Bipolar Disorder

D - distractibility

I - impulsivity
G - grandiosity
F - flight of ideas/racing thoughts
A - activity/energy increase

S - sleep needs diminish

T - talkative

What is the acronym for SX of mania?

Distractibility

Trouble focusing; easily pulled away from one thought/task by irrelevant stimuli

Impulsivity

Engaging in risky/pleasure-seeking behaviors without thinking about consequences

Grandiosity

High self-esteem/unrealistic beliefs about one’s abilities or importance

Flight of ideas/racing thoughts

Rapidly shifting from one topic to other

Activity/energy increase

Increased goal-directed activity; ex. starting multiple projects or physical restlessness

Sleep needs diminish

Less need for sleep without feeling tired

1. Period of abnormal + persistent

2. Pt. must have 3 or more (4 if mood is irritable) symptoms during mood disturbance and high energy/activity

3. Mood disturbance is so severe to cause impairment

4. Episode IS NOT caused by physiological effects of a substance (drug abuse, medication, or other treatment) or to another medical condition

What is the DSM-5 criteria for BPD?

• Elevated, expansive, irritable mood

• Increase in goal-directed activity (lasting at least 1 wk and present most of the day, nearly everyday)

What is classified as a period of abnormal and persistent behavior?

• Impairment in social/occupational functioning or need to hospitalization to prevent harm to self or others 

• If there are psychotic features

What is classified as severe mood disturbance causing impairment?

1. Acute

2. Continuation

3. Maintenance

What are the 3 phases of BPD?

Prevent injury and maintain safety

What is the goal of the acute phase of BPD?

• Demonstrate self-control w/ aid of staff presence or med AEB by absence of harm to others

• Make no attempt at self-harm w/ aid of staff presence or med, demonstrated during regular, formal, eyes-on safety checks throughout acute mania

• Maintain stable cardiac status, stable VS

How do you prevent injury and maintain safety?

Food/fluid, sleep, self-care needs, med management, close observation

What is meant by medical stabilization?

Continue the resolution of problematic symptoms, prevent replace, and limit the severity/duration of future episodes

What is the goal of the continuation and maintenance phase?

• Pt and family will attend psychoeducational classes

• Support groups

• Therapies

• Communication and problem-solving skills training

• Maintain med adherence

What is done to accomplish the goal of the continuation and maintenance phase?

• Knowledge of disease process

• Knowledge of med

• Consequences of substance use as a risk factor for future relapse

• Early s/s of relapse

What is taught in psychoeducational classes?

1. Use firm and calm approach

2. Use short and concise explanations/ statements

3. Remain neutral; avoid power struggles and value judgements

4. Be consistent in approach and explanations

5. Have frequent staff meetings to plan consistent approaches and to set agreed on limits

6. With the staff, decide on limits and tell patient in simple, concrete terms with consequence 

7. Continue to use active listening to hear and act on legitimate complaints

8. Firmly redirect energy into more appropriate and constructive channels (use distraction techniques)

9. AVOID splitting; maintain consistency

What interventions would you use for acute mania: communication?

• Milieu

• Nutrition

• Sleep/rest

• Hygiene/elimination

What are the types of interventions for acute mania: safety and physical needs?

• Maintain low level of stimuli (keep pt. away from bright lights, loud noises, and people)

• Provide structured, noncompetitive, or solitary activities with nurse

• Redirect agitated behavior through physical exercise such as walking

• Use antipsychotics, sedative drugs, and seclusion to minimize physical harm

• Monitor for signs of lithium toxicity

• Protect pt. from giving away money and possessions 

• Protect pt. from inappropriate behavior (ex. sexually acting out)

MILIEU interventions for acute mania: safety and physical needs?

Hold until rational judgement returns

What should you do to protect pt. from giving away money and possessions?

• Monitor (intake, output, vitals, labs: mg, k, na for cardiac status)

• Offer: high calorie protein drinks, milkshakes, finger foods (sandwiches, fruit)

• Frequently remind pt. to eat

NUTRITION interventions for acute mania: safety and physical needs?

• Keep pt. in areas of low stimulation

• At night provide: warm baths, soothing music, med, avoid caffeine

• Encourage frequent rest during the day

SLEEP/REST interventions for acute mania: safety and physical needs?

• Supervise choice of clothes (minimize flamboyant/bizarre clothing)

• Give simple, step-by-step reminders for hygiene and dress

• Monitor bowel habits (offer fluid and food high in fiber, need for laxative, and encourage bathroom use)

HYGIENE/ELIMINATION interventions for acute mania: safety and physical needs?

1. Therapeutic

2. Maintenance

3. Toxic

4. Life threatening

What are the types of lithium levels?

<0.4-1

What are Therapeutic lithium levels?

Signs:

• Fine hand tremor

• Polyuria

• Mild thirst

• Nausea

• Discomfort

• Weight gain

• Acne

• Cognitive problems

• Hair loss

S/S and interventions of Therapeutic lithium levels?

• Give with food to decrease nausea

• Weight gain helped with diet, exercise, nutritional management

What are the Therapeutic interventions for lithium levels?

<1.5

What are Maintenance lithium levels?

Increased:

• Nausea

• Vomiting

• Diarrhea

• Thirst

• Polyuria

• Slurred speech

• Muscle weakness

S/S and interventions of Maintenance lithium levels?

• Hold meds

• Measure blood lithium levels

• Reevaluate dosage

What are the Maintenance interventions for lithium levels?

1.5-2

What are Toxic lithium levels?

• Coarse hand tremor

• Persistant GI upset

• Confusion

• Muscle hyperirritability

• EEG changes

• Incoordination

S/S and interventions of Toxic lithium levels?

• Hold meds

• Measure blood lithium levels

• Reevaluate dosage

• Treat more serious symptoms

What are the Toxic interventions for lithium levels?

2-2.5+

What are Life Threatening lithium levels?

• Ataxia

• Serious EEG changes

• Blurred vision

• Chronic movements

• Dilute urine (large amounts)

• Tinnitus

• Seizures

• Stupor

• Severe hypotension 

• Pulmonary complications

• Death

S/S and interventions of Life Threatening lithium levels?

• No known antidote

• Stop drug

• If alert give emetic

• Gastric lavage

• Urea, mannitol + aminophylline to fasten excretion

• Hemodialysis

What are the Life Threatening interventions for lithium levels?

1. Lithium works to stabilize mood and low extremes in behavior and helps to prevent relapse (continue even when symptoms no longer present)

2. Lithium blood levels must be monitored

3. Kidney function should be assessed (before treatment, then yearly)

4. Thyroid-stimulating hormone (TSH) should be measured (before treatment, then yearly)

5. Lithium is not addictive

6. Eat normal diet with consistent salt and fluid intake

7. Stop taking lithium and call HCP if you have: excessive diarrhea, vomiting, sweating (leading to toxicity)

8. Take lithium with meals to prevent GI irritation

9. Tell HCP your entire medical history including meds

10. DO NOT take diuretics with lithium

11. DO NOT take OTC meds, NSAIDS, or antacids with lithium

12. Consult HCP or nutritionist if changing your diet

13. Taper dosing if lithium is discontinued to minimize risk of relapse

14. Know side/toxic effects

What are patient teaching points for a patient on lithium?

• Increased risk for birth defects

• Weight gain

• Blood dyscarasias (agranulocytosis, aplastic anemia, thrombocytopenia)

• Skin rashes

• Hives

• Steven-Johnson syndrome

• Toxic epidermal necrolysis

• Hyponatremia

• Jaundice

What are some specific effects of Carbamazepine?

• Birth defects, neutral tube defects

• High risk for polycystic ovarian syndrome

• Hepatitis

• Pancreatitis

• Thrombocytopenia

• Encephalopathy

• Weight gain

• Metabolic issues

What are some specific effects of Valporic acid, valproate, divalproex?

• Birth defecs

• May be lowered by birth control; dose my be increased if birth control is started

• Weight gain

• Stevens-Johnson syndrome

• Toxic epidermal necrolysis

• Aseptic meningitis (headache, fever, nausea, confusion, stiff neck)

What are some specific effects of Lagmotrigine?

• Birth defects

• Weight loss

• Impaired concentration, cognitive dulling/slowing

• Fatigue

• Visual disturbances (blurring, double vision, eye pain)

What are some specific effects of Tropiramate?

• Lamotrigine 

• Topiramate

• Oxcarbazepine

• Anxiolytics

• 2nd gen antipsychotics

• quetiapine monotherapy

What other classes of meds might be used to treat BPD?