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What are the 3 types of BPDs?
- Bipolar I: episodes of full mania
- Bipolar II: severe depression and hypomania
- Cyclothermia: hypomania and mild depression
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Describe the epidemiology of BPD
- Bipolar I is more common in males while BPD II is more common in females
- Accounts for about 1/7 of all psych admission and is 5x more likely to be arrested
- Cyclothymia usually begins in adolescence or early adulthood
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Describe comorbidity and BPD
- 15% suicide rate- SAFTEY
- 70% alcohol abuse
- 90% reoccurrence rate with an ave of 9 episodes
- Personality Disorders and non med compliance
- Social Phobias/Panic Disorder
- Eating Disorders
- ADHD
- Highest Axis 1 comorbidity/risk for dual diagnosis due to self medicating with substances (alcohol #1, street drugs #2)
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What are the key points for BPD?
- Costly, common, treatable
- Defined by recurrent episodes of mania or hypomania and depression
- Often misdiagnosed (9-10 yrs of symptoms before getting treatment)
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Compare and contrast BPD and depression
- Important to diagnosis correctly as treatment and prognosis is different. Must get an accurate and thorough history on assessment
- Bipolar: earlier age of symptom onset, more fears
- Unipolar: more cognitive/somatic complaints
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What is the DSM 5 criteria for BPD?
- 1. Distinct period of abnormally and persistent elevated, expansive or irritable mood for at least
- -4 days for hypomania
- -2 week for mania
- 2. During mood disturbances, at least 3 symptoms of BPD
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What are the s/s of BPD?
- Increased activity level
- Sexual or psychomotor agitation
- Unusual talkativeness (pressured speech)
- Flight of ideas (racing thoughts)
- Reduced sleep (exhaustion can be fatal)
- Inflated self esteem, grandiosity
- Distractibility
- Risky behaviors
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What is the differential diagnosis for Bipolar I, Bipolar II and Cyclothymia?
- Bipolar I: at least one episode of mania alternating with major depression
- Bipolar II: Hypomaniac episode(s) alternating with major depression
- Cyclothymia: hypomanic episodes alternating with minor depressive episodes (2yrs)
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What are some clues to diagnose BPD?
- History of mania
- family history of BPD
- earlier age of onset of symptoms
- Elevated or irritable mood
- School truancy or failures
- Occupational failures
- Multiple failed relationships/divorce
- Female
- Multiple episodes
- Abrupt onset and termination of depressive episodes
- Worsening with antidepressant treatment
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What are mixed states?
- Bipolar mixed states: depression and mania co-occuring
- Depressive mixed states: core of depression, but with racing thoughts
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What is the DIG FAST criteria?
- Diagnostic criteria for manic episodes
- D: Distractibility
- I: Indiscretions (Excessive pleasure activities)
- G: grandiosity
- F: flight of ideas
- A: activity increase
- S: sleep deficits
- T: talkativeness
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How do genetics contribute to BPD?
- Extreme genetic link
- Genograms are important for family history
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What is hyperthymic temperment or "soft bipolarity"?
- Exuberant, upbeat, over energetic, over confident
- Verbally aggressive, self assured
- Strong willed, self employed, risk taking, sensation seeking
- History of legal problems
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What are the s/s of soft bipolarity?
- 3 or more:
- -marriages
- -major depressive episodes with failed drug trials
- -distinct professions
- -languages (3 or more)
- -1st degree relatives with affective illness
- (triad of red: red car, red shoes, red tie/scarf is a sign of mania)
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What are the 3 stages of manic states
- Hypomania
- Acute Mania
- Delirious/Psychotic mania
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What assessments should be done for Stage 1 Hypomania?
- Mood: fluctuation. Cheerful to irritable, hostile nature of person=hostile
- Behavior: extroverted, sociable, inappropriate, easily distracted
- Cognition: rapid flow of ideas, flighty, exalted sense of self
- Compliance is an issue with someone in hypomania because they feel good and want to stay there
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What assessments should be done for stage II Mania?
- 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 of your self-worth, talents, abilities? Positive about the future? Talkative? Distinctly more social? Irritable?
- On those days of energy, do your thoughts feel as if they're racing?
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What are the assessments for Stage III delirious Mania
- Mood: unstable- euphoric to irritation/anger, continuous high
- Behavior: psychomotor hypersensitivity/nonstop. ***constitutes an emergency as the body cannot maintain this state**
- Thought Process: flight of ideas, clang associations, pressured speech, hallucinations/delusions
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What are the S/S of delirious mania?
- ***True emergency as body cannot maintain this state
- Totally out of touch with reality
- Grandiosity
- Clang associations
- Totally disorganized
- Experience hallucinations
- Extremely dangerous/violent. Extremely labile
- Hypereligious
- Stupor
- Requires chemical/physical restraints
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Describe safety assessments for BPD
- Death from exhaustion, not eating, not sleeping
- Poor impulse control leading to harm or self/others
- Suicide rates 20x higher
- Uncontrolled spending (protect from doing so)
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Why is it important to assess the medical status of someone with BPD?
- Rule out all other physical causes for symptoms
- Mania secondary to medical condition or drug/meds:
- -stroke, hyperthyroidism, TBI
- -assess for substance use/abuse and anxiety disorders
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What are the priority nursing diagnosis' for BPD?
- 1. Risk for Injury
- 2. Risk for violence to self or others
- 3. Imbalance nutrition, less than requirements
- 4. Disturbed sleep pattern
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What are some communication techniques to use with BPD clients?
- Firm, calm approach
- Short, concise explanations
- Be neutral; avoid power struggles and do not join in joking
- Consistent approach and expectations
- Convey limits, consequences
- Act on legitimate complaints
- Redirect energy
- No group therapy for manic clients
- Consistent staff and staff meetings for expectations
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How can environment be structured for clients with BPD?
- Maintain a 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 away money or possessions
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What are the goals of treatment for BPD?
- 1. SAFETY
- 2. reduce presenting symptoms
- 3. stabilize mood
- 4. improve functioning
- 5. improve quality of life
- 6. prevent relapse
- 7. prevent consequences
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What nursing interventions can be taken for BPD?
- Prevent injury
- Prevent exhaustion
- Maintain adequate hydration.nutrition
- Decrease psychomotor agitation
- Encourage appropriate social interactions
- Limit setting
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Describe nutrition considerations for BPD clients, including elimination
- Monitor I/O and VS
- Offer frequent, high calorie protein drinks
- Provide finger foods
- Remind client to eat
- Walk or sit with client to encourage eating
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Describe sleep considerations for clients with BPD
- Encourage rest periods during day
- Reduce stimulation
- Avoid Caffeine
- Use sleep-inducing interventions (even meds if necessary)
- Sleep deprivation is a major concern as it may lead to hallucinations***
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Describe elimination considerations for a client with BPD
- Use a toileting schedule
- Monitor bowel eliminations
- Offer high fiber foods
- Evaluate need for laxative
- Encourage client to go to the bathroom
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Describe hygiene considerations for clients with BPD
- Supervise bathing, as necessary
- Minimize choice of clothing
- Give simple step by step reminders
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What pharmacological intervention is used for BPD? Describe
- Mood Stabilizer Lithium Carbonate
- Half life of 24 hrs, so lasts taken 8-12hrs after last dose for at least 1-2 wks until in ther range of 0.5-1.5 mEq/L
- Must have adequate renal function and thyroid function
- Get renal and thyroid labs
- In the long term it may damage thyroid
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Describe Mild Lithium Toxicity
- 1.5-2.0 mEq/L
- Course hand tremors, confusion
- Hyperirritability of muscles
- Drowsiness, lack of coordination
- Persistent GI upset
- Salivary gland swelling
- Excessive salivation
- EKG changes
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Describe Moderate Lithium Toxicity
- 2.0-2.5 mEq/L
- Ataxia
- Tinnitus
- Blurred Vision
- Clonic movements/seizures
- Stupor/coma
- Large output of dilute urine due to kidney failure
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Describe Severe Lithium Toxicity
- >2.5 mEq/L
- complex involvement of multiple organ systems (E/F imbalances)
- Irreversible organ damage
- Death
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What interventions can be taken for lithium toxicity?
- Dehydration is a main trigger for lithium toxicity, so stay hydrated*
- 1. D/C med immediately
- 2. Notify MD
- 3. obtain VS
- 4. obtain state lithium level
- 5. labs- electrolytes, BUN, creatinine, UA, CBC
- 6. Hydration- large bore IVS
- 7. consider emetic if awake
- 8. Hemodialysis
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Aside from Lithium, what other medications can be used for BPD?
- Anti-epileptic meds as mood stabilizers:
- Valproic Acid (Depakote)*
- Carbamazepine (Tegretol)
- Lamotrigine (Lamictal)
- Oxcarbazepine (Trileptal)
- Topiramate (Topamax)
- Gabapentin (Neurontin)
- Anti-anxiety meds:
- -Clonazepam (Klonopin)*
- -Lorazepam (Ativan)
- Others:
- -Aripiprazole (Abilify)
- -Olanzapine (Zyprexa)
- -Risperidone (Risperdal)*
- -Haloperidol (Haldol)
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What are advantages and disadvantages of using Lamotrigine (Lamictal) to treat BPD?
- Advantages:
- -bipolar depression
- -rapid cycling
- -prophylaxis
- -bipolar I and II
- -unipolar depression
- -No weight gain
- -no labs, no sedation
- -no cognitive dulling
- -drug of choice if lithium cannot be used
- Disadvantages:
- -slow dosage titration limits acute use
- -High rate of benign skin rashes
- -Stevens johnson syndrome
- -valproate will double serum lamictal levels
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What teaching needs to be done for clients on Lamotrigine (Lamictal)?
- Not to change soaps, laundry detergents, OTC products, unusual foods, etc, during the first 1-6wks of lamictal titration
- Assess for rash and discontinue if rash is severe, painful, rapidly evolving, blistering or if systemic symptoms begin to occur
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What are some ways to increase client medication compliance for BPD?
- Assist the client to overcome denial and promote compliance by:
- -establishing a therapeutic alliance
- -maintain regular appointments/visits
- -involve family in care
- -educate client about side effects
- -risperdal consta IM is helpful
- -DBSA (depression, bipolar support alliance) is outpatient group therapy for clients and family. Involved families decrease the relapse rate
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What are some drugs/substances that precipitate an manic episode?
- ETOH
- Caffeine
- Bronchodilators
- Cocaine
- Steroids
- Pseudophedrine (Sudafed)
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What are some common triggers for mania?
- Sleep deprivation
- Exposure to light
- Stress
- Summer
- Arguments
- Time change
- Social Events
- Shopping Centers
- Lack of structure
- Television
- Driving in traffic
- Overcommitting
- Every day obligations
- Holidays
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