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1.Why Paul started experiencing problems at school at 14 years of age although he was a bright student?

2.What is the main reason behind suicide attempts for Paul?

3.Does Paul’s employer recently force him to work extra hours or beyond capability?

4.Does Paul has any carer to fulfil his daily life need?


Document what you consider are the key issues in this Case Study here.

Do not rewrite the case history from the case study documents.

High intent to kill and increased tendency to cause self-harm is one of the key issues in the case study. There is a need to find out the cause behind repeated suicidal attempts. Continuous use of medication is also an issue for patient and finding links between suicide attempts and medication use is important.

Another issue of concern is that apart from depressive thought, his concentration level, energy and sleep has dropped too. This issue needs to be considered before preparing care plan.

Provide a rationale - Why are these questions relevant to your learning about this Case Study? 

  1. Obtaining more information related to the cause behind problem behaviour is necessary to find out any events in school life that affected behaviour and mental health of Paul at young age. This may help to identify any event of abuse as types of maltreatment also exerts specific effects on mental health.
  2. The case study documents reveal several occasions when Paul tried to commit suicide. However, there is no information regarding the reasons for suicide attempts. Finding this link is necessary to understand the risk factor of poor mental status for Paul.
  3. The letter from the psychiatrist revealed relapse of depressive phase in Paul because of increase in work pressure. Getting answer to the question will help to understand the nature of work and its impact on treatment outcomes.
  4. The information obtained from this would help to understand whether nutritional needs and daily care needs of Paul is adequately addressed or not.

Describe the disorder presented in this scenario – include in-text referencing

The client Paul in the scenario is mainly suffering from bipolar disorder, a mental health condition in which people experience extreme shift of mood. It mainly leads to a stage of mania or euphoric feeling followed or a phase of depression resulting in deep sadness and loss of energy (Vancampfort et al. 2015). 

What are the clinical manifestations associated with this disorder?  One of the major clinical manifestations of bipolar disorders, is the sudden fluctuations outlining extremities in mood and behaviour (Duffy et al. 2014). This results in major transformations pertaining to the emotional outcomes of the individual, which can be difficult to predict. Such extreme variations in mood and behaviour can be observed in the form of ‘manic episodes’ where at one time, the concerned patient can present outbursts of high energy and excitability, where as in other periods, he or she may exhibit symptoms outlining severe depression and lack of self esteem. When associated with the case study of Paul, the clinical manifestations of his bipolar disorder are evident as observed in his previous episodes of energy and enthusiasm, followed by recent relapse of possessing detrimental self-esteem and inclination to suicide (Axelson et al. 2015).  

What are the common treatment options for this disorder?  Due to lack of specified treatment cures for bipolar disorder, general medications form the cornerstone of management of this mental disorder. Pharmacological treatments generally encompass a comprehensive medication plan which includes the usage of antidepressants, antipsychotics and mood stabilizers. Antipsychotic  medications are prescribed for the mitigation of the additional psychological symptoms of the patient, while medications outlined as mood stabilizers are prescribed for the purpose of managing hypomania or manic situations. Antidepressants are suggested for the treatment of situations when the patient exhibits extreme depression (Pacchiarotti et al. 2015). Additionally, for the management of further negative consequences concerning the consumption of antidepressants leading to exhibition of suicidal tendencies, alternative mitigation options may be used such as psychotherapy (Inder et al. 2016). An additional treatment option is Dual Diagnosis Treatment for the purpose of management of bipolar disorder accompanied with substance abuse. As evident from the case study, Paul has been prescribed Lithium Carbonate and Quetiapine, which are recognized as common drugs for the treatment of bipolardisorder (Sajid et al. 2016).


Identify the appropriate NMBA Registered Nurse Standards for Practice

that would be applicable for you as an RN in supporting the person in this Case Study: As outlined by the Nursing ad Midwifery Board of Australia Standards for Practice, one of the most important and appropriate Code of Practice, which should be followed by the Registered Nurse in supporting the bipolar case study of Paul, is Standard 2. This standard pertains to the importance of engagement in therapeutic and professional relationships by the concerned registered nurse (Scanlon et al. 2016). This would require the registered nurse to perform effective communication strategies with the patient, considering required sensitivity to the needs and interest of the patient, along with provision of respect pertaining to his or her dignity or rights. Despite maintenance of adequate professionalism, the registered nurse is required to engage in empathetic and compassionate conversation with the patient, for the purpose of recognising the client specific needs with politeness (Halcolm et al. 2017). Hence, with respect to Paul, the registered nurse should follow standard 2 for practice, in order to establish harmonizing yet professional relationships for his betterment. Hence, she should critically observe the occurrences of manic symptoms of Paul, for the purpose of his treatment, while simultaneously, engaging in affectionate and polite conversation with him. She should also engage in effective delegation activities, for the purpose of provision of a holistic treatment for Paul, amongst various levels of nursing staff (Cashin et al. 2017). 

Provide an outline of how you would support this person during your shift: One of the activities performed by the registered nurse, would be the timely administration of the medications, required for the purpose of reduction in the depressive and excitability symptoms of Paul. The registered nurse should also be in possession of adequate knowledge and careful observation of the symptoms exhibited by him, as a consequences of the side effects resulting from consumption of the same (Garcia et al. 2016). An additional support strategy by the registered nurse in the management of Paul, would be the implementation of a family-centred approach. With respect to this, the concerned registered nurse should engage in adequate collaborative and cordial relationships, with the family members of Paul, by involving the in the formulation and modification of his treatment plan, as per his changing symptoms (Nestsiarovich et al. 2017). In additional, the registered nurse should also engage in the utilisation of a shared care plan for the support of Paul during the shift timings. This would involve a collaborative treatment approach involving shared activities by the concerned nurse as well as the specified general practitioner. While the decision of the general practitioner will form the cornerstone of Paul’s treatment, the registered nurse in his absence may also exercise this role, and acquire further help from the local mental health organization in the immediate vicinity of the clinical setting (Lovell et al. 2018).  

Clinical Manifestations of Bipolar Disorder

Provide justification for your chosen interventions: The diligent performance of the registered nurse, concerning the timely administration of prescribed medications, is of utmost importance for the management of patients possessing symptoms of bipolar disorder. This is due to the absence of specific cure options for bipolar disorder, hence necessitating the timely ingestion of prescribed medications, for the purpose of reduction of the mania and depressive symptoms in the patient. Improper medication has been associated with the occurrence of relapse symptoms in the bipolar patient, hence requiring careful observation of the behavioural symptoms exhibited by the concerned patient, in the light of possible emergency situations (Ralat et al. 2018). The occurrence of bipolar symptoms in the concerned patient, is often a cause for major distress in the family, as clearly evident by in the letter written by Paul’s mother. Hence, usage of a family centred approach is required to adequately update, inform and involve the concerned patient’s family, as an ethical consideration to assure safety, security and utmost priority to the client (Lee et al. 2018). With respect to the sudden fluctuations in the mood of the bipolar patient, as evident in the case study of Paul, a shared care plan is of utmost importance for the purpose of management of medical emergencies, which may occur due to the suicidal tendencies exhibited by Paul (Farrelly et al. 2016). 

Identify the  safety concerns for the patient in this Case Study: As outlined by the case study, Paul is currently suffering from severe depressive episodes, where he is exhibiting negligible self-esteem, a lack of hope for his future, followed by a suicidal desires. Hence, one of the major safety concerns for Paul is the possibility of conducting suicide or associated self-harming behaviour. While one of the key management strategies aimed at prevention of the same is administration adequate medication, the registered nurse may be required to undertake additional safety mitigation tasks. This would involve alerting the additional staff members such as the enrolled or assistant nurses who are part of Paul’s care team, in order to be observant concerning his symptoms (Hayes 2016). An additional method would be appointment of a medical emergency tam, who would exhibit prompt response pertaining to occurrences of the same, along with informing the concerned family members, who may also engage in active observation and reporting in the event of such safety concerns. Further, the registered nurse must engage in empathetic conversation with Paul, in order to politely inform him regarding his safety concerns (Lin, Berk and Hsu 2017).

Common Treatment Options for Bipolar Disorder

Provide a justification for your thoughts using the professional literature to support your argument here – include in-text referencing 

The reason for major concerns of Paul’s safety, is due to his exhibition of suicidal tendencies. Hence, there is an immediate need to adopt emergency medical safety practices since patients who suffer from bipolar disorders exhibit considerable tendencies of hypomania characterized by an interest towards self-harm and suicide (da Silva Costa 2015). I also believe that there is an immediate requirement to inform an alert Paul’s family, concerning the risk to his possible safety, along with the importance of adhering to principles of family-centred approach for the treatment of the concerned patient (Rodgers et al. 2014).

Also, the need for allotting and alerting a suitable medical team for the purpose of Paul’s treatment, is high since I believe Paul’s tendency to suicide and harm himself has to be prevented at the earliest. Paul has also exhibited considerable relapsing of symptoms, especially observed after his modified medication plan. Hence, I believe the need of the hour is to not only strengthen his treatment plan but to also further revise his medication, considering the side effects of lithium carbonate (Zeng et al. 2015).


Axelson, D., Goldstein, B., Goldstein, T., Monk, K., Yu, H., Hickey, M.B., Sakolsky, D., Diler, R., Hafeman, D., Merranko, J. and Iyengar, S., 2015. Diagnostic precursors to bipolar disorder in offspring of parents with bipolar disorder: a longitudinal study. American Journal of Psychiatry, 172(7), pp.638-646.

Cashin, A., Heartfield, M., Bryce, J., Devey, L., Buckley, T., Cox, D., Kerdo, E., Kelly, J., Thoms, D. and Fisher, M., 2017. Standards for practice for registered nurses in Australia. Collegian, 24(3), pp.255-266.

da Silva Costa, L., Alencar, Á.P., Neto, P.J.N., dos Santos, M.D.S.V., da Silva, C.G.L., Pinheiro, S.D.F.L., Silveira, R.T., Bianco, B.A.V., Júnior, R.F.F.P., de Lima, M.A.P. and Reis, A.O.A., 2015. Risk factors for suicide in bipolar disorder: a systematic review. Journal of affective disorders, 170, pp.237-254.

Duffy, A., Horrocks, J., Doucette, S., Keown-Stoneman, C., McCloskey, S. and Grof, P., 2014. The developmental trajectory of bipolar disorder. The British Journal of Psychiatry, 204(2), pp.122-128.

Farrelly, S., Lester, H., Rose, D., Birchwood, M., Marshall, M., Waheed, W., Henderson, R.C., Szmukler, G. and Thornicroft, G., 2016. Barriers to shared decision making in mental health care: qualitative study of the Joint Crisis Plan for psychosis. Health Expectations, 19(2), pp.448-458.

García, S., Martínez-Cengotitabengoa, M., López-Zurbano, S., Zorrilla, I., López, P., Vieta, E. and González-Pinto, A., 2016. Adherence to antipsychotic medication in bipolar disorder and schizophrenic patients: a systematic review. Journal of clinical psychopharmacology, 36(4), p.355.

Appropriate NMBA Registered Nurse Standards for Practice

Halcomb, E., Stephens, M., Bryce, J., Foley, E. and Ashley, C., 2017. The development of professional practice standards for Australian general practice nurses. Journal of advanced nursing, 73(8), pp.1958-1969.

Hayes, J.F., Pitman, A., Marston, L., Walters, K., Geddes, J.R., King, M. and Osborn, D.P., 2016. Self-harm, unintentional injury, and suicide in bipolar disorder during maintenance mood stabilizer treatment: a UK population-based electronic health records study. JAMA psychiatry, 73(6), pp.630-637.

Inder, M.L., Crowe, M.T., Luty, S.E., Carter, J.D., Moor, S., Frampton, C.M. and Joyce, P.R., 2016. Prospective rates of suicide attempts and nonsuicidal self-injury by young people with bipolar disorder participating in a psychotherapy study. Australian & New Zealand Journal of Psychiatry, 50(2), pp.167-173.

Lee, H.J., Lin, E.C.L., Chen, M.B., Su, T.P. and Chiang, L.C., 2018. Randomized, controlled trial of a brief family?centred care programme for hospitalized patients with bipolar disorder and their family caregivers. International journal of mental health nursing, 27(1), pp.61-71.

Lin, E.C.L., Berk, M. and Hsu, P.C., 2017. A nurse-led psychoeducational program BalancingMySwing improves medication adherence among Taiwanese Han-Chinese with bipolar II disorder. Neuropsychiatry, 7(4), pp.302-309.

Lovell, K., Bee, P., Brooks, H., Cahoon, P., Callaghan, P., Carter, L.A., Cree, L., Davies, L., Drake, R., Fraser, C. and Gibbons, C., 2018. Embedding shared decision-making in the care of patients with severe and enduring mental health problems: The EQUIP pragmatic cluster randomised trial. PloS one, 13(8), p.e0201533.

Nestsiarovich, A., Hurwitz, N.G., Nelson, S.J., Crisanti, A.S., Kerner, B., Kuntz, M.J., Smith, A.N., Volesky, E., Schroeter, Q.L., DeShaw, J.L. and Young, S.S., 2017. Systemic challenges in bipolar disorder management: A patient?centered approach. Bipolar disorders, 19(8), pp.676-688.

Pacchiarotti, I., Murru, A., Kotzalidis, G.D., Bonnin, C.M., Mazzarini, L., Colom, F. and Vieta, E., 2015. Hyperprolactinemia and medications for bipolar disorder: systematic review of a neglected issue in clinical practice. European Neuropsychopharmacology, 25(8), pp.1045-1059.

Ralat, S.I., Depp, C.A. and Bernal, G., 2018. Reasons for nonadherence to psychiatric medication and cardiovascular risk factors treatment among Latino bipolar disorder patients living in Puerto Rico: a qualitative study. Community mental health journal, 54(6), pp.707-716.

Rodgers, S., Holtforth, M.G., Müller, M., Hengartner, M.P., Rössler, W. and Ajdacic-Gross, V., 2014. Symptom-based subtypes of depression and their psychosocial correlates: a person-centered approach focusing on the influence of sex. Journal of affective disorders, 156, pp.92-103.

Sajid, A., Whiteman, A., Bell, R.L., Greene, M.S., Engleman, E.A. and Chambers, R.A., 2016. Prescription drug monitoring program data tracking of opioid addiction treatment outcomes in integrated dual diagnosis care involving injectable naltrexone. The American journal on addictions, 25(7), pp.557-564.

Scanlon, A., Cashin, A., Bryce, J., Kelly, J.G. and Buckely, T., 2016. The complexities of defining nurse practitioner scope of practice in the Australian context. Collegian, 23(1), pp.129-142.

Vancampfort, D., Stubbs, B., Mitchell, A.J., De Hert, M., Wampers, M., Ward, P.B., Rosenbaum, S. and Correll, C.U., 2015. Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders, bipolar disorder and major depressive disorder: a systematic review and meta?analysis. World Psychiatry, 14(3), pp.339-347.

Zeng, R., Cohen, L.J., Tanis, T., Qizilbash, A., Lopatyuk, Y., Yaseen, Z.S. and Galynker, I., 2015. Assessing the contribution of borderline personality disorder and features to suicide risk in psychiatric inpatients with bipolar disorder, major depression and schizoaffective disorder. Psychiatry research, 226(1), pp.361-367.

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