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What are the 3 types of Bipolar disorders?
- Bipolar 1: More common in males
- Bipolar 2: More common is females
- Cyclothymia: usually begins in adolescence or early adulthood
What is the suicide rate in bipolar? What is the most common morbidity with bipolar? What is the median number of manic episodes?
- suicide rate is 15%
- Alcohol abuse (or substance abuse) is big comorbidity
- median # of episodes is 9
What are the key points of bipolar disorder? wat is it defined by?
- costly, common and treatable
- Defined by recurrent episodes of mania or hypomania and depression
- *it is often misdiagnosed
What is the difference between bipolar and depression?
- Bipolar: earlier age of onset, more fears
- Unipolar: more cognitive/somatic symptoms
What is the dsm-5 criteria for bipolar disorder?
- Distinct period of abnormally and persistent elevated, expamsive or irritable mood for at least *four days for hypomania *1 week for mania
- During mood disturbance, at least 3 of the following symptoms:
- increased activity level
- sexual or psychomotor agitation
- unusual talkativeness (pressured speech [you won't get a word in, they just keep talking])
- flight of ideas
- reduced sleep
- inflated self esteem, grandiosity
- risky behavior
Why is bipolar often mis or undiagnosed? What is the most common misdiagnosis?
- 35-60% have depression first
- Depression is far more prevalent than mania
- May have many depressive episodes prior to mania
- Many will not report mania/hypomania
- May progress to psychosis
- Lag between symptom onset and first treatment with mood stabilizer
- most common misdiagnosis: depression
The lag between symptom onset and first treatment with mood stabilizer is dangerous, why?
- (average lag time is 9.8 years)
- the greater the lag the worse social functioning, more hospitalizations, higher suicide rates
What are the differences among the three types of bipolar (for diagnosis)?
- Bipolar 1: At least one episode of mania, alternating wit major depression
- Bipolar 2: hypomanic episode(s) alternating with major depression
- Cyclothymia: hypomanic episodes alternating wit minor depressive episodes (2 years)
What are clues to the diagnosis for bipolar disorder?
- history of mania
- family history of bipolar
- earlier age onset of symptoms
- elevated or irritable mood
- school truancy or failure
- occupational failure
- multiple failed relationships
- multiple episodes
- abrupt onset and termination of depressive episodes
- Worsening with antidepressant treatment
- severe anhedonia(inability to feel pleasure)
What is the biggest comorbidity in childhood?
- *beware of stimulant use without mood stabilizer
What are the different types of mixed states?
- Bipolar mixed states: depression and mania co-occurring
- Depressive mixed states: core of depression, but with racing thoughts
What is the mnemonic for the diagnostic criteria for bipolar?
- DIG FAST
- D: distractibility
- I: indiscretions (excessive pleasure activities)
- F: flight of ideas
- A: activity increase
- S: sleep deficits
What are the other common comorbidities with bipolar?
- substance use disorders-highest
- *Risk for suicide
- personality disorders- non med compliant
- Eating disorders
describe substance abuse and bipolar disorder
- bipolar d/o is the highest axis 1 disorder comorbid/concurrent with substance abuse
- bipolar disorder is second to antisocial personality disorder in terms of concurrent substance abuse
- Substance use adversely effects medication, produces earlier onset of symptoms and often leads to hospitalizati
How much do genetics play in BP D/O
- 28% likely with one parent
- 3x the risk with both parents
What is hyperthymic temperament or soft bipolarity?
- exuberant, upbeat, over energetic, overconfident
- verbally aggressive, self assured
- Strong willed, self employed, risk taking, sensation seeking
- history of legal problems
What is soft bipolarity?
- 3 or more
- major depressive episodes with failed drug trials
- distinct professions
- 1st degree relatives with affective illness
What are the 3 stages of manic states?
- acute mania
- delirious mania
What are the characteristics of mania?
- Thought processes and cognitive function:
What is stage 1 for hypomania-assessment?
- Mood: fluctuating, cheerful to irritable, hostile nature of person=volatile
- Behavior: extroverted, sociable, inappropriate, easily distracted
- Cognition: rapid flow of ideas, flighty, exalted sense of self
What are the questions for detecting hypomania?
- Do you have days of energy or ideas that come and go abruptly?
- On those days of energy, are you productive? creative? feel unconquerable? convinced your self worth, talents, abilities? Positive about the future? talkative? distinctly social? irritable?
- On those days of energy, do your thoughts feel as if thy're racing?
What is stage 2? assessment for stage 2?
- stage 2-mania
- Mood: unstable- euphoric to irritation/anger continuous high
- Behavior: psychomotor hyperactivity/nonstop activity; constitutes an emergency
- thought process: flight of ideas
- clang associations
- pressured speech
What is stage 3?
- Delirious mania
- totally out of touch with reality
- clang associations
- totally disorganized
- experience hallucinations
- extremely dangerous
- requires chemical/physical restraints
What should you assess in mania? Why?
- assess danger to self and others
- because death can occur from exhaustion, not eating or sleeping
- poor impulse control can lead to self harm or harm of others
- suicide is 20 times higher
- uncontrolled spending
- protect from giving away
- Assess medical status
- mania secondary to medical condition or drugs/meds
- because stroke, hyperthyroidism, traumatic brain injury can occur
- assess for substance use and anxiety disorders
- (have exceptionally co-morbidity)
how should you communicate with clients with Bipolar?
- firm, calm approach
- sort, concise explanations
- be neutral; avoid power struggles, do not join in joking
- consistent approach and expectations
- convey limits, consequences
- act on legitimate complaints redirect energy
How should the nurse structure the environment?
- Maintain low level of stimuli
- structured solitary activities with staff
- redirect violent behavior
- minimize physical harm: medication/seclusion
- observe for medication side effects/toxicity
- protect from consequences of behavior, such as giving way money or possessions
What are the goals for treatment?
- reduce presenting symptoms
- stabilize mood
- improve functioning
- improve quality of life
- prevent relapse
- prevent consequences
What are the nursing interventions?
- Prevent injury
- prevent exhaustion
- maintain adequate hydration/nutrition
- decrease psychomotor agitation
- encourage appropriate social interactions
- limit setting
What nutrition care should you do for bipolar?
- monitor I&O and vitals
- offer frequent high-calorie protein drinks
- provide finger foods
- remind client to eat
- walk or sit with client to encourage eating
What elimination care is needed?
- monitor bowel elimination
- offer high fiber foods
- evaluate need for laxative
- encourage client to go to bathroom
What should you do to promote sleep?
- encourage rest periods during day
- reduce stimulation
- avoid caffeine
- use sleep inducing interventions
What hygiene care needs are necessary?
- supervise bathing as necessary
- minimize choices of clothing give simple step by step reminders
What medication is big for bipolar?
- Lithium carbonate
- half life: 24 hours
- Labs: 8-12 hours after last dose
- Therapeutic and toxic levels
- therapeutic: 0.5-1.5 mEq/L
- Maintenance: .8-1.2 mEq/L and above
What is mild toxicity of lithium? Wat will you see?
- coarse hand tremors, confusion
- hyperirritability of muscles
- drowsiness, lack of coordination
- persistent GI upset
- Salivary gland swelling
- excessive salivation
- EKG changes
What is moderate toxicity? What will you see?
- blurred vision
- clonic movement/seizures
- large output of dilute urine
What is severe toxicity?what will you see?
- greater than 2.5mEq/L
- complex involvement of multiple organ systems
- irreversible organ damage
What are the interventions for lithium toxicity?
- D/C immediately
- Notify MD
- Obtain vitals
- obtain lithium level
- Labs: electrolytes, BUN, creatinine, UA, CBC
- consider emetic if awake
What medications besides lithium are used?
nvalproic Acid ( Depakote)
What antianxiety meds are used for Bipolar?
- Clonazepam (Klonopin)
- Lorazepam (ativan
- Orally or IM for agitation or psychosis
What antipsychotics are used for bipolar?
- aripiprazole (abilify) IM or PO
- Olanzapine (zyprexa) IM
- risperidone (riperadal) Consta IM every 2 weeks
- Haloperidol (haldol) IM
What are the advantages and disadvantages of lamictal?
- Advantages: bipolar depression, rapid-cycling, propylaxis, bipolar I and II, unipolar depressions; very well tolerated, no weight gain, no labs, no sedation, no cognitive dulling
- Disadvantages: slow dosage titration limits acute utility, skin issues, high rate of benign skin rashes, fear of Steven Johnson's, increased risk of SJS with aggressive dosing
- Valproate will double lamictal serum levels
What education is needed for clients on lamictal for ski rash safety?
- warn clients not to change soaps, laundry detergents, OTC products, unusual foods during first 6 weeks of lamotrigine titration
- Assess rash (severity, location and feautures)
- discontinue if: rash os severe, painful, or rapidly evolving. any blistering, systemic symptoms, mucous membrane involvement
How can you help to maintain compliance?
- Assist client to overcom denial and promote compliance by: establishing a therapeutic alliance
- maintai regular appointments/visits
- involve family in care
- educate client about side effects
- risperdal consta IM
What are common triggers for mania?
- Sleep deprivation
- exposure to light
- time change
- social events
- shopping centers
- lack of structure
- driving in traffic
- every day obligations