Week 2 - Bipolar Flashcards
Bipolar I disorder
-Most ________ form
-Highest mortality rate of the three
-At least 1 manic episode
Bipolar II disorder
-At least 1 ________ episode
-At least 1 major depressive episode
Cyclothymic disorder
-Altermate with symptoms of mild to moderate depression for at least __ years (adults)
-Rapid cycling possible
Bipolar I disorder
-Most severe form
-Highest mortality rate of the three
-At least 1 manic episode
Bipolar II disorder
-At least 1 hypomanic episode
-At least 1 major depressive episode
Cyclothymic disorder
-Altermate with symptoms of mild to moderate depression for at least 2 years (adults)
-Rapid cycling possible
Hypomania
-A ___________________ mania
-Tends to be euphoric and often increases functioning
-Usually accompanied by excessive activity and energy
Bipolar II disorder must have at least 1 hypomanic episode
Hypomania
-A low-level and less dramatic mania
-Tends to be euphoric and often increases functioning
-Usually accompanied by excessive activity and energy
Bipolar II disorder must have at least 1 hypomanic episode
Other Bipolar Disorders
Substance/medication-induced bipolar and related disorder
Bipolar and related disorder due to another medical condition
Substance/medication-induced bipolar and related disorder
Bipolar and related disorder due to another medical condition
Just as you arrive on your unit, you learn that a new patient is soon to arrive. You learn that it’s the woman you saw downstairs. Based on what you have seen of this patient already and what she has said, what symptoms might you expect to see when she arrives?
Catatonia
Expression of racing thoughts
Low self esteem and tearfulness
Lack of interest in her environment
Expression of racing thoughts
Bipolar - Epidemiology
Lifetime risk for overall: nearly 4%
Men & women: nearly ______ rates
Severe postpartum psychosis = ____ greater risk
Children & adolescents
>Disruptive mood dysregulation disorder
Cyclothymic disorder
-Adolescence/early adulthood
-50% risk of subsequent bipolar I or II
Lifetime risk for overall: nearly 4%
Men & women: nearly equal rates
Severe postpartum psychosis = 4X greater risk
Children & adolescents
>Disruptive mood dysregulation disorder
Cyclothymic disorder
-Adolescence/early adulthood
-50% risk of subsequent bipolar I or II
Comorbidity: Bipolar I Disorder
Nearly all anxiety disorders are associated with bipolar I, affecting about 75% with this disorder
>Panic attacks, social anxiety disorder, phobias
Other disorders may complicate clinical presentation/management of bipolar I
>Attention-deficit/hyperactivity
>All disruptive, impulse-control or conduct disorders
Substance use disorder present in over half of those with bipolar I
Serious medical conditions
Nearly all anxiety disorders are associated with bipolar I, affecting about 75% with this disorder
>Panic attacks, social anxiety disorder, phobias
Other disorders may complicate clinical presentation/management of bipolar I
>Attention-deficit/hyperactivity
>All disruptive, impulse-control or conduct disorders
Substance use disorder present in over half of those with bipolar I
Serious medical conditions
Comorbidity: Bipolar II Disorder
___% of individuals with bipolar II have comorbid anxiety disorders
Eating disorders, particularly binge-eating disorder
Substance use disorders
75
Comorbidity: Cyclothymic Disorder
Substance use disorders common
Sleep disorders
Attention-deficit/hyperactivity disorder more common among children with cyclothymic disorder than with other mental health conditions
Substance use disorders common
Sleep disorders
Attention-deficit/hyperactivity disorder more common among children with cyclothymic disorder than with other mental health conditions
bipolar risk factors
Biological factors
-Genetic
-Neurobiological
-Neuroendocrine
-Peripheral inflammation
Environmental factors
Cognitive factors
Biological factors
-Genetic
-Neurobiological
-Neuroendocrine
-Peripheral inflammation
Environmental factors
Cognitive factors
Bipolar Thought processes and speech patterns
-Pressured speech
-Circumstantial speech
-Tangential speech
-Loose associations
-Flight of ideas
-Clang associations
Thought content
-Grandiose delusions
-Persecutory delusions
Bipolar Thought processes and speech patterns
-Pressured speech
-Circumstantial speech
-Tangential speech
-Loose associations
-Flight of ideas
-Clang associations
Thought content
-Grandiose delusions
-Persecutory delusions
Cognitive dysfunction: clinical implications
-Affects overall function
Cognitive deficits correlate with:
-manic episodes
-history of psychosis
-chronicity of illness
-poor functional outcome
-Affects overall function
Cognitive deficits correlate with:
-manic episodes
-history of psychosis
-chronicity of illness
-poor functional outcome
Ms. A keeps mentioning she’s writing a prize-winning novel about her life and is pretty sure a famous actor will want to play the role of herself. What type of symptom is she displaying?
Flight of ideas
Tangential speech
Loose associations
Grandiose delusion
Grandiose delusion
Self-Assessment
Discomfort is common
Enhance your professional ability by—
-Sharing/acknowledging uncomfortable feelings with staff or nursing faculty member
-Collaborating with staff and nursing faculty member
-Sharing your experience with peers in post conference
Discomfort is common
Enhance your professional ability by—
-Sharing/acknowledging uncomfortable feelings with staff or nursing faculty member
-Collaborating with staff and nursing faculty member
-Sharing your experience with peers in post conference
The team meets with Ms. A to identify outcomes and develop a care plan for her. She asks why safety is such a big concern. Why indeed?
She’s at risk for exhaustion
She’s at risk for dehydration
She’s having difficulty perceiving reality
All of the above
All of the above
Bipolar assessment
Danger to self or others
Need for protection from uninhibited behaviors
Need for hospitalization
Medical status
Coexisting medical conditions
Family’s understanding
Danger to self or others
Need for protection from uninhibited behaviors
Need for hospitalization
Medical status
Coexisting medical conditions
Family’s understanding
Bipolar nursing diagnosis
Risk for injury
Risk for violence
Sleep deprivation
Impaired cognition
Impaired concentration
Self-care deficit (feeding, bathing, dressing)
Impaired socialization
Risk for injury
Risk for violence
Sleep deprivation
Impaired cognition
Impaired concentration
Self-care deficit (feeding, bathing, dressing)
Impaired socialization
Outcomes
Acute phase
-Prevent injury
-Maintain stable cardiac status
-Maintain hydration/tissue integrity
-Get sufficient sleep & rest
-Demonstrate thought self-control
-Attempt no self-harm
Acute phase
-Prevent injury
-Maintain stable cardiac status
-Maintain hydration/tissue integrity
-Get sufficient sleep & rest
-Demonstrate thought self-control
-Attempt no self-harm
Depressive episodes
-Hospitalization for suicidal, psychotic, or catatonic signs
-Medication concerns about bringing on a manic phase
Manic episodes
-Hospitalization for acute mania (bipolar I disorder)
-Communicating challenges and strategies
Depressive episodes
-Hospitalization for suicidal, psychotic, or catatonic signs
-Medication concerns about bringing on a manic phase
Manic episodes
-Hospitalization for acute mania (bipolar I disorder)
-Communicating challenges and strategies
Implementation: Acute Mania (Hospitalization)
Provides safety for a person experiencing acute mania
Imposes external control on destructive behaviors
Provides medication for stabilization
Provides safety for a person experiencing acute mania
Imposes external control on destructive behaviors
Provides medication for stabilization
Communication techniques
Use firm and calm approach
>Provides structure & control
Use short, concise explanations
>Minimizes potential for manipulative behaviors
Identify expectations in simple, concrete terms
>Offers safety as patient experiences outside controls while understanding reasons for treatment choices
Use firm and calm approach
>Provides structure & control
Use short, concise explanations
>Minimizes potential for manipulative behaviors
Identify expectations in simple, concrete terms
>Offers safety as patient experiences outside controls while understanding reasons for treatment choices
Communication techniques continued
Hear and act on legitimate complaints
>Reduces helpless feelings; minimizes acting out
Firmly redirect energy into more appropriate channels
>Distractibility is the most effective tool for a patient experiencing mania
Hear and act on legitimate complaints
>Reduces helpless feelings; minimizes acting out
Firmly redirect energy into more appropriate channels
>Distractibility is the most effective tool for a patient experiencing mania
Maintenence
Focus on preventing ________
________ adherence is essential
Regular and adequate ________
Healthy ________
Community support
Engagement with community resources
Use of outpatient facilities
Focus on preventing relapse
Medication adherence is essential
Regular and adequate sleep
Healthy nutrition
Community support
Engagement with community resources
Use of outpatient facilities
Health teaching/promotion
Information on bipolar illness
>Understanding its recurrent nature
Warning signs of impending episodes
Importance of regularity
-Sleep patterns
-Meals
-Exercise
-Other activities
Group and individual therapy
Information on bipolar illness
>Understanding its recurrent nature
Warning signs of impending episodes
Importance of regularity
-Sleep patterns
-Meals
-Exercise
-Other activities
Group and individual therapy
Biological: Pharmacotherapy
Two main foci
–Agitation
–Mood stabilization
Two main foci
–Agitation
–Mood stabilization
Lithium carbonate
Indications
Therapeutic levels
Toxic levels
Maintenance therapy
Patient and Family Teaching
Contraindications
Sherpath AIanswered:
Indications: Treatment of manic episodes in bipolar disorder, maintenance therapy to prevent manic episodes.
Therapeutic levels: 0.6 - 1.2 mEq/L
Toxic levels: Generally above 1.5 mEq/L
Maintenance therapy: Lithium is indicated for long-term maintenance treatment to prevent relapse of manic or depressive episodes in bipolar disorder.
Patient and Family Teaching: Advise maintaining normal salt and fluid intake, monitoring for side effects like tremor or GI upset, getting regular blood tests, and compliance with medication.
Contraindications: Severe renal impairment, untreated cardiovascular disease, dehydration, sodium depletion, brain or skull injury.
Anticonvulsants
Valproate (Depakote)
Carbamazepine (Equetro)
Lamotrigine (Lamictal)
Anticonvulsants
Valproate (Depakote)
Carbamazepine (Equetro)
Lamotrigine (Lamictal)
Second-Generation Antipsychotics
Examples:
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Asenapine (Saphris)
Cariprazine (Vraylar)
Examples:
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Asenapine (Saphris)
Cariprazine (Vraylar)
Integrative Therapy
Omega-3 Fatty Acids: Cod liver oil, Fish oil
No evidence to support use in treating mania
Strong evidence they may improve depressive symptoms
Omega-3 Fatty Acids: Cod liver oil, Fish oil
No evidence to support use in treating mania
Strong evidence they may improve depressive symptoms
Electroconvulsive Therapy (ECT)
-Passes an electric current through the brain
-Most commonly used with patients who have bipolar disorder with severe levels of __________
Repetitive Transcranial Magnetic Stimulation (rTMS)
-FDA approval for ________________ major depressive disorder, but has not been approved for bipolar depression
Electroconvulsive Therapy (ECT)
-Passes an electric current through the brain
-Most commonly used with patients who have bipolar disorder with severe levels of depression
Repetitive Transcranial Magnetic Stimulation (rTMS)
-FDA approval for treatment-resistant major depressive disorder, but has not been approved for bipolar depression
Cognitive-Behavioral Therapy (CBT)
-Usually an adjunct to pharmacotherapy
Interpersonal and Social Rhythm Therapy
-Aims to regulate social routines and stabilize interpersonal relationships to improve depression and prevent relapse
Family-Focused Therapy
-Helps improve communication among family members
Cognitive-Behavioral Therapy (CBT)
-Usually an adjunct to pharmacotherapy
Interpersonal and Social Rhythm Therapy
-Aims to regulate social routines and stabilize interpersonal relationships to improve depression and prevent relapse
Family-Focused Therapy
-Helps improve communication among family members
Which anticonvulsant medication might be prescribed for a patient with bipolar disorder?
Divalproex sodium (Depakote)
Clonazepam (Klonopin)
Olanzapine (Zyprexa)
Lithium (Lithobid)
Divalproex sodium (Depakote)
Which condition is a sign of advanced lithium toxicity?
Sedation
Confusion
Mild thirst
Blurred vision
Blurred vision
Blurred vision is a sign of advanced lithium toxicity that is seen when the blood plasma level of lithium is 2 to 2.5 mEq/L. Sedation and confusion are early signs of lithium toxicity that are seen when the blood plasma level of lithium is 1.5 to 2 mEq/L. Mild thirst is not associated with signs of advanced toxicity.
Which is the usual age of onset for cyclothymic disorders?
Childhood
Adolescence
Middle adulthood
Late adulthood
Adolescence
Which term applies to the patient’s behavior when displaying a period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extremely goal-directed activity?
Mania
Hypomania
Flight of ideas
Loose associations
Mania
Which outcome noted in the plan of care is the most important for a patient in the manic phase of bipolar I disorder?
Decreasing food intake
Increasing physical activity
Sleeping for 8 to 10 hours a night
Maintaining a stable cardiac status
Maintaining a stable cardiac status
During the manic phase of bipolar I disorder, the most important outcome for the patient is to maintain a stable cardiac status because cardiac problems can be life threatening. Other important outcomes include increasing food and fluid intake, ensuring at least 4 to 6 hours of sleep a night, and decreasing physical activity.
A nurse caring for a patient with mania observes that the patient has persistent gastrointestinal upset. The nurse believes that the patient is showing advanced signs of lithium toxicity and tests the serum levels of lithium in the patient. Which concentration of lithium does the nurse expect to find in the patient’s blood serum?
0.5 mEq/L
1.8 mEq/L
2.5 mEq/L
3.4 mEq/L
1.8 mEq/L
Serum levels of more than 1.8 mEq/L can cause advanced signs of toxicity such as gastrointestinal upset, mental confusion, incoordination, and sedation. A serum level of 0.5 mEq/L indicates the therapeutic level of lithium. Serum levels of 2.5 and 3.4 mEq/L indicate severe toxicity. The symptoms of severe toxicity include oliguria, convulsions, severe hypotension, and death.
Suicide is a serious risk because nearly ___% of those diagnosed with bipolar disorder commit suicide.
20
Which adverse effect of carbamazepine would the nurse report on chronic administration of the drug in a patient experiencing mania with rapid-cycling manic symptoms?
Convulsions
Severe hypotension
Bone marrow suppression
Changes in the electroencephalograph
Bone marrow suppression
A client experiencing acute mania undresses in the group room and dances. How should the nurse intervene initially?
letting the client stay in the group room and moving the other clients to a different area.
firmly telling the client, “Stop dancing and put on your clothing.”
putting a blanket around the client and walking with the client to a quiet room.
quietly asking the client, “Why don’t you put your clothes on?”
putting a blanket around the client and walking with the client to a quiet room.
Which nursing diagnosis would most likely apply to a client diagnosed with major depressive disorder as well as one experiencing acute mania?
Defensive coping
Fluid volume excess
Disturbed sleep pattern
Deficient diversional activity
Disturbed sleep pattern
A client diagnosed with bipolar disorder who takes lithium carbonate 300 mg three times daily reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with what?
a large glass of juice.
an antacid.
an antiemetic.
food.
food.
The nurse receives a laboratory report indicating a client’s serum level is 1 mEq/L. The client’s last dose of lithium was 8 hours ago. What does this result indicate?
above therapeutic limits.
below therapeutic limits.
within therapeutic limits.
invalid because of the time lapse since the last dose.
within therapeutic limits.
Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.6 to 1.2 mEq/L.
While the exact cause of bipolar disorder has not been determined; however, what is consistent for most clients?
excess sensitivity in dopamine receptors may trigger episodes.
several factors, including genetics, are implicated.
brain structures were altered by stress early in life.
inadequate norepinephrine reuptake disturbs circadian rhythms.
several factors, including genetics, are implicated.
A client demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen?
To minimize the side effects of lithium.
To bring hyperactivity under rapid control.
To enhance the antimanic actions of lithium.
To be used for long-term control of hyperactivity.
To bring hyperactivity under rapid control.
At a unit meeting, the staff discusses decor for a special room for clients with acute mania. Which suggestion is appropriate?
Deep colors for walls and upholstery
Brightly colored walls and print drapes
Neutral walls with pale, simple accessories
An extra-large window with a view of the street
Neutral walls with pale, simple accessories
A client diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The client threatens to hit another client. Which comment by the nurse is appropriate?
“Do not hit anyone. If you are unable to control yourself, we will help you.”
“If you do that one more time, you will be secluded immediately.”
“You know we will not let you hit anyone. Why do you continue this behavior?”
“Stop that! No one did anything to provoke an attack by you.”
“Do not hit anyone. If you are unable to control yourself, we will help you.”
A health teaching plan for a client taking lithium should include which instructions?
drink twice the usual daily amount of fluid.
avoid eating aged cheese, processed meats, and red wine.
double the lithium dose if diarrhea or vomiting occurs.
maintain normal salt and fluids in the diet.
maintain normal salt and fluids in the diet.
Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.
