Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02

Copyright © 2008. F.A. Davis Company

Essentials of Psychiatric Mental Health Nursing, 4th EditionEssentials of Psychiatric Mental Health Nursing, 4th Edition

Chapter 16Chapter 16

Mood DisordersPart II



Bipolar Disorder (Mania)Bipolar Disorder (Mania)Etiological implications

Biological theories: Strong hereditary implications

Biochemical influences: Possible excess of norepinephrine, serotonin, and/or dopamine



Bipolar Disorder (Mania) (cont.)Bipolar Disorder (Mania) (cont.) Biological theories (cont.):

Electrolytes

Physiological influences Brain lesions Medication side effects-most common steroids,

also amphetamines, antidepressants, and high doses of anticonvulsants during manic episodes



Bipolar Disorders (Mania) (cont.)Bipolar Disorders (Mania) (cont.) Psychosocial theories

Credibility of psychosocial theories has declined in recent years

Bipolar disorder viewed as brain disorder Theoretical integration

Bipolar disorder likely results from an interaction between genetic, biological, and psychosocial determinants.



Bipolar Disorder: Developmental Bipolar Disorder: Developmental ImplicationsImplicationsChildhood and adolescence Lifetime prevalence of pediatric and adolescent

bipolar disorders is estimated at about 1%. Diagnosis is difficult. Guidelines for diagnosis and treatment have been

developed by the Child and Adolescent Bipolar Foundation (CABF).



Bipolar Disorder: Developmental Bipolar Disorder: Developmental Implications (cont.)Implications (cont.)Childhood and adolescence (cont.) The CABF recommends the use of FIND

(frequency, intensity, number,

and duration) in making a

diagnosis of bipolar disorder

in children and adolescents.



Bipolar Disorder: Developmental Bipolar Disorder: Developmental Implications (cont.)Implications (cont.)Childhood and adolescence (cont.) FIND:

Frequency: Symptoms occur most days in a week

Intensity: Symptoms are severe enough to cause extreme disturbance

Number: Symptoms occur 3 or 4 times a day Duration: Symptoms occur 4 or more hours a

day



Bipolar Disorder: Developmental Bipolar Disorder: Developmental Implications (cont.)Implications (cont.)Childhood and adolescence (cont.) Symptoms include:

Euphoric/expansive mood: Extremely happy, silly, or giddy.

Irritable mood: Hostility and rage, often over trivial matters.

Grandiosity: Believes abilities to be better than everyone else’s.

Decreased need for sleep: May only sleep 4 or 5 hours per night and wake up feeling rested.



Bipolar Disorder: Developmental Bipolar Disorder: Developmental Implications (cont.)Implications (cont.)Childhood and adolescence (cont.) Symptoms (cont.):

Pressured speech: Loud, intrusive, difficult to interrupt.

Racing thoughts: Rapid change of topics Distractibility: Unable to focus on school lessons Increase in goal-directed activity/psychomotor

agitation: Activities become obsessive. Increased psychomotor agitation.



Bipolar Disorder: Developmental Bipolar Disorder: Developmental Implications (cont.)Implications (cont.)

Childhood and adolescence (cont.) Symptoms (cont.):

Excessive involvement in pleasurable or risky activities: Exhibits behavior that has an erotic, pleasure-seeking quality about it.

Psychosis: May experience hallucinations and delusions.

Suicidality: May exhibit suicidal behavior during a depressed or mixed episode or when psychotic.



Bipolar Disorder: Developmental Bipolar Disorder: Developmental Implications (cont.)Implications (cont.)Childhood and adolescence (cont.) Treatment strategies:

Psychopharmacology: Lithium Divalproex Carbamazepine Atypical antipsychotics



Bipolar Disorder: Developmental Bipolar Disorder: Developmental Implications (cont.)Implications (cont.)Childhood and adolescence (cont.) Treatment strategies (cont.):

ADHD is most common comorbid condition ADHD agents may exacerbate mania and

should be administered only after bipolar symptoms have been controlled



Bipolar Disorder: Developmental Bipolar Disorder: Developmental Implications (cont.)Implications (cont.)

Childhood and adolescence (cont.) Treatment strategies (cont.):

Family interventions:Psychoeducation about bipolar

disorderCommunication trainingProblem-solving skills training



Nursing Process/AssessmentNursing 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 hospitalizationMood: cheerful and expansiveCognition and perception: self-exultation; easily distracted

Activity and behavior: increased motor activity; extroverted; superficial



AssessmentAssessment 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.)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. Has become relatively rare since

the availability of antipsychotic

medication



Nursing DiagnosisNursing 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.)Nursing Diagnosis (cont.) Risk for violence: Self-directed or other-

directed related to: Manic excitement Delusional thinking Hallucinations



Nursing Diagnosis (cont.)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.)Nursing Diagnosis (cont.) Disturbed thought processes related to:

Biochemical alterations in the brain Evidenced by

delusions of grandeur and persecution



Nursing Diagnosis (cont.)Nursing Diagnosis (cont.) Disturbed sensory perception related to:

Biochemical alterations in the brain and to possible sleep deprivationEvidenced by:

auditory and visual hallucinations



Nursing Diagnosis (cont.)Nursing Diagnosis (cont.) Impaired social interaction related to:

Egocentric and narcissistic behavior Insomnia related to:

Excessive hyperactivity and agitation



Criteria for Measuring OutcomesCriteria 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 Criteria for Measuring Outcomes (cont.)(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 Criteria for Measuring Outcomes (cont.)(cont.) The client (cont.):

Accepts responsibility for own behaviors Does not manipulate others for gratification of

own needs Interacts appropriately with others



Planning/ImplementationPlanning/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 EducationClient/Family Education Nature of illness

Causes of bipolar disorder Cyclic nature of the illness Symptoms of depression Symptoms of mania



Client/Family Education (cont.)Client/Family Education (cont.) Management of illness

Medication management Assertive techniques Anger management



Client/Family Education (cont.)Client/Family Education (cont.) Support services

Crisis hotline Support groups Individual psychotherapy Legal/financial assistance



EvaluationEvaluation Evaluation of the effectiveness of the

nursing interventions is measured by fulfillment of the outcome criteria.



Evaluation (cont.)Evaluation (cont.) Has the client avoided personal injury? Has violence to client or others been

prevented? Has agitation subsided?



Evaluation (cont.)Evaluation (cont.) Have nutritional status and weight been

stabilized? Have delusions and hallucinations ceased?



Treatment Modalities for Mood Treatment Modalities for Mood DisordersDisorders Psychological treatment

Individual psychotherapy Group therapy Family therapy Cognitive therapy



Treatment Modalities for Mood Treatment Modalities for Mood Disorders (cont.)Disorders (cont.) Organic treatments-may take up to 4 weeks for

symptoms to subside! Psychopharmacology

For depression Tricyclic antidepressants MAO Inhibitors SSRIs Others

* Maprotiline * Mirtazapine* Amoxapine * Nefazodone* Trazodone * Venlafaxine* Bupropion * Duloxetine



Treatment Modalities for Mood Treatment Modalities for Mood Disorders (cont.)Disorders (cont.) Psychopharmacology (cont.) For mania:

Lithium carbonate Anticonvulsants Verapamil Atypical antipsychotics



Treatment Modalities for MoodTreatment Modalities for Mood

Disorders (cont.)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 Nursing Process: Suicide AssessmentAssessment Epidemiological factors

Marital status: Single, divorced, and widowed people have rates four to five times greater than those who are married



Nursing Process: Suicide Nursing Process: Suicide Assessment (cont.)Assessment (cont.) Epidemiological factors (cont.)

Gender: Women attempt suicide more often; however, more men succeed

Age: Suicide highest in persons older than 50 years; adolescents also at

high risk




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.




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.




Ethnicity: Whites are at highest risk for suicide, followed by Native Americans, then by African Americans.



Nursing Process: Suicide Nursing Process: Suicide Assessment (cont.)Assessment (cont.) Presenting symptoms/medical–psychiatric

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 Nursing Process: Suicide Assessment (cont.)Assessment (cont.) 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.”



Nursing Process: Suicide Nursing Process: Suicide Assessment (cont.)Assessment (cont.) Analysis of the suicidal crisis

Interpersonal support system The precipitating stressor Relevant history Life-stage issues Psychiatric/medical/family history Coping strategies



Nursing ProcessNursing 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.)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.)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/ImplementationPlanning/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 Intervention with the Outpatient Suicidal ClientSuicidal 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 Information for Family/Friends of Suicidal ClientSuicidal 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 Intervention with Families and Friends of Suicide VictimsFriends 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/EvaluationNursing 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.)Nursing Process/Evaluation (cont.) Long-term goals for the suicidal client would

be to: Develop and maintain a more positive self-

concept Learn more effective ways to express feelings to

others Achieve successful interpersonal relationships Feel accepted by others and achieve a sense of

belonging

Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02

Health & Medicine

Transcript of Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02