Varcarolis: Essentials of Psychiatric Mental Health Nursing, 2nd Edition Chapter 16: Bipolar Spectr

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Varcarolis: Essentials of Psychiatric Mental Health Nursing, 2nd Edition Chapter 16: Bipolar Spectrum Disorders
Case Studies and Nursing Care Plans

Bipolar Disorder

Ms. Highan was recently “let go” from her position as a flight attendant after she had taken the company’s advertising theme, “Fly the friendly skies,” much too literally. She had been found in compromising positions several times with crew members and customers. The “last straw” came when she failed to respond to a customer who said to her, “Ma’am, do you know who I am?” Her response was a broadcast to the entire terminal pleading for someone to come and help identify this “very important person” (VIP). Neither the airlines nor the senator found it amusing.

Later she is found sitting on the tarmac of the airfield with a bag full of “tiny liquor bottles and little packets of peanuts and pretzels,” When airport security attempts to approach her, she tells them, “Back off!” and says she plans to “get back on a plane, one way or another.” She appears overly cheerful and is constantly talking, laughing, and making jokes. She is coy and flirtatious with the security officers, saying at one point, “Boys in blue are fun to do.”

She is dressed in what most likely was her uniform at one time; however, it now has glitter and rhinestone embellishments. Airport security became activated when she bolted for a plane taxiing for takeoff. She is now considered a threat to herself and to others. Security subdues her and plans to transport her to the local emergency department (ED) for evaluation. Immediately, her once-jovial mood turns to anger and rage; in a matter of minutes, she is asking for a cigarette and referring to the security officers as her “boys.”

After admission to the ED, Ms. Highan is seen by a psychiatrist. The emergency nurse calls her next of kin, an adult daughter, who reports that her mom has “been off her meds for the past 8 months because they were making her gain weight and she could not maintain her ‘flight weight.'” The daughter believes that her mother has been eating less because she looks thinner than she did before―her daughter guesses that her mother has lost 15 pounds. On one occasion, she stopped by her mom’s once-pristine home, only to find everything in complete disarray. “My mom spends every day, even into the wee hours of the night, in front of a computer or on the phone, calling or e-mailing anyone pilots, stewardesses, and supervisorsgiving them instructions on how to improve the airline.

The ER psychiatrist contacts Ms. Highan’s physician to review her history and to discuss medical management. Her initial laboratory work and vital signs are within normal limits. The decision is made to hospitalize her during the acute manic phase and restart her medication.

Assessment

Objective Data

Subjective Data

Self-Assessment

Mr. Atkins has worked as a nurse on the psychiatric unit for 2 years. He has learned to manage many of the challenging behaviors associated with the manic defense mechanisms. For example, verbal insults are no longer taken personally, even when the remarks are cutting and hit close to home. He is able to recognize and set limits on certain tactics used by the patient who is experiencing mania to split the staff. This unit’s staff members work closely together and have good communication, making the atmosphere positive and supportive. Frequent and effective communications are needed to maximize external controls, and to maintain consistency in nursing care.

The only difficulties Mr. Atkins anticipates with Ms. Highan’s behavior are the sexual advances and loud sexual comments she makes toward him. He knows these comments could make him anxious, and his concern is that his anxiety might be picked up by the patient. When he discusses this concern with the unit coordinator, they decide that two nurses should provide care for Ms. Highan. Neither Mr. Atkins nor any male staff member will be alone with Ms. Highan in her room at any time. If Ms. Highan’s sexual remarks or acting-out behaviors make him anxious, then Mr. Atkins will ask for relief.

Mr. Atkins is also concerned about Ms. Highan’s financial status. He knows that she is unemployed and will have difficulty resuming work if she so desires. He plans to enlist the hospital case manager to assist Ms. Highan on housing, insurance, and finances.

Diagnoses

Outcomes Identification

Planning

Short-Term Goal Intervention Rationale Evaluation

EVALUATION

SCIENCE
HEALTH SCIENCE
NURSING
NUR 2520

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