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. 

 

Review the case study and answer all questions with a scholarly response using APA and include 2 scholarly references, per case. Answer both case studies on the same document.

Case Studies will be put through TURN-It-In (anti-Plagiarism program) 

Turn it in Score must be less than 15% or will not be accepted for credit, must be your own work and in your own words.  Please see College Handbook with reference to Academic Misconduct Statement.

Jonise Flynn 

Strengths Revealed from Gallup Assessment

Leaders are known to possess a variety of characteristics that motivate followers to work towards a common goal. My results from the Gallup test revealed that my leadership strengths are achiever, competition, input, learner, and restorative. It is essential as a leader to recognize your strengths and weaknesses to guide others towards positive outcomes. Gallup (2020) describes an achiever as someone who works beyond the requirements. An achiever spends more time working on a goal than any other task (Gallup, 2020). The strength of competition drives a person to always want to be the best at whatever job (Gallup, 2020). Competitors are always comparing themselves to others to gain insight on how to be ahead of their competitors (Gallup, 2020). The strength of input arouses curiosity and inquisition. A person with the strength of input is always inquisitive about innovative events and seeking new information (Gallup, 2020). The strength of input refers to those persons who are knowledge seekers (Gallup, 2020). Much like input, the learner also has a strong sense of curiosity. The learner wants to be continuously taught and gather new ideas to expand current expertise (Gallup, 2020). Finally, the restorative strength is reserved for persons who seek perfection and are continuously reviewing ideas and avenues to reach a high-level goal (Gallup,2020). Overall, the described strengths each contribute to leadership characteristics.

Strengthening Core Values

The assessment not only reveals strengths but also shows my underlying weaknesses. I need to strengthen a few core values or beliefs after reviewing my assessment results. Oh et al. (2018) informs us that maintaining core values in leadership inspires subordinates to have a more incredible passion for their work, set higher standards, and work towards organizational goals. When core values are aligned to meet the organization’s needs, job satisfaction occurs (Oh et al., 2018). Marshall & Brome (2017) states that having defined beliefs “models the way” for others, articulating the significance of everyone’s participation in organizational goals(p.120). One core value that I need to strengthen based on my results is self-confidence. The strength of competition fuels my efforts to compare to others and want to do better continually. With competition, however, also comes self-doubt. I need to look less at what others are doing and ensure myself that I am making the right decisions for the organization. Strengthening my self-confidence also inspires others to trust me to be a confident, reliable leader.

Another core value that I need to evaluate is communication. An effective leader needs o to be able to commend others on their achievements and offer constructive criticism. There are staff members that have been on the unit longer than I have, and sometimes I find it hard to communicate criticism efficiently due to the feeling of not wanting to offend anyone. As a leader, I need to work on ways to communicate both successes and failures to the staff so that they are cognizant of their need for improvement. Communicating and helping staff understand where they could accelerate contributes to the success of the organization.

Improving my Strengths

My two strengths that need to be improved as a developing leader are learner and restorative. As a learner, I always want to acquire new knowledge. I’m always looking for an opportunity to understand how to run the unit better, care for specific patient populations, and much more successfully. My strength in restorative is what drives my strength in the learner area. My strength of restorative urges me to seek daily improvements, which triggers my learner curiosity. Using my restorative strength, I strive to improve on how we deliver patient care daily and how the team interacts to meet organizational needs. With both my strengths, to improve, I need to look for more learning and restorative opportunities. Instead of being consumed by nursing tasks, I should incorporate periods of learning and evaluation for restoration. These two strengths are sometimes overshadowed by workloads that, as a leader, I forget to use those strengths to better the organization.

Strengthening My Characteristics

One characteristic that I need to strengthen is in agreeableness. States that due to the amount of time nurses spend connecting with interdisciplinary persons, agreeableness is a characteristic that is necessary for quality patient care. With the workloads, all departments can become frustrated, and sometimes we take the discontent out on each other. Working on being more agreeable can significantly improve patient care and influence how followers also interact with other departments. 

Another characteristic that I would like to work on is emotional stability. Results from a study show that emotional instability is high in the nursing profession due to burnout and job dissatisfaction. As a leader, I must work on my emotional stability to model behaviors for others. There are times when the work gets overwhelming, and I find myself complaining out loud. When I feel emotionally overwhelmed, I need to focus on maintaining emotional stability because it influences how others portray the work environment. The only way to keep a positive environment is to set the tone as a great leader.

In conclusion, although the assessment revealed many of my strengths, weaknesses also exist. There are many aspects of becoming a leader that I need to focus on and further develop. Core values, current strengths, and characteristics are all essential areas of self-development that improve patient experience and those of organizational members. 

References

Çakıroğlu, O. Ç., & Harmancı Seren, A. K. (2019). The relationship between attitudes towards change and five factor personality traits in nurses. Journal of Psychiatric Nursing/Psikiyatri Hemsireleri Dernegi, 10(3).https://doi.org/10.14744/phd.2019.34713

Gallup. (2020).Jonise Flynn: Strengths insight guide. Retrieved on September 30, 2020, from https://gx.gallup.com/services/pdf?v=pdfGeneration.prince.7.0.binPath

Marshall, E., & Broome, M. (2017). Transformational leadership in nursing: From expert clinician to influential leader (2nd ed.). New York, NY: Springer.

Oh, J., Cho, D., & Lim, D. H. (2018). Authentic leadership and work engagement: the mediating effect of practicing core values. Leadership & Organization Development Journal.https://doi.org/10.1108/LODJ-02-2016-0030

Anita Herrera 

Description of the Assessment

            This writer has completed the StrengthsFinder assessment which resulted in the following characteristics: Input, Positivity, Responsibility, Futuristic and Learner. The Input attribute is summarized as having the zeal to collect enough insight to thoughtfully examine an abstract concept, theory, or idea. The Positivity attribute is descriptive as generous with praise, quick to smile and always on the lookout for the positive in situations surrounding this writer. Responsibility is characterized by the taking psychological ownership for anything this writer commits to, and whether large or small, feels emotionally bound to follow it through to completion. Being a Futuristic is described as the kind of person who loves to peer over the horizon, fascinated about the future and sees in detail what the future might hold, which helps pulls this writer forward, into tomorrow. The final strength identified was Learner. This described the writer as someone who is very much interested and determined to learn new things and drawn to the process of learning. The process, more than the content or the results is especially exciting to this writer (Gallup, Inc., 2020).

Core Values

            The information the StrengthsFinder Assessment generated is interesting. It helps an individual to keep grounded and provide perspective. It also helps to manage the direction in life and work as a leader. Two core values that were identified were Honesty and Confidence. Honesty should be the bedrock of an individual’s foundation, as it will define who a person is before others can know more. If things are dealt with in truth, it allows individuals to live a life with far less worry. Analytical minds can be used to think of new ideas, rather than lies and excuses. Honest intentions in speech and action gain the attention and respect of others. Honesty promotes openness, empowers us and enables us to develop consistency in how we present the facts. Honesty sharpens our perception and allows us to observe everything around us with clarity. Honesty in the workplace is key to building a strong team that trusts each other. To build integrity and a good reputation among coworkers, it is important to always keep your word when you say you are going to do something. When mistakes are made, take responsibility for them. Be transparent in everything said or done. Also respect confidential information, whether business-related or personal.

            A major component of confidence is the value a person place on him/herself. Confidence is about the faith you have in your abilities, the person you are, and how you view your most important relationship. With confidence, one can rise to the top of their profession. It keeps one balanced and grounded. It is a powerful value that gives so much definition to the core of who we are. Confidence gives us the strength to pursue our dreams. It psyches us up to get the job or opportunity we have prepared and dreamed about (Scully, 2015).

Strengths Identified

            There are two personal strengths this writer identified from the StrengthsFinder assessment. The first strength is the ability to learn new skills. Knowing how to actively grow and develop a skill is a skill itself, and if you understand how the principles of learning work, it will be easier to learn any new skill in the future. It is therefore worth putting some effort into understanding the benefits of not staying away from new skills. This writer has never been afraid to learn new procedures introduced at the place of work. New ideas are greatly appreciated and embraced no matter how big or small. It is important to learn new things especially, new technologies since the world is currently evolving around technology. New software use at work might be challenging, but this writer endeavors to delve into it and make it easier for others to learn, without being intimidated. My willingness to soak up with newness calm others fears and spur them into action (Gallup, Inc., 2020).

            The second strength identified is being positive about everything. People exceptionally talented in the positivity theme have contagious enthusiasm. This writer brings enthusiasm to people, group and place of work. Stimulating my team to be more productive and hopeful at work is what this writer is best known for. When colleagues complain about a task that needs to be finished within a timeframe, this writer tries to make it fun for everyone to feel energized from start to finish. Even if it is not going on well as planned, because they most of the times rely on this writer to help them rise above frustrations, energy will be focused on good things that have been previously achieved to see the need to take it to the next level. This writer can deliberately help others see the things that are going well for them and keep their eyes on the positive.

Areas for Improvement

            Out of the four domains of team strengths from the StrengthsFinder Assessment: Executing, Influencing, Relationship Building and Strategic Thinking, this writer needs to improve on the Influencing aspect. The ability to influence is an essential leadership skill. To influence is to have an impact on the behaviors, attitudes, opinions and choices of others. Influence is not to be confused with power or control. It is not about manipulating others to get your way.

            The first characteristic to improve on is communication. Being able to communicate as a leader is vital. That means it does not matter what the issue is, it must be communicated for everyone to be on the same page. Communication skills are abilities this writer needs to use when giving and receiving different kinds of information. Some examples include communicating ideas, feelings or what is happening. Communication skills involve listening, speaking, observing and empathizing. This writer needs to improve on how information is given across to bring the best out of situations. Communication skills are needed to speak appropriately with a wide variety of people whilst maintaining good eye contact, demonstrate a varied vocabulary and tailor your language to your audience, listen effectively, present ideas appropriately, write clearly and concisely, and work well in a group.

            The second characteristic that needs to be worked on Self Assurance. This is described as the ability to take risks and manage one’s own life. Individuals with this characteristic have an inner compass that gives them certainty in their decisions. People with the strength of Self-Assurance have great faith in their own strengths. They are confident in their abilities and their judgments. They know they are unique, and this gives them confidence to face challenging situations. This writer needs to have this characteristic to believe in the abilities and capacities and know I can deliver exactly what is needed (Khalil, 2016). People who have Self Assurance behave as if they have an inner compass pointing them in the right direction, and they believe this right direction is right. They might act right even when they are not. This confidence impacts people, it increases their belief and confidence in themselves. This writer needs to master self-assurance characters so that confidence in others does not intimidate, but to encourage to be even more confident.

References

Gallup, Inc. (2020). Your Signature Theme Report.

Khalil, R. (2016). Influence of extroversion and introversion on decision making ability. International Journal of Research in Medical Sciences, 4(5), 1534-1538. http://dx.doi.org/10.18203/2320-6012.ijrms20161224

Laureate Education. (Producer). (2018). The leader in you [Video webcast]. Retrieved from https://class.waldenu.edu/bbcwebdav/institution/USW1/202030_27/MS_NURS/NURS6053_module03.html?course_uid

Marshall, E., & Broome, M. (2017). Transformational leadership in nursing: From expert clinician to influential leader (2nd. ed.). New York, NY: Springer

Scully, N. J. (2015). Leadership in nursing: The importance of recognizing inherent values and attributes to secure a positive future for the profession. Collegian, 22(4), 439-444. 

3 sources for each response

All articles that I access, for any purpose, are evidence-based, peer reviewed literature. I usually obtain literature from the university library, but I have used CINAHL previously. I used the Chamberlain University Library for this assignment, which took me to ProQuest. Both articles I accessed were published in nursing literature related to my topic of concern.

The problem I identified just yesterday was that out of 58 students in my Pharmacology class, 6 of these students evidently had issues with how to use the Publication Manual of the American Psychological Association [APA] (use of quotation marks, citations, and references [also, using WebMD and WebEx] and they don’t know how to properly develop the reference list). I don’t think there was intentional plagiarism by a few students, but I looked for articles on how to help students with this kind of work. Again, for this literature search I utilized the Chamberlain Library and clicked on the “search articles” header, and from their I went straight to ProQuest Nursing. From there, I used the advanced search putting in key words: nursing students and APA, followed by checking the Peer Review box. Although I found 479 results, there is a dearth in more current literature that specifically addresses APA formatting in writing (McGuire, Gerber, Elgsti, & Currin, 2001), where the 4th edition of the APA manual was used as a reference. When I narrowed the date of publication down to 2010 to 2019, I found 279 results that were all over the map (279 results), and I found few that were focused on APA usage by nursing students.

I was able to locate one current article that was published in Nursing Open by authors at two Canadian schools of nursing. The authors identified the purpose: “To explore self-efficacy among first-year nursing students in the context of disciple-specific writing” (Mitchell, Harrington & McMillan, 2017, p. 240). The design was identified as a quasi-experimental study, and the methods used were data collection before and after a writing course was completed by nursing students during orientation (Mitchell et al.). The researchers described participants as 132 Baccalaureate nursing students that were spilt into 3 groups: full study participants that received the course and were tested pre- and post-course; experiment only group that did not receive the course but had both the pre- and post-test; and, a control group that had a pre- and post-test within a specific timeframe. The study was noted to have ethical (IRB) approval, and the authors also described the course with sources identified and these, in my opinion, seemed sound based on the topics and were taken from credible literature including the Journal of Nursing Education, Journal on Excellence in College Teaching, Nurse Education in Practice, Quality Advancement in Nursing Education, and others. The authors reviewed and discussed relevant literature review in the article as well. The authors used citations, references, and tables to substantiate the findings of the study. Study limitations were clearly identified as well as suggestions for further research.

The Self-Efficacy Scale for Academic Writing (SESAW) was created by Mitchell using a 4-point Likert Scale for 10 questions in the test. They also used the STAI (State Trait of Anxiety Inventory) tool by Spielberger (as cited by Mitchell et al.). A “One-way Analysis of Variance (ANOVA)” (Mitchell, et al., p. 243) was used by the authors for statistical significance. Pearson’s r calculations were used for statistical analysis as well as independent t tests. Results of the study findings are indicated by Mitchell et al., are as follows:

1. An improvement in APA usage and grammar over time

2. Correlations between anxiety trait and SESAW identified

3. Students that entered nursing school directly from high school did not do as well as others who had more academic experience

4. English as Second Language students showed no difference in performance

In the final conclusions, Mitchell et al., noted that the study indicates: “discipline-specific

writing instruction can influence writing self-efficacy in first year nursing students.” (p. 249).

              I plan to share this article with Chamberlain University leadership in hopes that we could have something like this for all our students and before they start their nursing courses (perhaps during orientation?). Moreover, I really wish I could focus my DNP project on just such a topic, but I don’t suppose it’s clinical enough. I look forward to hearing your thoughts and suggestions as well, even on my reference of an article without a DOI that I struggled with (see below).

References

McGuire, S.L., Gerber, D.E., & Currin, M.D. (2001). Helping students use APA format. Journal of

Nursing Education, 40(9), 414-416. URL: https://chamberlainuniversity.idm.oclc.org/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdocview%2F203935573%3Faccountid%3D147674 (Links to an external site.) accessed on 29 Sept 2020.

Mitchell K.M., Harrigan T. & McMillan, D.E. (2017). Writing self‐efficacy in nursing students: The

influence of a discipline‐specific writing environment. Nursing Open, 4(4), 240-50.

DOI:10.1002/nop2.90 accessed 29 Sept 2020.

I NEED A COMMENT FOR THIS POST WITH AT LEAST TWO PARAGRAPH AND TWO SOURCES NO LATER THAN FIVE YEARS