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MOOD AND MOOD DISORDERSA. HISTORICAL PERSPECTIVE
Depression have been documented since the ancient times
Egyptian papyrus (1500 BC) contains a discourse on old age and says
the heart grows heavy and remembers not yesterday
King Saul = alternate moods of elation and depression
Emil Krapelin (1896) identified bipolar disorder as MANIC-DEPRESSIVE
PSYCHOSIS
Hippocrates (460-375? BC) knew the symptoms of depression well and
believed that it resulted from a surplus of black bile which is termed
melancholein the Greek language
Treatment of mood disorders were not effective until the development of
the convulsion-producing drug pentylenetetrazol (Metrazol) by Meduna
followed by the introduction of ECT by Cerletti and Bini in 1938
B. GRIEF & LOSSLOSS
Change in status of a significant other
Any change in individuals situation that reduces the probability of
achieving implicit or explicit goals
An actual or potential situation in which a valued object, person, or other
aspect is inaccessible or changed so that it is no longer perceived as
valuable
Types:
1. sudden2.
gradual
3. predictable4. unexpected5. perceived6. anticipatory
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7. temporary8. permanent
GRIEFNormal, appropriate emotional response to an external and consciously
recognized loss
Time-limited and subsides gradually
Is all-consuming, having a physical, social, spiritual, and psychological
impact on an individual that may impair daily functioning
Feelings vary in intensity; does not necessarily follow a particular pattern,
and the time spent in the grieving process varies considerably, from
weeks to years
Mourningindividuals outward expression of grief regarding the loss of alove object or person
Bereavement process of grief; feelings of sadness, insomnia, poorappetite, deprivation or desolation
Anticipatory griefrefers to the reactions that occur when an individual family, significant
other, or friends are expecting a loss or death to occur; allows the
individual and others to get used to the reality of the loss or death and to
complete the unfinished business
Unresolved or Dysfunctional griefcould occur if the individual is unable to work through the grief process
after a reasonable time
usually an actual or perceived loss of someone or something of great
value to a person
include expressions of distress or denial of the loss, changes in eating andsleeping habits, mood disturbances (anger, hostility, crying), and
alterations in activity levels including libido
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idealizes the lost person or object, relives past experiences, loses the
ability to concentrate, and is unable to work purposefully because of
developmental regression
may exhibit symptoms of anxiety, depression, or psychosis
GRIEF DEPRESSION- disturbance in mood that is
normal, universal, and
necessary in the life experience
of an individual
- disturbance in mood that is apathological elaboration of grief;
related to grief but not the same
- reaction to the real loss of ahighly valued object that may be
tangible or intangible
- reaction to the actual,threatened, or imagined loss of
a valued object, tangible or
intangible; an overwhelming
response to what the individual
considers a catastrophic loss
- self-limiting and graduallydiminishes over a period of
about a year, except in the
elderly
- not self-limiting, goes beyondgrief in duration and intensity;
prolonged and severe
GRIEF DEPRESSION- has different phases - does not enter the phase of
restitution within a few weeks or
months; professional help is
often required
DIFFERENT STAGES OF GRIEFSTAUDACHER (2000) WESTBERG (2004) KUBLER-ROSS (1969)
ShockDisorganization
Shock
Expressing emotion
DenialAnger
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Subsides when the client realizes that someone will help him or her
to express feelings while accepting reality
2. AngerWhy me?, Why now?, Its not fair
May appear difficult, demanding, and ungrateful during this time
3. BargainingIf I promise to take my medication, will I get better,If I get better,
Ill never miss church ever again
Dying client acknowledges his or her fate but is not quite ready to
die at this time
Bargaining to prolong ones life
Cline is ready to take care of unfinished business or begins to
anticipate various losses, including death
4. DepressionWatching the depressed client mourn for future losses
Dying patient is about to lose not just one loved person but
everyone he has ever loved and everything that has been
meaningful to him
5. AcceptanceIm ready
Client has achieved inner and outer peace to a personal victory
over fear
May want only one or two significant people to sit quietly by the
clients side, touching and comforting him or her
RESPONSES AND SYMPTOMS OF THE GRIEVING CLIENTCOGNITIVE Disruption of assumptions and beliefs
Questioning and trying to make sense of the loss
Attempting to keep the lost one present
Believing in the afterlife as though the lost one is the
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guide
EMOTIONAL Anger, sadness, anxiety
Resentment
GuiltFeeling numb
Vacillating emotions
Profound sorrow, loneliness
Intense desire to restore bond with lost one or object
Depression, apathy, despair during phase of
disorganization and despair
Sense of independence and confidence as phase of
reorganization evolves
SPIRITUAL Disillusioned and angry with God
Anguish of abandonment or perceived abandonment
Hopelessness, meaningless
BEHAVIORAL Functioning automatically
Tearful sobbing, uncontrollable crying
Great restlessness, searching behaviors
Irritability and hostility
Seeking and avoiding places and activities shared with
lost one
Keeping valuables of lost one while wanting to discard
them
Possibly abusing drugs or alcohol
Possible suicidal or homicidal gestures or attempts
Seeking activity and personal reflection during phasesor reorganization
PHYSIOLOGIC Headaches, insomnia
Impaired appetite, weight loss
Lack of energy
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Palpitations, indigestion
Changes in immune and endocrine system
COPING REACTION TO DEATH THROUGHOUT THE LIFE CYCLE1. TODDLER
No specific concept of death and thinks only in the terms of the
living
Reacts more to pain and discomfort of illness and immobilization
Separation anxiety
Interventions:
a. Focus on parentsb. Assist parents to deal with their feelingsc. Encourage parents participation in childs care
2. PRESCHOOLERDeath is a kind of SLEEPING; form of punishment
Life and death can change place with one another
If a pet dies, may request funeral and burial
Interventions:
a. Utilize play for expressing thoughts and feelingsb. Explain what is death that it is final and not sleepc. Permit a choice of attending a funeral
3. SCHOOL AGEDeath is personified
Child fears mutilation and punishment
Anxiety is alleviated by nightmares and superstition
Death is perceived as a final processInterventions:
a. Accepts regressive or protest behaviorb. Encourage verbalization of feelings
4. ADOLESCENT
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Mature understanding of death
May have strong emotions about death, silent, withdrawn, angry
Worry about physical changes
Interventions:
a. Support maturational crisisb. Encourage verbalization of feelingsc. Respect need for privacy and personal expression of
anger, sadness or fear
5. ADULTDeath is a disruption of lifestyle
Death is viewed on terms of its effect on significant others
6. OLDER ADULTEmphasis is on religious beliefs for comfort. A time of reflection, rest and
peace
INTERVENTIONS FOR THE CLIENT WHO IS GRIEVING1. Explore clients perception and meaning of his or her loss 2. Allow adaptive denial3. Encourage or assist the client to reach out for and accept support4. Encourage client to review personal strengths and power5. Encourage client to care for himself or herself6. Use therapeutic communication7. Establish rapport and maintain interpersonal skills8. Provide an open accepting environment9. Provide various diversional activities10.
Provide teaching about common symptoms of grief
11.Reinforce goal-directed activities12.Bring together similar aggrieved persons, to encourage communication,
share experiences of the loss and to offer companionship, social and
emotional support
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C. MOOD DISORDERSPrevious referred to as affective disordersEncompass a large group of disorders involving pathological and related
disordersCan occur in any ageTwo main categories:
1. Depressive disorders2. Bipolar disorders
ETIOLOGY
A. Genetic TheoryHigher correlations of mood disorders between depressed
adoptees and biologic parents than adoptive parents
Twins identical twin has mood disorder = other twin 70% of
having the disorder
Dominant gene may influence or predispose a person to react more
readily to experiences of loss or grief
B. Biochemical TheoryNorepinephrine and serotonin regulate mood, control drives such
as hunger, sex, and thirst if at receptor sites can cause mood
elevation, if can lead to depression
Dopamine if depressed, if in mania
1. Neuroendocrine Regulationcortisol levels
Normally cortisol peaks in the early morning, level off during
the day, and reach the lowest point in the eveningAlso affected by thyroid gland
Decreased nocturnal secretion of melatonin; decreased
levels of prolactin, FSH and testosterone; sleep-induced
stimulation of growth hormone
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C. Biologic TheoryBiologic relation between depression and various medical
conditions
1. Neurodegenerative DiseasesAlzheimers disease, Parkinsons disease, Multiple Sclerosis
Prognosis of the disease
Degenerative changes in the neural system
2. ImmunotherapyCytokine therapy
Pancreatic tumors
Cancer drugs
3. Medical ConditionsHypothalamic-pituitary-adrenal axis
4. PainPain that is biologic in origin leads to psychomotor agitation,
agitation leads to irritability, irritability leads to aggression,
aggression leads to depression and more pain, often
resulting in disability
D. Psychodynamic TheoryBereavement normally produces symptoms resembling a mood
disorder
Any loss or disappointment later in life reactivates a delayed grief
reaction that is accompanied by self criticism, guilt, and anger
turned inward
Mania = defense mechanism
E.Behavioral Theory : Learned Helplessness
Form of acquired or learned behavior
Little positive reinforcement = withdrawn, overwhelmed, passive,
giving up hope, shunning responsibility
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Depressed mood could improve if client develops sense of control
and mastery of the environment
F. Cognitive TheoryThoughts are maintained by reinforcement, thus contributing to a
mood disorder
G. Life Events and Environmental Theory
RISK FACTORS FOR MOOD DISORDERS
1. Prior episodes of depression2. Family history of depressive disorders3. Prior suicide attempts4. Female5. Age of onset younger than 40 years6. Pospartum period7. Medical comorbidity8. Lack of social support9. Stressful life events10.Current alcohol or substance abuse11.Presence of anxiety, eating disorder, OCD, somatization disorder,
personality disorder, grief, and adjustment reactions
DEPRESSIVE DISORDERS1. Mild Depression
Affective symptoms of sadness
Less responsive to the environment and may complain of physical
discomfort2. Moderate Depression (dysthymia)
Symptoms are less severe than those experienced in major
depressive disorders
No psychotic features
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Verbalize feelings of guilt, inadequacy, and irritability
Lack if interest and productivity
Clinical symptoms usually persist for 2 years or more and may
occur continuously or intermittently with normal mood swings for a
few days or weeks
3. With Psychotic FeaturesImpairment of reality testing
4. Melancholic TypeLoss of interest in all activities
Depression is worse in he morning
Prior history of major depressive episodes having responded well to
somatic anti-depressant therapy
5. Seasonal Pattern (Seasonal Affective Disorder)Has been (at least) 3 years pattern of onset of depressive disorder
beginning between the early part of October and end of November
and ending between February and mid April
Two subtypes:
a. Fall-onset SAD (increased sleep, appetite, carbohydratecravings; weight gain; interpersonal conflict; irritability;
heaviness in the extremities)
b. Spring-onset SAD (insomnia, weight loss, poor appetite)6. Postpartum or Maternity Blues
Normal after birth
Labile mood and affect, crying spells, sadness, insomnia, anxiety
Begin approximately 1 day after delivery, usually peak in 3-7 days
and disappear with no medical treatment7. Postpartum Depression
Meets all criteria for a major depressive disorder, with onset within
4 weeks of delivery
8. Postpartum Psychosis
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Develops within 3 weeks of delivery
Fatigue, sadness, emotional lability, poor memory, and confusion
progressing to delusions, hallucinations, poor insight and judgment,
and loss of contact with reality
MAJOR DEPRESSIVE DISORDERSingle episode or recurrent loss of interest or pleasures in usual activities
and past time
Evidence of interference in social and occupational functioning for at least
2 weeks
A. SYMPTOMATOLOGYAFFECT THOUGHT
CONTENT/PROCESS
PHYSIOLOGIC VERBAL SOCIAL
Sadness
Helplessness
Hopelessness
Gloomy
Pessimistic
Feeling of
worthlessness
Slow
Difficult concentration
Hallucination
Delusion
Weakness
Fatigue
Irritability
Excessive
eating/drinking
Anorexia
Weight
gain/loss
Constipation
Urinary
retention
Limited
Content is
all about
life
regrets
Intense
focus on
self
B. NURSING DIAGNOSES1.
Risk for violence, self-directed or directed at others
2. Impaired Verbal Communication3. Decisional Conflict4. Altered Role Performance5. Hopelessness
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6. Deficit in Diversional Activity7. Fatigue8. Self-care Deficit9. Altered Thought Processes10.Self-esteem Disturbance11.Spiritual Distress12.Anxiety
C. THERAPEUTIC NURSING MANAGEMENT1. Safe Environment2. Psychological therapy3. Social Treatment4. Psychopharmacologic and Somatic treatments
D. NURSING INTERVENTIONS1. Priority for care is always the clients safety2. Use of behavioral contracts3. Assess regularly for suicidal ideation or plan4. Observe client for distorted, negative thinking5. Assist client to learn and use problem-solving and stress
management skills
6. Avoid doing too much for the client, as this will only increase clientsdependence and decrease self-esteem
7. Provide assessment and interventions related to appropriatenutrition, fluids, sleep, exercise, and hygiene, and to provide health
education
8. Explore meaningful losses in the clients life9.
Encourage daily exercise
10.Offer small, high-calorie, high-protein snacks and fluids throughoutthe day
11.Stay with the client during meals12.Weigh client weekly
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E. CLIENT AND FAMILY EDUCATION1. Discuss with the client and family the possible environmental or
situational causes, contributing factors, and triggers for serious
depression
2. Help client and family to identify the internal and external indicatorsof major depressive disorder
3. Teach about:a. Suicide preventionb. Stress management and problem solvingc. Symptoms managementd. Medicationse. Family support,, understanding, copingf. Social skills strengtheningg. Self-care assistance when neededh. Grief resolution
BIPOLAR DISORDER- formerly known as manic depression- involves extreme mood swings from episodes of mania to episodes of
depression
- Bipolar I: characterized by one or more manic or mixed episodes in whichthe individual experiences rapidly alternating moods accompanied by
symptoms of manic mood and a major depressive episode
- Bipolar II: characterized by recurrent major depressive episodes withhypomanic episodes occurring with a particular severity, frequency, and
duration; has a presence or history of one or more major depressiveepisodes alternating with at least one hypomanic episode
- Cyclothymic: identical to the symptoms of Bipolar II, except that they aregenerally less severe; changes in mood are irregular, abrupt, sometimes
occurring within hours
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A. SYMPTOMATOLOGY (MANIA)1. Mood that is abnormally and persistently elevated, expansive, or
irritable lasting at least 1 week
2. Inflated self-esteem or grandiosity3. Insomnia4. Increased talking or increased pressure to keep talking5. Flight of ideas or subjective feeling of racing thoughts6. Easily distractable7. Increased goal-directed activity or psychomotor activity8. Excessive overinvolvement in pleasurable activities usually
associated with a high potential for painful consequences
B. NURSING DIAGNOSES1. High risk for violence, directed at self or others2. Impaired Verbal Communication3. Anxiety4. Ineffective Individual Coping5. Disturbance of Self-Esteem6. Alteration in Thought Processes7. Alteration in Sensory Perceptions8. Self-Care Deficit9. Sleep Pattern Disturbances10.Alteration in Nutrition
C. THERAPEUTIC NURSING MANAGEMENT1. Environment2. Psychologial Treatment3.
Somatic and Psychopharmacologic Treatment
D. NURSING INTERVENTIONS1. Remove hazardous objects from the environment2. Assess client closely for fatigue3. Use comfort measure to promote sleep
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4. Provide frequent rest periods5. Monitor the clients sleep patterns6. Provide a private room if possible7. Administer a hypnotic or sedative as prescribed8. Encourage verbalization of feelings9. Use calm, slow interactions10.Help the client focus on one topic during the conversation11. Ignore or distract the client from grandiose thinking12.Present reality to the client13.Dont argue with the client14.Limit group activities and assess the clients tolerance level15.Provide high-calorie finger foods and fluids16.Supervise the clients choice ofclothing17.Reduce environmental stimuli18.Set limits on inappropriate behaviors19.Provide physical activities and outlets for tension20.Avoid competitive games21.Provide gross motor activities, such as walking22.Provide structured activities or one-to-one activities with the nurse23.Provide simple and direct explanations for routine procedures
E. CLIENT AND FAMILY EDUCATION1. Discuss with the client and family the possible environmental or
situational causes, contributing factors, and triggers for a mood
disorder with recurrent episodes of depression and mania
2. Help the client and family to identify the internal and externalindicators of bipolar disorders
3. Teach about:a. Self-monitoringb. Medication therapy and importance of blood levels and
monitoring
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c. Self-care, including adequate nutrition, hygiene and sleepd. How to decrease stimuli and use other methods to control
symptoms and decrease anxiety
e. No harm to self or othersf. Use of self-help groups
D. SUICIDEmost common means are guns, explosives, hanging and poison
women make more attempts, but men actually commit suicide
A. HIGH-RISK GROUPS1. History2. Family history of suicide attempts3. Adolescents4. Elderly clients5. Disabled or terminally ill clients6. Clients with personality disorders7. Clients with organic brain syndrome or dementia8. Depressed or psychotic clients9. Substance abusers
B. CLUES1. Giving away personal, special, and prized possessions2. Canceling social engagements3. Making out or changing a will4. Taking out or changing insurance policies5. Positive or negative changes in behavior6.
Poor appetite
7. Sleeping difficulties8. Feelings of hopelessness9. Difficulty in concentrating10.Loss of interest in activities
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11.Client statements that indicate an intent to attempt suicide12.Sudden calmness or improvement in a depressed client13.Client questions about poisons, guns, or other lethal objects
C. ASSESSMENT1. The plan
a. Does the client have a plan?b. What is the plan, how lethal is the plan, and how likely is
death to occur?
c. Does the client have the means to carry out the plan?2. Client history of attempts
a. Suicide attempts in the past and the outcomesb. Was the client accidentally rescued?c. Have the past attempts and methods been the same, or
have methods increased in lethality?
3. Psychosociala. Is the client alone or alienated from others?b. Is hostility or depression present?c. Do hallucinations exist?d. Is substance abuse present?e. Any recent losses or physical illness?f. Any environmental or lifestyle changes?
D. IMPLEMENTATION1. Initiate suicide precautions2. Remove harmful objects3. Do not leave the client alone4.
Provide one-to-one supervision at all times
5. Provide a nonjudgmental, caring attitude6. Develop a contract that is written, dated, and signed and indicates
alternative behavior at times of suicidal thoughts
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7. Encourage client to talk about feelings and to identify positiveaspects about self
8. Encourage active participation in own care9. Keep the client active by assigning simple tasks10.Check that visitors do not leave harmful objects in the clients room 11. Identify support systems12.Do not allow the client to leave the unit unless accompanied by
staff members
13.Continue to assess the clients suicide potential
PSYCHOPHARMACOLOGIC TREATMENTA. SELECTIVE SEROTONIN REUPTAKE IINHIBITORS (SSRI)
Citalopram (Celexa)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine Hydrochloride (Paxil)
Sertraline Hydrochloride (Zoloft)
Venlaxafine (Effexor)
Description:
- inhibit serotonin reuptake- produce an antidepressant response
Side Effects:
Nausea & diarrhea
Dry mouth
CNS stimulation
Photosensitivity
Insomnia
Nervousness
Headache
Dizziness
Weight loss
Implementation:
1. Monitor vital signs2. Monitor weight3.
Initiate safety precautions, particularly if dizziness occurs
4. Instruct the client to take a single dose in the morning to prevent insomnia5. Administer with a snack or meal to reduce the risk of dizziness and
lightheadedness
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6. Monitor the suicidal client, especially during improved mood and increasedenergy levels
7. Instruct the client on fluoxetine (Prozac) to take the medication early in theday to avoid interference with sleep
8. For the client on long-term therapy, monitor liver and renal function tests9. Monitor WBC and neutrophil counts and discontinue the medication as
prescribed, if levels are below normal
10. If priapism occurs, discontinue the medication immediately and notify thephysician
11. Instruct the client to change positions slowly to avoid hypotensive effect12. Instruct the client to avoid alcohol13. Instruct the client to report any visual changes to the client14. Instruct the client to take drugs exactly as prescribed15. Instruct client to avoid operating hazardous machinery, including an
automobile, if drowsiness occurs
B. TRICYCLIC ANTIDEPRESSANTS (TCA)(Pamelor) Nortriptyline(Elavil) Amitriptyline(Norpramin) Desipramine Hydrocholoride(Tofranil) Imipramine(Anafranil) Clomipramine(Sinequan) Doxepin Hydrochloride
Bupropion (Wellbutrin)
Amoxapine (Asendin)
Maprotiline (Ludiomil)
Mirtazapine (Remeron)
Trazodone (Desyrel)
Nefazodone (Serzone)
Description:
- block the reuptake of norepinephrine and serotonin at the presynapticneuron
-
used to treat depression- may reduce seizure threshold- may reduce effectiveness of antihypertensive agents- concurrent use with alcohol or antihistamines can cause CNS depression- concurrent use with MAOIs may cause hypertensive crisis
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Side Effects:
Anticholinergic effects
Dry mouth
GI motility and
constipation
Difficulty voiding
Dilated pupils and blurred
vision
Photosensitivity
CV disturbances
Tachycardia, dysrhythmias
Orthostatic hypotension
Sedation
Weight gain
Anxiety, restlessness,
irritability
or libido, with
ejaculatory and erection
disturbances
Implementation:
1. Instruct client that medication may take several weeks to produce thedesired effect (client response may not occur until 2-4 weeks after the 1st
dose)
2. Monitor the suicidal client, especially during improved mood and increasedenergy levels
3. Instruct client to change positions slowly to avoid hypotensive effect4. Monitor pattern of daily bowel activity5. Assess for urinary retention6. For the client on long-term therapy, monitor liver and renal function tests7. Administer with food or milk if GI distress occurs8. Administer the entire daily dose at one time, preferably at bed time9. Instruct the client to avoid alcohol and nonprescription medications, to
prevent adverse medication interactions
10. Instruct the client to avoid driving and other activities requiring alertness11.When the medication is discontinued, it should be tapered gradually12.
Instruct the client to avoid exercise and high temperatures
C. MONOAMINE OXIDASE INHIBITOR (MAOI)(Parnate) Tranylcypromine Sulfate
(Marplan) Isocarboxazid(Nardil) Phenelzine Sulfate
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Description:
- inhibition of MAO enzymes thus metabolizes amines, norepinephrine, andserotonin, and the concentrations of this amines
- used for depression in the client who has not responded to otherantidepressant therapies, including ECT
- concurrent use with amphetamines, antidepressants, dopamine,epinephrine, guanethidine, levodopa, methyldopa, nasal decongestants,
norepinephrine, reserpine, tyramine-containing foods, or vasoconstrictors
= hypertensive crisis- concurrent use with narcotic analgesics = hypertension, hypotension,
coma, seizures
Side Effects:
Orthostatic hypotension
Restlessness
Insomnia
Weakness, lethargy
Dizziness
GI upset
Dry mouth
Weight gain
Peripheral edema
Anticholinergic effects
CNS stimulation
Delay in ejaculations
Hypertensive Crisis:Hypertension
Occipital headache
Neck stiffness and soreness
Nausea and vomiting
Sweating
Fever and chills
Clammy skin
Dilated pupils
Palpitations, tachycardia, bradycardia
Constricting chest pain
- ANTIDOTE: Phentolamine (Regitine) 5-10 mg IVTTImplementation:
1. Monitor blood pressure frequently for hypertension2.
Monitor for signs of hypertensive crisis
3. If palpitations or frequent headaches occur, discontinue the medicationand notify the physician
4. Administer with food if GI distress occurs
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5. Instruct the client that the medication effect may be noted during the firstweek of therapy, but maximum benefit may take up to 3 weeks
6. Instruct the client to report headache, neck stiffness, or neck sorenessimmediately
7. Instruct client to change positions slowly to prevent orthostatichypotension
8. Instruct the client to avoid caffeine or OTC preparations9. Monitor for compliance with medication administration10. Instruct the client to carry a Medic-Alert card indicating that a MAOI
medication has been prescribed
11.Avoid administering the medication in the evening because insomnia mayresult
12.MAOIs should be tapered and discontinued 7-14 days before surgery13.When the medication is discontinued, it should be discontinued gradually14. Instruct the client to avoid foods that require bacteria or molds fort heir
preparation or preservation or those that contain tyramine
FOODS TO AVOID
Cheese, especially aged, except
cottage cheese
Sour cream
Pickled herring
Avocados
Bananas
PapayaBroad beans
Figs
Overripe fruit
Brewers yeast
Meat extracts and tenderizers
Yogurt
Sausage, bologna, pepperoni, salami
Soy sauce
Raisins
Red wine, beer, sherryBeef or chicken liver
Caffeine as coffee, tea, or chocolate
D. ANTIMANIC MEDICATIONS
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Lithium Carbonate (Eskalith, Lithane, Lithobid)
Lithium Citrate (Cibalith-Si)
Description:
- affect cellular transport mechanism and alter both the presynaptic andpostsynaptic events affecting serotonin, thus enhancing serotonin
functioning
- use with diuretics, fluoxetine, methyldopa, or NSAIDS lithiumreabsorption by the kidney or inhibits lithium excretion = risk of lithium
toxicity
- acetazolamide, aminophylline, phenothiazines, or sodium bicarbonate =renal excretion of lithium = ruedce drug effectiveness
- therapeutic drug level: 0.5 1.5 mEq/l- maintenance level: 0.6 1.2 mEq/l- lithium level = sodium intake, fluid and electrolyte loss associated with
severe sweating, dehydration, diarrhea, or diuretic therapy, illness, and
overdose
- serum lithium levels should be checked every 1 2 months or wheneverany behavioral change suggests an altered serum level
- blood samples to check serum lithium level should be drawn in themorning 12 hours after last dose was taken
Side Effects:
Polyuria
Polydipsia
Anorexia,nausea
Dry mouth
Mild thirst
Weight gain
Abdominal bloating
Soft stools or diarrhea
Fine hand tremors
Inability to concentrate
Muscle weakness
Lethargy
Fatigue
Headache
Hair loss
Implementation:
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1. Monitor the suicidal client during improved mood and increased energylevels
2. Administer the medication with food to minimize GI irritation3. Instruct the client to maintain a fluid intake of 6-8 glasses per day4. Instruct the client to avoid excessive amounts of coffee, tea, or cola, which
have a diuretic effect
5. Instruct the client to maintain an adequate salt intake6. Do not administer diuretics while the client is taking lithium7. Instruct the client to avoid alcohol8. Instruct the client to avoid OTC medications9. Instruct the client that he or she may take a missed dose within 2 hours of
the scheduled time; otherwise the client should skip the missed dose and
take the next dose at the scheduled time
10. Instruct the client not to adjust the dosage without consulting thephysician, because lithium should be tapered off and not discontinued
abruptly
11. Instruct the client in the signs and symptoms of toxicity12. Instruct the client to notify the physician if polyuria, prolonged vomiting,
diarrhea, or fever occurs
13. Instruct the client that the therapeutic response to the medications will benoted in 1-3 weeks
14.Monitor ECG, renal function tests, and thyroid testsLithium ToxicityDescription:
- occurs when ingested lithium cannot be detoxified and excreted by thekidneys
- symptoms begin when serum lithium level is 1.5-2 mEq/lMild: Serum lithium level is 1.5 mEq/l
Apathy
Lethargy
Diminished concentration
Mild ataxia
Coarse hand tremors
Slight muscle weakness
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Moderate: Serum lithium level of 1.5-2.5 mEq/l
Nausea, vomiting
Severe diarrhea
Mild to moderate ataxia and incoordination
Slurred speech
Tinnitus
Blurred vision
Muscle twitching
Irregular tremor
Severe: Serum lithium level above 2.5 mEq/l
Nystagmus
Muscle Fasciculations
Deep tendon hyperreflexia
Visual or tactile hallucinations
Oliguria or anuria
Impaired LOC
Grand mal seizure or coma leading to
death
Implementation: (Lithium Toxicity)
1. Hold lithium and notify the physician2. Monitor vital signs and LOC3. Monitor cardiac status4. Prepare to obtain lithium level; electrolyte, BUN, and creatinine counts;
CBC
5. Monitor for suicidal tendencies and institute suicide precautions
SOMATIC TREATMENTELECTROCONVULSIVE TTHERAPY (ECT)Description:
- consists of inducing a grand mal (tonic-clonic) seizure by passing anelectric current through electrodes that are attached to the temples
- usual course is 6-12 treatments given two to three times per week- maintenance ECT once a month may help to decrease the relapse rate for
the client with recurrent depression- not necessarily effective in clients with dysrhythmic depression or those
with depression and personality disorders, those with drug dependence,
or those with depression secondary to situational or social difficulties
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- at-risk clients include those with recent MI, CVA or cerebrovascularmalformation, or clients with intracranial mass lesion
Types:
1. Unmodified2. Modified
Uses:
1. Clients with major depressive and bipolar disorders2. Clients who have depression with marked psychomotor retardation and
stupor
3. Manic clients who are resistant to lithium and antipsychotic medications4. Clients with schizophrenia, those with schizoaffective syndromes, and
psychotic clients
Indications for Use:
1. When antidepressants have no effect2. When there is a need for a rapid definitive response3. The client is in extreme agitation or stupor4. The risks of other treatments outweigh the risks of ECT5. Client has a history of poor medication response, a history of good ECT
response, or both
6. Client prefers itSide Effects:
Memory loss
Difficulty learning new
information
Headache
Weight gain
Disorientation, confusion
Hypertension
Occasional cardiac
arrhythmias
Preprocedure:
1.
Explain the procedure to the client2. Encourage the client to discuss feelings, including myths regarding ECT3. Teach the client and family what to expect4. Informed consent must be obtained when voluntary clients are being
treated
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5. For involuntary clients, when informed consent cannot be obtained,permission may be obtained from the next of kin
6. NPO after midnight or at least 4 hours prior to treatment7. Baseline V/S are recorded8. The client is requested to void9. Hairpins, contact lenses and dentures are removed10.Administer pre-op meds if prescribed; Glycopyrolate (Robinul) orAtropine
sulfateDuring the Procedure:
1. Attach client to cardiac monitor2. An IV line is inserted, and EEG and ECG electrodes are attached3. 100% oxygen by mask via positive pressure is administered throughout
the procedure
4. An airway or bite block is placed to prevent biting of the tongue5. Electrical stimulus is administered, and the seizure should last 30-60
seconds
Postprocedure:
1. Client is transported to a recovery room with the cardiac monitor in place,where oxygen, suction, and other emergency equipment is available
2. Once the client is awake, talk to the client and monitor V/S3. Provide frequent orientation and reassurance4. Client returns to the nursing unit when a 90% oxygen saturation level is
maintained, V/S are stable, and mental status satisfactory
5. Assess the gag reflex prior to giving the client fluids, food, or medication
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