Bipolar

Capstone Presentation
By: Jennifer Kiaha-Raquino

13 year old
Caucasian
Female
DSM Diagnosis:
I - Bipolar NOS
II - Deferred
III None
IV Social, School
V GAF 50
Legal Status MH-5

Reason for Admission

Admitted for suicidal

ideations with plan to
shoot self with fathers gun.
Patient reported to
outpatient therapist that
she is having trouble with a
friend at school therefore
had suicidal ideations.

Financial data/insurance/implications
Patient is a minor with no job all finances are
provided by mother and father.
Patient has Quest Alohacare with 100% coverage.
There should be no implications to her treatment.

Patients description of problem

Patient stated I wanted to kill myself. When
asked if she had a plan patient stated Yes with
my fathers gun, I know where he keeps it.

Ethnicity/religious/spiritual
concerns & implications
Patient stated that she believes in God but does
not practice a religion and does not require any
accommodations. She does not have any
concerns.

Patients Strengths & Limitations

Strengths
Has a supportive
family
Gets good grades
Outgoing personality
Loves outdoor sports

Limitations
Gets angry easily
Only child
Gets into fights at
school
Misses grandfather
who passed away a
year ago

Medications:
Order: Lamotrigine (Lamictal) 100mg PO BID
Drug class: Anticonvulsant
Pts target sx: Bipolar d/o symptoms
Total 24h dose: 200mg daily
Recommended range: 200mg/day-Max
Current Side effects: dizziness, headache, nausea, blurred vision, rhinitis
Order: Paliperidone (Invega) 6mg PO q bedtime
Drug class: Atypical antipsychotic
Pts target sx: Bipolar d/o symptoms
Total 24h dose: 6mg
Recommended range: 6mg/day- Max
Current Side effects: akathisia, anxiety, headache, cough, somnolence, fatigue

Medical Issues/ Labs

Multiple drug screening and Hcg All negative
UA All WNL

CBC All WNL

CMP- Everything WNL except alkaline
phosphatase which was elevated to 270 IU/Lnormal range is 44-147 IU/L which indication liver
function and damage from medications or a
growth spurt.

Mental Status Assessment

Behavior: Cooperative and friendly throughout interactions. Moderate impulsiveness noted suddenly
stands up at times. Some restlessness and fidgeting of hands noted. Squirms in seat frequently.
Affect: Stabile wide ranged affect appropriate for situation and conversation. Shifts from comfortable
to anxious frequently.
Sensorium: Alert and oriented to person, place, time, and situation.
Imagery: No reports of hallucinations, illusions, or delusions.

Cognition: Thought process concrete, coherent, and linear. Thought content of suicidal ideations with
a plan. Poor insight to illness. Impulsive judgement.
Interpersonal relationships: Has difficulty forming relationships with peers.
Developmental level: (Assets & barriers):
Ericksons- Identity versus Role Confusion- Teens need to develop a sense of self and identity. With
success the teen will stay true to self. Failure leads to role confusion and weak sense of self.

Hospital Treatment Plan

1. Anger Management
2. Coping Skills
3. Social Skills

Discharge plan / Community Resources

Plan is to be discharged home on Big Island with
mother and father.
Community resources I would recommend are
support groups and continued outpatient therapy
for patient and parents.

TM33
Scored 3 = No
precautions
Patent states she is
able to inform staff
if she feels that she
is unable to
maintain safety.

Self Esteem
Assessment
Scored 6 =
moderately low
self esteem

Patients symptoms vs DSM criteria

Patient Symptoms

DSM criteria

My patient did not have obvious

manic or depressive symptoms
during my interview with her. I do
suspect a possible subsiding
hypomanic episode.

For bipolar 1 diagnosis the patient

has to have at least one or more
manic or mixed episodes and
depressed episodes in the past.

She was talkative with some

impulsiveness.
She also has a very brief
depressive state that lasted 30
min. after a phone call with
father.

For bipolar 2 diagnosis the patient

has to have major depressive
episodes and at least one
hypomanic episode.

3 Highest Priorities in Order of Acuity

1. P: Suicidal Ideation
E: Evidenced by patient reporting having a plan for suicide by using fathers gun to
shoot self.
S: Admission as inpatient. Suicide/ Safety precautions initiated. Routine body
checks. Routine visual safety checks. TM33 assessment per shift and as needed.
2. P: Anger Management/ Coping Skills
E: Patient reports getting into fights at school with peers. Self-harm behaviors
Evidenced by scratching self with pencil.
S: Have patient identify personal situations that may cause anger. Have patient
identify ways to calm self when angry. Have patient verbalize to staff when
feeling anger. Have PRN medication available for angry outbursts.
3. P: Difficulty with peer relationships / Social Skills.
E: Evidenced by patient reports of fighting in school.
S: Teach positive social skills. Group, individual, and family therapy to improve self
esteem.

Prioritization with rationale

1- Suicidal ideations with a highly lethal plan. Ongoing
assessment and safety of the patient is the number one
concern.
2- Anger Management / Coping Skills. Patient reports resorting
to fighting with peers at school when conflict arises. Ongoing
reinforcement of positive coping skills and well as being aware
of anger will enforce safety of others in the milieu.
3- Difficulty with peer relationships / Social Skills. Patient has
moderately low self esteem, poor peer relationships, bipolar
disorder, and is in Eriksons stage of identity versus role confusion.
Developing social skills and peer relationships are of important to
establish for this patient stage of development.

Priority #

CARE PLAN

Create 3 plans of care one for each of your priorities identified.

Nursing Diagnosis: Risk for Self-Directed Violence
P: Suicidal ideation with plan.
E: Evidenced by patient reporting having a plan for suicide by using fathers gun to shoot self.
S: Admission as inpatient. Suicide/ Safety precautions initiated. Routine body checks. Routine visual safety checks. TM33
assessment per shift and as needed. Therapy sessions.
LT goal: Patient will report no suicidal ideations for one month.
ST goal: Patient will remain safe and verbalize ability to notify staff if suicidal ideations occur by end of shift and throughout
hospital stay.
Gulanick, M. & Myers, J. (2011). Nursing care plans diagnoses, interventions, and outcomes. St.Lous, MO: Elsevier.
Scientific Rationale

Intervention & Frequency

(In complete sentences!)

(Reference in APA format, including page number)

Evaluation

Provide a safe environment. Always

ongoing.

Suicide precautions are used to prevent the patient from

acting on sudden self-destructive impulses. These measures
include removing potentially harmful objects (e.g., electrical
appliances, sharp instruments, belts and ties, glass items,
and medications) and maintaining visual contact with the
patient at all times. (Gulanick & Myers 2011 pg.2)

Met- Inpatient status. Milieu kept

safe by all staff members. No
harmful items available to patient.

Encourage verbalization of negative

feelings within appropriate limits.
Every shift.

Patients need the opportunity to discuss negative thoughts

and intentions to harm themselves. Verbalization of these
feelings may lessen their intensity. Patients also need to see
that staff can tolerate discussion of suicide ideation.
(Gulanick & Myers 2011 pg.2)

Met- Able to have 1:1 discussion

with patient about suicidal
ideations. TM33 performed.

Spend time with the patient. Every

shift.

This interaction may provide a sense of security and

reinforce self-worth. (Gulanick & Myers 2011 pg.2)

Met- Able to have 1:1 discussion

with patient as well as group
interactions.

Develop a verbal or written contract

stating that the patient will not act
on impulse to do self-harm. Review
and update the contract as needed.
On admission and as needed.

The patient benefits from talking about suicide ideation with

trusted staff. A written or verbal agreement establishes
permission to discuss the subject, makes a commitment not
to act on impulse, and defines a plan of action in case
impulse occurs. (Gulanick & Myers 2011 pg.2)

Met- Contract developed on

admission with staff, will update as
needed.

Priority #2

CARE PLAN

Create 3 plans of care one for each of your priorities identified.

Nursing Diagnosis: Ineffective coping skills
P: Anger management/ ineffective coping skills
E: Patient reports getting into fights at school with peers. Self-harm behaviors evidenced by scratching self with pencil.
S: Have patient identify personal situations that may cause anger. Have patient identify ways to calm self when angry.
Have patient verbalize to staff when feeling anger. Have PRN medication available for angry outbursts.
LT goal: Patient will be able to stop and refocus when feeling angry or unable to cope within 3 weeks.
ST goal: Patient will not have any angry outbursts or ineffective coping for 3 days.
Gulanick, M. & Myers, J. (2011). Nursing care plans diagnoses, interventions, and outcomes. St.Lous, MO: Elsevier.

Intervention & Frequency

Scientific Rationale

(In complete sentences!)

(Reference in APA format, including page number)

Evaluation

Assess specific stressors. Daily.

Accurate appraisal can facilitate development

of appropriate coping strategies. Persistent
stressors may exhaust the patients ability to
maintain effective coping. (Gulanick & Myers
2011 pg.50)

Partially met- Patient able to identify

stressors at school. Such as grades dropping,
people not liking her because she is new to
the school.

Assess all available and useful coping

methods. Daily.

Patients with a history of ineffective coping

may need new resources, but a survey of what
has been useful or what has not been helpful
is important information. (Gulanick & Myers
2011 pg.50)

Partially met- Able to discuss talking to father

as a source of coping as well as playing
sports.

Identify ineffective behaviors. Daily.

This helps in focusing on more appropriate

strategies. (Gulanick & Myers 2011 pg.51)

Partially met- Patient able to state that

fighting at school is an ineffective coping
behavior.

Assist the patient with problem solving

in a constructive manner. Daily.

Constructive problem solving can promote

independence and a sense of autonomy.
(Gulanick & Myers 2011 pg.51)

Partially met- Patient was able to identify

constructive problem solving independently.

Priority #

CARE PLAN

Create 3 plans of care one for each of your priorities identified.

Nursing Diagnosis: Social isolation, ineffective social relationships.
P: Difficulty with peer relationships, poor social skills.
E: Evidenced by patient reports of fighting in school.
S: Teach positive social skills. Group, individual, and family therapy to improve self
esteem.
LT goal: Patient will gain a positive peer relationship in 4 weeks.
ST goal: Patient will participate and tolerate group activities by end of shit.
Gulanick, M. & Myers, J. (2011). Nursing care plans diagnoses, interventions, and outcomes. St.Lous, MO: Elsevier.

Intervention & Frequency

Assist the patient in determining socially

adaptive behaviors. Daily.

Acknowledge the patients involvement in

activities of daily living (i.e., going to school,
taking care of own physical needs). Weekly.
Encourage participation in group
activities as tolerated. Every Shift.
Assist the patient in identifying social
interests and people who have meaning
to him or her. Weekly.

Scientific Rationale

(In complete sentences!)

(Reference in APA format, including page number)

The manic patient may engage in behaviors that

negatively affect his or her ability to maintain
relationships and a sense of belonging in the home or
workplace. Some patients with bipolar disorder may
insist that the manic phase of their illness gives them a
feeling of being powerful, energized, and omnipotent.
Consequently, the patient may be reluctant to give up
this feeling despite its obvious negative effects.
(Gulanick & Myers 2011 pg.4)
Acknowledgment recognizes and reinforces
positive efforts. (Gulanick & Myers 2011 pg.4)
The patient needs to feel some degree of control.
Allow the patient to set his or her own pace in
social situations when contact with others can be
anxiety provoking. (Gulanick & Myers 2011 pg.4)
Patients may have difficulty accessing this
information because of their overwhelming
feelings of worthlessness. (Gulanick & Myers
2011 pg.4)

Evaluation

Partially met- Patient able to state being

adaptive to gain friends.

Partially met Discussed with patient

about attending school regularly despite
having difficulties with others at times.
Met- Patient participated in group
activities and enjoyed self.
Met- Discussed outdoor team sports as a
way to develop positive social
relationships with peers.

Evidenced Based Article

Neurofunctional changes in adolescent

cannabis users with and without bipolar disorder
This study was a first of its kind. MRI scans were used to assess
brains of children with and without bipolar disorder and co
morbid cannabis use. Studies show that 60% of those with
bipolar also have a co morbid substance use disorder. The MRI
scans showed less activations in the emotional centers of the
brain of those that have bipolar d/o and cannabis use
compared to those with only bipolar disorder. It may indicate
that cannabis has a unique effect on the brain of those with
bipolar disorder. More studies need to be done since cannabis
use is relatively high among those with bipolar disorder.

The Big Picture

Only Child

13 years old
Identify
versus role
confusion

Supportive
Parents
Bipolar d/o

Medications
ordered

Loves sports,
gets good
grades

Anger easily
fights at
school

Loss of
grandfather

Caucasian
female
Believes in
God no
specific
religion

The Big Picture

Putting everything together with this patient there is a lot
of hope. With continued positive family support,
continued outside therapy, and continued medication
evaluations this patient will be able to manage her
bipolar disorder very well. Her age and developmental
stages she is in will be beneficial to address and support
to ensure adequate growth especially since she has a
mental illness to deal with as well. Her plan of care is very
relevant and very attainable. The only changes I would
make is to have a case manager follow her through out
her adolescence to ensure proper care is attained.

Whats needed to recover

Along with continued family support, continued
outpatient therapy, and continued medication
evaluation this patient needs to learn about her illness
and medication. Self awareness, self esteem, and
coping skills are important for her recovery.
Outside of medical treatment and therapy my wish for
this patient is to not have suicidal ideations and to find a
friend that accepts her for who she is and provides a
positive influence on her as well as a sense of belonging
and peer support.