Module 3

CASE ANALYSIS #2

Situation #1:

Alice, age 29, has been working in the typing pool of a large corporation for 6 years. Her immediate
supervisor recently retired and Alice was promoted to supervisor, in charge of 20 people in the
department. Alice was flattered by the promotion but anxious about the additional responsibility of the
position. Shortly after the promotion, she overheard two of her former coworkers saying, “Why in the
world did they choose her? She’s not the best one for the job. I know I won’t be able to respect her as a
boss!” hearing these comments added to Alice’s anxiety and self-doubt.

Shortly after Alice began her new duties, her friends and coworkers noticed a change. She had a great
deal of energy and worked long hours on her job. She began to speak very loudly and rapidly. Her
roommate noticed that Alice slept very little, yet seldom appeared tired. Every night she would go out to
bars and dances. Sometimes she brought men she had just met home to the apartment, something she
had never done before. She bought lots of clothes and make-up and her hair restyled in a more youthful
look. She failed to pay her share of the rent and bills but came home with a brand new convertible. She
lost her temper and screamed at her roommate to “Mind your own business!” when asked to pay her
share.

She became irritable at work, and several of her subordinates reported her behavior to the corporate
manager. When the manager confronted Alice about her behavior, she lost control, shouting, cursing,
and striking out at anyone and anything that happened to be within her reach. The security officers
restrained her and took her to the emergency department of the hospital, where she was admitted to
the psychiatric facility. She had no previous history of psychiatric illness.

The psychiatrist assigned a diagnosis of bipolar 1 disorder and wrote orders for olanzapine (Zyprexa)
15mg PO STAT, olanzapine PO qd, and lithium carbonate qid.
NURSING DIAGNOSIS: RISK FOR VIOLENCE: SELF-DIRECTED OR OTHER-DIRECTED

RELATED TO: Manic excitement

OUTCOME CRITERIA NURSING INTERVENTION RATIONALE

Short-Term Goal: 1. Maintain low level of stimuli 1. This will minimize anxiety,
 Client’s agitation will be in client’s environment (low agitation, and suspiciousness.
maintained at a lighting, few people, simple
manageable level with décor, low noise level).
the administration of
tranquilizing medication 2. Observe client’s behavior 2. This is important so that
during the first week of frequently. Do this while intervention can occur if
treatment (decreasing carrying out routine activities so required to ensure client’s (and
risk of violence to self as to avoid creating others’) safety.
or others). suspiciousness in the individual.

3. Ensure that all sharp objects, 3. These objects must be

glass or mirrored items, belts, removed so that client (in an
Long-Term Goal: ties, and smoking materials, agitated, hyperactive state)
 Client will not harm self have been removed from cannot use them to harm self
or others. client’s environment. or others.

4. Maintain and convey a calm 4. Anxiety is contagious and can

attitude to client. Respond be transmitted from staff to
matter-of-factly to verbal client.
hostility.

5. As anxiety increases, offer 5. Offering alternatives to the

some alternatives: to client gives him or her a feeling
participate in a physical activity of some control over the
(e.g., punching bag, physical situation.
exercise), talking about the
situation, taking some
antianxiety medication.

6. Have sufficient staff available 6. This conveys evidence of

to indicate a show of strength control over the situation and
to client if it becomes provides some physical security
necessary. for staff.
7. Client should be offered an
7. If client is not calmed by avenue of the “least restrictive
“talking down” or by alternative.” Restraints should
medication, use of mechanical be used only as a last resort,
restraints may be necessary. after all other interventions
have been unsuccessful, and the
client is clearly at risk of harm to
self or others.
 8. Client safety is a nursing
8. If restraint is deemed priority.
necessary, ensure that sufficient
staff is available to assist. Follow
protocol established by the
institution. The Joint
Commission (formerly the Joint
Commission on Accreditation of
Healthcare Organizations
[JCAHO] requires that an in-
person evaluation by a
physician or other licensed
independent practitioner (LIP)
be conducted within 1 hour of
the initiation of the restraint or
seclusion
(The Joint Commission, 2010).
The physician or LIP must
reissue a new order for
restraints every 4 hours for
adults and every 1 to 2 hours
for children and adolescents. 9. This ensures that needs for
circulation, nutrition, hydration,
9. The Joint Commission and elimination are met. Client
requires that the client in safety is a nursing priority.
restraints be observed at least
every 15 minutes to ensure that
circulation to extremities is not
compromised (check
temperature, color, pulses); to
assist the client with needs
related to nutrition, hydration,
and elimination; and to position
the client so that comfort is
facilitated and aspiration can be
prevented. Some institutions
may require continuous one-to-
one monitoring of restrained
clients, particularly those who
are highly agitated, and for
whom there is a high risk of
self- or accidental injury. 10. Gradual removal of
restraints minimizes potential
10. As agitation decreases, for injury to client and staff.
assess the client’s readiness for
restraint removal or reduction.
Remove restraints gradually,
one at a time while assessing
 the client’s response.

DTR # 1

DRUG/ ROUTE CLASSIFICATION INDICATION/ SIDE NURSING

/ MECHANISM CONTRAINDICATION EFFECTS/ RESPONSIBILITIES
OF ACTION ADVERSE
EFFECTS
GENERIC NAME: ATYPICAL INDICATION: Dizziness, BEFORE:
OLANZAPINE ANTIPSYCHOSIS Short- term treatment drowsiness,  Assess for
of acute manic weight gain, contraindicatio
episodes linked to high ns or cautions
BRAND NAME: PREGNANCY Bipolar I disorder. cholesterol, for the use of
ZYPREXA CATEGORY: dry mouth, the drug
C weakness, including any
ROUTE OF CONTRAINDICATION: insomnia, known allergies
ADMINISTRATION  Contraindicate constipatio to these drugs
: ACTION: d in patients n, within the last
P.O May block hypersensitive indigestion, 24 hours or
dopamine and to drug. high blood scheduled in
DOSE: 5- HT₂  Use cautiously sugar, low the next 48
15 mg receptors. in patients blood hours.
with heart pressure,  Assess
disease, tremor and temperature;
cerebrovascul restlessness skin color and
ar disease, . lesions; CNS
conditions orientation,
that affect, reflexes,
predispose and bilateral
patient to grip strength;
hypotension, bowel sounds
history of and reported
seizures or output; pulse,
conditions auscultation,
that might and blood
lower the pressure,
seizure including
threshold and orthostatic
hepatic blood
impairment. pressure;
 Use cautiously respiration rate
in elderly and
patients, adventitious
those with a sounds; and
history of urinary output.
paralytic ileus,  Advise pt. to
and those at take
risk for consistently;
aspiration that is, always
pneumonia, with or always
prostatic without food.
hyperplasia,  Observe 15
or angle- rights of
closure medication
glaucoma. administration.
 Monitor v/s for
baseline.
DURING:
 Take drug
exactly as
prescribed.
Avoid OTC and
alcohol unless
consulted to
healthcare
provider.
 Do not allow
patient to crush
or chew
sustained
release
Capsules.
 If administering
parenteral
forms, keep
patient
recumbent
for 30 minutes.
 Provide
sugarless candy
and ice chips.
AFTER:
 Report any side
effects.
 Monitor vital
signs.
 Evaluate the
effectiveness of
the teaching
plan (patient
can give the
drug name and
dosage,
possible
adverse
 effects to watch
for, specific
measures to
prevent
adverse effects,
and warning
signs to report).
 Monitor the
effectiveness of
comfort
measures and
compliance
with the
regimen.

REFERENCE:
NURSING DRUG
HANDBOOK
By: Wolters Kluwer

KARCH FOCUS ON
NURSING
PHARMACOLOGY 6TH
EDITION
BY: Amy M. Karch

DTR # 2

DRUG/ ROUTE CLASSIFICATIO INDICATION/ SIDE NURSING

N/ CONTRAINDICATION EFFECTS/ RESPONSIBILITIES
MECHANISM ADVERSE
OF ACTION EFFECTS
GENERIC NAME: ANTIMANICS INDICATION: Central BEFORE:
LITHIUM Treatment of manic nervous  Assess for
CARBONATE episodes of bipolar, system contraindicatio
PREGNANCY manic-depressive problems, ns or cautions
CATEGORY: illness. including for the use of
BRAND NAME: D lethargy, the drug
CARBOLITH slurred including any
 LITHANE CONTRAINDICATION: speech, known allergies
LITHOBID ACTION:  Contraindicat muscle to these drugs
Alters sodium ed if therapy weakness, within the last
ROUTE OF transport in can’t be and fi ne 24 hours or
ADMINISTRATION nerve and closely tremor; scheduled in
: muscle monitored. polyuria, the next 48
P.O cells; inhibits  Use extreme gastric hours.
the release of caution in toxicity, with  Assess
FREQUENCY: norepinephrine patients nausea, temperature;
Q.I.D. and dopamine, receiving vomiting, skin color and
but not neuromuscula and diarrhea lesions; CNS
serotonin, from r blockers and progressing; orientation,
stimulated diuretics; in cardiovascul affect, reflexes,
neurons; elderly ar collapse, and bilateral
increases the patients or coma; grip strength;
intra neuronal debilitated adverse bowel sounds
stores of patients and effects are and reported
norepinephrine in patients w/ related to output; pulse,
and dopamine thyroid serum drug auscultation,
slightly; and disease, levels. and blood
decreases seizure pressure,
the intra disorder, including
neuronal infection, orthostatic
content of renal or CV blood
second disease, pressure;
messengers. severe respiration rate
debilitation or and
dehydration adventitious
or sodium sounds; and
depletion. urinary output.
 Patients with  Advise pt. to
Brugada take
syndrome consistently;
(abnormal that is, always
ECG w/ with or always
increased risk without food.
of sudden  Observe 15
death) or w/ rights of
risk factors for medication
this condition administration.
shouldn’t take  Monitor v/s for
lithium. baseline.
DURING:
 Take drug
exactly as
prescribed.
Avoid OTC and
alcohol unless
 consulted to
healthcare
provider.
 Do not allow
patient to
crush or chew
sustained
release
Capsules.
 If administering
parenteral
forms, keep
patient
recumbent
for 30 minutes.
 Provide
sugarless candy
and ice chips.
AFTER:
 Report any side
effects.
 Monitor vital
signs.
 Evaluate the
effectiveness of
the teaching
plan (patient
can give the
drug name and
dosage,
possible
adverse
effects to
watch for,
specific
measures to
prevent
adverse effects,
and warning
signs to
report).
 Monitor the
effectiveness of
comfort
measures and
compliance
with the
regimen.
 REFERENCE:
NURSING DRUG
HANDBOOK
By: Wolters Kluwer

KARCH FOCUS ON
NURSING
PHARMACOLOGY 6TH
EDITION
BY: Amy M. Karch

PSYCHOTHERAPY PLAN/ MANAGEMENT

I. INDIVIDUAL PSYCHOTHERAPY

 Interpersonal and social rhythm therapy

II. COGNITIVE THERAPY

 Therapy focuses on changing “automatic thoughts” that occur spontaneously and contribute to
the distorted affect.
 Example of automatic thoughts in bipolar mania include:
 Personalizing: “She’s this happy only when
she’s with me.”
 All or nothing: “Everything I do is great.”
 Mind reading: “She thinks I’m wonderful.”
 Discounting negatives: “None of those mistakes are really important.”

III. THE RECOVERY MODEL

  The clinician and client work together to develop a treatment plan that is in alignment with the
goals set forth by the client.
 Some of these strategies include the following:
 Become an expert on the disorder
 Take medications regularly
 Become aware of earliest symptoms
 Develop a plan for emergencies
 Identify and reduce sources of stress: Know
 when to seek help
 Develop a personal support system
 Develop a plan for emergencies

IV. TO ASSIST CLIENT IN CONTROLLING BEHAVIOR

 Contract with client regarding safety of self-behavior.

 Approach in positive manner.

V. TO PROMOTE SAFETY IN EVENT OF VIOLENT BEHAVIOR

 Provide a safe, quiet environment and remove items from the client’s environment that could
be used to inflict harm to self or others.

VI. TO PROMOTE WELLNESS

 Promote client involvement in planning care within limits of situation, allowing for meeting own
needs for enjoyment.