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You are a newly registered nurse working in a large metropolitan hospital on an early shift in a busy medical ward.  You have been allocated Paul KABLE to care for as a 1:1 special in a single bed side-room. You are given the following hand-over by the night duty RN.

Paul is a  30 year old male admitted yesterday post overdose of Diazepam, Lithium Carbonate and Quetiapine. Paul has a diagnosis of Bi Polar Disorder and is currently on an ITO-L1 which requires review today. Overnight Paul has been occasionally drowsy, but at other times very restless and agitated.  His conversation has some delusional content at times. Paul appears confused and is likely to be experiencing a delirium related to the intentional overdose of prescribed medications. 

Paul has an intravenous line of normal saline 1 litre over 8 hours – started 4 hours ago. The last ECG showed lengthening of Q-T interval and a repeat ECG is booked for 10:00 AM.  

TPR & BP are within normal limits – for checking 4 hourly along with neurological observations until reviewed by treating Medical team. 

Paul's behaviour has not presented any significant management problems overnight in the ward.  However when he presented to the Emergency Department in a severely agitated state a Code Black (Aggressive incident) was initiated.  Because of Paul's fluctuating sensorium he is to be considered at risk and steps are needed to ensure his protection .

Paul is not to be given any medication unless severely agitated. The Consultation-Liaison psychiatry team are aware of his admission to the medical ward and will review Paul later this morning. Over the next few hours it is likely that Paul will become more alert and likely more distressed and agitated. You are advised to call for assistance if you have any concerns. 

In a parting comment the night duty RN states that - "I do not know why we are wasting time on looking after a gay male high school teacher who wants to kill themselves, there are plenty of sick people out there who need hospital beds".

Following this handover you have the time to review Paul's admission notes where you will find a number of documents which highlight past and recent concerns.

(All of these documents can be found in the Learnonline Notice Board over the duration of the course).

  1. Emergency Department Mental Health Assessment
  2. Private Psychiatrist letter to Mental Health case manager
  3. Letter from employer to Mental Health case manager
  4. Letter from Mother to Mental Health case manager
  5. Recent letter from identified client to Mental Health case manager

Physical changes

-       Paying attention to the body of the patient is critical. This aspect will look into how the is having headaches, restlessness, and agitations. Further food-drug interaction will be assessed for the patient.

Behavioral changes

-       Assessing the patient restlessness and assessing the impulsive actions noted from the assessments. Further caffeine intake will be assessed

Identification of traits

-       Identifying the traits from the various assessments and enabling assistance in countering this trait facing the patient.

The patient is currently having various issues which need management. The following are the key issues which affect the patient;

-       Increased mood concentration disorder

-       Increased destruction

-       Poor nutrition and lack of sleep apnea

Often bipolar disorder causes patients to experience intense mood disorder swinging from high to low deprive moods. Research has indicated that patients who had bipolar II are more likely to relapse often. This can lead to depression to mania or hypomania.

The above key issues depict the challenges which the patient to be supported and assisted. Understating the patient case assessment and offering the right supportive environment at the faculty is key towards the treatment processes.

As the patient assessment illustrates the patient progress, the neurological causes of the relapse can be determined. Thus s the best critical way of mitigating the patient relapse is through. Further assisting the patient in the following process will be key;

-       Sticking well with the treatment pan

-       Enhancing adequate sleep for the patient

-       Enhancing patient eating process

-       Assessing cognitive therapy behavior of the patient and assisting in the stabilization process.

Hence understanding the patient and noting the behavioral and physical changes is key to enhance the treatment process.

Critical questions

1.What the cognitive behavioral mechanisms of the patient.

2. What are the coping mechanism for the patient

3. what are the patient interpersonal and social therapy mechanisms

Cognitive behavioral therapy mechanisms are essential in assessing the patient thoughts which have an effect on emotions. Further negative changes and behavioral patterns are made positive. In this case, the management of symptoms and avoiding triggers will be key. Cognitive bipolar therapy is a combination of technique between medication and psychotherapy. CBT is essential in various ways that are managing the symptoms of the illness. Further, it is key for preventing behaviors which are caused by relapse, (Swartz & Swanson, 2014 pp 255-259).

Cognitive behavior therapy works in such a way by challenging the negative thoughts of the patient and enhancing patient control to get rid of them. The therapy is usually short term and is focussed on eliminating specific patient problems. CBT therapy helps in identifying the underlying problem, examining the thoughts and behavior of the patient and his emotions, (Rowland et al., 2013 pp 25).

Research undertaken indicates that improvement of bipolar can be achieved using cognitive therapy according to the American Psychology Association, (Diagnostic and Statistical Manual of Mental Disorders, 2013). Good treatment offers outcomes in which patients are stabilized with behavioral and cognitive skills in overcoming the triggers of managing it effectively.

Interpersonal and social therapy for the patient needs to be assessed. This improves medications and adherence, managing stressful life events and decreasing learning skills which help in improving the development of future episodes. The efficiency of Interpersonal and adjunctive therapy has been supported from studies undertaken which show, changing the regular daily routines, ( Blixen, Perzynski, Bokach, Howland & Sajatovic, 2016 pp 640 ). Often as observed from the case study the patient is experienced disturbed sleep, probably triggering mania. This therapy assessment can be effective in managing the disruption occasioned by the patient.

The coping mechanism is crucial in the management of bipolar disorder. The triggers often caused by the disease can be seasonal such as stressful events, thus it can be impossible to avoid lifestyle and mood management strategies. Key coping mechanisms which can be obtained from such include controlling patient stress. Stress is often a major factor in triggering bipolar. Further assessing caffeine and drugs is effective in reducing bipolar disorder for the patient. Hence in assessing the coping mechanisms of the patient, this will inform on further deliberations of the care at the ward, (Goossens, KUpka, Beentjes & Achterberg, 2010 pp 1204).

Relapse bipolar disorder

Bipolar disorder refers to severe and disabling mental state condition which has tremendous effects on the patient, (Collins, Tranter & Irvine, 2012). According to the Diagnostic and Statistical Manual of Mental disorders, there are two broad types of bipolar; that bipolar I and II. The patient in the case study suffers from relapse bipolar I. The brain disorder is responsible for the mental state of the patients which can have a disability on the patient, leading to the diminished regular activity of the patient and changes on the functioning and appetite changes, unstable emotions and changing sleeping disorders. Further, it leads to relationship maintenance disorders for the patient, (Salvatore et al, 2007).

Bipolar is a global problem with lifetime prevalence rates of type and other associated disorders being estimated at a range of between 0.2% to 1.6%. over 60-75 % of the patients occasioned relapse within 2-5 years, while 90% of the patients experiencing a recurrence of the bipolar disorders, ( Krans & Cherney, 2016).

Bipolar disorder is often affected by risks factors such as genetics and medications, (Schulze et al., 2009).  Untreated disorder on a patient is often a high risk for suicide as observed from the patient in the case study where the patient had attempted suicide.  Often detecting the mild forms of bipolar disorders is not straightforward and this lead to underestimation. Lack of adequate patient information often leads to a failure to detect and control the risks factors associated with a bipolar disease.

Gaining adequate knowledge on the bipolar is of great importance. Bipolar disorders have been shown to have patients experiencing recurrence. According to WHO, bipolar disorder is the leading cause of disability globally. In some studies, it has been shown that nonadherence of treatment is the leading cause of reoccurrence of the disorder among patients.

Treatment of bipolar disorders is enhanced treatment on specializing diagnosis and treating mental health. The bipolar living condition can be managed through medications, treatment and substance abuse management. A number of medications are effective in managing bipolar; the medications include mood stabilizers which controls maniac and hypomania disorders with drugs such as lithium, valproic acid, carbamazepine, lamotrigine among others. Administration of antipsychotics, aimed at reducing the mania symptoms. Antidepressants helps in managing depression. Administration of antidepressants and anti-anxiety medications which is geared towards improving anxiety and sleep management, (Jann, 2014).

recovery and person-centered approach to patient status outcomes

NMBA Registered Nurse Standards for Practice

In a person-centered approach process, views and diagnosis clinical diagnosis for the whole person through a deeper integrative diagnosis, with the intention of providing positive health status, (Salloum, 2013 pp 198). Hence as a nurse nitrating concepts of person's centered approach with NMBA standards form an effective way of handling patient start.

Registered nurse standards are essential for providing care in a varied range of patient settings. These standards are essential in maintaining appropriate care for the patient. They play a crucial role in promoting quality of care through clinical practice. Essential standards crucial for the patient in the case study s to offer nursing practice in line with competency no 1.2. Nursing standards and care required for performing interventions which are in accordance with standards and practice for mental health. This will be established through a comprehensive assessment based on the accurate data and information obtained from the patient.

Further, registered nurse role is geared towards standards 2.6 of integrating nursing and health knowledge, attitudes and skills in order to provide effective nursing care, in maintaining the current knowledge base and questioning and strengthening interventions prescribed for the patient in the case study as per treatment protocol.

Appropriate nursing interventions for the patient entails the following activities;

-       Observing the patient after every 15 minutes due to the suicidal and remove of any dangerous objects in the room

-       Reinforcing patient status through assisting the patient on assessing positive and negative aspects of his life, encouraging the positive expression of feelings, enabling occupational /recreational therapy, enhancing client participation through drug enhancement on using mood stabilizing drugs.

-       Engaging interpersonal therapy for the patient, in this case, cognitive behavioral therapy.

These nursing interventions are key to enhancing patient outcomes.

Offering support in terms of nurse-patient interaction is key towards building a trustworthy relationship. As a nurse, making a positive contribution for the patient care is necessary for providing psychoeducation, prevention of relapse and offering physical care in order to make positive differences on the patient.

The patient as observed from the assessment reports has expressed suicidal attempts, it is key to ask the patient if they have thoughts of self-harm and injury. Enhancing the screening process is key in an empathic and non-judgmental manner for the patient I key. An increased risk of suicide is often noted during anxiousness or agitation of drugs. Hence assessing patient safety is critical in this process so as to assure of patient safety during my shift.

Reflect on the parting comments made by the night duty RN

The patient has a positive outcome and forms the comments it is evident that there is positive patient outcome being observed after his case management at the health facility. The patient has built a positive patient relationship with the staff at the facility and he continues to provide effective collaboration for his medication process.

Patient Paul has come to accept his mental status health and is willing to initiate change through the recovery process as documented by the RN. His mental status is quite stable compared to the previous admission period, from the assessment the registered nurse is irresponsible and promotes abuse and form of gender racism. RN statement is responsiveness and lacks good ethical practice as a practicing nurse. The statement doesn't depict NMBA codes of practice for nurses, as the standards professionalism in the work services and not to use prejudice statements.

Stereotyping and prejudice have been observed in the nursing profession, this leads to devaluation. It is at times a concept which is often based on previous experiences. This preconception often predisposes individuals to adopt certain behaviors in face of their subjects who are the nurses, ( Jesus et al., 2010). RN nurses displayed total disrespect to the patient and furthermore to her work ethics which don't allow for such negative statements. The role of nurses is stipulated carefully based on NMBA standards which advocate positive patient outcomes through ethical service provision.

The positive patient decision-making process is influenced by the nature of established relationships and health care systems related to and surrounding people offering care to the patient. The RN handing over the patient seems not to offer and established a positive patient relationship as indicated.

Hence it is critical to involve the patient in the treatment process and to empower the patient to achieve better health outcomes. Thus my role as a registered nurse is to seek patient-centered approaches to enhancing coping therapies for the patient so as to achieve positive patient outcomes. Taking into consideration the assessments there is a need to support the patient in my shift so as to improve patient outcomes and calculating positive behavior to the patient. 

References

Blixen, C., Perzynski, A.T., Bukach, A., Howland, M. and Sajatovic, M., 2016. Patients’ perceptions of barriers to self-managing bipolar disorder: A qualitative study. International Journal of Social Psychiatry, 62(7), pp.635-645

Collins, E., Tranter, S. and Irvine, F., 2012. The physical health of the seriously mentally ill: an overview of the literature. Journal of Psychiatric and Mental Health Nursing, 19(7), pp.638-646.

DSM-5 American Psychiatric Association, 2013. Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Publishing.

Goossens, P.J.J., Kupka, R.W., Beentjes, T.A.A., and van Achterberg, T., 2010. Recognizing prodromes of manic or depressive recurrence in outpatients with bipolar disorder: A cross-sectional study. International journal of nursing studies, 47(10), pp.1201-1207.

Jann, M.W., 2014. Diagnosis and treatment of bipolar disorders in adults: a review of the evidence on pharmacologic treatments. American health & drug benefits, 7(9), p.489.

Jesus, E.D.S., Marques, L.R., Assis, L.C.F., Alves, T.B., Freitas, G.F.D. and Oguisso, T., 2010. Prejudice in nursing: perception of nurses educated in different decades. Revista da Escola de Enfermagem da USP, 44(1), pp.166-173.

Krans, B. & Cherney, K. (2016). The history of bipolar disorder. Retrieved from ht1p://www.healthline.com /health/bipolar-disorder /history-bit

Rowland, J.E., Hamilton, M.K., Lino, B.J., Ly, P., Denny, K., Hwang, E.J., Mitchell, P.B., Carr, V.J. and Green, M.J., 2013. Cognitive regulation of negative affect in schizophrenia and bipolar disorder. Psychiatry research, 208(1), pp.21-28.

Salloum, I.M., 2014. A person-centered approach to diagnosis and care for Bipolar Disorder and Alcoholism. International Journal of Person Centered Medicine, 3(3), pp.198-204.

Salvatore, P., Tohen, M., Khalsa, H.M.K., Baethge, C., Tondo, L. and Baldessarini, R.J., 2007. Longitudinal research on bipolar disorders. Epidemiology and Psychiatric Sciences, 16(2), pp.109-117.

Schulze, T.G., Detera-Wadleigh, S.D., Akula, N., Gupta, A., Kassem, L., Steele, J., Pearl, J., Strohmaier, J., Breuer, R., Schwarz, M. and Propping, P., 2009. Two variants in Ankyrin 3 (ANK3) are independent genetic risk factors for bipolar disorder. Molecular psychiatry, 14(5), p.487.

Swartz, H.A. and Swanson, J., 2014. Psychotherapy for bipolar disorder in adults: a review of the evidence. Focus, 12(3), pp.251-266.

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