Download nursing care of depression and bipolar

Mood Disorders
Goals of Interdisciplinary Treatment
• Reduce, remove symptoms.
• Restore occupational and psychosocial
functioning.
• Reduce likelihood of relapse.
• Safety is a priority. Suicide assessment
Family Response
• Affects the whole family
• Often has financial hardships
Priority Care Issues
• Safety
• Risk for suicide
Nursing Management:
Biologic Domain
Assessment
– Systems Review (CNS, endocrine, anemia,
chronic pain, etc.)
– Physical exam: palpation of the neck for
thyroid abnormalities
– Appetite and weight
– Sleep disturbance
– Decreased energy
Nursing Diagnosis:
Biologic Domain
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Disturbed sleep pattern
Imbalanced nutrition
Fatigue
Many other possible
– Failure to thrive
– Bathing/hygiene deficit
– Pain
Nursing Interventions:
Biologic Domain
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Sleep hygiene
Nutritional intervention
Exercise
Pharmacologic interventions
– Acute
– Continuation
– Maintenance
– Discontinuation
Psychopharmacologic Interventions
• Cyclic antidepressants
• Selective Serotonin Reuptake Inhibitors
(SSRIs)
– Fluoxetine, sertraline, fluvoxamine, paroxtine,
citalopram, escitalopram
• Monoamine Oxidase Inhibitors (MAOIs)
– Phenelzine (Nardil), Tranylcypromine (Parnate)
• Atypical antidepressants
– Trazodone, bupropion, nefazodone,
venalfaxine and mirtazapine
Pharmacological Nursing Interventions
Monitoring and Administration
– Observe taking meds (acute phase)
– Vital signs (observe for orthostatic
hypotension), lab reports
– Diet restrictions as appropriate
Side Effects: SSRIs
• GI Distress
– Fluoxetine (Prozac)
– Sertraline (Zoloft)
– Paroxetine (Paxil)
– Fluvoxamine (Luvox)
• Low Anticholinergic
– Fluoxetine (Prozac)
– Fluoxetine (Luvox)
• Low sedation (All)
• Sexual Dysfunction (All)
• Orthostatic Hypotension
– Fluoxetine (Prozac)
– Fluvoxamine (Luvox)
Side Effects of TCAs: Anticholinergic and
Antihistaminic
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Sedation and drowsiness
Weight gain
Hypotension
Potentiation of CNS system drugs
Blurred vision
Dry mouth
Constipation
Urinary retention
Sinus tachycardia
Decreased memory
Monamine Oxidase Inhibitors
• Indications
– Depression with personality disorders, panic or
social phobia
• Side Effects
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Hypertensive crisis/interaction with food
Sudden, severe pounding or explosive headache
Anticholinergic
Elderly - sensitive to orthostatic hypotension
Sexual dysfunction
Serotonin Syndrome
• More likely to be reported in patients taking two or
more serotonin antagonists
• Usually mild, but can cause death
• Rapid onset (compared to NMS)
• Symptoms
– Mental status, agitation, myoclonus, hyperreflexia, fever,
shivering, diaphoresis, ataxia and diarrhea
• Treatment
– Stop offending drug.
– Provide supportive treatment.
– Notify physician.
Drug-drug Interactions
• SSRIs inhibit 1A2 system. (Theophylline
must be reduced.)
• Smoking induces 1A2 system; smokers
may need higher dosage.
• Fluoxetine and paroxetine inhibit 2D6.
Can increase plasma levels of TCA, so
avoid giving these meds with TCA.
Amitriptyline
Butriptyline
Clomipramine
Desipramine
Dosulepin
Doxepin
Imipramine
Iprindole
Lofepramine
Nortriptyline
Protriptyline
Trimipramine
Teaching Points
• If depression goes untreated or is
inadequately treated, episodes become
more frequent, severe and longer in
duration.
• Importance of continuing medication
Other Somatic Treatments
• Electroconvulsive therapy
• Light therapy
– SAD
– Light - very bright, full-spectrum light, usually
2,500 lux
– Immediately upon rising
– Exposure as little as 30 minutes and then increase
– Full effect after two weeks
Nursing Management:
Assessment
Psychological
–Assessment scales self-report
–Mood and affect
–Thought content
–Suicidal behavior
–Cognition and memory
Nursing Diagnoses
Psychological Domain
• Anxiety
• Decisional conflict
• Fatigue
• Grieving, dysfunctional
• Hopelessness
• Self-esteem, low
• Risk for suicide
Psychological Interventions
Nurse-Patient Relationship
– Withdrawn patients have difficulty
expressing feelings.
– Nurse should be warm and empathic, but
not a cheerleader.
– Therapeutic Dialogue.
Psychological Interventions
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Cognitive therapy - psychotherapy
Behavior therapy
Interpersonal therapy
Marital and family therapy
Group therapy
Patient and family education
Nursing Management:
Assessment
Social Domain
• Developmental history
• Family psychiatric history
• Quality of support system
• Role of substance abuse in relationships
• Work history
• Physical and sexual abuse
Social Nursing Interventions
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Patient and family education
Medication adherence
Marital and family therapy
Group therapy
Continuum of Care
• Non-psychiatric setting
• Acute care – hospitalization
• Outpatient
Types of Bipolar
• Bipolar I
– Combinations of major depression and full
manic episode
– Mixed episodes: alternating between manic and
depressive episodes
• Bipolar II
– Combination of major depression and
hypomania (less severe form of mania)
Treatment Issues
• Complex issues treated by an
interdisciplinary team
• Priority issues:
• Safety from poor judgement and risk-taking
behaviors
• Risk for suicide during depressive disorders
• Devastating to families, especially
dealing with the consequences of
impulsive behavior
Nursing Management:
Biologic Domain
• Assessment
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Evaluation of mania symptoms
Sleep may be nonexistent.
Irritability and physical exhaustion
Eating habits, weight loss
Lab studies - thyroid
Hypersexual, risky behaviors
Pharmacologic (may be triggered by antidepressant), alcohol
use
• Nursing diagnosis
– Disturbed sleep pattern, sleep deprivation
– Imbalanced nutrition, hypothermia, deficit fluid balance
Nursing Interventions:
Biologic Domain
• Physical care
• Pharmacologic
– Acute - symptom reduction and
stabilization
– Continuation – prevention of relapse
– Maintenance - sustained remission
– Discontinuation - very carefully, if at all
• Electroconvulsive therapy
Mood Stabilizers
• Lithium Carbonate (Eskalith)
– Mechanism of action: unknown
– Blood levels 0.5-1.2
– Side effects: GI, weight gain
• Divalproex Sodium (Depakote)
– Increase inhibitory transmitter, GABA
– Sedation, tremor
• Carbamazepine
Mood Stabilizers
• Lithium Carbonate
• Drug profile
• Lithium blood levels
• Divalproex sodium (Depokote) (Drug Profile)
• Carbamazapine (Tegretol)
• Baseline liver function tests and complete blood count
• Newer anticonvulsants
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Topiramate (Topamax)
Other Medications Used
• Antidepressants
– Used during depressed phases
– Can trigger manic phase
• Antipsychotics
– Psychosis
– Mania
– Dosage usually lower
• Benzodiazepines
– Short-term for agitation
Other Medication Issues
• Monitoring important
• Side effect monitoring important because
taking more than one medication
• Drug-drug interactions
– Especially, alcohol, drugs, OTC and herbal
supplements
• Teaching points
– Lithium (Change in salt intake can affect lithium.)
– Most of these medications cause weight gain.
– Check before using OTC.
Nursing Management:
Psychological Domain
Assessment
– Mood
– Cognitive
Nursing Diagnosis
– Disturbed sensory
perception
– Thought
– Disturbed thought
processes
– Defensive coping
– Risk for suicide
– Risk for violence
– Ineffective coping
Disturbances
– Stress and coping
factors
– Risk assessment
Nursing Management:
Social Domain
• Assessment
– Social and occupational changes
– Cultural views of mental illness
• Nursing Diagnosis
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Ineffective role performance
Interrupted family processes
Impaired social interaction
Impaired parenting
Compromised family coping
Nursing Interventions:
Social Domain
• Protect from over-extending boundaries
• Support groups
• Family interventions
– Marital and family interventions
Continuum of Care
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Inpatient management – short-term
Intensive outpatient programs
Frequent office visits
Crisis telephone calls
Family session or -