Chapter 29

A disorder which is characterized by mood swings from profound depression to extreme euphoria (Mania), this coexists with periods of normalcy.

Mania: an alteration in mood that is expressed by feelings of elation, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

Mood SwingsChronic; recurringDelusions/ HallucinationsSeasonal pattern onsetMay require hospitalizationHighest lifetime suicide rate

High genetic relationship Imbalances in neurotransmitters Lesions or brain trauma in the limbic

system Medications (steroids/seizure

meds/antidepressants/ narcotics) Psychosocial- this theory is declining

due to the evidence based research which acknowledges this disease as a biological disease of the brain.

Substance abusePersonality DisordersAnxiety DisordersEating DisordersADHD

Milder clinical picture No marked occupational/ social impairment Cheerful and expanded personality Does not require hospitalization Rapid flow of ideas, hyperactivity, social

butterfly Does not include psychosis Increased libido Anorexia, weight loss, spending large amts

without thinking of any repercussions

Mood is elevated, expansive, irritable Euphoric, on a huge “high”, that changes

to anger or crying without any warning. Impaired occupation/social functioning

and relationships May become psychotic, thoughts are

disjointed, flight of ideas, pressured speech

Excessive/frenzied motor activity/no impulse control/ sexually manipulative

Hallucinations/ delusions Inexhaustible/ no sleep/ no eat!Hygiene and grooming neglectedDress may by flamboyant/ excessive

makeup/ bizarreYou feel pressured and nervous

talking to them and after your interview you are tired

This is an emergency because the client can have a severe clouding of consciousness with the mania symptoms intensifying

Confusion/ disorientation/panic Delusions of persecution/ grandeur/

religiosity Safety is at stake; they are so physically

exhausted and have been overworking their cardiovascular system for days.

Bipolar I

Bipolar II

Cyclothymic

Rapid Cycling

Upper socioeconomic class

Educational and Occupational status

Level of mood

Elated mood ▪ (hypomania)

▪ VS

MANIA, EUPHORIC▪ (manic)

Assess Behavior

Assess Thought Process Flight of ideas, speech, communication,c

lang associations, grandiosity

Assess Cognitive Functions Cognitive difficulties in psychosocial areas Impairment core features

Resists control

Splitting

Aggressively demanding

Setting limits

Shallow relationships

Danger to self and othersControlsHospitalizationMedical StatusCo-existing conditionPt/family education

See page 548 for excellent concept map on this!!!!

The client will: Exhibit no signs of physical injury Not harm self or others No longer exhibit physical anxiety/agitation Eat a balanced diet Accept responsibility for their behaviors Will sleep 6-8 hours a night Will not manipulate others for self

gratification

Any thoughts?

I’ll start:▪ Risk for violence: self directed or other

directed

▪ Short term goal- client will recognize increasing anxiety and will report this to staff for assistance

▪ Longterm goal- client will not harm self or others

Therapies once meds initiated Cognitive therapy ECT/TMS Basic interventions:

Reduce stimuli Lower lights in room Remove dangerous items from room/observe for

safety per unit protocal Provide finger foods/high calorie/ juice/ milk Set limits on manipulative behavior/ remain calm

Mood Stabilizers/ Lithium Carbonate

Initially mania treated with antipsychotics or Valproic Acid until Lithium level is therapeutic (7-10 days)

Therapeutic level Maintenance level

Normal side effects expected: Drowsy, headache, thirst, pulse irregularities,

polyuria, and weight gain ….look at Lithium as a SALT..it causes similar effects

Early Toxicity signs Ataxia, severe diarrhea, blurred vision, N/V, tinnitis

Advanced Toxicity signs Excessive dilute urine, tremors, seizure, impaired

consciousness, arrhythmias, coma, ..death

* There is a very slim margin between therapeutic and TOXIC

Levels must be checked weekly until therapeutic level reached, then monitored monthly during maintenance therapy.

So what do we do if the client is experiencing toxicity?

STOP THE LITHIUM The monitor for arrythmias Hydrate maintaining fluid and electrolyte

balance

Antiepileptics Depakote/ Tegretol/ Lamictal

These drugs are sometimes used while Lithium is reaching levels or may be used alone. It decreases the firing of neurons, therefore slowing down the client.

Anxiolytics- Clonazepam and Lorazepam Acute Mania / psychomotor agitation

Antipsychotics▪ Olanzapine▪ Quetiapine▪ Risperidone▪ (These can be used alone or with lithium)

Severe treatment resistant mania Rapid Cyclers Paranoid Acutely Suicidal

Used when meds have failed. ECT creates a grand mal seizure which “reboots” the brain. TMS are more specific waves of electricity to specific nerve cells, this does not cause a grand mal. TMS is one of the newer technologies being used.

Seclusion / Restraints (what is seclusion)

Rationale Documented Justification Complex therapeutic, ethical and legal

issues Restraint/ Seclusion policy/ Protocal

NEVER USED AS PUNISHMENT/ STAFF CONVIENENCE

Depression and Bipolar Support Alliance (DBSA)

National Alliance for the Mentally Ill (NAMI)

National Mental Health Association

Manic-Depressive Association

Drink???

Do drugs????

Why knowing their diagnosis do you think a bipolar client will become noncompliant with meds and then use substances?

MOVIE TIME!

http://www.youtube.com/watch?v=zEmZ8clcEUs&feature=related

Mostly application questions, what will you say??? Remember restate for clarification, set limits

Know the drugs and any client teaching ( ie MAOI, TCA etc). Meds that are used for EPS , anticholinergic effects, side effects

Treatments : ECT (interventions and monitoring) , seclusion (removing stimuli)

Documentation of care, planning care Client teaching for meds, resources, diet Nursing diagnosis priorities Chemical dependency, care of client, crisis

intervention