Exam 2 Flashcards
Bipolar I disorder
- most severe bipolar; shifts in mood, energy, and ability to function
- at least one Mania episode followed by hypomanic or major depressive episode; chronic interpersonal or occupational difficulties exist even during remission
Bipolar I comorbidities (5)
-75% also have anxiety (panic attacks, social anxiety, specific phobias)
->50% have AUD (probably due to self-medication attempts).
-ADHD, disruptive,impulse-control, conduct disorders likely
-higher rates of migraines
-metabolic syndrome -> heart disease, stroke, diabetes
Bipolar II (3)
a.at least one hypomanic episode and at least one major depressive episode
b. psychosis possible in depressive episodes but hypomania has no psychosis
c. assess anyone with depression for hypomania due to bipolar’s increased mortality and morbidity
Comorbidities of Bipolar II (3)
- 75% have anxiety (usually prior to episodes)
- 14% have eating disorders (binge-eating) which is associated with depressive side
-37% have SUD which is associated with hypomanic side
Cyclothymic Disorder (2)
-episodes do not meet criteria of major depressive or bipolar II, but symptoms disturbing enough to cause social and occupational impairment; 15-50% progress to bipolar
-symptoms of hypomania alternate with symptoms of mild to moderate depression for at least 2 yrs in adults and 1 yr in children
How does hypomania differ in clyclothymic vs bipolar
-tend to have irritable hypomanic episodes (children have irritability and sleep disturbance)
Comorbidities of Cyclothymic (3)
SUD, Sleep disorders, ADHD (for children)
How does mood look in bipolar disorder? (3)
-Unstable euphoria that could quickly change to irritation and anger
-Boundless enthusiasm, friendliness, self-confidence
-More time depressed vs manic
How does behavior look in bipolar? (5)
o Big appetites for social, spending, activities, sex
o Makes grand plans and stays busy all hours of day and night
o Easily distracted
o May manipulate and exploit vulnerabilities of others
o May skip sleep for days -> worsens mania and physical exhaustion
Pressured speech
fast (rapid to frenetic) with inappropriate sense of urgency; often loud and incoherent; individual may dominate conversation
Circumstantial speech
addition of unnecessary details when communicating; person eventually gets to the point
Tangential speech:
similar to circumstantial speech, but they forget the point but often a common word connects sentences to each other (awareness of losing the point and less tangential speech indicate less thought disturbance)
Name the Thought Process:
Ex. I had to do my laundry that day because it was Saturday. On Saturday, I always watch Ninja Turtles on television. Have you seen those 60-inch televisions? Giants. I used to think of giants as I fell asleep, and I thought that sleep activated them.
Tangenital speech
Loose associations
disordered way of processing information; thoughts are only loosely connected to each other in person’s conversation
Name the thought process
Ex. The sky’s the limit now that I have money. I took a flight, you know, from Kennedy. Drinking beer is a belly full of bags
Loose associations
Flight of ideas
continuous flow of rapid, verbose, circumstantial speech with abrupt changes from topic to topic
Speech may be disorganized and incoherent; often uses associations, plays on words, jokes, teasing
Name the thought process:
How are you doing, kid, no kidding around, I’m going home … home sweet home … home is where the heart is, the heart of the matter is I want out and that ain’t hay … hey, Doc … get me out of this place.
Flight of ideas
Clang associations (and when it happens)
stringing together of words because of their rhyming sounds, w/o regard to meaning
may happen after flight of ideas as mania escalates
Name the thought process:
Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote.
Clang associations
Grandiose delusions
highly inflated self-regard; apparent in both ideas expressed and person’s behavior (religious, science fiction, supernatural themes are common)
ex. Brianna believes she is a famous playwriter
Persecutory delusions
common in BPD and Schizo; Believing that one is being singled out for harm or prevented from making progress by others
Ex. God or FBI is watching
Who experiences cognitive deficits in BPD?
-Some people have mild cognitive deficits like those seen in schizophrenia (More likely with BPD I vs BPD II)
What are the clinical implications of cognitive dysfunction bipolar disorder? (3)
-Impaired overall function
-correlated w/ greater # of manic episodes, history of psychosis, chronicity of illness, and poor functional outcome.
-Medication selection should consider not only the efficacy of the drug but also the cognitive impact
on patient
Why is early diagnosis and treatment crucial for BPD? (3)
to prevent illness progression, cognitive deficits, and poor outcome.
What is the nursing diagnosis and outcome for the following signs and symptoms:
Auditory hallucinations, agitation, impulsivity, poor judgment
Diagnosis: risk for injury
Outcome: No injury: Delusional content reduced or eliminated, hallucinations reduced or eliminated, thinking is objectively clearer, redirectable
What is the nursing diagnosis and outcome for the following signs and symptoms:
Alteration in cognitive functioning, impulsiveness, sexual advances, threatening violence, agitation
Diagnosis: risk for violence
Outcome: No aggressive behavior: Refrains from harming others, controls impulses, respects others’ space
What is the nursing diagnosis and outcome for the following signs and symptoms:
Agitation, anxiety, confusion, perceptual disorders, restlessness
Diagnosis: sleep deprivation
Outcome: Adequate sleep: Sleeps 4–6 h a night, reports feeling refreshed after sleep
What is the nursing diagnosis and outcome for the following signs and symptoms:
Deficits in verbal communication, working memory, executive functioning, reasoning, problem solving
Diagnosis: Impaired cognition; Impaired concentration
Outcome: Improved cognition: Demonstrates increase in concentration, improved memory, and hallucinations are absent
What is the nursing diagnosis and outcome for the following signs and symptoms:
Minimal calorie intake, poor hygiene, clothing unclean
Diagnosis: self-care deficit
Outcome: Able to self-care: Completes meals, tends to hygiene, clean and appropriate clothing
What is the nursing diagnosis and outcome for the following signs and symptoms:
Dysfunctional interaction with others, pressured speech, flight of ideas, annoyance or taunting of others, loud and crass speech
Diagnosis: impaired socialization
Outcome: Improved socialization: Initiates and maintains goal-directed and mutually satisfying verbal exchanges
Goal for acute interventions of BPD
Goals: symptom reduction and achieving remission
Goal for maintenance interventions of BPD
Goals: prevent future exacerbation of mania or hypomania through education, support, problem-solving
6 patient outcome goals for acute BPD
i. well hydration
ii. stable cardiac status
iii. tissue integrity
iv. Sufficient sleep and rest
v. Self-control with aid of staff or medication
vi. No self-harm attempts
4 patient outcome goals for maintenance BPD
i. identify risk factors for development of acute mania
ii. Attend daily group therapy
iii. resume function in community
iv. Identify new coping skills
What planning happens in maintenance BPD? (2)
a. May need medication for a lifetime
b. Often have to face the hardships that resulted from acute phase, so patients need support to recover from illness and repair their lives
5 barriers to BPD treatment
- individuals often ambivalent (avg. 10 yrs before getting treatment)
- lack of adherence to mood stabilizers often leads to relapse.
- self-medicating w/ alcohol complicates things and delays treatment
- patients may minimize or deny consequences of their behavior
- patient may be reluctant to give up the mania or hypomania
When is hospitalization indicated for BPD depressive episodes?
when suicidal ideation, psychosis, catatonia
What is purpose of hospitalization in acute BPD? (3)
a. provide safety in BPD I mania via imposing external control and stabilizing with medication
b. limits set in firm, nonthreatening, and neutral manner to prevent escalation of behavior and safe boundaries
c. Ensure structure, clear expectations, needs are met (nutrition, sleep, hygiene, elimination)
What is key to BPD maintenance? (4)
medication adherence, regular sleep, healthy nutrition, community support
Why are outpatient clinics and psychiatric home care useful in BPD maintenance? (4)
Provide structure, medication management, decrease in social isolation, offer channel for time and energy
Three areas of health teaching for BPD
-stress importance of regular sleep patterns (poor sleep can lead to exhaustion and manic behavior), meals, exercise, coping strategies
-aim teaching at weight reduction and management b-c many BPD medicine have metabolic syndrome as an adverse effect
-to improve treatment adherence, follow collaborative-care model and use self-managed responsibility
What can restraints never be for?
punishment or staff convenience
What is usually the immediate treatment in acute phase of BPD?
antipsychotic for BPD
What is the rationale for the following intervention in BPD?
Use firm and calm approach: “John, come with me. Eat this sandwich.”
Structure and control are provided for a patient who is out of control. Believing that someone is in control may improve feelings of security.
What is the rationale for the following intervention in BPD?
Use short and concise explanations or statements.
Structure and control are provided for a patient who is out of control. Believing that someone is in control may improve feelings of security.
What is the rationale for the following intervention in BPD?
Be consistent in approach and expectations.
Consistent limits and expectations minimize potential for patient’s manipulation of staff.
What is the rationale for the following intervention in BPD?
Identify expectations in simple, concrete terms with consequences.
Example: “John, do not yell at or hit Peter. If you cannot control yourself, we will help you.” Or “The seclusion room will help you feel less out of control and prevent harm to yourself and others.”
Clear expectations help the patient experience outside controls as well as understand reasons for medication, seclusion, or restraints (if he or she is not able to control behaviors).
What is the rationale for the following intervention in BPD?
Hear and act on legitimate complaints.
Underlying feelings of helplessness are reduced, and acting-out behaviors are minimized.
What is the rationale for the following intervention in BPD?
Firmly redirect energy into more appropriate and constructive channels.
Distractibility is the most effective tool with the patient experiencing mania.
What is the rationale for the following intervention in BPD?
Maintain low level of stimuli in patient’s environment (e.g., away from bright lights, loud noises, and people).
Escalation of anxiety can be decreased.
What is the rationale for the following intervention in BPD?
Provide structured solitary activities with nurse or aide.
Structure provides security and focus.
What is the rationale for the following intervention in BPD?
Provide frequent high-calorie fluids.
Serious nutritional deficiencies and dehydration are addressed.
What is the rationale for the following intervention in BPD?
Redirect aggressive behavior.
Physical exercise can decrease tension and provide focus.
What is the rationale for the following intervention in BPD?
In acute mania, use as needed medication, seclusion, and/or restraint to minimize physical harm.
Exhaustion can result from dehydration, lack of sleep, and constant physical activity.
What is the rationale for the following intervention in BPD?
Encourage frequent rest periods during the day.
Lack of sleep can lead to exhaustion and increase mania.
What is the rationale for the following intervention in Bipolar Disorder?
Keep patient in areas of low stimulation.
Relaxation is promoted, and manic behavior is minimized.
What is used for severe agitation in Bipolar Disorder? What about less severe agitation?
Severe: Lithium OR divalproex plus an SGA (olanzapine, risperidone)
Less severe: one of the above
Which benzodiazepines are used in Bipolar Disorder agitation? What is their purpose? Why are they short-term
clonazepam and lorazepam—high potency may be used
Purpose: calm agitation, reduce insomnia, aggression, and panic
-short term only for mania b-c dependency concerns)
Purpose of lithium in Bipolar Disorder
acute mania and maintenance to prevent relapse
What to note about onset of Lithium? (2)
10-21 days (slow, so often supplemented with SGA, anticonvulsants and antianxiety drugs)
-weight gain may happen initially esp for females
What to note about taking lithium? (4)
-Not addictive but taper dose to reduce relapse of mania though)
- maintain sodium and fluid levels( 1500–3000 mL/day or six 12-oz glasses of fluid)
-take with meals to reduce stomach irritation)
-narrow therapeutic range so check levels regularly
Signs of <1.5 mEq/L Lithium toxicity (8)
-N/V/D
-thirst
-polyuria (producing too much urine)
-lethargy, sedation
- fine hand tremor
- Renal toxicity
- goiter
- hypothyroidism
Interventions of <1.5 mEq/L Lithium toxicity (2)
Doses should be kept low.
assess Kidney function and thyroid levels before treatment and then on an annual basis.
Interventions of 1.5-2.0 mEq/L early Lithium toxicity (2)
-hold medication
-measure blood lithium levels
-reevaluate dosage
Signs of 1.5-2.0 mEq/L early Lithium toxicity (7)
-GI upset
- coarse hand tremor
- confusion
- hyperirritability of muscles,
- EEG changes
-sedation
-incoordination
Signs 2.0–2.5 mEq/L advanced Lithium toxicity (10)
Ataxia
giddiness
serious EEG changes
blurred vision
clonic or seizure movements
large output of dilute urine, stupor
severe hypotension
coma
Death is usually secondary to pulmonary complications.
Interventions of 2.0–2.5 mEq/L advanced Lithium toxicity (3)
-hospitalization
-hold drug and haste excretion
- Whole bowel irrigation may be done to prevent further absorption
Signs of >2.5 mEq/L severe Lithium toxicity (3)
convulsions, oliguria (none or small amount of urine), death
Interventions of >2.5 mEq/L severe Lithium toxicity
-same as others plus hemodialysis
5 precautions for lithium
avoid diuretics, NSAIDS, if N/V/D present
7 Contraindications for Lithium
- children under 12
pregnant and breast-feeding
brain damage
Cardiovascular,renal, thyroid diseases
myasthenia gravis
When are anticonvulants used in BPD? (5)
o continuously cycling patients
o no family history of BPD
o to diminish impulsive and aggressive behavior in nonpsychotic pts
o useful when alcohol or benzodiazepine withdrawal
o useful to control mania (within 2 wks) and depression (within 3 wks)
Valporate usage
- FDA approved anticonvulsant for acute mania and preventing future manic episodes; black box warning though for teratogenicity
o Divalproex and valproic acid
Why is Carbamazepine a 2nd line treatment for BPD?
anticonvulsant; 2nd line due to black box for stevens-Johnson syndrome and toxic epidermal necrolysis (greatest for asian descent
6 common Adverse effects of Valporate
weakness, somnolence, indigestion, diarrhea, dizziness, vomiting
Lamotrigine
o FDA approved for BPD maintenance therapy (18 and up)
Unique and most serious side effects of Lamtrigine
Unique side effects: rash
Most serious side effects (greater risk in children 2-16 and with valproate coadministration): toxic epidermal necrolysis, Stevens-Johnson syndrome
Role of SGAs in BPD treatment
-many approved for acute mania
-sedative properties help with insomnia, anxiety, agitation; also some mood-stabilizing properties
7 SGAs used in BPD
Olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, asenapine, cariprazine
What is treatment for Bipolar depression? Why should you not treat with just antidepressant
treatment with only antidepressant increases risk of manic episode, so combine with a mood stabilizer
o SGAs (lurasidone, quetiapine, cariprazine)
o Symbyax (combo of SGA olanzapine and SSRI fluoxetine)
6 Risk factors for suicide
-previous attempts
- SUD
- psychiatric conditions
- family hx of suicide
-hx of trauma
- suicide survivor (close to someone who committed suicide
2 Protective factors for suicide
-access to mental health
-strong social life
Verbal and nonverbal cues of suicide (2)
- Clues may be in overt/open or concealed/covert statements to someone patient trusts like nurse)
- be wary of sudden bursts in energy, giving away possessions
5 Hard methods of suicide
gun, hanging, poison, car crash, jumping
3 soft methods of suicide
pills, gases, cutting wrists
6 specific questions to ask about suicide
- Have you ever felt that life was not worth living?
- Have you been thinking about death recently?
- Do you ever think about suicide?
- Have you ever attempted suicide?
- Do you have a plan for ending your life?
- If so, what is your plan for suicide?
What are four suicide precautions in the hospital?
- One-to-one observation, 24hrs
- Record mood, verbatim statements, behavior (esp hands)
- Remove glass, silverware, “sharps”, strangulation risks
- Observe patient swallowing medication
What is a patient safety plan?
six step written plan identifying patient’s warning signs, coping strategies, social settings, reasons to live, people who can distract; it also includes who patient should contact for help
Persistent Depressive disorder (2)
chronic low-level depression most of the day for the majority of days AND at least two of the following: increased/decreased appetite, insomnia/hypersomnia, low energy, poor self-esteem, difficulty thinking, hopelessness
-feelings last 2 yrs in adults, 1 yr in children and adolescents; often early onset
-not severe enough for hospitalization
Major depressive disorder (3)
-persistent depression lasting a minimum of 2 weeks (may last 5-6 months or even > 2 yrs)
-Primary symptoms: depressed mood, loss of interest/pleasure
-Secondary symptoms: significant weight changes, insomnia or hypersomnia, psychomotor retardation or agitation, fatigue, feeling worthless, thinking problems, thoughts on death (suicidal ideation, hx of suicide, suicide plan)
Bereavement exclusion and 3 rationales
in the past clinicians would not diagnose someone with depression in 1st 2 months after significant loss;
Rationale:
* Normal mourning may be labeled pathological
* Psychiatric diagnosis can result in lifelong label
*Unnecessary medications may be prescribed
Seasonal Affective Disorder
major depressive disorder with seasonal pattern; typically depression in fall and winter and remission in spring
-at least two seasonal depressive episodes within 2 yrs
5 Key findings of depression assessment
depressed mood, anhedonia (inability to fell pleasure), anxiety; difficulty recognizing their strengths, comorbid chronic pain
5 factors that increase risk of comorbid suicidality and depression
hopelessness, SUD, recent loss or separation, hx of past attempts, and acute suicidal ideation
What to note about depression in children and adolescents? (2)
Children and Adolescents (often overlooked)
-Core symptoms: sadness and loss of pleasure but may look clinically different from adult aka crying, withdrawal, SUD, sexual promiscuity
What to note about depression and older adults (3)
Older Adults (often overlooked)
-difficult to determine if fatigue, pain, weakness result of illness or depression
-Use Geriatric Depression Scale (yes or no questions, reliable and valid)
Appearance in depression (3)
neglected personal hygiene, grooming, dressing; lack of eye contact; slumped posture
Behavior in depression (5)
-Anergia (abnormal lack of energy)
-psychomotor retardation (fixed gaze, slow movements, lack of facial expressions, even incontinence)
-some have psychomotor agitation (pacing, tension-relieving behaviors)
-Vegetative signs of depression (alteration in physical life and growth activities) including appetite changes, bowel changes, sleep disturbance
-low libido or impotence
Feelings and Emotions in depression (5)
specific and can change quickly
- worthlessness (inadequate to unrealistic negative self-eval),
- guilt (ruminate over failures),
- helplessness (inability to problem solve)
- hopelessness (^ suicidality),
- anger and irritability (active byproducts)
Affect vs mood in depression
Mood is general emotional state (often depressed)
Affect is outward emotional state; may be congruent or incongruent with mood (often constricted, blunt, or flat)
Speech in depression
slow and softy; may also be monotone and lack spontaneity
Thought Processes in depression
poverty of thought (slow thinking), responses slow or absent, may even be mute in severe depression
Thought content and perceptions in depression
psychosis (delusions and hallucinations) may be present and ^ suicidality; psychosis may be mood congruent or incongruent
Cognitive Changes and judgement in depression
impaired concentration ( attention, short-term and working memory, verbal and nonverbal learning) which may linger after treatment
-poor judgment may lead to indecisiveness
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Previous suicidal attempts, putting affairs in order, giving away prized possessions, suicidal ideation (has plan, ability to carry it out), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness
Diagnosis: risk for suicide
Outcomes:Decreased suicide risk: Expresses feelings, verbalizes suicidal ideas, refrains from suicide attempts, plans for the future
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope
Diagnosis: Impaired coping
Outcomes: Improved coping: Identifies ineffective and effective coping, uses support system, uses new coping strategies, engages in personal actions to manage stressors effectively
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Dull/sad affect, no eye contact, preoccupation with own thoughts, seeks to be alone, uncommunicative, withdrawn, feels rejected and not good enough
Diagnosis: social isolation
Outcomes: Decreased social isolation: Attends group meetings, interacts spontaneously with others, talks with the nurse in 1:1, demonstrates interest in engaging with others
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Questioning meaning of life and existence, anger toward greater power, feeling abandoned, perceived suffering
Diagnosis: spiritual distress
Outcomes: Decreased spiritual distress: Shares feelings of connectedness with self, others, and a higher power, identifies meaning and purpose in life
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Exaggerates negative feedback about self, excessive seeking of reassurance, guilt, indecisive and nonassertive behavior, poor eye contact, shame
Diagnosis: chronic low self-esteem
Outcomes: Improved self-esteem: Identifies strengths, verbalizes self-acceptance, participates in groups, expresses a personal judgment of self-worth
Recovery model in depression management
used with partnerships with patient and healthcare professionals so patients exercise control over treatment to reach their individual goals
What does inclusion of family in health teaching for depression accomplish? (3)
increase their understanding and acceptance of patient, increase patient’s adherence to aftercare facilities, and improves patient adjustment after discharge
Main treatment of depression
combo of psychotherapy and antidepressant
What may be used if someone acutely suicidal since antidepressants have slow onset?
Electroconvulsive therapy
Goals for acute and maintenance MDD treatment
Acute: reduction of symptoms and restoration of psychosocial and work function
Maintenance: prevention of relapse
What do all antidepressants have in common? (5)
- All have similar efficacy( in improving self-concept, social withdrawal, vegetative signs, activity level)
- May induce psychotic or manic episode in those with schizophrenia or bipolar disorder
- All have delayed response (3 month trials)–1-3 wks for improvement to be seen, maintain for 6-9 months after remission of symptoms
-discontinuation syndrome
- black box warning for suicidal thoughts and behaviors
What determines selection of antidepressant? (5)
safety profiles, side effects, ease of administration, hx of past response, genotyping ( when available)
What symptoms do antidepressants target? (8)
sleep, appetite, fatigue, libido, psychomotor issues, diurnal variations in mood (bad in morning), impaired concentration, anhedonism
4 things to note about SSRIs and depression
- 1st line of treatment for major depression (w/ anxiety and psychomotor agitation as well)
-Some SSRIs activate and others sedate; choice depends on patient symptoms
-Risk of lethal overdose minimized with SSRIs
-low side-effect profile and no anticholinergic effects
Most toxic effect of SSRIs
serotonin syndrome (rare and life-threatening, increased risk when coadministration with MAOI or lithium; wait 2-5 wks between the two
10 Symptoms of Serotonin syndrome
- Hyperactivity or restlessness
- Tachycardia → cardiovascular shock
- Fever → hyperpyrexia
- Elevated BP
- Delirium
- Irrationality, mood swings, hostility
- Seizures → status epilepticus
- Myoclonus (jerk), incoordination, rigidity
- Abdominal pain, diarrhea, bloating
- Apnea → death
