Nursing Care of the Patient with Bipolar Disorder – Flashcards
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Manic Hypomanic Euthymia Dysthymia Major depressive episode
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Moods
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Can be current episode depressed or manic
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Bipolar 1
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Alteration between major depressive episode & hypomania Can never have had a manic episode before
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Bipolar 2
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Alteration between not-quite hypomania or dysthymia
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Cyclothymia
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Depressed or sad for 2 weeks plus 5 SIGECAPS
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Depressed Episode
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Sleep
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S
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Interest
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I
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Guilt
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G
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Energy
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E
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Concentrations
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C
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Appetite
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A
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Psychomotor retardation
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P
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Suicidal Ideation
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S
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One week of abnormally & persistent elevated, expansive or irritable mood & abnormally & persistently increased goal directed activity or energy plus 3 DIGFAST
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Manic Episode
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Distractible
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D
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Impulsive acts with painful consequences Opposite dystonia
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I
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Grandiosity Increased self-esteem
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G
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Flight of ideas Racing thought
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F
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Activity increased
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A
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Sleep decreased
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S
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Talkative Hyperverbal or pressured speech
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T
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4 days of euphoric, expansive or irritable mood with at least 3 DIGFAST symptoms Change in functioning but does not impair social or occupational functioning & does not require hospitalization No psychosis
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Hypomanic Episode
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Genetics Kindling effect Neurotransmitters Environmental
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Physiological
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The more times an episode happens, the easier it becomes for them to occur Building new pathways Early intervention is critical
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Kindling Effect
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Lack of a protein involved in neurons firing Some medications directed towards this
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Genetics
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Too much dopamine & norepinephrine Not enough serotonin & acetylcholine
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Neurotransmitters
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Differential diagnosis Mood disorder questionnaire (self) Young mania rating scale (clinician/used in research) Labs needed if on medications
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Assessments
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Neuroanatomical changes Medications side effects Metabolic diseases Neurological diseases
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Differential Diagnosis
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Frontotemporal lesions/tumor can cause secondary mania
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Neuroanatomical Changes
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Steroids for SLE/MS Amphetamine/stimulants Anticonvulsants Antidepressants Narcotics L-dopa
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Medication Side Effects
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Hyperthyroidism Cushing's disease
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Metabolic Diseases
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HIV Syphilis ADHD Brain injuries CVA TBI
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Neurological Diseases
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Self
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Mood Disorder Questionnaire
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Clinician Used in research
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Young Mania Rating Scale
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Early identification ; treatment of manic or depressed symptoms Barriers to treatment
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Health Promotion
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Mindful of sleep Not sleeping can be a trigger
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Early Identification ; Treatment of Manic or Depressed Symptoms
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Side effects of medications Mania can be enjoyable versus depression Life long treatment Dual diagnosis Anosognosia
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Barriers to Treatment
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Psychiatric diagnosis ; substance abuse
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Dual Diagnosis
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Lack of insight Unaware they are sick
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Anosognosia
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Risk for self harm Maintain safety
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Nursing Diagnosis Mania
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Lithobid/Eskalith Gold standard Lots of side effects Very effective Lab management Pill/capsule/liquid Fluid/electrolyte balance issues Naturally occurring salt Inverse relationship with sodium Not metabolized, excreted by the kidneys
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Lithium Carbonate; Lithium Citrate
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Decreased sodium intake increases lithium (toxicity) Substituted in neurons for sodium Change in diet/sweat/vomit/diarrhea can cause hyponaturemia
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Inverse Relationship with Sodium
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0.6-1.2 mEq/L
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Lithium Therapeutic Level
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Fine hand tremor Weight gain Dehydration GI Polydipsia Leukocytosis Teratogen
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Lithium Side Effects
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Nausea on ; off No vomit/diarrhea Nonspecific
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GI
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Thyroid Kidney
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Long Term Side Effects of Lithium
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Stress on the kidneys Especially if taken with: NSAIDs CCB Phenothiazides
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Nephrotoxicity
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BUN Creatinine TSH
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Labs
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Hold lithium May give fluids
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Lithium Toxicity
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Blurry vision Ataxia Tinnitus Persistent NVD
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1.5-2.0
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Confusion Giddiness Persistent gross tremor Psychomotor retardation Excessive urine output
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2.0-3.5
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Impaired LOC Nystagmus Arrhythmias Oliguria/anuria Acute renal failure Seizure Coma Death
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;3.5
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Antidepressants can trigger mania Atypical antipsychotics Anticonvulsant
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Mood Stabilizers
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Most approved to treat bipolar mania (monotherapy) Helps calm the agitation of mania while waiting for therapeutic drug level Need to weigh advantages/drawbacks of metabolic effects of the medication
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Atypical Antipsychotics
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Most commonly used Common to be on one or more or lithium to treat side effects but treat DoNT TiLt
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Anticonvulsants
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divalproex sodium (Depakote); valporic acid (Depakene) gabapentin (Neurontin) carbamazepine (Tegretol/Equero ER) oxcarbazepine (Trileptal) lamotrigine (Lamictal) topiramate (Topamax)
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DoNT TiLT
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Can come in sprinkles Enteric coated, not liquid Long acting
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Depakote
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Short acting
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Depakene
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GI Sedation Weight gain Blood dyscrasias Teratogen Hepatotoxicity
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General Side Effects of Anticonvulsants
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Alopecia PCOS (polycystic ovarian syndrome) Don't give to young woman
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Depakote Side Effects
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Stevens Johnson Syndrome Infection of the skin Looks like acne/rash or worse Difficult to control Can die
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Lamictal Side Effects
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50-100/125 (high in manic state) VAL
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Depakote/Depakene Therapeutic Levels
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Tegretol 4-12 mcG/mL TEG
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carbamazepine Therapeutic Levels
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LFT BUN
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Labs for Anticonvulsants
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Milieu therapy Level of care
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Therapeutic Measures
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Safety Reduce stimulation Limit setting Nutrition & sleep promotion
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Milieu Therapy
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Inpatient IOP PHP Day program VNA Clubhouse Peer recovery AA/NA/detox
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Level of Care
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Therapeutic communication
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Communication & Documentation
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Don't argue Concrete, firm, clear ; kind Set limits Distract Don't take things personally Acknowledge
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Therapeutic Communication
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Information technology Quality indicators TJC national patient safety goal
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Utilization of Resources
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Patient specific signs & symptoms of relapse & plan Person identified to help monitor for relapse Effective management of symptoms Coping skills
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Patient/Family Education & Referral
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Lithium Lithium & anticonvulsants
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Managing Side Effects of Medications
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Frequent lab monitoring Nutrition Precipitants to toxicity Precipitants to sub-therapeutic levels Caution medication that affect renal function
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Lithium
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Consistent amounts of sodium & water
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Nutrition
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Vomiting Diarrhea Low sodium diet
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Precipitants to Toxicity
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Too much water High sodium diet
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Precipitants to Sub-Therapeutic Level
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Pregnancy risk Weight gain Sedation
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Lithium & Anticonvulsants
