NURS 6630: Assessing and Treating Patients with Bipolar Disorder Essay

NURS 6630: Assessing and Treating Patients with Bipolar Disorder Essay

NURS 6630: Assessing and Treating Patients with Bipolar Disorder Essay

Bipolar disorder is a mood disorder characterized by mania and depression episodes, which alternate, although most persons predominate with either mania or depression. The disorder starts with an acute phase of symptoms, followed by a recurrent course of remission and relapse (Carvalho et al., 2020). A manic episode is described as a period of constantly expansive, elevated, or irritable mood and an apparent increase in energy. A patient can have a hypomanic episode, a less severe form of mania involving a discrete episode that lasts four or more days. Depressive episodes usually last longer than manic or hypomanic episodes (Carvalho et al., 2020). The purpose of this paper is to discuss the case of a patient with Bipolar disorder, including her treatment plan and ethical considerations impacting treatment.

Introduction to the Case

The case scenario is about a 26-year-old female client of Korean descent on her first follow-up visit for bipolar I disorder. The client weighs 110 lbs and is 5′ 5. She states that she is in a fantastic mood and hates sleep because it is not fun. Her medical records show that she is in good overall health and lab studies are within normal limits. Nevertheless, genetic testing shows she has a CYP2D6*10 allele. She stopped taking Lithium two weeks ago. The PMHNP administers the Young Mania Rating Scale (YMRS), for which she scores 22. Patient factors that may influence prescribing decisions include the past and current medications, previous treatment response, medical and psychiatric comorbidities, side effects of previous medications, and the patient’s treatment preferences (Carvalho et al., 2020). In addition, the current mood state (mania/depression) will determine the medication to prescribe.

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Decision #1

Start Lithium 300 mg orally BID.

Why I Selected This Decision

Lithium was selected because it is the preferred agent in patients with classical mania. According to Baldessarini et al. (2019), Lithium has been a fundamental medication for BD for decades and is still regarded as first-line therapy. Lithium has a short-term benefit for acute mania and increases the time before a relapse to any mood episode in bipolar adult patients.

Why I Did Not Select the Other Two Options

Risperdal was not an appropriate choice because it is not recommended in patients who are positive for the CYP2D6*10 allele. According to Cui et al. (2020), explain persons with positive for CYP2D6*10 allele have a lower metabolism rate for risperidone. The decreased metabolism rate reduces the clearance of Risperdal, resulting in elevated serum levels of the drug, which would cause sedation and ultimately low drug compliance. Seroquel is not also ideal due to its side effects on metabolism, causing high levels of total cholesterol and triglycerides and weight gain (Butler et al., 2018). The patient has a high BMI, and Seroquel would worsen it.

What I Was Hoping To Achieve

I hoped that Lithium would alleviate the manic symptoms and reduce the YMRS score to below 12 within four weeks. A study by Butler et al. (2018) showed that Lithium alleviates acute mania in the short term and prolongs the period to relapse in the long term. It effectively manages an acute episode of either depression/mania and is efficacious in preventing relapse of both episodes.

Ethical Considerations

The PMHNP considered the ethical principles of beneficence by selecting the medication associated with the best treatment outcomes, which promotes the better good. Besides, nonmaleficence was upheld by analyzing the available drugs for side effects and selecting the one with modest side effects to avoid harming the patient (Ostacher, 2019).

Decision #2

Assess the patient’s rationale for non-compliance to identify the reason for non-compliance and educate the client on drug effects and pharmacology.

Why I Selected This Decision

The decision was selected because the patient took her medication on and off whenever she needed it. Non-compliance had resulted in failure to progress with treatment. Jawad et al. (2018) explain that various factors contribute to medication non-adherence, including drug side effects,  poor understanding of the medication, complex drug regimens, negative patient attitudes to medication, and comorbid substance abuse. These factors become obstacles to attaining the perceived treatment benefits and positive outcomes.

Why I Did Not Select the Other Two Options

I did not increase the Lithium dose to 450 mg because the patient’s non-compliance to treatment would have persisted if the contributing factors were not first addressed. Besides, I did not change to Depakote because we had not established the effect of Lithium in treating mania. Caution is needed when switching from Lithium and should be done if the expected effect was not achieved even with adequate medication compliance.

What I Was Hoping To Achieve

I was hoping that assessing the reason for non-compliance would help identify the factors causing the patient to take her medication on and off and address them promptly. Butt et al. (2018) explain that proper recognition of non-compliance is essential to improve the quality of therapy, and appropriate approaches should be taken so that treatment can be achieved.

Ethical Considerations

Autonomy was observed when the PMHNP engaged the patient in identifying the factors causing non-compliance (Ostacher, 2019). Involving the patient in identifying and addressing the factors will increase compliance, thus promoting better health outcomes, upholding beneficence.

Decision #3

Change Lithium to sustained-release preparation at the same dose and frequency.

Why I Selected This Decision

                I changed Lithium to sustained-release since the patient complained of nausea and diarrhea associated with the initial drug preparation. Lithium sustained release formulation minimizes the drug’s side effects yet still provides the desired outcomes from its mood-stabilizing properties. Pelacchi et al. (2022) assert that switching from an immediate-release to sustained-release lithium formulation does not affect the efficacy of the medication.

Why I Did Not Select the Other Two Options

Changing to Depakote was not ideal because Lithium had not been established as ineffective in managing bipolar symptoms. Besides, it is associated with adverse effects of hepatic and hematological dysfunction, which might result in poor health outcomes. Besides, Trileptal was not ideal because it is indicated as a second-line treatment when first-line agents are ineffective.

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What I Was Hoping To Achieve

I hoped switching to sustained release would alleviate the drug’s side effects of nausea and diarrhea, thus promoting compliance and desired drug effects. Advantages of sustained-release formulations include decreased local adverse effects in the GI and adverse effects related to peak blood levels and enhanced compliance (Pelacchi et al., 2022).

Ethical Considerations

Beneficence and nonmaleficence were promoted by switching to a formulation associated with minimal side effects, increasing compliance, and improving patient outcomes. Autonomy would impact the treatment plan if the patient reported persistent side effects and requested a change in the treatment plan (Ostacher, 2019).

Conclusion

The patient factors influencing her treatment plan include current medications, previous treatment response, medical and psychiatric comorbidities, side effects of previous medications, and the patient’s treatment preferences. The first treatment decision was to start the patient on Lithium 300 mg BD. Lithium was selected because it is recommended as first-line therapy (Baldessarini et al., 2019). Risperdal was not chosen because it would cause sedation in the patient, which would decrease the compliance rate (Cui et al., 2020). Seroquel was not also selected due to its side effects of increasing Total cholesterol and triglyceride and weight gain. The patient took the medication on and off, which resulted in failure to achieve the desired treatment outcomes. This led to the decision to assess the patient’s reason for failing to comply with treatment and address these factors.

The patient reported side effects of nausea and diarrhea, which led to the decision to change Lithium from immediate preparation to sustained preparation. Lithium sustained release is associated with reduced side effects and increased compliance (Pelacchi et al., 2022). Ethical considerations in planning the treatment included ethical principles of beneficence, nonmaleficence, and autonomy. The PMHNP made treatment decisions supported by best practices associated with effective treatment outcomes.

References

Baldessarini, R. J., Tondo, L., & Vázquez, G. H. (2019). Pharmacological treatment of adult bipolar disorder. Molecular psychiatry, 24(2), 198–217. https://doi.org/10.1038/s41380-018-0044-2

Butler, M., Urosevic, S., Desai, P., Sponheim, S. R., Popp, J., Nelson, V. A., … & Sunderlin, B. (2018). Treatment for Bipolar Disorder in Adults: A Systematic Review.

Butt, H., Muzaffar, Z., Rasool, F., & Mohsin, M. (2018). Assessment Of Patient Compliance, Its Associated Factors, And Predictable Interventions. Value in Health, 21, S1. https://doi.org/10.1016/j.jval.2018.07.009

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar Disorder. The New England journal of medicine, 383(1), 58–66. https://doi.org/10.1056/NEJMra1906193

Cui, Y., Yan, H., Su, Y., Wang, L., Lu, T., Zhang, D., & Yue, W. (2020). CYP2D6 Genotype-Based Dose Recommendations for Risperidone in Asian People. Frontiers in pharmacology, 11, 936. https://doi.org/10.3389/fphar.2020.00936

Ostacher, M. J. (2019). Ethical Issues in the Diagnosis and Treatment of Bipolar Disorders. FOCUS, A Journal of the American Psychiatric Association, 17(3), 265-268. https://doi.org/10.1176/appi.focus.20190010

Pelacchi, F., Dell’Osso, L., Bondi, E., Amore, M., Fagiolini, A., Iazzetta, P., … & SALT Study Group. (2022). Clinical evaluation of switching from immediate‐release to prolonged‐release Lithium in bipolar patients, poorly tolerant to Lithium immediate‐release treatment: A randomized clinical trial. Brain and Behavior, e2485. https://doi.org/10.1002/brb3.2485

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Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.–
Levels of Achievement:
Excellent

Point range: 90–100 9 (9.00%) – 10 (10.00%)
Good

Point range: 80–89 8 (8.00%) – 8 (8.00%)
Fair

Point range: 70–79 7 (7.00%) – 7 (7.00%)
Poor

Point range: 0–69 0 (0.00%) – 6 (6.00%)
Decision #1 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.–
Levels of Achievement:
Excellent

Point range: 90–100 18 (18.00%) – 20 (20.00%)
Good

Point range: 80–89 16 (16.00%) – 17 (17.00%)
Fair

Point range: 70–79 14 (14.00%) – 15 (15.00%)
Poor

Point range: 0–69 0 (0.00%) – 13 (13.00%)
Decision #2 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.–
Levels of Achievement:
Excellent

Point range: 90–100 18 (18.00%) – 20 (20.00%)
Good

Point range: 80–89 16 (16.00%) – 17 (17.00%)
Fair

Point range: 70–79 14 (14.00%) – 15 (15.00%)
Poor

Point range: 0–69 0 (0.00%) – 13 (13.00%)
Decision #3 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.–
Levels of Achievement:
Excellent

Point range: 90–100 18 (18.00%) – 20 (20.00%)
Good

Point range: 80–89 16 (16.00%) – 17 (17.00%)
Fair

Point range: 70–79 14 (14.00%) – 15 (15.00%)
Poor

Point range: 0–69 0 (0.00%) – 13 (13.00%)
Conclusion (1 page)

• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.–
Levels of Achievement:
Excellent

Point range: 90–100 14 (14.00%) – 15 (15.00%)
Good

Point range: 80–89 12 (12.00%) – 13 (13.00%)
Fair

Point range: 70–79 11 (11.00%) – 11 (11.00%)
Poor

Point range: 0–69 0 (0.00%) – 10 (10.00%)
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–
Levels of Achievement:
Excellent

Point range: 90–100 5 (5.00%) – 5 (5.00%)
Good

Point range: 80–89 4 (4.00%) – 4 (4.00%)
Fair

Point range: 70–79 3.5 (3.50%) – 3.5 (3.50%)
Poor

Point range: 0–69 0 (0.00%) – 3 (3.00%)
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–
Levels of Achievement:
Excellent

Point range: 90–100 5 (5.00%) – 5 (5.00%)
Good

Point range: 80–89 4 (4.00%) – 4 (4.00%)
Fair

Point range: 70–79 3.5 (3.50%) – 3.5 (3.50%)
Poor

Point range: 0–69 0 (0.00%) – 3 (3.00%)
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.–
Levels of Achievement:
Excellent

Point range: 90–100 5 (5.00%) – 5 (5.00%)
Good

Point range: 80–89 4 (4.00%) – 4 (4.00%)
Fair

Point range: 70–79 3.5 (3.50%) – 3.5 (3.50%)
Poor

Point range: 0–69 0 (0.00%) – 3 (3.00%)
Name:NURS_6630_Week5_Assignment_Rubric