Passage / Scenario

The nurse in the behavioral health clinic is caring for a 48-year-old male client.
ÔÇó Diagnostic Results
Diagnostic, Result ,Reference Range
Calcium, 10.5 mg/di (2.75mmol/I), 9.0-10.5 mg/dL (2.25-2.75 mmol/L)
Chloride, 99 mEq/1 (99 mmol/l), 98 to 106 mEq/L (98 to 106 mmol/l)
Creatinine, 0.9 mg/dI (79.6mcmol/L), 0.6 to 1.2 mg/di (53-106 mcmol/L)
Potassium, 3.8 mEq/1 (3.8, mmol/D), 3.5-5.0 mEq/L (3.5-5.0 mmol/L)
Sodium,137 mEq/1 (137mmol/l), 135 to 145 mEq/1 (135 to 145 mmol/I)
Blood urea nitrogen,12 mg/di (4.2mmol/I), 10-20 mg/dL (3.6-7.1 mmol/L)
Fasting glucose ,202 mg/dL (11.2mmol/L), 70-110 mg/dL (4-6 mmol/L)
White blood cell, 11,000/mm3 (11 × 109 /L), 5,000-10,000/mm 3 (5-10 × 109 /L)
Hemoglobin (Hgb), 15 g/dL (150 g/L), Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)
Hematocrit (Hct), 45% (0.47), Male: 42%-52% (0.42-0.52) Female: 37%-47% (0.37-0.47)
Lithium level, 0.4 mEg/L , 0.6-1.2 mEg/L
ÔÇó Progress Notes
1250: Client reports suboptimal adherence with lithium because of thirst and urination. Client agreed to continue the trial of medication. Will discontinue ziprasidone because of tardive dyskinesia. Will follow up more regularly, considering we are going to monotherapy for mood stabilization.
ÔÇó Orders
1251:
ÔÇó discontinue ziprasidone
ÔÇó continue lithium 900 mg p.o. qHS
ÔÇó hemoglobin A1C
ÔÇó valbenazine 40 mg p.o. daily
ÔÇó follow-up in one week
ÔÇó lithium level in one week
ÔÇó NursesÔÇÖ Notes
1230: Client presents for a follow-up appointment. He reports 100% adherence with prescribed ziprasidone. Two weeks ago, he was prescribed lithium, for which he reports a mild thirst. This thirst is causing him to go to the bathroom more frequently overnight. He reports that he recently got a second job to save for a vacation. On assessment, the client is alert and completely oriented. He had a logical thought process. Lung sounds clear bilaterally, and peripheral pulses were 2+. Skin is warm, dry, and normal for ethnicity. Rapid eye blinking and persistent chewing motions in his mouth despite not eating any food or gum. He reports that this started two weeks ago. Current weight is 128 kg (282 pounds). Current BMI is 26kg/m2. Previous weight one month ago was 126 kg (277 pounds). The most recent hospitalization was one month ago for a manic episode. Laboratory data reviewed.
One week follow-up visit
0900: Client returns for a follow-up visit, reporting full adherence to the prescribed lithium. He reports that he is still gaining weight and is interested in participating in low-impact activities for weight loss. He experienced significant symptom improvement with tardive dyskinesia, with only light chewing motion in the mouth. On assessment, the clientÔÇÖs affect is full range, and he exhibited no abnormal facial movements except a slight fine hand tremor. Hemoglobin A1C lab reviewed and was 6.3% [5.7-7%]. The most recent lithium level was 0.8 mEq/L [0.6-1.2 mEq/L].