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The Client with a Mood Disorder

The Client with a Mood Disorder. Disturbance of mood. Depression or elation(mania) Bipolar disorder Cyclothymic disorder Dysthymic disorder. Etiology. Theories: Genetics – approximately 7% of populations 20% if close relative has disorder

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The Client with a Mood Disorder

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  1. The Client with a Mood Disorder

  2. Disturbance of mood • Depression or elation(mania) • Bipolar disorder • Cyclothymic disorder • Dysthymic disorder

  3. Etiology • Theories: • Genetics – • approximately 7% of populations • 20% if close relative has disorder • Biochemical: dysregulation in norepinephrine & seratonin • Psychoanalytic: anger turned inward(Freud)

  4. Bipolar Disorderacross the lifespan

  5. http://www.intelecomonline.net/VideoPlayer.aspx?Code=16499A3C13AF531782C780423F05F10047AFE015421C6F59C59D1C4BE29966419DB0DE9907C7277588086571A5E90DCBhttp://www.intelecomonline.net/VideoPlayer.aspx?Code=16499A3C13AF531782C780423F05F10047AFE015421C6F59C59D1C4BE29966419DB0DE9907C7277588086571A5E90DCB

  6. Bipolar disorder (Manic episode) • Onset - before 30 • Characterized by “abnormally and persistently elevated, expansive, or irritable mood.” • 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

  7. Assessment of Physiologic Integrity (Manic client)) • May not eat or drink for days • Excessive or poor grooming/hygiene • Has not slept for days & does not feel the need to sleep (insomnia) • Fatigue • Extremely poor judgment leading to • Increased risk for injury • Exhibits seductive or aggressive behavior • Electrolyte imbalance

  8. Assessment of Psychologic Integrity(manic client) • May have psychotic symptoms i.e hallucinations/delusions of grandeur • Labile mood swings (hostile/angry) • Pressured speech/tangential • Racing thoughts –”flight of ideas” • Risk for other directed violence • Flirtatious/seductive

  9. PET Scan: Top Row = Normal BrainMiddle Row = Hypomanic BrainBottom Row= Depressed BrainM. Phelps, L. Baxter, J. Mazziotta UCLA

  10. 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 levels:300mg t.i.d. –q.i.d. • Long term Maintenance level between 0.6 –1.2 mEq/L • Q Monthly checks

  11. Lithium toxicity • Toxicity levels: blood levels > 2.0 mEq/L • Signs/symptoms: • tremors • Nausea/vomiting • Thirst • Polyuria • Coma, seizures, cardiac arrest

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

  13. 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 (5-8x’s greater than population) Mood Stabilizers

  14. Lamotrigine(Lamictal) Topiramate(Topamax) Gabapentin (Neurontin) Oxcarbazepine (Trileptal) Can cause serious rashes > in children; Stevens-Johnson syndrome Common s/e’s all mood stabilizers: Dizziness, hypotension, ataxia - Monitor gait, & B/P, give w/food; Teach client about s/e’s Mood stabilizers con’t.

  15. 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 (prevent injuries) • Accept hostility-do not argue/challenge client • Assist with ADL’S as needed, • Observe for s/e’s meds/AVOID DIURETICS • Provide Teaching re: med compliance • Maintain fluid/salt intake

  16. Depression and Suicide

  17. http://www.intelecomonline.net/VideoPlayer.aspx?Code=16499A3C13AF531782C780423F05F1009EE913D6C0FF60AFCD7B80DD7CA52EE01EC50279787EE6A04E3B999A519F5108http://www.intelecomonline.net/VideoPlayer.aspx?Code=16499A3C13AF531782C780423F05F1009EE913D6C0FF60AFCD7B80DD7CA52EE01EC50279787EE6A04E3B999A519F5108

  18. Children with depression • Symptoms of depression in children may include: • Apathy • Irritability and • Persistent Sadness

  19. Client with Major Depression: Effect on Physiologic Integrity& related Nursing Diagnosis • Early morning awakening-insomnia at night (Altered sleep patterns) • Fatigue • Decreased grooming & ADL’s (self-care deficit) • Constipation (altered elimination patterns) • Anorexia w/wt. loss (altered nutrition<bodyrequirements) • Loss of sexual interest (Impaired rolerelationships) • Psychomotor retardation (Impaired mobility/Activity intolerance) • Somatic complaints (Ineffective coping) • Amenorrhea (Altered health patterns)

  20. Effects on Psychologic integrity& related Nursing Diagnosis • Loss of ambition (avolition), • Lack of interest (anhedonia) in activities/sex • Feelings of boredom/sadness • Feels helpless/hopeless/powerless/tearful • Low self-esteem (Self esteem disturbance) • Attention/concentration deficit & • Difficulty w/decision making (Altered thought process) • Demanding/dependent behaviors • Suicidal ideation- (Risk for suicide may ↑ as depression begins to lift and energyreturns)

  21. Elderly Depressed client • Compaints of impaired memory • Decreased attention/concentration • Increased forgetfulness/confusion/ somatic complaints • Self-care deficits • Functional changes in daily activities • Highest suicide risk –older, single, (widowed/divorced) white male/chronic illness/pain • Somatic complaints & delusions

  22. Nursing Interventions • Monitor I & O weight • Maintain routine/schedule of activities • Remove harmful objects/protect from self-harm • Assess suicidal ideation/contract for safety/ check client frequently( Risk increases as depression lifts!) • Assist with ADL’s/hygiene/grooming • Encourage positive self-talk

  23. “Suicide - it’s the only way out”

  24. Risk for Self-harm: suicide

  25. Assessment of Risk factors for Suicide • Expression of hopelessness, helplessness, worthlessness • Client has a formulated plan • Client has the ability to carry out the plan • There is a history of previous attempts or family history • Recent attempts have become more painful,violent or lethal

  26. Assessment of Risk factors for Suicide • The client is white male adolescent or single, widowed,divorced male>55 years old, lives alone. • Client may be terminally ill, addicted or psychotic • Clinet gives away personal belongings, settles financial accounts, etc. • Clinet is in the early stage of antidepressant treatment and his/her mood & activity level has begun to elevate. • The client’s mood and activity level suddenly changes.

  27. ANTIDEPRESSANTS: Tricyclic’s(TCA’s): Elavil, Disipramine. Imipramine MAOI’s: Marplan,Nardil Parnate Selective Serotonin Reuptake inhibitors(SSRI’s) I.e. Prozac, Paxil, Celexa, Lexapro, Zoloft SNRI’s I.e. effexor Miscellaneous: Remeron, cymbalta,Wellbutrin Medical management of Depression

  28. SSRI’s: 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/food Encourage adequate fluids Antidepressant therapy (SSRI’s)

  29. Venlafaxine(Effexor) Duloxetine(Cymbalta) Bupropion(Wellbutrin) Nefazodone(Serzone) Mirtazapine(Remeron) May alter labs: AST ALT, alk phos, Createnine,gluc,lytes; Monitor for ↑B/P & HR Can lower seizure threshold; ↑B/P,HR (as above) Check labs:AST,ALT LDH,chol,glu,Hct Sedation:Give in PM,monitor wt. gain,sex dysfunction,constipation Atypical antidepressants

  30. Amitriptyline(Elavil) Amoxapine(Asendin) Doxepin(Sinequan) Imipramine(Tofranil) Desipramine (Norpramine) Nortriptyline(Pamelor) Monitor & educate client: cholinergic s/e’s i.e. dry mouth, blurred vision, constipation,Ortho-B/P, **cardiac dysrhythmias/functionlethal in OD *caution use in elderly Tricyclic Antidepressants

  31. Isocarboxazid (Marplan) Phenelzine (Nardil) Tranlcypromine (Parnate) Educate regarding: low tyramine diet potentially fatal drug to drug interactions i.e. Meperidine, SSRI’s,TCA’s, amphetamine *can be lethal in OD Monoamine Oxidase Inhibitors

  32. Electroconvulsive Therapy Saves Lives. But 70 Years After It First Gained Currency as a Treatment For Major Depression, ECT Continues to Court Controversy The controversy of ECT treatments

  33. Electro Convulsive Therapy • Normal Pre-op preparation: NPO after 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

  34. ECT of Yesterday

  35. Patients received treatment without anesthesia Held down by straps Sometimes experienced broken bones from violent seizures ECT later viewed negatively-seen as last resort treatment. ECT treatments in 1950’s

  36. A case for ECT [as reported in the Washington Post July 24, 2007] Mr. M. woke up at 5 a.m. one morning nearly 10 years ago and heard a message in his head telling him to kill himself. He wrote a goodbye note to his wife, then jumped off the back deck of their home, falling the 14 feet hard enough to wake her with the sound of his thud. The 66-year-old organic chemist succeeded only in smashing his knees and skull. After surgery he was transferred to an intensive psychiatric care unit. Mr. M. had been depressed for about six months. He suffered from poor sleep, and he told his wife that he could not go on vacation as he believed he could not walk. During his 4 month hospitalization, Mr. M received a several unsuccessful trials of antidepressants. Mr. M. an older individual with "treatment-resistant" depression, decided to try ECT weeks after his psychiatrist and wife first urged him to do so. By the seventh of his 12 treatments, he felt his depression lift. "He sat up and said, “I'm not depressed anymore”

  37. No longer viewed as a last resort treatment Patient receives anesthesia Controlled medical environment Specially trained Doctors and Nurses Maintenance therapy prevents relapse Effective in treating major depression in older adults Current use of ECT

  38. Dealing with Inappropriate behaviors

  39. 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

  40. DE-ESCALATING 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 client’s needs • Avoid verbal struggles • Provide clear options/deal with behaviors • Assist with problem solving/decision making

  41. Dealing with Manipulative behaviors • Set clear,consistent, realistic • 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

  42. NCLEX Review Questionsthe client with a mood disorder

  43. 1.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 client’s: • 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 includes sexual innuendos and teasing the staff

  44. 2. 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

  45. 3. 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

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

  47. 5. 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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