ST.

PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

A.Y. 1st SEMESTER 2020-2021

Mary Rose S. Gargar
BSN-IV

CASE A

You are working the day shift on a medicine inpatient unit. You are discussing discharge
instructions with J.B., an 86-year-old man who was admitted for mitral valve repair. His serum
blood glucose had been averaging 250 mg/dL or higher for the past several months. During this
admission, his dosage of insulin was adjusted, and he was given additional education in managing
his diet. While you are giving these instructions, J.B. tells you his wife died 9 months ago. He
becomes tearful when telling you about that loss and the loneliness he has been feeling. He tells
you he just doesn't feel good lately, feels sad much of the time, and hasn't been involved in his
normal activities. He has few friends left in the community because most of them have passed
away. He has a daughter in town, but she is busy with her work and grandchildren. He also tells
you that he has been feeling so down the past few months that he has had thoughts about suicide.

1. What other information should you ask J.B. regarding his thoughts of suicide?
 Mr. J.B do you have a plan to harm yourself?
 If so what is your plan and is this plan specific?
 Do you have the resources to conduct this plan?
 When and where was the last time you premeditated to activate this plan?
 Have you ever attempted suicide before?
 Has any relatives committed suicide before?
 Are you on any new medications?
 Have you made provisions for your death?

2. What characteristics of J.B. put him at high risk for suicide?

 The things that put Mr. J.B at high risk for suicide is the fact that he lost his wife, his age,
the lack of a strong support system, his seclusion, his health status as a diabetic and the
fact that he’s thinking of suicide.
 The highest suicide rate among males is in those aged 75 years or older.
 Depression often occurs with chronic illnesses, such as diabetes mellitus, cardiovascular
disease, stroke, and cancer.
 Loneliness or social isolation are risk factors, and he has had a recent loss.

3. Which psychiatric disorders can result in suicidal ideations or gestures?

 Anxiety Disorder
 Borderline and Antisocial Personality Disorder
 Dysthymic Disorder
 Major Depressive & Bipolar
 Schizophrenia
 Panic Disorder
 Substance abuse (alcoholism, addicts, etc.)

4. What questions would you ask J.B. to determine whether he is clinically depressed?
 ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

A.Y. 1st SEMESTER 2020-2021

 On a scale from 0-10, with 0 being minor and 10 being the most severe, how severe has
these thoughts been?
 How long have you been feeling that way?
 Have you had any difficulties concentrating lately?
 Are you having difficulties performing any of your daily activities?
 Have you lost interest in the activities that you loved before?
 What do you do when you start to feel this way?
 Can you tell me of any recent changes to your appetite? Did you have any recent weight
loss or gain?
 Can you describe your pattern and the amount of sleep you get daily?

5. Ill people often have trouble sleeping, experience a change in appetite, reduce their level of
activity, and have thoughts of death. How can you tell the difference between old age with illness
and depression?
 Whereas as the elderly may have difficulties with their sleep and appetite changes in
regards to the normal aging cycle, which as a result decreases their activity associated
with their illness, they do not perceive themselves in a depressing way and want to
cause harm or death to themselves.

6. List five of the most common signs of depression.

 Persistent sad mood
 Loss of interest in activities that were once pleasurable
 Insomnia or hypersomnia
 A significant change in appetite with weight loss or weight gain
 Loss of energy
 Difficulty with concentration
 Feelings of worthlessness or guilt
 Thoughts of death or suicide
 Isolating oneself from others

You use the SAD PERSONS scale to assess J.B.'s potential for suicide and find that he is at a 4 on the 10-
point scale. You are concerned about his statements.

7. What immediate interventions would you carry out for J.B.?

You decide to notify J.B.'s physician about your findings. The attending physician calls in a
psychiatrist to evaluate J.B.
 Sustaining a safe environment for J.B. is my first priority. This includes frequently
assessing his capability for suicide. In addition, I would remove all potentially harmful
objects like sharp objects, knives, belts, ties etc. from the room.

8. Identify two treatments that are available for depression.

 Individual Psychotherapy
 Antidepressants

9. Would J.B. be a candidate for electroconvulsive therapy (ECT)? Why or why not?
 ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

A.Y. 1st SEMESTER 2020-2021

 Mr. J.B has never had treatment for depression before so he hasn’t failed any other
treatment; in addition, the fact that he has cardiac problems is a big contraindication
when it comes to ECT. Therefore, Mr. J.B is not a good candidate for ECT.

The psychiatrist on call comes in to evaluate J.B. After meeting with J.B., the psychiatrist writes an order
for escitalopram (Lexapro) 10 mg daily at bedtime. J.B. is scheduled to see the psychiatrist the day after
he is discharged from the hospital.

10. What special instructions will you give him regarding the Lexapro? (Select all that apply.)
a. The full effects of the medication might not be seen for 4 to 6 weeks.
b. The medication may cause nausea, dry mouth, sedation, and insomnia.
c. There are no known food interactions.
d. The herbal product, St. John's wort, will enhance the action of the Lexapro.
e. Taking a glass of wine at bedtime will help him go to sleep.

11. Why do you think that a drug in the SSRI class was chosen over a tricyclic antidepressant or a
monoamine oxidase inhibitor (MAOI)?
 SRIs have fewer side effects compared to TCAs and MAOIs. Besides MAOIs and TCAs
having an increased sedation effect which would escalate the patient’s fall risk; the use
of TCA the elderly and in patients with a heart condition is a big contraindication
because they cause postural hypotension, and diet could be difficult due to avoidance of
tyramine containing foods. Whereas, MAOIs can cause hypertensive crises and since Mr.
J.B he has a mitral valve problem SSRIs are the best choice at this time.

J.B.'s daughter visits him in the hospital, and they have a long talk. She is shocked when she realizes that
her father is lonely to the point of considering suicide and tells you that she will do all she can to help him
when he goes home.

12. What important information needs to be conveyed to J.B.'s daughter about the first few weeks of
therapy with the SSRI?
 I would inform Mr. J.B’s daughter should inform the physician of commonly used OTC
drugs, as there is potential for drug interaction. In addition, that it takes a few weeks for
the medication to reach its therapeutic level and that she should encourage him to
adhere to the medication regimen. Also, she should encourage him to avoid using
alcohol while taking this medication. In addition, she should report any observation of
worsening depression or the emergence of suicide. This medication shouldn’t be
stopped abruptly because this medication should be tapered down. Moreover, she
should follow up with the doctor as scheduled to monitor the effects of this medication
and its progress.

CASE B
 ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

A.Y. 1st SEMESTER 2020-2021

You are the RN case manager in an outpatient mental health clinic. S.T. is here today for her
outpatient mental health appointment. She has a diagnosis of bipolar disorder and has been stable
for the past 3 years. Her last episode was one of mania that required hospitalization. She is 29
years old, married, with two children ages 2 and 4. She reports that her mood is better than it has
been in a long time and she has lots of energy. When asked whether she thinks this is a recurrence
of mania, she says no, she thinks that things are just finally getting better.

1. It is common for patients with bipolar illness to deny the onset of mania because it feels good.
What other information would be important to ask S.T.?
 How many hours of sleep is gets each night?
 Does she experience racing thoughts?
 If she had any hobbies that she is actively involved in currently
 Has she received any comments from other people regarding her behavior?

2. What other information would help determine whether S.T. is experiencing the onset of a manic
or hypomanic episode?
 With observing HIPPA, speak with S.T.’s husband for possible collaborating information.
In accordance with HIPAA laws, the husband may provide information only if he is
present during the interview or by requesting permission from S.T. to talk to her
husband regarding her care. It is advisable to reference any facility policy, state laws,
health advocacy laws, power of attorney laws and durable power of attorney laws.
 Assess other clues such as nonverbal communication, body language and eye
movements.
 Ask S.T. to keep a 24-hour food diary.

3. Bipolar disorder is a disorder of mood, characterized by episodes of depression, mania, or

hypomania. What symptoms might you see if S.T. is experiencing mania or hypomania?
 Inflated self-esteem or delusions of grandeur (belief that they have special powers or
abilities) i.e. being the Queen of Sylvania.
 Diminished sleep requirements
 More animated than normal for her
 Stress to continue talking
 Racing thoughts or flighty ideas displaying inability to maintain a single train of thought
 Easily confused
 Intensification in goal-directed activity
 Tension
 Extreme participation in enjoyable events that may potentially lead to painful penalties

4. How is hypomania different from mania?

 Mania symptoms affect significant deficiency in social or professional operating.
 Mania may necessitate hospitalization to guard the patients from harm to themselves or
others.
 Manic symptoms usually last approximately a week.
 ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

A.Y. 1st SEMESTER 2020-2021

 Hypomanic symptoms endure about four days.
 The hypomanic episode accompanies a change in behavior that usually is atypical of a
person and is obvious to others.
 It is unusual for hypomanic symptoms to cause significant deficiency in social or
occupational activities.
 Hospitalization is not necessary in hypomanic symptoms nor do the symptoms include
psychosis.

Lithium (Eskalith) is commonly used to treat bipolar disorder. S.T. has been taking lithium for several
years.

5. When S.T. first started taking lithium, she would have been cautioned to report side effects.
Which are common side effects of lithium? (Select all that apply.)

a. Thirst
b. Nausea
c. Constipation
d. Tremor
e. Dizziness

6. Lithium toxicity can occur in patients taking lithium. What are the symptoms of lithium toxicity?
(Select all that apply.)
a. Vomiting
b. Insomnia
c. Dyspnea
d. Diarrhea
e. Confusion

7. S.T.'s maintenance lithium level results are reported as 1.0 mEq/L. Interpret these results.
 These levels are within therapeutic levels. Not action required in relation to the levels.

8. What other laboratory examinations should be routinely drawn while S.T. is taking lithium?
 Lithium level
 Thyroid function tests
 Creatinine
 UA

9. What instructions should have been given to S.T. when she began lithium therapy?
 Importance of maintaining adequate hydration at all times; especially when perspiring
heavily or with loss of fluids due to vomiting or diarrhea.
 Know the symptoms of toxicity. Hold the next dose of lithium and notify the HCP
immediately if symptoms of toxicity occur.

10. Aside from lithium, what other medications are used to treat bipolar disorder?
 ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

A.Y. 1st SEMESTER 2020-2021

 Bipolar disorder may also get prescriptions of Antiseizure medications. These include
divalproex (Depakote) and carbamazepine (Tegretol). When using these medications, it
is necessary to monitor blood level. Divalproex requires monitoring of liver enzymes.
Carbamazepine requires routine CBC monitoring.
 The FDA has also approved two of the atypical antipsychotics drugs, quetiapine
(Seroquel) and olanzapine (Zyprexa), for treating bipolar disorder

11. Given her history of bipolar disorder, what should you teach S.T. to minimize mood swings?
S.T. is told that her lithium level is within normal limits, and states, “I feel better than I've felt in
ages!” She expresses hope that this will last a long time.
 Avoid any triggers of stress she knows she has.
 Maintain regular schedule for sleep and exercise.
 Eat a healthy diet.
 Avoid excessive caffeine intake.
 Take medications consistently.