Case study - Bipolar I disorder: Nursing

Nurse Nikil works on an inpatient psychiatric unit and is caring for Octavia, a 28-year-old with a history of bipolar I disorder, who was recently admitted for a manic episode.

After settling Octavia in her room, Nurse Nikil goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Octavia’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Nikil recognizes important cues, including Octavia’s vital signs, which are temperature 98.4 F or 36.9 C, heart rate 75 beats per minute, respirations 16 breaths per minute, and blood pressure 117/72 mmHg.

Upon entering her room, Nurse Nikil notes Octavia is pacing back and forth, stopping intermittently to rearrange the items on her bedside table.

Nurse Nikil: Hi Octavia, I see you’re cleaning your room. Could you pause for a moment and speak with me?

Octavia: Oh sure, I totally have time for you. Don’t you see I’m doing something important?

I really need to get my room cleaned so I can start writing. I have an amazing idea for a best-selling book about a forest like the one I grew up next to.

My mom would know the name. I should call her.

Do you have her number? Oh, look, what’s that on the floor?

I’ll fix it! Next, Nurse Nikil analyzes these cues.

They review the electronic health record, or EHR, and note Octavia is prescribed lithium but reports that she stopped taking it about two weeks ago.

They note Octavia's blood level of lithium is 0.5 mEq/L, but Nurse Nikil knows that the therapeutic index should be between 0.6 and 1.0 mEq/L.

The nursing report from the night shift also stated that Octavia did not sleep. Nurse Nikil recognizes patients with bipolar I disorder experience extremes in emotions, moving from manic to depressive moods.

Those in a manic state experience a persistent period of extreme emotions and may have symptoms, like racing thoughts, hyperactivity, distractibility, insomnia, and feeling an inflated sense of self.

Nurse Nikil recognizes that Octavia needs mood stabilization and medication management. Now, using the information they've gathered, along with Octavia’s medical history, Nurse Nikil chooses a priority hypothesis of disturbed thought processes.

Then, they generate solutions to address Octavia’s manic episode that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Octavia will resume medication management for her bipolar I disorder by time of discharge.

Nurse Nikil then takes action to implement these solutions. Nurse Nikil checks the EHR and sees that Octavia is prescribed a dose of lithium.

Nurse Nikil enters Octavia’s room. Nurse Nikil: Hi Octavia, I have your lithium for you.

Octavia: I’m kind of busy right now. Can you just put it on the table, and I’ll take it later?

Nurse Nikil: Is there a reason you don’t want to take your medication? Octavia: Honestly, I’m too busy.

Plus, I’ve been off it for a while now, and I’m fine. I don’t have time to go to the pharmacy, I’ve got things to do.

Nurse Nikil: I see. It's important for you to take your lithium every day to manage your symptoms.

It’s not healthy to go days without sleeping. Octavia: I’m aware.

Why do you care anyways?! Nurse Nikil: I’m here to support you, so I’ll stay with you until you take the medicine.

Octavia: Ugh. I don’t see what the big deal is.

I’ll take it! I just want to go home.

Nurse Nikil then administers the lithium according to the principles of safe medication administration. Nurse Nikil: Good.

Now let’s discuss some ways for you to manage your bipolar disorder. First, we need to establish a plan so you can remember to take your medication.

Octavia: Fine. Nurse Nikil discusses strategies to promote medication adherence, such as setting an alarm on her phone and keeping the lithium on her bedside table, so she sees it upon waking up every morning.

Nurse Nikil then consults the social worker who sets up medication delivery to Octavia’s home, so she doesn’t have to drive to the pharmacy to pick it up.

Following the discussion, Nurse Nikil decreases environmental stimuli by dimming the lights in her room and lets her know the unit counselor will be here within the hour.

Prior to discharge, Nurse Nikil enters Octavia’s room to evaluate the outcome of their actions. Her vital signs are temperature 97.8 F or 36.6 C, heart rate 68 beats per minute, respirations 16 breaths per minute, and blood pressure 112/70 mmHg.

Octavia is sitting up in her bed and is having a conversation with the nursing assistant. She shows Nurse Nikil the alert she’s set on her phone to remind her to take her daily lithium.

Octavia also reports that her brother will pick her up from the hospital and take her to her appointment to meet with her outpatient therapist the next day.

Alright, as a quick recap…Nurse Nikil recognized and analyzed cues related to Octavia’s manic episode and prioritized hypotheses and generated solutions to address this problem.

Nurse Nikil then took action and implemented pharmacologic and nonpharmacologic measures, then evaluated Octavia’s outcomes and compared them to the expected outcome.

Since Octavia plans to resume medication management for bipolar I at home, Nurse Nikil determined the plan of care was successful.