Video Case Study - Caring for Patients With Biploar Disorder

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.

In collaboration with the registered nurse, RN Andre, 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? Next, Nurse Nikil analyzes these cues.

They review the electronic health record, or EHR, and note that prior to her hospitalization, Octavia had not been taking her lithium as prescribed.

The nursing report from the night shift also indicated that Octavia hasn't slept for the past two nights. Nurse Nikil recognizes patients with bipolar I disorder experience extremes in emotions, moving from manic to depressive moods.

The patient may have symptoms, like racing thoughts, hyperactivity, distractibility, insomnia, and feeling an inflated sense of self.

They understand that in patients experiencing mania, sleep disturbances can lead to exhaustion which can perpetuate manic or hypomanic episodes.

They also know that medications like lithium are prescribed to help with mood stabilization. Nurse Nikil recognizes that Octavia needs management of her manic episode to promote effective sleep.

Now, using the information they've gathered, along with Octavia’s medical history, Nurse Nikil reports their findings to RN Andre, and together they choose a priority hypothesis of insomnia.

Then, Nurse Nikil collaborates with RN Andre to generate solutions to address Octavia’s insomnia that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Octavia will demonstrate two sleep promotion strategies by the end of the shift.

Next, Nurse Nikil and RN Andre take action to implement these solutions. They check the EHR and see that Octavia is prescribed a dose of lithium, then they re-enter Octavia’s room.

Nurse Nikil: Hi Octavia, I have your lithium for you. Octavia: Fine, but 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 also not healthy to go days without sleeping.

Octavia: Yeah, I’m aware. OK.

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: Now, I heard you haven’t been sleeping well.

Nurse Andre and I want to help you develop a routine so you can get some rest tonight. Octavia: Why do you care anyways?!

RN Andre: We’re here to support you and help you get better so you can go home. Octavia: Okay.

Then, RN Andre discusses strategies to promote sleep including establishing a sleep schedule by going to bed and waking up at the same time every day, and to have a relaxing pre-sleep routine by reading a book, listening to soothing music, or taking a warm bath.

He also teaches her ways to decrease stimulation before bedtime, like limiting screentime and avoiding caffeinated beverages in the afternoons and evenings; and to make her sleep environment more inviting for sleep, by ensuring it’s dark, quiet, and cool.

Lastly, he reinforces the importance of taking her lithium everyday as prescribed to stabilize her mood and reduce episodes of mania which will help her sleep at night.

Before exiting the room, Nurse Nikil decreases environmental stimuli by dimming the lights and reducing the volume on the television.

Before their shift ends, 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 63 beats per minute, respirations 16 breaths per minute, and blood pressure 110/70 mmHg.

Octavia is sitting up in her bed with her pajamas on. She shows Nurse Nikil the alert she’s set on her phone to remind her to take her daily lithium and another alert to remind her to initiate her bedtime routine.

Octavia asks Nurse Nikil to play some relaxing music on the radio to help her calm down before bed. Alright, as a quick recap… Nurse Nikil recognized and analyzed cues related to Octavia’s insomnia due to her manic episode, and in collaboration with RN Andre, prioritized hypotheses and generated solutions to address this problem.

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

Since Octavia was able to partake in two sleep promotion strategies,