Mental health care plan in ED

[jetstar]

Hi there i am seeking some help with a care plan i am attempting to develop.

It is for a patient previously dx with bipolar who has presented to ED with signs of hypomania (pressure of speech, easily irritated, going out a lot, excessive spending). In previous manic episodes her husband suspected drug abuse and sexual encounters with work mates, and also reports her having issues with eating and drinking.

We are asked to make a care plan for her as an ED nurse, this is where i am quite confused as i really dont feel there are many nursing diagnosis and interventions i can conduct within the ED.

I was thinking of a mental status exam as well as general health assessment. But i am not sure if it is going too far to intervene with her nutritional requirements, as an ED nurse are you only concerned with immediate dangers to the patient?

I apologise for this being all over the place and do hope someone can shed some light on it for me.

Thanks!!

[Daytonite, BSN, RN]

what is important is that you assess what is going on with the patient and address her nursing problems. starting with a mental status exam as well as general health assessment is what you should do. and, yes, after identifying her nursing problem(s) you are going to mostly be concerned with nursing interventions that are going to be of a short term nature to "plug the dam", so to speak and get her out of the er safely and get her to other healthcare providers for later followup.

in care planning always follow the steps of the nursing process in the sequence that they occur.

step #1 - assessment. nursing assessment consists of (and in the er time can be a factor):

• a health history (review of systems) - bipolar with previous manic episodes where her husband suspected her of drug abuse and sexual encounters with work mates.
  
• performing a physical exam - pressure of speech, easily irritated
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - issues with eating and drinking. what are those? going out a lot, excessive spending. in the past: suspected drug abuse and sexual encounters (these are safety concerns).
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - as a student, now that you are sitting down to work on this care plan, you need to read about the pathophysiology, signs, symptoms and complications of bipolar disorder to get a better understanding of what you are dealing with here and also so you can compare the textbook to what you actually saw:
  
  • http://www.merck.com/mmpe/sec15/ch200/ch200c.html - bipolar disorders
    

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what meds was she on? was she taking them or not? what are their side effects and was she showing or having any evidence of the side effects?

step #2 - determining the nursing problems (nursing diagnoses). make a list of all the abnormal data that you collected above. that is what forms the evidence that becomes the basis for any nursing problems that you now can put a name (nursing diagnosis) to. since the evidence you posted wasn't very specific i am at a bit of a loss to help you out with some diagnoses here, but i hope i have given you some direction in what you need to do to get this care plan going. assessment data, as much as you can get, is the foundation of every plan of care.

[jetstar]

Thank you very much daytonite! That is helpful.

Unfortunately this is all the info provided in the case study, hence all i have to work with

I think due to not having much info most of my diagnosis will be Risk of... the only abnormal data i am certain of is her signs of hypomania.

Any further ideas would be great!!

[Daytonite, BSN, RN]

You've got two symptoms: pressure of speech (whatever that is) and easily irritated which can be turned into nursing diagnoses. And you have a husband who is concerned for her safety--any nursing diagnosis. Some teaching somewhere?

[rachelgeorgina]

"Risk of" are perhaps the most suitable diagnoses in this situation because you don't have anymore information, in all likelihood, the patient won't give you anymore information (non-compliance in hypomania is +++) and the disorder is very temperamental and afflictive, impulsive and changes faces often.

What abnormal things come with hypomania? & what risks are associated with these? What are the potential consequences of these risk factors?

Safety risks (drug abuse? sexual misconduct? impulsively - especially combined with feeling "very very good"?)

Social deviation (sexual misconduct? excessive spending?)

Poor general health (over/under eating?)

Important thing to assess (I think) is whether the patient has any "plans" - are they planning to tattoo themselves with pen ink, jump off a cliff, find jesus etc? The combination of impusivity and feeling over the moon at high speed can be really dangerous and should be of concern to the RN in the ED.

Are your other patient's at risk in any way from this patient? Not just via physical contact/verbal abuse, but does the patient's hypomania disrupt the ED environment that should be allowing these patient's to feel safe, calm and secure? On the flip side, is the ED environment aggravating the patient's mental state? Here in Australia we've begun opening PECC (Psychiatric Emergency Care Centres) as an adjuct to EDs in order to deal with psychiatric patients as the research shows that a) the ED environment can be very stimulating, especially to patient's experiencing mania and/or psychosis and aggravate their conditions and b) general medical EDs are not well equipped and trained to treat a psychiatric emergency that doesn't require swift medical action.