Bipolar Flashcards
What is Bipolar Disorder?
Characterized by mood swings from profound depression to extreme euphoria with intervening periods of normalcy.
- Delusions may be present
- Onset of symptoms may have seasonal patterns
Diagnosis - 5
- Bipolar I
- Bipolar II
- Cyclothymic Disorder
- Medication/Substance Induced
- Due to medical condition
Epidemiology
- average Onset early 20s
- prevalence equal in male and female
- following first manic episode disorder tends to be recurrent
Etiology
- Genetic
- Neuroanatomical Factors
- Biochemical
- Drug induced
Genetic Factors Prevalence
- Monozygotic twins - 60-80%
- Child of 2 parents with bipolar - 50-60 %
Etiology - Biochemical Influences - Mania vs Depression
(Dopamine, Norepinephrine, and Cholinergic Transmission
- Mania: Excess in Dopamine and Norepinephrine; Inadequacy in Cholinergic Transmission
- Depression: Deficiency in Dopamine and Norepinephrine; Excess in Cholinergic Transmission
Etiology - Neuroanatomical Factors
- Right-sided lesions to limbic system, temporobasal areas, basal ganglia, and thalamus induce mania
- Enlarged third ventricle
- Subcortical white matter
- Periventricular hyperintensities
Etiology - Medications
Steroids, Amphetamines, Narcotics and Anti-depressants
What is a manic episode?
- At least 1 week period of elevated, expansive or irritated mood.
- Causes marked impairment (i.e. Hospitalization)
- Not attributable to substances, medications, and medical conditions
Symptoms of Manic Episodes
- Inflated Self-Esteem/Grandiosity
- Decreased need for sleep
- Talkative/pressured speech
- Flight of ideas/racing thoughts
- Distractibility
- Increase in goal directed activity
- Excessive involvement in activities with potential for painful consequences
- Agitation, irritation, and aggression
Hypomanic episode
- 4 day period of elevated, expansive, or irritated mood
- Episode is a change of behavior
- Disturbance in mood and change in functioning are observable by others
- Not severe enough for marked impairment in functioning
- Not attributable to medications, substances, and medical conditions
Bipolar I vs II - Distinguishing Factors
- Manic
- Hypomanic
- Major Depressive Episode
- Marked impairment in functioning
Bipolar I
- Yes Manic episode - 1 week
- Maybe depressive episode and must be at least 2 weeks
- Yes marked impairment in functioning
Bipolar II
- No manic episode
- Yes hypomanic episode - 4 days
- Yes major depressive episode - at least 2 weeks
- No marked impairment in functioning
What is Cyclothymic Disorder?
- Chronic, fluctuating mood disturbance of at least 2 year duration
- Numerous periods of elevated mood (does not meet criteria for hypomanic)
- Numerous period of depressed mood (does not meet criteria for Major depressive episode)
- Never without symptoms for more than 2 months
What is substance/medication induced bipolar disorder?
- Direct result of physiological effects of a substance (withdrawal or ingestion)
- Causes significant distress or impairment
What is bipolar disorder due to another medical condition?
- Direct result of physiological consequence of another medical condition
- Causes significant distress or impairment
Bipolar in children
- hard to diagnose
- may present with co-morbid disorders or ADHD
- children with parents with bipolar at higher risk
Suicide Risk in Bipolar
- Lifetime risk 15 times higher than general population
Nursing Diagnoses
- Risk for Injury
- Risk for violence: self-directed or other directed
- imbalanced nutrition
- disturbed thought processes
- disturbed sensory perception
- insomnia
- impaired social interaction
Nursing Interventions
- Ensure safety of self and others
- Reduce environmental stimuli
- limit group activities
- stay with client who is agitated or hyperactive (may need 1:1)
- remove hazardous objects
- provide structure
- Mechanical restraints or seclusions
- limit setting
- administer medication
Restraints and Seclusion Guidelines
- Initiated only when less restrictive measures have proven ineffective
- Behavior poses danger to to self or others
- within 1 hour of restraint: 1 to 1 with MD, PA, RN, NP,
- New order every 4 hours for adults, 1-2 for children
- 15 minute checks or 1:1
- Rn monitor hourly
- Debriefing
Treatment
- Psychopharmocology
- Psychotherapy
- Recovery Model
- ECT (electric convulsive therapy)
Psychopharmocology - Mood stabilizers/anti-convulsants
Mood stabilizers: Lithium carbonate (Eskalith, Lithobid)
Anti-convulsants: Depakene, Depakote (Valproic Acid), Lamatrogine (Lamictil), Tegretol (Carbamezepine)
- Anti-convulsants can be used as mood stabilizers
- May take 1-3 weeks to take effect
- Patient on mood stabilizer needs to be on adjunctive treatment with with an antipsychotic or benzodiazepine until symptoms start to resolve
Psychopharmocology - Anti-Psychotics
Clozapine (Clozaril), Risperdone (Risperdal), Quetiapine (Seroquel), Olanzapine (Zyprexa), Aripiprazole (Abilify)
Lithium
Margin between therapeutic and toxic levels of Lithium carbonate are narrow
Ranges: Acute mania: 1.0-1.5
Maintenance: 0.6-1.2
Lithium side effects
- Drowsiness, dizziness, headache
- dry mouth, thirst
- GI upset, vomiting
- Polyuria, dehydration
- fine hand tremors
- weight gain
- lithium toxicity
- acne
Lithium Toxicity
- Life threatening
- renal impairment
- Nephrogenic diabetes insipidus
- hypotension, arrhythmias, pulse irregularities
Lithium Lab Test
Before Treatment:
- kidney and thyroid function
- ECG after 50
- Weight, BMI
Initiation of Treatment:
- 1-2 weeks untile stable
- Monthly after 6 months
Maintenance treatment:
- Every 3-6 months
- Kidney function 1-2 times a year
Anticonvulsants Side Effects: Valproic Acid (Depakote), Lamotrigine (Lamictil), Carbamazepine (Tegretol)
- Valproic Acid (depakote): sedation, weight gain, hepatotoxicity with liver failure, pancreatitis, and prolonged bleeding time
- Lamotrigine (Lamictile): Steven Johnson Syndrome
- Carbamazepine (Tegretol): Steven Johnson syndrome, aplastic aneumia, hyponatremia
Anticonvulsants Lab Tests: Carbamezapine (Tegretol), Valproic Acid (Depakote), Lamotrigine (Lamictil)
- Carbamezapine (Tegretol): Initiation: CBC, liver, kidney, thyroid function
Treatment: CBC every 2 weeks for 2 months, then every 3-6 months, liver, kidney, thyroid function every 6-12 months - Valproic Acid (Depakote): Initiation: platelet count, liver function, weight. Every 6 months
- Lamotrigine (Lamictil): None
Lithium treatment teaching
- sodium intake
- exercise
- adequate fluid intake 2500-3000 ml/day
- monitor weight
- contraceptive use
- take as prescribed
- carry id or card indicating they are taking lithium
- symptoms of toxicity
- caution when driving
Anti-convulsant teaching
- Do not stop med abruptly
- Report: skin rash, unusual bleeding, bruising, sore throat, malaise, fever, dark urine, yellow eyes or skin
- carry card identification of med
- caution with driving
- lab tests
Anti-psychotic teaching
- Do not discontinue abruptly
- use sunblock
- orthostatic hypotension
- stay hydrated
- ETOH avoidance
- good hygiene
- contraceptives,
- id card
- caution driving
