515 Bipolar Disorder_FA23 notes view.pdf

11/6/23 Mood Disorders: Bipolar Disorder Bryan R. Hansen, PhD, RN, APRN-CNS Tamar Rodney, PhD, RN, PMHNP-BC, CNE 1 Objectives • Identify signs and symptoms of bipolar disorder. • Apply general principles in developing therapeutic interactions with patients with symptoms of both depression and man...

11/6/23 Mood Disorders: Bipolar Disorder Bryan R. Hansen, PhD, RN, APRN-CNS Tamar Rodney, PhD, RN, PMHNP-BC, CNE 1 Objectives • Identify signs and symptoms of bipolar disorder. • Apply general principles in developing therapeutic interactions with patients with symptoms of both depression and mania. • Analyze social and cultural factors that impact nursing care of patients with mood disorders. • Determine appropriate and realistic goals for intervening with patients with depression. • Determine appropriate and realistic goals for intervening with patients with bipolar disorder. • Design nursing interventions that address the symptoms of depression and mania. 2 Clinical Picture • Bipolar I disorder – Most severe form – Highest mortality rate of the three – At least 1 manic episode • Bipolar II disorder – At least 1 hypomanic episode – At least 1 major depressive episode • Cyclothymic disorder – Altermate with symptoms of mild to moderate depression for at least 2 years (adults) – Rapid cycling possible 3 1 11/6/23 Other Bipolar Disorders • Substance/medication-induced bipolar and related disorder • Bipolar and related disorder due to another medical condition • Other specified bipolar and related disorder • unspecified bipolar and related disorder 4 Case Study • Debra has just been admitted to the psychiatric inpatient unit. She can hardly stand in one place and runs up and down the unit, laughing in an hysterical manner. Her associations are rapid, frequently changing topics mid-sentence. Her speech is pressured. If the nurse asks for clarification, Debra becomes irritable and snaps back an angry reply. She has been making sexual overtures to the male patients on the unit. Debra has not eaten properly for 2 days, and she is slightly dehydrated. Debra had not slept for 3 days before the hospitalization. 5 Audience Response Question Can Debra be accurately diagnosed with manic episode? A. Yes. This is a manic episode. B. No. This is a hypomanic episode. C. No. There is not enough evidence to distinguish mania from hypomania in this case. D. Impossible to tell; there are not enough behavioral clues at this point. 6 2 11/6/23 Correct Answer • The answer is A: Yes. This is a manic episode. – First, unlike hypomania, the episode is serious enough that Debra has just been admitted to the psychiatric inpatient unit. – She can hardly stand in one place and is hysterical. – Her associations are rapid, frequently changing topics midsentence. – Her speech is pressured, then irritable when asked for clarification. – She has made inappropriate sexual overtures. – She has not eaten properly for 2 days and did not sleep for 3 days before the hospitalization. 7 Epidemiology • Up to 21% of patients with major depression may actually have undiagnosed bipolar disorder • Bipolar – about an equal gender ratio • Cyclothymia-usually begins in adolescence or early adulthood 8 Risk Factors • Biological factors – Genetic – Neurobiological – Neuroendocrine • Psychological factors • Environmental factors 9 3 11/6/23 Assessment • Mood • Behavior • Thought processes and speech patterns • Cognitive functioning 10 Assessment (Cont.) • Speech patterns – Pressured speech – Circumstantial speech – Tangential speech – Loose associations – Flight of ideas – Clang associations • Thought content – Grandiose delusions – Persecutory delusions 11 Case Study Discussion • What are some problems that can be avoided if your manic patient gets proper treatment? 12 4 11/6/23 Self-Assessment • Manic patient – Persuasive and persistent – Seeks frequent or constant attention – Splitting • Staff member actions – Frequent staff meetings to deal with patient behavior and staff response – Set limits consistently 13 Assessment Guidelines Bipolar Disorder • Danger to self or others • Need for protection from uninhibited behaviors • Need for hospitalization • Medical status • Coexisting medical conditions • Family’s understanding 14 Outcomes Identification • Acute phase – Prevent injury • Continuation phase – Relapse prevention • Maintenance phase – Limit severity and duration of future episodes 15 5 11/6/23 Planning • Medical stabilization • Maintaining safety • Nursing care 16 Depression • Care similar as with patients with Major Depressive Disorder 17 Planning: Acute Manic Phase • Medical stabilization • Maintaining safety • In-hospital nursing care • ECT may be considered during the acute phase • Seclusion or restraint may be used as a LAST RESORT after ALL other interventions have failed. – Considered a treatment FAILURE! 18 6 11/6/23 Nursing Care for Acute Mania (Hospitalization) • Medication management • Decrease physical activity • Increase food and fluid intake • Ensure at least 4-6 hours of sleep per night • Decrease stimulation • Set limits; insight can be poor • Refocus and redirect • Educate re: illness and medication treatment – Strategies for relapse prevention – Support and educate family – Express hope; share evidence • Anticipate altercations with others and intervene early 19 Implementation • Depressive episodes – Hospitalization for suicidal, psychotic, or catatonic signs – Medication concerns about bringing on a manic phase • Manic episodes – Hospitalization for acute mania (bipolar I disorder) – Communicating challenges and strategies 20 Pharmacological Interventions • Two main foci – Agitation – Mood stabilization 21 7 11/6/23 Pharmacological Interventions (Cont.) • Lithium carbonate – Indications – Therapeutic and toxic levels • Therapeutic blood level: 0.8 to 1.4 mEq/L • Maintenance blood level: 0.4 to 1.3 mEq/L • Toxic blood level: 1.5 mEq/L and above – Maintenance therapy – Contraindications 22 Case Study Discussion If your patient is started on lithium. Discuss what patient teaching about this medication the nurse should provide before the patient is discharged. 23 Anticonvulsant Mood Stabilizers • Valproate (Depakote) • Carbamazepine (Tegretol) • Lamotrigine (Lamictal) 24 8 11/6/23 Second-Generation Antipsychotics • Olanzapine (Zyprexa) • Risperidone (Risperdal) • Aripiprazole (Abilify) • Asenaprine (Saphris) • Cariprazine (Vraylar) • Lurasidone (Latuda) • Quetiapine (Seroquel, Seroquel XR) • Ziprasidone (Geodon) 25 First-Generation Antipsychotics • Chlorpromazine (Thorazine) • Loxapine (Adasuve) inhaled 26 Other Treatments • ECT • Teamwork and safety • Seclusion protocol • Support groups • Health teaching and health promotion 27 9 11/6/23 Advanced Practice Interventions • Cognitive-behavioral therapy (CBT) • Interpersonal and social rhythm therapy • Family-focused therapy 28 Evaluation • Evaluate outcome criteria • Reassess care plan • Revise care plan if indicated 29 Case Study • Debra has been laughing, talking rapidly, with pressured speech. She is running from one part of the unit to the other. Her interactions with the staff and patients are abrupt, and sometimes she violates the individual’s personal space. 30 10 11/6/23 Audience Response Question What nursing intervention do you predict is most appropriate for Debra’s behavior? A. Offer a PRN medication. B. Offer seclusion. C. Offer restraints. D. Offer to pace with the patient 31 Audience Response Question Debra has not been able to eat sufficient calories to sustain her increased activity. What nursing intervention would assist her? A. Provide a larger high-calorie meal. B. Distract her to encourage eating. C. Provide an increase in high-calorie snacks. D. Provide frequent portable food items. 32 References • Halter, M. J. (2018). Chapter 13: Bipolar and related disorders. In M. J. Halter & E. M. Varcarolis (Eds.), • Keltner, N. L. (2018). Chapter 26: Bipolar disorders. In N. L. Keltner & D. Steele (Eds.). Psychiatric nursing (8th ed., pp. 292-306). St. Louis, MO: Elsevier. 33 11