Class 4: Mental Health Flashcards
Bipolar collaborative goal setting is always…
a balance between depression and hypomania or mania
Bipolar collaborative goal setting + patients must practice
Managing symptoms, making healthy decision, grieving what they can not do
Bipolar collaborative goal setting + nursing interventions are based on…
the degree of mastery that the patient has acquired
Acute phase of mania interventions
-Impose external control to maintain safety
-Provide medication
-Set limits and boundaries
Continuation phase of mania interventions
-Prevention of relapse, provide additional resources
-Facilitate medication adherence
Maintenance phase of mania interventions
-Minimize frequency and severity of relapse
NOC for bipolar disorder
-Decreased risk of harm to self or others
-Realistic self appraisal
-Increased self-care
-Develop healthy coping skills
-Adherence to medications
Realistic self appraisal
Seeing oneself as valuable and having realistic expectations of oneself and others
Develop healthy coping skills
-Developing accurate perception
-Maintain healthy supports
-Problem solving, conflict resolutions, identifying triggers and behaviors leading to relapse
-Ability to develop a plan and seek help
-MAPD
Adherence to medications
-Mood stabilizers
-Other: for the maintenance of good health (i.e. Thyroid medications)
Nursing interventions for bipolar disorder occur in 3 domains
Environmental, physiological, and therapeutic communication
Physiological interventions for bipolar disorder
Self care: Nutrition, sleep, elimination, attire and medication
Bipolar disorder labs
-Therapeutic trough levels for medications
-Kidney function
-BUN, GFR, Urea
-STIs
Therapeutic communication for bipolar disorder
-Strengths-based approach
-Maintains healthy boundaries
Therapeutic communication categories
-Personal Attributes; how you accept and manage the patient’s and your own emotions
-Communication Skills
-An unfolding process – Your ability to pace the therapeutic interaction and identify what is pertinent
The purpose of therapeutic communication
-Build a trusting rapport
-Decrease defensiveness, increase self-esteem
-Manage the consequences of past manic episodes
-Increase the patient’s social and life skills, improve strained relationships
LEAP approach in therapeutic communication is based on the idea that…
Building trusting relationships is key to being able to help people heal
LEAP approach
-L; listen
-E; empathize
-A; agree, identify the points that the nurse and patient can agree on, make it concrete, needs to be reality-based
-P; partner
Characteristics of therapeutic communication
-Honest
-Hopeful; identifying the patient’s strengths
-Resilient; conflict is not taking it personally
-Collaborative
-Mindful
What therapeutic communication sounds like
-Calm voice
-Presenting factual information
-Redirecting the patient to focus on the topic
Health teaching & promotion in bipolar disorder
-S&S of impending episodes (i.e. vegetative shifts)
-Side effects of medication
-Often collaborative; family, patient & healthcare team
Environmental interventions in bipolar disorder (overview)
-Promoting safety through milieu, groups, medication, seclusion & restraints
Milieu therapy
-Decrease stimuli
-Include structured activities ie. time for rest & nutrition
-Monitor relationships
Safety interventions
-Medication is used to promote long-term stability OR immediate safety and control
-Seclusion reduces stimuli, used when there is substantial risk of harm towards others
-Restraints are a last resort
Mood stabilizers
-Lithium
-Carbamazepine
-Valproic acid
-Lamotrigine
-CVL; anticonvulsants that also act as mood stabilizers
Medications + older adults
Increased risk for side effects due to decreased liver and renal functioning
Used in conjunction with mood stabilizers
Antipsychotics and benzodiazepines can be used in conjunction with mood stabilizers to treat symptoms r/t escalation and medical conditions resulting from extended manic episodes
Lithium MOA
-Generally unknown
-Alters the Na+ transport in nerve and muscle cells; explains why the movements of a patient experiencing Lithium toxicity are rigid AND why we monitor for cardiac arrhythmias
Lithium MOA cont’d
-Increases NE uptake and serotonin receptor sensitivity
-Use caution if the patient is also prescribed medications that decrease serotonin reuptake
Lithium dose
-Appropriate dose is calculated based on weight and benefit for the patient
-Initial dose is sub-therapeutic and the dose is slowly increased until a therapeutic level is reached
Lithium: Other information
-Metabolized in the liver & excreted through the kidneys
-Is a salt, so therapeutic levels can be altered by fluid and nutritional intake
Lithium interactions
-ACE I
-Diuretics
-Haldol; increased neurotoxicity without increasing the serum levels of Lithium
-NSAIDS; may decrease the renal clearance of Lithium; toxicity
Lithium side effects
-GI, pancreatitis, lethargy, weight gain, edema
-Tremor, sore throat, fever, rash, alopecia, jaundice
-Birth defects; epstein’s anomaly
Lithium implications for nursing
-Monitor salt and fluid intake, ins & outs
-CBC
-Assess for aMental status, gait, and flu-like symptoms
-Respiratory & suicide assessment
Lithium expected adverse effects
-<0.4-1.0mEq/L
-Hand tremor, polyuria, thirst, nausea, weight gain
-Symptoms start when dosing changes and reside in 2-3 weeks, start on low dose
Lithium early signs of toxicity
-<1.5mEq/L
-Hand tremor, polyuria, thirst, N/V, diarrhea, lethargy, slurred speech & muscle weakness
-Hold medications, get Li+ levels
-Rehydrate PRN
Lithium advanced signs of toxicity
-1.5-2.0mEq/L
-Coarse hand tremor, GI upset, confusion, sedation, incoordination, muscle hyperirritability & electroencephalographic changes
-Hold medications, get Li+ levels
-Rehydrate PRN
-Assess fall risk & MSE
Lithium severe signs of toxicity
-2.0-2.5 mEq/L
-Ataxia, aVision, confusion, large output of dilute urine, hypotension, seizures, clonic movements, pulmonary complications & serious electroencephalographic changes
-Stop medication, IV fluids, administer emetic if pt is alert, maybe hemodialysis
Carbamazepine & valproic acid MOA
-Release and reuptake of serotonin, NE, GABA, dopamine, & glutamate
-Presence of GABA increases the number of receptors for these medications
-Antikindling properties
Antikindling properties
Decrease sensitivity of nerve cells to electrical stimulation occurring in ion channels
Carbamazepine & valproic acid dose
-Based on weight
Carbamazepine & valproic acid: Other information
-Metabolized in the liver, excreted through the kidneys
-Binds to protein
-Easily crosses into the CNS
-Shorter half life; frequent dosing to avoid side effects
Carbamazepine & valproic acid: Interactions
-PO contraceptives & anticoagulants
-TCAs
-Acetaminophen
Carbamazepine & valproic acid side effects
-GI (even if enteracoated), pancreatitis, tremor, lethargy, weight gain
-Alopecia, jaundice (d/t increased liver enzymes and may lead to agranulocytosis)
-Sore throat, fever, rash
-Birth defects (spina bifida)
Adverse drug reaction with carbamazepine & valproic acid: Steven Johnson Syndrome
-Rash similar to hives begin on the person’s trunk
-Open sores appear on mucosal membranes
-The nurse needs to observe for Steven Johnson Syndrome specifically with Lamictal; however, it can happen with any drug (i.e. Tylenol, Ibuprofen). It is like an allergic reaction
Carbamazepine & valproic acid implications for nursing
-Fluids, CBC
-Assess for muscle rigidity & HTN, ins & outs
-Respiratory & suicide assessment
Carbamazepine & valproic acid: Managing toxicity
-Discontinue the medication, notify physician
-Manage S&S
Evaluation of mania
-VSS
-Attend to ADLs, consistent sleep/wake cycle
-The patient and family understand the diagnosis and implications on the well-being
-Med adherence
-Stable employment, healthy relationships
Physical restraint
-Brief period of time, in order to restore calm to the individual
-Does not refer to holding a person to apply a mechanical restraint
Acute control medication (Chemical) restraint
Psychotropic medication as an immediate response to control agitation or aggression
Seclusion
A person is placed in a room that confines them
Mechanical restraint
Either able or unable to ambulate
Physical restraints are..
Less traumatic than other restraint forms in children
In adults, before restraining
-De-escalation
-Chemical restraints used before mechanical
In older adults, restraints
-Consideration for fall risk and co-morbid diagnoses such as arthritis, osteoporosis, skin integrity, and delirium/dementia
Nursing responsibilities + restraints
-Some require immediate informed decisions, most develop over a long period of time and a 5 step framework can be used to make a decision regarding usage of restraints
Nursing responsibilities: Care planning (ADPIE, kind of)
-1.Observe
-2.Detective work
-3.Consider options and make a decision
-4.Implement the plan
-5.Monitor and review the plan
Physical risks of restraints
-Functional decline, incontinence
-Decrease circulation, pressure ulcers, nerve damage
Psychosocial risks of restraints
-R/t feelings
-Withdraw from therapeutic relationship
Restraint risks for staff
-Physical injury, emotional consequences
-Fractured team
-Legal repercussions
Restraint risks for co-patients and visitors
-Physical injury, emotional trauma, confusion
-Negative impact on relationships
-Destabilize current health status
