ECT and Bipolar

Question 1

When is ECT Used

Answer 1

Severe, refractory depression (works well on older patients)
Now for bipolar disorder
MAYBE for schizophrenia

Question 2

Nsg responsibilities for ECT

Answer 2

Teaching
Separate consent! (Issues?)
History & Physical, labs, EKG, CXR
Similar to Same Day Surgery Prep
Monitoring/ Vital Signs
Give anticholinergic – why? Which ones?
Robinul (glycopyrulate)
Atropine?

Question 3

ECT how is it done

Answer 3

Nurse prepares pt
Anesthesiologist gives:
sedative (Brevital or propofol)
muscle relaxant (succinylcholine)
Psychiatrist applies small current
Seizure/convulsion lasts about 60 seconds
Contraindications?
Increased ICP, HTN, EKG, MI, spine
Results…
Schedule

Question 4

ECT s/e

Answer 4

Short term memory loss
Mild temporary confusion
MINIMAL, if any, muscle soreness (mostly none)
Immediately following procedure: Hypertension
Side effects related to anesthesia?

Question 5

Bipolar general info

Answer 5

Characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy.
Delusions or hallucinations possible
Onset may reflect seasonal pattern*
(Differentiate from schizoaffective disorder)

Question 6

Bipolar characteristics

Answer 6

`Manic episode: mood is elevated, expansive, or irritable. Marked impairment in functioning.
Motor activity is excessive and can be frenzied (psychomotor agitation)
Psychotic features may be present
Hypomania: milder degree- no psychotic features – less impairment of functioning
New: Emphasis on activity as well as mood

Question 7

Bipolar vs Major depression dx

Answer 7

The diagnostic picture for depression in Bipolar Disorder is identical as that for Major Depression but must have a history of one or more manic episodes

Question 8

Manic sx of bipolar

Answer 8

Onset before 30
Elevated expansive irritable mood
Loud rapid running rhymind clanging vulgar speech
Wt loss
Grandiose
Delusions
Distratction
Hyperactive
Need for sleep
Inappropriate
FLight of ideas
Begins suddenly Escalates over several days

Question 9

Depressive sx of bipolar

Answer 9

Previous manic episodes
Dysphoric depressive despairing mood
No interest in pleasure
Negative views
Fatigure
Low appetite
Constipation
Insomnia
Low libido
Suicidal preoccupation
May be agitated or have movement retardation

Question 10

Types of bipolar disorder

Answer 10

Bipolar I Disorder – mania/depression
Bipolar II Disorder – hypomania/depression
Cyclothymic Disorder (next slide)
Bipolar Disorder Due to Another Medical Condition
Substance/Medication-Induced Bipolar Disorder
Other Specified or Unspecified Bipolar and Related Disorder

Question 11

Cyclothymic disorder

Answer 11

chronic mood disturbance of at least 2 years,
numerous episodes of hypomania and depressed mood
insufficient severity or duration to meet criteria for Bipolar I or II.
Never without symptoms for more than 2 months

Question 12

Bipolar biological factors

Answer 12

Genetics: concordance rate for monozygotic twins 60 – 80%

Gene expression/repression?

Question 13

Bipolar - Biogenic amines

Answer 13

Depression with decrease in norepinephrine and dopamine
mania with an excess of NE/ dopamine. (Supported by meds)
Electrolytes – (ELECTRICITY)

Question 14

Bipolar and electrolytes

Answer 14

Possible elevated levels of intracellular sodium and calcium

Question 15

Bipolar and neuro anatomy

Answer 15

MRI shows differences from normal brain

Risk factor: history of head trauma

Question 16

Bipolar from s/e of meds

Answer 16

Steroids, amphetamines, antidepressants, high doses of anticonvulsants and narcotics

Question 17

Bipolar and childhood

Answer 17

Many characteristics of ADD/ ADHD overlap with characteristics of childhood bipolar disorder
Overdiagnosed? (episodic MOOD changes, not just hyperactivity)
New in DSM 5: Disruptive Mood Dysregulation Disorder

Question 18

Bipolar and adolescence

Answer 18

Episodes of impulsivity, irritability, loss of control sometimes alternating with periods of withdrawal
Key to diagnosis: A behavioral change that lasts for several weeks.
Frequency: symptoms occur most days in the week
Intensity: severe enough to cause extreme disturbance.
Number: symptoms occur 3 or 4 times a day.
Duration: symptoms occur 4 or more hours per day.

Question 19

Cardinal sx of childhood/adolescent bipolar

Answer 19

Elation
Grandiosity
Flight of ideas/ racing thoughts
Decreased need for sleep
Hypersexuality

Question 20

Mania

Answer 20

Distinct period of abnormally & persistently elevated, expansive or irritable mood
(Can involve psychosis!)

Question 21

Mania sx

Answer 21

Inflated self esteem/grandiosity
 need for sleep
 talkativeness
Flight of ideas*
Distractibility
Excessive involvement in pleasurable activity that has a high potential for painful consequences (impulse control – spending, gambling, sex, drugs, no boundaries)
(Other findings: hyperactivity, impaired judgment, clang associations, pressured speech, religiosity)

Question 22

DIfferent types of mania

Answer 22

Hypomania
Acute Mania – labile mood, delusions
Delirious Mania – severe clouding of consciousness

Question 23

Delusions

Answer 23

Grandeur
Persecution/ paranoia
These are psychotic symptoms
What should you do?
Acknowledge feeling behind the delusion
Do not “buy into” the delusion

Question 24

Bipolar nsg dx

Answer 24

Life-threatening first, then remember Maslow’s hierarchy
Risk for injury or suicide
Risk for violence: self- or other- directed
Altered nutrition
Sleep pattern disturbance
Impaired social interaction
Altered thought processes
Sensory-perceptual alteration

Question 25

Bipolar nsg intervention

Answer 25

*Administer medication
Observe for med s.e.
Safety concerns – “show of strength”
oFirm, calm approach
Short explanations
Be neutral/no power struggles
Listen to legitimate complaints
 environmental stimuli
Structure activities
Offer hi calorie food & fluids
Be consistent – one primary nurse
Do not join in joking – remain apart, objective
Reinforce limits, maintain boundaries (manipulation, intrusiveness)
Redirect acting out
Encourage rest
1:1 supervision – when?
What about groups?
Monitor interaction with peers
Supervise grooming – why?
Gross motor activities
NO highly competitive games
Art/ writing
Seclusion/Restraints - when?

Question 26

Bipolar therapies

Answer 26

Medicate first! Which meds???
Cognitive
Behavioral
Family
The Recovery Model
(Dialectical Behavioral Therapy – DBT – Distress Tolerance)

Question 27

Bipolar relapse prevention

Answer 27

should be part of teaching process
What should you teach?
Changes in sleep patterns?
Changes in eating patterns?
Changes in mood
Medication compliance !