Chapter 17 "Bipolar and Related Disorders" NEW
Anticonvulsant
Increased CNS Depressant, Monitor if given with pain management
Ca Channel Blocker
May be given if Lithium controversial Verapamil (Calan/ Isoptin)
Management of Illness
Medication management such as dosage, SE, required blood tests, and not to stop meds abruptly, assertive techniques, and anger management
Side Effects General:
N/V, somnolence, dizziness, Blood Dyscrasias, diplopia, H/A, Increased PTT
Imbalanced Nutrition (Nursing Diagnosis)
Related to refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea.
the nurse is developing a plan of care for a newly admitted clietn with bipolar disorder. what is the most important for the nruse to include in the cleitns plan of care 1. obtain meds for sleep 2. work on solving a problem 3. exercise before bedtime 4. develop a sleep ritual
1 client with bipolar demonstrates extreme hyperactivity and a distrubed sleep pattern manifested by difficulty falling asleep and staying asleep
the nurse teaches a client with bipolar disorder effective coping strategies. the nurse determines that teaching was successful when the client states 1. i can decide what to do to prevent family conflict 2. i can handle problems without asking for any help 3. i can stay away from my friends when i feel distressed 4. i can ignore things that go wrong instead of getting upset
1 focus on strengths and abilities to prevent family conflict
10. A client experiencing mania states, "Everything I do is great." Using a cognitive approach, which nursing response would be most appropriate? 1. "Is there a time in your life when things didn't go as planned?" 2. "Everything you do is great." 3. "What are some other things you do well?" 4."Let's talk about the feelings you have about your childhood."
1. By asking, "Is there a time in your life when things didn't go as planned?" the nurse is using a cognitive approach to challenge the thought processes of the client.
11. A newly admitted client is experiencing a manic episode. The client's nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client? 1. Chicken fingers and French fries. 2. Grilled chicken and a baked potato. 3. Spaghetti and meatballs. 4. Chili and crackers.
1. Chicken fingers and French fries are finger foods, which the client would be able to eat during increased psychomotor activity, such as pacing. Because these foods are high in caloric value, they also meet the client's increased nutritional needs.
23. A client prescribed lithium carbonate (Lithium) 300 mg qam and 600 mg qhs presents in the ED with impaired consciousness, nystagmus, arrhythmias, and a history of recent seizure. Which serum lithium level would the nurse expect to assess? 1. 3.7 mEq/L. 2. 3.0 mEq/L. 3. 2.5 mEq/L. 4. 1.9 mEq/L.
1. Clients with a serum lithium level greater than 3.5 mEq/L may show signs such as impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, or cardiovascular collapse.
15. A client diagnosed with bipolar I disorder, most recent episode manic, is now ready for discharge. Which of the following resource services should be included in discharge teaching? Select all that apply. 1. Financial and legal assistance. 2. Crisis hotline. 3. Individual psychotherapy. 4. Support groups. 5. Family education groups.
1. During a manic episode, clients are likely to experience impulse control problems, which may lead to excessive spending. 2. Clients diagnosed with bipolar disorder can experience hyperactivity or depression, which may lead to ambivalence regarding his or her desire to live. Having access to a crisis hotline may help the client to de-escalate and make the difference between life and death decisions. 3. During a manic episode, a client most likely would have had difficulties in various aspects of interpersonal relationships, such as with family, friends, and coworkers. Individuals experiencing mania may be difficult candidates for psychotherapy because of their inability to focus. When the acute phase of the illness has passed, the client may decide to access an available resource to deal with interpersonal problems. Psychotherapy, in conjunction with medication maintenance treatment, and counseling may be useful in helping these individuals. 4. During a manic episode, a client would not be a willing candidate for any type of group therapy. However, when the acute phase of the illness has passed, this individual may want to access support groups to benefit therapeutically from peer support. 5. During a manic episode, a client may have jeopardized marriage or family functioning. Having access to a resource that would help this client restore adaptive family functioning may improve not only relationships but also noncompliance issues and dysfunctional behavioral patterns, and ultimately may reduce relapse rates. Family therapy is most effective with the combination of psychotherapeutic and pharmacotherapeutic treatment.
28. A client diagnosed with bipolar affective disorder is prescribed divalproex sodium (Depakote). Which of the following lab tests would the nurse need to monitor throughout drug therapy? Select all that apply. 1. Platelet count. 2. Aspartate aminotransferase (AST). 3. Fasting blood sugar (FBS). 4. Alanine aminotransferase (ALT). 5. Serum depakote level.
1. Platelet counts need to be monitored before and during therapy with Depakote because of the potential side effect of blood dyscrasias. 2. Aspartate aminotransferase is a liver enzyme test that needs to be monitored before and during therapy with Depakote because of the potential side effect of liver toxicity. 4. Alanine aminotransferase is a liver enzyme test that needs to be monitored before and during therapy with Depakote because of the potential side effect of liver toxicity. 5. Depakote levels need to be monitored to determine therapeutic levels and assess potential toxicity.
27. A client on an in-patient psychiatric unit is prescribed lamotrigine (Lamictal) 50 mg qd. After client teaching, which client statement reflects understanding of important information related to lamotrigine? 1. "I will call the doctor if I miss more than 5 days before restarting the medication." 2. "I will schedule an appointment for my blood to be drawn at the lab next week." 3. "I will call the doctor immediately if my temperature rises above 100°F." 4."I will stop my medication if I start having muscle rigidity of my face or neck."
1. When the medication is titrated incorrectly, the risk for Stevens Johnson syndrome increases. Clients need to be taught the importance of taking the medication as prescribed and accurately reporting adherence.
Mild toxicity:
1.5 -2.0mEq/L Greater Blood Level than1.5 mEq/L is toxic -Ataxia -Blurred vision -Severe diarrhea -Persistent N/V -Tinnitus
a client taking lithium asks the nurse why she has to have her blood drawn for a lithium level. what is the nurses most appropriate response 1. lithium levels are obtained to determine if you have any liver and renal damage 2. lithium levels demonstrate whether you are taking a therapeutic dose range of the drug 3. lithium levels indicate whether the drug has passed through your blood brain barrier 4. lithium levels are unnecessary if you commit to taking the drugs as ordered
2
55. The wife of a patient being treated with lithium for bipolar disorder states to the nurse, "My husband has been on lithium for 3 days and he's still as manic as ever." Which of the following is important for the nurse to include in patient/family education about lithium? 1) Lithium prevents relapse into depression but has no direct effects on manic episodes. 2) Lithium takes up to 3 weeks to reach peak effectiveness. 3) Lithium is a neurotransmitter that can trigger mania in some individuals. 4) Lithium can be rendered ineffective if the patient restricts sodium intake.
2) Lithium takes up to 3 weeks to reach peak effectiveness. This statement is true and is important for families and patients to understand so they don't prematurely interpret the medication to be ineffective.
33. A suicidal client with a history of manic behavior is admitted to the ED. The client's diagnosis is documented as "bipolar I disorder: depressed." What is the rationale for this diagnosis versus a diagnosis of major depressive disorder? 1) The physician does not believe the client is suffering from major depression. 2) The client has experienced a manic episode in the past. 3) The client does not exhibit psychotic symptoms. 4) There is no history of major depression in the client's family.
2) The client has experienced a manic episode in the past. According to the DSM-5 criteria, a manic episode rules out the diagnosis of major depressive disorder.
1. Which statement about the development of bipolar disorder is from a biochemical perspective? 1. Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is about 28%. 2. In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium. 3. Magnetic resonance imaging reveals enlarged third ventricles, subcortical white matter, and periventricular hyperintensity in those diagnosed with bipolar disorder. 4. Twin studies have indicated a concordance rate among monozygotic twins of 60% to 80%.
2. Alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium, is an example of a biochemical perspective in the development of bipolar disorder.
Moderate toxicity
2.0-3.0 mEq/L -Increased tremors -Muscle irritability -Psychomotor retardation -Confusion -Giddiness
the nurse is assessing the behavior of a client with hypomania. what behavior would the nruse expect form this client 1. on the verge of deprssion and the potential for a crisis 2. indecsive and vaillitating with a dminished ability to walk 3. irritable, with an elevated mood and increased motor activity 4. disorgazied, tending to exhibit impaired judgement
3
a nurse is teachign a client with bipolar disorder about the drug carbamazepine. the nurse determines that teachign was effective when the cleint states: 1. my hair will fall out after i take this med for a few months 2. i will drink plenty of water so i dont develop kidney problems 3. i need to have my blood counts checked periodically 4. i cant take anny other drugs while i am taking this one
3 most dangerous adverse effect of carbamazepine is bone marrow depression
12. A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation? 1. Join the milieu to assess the appropriateness of the laughter. 2. Redirect clients in the milieu to structured social activities, such as cards. 3. Privately discuss with the client the inappropriate provocative dress. 4. Administer prn antianxiety medication to calm the client.
3. Because dressing provocatively can precipitate sexual overtures that can be dangerous to the client, it is the priority of the nurse to discuss with the client the inappropriateness of this clothing choice.
25. Which list contains medications that the nurse may see prescribed to treat clients diagnosed with bipolar affective disorder? 1. Lithium carbonate (Lithium), loxapine (Loxitane), and carbamazepine (Tegretol). 2. Gabapentin (Neurontin), thiothixene (Navane), and clonazepam (Klonopin). 3. Divalproex sodium (Depakote), verapamil (Calan), and olanzapine (Zyprexa). 4. Lamotrigine (Lamictal), risperidone (Risperdal), and benztropine (Cogentin).
3. Divalproex sodium (Depakote), an anticonvulsant, and verapamil (Calan), a calcium channel blocker, are used in the long-term treatment of BPAD. Olanzapine (Zyprexa), an antipsychotic, has been approved by the FDA for the treatment of acute manic episodes.
21. A client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of dilute urine, tremors, and muscular irritability. These symptoms would lead the nurse to expect that the client's serum lithium level would be which of the following? 1. 0.6 mEq/L. 2. 1.5 mEq/L. 3. 2.6 mEq/L. 4. 3.5 mEq/L.
3. The client's symptoms described in the question support a serum lithium level of 2.6 mEq/L.
16. A nursing instructor is teaching about the etiology of mood disorders. Which statement by a nursing student best indicates an understanding of the etiology of mood disorders? 1. "When clients experience loss, they learn that it is inevitable and become hopeless and helpless." 2. "There are alterations in the neurochemicals, such as serotonin, that cause the client's symptoms." 3. "Evidence continues to support multiple causations related to an individual's susceptibility to mood symptoms." 4. "Current research suggests that a genetic component affects the development of mood disorders."
3. When the student states that there is support for multiple causations related to an individual's susceptibility to mood symptoms, the student understands the content presented about the etiology of mood disorders.
a client with bipolar disorder is reproting insomnia, restlessness, and clouded thinking. the nurse understand that this client is most likley experiencing 1. depression 2. cyclothymia 3. hypomania 4. mania
4
what is the most important info for the nurse to include when providing nutritional counseling for family members of clients with bipolar 1. if sufficient roughage isnt eaten while taking lithium, bowel problems will occur 2. if the intake of carbs increases, the lithium level will increase 3. if the intake of calories is reduced, the lithium level will icnrease 4. if the intake of sodium increases, the lithium level will decrease
4
Diagnostic Criteria for Manic Episode BOX 26 -1
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree, and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy), but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.
Theoretical integration
Bipolar disorder likely results from an interaction between genetic, biological, and psychosocial determinants
`Do not use in Pregnancy:
Cardiac Anomalies, Renal or Thyroid Disease
Bipolar Disorder
Characterized by mood swings from profound depression to extreme euphoria(mania). Delusions or hallucinations may or may not be present.
Bipolar Disorder
Cycles of mania and depression
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)
Affect
Emotional reaction associated with an experience
A (1.0 to 1.5 mEq/L)
The physician orders lithium carbonate 600 mg tid for a client newly diagnosed with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. What is the therapeutic range for acute mania? A) 1.0 to 1.5 mEq/L B) 10 to 15 mEq/L C) 0.5 to 1.0 mEq/L D) 5 to 10 mEq/L
Lithium
Use with caution Narrow Margin between Therapeutic & Toxicity 1.0-1.5 mEq/L for Acute Mania 0.6-1.2 mEq/L for maintenance 95% eliminated via Kidney
D (Attention deficit/hyperactivity disorder)
Which of the following is the most common comorbid condition in children with bipolar disorder? A) Schizophrenia B) Substance disorders C) Oppositional defiant disorder D) Attention deficit/hyperactivity disorder
9. The nurse is prioritizing nursing diagnoses in the plan of care for a client experiencing a manic episode. Number the diagnoses in order of the appropriate priority. ____ a. Disturbed sleep pattern evidenced by sleeping only 4-5 hours per night ____b. Risk for injury related to manic hyperactivity ____ c. Impaired social interaction evidenced by manipulation of others ____d. Imbalanced nutrition: Less than body requirements evidenced by loss of weight and poor skin turgor
a = 3, b = 1, c = 4, d = 2
3. The physician orders lithium carbonate 600 mg tid for a newly diagnosed client with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. Therapeutic range for acute mania is: a. 1.0 to 1.5 mEq/L b. 10 to 15 mEq/L c. 0.5 to 1.0 mEq/L d. 5 to 10 mEq/L
a. 1.0 to 1.5 mEq/L
4. Although historically lithium has been the medication of choice for mania, several others have been used with good results. Which of the following are used in the treatment of bipolar disorder? (Select all that apply.) a. Olanzepine (Zyprexa) b. Paroxetine (Paxil) c. Carbamazepine (Tegretol) d. Lamotrigine (Lamictal) e. Tranylcypromine (Parnate)
a. Olanzepine (Zyprexa) c. Carbamazepine (Tegretol) d. Lamotrigine (Lamictal)
Mania
alteration in mood that is expressed by feelings of elation inflate self esteem grandiosity hyperactivity agitation and accelerated thinking and speaking biological or psychological disorder
Medications that have been known to evoke mood symptoms:
anesthetics, analgesics anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antinuclear agents, cardiac meds, oral contraceptives, psychotropic meds, muscle relaxants, steroids, and sulfonamides
Psychopharmacology for Depression
antidepressants with care may trigger mania
Which statement about the development of bipolar disorder is from a biochemical perspective? a. Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. b. In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium. c. Magnetic resonance imaging studies have revealed enlarged third ventricles, subcortical white matter, and periventricular hyperintensity in individuals diagnosed with bipolar disorder. d. Twin studies have indicated a concordance rate among monozygotic twins of 60% to 80%.
b. In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium.
5. Margaret, a 68-year-old widow experiencing a manic episode, is admitted to the psychiatric unit after being brought to the emergency department by her sister-in-law. Margaret yells, "My sister-in-law is just jealous of me! She's trying to make it look like I'm insane!" This behavior is an example of: a. A delusion of grandeur b. A delusion of persecution c. A delusion of reference d. A delusion of control or influence
b. A delusion of persecution
7. A nurse is educating a client about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the client to be on the alert for? a. Fever, sore throat, malaise b. Tinnitus, severe diarrhea, ataxia c. Occipital headache, palpitations, chest pain d. Skin rash, marked rise in blood pressure, bradycardia
b. Tinnitus, severe diarrhea, ataxia
Which nursing charting entry is documentation of a behavioral symptom of mania? a. "Thoughts fragmented, flight of ideas noted." b. "Mood euphoric and expansive. Rates mood a 10/10." c. "Pacing halls throughout the day. Exhibits poor impulse control." d. "Easily distracted, unable to focus on goals."
c
2. Margaret, age 68, is diagnosed with bipolar I disorder, current episode manic. She is extremely hyperactive and has lost weight. One way to promote adequate nutritional intake for Margaret is to: a. Sit with her during meals to ensure that she eats everything on her tray. b. Have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes. c. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run." d. Tell Margaret that she will be on room restriction until she starts gaining weight.
c. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run."
Cyclothymic Disorder
chronic, at least 2 years duration, involving numerous periods of elevated mood that do not meet the criteria for a hypomanic episode and numerous periods of depressed mood of insufficient severity or duration to meet the criteria for major depressive episode; the individual is never without the symptoms for more than 2 months
Support Services
crisis hotline support groups individual psychotherapy Legal/financial assisstance
A client diagnosed with bipolar I disorder is experiencing auditory hallucinations and flight of ideas. Which medication combination would the nurse expect to be prescribed to treat these symptoms? a. Amitriptyline (Elavil) and divalproex sodium (Depakote) b. Verapamil (Calan) and topiramate (Topamax) c. Lithium carbonate (Eskalith) and clonazepam (Klonopin) d. Risperidone (Risperdal) and lamotrigine (Lamictal)
d
A nursing instructor is teaching about the criteria for the diagnosis of bipolar II disorder. Which student statement indicates that learning has occurred? a. "Clients diagnosed with bipolar II disorder experience a full syndrome of mania and have a history of symptoms of depression." b. "Clients diagnosed with bipolar II disorder experience numerous episodes of hypomania and dysthymia for at least 2 years." c. "Clients diagnosed with bipolar II disorder have mood disturbances that are directly associated with the physiological effects of a substance." d. "Clients diagnosed with bipolar II disorder experience recurrent bouts of depression with episodic occurrences of hypomania."
d
6. The most common comorbid condition in children with bipolar disorder is: a. Schizophrenia b. Substance disorders c. Oppositional defiant disorder d. Attention-deficit/hyperactivity disorder
d. Attention-deficit/hyperactivity disorder
Transactional model:
disorder results from interactions among genetic, biological, and psychosocial determinants
Evaluation
effectiveness of nursing interventions has client avoided personal injury nutritional status and weight stabilized have hallucinations ceased is behavior socially acceptable can they sleep do they understand the importance of continuing mendication
Affect
emotional reaction associated with an experience
Electroconvulsive Therapy
episodes of mania treated client does not tolerate med does not respond to med
Treatment modalities for Bipolar Disorder o Family Therapy
goal is to restore adaptive family functioning, most effective with psychotherapeutic and pharmacotherapeutic treatment
Treatment modalities for Bipolar Disorder o Group Therapy
helpful after acute phase has passed, have peer support
Hypomania
p.431(17-2) -Milder degree of clinical symptoms -Does not impair social or occupational function -Distinct period of abnormal or persistently elevated mood, increased energy -Lasting at least 4 or more days
Mood
pervasive and sustained emotion that may have a major influence eon a persons perception of the world o Depression, joy, elation, anger, anxiety
Treatment modalities for Bipolar Disorder o Electroconvulsive Therapy
used when the client doesn't tolerate or fails to respond to lithium or other drug treatment, or when life is threatened by dangerous behavior or exhaustion
Treatment modalities for Bipolar Disorder o Psychopharmacology with mood stabilizing agents
• LITHIUM: • Acute mania: 1.0-1.5 mEq/L • Maintenance: 0.6-1.2 mEq/L • Serum levels of 1.5-2.0 mEq/L- blurred vision, ataxia, tinnitus, persistent N/V/D • Serum levels of 2.0-3.5 mEq/L- excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness • Serum levels above 3.5 mEq/L- impaired consciousness, nystagmus, seizures, coma, oligura/anuria, arrhythmias, MI, cardiovascular collapse • If sodium intake is reduced or the body is depleted of its normal sodium, lithium is reabsorbed by the kidneys, increasing the possiblilty of toxicity; client must consume a diet adequate in sodium as well as 2,500-3,000 mL of fluid dialy • MOA not understood; 1-3 weeks for symptoms to subside
Developmental Childhood and Adolescence To differentiate between occasional spontaneous behaviors of childhood and behaviors associated with bipolar disorder- F-I-N-D
■ Frequency: Symptoms occur most days in a week. ■ Intensity: Symptoms are severe enough to cause extreme disturbance in one domain or moderate disturbance in two or more domains. ■ Number: Symptoms occur three or four times a day. ■ Duration: Symptoms occur 4 or more hours a day.
31. A patient arrives in the emergency department with impaired consciousness, nystagmus, and seizures. It is determined that he is suffering from lithium toxicity. With these symptoms, his lithium level would be expected to be above___________mEq/L.
These symptoms are manifestations of severe lithium toxicity and could include coma and cardiovascular collapse. They occur when the lithium level exceeds 3.5 mEq/L.
Increase risk of lithium toxicity when:
-sodium intake is less than 2g/day -sodium and fluids are lost due to excessive exercise -dehydration -gastrointestinal illness -fluid intake is less than 6-8 glasses H20 daily
Treatment
-withhold medication even if toxicity is only suspected -obtain immediate serum lithium level -monitor VS, electrolytes, BUN, creatinine -administer IV of NS -hemodialysis for severe toxicity
Symptoms may be categorized by degree of severity
Stage I: Hypomania Stage II: Acute Mania Stage III: Delirious Mania
42. A patient being treated with lamotrigine (Lamictal) develops a purplish skin rash that is blistering. This is a rare but potentially life-threatening reaction to the medication known as___________ syndrome.
Stevens-Johnson Although Stevens-Johnson syndrome is rare, it is a life-threatening condition that has been associated with Lamictal (as well as some other medications). It is one reason that nurses should educate patients taking the drug to immediately report skin rash to their prescribing physician.
Bipolar-predisposing factors
Strong underlying genetic vulnerability (p. 432) *Twins 60-80% Monozygotic twins 10-20% dizygotic twins *Etiology is unclear *Combined (genetic, biochemical, psychosocial influences, medication side effects, biogenic amines)
Stage II: Acute Mania
Symptoms of acute mania may be a progression in intensification of those experienced in hypomania, or they may be manifested directly. Most individuals experience marked impairment in functioning and require hospitalization (see Box 26-1). Mood - characterized by euphoria and elation. - The person appears to be on a continuous "high." However, the mood is always subject to frequent variation, easily changing to irritability and anger or even to sadness and crying. Cognition and Perception - become fragmented and often psychotic in acute mania. -Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speech (loquaciousness), with abrupt changes from topic to topic. - When flight of ideas is severe, speech may be disorganized and incoherent. - Distractibility becomes all-pervasive. Attention can be diverted by even the smallest of stimuli. Hallucinations and delusions (usually paranoid and grandiose) are common. Activity and Behavior Psychomotor activity is excessive. Sexual interest is increased. There is poor impulse control, and the individual who is normally discreet may become socially and sexually uninhibited. Excessive spending is common. - Individuals with acute mania have the ability to manipulate others to carry out their wishes, and if things go wrong, they can skillfully project responsibility for the failure onto others. - Energy seems inexhaustible, and the need for sleep is diminished. They may go for many days without sleep and still not feel tired. - Hygiene and grooming may be neglected. - Dress may be disorganized, flamboyant, or bizarre, and the use of excessive makeup or jewelry is common.
Physiological Influences
-Medication side effects -Brain lesions -Enlarged ventricles -Correlated with dysfunction in the prefrontal cortex, basal ganglia, temporal and frontal lobes of the forebrain and parts of the limbic system.
Client/Family Education
-Nature of illness -Causes of bipolar disorder -Cyclic nature of the illness -Symptoms of depression -Symptoms of mania
Severe Toxicity Sx/Life Threatening
> 3.0 mEq/L: -Diluted excessive Urine Output/ Oliguria/anuria -Tremors & muscle fasiculation -Hyper-reflexia -Tonic-clonic Seizures -Impaired consciousness -Arrhythmia -Coma -Death
Cyclothymic Disorder
-Chronic mood disturbance of at least 2 years. -Numerous elevated mood episodes, and depressed episodes of insufficient severity or duration to meet criteria for major depression. -Never without symptoms for more than 2 mos. -For at least 1 yr child, adolescents.
Support services
-Crisis hotline -Support groups -Individual psychotherapy -Legal/financial assistance
Nursing interventions are aimed at:
-Maintaining safety of client and others -Restoring client nutritional status -Maintain sufficient rest -Encouraging appropriate client interaction with others -Assisting client to define and test reality -Meeting client's self-care needs
Stage III: Delirious Mania
(rare) Delirious mania is a grave form of the disorder characterized by severe clouding of consciousness and an intensification of the symptoms associated with acute mania. Mood - very labile. - may exhibit feelings of despair, quickly converting to unrestrained merriment and ecstasy or becoming irritable or totally indifferent to the environment. - Panic anxiety may be evident. Cognition and Perception - clouding of consciousness, with accompanying confusion, disorientation, and sometimes stupor. - Other common manifestations include religiosity, delusions of grandeur or persecution, and auditory or visual hallucinations. -extremely distractible and incoherent. Activity and Behavior - Psychomotor activity is frenzied and characterized by agitated, purposeless movements. - The safety of these individuals is at stake unless this activity is curtailed. - Exhaustion, injury to self or others, and eventually death could occur without intervention.
Etiological implications
*Biological theories: Strong hereditary implications, electrolytes *Biochemical influences: Possible excess of norepinephrine, serotonin, and/or dopamine *Physiological influences- Brain lesions, medication side effects *Psychosocial theories- Credibility of psychosocial theories has declined in recent years --Bipolar disorder viewed as brain disorder
FIND (frequency, intensity, number, and duration)
*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 Due to Another Medical Condition
- Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological consequence of another medical condition - The mood disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. - Types of physiological influences are included in the discussion of predisposing factors associated with bipolar disorders. stroke, MS
Bipolar II
- Characterized by bouts of major depression with episodic occurrence of hypomania (not severe enough to cause marked impairment in social or occupational functioning) - Has NEVER met criteria for full manic episode - Could have psychotic or catatonic feature if it is a major depressive episode - May present with symptoms (or history) of depression or hypomania. - The diagnosis may specify whether the current or most recent episode is hypomanic, depressed, or with mixed features.
Predisposing - Psychosocial Theories
- Credibility declined - bipolar considered disease of brain
Childhood and Adolescence
- Diagnosis difficult because the developmental courses and sx are unique from those of adult - Sx may present with co-moid conduct disorders or ADHD - Guidelines for diagnoses and treatment have been developed
Bipolar 1
- Diagnosis given to an individual who is experiencing a manic episode or has a history of one or more manic episodes. - May also have experienced episodes of depression. - Current or most recent behavioral episode experienced. Ex: The specifier might be single manic episode (to describe individuals having a first episode of mania) or the specifier may be identified as current (or most recent) episode manic, hypomanic, mixed, or depressed (to describe individuals who have had recurrent mood episodes). - Psychotic or catatonic features may also be noted.
Criteria for measuring outcome
- Exhibits no evidence of whys injury - Has not harmed self or others - Is no longer exhibiting signs of physical agitation - Eats a well balanced diet with snacks to prevent weight loss and maintain nutritional status - Verbalizes an accurate interpretation of environment - Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations - Accepts responsibility for own behavior - Does not manipulate others for gratification of own needs - Interacts appropriately with others - Is able to fall asleep within 30 minutes of retiring - Is able to sleep 6 - 8 hours per night
Treatment modalities for Bipolar Disorder
- Individual Psychotherapy - Group Therapy - Family Therapy - Cognitive Therapy - ECT - Psychopharmacology
Bipolar nursing diagnoses
- Risk for Injury R/T extreme hyperactivity, inc agitation, and lack of control over purposeless and potentially injurious movements - Risk for Violence: Self directed or other directed R/T - Imbalanced Nutrition less than body requirements R/T refusal or inability to sit still long enough to eat AEB loss of weight, amenorrhea - Disturbed thought processes R/T biochemical alteration in brain, AEB delusions of grandeur and persecution and inaccurate interpretation of the environment - Disturbed sensory perception R/T biochemical alteration in the brain and to possible sleep deprivation AEB auditory and visual hallucinations - Impaired social interaction R/T egocentric and narcissistic behavior - Insomnia R/T excessive hyperactivity and agitation
Predisposing - Biological Theories
- cholinergic agents have profound effects on mod; there may be an imbalance between the biogenic mines and acetylcholine o Genetics- twin studies, family studies, other genetic studies o Biochemical influences- biogenic amines (deficiency of NE and dopamine; acetylcholine; cholinergic agents have profound effects on mood) o Physiological influences
Substance Induced bipolar disorder
- considered to be the direct result of physiological effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse or a medication). -The mood disturbance may involve elevated, expansive, or irritable mood, with inflated self-esteem, decreased need for sleep, and distractibility. -clinically significant distress or impairment in social, occupational, or other important areas of functioning. -Mood disturbances are associated with intoxication from substances such as alcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedatives, hypnotics, and anxiolytics. - Symptoms can occur with withdrawal from substances such as alcohol, amphetamines, cocaine, sedatives, hypnotics, and anxiolytics.
Developmental Childhood and Adolescence
- prevalence of pediatric and adolescent bipolar disorders is estimated to be about 1%,but children and adolescents are often difficult to diagnose -The developmental courses and symptom profiles of psychiatric disorders in children are unique; therefore, approaches to diagnosis and treatment cannot merely rely on strategies examined and implemented in a typical adult population - Symptoms difficult to assess - may also present with comorbid conduct disorders or attention-deficit/hyperactivity disorder (ADHD). - Because there is a genetic component and children of bipolar adults are at higher risk, family history may be particularly important
Delirious Mania (Stage III)
-A grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. -Rare as intervention has usually already occurred -Intense mood swings -Panic anxiety -Confusion -Disorientation -Stupor -Religiosity -Delusions of grandeur or persecution -Auditory or visual hallucinations -Psychomotor activity -If untreated safety is at stake
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 (pacing, flapping/waving hands); increased sexual interest; inexhaustible energy; goes without sleep; bizarre dress and make-up
Mania
-Alteration in mood Feelings of elation, inflated self esteem, grandiosity, hyperactivity, agitation, accelerated thinking/ speaking Manic Episode (page 430, Box 17-1) Distinct period of persistent, elevated mood -Lasting at least 1 week, present most of the day, nearly every day
Types of Bipolar Disorder
-Bipolar I Disorder -Bipolar II Disorder -Cyclothymic Disorder -Substance-Induced Bipolar Disorder -Bipolar Disorder Associated with Another Medical Condition
Client and Family Education (Bipolar Disorder)
-Causes of bipolar disorder -Cyclic nature of the illness -Symptoms of depression -Symptoms of mania
Bipolar Disorder
-Characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy -Delusions or hallucinations may or may not be part of clinical picture -Onset of symptoms may reflect seasonal pattern
Bipolar II Disorder
-Characterized by recurrent bouts of major depression with episodic occurrence of hypomania. -May have a history of depression or hypomania. -Has never met the criteria for a full manic episode. -Not severe enough to cause marked impairement in social or occupational functioning.
Side Effects:
-Chlorpromazine/Risperdol: TDK/Extrapyramidal Sx Tx TDK with Cogentin/Artane May be used Prophylactic -Agranulocytosis: Clozapine Blood work every week/If stable Q 2 Weeks -General: Aripiprazole/Risperidone/ Quentipine Wt gain/Increased Appitite/ Hyperglycemia & DMII /Dry mouth/Constipation/ECG Changes/HA
Cyclothymic Disorder
-Chronic mood disturbance -At least 2-year duration -Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for major depressive disorder. -Individual is never without symptoms for more than 2 months.
Developmental Implications in Childhood and Adolescence
-Difficult to diagnose -FIND -Frequency -Intensity -Number -Duration -Euphoric/Expansive mood -Irritable Mood -Aggression -Self-injuring behavior -Rage -Grandiosity -Decreased need for sleep -Pressured speech -Load and intrusive -Racing thoughts -Random and hard to follow -Distractibility -Increase in goal-directed activity -Obsessive -Excessive involvement in pleasurable or risky activities -Psychosis -Suicidality
What are the symptoms of Hypomania?
-Effected people tend to overestimate their capabilities -They feel inflated self-esteem or grandiosity -Increased alcohol consumption -They fail to see the obvious risks involved in their ventures -Making lots of plans -Flight of ideas -Excessive involvement in pleasurable activities -Increased interest in uncharacteristic sexual flirting -Decreased need for sleep or sleep disturbances -More sensitive than usual -They feel like taking too many responsibilities -They do it best attitude -Increase in goal-directed activity
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.
Psychopharmacology (Bipolar Disorder)
-For mania- -Lithium Carbonate -Anticonvulsants -Antipsychotics -For Depressive Phase- -Use antidepressants with care, may trigger mania
Bipolar Demographics
-Gender -Equal occurrence -Age Onset -Early 20's -Status -More common in single individuals -Socioeconomics -More common in those of higher economic classes. -6th leading cause of disability -Affects approx 5.7 million Americans
Biological Theories (Predisposing Factors)
-Genetics -Biochemical influences -Physiological influences -Psychosocial theories
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
Cyclothymic Disorder...
-Hypomanic and depression present for half the time -Criteria for major depressive, hypomanic never met -Cannot be explained by schizoaffective etc.. -Cannot be explained by substance abuse -Causes distress: impairment socially, occupational
Goals-
-Improve communication -Teach early warning signs -How to respond -Educate regarding necessary treatments
Treatment (Bipolar Disorder)
-Individual psychotherapy -Group therapy -Family therapy -Cognitive therapy -Psychopharmacology
During this time, 3 (or more) of these...
-Inflated self esteem, grandiosity -Decreased need for sleep -Talkative -FOI (flight of ideas) -Distractibility -Increase goal directed activity -Excessive involvement in activities that have high potential for painful consequences -Mood disturbance: marked impairment in social or occupational function -Not attributed to substance abuse
Management of illness
-Medication management -Assertive techniques -Anger management -Quiet milieu if manic
Mechanism of action
-Poorly understood -Is a salt that competes for salt receptors -Thought to normalize reuptake of several neurotransmitters -Effective for about 75% of clients with Bipolar Disorder
Symptoms...
-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. -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
Nursing Interventions (Bipolar Disorder)
-Protection from injury due to hyperactivity -Protection from harm to self or others -Restoration of nutritional status -Progression toward resolution of the grief process -Improvement in interactions with others -Acquiring sufficient rest and sleep
Family interventions: (FFT)
-Psychoeducation about bipolar disorder -Communication training -Problem-solving skills training
Treatment of Childhood and Adolescence
-Psychopharmacology -ADHD is most common comorbid condition -ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled.
Valproic Acid:
-Rash -Effective treatment of bipolar disorder with valproic acid is associated with serum levels of 45-125 μg/ml. -Toxicity above 100 μg/ml -More so in Patients with hypoalbuminemic patients
to do list:
-Restrict caffeine intake -Maintain adequate water intake (6-8 glasses/day) -Maintain adequate sodium intake (2g/day) -Drink fluids with electrolytes when exercising -Contact health care provider for severe gastrointestinal symptoms -Inform all health care providers about lithium therapy, especially when surgery is planned -Contact health care provider with S/S of toxicity -Maintain appointments for blood levels
Hypomania (Stage I)
-Symptoms are not very severe -Mood is cheerful and expensive -Underlying irritability -Nature is very volatile and fluctuating -Exhibits increased motor activity
Acute Mania (Stage II)
-Symptoms intensify from hypomania -Elation and euphoria -Little need for sleep -Continous "high" stage -Pressured speech -Flight of ideas -Hallucinations -Delusions -Excess psychomotor activity -Social and sexual inhibition
Bipolar I Disorder
-The individual is experiencing a manic episode or has a history of one or more manic episodes. -May have also experienced depressive episodes.
Serum half- life
-approximately 24 hours -Metabolized by the kidneys -Similar in chemical structure to sodium -If sodium intake is reduced or serum sodium level is low, lithium will be reabsorbed rather than excreted by the kidneys Toxic lithium levels may occur -Give salty snacks & add salt to food to avoid this
Upon initiation of lithium therapy
-blood levels are drawn every 1-3 days until therapeutic level is identified for individual client -When acute symptoms are resolved, lithium is decreased for maintenance treatment -Maintenance dose is one-half to two-thirds the acute dose -Blood levels are then monitored every 2-3 months or when a problem is suspected
A client on an inpatient psychiatric unit is prescribed lamotrigine (limictal) after playing teaching which plain statement reflects understanding of important information related to this drug 1. I will call the doctor if I miss more than five days before restarting the med 2. I will schedule an appointment for my blood to be drawn at the lab next week 3. I will call the doctor immediately if my temperature raises above 100 4. I will stop my medication if I start having muscle rigidity of my face or neck
1
Client prescribed lithium carbonate presents to ED with impaired consciousness the nystagmus arrhythmias and history of recent seizures, which serum lithium level with the nurse expect to assess 1. 3.7 2. 3.0 3. 2.5 4. 1.9
1
The client is newly prescribed lithium carbonate which teaching point by the nurse takes priority 1. Make sure your salt intake is consistent 2. Limit your fluid intake to 2000 mls per day 3. Monitor your caloric intake because of potential weight gain 4. get yourself into daily routine to assist in avoiding relapse
1
a client with bipolar tells the nurse that she just found out she is pregnant and is concerned bc she takes lithium. what is the most important information for the nurse to provide to this client 1. use of lithium usually results in serious congenital problems 2. thyroid problems can occur in the first trimester of pregnancy 3. lithium causes severe urine retention and increased risk of toxicity 4. women who take lithium are very likely to have a spontaneous abortion
1
family memebers of a client with bipolar tell the nurse that they are distressed about the clients increasing episodes of mania. they are unsure of what to do. what is the most important information for the nruse to give this family 1. learn ways to protect yourself from the clients behavior 2. know how to proceed with a voluntary commitment 3. establish ways to confront the client about reckless behavior 4. know when to safely increase medication during manic episodes
1
52. A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? 1) "Do not alter your dietary sodium intake." 2) "Have serum lithium levels checked every 6 months." 3) "Limit fluid intake to 1,000 mL per day." 4) "Adjust the dose if you feel out of control."
1) "Do not alter your dietary sodium intake." Clients taking lithium should consume a diet adequate in sodium and drink 2,500 to 3,000 mL of fluid per day. Lithium is a salt and competes in the body with sodium. If sodium is lost, the body will retain lithium, resulting in toxicity. Conversely, if sodium levels are significantly increased, it will reduce the level of lithium, resulting in decreased efficacy. Maintaining normal sodium and fluid levels is critical to maintaining therapeutic levels of lithium.
46. The physician has ordered lithium carbonate (Eskalith) for a client diagnosed with bipolar disorder. What is the most likely rationale for prescribing this drug? 1) Decrease hyperactivity 2) Control anger 3) Elevate the mood 4) Diminish anxiety
1) Decrease hyperactivity Lithium carbonate's primary therapeutic effect is to prevent or decrease the incidence of acute manic episodes and associated hyperactivity.
44. Sophie is admitted to an inpatient psychiatric unit in an acute manic episode. She is morbidly obese and believes she is a famous ballerina. She repeatedly runs from one end of the unit to the other and attempts to twirl around while standing on chairs in the patient lounge. She is prescribed temazepam (Restoril) for sleep, and since her admission she has generally slept for five to six hours each night. What should the nurse consider to be the priority nursing diagnosis? 1) Risk for Injury related to excessive hyperactivity. 2) Disturbed Sleep Pattern related to manic hyperactivity. 3) Imbalanced Nutrition, Less than Body Requirements, related to inadequate intake. 4) Situational Low Self-esteem related to embarrassment secondary to high-risk behaviors.
1) Risk for Injury related to excessive hyperactivity. According to Maslow's hierarchy of needs and this client's presentation, safety is a priority. The impulsiveness and hyperactivity seen in clients diagnosed with acute mania puts them at risk for injury.
8. A client diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R/T egocentrism. Which short-term outcome is an appropriate expectation for this client problem? 1. The client will have an appropriate one-on-one interaction with a peer by day 4. 2. The client will exchange personal information with peers at lunchtime. 3. The client will verbalize the desire to interact with peers by day 2. 4. The client will initiate an appropriate social relationship with a peer.
1. A client's having an appropriate one-on-one interaction with a peer is a successful outcome for the nursing diagnosis of impaired social interactions. The test taker should note that this outcome is specific, client centered, positive, realistic, and measurable and includes a time frame.
18. A nurse working with a client diagnosed with bipolar I disorder attempts to recognize the motivation behind the client's use of grandiosity. Which is the rationale for this nurse's action? 1. Understanding the reason behind a behavior would assist the nurse in accepting and relating to the client, not the behavior. 2. Change in behavior cannot occur until the client can accept responsibility for his or her own actions. 3. As self-esteem is increased, the client will meet individual needs without the use of manipulation. 4. Positive reinforcement would enhance self-esteem and promote desirable behaviors.
1. Grandiosity, which is defined as an exaggerated sense of self-importance, power, or status, is used by clients diagnosed with bipolar affective disorder to help reduce feelings of insecurity by increasing feelings of power and control. When the nurse understands the origin of this behavior, the nurse can better work with, and relate to, the client.
24. A client is newly prescribed lithium carbonate (Lithium). Which teaching point by the nurse takes priority? 1."Make sure your salt intake is consistent." 2. "Limit your fluid intake to 2000 mL/day." 3. "Monitor your caloric intake because of potential weight gain." 4."Get yourself in a daily routine to assist in avoiding relapse."
1. Lithium is similar in chemical structure to sodium, behaving in the body in much the same manner and competing with sodium at various sites in the body. If sodium intake is reduced, or the body is depleted of its normal sodium, lithium is reabsorbed by the kidneys, and this increases the potential for toxicity.
5. A newly admitted client diagnosed with bipolar I disorder is experiencing a manic episode. Which nursing diagnosis is a priority at this time? 1. Risk for violence: other-directed R/T poor impulse control. 2. Altered thought process R/T hallucinations. 3. Social isolation R/T manic excitement. 4. Low self-esteem R/T guilt about promiscuity.
1. Risk for violence: other-directed is defined as behaviors in which an individual demonstrates that he or she can be physically, emotionally, or sexually harmful to others. Because of poor impulse control, irritability, and hyperactive psychomotor behaviors experienced during a manic episode, this client is at risk for violence directed toward others. Keeping everyone in the milieu safe is always a nursing priority.
13. A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority? 1. Calmly redirect and remove the client from the milieu. 2. Administer prescribed prn intramuscular injection for agitation. 3. Ask the client to lower his or her voice while in the common area. 4. Obtain an order for seclusion to help decrease external stimuli.
1. When a client experiencing mania is yelling at other peers, it is the nurse's priority to address this situation immediately. Behaviors of this type can escalate into violence toward clients and staff members. By using a calm manner, the nurse avoids generating any further hostile behaviors, and by removing the client from the milieu, the nurse protects other clients on the unit.
the nruse needs to communicate with a client experiencing mania. how should the nurse address this client 1. in a light and joking manner 2. focus and redirect the conversation as necessary 3. allow the client to talk about several different topics 4. ask only open ended questions to facilitate conversation
2
41. A client diagnosed with bipolar disorder has been hospitalized for 2 weeks. The client asks the nurse, "Do you think that the doctor is ever going to discharge me?" Which is the appropriate nursing response? 1) "Ask your doctor when you can be discharged." 2) "Tell me more about your feelings about being hospitalized." 3) "You are not ready to go yet." 4) "Let the doctor know your feelings."
2) "Tell me more about your feelings about being hospitalized."
39. Tori has been diagnosed with bipolar I disorder and presents at her clinic appointment with complaints of feeling depressed and hopeless. What is the most important assessment for the nurse to make at this point? 1) If Tori has been taking her medication 2) If Tori is having thoughts of suicide 3) If Tori has had any new stressors in her life 4) If Tori is using alcohol
2) If Tori is having thoughts of suicide
40. A client newly diagnosed in a manic episode of bipolar disorder tells the nurse, "Now that I'm only sleeping 4 hours a night, I can get so much more work accomplished." Which ego defense mechanism is this client using? 1) Denial 2) Intellectualization 3) Rationalization 4) Suppression
2) Intellectualization Intellectualization occurs when an individual attempts to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis. The individual in the question is using reasoning to avoid dealing with feelings about the new diagnosis of bipolar disorder.
3. A nurse on an in-patient psychiatric unit receives report at 1500 hours. Which client would need to be assessed first? 1. A client on one-to-one status because of active suicidal ideations. 2. A client pacing the hall and experiencing irritability and flight of ideas. 3. A client diagnosed with hypomania monopolizing time in the milieu. 4. A client with a history of mania who is to be discharged in the morning.
2. A client's behavior of pacing the halls and experiencing irritability should be considered emergent and warrant immediate attention. Most assaultive behavior that occurs on an in-patient unit is preceded by a period of increasing hyperactivity. Because of these symptoms, this client would need to be assessed first.
14. A client newly admitted with bipolar I disorder has a nursing diagnosis of risk for injury R/T extreme hyperactivity. Which nursing intervention is appropriate? 1. Place the client in a room with another client experiencing similar symptoms. 2. Use prn antipsychotic medications as ordered by the physician. 3. Discuss consequences of the client's behaviors with the client daily. 4. Reinforce previously learned coping skills to decrease agitation.
2. A newly admitted client experiencing an extremely hyperactive episode as the result of bipolar I disorder would benefit from an antipsychotic medication to sedate the client quickly. A mood stabilizer may be given concurrently for maintenance therapy and to prevent or diminish the intensity of subsequent manic episodes.
the nurse is providing discharge teaching for a client who will be taking lithium. which conditon would necessitate a call to the clients health care provider 1. development of black tongue 2. increased lacrimation 3. periods of excitability 4. persistent gastrointestinal upset
4 indicates a milk to moderate toxic rxn to lithium
53. Cameron, who has been treated with lithium for several months, was recently placed on sodium-depleting diuretics by his family physician. He now presents in the ER with tremors, psychomotor retardation, confusion, and giddiness. What is the most likely reason for his symptoms? 1) Cameron's lithium level has dropped R/T sodium depletion and he is experiencing a return of manic symptoms. 2) Cameron is experiencing extrapyramidal symptoms R/T a drug:drug interaction. 3) Cameron is experiencing lithium toxicity R/T sodium depletion. 4) Cameron is experiencing psychosis R/T lithium toxicity.
3) Cameron is experiencing lithium toxicity R/T sodium depletion. Sodium depletion increases the risk for lithium toxicity, and Cameron's symptoms are consistent with lithium toxicity.
36. A client is diagnosed with bipolar disorder. The family describes the client as being "on the move." The client sleeps 3 to 4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which client response would the nurse expect? 1) Short, polite responses to interview questions. 2) Introspection related to present situation. 3) Inability to remain seated and racing thoughts. 4) Feelings of helplessness and hopelessness.
3) Inability to remain seated and racing thoughts. In the manic phase of bipolar disorder the client experiences hyperactivity, restlessness, and flight of ideas. This would cause the client to have difficulty remaining seated and have problems organizing thoughts.
51. A client demonstrating manic behavior has become demanding and hyperactive. Which is the most appropriate nursing intervention to address these client behaviors? 1) Help lessen the client's feelings of guilt and rejection. 2) Warn the client that restraints may be necessary if behavior does not improve. 3) Maintain a supportive, structured environment, setting firm limits in a nonthreatening manner. 4) Introduce the client to peers in order to increase interpersonal contacts.
3) Maintain a supportive, structured environment, setting firm limits in a nonthreatening manner. The client is having difficulty controlling behavior and maintaining impulse control. The nurse must help the client to do so in an objective, nonjudgmental way, focusing on the behavior and not the client.
50. A client diagnosed with bipolar disorder is experiencing hyperactive behavior and weight loss. Which nutritional intervention would be most therapeutic for this client? 1) Allow the client full kitchen privileges to eat anything as needed (prn). 2) Initiate tube feedings with nutritional supplements. 3) Provide small, frequent feedings of finger foods. 4) Provide a quiet place where the client can sit down to eat meals.
3) Provide small, frequent feedings of finger foods. The client experiencing mania is unable to sit still long enough to eat an adequate nutritious meal. Small, frequent feedings with finger foods allow the client to eat during periods of hyperactivity.
4. A client diagnosed with cyclothymia is newly admitted to an in-patient psychiatric unit. The client has a history of irritability and grandiosity and is currently sleeping 2 hours a night. Which nursing diagnoses takes priority? 1. Altered thought processes R/T biochemical alterations. 2. Social isolation R/T grandiosity. 3. Disturbed sleep patterns R/T agitation. 4. Risk for violence: self-directed R/T depressive symptoms.
3. Disturbed sleep patterns is defined as a time-limited disruption of sleep amount and quality. Because the client is sleeping only 2 hours a night, the client is meeting the defining characteristics of the nursing diagnosis of disturbed sleep patterns. This sleep problem is usually due to excessive hyperactivity and agitation.
9. A client seen in the emergency department is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse's priority intervention? 1. Place the client on a one-to-one observation to prevent injury. 2. Ask the physician for a psychiatric consultation. 3. Assess vital signs, and complete a physical assessment. 4. Reinforce relaxation techniques to decrease anxiety.
3. The nurse first should assess vital signs and complete a physical assessment to rule out a physical cause for the symptoms presented. Many physical problems manifest in symptoms that seem to be caused by psychological problems.
29. A client diagnosed with bipolar affective disorder is prescribed carbamazepine (Tegretol). The client exhibits nausea, vomiting, and anorexia. Which is an appropriate nursing intervention at this time? 1. Stop the medication, and notify the physician. 2. Hold the next dose until symptoms subside. 3. Administer the next dose with food. 4. Ask the physician for a stat carbamazepine (Tegretol) level.
3. When clients prescribed carbamazepine experience nausea, vomiting, and anorexia, it is important for the nurse to administer the medication with food to decrease these uncomfortable, but acceptable, side effects. If these side effects do not abate, other interventions may be necessary.
2. Which nursing charting entry is documentation of a behavioral symptom of mania? 1. "Thoughts fragmented, flight of ideas noted." 2. "Mood euphoric and expansive. Rates mood a 10/10." 3. "Pacing halls throughout the day. Exhibits poor impulse control." 4."Easily distracted, unable to focus on goals."
3. When the nurse documents, "Pacing halls throughout the day. Exhibits poor impulse control," the nurse is charting a behavioral symptom of mania. Psychomotor activities and uninhibited social and sexual behaviors are classified as behavioral symptoms.
54. A client is diagnosed with bipolar disorder. Which medication is the drug of choice for this diagnosis? 1) Risperidone (Risperdal) 2) Clozapine (Clozaril) 3) Lorazepam (Ativan) 4) Lithium carbonate (Eskalith)
4) Lithium carbonate (Eskalith) Lithium carbonate is the classic treatment and drug of choice for maintenance therapy for bipolar disorder. It stabilizes the mood lability that is characteristic of the disorder.
47. The activity therapist is planning an individualized program for a client diagnosed with bipolar I disorder: manic episode who is exhibiting hostility and excessive energy. Which activity would be most appropriate? 1) Writing memoirs 2) Team sports 3) Ping-pong 4) Walking
4) Walking Walking is the best activity choice because it is not considered competitive and provides an opportunity for the release of energy.
6. A client diagnosed with bipolar I disorder has a nursing diagnosis of disturbed thought process R/T biochemical alterations. Based on this diagnosis, which outcome would be appropriate? 1. The client will not experience injury throughout the shift. 2. The client will interact appropriately with others by day 3. 3. The client will be compliant with prescribed medications. 4. The client will distinguish reality from delusions by day 6.
4. Distinguishing reality from delusions by day 6 is an appropriate outcome for the nursing diagnosis of disturbed thought process R/T biochemical alterations. Altered thought processes have improved when the client can distinguish reality from delusions.
19. A nursing instructor is teaching about the criteria for the diagnosis of bipolar II disorder. Which student statement indicates that learning has occurred? 1. "Clients diagnosed with bipolar II disorder experience a full syndrome of mania and have a history of symptoms of depression." 2. "Clients diagnosed with bipolar II disorder experience numerous episodes of hypomania and dysthymia for at least 2 years." 3. "Clients diagnosed with bipolar II disorder have mood disturbances that are directly associated with the physiological effects of a substance." 4."Clients diagnosed with bipolar II disorder experience recurrent bouts of depression with episodic occurrences of hypomania."
4. Recurrent bouts of depression and episodic occurrences of hypomania are diagnostic criteria for bipolar II disorder. Experiencing a full manic episode would indicate a diagnosis of bipolar I disorder and rule out a diagnosis of bipolar II disorder.
20. A client diagnosed with bipolar I disorder is experiencing auditory hallucinations and flight of ideas. Which medication combination would the nurse expect to be prescribed to treat these symptoms? 1. Amitriptyline (Elavil) and divalproex sodium (Depakote). 2. Verapamil (Calan) and topiramate (Topamax). 3. Lithium carbonate (Eskalith) and clonazepam (Klonopin). 4. Risperidone (Risperdal) and lamotrigine (Lamictal).
4. Risperidone (Risperdal), an anti-psychotic, directly addresses the auditory hallucinations experienced by the client. Lamotrigine (Lamictal), a mood stabilizer, would address the classic symptoms of bipolar I disorder.
17. A nursing instructor is teaching about the psychosocial theory related to the development of bipolar disorder. Which student statement indicates that learning has occurred? 1. "The credibility of psychosocial theories in the etiology of bipolar disorder has strengthened in recent years." 2. "Individuals are genetically predisposed to being diagnosed with bipolar disorder if a parent is mentally ill." 3. "Following steroid, antidepressant, or amphetamine use, individuals can experience manic episodes." 4."The etiology of bipolar disorder is unclear, but it is possible that biological and psychosocial factors are influential."
4. The etiology of bipolar disorder is unclear; however, research evidence shows that biological and psychosocial factors are influential in the development of the disorder.
26. The nurse is evaluating lab test results for a client prescribed lithium carbonate (Lithium). The client's lithium level is 1.9 mEq/L. Which nursing intervention takes priority? 1. Give next dose because the lithium level is normal for acute mania. 2. Hold the next dose, and continue the medication as prescribed the following day. 3. Give the next dose after assessing for signs and symptoms of lithium toxicity. 4. Immediately notify the physician, and hold the dose until instructed further.
4. The nurse needs to notify the physician immediately of the serum lithium level, which is outside the therapeutic range, to avoid any risk for further toxicity.
2 (Valproic acid (Depakote)) Rationale: The nurse should anticipate that the physician may prescribe valproic acid in order to increase this client's medication adherence. Valproic acid is an anticonvulsant medication that can be used to treat bipolar disorder. One of the side effects of this medication is weight loss.
A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)
C (The bipolar condition would be stabilized first before medication for the ADHD would be given.)
A child with bipolar disorder also has attention deficit/hyperactivity disorder (ADHD). How would these comorbid conditions most likely be treated? A) No medication would be given for either condition. B) Medication would be given for both conditions simultaneously. C) The bipolar condition would be stabilized first before medication for the ADHD would be given. D) The ADHD would be treated before consideration of the bipolar disorder.
3 ("Weight gain is a common, but troubling, side effect.") (Rationale: The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication adherence and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.)
A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."
4 ("Zyprexa calms hyperactivity until the Eskalith takes effect.") (Rationale: The nurse should explain to the client's spouse that olanzapine can calm hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take 1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine, has been determined to be the first-line treatment for bipolar I disorder.)
A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."
4 (Symptoms indicate lithium carbonate toxicity.) (Rationale: The nurse should interpret that the client's symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly with maintenance therapy to ensure proper dosage.)
A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate consumption of foods high in tyramine. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate the development of lithium carbonate tolerance. 4. Symptoms indicate lithium carbonate toxicity.
2 (Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss) Rationale: The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Because of the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and physical health.
A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
1 (Risk for suicide R/T hopelessness) (Rationale: The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should always prioritize client safety. This client is at risk for suicide because of his or her recent suicide attempt.)
A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment
C (Quietly walk with her back to her room and help her change into something more appropriate.)
A client experiencing a manic episode enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? A) Tell the client she cannot wear this outfit while she is in the hospital. B) Do nothing, and allow her to learn from the responses of her peers. C) Quietly walk with her back to her room and help her change into something more appropriate. D) Explain to her that if she wears this outfit, she must remain in her room.
2 (Discontinue the fluoxetine and rethink the client's diagnosis.) (Rationale: A full manic episode emerging during antidepressant treatment (medication, electroconvulsive therapy, etc.), but persisting beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I diagnosis.)
A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Discontinue the fluoxetine and rethink the client's diagnosis. 3. Order benztropine (Cogentin) to address extrapyramidal symptoms. 4. Order olanzapine (Zyprexa) to address altered thoughts.
1 (Provide client with high-calorie finger foods throughout the day.) (Rationale: The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 lb by the end of the week. Because of the hyperactive state, the client will have difficulty sitting still to consume large meals.)
A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate total parenteral nutrition to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.
Substance-Induced Bipolar Disorder
A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance.
4 ("Agitated and pacing. Exhibiting grandiosity. Mood labile.") (Rationale: The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that one's abilities are better than everyone else's.)
A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."
4, 5 (Rationale: The following are selected criteria for the diagnosis of cyclothymic disorder. For at least one year in children and adolescents there have been numerous periods with hypomanic, not manic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. The symptoms are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not elsewhere classified. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.)
A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.) 1. Symptoms lasting for a minimum of two years 2. Numerous periods with manic symptoms 3. Possible comorbid diagnosis of a delusional disorder 4. Symptoms cause clinically significant impairment in important areas of functioning 5. Depressive symptoms that do not meet the criteria for major depressive episode
B (Tinnitus, severe diarrhea, ataxia)
A nurse is educating a client about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the client to be on the alert for? A) Fever, sore throat, malaise B) Tinnitus, severe diarrhea, ataxia C) Occipital headache, palpitations, chest pain D) Skin rash, marked rise in blood pressure, bradycardia
3 (3, 1, 4, 2) (Rationale: The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client's safety and physical health as most important.)
A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? Client Outcomes: 1. Maintains nutritional status 2. Interacts appropriately with peers 3. Remains free from injury 4. Sleeps 6 to 8 hours a night 1. 2, 1, 3, 4 2. 4, 1, 2, 3 3. 3, 1, 4, 2 4. 1, 4, 2, 3
4 ( "Treatment is compromised when clients choose not to take their medications.") (Rationale: The nursing student is accurate when stating that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose not to take their medications. Clients diagnosed with bipolar disorder feel most productive and creative during manic episodes. This may lead to purposeful medication nonadherence. Symptoms of bipolar disorder will reemerge if medication is stopped.)
A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients can't sleep." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications."
3 (During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.) (Rationale: Three or more of the following symptoms may be experienced in both hypomanic and manic episodes: Inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure to keep talking, flight of ideas and racing thoughts, distractibility, increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments). If there are psychotic features, the episode is, by definition, manic.)
A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.
Mood
A pervasive and sustained emotion that may have major influence on a persons perception of the world
Diagnostic Criteria for Hypomanic Episode BOX 26 - 2
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment).
A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management
ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.
Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder
ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.
A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs
ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.
The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.
ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.
A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of flu-id. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.
ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.
An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.
ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.
The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.
ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.
Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."
ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.
A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."
ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feed-back may seem heavy-handed and may incite anger.
A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure
ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.
A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood? a. Euphoric b. Irritable c. Suspicious d. Confident
ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.
Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patient's sleep patterns.
ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgment and inappropriate decision making that accompany hypomania.
A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior
ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.
A person was online continuously for over 24 hours, posting rhymes on official government web-sites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia
ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government web-sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.
A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.
ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.
The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bi-polar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."
ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.
This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding with-in 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.
ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.
A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.
ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for longterm control.
A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."
ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.
Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping
ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.
To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.
ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.
A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.
ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.
Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.
ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.
At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery
ANS: B The environment for a manic patient should be as simple and non-stimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.
An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 tea-spoon of salt added. d. take one dose of an over-the-counter anti-diarrheal medication now.
ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.
When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.
ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.
A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.
ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.
A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation
ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.
A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema
ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.
A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making
ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.
A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.
ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.
Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (La-mictal) d. aripiprazole (Abilify)
ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question.
Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream
ANS: C These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.
A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"
ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.
The plan of care for a patient in the manic state of bipolar disorder should include which inter-ventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.
ANS: C, D People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.
A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.
ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.
A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. risperidone (Risperdal) d. carbamazepine (Tegretol)
ANS: D Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. See relationship to audience response question.
A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.
ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.
Lithium Toxicity
Acute mania 1.0 to 1/5 mEq/L maintenance 0.6 to 1.2 mEq/L blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea (initial symptoms of toxicity) Serum levels: 1.5-2.0mE/L blurred vision ataxia tinnitus nausea and vomiting and severe diarrhea 2.0-3.5 excessive dilute urine inc tremors muscular irritability psychomotor retardation confusion
Mania
Alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Can occur as a biological, psychological or substance-induced condition.
Stage I: Hypomania
At this stage the disturbance is not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization (APA, 2013). Mood - cheerful and expansive - underlying irritability that surfaces rapidly when the person's wishes and desires go unfulfilled, however- The nature of the hypomanic person is very volatile and fluctuating (see Box 26-2). Cognition and Perception - Perceptions of the self are exalted—ideas of great worth and ability. Thinking is flighty, with a rapid flow of ideas. Perception of the environment is heightened, but the individual is so easily distracted by irrelevant stimuli that goal-directed activities are difficult. Activity and Behavior - Hypomanic individuals exhibit increased motor activity. - very extroverted and sociable, and because of this they attract numerous acquaintances. - lack the depth of personality and warmth to formulate close friendships. - talk and laugh a great deal, usually very loudly and often inappropriately. - Increased libido is common. - Some individuals experience anorexia and weight loss. - The exalted self-perception leads some hypomanic individuals to engage in inappropriate behaviors, such as phoning the President of the United States, or buying huge amounts on a credit card without having the resources to pay.
Bipolar Disorder Associated with a Medical Condition
Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological consequences of another medical condition.
Antipsychotics
Chlorpromazine, Olanzapine, Aripiprazole, Quentipine, Risperidone, Ziprasidone, Clozapine Chlorpromazine: -Becoming Obsolete TDK -Atypical Less SE -Used Alone or in Combination with Lithium
Bipolar 1 disorder (BOX 26-1)
Client is experiencing or has experienced a full syndrome of manic or mixed symptoms specifiers such as single manic episode, current episode manic, hypomanic, mixed or depressed features full spectrum of manic episode takes place; pt has manic episode or has a history of one or more manic episodes; pt may also have experienced episodes of depression; can experience a single manic episode or a current episode manic, hypomanic, mixed, or depressed
Treatment modalities for Bipolar Disorder o Cognitive Therapy
Client is taught to control thoughts and distortions o depression is characterized by 3 neg distortions; related to expectations of the environment, self, and future - environment and activities within it are viewed as unsatisfying, the self is unrealistically devalued, and the future is perceived as hopeless o Mania is characterized by exaggeratedly positive cognitions and perceptions; the individual perceives the self as highly valued and powerful; future is viewed with unrealistic optimism; therapy focuses on changing "automatic thoughts" that occur spontaneously and contribute to the distorted bipolar mania • Personalizing: "she's this happy only when she's with me" • All or nothing: "everything I do is great" • Mind reading: "she thinks I'm wonderful" • Discounting negatives: " none of those mistakes are really important"
Mood Stabilizing Agents
Clonazepam (Klonopin) Carbamazepine (Tegretol) Valproic Acid (Depakote/Depakene) Gabapentin (Neurontin) Lamotrigine (lamictal) Topiramate (Topamax) Oxcarbazepine (Trileptal)
45. Harold is admitted to the psychiatric unit with bipolar I disorder: manic episode in a highly agitated state. His speech is rapid and incoherent, he is pacing and in constant motion, and he is loudly proclaiming that his "lawyers are on the way and every one of you is going to be sued for malpractice." Which of the following nursing interventions are appropriate in this situation? Select all that apply. 1) Provide an environment with low levels of stimulation. 2) Set limits on Harold's threats by instructing him that he is not permitted to sue the staff. 3) Convey a calm attitude and voice when communicating with Harold. 4) Put Harold in seclusion with restraints for the protection of himself and others. 5) Offer activities that will provide safe outlets for Harold's agitation and excessive energy.
Correct 1: Even little amounts of stimulation can increase symptoms and agitation in an acutely manic patient. Providing an environment with low levels of stimulation is a priority to reduce the risk of further escalation. Feedback 2: Although setting limits on unacceptable behavior may be necessary with this client, this example of communication is not limit setting but rather is a defensive response by the nurse and would likely promote increased, not decreased, agitation. Correct 3: Even little amounts of stimulation can increase symptoms and agitation in an acutely manic patient. Conveying a calm attitude and voice contributes to a lower level of stimulation when communicating with this patient. Feedback 4: Seclusion and restraint would not be appropriate at this point. These interventions are appropriate only when all other efforts to help the patient remain in control have failed and there is imminent risk of harm to self and/or others. However, it would be prudent to have plans in place to manage aggressive behavior if it continues to escalate. Correct 5: Offering activities that provide safe outlets for the excessive energy and hyperactivity that occur in manic episodes can be an effective distraction and a tool to reduce agitation.
35. Kelly has come to the mental health clinic for an assessment at the request of her husband. Kelly refuses to talk to the nurse until her personal assistant arrives. She states, "Apparently you don't know that I'm a famous person, and when my fans get here, you'll be glad my personal assistant is here to manage the crowd." The nurse meets with the husband to begin the assessment process. Which of the following observations by the husband are consistent with symptoms of a manic episode? Select all that apply. 1) "She has concocted this story about having a personal assistant and being a famous person; none of it is true." 2) "She has over-extended our credit cards, buying huge quantities of unnecessary items." 3) "Ever since we married, she has had periods where she makes superficial cuts on her wrists and becomes convinced I'm going to divorce her." 4) "I've noticed her behaving in a very provocative manner around other men." 5) "When we go to a party she drinks more alcohol than anyone there and inevitably becomes loud and obnoxious."
Correct 1: Kelly's false belief that she is a famous person is evidence of a delusion of grandeur, which is a symptom of a manic episode. Correct 2: Excessive spending is a common symptom in manic episodes. Feedback 3: Although borderline personality disorder is often comorbid with bipolar disorder, this behavior is more characteristic of the former. Correct 4: In acute manic episodes, one of the symptoms is increased sex drive, which could manifest in provocative and/or high-risk behavior. Feedback 5: Although there is a high incidence of substance use disorder in this population, this behavior is more symptomatic of the substance use than a manic episode.
43. The psychiatrist has asked the nurse to make an assessment of how well Aaron is responding to the lithium he is being prescribed. Which of the following observations by the nurse suggest that Aaron's manic episode is subsiding? Select all that apply. 1) Aaron is able to finish his meals seated at a table. 2) Aaron is sleeping an average of six hours per night. 3) Aaron demonstrates an ability to listen and respond appropriately to questions. 4) Aaron complains of feeling less energetic and creative. 5) Aaron states he doesn't want to keep taking lithium.
Correct 1: One of the symptoms of a manic episode is hyperactivity. Aaron's ability to sit still long enough to finish a meal suggests that he is not excessively hyperactive. Correct 2: A hallmark symptom of a manic episode is lack of sleep, sometimes for days at a time. Aaron's ability to sleep for 6 hours a night is evidence that the manic episode is subsiding. Correct 3: Distractibility is a symptom in manic episodes that interferes with a person's ability to listen and respond appropriately. Aaron's ability to do this suggests the manic episode is subsiding. Correct 4: Lithium's desired effect is to reduce the excessive energy and hyperactivity associated with manic episodes, so Aaron's report of less energy suggests that the medication is having a therapeutic effect. It is not uncommon, though, for patients to be less satisfied with this change because the high energy and creativity that occur in manic episodes is pleasurable. Feedback 5: Although adherence to medication is an issue that needs to be discussed, refusal or lack of desire to take medication is not necessarily symptomatic of illness.
38. Barbara asks to speak to the nurse about her husband, who has been diagnosed with bipolar I disorder. She tells the nurse she is thinking of divorcing her husband because his agitation "comes out of nowhere" and is "impossible to manage." She also admits to being "fed up with his extramarital affairs" and says "I just don't know what to say anymore." The nurse recognizes that family psychoeducational treatment is important in improving adjustment and preventing relapses. Which of the following are components of family psychoeducational treatment that will be beneficial to Barbara on the basis of her expressed concerns? Select all that apply. 1) Problem-solving skills training 2) Communication training 3) Education about the illness 4) Codependency education 5) Divorce training
Correct 1: Teaching Barbara some problem-solving skills addresses her concern that she is having difficulty managing her husband's outbursts. One option for Barbara might be to strategize with her husband how they can problem-solve about what to do when he has difficulty managing his agitation. Correct 2: Teaching Barbara communication skills responds to her concern that "I don't know what to say." One option might be assertive communication skills training so that Barbara develops confidence in her ability to communicate concerns directly to her husband. Correct 3: Teaching Barbara about symptoms of the illness may help her to better understand the dynamics of her husband's engaging in high-risk activities such as extramarital affairs. Feedback 4: Codependency education may be a component in family psychoeducational treatment, but there is no evidence that this is an issue for Barbara. Feedback 5: Divorce training is not typically a component of family psychoeducation and may imply that problem solving is a hopeless venture. There are many avenues that families can access for support and education to facilitate adjustment and reduce or prevent relapses.
49. Donald's wife asks the nurse why her husband has been ordered an anticonvulsant when he's never had a seizure and his real problem is bipolar disorder. Which of these teaching points by the nurse are accurate? Select all that apply. 1) The mechanism of action for anticonvulsants in bipolar disorder is unclear. 2) Anticonvulsants are used to prevent seizures that may be an undesired effect of other medications the patient is taking. 3) Anticonvulsants have demonstrated mood stabilizing effects in patients with bipolar disorder. 4) The FDA does require that antiepileptic medications carry a warning label indicating an increased risk for suicidal thoughts and behavior. 5) Anticonvulsants are prescribed to prevent alcohol withdrawal, which is common in patients with bipolar disorder.
Correct 1: This is a true statement. Although anticonvulsants have demonstrated benefits in mood stabilization, the mechanism of action is unclear. Feedback 2: Anticonvulsants are used in this population for their mood-stabilizing benefits, not to manage side effects of other medications. Correct 3: The mood-stabilizing effect of anticonvulsants is the primary reason for their use in patients with bipolar disorder. Correct 4: Although anticonvulsant medication has positive effects on the mood, it may increase the risk for suicide ideation and attempts, and the FDA does require a warning label to that effect, so this teaching point is accurate. Feedback 5: Although there is a high incidence of substance abuse, including alcohol abuse in this population, the primary use for anticonvulsants in patients with bipolar disorder is for its mood-stabilizing effects.
37. The parents of a teenage son who was recently diagnosed with bipolar disorder ask the nurse to provide them with information about this illness, since they had previously been told their son had ADHD. Which of the following is evidence-based information that can be shared with the family? Select all that apply. 1) ADHD is the most common comorbid condition in children and adolescents with bipolar disorder. 2) Bipolar disorder in children and adolescents is an acute condition that they usually outgrow. 3) There is evidence to support that psychosocial therapy enhances the effectiveness of pharmacological therapy in treatment of bipolar disorder in children and adolescents. 4) Stimulants used in the treatment of ADHD can exacerbate mania in children and adolescents with bipolar disorder. 5) Medication discontinuation can be considered after the patient has been in remission for two months.
Correct 1: This statement is an accurate, evidence-based piece of information. Feedback 2: Evidence supports that bipolar disorder in children and adolescents is a chronic illness with a high risk of relapse. Sensitivity and caution are warranted in deciding if and when this is appropriate information to share with the family, since it can be devastating news to the family that their child has a chronic illness with a high risk for relapse. Correct 3: This is an evidence-based statement and informs the parents of important information for considering treatment options. Correct 4: This is an evidence-based statement and informs the parents of important information for considering treatment options. Feedback 5: This is an inaccurate statement. Some evidence suggests that tapering or discontinuation of medication should be considered only after 12 to 24 consecutive months of remission, and some clients may require long-term or life-long pharmacotherapy.
34. To assist the psychiatrist in determining appropriate medication needs, the nurse has been asked to assess whether a patient is in a hypomanic or an acute manic state. Which of the following symptoms are consistent with hypomania? Select all that apply. 1) Cheerful mood, but underlying irritability surfaces rapidly when needs are not fulfilled 2) Fragmented cognition and perception; often psychotic 3) Delusions of grandeur 4) Easily distracted, which sometimes interferes with completing goal-directed activity 5) Extroverted and sociable
Correct 1: This symptom is consistent with hypomania. In contrast, the individual in an acute manic state presents as euphoric, as if on a continuous "high." Feedback 2: This symptom is more consistent with acute mania. The individual with hypomania more often presents with flighty and rapid flow of ideas but not overt fragmentation. Feedback 3: The individual with hypomania may present with an exalted sense of self, but delusions of grandeur are manifesting of an acute manic episode. Correct 4: This symptom is consistent with hypomania. In contrast, the person in an acute manic episode manifests with inexhaustible energy, poor impulse control, and marked interference with completing tasks. Correct 5: The person in a hypomanic episode typically presents as extroverted and sociable. In contrast, the individual in an acute manic episode typically presents as uninhibited and manipulative. Dress and behavior may appear disorganized and bizarre.
48. Haley is a 35-year-old woman being assessed for complaints of racing thoughts, impulsive agitation, and distractibility. She denies having ever been diagnosed with a mental disorder. Which of the following items are important for the nurse to include in Haley's initial assessment to assist in identifying the correct diagnosis? Select all that apply. 1) Family history of thyroid disorders 2) Family history of depression or bipolar disorders 3) Medications and other substances currently being taken 4) Birth order 5) Interest in attending group therapy
Correct 1: Thyroid disorders, particularly hyperthyroidism, could manifest as the symptoms Haley is describing, and since these disorders show a familial tendency it is beneficial to assess for family history of these disorders. Correct 2: The symptoms Haley is experiencing could be evidence of a bipolar disorder. Bipolar disorders and depression show familial tendencies, so it is beneficial to assess for history of these. Correct 3: Several medications and other substances can produce the symptoms Haley is describing, so a thorough history of substance and medication use is essential. Feedback 4: Haley's birth order in the family is irrelevant in identifying the correct diagnosis. Feedback 5: Identifying interest in treatment options should follow thorough assessment and diagnosis. Exploring Haley's interest in group therapy at the initial assessment will not contribute to identifying the correct diagnosis.
Substance/Medication-Induced Bipolar
Direct result of physiological effects of a substance May involve... *elevated, expansive, irritability, inflated self esteem, decreased need for sleep, distractibility *Social impairment, disrupts function *Associated with Intoxication from substances- ETOH, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedatives, hypnotics, anxiolytics *Withdrawal from substances- ETOH, amphetamines, cocaine, sedatives, hypnotics, anxiolytics *Evoke Mood symptoms- Anesthetics, analgesics, anticholinergics, anticonvulsants....
Biochemical Influences
Excess of dopamine and norepinephrine have been linked.
32. Elizabeth has been taking lithium for 4 weeks and complains that she thinks she might have lithium toxicity. Which of these findings by the nurse are consistent with lithium toxicity? Select all that apply. 1) Elizabeth has had very little urine output in the last 24 hours. 2) Elizabeth has had several bouts of diarrhea in the last 24 hours. 3) Elizabeth's lithium level is 1.2 mEq/L. 4) Elizabeth's temperature is 99.6°F. 5) Elizabeth complains of less energy since she started taking lithium.
Feedback 1: Excessive output of dilute urine, not inadequate output, is evidence of lithium toxicity. Correct 2: Severe diarrhea can be a symptom of lithium toxicity, but when assessed in combination with her temperature and the lithium level, it does not appear that lithium toxicity is the cause of the diarrhea. Feedback 3: This level is within the therapeutic range, and toxicity symptoms don't begin to appear until the lithium level exceeds 1.5 mEq/L. Feedback 4: The elevated temperature is not a symptom of lithium toxicity and suggests there may be an infection or other issue that is contributing to the patient's complaint of diarrhea. Feedback 5: People often report feeling less energy when they are on lithium because it is in contrast to the high energy associated with manic episodes. Symptoms of lithium toxicity include drowsiness, mental confusion, impaired consciousness, or coma. There is no evidence of those CNS symptoms in this scenario.
Antipsychotics
Helps control Hallucinations & delusions Chlorpromazine (Thorazine) Olanzapine (Zyprexia) Aripiprazole (Abilify) Quentipine (Seraquel) Risperidone (Risperdal) Ziprasidone (Geodin)
Substance Induced bipolar disorder BOX 26 -3
For at least 2 years (at least one year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met. D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With anxious distress
Topiramate:
Less effective with oral contraceptives
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)
Psychopharmacology:
Lithium Divalproex Carbamazepine Atypical antipsychotics
Psychopharmacology for Mania
Lithium carbonate Anticonvulsants Verapamil Antipsychotics
Antimanic
Lithium carbonate:(Monitor Blood levels)
B (Risk for injury related to hyperactivity)
Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sister-in-law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. Margaret is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. What is the priority nursing diagnosis for Margaret? A) Imbalanced nutrition: less than body requirements related to not eating B) Risk for injury related to hyperactivity C) Disturbed sleep pattern related to agitation D) Ineffective coping related to denial of depression
C (Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run.")
Margaret, age 68, is diagnosed with Bipolar I Disorder, current episode manic. She is extremely hyperactive and has lost weight. What is one way to promote adequate nutritional intake for Margaret? A) Sit with her during meals to ensure that she eats everything on her tray. B) Have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes. C) Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run." D) Tell Margaret that she will be on room restriction until she starts gaining weight.
Bipolar I
One who is experiencing a manic episode History of one or more manic episodes Also have depression episodes Psychotic or catatonic features
A suicidal client with a history of manic behavior is admitted to the ED. The client's diagnosis is documented as bipolar I current episode depressed. What is the rationale or this diagnosis instead of a diagnosis of major depressive disorder
Past history of mania and current suicide attempt support Bipolar i
Treatment strategies:
Psychopharmacology: Lithium Divalproex Carbamazepine Atypical antipsychotics (risperidone)
Bipolar II
Recurrent bouts of MDD with episodic occurrence of hypomania May present with depression or hypomania Never experienced a full manic episode
Risk for Injury (Nursing Diagnosis)
Related to extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements.
Recovery Model (Bipolar Disorder)
Research provides support for recovery as an obtainable objective for individuals with bipolar disorder.
Psychosocial Theory
The credibility has declined in recent years for conditions such as schizophrenia and bipolar disorder as they are more often viewed as diseases of the brain with biological etiologies. Although environmental stressors may have slight influences.
30. A client thought to be cheeking medications is prescribed Lithium syrup 900 mg bid. The syrup contains 300 mg of lithium per 5 mL. At 0800, how many milliliters would the nurse administer? _____ mL.
The nurse would administer 15 mL.
7. The nurse is reviewing expected outcomes for a client diagnosed with bipolar I disorder. Number the outcomes presented in the order in which the nurse would address them. 1. _____ The client exhibits no evidence of physical injury. 2. _____ The client eats 70% of all finger foods offered. 3. _____ The client is able to access available out-patient resources. 4. _____ The client accepts responsibility for own behaviors.
The outcomes should be numbered as follows: 1, 2, 4, 3.
2 ("FIND" tool) (Rationale: The nurse should use the "FIND" tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.)
What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 1. "Risky Activity" tool 2. "FIND" tool 3. "Consensus Committee" tool 4. "Monotherapy" tool
2 (Empowerment of the consumer) (Rationale: The basic premise of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care and to enable a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.)
Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships
1, 2, 3 (Rationale: The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high because of the narrow margin between therapeutic doses and toxic levels. Fluid or sodium restriction can impact lithium levels.)
Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.) 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. Restrict sodium content. 5. Restrict fluids to 1,500 mL per day.
1, 2 (Rationale: It is difficult to diagnose a child or adolescent with bipolar disorder, because bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder.)
Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.) 1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. 2. Children are naturally active, energetic, and spontaneous. 3. Neurotransmitter levels vary considerably in accordance with age. 4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. 5. Genetic predisposition is not a reliable diagnostic determinant.
1. Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sisterin- law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for Margaret is: a. Imbalanced nutrition: less than body requirements related to not eating b. Risk for injury related to hyperactivity c. Disturbed sleep pattern related to agitation d. Ineffective coping related to denial of depression
b. Risk for injury related to hyperactivity
A client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of dilute urine, tremors, and muscular irritability. These symptoms would lead the nurse to expect the client's lithium serum level would be which of the following? a. 0.6mEq/L b. 1.5mEq/L c. 2.6mEq/L d. 3.5mEq/L
c
8. A client experiencing a manic episode enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? a. Tell the client she cannot wear this outfit while she is in the hospital. b. Do nothing and allow her to learn from the responses of her peers. c. Quietly walk with her back to her room and help her change into something more appropriate. d. Explain to her that if she wears this outfit she must remain in her room.
c. Quietly walk with her back to her room and help her change into something more appropriate.
10. A child with bipolar disorder also has attention-deficit/hyperactivity disorder (ADHD). How would these co-morbid conditions most likely be treated? a. No medication would be given for either condition. b. Medication would be given for both conditions simultaneously. c. The bipolar condition would be stabilized first before medication for the ADHD would be given. d. The ADHD would be treated before consideration of the bipolar disorder.
c. The bipolar condition would be stabilized first before medication for the ADHD would be given.
Bipolar
characterized by mood swings from profound depression to extreme euphoria with intervening period of normalcy o Delusions/hallucinations may or may not be a part of the clinical picture, and onset of symptoms may reflect a seasonal pattern
Do not use
if Hypersensitive to lithium
mood stabilizing agents
indication: prevent and treat of manic episodes associated with bipolar ex:
ADHD
is most common comorbid condition --ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled
Lithium
may modulate the effects of certain neurotransmitters such as norepinephrine serotonin dopamine SE: drowsniess dizziness thirst GI upset fine hand tremors pulse irrgularities polyuria, dehydration
Treatment modalities for Bipolar Disorder o Individual psychotherapy
not best bc client is trying to please the therapist and relationship remains shallow and rigid
Developmental Childhood and Adolescence SYMPTOMS
■ Euphoric/expansive mood. Extremely happy, silly, or giddy. ■ Irritable mood. Hostility and rage, often over trivial matters. The irritability may be accompanied by aggressive and/or self-injurious behavior. ■ Grandiosity. Believing that his or her abilities are better than everyone else's. ■ Decreased need for sleep. May sleep only 4 or 5 hours per night and wake up fresh and full of energy the next day. Or he or she may get up in the middle of the night and wander around the house looking for things to do. ■ Pressured speech. Rapid speech that is loud, intrusive, and difficult to interrupt. ■ Racing thoughts. Topics of conversation change rapidly, in a manner confusing to anyone listening. ■ Distractibility. It needs to reflect a change from baseline functioning, needs to occur in conjunction with a "manic" mood shift, and cannot be accounted for exclusively by another disorder, particularly ADHD Distractibility during a manic episode may be reflected in a child who is normally a B or C student and is unable to focus on any school lessons. ■ Increase in goal-directed activity/psychomotor agitation. A child who is not usually highly productive, during a manic episode becomes very projectoriented, increasing goal-directed activity to an obsessive level. Psychomotor agitation represents a distinct change from baseline behavior. ■ Excessive involvement in pleasurable or risky activities. hyper sexual, exhibiting behavior that has an erotic, pleasure-seeking quality about it. Adolescents may seek out sexual activity multiple times in a day. ■ Psychosis. psychotic symptoms, including hallucinations and delusions, are frequently present in children with bipolar disorder ■ Suicidality. Although not a core symptom of mania, at risk of suicidal ideation, intent, plans, and attempts during a depressed or mixed episode or when psychotic
