Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
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    Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02 Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02 Presentation Transcript

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