Mental health: Chapter 17
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. Gabapentin (Neurontin) E. Tranylcypromine (Parnate)
-Olanzepine (Zyprexa) -Carbamazepine (Tegretol) -Gabapentin (Neurontin)
A number of medications have also been known to evoke mood symptoms such as:
-anesthetics -analgesics -anticholinergics -anticonvulsants -antihypertensives -antiparkinsonian agents -antiulcer agents -cardiac meds -oral contreceptives -psychotropic meds -muscle relaxants -steroids -sulfaonamides
Medications for depressive phases:
-antidepressants *use with care (may trigger mania)
The mood of a hypomanic person is:
-cheerful -expansive -underlying irritability that surfaces rapidly when wishes and desires go unfulfilled
When taking lithium the client should:
-continue taking the medication on a regular basis, even when feeling well -should not drive or operate dangerous machinery until lithium levels are stabilized -notify physician if vomiting or diarrhea occurs -carry a card or other identification noting that he or she is taking lithium
Stage 2: Acute mania is characterized by...
-elation and euphoria; a continuous "high" -flight of ideas; accelerated, pressured speech -hallucinations and delusions -excessive motor activity -social and sexual inhibition -little need for sleep -neglected hygiene -dress may be disorganized, flamboyant or bizarre, excessive use of make up or jewelry is common
During a manic episode, the mood is:
-elevated -expansive -irritable
Evaluation of the nursing actions for the patient experiencing a manic episode may be facilitated by gathering information using the following types of questions:
-has the client avoided personal injury? -has violence to the client or others been prevented? -has agitation subsided? -have nutritional status and weight been stabilized? -have delusions and hallucinations ceased? -is the client able to make decisions about self care? -is behavior socially acceptable? -is the client able to sleep 6 to 8 hours per night and awaken feeling rested? -does the client understand the importance of maintenance medication therapy?
Hypomanic individuals exhibit:
-increased motor activity -exalted self perception -engages in inappropriate behaviors -increased libido
Treatment modalities for bipolar disorder:
-individual psychotherapy -group therapy -family therapy -cognitive therapy
Common manifestations of delirious mania:
-labile mood; panic anxiety -clouding of consciousness; disorientation -frenzied psychomotor activity -exhaustion and possibly death without intervention; injury to self or others
Medications for mania:
-lithium carbonate -anticonvulsants -verapamil -antipsychotics
When taking lithium, the patient should notify the physician if any of the following symptoms occur:
-persistant nausea/ vomiting -severe diarrhea -ataxia -blurred vision -tinnitus -excessive output of urine -increasing tremors -mental confusion
Examples of automatic thoughts in bipolar mania include the following:
-personalizing -all or nothing -mind reading -discounting negatives
Hypomanic individuals are perceived as being:
-very extrovertable -sociable -they lack the depth of personality and warmth to formulate close relationships -they talk and laugh a-lot and are seen as being loud and inappropriate
The nurse is prioritizing nursing diagnoses in the plan of care for a patient experiencing a manic episode. Number the nursing diagnoses in order of the appropriate priority. A. disturbed sleep pattern evidenced by sleeping only 4 to 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
1.) risk for injury related to manic hyperactivity 2.) imbalanced nutrition: less than body requirements evidenced by loss of weight and poor skin turgor 3.) disturbed sleep pattern evidenced by sleeping only 4 to 5 hours per night 4.) impaired social interaction evidenced by manipulation of others
What is hypomania?
A mild form of mania that lasts at least 4 days, marked by elation and hyperactivity. Also known as stage 1 of the manic states. Hospitalization is not required.
Extreme irritability and hyperactivity equals:
Acute mania
The impulsiveness and hyperactivity seen in clients diagnosed with ___________________ puts them at risk for injury.
Acute mania
"Everything I do is great" What automatic thought would this be described as?
All or nothing
Loss of pleasure and lack of interest in activities, hobbies, sexual activity.
Anhedonia
Characterized by more HIGHS than LOWS; more manic state
Bipolar 1 disorder
_____________________ is the diagnosis given to an individual who is experiencing a manic episode or has a history of one or more manic episodes. The client may also have experienced episodes of depression.
Bipolar 1 disorder
Characterized by more LOWS than HIGHS; more depressive state
Bipolar 2 disorder
_______________________ diagnostic category is characterized by recurrent bouts of major depression with episodic occurence of hypomania.
Bipolar 2 disorder
This disorder is 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 effects of another medical condition.
Bipolar disorder due to another medical condition
According to Maslow's Hierarchy of needs, maintaining ___________________ is always a priority.
Client safety
in ________________________, the individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of mood disorders.
Cognitive therapy
______________________________ is a chronic mood disturbance of at least 2 years, 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 a major depressive episode.
Cyclothymic disorder
Being completely out of touch with reality falls under:
Delirious mania
"None of those mistakes are really important" What automatic thought would this be described as?
Discounting negatives
Auditory and visual hallucinations; disorientation What nursing diagnosis is this in a person experiencing a manic episode?
Disturbed sensory perception
Delusions of grandeur and persecution; inaccurate interpretation of the environment. Seen in clients w/ delirious mania What nursing diagnosis is this in a person experiencing a manic episode?
Disturbed thought processes
Clients who are suicidal or those who have rapid cycling can also benefit from ____________.
ECT (electroconvulsive therapy)
Episodes of acute mania are occasionally treated with _____________, particularly when the client does not tolerate or fails to respond to lithium or other drug treatment, or when life is threatened by dangerous behaviors or exhaustion
ECT (electroconvulsive therapy)
The mood disturbance may involve:
Elevated, expansive, or irritable mood, with inflated self esteem, decreased need for sleep, and distractibility.
In _____________, the ultimate objectives in working with families of clients with mood disorders are to resolve the symptoms and initiate or restore adaptive family functioning.
Family therapy
__________________________ help members gain a sense of perspective on their condition and tangibly encourage them to link up with others who have common problems.
Group therapy/support groups
Euphoria equals:
Hypomania
The focus of this therapy is helping clients to regulate their social rhythms, or daily activities such as the sleep-wake cycle and exercise routines, that may otherwise disrupt underlying biologic rhythms and contribute to mood disturbances
IPSRT (interpersonal and social rhythm therapy)
___________ is a type of therapy specifically designed for bipolar patients.
IPSRT (interpersonal and social rhythm therapy)
CARE PLAN: Nursing diagnosis: _____________________________. Related to: refusal or inability to sit still long enough to eat Evidenced by: weight loss, amenorrhea
Imbalanced nutrition: less than body requirements
CARE PLAN: Nursing interventions for ___________________________________. 1. provide high protein, high calorie, nutritious finger foods and drinks that can be consumed "on the run" 2. have juice and snacks available on the unit at all times 3. maintain accurate record of intake, output, calorie count, and weight, monitor daily lab values 4. determine patients likes and dislikes and collaborate with dietitian to provide favorite foods 5. supplement diet with vitamins and minerals 6. walk or sit with patient while he or she eats
Imbalanced nutrition: less than body requirements
CARE PLAN: Short term goals: patient will consume sufficient finger foods and between meal snacks to meet recommended daily allowances of nutrients Long term goals: patient will exhibit no signs or symptoms of malnutrition Which nursing diagnosis are these goals directed at?
Imbalanced nutrition: less than body requirements
Loss of weight, amenorrhea, refusal or inability to sit still long enough to eat What nursing diagnosis is this in a person experiencing a manic episode?
Imbalanced nutrition: less than body requirements
CARE PLAN: Nursing diagnosis: _______________________________________. Related to: delusional thought processes (grandeur and or/persecution); underdeveloped ego and low self esteem Evidenced by: inability to develop satisfying relationships and manipulation of others for own desires
Impaired social interaction
CARE PLAN: Nursing interventions for _______________________________. 1. recognize the purpose manipulative behaviors serve for the patient: to reduce feelings of insecurity by increasing feelings of power and control 2. set limits on manipulative behaviors, explain to the patient what is expected and what the consequences are if the limits are violated, terms of the limitations must be agreed on by all staff who will be working with the patient 3. do not argue, bargain, or try to reason with the patient, merely state the limits and expectations, confront the patient as soon as possible when interactions with others are manipulative or explosive, follow through with established consequences for unacceptable behavior 4. provide positive reinforcement for nonmanipulative behaviors, explore feelings and help the patient seek more appropriate ways of dealing with them. 5. help the patient recognize that he or she must accept the consequences of own behaviors and refrain from attributing them to others 6. help the patient identify positive aspects about self, recognize accomplishments, and feel good about them
Impaired social interaction
CARE PLAN: Short term goals: patient will verbalize which of his or her interaction behaviors are appropriate and which are inappropriate within 1 week Long term goals: patient will demonstrate use of appropriate interaction skills as evidenced by lack of, or marked decrease in, manipulation of others to fulfill own desires Which nursing diagnosis are these goals directed at?
Impaired social interaction
Inability to develop satisfying relationships, manipulation of others for own desires, use of unsuccessful social interaction behaviors What nursing diagnosis is this in a person experiencing a manic episode?
Impaired social interaction
Substance and medication induced bipolar disorder causes:
Impairment in social, occupational, or other areas of functioning
Difficulty falling asleep, sleeping for only short periods What nursing diagnosis is this in a person experiencing a manic episode?
Insomnia
An alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Usually requires hospitalization and manic episodes can last up to 1 week.
Mania
Clients diagnosed with bipolar disorder feel most productive during a manic episode. This may lead to purposeful ___________________________.
Medication nonadherance
"She thinks i'm wonderful" What automatic thought would this be described as?
Mind reading
A standardized tool that places mood progression on a continuum from hypomania to acute mania to delirious mania.
Mood disorders questionnaire
"Im the only reason my husband is a successful business man" What automatic thought would this be described as?
Personalizing
Disturbance of mood can be a direct result of the:
Physiological effects of a substance
Four or more episodes of hypomania or acute mania within 1 year, associated with increase recurrence rate and resistance to treatment
Rapid cycling
A client who is experiencing frequent manic episodes has a delusional thought process and low self-esteem. The nurse finds that the client is trying to manipulate others for self-gratification. What intervention included in the client's care plan would the nurse expect to improve the client's self-esteem?
Reinforcing acceptable behaviors in the client
CARE PLAN: Nursing interventions for _______________________. 1. reduce environmental stimuli, assign private room with simple decor on quiet unit if possible, keep lighting and noise level low 2. remove hazardous objects and substances (including smoking materials) 3. stay with the patient who is hyperactive and agitated 4. provide structured schedule of activities that includes established rest periods throughout the day, limit group activities 5. provide physical activities 6. administer tranquilizing medication as ordered by physician
Risk for injury
CARE PLAN: Short term goal: patient will no longer exhibit potentially injurious movements after 24 hrs, with administration of tranquilizing medication Long term goal: patient will not experience injury Which nursing diagnosis are these goals directed at?
Risk for injury
CARE PLAN: Nursing diagnosis: ________________________ Related to: extreme hyperactivity Evidenced by: increased agitation and lack of control over purposeless and potentially injurious movements
Risk for injury
Extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements. What nursing diagnosis is this in a person experiencing a manic episode?
Risk for injury
In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? a. Risk for injury related to excessive hyperactivity b. Disturbed sleep pattern related to manic hyperactivity c. Imbalanced nutrition, less than body requirements, related to inadequate intake d. Situational low self-esteem related to embarrassment secondary to high-risk behaviors
Risk for injury related to excessive 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. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats 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. Imbalance nutrition: less than body requirement 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
Risk for injury related to hyperactivity
-Manic excitement -Delusional thinking -Hallucinations -Impulsivity What nursing diagnosis is this in a person experiencing a manic episode?
Risk for violence: self directed or other directed
CARE PLAN: Nursing diagnosis: ____________________________. Related to: manic excitement, delusional thinking, hallucinations
Risk for violence: self directed or other directed
CARE PLAN: Nursing interventions for __________________________________. 1. maintain a low level of stimuli in patients environment (low lighting, few people, simple decor, low noise level) 2. assess for concurrent substance use issues 3. observe patients behavior frequently, do this while carrying out routine activities so as to avoid creating suspiciousness in the individual 4. remove all sharp objects, glass, or mirrored items, belts, ties, and smoking materials from patients environment 5. intervene at the first signs of increased anxiety, agitation, or verbal or behavioral aggression using empathetic responses such as "you seem anxious" or "how can i help you?" 6. maintain and convey a calm attitude, respond matter of factly to verbal hostility 7. as anxiety increases, offer some alternative: to participate in a physical activity (walking, etc), talking about the situation, taking some anti-anxiety medication 8. have sufficient staff available to indicate a show of strength to patient if it becomes necessary 9. if patient is not calmed by "talking down" or by mediation, use of mechanical restraints may be necessary 10. if restraint is deemed necessary, ensure that sufficient staff is available to assist 11. observe the patient in restraints continuously and assess the patient at least every 15 mins to ensure that circulation to extremities is not compromised (check temp, color, pulse), assist the patients needs to nutrition, hydration, and elimination, position the patient so that comfort is facilitated and aspiration can be prevented 12. as agitation decrease, assess the patients readiness for restraint removal or reduction, remove restraints gradually, one at a time while assessing the patients response
Risk for violence: self directed or other directed
CARE PLAN: Short term goal: patients agitation will be maintained at a manageable level with the administration of tranquilizing medication during the first week of treatment Long term goal: patient will not harm self or others Which nursing diagnosis are these goals directed at?
Risk for violence: self directed or other directed
At this stage, the disturbance is not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization. What stage is this?
Stage 1: Hypomania
Symptoms of manic states can be described according to 3 stages:
Stage 1: Hypomania Stage 2: Acute mania Stage 3: Delirious mania
Marked impairment in functioning; usually requires hospitalization. What stage is this?
Stage 2: Acute mania
Grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare because of the advent of antipsychotic medication. What stage is this?
Stage 3: Delirious mania
A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance
Substance and medication induced bipolar disorder
When can symptoms occur with substance and medication-induced disorder?
Symptoms can occur during withdrawal from substances such as alcohol, amphetamines, cocaine, sedatives, hypnotics, and anxiolytics
The nurse is caring for a client with impaired social interaction. The nurse sets limits on the manipulative behavior of the client. What outcome in the client does the nurse expect from this intervention?
The client will develop appropriate interaction skills
__________________________________ is designed to allow consumers primary control over decisions about their own care and to enable a person w/ mental health problems to live a meaningful life in a community of his or her own choice while striving to achieve his or her own full potential.
The recovery model
Delirious mania is characterized by _____________________________________.
auditory or visual hallucinations
A ______________________________ is characterized by mood swings from profound depression to extreme euphoria (mania).
bipolar disorder
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) delusion of grandeur b) delusion of persecution c) delusion of reference d) delusion of control or influence
delusion of persecution
A patient experiencing delirious mania may exhibit feelings of:
despair, quickly converting to unrestrained merriment and ecstasy of becoming irritable or totally indifferent to the environment
The client with hypomanic episodes of bipolar disorder shows _______________________
distractibility
A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? A. do not skimp on dietary sodium intake B. have serum lithium levels checked every 6 months C. limit fluid intake to 1000 milliliter of fluid per day D. Adjust the dose if you feel out of control
do not skimp on dietary sodium intake
The basic premise of a recovery model is __________________________________________________.
empowerment of the consumer
Both ____________________________________ demonstrate effectiveness in managing bipolar depression.
lithium and mood stabilizers
Margaret, age 68, is diagnosed with Bipolar 1 Disorder, current manic episode. 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 her likes and dislikes c. provide high-calorie, nutritious finger foods and snacks that she can eat "on the run" d. tell her that she will be on room restriction until she starts gaining weight
provide high-calorie, nutritious finger foods and snacks that she can eat "on the run"
Katerina, who is 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 her, in front of the other patients, that she cannot dress like a w**** while she is in the hospital B. do nothing and allow her to learn from the response 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 is she wears this outfit, she must remain in her room
quietly walk with her back to her room and help her change into something more appropriate
clients taking lithium should consume a diet adequate in _______________ and drink 2,500 and 3,000 mL of fluid per day.
sodium
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
substance-disorders
The general goals in cognitive therapy are to obtain:
symptom relief as quickly as possible, assist the client in identifying dysfunctional patterns of thinking and behaving, and guide the client to evidence and logic that effectively test the validity of the dysfunctional thinking.
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
the bipolar condition would be stabilized first before medication for the ADHD would be given
The client with bipolar II disorder has symptoms of depression or hypomania, but...
the client does not experience full manic episodes
Maintaining normal sodium and fluid levels is critical to maintaining:
therapeutic levels of lithium and preventing toxicity
A nurse is educating a patient about his lithium therapy. She is explaining the signs and symptoms of lithium toxicity. Which of the following would she instruct the patient to be on alert for? A. fever, sore throat, malasie B. tinnitus, sever diarrhea, ataxia C. occipital headache, palpatations, chest pain D. skin rash, marked rise in BP, bradycardia
tinnitus, sever diarrhea, ataxia
The mood of a delirious person is:
very labile (liable to change)
