Bipolar Disorder

NCM 401

Ma. Tosca Cybil A. Torres, RN

Objectives:
At the end of this concept, the students will be able to: 1. Define key terms 2. Describe related epidemiological data 3. Identify causes of bipolar disorder 4. Explain the cognitive changes as they occur in various levels of bipolar disorder 5. Discuss the: a. role of neurobiological and psychosocial factors in bipolar disorders b. diagnostic criteria-DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders) for each type of bipolar disorders c. treatment modalities

Objectives:
Given a specific type of bipolar disorder, the students will be able to: 6. Asses the presenting s/sx using DSM-IV TR diagnostic criteria 7. Identify at least 4 relevant NDx 8. Submit a NCP (must include strategies to support family adaptation) Given hypothetical questions on the mood and behavioral changes of a patient with bipolar disorder, the students will be able to 9. State the appropriate caring behavior 10. Integrate Christian values

Key Terms:
Affect: emotional display or observable behaviors that are the expression of an experienced, subjective feeling. Examples of affect that are appropriate, blunted, flat, inappropriate, labile, restricted or constricted. Bipolar: the two extreme mood states of mania and depression illustrated in bipolar disorder Circumstantiality: a thought and speech process in which an individual digresses into unnecessary details and inappropriate unrelated thoughts while trying to express a central idea Cyclothymia: a condition in which numerous periods of abnormally elevated, expansive or irritable moods are experienced interspersed with periods of depressed mood Distractibility: the inability to maintain attention, shifting from one area or topic to another with minimal provocation, or attention being drawn too frequently to unimportant or irrelevant external stimuli. Dysphoria: a mood of general dissatisfaction, unpleasantness, restlessness, anxiety, discomfort and unhappiness observed in depressive states. Euphoria: an exaggerated feeling of well being or elation

Key Terms:
Flight of ideas: over productive speech characterized by rapid shifting from one topic to another and fragmented ideas Grandiosity: an inflated appraisal of ones worth, power, knowledge, importance, or identity and may include delusional thinking Mood: a consistent emotional state experienced by an individual over time that influences her perception of the world. Ex: dysphoric, elevated, expansive, euphoric, or irritable Pressured speech: disturbance in verbal expression of thought characterized by an overproduction of rapid speech that is frequently loud, unsolicited by social interaction, and difficult to interrupt. Racing thought: a rapid series of ideas that occur during manic episodes Rapid cycling: a type of bipolar disorder characterized by at least four episodes of depression, mania, or mixed states each year Tangentiality: a speech pattern that illustrates an inability to respond completely in a focused manner. Individuals may begin to respond appropriately but progress to related topics, never completing the originally desired response.

Review of Unipolar and Suicide

Bipolar Disorder Defined:

also known as manic-depressive illness a brain disorder that causes unusual shifts in a persons mood, energy, and ability to function symptoms are severe---involves dramatic shifts in mood from the highs of mania to the lows of major depression the cycles of bipolar disorder last for days, weeks, or months. Unlike ordinary mood swings, bipolar disorder is much more intense and disruptive to everyday functioning, affecting energy, activity levels, judgment, and behavior first manic or depressive episode of bipolar disorder usually occurs in the teenage years or early adulthood.

Bipolar Disorder

Causative Factors:
Theories and Perspectives 1. Psychodynamic, Existential, Cognitive-Behavioral and Developmental theories 2. Biological theories/Genetic Factors Biological theories Neurochemical and Neuroendocrine factors= Biogenic Amine theory Neuroanatomical factors Genetic Factors Genes located on the region of chromosome 18identification of region 22.3 of chromosome 21 and chromosome 11 Chronobiology study Kindling theory

Psychodynamic
Freud: looked at the self-depreciation of people with depression and attributed that selfreproach to anger turned inward related to either real or perceived loss. Feeling abandoned by this loss, people become angry while both loving and hating the lost object. Jacobson: compared the state of depression to a situation in which the ego is a powerless, helpless child victimized by the superego, much like a powerful sadistic mother who takes delight in torturing the child.

Example:
Traumatic events (loss of a child)

Feelings of self-loathing, shame, or guilt Feeling hopeless, sad, or empty. Loss of interest in things you used to enjoy

Existential Theory
Existential theorist believed that behavioral deviations result when a person is out of touch with himself or the environment. The person who is self-alienated is lonely, sad and feels hopeless. Lack of self awareness, coupled with harsh criticism, prevents the person from participating in satisfying relationships. The person is not free to choose from all possible alternatives because of self imposed restrictions. The person is avaoiding personal responsibilities and giving it to the wishes or demands of others.

Biogenic Amine theory

states that depression is caused by a deficiency of monoamines, particularly noradrenaline and serotonin serotonin plays an important role as a neurotransmitter in the modulation of anger, aggression, body temperature, mood, sleep, sexuality, appetite, and metabolism, as well as stimulating vomiting. norepinephrine as a stress hormone,affects parts of the brain where attention and responding actions are controlled.

The "kindling" theory

asserts that people who are genetically predisposed toward bipolar disorder can experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and becomes recurrent) by itself. Not all individuals experience subsequent mood episodes in the absence of positive or negative life events, however.

Cognitive-behavioral model of bipolar disorder

Aaron T. Beck's cognitive theory proposes that individuals who have a biological vulnerability to bipolar disorder and who hold problematic beliefs about themselves (e.g., the belief that they are worthless) can, when those vulnerabilities and beliefs are activated by life stressors, experience symptoms of bipolar disorder. Symptoms, in the cognitive-behavioral model, are made up of emotions (e.g., depression or elation), thoughts (e.g, "I'm worthless," or "I'm amazingly talented") and behaviors (e.g., passivity or excessive activity).

Neuroendocrine influence
Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression with the highest rates found among older clients. Post partum hormone alterations precipitate mood disorders such as postpartum depression About 5%-10% of people with depression have thyroid hormone dysfunction, notably an elevated TSH.

Chronobiology study
The variations of the timing and duration of biological activity in living organisms occur for many essential biological processes. The most important rhythm in chronobiology is the circadian rhythm, a roughly 24 hour cycle shown by physiological processes

Variations in Brain Structure and Impaired Functions in Bipolar Disorder

Structural variation/abnormality
-diencephalon (thalamus, mamillothalasmic tract and medullary lamina) -prefrontal cortex -frontal subcortical -brain lesions -midsagittal Areas reduction -Abnormal white brain matter( increase with age) -Medial temporal lobe (hippocampus, parahippocampal and periphinal cortices- episodes of depression and mania may result in hypercortisolemia, producing damage) -Basal ganglia

Functional Impairment (all decreased) -memory performance -verbal memory (recall of a story or single word) -attention dysfunction -verbal learning -verbal fluency -Psychomotor speed -declarative memory (conscious recollection of facts and events)

BIPOLAR DISORDER ACROSS THE LIFE SPAN

Comorbidity- Anxiety Bipolar type I OCD Panic Disorder GAD Phobia 14-30% 18-33% 42% 42-66% Bipolar type II 28% 5%

Comorbidity-Substance abuse Bipolar Alcohol Drugs 46% 41% Unipolar 21% 18%

Symptoms of Bipolar Disorder:

Bipolar disorder causes dramatic mood swings from overly high and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression.

Types of Mood Episodes

MANIA
Distinct period during which mood is abnormally and persistently elevated, expansive, or irritable. Period lasts 1 week(unless hospitalized and treated sooner) Plus at least 3 of the following symptoms: inflated selfesteem/grandiosity; decreased need for sleep; pressured speech; flight of ideas; distractibility; increased involvement in pleasureseeking activities with a high potential for painful consequences Some exhibit delusions and hallucinations

HYPOMANIA
less severe form of mania Period of abnormally elevated, expansive, or irritable mood lasting for 4 days plus 3 or 4 of the additional symptoms as described in mania never suffer from delusions and hallucinations able to carry on with their dayto-day lives often escalates to full-blown mania or is followed by a major depressive episode

BIPOLAR DEPRESSION
Last at least 2 weeks of depressed mood or loss of pleasure in nearly all activities plus four of the ff symptoms changes in appetite or weight, sleep, or psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts. These symptoms must be present everyday for 2 weeks and result in significant distress or impair social, occupational, or other important areas of functioning. Some have delusions and hallucinations---psychotic depression

MIXED
experiences both mania and depression nearly everyday for at least one week Often called rapid-cycling

Types of Bipolar Disorder

Bipolar I Disorder Mania and depression

classic manic-depressive form of the illness most severe type of bipolar disorder characterized by at least one manic episode or mixed episode typical course of Bipolar I Disorder involves recurring cycles between mania and depression

Diagnostic Criteria For Bipolar I Disorders

Bipolar I Disorder, Single Manic Episode
A. Presence of only one Manic Episode and no past Major Depressive Episodes.
Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms. B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify if: MIXED: if sx meet criteria for a mixed episode If the full criteria met for a manic, mixed, or major depressive episode, specify its current status and of features: Mild, Moderate, Severe w/o psychotic features With catatonic features With postpartum onset If the full criteria have not currently met for a manic, mixed, or major depressive episode, specify the current clinical status of the bipolar I disorder or features of the most recent episode In partial Remission, In Full Remission With catatonic features With postpartum onset

Bipolar I Disorder, Most Recent Episode Hypomanic

A. Currently (or most recently) in a Hypomanic Episode. B. There has previously been at least one Manic Episode or Mixed Episode. C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophrenifor Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Bipolar I Disorder, Most Recent Episode Manic

A. Currently (or most recently) in a Manic Episode. B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode. C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

 If the full criteria currently met for a manic episode, specify its current status and of features: Mild, Moderate, Severe w/o psychotic features With catatonic features With postpartum onset If the full criteria are not currently met for a manic episode, specify the current clinical status of the bipolar I disorder or features of the most recent manic episode In partial Remission, In Full Remission With catatonic features With postpartum onset

Bipolar I Disorder, Most Recent Episode Mixed A. Currently (or most recently) in a Mixed Episode. B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode. C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

 If the full criteria currently met for a Mixed episode, specify its current status and of features: Mild, Moderate, Severe w/o psychotic features With catatonic features With postpartum onset If the full criteria are not currently met for a Mixed episode, specify the current clinical status of the bipolar I disorder or features of the most recent Mixed episode In partial Remission, In Full Remission With catatonic features With postpartum onset

Bipolar I Disorder, Most Recent Episode Depressed A. Currently (or most recently) in a Major Depressive Episode. B. There has previously been at least one Manic Episode or Mixed Episode. C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

 If the full criteria currently met for a major depressive episode, specify its current status and of features: Mild, Moderate, Severe w/o psychotic features/Severe w/ psychotic features Chronic With catatonic features With melancholic features With atypical features With postpartum onset If the full criteria are not currently met for a major depressive episode, specify the current clinical status of the bipolar I disorder or features of the most recent major depressive episode In partial Remission, In Full Remission: Chronic With catatonic features With melancholic features With atypical features With postpartum onset

Bipolar I Disorder, Most Recent Episode Unspecified

A. Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Episode. B. There has previously been at least one Manic Episode or Mixed Episode. C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Bipolar II Disorder Hypomania and depression doesnt experience full-blown manic episodes illness involves episodes of hypomania and severe depression experienced at least one hypomanic episode and one major depressive episode

Diagnostic Criteria for Bipolar II Disorder

A. Presence (or history) of one or more Major Depressive Episodes. B. Presence (or history) of at least one Hypomanic Episode. C. There has never been a Manic Episode or a Mixed Episode. D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

 Specify current or most recent episode: Hypomanic: if currently (or most recently) in a hypomanic episode Depressed: if currently (or most recently) in a major depressive episode
If the full criteria have currently met for a major depressive episode, specify the current clinical status of the bipolar I disorder or features: Mild, Moderate, Severe w/o psychotic features/Severe w/ psychotic features Chronic With catatonic features With melancholic features With atypical features With postpartum onset

 If the full criteria are not currently met for a hypomanic or major depressive episode (only if it is the most recent type of mood episode)
In partial Remission, In Full Remission: Chronic With catatonic features With melancholic features With atypical features With postpartum onset

Cyclothymia Hypomania and mild depression

also known as cyclothymic disorder milder form of bipolar disorder consists of cyclical mood swings the highs and lows are not severe enough to qualify as either mania or major depression increased risk of developing full-blown bipolar disorder

Diagnostic Criteria for Cyclothymic Disorder

A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note: In children and adolescents, the duration must be at least 1 year. B. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

Diagnostic Criteria for Cyclothymic Disorder

C. No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance

Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I disorder and Cyclothymic Disorder may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed)
D. The symptoms in Criterion are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnostic criteria for SubstanceInduced Mood Disorder

A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: (1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities (2) elevated, expansive, or irritable mood B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): (1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal (2) medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a Mood Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Mood Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Mood Disorder (e.g., a history of recurrent Major Depressive Episodes).

Diagnostic criteria for SubstanceInduced Mood Disorder

D. The disturbance does not occur exclusively during the course of a delirium. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.

Diagnostic criteria for SubstanceInduced Mood Disorder

Specify type: With Depressive Features: if the predominant mood is depressed With Manic Features: if the predominant mood is elevated, euphoric, or irritable With Mixed Features: if symptoms of both mania and depression are present and neither predominates Specify if: With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome

Bipolar Disorder Not Otherwise Specified

The Bipolar Disorder Not Otherwise Specified category includes disorders with bipolar features that do not meet criteria for any specific Bipolar Disorder. Examples include: 1. Very rapid alternation (over days) between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for Manic, Hypomanic, or Major Depressive Episodes 2. Recurrent Hypomanic Episodes without intercurrent depressive symptoms 3. A Manic or Mixed Episode superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic Disorder Not Otherwise Specified 4. Hypomanic Episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of Cyclothymic Disorder 5. Situations in which the clinician has concluded that a Bipolar Disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced

Diagnostic Criteria for Mood Disorder due to (indicate the general medical condition)
A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the FF: the depressed mood or markedly diminished interest or pleasure in all, or almost all activities elevated, expansive, or irritable mood B. There is evidence from the history, PE, or lab findings that the disturbance is the direct physiological consequence of a general medical condition C. The disturbance is not better accounted for another mental disorder (ex: Adjustment disorder with depressed Mood in response to the stress of having a general medical condition) D. The disturbance does not occur exclusively during the course of a delirium E. The sx cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify Type: With Depressive features: if the predominant mood is depressed but the full criteria are not met for a major depressive episode With Major Depressive-Like episode: if the full criteria are met ( Expect criterion D) for a major depressive episode With Manic features: if the predominant mood is elevated, euphoric, or irritable With mixed features: if the sx of both mania and depression are present but neither predominates

Multi-axial system
The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability: Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders Axis II: underlying pervasive or personality conditions, as well as mental retardation Axis III: Acute medical conditions and physical disorders. Axis IV: psychosocial and environmental factors contributing to the disorder Axis V: Global Assessment of Functioning or Childrens Global Assessment Scale for children under the age of 18. (on a scale from 100 to 0)

Application of the Nursing Process: Depression

Assessment:
General appearance and motor behavior Mood and affect Thought process and content Sensorium and intellectual processes Judgment and insight Self-concept Roles and relationships Physiologic and self-care considerations Depression rating scale

General appearance and motor behavior

Looks sad or just look ill Posture is slouched with head down and minimal eye contact Psychomotor Retardation- slow body movement, slow cognitive processing, slow verbal interaction Minimal response to questions Latency response is seen when clients take up to 30 sec to respond to a question May exhibit signs of agitation or anxiety, wringing their hands and having difficulty sitting still. Psychomotor Agitation- increased body movements and thoughts such as pacing, accelerated thinking, and argumentativeness

Mood and affect

Describe themselves as hopeless, helpless, down, or anxious May also say that they are a burden on others, a failure at life, or may make other similar statements Easily frustrated and are angry with themselves or others They experience anhedonia Apathetic Affect is sad or depressed, may be flat with no emotional expressions Sits alone staring into space ot lost in thought Interacts minimally with a few words or gesture Overwhelmed by noise and people who might make demands on them Withdraws from stimulation of interaction with others

Thought process and content

Slow thinking process With severe depression, they may not respond verbally to questions Negative and pessimistic in their thinking Criticizes themselves harshly and focuses only on failures or negative attributes Ruminate- repeatedly going over the same thoughts May have psychotic symptoms delusions; they often believe they are responsible for all the tragedies in the world Thoughts of dying or committing suicide

Sensorium and intellectual processes

Oriented to person, time and place May experience difficulty with orientation esp. if they experience psychotic symptoms or are withdrawn from their environment Memory impairment is common Extreme difficulty concentrating or paying attention If psychotic, may hear degrading or belittling voices or may even have command hallucinations that orders them to commit suicide

Judgment and insight

Impaired judgment due to inability to use their cognitive abilities to solve problems or to make a decision Often cannot make decisions or choices because their extreme apathy or their negative belief that it doesnt matter anyway Intact insight; others have very limited insight and are totally unaware of their behavior, feelings or even illness

Self-concept

Sense of self-esteem is greatly reduced Uses phrases such as good for nothing or just worthless to describe themselves Feels guilty about not being able to function Personalize events or take responsibility for incidents over which they have no control Believe that others would be better of without them, which leads to suicide thoughts

Roles and Relationships

Difficulty fulfilling roles and relationships Have problems going to work or school; when there, they seem unable to carry out their responsibilities Family responsibilities are neglected Often avoid family and social relationships because they feel overwhelmed, experience no pleasure from interactions and feel unworthy Withdraws from relationships

Physiologic and self-care considerations

Pronounced weight losslack of appetite/disinterest in eating Sleep disturbances are common; either cannot sleep or they feel exhausted and unrefreshed no matter how much time they spend in bed Decreased libidomen often experience impotence Neglect personal hygienelack of interest or energy Constipation Dehydration

Depression rating scale

Helps create a diagnostic picture Self-rating scales of depressive symptoms include the Zung Self Rating Depression Scale and the Beck Depression Inventory Self rating scales are used for case-finding in the general public and may be used over the course of treatment to determine improvement from the clients perspective The Hamilton Rating Scale for Depressionclinician-rated depression scale used like a clinical interview---rates the range of clients behavior such as depressed mood, guilt, suicide, insomia, depersonalization, paranoid symptoms and obsessions.

Data Analysis:
Common Nsg Dx:
Risk for suicide Imbalanced Nutrition: Less Than Body Requirements Anxiety Ineffective Coping Hopelessness Ineffective Role Performance Self Care Deficit Chronic Low Self Esteem Disturbed Sleep Pattern Impaired Social Interaction

Outcome Identification:
Examples:
The client will: Not injure himslef or herself Independently carry out ADLs Establish a balance of rest, sleep and activity Establish a balance of adequate nutrition, hydration, and elimination Evaluate self attributes realistically Socialize with staff, peers, family, and friends Return to occupation or school activities Comply with antidepressant regimen Verbalize symptoms of a recurrence

Intervention:
Ex: Provide for safety of the client and others Institute suicide precaution if indicated Begin a therapeutic relationship by spending nondemanding time with the client Promote completion of ADLs by assisting the client only when necessary Establish adequate nutrition and hydration Promote rest and sleep Engage the client in activities Encourage the client to verbalize and describe emotions Work with the client to manage medications and side effects

Evaluation:
It is essential that the client feel safe and are not experiencing uncontrollable urges to commit suicide Participation in therapy and medication compliance produces more favorable outcomes for clients with depression Be able to identify signs of relapse and seek treatment immediately can significantly decrease the severity of a depressive episode.

Application of Nursing Process: Mania

Assessment:
General appearance and motor behavior Mood and affect Thought process and content Sensorium and intellectual processes Judgment and insight Self-concept Roles and relationships Physiologic and self-care considerations

General appearance and motor behavior

Psychomotor agitation and seem to be in perpetual motion; sitting still is difficult In manic phase, may wear clothes that reflect elevated mood---brightly colored clothes, flamboyant, attention-getting, sexually aggressive Pressured speech Interrupts and cannot listen to others---if interrupted, often starts over from the beginning

Mood and affect

Euphoric, exuberant activity, grandiosity, and false sense of well-being Projection of all-knowing and all-powerful image may be an unconscious defense against underlying low self-esteem Some manifest mania with an angry, verbally aggressive tone and are sarcastic and irritable esp. when others set limits to their behavior Mood is quite labile

Thought process and content

Cognitive thinking and ability is confused and jumbled with thoughts racing one after the other flight of ideas Cannot connect concepts and jump from one subject to another Circumstantiality and tangentiality Unable to communicate thoughts or needs that others understand Starts projects at one time but cannot carry any to completion Do not consider risks or personal experience, abilities or resources Some experience psychotic features grandiose delusions

Sensorium and intellectual processes

Oriented to person and place but rarely to time Intellectual function is difficult to assess during the manic phase Claims to have many abilities that they do not possess Impaired ability to concentrate or pay attention If psychoticmay experience hallucinations

Judgment and insight

Easily angered and irritated Strike back at what they perceive as censorship by others because they impose no restrictions on themselves Impulsive and rarely think before acting or speaking Insight is limited---believes they are fine and have no problems Blames any difficulties on others

Self-concept
Exaggerated self-esteembelieves they can accomplish anything Rarely discuss their self-concept realistically A false sense of well being masks difficulties with chronic low self-esteem

Roles and Relationships

Rarely can fulfill role responsibilities Have trouble at work or school---too distracted and hyperactive to pay attention to children or ADLs Begins many tasks or projects but completes few Have a great need to socialize but little understanding of their excessive, overpowering, and confrontational social interactions, Their need for socialization often leads to promiscuity Invades the intimate space and personal business or others Labile emotions Can become hostile to others whom they perceive as standing in way of desired goals Cannot postpone or delay gratifications

Physiologic and self-care considerations

Can go days w/o sleep or food and not even realize they are hungry or tired Unwilling to stop or unable to rest or sleep even on the brink of physical exhaustion Ignores personal hygiene as boring when they have more important things to do Throws away possessions or destroy valued items May physically injure themselves Tend to ignore or be unaware of health needs

Data Analysis:
Common Nsg Dx:
Risk for Other-Directed Violence Risk for Injury Imbalanced Nutrition: Less Than Body Requirements Ineffective Coping Noncompliance Hopelessness Ineffective Role Performance Self Care Deficit Chronic Low Self Esteem Disturbed Sleep Pattern

Outcome Identification:
Examples:
The client will: Not injure himself or herself Independently carry out ADLs Establish a balance of rest, sleep and activity Establish a balance of adequate nutrition, hydration, and elimination Participate in self-care activities Engage in socially appropriate, reality-based interaction Evaluate self attributes realistically Verbalize knowledge of his or her illness or treatment

Intervention:
Provide for clients physical safely and safety of those around the client. Set limits on clients behavior when needed Remind the client to respect distances between self and others Use short, simple sentences to communicate Clarify the meaning of clients communication Frequently provide finger foods that are high in calories and protein Promote rest and sleep Promote the clients dignity when inappropriate behavior occurs Channel clients need for movement into socially acceptable motor activities Manage medication regimen Provide client and family teaching

Evaluation:
The evaluation of the tx for Bipolar Disorder includes but is not limited to the FF: Safety issues Comparison of mood and affect between start of treatment and present Adherence to treatment regimen of medication and psychotherapy Changes in clients perception of quality of life Achievement of specific goals of treatment including new coping methods

Treatment Modalities:
Top Rated Choices for Initial Medications
Euphoric mania or hypomania Mixed or dysphoric mania Mania with psychosis Lithium or divalproex Divalproex Divalproex or Lithium w/ antipsychotic (atypical or conventional)

Commonly Used mood stabilizers, usual Adult doses and therapeutic serum levels
Mood Stabilizer
Lithium (Eskalith, Lithobid, Lithonate) Divalproex (Depakote)
Other anticonvulsants used as mood stabilizers

Adult Dose Range Therapeutic Serum Levels

600-1800mg/d 0.6-1.2mEq/L

750-4200mg/d

50-100u/ml

Carbamazipine (Tegretol, Carbatrol)

Lamotrigine (Lamictal) Topiramate ( Topamax)

400-1600mg/d
300-500mg/dl 400-1600mg/d

412u/ml

N/A

Antidepressants used in Bipolar Disorder

Buproprion (Wellbutrin) Selective Serotonin Reuptake Inhibitors (SSRIs) Flouxetine(Proxac) Fluvoxamine(Luvox) Paroxetine(Paxil) Setraline(Zoloft) Ventafaxine(Effexor) If these are ineffective or cause undesirable side effects, other choices include: Mirtazapine (Remeron) Nefazodone (Serzone)

MAOIs: Phenelzine (Nardil) Tranylcypromine (Parnate)

TCAs: Amitriptyline (Elavil) Desipramine (Norpramine, Pertofrane) Imipramine (Tofranil) Nortriptyline (Pamelor) Current Atypical Antipsychotic Olanzapine ( Zyprexa) Quetiapine (Seroquel) Risperidone (Risperidal) Clozapine (Clozaril) Ziprasidone (Geodon)

End of concept