Nursing Case Study for Bipolar Disorder
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Outline
Kelli is a 20-year-old patient brought to the ER after being reported by neighbors in her apartment complex for disruptive behavior. Law enforcement and emergency medical services were called, and, as a team, decided she needed a higher level of medical care.
The patient says she is” on a break from art college” but works at a local restaurant as a server and occasionally cleans houses as well. She has also sold her paintings and drawings in the past as well. She denies taking any medication. She also says, “I don’t understand why I am here. I was working on my art projects, and I guess I played my music too loud or something. I said I’d come here so I would not be arrested.”
What are some questions that should be included in the initial assessment?
- Ask about drug and alcohol consumption and previous episodes. Make sure she does not intend to harm herself or others. Check to see why the patient does not understand coming to a medical treatment facility (make sure she is lucid). Ask about trauma or accidents.
What interventions do you anticipate being ordered by the provider?
- Obtain old medical charts (there may be a pattern). Screen for drugs and alcohol. Assess for trauma (especially head injury, so neuro checks). Complete a thorough medical history to rule out medical reasons for behavior. Conduct a medical examination including labs (eg. thyroid-stimulating hormone, complete blood count, chemistries)
Kelli’s drug and alcohol tests are negative. Her roommate is now at the bedside and asks to speak to staff privately. She expresses concern that Kelli can be emotional at times as well as going days without sleep then not being able to get out of bed. The nurse returns to further evaluate the patient.
With this new information, what might the nurse ask Kelli?
- Ask about “periods of unusually intense emotion, changes in sleep patterns and activity levels, and uncharacteristic behavior—often without recognizing their likely harmful or undesirable effects” (from NIH). Dig deeper to find if these “episodes” last for long or short periods. Specifically, ask about extreme highs and lows, change in appetite, racing thoughts vs concentration difficulty, risky behaviors (eg gambling, extreme shopping sprees, sexual promiscuity), anxiety, excessive talking, thoughts of death/dying.
Kelli admits to being able to stay awake for what seems like entire weekends without being tired, but that is when she says her creativity is best. When she was attending college and living in the dorms, she says she had lots of friends but worried about what she calls “all the partying.” This is because she liked to “hook up” with strangers because it was fun, but she worries about possible sexually transmitted infections now that she is older. She says she was extremely popular, and her talent was at its peak. But there are times she could not pay attention in class or even get out of bed, so she dropped out of school. Sometimes, she cannot even touch her art supplies, but says she is probably the “most talented artist around.”
What signs and symptoms indicate Kelli may have bipolar disorder?
- Sleep disturbances, cycling between being creative and not being able to concentrate, sexual promiscuity, feelings of grandiosity, loss of pleasure of usual activities
Are there risk factors for this condition?
- The exact cause of bipolar disorder is not clear. The problem may be related to an imbalance of chemicals in the brain such as norepinephrine, serotonin, or dopamine. These chemicals allow cells to communicate with each other and play an essential role in all brain functions, including movement, sensation, memory, and emotions.
- Approximately one to three percent of people worldwide have bipolar disorder. People with a family history of bipolar disorder are at increased risk of developing the condition. Most people develop the first symptoms of bipolar disorder between age 15 to 30 years.
Kelli’s medical records have arrived, and the provider advises nursing staff she has a history of being brought to the ER for similar episodes. The provider says, “This patient is a schizophrenic. We don’t have time for this.”
What is the best response to the provider’s statement?
- As the patient’s advocate, the nurse should advise the provider this is inappropriate. First, it is a disparaging remark. Second, if he means schizophrenic, that is not accurate and as an ER physician should refer the patient for further psychiatric screening and evaluation.
- It is never wrong to stand up to providers or colleagues, but it should be done respectfully and NOT in front of the patient when at all possible.
Kelli rests quietly in the exam room with her roommate at the bedside. She asks, “Can someone help me get better? I am tired of this. I am such a burden on everyone.”
What should the nurse screen Kelli for at this point?
- Suicidal ideations include whether she has a plan or has attempted suicide in the past. Suicide screening is an ongoing process and not just a few questions at admission. Per UpToDate, “A review estimated that approximately 10 to 15 percent of bipolar patients die by suicide and many studies indicate that the rate of suicide deaths in patients is greater than the rate in the general population.”
How can the nurse address Kelli’s question about help?
- Something like (from uptodate), “Treatment of mania focuses on managing symptoms and keeping you safe. In the early phase of mania (called the acute phase), you may be psychotic (having false, fixed beliefs or hearing voices or seeing things others cannot see or hear). You may not be able to make good decisions and you may be at risk of hurting yourself or others. You may need to be treated in a hospital temporarily, until your medicine begins to work.”
- Also, “Once the worst symptoms of mania or depression are under control, treatment focuses on preventing a recurrence. People who have suffered a manic episode are often advised to continue taking medicine(s) to control bipolar disorder. Although medicines are the treatment of choice for bipolar disorder, counseling and talk therapy also have an important role in treatment. This is especially true after an acute episode has passed. Psychotherapy may include individual counseling as well as education, marital and family therapy, or treatment of alcohol and/or drug abuse. Therapy can help you to stick with your medicine, which can decrease the risk of relapse and the need for hospitalization.”
Kelli is amenable to being held for the state’s required psychological hold. She says she wants to be able to live her life as “normally” as possible. She asks about medications that may be available to help.
What patient education about medications should the nurse provide at this time?
- While it is beyond the scope of the RN to prescribe medications, generalized education on pharmaceutical options is acceptable. Saying something like, “Treatments with medications is recommended for people with bipolar disorder, and studies show starting it early and maintaining it is best.” Point out there may be multiple medications needed and they may need to be changed and/or adjusted for her individual responses.
The nurse knows which medications may be prescribed for long-term management of this condition?
- Mood stabilizers (examples: lithium, valproic acid, divalproex sodium, carbamazepine,and lamotrigine). Antipsychotics. [examples: olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris)]
Antidepressants or antidepressant-antipsychotic combo like Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine
Anti-anxiety medications (example: benzodiazepines)
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Transcript
Hey everyone. My name is Abby. We’re going to go through a case study for bipolar disorder together. Let’s get started in this scenario. We have a patient named Kelli. She’s 20 years old and brought to the ER after being reported by her neighbors in her apartment complex for a disruption. Law enforcement and emergency medical services were called, and, as a team, decided that she needed a higher level of care. The patient says that she is on a break from art college and works at a local restaurant as a server and occasionally cleans houses as well. She has also sold her paintings and drawings in the past. She denies taking any medication. She states, “I don’t understand why I’m here. I was working on my art projects and I guess I played my music too loudly or something. I said, I’d come here. So I would not be arrested. Now that we have the scenario, let’s take a look at our critical thinking checks number one and number two below.
Great job. Kelli’s drug and alcohol tests were negative. Her roommate is now at the bedside and asked to speak to staff privately. She expresses concern that Kelli has been very emotional at times and going for days without sleep and then not being able to get out of bed. These are some pretty major fluctuations. The nurse returns to further evaluate the patient. Now that we have some more information, let’s take a look at our critical thinking check number three below.
Well done. Kelli admits to being able to stay awake for what seems like entire weekends without being tired. And that is when she says her creativity was best when she was attending college and living in the dorms. She said she had lots of friends, but worried about what she calls, “all the partying.” This is because she liked to hook up with strangers because it was fun. But she worries about possibly contracting some sexually transmitted infections. Now that she is older, she says she was extremely popular and her talent was at its peak at this time. But there are times she could not pay attention in class or even get out of bed, so she dropped out of school. Sometimes she could not even touch her art supplies, but says she is probably the “most talented artist around.” In light of this new info, let’s take a look at our critical thinking checks. Number four and number five below.
Great job. Kelli’s medical records have arrived, and the provider advises nursing staff that she has a history of being brought to the ER for similar episodes. The provider says, “This patient is a schizophrenic. We don’t have time for this.” Knowing that information, let’s take a look at our critical thinking check number six below.
Well done. Kelli is now resting quietly in the exam room with her roommate at her bedside. She asks, “Can someone help me get better? I am tired of this. I am such a burden on everyone.” Now, what does this tell you that we might be concerned about? Take a look at our critical thinking checks number seven and number eight below. And you decide.
Great job. Kelli is amenable to being held for the state’s required psychological hold. She says she wants to be able to live her life as normally as possible. She asks about medications that may be available to help. Now that we have some more information, let’s take a look at our critical thinking checks. Number nine and number 10 below.
Fantastic work. This wraps up our case study on bipolar disorder. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you guys now go out and be your best self today. And as always happy nursing.
References:
Bipolar disorder in adults: Clinical features
Author:Trisha Suppes, MD, PhD updated Jan 2020; Bipolar disorder in adults: Assessment and diagnosis
Author:Trisha Suppes, MD, PhD updated Feb 2021; Bipolar disorder in adults: Choosing maintenance treatment
Author:Robert M Post, MD updated Dec 2021
U.S. Department of Health and Human Services. (n.d.). Bipolar disorder. National Institute of Mental Health. Retrieved January 3, 2022, from https://www.nimh.nih.gov/health/topics/bipolar-disorder
Source is National Institute of Health (NIH)
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