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Mental Health Fall '12
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Chapter 29
A disorder which is characterized by mood swings from profound depression to extreme euphoria (Mania), this coexists with periods of normalcy.
Mania: an alteration in mood that is expressed by feelings of elation, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.
Mood SwingsChronic; recurringDelusions/ HallucinationsSeasonal pattern onsetMay require hospitalizationHighest lifetime suicide rate
High genetic relationship Imbalances in neurotransmitters Lesions or brain trauma in the limbic
system Medications (steroids/seizure
meds/antidepressants/ narcotics) Psychosocial- this theory is declining
due to the evidence based research which acknowledges this disease as a biological disease of the brain.
Substance abusePersonality DisordersAnxiety DisordersEating DisordersADHD
Milder clinical picture No marked occupational/ social impairment Cheerful and expanded personality Does not require hospitalization Rapid flow of ideas, hyperactivity, social
butterfly Does not include psychosis Increased libido Anorexia, weight loss, spending large amts
without thinking of any repercussions
Mood is elevated, expansive, irritable Euphoric, on a huge “high”, that changes
to anger or crying without any warning. Impaired occupation/social functioning
and relationships May become psychotic, thoughts are
disjointed, flight of ideas, pressured speech
Excessive/frenzied motor activity/no impulse control/ sexually manipulative
Hallucinations/ delusions Inexhaustible/ no sleep/ no eat!Hygiene and grooming neglectedDress may by flamboyant/ excessive
makeup/ bizarreYou feel pressured and nervous
talking to them and after your interview you are tired
This is an emergency because the client can have a severe clouding of consciousness with the mania symptoms intensifying
Confusion/ disorientation/panic Delusions of persecution/ grandeur/
religiosity Safety is at stake; they are so physically
exhausted and have been overworking their cardiovascular system for days.
Bipolar I
Bipolar II
Cyclothymic
Rapid Cycling
Upper socioeconomic class
Educational and Occupational status
Level of mood
Elated mood ▪ (hypomania)
▪ VS
MANIA, EUPHORIC▪ (manic)
Assess Behavior
Assess Thought Process Flight of ideas, speech, communication,c
lang associations, grandiosity
Assess Cognitive Functions Cognitive difficulties in psychosocial areas Impairment core features
Resists control
Splitting
Aggressively demanding
Setting limits
Shallow relationships
Danger to self and othersControlsHospitalizationMedical StatusCo-existing conditionPt/family education
See page 548 for excellent concept map on this!!!!
The client will: Exhibit no signs of physical injury Not harm self or others No longer exhibit physical anxiety/agitation Eat a balanced diet Accept responsibility for their behaviors Will sleep 6-8 hours a night Will not manipulate others for self
gratification
Any thoughts?
I’ll start:▪ Risk for violence: self directed or other
directed
▪ Short term goal- client will recognize increasing anxiety and will report this to staff for assistance
▪ Longterm goal- client will not harm self or others
Therapies once meds initiated Cognitive therapy ECT/TMS Basic interventions:
Reduce stimuli Lower lights in room Remove dangerous items from room/observe for
safety per unit protocal Provide finger foods/high calorie/ juice/ milk Set limits on manipulative behavior/ remain calm
Mood Stabilizers/ Lithium Carbonate
Initially mania treated with antipsychotics or Valproic Acid until Lithium level is therapeutic (7-10 days)
Therapeutic level Maintenance level
Normal side effects expected: Drowsy, headache, thirst, pulse irregularities,
polyuria, and weight gain ….look at Lithium as a SALT..it causes similar effects
Early Toxicity signs Ataxia, severe diarrhea, blurred vision, N/V, tinnitis
Advanced Toxicity signs Excessive dilute urine, tremors, seizure, impaired
consciousness, arrhythmias, coma, ..death
* There is a very slim margin between therapeutic and TOXIC
Levels must be checked weekly until therapeutic level reached, then monitored monthly during maintenance therapy.
So what do we do if the client is experiencing toxicity?
STOP THE LITHIUM The monitor for arrythmias Hydrate maintaining fluid and electrolyte
balance
Antiepileptics Depakote/ Tegretol/ Lamictal
These drugs are sometimes used while Lithium is reaching levels or may be used alone. It decreases the firing of neurons, therefore slowing down the client.
Anxiolytics- Clonazepam and Lorazepam Acute Mania / psychomotor agitation
Antipsychotics▪ Olanzapine▪ Quetiapine▪ Risperidone▪ (These can be used alone or with lithium)
Severe treatment resistant mania Rapid Cyclers Paranoid Acutely Suicidal
Used when meds have failed. ECT creates a grand mal seizure which “reboots” the brain. TMS are more specific waves of electricity to specific nerve cells, this does not cause a grand mal. TMS is one of the newer technologies being used.
Seclusion / Restraints (what is seclusion)
Rationale Documented Justification Complex therapeutic, ethical and legal
issues Restraint/ Seclusion policy/ Protocal
NEVER USED AS PUNISHMENT/ STAFF CONVIENENCE
Depression and Bipolar Support Alliance (DBSA)
National Alliance for the Mentally Ill (NAMI)
National Mental Health Association
Manic-Depressive Association
Drink???
Do drugs????
Why knowing their diagnosis do you think a bipolar client will become noncompliant with meds and then use substances?
MOVIE TIME!
http://www.youtube.com/watch?v=zEmZ8clcEUs&feature=related
Mostly application questions, what will you say??? Remember restate for clarification, set limits
Know the drugs and any client teaching ( ie MAOI, TCA etc). Meds that are used for EPS , anticholinergic effects, side effects
Treatments : ECT (interventions and monitoring) , seclusion (removing stimuli)
Documentation of care, planning care Client teaching for meds, resources, diet Nursing diagnosis priorities Chemical dependency, care of client, crisis
intervention