Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02


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Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02

  1. 1. Chapter 16 Mood Disorders Part II
  2. 2. Bipolar Disorder (Mania) <ul><li>Etiological implications </li></ul><ul><ul><li>Biological theories : </li></ul></ul><ul><ul><ul><li>Strong hereditary </li></ul></ul></ul><ul><ul><ul><li> implications </li></ul></ul></ul><ul><ul><ul><li>Biochemical influences : </li></ul></ul></ul><ul><ul><ul><li>Possible excess of </li></ul></ul></ul><ul><ul><ul><li> norepinephrine, serotonin, </li></ul></ul></ul><ul><ul><ul><li> and/or dopamine </li></ul></ul></ul>
  3. 3. Bipolar Disorder (Mania) (cont.) <ul><li>Biological theories (cont.) : </li></ul><ul><ul><li>Electrolytes </li></ul></ul><ul><li>Physiological influences </li></ul><ul><ul><li>Brain lesions </li></ul></ul><ul><ul><li>Medication side effects-most common steroids, also amphetamines, antidepressants, and high doses of anticonvulsants during manic episodes </li></ul></ul>
  4. 4. Bipolar Disorders (Mania) (cont.) <ul><li>Psychosocial theories </li></ul><ul><ul><li>Credibility of psychosocial theories has declined in recent years </li></ul></ul><ul><ul><li>Bipolar disorder viewed as brain disorder </li></ul></ul><ul><li>Theoretical integration </li></ul><ul><ul><li>Bipolar disorder likely results from an interaction between genetic, biological, and psychosocial determinants. </li></ul></ul>
  5. 5. Bipolar Disorder: Developmental Implications <ul><li>Childhood and adolescence </li></ul><ul><li>Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1%. </li></ul><ul><li>Diagnosis is difficult. </li></ul><ul><li>Guidelines for diagnosis and treatment have been developed by the Child and Adolescent Bipolar Foundation (CABF). </li></ul>
  6. 6. Bipolar Disorder: Developmental Implications (cont.) <ul><li>Childhood and adolescence (cont.) </li></ul><ul><li>The CABF recommends the use of FIND (frequency, intensity, number, </li></ul><ul><li>and duration) in making a </li></ul><ul><li>diagnosis of bipolar disorder </li></ul><ul><li>in children and adolescents. </li></ul>
  7. 7. Bipolar Disorder: Developmental Implications (cont.) <ul><li>Childhood and adolescence (cont.) </li></ul><ul><li>FIND: </li></ul><ul><ul><li>Frequency : Symptoms occur most days in a week </li></ul></ul><ul><ul><li>Intensity : Symptoms are severe enough to cause extreme disturbance </li></ul></ul><ul><ul><li>Number : Symptoms occur 3 or 4 times a day </li></ul></ul><ul><ul><li>Duration : Symptoms occur 4 or more hours a day </li></ul></ul>
  8. 8. Bipolar Disorder: Developmental Implications (cont.) <ul><li>Childhood and adolescence (cont.) </li></ul><ul><li>Symptoms include: </li></ul><ul><ul><li>Euphoric/expansive mood : Extremely happy, silly, or giddy. </li></ul></ul><ul><ul><li>Irritable mood : Hostility and rage, </li></ul></ul><ul><ul><li>often over trivial matters. </li></ul></ul><ul><ul><li>Grandiosity : Believes abilities to be </li></ul></ul><ul><ul><li>better than everyone else’s. </li></ul></ul><ul><ul><li>Decreased need for sleep : May only sleep 4 or 5 hours per night and wake up feeling rested. </li></ul></ul>
  9. 9. Bipolar Disorder: Developmental Implications (cont.) <ul><li>Childhood and adolescence (cont.) </li></ul><ul><li>Symptoms (cont.): </li></ul><ul><ul><li>Pressured speech : Loud, intrusive, </li></ul></ul><ul><ul><li>difficult to interrupt. </li></ul></ul><ul><ul><li>Racing thoughts : Rapid change of topics </li></ul></ul><ul><ul><li>Distractibility : Unable to focus on school lessons </li></ul></ul><ul><ul><li>Increase in goal-directed activity/psychomotor agitation : Activities become obsessive. Increased psychomotor agitation. </li></ul></ul>
  10. 10. Bipolar Disorder: Developmental Implications (cont.) <ul><li>Childhood and adolescence (cont.) </li></ul><ul><li>Symptoms (cont.): </li></ul><ul><ul><li>Excessive involvement in pleasurable or risky activities : Exhibits behavior that has an erotic, pleasure-seeking quality about it. </li></ul></ul><ul><ul><li>Psychosis : May experience </li></ul></ul><ul><ul><li>hallucinations and delusions. </li></ul></ul><ul><ul><li>Suicidality : May exhibit suicidal </li></ul></ul><ul><ul><li>behavior during a depressed or </li></ul></ul><ul><ul><li>mixed episode or when psychotic. </li></ul></ul>
  11. 11. Bipolar Disorder: Developmental Implications (cont.) <ul><li>Childhood and adolescence (cont.) </li></ul><ul><li>Treatment strategies: </li></ul><ul><ul><li>Psychopharmacology: </li></ul></ul><ul><ul><ul><li>Lithium </li></ul></ul></ul><ul><ul><ul><li>Divalproex </li></ul></ul></ul><ul><ul><ul><li>Carbamazepine </li></ul></ul></ul><ul><ul><ul><li>Atypical antipsychotics </li></ul></ul></ul>
  12. 12. Bipolar Disorder: Developmental Implications (cont.) <ul><li>Childhood and adolescence (cont.) </li></ul><ul><li>Treatment strategies (cont.): </li></ul><ul><ul><li>ADHD is most common comorbid condition </li></ul></ul><ul><ul><li>ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled </li></ul></ul>
  13. 13. Bipolar Disorder: Developmental Implications (cont.) <ul><li>Childhood and adolescence (cont.) </li></ul><ul><li>Treatment strategies (cont.): </li></ul><ul><ul><li>Family interventions: </li></ul></ul><ul><ul><ul><li>Psychoeducation about bipolar </li></ul></ul></ul><ul><ul><ul><li>disorder </li></ul></ul></ul><ul><ul><ul><li>Communication training </li></ul></ul></ul><ul><ul><ul><li>Problem-solving skills training </li></ul></ul></ul>
  14. 14. Nursing Process/Assessment <ul><li>Symptoms may be categorized by degree of severity </li></ul><ul><ul><li>Stage I—Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization </li></ul></ul><ul><ul><ul><li>Mood: cheerful and expansive </li></ul></ul></ul><ul><ul><ul><li>Cognition and perception: self- </li></ul></ul></ul><ul><ul><ul><li>exultation; easily distracted </li></ul></ul></ul><ul><ul><ul><li>Activity and behavior: increased </li></ul></ul></ul><ul><ul><ul><li>motor activity; extroverted; superficial </li></ul></ul></ul>
  15. 15. Assessment <ul><ul><li>Stage II—Acute mania: intensification of hypomanic symptoms; requires hospitalization </li></ul></ul><ul><ul><ul><li>Mood: euphoria and elation </li></ul></ul></ul><ul><ul><ul><li>Cognition and perception: fragmented, disjointed thinking; pressured speech; flight of ideas; hallucinations and delusions </li></ul></ul></ul><ul><ul><ul><li>Activity and behavior: excessive </li></ul></ul></ul><ul><ul><ul><li>psychomotor behavior; increased </li></ul></ul></ul><ul><ul><ul><li>sexual interest; inexhaustible energy; </li></ul></ul></ul><ul><ul><ul><li>goes without sleep; bizarre dress and </li></ul></ul></ul><ul><ul><ul><li>make-up </li></ul></ul></ul>
  16. 16. Assessment (cont.) <ul><li>Stage III—Delirious mania: A grave form of the disorder, characterized by severe clouding of consciousness and representing an intensification of the symptoms associated with acute mania. </li></ul><ul><ul><li>Has become relatively rare since </li></ul></ul><ul><ul><li>the availability of antipsychotic </li></ul></ul><ul><ul><li>medication </li></ul></ul>
  17. 18. Nursing Diagnosis <ul><li>Risk for Injury related to: </li></ul><ul><ul><li>Extreme hyperactivity </li></ul></ul><ul><ul><ul><li>Evidenced by: </li></ul></ul></ul><ul><ul><ul><ul><li>Increased agitation and lack of control over purposeless and potentially injurious movements </li></ul></ul></ul></ul>
  18. 19. Nursing Diagnosis (cont.) <ul><li>Risk for violence: Self-directed or other-directed related to: </li></ul><ul><ul><li>Manic excitement </li></ul></ul><ul><ul><li>Delusional thinking </li></ul></ul><ul><ul><li>Hallucinations </li></ul></ul>
  19. 20. Nursing Diagnosis (cont.) <ul><li>Imbalanced Nutrition less than body requirements related to: </li></ul><ul><ul><li>Refusal or inability to sit still long enough to eat </li></ul></ul><ul><ul><ul><li>Evidenced by : </li></ul></ul></ul><ul><ul><ul><ul><li>Loss of weight, amenorrhea </li></ul></ul></ul></ul>
  20. 21. Nursing Diagnosis (cont.) <ul><li>Disturbed thought processes related to: </li></ul><ul><ul><ul><li>Biochemical alterations in the brain </li></ul></ul></ul><ul><ul><ul><ul><li>Evidenced by </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>delusions of grandeur and persecution </li></ul></ul></ul></ul></ul>
  21. 22. Nursing Diagnosis (cont.) <ul><li>Disturbed sensory perception related to: </li></ul><ul><ul><li>Biochemical alterations in the brain and to possible sleep deprivation </li></ul></ul><ul><ul><ul><li>Evidenced by: </li></ul></ul></ul><ul><ul><ul><ul><li>auditory and visual hallucinations </li></ul></ul></ul></ul>
  22. 23. Nursing Diagnosis (cont.) <ul><li>Impaired social interaction related to: </li></ul><ul><ul><li>Egocentric and narcissistic behavior </li></ul></ul><ul><li>Insomnia related to: </li></ul><ul><ul><li>Excessive hyperactivity and agitation </li></ul></ul>
  23. 24. Criteria for Measuring Outcomes <ul><li>The client: </li></ul><ul><ul><li>Exhibits no evidence of physical injury </li></ul></ul><ul><ul><li>Has not harmed self or others </li></ul></ul><ul><ul><li>Is no longer exhibiting signs of physical agitation </li></ul></ul>
  24. 25. Criteria for Measuring Outcomes (cont.) <ul><li>The client (cont.): </li></ul><ul><ul><li>Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status </li></ul></ul><ul><ul><li>Verbalizes an accurate interpretation of the environment </li></ul></ul><ul><ul><li>Verbalizes that hallucinatory </li></ul></ul><ul><ul><li>activity has ceased and </li></ul></ul><ul><ul><li>demonstrates no outward </li></ul></ul><ul><ul><li>behavior indicating hallucinations </li></ul></ul>
  25. 26. Criteria for Measuring Outcomes (cont.) <ul><li>The client (cont.): </li></ul><ul><ul><li>Accepts responsibility for own behaviors </li></ul></ul><ul><ul><li>Does not manipulate others for gratification of own needs </li></ul></ul><ul><ul><li>Interacts appropriately with others </li></ul></ul>
  26. 27. Planning/Implementation <ul><li>Nursing interventions are aimed at: </li></ul><ul><ul><li>Maintaining safety of client and others </li></ul></ul><ul><ul><li>Restoring client nutritional status </li></ul></ul><ul><ul><li>Encouraging appropriate client interaction with others </li></ul></ul><ul><ul><li>Assisting client to define and test reality </li></ul></ul><ul><ul><li>Meeting client’s self-care needs </li></ul></ul>
  27. 28. Client/Family Education <ul><li>Nature of illness </li></ul><ul><ul><li>Causes of bipolar disorder </li></ul></ul><ul><ul><li>Cyclic nature of the illness </li></ul></ul><ul><ul><li>Symptoms of depression </li></ul></ul><ul><ul><li>Symptoms of mania </li></ul></ul>
  28. 29. Client/Family Education (cont.) <ul><li>Management of illness </li></ul><ul><ul><li>Medication management </li></ul></ul><ul><ul><li>Assertive techniques </li></ul></ul><ul><ul><li>Anger management </li></ul></ul>
  29. 30. Client/Family Education (cont.) <ul><li>Support services </li></ul><ul><ul><li>Crisis hotline </li></ul></ul><ul><ul><li>Support groups </li></ul></ul><ul><ul><li>Individual psychotherapy </li></ul></ul><ul><ul><li>Legal/financial assistance </li></ul></ul>
  30. 31. Evaluation <ul><li>Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria. </li></ul>
  31. 32. Evaluation (cont.) <ul><li>Has the client avoided personal injury? </li></ul><ul><li>Has violence to client or others been prevented? </li></ul><ul><li>Has agitation subsided? </li></ul>
  32. 33. Evaluation (cont.) <ul><li>Have nutritional status and weight been stabilized? </li></ul><ul><li>Have delusions and hallucinations ceased? </li></ul>
  33. 34. Treatment Modalities for Mood Disorders <ul><li>Psychological treatment </li></ul><ul><ul><li>Individual psychotherapy </li></ul></ul><ul><ul><li>Group therapy </li></ul></ul><ul><ul><li>Family therapy </li></ul></ul><ul><ul><li>Cognitive therapy </li></ul></ul>
  34. 35. Treatment Modalities for Mood Disorders (cont.) <ul><li>Organic treatments-may take up to 4 weeks for symptoms to subside! </li></ul><ul><li>Psychopharmacology </li></ul><ul><ul><li>For depression </li></ul></ul><ul><ul><ul><li>Tricyclic antidepressants </li></ul></ul></ul><ul><ul><ul><li>MAO Inhibitors </li></ul></ul></ul><ul><ul><ul><li>SSRIs </li></ul></ul></ul><ul><ul><ul><li>Others </li></ul></ul></ul><ul><ul><ul><ul><li>* Maprotiline * Mirtazapine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* Amoxapine * Nefazodone </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* Trazodone * Venlafaxine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* Bupropion * Duloxetine </li></ul></ul></ul></ul>
  35. 36. Treatment Modalities for Mood Disorders (cont.) <ul><li>Psychopharmacology (cont.) </li></ul><ul><li>For mania: </li></ul><ul><ul><li>Lithium carbonate </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Verapamil </li></ul></ul><ul><ul><li>Atypical antipsychotics </li></ul></ul>
  36. 37. Treatment Modalities for Mood Disorders (cont.) <ul><li>Electroconvulsive therapy </li></ul><ul><li>For depression and mania </li></ul><ul><ul><li>Mechanism of action: thought to </li></ul></ul><ul><ul><li>increase levels of biogenic amines </li></ul></ul><ul><ul><li>Side effects: temporary memory loss and confusion </li></ul></ul><ul><ul><li>Risks: mortality; permanent memory loss; brain damage </li></ul></ul><ul><ul><li>Medications: pretreatment medication; muscle relaxant; short-acting anesthetic </li></ul></ul>
  37. 38. Nursing Process: Suicide Assessment <ul><li>Epidemiological factors </li></ul><ul><ul><li>Marital status : </li></ul></ul><ul><ul><ul><li>Single, divorced, and widowed people have rates four to five times greater than those who are married </li></ul></ul></ul>
  38. 39. Nursing Process: Suicide Assessment (cont.) <ul><li>Epidemiological factors (cont.) </li></ul><ul><ul><li>Gender : Women attempt suicide more often; however, more men succeed </li></ul></ul><ul><ul><li>Age : Suicide highest in persons older than 50 years; adolescents also at </li></ul></ul><ul><ul><li>high risk </li></ul></ul>
  39. 40. Nursing Process: Suicide Assessment (cont.) <ul><li>Epidemiological factors (cont.) </li></ul><ul><ul><li>Religion : Protestants have significantly higher rates of suicide than Catholics and Jews. A strong feeling of cohesiveness within a religious organization seems to be an important factor. </li></ul></ul>
  40. 41. Nursing Process: Suicide Assessment (cont.) <ul><li>Epidemiological factors (cont.) </li></ul><ul><ul><li>Socioeconomic status : People in the highest and lowest social classes have higher suicide rates than those in the middle classes. </li></ul></ul><ul><ul><li>Professionals : Professional healthcare personnel and business executives are at the highest risk. </li></ul></ul>
  41. 42. Nursing Process: Suicide Assessment (cont.) <ul><li>Epidemiological factors (cont.) </li></ul><ul><ul><li>Ethnicity : Whites are at highest risk for suicide, followed by Native Americans, then by African Americans. </li></ul></ul>
  42. 43. Nursing Process: Suicide Assessment (cont.) <ul><li>Presenting symptoms/medical – psychiatric diagnosis </li></ul><ul><ul><li>Mood disorders (major depression and bipolar </li></ul></ul><ul><ul><li>disorders) are the most common disorders that precede suicide. </li></ul></ul><ul><ul><li>Other disorders include </li></ul></ul><ul><ul><ul><li>Anxiety disorders </li></ul></ul></ul><ul><ul><ul><li>Schizophrenia </li></ul></ul></ul><ul><ul><ul><li>Borderline personality disorder </li></ul></ul></ul><ul><ul><ul><li>Antisocial personality disorder </li></ul></ul></ul>
  43. 44. Nursing Process: Suicide Assessment (cont.) <ul><li>Suicidal ideas or acts </li></ul><ul><ul><li>Assess: Intent; plan; means; lethality of means; previous attempts </li></ul></ul><ul><ul><li>Verbal clues: </li></ul></ul><ul><ul><ul><li>Direct statements: “I want to die.” </li></ul></ul></ul><ul><ul><ul><li>Indirect statements: “I don’t </li></ul></ul></ul><ul><ul><ul><li>have anything to live for </li></ul></ul></ul><ul><ul><ul><li>anymore.” </li></ul></ul></ul>
  44. 45. Nursing Process: Suicide Assessment (cont.) <ul><li>Analysis of the suicidal crisis </li></ul><ul><ul><li>Interpersonal support system </li></ul></ul><ul><ul><li>The precipitating stressor </li></ul></ul><ul><ul><li>Relevant history </li></ul></ul><ul><ul><li>Life-stage issues </li></ul></ul><ul><ul><li>Psychiatric/medical/family history </li></ul></ul><ul><ul><li>Coping strategies </li></ul></ul>
  45. 46. Nursing Process <ul><li>Diagnosis/Outcome Identification </li></ul><ul><ul><li>Risk for suicide related to feelings of hopelessness and desperation </li></ul></ul><ul><ul><li>Outcome: The client has experienced no physical harm to self </li></ul></ul>
  46. 47. Nursing Process (cont.) <ul><li>Diagnosis/Outcome Identification (cont.) </li></ul><ul><li>Hopelessness related to absence of support systems and perception of worthlessness </li></ul><ul><li>Outcome: Expresses some optimism and hope for the future </li></ul>
  47. 48. Nursing Process (cont.) <ul><li>Planning/Implementation </li></ul><ul><ul><li>Establish a therapeutic relationship to convey acceptance of the person. </li></ul></ul><ul><ul><li>Communicate the potential for suicide to team members. </li></ul></ul><ul><ul><li>Stay with the person to convey support throughout the current crisis. </li></ul></ul>
  48. 49. Planning/Implementation <ul><li>Accept the person, which will show unconditional positive regard. </li></ul><ul><li>Listen to the person. </li></ul><ul><li>Secure a no-suicide contract (verbally or in writing) for a specified amount of time. </li></ul>
  49. 50. Intervention with the Outpatient Suicidal Client <ul><li>Do not leave the person alone. </li></ul><ul><li>Establish a no-suicide contract. </li></ul><ul><li>Enlist help of family and friends. </li></ul><ul><li>Schedule daily appointments. </li></ul><ul><li>Establish trusting relationship. </li></ul><ul><li>Talk directly about client’s plans for suicide. </li></ul><ul><li>Discuss current crisis situation. </li></ul><ul><li>Identify areas of client control. </li></ul><ul><li>Antidepressant medication. </li></ul>
  50. 51. Information for Family/Friends of Suicidal Client <ul><li>Take any hint of suicide seriously. </li></ul><ul><li>Report threats of suicide immediately. </li></ul><ul><li>Be a good listener; stay with the person. </li></ul><ul><li>Express concern about the person’s welfare. </li></ul><ul><li>Be aware of resources for assistance. </li></ul><ul><li>Restrict access to firearms or other means of self-harm. </li></ul><ul><li>Instill hope. Express love for the person. </li></ul><ul><li>Encourage professional help. </li></ul><ul><li>Be nonjudgmental. </li></ul>
  51. 52. Intervention with Families and Friends of Suicide Victims <ul><li>Encourage them to talk about the suicide. </li></ul><ul><li>Be aware of blaming or scapegoating. </li></ul><ul><li>Listen to feelings of guilt. </li></ul><ul><li>Encourage discussion of relationship with lost loved one. </li></ul><ul><li>Encourage grieving at own personal pace. </li></ul><ul><li>Discuss coping strategies. </li></ul><ul><li>Identify resources that provide support. </li></ul>
  52. 53. Nursing Process/Evaluation <ul><li>Evaluation of the suicidal client is an ongoing process accomplished through continuous reassessment of the client as well as determination of the goal achievement. </li></ul>
  53. 54. Nursing Process/Evaluation (cont.) <ul><li>Long-term goals for the suicidal client would be to: </li></ul><ul><ul><li>Develop and maintain a more positive self-concept </li></ul></ul><ul><ul><li>Learn more effective ways to express feelings to others </li></ul></ul><ul><ul><li>Achieve successful interpersonal relationships </li></ul></ul><ul><ul><li>Feel accepted by others and achieve a sense of belonging </li></ul></ul>