Bipolar - Nursing Case Study

Pathophysiology

• Primary mechanism: Bipolar disorder is characterized by dysregulation of neurotransmitter systems, particularly involving dopamine, serotonin, and glutamate, which leads to mood instability and alternating episodes of mania and depression.

• Secondary mechanism: Structural and functional brain alterations, especially in the prefrontal cortex and limbic regions, contribute to impaired emotional regulation and cognitive function, exacerbating mood swings.

• Key complication: This neurochemical and structural imbalance can lead to impaired psychosocial functioning, increased risk of comorbidities such as anxiety and substance abuse, and challenges in adherence to treatment plans.

Patient Profile

Demographics:

45-year-old female, high school teacher

History:

• Key past medical history: Diagnosed with Bipolar Disorder Type II five years ago, history of hypertension

• Current medications: Lithium 900 mg daily, Lisinopril 20 mg daily, Lamotrigine 100 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased mood swings and difficulty managing daily activities

• Key symptoms: Rapid cycling between depressive and hypomanic episodes, insomnia, decreased appetite, increased irritability

• Vital signs: Blood pressure 150/95 mmHg, heart rate 110 bpm, respiratory rate 20 breaths per minute, temperature 98.9°F

Section 1

As the healthcare team conducts an initial assessment, they note that the patient's rapid mood cycling and insomnia have worsened over the past few weeks. Her blood pressure remains elevated at 150/95 mmHg, and her heart rate is persistently high at 110 bpm, suggesting a possible exacerbation of her hypertension due to stress and lack of sleep. The patient reports feeling increasingly overwhelmed, with her teaching responsibilities becoming difficult to manage. Her irritability and decreased appetite have also led to weight loss, which she attributes to both decreased food intake and high levels of stress. Upon further questioning, she reveals that she occasionally forgets to take her medications, especially during hypomanic episodes when she feels more energetic and less concerned about her health.

Laboratory tests are ordered to evaluate her current condition, revealing a subtherapeutic level of lithium at 0.4 mEq/L (normal therapeutic range: 0.6-1.2 mEq/L). This finding suggests that her medication adherence might be more inconsistent than initially suspected, contributing to the increased mood instability and rapid cycling. Additionally, her serum sodium levels are slightly low at 133 mEq/L, raising concerns about potential lithium-induced nephrogenic diabetes insipidus or dehydration, which might be exacerbating her hypertension and heart rate issues. These findings prompt the healthcare team to consider adjusting her treatment plan, addressing both her mood stabilization and hypertension more aggressively while ensuring she receives proper education on the importance of medication adherence.

The patient’s worsening symptoms and lab results indicate a need for a comprehensive approach that includes medication adjustment, lifestyle modification, and psychoeducation. The team discusses the potential benefits of re-evaluating her lithium dosage, considering an adjunctive mood stabilizer, and possibly consulting with a psychiatrist for a more tailored pharmacological strategy. Additionally, they plan to engage the patient in regular counseling sessions to improve her coping strategies and adherence to the treatment regimen. This integrated approach aims to stabilize her mood, enhance her quality of life, and prevent further complications associated with bipolar disorder and hypertension.

Section 2

As the healthcare team implements the revised treatment plan, the patient returns for a follow-up visit two weeks later. During this visit, a significant change in her status is noted. The patient reports an improvement in her mood stability, and her rapid cycling has reduced from several episodes a day to only one or two per week. However, she still experiences occasional insomnia, though it is less severe than before. Her compliance with the newly adjusted lithium dosage, now increased to achieve therapeutic levels, is confirmed through her latest lab results, which show a serum lithium level of 0.8 mEq/L. This suggests improved adherence, likely influenced by the recent psychoeducation sessions that emphasized the importance of consistent medication intake.

Despite progress in mood stabilization, new complications have emerged. The patient's blood pressure remains elevated at 145/92 mmHg, and her heart rate is still slightly tachycardic at 105 bpm. Additionally, the patient reports new-onset muscle weakness and increased thirst, prompting the team to investigate further. Repeat laboratory tests reveal a further decrease in her serum sodium level to 130 mEq/L, raising concerns about potential lithium-induced nephrogenic diabetes insipidus. The team considers these findings in the context of her ongoing hypertension and decides to pursue a nephrology consultation to evaluate the need for interventions such as fluid management or medication adjustments.

The healthcare team recognizes the need to address these new complications promptly to prevent further impacts on the patient's cardiovascular health and overall well-being. The nephrology evaluation aims to provide insights into managing her potential lithium side effects, while the psychiatric team continues to support her mental health stabilization. This integrated approach, alongside regular monitoring, is intended to optimize the patient's treatment outcomes and maintain her progress in managing both her bipolar disorder and associated physical health challenges.

Section 3

Following the nephrology consultation, the healthcare team receives new diagnostic results that provide further clarity on the patient's condition. The assessment confirms the suspicion of lithium-induced nephrogenic diabetes insipidus, characterized by the patient's polyuria, increased thirst, and low serum sodium levels. Her urine osmolality is notably low at 150 mOsm/kg, reinforcing the diagnosis. Given these findings, the team decides to initiate a conservative approach to manage the nephrogenic diabetes insipidus, which includes advising the patient on maintaining adequate hydration and monitoring her fluid intake closely. They also discuss the possibility of introducing amiloride, a potassium-sparing diuretic, to help mitigate the renal effects of lithium without significantly impacting her serum potassium levels.

In addition to addressing her renal complications, the team revisits the patient's cardiovascular status. Despite the mood stabilization, her blood pressure remains elevated, and her heart rate continues to show mild tachycardia. This necessitates a careful evaluation of her current medication regimen. The team considers the potential contribution of lithium to her cardiovascular symptoms and discusses the introduction of an antihypertensive agent, such as an ACE inhibitor, to manage her elevated blood pressure more effectively. They also explore lifestyle modifications, including dietary changes and stress management techniques, as adjunctive measures to improve her cardiovascular health.

The integration of these new interventions into the patient's treatment plan presents an opportunity for the healthcare team to exercise clinical reasoning. They must weigh the benefits of continuing lithium for mood stabilization against the risks of its side effects, carefully monitoring her renal function and cardiovascular parameters. This comprehensive, interdisciplinary approach not only aims to address the immediate complications but also sets the stage for the next phase of her care, focusing on achieving a delicate balance between mental health stabilization and physical health management.

Section 4

As the healthcare team continues to monitor the patient, they notice a change in her status. Over the course of several days, her polyuria persists, but she begins to exhibit signs of dehydration despite adhering to the recommended hydration plan. Her skin turgor is slightly reduced, and she reports feeling more fatigued than usual. A repeat set of laboratory tests reveals an increase in her serum sodium levels to 148 mmol/L, indicating a developing hypernatremia. The team notes that her urine output has slightly decreased, yet her urine remains dilute, with an osmolality still at 150 mOsm/kg. These findings suggest a need to reassess her fluid management strategy and consider adjusting her treatment plan.

In response to these new complications, the healthcare team decides to initiate the use of amiloride, aiming to improve her renal response to antidiuretic hormone and reduce urinary water loss. Additionally, they increase their focus on educating the patient about recognizing early signs of dehydration and ensuring a balanced fluid intake. Concurrently, they continue to monitor her cardiovascular status closely, as her blood pressure remains elevated at 150/95 mmHg, and her heart rate is consistently around 105 bpm. Given these cardiovascular metrics and her electrolyte imbalance, the team considers adjusting her antihypertensive regimen, potentially introducing a low-dose ACE inhibitor while maintaining vigilance for any interactions with her existing medications.

These developments necessitate careful clinical reasoning to balance the patient's mental health needs with her emerging physical health issues. The interdisciplinary team must collaborate to adjust her treatment plan dynamically, ensuring that each intervention is tailored to address her complex presentation. This ongoing process will guide the next steps in her care, aiming to stabilize her condition while preventing further complications.

Section 5

As the healthcare team continues to monitor the patient's response to the initiated interventions, they begin to observe a change in her status indicative of further complications. Three days into the administration of amiloride, the patient's serum sodium levels have decreased slightly to 146 mmol/L, suggesting a mild improvement in her hypernatremia. However, the patient now reports experiencing intermittent headaches and dizziness, particularly when transitioning from sitting to standing. Her blood pressure remains elevated at 152/98 mmHg, and her heart rate has increased to 110 bpm. These symptoms raise concerns about potential orthostatic hypotension, possibly exacerbated by her fluid shifts and the introduction of new medications.

A repeat urinalysis shows a marginal increase in urine osmolality to 200 mOsm/kg, indicating a slight improvement in her renal concentrating ability. Despite these changes, the patient's skin turgor remains slightly reduced, and she continues to express fatigue and a feeling of dryness in her mouth. The interdisciplinary team carefully considers these findings, weighing the benefits of continuing amiloride against the risk of exacerbating her cardiovascular symptoms. Additionally, they ponder whether the introduction of a low-dose ACE inhibitor might further complicate her fluid and electrolyte balance, especially given her fluctuating blood pressure and recent presentation of postural dizziness.

In response to these developments, the team prioritizes further diagnostic evaluations, including an echocardiogram to assess her cardiac function and a comprehensive review of her medication regimen, ensuring no adverse interactions contribute to her symptoms. They also intensify their focus on patient education, emphasizing the importance of slow positional changes to mitigate dizziness and promoting consistent monitoring of her fluid intake and output. These steps aim to stabilize her condition while addressing the multifactorial nature of her health challenges, guiding the next phase of her treatment plan.