Bipolar Disorder Mania - Nursing Case Study

Pathophysiology

• Primary mechanism: Dysregulation of neurotransmitters, particularly increased dopamine and norepinephrine, leads to heightened arousal, impulsivity, and euphoria characteristic of manic episodes.

• Secondary mechanism: Altered neuroplasticity and synaptic connectivity, particularly in the prefrontal cortex and limbic system, disrupt emotional regulation and decision-making processes.

• Key complication: Persistent manic episodes can lead to severe functional impairment, increased risk of substance abuse, and potential progression to psychosis, necessitating comprehensive management strategies.

Patient Profile

Demographics:

47, male, software engineer

History:

• Key past medical history: Bipolar Disorder Type I, hypertension, hyperlipidemia, history of substance abuse (alcohol and cocaine)

• Current medications: Lithium, Quetiapine, Lisinopril, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe agitation and inability to sleep for 5 consecutive nights

• Key symptoms: Pressured speech, grandiosity, flight of ideas, decreased need for sleep, and increased risky behavior

• Vital signs: Blood pressure 168/102 mmHg, heart rate 128 bpm, respiratory rate 24 breaths per minute, temperature 99.1°F, oxygen saturation 94% on room air

Section 1

Initial assessment findings revealed that the patient, a 47-year-old male with a known history of Bipolar Disorder Type I, was exhibiting severe manic symptoms characterized by heightened agitation, pressured speech, grandiosity, flight of ideas, and a marked decrease in the need for sleep. His vital signs indicated significant hemodynamic instability, with a blood pressure of 168/102 mmHg and a heart rate of 128 bpm, suggesting sympathetic overdrive. The patient's respiratory rate was elevated at 24 breaths per minute, with an oxygen saturation of 94% on room air, indicating a potential compromise in respiratory function due to hyperactivity and agitation. Despite being on lithium and quetiapine, his symptoms suggested a potential sub-therapeutic level of medication or non-compliance, which is critical to assess given his history of substance abuse.

During the initial examination, the patient displayed disorganized thoughts and had difficulty maintaining focus during the interview, further complicating the assessment of his mental status. There was evidence of increased risky behavior, as reported by his family, which included excessive spending and erratic social interactions that were uncharacteristic of his baseline behavior. Neurologically, the patient was oriented to person but not to time or place, raising concerns about potential progression towards psychosis. Given the acute presentation and the risk of further complications, such as cardiovascular events or escalation into psychotic episodes, immediate psychiatric evaluation and stabilization were prioritized.

To facilitate comprehensive management, a detailed medication reconciliation was conducted, revealing that the patient had inconsistently taken his prescribed medications over the past month, which may have contributed to the exacerbation of manic symptoms. The findings necessitated a multifaceted intervention strategy, including medication adjustment, potential inpatient psychiatric care for stabilization, and the involvement of a multidisciplinary team to address both the psychological and physiological needs of the patient. The complexity of the case highlighted the need for advanced clinical reasoning to mitigate risks and optimize the patient's recovery trajectory.

Section 2

Following the initial assessment, new diagnostic results were obtained to further elucidate the patient's condition and guide the management plan. Laboratory tests revealed a sub-therapeutic lithium level of 0.4 mEq/L, confirming the suspicion of non-compliance or inadequate dosing. Additionally, a toxicology screen was positive for cocaine, indicating recent substance use, which likely exacerbated the manic episode. Thyroid function tests were performed, revealing a slightly elevated free T4 level with suppressed TSH, suggesting hyperthyroidism as a potential contributing factor to the manic symptoms. An ECG was done due to the patient's tachycardia, showing sinus tachycardia with no acute ischemic changes, but with a prolonged QT interval, raising concerns about potential cardiac complications, particularly in the context of quetiapine use.

Given the complexity of the findings, the patient's treatment plan was revised. The lithium dosage was carefully titrated under close monitoring of renal function and electrolyte levels, while quetiapine was adjusted with caution due to the QT prolongation. A beta-blocker was introduced to manage the tachycardia and hypertension, with the goal of stabilizing the patient's cardiovascular status. In light of the positive cocaine screen, the patient was referred to the addiction services team to address his substance use disorder, a critical step in preventing further manic episodes. Endocrinology was consulted to evaluate the thyroid dysfunction and its potential impact on the patient's psychiatric state.

As the patient was transferred to an inpatient psychiatric unit for stabilization, the multidisciplinary team focused on comprehensive care, including psychiatric support, medication adherence counseling, and education on the interaction between substance use and bipolar disorder. The integration of these services aimed to mitigate the risk of future exacerbations and promote long-term stability. The case required ongoing critical evaluation and adjustment of the treatment plan, emphasizing the need for vigilant monitoring and collaboration across specialties to navigate the intricacies of this patient's condition.

Section 3

As the patient settled into the inpatient psychiatric unit, the initial days of stabilization posed notable challenges. Despite the introduction of a beta-blocker, the patient's heart rate remained elevated, with recordings consistently in the range of 110-120 beats per minute. Blood pressure levels, though slightly improved, fluctuated between 140/90 mmHg and 150/95 mmHg, indicating persistent cardiovascular instability. The nursing team conducted frequent cardiac assessments, noting occasional palpitations reported by the patient, raising concerns about potential arrhythmias. The patient's lithium level, after careful titration, increased to 0.7 mEq/L, suggesting improved compliance, yet still below the therapeutic target range, necessitating further adjustments under close supervision.

In parallel, the patient exhibited signs of heightened agitation and irritability, complicating efforts to engage him in therapeutic activities and education sessions. These behavioral manifestations coincided with worsening insomnia, despite prescribed sleep aids, and prompted the care team to explore underlying factors. A repeat thyroid function test revealed an increasing trend in free T4 levels, now at 2.3 ng/dL, with TSH persistently suppressed at less than 0.01 μIU/mL, suggesting an exacerbation of hyperthyroid symptoms. This prompted the endocrinology team to initiate treatment with antithyroid medication, aiming to bring the thyroid function under control, and potentially alleviate the psychiatric symptoms.

The combination of ongoing substance cravings, as reported by the patient, and the physiological stress of hyperthyroidism presented a formidable challenge to the multidisciplinary team. The addiction services team intensified their engagement, introducing cognitive-behavioral strategies aimed at curbing substance-seeking behaviors. Simultaneously, the psychiatric team worked on optimizing pharmacotherapy, mindful of the delicate balance required in managing the patient's complex presentation. This period of care highlighted the intricate interplay between physical and mental health factors, underscoring the importance of an integrated, patient-centered approach. As the team continued to navigate these complexities, they remained vigilant for any signs of emerging complications or shifts in the patient's clinical status that might demand further intervention.

Section 4

As the patient approached the end of the first week of hospitalization, a change in status became increasingly apparent. The nursing team observed a marked increase in the patient's agitation levels, with episodes of disorganized speech and flight of ideas becoming more pronounced. Despite the initiation of antithyroid medication, the patient's hyperthyroid symptoms showed minimal improvement, suggesting a delay in therapeutic response. The patient's sleep continued to be severely disrupted, with only 1-2 hours of rest per night, further exacerbating his manic symptoms. Vital signs revealed a concerning trend: heart rate now consistently above 125 beats per minute, and blood pressure readings reaching as high as 160/100 mmHg. These signs pointed to worsening cardiovascular strain, raising alarms about the potential for more severe complications such as tachyarrhythmias.

In response to these developments, the multidisciplinary team convened to reassess the treatment plan. The psychiatry team, recognizing the limited efficacy of current pharmacotherapy, considered the introduction of an atypical antipsychotic to manage the manic symptoms more effectively. This decision required careful deliberation due to the patient's existing cardiac instability and the risk of side effects that could complicate the clinical picture. Concurrently, the endocrinology team expedited the titration of antithyroid medication, aiming to hasten the stabilization of thyroid hormone levels. Laboratory tests were repeated, revealing a free T4 level now at 2.5 ng/dL, with TSH remaining suppressed, confirming the need for aggressive intervention.

Amidst these challenges, the addiction services team noted a breakthrough; the patient, during a particularly lucid moment, expressed awareness of the negative impact of his substance use on his mental health and expressed a willingness to engage more actively in therapy. This pivotal insight opened an avenue for deeper therapeutic engagement, offering a glimmer of hope amidst the ongoing complexities. The team remained vigilant, aware that the patient's journey would require continuous monitoring and dynamic adjustments to the treatment regimen to safely navigate the intricate interplay of psychiatric, endocrine, and cardiovascular factors.

Section 5

As the patient entered the second week of hospitalization, the nursing team observed a significant change in his status. The introduction of the atypical antipsychotic medication seemed to offer some initial benefit, as the patient's episodes of disorganized speech and flight of ideas began to decrease in frequency. However, this improvement was accompanied by the emergence of new complications. The patient developed signs of extrapyramidal symptoms, including mild tremors and rigidity, which required immediate attention from the medical team. Concurrently, his cardiovascular status remained precarious; despite attempts to manage his blood pressure and heart rate, the patient experienced an episode of supraventricular tachycardia (SVT), with heart rates spiking to 180 beats per minute. This event prompted an urgent cardiology consultation to determine the appropriate intervention to stabilize his cardiac function.

Further diagnostic tests were conducted to assess the impact of ongoing treatment adjustments. An electrocardiogram confirmed the presence of SVT, and blood tests revealed electrolyte imbalances, including hypokalemia, with a potassium level of 2.8 mmol/L. This electrolyte disturbance was likely contributing to the cardiac instability and was identified as a priority for correction. Additionally, thyroid function tests showed some progress; free T4 levels had decreased slightly to 2.2 ng/dL, signaling a slow but positive response to the increased antithyroid medication dosage. Nonetheless, the persistent suppression of TSH underscored the need for continued aggressive management of his hyperthyroid state.

Amidst these developments, the patient's willingness to engage in substance use therapy became an essential focus. The team capitalized on his readiness by facilitating sessions with both the addiction services and psychiatric teams to reinforce the connection between his mental health stabilization and substance abstinence. This integrated approach aimed to support the patient in achieving a more sustained recovery, addressing not only the acute medical concerns but also the underlying factors contributing to his psychiatric instability. As the team prepared for the next phase of care, they remained acutely aware of the delicate balance required to manage the intertwined complexities of the patient's condition, keeping a vigilant eye on his cardiac health and psychiatric progress.