The Client with a The Client with a Mood DisorderMood Disorder

Disturbance of moodDisturbance of mood• Depression or elation(mania)• Bipolar disorder• Cyclothymic disorder• Dysthymic disorder

EtiologyEtiology• Theories: Genetics – approximately 7% of populations20% if close relative has disorderBiochemical: dysregulation in

norepinephrine & seratoninPsychoanalytic: anger turned

inward(Freud)

Bipolar DisorderBipolar Disorderacross the lifespanacross the lifespan

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Bipolar disorder (Manic episode)Bipolar disorder (Manic episode)

• Onset - before 30• Characterized by “abnormally and persistently

elevated, expansive, or irritable mood.”

Mental Status ASSESSMENT:• hyperactivity, euphoria,pressured speech• sarcasm,easily angered,aggressive,hostile• exaggerated or delusional self-confidence,• Flight of ideas, grandiose, persecutory delusions• Inappropriate dress/attire• Short-term depression –Risk for suicide

Assessment of Physiologic Integrity Assessment of Physiologic Integrity (Manic client))(Manic client))

May not eat or drink for daysExcessive or poor grooming/hygieneHas not slept for days & does not feel the

need to sleep (insomnia)FatigueExtremely poor judgment leading to Increased risk for injuryExhibits seductive or aggressive behaviorElectrolyte imbalance

Assessment of Psychologic Assessment of Psychologic Integrity(manic client)Integrity(manic client)

May have psychotic symptoms i.e hallucinations/delusions of grandeur

Labile mood swings (hostile/angry)Pressured speech/tangentialRacing thoughts –”flight of ideas”Risk for other directed violenceFlirtatious/seductive

PET Scan: Top Row = Normal BrainPET Scan: Top Row = Normal BrainMiddle Row = Hypomanic BrainMiddle Row = Hypomanic BrainBottom Row= Depressed BrainBottom Row= Depressed Brain

M. Phelps, L. Baxter, J. Mazziotta UCLAM. Phelps, L. Baxter, J. Mazziotta UCLA

Medical managementMedical managementanti-manic druganti-manic drug

• Lithium Carbonate(eskalith, lithane, lithotabs)• Starting dose – 600mg t.i.d.• Maintain blood serum level of 1.0 – 1.5 mEq/L• Check blood. Serum levels 2x’/WK. 12 HRS after

last dose is administered.• Maintenance dose levels:300mg t.i.d. –q.i.d.• Long term Maintenance level between 0.6 –1.2

mEq/L• Q Monthly checks

Lithium toxicityLithium toxicity• Toxicity levels: blood levels > 2.0

mEq/L• Signs/symptoms: tremorsNausea/vomitingThirstPolyuriaComa, seizures, cardiac arrest

Use of antiPsychotics to control delusions, agitation, psychotic behaviors include:

i.e. Haloperidol(haldol), Fluphenazine(prolixin),

Risperidone(risperdol)Perphenazine(trilifon)Quitipine(seroquel)Olanzapine(zyprexa)

Mood StabilizersMood Stabilizers• Valproic

Acid(Depakote) etc.

• Carbamazepine(Tegretol)

• Check liver functions (at start & q 6 mos.)

Can cause hepatic failure/life threatening pancreatitis

• Can cause aplastic anemia & agranulocytosis

(5-8x’s greater than population)

Mood stabilizers con’t.Mood stabilizers con’t.• Lamotrigine(Lamictal)

• Topiramate(Topamax)• Gabapentin

(Neurontin)• Oxcarbazepine (Trileptal)

• Can cause serious rashes > in children; Stevens-Johnson syndrome

• Common s/e’s all mood stabilizers:

Dizziness, hypotension, ataxia -

Monitor gait, & B/P, give w/food; Teach client about s/e’s

Nursing Interventions-Nursing Interventions-Bipolar ClientBipolar Client

• Determine what client is attempting to say• Help client to maintain focus/SET LIMITS• Offer finger foods/boxed, canned fluids• Provide quiet, non-stimulating environment• Stay with client/use silence as needed• Remove harmful objects (prevent injuries)• Accept hostility-do not argue/challenge client• Assist with ADL’S as needed,• Observe for s/e’s meds/AVOID DIURETICS• Provide Teaching re: med compliance• Maintain fluid/salt intake

Depression and SuicideDepression and Suicide

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Children with depressionChildren with depression

• Symptoms of depression in children may include:

• Apathy• Irritability and • Persistent Sadness

Client with Major Depression:Client with Major Depression: Effect on Physiologic Integrity& related Effect on Physiologic Integrity& related

Nursing DiagnosisNursing Diagnosis Early morning awakening-insomnia at night (Altered sleep

patterns) Fatigue Decreased grooming & ADL’s (self-care deficit)

Constipation (altered elimination patterns)

Anorexia w/wt. loss (altered nutrition<body requirements) Loss of sexual interest (Impaired role relationships) Psychomotor retardation (Impaired mobility/Activity

intolerance) Somatic complaints (Ineffective coping) Amenorrhea (Altered health patterns)

Effects on Psychologic integrity& Effects on Psychologic integrity& related Nursing Diagnosisrelated Nursing Diagnosis

Loss of ambition (avolition), Lack of interest (anhedonia) in activities/sex Feelings of boredom/sadness Feels helpless/hopeless/powerless/tearful Low self-esteem (Self esteem disturbance) Attention/concentration deficit & Difficulty w/decision making

(Altered thought process) Demanding/dependent behaviors Suicidal ideation- (Risk for suicide may ↑ as

depression begins to lift and energy returns)

Elderly Depressed clientElderly Depressed client• Compaints of impaired memory• Decreased attention/concentration• Increased forgetfulness/confusion/ somatic

complaints• Self-care deficits• Functional changes in daily activities• Highest suicide risk –older, single,

(widowed/divorced) white male/chronic illness/pain

• Somatic complaints & delusions

Nursing InterventionsNursing Interventions• Monitor I & O weight• Maintain routine/schedule of activities• Remove harmful objects/protect from self-

harm• Assess suicidal ideation/contract for

safety/ check client frequently( Risk increases as depression lifts!)

• Assist with ADL’s/hygiene/grooming• Encourage positive self-talk

““Suicide - it’s the only way out”Suicide - it’s the only way out”

Risk for Self-harm: suicideRisk for Self-harm: suicide

Assessment of Risk factors for Assessment of Risk factors for SuicideSuicide

Expression of hopelessness, helplessness, worthlessness

Client has a formulated planClient has the ability to carry out the

planThere is a history of previous

attempts or family historyRecent attempts have become more

painful,violent or lethal

Assessment of Risk factors for Assessment of Risk factors for SuicideSuicide

The client is white male adolescent or single, widowed,divorced male>55 years old, lives alone.

Client may be terminally ill, addicted or psychotic Clinet gives away personal belongings, settles

financial accounts, etc. Clinet is in the early stage of antidepressant

treatment and his/her mood & activity level has begun to elevate.

The client’s mood and activity level suddenly changes.

Medical management of Medical management of DepressionDepression

• ANTIDEPRESSANTS:• Tricyclic’s(TCA’s): Elavil,

Disipramine. Imipramine• MAOI’s: Marplan,Nardil

Parnate• Selective Serotonin

Reuptake inhibitors(SSRI’s) I.e. Prozac, Paxil, Celexa, Lexapro, Zoloft

• SNRI’s I.e. effexor• Miscellaneous: Remeron,

cymbalta,Wellbutrin

Antidepressant therapy (SSRI’s)Antidepressant therapy (SSRI’s)SSRI’s:Fluoxetine(Prozac)-

give in AMSertaline (Zoloft)

give in PM if drowsyParoxetine (Paxil)

give in PM if drowsyCitalopram(Celexa)Escitalopram

(Lexapro)

Monitor for:• Hyponatremia• sexual dysfunction• orthostatic B/P• Give w/food• Encourage

adequate fluids

Atypical antidepressantsAtypical antidepressants Venlafaxine(Effexor)

Duloxetine(Cymbalta)

Bupropion(Wellbutrin) Nefazodone(Serzone)

Mirtazapine(Remeron)

• May alter labs: AST ALT, alk phos, Createnine,gluc,lytes;

• Monitor for ↑B/P & HR • Can lower seizure

threshold; ↑B/P,HR• (as above)• Check labs:AST,ALT

LDH,chol,glu,Hct

• Sedation:Give in PM,monitor wt. gain,sex dysfunction,constipation

Tricyclic AntidepressantsTricyclic Antidepressants• Amitriptyline(Elavil)• Amoxapine(Asendin)

• Doxepin(Sinequan)• Imipramine(Tofranil)

• Desipramine (Norpramine)• Nortriptyline(Pamelor)

• Monitor & educate client: cholinergic s/e’s i.e. dry mouth, blurred vision, constipation,Ortho-B/P, **cardiac dysrhythmias/functionlethal in OD

*caution use in elderly

Monoamine Oxidase Monoamine Oxidase InhibitorsInhibitors

• Isocarboxazid (Marplan)

• Phenelzine (Nardil)• Tranlcypromine

(Parnate)

• Educate regarding: low tyramine diet

• potentially fatal drug to drug interactions i.e. Meperidine,

SSRI’s,TCA’s, amphetamine

*can be lethal in OD

The controversy of ECT The controversy of ECT treatmentstreatments

• Electroconvulsive Therapy Saves Lives. But 70 Years After It First Gained Currency as a Treatment For Major Depression, ECT Continues to Court Controversy

Electro Convulsive TherapyElectro Convulsive Therapy• Normal Pre-op preparation: NPO after

midnight• Informed consent• Remove hairpins, dentures, nail polish• Loose fitting clothing or hospital gown• Check vital signs after procedure• Reorient and assure any memory loss is

temporary• Assist to room or significant other if out -

patient

ECT of YesterdayECT of Yesterday

ECT treatments in 1950’sECT treatments in 1950’s• Patients received

treatment without anesthesia

• Held down by straps• Sometimes

experienced broken bones from violent seizures

• ECT later viewed negatively-seen as last resort treatment.

A case for A case for ECT ECT [as reported in the Washington Post July [as reported in the Washington Post July 24, 2007]24, 2007]

Mr. M. woke up at 5 a.m. one morning nearly 10 years ago and heard a message in his head telling him to kill himself. He wrote a goodbye note to his wife, then jumped off the back deck of their home, falling the 14 feet hard enough to wake her with the sound of his thud.

The 66-year-old organic chemist succeeded only in smashing his knees and skull. After surgery he was transferred to an intensive psychiatric care unit.

Mr. M. had been depressed for about six months. He suffered from poor sleep, and he told his wife that he could not go on vacation as he believed he could not walk. During his 4 month hospitalization, Mr. M received a several unsuccessful trials of antidepressants.

Mr. M. an older individual with "treatment-resistant" depression, decided to try ECT weeks after his psychiatrist and wife first urged him to do so. By the seventh of his 12 treatments, he felt his depression lift.

"He sat up and said, “I'm not depressed anymore”

Current use of ECTCurrent use of ECT• No longer viewed as a

last resort treatment• Patient receives

anesthesia• Controlled medical

environment• Specially trained

Doctors and Nurses• Maintenance therapy

prevents relapse• Effective in treating

major depression in older adults

Dealing with Inappropriate Dealing with Inappropriate behaviorsbehaviors

AGGRESSIVE BEHAVIORSAGGRESSIVE BEHAVIORSAssist client to identify feelings of

frustration/aggressionEncourage discussion of feelings rather

than acting outAssist client to identify precipitating

events/situations that lead to aggressive behaviors

Define consequences for selfAssist client to Identify previous coping

skillsAssist client in problem solving techniques

DE-ESCALATING TECHNIQUESDE-ESCALATING TECHNIQUES

Maintain safety of client/others/selfMaintain distance from client/use non-

threatening postureUse calm approach/communicate in a calm

manner/use clear tone of voiceIdentify client’s needsAvoid verbal strugglesProvide clear options/deal with behaviorsAssist with problem solving/decision

making

Dealing with Manipulative behaviorsDealing with Manipulative behaviors

Set clear,consistent, realisticAvoid power struggles/arguingAssist client to set limits on own

behaviorBe clear re: consequences associated

with exceeding set limits/follow through with the consequencesin non punitive manner if necessary

NCLEX Review QuestionsNCLEX Review Questionsthe client with a mood disorderthe client with a mood disorder

1.The nurse assesses a client with admitting diagnosis of Bipolar affective disorder mania. The symptom presented by the client that requires the nurses immediate interventions the client’s:

A. Outlandish behaviors/inappropriate dress.B. Grandiose delusions of being royal decendents

of King AuthorC. Non-stop physical activity and poor nutritional

intakeD. Constant incessant talking that includes sexual

innuendos and teasing the staff

2. The nurse needs to assess a client for depression. Identify the signs and symptoms that are most characteristic of this disorder. (Select all that apply)

A. DiarrheaB. ConstipationC. Sleep disturbanceD. Increased appetiteE. AnhedoniaF. Poor appetite

3. When assessing clients who are exhibiting a depressed episode and those who are exhibiting a manic episode of bipolar mood disorder; what characteristic common to both disorders is the nurse likely to note?

A. Suicidal tendencyB. Underlying hostilityC. DelusionsD. Flight of ideas

4. A 19 year-old client is brought to the ER after slashing both wrists. What is the nurse’s first concern?

A. Stabilization of the physical conditionB. Determine the causative factors

relevant to client’s wrist slashingC. Reduction of anxietyD. Obtain a detailed nursing history

5. Which assessment findings would lead the nurse to suspect that a client is at a high risk for suicide? (Select all that apply)

A. Hopelessness accompanied by withdrawalB. Several available supportsC. Marked degree of hostilityD. Mostly constructive coping mechanismsE. Continual abuse of alcohol &/or drugs F. History of multiple previous lethal attempts

6.What feeling tone is the nurse most likely to see the client demonstrate during a major depression with psychotic features?

A. SuspicionB. AgitationC. LonelinessD. Worthlessness

7. A female client with bipolar I disorder is noted to wear excessive make-up, brightly colored evening clothes that do not match, a vest, three different scarves, and several necklaces and bracelets. Several peers on the unit have been laughing about her appearance. Which nursing action would best preserve the client’s self-esteem?

A. Help the client change into more appropriate attire.

B. Explain to the peer group that the client has bipolar disorder.

C. Discuss issues of good groomingat the community meeting.

D. Tell the client that she must select less flamboyant clothing.

8. A priority nursing intervention for a client who underwent ECT treatment a half hour ago, would be:

A. Monitor vital-signsB. Offer oral fluidsC. Encourage group participationD. Evaluate ECT effectiveness

9. Which of the following statements made by a client regarding the medication Lithium indicate a need for additional client education regarding this treatment?

A. “I will drink 8 – 12 glasses of liquids daily.”B. “I will restrict my salt intake.”C. “I will take my medications with food.”D. “I will have my blood drawn as the physician

orders.”

10. The nurse is admitting a client with mania and a nursing diagnosis of imbalanced nutrition: less than body requirements as evidenced by reported inadequate food intake. When intervening with this client the nurse should: (select all that apply)

A. Offer 3 well-balanced meals per dayB. Provide high calorie snacksC. Arrange for “finger-foods” for the clientD. Offer food Q 15 minutes during the first

hour after admission to the unitE. Encourage the client to avoid activitiesF. Offer the client juice and cold beverages

11. A nurse prepares a plan of care for a client admitted for a manic episode. Identify the nursing diagnoses that would most likely be chosen?

(Select all that apply)A. Imbalanced nutrition: more than body

requirementsB. Sleep deprivationC. Risk for deficient fluid volumeD. Social isolationE. Disturbed thought process

12. Which of the following would the nurse assess as indicative of neuro-vegetative changes in a client with severe depression? (Select all that apply)

A. Loss of energyB. Flat affectC. Sleep disturbance/insomniaD. ConstipationE. PerseverationF. Loss of appetite/weight loss