Case Study: Examining a Diagnosis-Bipolar Disorder Essay

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Case Study: Examining a Diagnosis-Bipolar Disorder Essay

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. Case Study: Examining a Diagnosis-Bipolar Disorder Essay

Decision #1 (1 page)

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.

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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.

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.

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.

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. Case Study: Examining a Diagnosis-Bipolar Disorder Essay

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 did well enough on Lithium to be discharged from the hospital but admits she has not been taking it as prescribed. When further questioned on the subject, she provides no additional details.

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

Decision point two

Decision point three

Begin Lithium 300 mg orally 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

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

-Assess for rationale for non-compliance and educate client

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. Case Study: Examining a Diagnosis-Bipolar Disorder Essay

-Consider hospitalization

-Change to abilify 10 mg orally at HS

Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology

RESULTS OF DECISION POINT TWO

–Client returns to clinic in four weeks

-Client states that the drug makes her nauseated and gives her diarrhea

-Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again

-Change to Depakote ER 500 mg at HS

In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.

-Change Lithium to sustained release preparation at same dose and frequency

-Change to trileptal 300 mg orally BID

Switch to Depakote ER 500 mg orally at HS

RESULTS OF DECISION POINT TWO

– Client returns to clinic in four weeks

– Client reports that she has been compliant and you notice a marked reduction in manic symptoms. Young Mania Rating Scale was 11 (50% reduction from first office visit)

– Client reports that she has gained 6 pounds over the last 4 weeks and wants to stop the medication because of this

-Educate client regarding diet/weight loss and continue client on the same drug/dose

The PMHNP should begin by educating the client regarding weight loss/and importance of diet/exercise while taking Depakote which can cause weight gain. Decreasing the dose of Depakote would not be appropriate as she still has symptoms and decreasing dose of Depakote may result in some weight loss, it may result in a return of manic symptoms. The PMHNP can switch to Zyprexa but if weight gain is the issue, then this will be compounded by Zyprexa which is associated with significant weight gain (up to 20 kg over a 24 month period).

-Decrease Depakote ER to 250 mg orally at HS

-Switch medication to Zyprexa 15 mg orally daily at HS

The PMHNP should begin by educating the client regarding weight loss/and importance of diet/exercise while taking Depakote which can cause weight gain. Decreasing the dose of Depakote would not be appropriate as she still has symptoms and decreasing dose of Depakote may result in some weight loss, it may result in a return of manic symptoms. The PMHNP can switch to Zyprexa but if weight gain is the issue, then this will be compounded by Zyprexa which is associated with significant weight gain (up to 20 kg over a 24 month period).

Decision point one

Decision point two

Decision point three

Begin Risperdal 1 mg orally BID

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”

Discontinue Risperdal and start Lithium sustained release 300 mg orally BID

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks

-Client no longer lethargic after the end of the first week

-Client has a slight decrease in her Young Mania Rating Scale (from 22 to 19) Case Study: Examining a Diagnosis-Bipolar Disorder Essay

-Client reports that her sleep is again decreasing, but that overall, she is happy

-Increase Lithium SR to 450 mg orally BID

Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may be demonstrating slower clearance of Risperdal from her system, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The client responded well to the discontinuation of Risperdal and after about a week of drug cessation, she was no longer lethargic/sedate. However, in the following 3 weeks, she had experienced increased symptoms, although a slight improvement in YMSR score was noted. The PMHNP could make no changes at this time and allow the lithium to remain at its current dose for an additional 4 weeks and reassess. Conversely, the PMHNP can increase the lithium to 450 mg orally BID and then reassess in 4. The additional milligrams may hasten mood stabilization. Risperdal 0.5 mg orally BID may be appropriate if the clients’ symptoms are worsening, however, the PMHNP would need to have the client return to the office sooner than 4 weeks for an interim visit to assess effects of drug and presence of somnolence/lethargy.

-Re-start Risperdal at 0.5 mg orally BID

-Make no changes at this time and reevaluate in 4 weeks

Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may be demonstrating slower clearance of Risperdal from her system, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The client responded well to the discontinuation of Risperdal and after about a week of drug cessation, she was no longer lethargic/sedate. However, in the following 3 weeks, she had experienced increased symptoms, although a slight improvement in YMSR score was noted. The PMHNP could make no changes at this time and allow the lithium to remain at its current dose for an additional 4 weeks and reassess. Conversely, the PMHNP can increase the lithium to 450 mg orally BID and then reassess in 4. The additional milligrams may hasten mood stabilization. Risperdal 0.5 mg orally BID may be appropriate if the clients’ symptoms are worsening, however, the PMHNP would need to have the client return to the office sooner than 4 weeks for an interim visit to assess effects of drug and presence of somnolence/lethargy.

Decrease Risperdal to 1 mg at HS

RESULTS OF DECISION POINT TWO

-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)

-Continue at same dose of Risperdal and reassess in 4 weeks

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.

-Increase Risperdal back to 1 mg orally BID

-Change to Latuda 40 mg orally daily

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.

Change Risperdal to 2 mg at HS

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks

-Client’s mother accompanies client again to today’s appointment and states “I think she’s getting worse, that medication is no good- look at her!”

-Client remains quite sedate and lethargic

-Decrease Risperdal to 1 mg orally at HS

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, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The change of administration time may help with sedation, somewhat, but if she is not clearing the drug from her system, she is accumulating the medication and this is resulting in sedation. The PMHNP should consider decreasing the drug to 1 mg orally daily at HS secondary to decreased clearance of the drug. The PMHNP could discontinue Risperdal and begin Seroquel XR, but the dose is quite high and BID administration would likely result in sedation as well. Seroquel XR is also dosed only once a day. Discontinuation of Risperdal in favor of Geodon may also be an appropriate choice as Geodon is cleared by approximately one third through the CYP-3A4,1A2 alleles and the remaining two-thirds of the drug are cleared through aldehyde oxidase, which means that it should not cause the same sedation of the client is currently experiencing with Risperdal. Geodon must be administered with a 500 calorie meal in order to assure adequate absorption.

-Discontinue Risperdal and begin Seroquel XR 400 mg orally BID

-Discontinue Risperdal and Geodon 40 mg orally BID with 500 calorie meal

Decision point one

Decision point two

Decision point three

Begin Seroquel XR 300 mg orally at HS

RESULTS OF DECISION POINT ONE

-Client returns to clinic in four weeks

-Client is reporting that she sleeps a bit more at bedtime

-Client states that she has gained about 2 or 3 pounds, which she does not like

-Client also reports that she has been constipated since starting this medication

-Client is also complaining of dry mouth which she does not like.

-Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18

-Client is reporting really good mood, but is asking for a different medication because of the weight gain

Increase Seroquel XR 400 mg orally at HS

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks

-Client reports that her constipation is worse and that she has now gained a total of 7 pounds since starting this drug

-Client feels that you are not listening to her concerns and is very upset

-Client’s Young Mania Rating Scale has decreased from 18 to 14

– Increase Seroquel XR to 600 mg orally at HS

The client is becoming frustrated and feels that the PMHNP does not hear her concerns about weight gain and constipation, which can be causing a rupture in the therapeutic relationship. In addition, after 8 weeks, the client still has significant manic symptoms despite the fact that they have decreased, they are still present.

The PMHNP could discontinue the Seroquel XR and begin Geodon. This may be an appropriate choice as Geodon is cleared by approximately one third through the CYP-3A4,1A2 alleles and the remaining two-thirds of the drug are cleared through aldehyde oxidase, which means that it should not cause the same adverse effects as Seroquel. Although this drug is metabolized through 2D6, the PMHNP needs to remember that this is a minor pathway for metabolism and 3A4 is the major pathway through which this drug is metabolized. Geodon must be administered with a 500 calorie meal in order to assure adequate absorption.

In this case, the Seroquel is causing side effects through the muscarinic 1 receptors. The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.

Decreasing Seroquel as suggested in the third choice may result in a decrease in side effects, but addition of Depakote can also result in weight gain- which is one of the side effects that the client has found objectionable.

– Discontinue Seroquel XR and Geodon 40 mg orally BID with 500 calorie meal

In this case, the Seroquel is causing side effects through the muscarinic 1 receptors. The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.

– Decreased Seroquel XR to 200 mg orally at HS and beging Depakote ER 500 mg orally at HS

The client is becoming frustrated and feels that the PMHNP does not hear her concerns about weight gain and constipation, which can be causing a rupture in the therapeutic relationship. In addition, after 8 weeks, the client still has significant manic symptoms despite the fact that they have decreased, they are still present.

Discontinue Seroquel and Geodon 40 mg orally BID with 500 calorie meal

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks

– Client demonstrates a 50% decrease in score on the Young Mania Rating Scale (from 22 to 11)

-Client denies any additional weight gain and denies any additional side effects Case Study: Examining a Diagnosis-Bipolar Disorder Essay

-Continue same dose and reassess in 4 weeks

The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.

Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects.

Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended release may overcome the difficulties she was experiencing with side effects. The PMHNP would need to educate client regarding side effects of medication and need to maintain compliance.

-Increase Geodon to 60 mg orally BID with a 500 calorie meal

Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects.

-Augment with Lithium sustained release 300 mg orally BID

The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.

Continue same dose of Seroquel and counsel client regarding ways to prevent constipation

RESULTS OF DECISION POINT TWO

-Client returns to clinic in four weeks

– Client continues to experience constipation and has gained an additional 5 pounds

– Client feels that her PMHNP is not sympathetic to her concerns and states “I want to stop medication altogether, this is no way to live!”

-Discontinue Seroquel and go back to Lithium , but this time, using an extended release preparation

Discontinuation of the Seroquel in favor of extended release lithium may be appropriate to overcome initial side effects that resulted in discontinuation of lithium, but Lithium takes several weeks to bring about control of manic symptoms. An atypical antipsychotic will need to be used until lithium’s effects can be realized.

Similarly, discontinuation of Seroquel and initiation of Lamictal is not appropriate as the dose of 100 mg is too high. Lamictal must be slowly and cautiously titrated from a starting dose of 25 mg orally daily- otherwise, an increased risk of Steven Johnson Syndrome can occur. Secondly, the Lamictal is not indicated for bipolar mania.

– Discontinue Seroquel and begin Geodon 40 mg orally BID with 500 mg calorie meal

Similarly, discontinuation of Seroquel and initiation of Lamictal is not appropriate as the dose of 100 mg is too high. Lamictal must be slowly and cautiously titrated from a starting dose of 25 mg orally daily- otherwise, an increased risk of Steven Johnson Syndrome can occur. Secondly, the Lamictal is not indicated for bipolar mania.

-Discontinue Seroquel and begin Lamictal 100 mg orally daily.

Discontinuation of the Seroquel in favor of extended release lithium may be appropriate to overcome initial side effects that resulted in discontinuation of lithium, but Lithium takes several weeks to bring about control of manic symptoms. An atypical antipsychotic will need to be used until lithium’s effects can be realized.

Case overview

The patient is 26 years old Korean woman on her first day of the appointment, after 21 days of hospitalization for acute onset of mania. The patient states that she is in a fantastic mood and hates sleep because it Is not fun. She likes to talk, dance, and sing. Her Genetic testing- GeneSight reveals that she is positive for the CYP2D6*10 allele. Her laboratory workups are normal. The patient was put on lithium but has not been taking it as prescribed. On examination, she is overweight, quite busy playing with things on the desk, and shifting from the side of the chair. The patient is alert and 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, and tangential. The self-reported mood is euthymic. Affect broad. The patient denies visual or auditory hallucinations, and no overt delusional or paranoid thought processes are readily apparent. Judgment is grossly intact, but insight is impaired. She is currently denying suicidal or homicidal ideation. The Young Mania Rating Scale (YMRS) score is 22. Case Study: Examining a Diagnosis-Bipolar Disorder Essay

Bipolar

Bipolar is a mood disorder characterized by episodes of mania and hypomania in alternate seasons. It is a psychiatric disorder common in patients with a genetic predisposition to bipolar and personality disorders. It has a manic episode which presents with grandiosity, loss of need for sleep, pressured speech, flight of ideas, racing thoughts, increased level of goal-focused activity, excessive pleasurable activities, and excessive talking (Carvalho, et al, 2020). This episode lasts for about one week and it is followed by a hypomanic episode. The clinical signs and symptoms of the manic episode are depressed mod, loss of interest and pleasure, hypersomnia, psychomotor agitation, worthlessness, fatigue, decreased concentration, and suicidal ideation. Bipolar is prevalent in 5% of the total population in the united states of America. The age of onset is from 15 years and over 50 years old, especially in females. Risk factors for bipolar are biochemical, neurophysiologic, psychodynamic, environmental, and pharmacological factors.

The biochemical factors are the use of drugs such as cocaine, which triggers serotonin and noradrenaline, causing manic episodes. Neurophysiologic factors involve defects in the structural cortical-cognitive brain network that may cause activation of emotions and emotional responses. Psychodynamic factors are associated with depressive mood and low self-esteem. Environmental factors cause stress and external pressures cause emotional responses. Pharmacological factors, for example, the use of antidepressants triggers manic episodes. The patient has a bipolar manic phase because she is in a happy mood and doesn’t want to sleep. This essay describes the three decisions in treating the patient and the impact of ethical considerations during treatment.

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Decision 1

Decision selected

Begin Seroquel XR 300 mg orally at HS

Reason for selecting this decision

Seroquel is a second-generation antipsychotic with a high affinity for the 5-HT2 receptors and mediates its effects through antagonist actions. It also has a high affinity for muscarinic, dopamine, muscarinic, and adrenergic receptors that improve mood, sleep, and concentration (Abdyrakhmanova, et al, 2021). It also relieves the positive symptoms of psychosis and schizophrenia. It is FDA approved for acute mania, psychosis, schizophrenia, and bipolar. Due to its antagonist mechanism, it causes dry mouth, weight gain, constipation, and dizziness. I chose this drug because it is given at an optimal dose to relieve a patient’s symptoms.

Reasons for excluding other decisions

Lithium is a mood stabilizer FDA-approved for bipolar and dysthymic disorders. It is the first-line treatment in treating bipolar and may be used as adjunctive therapy for mania (Rybakowski, J. K. 2018). Lithium alters the metabolism of other neurotransmitters to alter their genomic expression in them, hence reducing the grandiose symptoms. I did not select lithium because the patient has not been compliant. Moreover, it has unpleasant effects like confusion, tremors, delirium, and seizures. Risperdal is an atypical antipsychotic FDA approved for bipolar and schizophrenia. It has antagonism at the D2 receptors to treat the negative and positive symptom (Wilcox, et al, 2019) . I did not select the drug because it has extrapyramidal effects like dystonia, akathisia, parkinsonism, tremors, and shaffling gait. Case Study: Examining a Diagnosis-Bipolar Disorder Essay

What are your expectations for making the decisions?

The expectation of initiating this treatment was to relieve the symptoms of inability to sleep and grandiosity. To reduce the young mania scale to less than 22.

The impact of ethical consideration in treatment and communication

Ethics are the moral value that guides nursing practice in assessment and treatment. In this decision point, the nurse uses the principle of justice and beneficence. Justice Is a principle that allows nurses to treat all patients equally and in a righteous manner, especially during the assessment. Beneficence is the principle of doing good for the interest of the patient (McCradden, et al, 2020). The nurse initiates treatment for the patient to enable recovery.

Decision 2

Decision selected

Discontinue Seroquel and start Geodon 40 mg orally BID with 500 calorie meal

Reason for selecting this decision

The patient complains of constipation and weight gain after initiating the treatment. She reports a slight improvement in the symptoms. Therefore, switching the patient to Geodon will improve the symptoms of bipolar, help in weight loss, and stop constipation. Geodon is an atypical antipsychotic that FDA approved for treating psychosis and bipolar. It has a higher affinity for dopaminergic and serotonin receptors that helps in reliving the positive symptoms. It is taken orally together with meals-high fat content to increase the drug bioavailability (Yeh, et al, 2018). I chose this drug because of its efficiency to treat patients’ symptoms and has fewer side effects.

Reasons for excluding other decisions

Increasing the dosage of Seroquel from 300mg to 400mg has a mild impact on the patient’s symptoms but worsens the side effects of gaining weight and constipation (Abdyrakhmanova, et al, 2021). The patient is obese and gaining more weight makes them uncomfortable. Therefore, I did not make this decision to ensure the psychological well-being of the patient. Continuing with the same dose and offering a solution for constipation is not a good idea for this patient because the drug has the effect of gaining weight.

What are your expectations for making the decisions?

The expectations for changing to Geodon are to improve the manic symptoms, reduce weight, and stop constipation. Case Study: Examining a Diagnosis-Bipolar Disorder Essay

The impact of ethical consideration in treatment and communication

At this decision point, the nurse considers the principle of autonomy. Autonomy is the respect for a person’s decision or preference regarding their health (McCradden, et al, 2020). The patient requests the nurse to prescribe a drug that will ease her bowel movement and stop weight gain.

Decision 3

Decision selected

Increase Geodon to 60mg

Reason for selecting this decision

I increased the dosage of the drug to increase the effective therapeutic concentration of the drug. The recommended dose is a maximum of 80mg. therefore, increasing by 20mg and monitoring the side effects helps reach the maximum therapeutic goal.

Reasons for excluding other decisions

I did not augment the patient with lithium because of the drug’s adverse effects. Moreover, she is not compliant with the drug because of its unpleasant effects. I did not maintain Geodon at 40mg because the American psychiatric association guidelines recommend dose adjustment to 60mg to achieve the therapeutic goal.

What are your expectations for making the decisions?

The expectations of increasing the dosage to 60mg are to improve the symptoms with minimum side effects.

The impact of ethical consideration in treatment and communication

The nurse incorporates the principle of non-maleficence. Non-maleficence is not doing harm intentionally or unintentionally (McCradden, et al, 2020). The nurse protects the patient from medical harm by prescribing treatment with fewer side effects on the patient.

Conclusion

Bipolar is a mood disorder characterized by episodes of mania and hypomania. Risk factors for bipolar are biochemical, neurophysiologic, psychodynamic, environmental, and pharmacological factors. The client has a CYP2D6*10 allele that predisposed her to bipolar. Treatment methods for bipolar are antipsychotics or antidepressants to relieve the symptoms. The recommendable drug should be effcective with no unpleasant effects on the body. The majority of antipsychotics slow down lipid metabolism resulting in hyperlipidemia and weight gain. Undesirable effects of drugs are dry mouth, constipation, drowsiness, confusion, tremors, ataxia, and convulsions. Ethical principles are the moral values that guide nursing practice. Examples are beneficence, justice, fairness, consent, respect for autonomy, confidentiality, and non-maleficence.

References

Abdyrakhmanova, A. K., Shnayder, N. A., Neznanov, N. G., & Nasyrova, R. F. (2021). Pharmacogenetics of quetiapine. Personalized Psychiatry and Neurology, 1(1), 73-83. https://doi.org/10.52667/2712-9179-2021-1-1-73-83

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66. https://www.nejm.org/doi/full/10.1056/NEJMra1906193

McCradden, M. D., Joshi, S., Anderson, J. A., Mazwi, M., Goldenberg, A., & Zlotnik Shaul, R. (2020). Patient safety and quality improvement: Ethical principles for a regulatory approach to bias in healthcare machine learning. Journal of the American Medical Informatics Association, 27(12), 2024-2027. https://doi.org/10.1093/jamia/ocaa085

Rybakowski, J. K. (2018). Challenging the negative perception of lithium and optimizing its long-term administration. Frontiers in molecular neuroscience, 11, 349. https://doi.org/10.3389/fnmol.2018.00349

Wilcox, M.A., Coppola, D., Bailey, N. et al. Risperdal® CONSTA® Needle Detachment. Incidence Rates Before and After Kit Redesign: A Retrospective Study using Electronic Health Records and Natural Language Processing in the Department of Veterans Affairs. Neurol Ther 8, 95–108 (2019). https://doi.org/10.1007/s40120-019-0130-7

Yeh, Y. C., Yu, X., Zhang, C., Hao, W., Du, F., Liu, D., … & Gao, X. (2018). Literature review and economic evaluation of oral and intramuscular ziprasidone treatment among patients with schizophrenia in China. General Psychiatry, 31(3). https://doi.org/10.1136%2Fgpsych-2018-100016 Case Study: Examining a Diagnosis-Bipolar Disorder Essay