NU 125 Mental Health Nursing: Bipolar Disorder

Epidemiology of Bipolar Disorder

- Same in men and women

- High suicide risk

- Affects 4% of American adults with 83% being severe cases

Average age of onset for bipolar disorder

25 years old

BPD is the ______ leading cause of disability in the middle age group.

6th

Etiology of Bipolar Disorder

exact etiology is unknown, evidence supports a chemical imbalance in the brain

Pruning

the degradation of synapses and dying off of neurons

Theories regarding BPD consider..

hereditary factors and environmental triggers

Genetics in BPD

there is a familial risk for bipolar disorder, if parents have it there is a higher risk of bipolar disorder in children

Biochemical theories

Mania

Depression

Mania

excess of norepinephrine and dopamine

Depression

deficiency of norepinephrine and dopamine

Seratonin is ___ in both states.

low

Can medications trigger manic episodes?

yes, such as steroids or SSRIs

The credibility of psychosocial theories for the cause of BPD have declined because..

it is now viewed as a disease of the brain

Theoretical Integration (Transactional Model)

Bipolar disorder likely results from an interaction between genetic, biological, and psychosocial factors

Types of Bipolar Disorder

Bipolar I

Bipolar II

Cyclothymia

Neurotransmitter involved in Bipolar Disorder

dopamine

Bipolar I

client experiences at least one manic episode or mixed episode and a depressive episode

Bipolar I is more ____ symptoms and is _____ more often than bipolar II.

dramatic, hospitalized

Rapid cycling

in bipolar I, the client experiences four or more episodes of acute mania within a year

Manic episode

elevated, expansive, and irritable mood with hyperactivity, flight of ideas, and poor judgment

Depressive episode

feeling of hopelessness, guilt, or worthlessness with a decrease in interest in pleasure and decreased energy, appetite, and libido

Someone in a manic or depressive episode may have..

suicidal ideation or thoughts

Bipolar II

characterized by bouts of depression with episodic occurrence of hypomania

With bipolar II, the individual has..

normal judgement and less impact on function than bipolar I

Does someone with bipolar II experience an episode that meets the full criteria of mania or mixed symptomology?

no

Cyclothymia

chronic mood disturbance involving many episodes of hypomania symptoms and depressed mood for at least two years

Is the patient ever without hypomania or depressive symptoms?

no

What does cyclothymia result in for the individual experiencing it?

significant distress in social, occupational, or other areas of functioning

Children and Adolescents with BPD

hard to diagnose as it is relatively rare in children

True bipolar disorder is considered..

a chronic illness

There is a connection between ____ and the development of BPD in youth.

ADHD

Diagnostic Criteria for Mania

abnormally and persistently elevated, expansive, or irritable mood lasting one week and have 3 or more of the listed symptoms during the disturbance

Listed Symptoms for Mania (Must have 3+)

Inflated self-esteem or grandiosity

Decreased need for sleep

More talkative or pressure to keep talking

Flight of ideas

Distractability

Psychomotor agitation

Excessive involvement in pleasurable activities

3 Stages of Mania

Stage I: Hypomania

Stage II: Acute mania

Stage III: Delirious mania

What 3 areas are being examined when evaluating stages of mania?

Mood

Cognition/perception

Behavior

Stage I: Hypomania

disturbance in function is not severe

Mood in hypomania

cheerful and expansive, underlying irritability

Cognition and perception in hypomania

ideas of great self worth and ability

Behavior in hypomania

increased motor activity, being loud, talking and laughing a lot

Is hospitalization always needed in stage I?

no

Stage II: Acute mania

disturbance in functioning is severe and the goals are to maintain safety, limit setting, and stabilize patient

Mood in acute mania

euphoric, elated, labile, crying

Cognition and perception in acute mania

fragmented, psychotic with paranoid or grandiose thoughts

Behavior in acute mania

poor impulse control, days without sleeping, inappropriate or excessive dress

Is hospitalization needed in Stage II?

it may be

Stage III: Delirious Mania

grave form of mania with severe clouding of consciousness that is rare with the availability of antipsychotic medications

Mood in delirious mania

very labile, panic anxiety

Cognition and perception in delirious mania

confused, disoriented, distractible, and incoherent

Behavior in delirious mania

agitated, purposeless movements

Nursing Assessment for Mania/BPD

Safety issues

Mood

Speech

Sleep

Appetite

Behavior

Thoughts/perceptions

Delusions

Hallucinations

Energy

Labs

Medications

Substance use

Collateral sources

What must be prioritized when making a nursing diagnosis and planning outcomes?

1. Potential for self-harm

2. Disturbed thought process

3. Sleep disturbance

4. Imbalanced nutrition

Nursing Interventions

Assess risk for harm to self and others

Decrease stimulation

Assess eating and sleeping habits

Contain mania symptoms

Milieu managemnet

Use therapeutic communication

Address behaviors

Provide education to client and family

Medication management

Education topics for patient and family may include..

Medications and symptom management

Causes and nature of illness/symptoms

Importance of regular sleep and activity

Support groups, crisis hotline, treatment, legal services

Treatment modalities for BPD

Psychopharmacology

Individual therapy

Group therapy

Family therapy

Cognitive therapy

Electroconvulsive Therapy

Cognitive therapy

assists in identifying dysfunctional patterns of thinking and connects thoughts, feelings, and behaviors

Electroconvulsive Therapy (ECT)

used to treat depression and acute mania when an individual fails to respond to drug treatment

Is there a cure for BPD?

no

Recovery Model

makes recovery possible in the sense of learning how to prevent and minimize symptoms and cope with the effects of the illness on one's life

Recovery is a _____ process.

continous

How can recovery be facilitated?

Patient identifies goals and works with the clinician to develop and carry out a treatment plan to achieve previously set goals

Mood Stabilizers

Antimanic

Anticonvulsants

Antipsychotics

Antimanic

Lithium carbonate

Anticonvulsants (off-label use)

Depakote

Tegretol

Antipsychotics

Zyprexa (olanzapine)

Abillify (aripiprazole)

What should be checked before using medications?

pregnancy and other labs

Lithium

first drug approved for treatment of mania by the FDA and is not a PRN medication

PRN

as needed

With lithium, be sure the patient..

drinks fluids and has sufficient salt intake

Action of Lithium

unknown but alters sodium transport across cell membranes and metabolism of neurotransmitters

Common side effects of Lithium

thirst, fine hand tremors, thyroid dysfunction, polyuria, dizziness, headache, GI upset

Do not use lithium if..

patient has severe kidney disease, dehydration, sodium depletion, or allergy

What should be used cautiously with lithium? Why?

diuretics because they can increase lithium levels

Lithium toxicity

life-threatening condition of too much lithium in the blood

Lithium toxicity level

1.5-2.5

Early symptoms of lithium toxicity

blurred vision, ataxia, tinnitus, increased tremor, severe nausea vomiting and diarrhea

Lithium toxicity can cause..

death

Lamictal (lamotragine) side effect

Ataxic gait, drowsy, blood dyscrasia, rash, Stevens-Johnson syndrome

What should be checked before administering anticonvulsants?

LFL and pregnancy

Antipsychotics that are FDA approved for bipolar, mania

Zyprexa (olanzapine)

Abilify (aripiprazole)

Seroquel (quetiapine)

Risperdal (risperidone)

Geodon( ziprasidone)

Antipsychotics can be used..

alone or in combination with lithium

Medication Education for Antipsychotics

Caution with driving due to drowsiness/dizziness

Do not stop abruptly

Use sunblock

Rise slowly from sitting (orthostatic hypotension)

Frequent sips of water

Avoid drinking