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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
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
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
- Highest Axis 1 comorbidity/risk for dual diagnosis due to self medicating with substances (alcohol #1, street drugs #2)
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)
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
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
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
- Risky behaviors
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)
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
- Multiple episodes
- Abrupt onset and termination of depressive episodes
- Worsening with antidepressant treatment
What are mixed states?
- Bipolar mixed states: depression and mania co-occuring
- Depressive mixed states: core of depression, but with racing thoughts
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
How do genetics contribute to BPD?
- Extreme genetic link
- Genograms are important for family history
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
What are the s/s of soft bipolarity?
- 3 or more:
- -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)
What are the 3 stages of manic states
- Acute Mania
- Delirious/Psychotic mania
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
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?
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
What are the S/S of delirious mania?
- ***True emergency as body cannot maintain this state
- Totally out of touch with reality
- Clang associations
- Totally disorganized
- Experience hallucinations
- Extremely dangerous/violent. Extremely labile
- Requires chemical/physical restraints
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)
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
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
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
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
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
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
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
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***
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
Describe hygiene considerations for clients with BPD
- Supervise bathing, as necessary
- Minimize choice of clothing
- Give simple step by step reminders
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
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
Describe Moderate Lithium Toxicity
- 2.0-2.5 mEq/L
- Blurred Vision
- Clonic movements/seizures
- Large output of dilute urine due to kidney failure
Describe Severe Lithium Toxicity
- >2.5 mEq/L
- complex involvement of multiple organ systems (E/F imbalances)
- Irreversible organ damage
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
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)
- -Aripiprazole (Abilify)
- -Olanzapine (Zyprexa)
- -Risperidone (Risperdal)*
- -Haloperidol (Haldol)
What are advantages and disadvantages of using Lamotrigine (Lamictal) to treat BPD?
- -bipolar depression
- -rapid cycling
- -bipolar I and II
- -unipolar depression
- -No weight gain
- -no labs, no sedation
- -no cognitive dulling
- -drug of choice if lithium cannot be used
- -slow dosage titration limits acute use
- -High rate of benign skin rashes
- -Stevens johnson syndrome
- -valproate will double serum lamictal levels
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
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
What are some drugs/substances that precipitate an manic episode?
- Pseudophedrine (Sudafed)
What are some common triggers for mania?
- Sleep deprivation
- Exposure to light
- Time change
- Social Events
- Shopping Centers
- Lack of structure
- Driving in traffic
- Every day obligations