Assessment And Management Of Bipolar Affective Disorder: A Case Study Essay.

Background

You are to write a care study (essay). This can be based on either one of the scenarios provided or you may select a patient(s) of interest from your practice experience and relevant to your field of practice.  The essay will draw upon relevant theoretical concepts supporting the shared decision making process in the assessment planning and interventions to meet the patient’s / client’s needs. You will include a critical review of the patient’s complex needs using a bio-psychosocial perspective and demonstrate how effective shared decision making may prevent deterioration/crisis, enhance coping and/or recovery or contribute to good end of life care. You will consider the nurse’s role where dependency levels change and where there needs to be care escalation, referring to the use of appropriate assessment skills to identify risk.  In evaluating the planning and delivery of nursing care (including therapeutic interventions) you will need to discriminate between the research evidence available to support the care proposed. A systematic approach in assessment and care delivery must be evident with reference to national and /or professional guidelines to support shared decisions.

James is 28 years old and has a diagnosis of Bipolar Affective Disorder.

James has been placed on a Section 136 and is in the local mental health unit place of safety. Police had been called to the local park at approx. 4pm by members of the public expressing concerns that a man was upsetting children who were using the paddling pool. On arrival police found James lying down near the paddling pool, waving his arms, shouting and screaming. James was only wearing long shorts, and was noticeably sunburnt.  James recognised one of the police officers from a previous encounter and reluctantly talked to the officers.  The police were concerned for James’ wellbeing and felt he warranted further assessment therefore placed him on Section 136.  On route to the mental health unit James continued to shout and made several attempts to leave the police van whilst the vehicle was in motion, claiming he was invincible.

James has an 8 year history of Bipolar Disorder I. He has had numerous admissions, the majority under the Mental Health Act when he has been extremely manic, grandiose and behaviours such as excessive spending, leaving the house naked, painting the outside of the flat in the early hours of the morning.  James has been under the care of the CMHT Recovery team for the last 3 years since his last admission.  James has a history of non-compliance with medication usually as a result of psychosocial stressors.

James is the eldest of 3 boys. His youngest brother, aged 20, has a diagnosis of Asperger’s. His middle brother is married, has a 6 year old daughter, and lives locally. James sees his brothers regularly and dotes on his niece.  James’s father is 52 and also lives locally. James’ mother died of breast cancer 8 years ago. James has Sunday lunch with his father every week.

James finished school with 3 A Levels and had begun studying Medicine when he first became ill. Unfortunately, James was not able to return to university and complete his studies.  James has been looking for work and has been offered temporary unskilled work, James feels frustrated by not having a career.

Appendectomy at 8 years old

James does not smoke or drink alcohol.

Lithium 600mg BD

At the Mental Health Unit James is assessed by the duty psychiatrist and senior nurse. James is noticeably calmer in the mental health unit compared to the police van. He makes no attempts to leave and is very happy to see a doctor he recognises.

During the assessment James insists he has taken his lithium and states his prescription is due next week. In the property bag provided by the police there is a medication box with 10x 600mg capsules remaining, multiple receipts and a credit card in a travelcard wallet, and a mobile phone, which James immediately retrieves when he sees it.

James is noticeably sunburnt and complains of a headache. He reports to have had persistent headaches for the last month. He does drink the water offered to him and requests more. James refuses for his temperature to be taken but agrees for his BP and pulse to be done.

Pulse: 80bpm   BP: 145/85

As the assessment progresses James becomes more irritable, frustrated by the questions and wants to leave. He maintains the only problem he has is the persistent headaches.  He makes several attempts to call his brother on his mobile but only gets the answer machine. James is overheard leaving a message saying “they are at it again”, “the police are colluding with the Drs again”, “why are they doing this to me, don’t they know who I am”.

Background

A bipolar disorder may also be referred to as a manic-depressive illness. It is a disorder of the brain that causes strange variations activity levels, mood, energy, and the ability to carry out normal daily activities. The mood swings may include hypomania and depression. Individuals with this disorder may, therefore, experience periods during when they feel excessively energized and happy while other periods they experience extreme sadness (Carr et al., 2016). There are four types of bipolar disorders that include Bipolar I Disorder, Bipolar II disorder, cyclothymia, and other types that may be specified or unspecified (Craddock and Sklar, 2013, p. 1658). In this essay, we will talk about people with bipolar disorder I (PWBD). It is important to have a good understanding of bipolar disorder and its signs and symptoms so that the best clinical interventions can be initiated.

The essay talks about an outline of the service user from the presented scenario that may include any information about the illness. The essay also explores any appropriate theoretical concepts that are useful in the assessment and delivery of intervention that could help the service user. Additionally, the essay talks about the role of the nurse in the assessment, planning, and delivery and evaluation of care. The essay further talks about the significance of collaborative decision-making in preventing patient deterioration and enhancing recovery. Finally, the essay critically analyzes the concepts around risk assessment, risk stratification, and risk management in addition to the local services and interventions that may be available.

This topic is of special importance to the patients, their families, and health practitioners. Understanding the concept around bipolar disorder may help an individual in recognizing the symptoms depending on their mood swings and seek medication before these symptoms become severe. Therefore, one can call their doctor and work with the doctor in collaboration to manage the disorder (Ghaemi et al., 2014, p. 102). It is additionally worth noting that having enough knowledge regarding this topic helps an individual in understanding the medication that may be administered to them and all the potential side effects (Hodgkin et al., 2018). This topic also helps individuals to learn about the lifestyle changes that they may make to help in reducing mood swings.

The patient in the provided scenario is a 28-year-old man who has also been diagnosed with Bipolar Affective Disorder. This condition is otherwise known as bipolar disorder. He has a bipolar I disorder that dates back to 8 years ago. Having bipolar disorder makes the patient’s mood alternate between mania and depression with periods of normal mood in between. An individual feels more productive at work and is confident of accomplishing anything they set their mind to. Then all of a sudden, they start experiencing extreme depression, and they feel unworthy. There is a feeling of excitement that suddenly changes to a feeling of sadness that never goes away. An individual changes from being full of energy to being extremely tired.

The life journey of people with bipolar disorder I is always a tricky one that demands a lot of care to help the individuals with this disorder. They have to experience a battle between their emotions and intellect on a daily basis. They have to remind themselves of all the things they must do to survive, and sometimes the only way to do this is by reminding themselves that they have a purpose in this life (Duffy et al., 2014, p. 123). The service users will hear a lot of voices in their minds telling them a lot of negative things that can make them engage in harmful activities. The most important way to tackle this problem is by learning from yesterday, living for today, and hoping for tomorrow.

Service User

Bipolar disorder is ranked as the fourth most common mental health illness. The first three include depression, anxiety, and schizophrenia. In the UK, around 2% of the population experiences a lifetime prevalence of bipolar disorder. Women between the age of 16-24 experience the highest rate of bipolar disorders (Laursen, 2011, p. 102). Men, on the other hand, averaged around 3% positive outcomes on bipolar at several age groups. Additionally, younger people are at higher risk of having a bipolar disorder when compared to the adults (Dols et al., 2014, p. 115).

Patients with bipolar disorder die from some causes that may include heart diseases and flu. Death rates are reportedly high among individuals with bipolar disorder with a reduction of around 10-20 years in life expectancy (Laursen, 2011, p. 103). The most elevated cause of death among people with bipolar disorder is suicide (Malhi et al., 2013, p. 566). According to WHO reports, over 90% of individuals recovering from bipolar disorder experience relapses in different episodes of their lives. The reports further indicate that within 2 to 5 years, approximately 60-75% of patients experience relapses.

The treatment of this disorder is very challenging for the primary care service providers and diagnosing it is even more difficult. This difficulty is in most cases caused by the negative attitudes of the patients towards the available services . They live in denial due to the fear of stigmatization that comes from having this disorder. There is also limited education regarding this disorder leading to a confusing presentation of bipolar disorder that has caused several cases of misdiagnosis. The education is also important to help patients with drug adherence. The service user from the presented scenario has a history of drug non-adherence despite being under the care of CMHT for the past three years.

The assessment, planning, and delivery of interventions in mental health are important yet quite challenging. The main goal of a mental health service is the provision of significant health outcomes for service users. It can also be a challenge because, the choice of methods, outcome measures, and outcome domains involve a balance between clinical, ethical and conceptual considerations. This assessment, planning, and delivery of the interventions encompass a critical review of the medical model, recovery model, and bio-psychosocial approach within the field of mental health (Grunze, 2015, p. 660).

The biopsychosocial approach argues that we have biological, social, and psychological factors that determine the condition of mental health of an individual. This approach further provides evidence that a mentally sound individual may still experience a bipolar disorder at some point in life. It is additionally important to note that this approach gives room for an extensive evaluation of the patient and this is quite necessary for achieving successes in the treatment of mental health conditions such as a bipolar disorder. It involves the general medical history, substances and medications, and the family history of the service user. Like in the provided scenario, the service user has a medical history of bipolar disorder and uses lithium 600mg medication. It also involves childhood experiences and personality disorders. This model, however, has a drawback in that it may reinforce the stigma that is normally associated with mental illness because it may suggest that bipolar conditions are simply volitional rather than medical conditions.

Assessment

Bipolar disorder in most cases is misdiagnosed, and its prevalence is often underestimated. This is because it rarely appears to respond to the normal treatment procedures of depression thus leading to an increase in mortality and morbidity (Ghaemi and Dalley, 2014, p. 317). The nurses, therefore, can impact significant care for these service users by recognizing and assessing the bipolar disorder (Culpepper, 2014.). They also manage to treat the patients with the most appropriate stabilizers and therapies.

A nurse applies a dynamic and systematic approach in the collection and analysis of data to perform a systematic assessment of the patient and come up with a care plan and the necessary interventions for patients with bipolar disorder (Carvalho and Vieta, 2017). The assessment is done to establish a database regarding how the client responds to illness and their ability to handle health care needs. The nurse uses physical care, relapse prevention, and psycho-education to make a positive development to this condition of bipolar disorder.

The management of bipolar disorder can be done at both the community setting and inpatient setting. The nurses set aside treatment goals for both short-term and long-term bipolar disorders. The short-term goals differ from the long-term goals in that the short-term goals focus on stabilization and safety whereas the long-term goals focus on relapse prevention and the reduction of the severity of depressive episodes (Geddes and Miklowitz, 2013, p. 1675). The nurse must ensure that safety is the number one priority since bipolar patients are at high risk of self-harm. The service users admitted to hospitals with the condition of bipolar disorder like in the presented scenario may show signs of delusions, anger, impulsivity, and irritability and they may thus risk harming themselves (Mondimore, 2014). The nurses, therefore, may administer to help in stabilizing the patient thus allowing a quick recovery.

The nurses also need to educate the service users regarding bipolar disorder and emphasizing the necessity for adhering to medication with the aim of improving patient outcome. The education also helps the families of the patients in understanding bipolar disorder and the best care plan for the patients.

The importance of nurses in the delivery of efficient and high-quality care cannot be underestimated. There are occasions when the needs of the service user may change thus calling for an escalation of care. This is when the focus of the role of the nurse might change to accommodate the change in the needs of the service user. Extremely depressed patients are at a higher risk of self-harm and may, therefore, require urgent care to prevent them from harming themselves (Goodrich et al., 2013, p.383). There other presentations may include insomnia, fatigue, indecisiveness, and restlessness among others. The change in nursing roles is important in addressing the condition of the service user and ensuring quality health outcomes while at the same time preventing patient deterioration.

The change may include the application of Mental Health Laws to help the service user in handling their bipolar disorder condition. The mental health law specifically provides for an assessment of mental health, detention, and compulsory treatment for any patient with a serious mental illness that may involve bipolar disorder (Planner et al., 2014, p. 458). According to the Mental Health Act 2014, the compulsory treatment is most suitable in preventing the service user from harming him/herself.

Planning and Intervention

Once the nurse diagnoses an individual with a particular mental health condition such as a bipolar disorder that escalates and may pose a danger to the service user the nurse may then force the service user to be referred for a different type of treatment according to section 5 of the Mental Health Act 2014. This forceful treatment may be important in preventing patient deterioration which may cause further psychological or physical harm. However, consent is very important in health care, and a patient must agree to a certain clinical procedure or have a close family member consent to the treatment procedure on their behalf. Therefore, this compulsory treatment may violate the patient’s right to consent. This is the reason why a compulsory patient must be issued with a written statement of their rights as patients as soon as they become compulsory patients.

Collaborative decision making is when health practitioners and the patients work together to come up with the perfect decision that may help in care provision. The nurse brings their knowledge of understanding the clinical condition, the potential interventions, and the likely risks and benefits of alternative interventions (Fisher et al., 2016, p. 1108). The service user, on the other hand, comes with the knowledge of a good understanding of their values, preferences, and goals. It can, therefore, be argued that a collaborative decision making involves all the parties involved coming up with their respective views and negotiating a plan that both agree is consistent, ethical, and congruent with the preferences of the patient.

Several studies have revealed that the shared decision making in the healthcare setting increases the quality of life of the service users, improves the quality of communication with the health practitioners which consequently leads to greater therapeutic alliance and improved drug adherence (Morant et al., 2016, p. 1005).  It is also important to note that collaborative decision making improves patient satisfaction and lowers the decision conflicts that may arise from being poorly informed or not informed at all regarding the clinical decision. Collaborative decision making also enhances a better follow-through regarding the treatment recommendations thus leading to improved health outcomes.

It is, however, important to note that the implementation of collaborative decision making has a lot of challenges. For example, from the provided scenario, we notice that the service user is paranoid about the clinical procedures recommended by the nurse. He even claims that the doctors are colluding with the police. This is an implication that he does not trust anyone and thus convincing him to participate in a collaborative decision making is a huge challenge. He becomes increasingly irritable and frustrated to be engaged in making an informed decision regarding the best care plan for his condition.

In most cases, patients want to be heard and have their desires made part of the decision making process. This, however, may not be easy especially in mental health conditions because a patient with a bipolar disorder may not be in the right state of mind to make an informed decision. We can take an example from the chosen scenario where the service user was insisting that his only problem is a persistent headache he has been experiencing for months. It is, however, clear that a headache is not his only problem and therefore listening to him and ignoring the assessment results may cause serious health deterioration. It is thus important that the nurse uses their clinical assessment in addition to the patient desires to come up with the best care intervention that suits the patient thus ensuring quality health outcomes.  

Delivery of Nursing Care

Risk stratification uses a particular process to identify individuals that have a higher likelihood of suffering an unplanned hospitalization or health deterioration and thus provide an appropriate care plan. Risk stratification is important in providing the trigger that is required to plan, communicate, and monitor the available care plans. The best setting for this service is found in hospitals, emergency departments, and ambulances among others (Jones et al., 2016). Care strategies that are coordinated and evidence-based are thus planned according to the need that has been identified. From the provided scenario, the service user could have been helped at an earlier stage through risk stratification and thus prevent deterioration as was witnessed from the patient assessment.

It is also important that the nurse clarifies the nature of the presenting problem and after that determine the current form of the bipolar disorder whether it is mania, depression, or a combination of the two. This is possible through risk assessment during which the practitioner may also assess whether the service user is psychotic and identify if these psychotic symptoms may be an indication of high risk (Phillips and Kupfer, 2013, p.1669). The patient may also be assessed with the aim of determining their ability to make informed decisions and sound judgments. Risk assessment may be done by seeking information from other sources such as family members, close friends, colleagues, or in rare occasions, unrelated observers. In the chosen case scenario, the police receive calls from unrelated observers that this particular service user is upsetting children using the paddling pool (Rosa et al., 2014). On arrival, the police assess him and determine that his condition requires further assessment and is thus placed in section 136 and transported to a health facility.

At the hospital, the nurses perform risk management on him to prevent him from harming himself. The key intervention in managing risks is through communication. The health practitioner should advise the service user of the nature of the problem and emphasize their level of concern. Specific interventions that include medications are important in managing risks associated with bipolar disorder (Videbeck and Videbeck, 2013). From the presented scenario, the service user is administered with lithium 600mg to help in controlling the bipolar disorder.

People with bipolar disorder need medical attention to put their symptoms under control. Continuing the medication on a long-term basis helps in reducing the severity and frequency of occurrence of bipolar mood episodes. It is important that as a patient, one works with their doctor to come up with the right combination of drugs that can help in ensuring a quick recovery. Some of the most important and readily available therapeutic interventions for service users include cognitive behavioral therapy, family-focused therapy, and social rhythm and interpersonal therapy.

In cognitive behavioral therapy, the service user examines how their thoughts affect their emotions. This is also the time when they learn how to change their negative thinking behaviors into more positive behaviors. This therapy helps in avoiding relapses, managing symptoms and solving problems (Young and Grunze, 2013, p. 6). Interpersonal therapy reduces stress by addressing and solving interpersonal problems. It is a relationship-oriented approach that helps in improving health outcomes. The family-focused therapy aims to restore a supportive home environment (Vallarino et al., 2015, p. 556). This is possible by educating the family member regarding bipolar disorder and the best way to respond to the disease. Other interventions that are readily available in local services include medication, psychotherapy, education, and lifestyle management among others.  

Risk Assessment and Management

Conclusion

A bipolar disorder causes strange variations activity levels, mood, energy, and the ability to carry out normal daily activities. There are four types of bipolar disorders that include Bipolar I Disorder, Bipolar II disorder, cyclothymia, and other types that may be specified or unspecified. Several theoretical concepts support the assessment, planning, and delivery of interventions to help the patients with bipolar disorders. The assessment, planning, and delivery of the interventions encompass a critical review of the medical model, recovery model, and bio-psychosocial approach within the field of mental health.

There are instances when bipolar disorder can be misdiagnosed, and its prevalence underestimated. The nurses, therefore, can impact significant care for these service users by recognizing and assessing the bipolar disorder. The nurses also need to educate the service users regarding bipolar disorder and emphasizing the necessity for adhering to medication with the aim of improving patient outcome.

Collaborative decision making is also important in realizing quality health outcomes. The nurse brings their knowledge of understanding the clinical condition, the potential interventions, and the likely risks and benefits of alternative interventions. The service user, on the other hand, comes with the knowledge of a good understanding of their values, preferences, and goals. It is, however, important to note that the implementation of collaborative decision making has a lot of challenges. For example, from the provided scenario, we notice that the service user is paranoid about the clinical procedures recommended by the nurse.

• Management of bipolar disorder should focus on a strong therapeutic relationship.
• Prompt action should be taken once a bipolar disorder has been detected to initiate an appropriate assessment thus aiding in providing quality care.
• The management of this disorder should rely on the integration of clinical experiences and evidence-based data.

References

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