Assignment: “Captain of the Ship” Project – Bipolar Disorders

Running head: WEEK 5 CAPTAIN OF THE SHIP 1

Week 5 Captain of the Ship

Wendie Malkinski

Walden University

Nurs 6670

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WEEK 5 CAPTAIN OF THE SHIP 2

Abstract

“. Bipolar disorder, formerly called manic depression, is a mental health condition that causes

extreme mood swings that include emotional highs (mania or hypomania) and lows

(depression). “("Mayo Clinic," 2019, para. 1)

Patients with Bipolar disorder tend to have cyclic periods with relatively normal moods.

There are actually two types of bipolar. Bipolar type 1 comes with a full manic episode, bipolar 2

experiences a hypomanic episode (not a fulminic episode )(DSM 5, 2017)(DSM 5, 2017)

Keywords: depression, manic

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WEEK 5 CAPTAIN OF THE SHIP 3

Week 5 Captain of the Ship

HPI & Clinical Impression of the Patient

H.P. is a 27 y/o African American Female who was transferred to the inpatient psychiatric

unit for admission from the Emergency room . She had attempted to drink a bottle of Nyquil

when her mother came in and caught her before she could carry out the attempt. When asked

why she did it she states “ I just want to die ! I’ve lost my son, my boyfriend and my apartment!”

Review of the pt. chart shows diagnoses of bipolar I disorder where she was taking Lithium and

Prozac daily. In speaking with the pt. and her mother they admit that the pt. has not been on her

medications in. some weeks. When asked why she wanted to die she stated “ I lost my job, my

boyfriend and now my son”. Permission was obtained from the pt. to speak with her mother and

her boyfriend.

Up until this point she had been living with her boyfriend in a one bedroom apartment

and working part time in a daycare center while going to school working on a degree in early

childhood development. She was recently fired from her job due to “ bizarre behavior” to include

using foul language in front of the children, and statements to other employees such as “I’m

going to be your boss someday and I’ll fire all of you”. She has been unable to concentrate at

school turning in assignments late receiving failing grades.

Her boyfriend describes her maxing out his credit cards with online shopping , and she

recently began yelling and cursing at their 4 y/o child. He also goes on to describe marijuana use

at times .He states “ I can’t take it anymore, I have to end the relationship for mine and my son’s

sanity.” After the relationship ended the pt. moved back in with her mother.

At the present time on the unit she is refusing to take the prescribed medications stating “

I can’t remember to take pills every day”. There has been some progress from the beginning of

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WEEK 5 CAPTAIN OF THE SHIP 4

her stay 3 days ago when she began uttering “ I want to get the hell out of here there is nothing

wrong with me!”

In interviewing the pt., she has described a 20 lb. weight gain over the last 2 months with

a concern from her PCP for hypertension. Today’s bp reading is 140/89 heart rate 110. . The pt.

states “ I need to be healthier”

After pulling the pt. chart for lab results and such, I found that her tox screen was only

positive for cannabis, alcohol level was negative. An incidental finding was an elevated TSH

level.

Medical/Surgical History

The pt. is a 27 y/o African American female height 5 feet 2 inches and weight is 180 lbs.

with a BMI of 32.9. Her last physical as 14 months ago. She reports “ I didn’t have time to cook

in between working and going to class, so I eat a lot of fast food” The pt. reports very little

exercise as well. The only medical problem in the pt. past is hypertension. Surgical

history includes a c-section for her son.

Differential Diagnoses

I agree with the differential diagnoses of Bipolar I disorder for the pt., as she fits the

criteria including:

 Elevated mood for at least one week (including manic episode)

 Engaging in pleasurable activities - spending money on other’s credit cards

 More talkative

 Grandiosity

 Distractibility("Mayo Clinic," 2019)

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WEEK 5 CAPTAIN OF THE SHIP 5

Pharmacological Treatments

This pt. had been on Prozac and Lithium which meets criteria for the treatment of bipolar

I disorder, however , I would choose to discontinue this sue to the fact that the pt. herself has

explained she cannot be compliant with these daily medications.

With this in mind, I would recommend a once monthly injectable of

Aripiprazole (Abilify) . “Aripiprazole interacts with multiple receptors in the brain, which may

contribute to its specific clinical effects. It has high affinity for dopamine D2 and D3 receptors

and serotonin 5HT1A and 5HT2A receptors, and moderate affinity for dopamine D4 and

serotonin 5HT2C and 5HT7 receptors”(Torres, 2018, para. 2)

Whereas the Lithium/Prozac combination do not hit as many. Non-compliance with meds

in Bipolar I pt. is anywhere from 20-60%.(Torres, 2018) The use of injectables increases

compliance about 20% when taken properly.

Primary Care Needs

H.P. will need blood pressure monitoring , and to be possible started on levothyroxine, for

hypothyroid. This could account for her weight gain having hypothyroidism. This can also cause

shifts in mood.("Mayo Clinic," 2019). This would need to be investigated before the pt. is started

on monthly injectable medications. Plus, CBC and CMP to monitor for anemia, kidney issues

would be helpful as well.

Psychotherapy

I would choose initially for this pt. to go to individual and family CBT, as there is a small

child involved. CBT benefits Bipolar pt. by helping them reframe their thoughts in a more

positive way. Also, H.P.’s illness has affected her family and I believe they should all attend

counseling together.(DSM 5, 2017)

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WEEK 5 CAPTAIN OF THE SHIP 6

Community Resources

In talking with the social worker involved with this case, H.P. has scholarships that are

available to single moms to help them return to college. Also, in the area where she live the Y

center has support groups that she can attend for free . As well as there is copay help for the

monthly injectable medication where H.P. only has to pay $5 a month.

Follow Up Care Plan

I would recommend that H.P. f/u in 2 weeks with me to see how the injectable is working

out and immediately with PCP. Also, she would need to see her therapist within 1 week.

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WEEK 5 CAPTAIN OF THE SHIP 7

References

Bipolar Disorder. (2019). Retrieved from https://www.mayoclinic.org/diseases-

conditions/bipolar-disorder/symptoms-causes/syc-20355955

Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition. (2017).

http://dx.doi.org/Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition

https://doi-org.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596 Full Access

Torres, V. (2018). Spotlight on once-monthly long-acting injectable aripiprazole and its potential

as maintenance treatment for bipolar I disorder in adult patients. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5768291/

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