Mental Health Quiz 4 Outline Bipolar disorder ATI pg 73 - Bipolar 1: At least one episode of mania alternating with depression, it is more common in men o Mania: Abnormally elevated mood; expansive or irritable; lasts at least 1 week; usually requires hospitalization - Bipolar 2: One or more hypomanic episodes alternating with major depressive episodes; more common in women o Hypomanic: less severe mania which lasts at least 4 days with 3 or more s/s of mania; no hospitalization is required - Cyclothymic: at least 2 years of repeated hypomanic manifestations that don’t meet the criteria for hypomanic episodes alternating with minor depressive moods o Rapid Cycling: 4 or more episodes of hypomania or acute mania within 1 year and is associated with increased recurrence and resistance to treatment. - Acute Phase o Hospitalization can be required o Reduction of mania and pt safety are the goals o Risk of harm to self or others is determined o One to one supervision can be indicated - Continuation Phase o Treatment is usually 4 to 9 months long o Relapse prevention through education, medication adherence, and psychotherapy is the goal - Maintenance Phase o Treatment generally continues throughout the patient’s lifetime o Prevention of future manic episodes is the goal - Assessment ATI pg 73-74 o Risk Factors: § Genetics: having an immediate family member with bipolar disorder • § 5-10 times more likely to have BPD Physiological • Neurobiological disorder: norepinephrine, dopamine (controls body movements, thinking and emotions) and serotonin (controls mood) o Too much= mania, too little = depression • Neuroendocrine disorder: hypothyroidism associated with depressed mood and in some patients experiencing rapid cycling § Environmental • Increased stress in the environment can trigger mania and depression and increase risk for severe manifestations in genetically susceptible children o Mood § Manic: Elevated, expansive, irritable § Depressive: Dysphoric, depressive, despairing o Behavior § § Manic: • Speech: loud, rapid, rhyming, vulgar, clanging, punning • Possible weight loss • Distracted, hyperactive, inappropriate, decreased need for sleep Depressive: • Decreased interest in pleasure • Negative views • Fatigue, insomnia • Decreased appetite, decreased libido • Suicidal preoccupation • May be agitated or have movement retardation o Thought Process: § Manic: • Flight of ideas: rapid continuous speech with sudden and frequent topic changes • Grandiosity: grandiose view of self and abilities • Impulsivity: spending money, giving away money or possessions o Cognitive Functioning - Nursing actions ATI pg 74 o Therapeutic Mileu § Safe environment, assess regularly for suicidal thoughts/ escalating behaviors § Decrease stimulation without isolating patient § Frequent rest periods § Provide outlets for physical activity § Protect from poor judgement and impulsive behavior o Maintenance of self care needs § Monitor sleep, fluid intake, and nutrition § Give finger foods high in calories § Supervise choice of clothes § Give step by step reminders for hygiene and dress o Communication - § Calm, matter of fact, specific approach § Give concise explanation § Provider consistency with expectations and limit setting § Avoid power struggles and don’t react personally to patient comments § Listen to and act on legitimate client grievances § Reinforce nonmanipulative behavior § Use therapeutic communication Complications of Bipolar Disorder ATI pg 74 o Possible exhaustion and possible death § Pt in a true manic state usually will not stop moving and does not eat, drink, or sleep • This can become a medical emergency o Nursing Actions § Prevent self-harm § Decrease patient physical activity § Ensure adequate food and fluid intake § Promote an adequate amount of sleep each night § Assist with self-care needs § Manage medications Medications for Bipolar Disorder - Lithium (Mood Stabilizer) o Controls episodes of acute mania, helps prevent return of mania or depression, and decreases incidence of suicide o Complications § GI Distress: Nausea, diarrhea, abdominal pain • § § § Give lithium with meals or milk Fine hand tremors: Can increase with stress or caffeine • Administer beta blocker (propranolol) • Decrease dosage or give in divided doses or use long acting Poluria,mild thirst • Use a potassium sparing diuretic • Pt should drink 1.5-3 L of water a day Renal Toxicity • Monitor I & O • Adjust dose and keep dose at the lowest level necessary • § § Goiter and hypothyroidism ( with long term treatment) • Assess baselines T3,T4, and TSH levels • Administer levothyroxine Brady dysrhythmias, hypotension, and electrolyte imbalance • § Assess BUN and Creatinine Pt should maintain adequate fluid and sodium intake Weight Gain • Educate patient on a healthy diet and a regular exercise regimen o Different toxicity levels § Early (1.5-2.0 mEq/L) • S/S: metal confusion, sedation, poor coordination, tremors, GI distress (N/V/D) • Medication should be withheld, administer a new dose based on lithium and sodium levels and promote excretion. § Advanced (2.0-2.5 mEq/L) • S/S: extreme polyuria of dilute urine, tinnitus, jerking movements, blurred vision, ataxia, seizures, severe hypotension, and stupor leading to a coma, possible death from respiratory complications • Administer emetic to alert patients, or administer gastric lavage • Urea, mannitol, or aminophylline can be used to increase excretion. § Severe (greater than 2.5 mEq/L) • S/S: rapid progression of manifestations leafing to coma and death • May need hemodialysis o Nursing actions § § Monitor plasma lithium levels • Every 2-3 days until stable, then every 1-3 months • Obtain in the morning, 10-12 hours after last dose During initial treatment, higher levels might be needed • 1-1.5 mEq/L § Maintenance level : 0.6-1.2 mEq/ L § Effects begin within 5-7 days, MAX benefits seen in 1-3 weeks § IMPORTANT: FLUID AND SODIUM INTAKE o Interactions § Diuretics, NSAIDS, and anticholinergics (antihistamines, TCAs) o Lab values to monitor for lithium - § Creatinine § Sodium § TSH § T4 § Lithium Mood stabilizers o Treat and prevent relapse of manic episodes § Particularly useful for patients with mixed mania and rapid-cycling o Carbamazepine § CNS: Nystagmus, double vision, headache, vertigo, staggering gait § Blood Dyscrasias • Obtain baseline CBC and platelets o WBC: leukopenia (infection) o RBC: Anemia § Pale, Fatigue o Platelets: Thrombocytopenia • Monitor s/s of thrombocytopenia o Bruising, bleeding gums • Monitor s/s of infection o Fever, lethargic o Valproate § GI effects: N/V, indigestion § Hepatotoxicity § • s/s: anorexia, jaundice, N/V, fatigue, abdominal pain • Obtain baseline LFT and monitor Pancreatitis • s/s: N/V, abdominal pain § Thrombocytopenia: monitor platelets § Weight Gain § Teratogenesis o Lamotrigine § Double or blurred vision, dizziness, and headache § Steven Johnson Syndrome • Serious Skin rashes Obsessive Compulsive Disorders ATI pg 58 - Intrusive thoughts + unrealistic obsessions + tries to control these thoughts with compulsive disorders - Body Dysmorphic Disorder o Pt becomes preoccupied with an imagined defective body part which results in obsessional thinking and compulsive disorder (mirror checking, camouflaging) - Hoarding Disorder o Pt has an obsessive desire to save items regardless of value and experiences extreme stress with thoughts of discarding or getting rid of items Anxiety disorders ATI pg 57-58 - Trichotillomania (Hair pulling disorder) o Trichophagia (swallowing the hair) is common and can lead to hair masses (trichobezoars), which can progress to abdominal obstruction or perforation which is called Rapunzel syndrome - Dermatillomania (Skin picking Disorder) - Social Anxiety Disorder (excess fear of social situation) - Separation Anxiety Disorder (fear/anxiety when separated from someone they are emotionally attached to) - General anxiety disorder o Uncontrollable excessive worry for at least 6 months o Characteristics: restlessness, muscle tension, avoidance of stressful activities, increase time and effort required to prepare for stressful events or activities, procrastination in decision making, sleep disturbance. - Panic disorder o Recurrent panic attacks (usually last 15 to 30 minutes) 4 or more usually present o S/S: palpitations, SOB, choking or smothering sensation, chest pain, nauseas, feelings of depersonalization, fear of dying or insanity, chills, or hot flashes o The pt can experience behavior changes and/or persistent worries about when the next attack will occur - Specific Phobias (Irrational fear of a certain object or situation) Anxiety levels ATI pg 21 - Mild (has an identifiable cause) o Occurs in normal everyday living, o Characteristics: mild discomfort, restlessness, irritability, impatience, and apprehension § Ex: pt is pacing up and down the hallway. o Mild tension relieving behaviors: finger or foot tapping, fidgeting, lipchewing - Moderate (occurs when mild anxiety escalates) o Slightly reduced perception and processing of info occurs, selective inattention can occur. o Ability to think clearly is impaired, but learning and problem- solving can still occur o Other characteristics: concentration difficulties, tiredness, pacing, change in voice pitch, voice tremors, shakiness, increased heart, and respiration rate o Somatic manifestations: headaches, backache, urinary urgency and frequency, and insomnia o Someone with moderate anxiety usually benefits from the direction of others - Severe (pt cannot take directions from others) o Perceptual field is greatly reduced o NO LEARNING OR PROBLEM SOLVING o Patient cannot learn at this level § Pt can be DEESCALATED to a mild or moderate anxiety level and THEN they can be taught o Functioning is effective, behaviors are automatic o Characteristics: Confusion, feeling of impending doom, hyperventilation, tachycardia, withdrawal, loud and rapid speech, aimless activity - Panic Level (markedly disturbed behavior) o Pt is not able to process what is occurring in the environment and can lose touch with reality o Pt experiences EXTREME fright and horror § Can also experience SEVERE hyperactivity, flight, or immobility o Other Characteristics: Dysfunction in speech, dilated pupils, severe shakiness, severe withdrawal, inability to sleep, delusion, and hallucinations - Nursing Interventions for Anxiety levels ATI pg 21-22 o Mild to Moderate § Use active listening to demonstrate willingness to help, and use specific communication techniques such as: open ended questions, giving broad openings, exploring, and seeking clarification • Encourages the patient to express feelings, develop trust, and identify source of anxiety § Provide a calm presence, recognizing the patient’s distress • § Assists the patient to focus and begin to problem solve Evaluate past coping mechanisms • Assists the patient to identify adaptive and maladaptive coping mechanisms. § Explore alternatives to problem situations • § Offers options for problem solving Encourage Participation in activities such as exercise that can temporarily relieve feelings of inner tension • Provides an outlet for pent up tension, promotes endorphin release, and improve mental well being o Severe to Panic Level § Provider an environment that meets the physical and safety needs of the patient. Remain with the patient and remain calm • This minimizes the risk to the patient, who might be unaware of the need for basic things such as fluids, food, and sleep § Provide a quiet environment with minimal stimulation • Helps to prevent intensification of the current anxiety level § Use meds and restraints, but only after less restrictive interventions have failed to decrease anxiety to safer levels • Meds and/or restrains might be necessary to prevent harm to the patient, other patients, and providers § Encourage gross motor activities such as walking and other forms of exercise. • Provides an outlet for pent up tension, promotes endorphin release, and improve mental well being § Set limits by using firm, short, and simple statements, Repetition can be necessary. Speak slowly and in a low-pitched voice. • Can minimize risk to patient and providers, Clear simple communication facilitates understanding § Direct the patient to acknowledge reality and focus on what is present in the environment • - Focusing on reality helps with reducing the patient’s anxiety level Cognitive Behavioral Therapy ATI pg 38 o Cognitive reframing § Changing cognitive distortions can decrease anxiety § Cognitive reframing helps identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk • Priority Restructuring: Helps pt identify what requires priority • Journal Keeping: Helps pt write down stressful thoughts and has a positive effect on well-being • Assertiveness training: Teaches pt to express feelings and solve problems in a non-aggressive manner • Monitoring thoughts: Helps pt to be aware of negative thoughts o Relaxation Breathing § Guided imagery, breathing exercises, progressive muscle movements § Ex: relaxation, meditation, physical exercise o Systematic Desensitization § Planned, progressive, or graduated exposure to anxiety-provoking stimuli • During exposure the pt uses relaxation techniques to reduce anxiety o Response prevention § Preventing a pt from performing compulsive behavior with the intent that anxiety will decrease o Thought stopping § Teaches a pt to say “STOP” when negative thoughts or compulsive behaviors arise and then substitute with a positive thought § Goal is for the patient to eventually use the command silently o Flooding § While with a therapist, a patient is exposed to a great deal of undesirable stimulus to attempt to turn off the anxiety response o Modeling § Pt sees a demonstration of appropriate behavior in a stressful situation; in order to later imitate the same behavior o Aversion therapy § Pairing of maladaptive behavior with a punishment or unpleasant stimulu to promote a change in behavior • EX: Rubber band to stop you from chewing your hair o Operant conditioning § - Pt receives positive rewards for good behavior Defense mechanism ATI pg 19-20 o Adaptive: helps people achieve their goals in acceptable ways and reduce anxiety o Maladaptive: interferes with functioning, relationships, and orientation to reality and are used in excess o Undoing § Performing an act to make up for a prior behavior (commonly seen in children: also think OCD) § Adaptive: Adolescent completes their chores, without being prompted, after a fight with his parents § Maladaptive: Boyfriend buys his partner flowers after abusing her o Splitting § Demonstrating an inability to reconcile negative and positive attributes of self or others into a cohesive imagine § Adaptive: N/A § Maladaptive: A married patient who is attracted to another person accuses their partner of having an affair.
