The Client with a Mood Disorder
Disturbance of mood Depression or elation(mania) Bipolar disorder Cyclothymic disorder Dysthymic disorder
Etiology Theories: Genetics – approximately 7% of populations 20% if close relative has disorder Biochemical: dysregulation in norepinephrine & seratonin Psychoanalytic: anger turned inward(Freud)
Bipolar Disorder across the lifespan
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Bipolar disorder (Manic episode) Onset - before 30 Characterized by “abnormally and persistently elevated, expansive, or irritable mood.” Mental Status ASSESSMENT: hyperactivity, euphoria,pressured speech sarcasm,easily angered,aggressive,hostile exaggerated or delusional self-confidence, Flight of ideas, grandiose, persecutory delusions Inappropriate dress/attire Short-term depression –Risk for suicide
Assessment of Physiologic Integrity (Manic client)) May not eat or drink for days Excessive or poor grooming/hygiene Has not slept for days & does not feel the need to sleep (insomnia) Fatigue Extremely poor judgment leading to Increased risk for injury Exhibits seductive or aggressive behavior Electrolyte imbalance
Assessment of Psychologic Integrity(manic client) May have psychotic symptoms i.e hallucinations/delusions of grandeur Labile mood swings (hostile/angry) Pressured speech/tangential Racing thoughts –”flight of ideas” Risk for other directed violence Flirtatious/seductive
PET Scan: Top Row = Normal Brain Middle Row = Hypomanic Brain Bottom Row= Depressed Brain M. Phelps, L. Baxter, J. Mazziotta UCLA
Medical management anti-manic drug Lithium Carbonate(eskalith, lithane, lithotabs) Starting dose – 600mg t.i.d. Maintain blood serum level of 1.0 – 1.5 mEq/L Check blood. Serum levels 2x’/WK. 12 HRS after last dose is administered. Maintenance dose levels:300mg t.i.d. –q.i.d. Long term Maintenance level between 0.6 –1.2 mEq/L Q Monthly checks
Lithium toxicity Toxicity levels: blood levels > 2.0 mEq/L Signs/symptoms: tremors Nausea/vomiting Thirst Polyuria Coma, seizures, cardiac arrest
Use of antiPsychotics to control delusions, agitation, psychotic behaviors include: i.e. Haloperidol(haldol), Fluphenazine(prolixin), Risperidone(risperdol) Perphenazine(trilifon) Quitipine(seroquel) Olanzapine(zyprexa)
Mood Stabilizers Valproic Acid(Depakote) etc. Carbamazepine (Tegretol) Check liver functions (at start & q 6 mos.) Can cause hepatic failure/life threatening pancreatitis Can cause aplastic anemia & agranulocytosis (5-8x’s greater than population)
Mood stabilizers con’t. Lamotrigine(Lamictal) Topiramate(Topamax) Gabapentin (Neurontin) Oxcarbazepine (Trileptal) Can cause serious rashes > in children; Stevens-Johnson syndrome Common s/e’s all mood stabilizers: Dizziness, hypotension, ataxia - Monitor gait, & B/P, give w/food; Teach client about s/e’s
Nursing Interventions- Bipolar Client Determine what client is attempting to say Help client to maintain focus/SET LIMITS Offer finger foods/boxed, canned fluids Provide quiet, non-stimulating environment Stay with client/use silence as needed Remove harmful objects (prevent injuries) Accept hostility-do not argue/challenge client Assist with ADL’S as needed, Observe for s/e’s meds/AVOID DIURETICS Provide Teaching re: med compliance Maintain fluid/salt intake
Depression and Suicide
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Children with depression Symptoms of depression in children may include: Apathy Irritability and Persistent Sadness
Client with Major Depression: Effect on Physiologic Integrity& related Nursing Diagnosis EEarly morning awakening-insomnia at night (Altered sleep patterns ) FFatigue DDecreased grooming & ADL’s (self-care deficit) CConstipation (altered elimination patterns) AAnorexia w/wt. loss (altered nutrition<body requirements) LLoss of sexual interest (Impaired role relationships) PPsychomotor retardation ( Impaired mobility/Activity intolerance) SSomatic complaints (Ineffective coping) AAmenorrhea (Altered health patterns)
Effects on Psychologic integrity& related Nursing Diagnosis Loss of ambition (avolition), Lack of interest (anhedonia) in activities/sex Feelings of boredom/sadness Feels helpless/hopeless/powerless/tearful Low self-esteem (Self esteem disturbance) Attention/concentration deficit & Difficulty w/decision making (Altered thought process) Demanding/dependent behaviors Suicidal ideation- (Risk for suicide may ↑ as depression begins to lift and energy returns)
Elderly Depressed client Compaints of impaired memory Decreased attention/concentration Increased forgetfulness/confusion/ somatic complaints Self-care deficits Functional changes in daily activities Highest suicide risk –older, single, (widowed/divorced) white male/chronic illness/pain Somatic complaints & delusions
Nursing Interventions Monitor I & O weight Maintain routine/schedule of activities Remove harmful objects/protect from self- harm Assess suicidal ideation/contract for safety/ check client frequently( Risk increases as depression lifts!) Assist with ADL’s/hygiene/grooming Encourage positive self-talk
“Suicide - it’s the only way out”
Risk for Self-harm: suicide
Assessment of Risk factors for Suicide Expression of hopelessness, helplessness, worthlessness Client has a formulated plan Client has the ability to carry out the plan There is a history of previous attempts or family history Recent attempts have become more painful,violent or lethal
Assessment of Risk factors for Suicide The client is white male adolescent or single, widowed,divorced male>55 years old, lives alone. Client may be terminally ill, addicted or psychotic Clinet gives away personal belongings, settles financial accounts, etc. Clinet is in the early stage of antidepressant treatment and his/her mood & activity level has begun to elevate. The client’s mood and activity level suddenly changes.
Medical management of Depression ANTIDEPRESSANTS: Tricyclic’s(TCA’s): Elavil, Disipramine. Imipramine MAOI’s: Marplan,Nardil Parnate Selective Serotonin Reuptake inhibitors(SSRI’s) I.e. Prozac, Paxil, Celexa, Lexapro, Zoloft SNRI’s I.e. effexor Miscellaneous: Remeron, cymbalta,Wellbutrin
Antidepressant therapy (SSRI’s) SSRI’s: Fluoxetine(Prozac)- give in AM Sertaline (Zoloft) give in PM if drowsy Paroxetine (Paxil) give in PM if drowsy Citalopram(Celexa) Escitalopram (Lexapro) Monitor for: Hyponatremia sexual dysfunction orthostatic B/P Give w/food Encourage adequate fluids
Atypical antidepressants Venlafaxine(Effexor) Duloxetine(Cymbalta) Bupropion(Wellbutrin) Nefazodone(Serzone) Mirtazapine(Remeron) May alter labs: AST ALT, alk phos, Createnine,gluc,lytes; Monitor for ↑ B/P & HR Can lower seizure threshold; ↑ B/P,HR (as above) Check labs:AST,ALT LDH,chol,glu,Hct Sedation:Give in PM,monitor wt. gain,sex dysfunction,constipation
Tricyclic Antidepressants Amitriptyline( Elavil ) Amoxapine (Asendin) Doxepin(Sinequan) Imipramine (Tofranil) Desipramine (Norpramine ) Nortriptyline(Pamelor) Monitor & educate client: cholinergic s/e’s i.e. dry mouth, blurred vision, constipation,Ortho- B/P, **cardiac dysrhythmias/funct ionlethal in OD *caution use in elderly
Monoamine Oxidase Inhibitors Isocarboxazid (Marplan) Phenelzine (Nardil) Tranlcypromine (Parnate) Educate regarding: low tyramine diet potentially fatal drug to drug interactions i.e. Meperidine, SSRI’s,TCA’s, amphetamine *can be lethal in OD
The controversy of ECT treatments Electroconvulsive Therapy Saves Lives. But 70 Years After It First Gained Currency as a Treatment For Major Depression, ECT Continues to Court Controversy
Electro Convulsive Therapy Normal Pre-op preparation: NPO after midnight Informed consent Remove hairpins, dentures, nail polish Loose fitting clothing or hospital gown Check vital signs after procedure Reorient and assure any memory loss is temporary Assist to room or significant other if out - patient
ECT of Yesterday
ECT treatments in 1950’s Patients received treatment without anesthesia Held down by straps Sometimes experienced broken bones from violent seizures ECT later viewed negatively-seen as last resort treatment.
A case for ECT [as reported in the Washington Post July 24, 2007] Mr. M. woke up at 5 a.m. one morning nearly 10 years ago and heard a message in his head telling him to kill himself. He wrote a goodbye note to his wife, then jumped off the back deck of their home, falling the 14 feet hard enough to wake her with the sound of his thud. The 66-year-old organic chemist succeeded only in smashing his knees and skull. After surgery he was transferred to an intensive psychiatric care unit. Mr. M. had been depressed for about six months. He suffered from poor sleep, and he told his wife that he could not go on vacation as he believed he could not walk. During his 4 month hospitalization, Mr. M received a several unsuccessful trials of antidepressants. Mr. M. an older individual with "treatment-resistant" depression, decided to try ECT weeks after his psychiatrist and wife first urged him to do so. By the seventh of his 12 treatments, he felt his depression lift. "He sat up and said, “I'm not depressed anymore”
Current use of ECT No longer viewed as a last resort treatment Patient receives anesthesia Controlled medical environment Specially trained Doctors and Nurses Maintenance therapy prevents relapse Effective in treating major depression in older adults
Dealing with Inappropriate behaviors
AGGRESSIVE BEHAVIORS Assist client to identify feelings of frustration/aggression Encourage discussion of feelings rather than acting out Assist client to identify precipitating events/situations that lead to aggressive behaviors Define consequences for self Assist client to Identify previous coping skills Assist client in problem solving techniques
DE-ESCALATING TECHNIQUES Maintain safety of client/others/self Maintain distance from client/use non- threatening posture Use calm approach/communicate in a calm manner/use clear tone of voice Identify client’s needs Avoid verbal struggles Provide clear options/deal with behaviors Assist with problem solving/decision making
Dealing with Manipulative behaviors Set clear,consistent, realistic Avoid power struggles/arguing Assist client to set limits on own behavior Be clear re: consequences associated with exceeding set limits/follow through with the consequences in non punitive manner if necessary
NCLEX Review Questions the client with a mood disorder
1.The nurse assesses a client with admitting diagnosis of Bipolar affective disorder mania. The symptom presented by the client that requires the nurses immediate interventions the client’s: A.Outlandish behaviors/inappropriate dress. B.Grandiose delusions of being royal decendents of King Author C.Non-stop physical activity and poor nutritional intake D.Constant incessant talking that includes sexual innuendos and teasing the staff
2. The nurse needs to assess a client for depression. Identify the signs and symptoms that are most characteristic of this disorder. (Select all that apply) A.Diarrhea B.Constipation C.Sleep disturbance D.Increased appetite E.Anhedonia F.Poor appetite
3. When assessing clients who are exhibiting a depressed episode and those who are exhibiting a manic episode of bipolar mood disorder; what characteristic common to both disorders is the nurse likely to note? A.Suicidal tendency B.Underlying hostility C.Delusions D.Flight of ideas
4. A 19 year-old client is brought to the ER after slashing both wrists. What is the nurse’s first concern? A.Stabilization of the physical condition B.Determine the causative factors relevant to client’s wrist slashing C.Reduction of anxiety D.Obtain a detailed nursing history
5. Which assessment findings would lead the nurse to suspect that a client is at a high risk for suicide? (Select all that apply) A.Hopelessness accompanied by withdrawal B.Several available supports C.Marked degree of hostility D.Mostly constructive coping mechanisms E.Continual abuse of alcohol &/or drugs F.History of multiple previous lethal attempts
6.What feeling tone is the nurse most likely to see the client demonstrate during a major depression with psychotic features? A.Suspicion B.Agitation C.Loneliness D.Worthlessness
7. A female client with bipolar I disorder is noted to wear excessive make-up, brightly colored evening clothes that do not match, a vest, three different scarves, and several necklaces and bracelets. Several peers on the unit have been laughing about her appearance. Which nursing action would best preserve the client’s self- esteem? A.Help the client change into more appropriate attire. B.Explain to the peer group that the client has bipolar disorder. C.Discuss issues of good groomingat the community meeting. D.Tell the client that she must select less flamboyant clothing.
8. A priority nursing intervention for a client who underwent ECT treatment a half hour ago, would be: A.Monitor vital-signs B.Offer oral fluids C.Encourage group participation D.Evaluate ECT effectiveness
9.Which of the following statements made by a client regarding the medication Lithium indicate a need for additional client education regarding this treatment? A.“I will drink 8 – 12 glasses of liquids daily.” B.“I will restrict my salt intake.” C.“I will take my medications with food.” D.“I will have my blood drawn as the physician orders.”
10. The nurse is admitting a client with mania and a nursing diagnosis of imbalanced nutrition: less than body requirements as evidenced by reported inadequate food intake. When intervening with this client the nurse should: (select all that apply) A.Offer 3 well-balanced meals per day B.Provide high calorie snacks C.Arrange for “finger-foods” for the client D.Offer food Q 15 minutes during the first hour after admission to the unit E.Encourage the client to avoid activities F.Offer the client juice and cold beverages
11. A nurse prepares a plan of care for a client admitted for a manic episode. Identify the nursing diagnoses that would most likely be chosen? (Select all that apply) A. Imbalanced nutrition: more than body requirements B. Sleep deprivation C. Risk for deficient fluid volume D. Social isolation E. Disturbed thought process
12. Which of the following would the nurse assess as indicative of neuro-vegetative changes in a client with severe depression? (Select all that apply) A. Loss of energy B. Flat affect C. Sleep disturbance/insomnia D. Constipation E. Perseveration F. Loss of appetite/weight loss