Bipolar Therapy
Client of Korean Descent/Ancestry

BACKGROUND INFORMATION

The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder. 

Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”

She weights 110 lbs. and is 5’ 5” 

SUBJECTIVE

Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.” 

You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work. 

Genetic testing reveals that she is positive for CYP2D6*10 allele. 

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago. 

MENTAL STATUS EXAM

The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.

The Young Mania Rating Scale (YMRS) score is 22

RESOURCES

§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6

Decision Point One

Select what the PMHNP should do:

Begin Lithium 300 mg orally BID

Begin Risperdal 1 mg orally BID

Begin Seroquel XR 100 mg orally at HS

Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

• Decision #1
  • Which decision did you select?
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

Choice one: I choose to start Seroquel

Decision Point One

Begin Seroquel XR 100 mg orally at HS

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client is reporting that she sleeps a bit more at bedtime
• Client states that she has gained about 2 or 3 pounds, which she does not like
• Client also reports that she has been constipated since starting this medication
• Client is also complaining of dry mouth which she does not like.
• Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18
• Client is reporting really good mood, but is asking for a different medication because of the weight gain

Decision Point Two

Select what the PMHNP should do next:

Increase Seroquel XR to 300 mg orally daily 

Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal 

Continue same dose of Seroquel and counsel client regarding ways to prevent constipation

I choose to discontinue Seroquel and start Geodon 40 mg orally BID. ADminister with 500 calorie meal

Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal 

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client demonstrates a 50% decrease in score on the Young Mania Rating Scale (from 22 to 11)
• Client denies any additional weight gain and denies any additional side effects

Decision Point Three

Select what the PMHNP should do next:

Continue same dose and reassess in 4 weeks 

Increase Geodon to 60 mg orally BID with a 500 calorie meal 

Augment with Lithium sustained release 300 mg orally BID

I now choose to continue same dose and reassess in 4 weeks

Decision Point Three

Continue same dose and reassess in 4 weeks 

Guidance to Student
The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.

Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects.

Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended release may overcome the difficulties she was experiencing with side effects. The PMHNP would need to educate client regarding side effects of medication and need to maintain compliance. 

What role does your facility play in keeping people healthy? Would the Health Leads program work in your facility? Why or why not?

List 8  PROGRESS NOTES in SOAP format of the   Psychiatric Mental Health Nurse Practitioner Role  with  Child and Adolescents  . Describe the   activities you completed during this   time   period with patients.

NOTE: ( The progress notes has to be related with what the      Psychiatric Mental Health Nurse Practitioner do with Child and      adolescents with different psychiatric conditions). 8 different  notes     with different patients scenarios. 

Requirements:

You are a family nurse practitioner working in an outpatient primary care office of a large hospital system. The practice has been operating for over 15 years, and many of the administrative and clinical staff were hired when the practice opened. You have been in the practice for less than 3 months. In that short amount of time, you have witnessed several of the clinical staff engaging in heated arguments with each other, sometimes in patient areas. You overhear an argument occurring today between two staff. You pick up a patient’s chart and notice a very low blood pressure that the medical assistant failed to notify you about. When you confront the MA, she states that she was going to report the vital signs to you when she became engaged in the heated argument you overheard and forgot to notify you. 

Unfortunately, this pattern of behavior is not unusual in this practice. Working with staff who cannot cooperate effectively can negatively influence your ability to spend time with patients, can impede the flow of patients through the office, and could impact patient safety. 

Case Study Responses: 

1. Analyze the case study for potential issues for members of the healthcare team from office conflict. Contrast the potential effects for each member of the healthcare team based upon the required readings from the week. Discuss the potential ethical and legal implications for each of the following practice members: 
   • Medical assistant 
   • Nurse Practitioner 
   • Medical Director 
   • Practice 
2. What strategies would you implement to prevent further episodes of potentially dangerous patient outcomes? 
3. What leadership qualities would you apply to effect positive change in the practice? Focus on the culture of the practice. 

Letz, K. (2017). The NP guide: Essential knowledge for nurse practitioner practice. (3rd ed.). American College of Nurse Practitioner Faculty. 

• Chapter 10 Corporate Compliance/ Legal Ease

Buppert, C. (2017). Nurse practitioner’s business practice & legal guide (6th ed.). Jones & Bartlett Publishers.

• Chapter 8 Risk Management

Feedback from professor that needs to be fixed From rough draft uploaded below 

Your paper is a great start to your final draft. You are on the right track. You have some clear information in your paper about the history of police brutality and the idea of when it started. I would like to see the claim/argument made about the action of police brutality, not the history of when it started. This is not a strong claim or one that produces the critical reasoning I would like to see in this paper. After you have developed that, then produce the counterargument on the opposite side of the claim.  The inclusion of historical data and information can be used to support either side and you can demonstrate the subjective interpretations that are being used on each side around the topic.  The goal is to choose one side of the argument and then explain all of the questions in relation to that argument. 

Many of components you were missing included the research and data surrounding the issue. You can also look at the percentages of people on each side, states data, historical data of reported cases. It looked like all of the cases you mentioned were against African Americans. This is alright, if you want to stick to that population. Just be clear that it is not all cases and forms of police brutality. Be analytical and assess the argument, not just the topic. 

Please read through my comments so you know what needs to change,what is missing, and what may need some clarification. It is especially important to review each of the questions for the final paper and make sure that after you state the claim/argument regarding guns, that you then answer according to that statement.

what the guide lines are below.

The goal of this paper is to construct a fair-minded, unbiased, analytical analysis of a topic in a comprehensive essay.

• This is not an opinion piece or a persuasive essaythat simply aims to prove or reinforce what you already believe. This would be confirmation bias, and bias must be avoided in this project.
• This project needs to avoid harsh rhetoric or language that is harmful and hurtful in nature. The point is to be objective and unemotional in your approach.
• This essay should be written in a fair, academic, respectful, and analytical manner regardless of any of your opinions, feelings, or preconceived notions about the topic.
• Both sides of your topic must be treated with equal attention, both in terms of the number and quality of sources and in the depth and breadth of their presentation in your essay. Both sides should be addressed in the same number of paragraphs in roughly equivalent detail, and should be supported by the same number of quality sources.
• You must identify and define rhetorical devices and logical fallacies on both sides of the argument. Be sure you indicate which specific rhetorical device and fallacy you have found, and there is evidence in your sources of these course concepts in practice that is cited in your paper.
• You will present statements and claims for analyzing both sides of the topic. Only then should you state you own conclusion as an objective, critical thinker given the information presented.

Essay Format: Your essay must be 5–7 pages (1600–1900 words) in length. The abstract, title page, and reference list do not count in the page or word count. The essay must have the following elements:

• Times New Roman
• 12-point
• Double-spaced
• 1-inch margins
• Proper Level I and Level II APA section headings for all major sections of the essay
• All other applicable APA formatting

Required Elements:

• A properly formatted APA title page
• A properly formatted APA abstract
• Body of the paper 
  • Introduction: Identify the issue. Provide the necessary background and/or important recent developments. Define key terms and concepts. Engage the reader and explain the broader significance of the issue.
  • Arguments and Counterarguments: Summarize the best arguments on both sides of the issue. Include relevant research from credible sources used to support each conclusion. Devote at least one paragraph to each side.
  • Evaluation of Critical Thinking: Assess the strength of the arguments and the quality of thinking surrounding this issue. 
    • Identify weaknesses in critical thinking such as fallacies, rhetorical devices, vague language, and cognitive biases. Provide specific examples of how these weaknesses appear in arguments you encountered, using terminology and definitions from the course. Be specific! Present evidence from your sources that show these fallacies/biases being used.
    • Evaluate the quality of scientific and anecdotal evidence using the standards ofinductive and deductive reasoningdescribed in the course. Consider the quality of causal relationship, analogies, generalizations, and/or moral reasoning.
  • Conclusion: Analyze the totality of research and offer a critical thinker’s response to the issue. Identify your own position and experience with the issue and explain how your thinking of the subject has evolved as a result of your analysis. Your conclusion does not have to be absolute, but it should not be equivocal. If both sides have good arguments, which is better, even if only slightly better, and what is the argument that tips the scales in the sides’ favor? Why does that point tip the scales?
• A properly formatted APA reference list 
  • Sources should appear in alphabetical order according to the last name of the first author listed on the source.
  • If there is no author(s), then the source should be cited by title or organization.

Sources and Research Sources: You must use five scholarly or academic sources and all research should be published within the last five years. Sources not scholarly or academic in nature may affect your grade. It is highly recommended that most of your research be conducted via the WCU Library.

Eligible sources listed best-to-worst: 

• Peer-reviewed journal articles 
  • Peer review is the process that allows scientists to trust the reliability of published journal articles. The only way to tell if a journal article has been peer reviewed is to look for information about the journal, normally on the publisher’s website. Most databases do not indicate if an article is peer reviewed or not.
  • The WCU library contains many of peer-reviewed sources. This is going to be the most desired type of evidence to use for any paper at WCU.
• Scholarly research articles 
  • Research articles (original research articles, primary research articles, or case studies) are your standard scientific articles. Most often published in peer-reviewed journals, primary research articles report on the findings of a scientist’s work.
  • They almost always include a description of how the research was conducted and what the results mean. This is also a highly desirable type of research to use for your papers.
• Government and state reports 
  • Many government agencies like the Department of Health and Human Services (HHS), the Centers for Disease Control and Prevention (CDC), National Institute of Mental Health (NIHM), and the Federal Bureau of Investigation (FBI) may have studies and statistics that may be useful for your topic. However, these sources are usually informational reports in nature, and therefore they rarely dig into the critical arguments used by the sides of a topic.
  • Though usually credible and reliable source, government reports should generally be used as supplemental, secondary sources to support or rebut academic sources. They should not be the main sources of your argument.
• Other articles or sources 
  • When this general term is used for an assignment, get clarification from your instructor about the source requirements. These are articles or sources that have been well researched and include a lot of citations. When you assess these resources, make sure that they are appropriate to use as evidence because they may contain bias. You should look at the sources these articles are using, determine if they are legitimate, reputable, and credible, and then make a judgment call.
  • These types of articles are the least desirable type of articles from the list of acceptable types to use (depending on each course’s expectations). 
    • Review articles
    • Editorials, opinion, commentary, and perspectives
    • Trade publication articles
    • Technical reports
    • Documentaries
    • Interviews or TED talks

Sources that may not be used on this essay include the following: 

• Wikipedia and information from freelance websites (check with your professor before using these sources)
• Information from general or reference sources such as dictionaries, encyclopedias, general information websites, or other reference works online or in print. Check with your teacher regarding textbooks from other courses or other sources if you are not sure.
• Articles from publications or magazines that lack research to back up their claims
• Religious texts of any kind
• Obviously or highly biased sources that contain no credible or reputable support