Nursing Care of the Manic Patient – Flashcards
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Bipolar I Disorder
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Manic and major depressive episodes
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Bipolar II Disorder
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Hypomanic and major depressive episodes
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Cyclothymic Disorder
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Chronic mood disturbance of 2yr duration with multiple episodes of hypomania and dysthymia
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Dysthymia
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mood disorder where patient generally feels "low" less severe than major depression
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Schizoaffective Disorder
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Bipolar Subtypehnjm
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Diagnostic Criteria for Manic Episodes
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period of time where mood is abnormally and persistently elevated, expansive, or irritable (4+ days for hypomania 7 days for mania) + 3 symptoms listed (irritable mood must be 4 symptoms) + impairment in social or occupational relationships or needs hospitalization to prevent harm or psychosis is present + symptoms cannot be r/t substance use or medical condition
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Types of symptoms associated with Manic episodes
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Inflated self esteem decreased need for sleep pressured speech flight of ideas distractibility need to fulfill goal oriented actives or psychomotor agitation excessive involvement in pleasurable activities with the potential for harm
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"MANIC EPISODE" Mnemonicuiiklnmkjhvhkjmhvbmvnmb,no,mbbm,mb,m,b.mn,n.m. ,n..mn,. M. ,n, , ,
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Mood swings, Active/Aggressive behavior, Nothing is wrong, Impulsive/Intrusive behavior, Can't sit still or stop talking Euphoric mood, Poor judgement/Provocative behavior, Increased sexual interest, Substance abuse, Omnipotent feelings, Decreased need for sleep, Endless energy
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Hypomania
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3+ symptoms of mania for 4+ days associated w/ change in function noticed by others does not require hospitalization psychotic symptoms are NOT present
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Elevated Moodyujn. Vnbm. Bm. ,m. . ,M.knbknihl
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mood disturbance associated with feelings of euphoria; unusually cheerful or "high" w/ an infectious quality
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Expansive Mood
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mood disturbance characterized by unceasing and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions
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Irritable Mood
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mood disturbance that could be predominant or is exacerbated when desires are thwarted or when sleep deprivation sets in
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Labile Mood
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mood disturbance that occurs as pt rapidly shifts from one extreme to another
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Psychotic Symptoms in Mania
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Delusions or hallucinations
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Common delusions or hallucinations associated with Mania
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inflated sense of self worth inflated sense of power and control belief that superior knowledge is possessed belief that one has a "special" identity or privileged relationship with some deity or celebrity
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Rapid Cycling
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4+ episodes of illness within 12 months ***some pt's cycle several times per day! Also tends to develop later in course of illness
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Mixed episodes
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manic and depressive symptoms co-exist simultaneously present in the pt depressed mood is simply accompanied by Manic activation
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Facts about epidemiology
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2.6% (5.7 million) Americans over 18 have bipolar; 1.3% of the world affects men and women equally; does not vary by social classes, races, or ethnic groups median age of onset is 25yo
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How many bipolar pts experience symptoms prior to 20?
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one in five
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How early can some patients be diagnosed? Are there any benefits to early diagnosis?
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Younger pt generally have cyclothymia but can be diagnosed as bipolar in elementary school some evidence suggests early treatment can have positive effects on the severity and course of the disease
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How common is it for pts with cyclothymia to have a manic episode at some point?
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50% of pts
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Women with bipolar
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3x's more likely to experience rapid cycling generally have more depressive and mixed episodes
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Some consequences of a manic attack
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financial ruin, shame and guilt, family stress and conflicts, loss of dignity and damage to reputation, instability in occupational, family, or social roles and relationships
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Suicide in Bipolar Patients
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25-50% of pts with bipolar attempt suicide at least once 11-19% of bipolar pts succeed
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Direct Care Costs
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treatment costs r/t inpatient and outpatient care
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Indirect Costs
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costs of things caused by the bipolar pts ex: use of criminal system, lost of productivity of wage earners, homemakers, and caregivers, as well as those who commit suicide
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Etiology
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Genetics Neurotransmitter imbalance Stress Disturbed sleep and circadian rhythm patterns
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kindling
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theory is supported by the efficiency of anticonvulsant drugs
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Mania represents....?
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an attempt to ward off depression a symbolic effort to devour the environment so that threats are eliminated or controlled warding off of the effects of a dominant superego (Id takes over!)
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Other conditions associated with Mania
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substance abuse anxiety disorder thyroid problems (hyperthyroidism) Epilepsy Huntington's Disease Neurosyphylis cerebral neoplasms Traumatic brain injury Systemic lupus erythematosus
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Drugs associated with manic states
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amphetamines antidepreesants cocaine corticosteroids hallucinogens levodopa opiates
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Lithium Carbonate
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mood stabilizer, first line of treatment; effective in 70-80% of population, especially in preventing mania; may reduce risk of suicide
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How does Li work?
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stabilizes glutamate levels Too much - mania & Too little - depression *increase grey matter by 15% in cingulate and paralimbic areas which regulate attention and emotional control
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Lithium Therapy
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Narrow therapeutic index: 0.4-1.3mEq/l toxicity (1.5mEq/l) can be fatal (2.0mEq/l) *takes up to three weeks or more to see full effect **NOT rec. for first trimester or during breastfeeding
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What makes Li a tricky therapy option?
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Inverse relationship with sodium (Na)
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Side effects of Lithium
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fine tremor wt gain polyuria fatigue mental "dullness" ECG changes Hypothyroidism Nausea Metallic taste
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Symptoms of Lithium Toxicity
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nystagmus coarse tremor hypotension Irregular pulse impaired LOC Ataxia Slurred speech Vomiting/Diarrhea Seizures Cardiovascular collapse Coma/Death
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What anticonvulsants are used for the treatment of bipolar disorder?
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Depakote (calproate; valproic acid) Tegretol (carbamazepine) Lamictal (lamotrigine)
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Depakote (calproate; valproic acid)
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effects occur within 4-5 days avg dose: 500-1000mg/day Therapeutic range: 50-100mcg/mL so monitor blood levels Side effects: GI upset, wt gain, hair loss, Monitor LFT's and CBC's (thrombocytopenia can occur)
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Tegretol (Carbamazepine)
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Delayed onset of action until steady state is achieved Avg. dose: 400-1200mg/day Therapeutic range: 4-12mcg/mL Fatal complications: aplastic anemia; agranulocytosis; thrombocytopenia **don't use with drugs that also cause blood dyscrasias
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Lamictal (Lamotrigine)
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another "first line" treatment that's generally well tolerated associated w/ Steven Johnson's Syndrome
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Antipsychotics used for acute manic phase
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Seroquel (quetiapine) Zyprexa (olanzapine) Geodon (siprasidone) Abilify (apripiprazole) Risperdal (risperidone) Haldol (haloperidol)
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Medications to rapidly stabilize a manic pt
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Antipsychotics and benzodiazepines *typical cocktail: Haldol 5-10mg w/ Ativan 2mg ---Can also give EPS (cogentin, artane, benadryl)
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Antidepressant use in bipolar pts
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must be vary cautious bc they can induce mania!!
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Do bipolar people enjoy their medications?
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poor compliance... enjoy the high from coming off... generally realize destruction once back on meds again
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Integrated Family and Individual Therapy (IFIT)
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psychosocial intervention that can help pts maintain stability and avoid complications
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What are the components of IFIT?
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psycho-education individual therapy interpersonal therapy family therapy social rhythm therapy
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Assessment of Manic Patient
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Physical (priority) Risk for danger Mental Teaching needs
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Physical Assessment
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VS, nutrition & hydration, sleep pattern, untreated injuries, status of co-existing medical problems, elimination, hygiene, substance withdrawal symptoms
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When Assessing Risk for Danger to Self or Others things are to watch for include....?
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impaired impulse control and poor judgement inability to delay gratification and tolerate frustration past hx of violence verbal threats response to limit setting (Can you redirect pt?) hx of recent substance abuse
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Assessment of Mental Status
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Appearance; Attitude; Behavior; Speech; Mood/Affect; Thought processes; Thought content; Perceptions; Judgement; Insight
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Questions to ask when assessing teaching needs of bipolar pt and family members or friends?
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how much they know? Identify prodromal symptoms? Understand medications and legal issues with involuntary treatment? How to access help? How to access external resources?
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Nursing Diagnosises for Manic Pt's are centered around what topics?
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Safety Physical Integrity Psychosis Coping & Adaption Family Stressors
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Examples of safety related diagnosis
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Risk for injury Risk for violence
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Examples of physical integrity related diagnosis
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Sleep pattern disturbances Altered nutrition Fluid volume deficit Self-care deficit Altered elimination
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Psychosis diagnosis for manic patients
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Disturbed thought processes Altered perceptions
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Coping & Adaptation diagnosis for manic pts
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Ineffective/Defensive coping Impaired social interactions Noncompliance
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Diagnosis r/t family stressors in manic pts
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Altered family process Caregiver role strain Altered/Unjustified roles and dynamics
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Nursing Interventions for Manic patients
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Establish Pt to Nurse relationship Use therapeutic communication Maintain physiological integrity Therapeutic milieu management Encourage therapeutic activities Patient teaching
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Things to remember when establishing a Nurse-Patient relationship
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Expect to be provoked and put to the test bc setting limits/boundaries is challenging with manic pts Understand pt's limitations. And be realistic!! Safeguard the pt's dignity Avoid reinforcing "entertaining" (attention seeking) behaviors Avoid getting into control battles w/ pt (choose battles wisely!) Distractibility is a helpful tool Control personal feelings and responses Use firm, consistent approach while avoiding "staff splitting" situations
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Things to remember about therapeutic communication with a manic patient
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-VERY short attention span -use "firm kindness" -Speak calmly w/ low-pitched voice in a neutral tone -Offer simple, clear, short and direct instructions or explanations (best in low stimulus environments) -Model appropriate pace for talking
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To create a therapeutic milieu to meet the needs of the patient...
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Provide safe and comfortable environment with appropriate amount of stimulation Provide structure with flexibility Choose roommates carefully Maintain consistent schedule Provide outlets for excess energy
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Ideal Therapeutic Activities for the Manic Patient
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Outlet for excess physical energy Requires short amount of time Can be performed alone or with staff Requires minimal concentration, attention to detail, and adherence to rules Does NOT require the use of social skills, teamwork, or cooperation w/ others
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Nursing Interventions r/t physical risk factors
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Provide adequate nutrition and hydration (high protein, high carb finger foods and drinks frequently) Weigh pt daily Monitor I&O Provide rest periods and promote good sleep hygiene Monitor VS Assist with self care activities PRN
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Desired outcomes of pts with mania
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-remain safe w/o harming self or others -show self control in milieu activities and social interactions -take proper care of body (nutrition, sleep, activity, personal care) -act in a socially appropriate manner -demonstrate logical, reality based thought processes -take prescribed medications
