Which behavior exhibited by a patient with mania should the nurse choose to address first?
A. Indiscriminate sexual relations
The immediate safetyof the patient and other patients on the unit is the priority. Limits regarding patient-to-patient contact and relations should be communicated and behavior should be monitored.
While excessive spending of money is commonly found in mania, it is not an immediate safety issue.
“Being at one with the world” may be part of a delusional (false thoughts) system that commonly happens during mania. Delusions should be monitored, but this one does not sound dangerous and in need of any particular action.
Flight of ideas, or jumping from topic to topic, is also a common symptom in mania. While they may make communication difficult, they are not a priority concern.
The nurse is caring for a patient experiencing mania. Which is the most appropriate nursing intervention?
D. Provide consistency among staff members when working with the patient.
Patients experiencing mania have the ability to staff split, or divide the staff into“good guys” or “bad guys.” Providing consistency among all staff members is imperative.
Limits must be set and carried out by all staff members if the plan of care is to be effective.
Because the nurse cannot control the patient’s emotions, the preferred approach is to establish and maintain limits for the duration of admission.
The nurse is planning care for a patient experiencing the acute phase of mania. Which is the priority intervention?
D. Prevent injury.
Safety is always the highest priority in planning care. All other interventions may be included in the plan of care, but the priority is to keep the patient safe.
What critical information should the nurse provide about the use of lithium?
B. “It will take 1 to 2 weeks and maybe longer for this medication to start working fully.”
Lithium, although not a cure, is effective in controlling hypersexuality and feelings of anxiety, elation, grandiosity, and expansiveness. It takes 7 to 14 days and sometimes longer to reach therapeutic levels in the patient’s blood.
T/F: The (teaching) plan of care has been effective when the patient can identify signs and symptoms of relapse, describe the purpose of his medications, and describe problem-solving techniques.
True
The first-line drug used to treat mania is
C. lithium.
Lithium, a mood stabilizer, is the first-line drug for use in treating bipolar disorder. Text page: 290
A person who has numerous hypomanic and dysthymic episodes can be assessed as having
B. cyclothymia.
Cyclothymia refers to mood swings involving hypomania and dysthymia of 2 years' duration. The mood swings are not severe enough to prompt hospitalization. Text page: 281
T/F: Hyperactivity and distractibility are basic to manic episodes.
True
When a client experiences 4 or more mood episodes in a 12 month period, the client is said to be:
A. rapid cycling.
Rapid cycling infers 4 or more mood episodes in a 12 month period as well as more severe symptomology. Text page: 365
Which room placement would be best for a client experiencing a manic episode?
A. A single room near the nurse's station
The room placement that provides a nonstimulating environment is best. Being near the nurse's station means close supervision can occur. Text page: 289
When a hyperactive manic client expresses the intent to strike another client, the initial nursing intervention should be
D. verbal limit setting.
Verbal limit setting should always precede more restrictive measures. Text page: 290
T/F: Many clients find that taking lithium with or shortly before meals minimizes gastric distress.
False
Many clients find that taking lithium with or shortly after (not before) meals minimizes gastric distress. Text page: 294
T/F: Manic clients often respond well to the invitation to write. They will fill reams of paper. While writing they are less physically active.
True
A bipolar client whose continuing phase treatment consists of lithium therapy and cognitive-behavioral therapy may become noncompliant with medication. Which factor would be of least concern to the nurse developing a psychoeducation plan to foster compliance?
D. The voices tell the client to stop taking it
Manic clients may hallucinate during the delirious state but generally do not hear voices. Psychoeducation would not be going on during the time the client is delirious. Text page: 298
A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." The best approach for the nurse to use would be
D. "It's time to work on your art project."
Distractibility works as the nurse's friend. Rather than discuss the invitation, the nurse may be more effective by redirecting the client. Text page: 291
A desired outcome for the maintenance phase of treatment for a manic client would be that the client will
A. adhere to follow-up medical appointments.
The client would be living in the community during the maintenance phase. Keeping follow-up appointments is highly desirable. Text page: 288
What action should the nurse take on learning that a manic client's serum lithium level is 1.8 mEq/L?
D. Withhold medication and notify the physician
The client's lithium level has exceeded desirable limits.
Active: 0.8-1.4 mEq/L
- given as 300-600 mg tid to reach therapeutic level.
Maintenance: 0.4-1.3 mEq/L
Additional doses of the medication should be withheld and the physician notified. Text page: 293
To plan care for a manic client the nurse must consider that lithium cannot be started until
A. the physical examination and laboratory tests are analyzed.
Lithium should not be given to clients with impaired renal or thyroid function. A thorough physical examination and various laboratory tests are necessary to rule out other organic causes for the behavior and to ensure that the lithium can be excreted normally. Text page: 294
A manic client in the acute phase is verbally and physically aggressive to himself. The nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviors has been identified. A desirable short-term goal would be that the client will
D. Making no attempts at self-harm within 12 hrs. of admission.
Whenever aggressive verbal or physical behaviors are demonstrated, a desirable goal is cessation of those behaviors. Verbal and physical aggression are most apt to occur when staff are trying to structure the client's behavior for his or her own safety or the safety of others. Text page: 288
Side effects of Lithium at therapeutic levels:
<0.4-1.0 mEq/L
fine hand tremor
polyuria
mild thirst
mild nausea
general discomfort
weight gain
Interventions for Lithium at therapeutic levels:
<0.4-1.0 mEq/L
Symptoms may persist throughout therapy.
Symptoms often subside during treatment.
Weight gain may be helped with diet, exercise, and nutritional management.
Side effects of Lithium at "early toxicity":
<1.5 mEq/L
Nausea
vomiting
diarrhea
thirst
polyuria
lethargy
slurred speech
muscle weakness
fine hand tremor
Side effects of Lithium at "advanced toxicity":
1.5-2.0 mEq/L
Coarse hand tremor
persistent gastrointestinal upset
mental confusion
muscle hyperirritability
electroencephalographic changes
incoordination
sedation
Side effects of Lithium at sever toxicity:
2.0-2.5 mEq/L
Ataxia
confusion
large output of dilute urine
serious electroencephalographic changes
blurred vision
clonic movements
seizures
stupor
severe hypotension
coma
death is usually secondary to pulmonary complications.
Interventions for Lithium at "early toxicity":
<1.5 mEq/L
Medication should be withheld
blood lithium levels measured
dosage reevaluated
Dehydration, if present, should be addressed.
Interventions for Lithium at "advanced toxicity":
1.5-2.0 mEq/L
These depending on severity of circumstances, i.e. same as
Early
Medication should be withheld
blood lithium levels measured
dosage reevaluated
Dehydration, if present, should be addressed.
Severe
Hospitalization is indicated
The drug is stopped, and excretion is hastened
If patient is alert, an emetic is administered
Interventions for Lithium at "sever toxicity":
2.0-2.5 mEq/L
Hospitalization is indicated
The drug is stopped, and excretion is hastened
If patient is alert, an emetic is administered
Lithium Signs and Interventions @ >2.5 mEq/L
(also considered "sever toxicity")
Convulsions, oliguria, and deathcan occur.
In addition to the interventions above, hemodialysis may be used in severe cases.
Trade name for divalproex sodium
Depakote, it is an anticonvulsant
Generic name for Depakote
valproate
valproic acid
divalproex sodium
it is an anticonvulsant
Generic name for Tegretol
carbamazepine, it is an anticonvulsant
Trade name for carbamazepine
Tegretol, it is an anticonvulsant
divalproex sodium is recommended for:
trade name Depakote or valproic acid(Depakene) - both are generic "Valproate"
Lithium nonresponders, who are in acute mania, rapid cycling, in dysphoric mania (a "mixed episode" - symptoms of mania and depression occur simultaneously), or have not responded to carbamazepine.
extreme manic, including aggressive Pts.
For severe manic episodes lithium or Depakote may be given with an atypical antipsychotic such as olanzapine (Zyprexa) or riperidone (Risperdal)
off-label is it used for panic disorders and PTSD.
divalproex sodium side effects
trade name Depakote or valproic acid(Depakene) - both are generic "Valproate"
trade name Depakote or valproic acid(Depakene) - both are generic "Valproate"
baseline liver function & CBC before starting, repeated.
therapeutic levels monitored
carbamazepine recommended for
trade name Tegretol
for bipolar
Some Pts that are "treatment resistant” for bipolar, i.e. do not respond to lithium alone, improve after taking Tegretol & lithium or Tegretol & and antipsychotic.
Tegretol seems to work better in rapid cycling and in severely angry paranoid Pts. experiencing manias than in euphoric, overactive, overfriendly Pts. w/ mania.
off-label is it used for panic disorders and PTSD.
carbamazepine side effects
trade name Tegretol
for bipolar
Common: anticholinergic (e.g. dry mouth , constipation, urinary retention, blurred vision), orthostasis ("standing" - how the hell is this a 'side effect'), sedation & ataxia (lack of voluntary coordination of muscle movements)
Rarely: bone marrow suppression
carbamazepine admin guidelines
trade name Tegretol
for bipolar
baseline liver function, CBC, EKG & electrolytes before starting
toxic levels (>12 mcg/mL) are monitored
There is noestablished therapeutic levels for bipolar
Three anticonvulsant drugs have demonstrated efficacy and been approved for the treatment of mood disorders:
valproate, as divalproex sodium(Depakote) or valproic acid(Depakene)
carbamazepine (Tegretol)
lamotrigine (Lamictal)
How?
Superior for continuously cycling patients
More effective when there is no family history of bipolar disease
Effective at dampening affective swings in schizoaffective patients
Effective at diminishing impulsive and aggressive behavior in some nonpsychotic patients
Helpful in cases of alcohol and benzodiazepine withdrawal
Beneficial in controlling mania (within 2 weeks) and depression (within 3 weeks or longer)
Bipolar I
At least one episode of mania alternates with major depression
Somewhat more common in men
Bipolar II
Hypomanic episodes alternate with major depression
No psychosis present
More common among women
Hypomania in II tends to be euphoric and often increases functioning
Women with bipolar
tend to
abuse alcohol
commit suicide
develop thyroid disease
Men with bipolar
tend to
Have legal problems
Commit acts of violence
Cyclothymia
Hypomanic episodes alternate with minor depression
At least 2 years duration for Dx
Irritable (as opposed to euphoric) manic episodes
Hospitalization is not usually required
T/F: Either hypomania and mania of a bipolar Pt can be caused by the direct physiological effects of a substance, such as drug abuse, medication or other medical condition.
False: symptoms are not due to these factors.
Bipolar disorders are XX to YY% heritable.
80 to 90
It is likely polygenic.
Neurotransmitters:
norepinephrine
dopamine
serotonin
Too much?
Too little?
Mania
Depression
Hypothyroidism is known to be associated with AAA, and it is seen in some patients experiencing BBB.
A. Depression
B. Rapid Cycling
T/F: The nonstop physical activity of hypomania as well as "full-blown": mania can lead to physical exhaustion and even deathand therefore constitutes an emergency.
True
p. 284 right-bottom
Grandiosity can be a symptom in:
Manic phase of bipolar
Narcissistic personality disorder
Phases and Goals of Bipolar Therapy
Acute (6-12 weeks):
Medically stabilize Pt.
Hydration
Stable cardiac status
Sufficient sleep/rest
Thought self-control
No self-harm
Continuation: 4-9months
Relapse prevention
Psychoeducation
Support groups or interpersonal therapy
Communication and problem-solving skills
Maintenance (> 1 year):
Relapse prevention
Limitation of severity & duration of future episodes
A female client who is in a manic state emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. The nurse should initiate which intervention first?
B. Quietly approach the client, escort her to her room, and help her to get dressed.
A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety for the client. Insisting that the client go to her room may cause the nurse to be met with a great deal of resistance. Confronting the client and offering her a consequence of time out may be meaningless to her. Asking other clients to ignore her is inappropriate. A quiet but firm approach while distracting the client (walking her to her room and helping her to get dressed) achieves the goal of having the client dressed appropriately and preserving her psychosocial integrity.
What portion of people with bipolar disorder have another Axis I psychiatric disorder?
More than half
p. 281
Bipolar II Pts. may not have manic episodes as strong as Bipolar I pts., but ?
II has associated with it significant morbidity and mortality as a result of the severe depression.
Axis II borderline personality disorder pts. are AAA% BBB (more or less) likely to have a comorbid axis I bipolar disorder.
A. ~20% (19.4%)
B. more
T/F: Religious preoccupation is a common symptom of mania.
True
T/F Delusions and/or hallucinations, being psychotic symptoms, may be present in a pt. experiencing a hypomanic episode.
False
There is no evidence of this.
p. 287
T/F: Mania may be substance-induced, i.e. caused by use or abuse of a substance or drug or by toxin exposure.
True according to p. 288
This is contrary to the DSM quoted on p. 282: "Symptoms (of mania or hypomania)are not due to direct physiological effects of substance (e.g. drug abuse, medication…"
Pts. that were previously suffering depression, but are now manic may have what done?
Antidepressants, previously prescribed are often tapered or discontinued to reduce mania or hypomania.
Lithium takes AAA to BBB or longer to be effective. What can be done?
A. 7
B. 14
An antipsychotic or benzodiazepine can be used to prevent exhaustion, coronary collapse and deathuntil lithium reaches therapeutic levels.
Lithium Teaching
Normal salt and fluid intake. (Lithium decreases sodium reabsorption. Low sodium leads to relative increases in lithium retention raising levels to those that may be toxic.
Stop taking lithium if you have excessive diarrhea, vomiting or sweating, since dehydration can also raise lithium to toxic levels.
No diuretics.
Take with meals
Long-term risks of lithium therapy and necessary monitoring?
Hypothyroidism
Impairment of kidney's ability to concentrate urine
Periodic assessment of thyroid and renal function
Implicit is that thyroid and renal function must be evaluated BEFORE starting on lithium Tx.
Lithium Tx is contraindicated in these pts:
Thyroid disease
Renal disease
Cardiovascular disease
Brain damage
Myasthenia gravis - neuromuscular disease leading to fluctuating muscle weakness and fatigability
Pregnant or breast-feeding
Children younger than 12
A nurse is caring for a client who has bipolar disorder and is in a manic state. The nurse determines that which menu choice would be best for this client?
A. Cheeseburger, banana, milk
The client in a manic state often has inadequate food and fluid intake as a result of physical agitation. Foods that the client can eat "on the run" are best because the client is too active to sit at meals and use utensils. Additionally, clients in a manic state should not have any products that contain caffeine.
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit and is planning an on-unit supper. To decrease stimulation, the nurse should encourage the client to:
D. Postpone the dance and engage in a writing activity.
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance or supper may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 3 encourage planning the activity and therefore increase client
stimulation. Option 4 could result in an angry outburst by the client.
