Week 7: Bipolar Disorder

What is mania?

Once someone has/is experiencing delusions and hallucinations

What is hypomania?

Elevated, expansive, or irritable mood for at least 4 days, where the episode is noticeable to others due to a change in function, but severity does not require hospitalization, no psychotic features

What is lability?

Extreme mood swings, with irritability or sudden outbursts of misplaced rage

What is cyclothymia?

Alternate with symptoms of mild-moderate depression for at least 2 years; multiple hypomanic symptoms but not episodes

What are the anticonvulsant mood stabilizer medications used to manage bipolar?

Sodium valproate/divalproex sodium/valproic acid, carbamazepine, lamotrigine, and gabapentin

What are the other medications used to manage bipolar?

Symbax (combo of olanzapine and fluoxetine) and lithium carbonate

What are some antipsychotic medications that are used to manage bipolar?

olanzapine, risperidone, aripiprazole, quetiapine

What are some benzodiazepines that are used to manage bipolar?

diazepam and lorazepam

What are risk factors for bipolar disorder?

Genetics (runs in families), neurotransmitters, and environmental factors (stress, adverse events)

What neurotransmitters are related to bipolar disorder?

Norepinephrine, dopamine, GABA, and serotonin

What is Bipolar I disorder?

Most severe form with at least 1 manic episode; alternating manic and major depressive episodes (highs mirror the lows in length and intensity)

What acronym is used to help us remember the s/s of mania and hypomania?

DIGFAST

What does DIGFAST stand for?

Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, and Talkativeness

What does mania look like?

Mood lability, low frustration tolerance, feels misunderstood, dramatic mannerisms, uses jokes/puns to cope, flamboyant or sexually suggestive ideas

What is Bipolar II Disorder?

At least 1 hypomanic episode and at least one major depressive episode; never has had a manic episode

What are mixed features?

Symptoms of both depression and mania occur at the same time

What is rapid cycling?

Four or more manic episodes; Partial or full remission for 2 months at a time or switch to opposite episode; high risk of recurrence; greater severity of illness

What mood assessments would match bipolar disorders?

Mania, hypomania, depression, lability

What behavior assessments would match bipolar disorders?

Agitated, manipulative, restless, pacing

What thought process assessments would match bipolar disorders?

Loose, tangential, flight of ideas

What thought content assessments would match bipolar disorders?

Grandiose, paranoid, persecutory delusions

What speech patterns would match bipolar disorders?

Pressured, circumstantial, clang

What cognitive functioning assessment would match bipolar disorders?

Deficits possible

What should you assess a bipolar patient for?

Danger to self or others, need for protection from uninhibited behaviors, need for hospitalization, medical status, coexisting medical conditions, family’s understanding

What are nursing interventions for patients with acute mania?

Managing medications, decreasing physical activity, increasing food and fluid intake, ensuring at least 4-6 hours of sleep per night, intervening for self-care needs, and setting limits on behaviors

What should the nurse teach a patient with bipolar disorder and their families?

The chronic and episodic nature of the disorder, medication adherence, expected side effects of the medications, s/s of a relapse, phone numbers of emergency contact people should be in an easy to get to place, use of alcohol/drugs/caffeine/OCT meds can cause relapse, good sleep is vital, coping strategies are important, group and individual therapy is valuable

What medications are used for acute mania?

Lithium plus a 2nd gen antipsychotic medication or divalproex plus a 2nd gen antipsychotic medication

What medications are good for severe agitation and sleep)

Benzodiazepines

What medications are used for hypomania?

Only use lithium or divalproex

What is considered a medical emergency?

Acute mania

What is lithium carbonate used for?

Acute mania and maintenance treatment

What is symbax (combo of olanzapine and fluoxetine) used for?

Use for patients with more depressive episodes and who have Bipolar II

What should not be used for mood stabilization for a patient with a bipolar disorder?

Just an antidepressant by itself because it can throw them into a manic episode

What is lithium contraindicated with?

Cardiovascular disease, renal disease, brain damage, thyroid disease, pregnant or breastfeeding mothers

What is the therapeutic blood level of lithium?

0.6-1.4 mEq/L

What is the toxic blood level of lithium?

1.5mEq/L and above

What are expected side effects for lithium?

N/V/D, thirst, polyuria, lethargy, sedation, fine hand tremor

What are early signs of lithium toxicity?

GI upset, coarse hand tremor, confusion, hyperirritability of muscles, sedation, incoordination

What are nursing interventions for early signs of lithium toxicity?

Medication should be withheld, blood lithium levels should be measured, and dosages should be reevaluated

What are advanced signs of lithium toxicity?

Blurred vision, clonic movements, large output of dilute urine, severe hypotension, seizures, stupor, coma, death secondary to pulmonary complications

What are nursing interventions for advanced signs of lithium toxicity?

Hospitalization of the patient, medication is stopped, whole bowel irrigation may be done to prevent further absorption of the lithium

What are signs of severe lithium toxicity?

Convulsions, oliguria, death

What are nursing interventions for severe signs of lithium toxicity?

Hospitalization of the patient, medication is stopped, whole bowel irrigation may be done to prevent further absorption of lithium, hemodialysis in severe cases

What needs to be monitored for patients taking lithium to manage their bipolar disorder?

Initial labs 1-2 times per week then monitor creatinine, thyroid hormones, and CBC every 6mon

What are potential complications of lithium?

Potential for kidney damage, decreased thyroid function, dry skin, hair loss, constipation, bradycardia, and cold intolerance

What important teaching topics for a patient on lithium for the management of their bipolar disorder?

Increased risk for SI when lithium is discontinued; maintain normal sodium intake; hydration is very important (hydrate more if exercising to replace the sweat; if illness causes loss of fluids call MD, intermittent blood tests are required

What are important things to know about valproate/ divalproex?

Check serum levels, longer periods of mood stabilization

What are important things to know about carbamazepine?

Risk for low WBCs (check serum levels), check hepatic and renal function, effective in patients who have no response to lithium, rash may be life threatening

What is lamotrigine used for?

For rapid cycling and depressed phase of bipolar illness

What is gabapentin used for?

May be effective for acute mania, mood stabilization, and rapid cycling

What is the lamotrigine rash?

An allergic reaction from the medication that shows up in rash form, which can advance to Stevens-Johnson Syndrome

What is Stevens-Johnson syndrome?

It presents with a serious rash, flu-like symptoms, sore throat, fever, chills, blisters, and burning eyes; it can further advance to toxic epidermal necrosis (fatal)

What should the nurse do if they have a lamotrigine-related rash?

Stop the medication immediately and call the PCP