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Chapter 15 Mood Disorders Part II Bipolar Disorder (Mania) Etiological implications Biological theories: Strong hereditary implications Biochemical influences: Possible excess of norepinephrine, serotonin, and/or dopamine Bipolar Disorder (Mania) (cont.) Physiological influences Alterations in electrolyte transfer resulting in increased levels of intracellular sodium and calcium Brain lesions Medication side effects Steroids Amphetamines Antidepressants Bipolar Disorders (Mania) (cont.) Psychosocial theories Credibility of psychosocial theories has declined in recent years Bipolar disorder viewed as brain disorder Development Implications Childhood & Adolescence CABF group. The use of FIND (frequency, intensity, number, and duration). Mania in Children; symptoms Euophoria Irritable mood Grandiosity Decreased need for sleep Pressured speech Racing thoughts Distractibility Increased psychomotor agitation Psychosis suicidality Nursing Process/Assessment Symptoms may be categorized by degree of severity Stage I—Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization Mood: cheerful and expansive Cognition and perception: self-exaltation; easily distracted Activity and behavior: increased motor activity; extroverted; superficial Assessment Stage II—Acute mania: intensification of hypomanic symptoms; requires hospitalization Mood: euphoria and elation Cognition and perception: fragmented, disjointed thinking; pressured speech; flight of ideas; hallucinations and delusions Activity and behavior: excessive psychomotor behavior; increased sexual interest; inexhaustible energy; goes without sleep; bizarre dress and make-up Assessment (cont.) Stage III—Delirious mania: A grave form of the disorder, characterized by severe clouding of consciousness and representing an intensification of the symptoms associated with acute mania Mood: labile, from ecstasy to despair Cognition and perception: confusion, disorientation, hallucinations, delusions Activity and behavior: frenzied psychomotor activity; agitated, purposeless movements; exhaustion and death can occur without intervention Nursing Diagnosis Risk for Injury related to: Extreme hyperactivity evidenced by increased agitation and lack of control over purposeless and potentially injurious movements Nursing Diagnosis (cont.) Risk for violence: Self-directed or other-directed related to: Manic excitement Delusional thinking Hallucinations Nursing Diagnosis (cont.) Imbalanced Nutrition less than body requirements related to: Refusal or inability to sit still long enough to eat evidenced by loss of weight, amenorrhea Nursing Diagnosis (cont.) Disturbed thought processes related to: Biochemical alterations in the brain evidenced by delusions of grandeur and persecution Nursing Diagnosis (cont.) Disturbed sensory perception related to: Biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations Nursing Diagnosis (cont.) Impaired Social Interaction related to: Egocentric and narcissistic behavior Disturbed sleep pattern related to: Excessive hyperactivity and agitation Criteria for Measuring Outcomes The client Exhibits no evidence of physical injury Has not harmed self or others Is no longer exhibiting signs of physical agitation Criteria for Measuring Outcomes (cont.) The client (cont.) Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status Verbalizes an accurate interpretation of the environment Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations Criteria for Measuring Outcomes (cont.) The client (cont.) Accepts responsibility for own behaviors Does not manipulate others for gratification of own needs Interacts appropriately with others Planning/Implementation Nursing interventions are aimed at: Maintaining safety of client and others Restoring client nutritional status Encouraging appropriate client interaction with others Assisting client to define and test reality Meeting client’s self-care needs Client/Family Education Nature of illness Causes of bipolar disorder Cyclic nature of the illness Symptoms of depression Symptoms of mania Client/Family Education (cont.) Management of illness Medication management Assertive techniques Anger management Client/Family Education (cont.) Support services Crisis hotline Support groups Individual psychotherapy Legal/financial assistance Evaluation Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria. Evaluation (cont.) Has the client avoided personal injury? Has violence to client or others been prevented? Has agitation subsided? Evaluation (cont.) Have nutritional status and weight been stabilized? Have delusions and hallucinations ceased? Treatment Modalities for Mood Disorders Psychological treatment Individual psychotherapy Group therapy Family therapy Cognitive therapy Treatment Modalities for Mood Disorders (cont.) Organic Treatments Psychopharmacology For Depression Tricyclic antidepressants MAO Inhibitors SSRIs Others * Maprotiline * Mirtazapine * Amoxapine * Serzone * Trazodone * Effexor * Bupropion Treatment Modalities for Mood Disorders (cont.) Psychopharmacology (cont.) For mania: Lithium carbonate Anticonvulsants Verapamil Olanzapine Treatment Modalities for Mood Disorders (cont.) Electroconvulsive Therapy For depression and mania Mechanism of action: thought to increase levels of biogenic amines Side effects: temporary memory loss and confusion Risks: mortality; permanent memory loss; brain damage Medications: pretreatment medication; muscle relaxant; short-acting anesthetic Nursing Process: Suicide Assessment Epidemiological factors Marital status: Suicide rate for single people twice that of married people Single, divorced, and widowed people have rates four to five times greater than those who are married Nursing Process: Suicide Assessment (cont.) Epidemiological factors (cont.) Gender: Women attempt suicide more often; more men succeed Age: Suicide highest in persons older than 50 years; adolescents also at high risk Nursing Process: Suicide Assessment (cont.) Epidemiological factors (cont.) Religion: Protestants have significantly higher rates of suicide than Catholics and Jews. A strong feeling of cohesiveness within a religious organization seems to be an important factor. Nursing Process: Suicide Assessment (cont.) Epidemiological factors (cont.) Socioeconomic status: People in the highest and lowest social classes have higher suicide rates than those in the middle classes. Professionals: Professional healthcare personnel and business executives are at the highest risk. Nursing Process: Suicide Assessment (cont.) Epidemiological factors (cont.) Ethnicity: Whites are at highest risk for suicide, followed by Native Americans, then by African Americans. Nursing Process: Suicide Assessment (cont.) Presenting symptoms/Medicalpsychiatric diagnosis Mood disorders (major depression and bipolar disorders) are the most common disorders that precede suicide. Other disorders include Anxiety disorders Schizophrenia Borderline personality disorder Antisocial personality disorder Nursing Process: Suicide Assessment Suicidal ideas or acts Assess: Intent; plan; means; lethality of means; previous attempts Verbal clues: Direct statements: “I want to die.” Indirect statements: “I don’t have anything to live for anymore.” (cont.) Nursing Process: Suicide Assessment (cont.) Interpersonal support system Analysis of the suicidal crisis The precipitating stressor Relevant history Life-stage issues Psychiatric/medical/family history Coping strategies Nursing Process Diagnosis/Outcome Identification Risk for suicide related to feelings of hopelessness and desperation Outcome: The client has experienced no physical harm to self Nursing Process (cont.) Diagnosis/Outcome Identification (cont.) Hopelessness related to absence of support systems and perception of worthlessness Outcome: Expresses some optimism and hope for the future Nursing Process (cont.) Planning/Implementation Establish a therapeutic relationship to convey acceptance of the person. Communicate the potential for suicide to team members. Stay with the person to convey support throughout the current crisis. Planning/Implementation Accept the person, which will show unconditional positive regard. Listen to the person. Secure a no-suicide contract (verbally or in writing) for a specified amount of time. Intervention with the Outpatient Suicidal Client Do not leave the person alone. Establish a no-suicide contract. Enlist help of family and friends. Schedule daily appointments. Establish trusting relationship. Talk directly about client’s plans for suicide. Discuss current crisis situation. Identify areas of client control. Antidepressant medication. Information for Family/Friends of Suicidal Client Take any hint of suicide seriously. Report threats of suicide immediately. Be a good listener; stay with the person. Express concern about the person’s welfare. Be aware of resources for assistance. Restrict access to firearms or other means of self-harm. Instill hope. Express love for the person. Encourage professional help. Be nonjudgmental. Intervention with Families and Friends of Suicide Victims Encourage them to talk about the suicide. Be aware of blaming or scapegoating. Listen to feelings of guilt. Encourage discussion of relationship with lost loved one. Encourage grieving at own personal pace. Discuss coping strategies. Identify resources that provide support. Nursing Process/Evaluation Evaluation of the suicidal client is an ongoing process accomplished through continuous reassessment of the client as well as determination of the goal achievement. Nursing Process/Evaluation (cont.) Long-term goals for the suicidal client would be to: Develop and maintain a more positive selfconcept Learn more effective ways to express feelings to others Achieve successful interpersonal relationships Feel accepted by others and achieve a sense of belonging