Week 7: Care of Persons with Bipolar Disorder and Hypertension

S/s of Bipolar 1 disorder:

-experience manic episodes

-hypomania (nearly always)

-major depressive episodes

S/s of Bipolar 2 disorder:

-at least one hypomanic episode

-at least one major depressive episode

-absence of manic episodes

What is bipolar disorder?

Mood disorders with recurrent episodes of depression and mania

Nursing considerations for acute phase of bipolar disorder (mania):

-provide a safe environment during the acute phase.

-assess the client regularly for suicidal thoughts, intentions, and escalating behavior

-decrease stimulation without isolating the client if possible

-provide outlets for physical activity

Nursing considerations for continuation phase of bipolar disorder:

-remission of manifestations

-relapse prevention thru education, med adherence, and psychotherapy are goals

Nursing considerations for maintenance phase of bipolar disorder:

-increase ability to function

-prevention of future manic episodes is the goal

What is mania?

-An abnormally elevated mood, which can also be described as expansive or irritable

-usually requires hospitalization

-Manic episodes last at least 1 week

What is hypomania?

-A less severe episode of mania that lasts at least 4 days accompanied by three or more manifestations of mania

-Hospitalization is not required, and the client who has hypomania is less impaired

-can progress to mania

What is rapid cycling?

Four or more episodes of hypomania or acute mania within 1 year

What is bipolar 1 disorder?

at least one episode of mania alternating with major depression

What is bipolar 2 disorder?

one or more hypomanic episodes alternating with major depressive episodes

Risk factors for bipolar disorder:

-genetics (family history)

-stressful events or major life changes

-substance use disorder

-circadian dysregulation

Things can increase likelihood of bipolar relapse:

-substance use (alcohol, cocaine, caffeine) leads to mania

-sleep disturbances

-psychological stressors (stress)

S/s of mania:

-labile mood w/euphoria

-agitation and irritability

-restlessness

-flight of ideas; rapid, continuous speech, frequent topic change

-impulsivity

-poor judgement

-decreased sleep

-onset before age 25

S/s of depressive bipolar:

-flat, blunted, labile affect

-tearfulness, crying

-lack of energy

-anhedonia

-self destructive behavior

-decrease in personal hygiene

-loss of appetite/sleep

What is ECT?

-can be used to subdue extreme manic behavior,

-done when pharmacological therapy, such as lithium, has not worked

Lithium:

-monitor blood levels

-the higher the sodium level the lower the lithium level

-the lesser body fluid the lower the lithium level

Which race has more prevalent hypertension?

Black Americans

-develop at younger age

-tend to be more severe/resistant

-associated w/SDOH, disparities, limited access, chronic stress

What is resistant hypertension?

blood pressure that remains above goal despite the concurrent use of three antihypertensive agents of different classes

Hypertension definition:

BP > 130/80 OR currently using prescription medication to lower BP

Nursing considerations for Hydrochlorothiazide:

Thiazide Diuretics

-monitor for hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia

-can cause hyperuricemia

-monitor for gout

Nursing considerations for Lisinopril:

Angiotensin-Converting Enzymes (ACEi) Inhibitors

-most common side effect is fatigue

-can cause dry, hacking cough (angioedema is rare)

-Hyperkalemia (when paired w/potassium-sparing diuretic or K supplements)

-avoid during pregnancy

Nursing considerations for Losartan:

Angiotensin II Receptor Blockers (ARBs)

-most common side effect is fatigue

-less likely to cause dry cough (angioedema is rare)

-Hyperkalemia (when paired w/potassium-sparing diuretic or K supplements)

-avoid during pregnancy

Nursing considerations for Amlodipine:

Calcium Channel Blockers (CCBs)

-results in blood vessel dilaton

Relationship between body position and preload:

-bringing the HOB down or putting someone in trendelenburg can increase BP

Nursing considerations for measuring BP:

-at first visit, record BP in both arms

-use higher BP for following visits

-requires two separate visits for diagnosis

-cuff's length is 80-100% of circumference

-cuff's width is 40%

-keep feet flat, don't talk, no exercise, sit upright

Hypertensive emergency guidelines:

BP higher than 180/120 mmHg is CRISIS

-can be symptomatic or asymptomatic

Stage 1 Hypertension guideline:

BP > 130/80

S: 130-139

D: 80-89

Stage 2 Hypertension guideline:

BP > 140/90

S: 140+

D: 90+

Relationship between cuff size and reading:

if cuff size is too small = high reading

if cuff size is too large = low reading

Modifiable risk factors for hypertension:

-smoking

-diabetes

-high cholesterol/salt/unhealthy diet

-sedentary lifestyle

-physical inactivity

Non modifiable risk factors for hypertension:

-increased age

-family history

-low socioeconomic status

-male

-obstructive sleep apnea

-psychosocial stress

Non-pharmacologic interventions for hypertension management:

-reduce weight (if BMI > 24.9)

-follow heart healthy eating plan (DASH diet)

-lower sodium intake and increase potassium intake

-increase physical activity (150 mins moderate OR 75 mins vigorous per week)

-limit alcohol intake (2x M and 1x W)

-avoid tobacco products

Recommended sodium intake:

2,300 mg of sodium per day for healthy adults

1,500 mg of sodium per day for higher risk factors

Recommended potassium intake:

aim for 3,500-5,00 mg per day

-potassium relaxes the walls of the blood vessels

What is primary hypertension?

elevated BP without an identifiable cause

-90-95% of adults

-obesity is in this category

What is secondary hypertension?

elevated BP with an identifiable cause

-5-10% of adults

-e: tumor on adrenal gland

S/s of hypertensive emergency:

BARKH acronym:

B: brain (stroke)

A: arteries (aortic or abd dissection)

R: retina (double vision, vision loss)

K: kidneys (acute kidney injury)

H: heart (chest pain, SOB, pulmonary edema)

Can a hypertensive crisis be asympomatic?

YES, patients can experience crisis and not be experiencing symptoms of target organ damage

-hypertension is silent killer

MOA for Hydrochlorothiazide

blocks reabsorption of electrolytes and water in the distal tubule to decrease preload and BP

MOA for lisinopril:

prevents conversion of angiotension 1 to 2

-should be given to pts with HTN, diabetes, chronic kidney disease

MOA for losartan:

-prevent vasoconstrictor effects

-prescribed when pts cannot tolerate ACEi

Nursing considerations for all antihypertensives:

-check VS (BP and HR trends)

-hold if VS do not meet parameters

-assess fluid volume status

-assess electrolytes

-educate pts to rise slowly to prevent falls due to orthostatic hypotension

Common s/s of antihypertensives:

-frequent voiding

-orthostatic hypotension

-feeling tired, weak, drowsy, lack of energy

-erectile dysfunction

Reasons why patients might not take antihypertensive medications:

-fear of side effects

-misunderstanding of need for medicine

-lack of symptoms (silent killer)

-depression

-cost

-too many meds

-worry about being dependent

-mistrust of medical professionals

factors influencing blood pressure

blood pressure = cardiac output x peripheral vasuclar resistance

cardiac output = heart rate x stroke volume

stroke volume

preload, contractility and afterload

autonomic nervous system controls …..

the heart rate

sympathetic nervous system increases beta-1 receptors → increases HR and contractility

factors that influence preload

circulating blood volume (RAAS system increases preload, ADH increases preload)

venous return (venodilation decreases preload)

a rapid heart rate decreases preload

factors that influence contractility

autonomic nervous system - sympathetic nervous system increases beta-1 receptors → increases contractility

parasympathetic nervous system decreases cardiac contractility

decrease in calcium ion concentration decreases contractility

factors that influence afterload/PVR/SVR

blood vessel diameter (activation of alpha 1 adrenergic receptors causes vasoconstriction → increases SVR

activation of beta 2 adrenergic receptors causes vasodilation→ decreases SVR

activation of the RAAS system causes vasoconstriction → increases SVR

ADH hormone causes arterial vasoconstriction →increases SVR

weight gain increases SVR

elevated heart rate

120-129 AND less than 80

stage 1 hypertension first line medications

one or combination of two

thiazide diuretics, ACEIs, ARBS, CCBs,

stage 2 hypertension medications

two or more of the first line medications of different classes

beta blockers can be used used to treat HTN but are not considered first line medications

thiazide diuretics indication

preferred over loop diuretics for HTN because the diuresis is lower

nursing considerations for thiazide diuretics

monitor for hypo natremia/kalemia/calcemia/hypomagnesemia

can cause hyperuricemia

monitor for gout

thiazide diuretics affect….

preload

ACEIs affect ….

preload, afterload and blood vessel diameter

indications of calcium channel blockers

used to treat htn

also used for angina, cardiac dysrhythmias, HF

side effects of CCB

headache, dizziness, pedal edema