Bipolar Depression/Mania UNFOLDING Reasoning, Exams of Nursing

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© 2016 Keith Rischer/www.KeithRN.com

Bipolar Depression/Mania

UNFOLDING Reasoning

Brenden Manahan, 35 years old

Primary Concept Mood and Affect Interrelated Concepts (In order of emphasis)

1. Psychosis
2. Clinical Judgment
3. Patient Education
4. Communication History of Present Problem:

Bipolar Depression/Mania

Brenden Manahan is a 35-year-old male, who has been admitted to the crisis intervention unit for exacerbation of his bipolar disorder. He was admitted on a 501 (involuntary inpatient admission, patient has been deemed either dangerous to self or others) and brought to the hospital by police because his mother feared for his safety. In the past few weeks, he stopped taking his medication because he feared that his mother was poisoning him. Brenden has not slept in the past four days due to racing thoughts. He believes that he is the head of the CIA and told his mother that he needed her car to go to CIA headquarters in McLean, Virginia, and fire everyone. When the police

© 2016 Keith Rischer/www.KeithRN.com arrived, they noted that Brenden was speaking at a very rapid rate and pace and was becoming increasingly agitated. He began yelling that the police where there to poison him and prevent him from returning to his job. He has been admitted to the locked mental health unit for evaluation of his mental capacity and stabilization. Brenden will participate in the following education groups: medication education, and bipolar illness education. The goal is to resume lithium carbonate and divalproex sodium. Personal/Social History: Brenden was diagnosed at 19 with bipolar I, and subsequently has been admitted six times due to non-adherence to the medication regimen. Brenden is divorced and has a 3-year-old son who lives with his mother. He was recently in court to have his visitations reduced to one supervised visit a week. He lives with his mother, who is supportive. What data from the histories is important and RELEVANT and has clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: Patient is being admitted for an exacerbation of his bipolar disorder. Patient had stopped taking his medication because he feared his mother was poisoning the medication. He’s not slept in four days due to racing thoughts. He believes he is the head of the CIA and needed his mother’s car to drive to McLean, VA. When the police arrived, they noted that he was speaking rapidly and becoming increasingly agitated, yelling at the police that they were there to poison him and prevent him from returning to his job. Relapses and exacerbation episodes can be a progressive pattern of this disorder leading to remission and relapse. This is a delusion not uncommon in the manic phase of bipolar and raises the question of whether or not he was on a high enough dose of medication. Lack of sleep is a clinical red flag for the manic phase of bipolar disorder. This is a delusion also not uncommon with a manic phase of bipolar disorder. Clients who present with pressured speech may be difficult to work with because they're hard to understand because their brain is moving very rapidly. They can behave very impulsively it may be difficult to manage this phase of their illness and it will take time to build trust. His yelling at the police is also indication of his poor judgment. RELEVANT Data from Social History: Clinical Significance: He has been admitted six times in the past due to medication non-adherence. Patient was recently in court to have his parental visitations reduced to one visit per week. The clinical significance is that there can be a rolling door syndrome when working with clients who have this mental illness with frequent admissions due to non-adherence to medication and inadequate outpatient services. This psychosocial stressor in the relationship with the child’s mother and also the reduction in visitation and the legal issues associated with that can be a precipitating factor in bringing on a manic phase as stress can trigger symptoms.

Current VS: WILDA Pain Assessment (5th^ VS):

T: 99.1 F/37.3 C (oral) W ords: Patient denies P: 110 ( regular) I ntensity: R: 28 (regular) L ocation: BP: 142/84 D uration: O2 sat: 99% room air A ggravate: A lleviate: Patient Care Begins: What VS data are RELEVANT and must be recognized as clinically significant by the nurse?

© 2016 Keith Rischer/www.KeithRN.com RELEVANT VS Data: Clinical Significance: BP: 142/ T: 99.1 F P: 110 R: 28 His blood pressure, temperature, and pulse being a little bit elevated indicates that he's agitated and anxious which is in accordance with someone that's in a manic phase. It's a clinical red flag, in this case, because he's manic. They represent the increased physiologic metabolic demand on his body. The respiratory elevation can result in hyperventilation with symptoms of lightheadedness, dizziness, shortness of breath, heart palpitations, and numbness. His vital signs are elevated in a way that makes us want to watch him carefully and repeat those and it tells us that his body is under increased physiologic demand.

Current Assessment:

GENERAL

APPEARANCE:

Is disheveled, and according to his mother, he has not showered in several days. NEURO: Oriented to person and place but not to time, impaired ability to concentrate, labile emotions, has not slept for four days RESP: Breath sounds clear however, patient is breathing rapidly and deeply CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants, has adequate appetite. GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact CHEMICAL USE: Denies both use/abuse of ETOH or other street drugs What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Patient is disheveled and hasn't showered in several days, according to his mom. Patient is only oriented to place and person and has labile emotions. Patient denies use of alcohol or other street drugs. This is significant as it shows patient is currently in a manic state and his hygiene is deteriorating. He is unable to perform self-care due to his deteriorating mental status. He could be a safety risk to himself and others because of his emotional state. His manic behavior, irritability, and his tendency to be impulsive makes him potentially dangerous. His behavior is not due to any chemicals and offers information for a differential diagnosis. That's a piece of history we're going to want to validate.

Mental Status Examination:

APPEARANCE: (^) Is disheveled, and according to his mother he has not showered in several days. He is unshaven, and has a significant odor coming from his body and or clothes. His clothes are not consistent with the weather, it is 95 degrees and is wearing multiple layers of clothing and has winter boots on. MOTOR BEHAVIOR: Psychomotor agitation present, appears restless; he is unable to sit still SPEECH: Talking fast with pressured speech. MOOD/AFFECT: Appears ecstatic, bright affect THOUGHT PROCESS: Delusional, flight of ideas/ jumping from one idea to another THOUGHT CONTENT: Believes that the CIA is controlling the nurses’ actions and following him and that he must get to the CIA headquarters immediately. PERCEPTION: Denies hallucinations INSIGHT/JUDGMENT: Has lack of insight into current condition and reason for inpatient hospitalization COGNITION: Oriented to person and place but not to time, his immediate and recall were intact but remote memory is not. INTERACTION: Approaches others, but does not engage in lasting conversation

© 2016 Keith Rischer/www.KeithRN.com SUICIDAL/HOMICIDAL: Denies homicidal/suicidal ideation What MSE assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: Pt is disheveled; has not showered in several days; is wearing multiple layers in 95-degree weather. -Pt is agitated and restless; unable to sit still, has rapid speech; and displays an ecstatic, bright affect. Patient is delusional; believes CIA is controlling the nurse’s actions; must get to the CIA headquarters immediately. He has a lack of insight and very poor judgment at the moment and is oriented only to person and place. His appearance suggests that he is unable to care for himself due to his deteriorating mental status and that he's a vulnerable adult and dangerous to himself. The psychomotor behaviors – agitation, restlessness, unable to sit still, rapid speech, and ecstatic and bright affect, delusions and flights of ideas – all confirm his manic state. He's actively delusional and paranoid and this is a clinical red flag which can make him unpredictable, and he may unintentionally hurt himself, others, or become combative. This means for the nurse that you'll have to take safety precautions when interviewing him, place yourself in the room so that you're closest to the door, recognizing that he can be impulsively combative and that his delusion may prevent him from realizing he's in the hospital. He may have difficulty really understanding what's happening to him, so this is going to take a lot more care and patience to deal with him.

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: Bipolar depression 1. Lithium 600 mg PO BID

2. Depakote 750 mg PO daily Lithium salt Anticonvulsant Lithium is the drug used to reduce the patient’s symptoms of mania. Depakote is being used currently to stabilize patient’s mood. Lab Results:

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

Complete Blood Count (CBC:) Current: High/Low/WNL? WBC (4.5–11.0 mm 3) 8.9 WNL Hgb (12–16 g/dL) 12.9 WNL Platelets (150-450 x10 3 /μl) 325 WNL Neutrophil % (42–72) 70 WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance:

WBC (WNL)

Hgb (WNL) Platelets (WNL) Neutrophils (WNL) This tells us client has no infection or inflammatory processes present. This tells us no anemia or acute/chronic blood loss is occurring. This tells us no anemia or blood loss is occurring. This tells us client has no infection or inflammatory processes present. Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Sodium (135–145 mEq/L) 142 WNL Potassium (3.5–5.0 mEq/L) 4.0 WNL Glucose (70–110 mg/dL) 102 WNL Creatinine (0.6–1.2 mg/dL) 1.0 WNL

RELEVANT Lab(s): Clinical Significance:

Sodium (WNL) Potassium (WNL) Glucose (WNL) Creatinine (WNL) Indicates fluid and electrolyte balance. Will continue to monitor. His muscle – including cardiac muscle – has adequate potassium to function properly. Glucose is required for energy for our tissues. Kidneys are adequately perfused and functioning.

Therapeutic Blood Levels: Current: High/Low/WNL?

Lithium (0.8 to 1.2 mEq/L) 0.2 mEq/L Low

RELEVANT Lab(s): Clinical Significance:

Lithium: 0.2 mEq/L Lithium levels are below therapeutic levels due to his history of medication nonadherence, which can lead to an exacerbation of his bipolar disorder and mood swings. We will continue to monitor patient to ensure the lithium reaches therapeutic levels and monitor for signs and symptoms of toxicity. Lithium could take several weeks until blood levels are in therapeutic range, so we want to get him restarted on it as soon as possible. Additional medications will be required

temporarily, in the meantime, to help patient’s manic episodes decrease.

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Lithium: 0. 0.5-1.5 mEq/L Lithium alters sodium transport in nerve and muscle cells resulting in intraneuronal metabolism of catecholamines; however, the specific mechanism of action in mania is unknown. First, we would alert the physician that the therapeutic blood level is subtherapeutic and ask for the order to start the lithium. Next, we would closely assess his physiologic status for adverse effects relating to both mania and physical exhaustion. Lastly, we would make it a priority to ensure that he receives other medications that will promote rest including trazadone and lorazepam (because it’s going to take several weeks for the lithium to work). Clinical Reasoning Begins…

1. What is the primary problem that your patient is most likely presenting with?

Acute exacerbation of bipolar I disorder presenting with a manic episode.

2. What is the underlying cause/pathophysiology of this concern?

Typical of most serious and persistent mental illnesses, there is no definitive cause, and the etiology isn’t quite

understood. There are things that we know are associated, such as: sometimes it runs in families; sometimes there's a

pattern of adverse childhood events; we know that current life stressors can bring on symptoms; but we don't know

the mechanisms.

Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Admit to unit and engage patient in milieu, but first inspect for harmful items. Urine drug screen Lithium 600 mg PO BID Depakote 375 mg PO BID Trazodone 100 mg PO PRN sleep Lorazepam 1 mg PO BID The patient is currently a risk to himself and others. By law, we’re required to admit him in order to treat him. Milieu therapy will help create a safe and supportive environment for him. Urine analysis will help determine if the patient is currently on any other substances and, if so, which ones. This allows us to determine if his symptoms are purely due to his acute exacerbation of bipolar I or if it's due to some substance abuse. The patient was previously taking lithium and tolerated it well. Restarting this medication will help stabilize his condition. The Depakote will help decrease manic episodes by helping him quit cycling. Trazadone will help with sleep and it has a mild antidepressant effect. Lorazepam will help decrease the manic episodes and help calm him enough to sleep. The patient will be admitted safely to a safe and therapeutic environment for treatment. He will provide urine sample for analysis. The patient will agree to taking lithium and it will assist in stabilizing his mood. Patient will have decreased cycles of mania and depression. Trazodone will help to calm him and ease his anxiety. It has a tranquilizing effect on the central nervous system with effects on the respiratory and cardiovascular systems, so the

lorazepam is going to help bring down his pulse and respirations.

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: Urine drug screen Lithium 600 mg PO TID Depakote 375 mg PO BID Trazodone 400 mg PO PRN sleep Lorazepam 1 mg PO BID Admit to unit and engage patient in milieu but first inspect for harmful items. First priority- Admit to unit and engage patient in milieu but first inspect for harmful items. Second priority- Lithium 600 mg PO TID Depakote 375 mg PO BID Trazodone 400 mg PO PRN sleep Lorazepam 1 mg PO BID Third priority- Urine drug screen We want to make sure the patient doesn’t have any potentially harmful items he can harm himself of others with, then, we want to get him admitted to the unit and begin milieu therapy. In this case, because of the mania and because of the length of time he's already been this manic, we want to make sure he's safe and get some medicine in him because that's the only thing that's going to help and we don't want him going endlessly in constant motion and irritable. At some point, he's going to realize he can't leave, and we have to be prepared to deal with that, as well, so we want to get some medicine in him. Even if he has other drugs on board we're still going to give him these medicines first, as we know what his vital signs are and what his labs looks like, so the urine drug screen would be done as the last priority. Collaborative Care: Nursing

3. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)

Disturbed sleep pattern and episodes of delusions secondary to his manic phase, so getting him to rest and sleep is top priority right now. Developing the therapeutic relationship. That's really important from the very first moment because we're going to really have to rely on that in order to get his cooperation. There's a risk for injury relative to his mood alteration because of his restlessness and hyperactivity, so again, he's at risk for being assaultive. He has a disturbed thought process, also relative to his mood alteration. He's delusional, very delusional, with pressured speech and alteration in nutrition. We're going to have to watch his biological signs: his food and fluid intake, and we know he hasn't slept in four days complicated by the loss of a relationship and the change in his custody agreement and visitation with his child.

4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: Disturbed sleep pattern: We want to promote good sleep hygiene by encouraging a calming ritual before bed: offering milk and protein foods that have tryptophan in them; a silent calm environment during sleep; limiting caffeine; and promoting routines that induce comfort and relaxation. Disturbed thought process: Orient client by calling him by name and answering his question. Introduce yourself on each contact, frequently mentioning the Rituals and routines induce comfort and relaxation. Tryptophan is a precursor to serotonin thought to induce sleep and we want to avoid stimulants that inhibit sleep. These interventions help reinforce reality and provide cues that maintain orientation and in order to ensure the patient is taking the medication as prescribed we have to be sure Patient will be able to relax and sleep at least 6 hours per night. The patient will have increased attention evidenced by his ability to talk with staff or engage in group activities.

time, date, and place. Exhibit a non- judgmental attitude, help the client develop coping skills and problem-solving abilities, check his mouth after giving medications to ensure that they've been swallowed, and promote a safe and controlled environment with decreased stimuli. Ensure that he receives his medication and monitor their effect. Alteration in nutrition. Monitor the client’s intake of food and fluid including protein. Self-Care deficit: We know he has an impaired ability to perform bathing, hygiene, washing of clothing, and dressing appropriately, but we want him to participate in self-care activities like bathing and grooming perhaps with your assistance within 24 hours. Knowledge deficit: Teach the patient about his condition, principles of management, and the importance of medication compliance. Educate the patient on the disease process and how to recognize early symptoms and provide medication teaching and monitor for medication effect and compliance. Coping skills: Encourage the use of adaptive coping skills, stress coping, and anticipatory planning. Therapeutic relationship: Build rapport, maintain a safe and secure environment, avoid use of force or restraints whenever possible, increase the dosage of medication as needed, and establish a therapeutic alliance by employing an empathetic and nonjudgmental attitude. Risk for injury: Check the client’s room for potentially destructive items like sharp objects, belts, etc. Provide for the client's safety and protect the client from himself as well as from others and protect others from him by using close observation. Implement a contract for safety and PRN medication. he swallowed it. The client is unaware of his physical needs and may ignore his feelings of thirst and hunger and he may be paranoid and need to have closed containers of food served to him. Due to the client's delusions and paranoia, he may be fearful of showering and unaware of his need for hygiene, but once done, the personal hygiene can foster feelings of well-being and comfort and safety. The patient will attend illness education and medication education groups within three to four days and begin to acknowledge his bipolar disorder. Reviewing coping skills which have helped the patient in the past and help him identify new and effective coping skills as needed for new situations. Establishing a therapeutic relationship builds trust, decreases isolation, encourages the patient to let you know what he's thinking and feeling, and lets you help him solve problems. The nurse assesses the ability for the patient to engage in a contract for safety within 24 hours and will be on close observation of at least every 15 minutes in order to maintain his safety. He'll demonstrate a decrease in delusions and increase in reality orientation within three days. The client will begin eating nutritious food within 48 hours The patient will regain function as evidenced by performing hygiene activities independently after the first day. The patient will comply with his medication regimen throughout his hospitalization and, hopefully, after discharge. The patient will verbalize at least two new affective coping skills by discharge. The client will begin having conversations with nursing staff, at least twice a day, by day three of admission. The patient will remain free of injury for the duration of the visit and will not hurt anyone else.

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

The body system we would assess would be the neurological system by using the Mental Status Exam.

6. What is the most likely complication/problem that the nurse should anticipate? The most likely complication is the display of aggressive, assaultive behavior. He certainly could reveal some suicidal ideations and we're going to ask him about it on a regular basis or ask him if there's anybody he's mad at but given how manic and irritable he is, and that he's going to be frustrated by having to function on the unit where he can't just go where he wants, being aggressive or assaultive is the number one concern**_.

7. What nursing assessments will identify this complication EARLY if it develops?_** He could start yelling, invading other people’s space, displaying more erratic gestures. He could be reaching out to others or holding out his fists, his posture could become particularly erect as he is barreling through people or gesturing in ways that someone could get hit – even accidentally – then it's time to intervene more immediately. If we've already given a PRN and his behavior is still escalating and we have more medicine we can give, that would be the time to do it. I would offer the medication to him but if he is not willing to take more medicine and we're not able to verbally redirect him, then we have to put hands on especially if he verbally threatens anyone. 8. What nursing interventions will you initiate if this complication develops? We would remain calm and speak in a calm, but firm, voice without an emotional response. We would not yell at him, so we have to speak loud enough to be heard and act confident even if we don't feel that way. We don't want to look like we're getting agitated. We will use de-escalation techniques, which are essentially therapeutic communication techniques, to empathize with him. We want to let him know we need him to lower his voice by saying, “it sounds like you're upset; I'd like you to talk to me about it and let me know what I can do to help.” It is important to avoid power struggles which will only escalate their behavior. Whatever we say needs to communicate, “I'm on your side; I'm empathizing with you; I recognize you're uncomfortable; I need your cooperation, if you wouldn't mind lowering your voice a little bit.” We want to ensure he understands who we are so we might need to repeat our name and our role and that we're there to help and then give him lots of opportunities to tell us how he's feeling and why he's upset and what's on his mind. I would want to be as reassuring as I can in a situation like this and my team and I would have signals we can give each other either such as eye contact signals or signals with our hands or our words that tell the rest of the team we need them to gather around, so that if in the next few moments, you have to put hands on, everybody has a role. The team would all do it together, we would never initiate hands on all by ourselves; we would always do that as a team.

Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Two hours later… The nurse observes the patient yelling and banging on the door of the unit. They need to let him out because he has to get to CIA headquarters to stop a terrorist attack. The staff tries to reorient him and the more they talk with him, the more agitated he becomes.

Current Assessment:

GENERAL

APPEARANCE:

Agitated, and delusional. Is restless and agitated.

1. Has the status improved or not as expected to this point?

No, his status has not improved as expected to this point. Yes, we need to contact his health care provider to let them know

that the treatment hasn't been effective and he's increasingly agitated and is now violent. While we're deescalating him, we need to escort him to a quiet room, and we need to contact the physician for at least 4mg of Ativan for agitation. We could offer it PO, if he's willing to take it orally, and if he refused that, we might put hands on and give it IM – or we may give him Haldol IM.

2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? Yes, we need to contact his health care provider to let them know that the treatment hasn't been effective and he's increasingly agitated and is now violent. While we're deescalating him, we need to escort him to a quiet room, and we need to contact the physician for at least 4mg of Ativan for agitation. We could offer it PO, if he's willing to take it orally, and if he refused that, we might put hands on and give it IM – or we may give him Haldol IM. 3. Based on your current evaluation, what are your nursing priorities and plan of care? I would offer the patient PRN Ativan. Encourage him to discuss his concerns - in a calm voice. Keep the patient in a quiet room until he's calm and when we walk him into it the quiet room, we have to tell him what he has to do before he can come out. We could say something to him like, “as soon as you're able to not be yelling and banging on the door, we will bring you back out.” I would remind the patient that he's in a safe environment and continue to do reality orientation, while recognizing that I can reorient him all I want (which is helpful to some degree) but it's not going to make him not delusional - he’s still going to be delusional. However, it might help him to be able to understand where he is and what's happening and realize that people are trying to help him. Nurse to Physician SBAR for Change in Status: S ituation: This is the nurse caring for Brenden Manahan, I'm contacting you because he's become increasingly agitated and delusional. B ackground: Mr. Manahan is a 35-year-old divorced, Caucasian male, admitted earlier today when the police became involved when his mother reported that she was fearful for his safety. He wanted her car to drive to CIA headquarters in McLean, VA., and fire everyone working there. He believes he has to stop a terrorist attack and he has not slept in four days.

A ssessment: The patient believes he's in the CIA, despite reality orientation, and feels that nursing staff are part of the counterterrorism unit of the CIA. He's become increasingly disruptive on the unit and there's concern that he will harm himself or someone else. He has been banging on the door of the unit. R ecommendation: I'd like an order for Ativan to help calm him, as well as an order for seclusion (with one-to-one supervision), to help deescalate the patient.

Education Priorities/Discharge Planning

1. What will be the most important discharge/education priorities you will discuss with Brenden about his medical condition to prevent future readmission with the same problem? First, will be the importance of medication compliance including problem solving with he and his mother about any barriers that exist to him getting his medication. We wany to know does he have coverage for his medication, and does he have transportation to pick it up? We want to ensure that they understand what the medication should do and what the side effects are. We want to determine if we can provide any additional support at home such as a home health nurse, or a case manager, who can help with identifying early symptoms and continue the medication education with he and his mother. We would want to offer health referrals for other kinds of services he'll need. He may require a psychiatrist for his medication and might need a therapist. He and his mother might need to see a therapist together, so we need to find out what kind of insurance they have and what kind of transportation they have. We need to be sure that he can access services once he leaves the hospital. 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? The teach-back method, of course, is the best method and because we're sending him home where he will be living with his mother, we want to get them together and assess whether that's still the best idea for both of them. Is she safe having him in the house? Do they both understand how to recognize early symptoms of decompensation? How does he feel about living in his mother 's house, does he feel demoralized or infantilized by the living situation? Would the mother be safer with him living elsewhere? It is important to get the patient and the family (in this case his mother) together to talk to each other about what they're learning so that we can identify gaps in their knowledge and teach them about the illness and early signs of decompensation and all the medications, what they should do, and all the side effects he may experience from them. Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? I think he's feeling angry, frustrated and probably confused. and that anger and frustration is just going to keep escalating if we can’t interrupt this manic cycle. He is likely scared because he thinks there's going to be a terrorist attack and that it is his responsibility to stop. He is probably feeling desperate and frantic to get out of the hospital. In addition, he has incorporated us into the delusion as he thinks we are part of the counterterrorism unit and that we should know better and should be helping him (to stop the terrorist attack) and we're not helping him. 2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? We will again utilize therapeutic communication techniques to keep empathizing with him to convey that we understand how desperate he must be feeling, and we understand that he's trying to save all of us and we're trying to protect him, as well. We can even say, “I know this doesn't make any sense to you but try to trust me; I am doing what's best for you.” We would just keep attempting to deescalate him and reassure him to try to gain his trust.

Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment.

1. What did I learn from this scenario? I learned that the manic and depressive episodes in a person with Bipolar I cycle over and over and the differences in Bipolar I and Bipolar II. 2. How can I use what has been learned from this scenario to improve patient care in the future? I would practice my therapeutic communication techniques to deescalate manic patients and use empathy to relate to the delusions that are very real to them.

References Skidmore-Roth, L. (2020). Mosby’s 2020 Nursing Drug Reference. St. Louis, MO: Mosby Elsevier. Jordan Halter, M. (2018). Varcarolis’ Foundations of Psychiatric-Mental Health Nursing: A Clinical Approach. 8th^ ed. St. Louis, MO: Elsevier