Bipolar Disorder Flashcards
1
Q
Bipolar is characterized by…
A
mania and depression
2
Q
Bipolar I disorder
A
- most significant
- at least one episode of mania with major depression
- psychosis may accompany the manic episode.
3
Q
Bipolar II disorder
A
- hypomanic episode alternating with major depression
- psychosis NOT present
- hypomania tends to be euphoric and depression tends to place the person at risk for suicide.
4
Q
Rapid cycling (bipolar I)
A
- 4 or more mood episodes in a 12 month period
- severe symptoms: poor global functioning, higher recurrence risk.
5
Q
Cyclothymic disorder (bipolar II)
A
- hypomanic episodes alternating with minor depressive episodes (at least 2 year duration)
- tend to have irritable hypomanic episodes
6
Q
Etiology of Bipolar disorder
A
- genetics play a role
- excessive levels of norepinephrine and dopamine
- decreased levels or serotonin
7
Q
Bipolar neurotransmitters….
A
- excessive levels of norepinephrine and dopamine
- decreased levels or serotonin
8
Q
Manic episodes
A
- hyperactivity
- involvement in pleasurable activities (spending a lot of money, giving money away, sex)
- push limits
- loud, rapid speech
- talkative
- no time to eat or sleep
- outlandish dress
- poor concentration
- poor judgement
- some may have psychotic symptoms
- may have altered sensory perception
- flight of ideas
- clang associations
- grandiose
9
Q
Diagnostic criteria for a manic episode
A
- elevated, expansive, or irritable mood lasting for at least 1 week
- AND 3 or more of the following…
- inflated self-esteem, decreased need for sleep, more talkative, flight of ideas, distractibility, increase in goal-directed activity, and increased involvement in pleasurable activities
10
Q
Hypomanic episode
A
- talks and jokes- “life of the party”
- talk is often sexual in nature
- pressured speech
- very social
- enthusiastic
- judgement may be poor
- NO halluciantions
- busy with grandiose plans
- increased sexual appetite
- may go without sleeping
- goes on buying sprees
11
Q
Co-morbidity of bipolar
A
- abuse of alcohol (and other substances) is common
- attempt to self medicate - relapse rates increase, response to lithium decreases, poor treatment compliance
12
Q
Assessment for bipolar
A
- danger to self
- need for control
- need for hospitalization
- medical status
- medical examination
- co-existing medical conditions
- understanding bipolar disorder
13
Q
Outcomes - Phase I (acute phase)
A
- be well hydrated in 24 hours
- maintain stable cardiac status
- maintain tissue integrity
- sufficient sleep and rest
- demonstrate control with aid of staff or medication
- make no attempt at self-harm with aid of staff or medication
14
Q
Outcomes - Phase II (continuation of treatment)
A
- lasts for 2 to 6 months
- relapse prevention
- education: knowledge of disease, early signs of relapse, medication. consequences of substance addictions for predicating further relapse, knowledge of early s/s, support groups
15
Q
Outcomes - Phase III (maintenance treatment)
A
- focus on relapse prevention
- limit the severity and duration of future episodes (coping skills, support groups, medication compliance)
16
Q
Nurse/patient relationship
A
matter of fact tone, clear concise directions and comments, limit setting, do not reinforce hallucinations, provide homogenous group if possible, respond to legitimate complaints, redirect patients to a more healthy activity, provide foods to be eaten on the run, provide high calorie snacks and maybe a vitamin supplement, provide a quiet place to sleep, lookout for splitting
17
Q
Milieu therapy
A
- control of hyperactivity usually includes anti-psychotic
- may need seclusion if out of control
- reduce environmental stimuli
- protect from self, injury, others, or staff
- prevent destruction of property
- follow protocols and document
18
Q
Lithium
A
- medication of choice for mania and depressive episodes
- inhibits about 80% of acute mania and hypomanic episodes within 10-21 days
- less effective in rapid cycling people
- must reach therapeutic blood levels to be effective - therefore anti-psychotic and benzodiazepine is also needed initially bc anti-psychotics have more immediate action
19
Q
Lithium can help control….
A
- insomnia
- psychomotor behavior
- hypersexuality
- paranoia
20
Q
Therapeutic level of lithium
A
0.4-1 mEq/L
SEs: fine hand tremors, polyuria, mild thirst, mild nausea and general discomfort, weight gain
21
Q
Early signs of lithium toxicity
A
level 1-1.5
- nausea, vomiting, diarrhea, thirst
- medication should be withheld, blood lithium levels measured, and dosage reevaluated
- dehydration if present should be addressed
22
Q
Advanced signs of lithium toxicity
A
- level 1.5-2
- coarse hand tremor
- persistent GI upset
- mental confusion
- muscle hyper-irritability
- EEG changes
- incoordination
- sedation
- interventions for early signs of toxicity should be used, depending on severity of circumstances.
23
Q
Severe toxicity of lithium
A
> 2
- ataxia
- confusion
- large output of dilute urine
- serious EEG changes
- blurred vision
- clonic movements
- seizures
- stupor
- severe hypotension
- coma
- Death secondary to PULMONARY complications
24
Q
Level >2.5 of lithium
A
- convulsions
- oliguria
- death
- in addition to toxic interventions, hemodialysis may be used in severe cases
- lithium is similar to sodium- if sodium is reduced, lithium is reabsorbed by the kidneys
25
Protocol for lithium
- initially, blood levels are measured weekly or biweekly
- once therapeutic levels are reached - check every month
- After 6 months to 1 year of stability - every 3 months
- blood drawn 8-12 hours after last dose
26
Major risks of long term use of lithium
- hypothyroidism
- impairment of the kidneys ability to concentrate urine
- need periodic follow-up to assess thyroid and renal function
27
Effects of lithium on the kidneys
- pre-existing kidney disease
- can allow a dangerous buildup of lithium in a short time
- increased fluid intake and urination are common (causing nephrogenic diabetes insipidus)
- in some cases may cause severe dehydration
28
Effects of lithium on thyroid
- interferes with thyroid function and so will need a yearly TSH
- hypothyroidism s/s: fatigue, sensitivity to cold, unexplained wt gain, hoarseness
- elevated blood cholesterol levels
- pain, stiffness or swelling in joints
- slowed heart rate
- impaired memory
- dry, rough skin
- depression
29
Anti-convulsant drugs
- taken when lithium does not work
- valporic acid (depakote, depakene)
- serious complications are rare
- SEs: wt gain, GI upset, sedation, tremors are rare, hair loss is rare
30
Valporic acid
- monitor liver function
- monitor platelet count
- women may develop polycystic ovarian syndrome
- may lead to birth defects and developmental delays in utero
31
Tegretol (carbamazepine)
- effective for pts who do not respond to lithium or valproates
- anti-convulsant
- for rapid cycling and severely paranoid pts
- SEs: less wt gain, sedation, nausea, anorexia, vomiting, drowsiness
- Adverse SE: leukopenia, agranulocytosis
32
Lamictal
- anti-convulsant drug
- used for bipolar depression and approved for acute maintenance therapy
- SEs: dizziness, double vision, HAs, potentially life threatening rash (d/c)
33
Newer anti-convulsant drugs
- topamax (topiramate) -helpful for mania and does not cause wt gain
- trileptal (oxcarbazepine) - similar to tegretol, better tolerated
34
Anti-anxiety medications
- Klonopin and ativan
- used for pts who are resistant to other treatments
- effective with psychomotor agitation seen in mania
- contraindicated in patients with history of substance abuse bc addictive
