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SOAPIE # ___1__
Student Name:
Elsa Strickland, Kim Stoessel, and Allison Woolf
Initials:
N
Unit/Room#
Age: 32
Admission Date:
Admitting Dx: Bipolar Mania
Gender: Female
Axis I: Bipolar Mania- characterized in
our book as mood swings from
profound depression to extreme
euphoria, with intervening periods of
normalcy. Some of the symptoms
associated with bipolar mania are
euphoric/expansive mood followed by
irritable mood, sometimes over trivial
manners. Also includes grandiosity,
decreased need for sleep, pressured
speech, racing thoughts,
distractibility, and increase in goal
oriented activity. This pts symptoms
are that she is sleeping very little and
she spent 1,000 dollars on clothes
and threw a party. She went home
from her party with a man she barely
knew. She was found in a football
stadium wearing little to no clothing
and talking to herself very rapidly.
When being interviewed, she jumps
from one topic to the next and
cusses. She claims that she is
working undercover at the hospital to
identify AIDS pts. She doesnt eat
full meals because she is unable to sit
still for extended periods of time.
Axis II: The pt fits the diagnosis of
Bipolar Mania due to her grandiosity
in spending money and partying. She
is often found to be irritable, cussing
at staff. She speaks rapidly, probably
due to the fact she has rapid
thoughts. She exhibits symptoms of
a psychosis state in that she believes
she is a undercover worker trying to
identify AIDS patients.
Date: 9/21/16
Medications:
Lithium Carbonate: 300mg tid
Lorazepam: 1mg PO tid
Haloperidol Lactate: 5mg IM q4hr
Ibuprofen: 400mg PO q6hr PRN
Magnesium Hydroxide: 400 mg/5 mL PO qhs
Benztropine Mesylate: 2mg PO tid PRN
Acetaminophen: 325-650 mg PO q4-6hr PRN
Discharge Plan:
Make sure she has an address to go home to,
indicate support people, set up appointments after
discharge and make sure she can go
Psycho-Social History:
Pt did well in college and graduated at 26 with an MBA. Since
then, she has worked in the administration dept of a large
corporation and has received many promotions. She has
always been described as moody. She is the 2nd child of 3. Her
father is an alcoholic diagnosed with bipolar disorder. Due to
this, he receives disability benefits. Her mother suffers from
depression and anxiety. She was married for about 1 year at
the age of 27. Currently lives alone and has been dating a man
for 2 years. She drinks only on special occasions and smokes
cigarettes when she drinks. She uses marijuana 2-3 times per
year. Her boyfriend is her primary support person. He states
that she turns to Adderall with a heavy work load and suspects
that she has been using it recently during the promotion
process.
General Diet:
Is not able to sit still long enough to eat an entire meal. Had a
bite or two of a sandwich that she was given upon admission.
Current Stressors:
Pt upset after not getting expected
promotion. Unable to talk about
marriage without getting angry.
Dose/route/sch
edule
Actual &
Recommended
Actual: 300 mg
PO tid
Recommended:
150- 450 mg PO /
dose
Class: Antimanic
Available
Routes of
Administration:
Oral
Name:
Lorazepam
(Ativan,
Lorazepam
Intensol)
Class:
Antianxiety,
Benzodiazepine
Actual: 1 mg PO
tid
Recommended:
0.5-2 mg PO /
dose
Available
Routes of
Administration:
IM, IV, Oral
MOA
Alters sodium
transport in
nerve and muscle
cells resulting in
intrneural
metabolism of
catecholamine.
Specific MOA
unknown.
Binds highly to
gammaaminobutyric
acid (GABA)benzodiazepine
receptor complex
without
displacing GABA.
Drug binds to its
attachment site
to improve
GABAs attraction
to its own
receptor site on
the GABAbenzodiazapine
receptor
complex. Exerts a
tranquilizing
actions on the
central nervous
Patient is expected to
demonstrate a reduction in
mania.
Patient is expected to
demonstrate a reduction in
anxiety associated with
diagnosis of bipolar disorder.
Nursing Implications
Actual: 5 mg IM
q4h
Recommended:
0.5- 20 mg PO /
dose
Available
Routes of
Administration:
Oral
Name: Ibuprofen
(Advil, Motrin, AG Profen,
Addaprin, Bufen,
Genpril, Caldolor,
Haltran)
Actual: 400 mg
PO q6h
Class: Analgesic,
NSAID, Propionic
Acid
Available
Routes of
Administration:
IV, Oral
Name:
Magnesium
Hydroxide
(Phillips Milk of
Magnesia,
Dulcolax Milk of
Magnesia, QC
Milk of Magnesia)
Actual: 400
mg/5 mL PO qhs
Class:
MagnesiumContaining
Antacid, Laxative
Available
Routes of
Administration:
Oral
Recommended:
200-800 mg PO /
dose
Recommended:
400 mg/5 mL PO,
800 mg/5 mL PO,
8 tablets/day PO /
dose
system.
Produces a
selective effect
on the central
nervous system
by competitive
blockade of
postsynaptic
dopamine (D2)
receptors in the
mesolimbic
dopaminergic
system and an
increased
turnover of brain
dopamine to
produce its
tranquilizing
effects.
A Non-steroidal
anti-anflamitory
drug that exibits
analgesic and
antipyretic
activities by
inhibiting
prostaglandin
synthesis.
Patient is on Benztropine
Mesylate and Lithium
Carbonate, which may cause
headaches and Lithium
Carbonate, Haloperidol, and
enztropine Mesylate, which
may cause fever.
Patient is on Lithium
Carbonate, Benztropine
Mesylate, and Lorazepam,
Haloperidol, which may
cause constipation.
Patient is expected to
experience a reduction in
fever in headaches.
Hypotension, constipation,
xerostomia, akathisia,
dystonia, extrapyramidal
disease, somnolence, blurred
vision, prolonged QT interval,
sudden cardiac death,
torsades de pointes, paralytic
ileus, agranulocytosis,
neuroleptic malignant
syndrome, seizure, tardive
dyskinesia, priapism
Hypermagnesemia
Patient Is expected to
experience a reduction in
constipation and pass stool
more easily.
Name:
Acetaminophen
(Tylenol,
Ganapap,
Feverall, Actamin
Maximum
Strength, Altenol,
Aminofen,
Ofirnev, Anacin
Aspirin Free)
Class: Analgesic,
Antipyretic
Actual: 2 mg PO
tid
Recommended:
0.5-2 mg PO /
dose
Available
Routes of
Administration:
IM, IV, Oral
Actual: 325-650
mg po q4-6h prn
Recommended:
80-1,000 mg po /
dose (do not
exceed 4,000
mg/24h)
Synthetic drug
with similar
structural
features found in
atropine and
diphenhydramine
. Anticholinergic
activity of the
drig is utilized in
treatment of
parkinsonism.
Patient is on Haloperidol,
which can result in
Parkinsonian side effects.
MOA unknown
but may be due
to an inhibition of
central
prostaglandin
synthesis and an
elevation of the
pain threshold.
Patient is on Benztropine
Mesylate and Lithium
Carbonate, which may cause
headaches.
Patient is expected to
experience a reduction in
Parkinsonian side effects
associated with Haloperidol.
Patient is expected to
experience a reduction in
headaches.
Tachycardia, constipation,
nausea, xerostomia, blurred
vision, dysuria, urinary
retention, anhidrosis, heat
stroke, hyperpyrexia,
increased body temperature,
paralytic ileus, confusion,
disorientation, drug-induced
psychosis, visual
hallucinations, heat stroke
Available
Routes of
Administration:
Enteral, IV,
Rectal, Oral