Mood Disorders | Moncrieff
How do you COMMUNICATE with Bipolar patients?
Firm, calm approach (for someone w/mania) Short, concise explanations Be neutral: avoid power struggles, do not join in joking Consistent approach and expectations Convey limits, consequences Act on legitimate complaints Redirect energy
The nurse is aware that a client taking medication that is controlling the symptoms of his or her bipolar disorder will have better treatment outcomes when which of the following is initiated? a) Decision influences from many family members b) Independent decision-making by the patient c) Shared decision-making d) Controlled decision-making by the therapist
c) Shared decision-making
A nurse is preparing to administer medications to a female client with bipolar disorder who is experiencing acute mania. Which of the following would be most appropriate for the nurse to do? a) Restrain the client before administering the medication. b) Tell the client firmly that she must take her medication. c) Notify the physician about the client's refusal of the medication. d) Allow the client to participate in the treatment decision.
d) Allow the client to participate in the treatment decision.
What is psychomotor agitation?
increased body movements and thoughts
What is psychomotor retardation?
overall slowed movements; a general slowing of all movements; slow cognitive processing and slow verbal interaction
What are mood disorders?
pervasive alterations in emotions that are manifested by depression or mania or both
What is labile?
rapidly changing or fluctuating, such as someone's mood or emotions
What is rumination?
repeatedly going over the same thoughts
Toxic serum levels for Lithium?
serum levels >1.5-2 mEq/L
What is pressured speech?
unrelenting, rapid, often loud talking without pauses
What is Lithium's action?
↑'s mood when depressed, ↓'s mood when manic
What is the neurotoxic lab range for Lithium?
0.6-1.2
What is the importance of MEDICATION COMPLIANCE for patients with Biplolar d/o?
Bipolar disorder is most treatable mental illness Client may enjoy feelings of hypomania— may not want to take meds Repeated manic episodes cause neurotoxic changes
How long does it take to reach therapeutic levels for Lithium?
7-28 days
What are Flight of Ideas (FOI)?
A continuous but fragmented use of language - train of thought changes frequently, often by chance stimuli from the environment
What is a Manic episode and what is the criteria?
A distinct period of abnormal elevation or irritability of mood for at least 1 week with at least 3 s/s
What are the warning signs of Bipolar illness?
A euphoric, or expansive mood Irritability and anger that is not consistent with the situation May be hostile Extreme cheerfulness or optimism Lack of judgment/insight Grandiosity, ↑ spending of money, sex, etc. Flight of ideas or racing thoughts; talking in a rush and changing from topic to topic; disorganized thoughts Decreased need for sleep Easily distracted Sudden rage, irritability, or paranoia
What is Clang Association?
A speech disorder common in mania where words are grouped together by their sound or rhyme, rather than their meaning
A client with bipolar disorder begins taking lithium carbonate (lithium), 300 mg four times a day. After 3 days of therapy, the client says, "My hands are shaking." The best response by the nurse is which of the following? A. "Fine motor tremors are an early effect of lithium therapy that usually subsides in a few weeks." B. "It is nothing to worry about unless it continues for the next month." C. "Tremors can be an early sign of toxicity, but we'll keep monitoring your lithium level to make sure you're okay." D. "You can expect tremors with lithium. You seem very concerned about such a small tremor."
A. "Fine motor tremors are an early effect of lithium therapy that usually subsides in a few weeks."
Which of the following activities would be appropriate for a client with mania? (select all) A. Drawing a picture B. Modeling clay C. Playing bingo D. Playing table tennis E. Stretching exercises F. Stringing beads
A. Drawing a picture B. Modeling clay E. Stretching exercises
Which of the following typifies the speech of a person in the acute phase of mania? A. Flight of ideas B. Psychomotor retardation C. Hesitant D. Mutism
A. Flight of ideas
Which assessment data would support a diagnosis of bipolar II disorder? A. Hypomania B. Behaviors that span at least a 6-day period C. Paranoia D. Behaviors requiring hospitalization
A. Hypomania
Which nursing intervention is likely to be most helpful in providing adequate nutrition while the patient is experiencing acute mania? A. Provide nutrient-rich finger foods so the patient can eat while walking and talking. B. Offer only liquids that are rich in calories. C. Make food available to the patient knowing he or she will eat when hungry. D. Insist that the patient join the other patients on the unit during mealtimes.
A. Provide nutrient-rich finger foods so the patient can eat while walking and talking.
A patient in acute mania is inappropriately humorous. Patients and staff are laughing at the patient's expense and embarrassment. The nurse should immediately: A. distract the patient to engage in another activity apart from the group. B. confront the group to stop the disrespectful behavior. C. join the group, and further assess the situation. D. consult the multidisciplinary team to determine the behavioral consequences for the staff.
A. distract the patient to engage in another activity apart from the group.
A client with mania begins dancing around the day room. When she twirled her skirt in front of the male clients, it was obvious she had no underpants on. The nurse distracts her and takes her to her room to put on underpants. The nurse acted as she did to: A. minimize the client's embarrassment about her present behavior. B. keep her from dancing with other clients. C. avoid embarrassing the male clients who are watching. D. teach her about proper attire and hygiene.
A. minimize the client's embarrassment about her present behavior.
What lab values are important to check for Valproic acid (Depakote)?
Baseline LFTs and Lipase are checked May cause liver or pancreatic damage (rare)
What are the GENERAL NURSING CARE interventions for people with Bipolar d/o?
Be patient Monitor Depakote or lithium levels Be honest and consistent Set reasonable limits Provide age-appropriate planned activitities (according to phase of disorder) Provide good nutrition (i.e. finger foods) Provide therapeutic communication
What is Lamotrigine's (Lamictal) therapeutic class?
Anticonvulsant
What is Valproic acid's (Depakote) therapeutic class?
Anticonvulsant
What is Lithium's therapeutic class?
Antimania
7. Identify the serum lithium level for maintenance and safety. A. 0.1 to 1.0 mEq/L B. 0.5 to 1.5 mEq/L C. 10 to 50 mEq/L D. 50 to 100 mEq/L
B. 0.5 to 1.5 mEq/L
Which assessment data would be inconsistent with a diagnosis of mania? A. The patient is demonstrating severe irritability. B. Family report that the mood change occurred gradually over a 5-day period. C. The behaviors have increased in severity since onset 2 weeks ago. D. The patient has been abusing alcohol consistently since onset of symptoms.
B. Family report that the mood change occurred gradually over a 5-day period.
What is the initial intervention implemented by the nurse when managing a manic patient whose behavior is disrupting a group therapy session? A. Setting behavioral limits for the patient that are appropriate and well defined B. Remaining involved with the patient while demonstrating a calm demeanor C. Communicating with the patient using brief, simple statements D. Removing the patient from the group to deescalate the situation
B. Remaining involved with the patient while demonstrating a calm demeanor
Client teaching for lamotrigine (Lamictal) should include which of the following? A. Eat a well-balanced diet to avoid weight gain. B. Report any rashes to your doctor immediately. C. Take each dose with food to avoid nausea. D. This drug may cause psychological dependence.
B. Report any rashes to your doctor immediately.
A nurse who understands the psychopathology of bipolar disorder is one who will: A. assist the patient to place numerous phone calls to friends and neighbors while on the inpatient unit. B. distract the patient with a fashion magazine when she wants to order 15 pairs of shoes from a catalog. C. provide frequent large meals to the patient who is experiencing flight of ideas. D. promote the therapeutic relationship with humor and joking behaviors.
B. distract the patient with a fashion magazine when she wants to order 15 pairs of shoes from a catalog.
It is most important for the nurse to include the significant others for which instruction when teaching a patient who is diagnosed with bipolar disorder? A. Calling the health care provider when facing a crisis situation B. Eating a heart-healthy diet and avoiding stress C. Watching for impending signs of relapse such as sleeping difficulties and irritability D. Receiving credit counseling in the case of large debt
C. Watching for impending signs of relapse such as sleeping difficulties and irritability
Manic individuals attempt to control others and to achieve their goals through: A. displaying tantrumlike behavior. B. physically aggressive behavior. C. manipulatively praising others. D. threatening to physically harm themselves.
C. manipulatively praising others.
What is Valproic acid's (Depakote) action?
Considered first-line by many docs Used if Li++ is contraindicated Used for rapid cycles, or dysphoric mania
What is DIG FAST?
Criteria for mania episode Distractibility Indiscretion Grandiosity Flight of ideas Activity Increased Sleep deprived Talkative
Which behavior is characteristic of a patient experiencing bipolar depression? A. Insomnia B. Weight loss C. Anorexia D. Carbohydrate craving
D. Carbohydrate craving
What is the rationale for a person taking lithium to have enough water and salt in his or her diet? A. Salt and water are necessary to dilute lithium to avoid toxicity. B. Water and salt convert lithium into a usable solute. C. Lithium is metabolized in the liver, necessitating increased water and salt. D. Lithium is a salt that has greater affinity for receptor sites than sodium chloride.
D. Lithium is a salt that has greater affinity for receptor sites than sodium chloride.
The nurse observes that a client with bipolar disorder is pacing in the hall, talking loudly and rapidly, and using elaborate hand gestures. The nurse concludes that the client is demonstrating which of the following? A. Aggression B. Anger C. Anxiety D. Psychomotor agitation
D. Psychomotor agitation
The signs of lithium toxicity include which of the following? A. Sedation, fever, restlessness B. Psychomotor agitation, insomnia, increased thirst C. Elevated WBC count, sweating, confusion D. Severe vomiting, diarrhea, weakness
D. Severe vomiting, diarrhea, weakness
Compare working with patients experiencing depression and those with bipolar disorder. Both groups of patients will require: A. careful monitoring of environmental stimuli. B. suicide and escape precautions. C. fall and seizure precautions. D. assessment of eating and sleeping patterns.
D. assessment of eating and sleeping patterns.
What are the EARLY s/s of LITHIUM TOXICITY that's <1.5 mEq/L?
Diarrhea FINE TREMORS N/V Thirst Polyuria Muscle weakeness Slurred speech
How do you provide care regarding SLEEP & HYGIENE for patients with Bipolar d/o?
Encourage rest periods during day (you don't want pts. to be sleeping in the morning) Reduce stimulation Avoid caffeine Use sleep-inducing interventions Supervise bathing, as necessary Minimize choices of clothing (laying out clothing would be one way) Give simple step-by-step reminders
What are the s/s of Manic episode?
Exaggerated self-esteem or grandiosity Decreased sleep Excessive talking Flight of ideas or appearance of racing thoughts Easily distracted Increase in goal-directed behavior & agitation Excessively involved in pleasurable, but dangerous activities (sex, spending money, giving away possessions, gambling)
What are the SEVERE s/s of LITHIUM TOXICITY that's >2.0-2.5 mEq/L?
Extreme polyuria of dilute urine Tinnitus Blurred vision ATAXIA Seizures Severe hypotension leading to coma and possible death from respiratory complications
What are the therapeutic levels for Valproic acid (Depakote)?
Has a wider therapeutic index Therapeutic level = 50-100 (some sources go up to 125 - person is in full-blown mania)
What is CAN HAM SUCS?
Li++ Toxicity Mnemonic Confusion An increase of thirst Nausea Hand tremors Ataxia Muscle twitches Seizures Uncontrolled eye movement Coma Slurred speech
How do you provide STRUCTURE for patients with Bipolar d/o?
Maintain low level of stimuli Structured solitary activities with staff (If they're very depressed, the may need to do something w/the nurse) Redirect violent behavior Minimize physical harm: medication/seclusion Protect from consequences of behavior, such as giving away money or possessions
What are the ADVANCED s/s of LITHIUM TOXICITY that's between 1.5-2.0 mEq/L?
Mental confusion Poor coordination COARSE TREMORS Ongoing GI distress (including N/V and diarrhea)
How do you provide care regarding NUTRITION & ELIMINATION for patients with Bipolar d/o?
Monitor intake, output and vital signs Offer frequent high calorie protein drinks Provide finger foods (for the person that can't sit down) Remind client to eat Monitor bowel elimination Offer high fiber foods Evaluate need for laxative Encourage client to go to bathroom
What are the characteristics of a person in a MANIC state?
Mood is labile, laughing to anger Talk is profane and crude Irritable Grandiose, out of contact with reality + HCN and Delusions - loss of contact w/reality Restless, disorganized, chaotic Too busy, no time for sex!
What is important to know about Lamotrigine (Lamictal)?
One of only 3 meds approved for depressed phase of bipolar Watch for skin rash (Steven-Johnson syndrome)
What are the SEVERE s/s of LITHIUM TOXICITY that's >2.5 mEq/L?
Rapid progression of manifestations leading to coma and death
What are some NURSING DIAGNOSES in Mood d/o?
Risk for violence: directed at self and others (more for depressed pt. than someone who is grandiose) Disturbance in self-concept: low self-esteem (it's to the other extreme) Risk for injury - Very big problem!! Dysfunctional grieving Social isolation Powerlessness Alteration in thought processes Alteration in nutrition: less than body requirements (or more than) Sleep pattern disturbance
What are the characteristics of a person in a HYPOMANIC state?
Talks & jokes - "life of the party" Talk is sexually familiar Euphoric, sociable Boundless self confidence No HCN or delusions Overactive, distractible, buoyant, charismatic Pleasure seeking - sex, spending money
What is the importance of ANXIOLYTICS and ANTIPSYCHOTICS for Biplolar d/o?
Used while mood stabilizers are "kicking in" Clonazepam (Klonopin) - most effective but has potential for addiction Ativan useful for short-term management of mania Haldol given to manage mania and aggressive behavior Olanzapine (Zyprexia) is the best of the new atypicals for treating bipolar on a long-term basis Risperdone (Risperdal), Quetiapine (Seroquel), Ziprasidone (Geodon), and Aripiprazole (Abilify) are also approved to tx mania
What are the contraindications for Valproic acid (Depakote)?
Woman of child-bearing age Liver or Pancreatic damage (tend to go more w/Lithium) People really sensitive to weight gain
What is mania?
a distinct period during which mood is abnormally and persistently elevated, expansive, or irritable
What is hypomania?
a period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days; does not impair the ability to function and does not involve psychotic features
Carbamazepine has a boxed warning for which of the following adverse effects? a) Agranulocytosis b) Liver damage c) Skin rash d) Birth defects
a) Agranulocytosis
Gary has been admitted to a psychiatric-mental health facility in a manic state. His wife accompanies him to the facility and informs you that he has been in a manic state for the past 2 weeks. She states that he has not slept for the past 2 days and that he has not eaten anything for at least 3 days. Which of the following would be the highest priority nursing diagnosis for Gary? a) Risk for Imbalanced Nutrition b) Ineffective Health Maintenance c) Risk for Suicide d) Disturbed Sleep Pattern
a) Risk for Imbalanced Nutrition
A client has been on lithium, 300 mg qid, for 3 weeks now. He approaches you, saying, "I feel like I'm going to toss my cookies, and I can't even hold this cup of coffee straight. Why can't I do the crossword puzzle? I usually can do them in about 5 minutes." What is the appropriate nursing intervention at this time? a) Try to refocus the client onto another task because his mania is causing him to be agitated. b) Talk with a colleague about the client's symptoms and get assistance in deciding what to do next. c) Explain to the client that these are normal side effects of the lithium and he will get accustomed to them over time. d) Further assess the client's symptoms, call the MD, hold the client's next dose of lithium, and have a blood level drawn because he is showing symptoms of toxicity.
d) Further assess the client's symptoms, call the MD, hold the client's next dose of lithium, and have a blood level drawn because he is showing symptoms of toxicity.
