22, 25, 27 Psych

Define what is myth or fact surrounding suicide and suicidal behavior

Myth	Fact
·        Suicide only affects people with mental health conditions	·        Many people with mental illness are not effected by SI, and not all people who attempt or die by suiceide have mental illness
·        Most suicides happen suddenly without warning	·        Warning signs, verbally, or behaviorally, precede most suicides
·        People who commit suicide are selfish and take the easy way out	·        Typically, people do not die by suicide because they do not want to live. People die by suicide because they want to end their suffering.
·        When people become suicidal, they will always be suicidal	·        Active suicidal ideation is often short term and situation specific. While suicidal thoughts can return, they are not permanent.
·        Talking about suicide will encourage suicide	·        Talking about suicide not only reduces the stigma but also allows individuals to seek help, rethink their opinions, and share their story with others

Suicide

The act of killing one’s self

Suicide mortality

• Death by suicide

• Suicide is ranked as the tenth leading cause of death and accounts for 14.2 deaths per 100,000 population.

• On average, 132 Americans die by suicide each day, with a suicide occurring every 11 minutes in the United States: a rate of 132 completed successful suicides per day.

• Prevalence may be understated

Suicide attempt

is a nonfatal, self-inflicted destructive act with explicit or implicit intent to die.

Parasuicide

• is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death (e.g., taking a sublethal drug).

• varies by intent.

• Some people truly wish to die, but others simply wish to feel nothing for a while. Still others want to send a message about their emotional state

• never normal and should always be taken seriously.

Suicide Ideation

thinking about and planning one’s own death.

List the warning signs of suicide:  IS PATH WARM

• I—Ideation: Talking or writing about death, dying, or suicide

  • Threatening or talking of wanting to hurt or kill self

  • Looking for ways to kill self: seeking access to firearms, available pills, or other means

• S—Substance abuse: Increased substance (alcohol or drug) use

• P—Purposelessness: No perceived reason for living; no sense of purpose in life

• A—Anxiety: Anxiety, agitation, unable to sleep, or sleeping all the time

• T—Trapped: Feeling trapped (like there is no way out)

• H—Hopelessness

• W—Withdrawal: Withdrawal from friends, family, and society

• A—Anger: Rage, uncontrolled anger, seeking revenge

• R—Recklessness: Acting reckless or engaging in risky activities, seemingly without thinking

• M—Mood change: Dramatic mood changes

suicide risk factors

• Family history of suicide

• Family history of child maltreatment

• Previous suicide attempt(s)

• History of mental disorders, particularly clinical depression

• History of alcohol and substance abuse

• Feelings of hopelessness

• Impulsive or aggressive tendencies

• Cultural and religious beliefs (e.g., belief that suicide is noble resolution of personal dilemma)

• Local epidemics of suicide

• Isolation, a feeling of being cut off from other people

• Barriers to accessing mental health treatment

• Loss (relational, social, work, or financial)

• Physical illness

• Easy access to lethal methods

• Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

• White

  • WM 70% suicide attempts

• Male>female

• LGBT

• Pandemic

Biologic theories of suicide

• Depression and Severe childhood trauma linked

• Extremely low levels of serotonin, Impairments in Serotonergic system

• Dysregulation in hypothalamic-pituitary axis

• abnormalities of neurotrophins and neurotrophin receptors

• abnormalities of neuroimmune functions

• Genetic Factors

  • Runs in families, 1st degree relatives: 2-8x increased risk

  • Suicidal behavior has a 50% concordance for completed suicide

  • gene/environment connection between early childhood sexual abuse and suicidality

    • lead to genetic changes that modify the expression of the neurologic system, impacting the biologic and psychological development.

    • Cant cope suicide

Social theories of suicide

• Social exposure to suicide increases risk especially with teens

• work through modeling and is more likely to occur when the individual contemplating suicide is of the same age, gender, and background as the person who died.

• prompted by the suicide of a friend, an acquaintance, online social networking, or an idolized celebrity. Actions of peer groups, media reports of suicide, and even billboards with content about suicide can trigger suicide behavior among adolescents

• Copycat suicides with celebs

• Economic Disadvantage

  • Poverty and economic disadvantage

  • Unemployed, unwed, low education, low income

  • Adolescents from low income=increased risk

  • Limited access to healthcare

Psychological theories of suicide

• Cognitive theories

  • Cognitive triad of hopelessness, helplessness, worthlessness

  • Linked to SI

  • Hopeless=more likely to self harm

• Emotional & Personality factors enhance perceptions of helplessness and hopelessness which contribute to poor self-esteem, and interfere with coping efforts

• Linked to SI:

  • Shame

  • Guilt

  • Despair

  • Emotion focused coping

• Loss and grief

• Emotional distress is potentiated but personality traits that contribute to poor self-esteem, impulsivity, and suicidal behavior.

  protective factors that help prevent suicide

a.       Effective clinical care for mental, physical, and substance abuse disorders

b.       Easy access to a variety of clinical interventions and support for help seeking

c.       Family and community support (connectedness)

d.       Support from ongoing medical and mental health care relationships

e.       Skills in problem-solving, conflict resolution, and nonviolent ways of handling disputes

f.         Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

Describe a suicide assessment:  plan/ intent/ means

• Apply the assessment process that delineates the (1) intent to die, (2) severity of ideation, (3) availability of means, and (4) degree of planning.

• Plan

• Intent

• Means

• INTENT TO DIE

  • Have you been thinking about hurting or killing yourself?

  • How seriously do you want to die?

  • Have you attempted suicide before?

  • Are there people or things in your life who might keep you from killing yourself?

• SEVERITY OF IDEATION

  • How often do you have these thoughts?

  • How long do they last?

  • How much do the thoughts distress you?

  • Can you dismiss them or do they tend to return?

  • Are they increasing in intensity and frequency?

• Degree of Planning

  • Have you made any plans to kill yourself? If yes, what are they?

  • Do you have access to the materials (e.g., gun, poison, pills) that you plan to use to kill yourself?

  • How likely is it that you could actually carry out the plan?

  • Have you done anything to put the plan into action?

  • Could you stop yourself from killing yourself?

Short term interventions for a suicidal person

• Instilling hope,

• restoring emotional stability

• reducing suicidal behavior

• ensuring safety.

long term interventions for a suicidal person

• encouraged to think of times in their lives when they were not so hopeless and consider how they may feel similarly in the future.

• Patients should be taught to expect setbacks and times when they are unable to see much of a future for themselves.

• Helping patients review the goals they already have achieved and at the same time set goals that can be achieved in the immediate future can help them manage periods of discouragement and hopelessness

1:1 and line

• Definition: One staff member is assigned to continuously monitor one specific patient.

• Proximity: The staff must remain within arm’s reach of the patient at all times.

• Purpose: Used for patients at high risk of harm to self or others (e.g., suicidal ideation, severe agitation).

• Responsibility: The assigned staff cannot leave the patient unattended, even briefly.

line and sight

• Definition: The patient must remain visibly within the staff’s direct line of sight at all times.

• Proximity: Staff may be at a short distance but must maintain uninterrupted visual contact.

• Purpose: Used for moderate-risk patients who require close observation but not constant physical proximity.

• Flexibility: Allows slightly more autonomy while still ensuring safety.

Describe what mood

pervasive and sustained emotion that influences one’s perception of the world and how one functions.

Mood variations

• Sadness

• Euphoria

• Anxiety

Primary alteration is MOOD – not thought or perception

• Blunted

• Bright

• Flat

• Inappropriate

• Labile

• Restricted or constricted

Affect

• outward emotional expression, is related to the concept of mood

• Gives clues to mood

Blunted

significantly reduced intensity of emotional expression

Bright

smiling, projection of a positive attitude

Flat

absent or nearly absent affective expression

Inappropriate

discordant affective expression accompanying the content of speech or ideation

Labile

varied, rapid, and abrupt shifts in affective expression

Restricted or constricted:

mildly reduced in the range and intensity of emotional expression

Disruptive Mood Dysregulation Disorder (DMDD)

• Characterized by severe irritability and outbursts of temper that are more severe than what would be expected developmentally and occur frequently

• Onset before age of 10 when children have verbal rages and/or are physically aggressive toward others or property.

• Outside range for normal child temper tantrums

Major depressive disorder MDD

• Progressively recurrent illness

• 1 or more major depressive episodes

• Episodes become more frequent, severe, and longer in duration

• Onset=any age, 20s is highest

• Relapse is higher for people who experienced initial symptoms at a younger age and incur other mental disorders

• Epidemiology

  • 10.4% in 12 months

  • 20.6% prevalence in lifetime

  • 18-29 higher prevalence

  • 65+ higher prevalence

  • Females>Males

  • White and Natives

  • 10% have another episode within 5-10yrs

• Risk Factors

  • episode of depression

  • Family history of depressive disorder

  • Lack of social support

  • Lack of coping abilities

  • Presence of life and environmental stressors

  • Current substance use or abuse

  • Medical and/or mental illness comorbidity

• Comorbidity

  • endocrine disorders, cardiovascular disease, and neurologic disorder

  • co-occur with psychiatric disorders

• Therapeutic Relationship

  • Establishment and maintenance of a supportive

  • relationship

  • Availability

  • Vigilance

  • Education

  • Encouragement

  • Guidance

  • Realistic goals

  • Support of individual strengths

• Nursing Interventions

  • Based on target symptoms, genetics, cultural,

  • race, ethnic, history, cost

  • Oral forms

  • Continue six months to a year after complete

  • remission

  • Recurrence – meds for at least another year

  • Illness reoccurs – continued indefinitely

  • Watch for saving meds – suicide attempt

List the criteria for major depressive disorder

• Diagnostic criteria

  • 1 or more major depressive episodes, depressed or loss of interest or pleasure in all things for at least 2 wks

  • 4/7 symptoms must be present

    • Disruption in sleep

    • Disruption in Appetite

    • Disruption in concentration

    • Disruption in energy

    • Psychomotor agitation or retardation

    • Excessive guilt or feelings of worthlessness

    • SI

Premenstrual Dysphoric disorder

• Final week before the onset of menses;

• recurring mood swings, sadness, or rejection

Persistent Depressive disorder

Mood disturbance that lasts more than 2 years with a depressed mood daily.

List components of RN assessment for an individual with major depressive disorder

• Assessment – review of physical systems, history of medical problems

  • (CNS function, endocrine function, anemia, chronic pain, autoimmune illness, diabetes or menopause) and surgeries, medical hospitalization, head injuries, episodes of loss of consciousness and pregnancies, childbirths, miscarriages, and abortions. LABS: CBC, liver function tests, thyroid function tests, urinalysis, and EKG

• Physical changes

  • appetite, sleep, energy level – recognize depression symptoms

• Current medications

  • herbal as well (consider lethality of medications); drug interactions

• Substance use

• Psychosocial

  • Mental status exam, mood and affect, thought content, cognition and memory, behavior (changes in relaxing and occupational functioning; spiritual/religious background); self-concept; stress and coping patterns, SUICIDE behavior and strength assessment

Describe role of ECT and rule out factors for ECT

• Electroconvulsive therapy

  • Severe depression

  • reserved for patients whose disorder is refractory or intolerant to initial drug treatments and who are so severely ill that rapid treatment is required (e.g., patients with malnutrition, catatonia, or suicidality).

• Nursing role:

  • provide educational and emotional support for the patient and family,

  • Assess baseline

  • Look for AE

• Contraindications

  • Increased ICP

  • Recent MI

  • Recent CVA

  • iRetinal detachment

  • Phenochromoytoma

  • People at risk with anesthesia

SSRI medications and potential side effects

• SSRI

  • Fluoxetine (Prozac)

  • Sertraline (Zoloft)

  • Paroxetine (Paxil)

  • Fluvoxamine (Luvox)

  • Citalopram (Celexa)

  • Escitalopram (Lexapro)

• SE

  • GI distress

  • Sedation

  • Anticholinergic effects

  • Wt gain or loss

  • Sexual dysfunction

  • Dizziness

  • Diaphoresis

SSRI contraindications

• Using MAOIs

• Liver impairment

• Seizure disorder

• SIADH, or severe hyponatremia

• Pregnancy

• Allergy to SSRI

• Using linezolid ort methylene blue

SNRI medications and potential side effects

• SNRI

  • Desvenlafaxine (Pristiq extended release)

  • Duloxetine (Cymbalta)

  • Levomilnacipran (Fetzima)

  • Venlafaxine (Effexor XR)

• SE

  • Gastrointestinal distress

  • Anticholinergic effects

  • Insomnia or sedation

  • Decreased appetite

  • Sexual dysfunction

  • Abnormal dreams

  • Dizziness

  • Jitteriness

  • Hypertension

  • Irritability

  • Photosensitivity

SNRI contraindications

• Using MAOIs

• Uncontrolled narrow-angle glaucoma

• Severe liver disease

• Renal impairment

• Hypersensitivity

• Uncontrolled HTN

• Seizures or BPD

List NDRI potential side effects

• NDRI

  • Nupropion (Wellbutrin)

• SE

  • Anticholinergic effects

  • Headache

  • Agitation

  • Gastrointestinal distress

  • Insomnia

  • Anorexia

  • Anxiety

  • Weight loss

  • Diarrhea and flatulence

List Alpha 2 agonist medications potential side effects

• Alpha 2 agonist medications

  • Mirtazapine (Remeron)

• SE

  • Sedation

  • Anticholinergic effects

  • Appetite increase

  • Weight gain

  • Hypercholesterolemia

  • Weakness and lack of energy

  • Dizziness

  • Hypertriglyceridemia

Explain MAOI’s and dietary restrictions

• MAOI

  • Isocarboxazid (Marplan)

• SE

  • Dizziness

  • Headache

  • Nausea

  • Dry mouth

  • Constipation

  • Drowsiness

  • Sleep disturbance

  • Orthostatic hypotension

Define/describe tricyclics and side effects

• TCA

  • Maprotiline

• SE

  • Drowsiness

  • Anticholinergic effects

  • Orthostatic hypotension

  • Palpitations

  • Tachycardia

  • Impaired coordination

  • Increased appetite

  • Diaphoresis

  • Weakness

  • Disorientation

  • Impotence

Explain the assessment of signs/symptoms of serotonin syndrome

a.       Mental Status Changes

                                                                              i.       Agitation

                                                                           ii.        Anxiety

                                                                         iii.        Restlessness

                                                                         iv.        Confusion

                                                                           v.        Delirium

                                                                         vi.        Hallucinations

                                                                       vii.        Coma (in severe cases)

b.      Autonomic Instability

                                                                              i.       Hyperthermia (elevated body temperature)

                                                                           ii.        Tachycardia

                                                                         iii.        Hypertension (or hypotension)

                                                                         iv.        Diaphoresis (excessive sweating)

                                                                           v.        Flushed skin

                                                                         vi.        Dilated pupils (mydriasis)

c.       Neuromuscular Abnormalities

                                                                              i.       Hyperreflexia (especially in lower extremities)

                                                                           ii.        Tremors

                                                                         iii.        Clonus (sustained or inducible)

                                                                         iv.        Muscle rigidity

                                                                           v.        Shivering

                                                                         vi.        Ataxia or incoordination

d.      Gastrointestinal Symptoms

                                                                              i.       Nausea

                                                                           ii.        Vomiting

                                                                         iii.        Diarrhea

                                                                         iv.        Abdominal cramps

e.       📋 Mnemonic: SHIVERS

S	Shivering
H	Hyperreflexia
I	Increased temperature
V	Vital sign instability
E	Encephalopathy (altered mental status)
R	Restlessness
S	Sweating (diaphoresis)

Describe the characteristics of Bipolar 1

• least one manic episode or mixed episode and a depressive episode have to occur

  • Manic episode 1 wk, 3-4 additional symptoms

    • Inflated Self-esteem or grandiosity

    • Decreased need for sleep

    • Being more talkative or having pressured speech

    • Flight of ideas or racing thoughts

    • Distractibility

    • Increase in goal-directed activity or psychomotor agitation

    • Excessive involvement in pleasurable activities that have a high

    • potential for painful consequences

• periods of mania or hypomania that alternate with depression.

• 1wk> of abnormally and persistently elevated, expansive, ore ittatable mood with abnormally increased goal-oriented behavior or energy

• Disturbed thought process A/V/H

• Poor concentration

• Early life 14-21

• No gender differences, men> risk for manic episodes,

• no racial differences AA misdiagnosed with schizophrenia

• Heritable

• Circadian deregulation

• Comorbid

  • Anxiety disorder

  • Substance use

  • IBS

  • Asthma

  • MS

  • Migraine

  • Cerebellar diseases

List and describe the symptoms of Bipolar 1

• Elevated mood expressed as

  • Euphoria

    • (exaggerated feelings of well-being)

  • Elation

    • feeling “high,” “ecstatic,” “on top of the world,” or “up in the clouds”

• Expansive mood

  • Lack of restraint in expressing feelings

  • overvalued sense of importance

  • constant and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions

• Mania: primarily characterized by an abnormally and persistently elevated, expansive, or irritable mood. (manic episode=1wk)

• Mood liability: alterations in moods with little or no change in external events.

• Rapid cycling: extreme form of mood lability that can occur in bipolar disorders. In its most severe form, rapid cycling includes continuous cycling between subthreshold mania and depression or hypomania and depression.

• unpredictable and variable

• Children

  • Reflects developmental level

  • Depression 1st

  • Often have other psychiatric disorders

  • ADHD

  • Conduct disorder

• 9>yrs exhibit more irritability and emotional liability

• Older children exhibit more classic symptoms:

  • Euphoria

  • Grandiosity

• The first contact with the mental health system often occurs when the behavior becomes disruptive, possibly 5 to 10 years after its onset.

• Older Adults

  • Symptoms are similar to the earlier onset bipolar disorder, but the incidence of mania decreases with age.

  • Older adults with bipolar disorder have more neurologic abnormalities and cognitive disturbances (confusion and disorientation) than younger patients

Describe the characteristics of Bipolar 2

Hypomanic - Same as for a manic episode EXCEPT – time criterion is at least 4 days (not 1 week) and no marked impairment in social or occupational functioning is present

Explain the difference between Bipolar 1 versus Bipolar 2

• Bipolar I disorder is more dramatic than bipolar II disorder, so it is easier to diagnose.

• the individual is mostly depressed, which can severely affect their social and occupational life.

• Even though there are brief periods of elevated, expansive, or irritable moods, bipolar II disorder is not as easily recognized as bipolar I disorder because the symptoms are less dramatic.  

• Hypomania, a mild form of mania, is characteristic of bipolar II disorder.

• Judgment remains fundamentally intact.

Describe the difference between mania and hypomania

• mild form of mania, is characteristic of bipolar II disorder.

• Here’s a clear comparison between mania and hypomania, both of which are elevated mood states seen in mood disorders like bipolar disorder:

Feature	b.      Mania	c.       Hypomania
Severity	e.       More severe; often requires hospitalization	f.         Less severe; does not require hospitalization
Functional Impact	h.       Marked impairment in social, occupational, or daily functioning	i.          May enhance productivity or sociability without major impairment
Duration	k.       Lasts at least 1 week (or any duration if hospitalization is needed)	l.          Lasts at least 4 consecutive days
Psychotic Features	n.       May include delusions or hallucinations	o.       No psychotic features
Risky Behavior	q.       Often extreme (e.g., reckless spending, sexual indiscretions)	r.         May occur but typically less dangerous
Mood Presentation	t.         Elevated, expansive, or irritable mood	u.       Elevated or irritable mood, but more controlled
Need for Intervention	w.     Usually requires urgent medical or psychiatric care	x.        Often managed outpatient unless it escalates

Describe cyclothymic disorder

• hypomanic symptoms occur alternating with numerous periods of depressive symptoms.

• However, these symptoms are less severe than the bipolar disorders. To be diagnosed with this disorder, the symptoms have to be present for at least 2 years of numerous periods of hypomanic symptoms.

• Mood Swings: Alternating episodes of elevated mood (similar to hypomania) and low mood (similar to mild depression).

• Duration: Symptoms persist for at least 2 years in adults (1 year in children/adolescents), with no symptom-free period longer than 2 months.

• Subthreshold Episodes: Neither the highs nor the lows meet full diagnostic criteria for mania, hypomania, or major depression.

• Functional Impact: Symptoms may cause social or occupational disruption, but are typically less severe than bipolar I or II.

• Treatment often includes mood stabilizers, psychotherapy, and psychoeducation.

List assessment factors for mood disorders

• Persistent sadness, irritability, or elevated mood

  • Flat, blunted, or inappropriate affect

  • Mood swings (e.g., from elation to irritability)

• Thought Content and Process

  • Presence of suicidal or homicidal ideation

  • Delusions or hallucinations (in severe cases)

  • Racing thoughts (bipolar), rumination (depression)

  • Hopelessness, worthlessness, or guilt

• Sleep Patterns

  • Insomnia or hypersomnia

  • Decreased need for sleep (in mania)

• Appetite and Weight

  • Increased or decreased appetite

  • Significant weight loss or gain

• Energy Level

  • Fatigue, lethargy (common in depression)

  • Hyperactivity, restlessness (common in mania)

• Concentration and Cognition

  • Difficulty concentrating or making decisions

  • Slowed thinking (depression) or distractibility (mania)

• Behavioral Observations

  • Social withdrawal or isolation

  • Agitation or psychomotor retardation

  • Risk-taking or impulsive behavior (in mania)

• Functional Impairment

  • Impact on occupational, academic, or social functioning

  • Inability to perform ADLs (activities of daily living)

• History

  • Personal or family history of mood disorders

  • Previous episodes of depression or mania

  • Trauma, loss, or major life stressors

• Substance Use

  • Alcohol or drug use (often co-occurs with mood disorders)

• Medical and Medication History

  • Chronic illnesses (e.g., hypothyroidism, chronic pain)

  • Medications that may contribute to mood symptoms (e.g., steroids)

List causal factors for mood disorders

• Family history of mood disorders

• Prior mood episodes

• Stressful life events

• Substance use

• Medical problems

• Particularly chronic or terminal illness

• Biologic theory

  • Circadian dysregulation

\List medications used to treat mood disorders including:  Lithium/ Depakote/ Lamictal/ Tegretol

Lithium

• Indications:

  • Mood stabilizer

• Mechanism of Action (MOA):

  • Alters sodium transport in nerve and muscle cells

• Adverse Effects:

  • Lithium toxicity

  • Tremor

  • Polyuria

  • Hypothyroidism

• Nursing Considerations:

  • Monitor serum lithium levels and renal function

  • Advise patient to maintain hydration

  • Assess for signs of toxicity (nausea, vomiting, confusion, tremors)

---

Depakote (Valproic Acid)

• Indications:

  • Antimanic agent

  • Epilepsy

  • Migraine

• Mechanism of Action (MOA):

  • Increases GABA levels

  • Blocks sodium channels

• Adverse Effects:

  • Sedation, tremor (dose-related)

  • Nausea, vomiting, indigestion, abdominal cramps

  • Anorexia and weight loss

  • Elevated liver enzymes, hepatic failure

  • Thrombocytopenia

  • Transient hair loss

• Nursing Considerations:

  • Use cautiously with salicylates (can increase serum levels → toxicity)

  • Take with food to reduce GI upset

  • Swallow tablets/capsules whole to prevent mouth/throat irritation

  • Avoid alcohol and sleep-inducing OTC products

  • Avoid driving or operating machinery until response known

  • Do not abruptly discontinue

  • Notify prescriber before taking any other medications or supplements

  • Keep follow-up appointments and monitor liver function and platelets

---

Lamictal (Lamotrigine)

• Indications:

  • Antiepileptic

  • Bipolar disorder (BPD)

• Mechanism of Action (MOA):

  • Inhibits sodium channels

  • Stabilizes neuronal membranes

• Adverse Effects:

  • Dizziness

  • Agranulocytosis

  • Somnolence (drowsiness)

  • CNS depression

  • Stevens-Johnson syndrome

  • Hypersensitivity reactions

  • Multiorgan failure

  • Blood dyscrasias

  • Suicidal behavior or ideation

• Nursing Considerations:

  • Do not drive until response is known

  • Discontinue immediately if a rash develops (may indicate Stevens-Johnson syndrome)

---

Tegretol (Carbamazepine)

• Indications:

  • Mood stabilizer

• Mechanism of Action (MOA):

  • Decreases synaptic transmission

  • Blocks sodium channels

• Adverse Effects:

  • Agranulocytosis

  • Aplastic anemia

  • Hyponatremia

• Nursing Considerations:

  • Monitor CBC and sodium levels regularly

  • Educate patient on signs of blood disorders (e.g., fever, sore throat, bruising)

Explain the assessment factors for Lithium including the therapeutic index

• Monitoring blood levels of lithium carbonate and divalproex sodium is an ongoing nursing assessment for patients receiving these medications. Side effects of mood stabilizers vary.

• <1.5mEq/L: Mild side effects

  • lethargy, drowsiness, coarse hand tremor, muscle weakness, nausea, vomiting, and diarrhea.

• 1.5-2.5mEq/L: Moderate toxicity

  • lethargy, drowsiness, coarse hand tremor, muscle weakness, nausea, vomiting, and diarrhea.

    • Severe diarrhea

    • Dry mouth

    • Nausea and vomiting

    • Mild to moderate ataxia

    • Incoordination

    • Dizziness, sluggishness, giddiness, vertigo

    • Slurred speech

    • Tinnitus

    • Blurred vision

    • Increasing tremor

    • Muscle irritability or twitching

    • Asymmetric deep tendon reflexes

    • Increased muscle tone

• >2.5mEq/L: Severe toxicity

  • grossly impaired consciousness, increased deep tendon reflexes, seizures, syncope, renal insufficiency, coma, and death.

  • Cardiac arrhythmias

  • Blackouts

  • Nystagmus

  • Coarse tremor

  • Fasciculations

  • Visual or tactile hallucinations

  • Oliguria, renal failure

  • Peripheral vascular collapse

  • Confusion

  • Seizures

  • Coma and death

Describe signs and symptoms of Lithium toxicity

• can range from mild to severe, requiring immediate medical attention and prompt intervention.

• Moderate toxicity

• lethargy, drowsiness, coarse hand tremor, muscle weakness, nausea, vomiting, and diarrhea.

• Severe toxicity

• grossly impaired consciousness, increased deep tendon reflexes, seizures, syncope, renal insufficiency, coma, and death.

Describe contraindications of Depakote

Use cautiously during pregnancy and lactation. Contraindicated in patients with hepatic disease or significant hepatic dysfunction. Administer cautiously with salicylates; may increase serum levels and result in toxicity.

Describe contraindications of Lamictal

• Known allergic reaction to Lamitrigine

• Coadministration with Valproate

• Rapid Dose Escalation

• Hepatic or renal impairment

• Pregnancy

• Pediatric Patients

List medications used for treatment of acute mania

• Aripiprazole (Abilify): 10-30mg/day

• Asenapine (Saphris): 5-10mg BID

• Cariprazine Vraylar: 3-6mg/day

• Risperidone: 2-6mg daily

• Olanzapine: 10-15 mg daily

• Ziprasidone: 40-80mg with food

List nursing interventions of a client who is manic

• Promoting adherence

• Set clear firm limits

• Teaching

• Promote safe environment, structured enviromnet

• Privacy & Dignity

• Give small, frequent high calorie meals/snacks

• Give rest

• Monitor hydration