Nurs 6630 Psychopharmacology Client of Korean Descent
Jay, an 18-year-old high school senior, presents with symptoms of difficulty sleeping and feeling sad, which results in an initial diagnosis of depression. His mother later reports, however, that Jay exhibits symptoms of irritability and risk-taking behaviors. (His little brother reported to his mother that they were driving over 90 miles an hour on the highway.) After further evaluation, Jay’s psychiatric mental health nurse practitioner diagnosed him with bipolar disorder.
Cases like this are not uncommon with bipolar disorder, as initial assessments rarely provides all the information needed. In your role, as a psychiatric mental health nurse practitioner, you must develop strategies for properly assessing and diagnosing these clients because treatments for bipolar disorder are significantly different than treatments for depression or other mood disorders.
This week, as you examine bipolar therapies, you explore the assessment and treatment of clients with bipolar disorder. You also consider ethical and legal implications of these therapies.
Photo Credit: [Vanessa Galeote]/[Hemera / Getty Images Plus]/Getty Images
Assignment: Assessing and Treating Clients with With Bipolar Disorder
Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients often present as depressive or manic, but may have both; and 2) many symptoms of bipolar disorder are similar to other disorders. Misdiagnosis is common, making it essential for you to have a deep understanding of the disorder’s pathophysiology. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with bipolar disorder.
Learning Objectives
Students will:
Assess client factors and history to develop personalized plans of bipolar therapy for clients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring bipolar therapy
Evaluate efficacy of treatment plans
Analyze ethical and legal implications related to prescribing bipolar therapy to clients across the lifespan
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
REQUIRED READINGS
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 6, “Mood Disorders”
Chapter 8, “Mood Stabilizers”
Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. New York, NY: Cambridge University Press.
To access the following chapters, click on the Illustrated Guides tab and then the Mood Stabilizers tab.
Chapter 4, “Lithium and Various Anticonvulsants as Mood Stabilizers for Bipolar Disorder”
Chapter 5, “Atypical Antipsychotics as Mood Stabilizers for Bipolar Disorder”
Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331-333. doi:10.1007/s40263-013-0060-3
Note: Retrieved from Walden Library databases.
Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6
Note: Retrieved from Walden Library databases.
REQUIRED MEDIA
Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author
Note: This case study will serve as the foundation for this week’s Assignment.
OPTIONAL RESOURCES
Mostafavi, A., Solhi, M., Mohammadi, M., Hamedi, M., Keshavarzi, M., & Akhondzadeh, S. (2014). Melatonin decreases olanzapine induced metabolic side-effects in adolescents with bipolar disorder: a randomized double-blind placebo-controlled trial. Acta Medica Iranica, 52(10), 734-739.
Retrieved from http://acta.tums.ac.ir/index.php/acta
To prepare for this Assignment:
Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.
The Assignment
Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
SUBMISSION AND GRADING INFORMATION
CASE STUDY
Client of Korean Descent/Ancestry
BACKGROUND INFORMATION
The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.
Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”
She weights 110 lbs. and is 5’ 5”
SUBJECTIVE
Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”
You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.
Genetic testing reveals that she is positive for CYP2D6*10 allele.
Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.
MENTAL STATUS EXAM
The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.
The Young Mania Rating Scale (YMRS) score is 22
RESOURCES
§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6
1. Decision Point One
Select what the PMHNP should do:
Begin Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 100 mg orally at HS
SELECTED ANSWER: Begin Risperdal 1 mg orally BID
Decision 2
Bipolar Therapy
Client of Korean Descent/Ancestry
2. Decision Point Two
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic
Client’s mother explains that “she has been like this since about a week after the last office visit”
Select what the PMHNP should do next:
Jay an 18-year-old high school senior presents with symptoms of difficulty sleeping and feeling sad
**Decision #1: Begin Risperdal 1 mg orally BID**
*Why this decision?*
Risperdal (risperidone) is an atypical antipsychotic commonly used as a mood stabilizer in the treatment of bipolar disorder, particularly during acute manic episodes [Stahl, S. M., & Ball, S., 2009]. Given the client’s presentation of acute mania, including rapid speech, pressured thoughts, and impaired insight, initiating Risperdal can help stabilize her mood and reduce symptoms of agitation and impulsivity.
*Expected outcome:*
By initiating Risperdal, the aim is to mitigate the symptoms of acute mania, including rapid speech, impulsivity, and impaired judgment. The goal is to achieve a reduction in manic symptoms, improve the client’s insight and judgment, and prevent potential harm associated with untreated mania.
*Difference in expectation vs. results:*
The decision to begin Risperdal was expected to lead to a reduction in manic symptoms, stabilizing the client’s mood and improving her overall functioning. However, the client’s subsequent presentation of sedation and lethargy suggests a potential adverse effect of Risperdal, which was not anticipated. Further assessment and adjustment of the treatment plan are warranted to address this side effect and optimize the client’s response to medication.
**Decision #2: Assess for Adverse Effects of Risperdal**
*Why this decision?*
Given the client’s current state of sedation and lethargy, it is crucial to assess for potential adverse effects of Risperdal, such as sedation, extrapyramidal symptoms, and metabolic changes [Stahl, S. M., & Ball, S., 2009]. These adverse effects may impact the client’s overall functioning and require prompt intervention to minimize harm.
*Expected outcome:*
By assessing for adverse effects of Risperdal, the goal is to identify and address any potential side effects that may be contributing to the client’s current presentation of sedation and lethargy. This assessment will inform further treatment decisions, such as dose adjustment or medication discontinuation, to optimize the client’s safety and well-being.
*Difference in expectation vs. results:*
The decision to assess for adverse effects of Risperdal was expected to lead to the identification and management of potential side effects contributing to the client’s sedation and lethargy. However, further assessment may reveal additional factors contributing to the client’s presentation, such as drug interactions or underlying medical conditions, which were not initially considered. Adjustments to the treatment plan may be necessary based on the findings of the assessment.
**Decision #3: Consider Alternative Mood Stabilizer**
*Why this decision?*
Considering the client’s adverse reaction to Risperdal, including sedation and lethargy, it may be prudent to consider alternative mood stabilizers with a lower risk of sedative effects or metabolic changes [Stahl, S. M., & Ball, S., 2009]. This decision aims to optimize the client’s response to treatment while minimizing adverse effects.
*Expected outcome:*
By considering alternative mood stabilizers, such as lithium or anticonvulsants, the goal is to identify a medication regimen that effectively stabilizes the client’s mood without causing significant sedation or other adverse effects. This decision may involve discontinuing Risperdal and initiating a new medication or adjusting the dosage of existing medications to achieve optimal therapeutic outcomes.
*Difference in expectation vs. results:*
The decision to consider alternative mood stabilizers was expected to lead to the identification of a medication regimen that effectively manages the client’s bipolar symptoms while minimizing adverse effects. However, the response to alternative medications may vary among individuals, and close monitoring of the client’s response and side effects is essential to ensure treatment efficacy and safety.
**Ethical Considerations:**
Ethical considerations in treating clients with bipolar disorder include informed consent, autonomy, beneficence, and nonmaleficence. It is essential to involve the client in treatment decisions, provide comprehensive education about the risks and benefits of medications, and respect their autonomy in choosing treatment options. Additionally, healthcare providers must prioritize the client’s safety and well-being, balancing the potential benefits of medication therapy with the risk of adverse effects. Open and honest communication with the client and their family members is crucial to building trust and promoting shared decision-making in the treatment process.
Nurs 6630 Psychopharmacology Client of Korean Descent
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