For acute mania: therapeutic level is 1-1.5 For maintenance: .6- 1.2 Not used in pregnancy.
Mood disorder bipolar order 8
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.
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.
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 neglected Dress may by flamboyant/ excessive makeup/ bizarre You 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.
Upper socioeconomic classEducational 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
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
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/ LamictalThese 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?
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