SOAPIE Worksheet NSG 357 L

SOAPIE # ___1__
Student Name:
Elsa Strickland, Kim Stoessel, and Allison Woolf
Initials:
N
Unit/Room#
Age: 32
Admission Date:
Admitting Dx: Bipolar Mania
Gender: Female
Axis I: Bipolar Mania- characterized in
our book as mood swings from
profound depression to extreme
euphoria, with intervening periods of
normalcy. Some of the symptoms
associated with bipolar mania are
euphoric/expansive mood followed by
irritable mood, sometimes over trivial
manners. Also includes grandiosity,
decreased need for sleep, pressured
speech, racing thoughts,
distractibility, and increase in goal
oriented activity. This pts symptoms
are that she is sleeping very little and
she spent 1,000 dollars on clothes
and threw a party. She went home
from her party with a man she barely
knew. She was found in a football
stadium wearing little to no clothing
and talking to herself very rapidly.
When being interviewed, she jumps
from one topic to the next and
cusses. She claims that she is
working undercover at the hospital to
identify AIDS pts. She doesnt eat
full meals because she is unable to sit
still for extended periods of time.
Axis II: The pt fits the diagnosis of
Bipolar Mania due to her grandiosity
in spending money and partying. She
is often found to be irritable, cussing
at staff. She speaks rapidly, probably
due to the fact she has rapid
thoughts. She exhibits symptoms of
a psychosis state in that she believes
she is a undercover worker trying to
identify AIDS patients.

HT: 56 Wt: 115

BMI: 18.6
VS: BP: 112/62, HR: 87, RR: 20, T: 99.8
MSE:
Pt wearing scrubs with pant legs rolled up and shirt tucked in
resembling a halter top. Excessive makeup. Came in and out of
the interview 4 times during the process. Rapid speech, jumps
from one topic to the next. Has trouble with answering
questions. Cusses and angrily accuses you of wasting her time.
Initially refused to meet for the interview and was
uncooperative. Hostile in regards to certain topics, such as her
divorce. Irritable and anxious. Denied any psychiatric history,
but records show 3 visits previously. Has vivid delusions in
which she is working undercover at the hospital in identifying
AIDS patients.

Date: 9/21/16
Medications:
Lithium Carbonate: 300mg tid
Lorazepam: 1mg PO tid
Haloperidol Lactate: 5mg IM q4hr
Ibuprofen: 400mg PO q6hr PRN
Magnesium Hydroxide: 400 mg/5 mL PO qhs
Benztropine Mesylate: 2mg PO tid PRN
Acetaminophen: 325-650 mg PO q4-6hr PRN
Discharge Plan:
Make sure she has an address to go home to,
indicate support people, set up appointments after
discharge and make sure she can go

Psycho-Social History:
Pt did well in college and graduated at 26 with an MBA. Since
then, she has worked in the administration dept of a large
corporation and has received many promotions. She has
always been described as moody. She is the 2nd child of 3. Her
father is an alcoholic diagnosed with bipolar disorder. Due to
this, he receives disability benefits. Her mother suffers from
depression and anxiety. She was married for about 1 year at
the age of 27. Currently lives alone and has been dating a man
for 2 years. She drinks only on special occasions and smokes
cigarettes when she drinks. She uses marijuana 2-3 times per
year. Her boyfriend is her primary support person. He states
that she turns to Adderall with a heavy work load and suspects
that she has been using it recently during the promotion
process.

Axis III: Hypothyroidism- With

hypothyroidism, Thyroid Stimulating
Hormone (TSH) is high and because
this acts in a negative feedback loop,

SOAPIE Worksheet NSG 357 L

T3 and T4 are low. These are the
hormones produced by the thyroid
that controls cellular metabolic
activity. They affect the BMR. If these
levels are low, then the pts
metabolic rate would decrease. If not
under control, you will see a pt with
weight gain, dry course hair, puffy
face, goiter, and cold intolerance. If
these symptoms are not controlled
with drugs, it could slow the pts
recovery progress. In the case study,
it states that the pt was not taking
her psychiatric drugs as needed. This
led us to believe she was not taking
her synthetic hormones for
hypothyroidism. She would need the
take these as needed for the rest of
her life to control her medical
condition.
Axis IV: She worked hard in college
and in her job and was striving
towards a promotion. She already had
several promotions and things were
going well for her. Since they
announced 2 weeks ago that she did
not get the job, she has been very
depressed and just laid in bed. She
came from a family of mental illness
and substance abuse. She was
married for less than a year and is a
hard subject for her to talk about, as
shown by her angry and accusatory
responses.
Axis V: 63. Pt has depressive cycles,
isnt sleeping much. Is able to hold
on to a job but isnt able to cope well
when problems arise. She turns to
drugs when stressed. She has a
boyfriend of 2 years who she
considers her main source of support.
Admission GAF unknown. GAF now 15
according to admission assessment:
makes comments that could be seen
as a threat to others, such as
somebody better do something soon
or theyll be sorry!; manic and

SOAPIE Worksheet NSG 357 L

psychotic episodes controlled with
medication; speech/thoughts illogical
at times.
Chief Complaint: Pt hospitalized for
manic episode related to underlying
diagnosis or bipolar disorder. Pt
reports she is working undercover at
the hospital to identify AIDS patients.
Allergies/Response: NKDA
WRAP: We are currently unaware if
the pt has a WRAP plan. If she does
not have one, we would bring up the
ideas and benefits of making one and
would offer her resources to start
one.
Psychiatric & Medical History:
She was diagnosed with
hypothyroidism. Psych diagnosis of
bipolar mania, with cycling of moods.
Current Symptoms:
Major depression after being passed
over for the promotion. 4 days later,
feeling exhilarated, she spent more
than $1000 on clothing and threw a
big party. Was picked up that night
and was wearing little clothing and
was talking to herself very loudly and
rapidly. Speech is very rapid with
flight of ideas. Is not able to sit long
enough to eat an entire meal.

History of Present Illness: (HPI)

Pt has always been described as moody; she has down times
and happy times. Was brought to the psych unit after being
picked up one night by the police and taken to the ED. Pt said
to have been wearing little clothing, carrying a bottle of
champagne, and talking loudly and rapidly to herself. Has been
started on Lithium, Ativan, and Haldol.
Fall Risk: Unknown

Diagnostic Tests & Labs

Serum TSH along with Serum Free T3 and T4 for
her hypothyroidism. LFTs for liver function in
regards to metabolizing drugs. We would want an
initial CBC, BMP, and BMR.
Any additional assessments (Attach): N/A

General Diet:
Is not able to sit still long enough to eat an entire meal. Had a
bite or two of a sandwich that she was given upon admission.

Current Stressors:
Pt upset after not getting expected
promotion. Unable to talk about
marriage without getting angry.

SOAPIE Worksheet NSG 357 L

Clinical Prep Worksheet p. 2: Nursing Care Plan
Pathophysiology Current Axis I, Axis II, Axis III Diagnoses from the literature and your patients actual symptoms:
See Axis I, Axis II, and Axis III Diagnoses and Symptoms described above.
(Link Diagnoses, behaviors, safety risks with 3-4 pertinent nursing goals and interventions. Address Axis I & III, pertinent safety diagnosis if applicable and a
health maintenance/knowledge deficit at a minimum.)
Nursing Dx:
Patient Outcomes
ASSESSMENT Intervention
ACTION Intervention
TEACHING Intervention
(Note priority and
SMART goals
(assess/monitor for)
pathophysiology of disease
process)
Imbalanced nutrition related to
Pt will finish 75 % of her
Monitor daily weights.
We will reference patient to
We will explain the
unwillingness to eat as
sandwich by the end of the
a dietician so they can,
importance of finishing
evidenced by not finishing
interview.
together, come up with a
meals by highlighting the
meals.
plan for success.
need to increase caloric
We will assess clients
intake.
Disrupted sleep patterns related
Pt will maintain a regular
current sleep/activity
We will help the pt establish
to excess energy as evidenced
schedule of sleeping and
pattern.
a routine for going to sleep
Teach pt about possibility of
by rapid speech and pacing.
waking.
along with times for
sleeping pills. We would also
sleeping and waking.
teach pt about the
Risk for feelings of
We will assess clients locus
We will encourage the
importance of sleep in the
powerlessness related to
Client will identify 3 factors of control related to her
client to share her beliefs,
recovery process.
institutional environment.
that are uncontrollable
health and institution of
thoughts, and expectations
We will teach the client the
along with stating feelings
living.
about her illness.
importance of taking part in
of powerlessness.
as many activities that are
offered to her, specifically
the ones in regards to ADLs.
Inadequate knowledge in
We will monitor for client
We will provide visual aids
regards to medications related
Client will describe the
actually taking her
to enhance learning.
We will teach her boyfriend
to cognitive limitation as
need and rationale for her
medications.
about the importance of
evidenced by her mental illness
specific medications by
maintain her medication
and not taking her pills.
discharge.
regimen.

SOAPIE Worksheet NSG 357 L

SOAPIE Worksheet NSG 357 L

Clinical Preparation Worksheet p. 3: Medications
Name & Class
(trade & generic)
Name: Lithium
Carbonate
(Eskalith,
Eskalith-CR,
Lithobid)

Dose/route/sch
edule
Actual &
Recommended
Actual: 300 mg
PO tid
Recommended:
150- 450 mg PO /
dose

Class: Antimanic
Available
Routes of
Administration:
Oral

Name:
Lorazepam
(Ativan,
Lorazepam
Intensol)
Class:
Antianxiety,
Benzodiazepine

Actual: 1 mg PO
tid
Recommended:
0.5-2 mg PO /
dose
Available
Routes of
Administration:
IM, IV, Oral

MOA

Rationale & Response

Why is this prescribed for your
patient and how are they
responding.

Alters sodium
transport in
nerve and muscle
cells resulting in
intrneural
metabolism of
catecholamine.
Specific MOA
unknown.

Patient has been diagnosed

with bipolar disorder.

Binds highly to
gammaaminobutyric
acid (GABA)benzodiazepine
receptor complex
without
displacing GABA.
Drug binds to its
attachment site
to improve
GABAs attraction
to its own
receptor site on
the GABAbenzodiazapine
receptor
complex. Exerts a
tranquilizing
actions on the
central nervous

Patient has demonstrated

signs of anxiety and has
been diagnosed with bipolar
disorder.

Patient is expected to
demonstrate a reduction in
mania.

Patient is expected to
demonstrate a reduction in
anxiety associated with
diagnosis of bipolar disorder.

Adverse reactions & Side

effects
Possible & Actual

Nursing Implications

Acne, hypothyroidism, weight

increased, gastritis, nausea,
xerostomia, leukocytosis, fine
tremor, hyperreflexia,
nephrotoxicity, polyuria,
potential sign of toxicity,
increased thirst,
cradyarrhythmia, brugada
syndrome, sinus node
dysfunction, transient
reduction in peripheral
circulation, erythema
multiforme, ataxia, coma,
pseudotumor cerebri,
increased intracranial
pressure and papilledema,
seizure, epileptiform, blurred
visiom, tinnitus, giddiness,
renal interstitial fibrosis,
angioedema
Asthemia, dizziness, sedated,
unsteadiness, depression,
acidosis, delirium

PT should avoid activities

requiring mental alertness or
coordination until drug effects are
realized. Council patients to seek
emergency assistance with
symptoms of Brugada syndrome.
Pt should maintain adequate fluid,
salt, and diet intake. Pt should be
advised about the multiple drugdrug interactions of the
medication. Pt should constantly
monitor for signs/symptoms of
Lithium toxicity due to the narrow
therapeutic range of the drug.

PT should avoid activities

requiring mental alertness or
coordination until drug effects are
realized. Pt should be advised
against sudden discontinuation of
the drug. Pt should not use
alcohol while on the medication.
Pt should avoid taking other CNS
depressant drugs while on the
medication. Pt should not take
missed doses after one hour of
the original scheduled time.

SOAPIE Worksheet NSG 357 L

Name:
Haloperidol
Lactate (Haldol)
Class:
Antipsychotic,
Butyrophenone,
Dopamine
Antagonist

Actual: 5 mg IM
q4h
Recommended:
0.5- 20 mg PO /
dose
Available
Routes of
Administration:
Oral

Name: Ibuprofen
(Advil, Motrin, AG Profen,
Addaprin, Bufen,
Genpril, Caldolor,
Haltran)

Actual: 400 mg
PO q6h

Class: Analgesic,
NSAID, Propionic
Acid

Available
Routes of
Administration:
IV, Oral

Name:
Magnesium
Hydroxide
(Phillips Milk of
Magnesia,
Dulcolax Milk of
Magnesia, QC
Milk of Magnesia)

Actual: 400
mg/5 mL PO qhs

Class:
MagnesiumContaining
Antacid, Laxative

Available
Routes of
Administration:
Oral

Recommended:
200-800 mg PO /
dose

Recommended:
400 mg/5 mL PO,
800 mg/5 mL PO,
8 tablets/day PO /
dose

system.
Produces a
selective effect
on the central
nervous system
by competitive
blockade of
postsynaptic
dopamine (D2)
receptors in the
mesolimbic
dopaminergic
system and an
increased
turnover of brain
dopamine to
produce its
tranquilizing
effects.

Patient has been diagnosed

with bipolar disorder and is
on Benztropine Mesylate,
which can cause psychosis.
Patient mood is expected to
stabilize between depressive
lows and psychotic highs.
Symptoms of psychosis are
expected to be better
controlled or subside

A Non-steroidal
anti-anflamitory
drug that exibits
analgesic and
antipyretic
activities by
inhibiting
prostaglandin
synthesis.

Patient is on Benztropine
Mesylate and Lithium
Carbonate, which may cause
headaches and Lithium
Carbonate, Haloperidol, and
enztropine Mesylate, which
may cause fever.

Pulls water into

the intestines to
induce
defecation.

Patient is on Lithium
Carbonate, Benztropine
Mesylate, and Lorazepam,
Haloperidol, which may
cause constipation.

Patient is expected to
experience a reduction in
fever in headaches.

Hypotension, constipation,
xerostomia, akathisia,
dystonia, extrapyramidal
disease, somnolence, blurred
vision, prolonged QT interval,
sudden cardiac death,
torsades de pointes, paralytic
ileus, agranulocytosis,
neuroleptic malignant
syndrome, seizure, tardive
dyskinesia, priapism

PT should avoid activities

requiring mental alertness or
coordination until drug effects are
realized. Drug may impair heat
regulation. Use with caution with
exercise, extreme heat, and
dehydration.. Pt should not use
alcohol while taking the
medication. Pt should be advised
against sudden discontinuation of
the drug. Elderly patients with
dementia-related psychosis are at
an increased risk for
cardiovascular or infectiousrelated deaths.

Hypotention, injection site

pain, rash, hypernatremia,
hypoalbuminemia,
pypoproteinemia, serum
lactate dehydrogenase level
elevated, flatulence,
heartburn, nausea, vomiting,
thrombocytosis, bacteremia,
dizziness, headache, serium
blood urea nitrogen raised,
urinary retention, bacterial
pneumonia

Pt should not take with additional

NSAIDS or Aspirin. Pt should
report signs/symptoms of cardiac
origin. Pt should report symptoms
of serious skin or allergic
reactions. Pt should take with
food or milk. Pt should not drink
alcohol or smoke while taking the
medication.

Hypermagnesemia

Pt should use with caution

nausea, vomiting, abdominal
pain, and renal disease.

Patient Is expected to
experience a reduction in
constipation and pass stool
more easily.

SOAPIE Worksheet NSG 357 L

NameL:
Benztropine
Mesylate
(Cogentin)
Class:
Anticholinergic,
Antiparkinsonian

Name:
Acetaminophen
(Tylenol,
Ganapap,
Feverall, Actamin
Maximum
Strength, Altenol,
Aminofen,
Ofirnev, Anacin
Aspirin Free)
Class: Analgesic,
Antipyretic

Actual: 2 mg PO
tid
Recommended:
0.5-2 mg PO /
dose
Available
Routes of
Administration:
IM, IV, Oral
Actual: 325-650
mg po q4-6h prn
Recommended:
80-1,000 mg po /
dose (do not
exceed 4,000
mg/24h)

Synthetic drug
with similar
structural
features found in
atropine and
diphenhydramine
. Anticholinergic
activity of the
drig is utilized in
treatment of
parkinsonism.

Patient is on Haloperidol,
which can result in
Parkinsonian side effects.

MOA unknown
but may be due
to an inhibition of
central
prostaglandin
synthesis and an
elevation of the
pain threshold.

Patient is on Benztropine
Mesylate and Lithium
Carbonate, which may cause
headaches.

Patient is expected to
experience a reduction in
Parkinsonian side effects
associated with Haloperidol.

Patient is expected to
experience a reduction in
headaches.

Tachycardia, constipation,
nausea, xerostomia, blurred
vision, dysuria, urinary
retention, anhidrosis, heat
stroke, hyperpyrexia,
increased body temperature,
paralytic ileus, confusion,
disorientation, drug-induced
psychosis, visual
hallucinations, heat stroke

Drug may impair heat regulation.

Use with caution with exercise,
extreme heat, and dehydration. Pt
should avoid activities requiring
mental alertness or coordination
until drug effects are realized. Pt
should not drink alcohol while
taking medication.

Pruritus, constipation, nausea,

vomiting, headache,
insomnia, agitation,
atelectasis, acute generalize
exanthematous postulosis,
Stevens-Johnson syndrome,
toxic epidermal necrolysis,
liver failure, pneumonitis

Advise pt to take no more than

4,000 mg in 24 hours. Pts should
not drink alcohol while taking this
medication.

Available
Routes of
Administration:
Enteral, IV,
Rectal, Oral

Citations in APA formatting.

Ackley, B.J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed.). St. Louis MO: Mosby.
Micromedex Drug Reference for Apple iOS (Version v1641) [Mobile application software]. Retrieved from http://itunes.apple.com