Presenting Behaviors of Patient - Case Study Example

Nursing Plan Patient "Sarah" The patient is a 39 year old woman who was brought into the emergency room because her husband is concerned with her behavior. She has always had episodes of hyperactivity and energy that were countered by symptoms of sadness to the point that she could not get out of bed. According to her husband these bouts became more pronounced after the death of her father. Currently the patient appears to be in a high euphoric state where she is spending money and may be having sex with some of her co-workers; she is spending a lot of time with a group of new friends going out and staying out much of the night. The patient has been fired from several jobs. When she does work it becomes difficult for co-workers as she moves into one of her depressive cycles. During this time she becomes "caustic" and "irritable". With her presenting behaviors the patient has been given a diagnosis of "Bipolar Disorder". The case study did not specifically say whether she was diagnosed with Bipolar Disorder I or II but from the presenting problems it appears to be Bipolar Disorder I. Textbook Diagnosis Criteria The DSM-IV (1994) describes Bipolar Disorder within several different categories. It describes 296.4x Bipolar I Disorder as having the "most recent episode manic." This is the case with the patient. The criteria for this is someone who has "most recently had a manic episode, there has been at least one major depressive episode" (DSM-IV, p. 357)and other types of disorders have been ruled out.. Bipolar Disorder usually begins between the ages of 21 and 30 and it has been statistically shown that over 50% of bipolar patients also have a challenge with substance abuse (Boyd and Nihart, 1998, 0. 456). Although it is only reported from the husband that substance abuse or drugs "may" be involved it is something that needs to be explored more thoroughly. The patient also started having bouts of depression before the age of 34 (their current age) and these periods exacerbated at the death of her father. Clinical issues that present themselves in Bipolar Disorder include an elevated or irritable mood, impaired functioning and several depressive and manic phases. There are also challenges with interpersonal relationships. The disorder also has behaviors of "reckless spending which can cause financial ruin and work related problems that can include difficulty in focusing" (Boyd and Nihart, p. 457). The patient has been spending money "recklessly" according to her husband on items that they cannot afford. The patient is also having problems with irritable mood and the depressive and manic phases; her husband brought her to the clinic because of these various behaviors. According to the husband this situation is also causing a strain on their marriage which is another reason he has "forced" his wife to seek help by threatening divorce. Presenting Behaviors of Patient Patient is a 39 year old married woman who has been sporadically unemployed and she has not been functioning well. Her husband brought her in to the emergency room of the hospital because of her current manic phase and he is worried about her behavior. Prior to coming into the hospital she has experienced depression symptoms with added feelings of listlessness and intermittent insomnia with a loss of appetite on some days. The last depression cycle lasted two months in which the patient could not get out of bed and often did not take care of her personal hygiene needs. This happened also when her father died two years ago. The patient currently went into a manic phase where she showed energy, hyperactivity and euphoria. In addition, she had strong sexual desire towards her husband and was bright and self-confident. This lasted for three weeks and it was followed with a week where she could not get out of bed, she slept excessively and complained of exhaustion. During her energetic periods, and during this current time, she spends money on shoes, hi-fi equipment and other goods. Although not substantiated, there may be sexual intercourse outside the marriage with various co-workers. The patient has also had problems on her jobs because of her behavior and she can become "irritable" and "caustic" as she goes into her depressive cycle. The bouts of depression may be linked to her fathers death. Currently she is in an energetic mood going out with new friends, shopping and "running up debt" according to her husband. There may also be drug abuse. If this is true, it is very important to monitor her medication. Medication The patient has been given sodium valproate. She was reluctant to take this medication which created problems for her stabilization and her current relationships with her husband. Nursing Diagnosis The patient appears to have challenges with mood swings. According to the case study she has already been diagnosed with Bipolar Disorder. It was apparent from the study that she needs intervention to assist her with mood swings. This is the most important aspect of her treatment so that she can begin to function more fully. With the treatment for the mood swings some of the other behaviors may disappear. Another area that may be in need of treatment is any substance abuse challenges. It is not known at this point whether this actually exists but it should be explored. The case study doe snot say whether the patient was talked to directly but it relied mostly on what the husband communicated. It is very important to do intake with the patient to see what they think of their behavior and how they are feeling. Because she was brought to the hospital against her will, having a conversation with her and explaining what is happening may have helped her become more comfortable with the course of treatment. Another need that the patient will have is counseling. In mood disorders and other aspects of mental illness some form of psychotherapy is necessary to work in conjunction with medication. Many researchers have found through a variety of studies that Cognitive Behavioral Therapy (CBT) works best for patients with mood disorders. Zaretsky et. al (2008) choose to look at two primary types of psychotherapy for bipolar patients: CBT and psychoeducation. They found that CBT was more effective than psychoeducation because it was able to reduce "residual depressive symptoms" in Bipolar disorder (Zaretsky et. al, p. 441). Their research studied 225 outpatients between the ages of 18 and 60 and consisted of both Bipolar I and II (Zaretsky, et. al, p. 442). Their research is important because it examined the power of CBT for this disorder. The patient could benefit form CBT and a recommendation should be made because it could help her deal with issues with her father that have been triggers to her depression in the past. When working as a psychiatric nurse it is important to know the difference between your role and the doctors role. In this case study the doctors job has already been done and the diagnosis has been made; it is up to the psychiatric nurse to carry out the orders and make sure that the patient is comfortable. The nurse should also note any other behaviors or information that may come up as the patient continues treatment. To this end the psychiatric nurse has the responsibility of knowing everything they can about the particular mental illness that they are working with and the interventions that are available. When this information is known, it allows the nurse to work more effectively with the patient. In this case it would be very beneficial for the nurse to understand Bipolar Disorder behavior so they can work with this patient to help them understand their illness and why they have a need for medication and counseling. Kaplan and Sadock (1996) spoke to the fact that many bipolar patients have problems with sleep. They state that these patients often "perceive" that they do not need a lot of sleep. They state that this is a "classic" manic symptom (p. 161). Perhaps this is one of the triggers that this patients husband can be aware of as he continues to live with his wife. This patient has shown bouts of insomnia and this may be one of the reasons why going out with her friends has been so rewarding for her lately. This is something that would need more exploration. Kaplan and Sadock also describe psychosocial factors for patients with bipolar disorder particularly with stressful life events. They state that studies have shown that in the first episodes of depression the brain may be malfunctioning in some way that causes a long-term change in the brains biology. They go on to say that this may influence certain neurotransmitters in the brain to have difficulty functioning (Kaplan and Sadock, p. 162). Andreasen (2001) is credited with doing extensive research on the brain to study mental illness. She backs up the thoughts of Kaplan and Sadock to show that the brain is affected by mental illness. She found that mood disorders are a brain disorder: When stressful experiences in our daily life get registered in our Cerebral cortex and limbic system as emotionally troubling, those Parts of the brain send an alert to other parts of the body so we are Prepared to cope (Andreasen, p. 235). Keeping this in mind it was also found through their research that the system in the brain that regulates cortisol does not work properly in a persons brain who has a mood disorder so it sends more cortisol to the brain than necessary. This creates problems with sleep and disturbs eating patterns (Andreasen, p. 236). Perhaps this is an area that should be tested for this patient to see whether there are physical reasons for her illness. Cause of Patients Bipolar Disorder There are no concrete reasons for Bipolar Disorder although the most popular reasons suggest that it is genetic, biological or that it is a brain malfunction. We may never know the reason for the patients condition but we can take a look at the psychosocial area. What is known about the patient is that the major aspects of her illness began after her father died. This could be a clue that what she is experiencing is grief and that the manic/depressive phases are a product of her grief. There is no medical history so it is not known whether her father suffered from depression or Bipolar Disorder and there is no indication of her relationship with her mother. Both of these pieces of information could be important to helping her with her recovery. This patient also has challenges with her marriage which may need to be explored. There may be a need for family counseling and education for her husband to understand more what he can do as a person living with his wife. If the psychosocial aspects of this patients life can be eased she may be able to make a full recovery from her illness and eventually get off her medication. Medication Currently the patient has been prescribed sodium valporate. This seems to be effective when she takes it. This medication is being used to stabilize her mood swings. All medication has side effects so the patient will need to communicate with the nurse if there are any problems. According to Barker (2003) it is important that the nurse informs the patient of any problems with the medication that may affect their lifestyle (p. 284). The case study does not say whether the patient was given instruction about the medication, its possible side effects, or the reason for taking it. A psychiatric nurse would be responsible for making sure that this information was transferred to the patient in a way that she could understand it. The nurse may have to find creative ways also so as not to frighten the patient. The nurse must have a thorough understanding of this medication, its dosages and how it might affect any other medications the patient may be on(Barker, p. 285); the nurse should also explore whether there is drug abuse because this could cause problems with the medication. McColm, Brown and Anderson (2006) state and individual with Bipolar Disorder can be one of the most challenging patients to deal with because of their behavior. They can become aggressive at times and often their symptoms can be indicative of other disorders (p. 46). One of the most challenging aspects can be when the individual is in their manic phase. At this point the patient is feeling great and cannot see why they have an "illness". The nurses job is to "convince" the individual of this fact can be difficult because they can come up with logical and reasonable reasons for why they do not need medication and so forth. It is also necessary to decide whether a patient is at risk of hurting themselves or others in their manic phase to make sure that everyone is protected. Nursing interventions should always be centered on patient need and the individual must be able to develop a relationship of trust with the nurse in charge of their care (McColm, et.al, p. 47). It is important to take into consideration any risk factors that may not be apparent in the beginning but may be in the future. As an example, many patients get aggressive when they are entering into or exhibiting a manic phase. Although the case study did not say anything to this affect, it is important to know whether this patient has ever been overly aggressive at work or with her husband. There may need to be a combination of medication that would also help the aggressiveness if necessary. The risk factor to harm someone would be dealt with separately. A psychiatric nurse should also read more of the research that has been done and that is currently being done on Bipolar Disorder because there may be some interventions that are new and are working. McColm, et. al suggest that there should be more research done on mania becaue the literature is lacking in this area; this could lead to further nursing research. Most of the literature has done studies on bipolar illness rather than on the incidence of mania (McColm, et. al p. 49). At some point in the future the patient from this case study will also need to learn to take care of their illness with or without medication. Many professionals suggest that the individual keep a chart that keeps track of the things that may trigger their mood swings. This can give an indication to them and to their doctors about specific situations that trigger either the depression or manic phase. Another aspect of the nurses role in this situation is to provide other resources that the individual may be able to use. As an example, there may be support groups in the area that help them understand how better to cope with their illness. Sometimes being able to talk to other people with similar challenges can help a person move towards their own recovery. The prognosis for this patient is good if she continues to take her medicine. If she does not it may be a more challenging life for her and for her husband. Time will tell as to whether she is open to counseling and to doing what she needs to do for herself. If she gets into counseling, she may be able to take care of any challenges she may be having that trigger her illness. References American Psychiatric Association. 1994. The diagnostic and statistical manual of mental disorders. Fourth Edition. (DSM-IV). Washington, DC: American Psychiatric Association. Andreasen, N.C. 2001. Brave new brain: Conquering mental illness in the era of the genome. NY: Oxford Press. Barker, P. ed. 2003. Psychiatric and mental health nursing: The craft of caring. NY: Oxford Press. Boyd, M.A. and Nihart, M.A. 1998. Psychiatric nursing contemporary practice. NY: Lippincott Publishing. Kaplan, H.I. and Sadock, B.J. 1996. Concise textbook of clinical psychiatry. Maryland: William & Wilkins. Murphy, K. 2006. Managing the ups and downs of bipolar disorder. Nursing 36 (10) p58-64. Available from EBSCOhost Academic Search Premier [AN: 22489263] [Accessed 14 April 2009]. McColm, R., Brown, J. and Anderson, J. 2006. Nursing interventions for the management of patients with mania. Nursing Standard. 20(17), p46-49. Available from EBSCOhost Academic Search Premier Database, [AN: 19654776]. [Accessed 14 April 2009]. Nursing Care Plan. 2007. Nursing Care Plan Blog. [WWW] URL: [Accessed 15 April 2009]. Zaretsky, A., Lancee, W., Miller, C., Harris, A., Parikh, S.V. 2008. Is cognitive-behavioral therapy more effective than psychoeducation in bipolar disorder? The Canadian Journal of Psychiatry, 53(7). Available from EBSCOhost Academic Search Premier Database, [AN: 33625653]. [Accessed 14 April 2009]. Read More