A patient with bipolar disorder currently experiencing rapid cycling and increased cardiovascular symptoms is being assessed. Despite adherence to her medication, she reports worsened insomnia and daytime fatigue. Considering her current medication regimen, which nursing intervention is most appropriate to improve her sleep hygiene and potentially stabilize her mood?

B) Suggest the patient establish a consistent bedtime routine and limit screen time before bed.

A) Encourage the patient to increase caffeine intake during the day to combat fatigue.

B) Suggest the patient establish a consistent bedtime routine and limit screen time before bed.

C) Advise the patient to take short naps throughout the day to reduce overall fatigue.

D) Recommend the patient engage in vigorous exercise close to bedtime to tire herself out.

A patient with rapid cycling bipolar disorder has had her quetiapine dosage increased and propranolol added to her regimen. She reports improved mood stability but continues to experience elevated cholesterol levels. Which nursing intervention is most appropriate to address the patient's current health needs?

B) Initiate a referral to a dietitian for dietary counseling and lifestyle modification.

A) Recommend an immediate reduction in quetiapine dosage to manage cholesterol levels.

B) Initiate a referral to a dietitian for dietary counseling and lifestyle modification.

C) Suggest increasing the propranolol dosage to further stabilize vital signs.

D) Encourage additional CBT sessions to address stress-related symptoms.

A patient with bipolar disorder has had her quetiapine dosage increased to manage mood instability. During a follow-up visit, she reports improvement in mood stability but presents with elevated cholesterol levels. What is the most appropriate nursing intervention to address this new finding?

B) Recommend the patient engage in regular physical activity and dietary modifications.

A) Suggest increasing the dosage of quetiapine to stabilize mood further.

B) Recommend the patient engage in regular physical activity and dietary modifications.

C) Advise the patient to stop taking quetiapine until cholesterol levels normalize.

D) Request a prescription for a lipid-lowering medication from the healthcare provider.

A patient on quetiapine presents with new symptoms of muscle stiffness, weight gain, and tremors. Which nursing intervention is most appropriate to address these symptoms while considering her metabolic health?

C) Advise the patient on the importance of adhering to the current medication regimen and schedule a follow-up to assess the need for medication adjustment.

A) Encourage the patient to increase her quetiapine dosage to manage mood symptoms more effectively.

B) Recommend the patient to immediately stop taking quetiapine and schedule an urgent follow-up with her healthcare provider.

C) Advise the patient on the importance of adhering to the current medication regimen and schedule a follow-up to assess the need for medication adjustment.

D) Instruct the patient to begin a high-intensity exercise program to counteract weight gain and improve mobility.

A patient on quetiapine presents with muscle stiffness, unexplained weight gain, and occasional hand tremors. The multidisciplinary team considers adjusting her medication regimen. Which nursing intervention is most critical to implement during this adjustment period to ensure patient safety and therapeutic effectiveness?

B) Monitor the patient closely for signs of worsening mood symptoms or new side effects.

A) Educate the patient about potential dietary changes to manage weight gain.

B) Monitor the patient closely for signs of worsening mood symptoms or new side effects.

C) Encourage the patient to maintain a daily exercise log to improve physical mobility.

D) Schedule more frequent CBT sessions to address the psychological impact of medication changes.

A patient on atypical antipsychotics presents with persistent tremors and has recently developed pre-diabetic glucose levels. Which nursing intervention is most appropriate to prioritize at this time?

C) Coordinate with the healthcare team to consider a medication change to a lower-risk atypical antipsychotic.

A) Educate the patient about dietary modifications to manage blood sugar levels.

B) Monitor the patient’s vital signs and glucose levels more frequently.

C) Coordinate with the healthcare team to consider a medication change to a lower-risk atypical antipsychotic.

D) Encourage the patient to increase physical activity to alleviate tremors.

A patient with a history of psychiatric illness and recent weight stabilization reports persistent hand tremors and a fasting glucose level in the pre-diabetic range. What is the most appropriate nursing action to address the patient's current symptoms and potential metabolic issues?

B) Educate the patient on dietary modifications to improve glucose control and refer to a dietitian.

A) Encourage the patient to increase physical activity to help manage weight and reduce tremors.

B) Educate the patient on dietary modifications to improve glucose control and refer to a dietitian.

C) Administer prescribed beta-blockers to manage tremors and monitor for side effects.

D) Instruct the patient to avoid caffeine and other stimulants to reduce tremors and anxiety.

A patient on a new atypical antipsychotic medication reports experiencing mild dizziness when standing, along with a decrease in hand tremors. Her seated blood pressure is 128/78 mmHg, dropping to 110/70 mmHg upon standing. Which nursing intervention is most appropriate to address the patient's orthostatic hypotension while also considering her pre-diabetic condition?

B) Advise the patient to perform leg exercises before standing to improve circulation.

A) Encourage the patient to increase her salt intake to raise blood pressure.

B) Advise the patient to perform leg exercises before standing to improve circulation.

C) Instruct the patient to drink more caffeinated beverages to manage dizziness.

D) Recommend the patient to wear compression stockings to prevent blood pooling.

A patient on an atypical antipsychotic is experiencing episodes of mild dizziness, particularly when standing up quickly. Her seated blood pressure is 128/78 mmHg, which drops to 110/70 mmHg upon standing. What is the most appropriate nursing intervention to address this patient's orthostatic hypotension?

B) Educate the patient on rising slowly from a seated or lying position

A) Advise the patient to increase salt intake significantly to raise blood pressure

B) Educate the patient on rising slowly from a seated or lying position

C) Recommend complete bed rest to prevent dizziness

D) Suggest discontinuing the atypical antipsychotic immediately

Bipolar Affective Disorder - Nursing Case Study

Pathophysiology

• Neurotransmitter Imbalance: Bipolar Affective Disorder is primarily linked to dysregulation of key neurotransmitters, including dopamine, serotonin, and norepinephrine, which are crucial for mood regulation. An imbalance can lead to manic and depressive episodes.

• Neuroplasticity Alterations: Structural and functional changes in the brain, such as reduced grey matter and altered connectivity in mood-regulating areas, contribute to the disorder. These changes affect emotional processing and mood stability.

• Key complication: Impaired neuroplasticity and neurotransmitter dysregulation can result in severe mood swings, impacting a patient's ability to maintain relationships, perform daily activities, and adhere to treatment, necessitating comprehensive nursing care.

Patient Profile

Demographics:

32-year-old female, graphic designer

History:

• Key past medical history: Diagnosed with Bipolar Affective Disorder 5 years ago; history of hypothyroidism

• Current medications: Lithium, Levothyroxine, Quetiapine

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased mood instability and episodes of severe depression

• Key symptoms: Frequent mood swings, insomnia, fatigue, loss of appetite, occasional anxiety

• Vital signs: Blood pressure 145/95 mmHg, heart rate 110 bpm, temperature 98.6°F, respiratory rate 18 breaths per minute

Section 1

Change in Patient Status:

Following the initial assessment, the patient reports a marked increase in mood instability, with rapid cycling between depressive and hypomanic states over the past two weeks. She describes experiencing heightened irritability, racing thoughts, and impulsive decision-making during hypomanic episodes, while her depressive phases are characterized by profound fatigue, feelings of hopelessness, and social withdrawal. Despite adherence to her medication regimen, these symptoms have intensified, raising concerns about the current effectiveness of her treatment plan. Additionally, her insomnia has worsened, contributing to daytime fatigue and impacting her performance at work.

The patient's vital signs reveal persistent hypertension and tachycardia, with blood pressure consistently elevated at 150/98 mmHg and a heart rate of 115 bpm. These cardiovascular changes may be attributable to the increased stress and anxiety associated with her mood fluctuations, but they also necessitate careful monitoring to rule out any potential adverse effects of her current medication regimen, particularly lithium. A recent serum lithium level indicates a concentration of 0.9 mEq/L, which is within the therapeutic range, yet her symptoms suggest a potential need for dosage reassessment or adjunctive therapy. Thyroid function tests return within normal limits, indicating that her hypothyroidism is well-managed with levothyroxine.

This change in patient status prompts a multidisciplinary approach to refine her treatment strategy. Collaboration with psychiatry may be essential to consider adjustments in her psychotropic medications, such as optimizing quetiapine dosages or introducing mood stabilizers to better manage her rapid cycling. Nursing interventions will focus on supporting medication adherence, providing psychoeducation about recognizing and managing triggers, and implementing strategies to enhance sleep hygiene. The patient's care team must remain vigilant for any emerging complications, such as lithium toxicity or cardiovascular events, as they navigate adjustments to her therapeutic regimen.

Section 2

Response to Interventions:

After a collaborative meeting with the multidisciplinary team, adjustments are made to the patient's treatment plan. Her quetiapine dosage is increased to better control her rapid cycling and mood instability. In addition, a low-dose beta-blocker, propranolol, is introduced to address her persistent tachycardia and hypertension, which are likely exacerbated by the stress of her mood fluctuations. The patient is also enrolled in cognitive behavioral therapy (CBT) sessions to help her develop coping strategies for managing stress and recognizing early signs of mood changes.

Two weeks later, during a follow-up appointment, the patient reports a slight improvement in her mood stability and a reduction in irritability and impulsive behaviors. Her depressive episodes are less frequent, though she still experiences some residual fatigue. Importantly, her sleep quality has improved marginally, with fewer nights of insomnia, attributed to both medication adjustments and improved sleep hygiene practices. Vital signs indicate a positive response to the propranolol, with her blood pressure reduced to 138/85 mmHg and heart rate at 90 bpm. Despite these improvements, she acknowledges ongoing challenges with maintaining focus at work and managing stressors in her personal life.

Lab work is repeated to monitor the patient's response to the new regimen. Serum lithium levels remain stable at 0.8 mEq/L, confirming adherence without risk of toxicity. However, the patient's lipid profile returns with elevated cholesterol levels, raising concerns about metabolic side effects potentially linked to the quetiapine increase. This finding necessitates dietary counseling and lifestyle modifications to prevent long-term complications. The care team agrees to continue monitoring her progress closely, with plans to reassess her treatment strategy in another four weeks, ensuring any emerging issues are promptly addressed.

Section 3

Four weeks later, during a routine follow-up, the patient presents with new complaints of muscle stiffness and unexplained weight gain, having put on approximately eight pounds since her last visit. She reports that her mobility feels slightly restricted, particularly in the mornings, and she has noticed occasional tremors in her hands that resolve by midday. These symptoms raise suspicions of emerging extrapyramidal side effects possibly linked to the increased quetiapine dosage. Upon assessment, her vital signs remain stable with a blood pressure of 135/82 mmHg and a heart rate of 88 bpm, indicating continued efficacy of the propranolol. However, her body mass index (BMI) has increased, necessitating a more comprehensive evaluation of her metabolic health.

The care team decides to conduct a thorough neurological examination and orders additional blood tests, including fasting glucose and thyroid function tests, to rule out other potential causes of her symptoms. The fasting glucose level returns at the upper limit of normal, prompting concerns about glucose metabolism. Thyroid function tests are within normal ranges, negating a possible thyroid disorder. The increase in weight and muscle stiffness are addressed through a referral to a dietitian for tailored nutritional guidance and recommendations for light physical activities that can be integrated into her daily routine.

Clinically, there is a need to balance the management of her mood symptoms with the minimization of adverse effects. The multidisciplinary team considers adjusting her medication regimen to reduce the quetiapine dosage while introducing a low-dose alternative atypical antipsychotic with a more favorable metabolic profile. The team also emphasizes the importance of adherence to CBT sessions, focusing on stress management techniques that align with her physical activity goals. As the patient continues to navigate these challenges, the team plans for close monitoring and follow-up visits to refine her treatment plan and address any further complications promptly.

Section 4

Four weeks after the initial adjustments to her treatment plan, the patient returns for a follow-up visit. She reports feeling slightly better in terms of muscle stiffness, which she attributes to the light physical activities recommended by the dietitian. Her weight has stabilized, showing no further increase, which suggests that the dietary modifications and exercise regimen have begun to have a positive impact. However, she continues to experience occasional hand tremors, particularly in the late afternoons, which have now become more noticeable and persistent than before. These tremors are causing her significant distress and affecting her ability to perform certain daily tasks, leading to increased anxiety about her condition.

During the assessment, her vital signs remain stable with a blood pressure of 132/80 mmHg and a heart rate of 86 bpm. However, a review of her recent blood tests reveals that her fasting glucose level has now crossed into the pre-diabetic range. This finding raises concerns about her long-term metabolic health, especially in light of the weight gain and the ongoing use of atypical antipsychotics. Given the persistence of the tremors and the new metabolic challenge, the care team considers further modification of her medication regimen, including a potential switch to a newer atypical antipsychotic known for a lower risk of extrapyramidal symptoms and metabolic disturbances.

The team also decides to initiate a referral to an endocrinologist for further evaluation of her glucose metabolism and to explore potential interventions that could help prevent the progression to diabetes. Additionally, a neurology consult is requested to assess the nature of her tremors and guide any necessary treatments. These steps aim to provide a comprehensive approach to managing both her psychiatric and physical health, ensuring that her treatment plan is as holistic and individualized as possible. As these elements of care are implemented, the team plans to maintain close monitoring, with more frequent follow-up visits to assess her response and address any emerging issues promptly.

Section 5

Two weeks after the medication adjustment and specialist referrals, the patient returns for another follow-up appointment. During this visit, she reports that the switch to the newer atypical antipsychotic has led to a noticeable reduction in hand tremors, which she now experiences less frequently and with reduced intensity. This improvement has positively impacted her daily activities and slightly alleviated her anxiety. Her mood appears more stable, and she expresses optimism about her current treatment plan. However, she mentions experiencing occasional episodes of mild dizziness, particularly when standing up quickly, which prompts the care team to evaluate for potential orthostatic hypotension as a side effect of the new medication.

During the assessment, her vital signs show a blood pressure of 128/78 mmHg when seated, but a drop to 110/70 mmHg upon standing, confirming the presence of orthostatic changes. Her heart rate remains stable at 88 bpm. A review of her latest blood tests indicates that her fasting glucose level remains in the pre-diabetic range, with a reading of 108 mg/dL, and her HbA1c has slightly increased to 5.8%. These findings reinforce the need for continued attention to her metabolic health, as discussed in her recent endocrinology consultation. The endocrinologist recommended a low-glycemic diet and increased physical activity, along with close monitoring of her glucose levels.

In response to the slight orthostatic hypotension, the care team decides to adjust her fluid intake and advises her on slow position changes to minimize dizziness. The team also reinforces the importance of adhering to the dietary and exercise recommendations to manage her glucose levels effectively. With these interventions in place, the team schedules another follow-up visit in four weeks to assess her progress, evaluate the stability of her tremors, and ensure that her metabolic parameters remain under control. This comprehensive approach aims to address both the psychiatric and physical health challenges she faces, providing a clear path forward in her treatment journey.