Chapter 16 Bipolar Spectrum Disorders

Question 1

Bipolar I -
Bipolar II -
Hypomanic
Dysthymia
Cyclothymic

Answer 1

Bipolar - used be called manic depressive -

Question 2

What is manic depressive
Real highs where go and go
Then when really lows - really depressed
Typ of way up and down
Full fledged manic
Real highs and low

Answer 2

Bipolar I -

Question 3

not as high manic stage
Really deep depressive stage
Is more Hypomanic - not full manic
Issue is depressed stage
Really major depression

Answer 3

Bipolar II -

Question 4

Not as high but on just above - some just how func; live whole life and operate on hypomanic

Answer 4

Hypomanic

Question 5

Operate below normal mood - not down to major depression - is chronic; present 2 yrs

Answer 5

Dysthymia

Question 6

Between hypomanic and dythmia - not as high/low
For 2 yrs
Feel better in AM but as day goes on they dip in mood

Answer 6

Cyclothymic

Question 7

Looking for congruency; make observation if incongruence so can talk about
Mood is defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of the world; internal emotion
Examples of mood: depression, joy, elation, anger, anxiety
Affect is described as the emotional reaction associated with an experience; how react to/show internal emotions

Answer 7

Intro

Question 8

The average age at onset is the early 20s
It is more common in single than in married persons
It occurs more often in the higher socioeconomic classes
Man and woman equally
Adolescents where suspect it - diagnosed earlier age; typ early 20s
Lot indivs affected with bipolar disorder
About equal to men and woman
Is one Leading causes of mental disability in middle age group

Answer 8

Epidemiology

Question 9

Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder

Answer 9

Type of Bipolar Disorders

Question 10

Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms
Client may also have experienced episodes of depression
Full blown manic - rearrange everything; racing thoughts, activities; vibrant in dress/makeup; sometimes childish in dress; everything is excess
Mood stabilizers do work for these indivs but sometimes they do not want work; feel invincible and have all answers; if on med and norm mood feels like dropping below so fight on med and not complaint because okay with manic stage - make people mad and are diff in group situations because aliente
Feels like horrible crash when get down
Great being up there; know starting into cycle run up debt and run credit card crazy - start spending lot money - spending lot money
Going on fire - need get in quieter place because make people mad and in people’s face and solving all probs - not want in group - need one to one
Depressions really down
Aka manic depressive
Full fledge manic highs and full fledge manic depressions; real highs and lows - experience both

Answer 10

Bipolar I Disorder

Question 11

Characterized by bouts of major depression with episodic occurrence of hypomania - not go as high/out as control/as high as someone who is bipolar I
Key act - depression; deepest depression
Really lows but Never full fledge manic
Has never met criteria for full blown manic episode
Depressions really down here compared to I

Answer 11

Bipolar II Disorder

Question 12

Chronic mood disturbance
Not seen diagnosed as much - learn to live with it or not seek treatment - if do is outpatient
At least 2-year duration of symptoms before diagnosed
Numerous episodes of hypomania (not full fledged mania) and depressed mood (not as low) of insufficient severity to meet the criteria for either bipolar I or II disorder - never go as low/high as bipolar I/II
Cycles of hypo and dysthymia

Answer 12

Cyclothymic Disorder

Question 13

Symptoms may be categorized by degree of severity.

Answer 13

Nursing process/assessment

Question 14

Stage I: Hypomania
Stage II: Acute mania

Answer 14

Symptoms may be categorized by degree of severity.

Question 15

Usually able to func; lot people live life here
Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization

Answer 15

Stage I: Hypomania

Question 16

Cheerful mood - rapid speech; increased motor activity
Rapid flow of ideas, heightened perception
Some Increased motor activity - not extent in full blown manic state

Answer 16

Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization

Question 17

Marked impairment in functioning; usually requires hospitalization - full fledge

Answer 17

Stage II: Acute mania

Question 18

Continually high
Elation and euphoria, a continuous “high”
Flight of ideas (from one thing to another, thread that can figure out going with all but bounces)), accelerated speech, pressured speech, Clang Association/speech - rhyming
Hallucinations and delusions - get to this point; thinking so misperception that see hallucinations and delusions; may get some psychotic symp like these
Excessive psychomotor activity
Social and sexual inhibition - lost to wind; approach people and becomes a prob
Little need for sleep and eating - not have time - writing novel and no time sleep/eat - need help them relax to where can sleep because lack of sleep is safety issue; eating: no time to sit down for 15-20 min - need give things to eat on run so get nutrition: finger foods - not take time to eat - Minds thinking so fast and no time to sleep/eat - then becomes safety issue and are one go - solve all probs

Answer 18

Marked impairment in functioning; usually requires hospitalization - full fledge

Question 19

1.A suicidal client, with a history of manic behavior, is admitted to the ED. The client’s diagnosis is documented as bipolar I disorder: current episode depressed. What is the rationale for this diagnosis instead of a diagnosis of major depressive disorder?
A. The physician does not believe the client is suffering from major depression.
B. The client has experienced a manic episode in the past.
C. The client does not exhibit psychotic symptoms.
D. There is no history of major depression in the client’s family.

Answer 19

Answer: B
Had at least one episode of manic - makes Bipolar I
The client’s past history of mania and current suicide attempt supports the diagnosis of bipolar I disorder: current episode depressed. Both manic and depression. According to the DSM-5 criteria, a manic episode rules out the diagnosis of major depressive disorder.

Question 20

Nursing interventions are aimed at:

Answer 20

planning/implementation as HCP

Question 21

Safety is always something to consider - safety from injury; on go and so hyperactive - in really manic state not leave alone; going and going if not help them; protecting from harm to self
Protection from injury due to hyperactivity
Protection from harm to self or others
Restoration of nutritional status - Finger foods - no utensils that are healthy; nutrition - do not time to sit down and eat for 20 min; grab and eat on run; package things can grab quickly
Progression toward resolution of the grief process
Improvement in interactions with others - Not see realistic danger in life
Acquiring sufficient rest and sleep - whatever relaxation and help with breathing and helping them relax but is challenge
**Denial of realistic danger, distractibility, flight of ideas, loose associations, Clang Associations - all happen to them; not see danger because distractable and all those; feel invincible when in manic stage
Aimed at preventing injury due to hyperacitivity - impulsive: go and do; protect from harm from self and others around them

Answer 21

Nursing interventions are aimed at:

Question 22

2.In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis?
A. Risk for injury related to excessive hyperactivity
B. Disturbed sleep pattern related to manic hyperactivity
C. Imbalanced nutrition, less than body requirements related to inadequate intake
D. Situational low self-esteem related to embarrassment secondary to high-risk behaviors

Answer 22

Answer: A
According to Maslow’s hierarchy of needs, maintaining client safety is always a priority. The impulsiveness and hyperactivity seen in clients diagnosed with acute mania puts them at risk for injury.
Acute manic - safety is priority

Question 23

Individual Psychotherapy
Group Therapy - really manic not good canditate at that point because get people’s face and creates probs
Family Therapy - fam needs lots of support; if bipolar I and extreme ups and down and II where so depressed drains fam and goes through cycles and cannot do it anymore so need support
Cognitive Therapy - reframing thinking; behavioral
Electroconvulsive therapy (ECT) - beneficial; helps them esp with depression and bipolar; see more likely if in depressed stage
Milieu management - trying to keep enviroment safe and therapeutic
Support groups for indiv and fam
Health teaching and health promotion - imp of sleep and nutrition; how handle (for fams) when in very manic (highs) or very depressed/suicidal (lows)

Answer 23

Treatment modalities of bipolar disorder

Question 24

Mood-Stabilizing Agents

Answer 24

Psychopharmacology

Question 25

Indications: prevention and treatment of manic episodes associated with bipolar disorder
Use variety
Examples: lithium carbonate, carbamazepine, valproic acid, lamotrigine , oxcarbazepine, verapamil, (anticonvulsants), topiramate (migraines), antipsychotics
Lithium - grandfather of med for bipolar

Answer 25

Mood-Stabilizing Agents

Question 26

For mania:
For depressive phase:

Answer 26

Psychopharm: mood stabilizers

Question 27

Lithium carbonate (mood stabilizer) - most common go to
Anticonvulsants Anticonvulsants—used most often with rapid cyclers which is viewed as over 4x/year; very useful for indivs who are rapid cyclers - go through ups and downs at least 4x/yr and found this helpful
Verapamil (antihypertensive) - calming effect
Antipsychotics - calming effect; chlorazaril - have do blood work on continual base to monitor WBC count

Answer 27

For mania:

Question 28

Use antidepressants with care (watch because may trigger mania) - in depressive phase - deal with depression and manic side of disorder

Answer 28

For depressive phase:

Question 29

Need blood lithium levels checked/monitored because fine line between therapeutic and non-therapeutic; initially do once a week then do once a month
Blood levels monitored because fine line between therapeutic and non-therapeutic
Therapeutic blood level: 0.8 to 1.4 mEq/L
Maintenance blood level: 0.4 to 1.3 mEq/L - try get in these levels
Toxic blood level: 1.5 to 2.0 mEq/L - get 1.5 need get checked and watch for signs of toxicity because go to 2 blood level of lithium very toxic: seizure and death if not watching; 1.5 not want any higher because not want at 2 and further in non-therapeutic level; signs of toxicity - non-therapeutic levels; not recognize and adjust dose - get seizures, resp issue, can be lifethreatening
Adverse effects

Answer 29

Mood stabilizer: Lithium

Question 30

**Takes 7-14 days to reach therapeutic level - let caregivers and pat know
Initial symptoms of toxicity include: Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea - may see this; hands tremor a bit - reach maintenance level of lithium goes away; want teach is that if flu like symp - not feeling well, achiness, pay attention to that and encourage have levels checked; feels like getting flu - toxicity
Ensure that client consumes adequate amount of sodium (unless phys reason why cut back) and plenty fluid (sev L of water) in diet
Lithium is a salt and need take in enough liquid and salt/Na in diet
Caution if exercise/really warm and sweating a lot - pay attention to blood level and how feeling because losing water and Na; taking lithium and when losing water and Na retains lithium that taking so levels go up

Answer 30

Toxic blood level: 1.5 to 2.0 mEq/L - get 1.5 need get checked because go to 2 blood level of lithium very toxic: seizure and death if not watching; 1.5 not want any higher because not want at 2

Question 31

Drowsiness, dizziness, headache
Dry mouth (cottonmouth - drinking plenty liquids and hard candy), thirst, GI upset, nausea/vomiting
Fine hand tremors - usually get better; most time once at therapeutic level subsides; need continually monitor
Hypotension, arrhythmias, pulse irregularities
Polyuria, dehydration
Weight gain - huge factors; usually gain weight and not fan of it; is consideration and challenge for staying on it; stops them from taking it: good chance of this - rather deal with manic (feel invincible and hate weight gain), need deal with
Potential for toxicity - can lead to seizures, death if high and not cut back

Answer 31

Monitor for side effects of lithium: - AE

Question 32

Need know s/s and same with client
Lithium

Answer 32

client/fam edu

Question 33

Take the medication regularly.
Do not skimp on dietary sodium. - not restrict salt because lithium is salt
Drink 6 to 8 glasses of water or more each day. - drink lots water
Notify physician if vomiting or diarrhea occur. - have flu like symp
Have serum lithium level checked every 1 to 2 months or as advised by physician once at maintenance level - imp get checked
**Be aware exercise and heat may affect levels - when sweating a lot losing water and salt - if on lithium happens if losing lot water and salt and need have levels check and potentially dosage changed because body holds onto lithium so levels increase - encourage drink water
Get lithium checked
Notify physician if any of the following symptoms occur: - give edu about of AE to notify PCP about; not recongize - can lead to seizures/death: FATAL situation; imp get levels checked

Answer 33

Lithium

Question 34

Persistent nausea and vomiting
Severe diarrhea
Ataxia
Blurred vision
Tinnitus
Excessive output of urine
Increasing tremors
Mental confusion

Answer 34

Notify physician if any of the following symptoms occur: - give edu about of AE to notify PCP about

Question 35

Anticonvulsant Drugs
Adverse effects (cont.)

Answer 35

Anticonvulsant medications

Question 36

divalproex (Depakote)
carbamazepine (Tegretol)
lamotrigine (Lamictal)
Often used for those who are rapid cyclers (rapid cycling 3-4 times/year)
Given if rapid cyclers; very effective

Answer 36

Anticonvulsant Drugs

Question 37

Refrain from discontinuing the drug abruptly. - not d/c abruptly; make sure under supervision; caution when going off of it; not decide go off of it
Report the following symptoms to the physician immediately: skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin or eyes.
Avoid using alcohol and over-the-counter medications without approval from physician

Answer 37

client/fam edu - Anticonvulsants

Question 38

On antianxiety, antidepressant with lithium
Anxiolytics (antianxiety)
Used in Mania/manic stage

Answer 38

Antianxiety: a review

Question 39

Common if have bipolar to lessen anxiety

Answer 39

Anxiolytics (antianxiety)

Question 40

Treatment-resistant mania
Psychomotor agitation

Answer 40

Used in Mania/manic stage

Question 41

Imp paying attention of not having too many AE; Not want lithium go high - devastating; teach about all stuff about meds; teach what bipolar disorder is and what means - fact is cyclic disorder; fams get tired: may know be because crazy spending - help recognize signs
Med edu imp - reinforcing with importance of taking meds
Help understand Nature of the Illness
Management of the Illness

Answer 41

Overall client/fam edu

Question 42

Some Causes of bipolar disorder
Cyclic nature of the illness - cycular
Symptoms of depression
Symptoms of mania
How handle symp and respond to it; imp for client and fam/cargiver edu

Answer 42

Help understand Nature of the Illness

Question 43

Medication management - how imp is; if taking lithium imp of getting blood drawn
Assertive techniques
Anger management - if in manic stage can be diff to deal with; pretty reasonable and redirect them most times

Answer 43

Management of the Illness

Question 44

3.A client, who is prescribed lithium carbonate, is being discharged from inpatient care. Which medication information should the nurse teach this client?
A. Do not skimp on dietary sodium intake.
B. Have serum lithium levels checked every six months.
C. Limit fluid intake to 1000 ml of fluid per day.
D. Adjust the dose if you feel out of control.

Answer 44

Correct answer: A
Clients taking lithium should consume a diet adequate in sodium and drink 2500 to 3000 ml of fluid per day. Lithium is a salt and competes in the body with sodium. If sodium is lost, the body will retain lithium with resulting toxicity. Maintaining normal sodium and fluid levels is critical to maintaining therapeutic levels of lithium and preventing toxicity.
Need drink lot fluids/day

Question 45

SAFETY
No injury/harm to self
eating/sleeping well; can in manic stage: get to point of hallucinations/delusions
Exhibits no evidence of physical injury - not physically injured; safe
Has not harmed self or others
Is no longer exhibiting signs of physical agitation - more on balance; not really high/low
Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status - eating well
Verbalizes an accurate interpretation of the environment - able to do this; verablize what is going on around them and perceptions - when manic their perceptions get fuzzy and when in major depression in dark hole
Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations
Accepts responsibility for own behaviors - cannot blame manic stage; owning emotions and behaviors: imp part treatment - esp in manic stage
Does not manipulate others for gratification of own needs
Interacts appropriately with others
Is able to fall asleep within 30 minutes of retiring
Is able to sleep 6 to 8 hours per night - is the hope; get good amount sleep because sleep deprivation is bad

Answer 45

Criteria for measuring outcomes - The Client: