Case+Study+Unit+III

Unit III Case Study: 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?

I was reading in the book about the Historionic disorder ( cluster B) they are very dramatic and emotional. The also wear very colorful/crazy clothes like this pt does. Abnormally elevated mood is a common symptom of Bipolar disorder. A bipolar pt may be in an unusually good mood, and then crash to a very low/depressed state. Pt's mood is labile, tells that she is looking her "movie agent" in the middle of the road at 2300 hrs (lack of sleep), "I'm too busy to bother eating." Pt is dressed in a bizarre long zebra striped coat, overdone/ bright makeup and strong body odor .< Patient is three times divorced and her children are in the custody of their father, showing the inability to form/sustain successful relationships. She is demonstrating unusual social activities by walking in the middle of the road against oncoming traffic. Other S/S of bipolar disorder include: poor judgment, lack of sleep and rest, racing thoughts, grandiosity, failure to eat, groom, bathe, dress self/dress self appropriately, Inability to sleep People with bipolar disorder do not talk in complete sentences. They dress in things that are inappropriate but get people’s attention. They change topic often and abruptly. They are constantly moving from activity, place, or idea without completing what they started in the first place. They tend to alienate themselves from family and friends. 2. Write three priority nursing diagnoses for this patient Wouldn't Anxiety, depression, and knowledge deficit also apply? The patient denies need for treatment, is she taking her meds for her disorder? . Risk for Injury a/e/b found walking in the middle of the road against traffic, Disturbed thought processes a/e/b telling nurse she is looking for her "movie agent", the reason for walking in the middle of the road, Self-Care deficit (bathing, grooming, dressing). Imbalance nutrition: less than body requires a/e/b her telling the nurse she is “too busy to bother eating.” 3. What will you include in your teaching plan for this patient regarding lithium/Eskalith therapy? Lithium is a very powerful drug that must be taken as ordered. The patient needs to be monitored as well while taking this drug. It is important to be sure the patient is able to understand the information you are giving them about this drug.Lithium blood levels should be monitored closely. It is very important that the patient adhere to the medication regime closely and follow up with her physician. It is very important to eat a normal, healthy diet with typical salt and fluid intake (6 12oz glasses a day). ( //Lithium will decrease sodium reabsorption which could lead to a sodium deficiency. In return, a low sodium intake will lead to an increase in lithium retention, resulting in Lithium toxicity //). Lithium may irritate the lining of the stomach, so it's important to take it with meals. Do not take any OTC drugs without consulting your physician first. Do not abruptly stop taking this drug. Self-help groups are available to provide support for people with Bipolar. 

Also, Lithium can make the pt unsually tired, teach pt to make position changes slowly. Stop taking lithium if excessive diarrhea, vomiting, / sweating are present. All these symptoms can lead to dehydration and high lithium levels in the blood. Do not take diuretics while you taking lithium. The use of alcohol, drugs abuse, even small amt of caffeine, and over-the-counter meds can produce a relapse. good sleep hygiene is critical to stability.Mania may be averted by the use of sleep meds. Groups and ind psychotherapy are invaluable for gaining insight and skills in relapse preventions, providing social support, and decreasing rehospitalizations. Lithium is not addicting and is used to treat the present emotional problems and prevent pt from having a relapse. It should not be stopped immediately, the dose as to be gradually reduce to prevent the chances of a relapse. Lithium should be taken with food to prevent stomach irritation and pt should drink six or more glasses of water to prevent lithium toxicity. 4. If the psychiatrist adds Depakote/valproic acid to the patient’s treatment regimen, what would you need to monitor and teach the patient? Depakote is used to treat bipolar disorder. If this drug is ordered for this patient, it is important to monitor liver function and blood platelet count. Depakote is given to pt who is not responding to lithium treatment. 5. What symptoms does the patient have that meet the criteria for the diagnosis of hyperthyroidism? The pt's weight loss supports hyperthyroidism. S/S of hyperthyroidism related to this patient include: Loss of appetite, weight loss, confusion/lethargy, impaired thinking, 6. How does hyperthyroidism affect the patient’s mood? The patient may experience "mood swings", A mood swing is a rapid or extreme change in mood. The patient may experience feelings of anxiety, restlesness, nervousness and irritability. 7. What is Lithium toxicity? What signs and symptoms would the patient exhibit? The therapeutic level (or Lithium level) should range from 0.4 and 1.3 mEq/L, Lithium toxicity occurrs when the blood serum levels of Lithium exceed 1.5 mEq/L. The S/S of Lithium toxicity include: Increasing diarrhea, thirst, polyuria, slurred speech & hand tremors. In **severe** Lithium toxicity, the patient may display signs of ataxia (failure of muscle coordination), confusion, large output of dilute urine, sever hypotension, seizures, blurred vision, convulsions, coma and death. Nausea, vomiting, persistent GI upset, muscle weakness and lethargy.
 * B**e specific.