Mental health nursing: Lithium

• These notes cover key aspects of mental health nursing, including medication management, adverse reactions, and patient care strategies.

Lithium

• Used as a mood stabilizer, and the gold standard for bipolar disorder treatment.
• Thought to enhance serotonin and/or GABA function, which are associated with mood regulation.
• Diuretics, fluoxetine, and NSAIDs can increase lithium levels by affecting kidney reabsorption or excretion, which increases the risk for toxicity.
• Decreased sodium intake and fluid/electrolyte loss can elevate lithium levels.
• Acetazolamide, theophylline, phenothiazines, and sodium bicarbonate can reduce lithium's effectiveness by increasing its renal excretion.
• The therapeutic dose range is 0.6-1.2 mmol/L, and can be reached within 4-5 days. A response can be seen in 1-3 weeks.
• Serum lithium levels need frequent checks after starting therapy, then every 1-2 months and as needed.
• Blood samples should be drawn 12 hours after the last dose, preferably in the morning.
• Lithium is not recommended during pregnancy due to the risk of fetal toxicity as it freely crosses the placental barrier.
• Side effects include polyuria, polydipsia, edema, dysrhythmia, anorexia/nausea, dry mouth/thirst, abdominal bloating, soft stools, fine hand tremors, inability to concentrate, muscle weakness, headache, and hypothyroidism/goiter.
• Monitor patients for side effects, administer the medication with food to minimize GI upset, and advise patients to avoid coffee, tea, diuretics, alcohol, and OTC medications without consulting their healthcare provider. They should also maintain adequate fluid and salt intake. For a missed dose within 2 hours, take the dose; otherwise, skip it and take the next dose at the scheduled time.

Lithium Toxicity

• Symptoms of toxicity typically appear when lithium levels reach 1.5 mmol/L.

Mild Toxicity (1.5 mmol/L)

• Symptoms include apathy, lethargy, diminished concentration, mild ataxia, coarse hand tremors, and slight muscle weakness.

Moderate Toxicity (1.5-2.0 mmol/L)

• Symptoms include nausea and vomiting, severe diarrhea, mild to moderate ataxia and incoordination, slurred speech, tinnitus, blurred vision, muscle twitching, and irregular tremor.

Severe Toxicity (greater than 2.0 mmol/L)

• Symptoms include nystagmus, muscle fasciculations, deep tendon hyperreflexia, visual or tactile hallucinations, oliguria/anuria, altered level of consciousness, tonic-clonic seizures, or coma, potentially leading to death.

Interventions for Lithium Toxicity

• Stop lithium administration.
• Notify the doctor.
• Monitor vital signs and level of consciousness.
• Monitor cardiac status.
• Prepare to collect blood samples for lithium, electrolytes, BUN, creatinine, and CBC.
• Monitor for suicidal tendencies and institute suicide precautions.

Clozapine

• An atypical antipsychotic used for schizophrenia or schizoaffective disorder.
• Can cause severe neutropenia, requiring a baseline neutrophil count of at least 1500 u/L before starting treatment and regular monitoring during treatment.
• May cause orthostatic hypotension, bradycardia, and syncope.
• The starting dose is typically 12.5 mg, with a target dose of 300-450 mg per day.
• Can cause seizures.
• Can cause myocarditis and cardiomyopathy.
• Increased mortality risk in elderly patients with dementia-related psychosis, and is therefore not recommended for use.
• Can cause QT interval prolongation, hyperglycemia, dyslipidemia, weight gain, NMS, hepatotoxicity, fever, and anticholinergic toxicity. Should not be used with other anticholinergics.
• Adverse effects include sedation, dizziness, headache, tremors, tachycardia, hypotension, syncope, hypersalivation, sweating, dry mouth, visual disturbances, constipation, nausea, and fever.

Side Effects of Opioid Withdrawal

• Clonidine, buprenorphine (Subutex), and methadone can cause opioid withdrawal.
• Side effects include constipation, dizziness, light-headedness, fatigue, nausea and vomiting, impaired balance and coordination, loss of appetite, irritability, and dry mouth.

Side Effects of Diazepam

• Diazepam, a benzodiazepine used during alcohol withdrawal, can cause drowsiness, loss of coordination, headache, and blurred vision.
• Should not be taken with opiates, muscle relaxants, or alcohol due to the increased risk of lethal overdose.

Side Effects of Haldol

• Haldol, a typical antipsychotic, can cause constipation, dizziness, drowsiness, dry mouth, and EPS.

Extrapyramidal Symptoms (EPS)

• Include parkinsonism, dystonia, akathisia, and tardive dyskinesia.
• Symptoms: protrusion of the tongue, chewing motion, involuntary movements of the body and limbs, tremors, rigidity, shuffling gait, dysphagia, and drooling
• Monitor patients for EPS, document findings, and report to the physician. Provide comfort and reassurance, and assist with ADLs.
• Expect to administer Cogentin (benztropine), an anticholinergic medication, to counteract excess cholinergic activity and reduce acute dystonia and parkinsonism.
• Other treatments include anticholinergic medications (benztropine or diphenhydramine), lowering the dose or switching medications, and using beta-blockers or benzodiazepines.

Neuroleptic Malignant Syndrome (NMS)

• A potentially fatal syndrome that can occur at any time during therapy with neuroleptic (antipsychotic) medications, typically first-generation antipsychotics.
• Second-generation antipsychotics like risperidone, olanzapine, and quetiapine can also cause NMS.
• Signs and symptoms include dyspnea/tachypnea, tachycardia/irregular pulse, autonomic dysfunction (hyperpyrexia, hypertension, tachycardia, tachypnea, diaphoresis, drooling), high or low BP, excessive weakness or fatigue, altered LOC, seizures, severe EPS and adverse effects, skeletal muscle rigidity, difficulty swallowing, oculogyric crisis, elevated WBC count, liver function results, and creatine phosphokinase levels.
• Interventions include notifying the healthcare provider, monitoring vital signs, initiating safety and seizure precautions, discontinuing the medication, monitoring LOC, using a cooling blanket to lower temperature, monitoring electrolyte levels, administering IV fluids as ordered, and monitoring for DVT and rhabdomyolysis.

Dementia

• Signs and symptoms include memory loss, aphasia, disorientation, poor judgment and decision making, difficulty with complex tasks, difficulty with coordination (apraxia), mood changes, personality changes, hallucinations/delusions, apathy or social withdrawal, and loss of independence in daily living.

Dementia vs. Delirium

• Dementia has a gradual onset, while delirium has a sudden onset.
• Dementia is progressive and irreversible, while delirium is fluctuating and reversible.
• Dementia involves clear consciousness, while delirium involves altered consciousness.
• Dementia is caused by neurodegenerative conditions, while delirium is caused by medical conditions, medications, infections, or anesthetics.

Serotonin Syndrome

• A serious drug reaction resulting from too much serotonin activity in the brain and body.
• The risk for serotonin syndrome greatly increases when SSRIs are combined with MAOIs.
• OTC cold medicine or St. John's Wort use also increases risk.
• Can progress to seizures, rhabdomyolysis, kidney failure, or death if untreated.
• Symptoms include hyperactivity/restlessness, tachycardia, fever, hypertension, tremors, hyperreflexia, diaphoresis, dilated pupils, agitation, anxiety, confusion, altered mental status (delirium), mood swings, seizures, muscle rigidity, and abdominal pain.
• Interventions include notifying the healthcare provider, stopping SSRIs, SNRIs, MAOIs, TCAs, lithium, and triptans, monitoring vital signs, applying cooling measures if needed, administering IV fluids and oxygen, using benzodiazepines to control agitation and tremors, and administering serotonin antagonists (cyproheptadine).

Patient Falls

• Ensure immediate safety, call for help, assess the patient (including neuro vitals if there is a head injury), notify the healthcare provider and SDM, document the incident, reassess falls risk, and initiate falls risk interventions.

Conflict Resolution with Colleagues

• Use open, respectful communication, reflect on the issue, and approach the person directly, calmly, and professionally, in private.
• Maintain respectful communication and try to find common ground to work as a team, and be focused on goals.
• Involve a charge nurse for mediation if necessary.
• Remain focused on the shared goal of providing safe and compassionate patient care, even when there is no personal connection.

Managing Dementia Patients

• Use patience, compassion, and trauma-informed care.
• Common behaviors seen include wandering, agitation, repetition, sundowning, and aggression, often triggered by fear or unmet needs.
• Identify the cause of the behavior, such as pain, fear, or overstimulation.
• Use validation rather than confrontation, speaking slowly and clearly, and redirecting patients with gentle cues.
• Provide clear choices.
• Maintain a routine and provide a calm and supportive environment to reduce anxiety and agitation.
• Communicate changes in behaviors to the team and family, so care plans can be adjusted accordingly.

Managing Escalating Patients

• Provide choices and medications, and use de-escalation tactics.
• Prioritize safety, stay calm, use a low, non-threatening tone, and give the patient space if needed.
• Identify what triggered the escalation, and use de-escalation techniques such as active listening, offering choices, and validating feelings.
• Avoid arguing or crowding them.
• Call for team support if necessary.
• Administer medications such as antipsychotics or benzodiazepines as prescribed.
• After the incident, reflect on what happened, what could have been done better, and what was done well. Communicate with the team, and ensure the patient is supported emotionally and physically.

Professional Development Goals

• Completing continuing education includes ACLS, TIC, crisis training, PICS training, GPA, pieces, ASIST, etc.