Based on the history provided, write a brief paragraph or two in narrative format of the additional questions you would ask the patient that would assist in the comprehensive treatment planning. With the data provided create a comprehensive nursing care plan. In addition, please write a paragraph addressing the information that would be important in the discharge plan for this particular patient.
45 year old female admitted with acute exacerbation of mania. Patient has a long history of Bipolar disorder, non-compliance with medications, and has recently experienced severe manic symptoms with over 7 days of not sleeping. She has been engaging in high risk behaviors that include impulsive self-harmful acts. She has begun drinking ETOH after 2 years of sobriety, failed to show up for work for 1 week, and has bought a one-way plane ticket to Paris. This patient has 2 previous psychiatric hospitalizations in her 30’s for suicidal ideation with a plan. PMH: none Psychiatric history: Alcohol dependence, Bipolar Disorder (diagnosed at age 31) Meds: Lamictal 150mg BID, Celexa 10mg QAM, Abilify 2.5mg QHS (stopped 2 months ago). NKDA
MSE: Thin female, appears stated age, dressed in shorts & t-shirt. Patient is unable to sit for the interview, getting up frequently & pacing in the room. She appears to be distracted by external stimuli. Poor eye contact. Speech is rapid, pressured, and rambling. Patient is oriented to place, person, and situation. She does not appear to be delusional, but mood is manic with expansive affect. Patient is unable to focus on the interview and began crying when she was redirected.
