It is extremely common for patients with mental health conditions to present in acute settings rather than specialty mental health settings with acute or chronic general medical illnesses. With a collaborative multidisciplinary team approach and with proper screening and treatment, successful outcomes for those patients in an acute care setting are becoming an increasingly more standard practice. (Cerimele et al., 2014)
Patients with serious mental health illnesses often experience excessive morbidity and mortality rates compared to the general population. Bipolar sufferers are twice as likely to experience a stroke, 1.6 times more likely to develop ischaemic heart disease, and 1.3 times more likely to have hypertension. As a nurse working in an acute care setting, it is important to assess both the patient's physical and mental health needs equally and promote healthy living activities. (Howard & Gamble, 2010)
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Mr. Walter Reed is a 69-year-old man who presented to the emergency department confused. Mr. Reed’s medical history included bipolar disorder, type 2 diabetes, and hypertension. After a thorough investigation, Mr. Reed was found to have raised serum creatine clearance. Mr. Reed's current medications on admission were:
- Lithium Carbonate, extended-release, 600mg orally, BD
- Metformin, extended-release, 1000mg, daily
- Candesartan 16mg orally, daily
Mr. Reed was admitted to the medical ward and Lithium was ceased due to raised serum creatine clearance and for renal function to stabilize. Mr. Reed was commenced on quetiapine once daily starting at 50mg to be titrated over time to 300mg daily. 3 weeks post-admission, Mr. Reed’s mood has deteriorated, and he has developed poor sleep patterns, decreased appetite, low mood, and has been neglecting daily activities such as showering. Mr. Reed has been spending most of the day in bed and states to the nurse he has been having suicidal thoughts and has been hoarding his night-time medications with the intent to overdose. Mr. Reed is showing signs of depression symptoms which is also a symptom of bipolar disorder.
Bipolar sufferers experience repeated episodes of high, elevated moods (mania) and episodes of low mood (clinical depression). These episodes can last days or weeks and interfere with how the person acts, thinks, and feels both physically and emotionally. In turn, this can interfere with a person’s safety, daily living needs, work, or study commitments, and relationships. (Black Dog Institute, 2019) A person suffering a depressive episode may experience changes including:
- Low mood – sadness, irritability, tearfulness
- Loss of interest in activities previously enjoyed
- Loss or gain of appetite – eating more or less than usual, losing or gaining weight without trying.
- Sleep pattern changes – sleeping for more periods of time, especially during the day, or trouble falling asleep and insomnia.
- Lack of motivation and energy.
- Feeling hopeless and worthless.
- Poor concentration and memory.
- Self-harm or suicidal thoughts. (Hungerford, Hodgson, Clancy & Mon., 2016)
Mr. Reed is experiencing a depressive low, likely from medication changes, and he has not been taking his medication, length of stay in the hospital, relationship breakdown with his wife, and symptoms of bipolar disorder. Healthcare workers are required to respond to mental health deterioration. This can be done in many ways which may include:
- Addressing patients’ needs – physically and mentally may include the well-being of family members as well.
- Increased frequency and/or level of nursing observations.
- Support and encouragement to the patient to manage their own mental state.
- Completion of the MMSE. - a short questionnaire used to measure cognitive impairment. K10 – a tool used to measure psychological distress. DASS 21 – a tool used to measure signs of depression
- Continuous monitoring by health staff
- Further assessment by a mental health clinician
- Use of additional PRN medications to treat symptoms. (Hungerford, Hodgson, Clancy & Mon., 2016)
Medication along with psychotherapy is an effective first-line treatment for bipolar disorder. Medications are used to treat episodes of depression, mania, or hypomania and can prevent these episodes from happening again. Mood-stabilizing medications can include lithium, sodium valproate, carbamazepine, or lamotrigine. If the person experiences psychotic symptoms such as hallucinations and delusions, they may require antipsychotic medications such as risperidone, quetiapine, or olanzapine. Antidepressant medication may also be prescribed to manage episodes of depression or suicidal thoughts. (Health Direct, 2019)
Mr. Reed was commenced on quetiapine due to lithium affecting the kidneys and contributing to reduced kidney function with long-term use. Excessive lithium use is contraindicated in patients with renal impairment and cardiovascular disease. As an alternative, quetiapine is the second-line maintenance drug after lithium for the long-term maintenance treatment of bipolar disorder. Quetiapine frequently causes drowsiness and can aid in Mr. Reed's insomnia at night time, in turn assisting with proper sleep-wake cycles. (Post, 2017)
Psychotherapy has been proven to increase mood stability, improve functioning, and fewer hospitalizations. Therapeutic interventions commonly used for bipolar disorder include cognitive behavioral therapy, family-focused therapy, psychoeducational, and interpersonal and social rhythm therapy (IPSRT). IPSRT primarily focuses on three areas: psychoeducation, particularly the understanding of the illness and the medication roles, lifestyle rhythms that encourage regular sleep, activity, and exercise, and interpersonal therapy to encourage the person to be aware of the connection between interpersonal conflict and mood dysregulation. (Ruegg, Watson, DelBello, Adler & Rodrigo Patino Duran, 2018)
Mr. Reed may be involved in behavioral and cognitive therapies that include education, relaxation exercises, coping skills training, stress management, or assertiveness training. The patient would learn these skills within an individual or group setting and be encouraged to practice skills learned outside the therapy setting. (Ruegg, Watson, DelBello, Adler & Rodrigo Patino Duran, 2018)
Mr. Reed’s wife, other family members, or close friends may be invited to attend therapy sessions. This would provide support and encouragement to the patient and assist loved ones to learn coping skills which could assist them as well. Family therapy can assist those caring for Mr. Reed to understand his condition, solve problems and cope constructively with the patient’s illness. Family therapy may assist with communication and repair relationships. (Ruegg, Watson, DelBello, Adler & Rodrigo Patino Duran, 2018)
Culture has an important role in how a person talks about their mental ill-health. It contributes to how and where a person seeks help and from whom, family, friends, or professionals. When assisting someone outside your own culture and beliefs, it is crucial you consider the spiritual or cultural contexts of a person’s behaviours. Being culturally aware will assist the person how to understand mental ill-health. Patient commitment and informed decision making are crucial for health and mental health communication, regardless of ethnicity. Providing adequate information and support to patients increases patient participation and improves treatment outcomes. The staff involved in Mr. Reed’s care needs to be mindful of his culture, social and family context, his explanatory models, his perception of the health professional, and the stigma associated with mental illness. (Kiropoulos, Blashki & Klimidis, 2005)
Bipolar disorder can be an isolating and challenging illness. Caring for someone with bipolar disorder requires an understanding of the person's triggers, providing the best treatment options and methods of preventing relapse, reducing probable negative consequences and providing tools and constructive strategies to enable the person, and their family to cope with the impact of the disease on their daily lives. (Health Direct, 2019)
The major factors for living with mental illness for Mr. Reed and his wife include distress from symptoms:
- Fear/anxiety/worry – Mr. Reed may be experiencing these symptoms due to the changes in his healthcare routines. Eg. Medications, new general health issues and exacerbation of mental health issues.
- Lack of energy or motivation – a common symptom of depression however Mr Redd is not taking his medication which could be causing these symptoms to become worse.
- Loss of control – Mr. Reed could be feeling this way due to being in hospital. Patients often report feeling this way due to health professionals making decisions about their health care without consulting them.
- Symptom control/management – Due to not taking his prescribed medications and lack of psychology input Mr. Reed has no coping strategies in place to deal with symptoms.
- Medication changes, and the side effects that come from that – Mr. Reed's medications were changed from Lithium to Quetiapine. Mr. Reed may not understand the reason why this has had to happen. Education regarding medications is very important to ensure patient compliance.
- Relationship breakdown – Mrs Reed is visibly stressed, and Mr. Reed can see that. This would put a lot of strain on their relationship and breakdown trust and communication between them. Both Mr and Mrs Reed require some supportive services.
- Prolonged hospital admission – being in hospital for long periods of time can affect a patient mentally and physically. Hospital admissions also affect the carer as their routines are disrupted to visiting their loved one each day.
- Financial worries – perhaps Mr. Reed is unable to work, and Mrs Reed can only work part-time so his wife can be available to care for her husband and poor self-esteem and self-acceptance.
Health professionals are governed by codes of practice that specify they practice in a lawful way and within the rules of ethical conduct. These include the Australian Association of Social Workers, 2008; Australian Nursing and midwifery council, 2008a, 2008b; Australia Psychological Society, 2007. Health professionals should include in their practice style principles of truthfulness, equity and equality, respect and dignity, sanctity and quality of life and privacy and confidentiality. (Hungerford, Hodgson, Clancy & Mon., 2016)
The Mental Health Act provides people with mental illness the right to autonomy, freedom and self-determination, and how we provide the least restrictive health care. The Mental Health Act provides protection to individuals and the community ensuring their rights are observed, and they have access to the appropriate care. (NSW Legislation, 2008)
The Mental Health Act provides health care agency's guidance concerning the treatment and care of their patients and involvement of carers. This includes assisting people with a mental illness to continue living, working and participating in the community. This happens by involving patients in their treatment plans and plans for ongoing care, using medication for therapeutic effect rather than punishment or restraint, ensuring the rights of carers by keeping them informed. (NSW Legislation, 2008)
The Mental Health Act also recognises the patient's age, gender, religious, cultural and language needs and ensures health professionals respect cultural needs without bias or stigma. (Directory et al., 2019)
Mr. Reed and his wife will have a range of needs that may be social and psychological meaning they will require access to doctors, nurses, psychiatrists, psychologists, social workers, occupational therapists and other therapists and the carer. The multidisciplinary team can provide continuity of care, present various skills, education, and support whilst providing a holistic view of Mr. Reed’s care needs. (Hungerford, Hodgson, Clancy & Mon., 2016)
Mr. Reed’s doctor and psychiatrist would work together to ensure that medications are correct and effective for any mental health and general health issues. Some medications may interact poorly together, this may require the input of a pharmacist as well to ensure the correct dosages and medications are being prescribed safely. The psychologist has the expertise to assess psychological functioning and can deliver therapies to Mr. Reed and his wife to assist with coping skills and build a stronger relationship. ('Multidisciplinary Team Care - HealthOne NSW', 2019)
Nurses both in the acute setting and in the community can provide support to both Mr. Reed and his wife, advocate for the patient were required, administer medications and monitor their effectiveness or side effects, assist with daily living activities and educate Mr. Reed and his wife on his condition. ('Multidisciplinary Team Care - HealthOne NSW', 2019)
Social workers would assess Mr. Reed and his wife’s needs regarding services required and arrange for the appropriate assessments to take place e.g., ACAT assessment due to his age of 69 to access services such as ITACS or community nursing. Social workers can also provide information about financial assistance available and assist to complete applications. Occupational therapists would assist in the rehabilitation of Mr. Reed by assessing his functional abilities in areas such as social skills or the ability to perform everyday tasks. Occupational therapies can provide individualized programs to help. They may also assist in the procurement of any equipment required for discharge to assist with completing daily tasks. (Hungerford, Hodgson, Clancy & Mon., 2016)
To conclude, Bipolar Disorder exists and is an issue worth focusing on. It affects people from varying backgrounds, cultures, professions, and philosophies – and it affects various – if not all – aspects of their life, as well, almost always in a detrimental way. It can keep a person from sleeping well at night, from eating and interacting with people, from doing things they enjoy, and even things they have to do – like going to work and other responsibilities. What is most tragic about Bipolar Disorder is the fact that it can occur suddenly and without any warning – it just happens. Nothing, in particular, may trigger it. Bipolar Disorder doesn’t discriminate by wealth, ethnicity, and religious creed.
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