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?