Assessing and Treating Clients with With Bipolar Disorder
Assessing and Treating Clients with With Bipolar Disorder
Week 5: Bipolar Therapy
Jay, an 18-year-old high school senior, presents with symptoms of difficulty sleeping and feeling sad, which results in an initial diagnosis of depression. His mother later reports, however, that Jay exhibits symptoms of irritability and risk-taking behaviors. (His little brother reported to his mother that they were driving over 90 miles an hour on the highway.) After further evaluation, Jay’s psychiatric mental health nurse practitioner diagnosed him with bipolar disorder. Assessing and Treating Clients with With Bipolar Disorder
Cases like this are not uncommon with bipolar disorder, as initial assessments rarely provides all the information needed. In your role, as a psychiatric mental health nurse practitioner, you must develop strategies for properly assessing and diagnosing these clients because treatments for bipolar disorder are significantly different than treatments for depression or other mood disorders.
This week, as you examine bipolar therapies, you explore the assessment and treatment of clients with bipolar disorder. You also consider ethical and legal implications of these therapies.
Learning Objectives: Assessing and Treating Clients with With Bipolar Disorder
Students will:
- Assess patient factors and history to develop personalized plans of bipolar therapy for patients
- Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring bipolar therapy
- Synthesize knowledge of providing care to patients presenting for bipolar therapy
- Analyze ethical and legal implications related to prescribing bipolar therapy to patients across the life span
Assignment: Assessing and Treating Patients With Bipolar Disorder
Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for patients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) patients often present as depressive or manic but may have both; and 2) many symptoms of bipolar disorder are similar to other disorders. Misdiagnosis is common, making it essential for you to have a deep understanding of the disorder’s pathophysiology. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with bipolar disorder. Assessing and Treating Clients with With Bipolar Disorder
To prepare for this Assignment: Assessing and Treating Clients with With Bipolar Disorder
- Review this week’s Learning Resources, including the Medication Resources indicated for this week.
- Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring bipolar therapy.
The Assignment: 5 pages: Assessing and Treating Clients with With Bipolar Disorder
Examine Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
- Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page): Assessing and Treating Clients with With Bipolar Disorder
- Which decision did you select?
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Assessing and Treating Clients with With Bipolar Disorder
Conclusion (1 page): Assessing and Treating Clients with With Bipolar Disorder
- Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. Assessing and Treating Clients with With Bipolar Disorder
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
By Day 7
Submit your Assignment.
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Grading Criteria: Assessing and Treating Clients with With Bipolar Disorder
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Week 5 Assignment Rubric
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Submit your Week 5 Assignment draft and review the originality report.
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Week 5 Assignment
Client of Korean Descent/Ancestry
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?” Assessing and Treating Clients with With Bipolar Disorder
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. Assessing and Treating Clients with With Bipolar Disorder
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. Assessing and Treating Clients with With Bipolar Disorder
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. Assessing and Treating Clients with With Bipolar Disorder
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
1. Decision Point One
Select what the PMHNP should do:
Begin Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 100 mg orally at HS
SELECTED ANSWER: Begin Risperdal 1 mg orally BID
Decision 2
Bipolar Therapy
Client of Korean Descent/Ancestry
2. Decision Point Two
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic
- Client’s mother explains that “she has been like this since about a week after the last office visit”
Select what the PMHNP should do next: Assessing and Treating Clients with With Bipolar Disorder
Discontinue Risperdal and start Lithium sustained release 300 mg orally BID
Decrease Risperdal to 1 mg at HS
Change Risperdal to 2 mg at HS
Answer selected: Decrease Risperdal to 1 mg at HS
Decision Point THREE
RESULTS OF DECISION POINT TWO: Assessing and Treating Clients with With Bipolar Disorder
- Client returns to clinic in four weeks
- Client is less sedate, less lethargic and shows symptom improvement
- Young Mania Rating Scale has decreased from 22 to 16 (a bit more than a 25% decrease in symptoms)
Decision Point Three
Select what the PMHNP should do next:
Continue at same dose of Risperdal and reassess in 4 weeks
Increase Risperdal back to 1 mg orally BID
Change to Latuda 40 mg orally daily
Selected answer: Continue at same dose of Risperdal and reassess in 4 weeks
Assessing and Treating Clients with With Bipolar Disorder
RESULTS FOR DECISION THREE AND SUMMARY
Guidance to Student
At this point, the PMHNP may be wise to allow the client to remain at the same dose and reassess in 4 weeks. Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may have slower clearance of Risperdal from her system, which may have resulted in higher than normal levels of Risperdal in the blood, which in turn resulted in sedation. Therefore, if we were to increase back to 1 mg orally BID, she may have the same side effects. Latuda is FDA approved for bipolar I depression, which is not the presentation we are attempting to treat. Additionally, it is quite expensive and many insurance companies will not pay for it until other agents have been attempted and failed. Assessing and Treating Clients with With Bipolar Disorder