Bipolar Disorder Case Study
This is a case study of Sarah, a 39 year old female who presented at the emergency department with her husband, who is worried about her recent behaviour. She is showing classic signs of Hypomania, which is commonly associated with Bipolar Disorder. Hypomania has distinguishing features and can be displayed with high energy levels, positive mood, irritability, inappropriate behaviour, heightened creativity and mystical experiences (Athanasos 2009). Bipolar Disorder sufferers not only experience highs like hypomania, but also the lows of depression. Diagnosis of Bipolar Disorder can only be made by a qualified health provider like a psychiatrist and is following one or more manic and depressive episodes (Parker 2007). There is no known cure
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for Bipolar Disorder but with medical management, a stable and productive life can be led with the condition well controlled (Athanasos 2009). This essay will provide the assessments undertaken with Sarah to obtain data that has then been used to develop the included nursing care plan. Nursing Diagnoses that identify nursing concerns and nursing interventions used to achieve desired outcomes are also discussed.
NURSING ASSESSMENTS
The first stage of the nursing process is the assessment of the patient. The assessment stage is used to collect, organise, validate and document data (Smith, Duell & Martin 2008) that is then used in the diagnosis and subsequent care plan for the patient. Assessment is done via an interview with the patient and anyone they consent to be involved. The assessment interview is the main way that the nurse can begin to develop a therapeutic relationship with the patient. A therapeutic nurse-patient relationship is paramount in obtaining positive outcomes for the patient. The interview should be conducted in a therapeutic milieu, one that is private with low stimulation and chosen by the patient with regard given to the safety of the nurse and the patient (Barling 2009). The way the nurse conducts themselves during the interview is vitally important to developing a therapeutic relationship. Nurses may intimidate the patient through unconscious behaviours or inconsideration comments. Therefore, nurses must use empathy, compassion, be understanding, be non-judgemental and they must be active listeners to develop a rapport and build trust with the patient (Usher, Foster & Luck 2009). Once all of the assessments listed below have been completed Sarah will be referred to a specialist for a full assessment and diagnosis.
The biopsychosocial model of assessment provides a comprehensive evaluation of the patient.
It allows information regarding the biological, psychological, sociological, developmental, spiritual and cultural aspects of the patient to be collected (Barling 2009). This assessment establishes a baseline by providing a snapshot of where the patient is that particular moment, creates a written record and helps to determine any changes during treatment. Assessments should be performed regularly to monitor any changes in behaviour following the initial assessment. Open ended questions will receive more constructive responses from the patient (Barling 2009). Biological aspects include questions regarding the patient 's current and past health status and a pharmacologic assessment will help to determine what treatment had been given previously, and what medications where prescribed (Geddes 2003). Questions regarding any other licit or illicit drug taking should also be asked. A physical examination with review of body systems and physical functions should also be undertaken to ascertain if there are any medical issues or problems and also to give a baseline for future reference. It will also help determine whether the medication that had been previously prescribed for Sarah has been adequately taken. This will also help to establish Sarah 's knowledge of the medication and whether Sarah and her husband require further education regarding the possible side effects of wrong …show more content…
administration.
Psychological assessments including mental status examination (MSE) which incorporates general observations of appearance, behaviour, attitude, mood, affect, orientation and emotions are also carried out. Whilst interviewing Sarah the nurse should be observing her speech. This will help to provide clues regarding her thoughts, emotional patterns and cognitive organisation. The way Sarah varies her emotional expression is vital to help identify what makes her happy, sad, angry, frustrated, irritated or helpless (Barling 2009). The behaviour shown by Sarah will help to identify any patterns to significant events, like the anniversary of the death of her father. The information derived from this examination will help to determine Sarah 's functional status and evaluate her present ability to cope with the disorder (Jones & Jones 2008). A risk factor assessment will establish whether Sarah is at risk of self harm, suicide or assault. This is significant in Sarah 's case as her husband had threatened her with divorce if she didn 't accompany him to the hospital, which in turn had caused anger for her due to this ultimatum. The risk assessment should be performed at regular intervals to promote safety of Sarah, her family and health care workers.
Social assessment of Sarah will help to provide information regarding her functional status, social systems, occupational, economic, legal status and quality of life (Jones & Jones 2008). Important information about Sarah 's recent shopping expeditions, extreme spending habits and partying all night will be documented with Sarah being able to express how she feels when this is happening and also, how she feels and deals with the emotions in the following days. This assessment will also reveal how she deals with the loss of her father and her feelings regarding her possible marital problems. A Spiritual assessment will provide a more complex understanding of Sarah and her beliefs and thoughts on God and Religion (Barling 2009). This assessment along with one regarding her culture will help to provide appropriate, competent nursing care.
NURSING DIAGNOSES
Diagnosis of Bipolar disorder is based on Sarah 's self-reported experiences, abnormalities in behaviour reported by her husband and evaluation by a qualified mental health professional (Goodwin 2003). Nursing diagnoses are made by analysing the data collected, drawing on knowledge and experience, applying diagnostic reasoning, identifying genuine and prospective health problems and making decisions on the patients needs (Crisp & Taylor 2003). From the data collected when assessing Sarah the nursing diagnoses would include a deficient of knowledge regarding her disorder, effective treatment and management due to her lack of managing the disorder. This nursing diagnosis will require an assessment from a qualified mental health professional to be undertaken to determine her level of knowledge and understanding. Sarah 's nursing diagnoses would include readiness for enhanced sleeping patterns due to her condition and deficit in self-care due to her lack of showering and eating following periods of hypomania. Excessive compulsive behaviours surrounding her spending money sprees, lack of social support networks following the disagreements with her husband, risk of social loss due to her lack of employment, grieving following her father 's death and suspected drug use are all issues that need to be discussed with Sarah as possible nursing concerns (Brown & Edwards 2008).
NURSING INTERVENTIONS
The formulated nursing diagnoses provide direction for the planning process and the selection of nursing interventions to achieve the desired outcomes (Crisp & Taylor, 2003). The legal requirement of informed consent must be upheld and Sarah should be consulted will all aspects of intervention. Initial intervention would include the nurse to request a full assessment from a qualified mental health professional to establish if admission to the hospital is required. Expected outcomes are what are expected to be achieved by implementation of nursing interventions. Discharge planning begins upon admission and this is an expected outcome for all patients (Brown & Edwards 2008). For Sarah, being discharged from hospital whilst maintaining and managing her disorder would be an expected outcome. It would be expected that Sarah and her family receive adequate education and support to allow this to happen. Sarah 's openness for health improvement should also help to make a difference in her outcome.
CONCLUSION
Nursing assessments are used to gather information regarding patients and by recording and analysing this information nursing diagnoses and comprehensive nursing care plans are created.
Nursing care plans are then used to document care given and desired outcomes of care for patients (Brown & Edwards 2008). Regular patient assessments are to be undertaken to make sure the nursing care plan still meets their needs. This essay has shown the relevant information required to apply the nursing process framework to develop a comprehensive plan of nursing care Sarah. It includes the nursing assessments, nursing diagnoses, nursing strategies and expected outcomes of the comprehensive nursing care
plan.
�
CARE PLAN FOR SARAH:
NURSING DIAGNOSIS / ISSUE
NURSING STRATEGIES
EXPECTED OUTCOME
Development of therapeutic relationship with Sarah.
Show empathy to Sarah.
Be open and honest at all times.
Maintain client privacy and confidentiality.
A therapeutic relationship develops and Sarah works collaboratively with health care professionals to facilitate change.
Further Assessment and Treatment.
Referral to Mental Health Professional for full psychiatric review.
Referral for Cognitive Behavioural Therapy (CBT).
Appointment of a Case Manager when Sarah is discharged from hospital.
Provide information and possible referral to a multidisciplinary team including Community Mental Health Service, Social Workers or Crisis Teams.
Sarah is assessed by mental health professional and receives appropriate and relevant treatment for her condition.
Sarah is aware that she is not alone and there are support systems available to her.
Legal Issues
Discussions with Sarah and her family regarding her Legal Rights and the Mental Health Act.
Sarah and her family are fully aware of their rights regarding privacy and confidentiality, admission and treatment.
Education of disorder.
Education and consultation of disorder and treatment options.
Provide information about management and care strategies.
Sarah and her family have an understanding of bipolar disorder that there is no cure, but condition can be controlled.
This will help the family to work together and reduce their anxiety.
Improved attitude and knowledge about treatments.
Improved social and family functioning.
Improved sense of well-being.
Psychoeducation, signs, planning and symptoms.
Help Sarah to recognise early warning signs of possible episodes, ie changes in physical, mental and emotional status.
Educate Sarah on the triggers and implement an action plan for her to use.
Implementation of action plan in the event of a crisis.
Educate Sarah on coping strategies.
Arm Sarah with tools to improve self-management of life stressors.
Prevention of relapse.
Maximisation of patient support.
Sarah is able to recognise the signs of an episode and is able to manage them effectively.
Sarah is comfortable in the knowledge that she is not alone in this and there are people who she can call upon.
Sarah is aware of life stressors and manages them effectively.
Compliance with Medication.
Educate Sarah on the effects of incorrect management of medication, possible side effects and precautions.
Arrange for pharmacist to meet with her to answer any further questions she may have regarding the medication.
Organise weekly reviews of the effectiveness of Sarah 's medication.
Sarah is aware of the importance of her medication and takes it as prescribed.
Increased medication adherence.
Sleep Deficit
Discussions regarding the need for regular sleep and promotion of self care.
Sarah to recognise importance of sleep and self care on her health.
Death of father.
Provide Sarah with information regarding grief counsellors.
Sarah seeks help in dealing with her grief.
Help to impact on positive outcome for Sarah.
Possible problems with Sarah 's marriage.
Provide Sarah and her husband with information regarding marriage guidance counsellors.
Sarah and her husband work through their issues together and improve their marital relationship.
Help to impact on positive outcome for Sarah.
Monitoring of Sarah 's progress.
Regular evaluations by mental health/case worker.
Monitoring of cognitive abilities and social behaviour.
To help improve the possibility of a positive outcome for Sarah.
Improved behaviours from Sarah due to improved mental health.
Family Therapy and Support.
Education of Sarah 's family regarding Bipolar Disorder and living with the disorder.
Provide family with information regarding community support programmes.
Regular attendance of Sarah and her family at these support programmes.
Allow Sarah 's family to be involved and support her in the management of the disorder which will help to impact on a positive outcome for Sarah.
Coping strategies following discharge.
Implementation of a Wellness programme.
Sarah manages her condition and is able to function well in the community..
Review of Care Plan with Sarah and her family.
Under the Mental Health Act the care plan must be prepared and revised in consultation with Sarah and her family.
Sarah and her family review and are aware of her care plan and abide by it.
�
REFERENCES:
Athanasos, P 2009, 'Mood disorders ' in R Elder, K Evans, D Nizette (eds), _Psychiatric and Mental Health Nursing_, 2nd edn, Elsevier Mosby, Sydney.
Barling, J 2009, 'Assessment and Diagnosis ' in R Elder, K Evans, D Nizette (eds), _Psychiatric and Mental Health Nursing_, 2nd edn, Elsevier Mosby, Sydney.
Brown, D & Edwards, H 2008, '_Lewis 's medical-surgical nursing - Assessment and Management of Clinical Problems '_, 2nd edn, Mosby Elsevier, Marrickville.
Crisp, J & Taylor, C 2003, _ 'Potter & Perry 's Fundamentals of Nursing '_, Elsevier Mosby, Marrickville.
Geddes, J 2003, 'Prodromal symptoms may be identified by people with bipolar mood disorder ' in _Evidence Based Mental Health_, 2003, vol. 6, p.105.
Goodwin, G M 2003, Evidenced based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology in _Journal Psychopharmacol_, 2003, vol 17, p 149,
Jones, M & Jones A 2008, 'Promotion of choice in the care of people with bipolar disorder: a mental health nursing perspective ' in _Journal of Psychiatric and Mental Health Nursing_, 2008, vol 15, pp.87-92.
Parker, G 2007, 'Bipolar Disorder: Assessment and management ', in _Australian Family Physician_, vol. 36, no. 3, March 2007.
Smith, S.F, Duell, D.J & Martin, B.C 2008, _Clinical Nursing Skills - Basic to Advanced Skills_, 7th edn, Pearson Education Inc, New Jersey.
Usher, K, Foster, K & Luck, L 2009, 'The patient as person ' in R Elder, K Evans, D Nizette (eds), _Psychiatric and Mental Health Nursing_, 2nd edn, Elsevier Mosby, Sydney.
for Bipolar Disorder but with medical management, a stable and productive life can be led with the condition well controlled (Athanasos 2009). This essay will provide the assessments undertaken with Sarah to obtain data that has then been used to develop the included nursing care plan. Nursing Diagnoses that identify nursing concerns and nursing interventions used to achieve desired outcomes are also discussed.
NURSING ASSESSMENTS
The first stage of the nursing process is the assessment of the patient. The assessment stage is used to collect, organise, validate and document data (Smith, Duell & Martin 2008) that is then used in the diagnosis and subsequent care plan for the patient. Assessment is done via an interview with the patient and anyone they consent to be involved. The assessment interview is the main way that the nurse can begin to develop a therapeutic relationship with the patient. A therapeutic nurse-patient relationship is paramount in obtaining positive outcomes for the patient. The interview should be conducted in a therapeutic milieu, one that is private with low stimulation and chosen by the patient with regard given to the safety of the nurse and the patient (Barling 2009). The way the nurse conducts themselves during the interview is vitally important to developing a therapeutic relationship. Nurses may intimidate the patient through unconscious behaviours or inconsideration comments. Therefore, nurses must use empathy, compassion, be understanding, be non-judgemental and they must be active listeners to develop a rapport and build trust with the patient (Usher, Foster & Luck 2009). Once all of the assessments listed below have been completed Sarah will be referred to a specialist for a full assessment and diagnosis.
The biopsychosocial model of assessment provides a comprehensive evaluation of the patient.
It allows information regarding the biological, psychological, sociological, developmental, spiritual and cultural aspects of the patient to be collected (Barling 2009). This assessment establishes a baseline by providing a snapshot of where the patient is that particular moment, creates a written record and helps to determine any changes during treatment. Assessments should be performed regularly to monitor any changes in behaviour following the initial assessment. Open ended questions will receive more constructive responses from the patient (Barling 2009). Biological aspects include questions regarding the patient 's current and past health status and a pharmacologic assessment will help to determine what treatment had been given previously, and what medications where prescribed (Geddes 2003). Questions regarding any other licit or illicit drug taking should also be asked. A physical examination with review of body systems and physical functions should also be undertaken to ascertain if there are any medical issues or problems and also to give a baseline for future reference. It will also help determine whether the medication that had been previously prescribed for Sarah has been adequately taken. This will also help to establish Sarah 's knowledge of the medication and whether Sarah and her husband require further education regarding the possible side effects of wrong …show more content…
administration.
Psychological assessments including mental status examination (MSE) which incorporates general observations of appearance, behaviour, attitude, mood, affect, orientation and emotions are also carried out. Whilst interviewing Sarah the nurse should be observing her speech. This will help to provide clues regarding her thoughts, emotional patterns and cognitive organisation. The way Sarah varies her emotional expression is vital to help identify what makes her happy, sad, angry, frustrated, irritated or helpless (Barling 2009). The behaviour shown by Sarah will help to identify any patterns to significant events, like the anniversary of the death of her father. The information derived from this examination will help to determine Sarah 's functional status and evaluate her present ability to cope with the disorder (Jones & Jones 2008). A risk factor assessment will establish whether Sarah is at risk of self harm, suicide or assault. This is significant in Sarah 's case as her husband had threatened her with divorce if she didn 't accompany him to the hospital, which in turn had caused anger for her due to this ultimatum. The risk assessment should be performed at regular intervals to promote safety of Sarah, her family and health care workers.
Social assessment of Sarah will help to provide information regarding her functional status, social systems, occupational, economic, legal status and quality of life (Jones & Jones 2008). Important information about Sarah 's recent shopping expeditions, extreme spending habits and partying all night will be documented with Sarah being able to express how she feels when this is happening and also, how she feels and deals with the emotions in the following days. This assessment will also reveal how she deals with the loss of her father and her feelings regarding her possible marital problems. A Spiritual assessment will provide a more complex understanding of Sarah and her beliefs and thoughts on God and Religion (Barling 2009). This assessment along with one regarding her culture will help to provide appropriate, competent nursing care.
NURSING DIAGNOSES
Diagnosis of Bipolar disorder is based on Sarah 's self-reported experiences, abnormalities in behaviour reported by her husband and evaluation by a qualified mental health professional (Goodwin 2003). Nursing diagnoses are made by analysing the data collected, drawing on knowledge and experience, applying diagnostic reasoning, identifying genuine and prospective health problems and making decisions on the patients needs (Crisp & Taylor 2003). From the data collected when assessing Sarah the nursing diagnoses would include a deficient of knowledge regarding her disorder, effective treatment and management due to her lack of managing the disorder. This nursing diagnosis will require an assessment from a qualified mental health professional to be undertaken to determine her level of knowledge and understanding. Sarah 's nursing diagnoses would include readiness for enhanced sleeping patterns due to her condition and deficit in self-care due to her lack of showering and eating following periods of hypomania. Excessive compulsive behaviours surrounding her spending money sprees, lack of social support networks following the disagreements with her husband, risk of social loss due to her lack of employment, grieving following her father 's death and suspected drug use are all issues that need to be discussed with Sarah as possible nursing concerns (Brown & Edwards 2008).
NURSING INTERVENTIONS
The formulated nursing diagnoses provide direction for the planning process and the selection of nursing interventions to achieve the desired outcomes (Crisp & Taylor, 2003). The legal requirement of informed consent must be upheld and Sarah should be consulted will all aspects of intervention. Initial intervention would include the nurse to request a full assessment from a qualified mental health professional to establish if admission to the hospital is required. Expected outcomes are what are expected to be achieved by implementation of nursing interventions. Discharge planning begins upon admission and this is an expected outcome for all patients (Brown & Edwards 2008). For Sarah, being discharged from hospital whilst maintaining and managing her disorder would be an expected outcome. It would be expected that Sarah and her family receive adequate education and support to allow this to happen. Sarah 's openness for health improvement should also help to make a difference in her outcome.
CONCLUSION
Nursing assessments are used to gather information regarding patients and by recording and analysing this information nursing diagnoses and comprehensive nursing care plans are created.
Nursing care plans are then used to document care given and desired outcomes of care for patients (Brown & Edwards 2008). Regular patient assessments are to be undertaken to make sure the nursing care plan still meets their needs. This essay has shown the relevant information required to apply the nursing process framework to develop a comprehensive plan of nursing care Sarah. It includes the nursing assessments, nursing diagnoses, nursing strategies and expected outcomes of the comprehensive nursing care
plan.
�
CARE PLAN FOR SARAH:
NURSING DIAGNOSIS / ISSUE
NURSING STRATEGIES
EXPECTED OUTCOME
Development of therapeutic relationship with Sarah.
Show empathy to Sarah.
Be open and honest at all times.
Maintain client privacy and confidentiality.
A therapeutic relationship develops and Sarah works collaboratively with health care professionals to facilitate change.
Further Assessment and Treatment.
Referral to Mental Health Professional for full psychiatric review.
Referral for Cognitive Behavioural Therapy (CBT).
Appointment of a Case Manager when Sarah is discharged from hospital.
Provide information and possible referral to a multidisciplinary team including Community Mental Health Service, Social Workers or Crisis Teams.
Sarah is assessed by mental health professional and receives appropriate and relevant treatment for her condition.
Sarah is aware that she is not alone and there are support systems available to her.
Legal Issues
Discussions with Sarah and her family regarding her Legal Rights and the Mental Health Act.
Sarah and her family are fully aware of their rights regarding privacy and confidentiality, admission and treatment.
Education of disorder.
Education and consultation of disorder and treatment options.
Provide information about management and care strategies.
Sarah and her family have an understanding of bipolar disorder that there is no cure, but condition can be controlled.
This will help the family to work together and reduce their anxiety.
Improved attitude and knowledge about treatments.
Improved social and family functioning.
Improved sense of well-being.
Psychoeducation, signs, planning and symptoms.
Help Sarah to recognise early warning signs of possible episodes, ie changes in physical, mental and emotional status.
Educate Sarah on the triggers and implement an action plan for her to use.
Implementation of action plan in the event of a crisis.
Educate Sarah on coping strategies.
Arm Sarah with tools to improve self-management of life stressors.
Prevention of relapse.
Maximisation of patient support.
Sarah is able to recognise the signs of an episode and is able to manage them effectively.
Sarah is comfortable in the knowledge that she is not alone in this and there are people who she can call upon.
Sarah is aware of life stressors and manages them effectively.
Compliance with Medication.
Educate Sarah on the effects of incorrect management of medication, possible side effects and precautions.
Arrange for pharmacist to meet with her to answer any further questions she may have regarding the medication.
Organise weekly reviews of the effectiveness of Sarah 's medication.
Sarah is aware of the importance of her medication and takes it as prescribed.
Increased medication adherence.
Sleep Deficit
Discussions regarding the need for regular sleep and promotion of self care.
Sarah to recognise importance of sleep and self care on her health.
Death of father.
Provide Sarah with information regarding grief counsellors.
Sarah seeks help in dealing with her grief.
Help to impact on positive outcome for Sarah.
Possible problems with Sarah 's marriage.
Provide Sarah and her husband with information regarding marriage guidance counsellors.
Sarah and her husband work through their issues together and improve their marital relationship.
Help to impact on positive outcome for Sarah.
Monitoring of Sarah 's progress.
Regular evaluations by mental health/case worker.
Monitoring of cognitive abilities and social behaviour.
To help improve the possibility of a positive outcome for Sarah.
Improved behaviours from Sarah due to improved mental health.
Family Therapy and Support.
Education of Sarah 's family regarding Bipolar Disorder and living with the disorder.
Provide family with information regarding community support programmes.
Regular attendance of Sarah and her family at these support programmes.
Allow Sarah 's family to be involved and support her in the management of the disorder which will help to impact on a positive outcome for Sarah.
Coping strategies following discharge.
Implementation of a Wellness programme.
Sarah manages her condition and is able to function well in the community..
Review of Care Plan with Sarah and her family.
Under the Mental Health Act the care plan must be prepared and revised in consultation with Sarah and her family.
Sarah and her family review and are aware of her care plan and abide by it.
�
REFERENCES:
Athanasos, P 2009, 'Mood disorders ' in R Elder, K Evans, D Nizette (eds), _Psychiatric and Mental Health Nursing_, 2nd edn, Elsevier Mosby, Sydney.
Barling, J 2009, 'Assessment and Diagnosis ' in R Elder, K Evans, D Nizette (eds), _Psychiatric and Mental Health Nursing_, 2nd edn, Elsevier Mosby, Sydney.
Brown, D & Edwards, H 2008, '_Lewis 's medical-surgical nursing - Assessment and Management of Clinical Problems '_, 2nd edn, Mosby Elsevier, Marrickville.
Crisp, J & Taylor, C 2003, _ 'Potter & Perry 's Fundamentals of Nursing '_, Elsevier Mosby, Marrickville.
Geddes, J 2003, 'Prodromal symptoms may be identified by people with bipolar mood disorder ' in _Evidence Based Mental Health_, 2003, vol. 6, p.105.
Goodwin, G M 2003, Evidenced based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology in _Journal Psychopharmacol_, 2003, vol 17, p 149,
Jones, M & Jones A 2008, 'Promotion of choice in the care of people with bipolar disorder: a mental health nursing perspective ' in _Journal of Psychiatric and Mental Health Nursing_, 2008, vol 15, pp.87-92.
Parker, G 2007, 'Bipolar Disorder: Assessment and management ', in _Australian Family Physician_, vol. 36, no. 3, March 2007.
Smith, S.F, Duell, D.J & Martin, B.C 2008, _Clinical Nursing Skills - Basic to Advanced Skills_, 7th edn, Pearson Education Inc, New Jersey.
Usher, K, Foster, K & Luck, L 2009, 'The patient as person ' in R Elder, K Evans, D Nizette (eds), _Psychiatric and Mental Health Nursing_, 2nd edn, Elsevier Mosby, Sydney.