NURS 260 Exam #2

Describe and recognize the normal aging process of memory functioning

-Age related memory deficiencies and slower response times have been reported. Short term memory seems to deteriorate with age because of poorer sorting strategies, long term does not show changes

-Well-educated, mentally active people don’t exhibit the same decline as others

-Time required for memory scanning is longer for both recent and remote recall

Describe and recognize the normal aging process of intellectual functioning

-High degree of regularity in intellectual functioning

-Knowledge acquired in the course of education/life experiences tend to remain stable or even increase over the adult life span

-Fluid abilities may decrease over time

Describe and recognize the normal aging process of learning ability

-Ability to learn doesn’t diminish with age though it is influenced by interests, activity, motivation, health, and experience

Describe the physical, emotional and spiritual needs of an aging adult

What is abnormal of the ageing process?

-Depression

-Alzheimer’s

What are different types of elder abuse?

-Neglect

-Financial

-Verbal

-Physical

-Emotional

-Spiritual

What are some physical declines that are normal in the ageing process?

-Decreased sensory abilities

-Decrease pulmonary function

-Decreased immune function

What are some functions that do not change in older adults?

-Intellectual function

-Capacity function

-Productive engagement in life

Identify s/s of depression in an older adult

-Excessive concern with physical health (tired, sleeping disturbance)

-Complaints of sadness less prominent

Describe elder abuse s/s and treatment options

What medications might you use for older adults who are depressed?

Define loneliness and the impact on the aging adult

What is delirium? (causes, onset, S/S, treatment approaches, interventions and outcomes)

-Causes:

• Systemic infections, febrile illness or hyperthermia, CNS disorders, Metabolic disorders, hypoxia, COPD, uncontrollable pain, nutritional deficiency, social isolation/sensory deprivation, cardiopulmonary disorders, substance intoxication, substance withdrawal, and medication-induced

-Onset:

• Characterized by a disturbance in attention and awareness and a change in cognition that develop rapidly over a short period of time. It can last for about a week to a month. RAPID ONSET

• Age of patient and duration of delirium influence rate of symptoms resolution.

-S/S:

• Disorganized thinking prevails reflected by speech that is rambling, irrelevant, pressure, and incoherent switching from subject to subject.

• Reasoning ability and goal directed behavior are impaired.

• Very distractible and requires repeated reminders to focus attention. Difficulty sustaining and shifting attention.

• Disorientation often in all three spheres, thought processes are disorganized, judgement is impaired, impaired decision-making ability, illusions misinterpreting the environment, hallucinations, and disturbance sleep-wake cycle.

-Treatment approaches:

• Antipsychotics or anti-anxiety agents may help control behavioral symptoms

• Never leave patient alone

• -Trained “sitters”

• Monitor vital signs

• Sleep-wake cycle

• Keep them safe

-Interventions and outcomes:

• Antipsyhotic meds like Haldol

  • Rationale: Few anticholinergic side effects small likelihood of sedation or hypotension

• Benzodiazepines

  • Used for delirium caused by the withdrawal of alcohol

• Physostigmine

  • For delirium caused by anticholinergic meds

• Palliative treatment with opiates often need with delirium for whom pain is an aggravating factor

• Somatic interventions

  • The choice of somatic interventions for delirium will depend on the specific features of a patient’s clinical condition

Differentiate between delirium, depression and dementia (onset of symptoms, s/s, treatment approaches, interventions and outcomes)

Delirium: Sudden, acute (hours to days)

Depression: May be gradual or related to life events

Dementia: Gradual, insidious onset (months to years)

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COURSE & DURATION

Delirium:

• Fluctuating throughout the day

• Symptoms worse at night

• Short duration if treated

Depression:

• Relatively stable throughout day

• Often worse in morning

• Can be episodic or chronic

Dementia:

• Progressive, chronic deterioration

• Symptoms relatively stable day-to-day

• Irreversible (in most cases)

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LEVEL OF CONSCIOUSNESS

Delirium:

• Altered/fluctuating

• Ranges from lethargy/stupor to hypervigilance

• Difficulty maintaining attention

Depression: Normal, alert

Dementia: Normal until late stages

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ATTENTION & MEMORY

Delirium:

• Significant attention deficits - easily distracted

• Difficulty engaging in conversation

• Recent memory impaired

Depression:

• Attention may be reduced

• Memory complaints prominent but performance normal on formal testing

• "I don't know" responses common

Dementia:

• Attention relatively preserved early on

• Progressive memory loss - especially recent events

• Tries to answer but confabulates

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PERCEPTUAL DISTURBANCES

Delirium:

• Illusions (misinterpretations - folds in bedclothes seen as rats)

• Hallucinations common (especially visual and tactile)

Depression: Absent (unless severe with psychotic features)

Dementia: May occur in later stages

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PHYSICAL SYMPTOMS

Delirium:

• Autonomic changes: tachycardia, sweating, flushed face, dilated pupils, elevated BP

• Sleep-wake cycle reversal

Depression:

• Excessive concern with physical health

• Fatigue, sleep problems

• Less prominent sadness in older adults

Dementia: Generally absent until late stages

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REVERSIBILITY

Delirium: ✅ Reversible if underlying cause corrected promptly

Depression: ✅ Treatable - symptoms improve with treatment

Dementia: ❌ Generally irreversible and progressive

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Critical Note:

⚠ Depression and dementia can COEXIST

⚠ Depression and delirium can COEXIST

⚠ Pseudodementia - depression mimicking dementia; symptoms disappear when depression is treated

What are medications are used to treat dementia, more specifically Alzheimer’s?

-Cholinesterase inhibitors

-NMDA receptor antagonists

What are examples of Cholinesterase inhibitors?

-Donepezil (Aricept)

-Rivastigmine (Exelon)

-Galantamine (Razadyne)

What are the target symptoms and side effects of Cholinesterase inhibitors?

-Target symptoms:

• Cognitive impairment

• Apathy

• Psychosis

• Agitation

• Anxiety

• Nighttime behavior

• ADL’s

-Side effects:

• Dizziness

• Headache

• GI upset

What are examples of NMDA receptor antagoists?

-Namenda (Memantine)

What are the target symptoms and side effects of NMDA receptor antagonists?

-Target symptoms: Cognitive impairment

-Side effects:

• Dizziness

• Headache

• Constipation

What are the stages of Alzheimer’s disease or dementia?

-Stage 1. No apparent symptoms

• Early stage. No decline in memories despite the changes that are beginning to occur in the brain

• PET scans can be used to detect changes

-Stage 2. Very mild changes

• Loses things, forgets names of people. Losses of short-term memory

• Aware of decline. Feels ashamed and depressed which makes sx worse

• Use of lists and structured routine help maintain sameness/order

• Noticed by others. Still okay to work/socialize

-Stage 3. Mild cognitive changes.

• Changes in thinking and reasoning that interfere with work performance

• May get lost when driving the car

• Concentration interrupted. Difficulty recalling names. Others notice.

• Decline in ability to organize or plan

-Stage 4. Moderate cognitive decline.

• Forget major events in personal history (child’s birthday, anniversaries)

• Declining ability to perform tasks (shopping, cooking, mangaing finances)

• Denies there is a problem. Engages in confabulation

• Depression and social isolation are common. Needs help to maintain safety.

-Stage 5. Moderately severe cognitive decline.

• Decrease in the ability to perform some independent ADL’s

• Forgets address, phone numbers, or relatives’ names

• Disoriented to time, place, but OK with self

• Frustration, withdrawal and self-absorption

-Stage 6. Severe cognitive decline.

• Forgets the name of spouse and misidentifies people

• Disoriented to surroundings

• Cannot manage ADL’s without assistance

• Sleeping is a problem

• Wandering, obsessiveness, agitation

• Symptoms worse in afternoon (sundowning)

-Stage 7. Very severe cognitive decline.

• Cannot recognize family members

• Confined to bed

• Aphasic

• Problems with immobility, decubitus, contractures

• Loses interest in food

• Body jerking

What would you do for a patient with dementia who wanders a lot and is on fall precaution?

Environmental & Safety Modifications

Electronic Monitoring:

✅ Electronic sensing systems to alert staff when patient attempts to stand or leave bed/wheelchair

✅ Door alarms to notify staff of wandering attempts

Physical Environment:

✅ Lower beds to reduce fall injury risk

✅ Reduction of obstacles in walking paths

✅ Improved lighting to enhance visibility and reduce confusion

✅ Mobility devices (walkers, canes) if appropriate

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Staffing & Supervision Approaches

✅ Adjust staffing patterns to provide closer monitoring

✅ Enhanced staff training on dementia care and fall prevention

✅ Never leave patient alone - constant supervision is key

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Therapeutic Interventions

Physical Strengthening:

✅ Strength training programs to improve balance and mobility

Behavioral Management:

✅ Tailored activities program (TAP) - addresses individual abilities and may reduce restlessness that leads to wandering

✅ Music therapy - consistently shown to reduce agitation

✅ Dementia mapping - specialized observation to determine patient-centered care approaches

Communication Approach:

✅ Warm, empathic, calm communication

✅ Simple, step-by-step instructions

✅ Introduce yourself with each encounter

✅ Provide simple, limited choices to maintain sense of control

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AVOID Restraints ⚠

Physical restraints should only be used as emergency last resort when there's threat to safety - never for behavior control.

Why? Restraints in elderly patients contribute to:

• Cognitive impairment

• Physical weakness

• Increased fall risk

• Anxiety and emotional withdrawal

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Use the DICE Approach

Describe - the wandering behavior and possible triggers

Investigate - Is there a modifiable cause? (pain, need to toilet, boredom, searching for something familiar)

Create - a revised care plan

Evaluate - Did the strategy work?

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What are interventions for family and community for neurocognitive disorders?

-Support caregivers

-Help them identify and explore the feelings of anger, guilt, and denial (grieving over a loved one)

What are interventions for neurocognitive disorders, like Alzheimer’s or dementia?

-Adjust daily routines to focus on the person, not the task

-Adjust interaction and communication strategies to ensure the person receives the message

-Changing reactions and response to behavior

-Monitor and adjust the environment

-MAKE SURE THEY ARE SAFE

What are the S/S of generalized anxiety disorder?

-The anxiety and worry are accompanied by at least three of the following physical or cognitive symptoms:

• Edginess or restlessness

• Tiring easily; more fatigued than usual

• Impaired concentration or feeling as though the mind goes blank

• Irritability (which may or may not be observable to others)

• Increased muscle aches or soreness

• Difficulty sleeping

What is the difference between everyday anxiety and anxiety disorder?

-Everyday anxiety is like worrying about paying bills, landing a job, a romantic breakup or other important life events. Anxiety disorder is constant and unsubstantiated worry that causes significant distress and interferes with daily life.

-Anxiety disorder is seemingly out-of-the-blue panic attacks and the preoccupation with the fear of having another one

What are interventions for GAD?

-Actively listen to the individual and encourage exploration of feelings

-Reassure individual about their safety

-Validate their feelings and concerns

-Explore alternative/new coping strategies

-Help acknowledge anxiety rather than deny or intellectualize it

-Assist in identifying behaviors that indicate individual is feeling anxious

-Assist individual with connecting anxiety with uncomfortable physical, emotional, or behavioral responses

-Discourage the use of caffeine, alcohol, or drugs to “calm the nerves”

-Provide information

-Teach the patient and family/significant others about anxiety disorders

-Educate the patient about the s/s of the disorder

-Support treatment adherence

-Promote care of sleep including nutrition and sleep

-Access informatics can provide patient information and learning tools to help reduce symptoms

-Daily routine to offer physical and emotinal safety

-Include the patient in decisions and individualized care

What are interventions for agoraphobia?

-Psychotherapy

• Individual “Talk” therapy

• Cognitive behavioral therapy

-Medication

• Benzodiazepines (episodic)

  • Xanax for social phobias

• Beta blockers

• SSRI’s

-Behavioral

• Systemic desensitization

  • Creation of graduate exposure to the fear stimuli. Encouraged to refrain from using avoidance response

• Implosion

  • Bombarding or flooding the patient with an exaggerated version of the phobic stimuli

-Education

• Explore the concept that phobias are learned behaviors that can be unlearned and discuss how new behaviors can be learned

What are interventions for panic?

-Recognize the signs

-Remain calm

-Stay with the individual

-Don’t make assumptions about what ther person needs

-Speak to the person in short, simple sentences using a soothing voice

• “I am here with you”

• “I won’t leave”

• “It won’t last long”

• “You are safe”

-Avoid repeating saying things like: “Don’t worry”

-Don’t repeatedly ask if they are alright

-Be predictable

-Help slow the person’s breathing by breathing with them or by counting slowly to 10

• Hand over the belly

• Slow, deep breathing

• Remind them to keep breathing

-Do not touch the individual unless invited to do so

-Grounding

• Ice cube

• Frozen orange

• Feet on the ground

What are the goals and outcomes of phobias?

-The patient will:

• Acknowledge and discuss the fears and concerns

• Verbalize feelings of anxiety and present ideas for how to manage those feelings

• Recognize signs of escalating anxiety and intervene before reaching panic level

• Function adaptively in the presence of the phobic object or situation without experiencing panic anxiety (phobic disorder)

• Verbalize a plan of action for responding in the presence of the phobic object or situation without developing panic anxiety (phobic disorder)

What is an example of an SNRI and the side effects of SNRIs?

-Example: Venlafaxine (Effexor)

-Side effects: Insomnia, palpitations, and increase blood pressure

What is an example of NaSSA and its side effects?

-Noradrenergic and specific Serotonin Antidepressant

-Example: Mirtazapine (Remeron)

-Side effects: Sedation, weight gain, and increase appetite

What is a benzodiazepine?

-Most commonly used anti-anxiety (anxiolytic) drug

-Acts through the CNS and have muscle relaxation, sedative, and anxiolytic and anticonvulsant effects

-It is short acting

What are example medications of Benzodiazepine?

-Alprazolam (Xanax)

-Lorazepam (Ativan)

-Chlordiazepoxide (Librium)

-Diazepam (Valium)

-Clonazepam (Klonopin)

What is the onset of action and half-life of Alprazolam (Xanax)?

-Onset of action: Fast-intermediate

-Half-life: 12-15 hours

What is the onset of action and half-life of Lorazepam (Ativan)?

-Onset of action: Intermediate

-Half-life: 12-20 hours

What is the onset of action and half-life of Chlordiazepoxide (Librium)

-Onset of action: Intermediate

-Half-life: 8-28 hours

What is the onset of action and half-life of Diazepam (Valium)

-Onset of action: Fast

-Half-life: 20-80 hours

What is the onset of action and half-life of Clonazepam (Klonopin)?

-Onset of action: Slow

-Half-life: 18-50 hours

What are the side effects of Benzodiazepine?

-Drowsiness/sedation

-Confusion

-Ataxia

-Dizziness

-Respiratory depression

-Increased irritability

-Tolerance, dependency

-Re-bound insomnia/anxiety

What is Withdrawal syndrome?

-Potentially life threatening

-DO NOT SUDDENLY STOP TAKING MEDICATION

-Typically, withdrawal symptoms begin

• Short acting: 6-8 hours after last dose

• Long acting: Within 24-48 hours after last dose

What are symptoms of Benzodiazepine Withdrawal syndrome?

-Agitation

-Anorexia

-Rebound anxiety

-Generalized seizures

-Psychosis (hallucinations)

What is the first line of treatment for anxiety disorder?

-Antidepressants

What are the nursing implications of SSRI, SNRI, NDRI, and NaSSA

-Can take 6-12 weeks to reach desired therapeutic effect

-Use with caution in patients who are taking other CNS medications or who have liver dysfunction

-Contraindicated with MAOIs

-Monitor for increased suicide ideation in all populations

-Avoid grapefruit juice due to its effect on the CYP3A4 enzyme that affects the bioavailability of the medication

-Abrupt cessation may lead to discontinuation syndrome

-Monitor for serotonin syndrome

What are the nursing implications of Benzodiazepines?

-Significant risk of dependence

• Ordered for short periods of time

-Dangerous in overdose

• Especially with alcohol

-Severe withdrawal symptoms if abruptly withdrawn

• Withdraw slowly

What are defense mechanisms?

-Serves to help the patient subconsciously distance themselves from unwanted feelings and prevent new unwanted ones from forming. Tension reduction is the overall goal of defense mechanisms. It is a protective mechanism.

-If someone is using a defense mechanism, DO NOT REMOVE unless they have found other things to replace it

What are the different types of defense mechanisms?

-Denial

-Displacement

-Intellectualization

-Projection

-Rationalization

-Reaction formation

-Regression

-Repression

-Sublimation

What is denial?

-Claiming/believing that what is true to be actually false

What is displacement?

-Redirecting emotions to a substitute target

-Example: yelling at a partner or child after being yelled at by a boss, as challenging the boss is unsafe

What is intellectualization?

-Taking an objective viewpoint

-Example: focusing on funeral logistics rather than grief, researching disease statistics after a diagnosis, or rationalizing a breakup instead of acknowledging sadness

What is projection?

-Attributing uncomfortable feelings to others

What is rationalization?

-Creating false but credible justifications

-Example: blaming external circumstances for personal failures (e.g., "I failed because the teacher hates me") or justifying unhealthy habits (e.g., "I'll smoke just this once because I'm stressed")

What is reaction formation?

-Overacting in the opposite way to the fear

-Example: being overly kind to someone you dislike or preaching strict morality to mask one's own desires.

What is regression?

-Going back to acting as a child

What is repression?

-Pushing uncomfortable thoughts into the subconscious

What is sublimation?

-Redirecting “wrong” urges into socially acceptable actions

-Example: A person with intense aggressive impulses joins a football team or takes up boxing to channel their anger into competitive, structured physical activity

What are the signs and symptoms of schizophrenia?

-Positive symptoms (Additions to a person’s experience and not normally present):

• Disturbance in thought content

  • Hallucinations

  • Delusions

• Disturbance in thought process

  • Disorganized thoughts

  • Disorganinzed speech

• Disturbance in behaviors

  • Erratic, strange, unexpected movements, posturing, waxy flexibility

  • Interpersonal interactions may be unpredictable or inappropriate in social situations

-Negative symptoms (A loss or deficiency in normal functioning):

• Disturbances in emotions

  • Affective flattening

  • Anhedonia

  • Avolition (Lack of motivation)

  • Alogia (Reduction in quantity or content of speech)

  • Asociality

-Cognitive

• Disturbances in cognition

  • Attention issues

  • Verbal fluency

  • Executive function

  • Decrease ability to understand social situations

  • Memory issues

  • Reasoning

What do you note when someone is experiencing hallucinations?

-Talking to themselves

-Assumes a “listening” pose, laughing or talking to self, stopping in midsentence

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. Which of the following is the most appropriate follow-up assessment based on this information?

A. Ask the patient if he is experiencing loose associations

B. Ask the patient if he needs more medication

C. Ask the patient if he is hearing something or someone other than the nurse’s voice

-D. Ask the patient if his neck is stiff

C. Ask the patient if he is hearing something or someone other than the nurse’s voice

What are the First Generation/Typical Antipsychotic agents?

-Thorazine (chlorpromazine)

-Haldol (haloperidol)

-Prolixin (fluphenazine)

What are the side effects of First Generation/Typical Antipsychotic agents?

-Anticholinergic effects

-EPS

-Agranulocytosis

-Orthostatic hypotension

-Tardive dyskinesia

-Neuroleptic malignant syndrome

What are the second generation Atypical antipsychotics?

-Clozaril (clozapine)

-Risperdal (risperidone)

-Zyprexa (olanzapine)

-Seroquel (quetiapine)

-Abilify (aripiprazole)

What are the common side effects of second generation Atypical antipsychotics?

-Drowsiness, light-headedness

-Anticholinergic symptoms (You dry up. Constipation, dry mouth, blurred vision)

-Metabolic syndrome (weight gain and hyperglycemia)

-QT interval prolongation

-Orthostatic hypotension

What are the nursing implications of monitoring and administering psychotropic medications?

-Takes 1-2 weeks to effect change

-Common: 6-12 weeks before changing prescription

• A change in medication is indicated if a reduction in symptoms is not seen

-Do not withdraw suddenly unless due to a medical emergency (e.g. NMS)

-Clozaril may be considered if a trial of atypical and typical antipsychotic agents provided ineffective

-Adherence is a challenge

-Long-acting or depot medications should be considered

-Medications taken for a lifetime unless patient develops:

• Neuroleptic malignant syndrome

• Agranulocytosis

• Tardive dyskinesia

What is the difference between first and second generation antipsychotics?

-First generation medications are used to treat the positive symptoms of schizophrenia

-Second generation medications are used to treat positive and negative of schizophrenia

What are the side effects of Clozaril and what are some tests you need to take?

-Agranulocytosis

-It is extremely low levels of white blood cells (neutrophils)

-Side effects of agranulocytosis: high fever, lesions of the mucous membranes and skin, and a sharp drop in circulating granular white blood cells

-Weekly blood tests for the first 6 months and then every two weeks after that

Educational topics for families of individuals

-Listen and emphasize and agree and partner

-LEAP

What is Cogentin?

-Treatment of EPS/movement disorders

-Warning: Avoid use in pregnancy, while breast feeding, hot weather. May aggravate symptoms of tardive dyskinesia

-Education: Take with meals to reduce dry mouth and gastric irritation. Good oral hygiene. Notify MD if increased heart rate. Do not abruptly stop medication…flu like symptoms

What is EPS?

-Extrapyramidal symptoms that are psychotropic adverse effects

-Includes, akathisia, akinesia, dystonia, Parkinsonian-like movements aka Pseudo-parkinsonism, tardive dyskinesia

What is tardive dyskinesia?

-An EPS that usually appears after prolonged treatment of

-Characterized by uncontrollable, repetitive movements, such as lip smacking, eye blinking, or limb jerking.

What is akathisia?

-Characterized by a subjective feeling of intense inner restlessness and a compelling, uncontrollable urge to move, often caused by antipsychotic medications

What is akinesia?

-The loss or severe impairment of voluntary muscle movement, characterized by an inability to initiate movement, leading to freezing or immobility

What is Neuroleptic Malignant Syndrome (NMS)?

-An uncommon potentially fatal idiosyncratic reaction to a neuroleptic medication

-Major manifestations: Fever, rigidity, and elevated creatine phosphokinase level

-Minor manifestations: Tachycardia, abnormal BP, tachypnea, altered consciousness, diaphoresis, and leukocytosis

-The presence of all three major or two major and four minor manifestations indicates a high probability of the presence of NMS if supported by clinical history

What are the S/S of Bipolar type 1?

-Emotional manifestations

• Elation

• Increased gratification

• Self-love

• Increased attachment

• Increased mirth response

-Cognitive manifestations

• Positive self-image

• Positive expectations

• Assignment ofblame

• Denial

• Delusions

-Motivational manifestations

• Impulse driven

• Action oriented

• Drive for independence

• Drive for self-enhancement

-Physical and vegetative manifestations

• Hyperactivity

• No appetite

• Increased libido

• Insomnia

• Increased tolerance for fatigue

What are the primary concerns we have with second generation antipsychotic medications?

-Metabolic syndrome like weight gain and hyperglycemia

-Dietary responses are important

What are the primary symptoms of bipolar I?

-Mania

-Not really a history of depression, but it can happen but it is not a hallmark

Memory tools for symptoms of Mania

-DIG FAST

-Distractibility

-Impulsivity

-Grandiosity (unrealistic overinflated sense of superiority, importance, or entitlement)

-Flight of ideas/racing thoughts

-Activity/energy increase

-Sleep needs diminish

-Talkative

What are the S/S of Bipolar II?

-Five or more symptoms must be present

-Depressed mood most of the day, nearly every day

-Loss of interest or pleasure in all, or almost all, activities

-Trouble falling asleep, waking up too early, or sleeping too much

-Significant weight loss or decrease or increase in appetite

-Engaging in purposeless movements, such as pacing

-Fatigue or loss of energy

-Diminished ability to think or concentrate, or indecisiveness

-Feeling hopeless, guilty, worthless, or thinking about death or suicide

What are the S/S of hypomania?

-A milder version of mania that lasts for a short period (usually a few days). Mania is a more severe form that lasts for a longer period (a week or more)

-Symptoms of hypomania are “not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization

-S/S:

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least four consecutive days and present most of the day, nearly every day

• During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:

  • Inflated self-esteem or grandiosity

  • Decreased need for sleep

  • More talkative than usual or pressure to keep talking

  • Flight of ideas or subjective experience that thoughts are racing

  • Distractibility

  • Increased in goal-directed activity

  • Excessive involvement in pleasurable activities that have high potential for painful consequence

• The disturbance in mood and the change in functioning are observable by others

• The episode is not severe enough to caused marked impairment in social or occupational functioning or to necessitate hospitalization

• The episode is not attributable to the physiological effects of a substance

What medications are the first line of treatment for bipolar disorders?

-Anticonvulsants

• Depakote (Valproic acid)

• Lamictal (Lamotrigine)

• Tegretol (Carbamazepine)

-Antimanic

• Lithium carbonate

What is Valproic Acid (Depakote)?

-A fatty acid that works by reducing activity of the protein kinase C pathway, enhancing the action of the inhibitory neurotransmitter GABA

-Recommended for acute mania of mixed episodes or rapid cycling

-Side effects:

• Elevated of liver enzymes

• Hand tremor

• Weight gain

• Transient hair loss

• Dose-related thrombocytopenia

What is Carbamazepine (Tegretol)?

-Alternative treatment for manic episodes when Lithium or Valproic Acid are ineffective

-More rapid onset than Lithium

-Chemically related to TCAs

-Side effects:

• Can decrease levels of olanzapine (Zyprexa), Clozaxpine (Clozaril), Risperidone (Risperdal), Aripiprazole (Abilify), Quetiapine (Seroquel), Valproic Acid (Depakote), and Lamotrigine topiramate (Lamictal)

• Decrease effectiveness of birth control pills

• Hyponatremia

• Increased risk for blood dyscrasias

• Agranulocytosis (S/S: Decrease in WBC, fever, infection, sore throat, sores in mouth, easily bruised, need to monitor CBC weekly, can be lethal)

What is Lamotrigine (Lamictal)

-Potential for the development of Steven-Johnson syndrome

What is Stevens-Johnson syndrome?

-AKA Toxic Epidermal Necrolysis

-Medical emergency and life threatening

-Causes skin tissue to die and detach

-Severe reaction triggered by medication

-First symptoms: Fever and flu like symptoms

-After 1-3 days: Red or purplish rash forms and skin begins to blister and peel leading to raw area of skin (painful)

-Starts on face, then to mucus membranes of eyes (conjunctivitis), mouth (trouble swallowing/breathing), and genitals (difficulty urinating)

What is Lithium Carbonate?

-No longer used as the first line of treatment for mania

-Now used for maintenance

-Requires a vigilant approach

-Narrow therapeutic index

What is the therapeutic serum level of Lithium?

-0.6 mEq/L - 1.4 mEq/L (acute mania)

-0.6 mEq/L - 1 mEq/L (maintenance)

What are common side effects of Lithium?

-Headache

-Occasional n/v, diarrhea

-Dizziness or drowsiness

-Mild hand tremors

-Dry mouth

-Increased urination and thirst

-Thinning of hair or hair loss

-Acne-like rash

How would you monitor therapeutic lithium levels?

-Frequency

• Every weel for 1st 1-2 months of treatment

• Then, evey month x3 months

• Then every 306 months

  • Concurrently complete UA and monitor renal and thyroid function

-Collection

• 10-14 hours after last lithium dose

• Generally, in the AM before first dose

How does Lithium impact sodium and caffeine consumption?

-Maintain a constant sodium and caffeine intake

-A sudden decrease in caffeine or sodium may increase lithium levels

-A sudden increase in caffeine or sodium may decrease lithium levels

What are the potential causative factors of lithium toxicity?

-Decreased sodium intake

-Diuretic therapy

-Decrease renal function

-Fluid and electrolyte loss

-Overdose

-Heart failure

-Nonsteroidal anti-inflammatory drug therapy

What medications are used to control mania?

-Atypical antipsychotic medication

• Olanzapine (Zyprexa)

• Aripoprazole (Abilify)

• Quetiapine (Seroquel)

• Risperidone (Risperdal)

What is Olanzapine (Zyprexa)?

-When given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis

What is Aripoprazole (Abilify)?

-Approved for treatment of mania or episode

-Maintenance treatment after a severe or sudden episode

What is Quetiapine (Seroquel)?

-Relieves the symptoms of severe and sudden mania

-The first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes

What is Risperidone (Risperdal)

-Used to control mania or mixed episodes

What antidepressants are used to treat symptoms of depression?

-Fluoxetine (Prozac)

-Paroxetime (Paxil)

-Sertraline (Zoloft)

What is Neurontin (Gabapentin)?

-Off-label use for bipolar disorder

-Used as an adjunct, not primary treatment

What are dangerous side effects of Gabapentin (Neurontin)?

-Call MD if:

• Fever, rash, swollen painful or tender lymph nodes in neck, armpit, groin

• Unusual bleeding/bruising

• Yellowing of eyes and skin

• May be sx of a serious life-threatening allergic reaction aka: DRESS

What is the rationale and concerns of Benzodiazepines?

-Rationale:

• Used as adjunctive treatment for anxiety in patients with bipolar disorder

• Modest anti-manic and antidepressant effect

-Concerns

• Risk for disinhibition

• Risk for dependence, tolerance, and abuse

What are nursing interventions for someone in mania?

-Avoid encouraging patient to express feelings or concerns

-Reduce stimulation in the environment

-Walk with patient during convesations

-Give patient space to reduce potential agitation

-Attend to patient care needs:

• Rest

• Nutrition

• Hydration

• Medication