STUDENT-Bipolar_Depression-SKINNY_Reasoning



© 2018 Keith Rischer/www.KeithRN.com

Bipolar Depression/Mania SKINNY Reasoning

Brenden Manahan, 35 years old

Primary Concept

Mood and Affect

Interrelated Concepts (In order of emphasis)

• Psychosis

• Clinical Judgment

• Patient Education

NCLEX Client Need Categories Percentage of Items from Each

Category/Subcategory

Covered in

Case Study Safe and Effective Care Environment

✓ Management of Care 17-23% ✓ ✓ Safety and Infection Control 9-15% ✓

Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity

✓ Basic Care and Comfort 6-12% ✓ ✓ Pharmacological and Parenteral Therapies 12-18% ✓ ✓ Reduction of Risk Potential 9-15% ✓ ✓ Physiological Adaptation 11-17% ✓

© 2018 Keith Rischer/www.KeithRN.com

SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Brenden Manahan is a 35-year-old male, who has been admitted to the crisis intervention unit for exacerbation of his

bipolar disorder. He was admitted on a 501 (involuntary inpatient admission, patient has been deemed either dangerous to

self or others) and brought to the hospital by police because his mother feared for his safety. In the past few weeks he

stopped taking his medication because he feared that his mother was poisoning him.

Brenden has not slept in the past four days due to racing thoughts. He believes that he is the head of the CIA and told

his mother that he needed her car to go to CIA headquarters in McLean, Virginia, and fire everyone. When the police

arrived they noted that Brenden was speaking at a very rapid rate and pace and was becoming increasingly agitated. He

began yelling that the police where there to poison him and prevent him from returning to his job.

He has been admitted to the locked mental health unit for evaluation of his mental capacity and stabilization. Brenden

will participate in the following education groups: medication education, and bipolar illness education. The goal is to

resume lithium carbonate and divalproex sodium.

Personal/Social History: Brenden was diagnosed at 19 with bipolar I, and subsequently has been admitted six times due to non-adherence to the

medication regimen. Brenden is divorced and has a 3-year-old son who lives with his mother. He was recently in court to

have his visitations reduced to one supervised visit a week. He lives with his mother, who is supportive.

What data from the histories is important and RELEVANT and has clinical significance for the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Patient Care Begins: What VS data are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT VS Data: Clinical Significance:

Current VS: WILDA Pain Assessment (5th VS): T: 99.1 F/37.3 C (oral) Words: Patient denies

P: 110 (regular) Intensity:

R: 28 (regular) Location:

BP: 142/84 Duration:

O2 sat: 99% room air Aggravate:

Alleviate:

© 2018 Keith Rischer/www.KeithRN.com

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Assessment Data: Clinical Significance:

What MSE assessment data is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Assessment Data: Clinical Significance:

Current Assessment: GENERAL

APPEARANCE:

Is disheveled, and according to his mother, he has not showered in several days.

NEURO: Oriented to person and place but not to time, impaired ability to concentrate, labile

emotions, has not slept for four days

RESP: Breath sounds clear however, patient is breathing rapidly and deeply

CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong,

equal with palpation at radial/pedal/post-tibial landmarks

GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants, has

adequate appetite.

GU: Voiding without difficulty, urine clear/yellow

SKIN: Skin integrity intact

CHEMICAL USE: Denies both use/abuse of ETOH or other street drugs

Mental Status Examination: APPEARANCE: Is disheveled, and according to his mother he has not showered in several days. He is

unshaven, and has a significant odor coming from his body and or clothes. His clothes are

not consistent with the weather, it is 95 degrees and is wearing multiple layers of clothing

and has winter boots on.

MOTOR BEHAVIOR: Psychomotor agitation present, appears restless; he is unable to sit still

SPEECH: Talking fast with pressured speech.

MOOD/AFFECT: Appears ecstatic, bright affect

THOUGHT PROCESS: Delusional, flight of ideas/ jumping from one idea to another

THOUGHT CONTENT: Believes that the CIA is controlling the nurses’ actions and following him and that he must

get to the CIA headquarters immediately.

PERCEPTION: Denies hallucinations

INSIGHT/JUDGMENT: Has lack of insight into current condition and reason for inpatient hospitalization

COGNITION: Oriented to person and place but not to time, his immediate and recall were intact but

remote memory is not.

INTERACTION: Approaches others, but does not engage in lasting conversation

SUICIDAL/HOMICIDAL: Denies homicidal/suicidal ideation

© 2018 Keith Rischer/www.KeithRN.com

Diagnostic Results: Basic Metabolic Panel (BMP)

Na K Gluc. Creat.

Current: 142 4.0 102 1.0

Complete Blood Count (CBC)

WBC % Neuts HGB PLTs

Current: 8.9 70 12.9 325

MISC.

Lithium

Current: 0.2

What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT

Diagnostic Data:

Clinical Significance:

© 2018 Keith Rischer/www.KeithRN.com

Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem?

(Management of Care/Physiologic Adaptation)

Problem: Pathophysiology in OWN Words:

Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)

Medical Management: Rationale: Expected Outcome: Admit to unit and engage

patient in milieu

Urine drug screen

Lithium 600 mg PO BID

Depakote 375 mg PO BID

Trazodone 100 mg PO PRN

sleep

Lorazepam 1 mg PO BID

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care)

Nursing PRIORITY:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

© 2018 Keith Rischer/www.KeithRN.com

4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

CARING/COMFORT:

How can you engage and show that this

pt. matters to you?

Physical comfort measures:

EMOTIONAL SUPPORT:

Principles to develop a therapeutic

relationship

SPIRITUAL CARE/SUPPORT:

CULTURAL CARE/SUPPORT:

(If Applicable)

5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance)

Interrelated Concepts In order of emphasisRow1:
Psychosis Clinical Judgment Patient Education:
NCLEX Client Need Categories:
Safe and Effective Care Environment:
Management of Care:
Safety and Infection Control:
Health Promotion and Maintenance:
Psychosocial Integrity:
Physiological Integrity:
Basic Care and Comfort:
Reduction of Risk Potential:
Physiological Adaptation:
RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
RELEVANT Data from Social HistoryRow1:
Clinical SignificanceRow1_2:
Current VS:
WILDA Pain Assessment 5th VS:
Words:
P 110 regular:
Patient deniesIntensity:
R 28 regular:
Patient deniesLocation:
BP 14284:
Patient deniesDuration:
O2 sat 99 room air:
Patient deniesAggravate Alleviate:
RELEVANT VS DataRow1:
Clinical SignificanceRow1_3:
Current Assessment:
Is disheveled and according to his mother he has not showered in several days:
NEURO:
RESP:
CARDIAC:
GI:
GU:
Voiding without difficulty urine clearyellow:
SKIN:
Skin integrity intact:
Denies both useabuse of ETOH or other street drugs:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_4:
Mental Status Examination:
APPEARANCE:
SPEECH:
Talking fast with pressured speech:
MOODAFFECT:
Appears ecstatic bright affect:
Delusional flight of ideas jumping from one idea to another:
THOUGHT CONTENT:
PERCEPTION:
Denies hallucinations:
COGNITION:
INTERACTION:
Denies homicidalsuicidal ideation:
RELEVANT Assessment DataRow1_2:
Clinical SignificanceRow1_5:
Basic Metabolic Panel BMPRow1:
Creat:
Current:
10:
Complete Blood Count CBCRow1:
PLTs:
Current_2:
325:
MISCRow1:
Lithium:
Current_3:
02:
RELEVANT Diagnostic DataRow1:
Clinical SignificanceRow1_6:
ProblemRow1:
Pathophysiology in OWN WordsRow1:
RationaleAdmit to unit and engage patient in milieu Urine drug screen Lithium 600 mg PO BID Depakote 375 mg PO BID Trazodone 100 mg PO PRN sleep Lorazepam 1 mg PO BID:
Expected OutcomeAdmit to unit and engage patient in milieu Urine drug screen Lithium 600 mg PO BID Depakote 375 mg PO BID Trazodone 100 mg PO PRN sleep Lorazepam 1 mg PO BID:
Nursing PRIORITY:
PRIORITY Nursing InterventionsRow1:
RationaleRow1:
Expected OutcomeRow1:
Psychosocial PRIORITIES:
RationaleCARINGCOMFORT How can you engage and show that this pt matters to you Physical comfort measures:
Expected OutcomeCARINGCOMFORT How can you engage and show that this pt matters to you Physical comfort measures:
RationaleEMOTIONAL SUPPORT Principles to develop a therapeutic relationship:
Expected OutcomeEMOTIONAL SUPPORT Principles to develop a therapeutic relationship:
RationaleSPIRITUAL CARESUPPORT:
Expected OutcomeSPIRITUAL CARESUPPORT:
RationaleCULTURAL CARESUPPORT If Applicable:
Expected OutcomeCULTURAL CARESUPPORT If Applicable:
Answer5:


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