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Lithium By: Stephanie Halbleib Goal To impart critical information about lithium to a target audience of first year nursing students. Objectives At the end of presentation participants will be able to: Describe what lithium is used for and how it works. Identify 5 side effects of lithium. Verbalize 3 contraindications related to lithium. Describe 2 nursing considerations for lithium. Content Outline • • • • • • • • • • • Generic and Brand Names Indications Actions Pharmacokinetics Dosage and Routes Side Effects Contraindications/Precautions Nursing Considerations Patient Teaching Summary Questions and Answers Brand Name: Lithobid, Eskalith, Lithonate, Lithotabs, Cibalith-S (syrup) Therapeutic Class: Antimanic/mood stabilizer Chemical Class: Alkaline metal Generic Name: lithium carbonate, lithium citrate (syrup) Pregnancy Category: D Indication Lithium is used to treat manic depressive disorder also called bipolar disorder. It works to stabilize the mood and reduce extremes in behavior by restoring the balance of certain natural substances in the brain. Action The exact mechanism of action is unknown, but lithium alters neuronal sodium transport. May alter sodium, potassium ion transport across cell membrane in nerve, muscle cells. May also balance biogenic amines of norepinephrine, serotonin in CNS areas involved in emotional responses. Action of Lithium Onset: rapid Peak: ½-12hours Duration: days Half life: 18-36 hours 1-3 weeks to reach steady state Pharmacokinetics Route: PO Tablet, Capsule, Extended-release table, Solution/syrup Therapeutic level: 0.4 -1mEq/L Steady state: 5 - 7 days Pharmacokinetics Absorption: Readily absorbed from the gastrointestinal tract and liver, with complete absorption occurring after about 8 hours. Absorption is not significantly impaired by food. Distribution: Lithium does not bind to protein. 80% of lithium is filtered and reabsorbed by the renal tubules. Distribution across the blood-brain barrier is slow; however, the cerebrospinal fluid lithium level is about 40% of the plasma concentration. Lithium is able to cross the placenta and is excreted in breast milk. Elimination: About 95% of lithium is eliminated by the kidney, entirely unchanged. Therefore, poor renal function impairs the excretion of lithium. Elimination can also be detected in sweat and saliva. Special Populations for the Elderly: Decreases rate of excretion; increases incidence of toxic effects. Therefore, lower doses and more frequent monitoring are recommended. Dosage and Route Capsules, Tablets Adults and children age 12 and older: Initial: 300-600mg t.i.d. Maintenance: 300mg t.i.d. q.i.d. Maximum: 2,400g daily E.R. Tablets Adults and children age 12 and older: Initial: 900-1,800mg daily divided does b.i.d. or t.i.d. Maintenance: 450mg b.i.d. or 300mg t.i.d. Maximum: 2,400g daily Syrup Adults and children age 12 and older: Initial: 8-16mEq (300-600mg) t.i.d. Maintenance: 8mEq (300mg) t.i.d or q.i.d. Maximum: Equivalent of 2,400g daily Children up to age 12: 0.4-0.5 mEq (15-20mg) per kg daily divided doses b.i.d. or t.i.d. Side Effects Lithium may cause: Sever symptoms: Restlessness Difficult control of fine hand movements Change in the taste food Swollen lips Loss of appetite Acne Stomach pain or bloating Hair loss Discomfort to cold temperatures Gas Indigestion Constipation Weight gain or loss Depression Dry mouth Joint or muscle pain Excessive saliva Tongue pain Thin, brittle fingernails or hair Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs Shaking or movements that you cannot control Muscle weakness, stiffness, twitching, or tightness Confusion and/or hallucinations Slow, jerky movements Frequent urination Blackouts or seizures Ringing in the ears Irregular, or pounding heartbeat or chest tightness Itching, rash Diarrhea or vomiting Slurred speech Painful or discolored fingers and toes Headache Changes in vision or crossed eyes Contraindications Precautions Hypersensitivity Any degree of cardiac, renal, or thyroid disease Severe cardiovascular or renal disease Dehydrated or debilitated patients Brugada syndrome Bone marrow depression Myeloproliferative Brain damage, or coma Sever hypertension or hypotension Alcohol use Pregnant or lactating patients Diabetes mellitus Fetal cardiac anomalies are associated with lithium use; however, potential maternal benefit may warrant use in some pregnant women Initial dosage should be decreased in the elderly Lithium can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Nursing Considerations Assessment: Assess mental status (orientation, mood, behavior) initially and periodically. Initiate suicide precautions if indicated. Monitor intake and output ratios. Report significant changes in totals. Unless contraindicated, fluid intake of at least 2,000-3,000mL/day. Weight should also be monitored at least every 3 months. Palpate thyroid gland to detect enlargement because drug may cause goiter. Lab test considerations: Evaluate renal and thyroid function, EGCs, WBC with differential, serum electrolytes, and glucose periodically during therapy. Toxicity and overdose: Monitor serum lithium levels twice weekly during initiation of therapy and every 2 months during chronic therapy. Draw blood samples in the morning immediately before next dose. Therapeutic levels range from 0.5-1.5mEq/L for acute mania and 0.6-1.2mEq/L for long term control. Serum concentration should not exceed 2.0mEq/L. Assess patient for symptoms of lithium toxicity (see next slide). If these occur, report before administering next dose. Implementation: Do not confuse lithium carbonate with lanthanum carbonate. Note that 5mL of lithium citrate equals 8mEq of lithium ion or 300mg of lithium carbonate. Administer with food or milk to minimize GI irritation. Extended-release preparations should be swallowed whole; do not break, crush, or chew. Dilute syrup with juice or other flavored drink before administering. Nursing Consideration for Toxicity Therapeutic level: 0.5-1.0 mEq/L Early indications: Less than1.5mEq/L Diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremor, slurred speech. Advise clients to withhold medication and notify the provider. Advanced indications: 1.5 to 2.0 mEq/L Ongoing gastrointestinal distress, including nausea, vomiting, and diarrhea; mental confusion; poor coordination; coarse tremors. Advise clients to withhold medication and notify the provider. Administer new dosage based on serum lithium levels. If manifestations are severe, it may be necessary to promote excretion. Severe toxicity: 2.0 to 2.5 mEq/L Extreme polyuria of dilute urine, tinnitus, blurred vision, ataxia, seizures, severe hypotension leading to coma and possibly death from respiratory complications Give alert clients an emetic. Perform gastric lavage or administer urea, mannitol, or aminophylline to increase the rate of excretion. Greater than: 2.5mEq/L Rapid progression of symptoms leading to coma and death. Hemodialysis. Patient Teaching Inform the patient that frequent urination, nausea, and thirst may occur during the first few days of treatment. Instruct patient to report signs of toxicity, such as diarrhea, drowsiness, muscle weakness, tremor, uncoordinated body movements, and vomiting. Low sodium levels may predispose patient to toxicity. Advise patient to drink 2,000-3,000mL fluid each day and eat a diet with consistent and moderate sodium intake. Excessive amounts of coffee, tea, and cola should be avoided because of diuretic effects. Avoid activities that cause excess sodium loss (heavy exertion, exercise in hot weather, saunas). Advise the patient that weight gain may occur. Review principles of low-calories diet. Instruct patient to take medication as directed, even if feeling well. Take missed doses as soon as remembered unless within 2 hours of next dose, or 6 hours if extended-release. Advise patient to use contraception and to consult health care professional if pregnancy is suspected or if breastfeeding. Lithium may cause dizziness or drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken or changes. Lithium is used to treat and prevent episodes of mania that occur in bipolar disorder. Summary Lithium is in a class of medications called anitmanic agents. It is not known how lithium works to stabilize a person’s mood. However, it is known that lithium does not act on the central nervous system. Comes as tablet, capsule, extended-release (ER) tablet, and syrup to be taken by mouth. Tablets, capsules, and syrup are usually taken 3-4 times a day. ER tablets are usually taken 2-3 times a day. It is important for your patients to follow a proper diet, including the right amounts of fluid and salt during your treatment. There are many side effects that can occur while on lithium. Make sure your patient understands to call their doctor if they are experience any unusual symptoms. Toxicity is can occur, therefore patients should know the early signs (diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremor, slurred speech). 1. What is 1 brand name of lithium? Questions 2. What is the indications or therapeutic uses lithium? 3. What is the action of lithium? 4. Name 5 possible side effects related to lithium? 5. Name 3 contradictions related to lithium? 6. Name 2 nursing consideration for lithium? 7. What is the therapeutic level of lithium? 8. What are some potential nursing diagnoses for a patient taking lithium? 9. What are some desired outcomes for patients taking lithium? 10.Name 1 other fact that you learned about lithium? Answers 1. Lithobid, Eskalith, Lithonate, Lithotabs, Cibalith-S (syrup). 2. The indications of use for lithium is to treat recurrent bipolar affective disorder, and to prevent bipolar disorder depression. 3. The exact mechanism of action is unknown, but lithium alters neuronal sodium transport. 4. Side effects see slide 10. 5. Contradictions see slide 11. 6. Nursing considerations see slides 12 and 13. 7. Therapeutic level is 0.5 to 1.0 mEq/L. 8. Disturbed thought process, ineffective coping, imbalanced nutrition: risk for more than body requirements. 9. Resolution of the symptoms of mania (hyperactivity, pressured speech, poor judgment, need for little sleep). Decreased incidence of mood swings in bipolar disorders. Improved affect in unipolar disorders. (Improvement in condition may require 1-3 weeks). Remission of depressive symptoms. 10. Answers will vary with every student. References Deglin, J. H., & Vallerand, A. H. (2009). Davis's drug guide for nurses (11th ed.). Philadelphia, Penn.: F.A. Davis. Karch, A. M. (2004). 2004 Lippincott's nursing drug guide. Philadelphia: Lippincott Williams & Wilkens. Retrieved March 4,2014, from web.squ.edu.om/medLib/MED_CD/E_CDs/Psychiatric Nursing Care Plans/monographs/thioridazine hydrochloride.htm Sullivan, K. (2010). 2010 nurse's drug handbook (9th ed.). Boston: Jones and Bartlett. Videbeck, S. L. (2011). Psychiatric-mental health nursing (5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.