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? This pt's symptoms that express Bipolar manic are the way she is dressed/presenting herself, the statement "she is looking for her “movie agent”' being the cause of her walking down the middle of a road against traffic at 2300 hours, her expressed enthusiasm, her statement that she is "too busy to bother eating", and her fast-paced subject changing . Neglect of family, failure to eat, groom or bathe due to agitation and distraction, inability to sleep because pt is too frantic and hyperactive, word salads,

2. Write three priority nursing diagnoses for this patient. · Risk for injury r/t to delusional thinking as evidenced by poor choice making. · Risk for imbalanced nutrition, less than body requirements as evidenced by recent weight loss. · Risk-prone health behavior r/t inadequate support group as evidenced by estrangement from family. · Bathing/hygiene self care deficit as evidenced by dirty clothes and strong body odor. · Sporadic wandering

3. What will you include in your teaching plan for this patient regarding lithium/Eskalith therapy? Be specific.
 * Provide the Pt. with written information on symptoms of miinor toxicity: vomiting, diarhea, poor coordination,fine motor tremors, weakness, lassitude; Major toxicity: coarse tremors, severe thirst, tinnitus, dilutre urine.
 * Advise the Pt. to monitor urine specfic gravity; emphasize need for follow-up care to determine lithium effects
 * Advise Pt. that contraception is needed since lithium may harm the fetus.
 * Caution Pt. not tooperate machinery until lithium lvels are stable and response determined; that benfitical effects may take 13weeks.
 * Provide to the Pt. a list of products that interact with lithium abd discuss need for adequate, stable intake of salt and fluids.
 * Advise to have lithium levels monitoered to ensure effectiveness

4. If the psychiatrist adds Depakote/valproic acid to the patient’s treatment regimen, what would you need to monitor and teach the patient? Liver function test, Platelet count, PT/INR, monitor therapeutic range- 50-100mcg/ml; Observe for therapeutic results of med. Teach patient- take with food/milk to reduce GI symptoms; Do not stop abruptly;Avoid harzardous activities until effect of drug is known, can cause drowsiness; Call doctor is malaise, weakness, lethargy, facial swelling, or vomiting occurs; notify prescriber if females become pregnant, or plan to become pregnant.

5. What symptoms does the patient have that meet the criteria for the diagnosis of hyperthyroidism? Weight loss, anxiety, restlessness, emotional lability, insomnia, depression.

6. How does hyperthyroidism affect the patient’s mood? The hypermetabolic state caused by hyperthyroidism can increase stimulation of the CNS as well as the level of thyroid hormones in the blood, which causes feelings of anxiety, overexcitement, distress, irritability, emotional lability, shakiness and restlessness.

7. What is Lithium toxicity? What signs and symptoms would the patient exhibit? When sodium levels exceed 1.5 to 2.5 mEq/L Pt. 's begin to produce Lithium toxicity. This includes gastrointestinal discomfort, tremors, confusion,somnolence, seizures, and possibly death. The most serious adverse effect is cardiac dystrhythmia. Other effects include drowiness, slurred speech, epiletic like seizures, choreoathtotic movementsand hypertension. Long term treatment may cause hypothyroidism.