Discussion 3
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Ms. Horowitz is brought to the emergency department (ED) after being found on the highway shortly after her car broke down. When the police came to her aid, she told them that she is “driving to fame and fortune.” She appears overly cheerful, constantly talking, laughing, and making jokes. At the same time, she walks back and forth beside the car, sometimes tweaking the cheek of one of the policemen. She is coy and flirtatious with the police officers, saying at one point, “Boys in blue are fun to do.”
She is dressed in a long red dress, a blue and orange scarf, many long chains, and a yellow and green turban. When she reaches into the car and starts drinking from an open bottle of bourbon, the police decide that her behavior and general condition might result in harm to herself or others. When they explain to Ms. Horowitz that they want to take her to the hospital for a general checkup, her jovial mood turns to anger and rage, yet 2 minutes after getting into the police car, she is singing “Carry Me Back to Old Virginny.”
On admission to the ED, Ms. Horowitz is seen by a psychiatrist, and her sister is called. The sister states that Ms. Horowitz stopped taking her lithium about 5 weeks ago and is becoming more agitated and out of control. She reports that Ms. Horowitz has not eaten in 2 days, has stayed up all night calling friends and strangers all over the country, and finally fled the house when the sister called an ambulance to take her to the hospital. The psychiatrist contacts Ms. Horowitz’s physician, and her previous history and medical management are discussed. It is decided that she should be hospitalized during the acute manic phase and restarted on lithium therapy. It is hoped that medications and a controlled environment will prevent further escalation of the manic state and prevent possible exhaustion and cardiac collapse.
Assessment
Objective Data
Little if anything to eat for days
Little if any sleep for days
History of mania
History of lithium maintenance
Constant physical activity: unable to sit
Loud and distracting to others
Anger when wishes are curtailed
Flight of ideas
Inappropriate dress
Remarks suggestive of sexual themes: calls nurse “lover”
Behavior that some patients find amusing
Remarks that suggest grandiose thinking
Poor judgment
Subjective Data
“Driving myself to fame and fortune.”
“I’m untouchable. I’ll get the FBI to set me free.”
“Let me be . . . set me free, lover.”
Self-Assessment
Mr. Atkins has worked as a nurse on the psychiatric unit for 2 years. He has learned to deal with many of the challenging behaviors associated with the manic defense. For example, he no longer takes most of the verbal insults personally even when the remarks are cutting and hit close to home. He is also better able to recognize and set limits on some of the tactics used by the patient experiencing mania to split the staff. The staff on this unit work closely with one another, making the atmosphere positive and supportive; therefore, communication is good among staff. Frequent and effective communication is needed to prevent staff splitting, maximize external controls, and maintain consistency in nursing care.
The only aspects of Ms. Horowitz’s behavior that Mr. Atkins thinks he may have difficulty with are the sexual advances and loud sexual comments she makes toward him. He knows that this could make him anxious, and his concern is that his anxiety might be picked up by the patient. He discusses this with the unit coordinator.
Diagnosis
Risk for injury related to dehydration and faulty judgment, as evidenced by inability to meet own physiological needs and set limits on own behavior
Defensive coping related to biochemical changes
Questions:
In assessing this patient, without referring back to the scenario above, recall at least three examples both objective and subjective data for this patient.
In this case study, we learn that the nurse is concerned that he may have difficulty with the sexual advances and loud sexual comments the patient makes toward him, saying that he knows that this could make him anxious, and his concern is that his anxiety might be picked up by the patient. Predict an appropriate response to his situation, then compare it with the answer provided.
This case study identifies two nursing diagnoses in particular: risk for injury related to dehydration and faulty judgment, as evidenced by inability to meet own physiological needs and set limits on own behavior; as well defensive coping related to biochemical changes. List at least three symptoms or behaviors that suggest defensive coping specifically.
Students must include 2 APA-style references within the last 5 years for their initial post and respond to at least 2 participating classmates, with a substantial descriptive answer, in order to receive full credit for this discussion.
