Assignment task:
Case Study with Clinical Judgment Questions: Bipolar Disorder
A 24-year-old male client presented to the emergency department last evening accompanied by their mother with whom they live. Client was only wearing a pair of shorts and a tee-shirt despite the outdoor temperature of 30 degrees Fahrenheit. Client presented as loud and demanding, stating they were "king of the country." Mother reports the client was diagnosed with Bipolar Disorder, Type I, while in college. Symptoms have been controlled with Lithium Carbonate, Risperidone, and out-patient therapy.
Mother believes the client has stopped taking their medications and is not sure the last time client saw their outpatient therapist. Reports the client has not slept for the past three nights, has lost approximately 10 lbs. in the past two weeks, and has not gone to work for a week. Client is employed as a computer software engineer but is stating "Those idiots at work don't how brilliant I am. I refuse to work for people who do not appreciate me!" Client was admitted to the inpatient mental health unit at 0200 this morning.
Hospital Day 1:
Nurse's Notes: 0400 Client admitted to inpatient unit. Initially refused to partake in nursing assessment process loudly stating "I am not staying in a room with any crazy guy! What do you have to eat around this place? I am starving!" Client adhered to assessment when advised they will have a private room and a sandwich was offered, which they were permitted to eat during the assessment.
Thought process is tangential and client is hyperactive. Client stood, stretched, and flexed muscles throughout the interview stating, "I need to keep my body in shape for all the ladies I date." Client admits to only taking prescribed medications "when I remember...I really don't need that stuff anymore." Reports minimal need for sleep or food over the past few days. Denies suicidal or homicidal ideations. Client permitted the nurse to take vital signs and draw bloodwork. Client placed on 1:1 safety precaution until further assessment by treatment team is completed.
Sitting in dayroom with mental health technician at present. Requires frequent redirection not to yell and/or wander on unit while other patients are sleeping.
Vital Signs:
Pulse: 92; Blood Pressure 136/88; Respirations: 22; Temperature: 98.3 po
Labs:
Lithium Level: 0.1 milliequivalents per liter (mEq/L)
Urine Drug Screen: Negative
Blood Alcohol Level (BAL): 0 %
Provider Orders:
Admit to in-patient mental health unit
1:1 Observation
Lithium Carbonate 300 mg po q am and 300 mg q HS
Risperidone-M 2 mg po daily
Risperidone 25 mg IM prn agitation (up to two doses per 24 hours)
Lorazepam 2 mg PO/IM prn anxiety or agitation (maximum daily dose 6 mg)
Milieu activities as tolerated
Lithium level every 2 days
Hospital Day 3:
0800 Nurse's Notes: Client is minimally participating in the therapeutic milieu. 1:1 observation maintained due to inappropriate behaviors including entering female patient rooms, often making provocative comments. Appetite improved, eating 75% of meals. Continues to deny suicidal or homicidal ideations. Lithium level drawn as ordered at 0600, awaiting results. Reports improved mood; denies suicidal ideation, intent, or plan. Compliant with medication regimen.
0830: Lithium level result = 0.30 milliequivalents per liter (mEq/L). Prescriber notified.
Vital Signs: Pulse: 80; Blood Pressure 122/80; Respirations: 18; Temperature: 98.4 po
New Medication Order: Lithium Carbonate 300 mg po q am and 600 mg q HS
Evaluate Outcomes (Evaluation)
A. Explain whether the client met, partially met, or did not meet the expected outcome. Support your response with client information provided.
B. Will the nurse need to revise the plan of care? If yes, describe how the plan of care should be modified.