Nurs6630 Week 4: Bipolar Therapy Assignment Paper

Nurs6630 Week 4: Bipolar Therapy Assignment Paper

Week 4: Bipolar Therapy

Jay, an 18-year-old high school senior, presents with symptoms of difficulty sleeping and feeling sad, which results in an initial diagnosis of depression. His mother later reports, however, that Jay exhibits symptoms of irritability and risk-taking behaviors. (His little brother reported to his mother that they were driving over 90 miles an hour on the highway.) After further evaluation, Jay’s psychiatric mental health nurse practitioner diagnosed him with bipolar disorder.Nurs6630 Week 4: Bipolar Therapy Assignment Paper

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Cases like this are not uncommon with bipolar disorder, as initial assessments rarely provides all the information needed. In your role, as a psychiatric mental health nurse practitioner, you must develop strategies for properly assessing and diagnosing these clients because treatments for bipolar disorder are significantly different than treatments for depression or other mood disorders.

This week, as you examine bipolar therapies, you explore the assessment and treatment of clients with bipolar disorder. You also consider ethical and legal implications of these therapies.

Photo Credit: [Vanessa Galeote]/[Hemera / Getty Images Plus]/Getty Images


Assignment: Assessing and Treating Clients with With Bipolar Disorder

Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients often present as depressive or manic, but may have both; and 2) many symptoms of bipolar disorder are similar to other disorders. Misdiagnosis is common, making it essential for you to have a deep understanding of the disorder’s pathophysiology. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with bipolar disorder.

Learning Objectives – Nurs6630 Week 4: Bipolar Therapy Assignment Paper

Students will:

  • Assess client factors and history to develop personalized plans of bipolar therapy for clients
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring bipolar therapy
  • Evaluate efficacy of treatment plans
  • Analyze ethical and legal implications related to prescribing bipolar therapy to clients across the lifespan

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

  • Chapter 6, “Mood Disorders”
  • Chapter 8, “Mood Stabilizers”

Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. New York, NY: Cambridge University Press.

To access the following chapters, click on the Illustrated Guides tab and then the Mood Stabilizers tab.

  • Chapter 4, “Lithium and Various Anticonvulsants as Mood Stabilizers for Bipolar Disorder”
  • Chapter 5, “Atypical Antipsychotics as Mood Stabilizers for Bipolar Disorder”

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

Note: Retrieved from Walden Library databases.

Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6

Note: Retrieved from Walden Library databases.

Required Media

Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources

Mostafavi, A., Solhi, M., Mohammadi, M., Hamedi, M., Keshavarzi, M., & Akhondzadeh, S. (2014). Melatonin decreases olanzapine induced metabolic side-effects in adolescents with bipolar disorder: a randomized double-blind placebo-controlled trial. Acta Medica Iranica, 52(10), 734-739.
Retrieved from http://acta.tums.ac.ir/index.php/acta

To prepare for this Assignment:

  • Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.

The Assignment

Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

  • Decision #1
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.Nurs6630 Week 4: Bipolar Therapy Assignment Paper

Bipolar Therapy – Client of Korean Descent/Ancestry

BACKGROUND INFORMATION

The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.

Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”

She weights 110 lbs. and is 5’ 5”

SUBJECTIVE

Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”

You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.

Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.

MENTAL STATUS EXAM

The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.

The Young Mania Rating Scale (YMRS) score is 22

RESOURCES

§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6

Decision Point One

Select what the PMHNP should do: (for each of the following meds I selected, The study options I got are followed after the meds and I included them for guide)

Begin Lithium 300 mg orally BID

Begin Risperdal 1 mg orally BID

Begin Seroquel XR 100 mg orally at HS

Bipolar Therapy
Client of Korean Descent/Ancestry

Decision Point One

Begin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”
  •  Today’s presentation is similar to the first day you met her

Decision Point Two

Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  •  Client states that the drug makes her nauseated and gives her diarrhea
  •  Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again.Nurs6630 Week 4: Bipolar Therapy Assignment Paper

Decision Point Three

Change Lithium to sustained release preparation at same dose and frequency

Guidance to Student
In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.

Bipolar Therapy
Client of Korean Descent/Ancestry

Decision Point One

Begin Risperdal 1 mg orally BID

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic
  •  Client’s mother explains that “she has been like this since about a week after the last office visit”

Decision Point Two

Decrease Risperdal to 1 mg at HS

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  •  Client is less sedate, less lethargic and shows symptom improvement
  •  Young Mania Rating Scale has decreased from 22 to 16 (a bit more than a 25% decrease in symptoms)

Decision Point Three

Continue at same dose of Risperdal and reassess in 4 weeks

Guidance to Student
At this point, the PMHNP may be wise to allow the client to remain at the same dose and reassess in 4 weeks. Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may have slower clearance of Risperdal from her system, which may have resulted in higher than normal levels of Risperdal in the blood, which in turn resulted in sedation. Therefore, if we were to increase back to 1 mg orally BID, she may have the same side effects. Latuda is FDA approved for bipolar I depression, which is not the presentation we are attempting to treat. Additionally, it is quite expensive and many insurance companies will not pay for it until other agents have been attempted and failed. Nurs6630 Week 4: Bipolar Therapy Assignment Paper

Bipolar Therapy
Client of Korean Descent/Ancestry

Decision Point One

Begin Seroquel XR 100 mg orally at HS

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Client is reporting that she sleeps a bit more at bedtime
  •  Client states that she has gained about 2 or 3 pounds, which she does not like
  •  Client also reports that she has been constipated since starting this medication
  •  Client is also complaining of dry mouth which she does not like.
  •  Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18
  •  Client is reporting really good mood, but is asking for a different medication because of the weight gain

Decision Point Two

Continue same dose of Seroquel and counsel client regarding ways to prevent constipation

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  •  Client continues to experience constipation and has gained an additional 5 pounds
  •  Client feels that her PMHNP is not sympathetic to her concerns and states “I want to stop medication altogether, this is no way to live!”

Decision Point Three

Discontinue Seroquel and go back to Lithium, but this time, using an extended release preparation

Guidance to Student
In this case, the Seroquel is causing side effects through the muscarinic 1 receptors. The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth. When this approach fails, changing drug therapy should be considered.

Discontinuation of the Seroquel in favor of extended release lithium may be appropriate to overcome initial side effects that resulted in discontinuation of lithium, but Lithium takes several weeks to bring about control of manic symptoms. An atypical antipsychotic will need to be used until lithium’s effects can be realized.

Similarly, discontinuation of Seroquel and initiation of Lamictal is not appropriate as the dose of 100 mg is too high. Lamictal must be slowly and cautiously titrated from a starting dose of 25 mg orally daily- otherwise, an increased risk of Steven Johnson Syndrome can occur. Secondly, the Lamictal is not indicated for bipolar mania. Nurs6630 Week 4: Bipolar Therapy Assignment Paper

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