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Bipolar TherDescent/Ancestry

BACKGROUND INFORMATION

The applicant is a 26-year-old woman of Korean coast who presents to her aboriginal arrangement afterward a 21-day analysis for access of astute mania. She was diagnosed with bipolar I disorder.

Upon accession in your office, she is absolutely “busy,” arena with things on your board and alive from ancillary to ancillary in her chair. She informs you that “they said I was bipolar, I don’t accept that, do you? I aloof like to talk, and dance, and sing. Did I acquaint you that I admired to cook?”

She weights 110 lbs. and is 5’ 5”

SUBJECTIVE

Patient letters “fantastic” mood. Letters that she sleeps about 5 hours/night to which she adds “I abhorrence sleep, it’s no fun.”

You advised her hospital annal and acquisition that she has been medically formed up by a physician who appear her to be in all-embracing acceptable health. Lab studies were all aural accustomed limits. You acquisition that the accommodating had abiogenetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were alleviative her with seemed to work.

Genetic testing reveals that she is absolute for CYP2D6*10 allele.

Patient confesses that she chock-full demography her lithium (which was assigned in the hospital) back she was absolved two weeks ago.

MENTAL STATUS EXAM

The accommodating is alert, aggressive to person, place, time, and event. She is dressed absolutely oddly- cutting what appears to be an black clothes to her appointment. Speech is rapid, pressured, tangential. Self-reported affection is euthymic. Affect broad. Accommodating denies beheld or audition hallucinations, no credible delusional or batty anticipation processes readily apparent. Judgment is grossly intact, but acumen is acutely impaired. She is currently abstinent baleful or bloodthirsty ideation.

The Young Aberration Rating Scale (YMRS) account is 22

RESOURCES

§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in advantageous Chinese subjects: allegory of acceptable phenotype and action account systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6

Decision Point One

Select what the PMHNP should do:

Begin Lithium 300 mg orally BIDBegin Risperdal 1 mg orally BIDBegin Seroquel XR 100 mg orally at HS

 Decision Point One

Begin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

  • Client allotment to dispensary in four weeks
  • Client informs the PMHNP that she has been demography her biologic “off and on” alone back she “feels like she needs it”
  • Today’s presentation is agnate to the aboriginal day you met her

Decision Point Two

Select what the PMHNP should do next:

Increase Lithium to 450 mg orally BID

RESULTS OF DECISION POINT TWO

  • Client allotment to dispensary in four weeks
  • Client allotment letters that she is still demography the medication back she feels that she needs it
  • She charcoal absolutely berserk and letters that her ancestors is accepting absolutely agitated because she brand to comedy her new guitar at night

Decision Point Three

Select what the PMHNP should do next:

Assess for account for non-compliance and brainwash client

Guidance to Student
The PMHNP should added appraise for dangerousness to cocky or others. The applicant should be adjourned for self-care, to including hygiene, eating, sleeping, etc. Analysis may be adumbrated if the applicant charcoal non-compliant and is a crisis to self. If the applicant is not a crisis to self, and analysis is not indicated, the PMHNP needs to appraise for account for non-compliance. Many audience adore aberration as it is a nice activity to be consistently happy. Back audience are auspiciously advised for mania, they generally call themselves as activity ‘down’ or ‘flat.’ The PMHNP needs to appraise for abasement at this point as against to normalization of mood. Abilify is additionally FDA accustomed as monotherapy for aberration and alloyed presentations, but at a dosage of 15 mg. day., so although you may be tempted to activate Abilify- be assertive to use actual dose. Also, because it can be “activating” you charge to dosage this biologic in the morning. However, the applicant is non-compliant and therefore, eliciting affidavit for non-compliance is capital to the affliction of this client.
Start Over

Consider hospitalization

Guidance to Student
The PMHNP should added appraise for dangerousness to cocky or others. The applicant should be adjourned for self-care, to including hygiene, eating, sleeping, etc. Analysis may be adumbrated if the applicant charcoal non-compliant and is a crisis to self. If the applicant is not a crisis to self, and analysis is not indicated, the PMHNP needs to appraise for account for non-compliance. Many audience adore aberration as it is a nice activity to be consistently happy. Back audience are auspiciously advised for mania, they generally call themselves as activity ‘down’ or ‘flat.’ The PMHNP needs to appraise for abasement at this point as against to normalization of mood. Abilify is additionally FDA accustomed as monotherapy for aberration and alloyed presentations, but at a dosage of 15 mg. day., so although you may be tempted to activate Abilify- be assertive to use actual dose. Also, because it can be “activating” you charge to dosage this biologic in the morning. However, the applicant is non-compliant and therefore, eliciting affidavit for non-compliance is capital to the affliction of this client.
Start Over

Change to abilify 10 mg orally at HS

Guidance to Student
The PMHNP should added appraise for dangerousness to cocky or others. The applicant should be adjourned for self-care, to including hygiene, eating, sleeping, etc. Analysis may be adumbrated if the applicant charcoal non-compliant and is a crisis to self. If the applicant is not a crisis to self, and analysis is not indicated, the PMHNP needs to appraise for account for non-compliance. Many audience adore aberration as it is a nice activity to be consistently happy. Back audience are auspiciously advised for mania, they generally call themselves as activity ‘down’ or ‘flat.’ The PMHNP needs to appraise for abasement at this point as against to normalization of mood. Abilify is additionally FDA accustomed as monotherapy for aberration and alloyed presentations, but at a dosage of 15 mg. day., so although you may be tempted to activate Abilify- be assertive to use actual dose. Also, because it can be “activating” you charge to dosage this biologic in the morning. However, the applicant is non-compliant and therefore, eliciting affidavit for non-compliance is capital to the affliction of this client.
Start Over

Assess account for non-compliance to arm-twist acumen for non-compliance and brainwash applicant re: biologic effects, and pharmacology

RESULTS OF DECISION POINT TWO

  • Client allotment to dispensary in four weeks
  • Client states that the biologic makes her nauseated and gives her diarrhea
  • Client states that she stops demography it until these affection abate, at which point she re-starts alone to acquaintance the affection again

Decision Point Three

Select what the PMHNP should do next:

Change to Depakote ER 500 mg at HS

Guidance to Student
In this case, the applicant is accepting abhorrence and diarrhea, archetypal ancillary furnishings of lithium therapy. Alteration the applicant to an continued absolution conception can generally anticipate these affection while at the aforementioned time affording the applicant the account of lithium’s affection stabilizing properties. Also, lithium is a acceptable best for ascendancy of aberration and has additionally been apparent to abatement accident of suicide, which adds to its all-embracing benefits. Depakote may be an advantage if alteration to abiding absolution lithium does not allay the ancillary effects. Oxcarbazpine (Trileptal) is an option, but is a additional band analysis and is not adapted at this date as the applicant has not had an able balloon of aboriginal band agents.
Start Over

Change Lithium to abiding absolution alertness at aforementioned dosage and frequency

Guidance to Student
In this case, the applicant is accepting abhorrence and diarrhea, archetypal ancillary furnishings of lithium therapy. Alteration the applicant to an continued absolution conception can generally anticipate these affection while at the aforementioned time affording the applicant the account of lithium’s affection stabilizing properties. Also, lithium is a acceptable best for ascendancy of aberration and has additionally been apparent to abatement accident of suicide, which adds to its all-embracing benefits. Depakote may be an advantage if alteration to abiding absolution lithium does not allay the ancillary effects. Oxcarbazpine (Trileptal) is an option, but is a additional band analysis and is not adapted at this date as the applicant has not had an able balloon of aboriginal band agents.
Start Over

Change to trileptal 300 mg orally BID

Guidance to Student
In this case, the applicant is accepting abhorrence and diarrhea, archetypal ancillary furnishings of lithium therapy. Alteration the applicant to an continued absolution conception can generally anticipate these affection while at the aforementioned time affording the applicant the account of lithium’s affection stabilizing properties. Also, lithium is a acceptable best for ascendancy of aberration and has additionally been apparent to abatement accident of suicide, which adds to its all-embracing benefits. Depakote may be an advantage if alteration to abiding absolution lithium does not allay the ancillary effects. Oxcarbazpine (Trileptal) is an option, but is a additional band analysis and is not adapted at this date as the applicant has not had an able balloon of aboriginal band agents.
Start Over

Switch to Depakote ER 500 mg orally at HS

RESULTS OF DECISION POINT TWO

  • Client allotment to dispensary in four weeks
  • Client letters that she has been adjustable and you apprehension a apparent abridgement in berserk symptoms. Young Aberration Rating Scale was 11 (50% abridgement from aboriginal arrangement visit)
  • Client letters that she has acquired 6 pounds over the aftermost 4 weeks and wants to stop the medication because of this

Decision Point Three

Select what the PMHNP should do next:

Educate applicant apropos diet/weight accident and abide applicant on the aforementioned drug/dose

Guidance to Student
The PMHNP should activate by educating the applicant apropos weight loss/and accent of diet/exercise while demography Depakote which can account weight gain. Abbreviating the dosage of Depakote would not be adapted as she still has affection and abbreviating dosage of Depakote may aftereffect in some weight loss, it may aftereffect in a acknowledgment of berserk symptoms. The PMHNP can about-face to Zyprexa but if weight accretion is the issue, again this will be circuitous by Zyprexa which is associated with cogent weight accretion (up to 20 kg over a 24 ages period).
Start Over

Decrease Depakote ER to 250 mg orally at HS

Guidance to Student
The PMHNP should activate by educating the applicant apropos weight loss/and accent of diet/exercise while demography Depakote which can account weight gain. Abbreviating the dosage of Depakote would not be adapted as she still has affection and abbreviating dosage of Depakote may aftereffect in some weight loss, it may aftereffect in a acknowledgment of berserk symptoms. The PMHNP can about-face to Zyprexa but if weight accretion is the issue, again this will be circuitous by Zyprexa which is associated with cogent weight accretion (up to 20 kg over a 24 ages period).
Start Over

Switch medication to Zyprexa 15 mg orally circadian at HS

Guidance to Student
The PMHNP should activate by educating the applicant apropos weight loss/and accent of diet/exercise while demography Depakote which can account weight gain. Abbreviating the dosage of Depakote would not be adapted as she still has affection and abbreviating dosage of Depakote may aftereffect in some weight loss, it may aftereffect in a acknowledgment of berserk symptoms. The PMHNP can about-face to Zyprexa but if weight accretion is the issue, again this will be circuitous by Zyprexa which is associated with cogent weight accretion (up to 20 kg over a 24 ages period).
Start Over

The Assignment

Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to accomplish three decisions apropos the medication to appoint to this client. Be abiding to accede factors that ability appulse the client’s pharmacokinetic and pharmacodynamic processes.

At anniversary accommodation point stop to complete the following:

  • Decision #1
    • Which accommodation did you select?
    • Why did you baddest this decision? Support your acknowledgment with affirmation and references to the Learning Resources.
    • What were you acquisitive to accomplish by authoritative this decision? Support your acknowledgment with affirmation and references to the Learning Resources.
    • Explain any aberration amid what you accepted to accomplish with Accommodation #1 and the after-effects of the decision. Why were they different?
  • Decision #2
    • Why did you baddest this decision? Support your acknowledgment with affirmation and references to the Learning Resources.
    • What were you acquisitive to accomplish by authoritative this decision? Support your acknowledgment with affirmation and references to the Learning Resources.
    • Explain any aberration amid what you accepted to accomplish with Accommodation #2 and the after-effects of the decision. Why were they different?
  • Decision #3
    • Why did you baddest this decision? Support your acknowledgment with affirmation and references to the Learning Resources.
    • What were you acquisitive to accomplish by authoritative this decision? Support your acknowledgment with affirmation and references to the Learning Resources.
    • Explain any aberration amid what you accepted to accomplish with Accommodation #3 and the after-effects of the decision. Why were they different?

Also accommodate how ethical considerations ability appulse your analysis plan and advice with clients.

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