Running head CASE STUDY AND CARE PLAN

Case Study and Care Plan Dermot Connolly Stenberg College PSYN 121-6 Acute Psychiatric Nursing Practice Clinical Dec 24th 2012

CASE STUDY AND CARE PLAN Case Study Psychological and physical health history, MM is a 41 year old Caucasian woman, married to Shawn with two children DM (12) and PM (4). She works as a care aid and although there is no recorded history of mental illness within the family. MM has a past history of bipolar disorder which she was first hospitalized for at the age of 19.MM has a history of medication non compliance resulting in a relapse of hypomania manic disorders. During her last admission, MM was stabilized on divalproex 750 mg at night time 500mg in the morning. After her discharge MM became incompliant with her

medication again despite remaining focused on her community follow up appointments with Dr. Gopinath. On Nov 3rd, MMs parental grandmother died who she was very close to. According to MMs family, soon afterwards she became increasing irritable, restless and was unable to stop herself from having racing thoughts. MM has being diagnosed with diabetes but has being managing it through a self administered raw food diet. MM has no history of alcohol of substance abuse and is a non smoker. Pathophysiology Summary MM has a known allergy to lithium which she reports as a burning sensation after administration. She reports having problems sleeping but was not on any sleeping medication at the time of her admission. In addition to mental health, MMs family is also concerned with her recent weight loss as a result of a self administered raw food diet in which she has lost 70ibs since April 2012. MM has no financial stressors and while she enjoys saving, she has no concerns with excessive spending. At the time of her admission, MM was not taking any medication. At the time of her admission, MMs blood pressure and pulse was slightly elevated

CASE STUDY AND CARE PLAN (blood pressure - 144 / 81, pulse 109) and her Sp O2 was 97%. MMs lab results were all normal but her blood glucose levels were slightly elevated (Spec = 5.5mmol/l fasting, actual reading = 6.6 mmol/l. Spec 7.8mmol/l random, actual reading = 10.5 mmol/l). Medical Diagnoses MM has being diagnosed with an Axis I bipolar 1 disorder with a current relapse of hypomania with a possibility to evolving mania secondary to compliance with medication. Medication non compliance has historically been a problem for MM who has being educated on

the link between medication compliance and bipolar relapse. (Healthy place, 2012). According to the DSM-IV, bipolar 1 disorder is characterized by the occurrence of one or more manic or mixed episodes. (DSM-IV, 2000). Diagnosis also includes a previous history of manic or mixed episodes accompanied with mood symptoms that cause stress or impaired social or occupational functioning. (DSM-IV, 2000). MM has a deferred Axis II diagnoses, indicating that an Axis II is believed to be present but not one that could be categorized at the time. (Michels & Michels, 1997). MM has an Axis III diagnoses outlining a history of diabetes and high blood pressure. MMs recent death of her grandmother was her diagnosis for her Axis IV Psychosocial / Environmental stressor and she was assigned an Axis V global Assessment of Functioning (GAF) of 35-40 indicating that she suffers some impairment to reality / communication or major impairment in other areas such as work, school, judgment or mood. (Psychiatric Assessment, nd).

Mental Status Exam (MSE) A. Attitude, Appearance, and General Behavior

CASE STUDY AND CARE PLAN MM is an age appropriate 41 year old Caucasian woman with green eyes, long brown hair and an Aztec tattoo on her upper left arm. She is dressed in hospital pajamas and dressing gown. Her hair is neat and well groomed, with long clean fingernails. MMs engages readily in conversation and sits upright in her chair at all times. Her speech is monotone and at the appropriate speed and pitch. She makes good eye contact and her psychomotor activity is normal. (Mental status examination guide, nd). B. Mood, Feelings and Affect MMs mood is calm, affect flat and interacts well with the other patients in the common area. MM reports that she is feeling tired from her medication and bored but apart from that she reports that she is feeling fine. She denies having thoughts of harming herself or others as this would be against the will of God. (Mental status examination guide, nd). C. Perceptual Disturbances MM denies any auditory hallucinations but claims to see ghosts wandering around the hospital ward. She denies that these ghosts are communicating to her but does state they interfere with her thought process. During interview, MM pointed to a mural on the wall of a tree stating she saw only violets which represented her and her husband. (Mental status examination guide, nd).

D. Thought Process Patient jumped from one conversation topic to the next without cohesion of thought or ideas. She made several unprovoked references to the death of her grandmother and her believe

CASE STUDY AND CARE PLAN that her soul was not free as she was buried in a crypt which was against Gods wishes. To help counteract her feelings towards her grandmothers burial, MM stated she buried a dead bird in the flower garden which symbolized the proper burial her grandmother should have received. During the interview she made several references to God and her belief that the bible stood for basic instructions before leaving earth. (Mental status examination guide, nd). E. Cognitive Functions MM was alert and oriented to person place and time with no concerns regarding remote or recent memory. (Mental status examination guide, nd). F. Concentration and Attention

MM has impaired concentration and attention evidenced by her difficulty to stay focused one conversation topic at a time. She has difficultly sitting still for long periods of time and enjoys keeping herself occupied my watering the plants every day, knowing each plant name by heart. (Mental status examination guide, nd). G. Judgment MMs has poor judgment and limited insight into the importance of taking her medication. (Mental status examination guide, nd).

H. Insightful

CASE STUDY AND CARE PLAN MM has poor insight into her condition. When asked if she believed she was ill she replied its complicated and would not expand on what she meant by this statement. (Mental status examination guide, nd). Eriksons Developmental Stage

According to Eriksons developmental stages of psychosocial development, MM is in her young adulthood. As a 41 year old woman some of the issues identified by Myers for this stage is intimacy and isolation. (Myers, 2007). Young adults often find it difficult to form close relationships and fall in love. Other times, young adults can feel socially isolated. (Myers, 2007). It is evident that MM meets the requirements of young adulthood as laid down by Erikson. She has being successful in forming a close and intimate relationship with her husband whom she has known for 15 years and to for 12 years. They have two children together and was accompanied by her husband on the date of her referral. Her family displayed concern for MMs behavior after her grandmothers death and encouraged her to seek psychiatric help. MM remains social with the other residents, frequently interacting with them and engaging with them in conversation. Medications MM is taking Clonazepam 1mg tablet PO BID 0800 and 2200 for anxiety; Divalproex EC 500 mg tablet PO BID 0800 and 2200 to decrease manic episodes; Quetiapine SR 300 mg tablet PO HS 2200 to treat her bi polar disorder and Trazodone 50 mg tablet PO HS 2200 to treat depression and insomnia. MM PRN medication includes; Lorazepam SL 1 mg tablet PO/SL BID for the treatment of anxiety; Loxapine 10 mg tablet PO TID for the treatment of symptoms of schizophrenia such as nervous and emotional disorders. (Medscape, 2012). While MM has a

CASE STUDY AND CARE PLAN history of medication non compliance, she is responding well to all medication with no reported side effects apart from feeling tired. The Big Picture MM still appears to exhibit many characteristics of bi polar disorder with periods of normal functioning evident during her interactions with the other patients in the common room and manic episodes as exhibited during her mental status examination. The therapeutic relationship developed with MM has helped to reduce her agitation and depression felt from the death of her grandmother. MM has volunteered to water the plants in the common room every day which helps to keep her mind focused on a specific task while also helping her to achieve a sense of purpose during her hospital stay. As MM is still displaying periods of mania, her

medication could be adjusted to help counteract this episodes. Her Divalproex for example could be increased from 1000 mg / day to 1500mg / day and still be within the usual oral daily dosage. I would suggest that this should be accompanied by increased monitoring for ataxia, drowsiness and weight gain. (Schultz & Videbeck, 2009). MMs Quetiapine dosage could also be increased from 300 mg / day where the normal dose range lies between 300 600 mg / day. (Schultz & Videbeck, 2009). I noted also that no suicide assessment was completed on MM during her initial consultation despite the fact that patient who suffer from bi polar disorder are a high risk for suicide. (Schultz & Videbeck, 2009).

NANDA Diagnosis

CASE STUDY AND CARE PLAN 1) Defensive Coping: MM has a history of medication noncompliance and resistance to change. She has poor insight into her condition and is at times quiet defensive. Overall Goal: Patient will become aware of her condition at the importance of medication compliance. 2) Disturbed Thought Process: MM has displayed poor concentration and random thought processes. She has also confirmed that she has experienced hallucinations. Overall Goal: Patient will demonstrate reduced hallucinations and will demonstrate an increased attention span 3) Feeding Self-Care Deficit: MM is on a self administered raw food diet and does not eat the hospital food. She has lost a lot of weight and there is concern that she is not receiving enough protein in her diet. Overall Goal: Nursing care plane will be developed assigning adequate nutrition, hydration and elimination goals for the patient.

4) Deficient Knowledge: MM has displayed poor insight into her illness and the importance of being compliant with her medication. Overall Goal: Patient will acknowledge that she is suffering from bi polar disorder and will develop an understating as to the need for treatment. Patient will also attend information seminars about her illness and its treatment.

References

CASE STUDY AND CARE PLAN American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., (DSM-IV). Text Revision. (2000). Washington, DC: American Psychiatric Association. Healthy place (2012). Bipolar treatment: Medications compliance. Retrieved from: http://www.healthyplace.com/bipolar-disorder/medication-noncompliance/bipolartreatment-medications-compliance/ Medscape (2012). Drugs, diseases and procedures. Retrieved from: http://reference.medscape.com/drugs Mental status examination guide (nd). Retrieved from Stenberg College clinical handout. Michels, K., J. & Michels, R. (1997). Clinical case conference: Clinical case: Unknown. The American Journal of Psychiatry. Retrieved from: http://ajp.psychiatryonline.org/article.aspx?articleid=172575 Myers, D., G. (2007). Psychology 8th ed. Worth Publishers

Psychiatric Assessment (nd). Psychiatric Assessment DSM-IV Multiaxial Assessment. Retrieved from Stenberg College clinical handout. Schultz, J. M & Videbeck, S.L. (2009). Lippincotts Manual of Psychiatric Nursing Care Plans (8th ed.) Lippincott Williams & Wilkins

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Appendix 1 Nursing Care Plan 1

Nursing Diagnosis

Desired Outcomes

Interventions (I)Independent (C) - Collaborative

Rationale & APA Reference

Evaluation of Interventions

NDX: (Problem) Disturbed thought process

Goal: Elimination of hallucinations. Patient will be

N1-(I) (C) Notice that if the patient is hallucinating, to engage the

R1Patients ability to react to hallucinations will be greatly

E1Patient reported seeing visual hallucinations when

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R/T: (etiology/factor): Disruption in cognitive operation and activities. Schultz & Videbeck (2009). AEB: (s/sx; defining characteristics) 1. Patient has displayed poor concentration and random thought processes. 2.Patient has experienced Visual hallucinations.

focused and task orientated. Client will 1. Patient will demonstrate reduced hallucinations 2. Patient will demonstrate an increased attention span Evaluation of Outcomes 1.At time of writing, patient was still experiencing visual hallucinations 2.At time of writing patient was still demonstrating poor concentration and random thought process Evaluation of Goal: (circle one) Goal met Goal not met Goal partially met (If goal not met, describe outcomes not met) Patient has not displayed a reduction in

patient in conversation that of in an activity.

impacted if they are engaged in real activities. Schultz & Videbeck (2009). R2Enables the patient to focus on simple conversations where more complex topics may prove more difficult. Schultz & Videbeck (2009). R3The patient is more likely to repeat a behavior if they receive positive reinforcement for it. Schultz & Videbeck (2009).

left alone with her own thoughts indicating that activity based tasks would be very beneficial. E2Patient engaged well when asked simple open ended questions. Focus and answers were appropriate. E3Patient responded well to verbal reinforcement encouraging her to continue with the watering of the common room flowers.

N2-(I) (C) Ensure all topics of conversation are based in reality and topics are kept simple. N3-(I) (C) Provide verbal reinforcement whenever the client refers to reality situations

N4-(I) (C) Where possible, remove or decrease environmental stimuli. If necessary remove the patient to a private room to help her remain focused.

R4The patients ability to react to stimuli is impaired and their concentration levels remain alert. Schultz & Videbeck (2009).

E4Patients attention span was greatly improved during 1:1 interactions.

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hallucinations and still had a poor thought process. Continuation of plan: (circle one) Continue plan of care Discontinue plan of care Revise plan of
care

Appendix 2 Nursing Care Plan 2

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Nursing Diagnosis

Desired Outcomes

Interventions (I)Independent (C) - Collaborative

Rationale & APA Reference

Evaluation of Interventions

NDX: (Problem) Deficient knowledge R/T: (etiology/factor): Absence or deficiency of cognitive information related to a specific topic. Schultz & Videbeck (2009). AEB: (s/sx; defining characteristics) 1. Patient has displayed poor insight into her illness 2. Patient has failed to see the importance of being compliant with her medication.

Goal: Increased awareness into medication compliance and illness insight. Client will 1. Patient will acknowledge that she is suffering from bi polar disorder and will develop an understating as to the need for treatment. 2. Patient will also attend information seminars about her illness and its treatment. Evaluation of Outcomes 1.At time of writing, patient was aware of her illness and the importance of being compliant

N1-(I) (C) Educate the patient and their family about bi polar disorder.

R1The patient or the family may have little or no knowledge about bi polar disorder. Schultz & Videbeck (2009).

E1Both the patient and her family were very aware of the nature of bi polar disorder as the patient had being receiving treatment for the condition since she was 19 years old. E2The patients family has already displayed their awareness into the signs of bi polar relapse as it was the patients husband who initiated her latest return to hospital following her unusual behavior at home. E3The patients lab results were all within the normal range. The patient has now being prescribed Lithium, carbamazepine or valproic acid.

N2-(I) (C) Educate the patient and their family about the signs and symptoms of bipolar relapse such as insomnia, poor hygiene and nutrition.

R2The patient and family will be able to recognize and act on the signs and symptoms of relapse. Schultz & Videbeck (2009).

N3-(I) (C) Stress the importance of taking medication regularly and on a continuous basis. Stress that this is required for the medication to be effective. Stress also not to stop taking the medication just because the patient is no longer displaying symptoms.

R3It is important to monitor blood serum levels to ensure they remain within the therapeutic range when the patient is on medication such as Lithium, carbamazepine or valproic acid. Schultz & Videbeck (2009).

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N4-(I) (C) Explain all information in a manner that is clear and concise. Follow up on all information with information booklets and other material. Check for the patient and families understanding and encourage questions.

R4The patient and family may have little or no knowledge of the toxicity of the patients medications. Encouraging participation through questions will enhance the learning experience. Schultz & Videbeck (2009).

E4The patient and her family has already displayed knowledge about the medications and the importance of adherence and dosage. Patient and family were presented with this information several times over the years.

with her medication. 2.At time of writing patient was a regular attendee to the group therapy sessions. Evaluation of Goal: (circle one) Goal met Goal not met Goal partially met (If goal not met,