Bipolar Depression/Mania

SKINNY Reasoning

Brenden Manahan, 35 years old

Primary Concept
Mood and Affect
Interrelated Concepts (In order of emphasis)
 Psychosis
 Clinical Judgment
 Patient Education

NCLEX Client Need Categories Percentage of Items from Each Covered in

Category/Subcategory Case Study
Safe and Effective Care Environment
 Management of Care 17-23% 
 Safety and Infection Control 9-15% 
Health Promotion and Maintenance 6-12% 
Psychosocial Integrity 6-12% 
Physiological Integrity
 Basic Care and Comfort 6-12% 
 Pharmacological and Parenteral Therapies 12-18% 
 Reduction of Risk Potential 9-15% 
 Physiological Adaptation 11-17% 

© 2018 Keith Rischer/www.KeithRN.com

 SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data

History of Present Problem:
Brenden Manahan is a 35-year-old male, who has been admitted to the crisis intervention unit for exacerbation of his
bipolar disorder. He was admitted on a 501 (involuntary inpatient admission, patient has been deemed either dangerous to
self or others) and brought to the hospital by police because his mother feared for his safety. In the past few weeks, he
stopped taking his medication because he feared that his mother was poisoning him.
Brenden has not slept in the past four days due to racing thoughts. He believes that he is the head of the CIA and told
his mother that he needed her car to go to CIA headquarters in McLean, Virginia, and fire everyone. When the police
arrived they noted that Brenden was speaking at a very rapid rate and pace and was becoming increasingly agitated. He
began yelling that the police where there to poison him and prevent him from returning to his job.
He has been admitted to the locked mental health unit for evaluation of his mental capacity and stabilization. Brenden
will participate in the following education groups: medication education, and bipolar illness education. The goal is to
resume lithium carbonate and divalproex sodium.

Personal/Social History:
Brenden was diagnosed at 19 with bipolar I, and subsequently has been admitted six times due to non-adherence to the
medication regimen. Brenden is divorced and has a 3-year-old son who lives with his mother. He was recently in court to
have his visitations reduced to one supervised visit a week. He lives with his mother, who is supportive.

What data from the histories is important and RELEVANT and has clinical significance for the nurse?
RELEVANT Data from Present Clinical Significance:
Problem:
1. Pt has been deemed dangerous to self or 1. Safety is the biggest concern.
others. 2. Adverse effects and withdrawals can occur.
2. Pt has stopped taking his medication 3. Not able to do what is best for himself.
abruptly. 4. Sleep deprivation is very dangerous and a sign of a manic episode.
3. Pt had to be taken involuntarily into 5. Clinical assessment finding in bipolar pts, disturbed speech patterns and
admission. grandiose delusions.
4. Pt has not slept in four days. 6. Symptoms of anxiety and stress.
5. Pt believes he is head of the CIA. 7. Safety is of concern if agitation continues.
6. Pt has a very rapid heart rate and pace.
7. Pt has become increasingly agitated.
RELEVANT Data from Social History: Clinical Significance:
1. Pt has been dx since 19 and admitted 1. Need to review medications for alternatives, been on treatment for 16
6x. years.
2. Pt does not adhere to medication 2. Need to re-evaluate previous therapies to encourage adherence to
regiment. medication.
3. Pt is divorced. 3. Major life change is a risk factor for manic episodes.
4. Pt has a 3-yr. old child who does not 4. High stress situation, risk factor.
live with him. 5. Could be a trigger for frustration.
5. Pt has limited and supervised visitation 6. Unable to be independent, risk for altered relationships due to symptoms
now. observed.
6. Pt is 35 and lives with his mother.

Current VS: WILDA Pain Assessment (5th VS):

T: 99.1 F/37.3 C (oral) Words: Patient denies
P: 110 (regular) Intensity:
R: 28 (regular) Location:
BP: 142/84 Duration:
O2 sat: 99% room air Aggravate:
Alleviate:
 Patient Care Begins:
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
1. Temp is 99.1 1. Temp is normal, no sign of fever and helps to rule out infection.
2. Pulse is 110 and regular 2. Pulse is slightly elevated, could be compensatory response to decreased
3. Respirations are 28 and regular cardiac output.
4. BP at 142/84 3. Respirations are elevated, pt is anxious and agitated. At risk for
5. Oxygen on room air is 99% hyperventilation. Normally 12-20 is expected.
4. BP is elevated, pt is agitated which could explain this finding.
5. Oxygen is adequate and indicates no airway obstruction.
 Current Assessment:
GENERAL Is disheveled, and according to his mother, he has not showered in several days.
APPEARANCE:
NEURO: Oriented to person and place but not to time, impaired ability to concentrate, labile
emotions, has not slept for four days
RESP: Breath sounds clear however, patient is breathing rapidly and deeply
CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial/pedal/post-tibial landmarks
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants, has
adequate appetite.
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact
CHEMICAL USE: Denies both use/abuse of ETOH or other street drugs

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
1. General: Disheveled, not showered in 1. Impaired function of self-care.
days. 2. Decline in sleep is a typical finding during a manic episode and prior to.
2. Neuro: Not fully oriented, labile Affects brain function/LOC and emotions. Confusion may increase risk to
emotions, impaired concentration, has harm self or others.
not slept in four days. 3. Rapid, deep breaths is common in a pt experience mania. If unable to calm
3. Respiratory: Rapid, deep breathing. oneself, it could lead to respiratory acidosis if hyperventilation continues.

Mental Status Examination:

APPEARANCE: Is disheveled, and according to his mother he has not showered in several days. He is
unshaven, and has a significant odor coming from his body and or clothes. His clothes are
not consistent with the weather, it is 95 degrees and is wearing multiple layers of clothing
and has winter boots on.
MOTOR BEHAVIOR: Psychomotor agitation present, appears restless; he is unable to sit still
SPEECH: Talking fast with pressured speech.
MOOD/AFFECT: Appears ecstatic, bright affect
THOUGHT PROCESS: Delusional, flight of ideas/ jumping from one idea to another
THOUGHT CONTENT: Believes that the CIA is controlling the nurses’ actions and following him and that he must
get to the CIA headquarters immediately.
PERCEPTION: Denies hallucinations
INSIGHT/JUDGMENT: Has lack of insight into current condition and reason for inpatient hospitalization
COGNITION: Oriented to person and place but not to time, his immediate and recall were intact but
remote memory is not intact.
INTERACTION: Approaches others, but does not engage in lasting conversation
SUICIDAL/HOMICIDAL: Denies homicidal/suicidal ideation

What MSE assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data: Clinical Significance:
 Not taking care of personal hygiene.  These are all findings that are relative to a manic episode and
 Wearing clothing not appropriate to weather. currently in a manic state.
 Restless, not able to sit still.  Displays impaired ability to provide self-care and self-awareness.
 Talking fast with slurred speech.  Even though pt denies ideations, he needs to be monitored closely to
 Delusional thoughts (CIA). Flight of ideas. protect from self-harm and to others as behaviors can shift suddenly.
 Pt not understanding why he’s been
hospitalized. Lack of insight.
 Minimal social interaction with others.
 Denies homicidal/suicidal ideation.
 Diagnostic Results:
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 142 4.0 102 1.0

Complete Blood Count (CBC)

WBC % Neuts HGB PLTs
Current: 8.9 70 12.9 325
MISC.
Lithium
Current: 0.2

What data must be interpreted as clinically significant by the nurse ? (Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Clinical Significance:
Diagnostic Data:
 All are within acceptable ranges;  Sodium: Sodium helps maintain lithium levels. Pt is on lithium and it is vital that
however, it is useful in he keep his sodium within a healthy range to avoid toxicity while on this drug.
determining any medication side Diet and exercise need to be balanced while on this medication to avoid a spike in
effects that could be attributing either direction.
to his current symptoms.  Potassium: Essential to normal cardiac conduction, pt is at risk for heart
complications if not regulated due to dysrhythmias that can occur with this
diagnosis. Also, if the pt becomes dehydrated the potassium levels could increase
leading to cardiac complications, along with lithium.
 Glucose: Vital fuel source for metabolism for every cell in the body, especially the
brain.
 Creatinine: Renal system impacts every body system and therefor is always
relevant. Lithium can negatively affect the kidneys, therefor it is not recommended
for patients with renal disease. Lithium is excreted in the kidneys, so we need to
monitor for kidney failure to avoid complications.
 Current Lithium therapeutic blood level is less than normal, most likely due to the
fact that the pt has not adhered to his medication regiment.
o Early signs of Lithium toxicity include; hand tremors, decrease in
coordination, dizziness, and lethargy.
o Late signs of Lithium toxicity include; blurred vision related to CNS
disturbances and dilute urine.
o Side effects of Lithium include; confusion, restlessness, nausea, diarrhea,
thirst, and weight gain.
 Part II: Put it All Together to THINK Like a Nurse!
1. After interpreting relevant clinical data, what is the primary problem?
(Management of Care/Physiologic Adaptation)
Problem: Pathophysiology in OWN Words:
The patient is most likely experiencing a Manic Episode: An exact cause and pathophysiology is unknown, but
manic episode. He has shown at least 3 of the heredity, changes in the level of brain neurotransmitters, and psychosocial
symptoms that are associated to a manic factors may be involved.
episode. A manic episode is defined as > 1 week of a persistently elevated, or irritable
 He has gone four days without sleep mood and an increase in goal-directed activity or energy, plus >3 additional
which is a symptom of a manic episode. symptoms:
He believes he is the head of the CIA  Inflated self-esteem or grandiosity
which shows an inflated self-esteem or  Decreased need for sleep
grandiosity. He has disturbed speech  Greater talkativeness than usual
patterns as evidenced by the rapid pace
 Flight of ideas or racing of thoughts
and flight of ideas. He has also been
easily agitated. He is most likely feeling  Distractibility
frustrated with feeling this boost of  Increased goal-directed activity
energy and euphoric sensation which  Excessive involvement in activities with high potential for painful
leads to agitation when opposed by others consequences (eg, buying sprees, foolish business investments)
and told what he is doing is wrong or
harmful.

Collaborative Care: Medical Management

2.State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Medical Management: Rationale: Expected Outcome:
 Admit to unit and engage patient in milieu  Pt is expressing symptoms of mania  Calming the pt down with a
 Urine drug screen which include pressure of speech, quiet and safe environment.
 Lithium 600 mg PO BID reduced need for sleep, flight of Allowing opportunity for
ideas, grandiosity, poor judgment, psychotherapy and
 Depakote 375 mg PO BID
aggressiveness, and possible hostility. medication to be
 Trazodone 100 mg PO PRN sleep
 UDT – tool to assess for any misuse, administered.
 Lorazepam 1 mg PO BID abuse, and diversion of controlled  UDT – clean specimen.
substances.  Lithium - Mood stabilizer.
 Lithium – Used in bipolar disorders,  Depakote – treat manic
particularly for manic phases and phases of bipolar disorder.
prevention of it.  Trazodone – Improve
 Depakote – Restores the balance of mood, appetite, and energy
certain neurotransmitters in the brain. level as well as decrease
 Trazodone – Anti-depressant, restore anxiety, and insomnia
the balance of serotonin in the brain. related to depression.
 Lorazepam - anti-anxiety, a  Lorazepam – calm the pt
benzodiazepine that acts on the CNS and reduce anxiety.
to produce a calming effect.
 Collaborative Care: Nursing
3.What nursing priority (ies) will guide your plan of care? (Management of Care)
Nursing PRIORITY: Getting acute mania under control.
Preventing relapse when remission occurs.
Returning to the prior level of functioning.
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
1. Matter-of-fact tone. 1. This tone minimizes the need for the pt to 1. By providing
2. Clear, concise directions and respond defensively and avoids power struggles. emotional support
comments. 2. When the nurse is confronted with pts who fall and responding to
3. Limit setting. into these areas (hyperactive, highly talkative, patients in a matter-
4. Safety. easily distracted, experience flight of ideas, have of-fact manner, the
poor judgment and a labile affect), it can be nurse conveys both
difficult to communicate with one another. Using control of the
pauses, raising your hand, and non-verbal cues, situation and
will assist in getting control again and allowing empathy.
conversation to be held. 2. As a pt starts to
3. When the nurse is leading a group, a talkative pt improve the nurse
can be disruptive. The nurse needs to protect be able to work out
vulnerable pts and keep them from being drawn one of these
into the anger that the manic pt feels. methods to indicate
4. It is important for the RN to prevent manic pts when the pt needs
from hurting themselves or others. It is reassuring to stop talking and
to the pts that the staff will not let them harm begins listening.
themselves or others. 3. No debating or
arguing, simply
state the expected
behaviors and move
on to avoid
engaging undesired
behaviors.
4. No harm will come
of anyone.
 4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES: Improve pt’s adherence to medication and increase his understanding of the
illness.

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

CARING/COMFORT:  1:1 conversation  It is important for him
How can you engage and show that o Allow time for him to speak freely and openly to feel safe and that
this pt. matters to you? away from prying eyes in a calm environment he is being heard.
 Foster independence / decision-making  Reinforce the
 Foster self-esteem patient’s effort to
Physical comfort measures:  Stress reality make simple
o I would want to encourage what is reality and decisions, this helps
respond to legitimate complaints but limit them move toward
attention towards fantasy perceptions from the health.
patient. Using a clear, concise tone in  Spend time with the
directions and comments. Interrupt ramblings, patient to develop
as needed. trust and accept the
 Encourage rest/sleep patient for where they
o While he is experiencing insomnia, it is vital to are at and focus on
provide a quiet place to sleep. Also structure their strengths.
his day to that there are fewer stimulating
activities towards bedtime. No caffeinated
drinks before bedtime. Assess his sleeping
habits regularly because he is not able to judge
his need for rest. Exhaustion and death have
resulted from a lack of rest.
EMOTIONAL SUPPORT:  Recognize anger  Knowing this is their
Principles to develop a o Acknowledge that he is upset and use de- immense emotional
therapeutic relationship escalation techniques such as remaining calm pain and not a
and using a soft voice, reassuring the patient reflection of how they
that you understand. truly feel helps to
understand their
anger.
SPIRITUAL CARE/SUPPORT:  Listen actively to the pt talk about their  Allows the pt the
religious/spiritual beliefs. opportunity to talk
 Encourage appropriate joy and humor. about is important to
them in this regard,
giving them meaning
and purpose possibly.
 Laughter lifts the
spirit, celebrates life
and keeps things in
perspective.
CULTURAL CARE/SUPPORT:  Culture is a critical component of pts lives that  Respect from the pt
(If Applicable) affects their health care attitudes and actions. and a better
relationship of care.

5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient
and/or family? (Health Promotion and Maintenance)
If you think you are about to hurt yourself or someone else, call 911. Medications given need to be taken as prescribed. Do not
stop without contacting your provider. Carry your medications with you in case of an emergency. Maintain appointments and
follow up care. Watch for triggers and practice new coping mechanisms that are healthy and not harmful. Tell someone if you
are feeling a manic or depressive period might be coming on. This is a disorder that takes multiple approaches, don’t give up.