Chap 26 - Bipolar Disorders

Psychopharmacology

-Lithium -Anticonvulsants -Atypical antipsychotics

Medical conditions that cause Mania

-anoxia -hyperthyroidism -hemodialysis -lyme disease -hypercalcemia -AIDS -stroke -brain tumor -multiple sclerosis -normal-pressure hydrocephalus -other neurologic disorders

Drugs that can cause Mania

-antidepressants -steroids -anticholinergics -stimulants -levodopa

Which assessment data would be inconsistent with a diagnosis of mania?

Family report that the mood change occurred gradually over a 5-day period Rationale: Manic episodes usually begin suddenly, escalate rapidly, and last from a few days to several months. To meet diagnostic criteria, the symptoms must persist for at least 1 week (or less if hospitalization is required). Manic episodes are characterized by an elevated, expansive, or irritable mood. Judgment is impaired, social blunders occur, and involvement with alcohol and drugs is common.

Manic individuals attempt to control others and to achieve their goals through:

manipulatively praising others Rationale: A common technique directed toward controlling others, especially to achieve personal goals, is to manipulate the self-esteem of others through praise and compliments. Manic individuals can become verbally abusive when they are not having their needs met, but rarely do they resort to physical aggression or self-harm.

Key Nursing Interventions for a Manic Episode: Patient who can't sleep - manic patients experience insomnia

- provide a quiet place to sleep - structure patient's days so that there are fewer stimulating activities toward bedtime - don't allow caffeinated drinks before bedtime - assess the amount of rest that patients are receiving. Manic patients aren't capable of judging the need for rest, & exhaustion & death have resulted from lack of rest

Key Nursing Interventions for a Manic Episode: Patients too busy to eat - use the following interventions to maintain patient's body weight

- Provide patients w/foods that can be eaten on the run (sometimes referred to as finger foods) because some patients can't sit long enough to eat - Provide high-protein, high-calorie snacks for patients. A vitamin supplement might be indicated - Weigh patients regularly (sometimes weighing daily is needed)

Key Nursing Interventions for a Manic Episode: Other interventions

- Reinforce reality. Manic patients also experience disturbances in perception. The intervention strategies outlined for other patients w/disturbed perceptions are recommended for manic patients as well - Respond to legitimate complaints. Although many frivolous complaints arise, the nurse must respond to legitimate complaints to defuse irritability & develop trust - Redirect patients into more healthy activity. The bipolar patient's distractibility serves as an intervention tool when the patient engages in nonproductive behavior

Facts about Bipolar Disorder (BD)

1. average age of onset is early twenties for both men & women 2. BD I occurs about equally in men & women 3. up to 50% of patients w/BD are nonadherent w/meds 4. in a given year, BD I affects more than 0.6% of the adult population 5. in a given year, all BD affect more than 1.8% of the adult population

Problems with alcohol & drug abuse in patients with BD

1. decreased compliance w/antimanic meds 2. compromised treatment results 3. increased hospitalizations 4. poorer treatment outcomes 5. earlier onset of mood symptoms 6. higher rates of anxiety 7. more suicide attempts 8. more accidents

Facts about Bipolar Disorder (BD)

6. people w/BD account for about 1/4th (25%) of all completed suicides 7. about 37% of patients w/BD relapse in the first year, & only 24% regain a "normal" life 8. untreated, a person w/BD might experience 10 or more episodes over a lifetime 9. BD runs in families 10. chronic interpersonal & occupational difficulties are experiences by 60% of people w/BD

Which behavior is characteristic of a patient experiencing bipolar depression?

Carbohydrate craving Rationale: Bipolar depression symptoms tend to be atypical. Atypical depressions cause an intense craving for carbohydrates; other characteristic behaviors include hypersomnia not insomnia, hyperphagia not anorexia, and weight gain not weight loss.

Which assessment data would support a diagnosis of bipolar II disorder?

Hypomania Rationale: Bipolar II disorder diagnoses require evidence of a hypomanic episode. For a hypomanic episode to be diagnosed, the length of the episode must be at least 4 days in duration but not severe enough to warrant hospitalization. Paranoid delusions are not a diagnostic criterion

Compare working with patients experiencing depression and those with bipolar disorder. Both groups of patients will require:

assessment of eating and sleeping patterns Rationale: Both groups experience variances in eating and sleeping and will need careful assessments and monitoring. The depressed patient is not generally in need of escape precautions. Only the manic patient requires a low-stimuli environment. It is not a given that both type of patients are at risk for falls or seizures.

Lithium

Narrow therapeutic index: 0.6 - 1.2 mEq/L

Bipolar Disorder I (BD I)

Patient experiences swings between manic episodes & major depression. **Most significant of the bipolar disorders

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the patient is experiencing acute mania?

Provide nutrient-rich finger foods so the patient can eat while walking and talking Rationale: Providing portable, nutrient-rich foods will best support the patient nutritionally during an acute manic episode, which represents an enormous calorie expenditure. Offering only liquids prevents intake of whole foods. The patient is often too distracted and busy to eat. Requiring the patient to join the group at mealtimes is not realistic for a patient in acute mania.

What is the initial intervention implemented by the nurse when managing a manic patient whose behavior is disrupting a group therapy session?

Remaining involved with the patient while demonstrating a calm demeanor Rationale: When the nurse is able to remain calm instead of becoming angry, it helps both the manic patient as well as the other patients in the group. The remaining options may become appropriate, but they would not be the initial intervention.

Bipolar Disorder II (BD II)

Similar to BD I with the major exception that, they never experience a manic episode. Only experience hypomanic episode & major depression

Anticonvulsants

The most beneficial are valproates -divalproex sodium (Depakote) -carbamazepine (Tegretol) -lamotrigine (Lamictal) -gabapentin (Neurontin) -oxcarbazepine (Trileptal) -topiramate (Topamax)

It is most important for the nurse to include the significant others for which instruction when teaching a patient who is diagnosed with bipolar disorder?

Watching for impending signs of relapse such as sleeping difficulties and irritability Rationale: It is most important to be proactive and to act so as to avoid a crisis situation. The significant others can assist the patient with self-monitoring and can aid in timely intervention by the health care professional. Eating well, counseling, and notifying a health care provider are important but do not take priority in this situation.

Can a person fall within the bipolar spectrum but not meet the DSM-5 criteria for bipolar disorder?

Yes. People can have subsyndromal levels of symptomatology. You have probably met people whose emotions are up and down to the extreme, but they are able to function socially, occupationally, and so on. For example, the diagnosis of cyclothymia is not "bipolar," but it is in the bipolar spectrum.

Cyclothymic Disorder

a swing between a hypomanic episode & dysthymia. The swings in either direction are not severe enough to have a diagnosis of manic episode & major depression

A patient in acute mania is inappropriately humorous. Patients and staff are laughing at the patient's expense and embarrassment. The nurse should immediately:

distract the patient to engage in another activity apart from the group Rationale: Utilizing the distractibility of the patient therapeutically and advocating in removing the patient from the embarrassing situation should take priority. The nurse should advocate for the patient first and foremost, then address the issue with the group. Staff behavior should be addressed but does not have priority.

A nurse who understands the psychopathology of bipolar disorder is one who will:

distract the patient with a fashion magazine when she wants to order 15 pairs of shoes from a catalog Rationale: Therapeutic use of distraction is most helpful when a patient experiences acute mania and demonstrates the best understanding of the disease process. Encouragement in any nontherapeutic activities does not reflect understanding of the patient's disease process by facilitating rest. Small, frequent meals that are portable are best for the patient; simple verbal directions and interruption of flight of ideas are therapeutic. Behaviors such as humor on the part of the nurse may serve to further escalate or fuel the patient's mania and inappropriate behavior (looseness, grandiosity, intrusiveness).