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MOOD DISORDERS Mood disorders Depression Bipolar Anxiety Name the Depressive Disorders Etiology of Depressive D/O Biochemical factors Neurotransmitter imbalance Genetic factors Cognitive factors Stressful life events Other causes Medical conditions Substances/medications Depression is on a Continuum Mild (grieving, loss) Moderate Severe (major depressive disorder) Sad versus Depressed Everyone is sad feels depressed at times Feeling depressed versus Clinical Depression Leading cause of disability in the US Often accompanies other disorders like schizophrenia, substance abuse and eating disorders Anxiety disorders like OCD, GAD, panic disorders usually have depression Borderline personality disorders usually have depression Biochemical Two main neurotransmitters Serotonin Norepinephrine When a stressful life event occurs these neurotranmitters are overtaxed and depletion occurs Depressive D/O Diagnostic Criteria Major Depressive D/O Persistent depressive disorder D/O-chronic or neurotic depression Be able to differentiate between MDD and DD Psychosocial Assessment Occupation 2. Educational level 3. Past history: medical, psychiatric*, medications 4. Client’s chief complaint/client’s perception 5. Labs 6. Comorbid medical &/or current neurological issues 7. Current prescribed medications/OTC meds Allergies Use of Alcohol/Tobacco 8. Coping abilities 9. Support systems 10. Cultural or spiritual beliefs or practices 1. What information would you like to obtain? A nurse in the ER is assessing a client suspected of being suicidal. Number the following assessment questions, beginning with the most critical and ending with the least critical. ___ “Are you currently thinking about suicide?” ___ “Do you have a gun in your possession?” ___ “ Do you have a plan to commit suicide?” ___ “Do you live alone? Do you have local friends or family?” Cognitive Theory A person’s thoughts will result in emotions. Researchers believe that negative early life experiences lead to illogical, irrational thoughts that remain dormant until major stress occurs. So automatic, negative repetitive thoughts cause depression Becks cognitive triad Assessment 1 Standardized depression screening tools Becks Depression Inventory Geriatric Depression Scale 2- Assess for suicide potential Key assessment findings Anergia Anxiety Psychomotor agitation (pacing) or Psychomotor retardation Somatic complaints- headaches, backaches Change in bowel or eating habits Sleep disturbances Feelings of helplessness and guilt Pharmacological Interventions Antidepressants SSRI’s Tricyclic antidepressants SNRI’s MAOI’s S/E- anticholinergic sedation Psychotherapy Cognitive therapy because people may acquire a predisposition to depression due to early life experience. And if bad enough where suicide is a constant threat ECT Treatment Dementia Delirium Depression Onset • Months to years • Hours to days • Weeks to months Cause or contributing factors • Alzheimer’s disease, vascular disease, HIV, neurological disease, chronic alcoholism, head trauma • Underlying medical condition; hypoglycemia, fever, dehydration, hypotension, infection (urinary tract), head injury, pain, adverse drug reaction, intoxication • Lifelong history, losses, loneliness, crises, declining health, medical conditions (stroke) LOC • Not altered • Altered • Not altered Activity level • Not altered; behaviors may worsen in evening (sundown syndrome) • Increased or reduced; restlessness, sundowning, sleep-wake cycle may be reversed • Usually decreased; lethargy, fatigue, lack of motivation, may sleep poorly and awaken in early morning Emotional state • Flat; delusions • Rapid swings; can be fearful, anxious, suspicious, aggressive, may have hallucinations &/or delusions • Extreme sadness, apathy, irritability, anxiety, paranoid ideation Speech & language • Incoherent, slow, inappropriate, rambling, repetitious • Rapid, inappropriate, incoherent, rambling • Slow, flat, low Course • Chronic, with deterioration over time • Acute, responds to treatment • Chronic, responds to treatment Bipolar Disorders Old term was manic-depression Its chronic Recurrent illness It is one type of mood disorders (disturbances in how one feels) Bipolar: Marked by shift in mood, energy and ability to function Swing from severe euphoria to severe depression Bipolar Disorder Bipolar I Disorders Bipolar II Disorder Describe Some Theories That Explain the Cause of Bipolar D/Os Biochemical factors Neurotransmitter imbalance Increase in norepinephrine & epinephrine Complex interactions among various chemicals, including neurotransmitters and hormones Overstimulation of the brain Genetic factors Stressful life events can trigger symptoms of bipolar disorder Assessment BiPolar Mental Status Examination (MSE) Appearance Behavior Speech Thought processes Perceptual disturbance Cognition Ideas of harming self or others Alcohol or substance abuse Martial or work problems Euphoric mood is unstable One minute over cheerful and joyous and suddenly angery and irritable S/sx: Laugh,joke,continuous talking Know no strangers Boundless energy and self-confidence Hostility, irritability, paranoia Flight of ideas- accelerated speech abruptly changing topics often leading to speech that is disorganized and incoherent Grandiosity- inflated self regard Nursing Interventions Safe/Supportive milieu Medication stabilization 3. Limit setting-manipulating behavior 4. Environment 1. 2. 5. 6. 7. Decreased stimuli Consistent & structured Time outs Quiet times Monitor for poor judgment Focus on reality Provide structured solitary activity Pharmacologic Treatment Mood Stabilizer Antimanic lithium carbonate Therapeutic range o 0.6- 1.2 mEq/L Early signs of toxicity o <1.5 mEq/L Advanced signs of toxicity o 1.5-2.0 mEq/L Severe toxicity o 2.0-2.5 mEq/L Anticonvulsants Anxiolytics Antipsychotics Pharmacological Treatments Bipolar 1-usually need combination of drugs 2- Antianxiety medications reduce agitation/anxiety Clonazepam (Klonopin) Lorazepam (Ativan) 3-Antipsychotic agents reduce delusions/hallucinations 4-Antidepressants reduce bipolar depression These type of drugs are used for a limited time only 3-Antipsychotic agents reduce delusions/hallucinations Helps with insomnia Anxiety Aggitation Zyprexa Quetiapine (Seroquel) Risperidone (Risperdal) Aripiprazole (Abilify) Tricyclic Antidepressants Name Some TCA’s clomipramine (Anafranil) Can be used for the Anxiety D/O, Obsessive Compulsive D/O (OCD) amitriptyline (Elavil) Can be used for nerve pain or for sedation doxepin (Sinequan) Can be used for agitation or restlessness AND MORE These have limited use But bipolar is a life long problem so what drugs are life long maintenance therapy??? Lithium Treats mania Reduces: Depressive episodes Grandiosity Prevents their recurrence Flight of ideas Anxiety Works when in therapeutic range takes 7-14 days Remember-it’s a treatment not a cure Irritability manipulativenss Antiepileptic Drugs If lithium not tolerated well some have been helped with antiepileptic drugs Carbamazepine (Tegretol) Divalproex (Depakote) Lamotrigine (Lamictal) Anxiety and Obsessive-Compulsive Disorders Types Mild-a normal experience of living Moderate- Now some problems grasping information(selective inattention) Severe-Perceptual field very reduced problem solving impossible Panic- Marked disturbed behavior Running, shouting, screaming or with drawal Anxiety disorders Separation anxiety Panic disorder Agoraphobia Generalized anxiety disorder Body dysmorphic disorder Have normal appearance but they think they have a defective body. Obsessed thinking about body Constant checking the mirror False assumptions about importance of appearance with fear of rejection Plastic surgery, over and over again Behavioral theories Anxiety is a learned response to specific stimuli or a conditioned response A child with an abusive mother is afraid of all women Or a child who has a parent afraid of lightening, is also afraid Both can benefit from modeling others behaviors- how people act in a storm or a woman who is safe and loving Behavioral therapy interventions Relaxation training Modeling Desensitization Thought stopping Cognitive theories Anxiety are caused by distortions in a peseon thoughts and perceptions. Overreacting to situations by making them appear dangerous. Cognitive therapy Interventions Cognitive restructuring by identifying negative beliefs, explore basis for this thought, reevaluate the situation, replace negative self talk with supportive ideas Nursing Interventions Maintain calm manner Always remain with the patient having acute severe panic Minimize environmental stimuli. Move to a quiet setting Speak low and slow Reinforce reality Keep patient safe Pharmacology Antidepressants Antianxiety drugs Crisis Acute, time limited occurrences linked to extreme emotion Name some in the country’s history Name some in the news lately Think of some in your personal life Crisis theory and the nursing process Nurses called on to deal with crisis in patients often both on an individual basis, community basis and world wide basis Crisis theory : Type of crisis Phases of crisis Aspects of crisis Types of crisis Maturational Situational Adventitious (disasters) These can be seen in combination and in that case even harder Phases of crisis 1- conflict occurs causing anxiety. Problem solving techniques used to solve the problem and therefore lower anxiety 2- if this fails, anxiety will rise along with feelings of discomfort. Trial and error methods used to solve problem 3- if trial and error fails, anxiety reaches severe and panic levels. Grief behavior begins such as withdrawn and flight. 4- if the problem continues, anxiety overwhelms and personality disorganization, depression, confusion and suicidal behavior can occur Nursing process Assessment: What is the persons perception of the event? What support system does the person have? What are the person’s personal coping skills? Diagnosis Made from assessment information Examples- overwhelmed, depressed- risk for self directed violence, hopelessness, powerlessness Confused, highly anxious- disturbed thought process, acute confusion Unable to function at work, school- ineffective coping planning Uses disaster nursing, mobile crisis units, group work, victim outreach programs Nurses involved in planning and intervening with individuals, group work or community work Implementation 2 major goals Patient safety Anxiety reduction Uses crisis intervention models showing interest and support. Never give false assurances- everything will be all right Nurse is adviser- It is the patient that solves the problem never the nurse grief The reaction to loss: Depression Loss of sleep Poor appetite Plus Kubler-Ross 4 stages: Shock Denial Anger Bargaining acceptance Disenfranchised grief Grief that is felt but cannot be publicly shown or openly acknowledged Example- a nurse losing a patient they had developed a bond with A lover, a neighbor, a co-worker etc This grief can be solitary and uncomfortable and very difficult to resolve because it can remain unspoken Grief Engendered by public tragedy Common public tragedies: Middle Eastern Terrorists Unrest in Middle East Explosion of the Challenger space ship Terrorist assaults 9/11 Katrina Yarnell firefighters Gabby Gifford Mass shootings in public places Theories of Grief One such theory was just discussed: Kubler-Ross The stages for every human do not occur exactly in that order taking a certain amount of time. Everyone reacts within their own framework The order it occurs can vary and well as the time in each phase varies Models help organize the stages but don’t provide a focus of care when assisting a patient though the process Nursing Considerations Grieving is normal Complicated grieving impairs functioning Things not common with normal grieving: guilt about actions taken or not taken by the survivor feelings that they are better off dead or should have died with the person preoccupation with worthlessness psychomotor retardation hallucinatory experience-seeing or hearing the deceased Interventions Give your full self-make eye contact, be in the moment, active listening Allow time for silence Know and share about the phenomena of normal grieving process Encourage support of family and friends Offer spiritual support and referrals if needed Be aware some people need grief counseling and support groups Remember, people in crisis are able to make decisions, help them PTSD 1- War 2- Violence like home invasions, rape Symptoms show up 3-4 months after the occurrence Entering the ER, don’t leave them alone! Flashbacks triggered by sight, sound, smell, feel Feels detached or empty inside Shows hyper vigilance or distrusting of people and or situations Avoids people and places that arouse painful memories