Assignment: Assessing and Treating Clients with Bipolar Disorder
Assignment: Assessing and Treating Clients with Bipolar Disorder
Bipolar-1-disorder is a condition characterized by the manic episodes, which disrupt an individual’s normalcy. The presenting symptoms include elevated mood and high energy. Studies show that diagnosis of the condition difficult since there are other mental disorders that present with mania or hypomania episodes. As a result, proper considerations have to be made in ensuring that the correct diagnosis is made and the condition is managed in time. The pharmacotherapeutic intervention selection for the condition depends on the levels of safety and effectiveness of the available drug (Stahl, 2013). A few reviews have demonstrated likely impacts of coordinated treatment programs for patients with bipolar disorder. The current paper analyzes a case of a Korean woman came to the PMNHP nurse after a 21-day hospitalization for acute mania alongside bipolar I disorder considering that her score from the Young Mania Rating Scale (YMRS) was 22 (Laureate Education, 2016f). Thus, in this paper, bipolar therapy is examined with considerations to making the right treatment choices amid ethical considerations.
Decision Point One
Selected Decision
Begin Risperdal 1 mg orally BID
Reason for the Selection
Risperdal is a second generation antipsychotic that has been used in management of the mental disorders such as bipolar. These antipsychotic has been proven effective in alleviating manic symptoms among patients with bipolar 1 (Stahl & Ball, 2009b). Its main action is through rebalancing the dopamine and serotonin levels thereby improving mood, thinking, and behavior. According to Castellan et al. (2013), studies show that there are “no consistent results reported about the relationship between cytochrome P450 (CYP) 2D6*10 allele and plasma 9‐OH‐RIS or active moiety levels of Risperdal, hence adequate clearance in right doses can be achieved” (p. 204). Additionally, lithium and Seroquel SR have also been used widely in the management of bipolar condition. However, lithium cannot be used in managing the patient in this case because of the non-compliance and poor adherence history from the Korean patient. Furthermore, combining the two medications could result in drug interactions leading to adverse effects to the patient (Daglas et al., 2016). As a result, it is not recommended to prescribe it again. Regarding the latter, its tolerability has been questioned in some subjects hence given the genetic make-up of the patient, it cannot be elected for the pharmacotherapeutic care plan. From the foregoing reasons, Risperdal prescription is the best option to use in this scenario.
Expected Results
Risperdal represses the manic symptoms within three weeks; therefore, patients using the drug experience positive outcomes within the stated period. During this period, the Asian patient should experience improved appearance, have reduction in the level of irritability, and demonstrate improved speech, tamed disruptive behavior, and good sleeping pattern (Stahl, 2013). Therefore, it is expected that the Korean patient will have a significant improvement by the fourth week of medication.
Difference between Expected Results and Actual Results
The patient visited the hospital after four weeks, and she was lethargic and sedated. It was stated that these symptoms appeared after one week of medication. This was contrary to the anticipated results of reduced bipolar symptoms. It was expected that the patient would have improved mood and appropriate thinking. The difference in the results is the side effects of the drug. The high amount of Risperdal in the blood leads to sedation. Given that the patient is from Korean ancestry and positive for CYP2D6*10 allele means that she may not have a swift clearance of Risperdal from the blood leading to accumulation (Demant, Vinberg, Kessing, & Miskowiak, 2015).
Decision Point Two
Selected Decision
Decrease Risperdal to 1 mg at HS
Reason for the Selection
Risperdal 1 mg orally BID did not fail to work during the second visit; it only caused some side effects. It is wise to alter the dosage to manage the side effects rather than cease the use of the drug. Altering Risperdal to 2 mg at HS may still attest to be a lot, and the side effects may not be sufficiently managed. A choice to switch back to lithium is still not right as the patient still has an attitude towards it (Demant, Vinberg, Kessing, & Miskowiak, 2015). Furthermore, it might confuse the patient on drugs used. Helping her cope with different dosage of the same drug will increase her confidence in drugs and appreciate that it is all about the alteration of the dosage.
Expected Results
As mentioned previously, Risperdal is effective in balancing dopamine and serotonin in the brains and thus managing mood, behavior and thought problems. The adverse effects have been ascribed to the accumulation of Risperdal in the patient’s blood. Lowering the dosage to Risperdal 1 mg at HS will warrant no accumulation of the drug in the patient’s blood as the body will be able to excrete it quite quickly. By altering the dosage, the patient should begin being less sedated and less lethargic. The patient should also begin experiencing improvement in the mood, have proper behaviors as well as think well (Demant, Vinberg, Kessing, & Miskowiak, 2015). This is the effect of Risperdal when taken in the correct amount.
Differences between Actual Results and Expected Results
The patient visited after four weeks, and she was less lethargic and sedated. Furthermore, the Young Mania Rating Scale had reduced from 22 to 16. The patient reported that there were no other side effects. These outcomes are very similar to the anticipated results. The side effects diminished quite faster than it was assumed and this the only difference and luckily in a positive direction. The results are similar because just as stated earlier, Risperdal is a proper medication for bipolar disorder. The adverse effects could not be used as a reason for discarding the drug in this case.
Decision Point Three
Selected Decision
The client will continue on the same dose of Risperdal and reassess in 4 weeks
Reasons for the Selection
The selected client was a Korean descent and was positive for CYP2D6*10 allele. Scientifically, the clearance level for the drug ought to be slower compared to the patient of different descent and without the allele (Castellan et al., 2013). Thus, by using the recommended dosage after the review, the PMNHP nurse will eliminate over dosage of Risperdal in the patient’s system. This intervention will protect the patient from suffering the side effects witnessed when the dosage was at 1 mg BID. Similarly, Latuda is approved for Bipolar I depression by the FDA; though, this case focused on bipolar I disorder (Stahl, 2013).
Expected Results
The dose should be maintained so long as the patient responds well to the treatment. The intervention aims at reducing the symptoms even further. The client responded positively to the current medication by week eight of using the drug. Therefore, it is apparent that the drug is working and helpful to the patient. As a consequence, the client’s quality of life will improve significantly as the symptoms diminished by about 50% (Stahl, 2013). Long-term, the Korean patient is expected to recover fully.
Differences between Expected Results and Actual Results
The decision to continue using the dose was consistent with the standard procedures. The clients’ history indicated that she has the CYP2D6*10 allele. The allele may hinder efforts to adjust the dosage because she responded negatively to higher doses (Chen et al., 2015). Since the nurses have to promote patients’ safety, retaining the dosage is consistent with the expected results.
Impact of Ethics on Intervention
In healthcare, ethical considerations play a huge role in the treatment plan. When handling patients having bipolar disorder, ethical considerations come centrally to the way the PMHNP approaches the treatment (Burdick, Ketter, Goldberg, & Calabrese, 2015; Chen et al., 2015). The patient is mentally unstable, and therefore the PMHNP nurse has to know the appropriate way to present any info to them and the exact time to do that. Ethical contemplations affected the way the patient was counseled to go on using Risperdal in an altered dosage after the first one had caused sedation and lethargy side effects.
When choosing among the drugs to use, ethical considerations were at the core since some drugs are known for specific side effects to several descents of people. For example, Seroquel XL is known for constipation and dry mouth. The patient had complained of comparable side effects when she used lithium in her previous medication. Ethical considerations demand that the PMHNP considers the long-term effects of the drugs such as damage to the teeth (Goodwin et al., 2016). Hence, the medication had to be foregone for a better alternative with relatively fewer adverse effects.
Conclusion
Developing the intervention therapy for bipolar I disorder patients requires a lot accuracy in the diagnostic protocols and results. People suffering from the condition may also present with other mental disorders therefore, it is necessary to perform the diagnosis with a lot of cautiousness. After the diagnosis, a pharmacotherapeutic intervention developed depending on side-effects and a patient understands of the same.
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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
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
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
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o 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.
In the provided case study, the 8-year-old Caucasian female patient came to the clinic accompanied by her parents for psychiatric evaluation. The patient’s teacher suggested that the patient might be having attention deficit hyperactivity disorder (ADHD). Their family physician also suggested that the patient should see a psychiatrist for further evaluation of her mental disorder. The patient parents came with a completed Conner’s Teacher Rating Scale-Revised screening tool, which revealed that the patient is easily distracted at school, and with a short attention span. The patient also displayed poor arithmetic, spelling, and reading skills in addition to being inattentive and forgetful most of the time. Her teacher claims that the patient even failing to complete her homework will lack interest in school activities. She also fails to follow instructions at times. Despite the patient’s parents being in denial that their daughter has ADHD, mental status examination results proved otherwise together with the Conner’s Teacher Rating Scale-Revised screening tool completed by the teacher, supporting the diagnosis of attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.
Developing a treatment plan for pediatric patients with mental disorders is quite challenging given the safety issues associated with this age group. However, appropriate prescriptive practice will involve considering patient-specific factors that might affect the pharmacokinetic and pharmacodynamic processes. Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. The purpose of this discussion is thus to demonstrate the appropriate decision-making process in the selection of the most appropriate intervention in the treatment of the 8-year-old attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.
Decision Point One
Selected Decision and Rationale
From the listed options, initiating Ritalin (methylphenidate) 10mg chewable tablets taken every morning was decided on as the initial intervention. Ritalin is recommended by most clinical guidelines as the first-line medication for the management of ADHD among both children and adults (Rodrigues et al., 2021). Despite the psychostimulant not being approved by the FDA, it has displayed great effectiveness in the management of ADHD with a desirable safety profile in most children from ages 6 to 15 years (American Psychiatric Association, 2013; Castells et al., 2021)). It has demonstrated a substantial impact in managing ADHD symptoms such as inattention, forgetfulness, impulsivity, diminished interest, and hyperactivity among children (Hodgkins et al., 2012). The chewable formulation is considered the best option for children with sweeteners to mask the bitter taste of the drug (Breaux et al., 2022). Consequently, the drug has a short onset of action of between 1 to 2 hours with a long duration of action of between 7.5 to 10.5 hours after oral administration (Mechler et al., 2021). This helps in the management of the patient’s symptoms all day long (Coghill et al., 2021).
Bupropion is associated with increased risks of seizures among children below the age of 10 years, hence not an appropriate decision (Coghill et al., 2021). Intuniv on the other hand is associated with cardiovascular side effects, hence should only be considered in case there is no other safer and more effective drug for use in the pediatric population (Rodrigues et al., 2021).
Expected Outcome
The patient will experience improved symptoms of ADHD in the next four weeks (Coghill et al., 2021). She should be able to improve her spelling, arithmetic, and language skills, in addition to being more attentive and able to concentrate on school work (Hodgkins et al., 2012). Her school performance will improve significantly within this period.
Ethical Considerations
The patient is 8 years of age, which gives the parents legal responsibility of making decisions concerning the health of their child (American Psychiatric Association, 2013). As such, the PMHNP must educate them adequately regarding the patient’s diagnosis and potential treatment options, to promote sound decision-making in promoting the health of their child (Rodrigues et al., 2021).
Decision Point Two
Selected Decision and Rationale
The second decision was to change the treatment regimen to long-acting Ritalin 20mg administered orally in the morning. Based on the treatment outcome, Ritalin displayed potential effectiveness given that the patient’s ADHD symptoms improved evidenced by her improved school performance (Breaux et al., 2022). However, since the medication was not able to manage the patient’s symptoms throughout the entire day, it was necessary to introduce a long-acting formulation to prolong the duration of action of the drug (American Psychiatric Association, 2013). Studies show that long-acting Ritalin lasts for between 8 to 12 hours hence, helps in managing the patient’s symptoms throughout the day (Castells et al., 2021). It is also administered once daily which is more convenient and much easier. The patient also reported a side effect of elevated pulse, which is a common self-limiting side effect of Ritalin that is expected to diminish with time (Coghill et al., 2021).
Continuing with the same drug at the same dosage was inappropriate as the patient would still exhibit ADHD symptoms later in the day, once the drug wears off from the body system (Mechler et al., 2021). Replacing Ritalin with Adderall is also inappropriate as Adderall is associated with increased incidences of suicidal events when used among children (Hodgkins et al., 2012).
Expected Outcome
The long-acting formulation is expected to manage the patient’s symptoms all day long within the following four weeks (Breaux et al., 2022). The patient’s school performance will improve even further. The side effect of elevated heart rate will resolve completely within this time (Coghill et al., 2021).
Ethical Considerations
In making this decision, the PMHNP had to consider several ethical principles including justice, beneficence, nonmaleficence, and respect for the patient’s autonomy (Breaux et al., 2022). The patient was quite comfortable with how the drug was working, but only concerned with the side effect, and effectiveness of the medication later in the day (Rodrigues et al., 2021). As such, it was necessary to respect the patient and display clinical judgment in making decisions that will promote the patient’s mental health.
Decision Point Three
Selected Decision and Rationale
Maintaining the patient on the current medication and reevaluating after four weeks, seemed to be the most appropriate decision for the third intervention. The patient reported great effectiveness and tolerance to the medication, with resolved side effects of an elevated pulse (Mechler et al., 2021). Previous evidence shows that once the optimal dose of Ritalin has been attained, it can take between 8 to 12 weeks to completely manage the patient’s symptoms of ADHD (American Psychiatric Association, 2013; Castells et al., 2021). Consequently, at safe doses, long-term use of the drug has been associated with limited possibilities of side effects, hence the need to reevaluate the patient within 4 weeks (Hodgkins et al., 2012). Studies also show that long-term use of Ritalin normally reduces the risks of side effects as the patient will display further tolerance to the drug, enhancing its safety profile (Breaux et al., 2022).
Increasing the dose of Ritalin to 30mg was not necessary at this point, as studies suggest that low effective doses are safer to use to promote positive outcomes, with reduced risks of side effects (Mechler et al., 2021). Consequently, obtaining EKG at this point was not necessary given that the patient’s pulse had already resolved back to normal for her age, with a recording of 92 during the current visit (Rodrigues et al., 2021).
Expected Outcome
With great compliance to the treatment regimen, the patient will report even further management of the ADHD symptoms over the following two weeks (Breaux et al., 2022). Her academic performance is also expected to improve (American Psychiatric Association, 2013). No side effects are expected.
Ethical Considerations
The nurse’s main objective is to promote the health of the patient and not harm. At this point, the patient was satisfied with the treatment outcome (Hodgkins et al., 2012). It was thus necessary to respect the patient’s autonomy and maintain the dose for further evaluation of the treatment outcome (Mechler et al., 2021).
Conclusion
The 8-year-old patient in the case study presented with symptoms of ADHD. Formulating a treatment plan for the patient involved consideration of certain patient-specific factors which affect her pharmacokinetic and pharmacodynamic processes (American Psychiatric Association, 2013). Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. Based on these factors, the first decision was to initiate a 10mg Ritalin chewable table once daily as recommended by most clinical guidelines given its effectiveness in the management of ADHD and safety for pediatric use (Coghill et al., 2021). Intuniv and bupropion were neglected because of their increased risks of side effects among children as reported by most studies (Mechler et al., 2021). After 4 weeks, the patient came back to the clinic reporting improved symptoms but with side effects of increased pulse rate. The second decision was thus to change the treatment regimen to long-acting Ritalin 20mg once daily in the morning, to prolong the duration of action of the medication throughout the day (Castells et al., 2021). Maintaining the dose would still lead to ineffectiveness, while Adderall display increased risks of suicidality hence neglected (Breaux et al., 2022).
The patient reported further improvement in ADHD symptoms all day long, with resolved side effects of elevated pulse, which led to the final decision of maintaining the treatment regimen and reevaluating the patient after 4 weeks. Obtaining EKG and increasing the dose of Ritalin was not necessarily due to safety issues (Hodgkins et al., 2012). Finally, the PMHNP encountered several ethical considerations in each decision process with the observation of ethical principles such as justice, respect for patient autonomy, not harm, and beneficence (Rodrigues et al., 2021).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Breaux, R., Dunn, N. C., Swanson, C. S., Larkin, E., Waxmonsky, J., & Baweja, M. D. (2022). A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD. Frontiers in Psychiatry, 151. https://doi.org/10.3389/fpsyt.2022.794044
Castells, X., Ramon, M., Cunill, R., Olivé, C., & Serrano, D. (2021). Relationship between treatment duration and efficacy of pharmacological treatment for ADHD: a meta-analysis and meta-regression of 87 randomized controlled clinical trials. Journal of attention disorders, 25(10), 1352-1361. https://doi.org/10.1177/1087054720903372
Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., … & Simonoff, E. (2021). The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). European Child & Adolescent Psychiatry, 1-25. https://doi.org/10.1007/s00787-021-01871-x
Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. https://doi.org/10.2165/11599630-000000000-00000
Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2021). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940
Rodrigues, R., Lai, M. C., Beswick, A., Gorman, D. A., Anagnostou, E., Szatmari, P., … & Ameis, S. H. (2021). Practitioner Review: Pharmacological treatment of attention‐deficit/hyperactivity disorder symptoms in children and youth with autism spectrum disorder: a systematic review and meta‐analysis. Journal of Child Psychology and Psychiatry, 62(6), 680-700. https://doi.org/10.1111/jcpp.13305
Bipolar disorder is defined as a manic-depressive disorder characterized by sudden shifts in energy, mood, and activity levels which affects the patient’s ability to conducts daily tasks. Such mood shifts are quite severe as compared to the normal ups and downs. There are three categories of bipolar disorder, such as bipolar 1 disorder, bipolar 2 disorder, and cyclothymic disorder. According to the National Comorbidity Survey Replication (NCS-R), approximately 2.8% of adults in the United States are diagnosed with bipolar each year. Out of those, about 82.9% experienced serious impairment (Patel et al., 2018). The symptoms of Bipolar undermine the quality of life of an individual, with suicidal cases increasing each year. However, with early diagnosis and treatment, the patient’s symptoms can be managed optimally, with improved outcomes. The paper reviews the case study of an Asian American woman suffering from bipolar, and the treatment choices made together with the ethical challenges encountered with each decision made.
They provide a case study is of a 26-year-old woman of Korean descent who comes in following a 21-day hospitalization because of the onset of acute mania. The patient was diagnosed with bipolar type 1 disorder. The patients seemed quite busy during the examination. Her mood was quite fantastic despite her hate for sleep. She was on lithium but stopped using it after she was discharged about two weeks before the current visit. She recorder a 22 score on the Young Mania Rating Scale (YMRS). Moreover, the decisions made for the patient will be influenced by their genetic makeup due to the presence of the CYP2D6*10 allele. Moreover, the BMI reveals that the patient is overweight. As such, that will be considered when prescribing the drugs.
Decision Point One
Begin Seroquel XR 100 mg orally at HS.
Reason Behind Decision 1
Study guidelines recommend the use of Seroquel (Quetiapine) as monotherapy for the management of acute depressive episodes of bipolar disorder. The mode of action of quetiapine is quite unknown. However, its active metabolite nor quetiapine has been associated with anxiolytic, antidepressant, and neurotrophic effects in humans. Consequently, studies show that the ratio between nor quetiapine/quetiapine plasma concentrations is associated with improved mood symptoms because of bipolar disorder (Garriga et al., 2017). Given that the patient is also Asian, and positive for CYP2D6*10 allele, which is the major route of metabolism of Quetiapine. This allele has been associated with improved bioavailability of toxicity of this medication. The patient had already stopped the use of lithium, two weeks before visiting the clinic, which disqualifies this option. Studies show that the dose of lithium should be gradually reduced over at least 4 weeks when changing the regimen to avoid risks of relapse. Risperdal on the other hand is associated with numerous side effects such as seizures and impaired judgment.
Expected Outcome
Within 4 weeks, the patient is expected to return to the clinic with improved maniac symptoms. She should be able to relax and sleep normally. Her score on the Young Mania Rating Scale (YMRS)is also expected to reduce by at least 50% (Garriga et al., 2017). However, the patient is expected to gain weight, given that this is a common side effect associated with Seroquel.
Ethical Considerations Impact on Treatment Plan
Based on ethical guidelines, the nurse needs to consider the patient’s race and formulated the best treatment plan for a desirable outcome (Mondimore, Abrams, & Tantor, 2018). The patient must also be informed of all the other treatment options together with both their positive and negative effects before making the decision. Lastly, the nurse needs to educate the patient on the importance of taking medication, for the effective provision of patient-centered care.
Decision 2:
Discontinue using Seroquel and Start 40mg Geodon 40 mg orally BID.
Reason Behind Decision 2:
The patient returned to the clinic after four weeks with mild improvement of manic symptoms. She however experienced adverse side effects such as constipation, dry mouth, and weight gain which she was not comfortable with. As such, it was necessary to discontinue using the drug and replacing it with Geodon. Geodon is a second-generation which act by antagonizing the D2, 5HT2A, and 5HT1D receptors, and metabolized through the CYP2D6*10 alleles, with improved bioavailability and reduced toxicity (Marzani, & Neff, 2021). The drug has been approved by the FDA for the management of manic or mixed episodes because of bipolar I disorder. The drug has also displayed high efficacy in both monotherapies and combination with other psychotropic agents. Administering a 500-calorie meal was necessary to control the patient’s body weight. Increasing the dose of Seroquel XR was not appropriate as this would have worsened the patient’s side effects of weight gain, constipation, and dry mouth. Consequently, continuing the same dose of the drug with only interventions of controlling constipation was not necessary as other side effects would be ignored and worsen with time.
Expected Outcome
The patient’s manic symptoms are expected to improve significantly within two weeks. Her score on the Young Mania Rating Scale (YMRS)is also expected to reduce by at least 50% (Marzani, & Neff, 2021). Her body weight should also reduce back to normal, with resolved symptoms of dry mouth and constipation.
Ethical Considerations Impact on Treatment Plan
Based on the results from the last intervention, the nurse is obliged to provide patient-centered care, by addressing the patient’s dislike of the side effects to promote trust and adherence to the treatment plan (Mondimore, Abrams, & Tantor, 2018). Consequently, the patient is an adult entitled to informed consent.
Decision 3:
Continue the same dose and reassess in 4 weeks.
Reason Behind Decision 1:
The patient displayed a 50% decrease in maniac symptoms, with resolved side effects. This indicates high tolerance and adherence to the treatment regimen. Consequently, studies show that Geodon takes up to 8 to 12 weeks to resolve maniac symptoms among bipolar 1 disorder patients. As such it was necessary to continue the same drug for continued improvement of the patient’s symptoms. The dose must also be maintained as an increased dose might improve the symptoms even further but with adverse effects with might affect the patient’s quality of life. Given that Geodon can also be used in combination therapy, augmenting it with lithium would have been an appropriate intervention (Zarate, J. C. A., & Manji, 2016). however, this intervention would have also provoked new side effects such as seizure, with increased peal burden.
Expected Outcome
Given that the previous results displayed improvement of the patient’s symptoms by 50%, it is expected that within the next four weeks, the patient will display complete remission of maniac symptoms. Consequently, no new side effects will be reported with a Young Mania Rating Scale (YMRS) score of less than 12 (Zarate, J. C. A., & Manji, 2016).
Ethical Considerations Impact on Treatment Plan
The nursing code of ethics requires the practitioner to promote patient’s health and avoid harm. The patient displayed improved symptoms, which was a solid indication of the effectiveness of the treatment plan. This also promotes patient trust creating a solid nurse-patient relationship (Mondimore, Abrams, & Tantor, 2018). As such, the patient must also be informed on the reasons behind the next intervention, with appropriate patient education on the need of maintaining compliance and medication side effects.
Conclusion
The patient in the case study was diagnosed with Bipolar disorder because of the onset of manic episodes. She however stopped taking her lithium medication once she was discharged. As a result, her symptoms started worsening and hence the need for appropriate medical intervention. Based on the provided options, the PMHNP decided to introduce another antipsychotic, Seroquel (Quetiapine), which only led to undesirable side effects such as weight gain, constipation, and dry mouth. The drug also displayed minimal remission of the patient’s maniac symptoms. As a result, it was necessary to change the drug regimen by replacing Seroquel (Quetiapine) with Geodon. The patient displayed a positive outcome with a 50% remission of patient symptoms. Consequently, the drug displayed no side effects showing high tolerance. As such, the same intervention was extended for another four weeks for further remission of patient symptoms. The patient was also educated on the need of maintaining compliance and side effects. Several ethical considerations were also encountered. For instance, the patient’s race contributed to the selection of the drug of choice because of variations in metabolic enzymes (Ward, & Citrome, 2020). She was also involved in making her health decision given that she is an adult. Lastly, the PMHNP made sure that the patient was well informed of all the positive and negative outcomes of the treatment plan, for better compliance.
References
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Marzani, G., & Neff, A. P. (2021). Bipolar Disorders: Evaluation and Treatment. American Family Physician, 103(4), 227-239.
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