psych ch 17.pdf

Chapter 17: Bipolar and Related Disorders Mood is defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. Examples of mood: Depression, joy, elation, anger, anxiety Affect is described as the emotional reaction associated with an exper...

Chapter 17: Bipolar and Related Disorders Mood is defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. Examples of mood: Depression, joy, elation, anger, anxiety Affect is described as the emotional reaction associated with an experience. Bipolar Disorders Causes extreme mood swings that include emotional highs and lows with intervening periods of normalcy Degree of emotional highs and lows differs based on specific disorder Types of Bipolar Disorders Bipolar 1 Disorder (most often times requires hospitalization) ○ The client has at least one episode of mania alternating with major depression (ati book) ○ Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms ○ Mania is very specific to bipolar 1 disorder Mania is an alteration in mood that may be expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, racing thoughts, and accelerated speech (book) Do we need to know about criteria for a manic episode?? Pg. 447 ○ May also have experienced episodes of depression ○ Speech: loud, rambling, clanging, vulgar, poor judgment ○ Issues with weight loss, distracted, hyperactive, decreased need for sleep, inappropriate dress Bipolar 2 Disorder (less severe) ○ The client has one or more hypomanic episodes alternating with major depressive episodes (ati book) ○ Characterized by bouts of major depression with episodic occurrence of hypomania ○ Feelings of worthlessness, increased anger, decreased pleasure, negative view, insomnia, suicidal ideation ○ Has never met criteria for a full manic episode Cyclothymic Disorder ○ The client has at least 2 years or repeated hypomanic manifestations that do NOT meet the criteria for hypomanic episodes alternating with minor depressive episodes (ati book) ○ Chronic mood disturbance; At least 2 year duration ○ Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either bipolar 1 or 2 disorder Predisposing Factors Genetics Physiological influences ○ Brain lesions ○ Enlarged ventricles ○ Medication side effects Biochemical influences ○ Imbalance of several neurotransmitters (norepinephrine and serotonin are low) Psychosocial theories ○ Credibility of psychosocial theories has declined in recent years ○ Bipolar disorder is viewed as a disease of the brain ○ Link between childhood trauma Developmental Implications: Childhood and Adolescence Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1% Disruptive mood dysregulation disorder (DMDD) → when a child has non discrete mood episodes, chronic irritability, and temper tantrums (book) Most common comorbid condition is ADHD Treatment strategies ○ Monotherapy with atypical antipsychotic or mood stabilizer ○ ADHD stimulant agents may exacerbate mania ○ Family interventions (educate to not go off of medications abruptly) ○ Psychoeducation about bipolar disorder ○ Communication training ○ Problem-solving skills training Nursing Process/Assessment ○ Symptoms may be categorized by degree of severity Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization ○ Specific to bipolar 2 disorder ○ Cheerful mood ○ Rapid flow of ideas; heightened perception (rapid flow speech) ○ Increased motor activity Acute mania: Marked impairment in functioning; usually requires hospitalization ○ Elation and euphoria; a continuous “high” but can easily change to irritability, anger, sadness, and crying ○ Flight of ideas; accelerated, pressured speech (loquaciousness) ○ Hallucinations and delusions ○ Excessive motor activity ○ Social and sexual inhibition ○ Little need for sleep Delirious mania: serious form of the disorder characterized by severe clouding of consciousness and an intensification of the symptoms associated with acute mania ○ Labile mood; panic anxiety ○ Clouding of consciousness; disorientation ○ Frenzied psychomotor activity ○ Exhaustion and possibly death without intervention Clinical Manifestations of Mania: Symptoms of Mania: “D I G F A S T” ○ Distractibility and easy frustration ○ Irresponsibility and erratic uninhibited behavior ○ Grandiosity ○ Flight of ideas ○ Activity increased with weight loss and increased libido ○ Sleep is decreased ○ Talkativeness Nursing Diagnosis Risk for injury related to ○ Extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements Risk for violence: self-directed or other-directed related to ○ Manic excitement  ○ Delusional thinking ○ Hallucinations ○ Impulsivity Imbalanced nutrition less than body requirements related to ○ Refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea Disturbed thought processes related to ○ Biochemical alterations in the brain, evidenced by delusions of grandeur and persecution, as well as inaccurate interpretation of the environment Disturbed sensory perception related to ○ Biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations Impaired social interaction related to ○ Egocentric and narcissistic behavior Insomnia related to ○ Excessive hyperactivity and agitation Criteria for Measuring Outcomes: The following criteria may be used for measuring outcomes in the care of the patient experiencing a manic episode The patient: ○ Exhibits no evidence of physical injury ○ Has not harmed self or others ○ Is no longer exhibiting signs of physical agitation ○ Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status ○ Verbalizes an accurate interpretation of the environment ○ Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations ○ Accepts responsibility for own behaviors ○ Does not manipulate others for gratification of own needs ○ Interacts appropriately with others ○ Is able to fall asleep within 30 minutes of retiring ○ Is able to sleep 6 to 8 hours per night Planning/Implementation Risk for Violence: Self-Directed or Other-Directed ○ Remove all dangerous objects from the environment. ○ Maintain a calm attitude. ○ If restraint is deemed necessary, ensure that sufficient staff are available to assist. Impaired Social Interaction ○ Set limits on manipulative behaviors. ○ Do not argue, bargain, or try to reason with the client. ○ Provide positive reinforcement. Imbalanced Nutrition: Less than Body Requirements / Insomnia ○ Provide clients with high-protein, high-calorie foods. ○ Maintain an accurate record of intake, output, and calorie count. ○ Monitor sleep patterns. Patient and Family Education Nature of the illness ○ Causes of bipolar disorder ○ Cyclic nature of the illness ○ Symptoms of depression  ○ Symptoms of mania Management of the illness ○ Medication management ○ Assertive techniques ○ Anger management Support services ○ Crisis hotline ○ Support groups ○ Therapy ○ Legal/financial assistance Treatment Modalities for Bipolar Disorder The Recovery Model ○ Learning how to live a safe, dignified, full, and self-determined life in the face of the enduring disability which may, at times, be associated with serious mental illness. ○ Although there is no cure for bipolar disorder, recovery is possible in the sense of learning to prevent and minimize symptoms, and to successfully cope with the effects of the illness on mood, career, and social life. In bipolar disorder, recovery is a continuous process. ○ Client identifies goals. ○ Client and clinician develop a treatment plan. ○ Client and clinician work on strategies to help the individual manage the bipolar illness. ○ Clinician serves as support person to help the individual achieve the previously identified goals. Electroconvulsive therapy (ECT) ○ Must have informed consent, establish IV for medication administration, hooked up to EEG monitor, during the process you have someone doing the bag valve mask for extra oxygen, VS monitoring (lecture) ○ Typically done in series, 2-3x in one month (lecture) ○ May have short term memory loss ○ Episodes of mania may be treated with ECT when Client does not tolerate medication. Client fails to respond to medication. Client’s life is threatened by dangerous behavior or exhaustion. Mood-Stabilizing Agents Lithium ○ Works on the intracellular level ○ Concerned with lithium toxicity (very narrow therapeutic range) Anticonvulsant medications ○ (Ex. carbamazepine, valproic acid, lamotrigine, topiramate, oxcarbazepine) Second-generation atypical antipsychotics ○ (Ex. olanzapine, aripiprazole, lurasidone, quetiapine) ○ Lurasidone is good for bipolar depression (lecture) Calcium channel blockers ○ (Ex. Verapamil, diltiazem, nimodipine) ○ Take med with meals ○ Monitor BP and HR Client/Family Education Lithium  An imperfect substitute for sodium, anything that depletes sodium will make more receptor sites available to lithium and increase the risk for lithium toxicity (normal lithium level is 0.6-1.2) ○ Take the medication regularly Has lots of drug-drug interactions (like NSAIDS) ○ Lithium can cause sodium depletion so do not exclude sodium from your everyday diet ○ Drink six to eight glasses of water each day ○ Have serum lithium level checked as advised At initiation of tx, monitor levels every 2-3 days until stable and then every 1-3 months (at book) Notify physician if any of the following symptoms occur, s/s of lithium toxicity: ○ Persistent nausea and vomiting, Severe diarrhea, Ataxia, Blurred vision, Tinnitus, Excessive output of urine, Increasing tremors, Mental confusion Anticonvulsants Refrain from discontinuing the drug abruptly Avoid using alcohol and over-the-counter medications without approval from physician Report the following symptoms immediately: skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin or eyes Antipsychotics Do not discontinue drug abruptly Use sunblock when outdoors Rise slowly from a sitting or lying position Avoid alcohol and over-the-counter medications Continue to take the medication, even if feeling well Report the following symptoms to physician: ○ Sore throat; fever; malaise, unusual bleeding; easy bruising; skin rash, persistent nausea and vomiting ○ Severe headache; rapid heart rate, difficulty urinating or excessive urination, muscle twitching, tremors ○ Darkly colored urine; pale stools ○ Yellow skin or eyes ○ Excessive thirst or hunger ○ Muscular incoordination or weakness Verapamil Do not discontinue the drug abruptly Rise slowly from sitting or lying position to prevent sudden drop in blood pressure Report the following symptoms to physician: ○ Irregular heartbeat; chest pain ○ Shortness of breath; pronounced dizziness ○ Swelling of hands and feet ○ Profound mood swings ○ Severe and persistent headache Clicker Question 1 A suicidal client with a history of manic behavior is admitted to the emergency department. The client’s diagnosis is documented as bipolar 1 disorder: current episode depressed. What is the rationale for this diagnosis instead of a diagnosis of major depressive disorder? A. The physician does not believe the client is suffering from major depression. B. The client has experienced a manic episode in the past.  C. The client does not exhibit psychotic symptoms. D. There is no history of major depression in the client’s family. Clicker Question 2 In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? A. Risk for injury related to excessive hyperactivity B. Disturbed sleep pattern related to manic hyperactivity C. Imbalanced nutrition, less than body requirements, related to inadequate intake D. Situational low self-esteem related to embarrassment secondary to high-risk behaviors Clicker Question 3 The nurse is providing medication education to a client on lithium. Which information should be included? Select All That Apply. A. Major changes in sodium level can cause toxicity. B. Weight loss is a common side effect. C. Serum lithium levels will need to be checked throughout treatment. D. Lithium should be taken on a PRN basis. E. Severe mental confusion, ataxia, tremors, severe diarrhea are symptoms of toxicity. Clicker Question 4 4. A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? A. Do not skimp on dietary sodium intake. B. H1ave serum lithium levels checked every 6 months. C. Limit fluid intake to 1000 milliliter of fluid per day. D. Adjust the dose if you feel out of control.