Chapter 14 BIPOLAR DISORDER Elsevier items and derived

Clinical Picture • Bipolar I Disorder • Bipolar II Disorder • Cyclothymia Elsevier items

Bipolar Disorder Characteristics • Symptoms of at least one episodes of mania, often accompanied by major depressive episodes • Bipolar Disorders are a group of mood disorders that include manic episodes, hypomanic episodes, mixed episodes, depressed episodes, and cyclothymic disorder • Clients with bipolar disorder experience the elevated mood symptoms seen in mania and hypomania Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3

Epidemiology Lifetime prevalence of bipolar disorder in the United States is 3. 9% • Bipolar I – more common in males • Bipolar II – more common in females • Cyclothymia – usually begins in adolescence or early adulthood Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4

Characteristics • Bipolar I disorder, manic: characterized by elation or irritability with excessive motor activity • Bipolar I disorder, mixed: characterized by mood swings ranging from depression to euphoria, with intervening periods of normal behavior • Bipolar II disorder: characterized by no manic or mixed episode but at least one hypomanic episode • Cyclothymic disorder: characterized by a chronic, fluctuating mood disturbance with frequent periods of hypomania and depression Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5

Mania • Inflated self-esteem or grandiosity • Decrease need for sleep • Pressured speech • Flight of ideas • Distractibility • Psychomotor agitation • Involvement in pleasurable activities Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6

Mania continued • Delusions (grandeur) • Hallucinations • Mood swings • Aggressive • Denial (nothing is wrong) • Irritability, intrusive • Can’t sit still Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7

Mania continued • Euphoric mood • Poor judgment, Provocative behavior • Increased sexual interest • Substance abuse • Omnipotent feelings • Endless energy Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8

Hypomania • Less extreme form of mania • Euphoric, feel wonderful, “on top of the world” • No psychotic features • Overly enthusiastic involvement in projects of an interpersonal, political, religious, or occupational nature. • Labile mood (euphoria to irritability) Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9

Hypomania continued • Increased sexual behaviors (flirting, making sexual overtures, multiple sexual relationships) • Dress flashy or seductive manner • Wear heavy make up • Pressured speech • Racing thoughts or flight of ideas Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 10

Mixed Episodes • Both mania and depression are present nearly every day in rapidly alternating succession over a period of at least a week. • Irritability and Agitation • Insomnia and appetite disturbance • Suicidal and psychotic thoughts Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11

Cyclothymic Disorder • Chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms • Begins in adolescence or early adulthood. • Free of severe symptoms that qualify for the diagnosis of manic disorder or major depressive disorder. • Moody, unpredictable, temperamental Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12

Etiology • Biological factors – Genetic – Neurobiological – Neuroendocrine • Psychological factors • Environmental factors Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 13

Assessment • Mood • Behavior • Thought processes and speech patterns – Flight of ideas – Clag associations – Grandiosity • Cognitive functioning Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 14

Self-Assessment • Manic patient – Manipulative – Aggressively demanding – Splitting • Staff member actions – Frequent staff meetings to deal with patient behavior and staff response – Set limits consistently Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 15

Assessment Guidelines Bipolar Disorder • Danger to self or others • Need for protection from uninhibited behaviors • Need for hospitalization • Medical status • Coexisting medical conditions • Family’s understanding Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16

Nursing Diagnosis • Risk for injury • Risk for violence (Other-directed or Self-directed) • Risk for suicide • Ineffective health maintenance related to hyperactivity • Disturbed sleep pattern • Disturbed thought process Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 17

Outcomes Identification • Acute phase – Prevent injury • Continuation phase – Relapse prevention • Maintenance phase Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18

Planning • Acute phase – Medical stabilization – Maintaining safety – Self-care needs • Continuation phase – – – Maintain medication adherence Psychoeducational teaching Referrals • Maintenance phase – Prevent relapse Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19

Implementation • Acute phase – highest priority is safety – Depressive episodes – Manic episodes • Continuation phase – Prevent relapse with follow-up care • Maintenance phase Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20

Nursing Interventions • Reduce environmental stimuli • Limit patient’s participation in group activities • Create a safe environment • Provide physical exercise as a substitute for increased motor activity • Avoid arguments or confrontations with the patient • Restrict caffeine intake • Limit the selection of clothing available • Keep the patient oriented to reality • Assist patient in focusing on a single task Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21

A Mnemonic for Symptoms of Bipolar Disorder “DIG FAST” • Distractability (unimportant things can easily divert your attention) • Indiscretion (impulsive pleasurable acts with painful consequences) • Grandiosity (or inflated ego) • Flight of ideas • Activity increase toward goals • Sleep deficits (less need for sleep) • Talkativeness (or feels pressured to keep on talking) Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22

Gordon’s Functional Health Pattern based on your client’s symptoms Nursing Diagnosis (NANDA) (Actual and/or potential) Include etiology and sign and symptoms Nursing Outcome Criteria (NOC) Measureable Goal during your shift Implementation (Independent and collaborative nursing intervention include further assessment, intervention and teaching) Rationale (Use APA citations) Evaluation Goal Met Goal not Met (If not met, what revisions would you make? ) Disrupted Nutritional. Metabolic Pattern of food and fluid consumption relative to increased metabolic need and pattern; indicators of lack of nutrient supply due hyperactivity and inattention Ineffective health maintenance related to hyperactivity as evidence by decrease need for food/fluid intake Patient will eat 50% to 75% of each meal, drink 4 to 6 glasses of fluids, plus snacks between meals with the aid of nursing interventions by (date) 1. Monitor 1. Minimize dehydration and electrolyte imbalance 2. Constant fluid and calorie are needed. Patient may be too active to sit during meals. 3. Unaware of nutritional needs and easily distracted. Goal met: Patient ate 75% of lunch today. Drinking fluids with reminders. Ate a few bites of snacks, then started preaching to other patients and pacing the unit. Care Plan intake, output and vital signs daily. 2. Encourage frequent high calorie protein drinks and finger food such as … 6 times a day. 3. Frequently remind patient on a daily basis to eat every meal and snacksan imprint of Elsevier Inc. Elsevier items and derived items © 2010, 2006 by Saunders, 23

Pharmacological Interventions • Lithium carbonate – Indications – Therapeutic and toxic levels • Therapeutic blood level 0. 8 to 1. 4 m. Eq/L • Maintenance blood level 0. 4 to 1. 3 m. Eq/L • Toxic blood level: 1. 5 to 2. 0 m. Eq/L – Maintenance therapy – Contraindications Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 24

Lithium Toxicity – Symptoms of Li Toxicity • Levels 1. 3 to 1. 5 m. Eq/L - Fine hand tremors, nausea, vomiting, diarrhea, confusion, ataxia, slurred speech, lethargy, thirst and polyuria, muscle weakness. • Nursing Consideration: Medication should be withheld, Assess patient for toxicity symptoms, blood levels measured, and evaluate dosage. Dehydration should be addressed. • Levels 1. 6 to 2. 0 Course hand tremors, GI upset, mental confusion, muscle hyperirritability, incoordination, sedation. • Nursing Consideration: See above • Levels > 2. 1 to 3. 0 m. Eq/L – Ataxia, Confusion, blurred vision, hypotension, Profound CNS depression, arrythmia, seizures, coma, death due to pulmonary complications • Hemodialysis may be used in severe cases. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 25

Anticonvulsant Drugs • Valproate (Depakote) • Carbamazepine (Tegretol) • Lamotrigine (Lamictal) Elsevier items and

Valproic Acid • Divalproex Sodium - Depakote® - (enteric coated) • Valproic Acid Syrup – Depakene® syrup • Valproic Acid – Depakene® (250 - 1, 500 mg/d) Therapeutic Range: (50 – 125 µg/m. L) for Mania – Side effects: • GI distress N/V/D - give with food • Drowsiness -give at bedtime • Tremor • Alopecia - zinc and selenium supplements • Weight gain - diet and regular exercise – Black box warnings: Hepatoxity, pancreatitis, teratogenicity Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 27

Mood Stabilizers continued • Carbamazepine - Tegretol® (200 - 1, 60 o mg/d) – Therapeutic Range: (4 – 12 m. L) – Anticonvulsant, bipolar disorder, trigeminal neuralgia – Side effects: sedation, dizziness, anticholinergic, rash, weight gain, hepatic dysfunction, leukopenia (rare) • Lamotrigine - Lamictal® (50 - 500 mg/d) – Anticonvulsant – Side effects: rash, dizziness, headache, sedation • Oxcarbazepine - Trileptal® (600 - 2, 400 mg/d) – Anticonvulsant – Side effects: sedation, dizziness, headache, nausea and vomiting Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 28

Antianxiety Drugs • Clonazepam (Klonopin) • Lorazepam (Ativan) Atypical Antipsychotics • Olanzapine (Zyprexa) • Risperidone (Risperdal) Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 29

Other Treatments • Electroconvulsive therapy (ECT) • Milieu management • Support groups • Health teaching and health promotion Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 30

Medication Teaching • Proper client education enhances the effectiveness of medication therapy and can improve client adherence and diminish non-adherence • Client education begins when medication therapy begins and is repeated during the course of the client’s hospitalization • Give instructions verbally and in writing • Include family members or significant others if they will supervise home administration Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 31

Advanced Practice Interventions • Psychotherapy – Cognitive-behavioral therapy (CBT) – Interpersonal and social rhythm therapy Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 32