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 Covered in
Each 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 Problem: Clinical Significance:
Exacerbation of Bipolar Disease Reason why patient was admitted on a 501 (involuntary inpatient
- Has been admitted previously admission)
- Dangerous to self, others, and police - May have some relationship between staff, relapse
- Noncompliant with medication regimen - Pt is at risk to harm himself and others
- -Agitated, rapid speech - Pt stopped taking lithium carbonate and divalproex, remission,
- Has not slept for four days and relapse
- Evidence why he is behaving this way
- Pt may not be able to follow directions or have ability to listen
- Pt cannot relax of sleep, symptom of mania, can make delusions
worse
RELEVANT Data from Social History: Clinical Significance:
Diagnosed at 19 Lets medical professionals how long pt has had disorder, how long
-Admitted six times in the past due to mother has been supporting son
non- - Previous admissions show relapse in illness
adherence to med regimen - May need to change care plan based on nonadherence to
- Has a three-year-old son medication regime
-Is divorced - Pt has limited access to son, may be related to instability and
-Lives with mother, who is supportive safety of son
- May be related to reasons of depression
- Mother may be Pt. support system
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 Aggrava
te:
Alleviat
e:
Patient Care Begins:
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Pts BP is elevated May be related to stress and agitation to how Pt is feeling
142/84 -Low grade fever
-Temp is slightly - Pulse is elevate, may be related to agitation, anxiety from how Pt is feeling
elevated 99.1 F - Respirations are increased as well, can be associated with the mania the patient is
-Pulse- 110 experiencing
-Resp: 28 -Increased HR may be from exacerbation from illness
© 2018 Keith Rischer/www.KeithRN.com
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:
Pt is disheveled These findings may be expected with Bipolar disease and depression,
-Not showered in several days clinical significance is important to provide a safe environment for Pt
-Has not slept in four days - May need an EKG to see what cardiac function is at
-Impaired ability to concentrate, labile -Sign Pt may be hydrated since urine is clear and yellow
emotions -Need to do a urine test to see if patient has anything in system also
-Pt resp. is raid and deep before
-Urine is clear and yellow administering medications in case he does have something in his
-Denies both use/abuse of system for
ETOH/street clearance
drugs
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.
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:
Pt is disheveled, has not showered in Judgement is impaired, may be reason for low grade fever
several days -He is a vulnerable adult that is unable to care for himself properly
-Inappropriate clothing attire, wearing -Pt is unable to sit still jumps form one idea to another which
multiple layers in 95-degree weather distractibility is a
-Pt is agitated and restless, unable to hallmark symptom of mania
sit -Pt mood doesn’t match; he has no reason to be ecstatic, nurse needs
still to set limits
-Rapid speech, ecstatic, bright mood and must have back towards door and close for exit, because Pt may
affect have sudden
-Delusional, believes CIA is change in mood, leading to Pt acting out and becoming dangerous
controlling -He may not believe you’re a nurse, lack of insight current condition,
the nurse’s actions, must get to the -Grandiose delusions
CIA -Findings are significant because Pt is demonstrating a relapse and
headquarters immediately exacerbation of
-Lacks insight and reason for his disease Bipolar 1, can result in Pt not taking care of personal
hospitalization hygiene, eating
-Conversations is not lasting when properly, moods can be elevated, hyperverbal, etc.
engaged -Certain medications or techniques can be administered to provide
safety to
himself and to staff, and to minimize stimulation for Pt
© 2018 Keith Rischer/www.KeithRN.com
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 labs are within Pts labs doesn’t indicate infection or abnormal values
normal Hgb levels are important to monitor to see levels of lithium if Pt is below or if values are
limits above therapeutic levels since it has narrow therapeutic window
© 2018 Keith Rischer/www.KeithRN.com
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:
bipolar Bipolar disorders are characterized by episodes of mania and depression,
which may alternate, although many patients have a predominance of one
or the other.
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 Pt will be in proper unit to monitor him, so he is Pt will not harm himself or
engage patient in safe from himself and others.Milieu can be when others, pt will be in
milieu patient is in proper unit environment he can sleep, and
have adequate fluids and food
Urine drug screen to make sure Pt isn’t on other
substances that could interact with medications Pt will drink fluids and help
and to check function of kidneys, also to check if Pt is dehydrated, Pt will
Urine drug screen
electrolyte statu clear anything that
shouldn’t be in system
Pt will have decreased
Lithium will reduce symptoms of mania mood swings and
Lithium 600 mg PO BID
abnormal behavior from
Bipolar.
Depakote 375 mg PO
Will help decrease manic episodes, combination Pt will have a decrease in
if lithium isn’t effective manic episode
BID
Pt hasn’t slept in four
days and help some of
Trazodone 100 mg PO that sleep deprivation
To help with sleep, mild antidepressant effect psychosis, pt will obtain
PRN sleep
adequate sleep and have
improved symptoms,
sense of wellbeing
Lorazepam 1 mg PO BID
To help calm him and ease any anxiety Pt will be able to calm
down, and reduce
thoughts contributing to
anxiety
Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (Management of Care)
Nursing PRIORITY: Risk for injury
-Therapeutic relationship
-Medication non-adherence
-Disturbed sleeping pattern
-Self-care deficit
-Disturbed thought process
-Alteration in nutrition
-knowledge deficit
-Coping skills
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
Risk for injury when clients' safety culture is improved, Pt will remain free of
Provide a safe environment for Pt injuries to himself,
by staff, and other
removing all possible hazards in the there is a decrease in client adverse patients for shift.
environment such as pen, razors, events. Patient will
room demonstrate behaviors
clutter, matches, and anything the that decrease his risk
Pt may for injuries
use to injure himself or others. throughout the shift.
Also, place
Pt in a room next to the nurse’s
station so
Pt can be monitored closely by staff
© 2018 Keith Rischer/www.KeithRN.com
4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES: it helps in relieving bipolar
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
CARING/COMFORT: Promote comfort and reduce anxiety. Promotes relaxation
How can you engage and show that
this pt. matters to you? Promotes good sleep
Physical comfort measures:
EMOTIONAL SUPPORT: By this way we can create a positive emotion Shows positive
Principles to develop a within the patient emotions towards the
therapeutic relationship
future life.
SPIRITUAL CARE/SUPPORT: Shows a positive attitude towards life Improves the spiritual
well being of the
patient
CULTURAL Change the mindset Improves positive
CARE/SUPPORT: (If thoughts
Applicable)
5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or
family? (Health Promotion and Maintenance)
The most important education discharge priorities to discuss with Brenden is adherence to
medication regimen, followed by education on reducing stress and coping mechanisms.
Educating Brenden on the signs and symptoms of relapse and to intervene early so signs and
symptoms do not get worse, or relapse does not occur.
© 2018 Keith Rischer/www.KeithRN.com
