Posted: January 8th, 2023
Assessing and Treating Clients with With Bipolar Disorder
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.Assessing and Treating Clients with With Bipolar Disorder.
Patient Initials: _______ Age: _______ Gender: _______
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.Assessing and Treating Clients with With Bipolar Disorder.
Sulfa drugs – rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet on no medication
5.) Allergic rhinitis
Past Surgical History (PSH):
Assessing and Treating Clients with With Bipolar Disorder.
Non-menstrating – TAH 1998
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.
Assessing and Treating Clients with With Bipolar Disorder.
She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.Assessing and Treating Clients with With Bipolar Disorder.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.Assessing and Treating Clients with With Bipolar Disorder.
Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.
Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.
Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.
CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.
GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.Assessing and Treating Clients with With Bipolar Disorder.
GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband.
MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.
Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.
Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.Assessing and Treating Clients with With Bipolar Disorder.
Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.
Endocrine: no endocrine symptoms or hormone therapies.
Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.
Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or tmegally
Chest/Lungs: CTA AP&L
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial
ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound
Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.
Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
CXR – cardiomegaly with air trapping and increased AP diameter
Normal sinus rhythm
Differential Diagnosis (DDx):
2.) HTN, controlled
3.) Tobacco abuse – 40 pack year history
4.) Allergy to sulfa drugs – rash
5.) GERD – quiet on no current medication
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
Assessing and Treating Clients with Bipolar Disorder
Bipolar disorder is a disabling mental health disorder that is typified by depressive and manic episodes. According to Jauhar & Young (2019) the prevalence of bipolar disorder is approximately 1%-2% and is associated with increased suicide risk and increased cognitive disabilities. The manic episodes are characterized by euphoria and extreme happiness; increased energy; high levels of energy; lack of sleep; racing mind; aggression; lack of focus when performing tasks; and engaging in risky behaviors. On the other hand, depressive episodes are characterized by sadness, reduced activity levels, fatigue; sleep problems; anxiety; forgetfulness; lack of concertation; and suicidal thoughts. A PMHNP should have a good understanding of bipolar disorder in order to ensure effective management of mental disorder (Stahl, 2008). This paper will review the provided case study, determine the proper treatment choices for the client and lastly discuss the ethical consideration during the client’s treatment.Assessing and Treating Clients with With Bipolar Disorder.
A 26-year-old Korean female presented for appointment after being hospitalized for 21 days for acute mania. The client reported that her mood was fantastic and experienced sleeplessness. Medical records indicated that her physical health was good and laboratory limits within the normal ranges. Genetic testing indicated that the client was positive for CYP2D6*10 allele. She further reported that was not adhering to the prescribed treatment (lithium). The mental status exam indicated that her speech was rapid, euthymic mood and broad affect. Even though her judgment appeared intact, her insight was impaired. The client’s YMRS score was 22.Assessing and Treating Clients with With Bipolar Disorder.
Decision Point One
The presented treatment choices included Lithium 300 mg orally BID; Risperdal 1 mg orally BID and Seroquel XR 100 mg orally at HS. The selected treatment choice for this client is Lithium 300 mg orally BID. This choice was selected because lithium stabilizes the mood and it is also FDA approved to treat manic-depressive and maintain treatment for patients with a history of mania, such as the client in the case study. Lithium works by altering transportation of sodium across nerve/muscle cell membranes and also changes the metabolism of serotonin and catecholamines and thus improves symptoms in bipolar disorder (Stahl, 2008).Assessing and Treating Clients with With Bipolar Disorder.
Even though Risperdal is FDA approved to treat manic episodes in people with bipolar and has also been demonstrated to be effective in treating manic episodes, Risperdal is associated with serious metabolic effects (Jauhar & Young, 2019). In addition, lithium has been used as the first-line treatment for manic episodes. In addition, even though Seroquel is FDA approved to treat acute mania in adults (Stahl, 2008), this choice was not selected because the client was already on lithium and was well tolerating the medication.
The treatment goal for this client was to achieve symptom remission or until the improvement stabilizes and continue the treatment to avoid symptom recurrence (Stahl, 2008). However, after four weeks the client did not show any symptom improvement. In addition, the client reported that she was not adhering to the treatment regimen. Therefore, the evident lack of symptom improvement can be attributed to the client’s failure to adhere to the prescribed treatment.
Decision Point Two
The presented treatment choices include increasing lithium to 450 mg orally BID; assessing the client’s reason for non-adherence to find out the reason for non-adherence and educate the client regarding the medication effects, and pharmacology; or change to Depakote ER 500 mg orally at HS. The selected choice is to assess the client’s reason for non-adherence to find out the reason for non-adherence and educate the client regarding the effects and pharmacology of the medication. According to Jawad et al (2018), non-adherence to bipolar medications such as lithium is common. Since sudden discontinuation of lithium can lead to relapse, it is important to assess the reasons why the client is not adhering to the treatment (Jawad et al, 2018). The choice of increasing the dose of lithium to 450 mg was not selected because the client has not fully adhered to the initial treatment and therefore the efficacy of the initial dose cannot be evaluated. Similarly, even though Depakote is FDA approved to treat acute mania (Stahl, 2019), the patient has not adhered to lithium, which is the first-line treatment of acute mania and thus the efficacy of the medication cannot be assessed.Assessing and Treating Clients with With Bipolar Disorder.
The treatment goal with this decision was to achieve symptom improvement/remission for the client (Stahl, 2019). However, after four weeks the client reported that the medication was causing nausea and diarrhea, which contributed to her non-adherence to the medication. Reported nausea and diarrhea are common side effects associated with lithium (Chakrabarti, 2018).
Decision Point Three
The provided treatment choices include changing to Depakote ER 500; changing lithium to sustained-release preparation; or changing to Trileptal 300 mg orally BID. The selected decision is changing lithium to sustained-release preparation. This treatment choice was chosen because the extended-release formulation will prevent the side effects the client is experiencing and also ensure the client’s benefits from mood stabilizing activity associated with lithium. Lithium is effective in controlling acute mania symptoms (Stahl, 2008). Even though Depakote is FDA approved to treat acute mania, the patient has not yet fully adhered to lithium and hence this option can only be feasible if the sustained release lithium fails to improve the side effects (Stahl, 2008). On the other hand, Trileptal was not selected because it is a second-line treatment option for people with bipolar and therefore it is not suitable at this stage since the client has not adequately tried the first-line pharmacological agents for bipolar disorder (Stahl, 2008).
With this treatment choice, the goal is that the client would achieve symptom remission and at the same time tolerate the medication, as evidenced by the lack of earlier side effects.
According to Richaa et al (2017) it is important for patients to consent to treatment before being treated. However, patient autonomy and preferences can be overlooked in case the client’s life is in danger or their mental illness is severe. When a PMHNP is treating clients with bipolar disorder, they are faced with ethical dilemmas of helping the clients attain the best health outcomes or respecting their autonomy. For this client, the autonomy would be the choice of the PMHNP because the client’s life is not in danger, and also her mental illness is not severe. In addition, it is important for the PMHNP to seek informed consent from the client, by explaining to the client all information about the available treatment choices, including the side effects (Richaa et al, 2017).Assessing and Treating Clients with With Bipolar Disorder.
The first selected treatment choice for this client is Lithium 300 mg orally BID because lithium is a mood stabilizer that is FDA approved as the first-line treatment in clients with acute mania. The second treatment choice is to assess the client’s reason for non-adherence to find out the reason for non-adherence and educate the client regarding the effects and pharmacology of the medication because non-adherence could be contributing to lack of symptom improvement. The last treatment choice is to change lithium to sustained-release preparation in order to eliminate the side effects the client is experiencing.
Assessing and Treating Clients with With Bipolar Disorder.
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