Assign 1-WK5(A)
(1) THE ASSIGNMENT IS ATTACHED ——Captain of the Ship Project – Bipolar Disorders. (Assign 1-WK5(A)
&
(2) SEE THE ATTACHED EXAMPLE FOR “Captain of the Ship Project” FOR GUIDANCE)
Assignment: “Captain of the Ship” Project – Bipolar Disorders
Bipolar disorders are severe disorders of mood that include both depressive episodes and expansive, grandiose, or manic episodes. During these times, the person may engage in activities with little awareness of the consequences because of accompanying psychosis. A diagnosis of bipolar disorder includes periods of mania or hypomania and periods of depression where the mood is down, hopeless, and suicidal. The neurovegetative symptoms of bipolar depression can be incapacitating. It is also important to differentiate the psychosis of bipolar disorder from schizophrenia.
In this Assignment, you will become the “captain of the ship” as you provide treatment recommendations and identify medical management, community support resources, and follow-up plans for a client with a bipolar disorder.
Assignment
For this Week– you will have an opportunity to develop a ‘Captain of the Ship’ project for Bipolar Disorder. Treating bipolar disorder can be a challenge and that is why we use recent research articles and algorithms to help us decide on medication options for patients. It is very important to try to select the appropriate medication on the first go-round. Otherwise, patients become frustrated and discouraged because of the length of time that is needed to determine effectiveness. Please do not used outdated articles, so that you can choose an effective and well-tolerated medication.
Remember (1) that there is an excellent example for ‘Captain of the Ship’ project attached with this ASSIGNMENT, BUT WRITTEN ON A DIFFERENT DISORDER. (2)
Here are your instructions:
This week, you will once again become “Captain of the Ship” as you take full responsibility for a client with a bipolar disorder by presenting the assessment of the client, recommending psychopharmacologic treatment and psychotherapy, identifying medical management needs, collaborative actions, community support, and recommending follow-up plans.
Instructions:
To prepare for this Assignment
Select an adult or older adult client with a bipolar disorder that you have seen in your practicum/clinical rotation site.
In 3-4 pages, write a treatment plan for your client. In which you do the following:
· Describe the history of the present illness (HPI) and clinical impression for the client.
· Recommend psychopharmacologic treatments based on evidence-based practice and describe specific and therapeutic end points for your psychopharmacologic agent. (This should relate to HPI and clinical impression.).
· Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
· Identify medical management needs, including primary care needs, specific to this client.
· Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client.
· Recommend a plan for follow-up intensity and frequency and collaboration with other providers.
N: B. (1)The Captain of the Ship project needs to show that you are evaluating the patient, making a diagnosis, providing treatment plans and outcomes as well as collaborating with other providers. The project MUST meet all these requirements. (2) The choice of medications should be clear, and the medical management should be clear. (3) Consider using the bipolar disorder algorithm from http://www.psychiatrictimes.com/bipolar-disorder/new-psychopharmacology-algorithms
Learning Resources
Required Readings
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
· Chapter 8, “Mood Disorders” (pp. 347–386)
Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Publications.
· Chapter 13, “Acute and Maintenance Treatment of Bipolar and Related Disorders”
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
· “Bipolar and Related Disorders”
Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.
Bipolar depression
Bipolar disorder
Bipolar maintenance
Mania
amoxapine aripiprazole armodafinil asenapine bupropion carbamazepine fluoxetine iloperidone lamotrigine lithium lurasidone modafinil olanzapine olanzapine-fluoxetine combination quetiapine risperidone sertindole valproate (divalproex) ziprasidone
alprazolam (adjunct) amoxapine aripiprazole asenapine bupropion carbamazepine chlorpromazine clonazepam (adjunct) cyamemazine doxepin fluoxetine flupenthixol fluphenazine gabapentin (adjunct) haloperidol iloperidone lamotrigine levetiracetam lithium lorazepam (adjunct)
loxapine lurasidone molindone olanzapine olanzapine-fluoxetine combination oxcarbazepine paliperidone perphenazine pipothiazine quetiapine risperidone sertindole thiothixene topiramate (adjunct) trifluoperazine valproate (divalproex) ziprasidone zonisamide zotepine zuclopenthixol
aripiprazole asenapine carbamazepine iloperidone lamotrigine lithium lurasidone olanzapine olanzapine-fluoxetine combination quetiapine risperidone (injectable) sertindole valproate (divalproex) ziprasidone
alprazolam (adjunct) aripiprazole asenapine carbamazepine chlorpromazine clonazepam (adjunct) iloperidone lamotrigine levetiracetam lithium lorazepam (adjunct) lurasidone olanzapine quetiapine risperidone sertindole valproate (divalproex) ziprasidone zotepine
Marsee, K., & Gross, A. F. (2013). Bipolar disorder or something else? Current Psychiatry, 12(2), 43–49. Retrieved from http://www.mdedge.com/currentpsychiatry/article/66320/bipolar-disorder/bipolar-disorder-or-something-else
Miller, L. J., Ghadiali, N. Y., Larusso, E. M., Wahlen, K. J., Avni-Barron, O., Mittal, L., & Greene, J. A. (2015). Bipolar disorder in women. Health Care for Women International, 36(4), 475–498. doi:10.1080/07399332.2014.962138
Schouws, S. M., Comijs, H. C., Dols, A., Beekman, A. F., & Stek, M. L. (2016). Five-year follow-up of cognitive impairment in older adults with bipolar disorder. Bipolar Disorders, 18(2), 148–154. doi:10.1111/bdi.12374
Ward, I. (2017). Pharmacologic options for bipolar disorder. Clinical Advisor, 20(3), 17–25.
Required Media
Laureate Education (Producer). (2017d). A young woman with depression [Multimedia file]. Baltimore, MD: Author.
Redfield Jamison, K. (Producer). (n.d.). Assessment & psychological treatment of bipolar disorder [Video file]. Mill Valley, CA: Psychotherapy.net.
Optional Resources
Malhi, G. S., McAulay, C., Gershon, S., Gessler, D., Fritz, K., Das, P., & Outhred, T. (2016). The lithium battery: Assessing the neurocognitive profile of lithium in bipolar disorder. Bipolar Disorders, 18(2), 102–115. doi:10.1111/bdi.12375
Samalin, L., de Chazeron, I., Vieta, E., Bellivier, F., & Llorca, P. (2016). Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder. Bipolar Disorders, 18(2), 164–173. doi:10.1111/bdi.12376
Week 5 Assignment 1 Captain of the Ship
Obsessive Compulsive
SSS University
Nurs 5555: PMHNP Role II
Dr. Jack Taa
January 10, 2017
Obsessive Compulsive Disorder (OCD) is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions (Sadock, Sadock, & Ruiz, 2014). These recurring obsessions or compulsions cause severe distress to the person. An obsession is a recurrent and intrusive thought while a compulsion is a conscious, standardized, recurrent behavior. The purpose of this paper is to explore management strategies of OCD in adult clients. As the PMHNP, I will discuss a case and recommend treatment modalities, medical management, follow-up plan and collaboration in the care of a client with OCD.
History of present illness (HPI) and Clinical Impression
HPI: K. K. a 22 yo CF referred for a psychiatric evaluation by her PCP. Karen reports a complaint of “I need help, I can’t keep a job because of these rituals I have.” She reports that she cannot maintain a job because of her rituals of checking locks. Karen has recurrent thoughts that she had left the door of her apartment and car unlocked. She reports leaving work several times daily to check the locks on both her car and apartment. Additionally, because she often had the thought that she had not locked the door to the car, it was difficult for her to leave the car or apartment until she had repeatedly checked that it was secured causing her to be late for work. She has been fired several times for tardiness and poor attendance however checking the locks decreases her anxiety about security. Karen denies any medical issues and is not currently taking any medications. She also denies the use of any alcohol, tobacco or illicit drugs. Reports a family history of depression in both maternal and paternal grandmothers. Karen recognizes that she is needs help and is eager to begin treatment.
Assessment: A healthy, well-groomed 22yo CF in no acute distress. A, A&Ox4, pleasant and appropriately dressed. Makes good eye contact however mood is depressed with a flat affect; recent and remoter memory are intact. Karen’s thoughts are circumstantial and preoccupied with obsessions and compulsions. Her insight and judgment are fair. Denies SI/HI/AVH.
Clinical Impression: Based on the diagnostic criteria in APA (2013), a diagnosis of OCD is made.
Psychopharmacology
If the patient’s symptoms cause a significant impairment in function or distress, treatment is recommended (Fenske and Petersen, 2015). Based on Karen’s report of losing several jobs because of tardiness and attendance, there is a significant impairment in social and home functionality. Karen also reports that her rituals cause her significant distress. The standard approach is to start treatment with an SSRI or clomipramine and then move to other pharmacological strategies if the SSRI is not effective (Sadock, Sadock, & Ruiz, 2014). I will initiate Prozac 40mg oral daily as it is Food and Drug Administration (FDA) approved for treatment of OCD (Stahl, 2014). I will have the patient return to clinic in week to assess for tolerability and increase to the suggested 80mg oral daily. Higher dosages have often been necessary for a beneficial effect (Stahl, 2014). I prefer to initiate with an SSRI (Prozac) as opposed to tricyclic (Clomipramine) for the less troubling adverse effects associated with Clomipramine. Karen will be informed that she might experience sleep disturbances, nausea, diarrhea, headache and anxiety which are all adverse effects of SSRIs. The desired outcome of pharmacotherapy is to reduce the patient’s intrusive thoughts that cause the compulsions that interfere with her home and work life. Well controlled studies have found that pharmacotherapy, behavior therapy, or combination of both is effective in significantly reducing the symptoms of patients with OCD (Fenske and Petersen, 2015).
Psychotherapy
Some studies indicate that behavior therapy is as effective as pharmacotherapies in OCD and some indicate that the beneficial effects are longer lasting with behavior therapy (Sadock, Sadock, & Ruiz, 2014). Many clinicians consider behavior therapy the treatment of choice for OCD and also because it can be conducted in both outpatient and inpatient settings. With the prinicpal behavioral approaches being exposure and response prevention, patients must be committed to improvement as Karen is. Behavior therapy will be initiated the same week as pharmacotherapy. The goal of therapy is to change the client’s behavior to reduce dysfunction and to improve her quality of life. A psychotherapist will be consulted to intiate and manage therapy sessions.
Medical Management
I will consult with Karen’s PCP for updates and additional concerns. Since she has been with her PCP for more than 5 years, he has good insight into her life. We will discuss baseline labs such as CBC, CMP, TSH, hepatic panel. Since with SSRIs, nausea, headache dry mouth and diarrhea are common side effects, monitoring the patient’s electrolytes is important. I would also recommend an EKG for baseline and follow up after medication initiation as SSRIs can lengthen the OT interval in otherwise health people (Sadock, Sadock, & Ruiz, 2014). Community resources such as the local chapter of the OCD Foundation will be provided to Karen for support services.
Follow -up Plan and Collaboration
Karen was instructed to follow up in 1 week to monitor tolerability and compliance of medicaiton and dose adjustment. Subsequently, she will return every 4 weeks for medication management. She is also instructed to begin behavior therapy the same week as medication are initiated and to follow up weekly for therapy sessions. I will consult with the therapist weekly for updates and any concerns or questions. I will reiterate and reinforce to both the PCP and therapist the importance of monitoring for suicidal ideations as the patient is taking an antidepressant and abuptly stopping will increase risk of suicide. About one-third of patients with OCD have major depressive disorder, and suicide is a risk for all patients with OCD (Sadock, Sadock, & Ruiz, 2014).
Conclusion
A poor prognosis is indicated by Karen yielding to rather than resisting compulsion or the need for hospitalization. A good prognosis for Karen is indicated by good home, social and occupational adjustment. The importance of an interdisciplinary team including PCP, therapist and other ancillaries will benefit the client for a better quality of life.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Fenske, N. & Petersen, K. (2015). Obsessive-Compulsive Disorder: Diagnosis and Management. American Family Physician, 92(10): 896-903. Retrieved from http://www.aafp.org.afp
/2015/1115/p896.html
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer
Stahl, S.M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.
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