The Client with a Mood Disorder

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The Client with a Mood Disorder
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Disturbance of mood

• Depression or elation(mania)
• Bipolar disorder
• Cyclothymic disorder
• Dysthymic disorder

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Etiology

• Theories
• Genetics
• approximately 7 of populations
• 20 if close relative has disorder
• Biochemical dysregulation in norepinephrine
  seratonin
• Psychoanalytic anger turned inward(Freud)

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Bipolar disorder (Manic episode)

• Onset - before 30
• Mental Status ASSESSMENT
• hyperactivity, euphoria,pressured speech
• sarcasm,easily angered,aggressive,hostile
• exaggerated or delusional self-confidence,
• Flight of ideas, grandiose, persecutory delusions
• Inappropriate dress/attire
• Short-term depression Risk for suicide

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Physiologic assessment

• Inability to sleep yet still active
• Decrease in ADLs(inappropriate dress/attire)
• Restlessness
• Sexually hyperactive/promiscuous
• Inability to eat/sleep due to distractibility and
  involvement in multiple task
• Dehydration

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Medical managementanti-manic drug

• Lithium Carbonate(eskalith, lithane, lithotabs)
• Starting dose 600mg t.i.d.
• Maintain blood serum level of 1.0 1.5 mEq/L
• Check blood. Serum levels 2x/WK. 12 HRS after
  last dose is administered.
• Maintenance dose levels300mg t.i.d. q.i.d.
• Maintain level between 0.6 1.2 mEq/L
• Q Monthly checks

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Lithium toxicity

• Toxicity levels blood levels gt 2.0 mEq/L
• Signs/symptoms
• Tremors
• Nausea/vomiting
• Thirst
• Polyuria
• Coma, seizures, cardiac arrest

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• Use of antipsychotics to control agitation,
  psychotic behaviors
• i.e. Haloperidol(haldol), Fluphenazine(prolixin),
• Risperidone(risperdol)
• Perphenazine(trilifon)
• Quitipine(seroquel)
• Olanzapine(zyprexa)

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• Valproic Acid(Depakote) etc.
• Carbamazepine
• (Tegretol)

• Check liver functions (at start q 6 mos.)
• Can cause hepatic failure/life threatening
  pancreatitis
• Can cause aplastic anemia agranulocytosis
  (5-8xs greater than population)

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Mood stabilizers cont.

• Lamotrigine(Lamictal)
• Topiramate(Topamax)
• Gabapentin (Neurontin)
• Oxcarbazepine
• (Trileptal)

• Can cause serious rashes gt in children
  Stevens-Johnson syndrome
• Common s/es all mood stabilizers
• Dizziness, hypotension, ataxia- Monitor gait,
  B/P give w/food Pt. teaching res/es

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Nursing Interventions/Bipolar client

• Determine what client is attempting to say
• Help client to maintain focus/SET LIMITS
• Offer finger foods/boxed, canned fluids
• Provide quiet, non-stimulating environment
• Stay with client/use silence as needed.
• Remove harmful objects
• Accept hostility-do not argue/challenge client
• Assist with ADLS as needed,
• Observe for s/es meds/AVOID DIURETICS
• Provide Teaching
• Maintain fluid/salt intake

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Client with Major Depression Effect on
Physiologic Integrity

• Early morning awakening-insomnia at night
• Fatigue
• Constipation
• Anorexia w/wt. loss
• Loss of sexual interest
• Psychomotor retardation
• Somatic complaints (chest pain/wheezing,
  inability to swallow, GI distress)
• Neurologic Sx.(agitation, memory difficulties,
  restlessness, sleep disturbance)
• amenorrhea

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Effects on Psychologic integrity

• Loss of ambition(avolition),
• Lack of interest (anhedonia) in activities/sex
• Feelings of boredom/sadness/tearfulness
• Feels helpless/hopeless/powerless/tearful
• Low self-esteem/feelings of inadequacy
• Attention/concentration deficit
• Difficulty w/decision making
• Demanding/dependent behaviors
• High risk for suicide!!! Especially when
  depression begins to lift and energy returns
• Violence (homicidal thoughts, violence against
  property, animals, caregivers)

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Medical management

• ANTIDEPRESSANTS
• Tricyclics Elavil, Disipramine, Imipramine
• MAOIs Marplan,Nardil Parnate
• Selective Serotonin Reuptake inhibitors(SSRIs)
• I.e. Prozac, Paxil, Celexa, Lexapro, Zoloft
• SNRIs i.e. effexor
• Miscellaneous Remeron, Cymbalta,Wellbutrin

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Antidepressant Therapy

• SSRIs
• Fluoxetine(Prozac)-give in AM
• Sertaline (Zoloft) give in PM if drowsy
• Paroxetine (Paxil) give in PM if drowsy
• Citalopram(Celexa)
• Escitalopram (Lexapro

• Monitor for
• Hyponatremia/sexual dysfunction orthostatic B/P
• Give w/foodenc adequate fluids

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Atypical antidepressants

• Venlafaxine(Effexor)
• Duloxetine(Cymbalta)
• Bupropion(Wellbutrin)
• Nefazodone(Serzone)
• Mirtazapine(Remeron)

• May alter labs AST ALT, alk phos,
  Createnine,gluc,lytes
• Monitor for inc B/P HR
• Can lower seizure threshold
• inc. B/P,HR
• (as above)
• Check labsAST,ALT LDH,chol,
• gluc,Hct
• Sedation Give in PM,
• Monitor wt. gain,
• Monitor sex dysfunction,
• constipation

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Tricyclic Antidepressants

• Amitriptyline(elavil)
• Amoxapine(Asendin)
• Doxepin(Sinequan)
• Imipramine(Tofranil)
• Desipramine(Norpramine)
• Nortriptyline(Pamelor)

• Monitor educate re cholinergic s/es dry
  mouth, blurred vision, constipation,Ortho-B/P,
  cardiac dysrhythmias/functionlethal in OD
• caution use in elderly

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Monoamine Oxidase Inhibitors

• Isocarboxazid (Marplan)
• Phenelzine (Nardil)
• Tranlcypromine (Parnate)

• Educate re low tyramine diet potentially fatal
  drug to drug interactions i.e. Meperidine,
• SSRIs,TCAs, amphetamine
• can be lethal in OD

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Assessment of client with depression

• Decrease in ADLs
• Decreased self-confidence/self-esteem
• Decrease emotion/physical activity/posture
• Loss of appetite,constipation,slowing body
  functions/metabolism
• Easily fatigued,inability to make decisions
• Internalizing hostility, withdrawal
• Decreased attention/concentration
• Elderly clients increased forgetfulness/confusio
  n/ memory loss/somatic complaints

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Nursing Interventions

• Monitor I O weight
• Maintain routine/schedule of activities
• Remove harmful objects/protect from self-harm
• Assess suicidal ideation/contract/ check
  frequently
• Assist with ADLs/hygiene/grooming
• Encourage positive self-talk

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Electro Convulsive Therapy

• Normal Pre-op preparation NPO p midnight
• Informed consent
• Remove hairpins, dentures, nail polish
• Loose fitting clothing or hospital gown
• Check vital signs after procedure
• Reorient and assure any memory loss is temporary
• Assist to room or significant other if out -
  patient

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Dealing with Inappropriate behaviors

• AGGRESSIVE BEHAVIORS
• Assist client to identify feelings of
  frustration/aggression
• Encourage discussion of feelings rather than
  acting out
• Assist client to identify precipitating
  events/situations that lead to aggressive
  behaviors
• Define consequences for self
• Assist client to Identify previous coping skills
• Assist client in problem solving techniques

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DEESCALATING TECHNIQUES

• Maintain safety of client/others/self
• Maintain distance from client/use non-threatening
  posture
• Use calm approach/communicate in a calm
  manner/use clear tone of voice
• Identify clients needs
• Avoid verbal struggles
• Provide clear options/deal with behaviors
• Assist with problem solving/decision making

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Dealing with Manipulative behaviors

• Set clear,consistent, realistic ,enforceable
  limits
• Communicate expected behaviors
• Avoid power struggles/arguing
• Assist client to set limits on own behavior
• Be clear re consequences associated with
  exceeding set limits/follow through with the
  consequences
• In non punitive manner if necessary

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• The nurse assesses a client with admitting
  diagnosis of Bipolar affective disorder mania.
  The symptom presented by the client that requires
  the nurses immediate interventions the clients
• Outlandish behaviors/inappropriate dress.
• Grandiose delusions of being royal decendents of
  King Author
• Non-stop physical activity and poor nutritional
  intake
• Constant incessant talking that inclkudes sexual
  innuendos and teasing the staff

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• The nurse needs to assess a client for
  depression. Identify the signs and symptoms that
  are most characteristic of this disorder. (Select
  all that apply)
• Diarrhea
• Constipation
• Sleep disturbance
• Increased appetite
• Anhedonia
• Poor appetite

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• When assessing clients who are exhibiting a
  depressed episode and those who are exhibiting a
  manic episode of bipolar mood disorder what
  characteristic common to both disorders is the
  nurse likely to note?
• Suicidal tendency
• Underlying hostility
• Delusions
• Flight of ideas

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• A 19 year-old client is brought to the ER after
  slashing both wrists. What is the nurses first
  concern?
• Stabilization of the physical condition
• Determine the causative factors relevant to
  clients wrist slashing
• Reduction of anxiety
• Obtain a detailed nursing history

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• Which assessment findings would lead the nurse to
  suspect that a client is at a high risk for
  suicide? (Select all that apply)
• Hopelessness accompanied by withdrawal
• Several available supports
• Marked degree of hostility
• Mostly constructive coping mechanisms
• Continual abuse of alcohol /or drugs
• History of multiple previous lethal attempts

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• What feeling tone is the nurse most likely to see
  the client demonstrate during a major depression
  with psychotic features?
• Suspicion
• Agitation
• Loneliness
• Worthlessness

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• A female client with bipolar I disorder is noted
  to wear excessive make-up, brightly colored
  evening clothes that do not match, a vest, three
  different scarves, and several necklaces and
  bracelets. Several peers on the unit have been
  laughing about her appearance. Which nursing
  action would best preserve the clients
  self-esteem?
• Help the client change into more appropriate
  attire.
• Explain to the peer group that the client has
  bipolar disorder.
• Discuss issues of good groomingat the community
  meeting.
• Tell the client that she must select less
  flamboyant clothing.

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• A priority nursing intervention for a client who
  underwent ECT treatment a half hour ago, would
  be
• Monitor vital-signs
• Offer oral fluids
• Encourage group participation
• Evaluate ECT effectiveness

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• Which of the following statements made by a
  client regarding the medication Lithium indicate
  a need for additional client education regarding
  this treatment?
• I will drink 8 12 glasses of liquids daily.
• I will restrict my salt intake.
• I will take my medications with food.
• I will have my blood drawn as the physician
  orders.

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• What assessment exam is a priority for the nurse
  to perform on a client with a mood disorder?
• Answer_________________________

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• The nurse is admitting a client with mania and a
  nursing diagnosis of imbalanced nutrition less
  than body requirements as evidenced by reported
  inadequate food intake. When intervening with
  this client the nurse should (select all that
  apply)
• Offer 3 well-balanced meals per day
• Provide high calorie snacks
• Arrange for finger-foods for the client
• Offer food Q 15 minutes during the first hour
  after admission to the unit
• Encourage the client to avoid activities
• Offer the client juice and cold beverages