NURS 6630 Midterm Exam 5

Assessing and Treating Patients with Bipolar Disorder

Introduction

Bipolar disorder is a psychiatric disorder that is typified by symptoms of depression and manic or hypomanic episodes. Bipolar type 1 is characterized by depressive and manic episodes. Symptoms of manic episodes include increased energy levels, aggression, talking excessively, risky behaviors, extreme happiness and euphoria, racing mind, lack of sleep, and lack of focus and concentration when carrying out tasks. The depressive episodes in bipolar disorder are typified by symptoms such as sadness, fatigue, social withdrawal, sleep disturbances, forgetfulness, suicidal ideation, poor concentration, and lack of interest in activities that were once appealing (Baldessarini et al., 2020).  A PMHNP needs to have a good understanding of mental health disorders like bipolar disorder to facilitate proper treatment and management of the disorder. The case study presents a Korean female client aged 28 years old who presented for assessment after 21-days of hospital admission for acute mania. The client’s self-reported mood was “fantastic” and she also reported that she was experiencing insomnia. Her medical records showed that she was in good health, while her lab findings were within the normal range. The client tested positive for the CYP2D6*10 allele. She reported that she had discontinued her lithium treatment. The MSE revealed that the client’s speech was rapid, while her mood revealed broad effect and euthymic mood. The MSE further revealed insight impairment, but her judgment was intact. Her YMRS score was 22, indicating bipolar type 1 disorder. The assignment focuses on the review of the case study in order to come up with the appropriate treatment decisions. Ethical considerations applied when making the decisions will also be analyzed.  NURS 6630 Midterm Exam 5

Decision Point One

The treatment choices for decision point one, were “Lithium 300 mg orally BID; Risperdal 1 mg orally BID and Seroquel XR 100 mg orally at HS.” The selected decision is lithium 300 mg. Lithium was chosen because the client was already taking the medication but discontinued it and also because the medication is an effective mood stabilizer. Lithium is also an FDA approved first-line treatment for bipolar type 1 disorder and mania symptoms such as for this client (Jelen & Young, 2020). The medication’s mechanism of action is by changing how sodium is transported across muscle and nerve cell membranes and also alters how catecholamines and serotonin are metabolized and therefore stabilizes mood and common symptoms of bipolar disorder (Alda, 2015).NURS 6630 Midterm Exam 5

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Risperdal was not selected due to its numerous metabolic side effects and also because the efficacy of lithium has not been tested (Yunusa & El Helou, 2020). Moreover, Seroquel was also not selected since the efficacy of lithium the first-line treatment choice for the client has not been tested due to the client’s discontinuation with the medication.

The decision aimed to ensure that the client would gradually achieve symptom remission.  This is due to lithium’s effectiveness and efficacy in treating and improving manic symptoms in individuals with bipolar (Jelen & Young, 2020). The decision also expected that she would not report any side effects.

Nonetheless, after four weeks the client did not manifest any improvement. The client had also discontinued lithium medication. Therefore, the lack of symptom improvement for the client is attributable to poor adherence to treatment.

Ethical principles relevant to the decision include informed consent. Informed consent should be obtained from patients before starting any treatment (Maldonado-Castellanos, 2020). This should involve educating patients about all the available treatment choices, including their side effects to allow patients to make informed choices.

Decision Point Two

The treatment options for decision point two are increase lithium to 450 mg, assess the reasons for the client not adhering to treatment and educate her about lithium medication, and to change from lithium to Depakote ER 500 mg. the decision that was chosen was to evaluate the reasons why the client was not adhering and educate her about the pharmacology and side effects associated with lithium. The reason for selecting this decision is because non-adherence to treatment is high among bipolar medications like lithium due to side effects associated with these medications (Volkmann et al., 2020). Therefore, it would be important to assess the reasons for her nonadherence. The option of having the lithium dose increased to 450 mg was not considered because the client reported nonadherence to lithium and thus the effectiveness of lithium, which is the client’s first-line treatment choice has not been evaluated. Likewise, Depakote was not considered because it is appropriate to first evaluate the efficacy of the first-line treatment (lithium) before changing her medication (Jelen & Young, 2020).

The treatment goal included identifying why the client was nonadherent in order to have the reasons addressed. Additionally, educating the client about the pharmacology and side effects of lithium can improve the client’s adherence to treatment (Volkmann et al., 2020).

The client reported that she was experiencing nausea and diarrhea after taking lithium and these side effects were causing her not to adhere to the treatment. Evidence shows that nausea and diarrhea are common side effects in individuals taking lithium (Volkmann et al., 2020).

The ethical principle applied when making this decision is the principle of beneficence. Beneficence takes into account and acts according to the patient’s best interests (Ethics Subcommittee of the Council on Ethics et al., 2020). Therefore, it was important to establish what was causing the non-compliance to treatment to address the issue.

Decision Point Three

The treatment choices in decision point three include changing to Depakote, changing to Trileptal, or changing lithium to sustained-release preparation. The appropriate decision is to have the treatment changed to sustained-release preparation. The rationale for this decision is because sustained-release preparations tend to have few side effects and at the same time they are effective mood stabilizers (Girardi et al., 2016). Evidence has demonstrated the efficacy of lithium in improving mania symptoms (Jelen & Young, 2020). Depakote was not chosen since the efficacy of lithium medication has not been assessed for this patient; therefore, the best option is to administer the patient with sustained-release lithium to improve her adherence and examine the efficacy of lithium to improve the patient’s mania symptoms. Trileptal was not chosen since it is a second-line treatment when treating bipolar and hence there is no clinical reason to start a second-line treatment, before testing the efficacy of the first-line treatment.

The treatment goal with this choice is to ensure that the client adheres to treatment and starts responding to the treatment. This will lead to symptom improvement and eventually, the client will attain complete symptom remission. Secondly, it is expected that the client will stop experiencing side effects.NURS 6630 Midterm Exam 5

Informed consent is pertinent in the decision, as the PMHNP needs to educate the client about lithium sustained-release preparation to ensure that she consents to the treatment at the point of knowledge (Maldonado-Castellanos, 2020). The autonomy of the patient was also respected since her judgment is not impaired and therefore her decision-making ability is intact.

Conclusion

Lithium 300 mg was the first treatment choice for this client. This is because the drug is an FDA approved mood stabilizer and a first-line treatment choice when treating people with bipolar type 1 disorder. However, after four weeks the client did not manifest any improvement and she reported that she discontinued the treatment. As a result, the second treatment decision involved investigating the reason why she was not adhering and educate her about the lithium medication, pharmacology, and the associated side effects. The outcome of this decision was that the client reported that nonadherence was due to the medication’s side effects. As a result, the third decision involved changing to lithium to sustained-release preparation. This is because lithium to sustained-release preparation is associated with a few side effects and hence this will improve her adherence and facilitate symptom improvement. The ethical considerations when making the treatment decisions for this client included patient autonomy, informed consent, and beneficence. It is important to obtain informed consent from patients before starting any treatment and the decision-making ability of the clients should be respected. For example, the patient’s judgment is intact and hence her decision-making ability should be respected. For the principle of beneficence, the PMHNP should prioritize the client’s best interests.

References

Alda M. (2015). Lithium in the treatment of bipolar disorder: pharmacology and pharmacogenetics. Molecular psychiatry, 20(6), 661–670. https://doi.org/10.1038/mp.2015.4

Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: a major unsolved challenge. International journal of bipolar disorders, 8(1), 1. https://doi.org/10.1186/s40345-019-0160-1

Ethics Subcommittee of the Council on Ethics, Bylaws, and Judicial Affairs (2020). Ethical practice during the COVID-19 pandemic. Journal of the American Dental Association (1939), 151(5), 377–378. https://doi.org/10.1016/j.adaj.2020.03.038

Girardi, P., Brugnoli, R., Manfredi, G., & Sani, G. (2016). Lithium in bipolar disorder: optimizing therapy using prolonged-release formulations. Drugs in R&D, 16(4), 293-302.NURS 6630 Midterm Exam 5

Jelen, L. A., & Young, A. H. (2020). The Treatment of Bipolar Depression: Current Status and Future Perspectives. Current Behavioral Neuroscience Reports, 7(1), 1-14.

Maldonado-Castellanos I. (2020). Ethical issues when planning mental health services after the COVID-19 outbreak. Asian journal of psychiatry, 54, 102285. https://doi.org/10.1016/j.ajp.2020.102285

Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium Treatment Over the Lifespan in Bipolar Disorders. Frontiers in psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377

Yunusa, I., & El Helou, M. L. (2020). The Use of Risperidone in Behavioral and Psychological Symptoms of Dementia: A Review of Pharmacology, Clinical Evidence, Regulatory Approvals, and Off-Label Use. Frontiers in pharmacology, 11, 596. https://doi.org

Assessing and Treating Clients with Bipolar Disorder

Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients 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 client case study in this week’s Learning Resources, consider how you might assess and treat
clients presenting with bipolar disorder.

Learning Objectives

Students will:

· Assess client factors and history to develop personalized plans of bipolar therapy for clients
· Analyze factors that influence pharmacokinetic and pharmacodynamic processes in
clients requiring bipolar therapy
· Evaluate efficacy of treatment plans
· Analyze ethical and legal implications related to prescribing bipolar therapy to clients
across the lifespan
To prepare for this Assignment:
· Review this week’s Learning Resources. Consider how to assess and treat clients
requiring bipolar therapy.

The Assignment

Examine Case Study: An Asian American Woman With Bipolar Disorder (https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/index.html )

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.

I want you to answer the questions given to you (decision points one, two, and three) before you click on the option. The answers will be based on your decisions Made and patient outcomes during the decision tree. I am looking for an essay that is long enough to cover the topic BUT short enough to keep my interest.  The course
page suggests writing 1 page per decision – my opinion is that it will be very difficult to justify your treatment decisions and provide scientific evidence in 1 page (especially for decision #1). I do not need you to tell me about the patient or the treatment options available to you – I am very familiar with the cases. Your introductory page should be an overview of the disease state you are treating along with a purpose statement for the assignment.  Remember this is a Pharmacology class that incorporates Pharmacotherapy and not a class on diagnosing disease. I want you to tell me why you selected an option (why is it the best option- using clinically relevant and patient specific data) AND why you did not choose the other options (with clinically relevant and patient specific data).
Introduction to the case (1 page)
· Briefly explain and summarize the disease state you are treating this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

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Decision #1
· 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. Again, provide STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place
to start!
· 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. Again, provide
STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place to start!
· 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. Again, provide STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place to start!
· 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.NURS 6630 Midterm Exam 5
Conclusion (1 page)
· 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.

After writing up your rationale at each decision point, I would ask yourself the following questions:
· Have I provided clinical data from a meta-analysis, case report or clinical trial to support the drug I picked being safe, efficacious and the best choice for this patient?
· Have I provided clinical data, etc. to support a clear rationale as to why the other treatment options are NOT optimal?
· Is the focus of my discussion on mechanism of action and receptors/neurotransmitters that the drug acts on? If the answer is YES, you should consider doing additional research to address the above two questions

Also include how ethical considerations might impact your treatment plan and communication with clients.
The rubric, as I interpret it, suggests 5 references cited with every assignment for full credit on this portion (20 points).  References used for your introductory paragraph, ethical considerations or conclusion do not count towards the 5 references required.  As a general rule of thumb, I would encourage you to reference AT LEAST two sources (not including the textbook) for each decision point – this will result in 6 references total for your clinical decision making. NURS 6630 Midterm Exam 5