence of rape. She was evicted from her apartment last week for refusing to pay rent. Her children are in the custody of their father, her first husband. She is admitted to the psych unit on an involuntary status. She is dressed in a long zebra striped coat, purple negligee and dirty high-top sneakers. She has a strong body odor. Her long dyed blond hair is matted to her scalp. Bright red lipstick is smeared crudely on her cheeks and lips and some of her fake orange fingernails are chipped and broken. Her speech is rapid and pressured and very loud. Mood is labile and her affect at this time is very bright. She tells the admitting nurse she is looking for her “movie agent”, thus the reason for walking in the middle of the road at 2300 hours. She denies any need for treatment, denies substance abuse. She states she has lost weight in the recent past because “I’m too busy to bother eating.” Her diagnoses are as follows:

Axis I: Bipolar Disorder, manic phase, recurrent, severe Axis II: None Axis III: Hyperthyroidism Axis IV: Financial problems, homelessness, estrangement from primary support group (family), chronic/severe mental illness, problems with medication adherence Axis V: GAF = 20

Her conversation is difficult to follow d/t not completing her sentences and changing topics rapidly. She refuses to sign the consent form to allow any family members to be contacted.

1. Identify the patient’s symptoms that support the diagnosis of Bipolar, manic. What are other symptoms of bipolar disorder? Her symptoms are not being able to complete her sentences, changing subjects rapidly, being found walking in the middle of the road against traffic. Also she was kicked out of her apartment for refusing to pay. She was wearing a long zebra print coat with a purple negligee and dirty high top sneakers. She has not bathed in a long time and her fake nails are chipped and broken. rapid and pressured speech and she beleives she is looking for her movie agent. She also has bright red smeared lip stick all over her cheeks and lips and her hair is matted to her scalp. Other symptoms of bipolar disorder are high self esteem during mania also a decreased need for sleep, easily distracted, increase in goal motivation. They also tend to have poor judgment and nutitional intake. They also tend to be very loud and hostile. S/S of mania - hyperactivity, impulsive actions, may be profane, manipulative, euphoric mood switching quickly to range or anger if upset.

2. Write three priority nursing diagnoses for this patient. 1.Imbalanced nutrition:less than body requirements related to manic state as evidenced by weight loss and patient states "I'm too busy to bother eating." 2.Disturbed thought process related to mental disorders as evidenced by inaccurate interpretation of environment (looking for her "movie agent" on the street in the middle of the night) 3. Ineffective coping related to her GAF of 20 as evidenced by her homelessness and family estrangement.

3. What will you include in your teaching plan for this patient regarding lithium/Eskalith therapy? Be specific. It is important to take this medication exactly as prescribed and continue to take it even if you are feeling better. If you miss a dose, take it as soon as you remember but not within 2 hours of you next dose (or within 6 hours for SR tabs). This medication may cause drowsiness or dizziness, avoid activities which require you to be fully alert, such as driving, until you are sure of how you are responding to this medication. Low sodium levels can cause this medication to reach toxic levels in the blood. Patient should drink 2-3 L of water per day and maintain a diet with a consistent and moderate amount of sodium. Limit intake of coffee, tea and cola because these can have a diuretic effect. Avoid activities that can cause excessive sodium loss through perspiration (heavy exercise, saunas). Notify your health care provider of fever, vomiting or diarrhea because these can also cause excessive sodium loss. Use contraception methods while on this medication and consult health care provider immediately if pregnancy is suspected. Review expected side effects as well as s/s of toxicity (vomiting, diarrhea, decreased coordination, weakness, muscle twitching) Stop medication and notify health care provider immediately if toxicity is suspected. Emphasize importance of periodic lab tests to monitor for lithium toxicity. Patients with cardiovascular disease or over 40 years of age need ECG before beginning and periodically throughout the course of therapy. Notify your health care provider immediately if fainting, irregular pulse or difficulty breathing occurs. (Judith Hopfer Deglin, 2009)

4. If the psychiatrist adds Depakote/valproic acid to the patient’s treatment regimen, what would you need to monitor and teach the patient? The doctor would need to obtain liver function studies, platelet count, RBC, WBC, and PT INR before starting treatment and these need to be monitored while the patient is on this medication. Also the patient would need to be tought to take the drug with food or milk to reduce GI affects. If they take capsules they can be swollowed whole or open up and sprinkled on a teaspoon of soft food. They should be told not to stop drug abruptly and to avoid any hazardous activity until they know the effects this medication will have on there body. They should not chew capsules because it could irritate there mouth and throat. Also they should be told to call the doctor if they feel weak, lethargic, have any facial sweeling loss of appetite or vomiting.

Pt needs to be informed of the importance of making all follow up dr appointments and lab visits, and discuss if client has a reliable transport (self, friend, family, services). The lab visits are very important, they will test liver function, a full CBC, INR to monitor for hepatotoxicity and pancreatitis. The pt also needs to be told that certain things are important to watch for and report immediately; low fever, dark urine, decreased output, clay colored stools, or jaundice. Stress the importance of abstaining from alcohol as it will add worsen CNS depressionTeach the pt to contact doctor is mood swings or depression get worse. This medication causes birth defects, and regular and effective birth control should be talked about as well.

5. What symptoms does the patient have that meet the criteria for the diagnosis of hyperthyroidism? her recent weight loss Hyperthyroidism can cause a rapid wieght loss, it can also cause a feelings of anxiety or irritability.

6. How does hyperthyroidism affect the patient’s mood? hyperthyroidism increases your metabolic rate and may cause a rapid irregular heartbeat and nervousness. In a manic patient these increases may add to the already manic state. It can also cause difficulty sleeping and anxiety attacks as well as increased irritabilty.

7. What is Lithium toxicity? What signs and symptoms would the patient exhibit? Lithium toxicity is when lithium blood serum levels get too high....the normal serum level for lithium ranges between 0.4 and 1.3 mEq/L. When serum levels are just slightly elevated the patient will exhibit slurred speech, muscle weakness, fine hand tremors, lethargy, thirst, polyuria, diarrhea, vomiting, and nausea. You should withhold the med check the lithium levels in the patient's blood stream and reevaluate the dosage. If serum levels are between 1.5 and 2.0 mEq/L the patient's exhibit coarse hand tremor, persistent gastrointestinal upset, mental confusion, muscle hyperirritability, changes in brain waves, incoordination and sedation. The interventions would be the same as for the earlier signs of toxicity. If serum levels go up to 2.5 mEq/L the patient will exhibit ataxia, confusion, excessive output of dilute urine, serious changes in brain waves, blurred vision, convulsive muscle spasms, seizures, stupor, severe hyptension and coma. If pulmonary complications are present death will occur. If the patient's serum levels exceed 2.5 there will be a reduced excretion of urine, convulsions will occur and finally death. In case of severe lithium toxicity the patient should be hospitalized and the drug stopped immediately. If the patient is conscience they will be given an emetic. To hasten lithium excretion the patient will be given a gastric lavage and given urea, mannitol and aminophylline. In the worst case scenario the patient will undergo hemodialysis. References Cited: Judith Hopfer Deglin, A. H. (2009). //Davis's Drug Guide for Nurses 11th Edition.// Philidelphia: F.A. Davis Company.