#775865 Topic: Part 2 – Assignment: Assessing and Treating Clients with With Bipolar Disorder
Number of Pages: 2 (Double Spaced)
Number of sources: 1
Writing Style: APA
Type of document: Research Paper
#775865 Topic: Part 2 – Assignment: Assessing and Treating Clients with With Bipolar Disorder Number of Pages: 2 (Double Spaced) Number of sources: 1 Writing Style: APA Type of document: Research Paper Academic Level:Master Category: Nursing ATTACHEMENTS; Order_Files_775826_1.docx (HAS THE INSTRUCTIONS WHAT NEED TO BE DONE AT 2 PAGES) Finished_Order_775826_3.docx (THE OTHER PART OF THE ASSIGNMENT WHICH IS PART OF THIS.) Included here is part 1 of this assignment. the writer already did a good job. The writer needs to use correct information on POINT TWO DECISION AND POINT THREE DECISION . The writer’s introduction is good, DECISION POINT ONE IS GOOD, AND THE CONCLUSION IS GOOD. You are supposed to work on the information herein for “POINT TWO DECISION AND POINT THREE DECISION” Decision Point Two 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) Client reports that her sleep is again decreasing, but that overall, she is happy Decision Point Three Increase Lithium SR to 450 mg orally BID Guidance to Student 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. Remember decision Two will have The Selected Decision: Reason for Selection Expected Results Disparities between the Expected Results and the Actual Results Remember decision Three will have The Selected Decision: Reason for Selection Expected Results Disparities between the Expected Results and the Actual Results
Decision Point Two
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)
Client reports that her sleep is again decreasing, but that overall, she is happy
Decision Point Three
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/04/mm/bipolar_therapy/img/pill-red.pngIncrease Lithium SR to 450 mg orally BID
Guidance to Student
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.
Remember decision Two will have
The Selected Decision:
Reason for Selection
Disparities between the Expected Results and the Actual Results
Remember decision Three will have
The Selected Decision:
Reason for Selection
Disparities between the Expected Results and the Actual Results
Running head: ASSESSING AND TREATING PATIENTS WITH BIPOLAR DISORDER 1
ASSESSING AND TREATING PATIENTS WITH BIPOLAR DISORDER 10
Assessing and Treating Patients with Bipolar Disorder
Assessing and Treating Patients with Bipolar Disease
Bipolar disorder is a mental condition that arouses episodes of high spirits and great moods as well as times of acute discouragement and hopelessness in the affected patients. This state of mind is referred to as hypomania (craziness) based on the seriousness of the patient’s condition or manifestations of cases of psychosis. During such moments, the patients tend to be too irritable, cheerful or lively. Many do not feel the need to rest during such cases of hyper moods and during times of distress and gloom, they cry, expressing a lot of negativity and avoid direct eye contact with others. Most patients also tend to settle on choices that may not suit them, totally disregarding the consequences thereof.
Research has shown that patients suffering from bipolar disorder are prone to suicidal thoughts, with the number of suicides ranging from 6% for those suffering for more than 20 years. There are those who take the option of self-destruction and go ahead to harm themselves, an estimated 30-40%. Other patients display cases of psychological conditions such as high tension. Some tend to seek comfort in substance abuse.
The causes of bipolar disorder are mainly attributed to hereditary (genetic) and ecological factors. Though not clearly understood by many people, people are exposed to many risk factors by qualities they would consider of minimal impact. Ecological factors may reveal a background marred by the mishandling of adolescence and long-term stress. Bipolar disorder can be classified as Bipolar 1if the patient has experienced more than one hyper case, whether or not depression was involved. Bipolar 2 condition is determined by the occurrence of more than one hypomanic case, with a massive depression episode. Patients, who have experienced less extreme drawn-out spans, are often diagnosed with cyclothymic turmoil and it is grouped separately due to compounding therapeutic or medication issues.
Bipolar disorder also manifests itself in terms of conditions such as schizophrenia, identity issues, substance utilize clutter, hyperactivity and restorative cases. Although medical testing may not necessarily be a requirement for the determination of bipolar disorder, it is necessary to conduct some blood tests or perform medical imaging, which is an effective measure of discounting other isolated conditions and problems.
Consider the case of a Korean woman aged 26 years, who gets an appointment at the clinic after 21 days of hospitalization for acute mania. The patient was diagnosed with Bipolar 1 disorder. Her behavior confirmed this possibility. While at the Nurse Practitioner’s desk, she played with items on the desk, swinging cheerfully from side to side in her chair. She told the Nurse Practitioner that though they said she was bipolar, she herself did not believe it, and questioned the nurse’s opinion of the same. To her, the condition she had was due to the fact that she loved dancing, talking, singing and cooking. These activities were all marked by episodes of wonderful moods. Her report showed that she had an approximate 5 hours of sleep per night, admitting that she hated sleeping as it was no fun (Laureate Education, 2016).
A quick review of the patient’s hospital records, it was acknowledged that she was in generally good health. Her laboratory results displayed at normal body conditions. However, the genetic testing confirmed her positive for the CYP2D6*10 allele. The patient then confessed to terminating her prescribed medication for lithium some two weeks back. On further assessment, the patient is found to be alert and oriented. She is dressed, oddly enough, in an evening gown to the doctor’s appointment. Her speech is quite rapid, tangential and shows signs of undergoing pressure. The patient reports that her mood is euthymic, and adamantly denies her apparent paranoid thoughts, visual and auditory hallucinations and overt delusions. Though her judgment was decidedly intact, she had an impaired kind of insight. The patient denied neither having suicidal nor homicidal ideations. On assessment according to the young mania rating scale, she scored 22.
To this effect, it is important to take a right selection of drug prescription in concurrence to medication requirements. The understanding that drugs which are metabolized by the inhibitors and substrates contained in CYP2D6 has helped in the selection of appropriate medication and set the outcome of prescribed treatment at positive levels.
Decision One: Risperdal Medication Commencement at 1 mg orally BID
The drug risperdal was selected for administration to the patient, specifically 1 mg of the drug taken orally BID. Risperdal (originally risperidone) is considered an atypical antipsychotic, a second-generation drug that is utilized in the treatment of the bipolar condition. CYP2D6 mainly metabolizes the drug . The cytochrome P450 (CYP) 2D6 mitochondrial system is involved in the metabolization and synthesizing of the drug. The drug is effective in that it provides balance serotonin and dopamine, thus enabling inclination and consideration in the conduct of the patient. Considering that the patient was diagnosed with bipolar disorder, Risperdal was prescribed as the best medical treatment given the prescriptions availed.
Lithium, though an alternative to risperdal, is considered less appropriate as it may not be effective where it clashes with the patient’s genetics and the tests thereof. The patient may also be unwilling to begin medication on lithium at 300mg as it is known to lack both inhibitory and inductive capabilities. Another alternative would be Seroquel XR, which is not preferred as it has dire side effects inclusive of weight gain and cases of severe constipation.
The results of medication were expected were expected to kick in after a period of four weeks, during which there were projected improvements in the patient’s sleeping, mood and speech. With the administration of risperdal, viability was considered as it helped in adjusting the mental action to the capacity and capability of establishing sound mindedness in the manner of handling situations in the case of patients.
Disparities in the Expected and Actual Results
The patient was readmitted four weeks later, accompanied by her mother. The patient appeared to be in a lethargic and sedated state, to which the mother responded had been the case for the last week or so. This was in conflict with the expected results that would have reduced the symptoms and effects of the bipolar disorder. However, this was confirmed to be a normal occurrence for patients on recovery in the improvement of the state of their minds and thinking patterns. The symptoms of medication cause this distinction in expected and varied results . The drug risperdal, consumed in large quantities, however, results in sedation (Stahl,2013). Considering the Korean descent of the patient and the diagnosis of CYP2D6*10 allele positivity, it was concluded that the patient may not have a good chance at prevention of risperdal quickly building up in her body. This build-up was singled out as the cause of the lethargic and sedated state.
Decision Two: Decrease of Risperdal Medication to an administration of 1 mg at HS
A second decision rule was necessary to be undertaken by the patient. This was not necessarily because the first decision that began the patient on risperdal 1 mg administered orally BID, was ineffective. The decision was influenced by CYP2D6 seeming to correlate with poor levels of metabolizing medication consumed. As concluded from the first decision, it was necessary to reduce medication because of medication buildup in the patients system. This conclusion is drawn from the ratio of risperdal to 9-hydroxyrisperidone (which has large amounts of CYP2D6 phenotype), which conclusively increases the risk factors for various side effects to the medication. These considerations guided the necessity to moderate risperdal administration to 2 mg HS, consecutively minimizing the said symptoms on the patient.
There could be an option of shifting the patient’s medication to lithium, but that would not be an informed decision in this case as the patient was still unfavorably indisposed towards it. Jumping form one conclusive medication to another may initiate conflicts where the patient may be inclined to think that positive results that gave her improved health were beyond her. Clinicians must support the patient through this by informing her about and helping her adapt to similar medication measurements prescribed, building her trust in the drugs and following directions of use.
Risperdal medication has always been effective in adjusting the serotonin and dopamine levels in the patient’s brain. It was thus helpful in regulating the conduct, disposition and thought patterns of the patient. However, the effects on the patient were attributed to the buildup of risperdal in her blood. This translated into the second decision rule to reduce risperdal measurement to 1 mg HS, eliminating the buildup of medication in the patient’s bloodstream. The body adjusts by effectively discharging the medication (Fountoulakis, 2015). This change in medication was projected to improve the patient’s general well being and minimize the side effects experienced from medication consumption. Gradually, positive changes in her state of mind, her sleeping patterns and propensity to be calm are expected.
Disparities between the Expected Results and the Actual Results
After the second decision rule was expected, the patient was back at the hospital a month later. On assessment, her ratings on the young mania rating scale had decreased from 22 to 16. The expected improvements were evident in her less lethargic and less sedated state of mind. The reduction rate in exhibitions of the symptoms of bipolar disorder was rated at an average 25%. However, the mark of success was at an estimated 50% (Stohl, 2013).
The expected results were ultimately correlated to the actual results, to the extent of the targeted side effects wearing off faster than what was projected (Weiss & Connery, 2014). The results were attributed to risperdal being an effective medication for bipolar disorder. This proved the superiority of risperdal to this effect. There exist other alternative medication such as dopamine D2, Alpha-adrenergic receptors and Serotonin 5-HT2A, which though they demonstrate positive effects on the patient’s mood, they displayed potent antagonism (Sajatovic, Subramoniam & Fuller, 2006).
Decision Three: Continuation of Risperdal Medication at the same Dosage
As seen from the second decision rule, the patient was responding positively to the prescribed risperdal dosage. It was decided best in the patient’s interests for her to continue with the same dosage, allowing for a reassessment after 4 weeks. However, it was noted that genetics CYP2D6*10 allele caused risperdal to clear from her system at a slower rate, which had caused the buildup in the first decision rule. Therefore, prescribing risperdal medication at 1 mg twice in a day per month may offset the patient into her previous constant states of being lethargic and sedated. Although a shift to Latuda could be considered, it would neither be appropriate nor effective as FDA endorses it strictly towards the treatment of Bipolar 1 disorder, and it is conclusively evident that the patient’s condition is not consistent with Bipolar 1 (Stahl, 2013). Its medication and administration are also costly, rendering it inconsumable by the patient. It was decided wisely for the patient to proceed with her medication, changes being made only when proved crucial.
Consistent and right use of risperdal medication by the patient translated into positive improvements and reduction in bipolar symptoms and side effects. This was an attributable 25% decrease in these indicators. The expected result was an estimated 50% decline after the fourth week (Stahl, 2013). It was also expected that the patient would experience moments of great sleep, a better frame of her mind, conduct herself in an ordinary manner and express legitimate and sane points of view. However, it was not a guarantee that the reactions derived from the main dosage would be experienced again.
Disparities between Actual Results and Expected Results
The results expected from the third decision rule, as discussed above, were general effectual shifts via reductions in bipolar symptoms. It was projected that the patient could ultimately fully recover should the patient continue appropriately on her medication. These outcomes can be compared to the projected results with the management of measurements (Vitello, 2013). The outcomes are expected because of the consistency in pharmacokinetics and pharmacodynamics. With these considerations, the objectives of treatment of bipolar disorder are dully accomplished.
Ethical Considerations on Treatment Strategy
Moral, ethical and legal considerations are crucial in the healthcare system. Moral contemplations are even more so crucial in the management of people with bipolar disorder, especially in regard to PMHNP approach (Weiss & Connery, 2014). Under PMHNP medication, the patient was found to be rationally unsound on most occasions. This means that clinicians have to inform them about their conditions, giving data and information as candidly as possible, and the opportunities available to her. They have to know and implement the best manner to approach the patient, considering the unstable state of mind and skewed view of reality. In the Korean patient’s case, clinicians were effective in guiding the patient in the correct utilization of the drug risperdal, given that the patient had suffered severe cases of sedation and lethargy after consuming the same drug on the first decision rule treatment plan.
Clinicians have to also morally choose the appropriate medication for each patient in relation to the specifics of their condition and the side effects the drugs exhibit. The drugs may not be functional and effective as they may elicit symptoms to the individuals that may leave them worse off than they were on admission. A case in pointer are the side effects of constipation, weight gain and dry mouths elicited by the drug Serequel XL. Lithium also had comparative symptoms on the patient discussed, and could not be used on her as her genetic makeup was resistant to the drug in previous solutions (Stahl, 2013). Morally, the long run effects of PMHNP should be critically considered, such as the destruction and weakening of teeth. As such, the final solution arrived at, morally, legally and ethically, must be the best and superior of all other alternatives with less side effects and adversities.
Bipolar disorder is a complex condition that warrants clinicians to critically analyze the patient. This is because the side effects of bipolar disorder are numerous and have similar characteristics to those of other diverse mental conditions. Treatment is possible but dire consideration should be given to the medication taken by the patient as many drugs have side effects that may result in harm to the patient and others.
After the initial treatment, many patients have relapsed and emerged worse off than before, with the adverse symptoms that definitely do not build up their health.Yet the drugs are well known for the treatment and management of the bipolar disease. It is crucial to accord the necessary help and treatment to a patient with the bipolar disorder as the mental state of the patient is shaky, unpredictable and unstable. It is also critical for the clinicians to project the correct medication, dosage, timeline of PMHNP and similar medication, especially on the consideration of the amount of tranquilization effective for each patient.
Fountoulakis, K. N. (2015). Bipolar disorder: An evidence-based guide to manic depression.
Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author.
Sajatovic, M., Subramoniam, M. & Fuller, M. A. (2006). Risperidone in the treatment of bipolar mania. Retrieved from: https://wwww.ncbi.nim.nih.gov/pmc/articles/pmc2671778
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331-333. doi:10.1007/s40263-013-0060-3
Weiss, R. D., & Connery, H. S. (2014). Integrated group therapy for bipolar disorder and substance abuse. New York: The Guilford Press.