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? patients symptoms of bipolar-manic: talking too fast / too much having inflated feeling of greatness ( looking for her movie agent) risky or impulsive behavior> walking in the middle of the road lets not leave out her incredible sense of style and makeup!!!!! pt's symptoms: increased speed, volume, and pressure of speech, poor judgment, racing thoughts, grandiosity Other symptoms of bipolar disorder: decreased need for sleep subjective experience that thoughts are racing distracted increase in goal directed activity excessive involvement in dangerous activities giving away money/prized possessions, constant activity, reduced need for sleep walking at 2300 hours in the middle of the road against traffic. Not oriented to the time, not sleeping, no sense of danger. Poor judgement includes: refusing to pay her rent with resutling eviction. Extremely unkempt shows forgetting or minimizing grooming. Speech being very rapid, pressured, and loud. Looking for her "movie agent" might show severe break from reality, as does her statement that she denies need for treatment. 2. Write three priority nursing diagnoses for this patient. imbalanced nutrition: less than body's requirements r/t failure to eat due to pt being too busy. Risk for imbalanced nutrition, less than body requirements may also relate to her hyperthyroidism Risk for injury as R/T poor judgement as E/B consumer found in the middle of the road walking against traffic risk for injury r/t poor judgment, poor nutritional intake, problems with medication adherence. impaired verbal communication r/t pt's inability to complete sentences, changing topics rapidly. Disturbed thought processes/chronic confusion r/t delusional thinking, loss of impulse control. ineffective health maintenance related to inability to make appropriate judgments as evidenced by walking into traffic at 2300 hrs. Ineffective Health Maintenance r/t inability to take responsibility for meeting basic health practices Self care deficit related to perceptual/cognitive impairment as evidenced by wearing lingerie in public and wearing lipstick on cheeks. ineffective sexuality pattern related to impaired relationship with significant other as evidenced by 3rd divorce Interrupted family processes as r/t neglect of family as e/b consumers loss of custody of children Impaired verbal communication as r/t continuos pressured speech as e/b consumers pressured, loud and fast pace speech 3. What will you include in your teaching plan for this patient regarding lithium/Eskalith therapy? Be specific. Teaching for Lithium: Continue taking the lithium even after the current episode is over, lithium treats the current emotional problem and prevents relapses. Take missed dose as soon as remembered unless within 2 hrs of next dose. Avoid activities requiring pt to be alert until pt's response is known, lithium can cause dizziness/drowsiness. Lithium is not addictive. The therapuetic and toxic dosage range is so close that its important you do not skip the blood tests to check serum levels. It is important to eat a normal diet with normal salt and fluid intake as lithium decreased sodium reabsorption in the kidneys which could lead to a sodium defiency. pt should avoid diuretics and activities that cause excess sodium loss A decrease in sodium intake can lead to litium retention which could produce toxicity. Stop taking if you have excessive diarrhea, vomiting or sweating. This can lead to dehydration which can raise the lithium levels in the blood to toxic levels. may cause weight gain, pt may need to start a low calorie diet take with meals as it will irritate the lining of the stomach talk to your doctor about having your kidneys and thyriod checked periodically Do not take otc meds without checking with a physician first Self help groups are available for support, the local self help group is...... You might find it helpful to have a list of side effects and toxic effects along with a contact person incase you need to verify what you are feeling If your doctor discontinues the lithium, do not worry you will be gradually tapered to minimize the risk of relapse.

4. If the psychiatrist adds Depakote/valproic acid to the patient’s treatment regimen, what would you need to monitor and teach the patient? monitor liver function and platelet count. pt teaching: importance of routine exams to monitor progress. inform dr. of medication regimen prior to any treatment/surgery, any adverse effects pt is having, and before taking any OTC drugs or herbal products. may cause dizziness/drowsiness. avoid activities requiring alertness until effects of medication are known. how to properly take medication, what to do if a dose is missed, and to not stop taking medication abruptly. Alcohol, opiates, barbituates, antihistimines will increase the depression of the CNS. Depakote may interfere with thyroid function tests

5. What symptoms does the patient have that meet the criteria for the diagnosis of hyperthyroidism? Some symptoms of hyperthroidism are increased metabolism, weight loss, restlessness, and agitation. Pt has lost weight. We don't know if she has lost weight due to forgetting to eat due to mania,or due to increased metabolism due to hyperthyroidism. Also symptoms would include the brittle fingernails and the course matted hair also insomnia, hair loss

6 . How does hyperthyroidism affect the patient’s mood? Hyperthyroidism may be contributing to her manic behavior of agitation hyperthyroidism can cause flight of thought, inability to finish sentence, excitability, mania. and poor judgement

7. What is Lithium toxicity? What signs and symptoms would the patient exhibit? <1.5 mEq/l early signs of toxicity: Nausea, vomiting,diarrhea, thirst,polyuria, lethargy,slurred speech,muscle weakness and fine hand tremor 1.5-2.0 mEq/l advanced signs of toxicity: Course hand tremor,persistent gastrointestinal upset,mental confusion,muscle hyperirratability,electroencephalographic changes, incoordination,sedation 2.0-2.5mEq/l Severe toxicity Ataxia, confusion,large output of dilute urine, serious electroencephalographic changes, blurred vision,clonic movements,seizures,stupor severe hypotension, coma; death is usually secondary to pulmonary complications.