MHM9S.pdf

11/16/23, 10:57 AM Realizeit for Student Summary Mood disorders interfere with a person’s life, plaguing the individual with drastic and long-term sadness, agitation, or elation. Accompanying self-doubt, guilt, and anger alter life activities, especially those that involve self-esteem, occupation,...

11/16/23, 10:57 AM Realizeit for Student Summary Mood disorders interfere with a person’s life, plaguing the individual with drastic and long-term sadness, agitation, or elation. Accompanying self-doubt, guilt, and anger alter life activities, especially those that involve self-esteem, occupation, and relationships. The primary mood disorders are major depressive disorder and bipolar disorder (formerly called manic-depressive illness). A major depressive episode lasts at least 2 weeks, during which the person experiences a depressed mood or loss of pleasure in nearly all activities. Several related mood disorders exist; one example is Premenstrual dysphoric disorder is a severe form of premenstrual syndrome and is defined as recurrent, moderate psychological and physical symptoms that occur during the week before menses and resolving with menstruation. Psychosocial stressors and interpersonal events appear to trigger certain physiological and chemical changes in the brain, which significantly alter the balance of neurotransmitters. Genetic studies implicate the transmission of major depression in first-degree relatives who are at twice the risk for developing depression compared with the general population. Neurochemical influences of neurotransmitters (chemical messengers) focus on serotonin and norepinephrine as the two major biogenic amines implicated in mood disorders. Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression, with the highest rates found among older clients. One psychodynamic theory example is: Children raised by rejecting or unloving parents are prone to feelings of insecurity and loneliness, making them susceptible to depression and helplessness. Major depression is twice as common in women and has a one-and-a-half to three times greater incidence in first-degree relatives than in the general population. An untreated episode of depression can last from a few weeks to months or even years, though most episodes clear in about 6 months. Some people have a single episode of depression, while 50% to 60% will have a recurrence of depression. Approximately 20% will develop a chronic form of depression. Electroconvulsive Therapy (ECT) involves application of electrodes to the head of the client to deliver an electrical impulse to the brain; this causes a seizure. It is believed that the shock stimulates brain chemistry to correct the chemical imbalance of depression. Generally, a minimum of six treatments are needed to see sustained improvement in depressive symptoms. Maximum benefit is achieved in 12 to 15 treatments. The goals of combined therapy are symptom remission, psychosocial restoration, prevention of relapse or recurrence, reduced secondary consequences such as marital discord or occupational difficulties, and increasing treatment compliance. The Hamilton Rating Scale for Depression is a clinician-rated depression scale used like a clinical interview. The clinician rates the range of the client’s behaviors, such as depressed mood, guilt, https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwuu… 1/5 11/16/23, 10:57 AM Realizeit for Student suicide, and insomnia. There is also a section to score diurnal variations, depersonalization (sense of unreality about the self), paranoid symptoms, and obsessions. Some nursing interventions for clients suffering from depression include: Provide for the safety of the client and others, institute suicide precautions if indicated, begin a therapeutic relationship by spending non-demanding time with the client, and/or promote completion of activities of daily living by assisting the client only as necessary. Major depression is a mood disorder that robs the person of joy, self-esteem, and energy. It interferes with relationships and occupational productivity. Symptoms of depression include sadness, disinterest in previously pleasurable activities, crying, lack of motivation, asocial behavior, and psychomotor retardation (slow thinking, talking, and movement). Sleep disturbances, somatic complaints, loss of energy, change in weight, and a sense of worthlessness are other common features. Medications are the primary therapy for major depression. These drugs fall into five major classes: selective serotonin reuptake inhibitors (SSRIs), serotonin/norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and atypical antidepressants. All of these classes are equally effective, as are the individual drugs within each class. Thus, differences among these drugs relate mainly to side effects and drug interactions. The risk for suicide may increase as clients begin taking antidepressants. Although suicidal thoughts are still present, the medication may increase the client’s energy, which may allow the client to carry out a suicide plan. SSRIs are considered to be first-line medications in the treatment of depression because they have a more favorable side effect profile (e.g., GI symptoms, sexual dysfunction, CNS stimulation, and increased risk of GI bleeding). SNRIs are similar to SSRIs in terms of therapeutic effects but exhibit more anticholinergic, CNS sedation, and cardiac conduction abnormalities. TCAs, second-line medications in the treatment of depression, produce a high incidence of adverse effects (e.g., sedation, orthostatic hypotension, cardiac dysrhythmias, anticholinergic effects, and weight gain). MAO inhibitors are used in the treatment of depression only if other antidepressants are not effective; there is a high incidence of food and drug interactions that potentially lead to hypertensive crisis. The nurse must carefully instruct clients receiving MAOIs to avoid foods containing tyramine because the combination produces a hypertensive crisis that can become life-threatening. Serotonin syndrome, a serious and sometimes fatal reaction characterized by hypertensive crisis, hyperpyrexia, extreme agitation progressing to delirium and coma, muscle rigidity, and seizures, may occur due to combined therapy with an SSRI or SNRI and an MAO inhibitor or other drug that potentiates serotonin neurotransmission. An SSRI or SNRI and an MAO inhibitor should not be given concurrently or within 2 weeks of each other. Fluoxetine, because of a long half-life, must be discontinued at least 5 weeks before starting an MAO inhibitor. Antidepressants must be taken for 2 to 4 weeks before depressive symptoms improve. Some antidepressant drugs are highly toxic and potentially lethal when taken in large doses. A BLACK BOX WARNING ♦ alerts health care provider to the increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwuu… 2/5 11/16/23, 10:57 AM Realizeit for Student Antidepressant discontinuation syndrome has been reported with sudden termination of most antidepressant drugs. Most authorities agree that there is insufficient evidence to support the use of St. John’s wort for treatment of depression. The FDA has issued a BLACK BOX WARNING ♦ for bupropion, because serious neuropsychiatric reactions have been reported with the administration of the drug for smoking cessation. Bipolar disorder ranks second only to major depression as a cause of worldwide disability. The lifetime risk for bipolar disorder is at least 1.2%, with a risk of completed suicide for 15%. Young men early in the course of the illness are at the highest risk for suicide, especially those with a history of suicide attempts or alcohol abuse as well as those recently discharged from the hospital. Clients often do not understand how their illness affects others. They may stop taking medications because they like the euphoria and feel burdened by the side effects, blood tests, and physicians’ visits needed to maintain treatment. Family members are concerned and exhausted by their loved ones’ behaviors; they often stay up late at night for fear that the manic person may do something impulsive and dangerous. The nurse analyzes assessment data to determine priorities and to establish a plan of care. Nursing diagnoses commonly established for clients in the manic phase are risk for otherdirected violence, risk for injury, imbalanced nutrition: less than body requirements, and/or ineffective coping. A few nursing interventions for a client experiencing mania include: Provide for the client’s physical safety and those around, set limits on the client’s behavior when needed, remind the client to respect distances between self and others, and/or use short, simple sentences to communicate. People with bipolar disorder cycle between mania, normalcy, and depression. They may also cycle only between mania and normalcy or between depression and normalcy. Clients with mania have a labile mood, are grandiose and manipulative, have high self-esteem, and believe they are capable of anything. They sleep little, are always in frantic motion, invade others’ boundaries, cannot sit still, and start many tasks. Speech is rapid and pressured, reflects rapid thinking, and may be circumstantial and tangential with features of rhyming, punning, and flight of ideas. Clients show poor judgment with little sense of safety needs and take physical, financial, occupational, or interpersonal risks. For clients with mania, the nurse must monitor food and fluid intake, rest and sleep, and behavior with a focus on safety until medications reduce the acute stage and clients resume responsibility for themselves. Remember that clients with mania may seem happy, but they are suffering inside. For clients with mania, delay client teaching until the acute manic phase is resolving. Schedule specific, short periods with depressed or agitated clients to eliminate unconscious avoidance of them. Do not try to fix a client’s problems. Use therapeutic techniques to help them find solutions. The foundation of treatment of mania has always been lithium (Lithobid). Today, many other drugs are used successfully in treating bipolar disorders, including atypical antipsychotics and antiepileptic agents. Lithium salts (Lithobid) are taken orally for the management of manic episodes and prevention of future episodes. These potentially toxic drugs can cause severe CNS, renal, and pulmonary problems that may lead to death. Despite the potential for serious adverse effects, lithium is used with caution because it is consistently effective in the treatment of mania. The therapeutically effective serum level is 0.5 to 1.2 mEq/L. Bipolar disorder is a mood disorder characterized by https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwuu… 3/5 11/16/23, 10:57 AM Realizeit for Student episodes of depression alternating with episodes of mania. There are two subtypes of this disorder, type I (characterized by episodes of major depression plus mania) and type II (characterized by episodes of major depression plus episodes of hypomania). Lithium is used to treat bipolar disorder. It is helpful for bipolar mania and can partially or completely eradicate cycling toward bipolar depression. Lithium is effective in 75% of clients but has a narrow range of safety; thus, ongoing monitoring of serum lithium levels is necessary to establish efficacy while preventing toxicity. Clients taking lithium must ingest adequate salt and water to avoid overdosing or underdosing because lithium salt uses the same postsynaptic receptor sites as sodium chloride does. Other antimanic drugs include sodium valproate, carbamazepine, other anticonvulsants, and clonazepam, which is also a benzodiazepine. Lithium is the drug of choice to treat bipolar disorder. Lithium has a narrow therapeutic index, and serum drug levels determine dosage, control of symptoms, and occurrence of adverse effects. The therapeutic range for the serum lithium level is 0.5 to 1.2 mEq/L. Symptoms of toxicity include severe diarrhea and vomiting, drowsiness, muscle weakness, and loss of coordination. Untreated, lithium toxicity leads to coma and death. Lithium is retained in the absence of sodium; thus, patients on a low-sodium diet are at greater risk of lithium toxicity. Other drugs useful in the treatment of bipolar disorder include atypical antipsychotics and some anticonvulsants. The FDA has issued a BLACK BOX WARNING ♦ for aripiprazole; use places the patient at risk for the development of compulsive or uncontrollable urges to gamble, shop, binge eat, or have sex. The FDA has issued a BLACK BOX WARNING ♦ concerning olanzapine because it can cause a drug reaction with eosinophilia and systemic symptoms. Suicidal thoughts are common in people with mood disorders, especially depression. Each year, more than 45,000 suicides are reported in the United States; this represents just under a 30% increase in the past two decades (Centers for Disease Control and Prevention [CDC], 2018). Active suicidal ideation is when a person thinks about and seeks ways to commit suicide. Passive suicidal ideation is when a person thinks about wanting to die or wishes he or she were dead but has no plans to cause his or her death. People with active suicidal ideation are considered more potentially lethal. Some suicides are done to place blame on a certain person, even to the point of planning how that person will be the one to discover the body. Most suicides are efforts to escape untenable situations. Nurses believe that one person can make a difference in another’s life. They must convey this belief when caring for suicidal people. Assisted suicide is a topic of national legal and ethical debate, with much attention focusing on the court decisions related to the actions of Dr. Jack Kevorkian, a physician who has participated in numerous assisted suicides. Those with a relative who committed suicide are at increased risk for suicide; the closer the relationship, the greater the risk. Most suicides happen on Monday mornings when most people return to work (another energy spurt). Research has shown that antidepressant treatment can actually give clients with depression the energy to act on suicidal ideation. Suicidal ideation means thinking of suicide. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwuu… 4/5 11/16/23, 10:57 AM Realizeit for Student People with increased rates of suicide include single adults, divorced men, adolescents, older adults, the very poor or very wealthy, urban dwellers, migrants, students, whites, people with mood disorders, substance abusers, people with medical or personality disorders, and people with psychosis. The nurse must be alert to clues to a client’s suicidal intent—both direct (making threats of suicide) and indirect (giving away prized possessions, putting their life in order, making vague goodbyes). Conducting a suicide lethality assessment involves determining the degree to which the person has planned his or her death, including time, method, tools, place, person to find the body, reason, and funeral plans. Nursing interventions for a client at risk for suicide involve keeping the person safe by instituting a no-suicide contract, ensuring close supervision, and removing objects that the person could use to commit suicide. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwuu… 5/5