Depression

DEPRESSION • • • •

A MOOD DISORDER A TERM THAT CAN BE USED IN MANY WAYS; IT CAN REFER TO A SYMPTOM, SYNDROME, DISORDER, OR ILLNESS. DOCTORS USE A DIAGNOSTIC AND STATISTIC MANUAL TO DIAGNOSE PATIENTS WITH THIS TYPE OF DISEASE. EITHER DEPRESSIVE OR BIPOLAR DEPRESSION SYNDROME CAN OCCUR AS PART OF A PHYSICAL ILLNESS, ANOTHER PSYCHIATRIC DISORDER, OR COGNITIVE IMPAIRMENT DISORDER

TWO MOST COMMON PRIMARY DEPRESSVIE DISORDERS •

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MAJOR DEPRESSIVE DISORDER O HISTORY OF 1 OR MORE MAJOR DEPRESSIVE DISORDERS O NO HISTORY OF MANIC OR HYPOMANIC EPISODES (BIPOLAR) – B/C IF THEY DID THEY WOULD BE BIPOLAR O SYMPTOMS REPRESENT A CHANGE IN PREVIOUS FUNCTIONING O SYMPTOMS CAUSE SIGNIFICANT DISTRESS OR IMPAIR SOCIAL, OCCUPATIONAL FUNCTIONING O SYMPTOMS HAVE LASTED FOR AT LEAST 2 WEEKS O EXPERIENCE SUBSTANTIAL PAIN, SUFFERING O WHEN A PERSON IS MAJORLY DEPRESSED THEY CAN HAVE DELUSIONAL OR PSYCHOTIC BEHAVIOR. O DELUSIONS OR HALLUCINATIONS RELATED TO LOW SELF ESTEEM O ONSET MAY BE WITHIN 4 WEEKS POSTPARTUM O ONSET DURING FALL OR WINTER MONTHS (SAD) SEASONAL AFFECTIVE DISORDER  HAPPENS IN THE WINTER TIME AND NOT GETTING OUT IN THE SUN MAKES THEM DEPRESSED DYSTHYMIA O MILD TO MODERATE IN DEGREE NO PSYCHOTIC SYMPTOMS O CHRONICALLY DEPRESSED MOOD FOR MOST OF THE DAY, MOST DAYS FOR TWO YEARS (1 YEAR FOR CHILDREN AND ADOLESCENTS); NOT HOSPITALIZED UNLESS SUICIDAL

EPIDEMIOLOGY • •

AT ANY GIVEN TIME15 % OF THE GENERAL POPULATION ARE DEPRESSED WOMEN HAVE A GREATER RISK OF DEVELOPING DEPRESSION THAN DO MEN

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ADOLESCENTS - SUICIDE IS A FACTOR – IT IS THE 3 LEADING CAUSE OF DEATH IN ADOLESCENTS ELDERLY – HIGHEST SUICIDE RATE ONLY ONE IN FOUR PEOPLE THAT HAVE DEPRESSION GET TREATMENT

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CAUSES OF DEPRESSION •

BIOLOGICAL THEORIES O GENETICS  IF YOU HAVE TWINS – ONE HAS DEPRESSION, OTHER HAS 60% CHANCE TO DEVELOP DEPRESSION O BIOCHEMICAL FACTORS

 NEUROTRANSMITTERS; IN RELATION TO STRESS. IF UNDER A LOT OF STRESS THEY  THE # OF NEUROTRANSMITTERS NEUROENDOCRINE DISTURBANCES  ABNORMAL HIGH HORMONE LEVELS PSYCHOSOCIAL FACTORS O COGNITIVE THEORY  DEPRESSION RESULTS VERY NEGATIVELY; FEEL NEGATIVE ABOUT EVERYTHING O LOSS  REACTION TO GRIEF – IF GRIEF IS NOT RESOLVED IT MAY  DEPRESSION; REAL OR SYMBOLIC LOSS O LEARNED HELPLESSNESS O

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HIGH LEVELS OF STRESS  TO ANXIETY THEN  DEPRESSION, THEY BLAME THEMSELVES FEEL HELPLESS AGED, THOSE LIVING IN GETTOS, AND WOMEN

CLINICAL MANIFESTATIONS • • • • •

SAD MOOD O

LOOK AT THE WORLD THROUGH GRAY COLORED GLASSES

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ALMOST TEARFUL

SLEEP DISTURBANCE O TERMINAL INSOMNIA / HYPOSOMINIA – WORST AT 2-3AM LOWEST POINT IN THEIR MOOD (USUALLY THE TIME TO COMMIT SUICIDE) INTERESTS DECREASE O ANHEDONIA – CANNOT FEEL PLEASURE GUILT, WORTHLESSNESS O EXCESSIVE INAPPROPRIATE GUILT; USUALLY FROM AN ACT THAT HAPPENED OVER 20 YEARS AGO THAT IS INSIGNIFICANT. THINK ABOUT THIS OVER AND OVER. DELUSIONS ARE FOCUSED ON THIS; BELIEVE BEING PUNISHED ENERGY DECREASED O NO “GET UP AND GO” O

HAVE TO PUSH THEMSELVES TO DO WHAT THEY NEED

MAY NOT DO ANYTHING AT ALL AND STAY IN BED ALL DAY COGNITION DECREASED O SLOWED SPEECH, DECREASED AMOUNTS OF SPEECH. AFFECTS THE ABILITY TO SOLVE PROBLEMS. DO NOT ANSWER FOR THE CLIENT APPETITE DISTURBANCE - SIGNIFICANT WEIGHT LOSS; MAY LOOSE 5% OF BODY WEIGHT IN A MONTH O

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PSYCHOMOTOR RETARDATION, AGITATION O EVERY FUNCTION OF THE BODY IS SLOW; EFFECTS PERISTALSIS; CONSTIPATION O MOVEMENT IS VERY SLOW O SOME CAN GET VERY AGITATED – MAY PACE, RING THEIR HANDS, OR BE VERY IRRITABLE, COMPLAIN OR CRY SOMATIZATION – HAVE PHYSICAL SYMTOMS THAT MASK DEPRESSION O SOMETIMES DEPRESSION IS EXPRESSED THROUGH PHYSICAL SYMPTOMS. O CAN BECOME DELUSIONAL ABOUT THE PHYSICAL SYMPTOMS. SUICIDE O RECURRENT THOUGHTS OF DEATH WITH A PLAN OR ATTEMPT

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THE ULTIMATE RESPONSE TO FEELINGS OF HOPELESSNESS; AN AMBIVALENT ACT; SO YOU MAY BE ABLE TO CHANGE THEIR MINDS THOUGHTS = EXTREME, SEVERE EMOTIONAL PAIN AGGRESSION TURNED TOWARD SELF 72% OF SUICIDES ARE COMMITTED BY WHITE MALES; WOMEN ATTEMPT MORE THAN MALES SEEN IN PROFESSIONAL MEN, LAWYERS, MD’S LOSSES OF ELDERLY THAT MAY TRIGGER DEPRESSION:  LOSS OF STATUS RELATED TO RETIREMENT; LOSS OF IDENTITY  TERMINAL ILLNESS, CHRONIC ILLNESS, PAIN  LOSS OF SPOUSE OR SOME TYPE OF PERSONAL LOSS  LOSS OF FRIENDS AND FAMILY

LIFESPAN CONSIDERATIONS • • •

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PRESCHOOLERS O CRY A LOT WITH NO REASON, LISTLESS, IRRITABLE, PROBLEMS WITH SLEEPING AND EATING CHILDREN O SAD, DECREASED APPETITE / SLEEP PATTERN CHANGE, SCHOOL PHOBIA – GRADES DROP ADOLESCENTS O HARD TO DETECT BECAUSE ACTS OF DEPRESSION ARE RELATED TO ACTS OF REBELLION; THAT ARE NORMAL FOR THAT AGE O MAY RUN AWAY, SEXUAL ACTING OUT, SLEEPING CHANGES AND EATING CHANGES O DO NOT VIEW DEATH AS PERMANENT ELDERLY O DETERMINE THE DIFFERENCE OF DEPRESSION AND DEMENTIA O CHRONIC ILLNESS HAS DEPRESSION AS A SIDE EFFECT: PARKINSON’S, MS, CANCER, ALZHEIMER’S

NURSING PLAN OF CARE RISK FOR SELF DIRECTED VIOLENCE • •

GOAL: KEEP THE PERSON SAFE IF YOU ASK THE PERSON ABOUT SUICIDE THAT DOESN’T MEAN YOU ARE PUTTING THE IDEA IN THEIR HEAD. BECAUSE YOU HAVE TO ASSESS IF THE PERSON IS SUICIDAL O ASK IF THEY HAVE EVER THOUGHT ABOUT TAKING THEIR OWN LIFE; IF YES O ASK WHAT PLANS, IF ANY, HAVE THEY MADE O ASSESS:

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S – SPECIFY (HOW SPECIFIC ARE THE DETAILS OF THE PLAN) L – LETHALITY (HOW QUICKLY CAN DEATH BE ACCOMPLISHED BY THAT METHOD) A – AVAILABILITY (WHAT ARE THE AVAILABILITIES OF THE PROPOSED WEAPON)

P – PROXIMITY (LIVING ARRANGEMENTS) NURSING PLAN OF CARE O ONE ON ONE OBSERVATION - DO NOT LET THEM OUT OF THEIR SIGHT O IRREGULAR SCHEDULE OF OBSERVATION - CHECK ON THEM IN SPORADIC TIMES O REMOVE ENVIRONMENTAL HAZARDS  GLASS, BELTS, RAZORS, SHOE LACES, MEDICATION, CORDS, SCISSORS, NAIL FILES O CONTRACT – WILL NOT COMMIT SUICIDE O SEEK OUT STAFF WHEN THOUGHTS EMERGE OF SUICIDE O WHEN THEY ARE FEELING BETTER, DISCUSS ALTERNATE SOLUTIONS AND NETWORK OF SUPPORT SYSTEMS  MORE LIKELY TO COMMIT SUICIDE EARLY IN THE MORNING  BE AWARE OF SUDDEN CHANGE IN PERSONALITY OR BEHAVIOR  BE AWARE IF THEY BEGIN TO GIVE THINGS AWAY OR MAKE A WILL

SELF ESTEEM DISTURBANCE – PG 585 • • • • • • •

WHEN YOU TALK WITH THEM YOU CAN BEGIN TO FEEL DEPRESSED TO EVALUATE YOURSELF ACCEPT THE CLIENT; BUT YOU WANT TO INTERRUPT THOSE THOUGHTS FOCUS ON STRENGTHS AND ACCOMPLISHMENTS ENCOURAGE TO PARTICIPATE IN GROUP ACTIVITIES; MAY MAKE SOMETHING ASSERTIVENESS INCREASES SELF ESTEEM ASSIST WITH PROBLEM SOLVING TO CHANGE AREAS THEY DON’T LIKE ABOUT THEMSELVES DON’T USE VALUED JUDGMENT 2

IF YOU SAY “YOU LOOK NICE THIS MORNING”; THEIR THINKING PROCESS IS THAT THEY MUST HAVE NOT EVER LOOKED GOOD UNTIL NOW. YOU COULD SAY “YOU HAVE ON A NEW DRESS THIS MORNING” ASSIST CLIENT IN SELF CARE O O

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ALTERATION IN THOUGHT PROCESSES • • •

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FOCUS ON REALITY; DON’T FOCUS ON DELUSIONS DO NOT ARGUE OR DENY THEIR DELUSIONS TEACH CLIENT TO “THOUGHT STOP” IF THE CLIENT SAYS, “ I HAVE MADE A MESS OF EVERYTHING, EVERYBODY WOULD BE BETTER OFF WITHOUT ME” – THE NURSE COULD SAY, “I UNDERSTAND YOU FEEL THIS WAY, BUT I DON’T SHARE THE LOW OPINION YOU HAVE OF YOURSELF, I THINK YOU’LL SEE YOURSELF IN A DIFFERENT LIGHT WHEN YOU ARE BETTER” TALK ABOUT REAL THINGS THAT ARE HAPPENING IN THE ENVIRONMENT ALSO IF THE CLIENT KEEPS THINKING NEGATIVE THOUGHTS; HAVE THE PATIENT INTERRUPT THEM BY SAYING STOP, CLAPPING HANDS OR SOMETHING. TRY TO CHANGE WHAT THEY ARE THINKING

INEFFECTIVE INDIVIDUAL COPING • • • • • • • •

HAS A PROBLEM MAKING DECISIONS SHOULD NOT BE ABLE TO MAKE ANY MAJOR LIFE DECISIONS BECAUSE THEY DO NOT HAVE THE CAPACITY TO DO THAT; YOU WANT THEM TO START THEM MAKING DECISIONS IN A SMALL WAY LET THEM CHOOSE WHAT THEY ARE GOING TO WEAR SET REALISTIC GOALS; IF THEY SET UNREALISTIC THEY WILL FEEL LIKE A FAILURE HELP IDENTIFY AREAS OF LIFE SITUATIONS THAT THEY CAN CONTROL HELP IDENTIFY AREAS OF LIFE SITUATIONS THAT THEY CANNOT CONTROL ANYTIME THEY DO SOMETHING POSITIVE; GIVE THEM POSITIVE FEEDBACK

SOCIAL ISOLATION / IMPAIRED SOCIAL INTERACTION – PG 565 • • • • • • • • • •

ESTABLISH A NURSE CLIENT RELATIONSHIP SPEND ABOUT 3 TEN MINUTE SESSIONS IN A DAY BE THERE ON TIME; MAY HAVE TO SIT IN SILENCE; STAY THERE; IF YOU LEAVE, THEY THINK THEY ARE NOT WORTH YOUR TIME. O WHILE SITTING IN SILENT, MAKE OBSERVATIONS ABOUT THE ENVIRONMENT – “IT IS COLD TODAY”, “THAT GROUP SEEMS LIVELY”, “I LIKE THE PICTURE ON THE WALL” DON’T LET THE CLIENT REMAIN IN THEIR ROOM ALONE – THEY HAVE TO GET INVOLVED ONCE THE CLIENT BECOMES COMFORTABLE WITH YOU; YOU CAN ADD ONE PERSON TO MEET WITH YOU AT A TIME. THEN LATER ADD ANOTHER PERSON. THEN CAN INVOLVE IN GROUP ACTIVITIES. VERY FRAGILE – ALERT THERAPIST THAT THIS IS A FRAGILE PATIENT TEACH SOCIAL SKILLS SO THAT THEY CAN APPROACH OTHERS ACTIVITY SCHEDULE - PRINT OUT AND GIVE TO PATIENT INVOLVE THEM IN ACTIVITIES EARLY IN THE MORNING PROVIDE POSITIVE REINFORCEMENT FOR INTERACTIONS WITH OTHERS

TOTAL SELF CARE DEFICIT VEGETATIVE SIGNS OF DEPRESSION • NUTRITION O USUALLY HAVE LOST UP TO 5% OF THEIR BODY WEIGHT; GET LIKES AND DISLIKES OF FOOD O DAILY WEIGHTS, WORK WITH DIETITIAN, MAY HAVE CALORIE COUNT. O BETTER WITH SMALL FREQUENT FEEDINGS AND A BEDTIME SNACK O INCREASE FLUIDS AND FIBER O MAY HAVE TO SPOON OR TUBE FEEDING • SLEEP PATTERN DISTURBANCE O HOURLY CHART DURING THE NIGHT – WHETHER ASLEEP OR AWAKE TO DETERMINE PATTERN OF SLEEP O DO NOT LET THEM SLEEP DURING THE DAY O SIDE EFFECT OF MEDICATION IS SLEEPINESS; SO GIVE MEDS AT BEDTIME O MAY GIVE A WARM DRINK OR WARM BATH. NO CAFFEINE, SOFT MUSIC; SEDATIVE TO SLEEP • GROOMING O MAY HAVE TO WALK THEM STEP-BY-STEP. LET THEM DO AS MUCH AS THEY CAN BUT YOU MAY HAVE TO EXPLAIN IT STEP BY STEP O SLOWED THINKING AND DIFFICULTY CONCENTRATING MAKE ORGANIZING SIMPLE TASKS DIFFICULT O BEING CLEAN AND WELL GROOMED CAN TEMPORARILY RAISE SELF-ESTEEM. • CONSTIPATION O INCREASE FIBER AND FLUIDS; MAY HAVE TO GIVE LAXATIVE O MONITOR INTAKE AND OUTPUT

MEDICAL PLAN OF CARE VERY TREATABLE WITH MEDICATIONS • TRICYLIC (ANTIDEPRESSANTS) O BLOCKS REUPTAKE OF NEUROTRANSMITTERS- MAKES MORE RECEPTORS SO MORE NERVE IMPULSES CAN GET THROUGH O TAKES 1-3 WEEKS BEFORE THEY START TO WORK O ELAVIL, ASCENDIN, PAMELOR O SIDE EFFECTS: ANTICHOLINERGIC – CAN’T SEE, CAN’T PEE, CAN’T SPIT, CAN’T SHIT 3

DRY MOUTH, CONSTIPATION, URINARY RETENTION, HYPERTENSION, CAN HAVE CARDIOVASCULAR SIDE EFFECTS. IF AN OVERDOSE OCCURS IT IS LETHAL BETTER IF TAKEN AT BEDTIME DO TO SLEEPY SIDE EFFECT IF SEVERELY ILL THEY MAY ONLY BE GIVEN A WEEK SUPPLY AT A TIME DRUG INTERACTIONS: CNS, MAOI’S, COUMADIN (DO NOT GIVE WITH THESE DRUGS) ELDERLY AT MOST RISK FOR THE ANTICHOLINERGIC SIDE EFFECTS   

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GIVE AT BEDTIME WITH FOOD ELDERLY – SAFETY INCREASE FLUIDS OBSERVE FOR URINARY AND CONSTIPATION – MEDICAL EMERGENCY OBSERVE FOR SUICIDE • THERAPEUTIC EFFECTS WILL NOT TAKE AFFECT FOR ABOUT 3 WEEKS

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1 LINE THERAPY FOR DEPRESSION PROZAC, ZOLOFT, PAXIL, CELEXA SIDE EFFECTS: NOT AS BAD AS TRICYLIC  AGITATION, ANXIETY, TREMORS, HA, SEXUAL DYSFUNCTION, INSOMNIA  BEST TAKE IN THE MORNING CENTRAL SEROTONIN SYNDROME  GETS TOO MUCH SEROTONIN – IF THE PERSON IS TAKING 2 ANTIDEPRESSANTS – NOT ENOUGH TIME HAS PASSED BETWEEN STOPPING ONE AND STARTING ANOTHER.  SHOULD NEVER BE GIVEN WITHIN 2 WEEKS OF AN MAOI  IF PROZAC YOU SHOULD WAIT 5 WEEKS BEFORE YOU START AN MAOI  ELEVATED BP, TACHYCARDIA, CV SHOCK AND DEATH SERIOUS  USE INDERAL TO TREAT SYMPTOMS SINGLE DOSE IN THE AM – DO NOT HAVE SEDATIVE SIDE EFFECT ST

THERAPEUTIC AFFECTS MAY NOT WORK FOR 4-5 WEEKS ELDERLY THE DOSES ARE DECREASED; CAN AGITATE THE ELDERLY CHILDREN THAT ARE DEPRESSED ARE USUALLY PUT ON THESE TYPE OF ANTIDEPRESSANTS

OTHER ANTIDEPRESSANTS O SELECTIVE SEROTONIN / NOREPINEPHERINE REUPTAKE INHIBITORS  SERZONE, EFFEXOR, LEXAPRO, CYMBALTA  SIDE EFFECTS • NAUSEA, SLEEPINESS, DRY MOUTH, DIZZINESS O DO NOT SEE THAT OFTEN – THEY ARE PUT ON THE SSRI’S FIRST ONLY IF THEY DO NOT WORK ARE THEY PUT ON THESE MEDICATIONS. ATYPICAL – MISC O DESYREL (TRAZODONE)  GIVEN FOR MILD TO MODERATE DEPRESSION  OFTEN USED AS A SLEEPING AID  CAN CAUSE PRIAPISM (WITHHOLD MEDICATION, NOTIFY MD IMMEDIATELY) EMERGENCY O WELBUTRIN (BUPROPION) - ZYBAN  EFFECTIVE FOR PEOPLE THAT CANNOT TAKE THE TRICYLIC ANTIDEPRESSANTS

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DO NOT SMOKE – REDUCES AFFECTIVENESS TIME TO TAKE AFFECT – 3 WEEKS

2 GENERATION ANTIDEPRESSANTS - SSRI O BLOCK REUPTAKE OF SEROTONIN

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START SLEEPING BETTER  MORE ACTIVITY  (AT HIGH RISK FOR SUICIDE BECAUSE THEY FEEL GOOD ENOUGH TO GO THROUGH WITH IT) – THE LAST THING TO LIFT WILL BE THE MOOD. • BE PATIENT, THE MOOD WILL GET BETTER TAKE AS PRESCRIBED – DO NOT STOP ABRUPTLY NO ALCOHOL OR CNS DEPRESSANTS

HAS A DOSE LIMIT – NO MORE THAN 150MG AT A TIME AND A TOTAL DOSE OF 450MG PER DAY MAY CAUSE SEIZURES

MAOI’S O O O

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HAS AN ENZYME THAT DISSOLVES THE NEUROTRANSMITTERS. STOP THE ENZYME FROM WORKING SO THEREFORE YOU HAVE MORE NEUROTRANSMITTERS IN THAT GAP??? NARDIL & PARNATE SIDE EFFECTS  ORTHOSTATIC HYPOTENSION HAVE BAD DRUG INTERACTIONS AND FOOD INTERACTIONS NO FOODS WITH TYRAMINE ( CHEESE, WINE, SAUSAGE, BEER, SMOKED OR PICKLED FISH, OTHER PICKLED FOODS, BEEF OR CHOPPED LIVER, AVOCADOS OR FIGS, CHINESE FOOD) NO OTC MEDS, OR OTHER ANTIDEPRESSANTS, NARCOTICS (DEMEROL – FATAL REACTION) NO GINSENG OR ST JOHNS WART CAN HAVE A HYPERTENSIVE CRISIS IF COMBINED WITH ANY OF THESE OR TOO MUCH TYRAMINE (CAN BE FATAL) 4

BP INCREASE, HA, STIFF OR SORE NECK, MAY HAVE TO GIVE MEDICATION TO RELIEVE THAT – PROCARDIA, THORAZINE. CAN TREAT THE HYPERTENSIVE CRISIS O MUST BE VERY COMPLIANT O USED FOR ATYPICAL DEPRESSION THAT IS NOT RESPONDING TO OTHER DRUGS O MUST START DIET 2 WEEKS BEFORE STARTING THE DRUG; STAY ON DIET 2 WEEKS AFTER STOPPING THE DRUG. ST. JOHNS WART O CAREFUL OF SUNLIGHT – MAY GET BAD BURN O DO NOT TAKE WITH MAOI’S OR ANY OTHER ANTIDEPRESSANT OR ANY OTHER CRITICAL MEDICATIONS SUCH AS: COUMADIN, CLOZARIL, THEOPHYOLINE, ORAL CONTRACEPTIVES. O DO NOT TAKE ANY OTHER DRUGS UNTIL OK’D BY PHYSICIAN ANTIPSYCHOTIC O IF DEPRESSED AND DELUSIONAL 

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CAUTION: IF CLIENT IS BIPOLAR AND THERE IS A DEPRESSED – BE CAREFUL BECAUSE ANY OF THESE MEDICATIONS CAN PUSH THE CLIENT INTO THE MANIC PHASE

ECT – ELECTROCONVULSIVE THERAPY • • •

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GRAND MAL SEIZURE ARTIFICIALLY INDUCED BY PASSING AN ELECTRIC CURRENT THROUGH THE BRAIN. ACTION IS UNKNOWN O MAY INCREASE NEUROTRANSMITTERS USED IN CLIENTS THAT THEY NEED A RAPID RESPONSE O IF SUICIDAL, IF THEY HAVE A HISTORY OF RESPONDING POORLY TO DRUGS O IF SEVERE PSYCHOLOGICAL RETARDATION AND THEY ARE NOT EATING OR DRINKING AND THEIR PHYSICAL HEALTH IS IN DANGER  (SO DEPRESSED THEY ARE STARVING THEMSELVES) CONTRAINDICATIONS O RECENT MI, CVA, OR BRAIN TUMOR 6-12 TREATMENTS 2-3 TIMES PER WEEK MAINTENANCE ONCE A WEEK OR ONCE A MONTH

NURSING CARE •

PRE ECT O O O O O O O

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INFORMED CONSENT – SPECIAL FOR ECT NPO FOR 6-8 HOURS VITAL SIGNS DENTURES, CONTACTS, HAIRPINS ARE REMOVED VOID BEFORE PROCEDURE GIVE ROBINUL OR ATROPINE - HELPS DRY SECRETIONS OR MINIMIZE BRADYCARDIA PROCESS  THEY ARE GIVEN A MUSCLE RELAXER  OXYGENATE THEM  AN ORAL AIRWAY  THEN THEY ARE SHOCKED  WANT SEIZURES TO LAST AT LEAST 30 SECONDS IF THEY ARE HYPERTENSIVE THEY WILL BE GIVEN AN ANTIHYPERTENSIVE MED PRIOR TO THE SHOCK

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RESPIRATIONS AND CARDIAC STATUS - MAKE SURE HAVE AN OPEN AIRWAY CHECK VS ORIENT DUE TO CONFUSION CHECK GAG REFLEX MEMORY LOSS GETS WORSE THE MORE TREATMENTS THEY HAVE

THERAPY PHOTO THERAPY • •

EXPOSURE TO SPECIAL LIGHTS THAT SIMULATE THE SUN IN THE TREATMENT FOR SAD 2-6 HOURS

PSYCHOLOGICAL THERAPY • •

MAY BE INDIVIDUAL PSYCHO THERAPY O SHORT TERM O FOCUS ON INTERPERSONAL RELATIONSHIPS COGNITIVE THERAPY O TRY TO CHANGE THE NEGATIVE THINKING PATTERNS

GROUP THERAPY • • • • •

INITIALLY MAY NOT BE A GOOD CANDIDATE BECAUSE THEY ARE NOT REACTING TO ONE TO ONE BUT MAY ATTEND GROUP AFTER GETTING COMFORTABLE WITH ONE TO ONE INCREASE SOCIALIZATION SHARE COMMON FEELINGS AND CONCERNS DECREASE FEELINGS OF ISOLATION SUPPORT FORM OTHER MEMBERS AND FEELING PART OF A GROUP 5

FAMILY THERAPY • • •

OPEN AND HONEST COMMUNICATION REINFORCE NON DEPRESSIVE BEHAVIOR PROBLEM SOLVING

BEHAVIOR THERAPY

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TRY TO DECREASE THE NUMBER OF NEGATIVE INTERACTIONS THE CLIENT HAS THEY WILL GET A MORE POSITIVE REINFORCEMENT FROM OTHER PEOPLE TEACHES COPING AND SOCIAL SKILLS

OCCUPATIONAL / RECREATIONAL THERAPY

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NON COMPETITIVE; ONE-TO-ONE ACTIVITY – SOMETHING THEY CAN DO THEMSELVES AND NOT FAIL SOMETHING SIMPLE AND MONOTONOUS – SOMETHING THEY DON’T HAVE TO THINK ABOUT O JIGSAW PUZZLE, HOOKING A RUG, NEEDLE WORK, IF THEY ALREADY KNOW HOW TO DO IT. O LOOKING AT A MAGAZINE, FOLDING LINEN YOU WANT THE ACTIVITIES TO BE A POSITIVE EXPERIENCE

MILIEU / ENVIRONMENT THERAPY • PREVENTION OF SUICIDE; SAFETY • STRUCTURED ROUTINE – KNOWING WHAT TO EXPECT DAY AFTER DAY • POSITIVE SELF ATTITUDE – CAN FEEL HOPE THAT THEY CAN DO BETTER YOU CAN SIT QUIETLY WITH A CLIENT IF THEY DO NOT FEEL LIKE TALKING

BIPOLAR I - MAJOR DEPRESSION AND MANIA BIPOLAR II - MAJOR DEPRESSION AND HYPOMANIA CYCLOTHYMIC DISORDER – MANIA • • • • • •

MAJOR DEPRESSION MARKED IMPAIRMENT IN OCCUPATIONAL, SOCIAL ACTIVITIES (MAJOR DAMAGE) AND RELATIONSHIPS HOSPITALIZATION NEEDED TO PROTECT CLIENT AND OTHERS FROM IRRESPONSIBLE OR AGGRESSIVE BEHAVIOR BEST THEY HAVE EVERY FELT IN THEIR LIFE THERE ARE PSYCHOTIC FEATURES O GRANDIOSE OR PARANOID DELUSIONS VERY SOCIABLE

HYPOMANIA • • • •

UNEQUIVOCAL CHANGE IN FUNCTIONING THAT IS UNCHARACTERISTIC OF THE PERSON NORMALLY O MARKED CHANGE NOT THEMSELVES O A LITTLE MANIC DOES NOT AFFECT SOCIAL OR OCCUPATIONAL FUNCTIONING O EX STAY AWAKE 6 DAYS AND NIGHTS TO GAMBLE THEN ABLE TO GO TO WORK EVERYDAY WITHOUT SLEEPING. NO DELUSIONS SO HOSPITALIZATION IS GENERALLY NOT NEEDED

CYCLOTHYMIC DISORDER

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ALTERNATING PERIODS OF DYSTHYMIA AND HYPOMANIA FOR AT LEAST 2 YEARS PERIODS OF NORMAL MOOD ARE NOT LONGER THAN 2 MONTHS HOSPITALIZATION NOT NECESSARY UNLESS SUICIDAL BEGINS IN ADOLESCENCE OR EARLY ADULT LIFE 15-50% CHANCE OF DEVELOPING BIPOLAR I OR II

CAUSES • • • •

GENETIC O EQUAL AMONG GENDER BIOCHEMICAL O INTERACTIONS BETWEEN NEUROTRANSMITTER AND HORMONES SOCIAL STATUS O HIGHER LEVELS OF EDUCATION, OCCUPATIONAL STATUS PSYCHOSOCIAL O DENIAL UNDERLYING DEPRESSION

CLINICAL MANIFESTATIONS • ELEVATED MOOD O O O

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HIGH, EUPHORIC, BUT CAN BE IRRITABLE, AND UNSTABLE CAN TURN FROM SOCIABLE TO IRRITABLE AND DEMANDING MAY BECOME ARGUMENTATIVE AND COMBATIVE ESPECIALLY WHEN YOU TRY TO SET LIMITS

INFLATED SELF-ESTEEM OR GRANDIOSITY 6

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CAN HAVE HALLUCINATIONS AND PERSECURITY DELUSIONS MARKED IMPAIRMENT OF JUDGMENT O O O

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DECREASED NEED FOR SLEEP TO BUSY TO SLEEP NOT AWARE OF NEED TO SLEEP CAN LEAD TO PHYSICAL EXHAUSTION

PRESSURED SPEECH FLIGHT OF IDEAS O

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BUYING SPREES SEXUAL INDISCRETIONS BAD INVESTMENTS

SLEEP DISTURBANCE O

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FROM DELUSIONS GIVE ADVICE ON MATTERS THEY KNOW NOTHING ABOUT SUPREME SELF CONFIDENCE CAN DO NO WRONG

IDEAS ARE COMING SO FAST, THEY CANNOT COMPLETE A THOUGHT THEY HAVE TO EXPRESS ANOTHER IDEA BEFORE THEY CAN COMPLETELY RESOLVE ANOTHER IDEA CAN BE CRUDE, IN A SEXUAL CONNOTATION

DISTRACTIBILITY O SHORT ATTENTION SPAN O IF THEY ARE ARGUING ABOUT SOMETHING THEY CAN EASILY BE DISTRACTED PSYCHOMOTOR AGITATION O INTRUSIVE IN OTHER PEOPLES BUSINESS O POORLY GROOMED O CONSTIPATED BECAUSE THEY DO NOT TAKE TIME TO GO TO THE BATHROOM COLORFUL AND BIZARRE DRESS

NURSING INTERVENTIONS • HIGH RISK FOR INJURY R/T HYPERACTIVITY O PLACE CLIENT IN PRIVATE OR QUIET ROOM  WHENEVER POSSIBLE O STAY WITH CLIENT AND DIVERT CLIENT AWAY FORM STIMULATING SITUATIONS O OFFER HIGH PROTEIN DRINK EVERY HOUR IN QUIET AREA O FREQUENTLY REMIND CLIENT TO TAKE 2 MORE SIPS O OFFER FINGER FOODS FREQUENTLY  SANDWICH, FRUIT  SOMETHING THEY CAN CARRY WITH THEM AND STILL EAT O CONTINUE • MUST BE MEDICATED O GIVEN AN ANTIPSYCHOTIC TO CALM THEM DOWN (HALDOL) THEY WORK FASTER. • MAKE SURE THEY EAT • QUIET AREA o NOT RIGHT NEXT TO THE NURSES STATION BECAUSE THERE IS TOO MUCH ACTIVITY. • SLEEP O THE ONLY THING THAT CAN REALLY HELP IS MEDICATE THEM  ENCOURAGE REST PERIODS AS MUCH AS POSSIBLE • CAN BE VIOLENT TO OTHER PEOPLE O CAN GET IN POWER STRUGGLES WITH THE STAFF O ATTITUDE HAS TO BE CALM O MATTER OF FACT. O IF YOU ARGUE WITH THEM IT ONLY ESCALATES THEM O AVOID POWER STRUGGLES O DIVERT ATTENTION O SET LIMITS AND PROVIDE CONTROL – PRN ATIVAN  EXPLAIN THAT SINCE YOU ARE UNABLE TO CONTROL YOURSELF WE ARE GOING TO TRY TO HELP YOU CONTROL YOURSELF O REDIRECT VIOLENT BEHAVIOR!!!!!!!!!!!!!!!!!!!!!  PUNCHING BAG • DON’T REINFORCE DELUSIONS O ORIENT TO REALITY • HAVE TO PROTECT FROM FAULTY JUDGMENT • HYGIENE 7

SUPERVISE MAY NEED TO GIVE THEM STEP BY STEP DIRECTIONS MAY NEED TO SUPERVISE DRESS AND MAKE-UP TO MAKE SURE IT IS APPROPRIATE ELIMINATION O TAKE TIME TO GO TO THE BATHROOM O INCREASE FLUIDS AND FIBER O O

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MEDICATION • CP: MEDICATION TOXICITY O MEDICATIONS NEED A BLOOD LEVEL O NEED TO MONITOR BLOOD LEVEL AND MONITOR FOR SIGNS OF TOXICITY. • ANTIPSYCHOTIC MEDS ARE GIVEN TO SLOW THEM DOWN TO PREVENT EXHAUSTION. AND ALSO IF THEY ARE HAVING DELUSIONS, IT WILL HELP CLEAR THAT UP. • LITHIUM O ANTIMANIC DRUG O NOT SURE HOW IT WORKS – POSSIBLE ALTERS SODIUM TRANSPORT……. O ACUTE MAINTENANCE  1 – 1.5MEQ/L  WHEN THE PERSON IS IN AN ACUTE MANIC STATE – THEIR BLOOD LEVEL HAS TO BE HIGHER TO WORK MORE AFFECTIVELY. O ONCE THEY HAVE CALMED DOWN THEY CAN BE REDUCED TO A MAINTENANCE LEVEL  .6 – 1.2 MEQ/L O

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 ANYTHING OVER 1.5 IS CONSIDERED TO BE TOXIC IN ORDER FOR LITHIUM TO WORK IT MUST REACH THESE LEVELS TO BE AFFECTIVE, SO IT WILL TAKE A WHILE. THAT IS WHY TAKING LITHIUM IS NOT AFFECTIVE RIGHT AWAY THAT IS WHY YOU HAVE TO ADD AN EXTRA NARCOTIC. MIGHT TAKE 7-14 DAYS BEFORE GETTING TO THE THERAPEUTIC BLOOD LEVEL. MONITORED WEEKLY OR BIWEEKLY BLOOD SHOULD BE DRAWN 8 – 12 HOURS AFTER A DOSE OF LITHIUM  GIVE EVENING DOSE THEN DRAW BLOOD IN THE MORNING BEFORE A.M. DOSE A MEDICAL WORKUP IS DONE BEFORE A CLIENT IS STARTED ON LITHIUM HAVE TO LOOK AT RENAL AND THYROID FUNCTION. ALSO CHECK ECG OF HEART CONTRAINDICATED IN PREGNANCY, BRAIN DAMAGE, CARDIOVASCULAR OR THYROID DISEASE. WILL CAUSE FETAL DAMAGE. TEACHING ABOUT LITHIUM  TAKE FOR AN INDEFINITE PERIOD OF TIME EVEN AFTER THEIR MOOD HAS STABILIZED  NEED TO KNOW WHAT LITHIUM LEVEL IS AND HOW OFTEN IT IS MONITORED.  THEY NEED TO BE ON A NORMAL OR REGULAR DIET.  NO LOW SODIUM DIETS  GOOD FLUID INTAKE – 1500 TO 3000CC PER DAY  MAY CAUSE NAUSEA – GIVE WITH FOOD  COMMON SYMPTOMS: HAND TREMOR, POLYURIA, MILD THIRST. S/S OF TOXICITY  NAUSEA, VOMITING, DIARRHEA, SLURRED SPEECH, MUSCLE WEAKNESS, COARSE TREMORS, SEIZURES.  LONG TERM AFFECTS OF LITHIUM – CAN CAUSE HYPERTHYROIDISM, IMPAIRS KIDNEYS ABILITY TO MAKE URINE.

ANTIPSYCHOTIC MEDICATIONS – IF DELUSIONS OR HALLUCINATIONS ANTICONVULSIVE MEDICATIONS O BEING USED AS MOOD STABILIZERS O MAIN ONE IS DEPAKOTE, TEGRETOL, NEURONTIN 8

NOT SURE HOW THEY WORK TEGRETOL  MONITOR CBC, FOR AGRANULOCYTOSIS OR APLASTIC ANEMIA  LEVEL 6-8 MG/L O DEPAKOTE – VALPROIC ACID  HAS TO HAVE LEVELS DONE ALSO. MAY AFFECT LIVER SO LIVER FUNCTION TESTS ARE NEEDED  LEVEL IS 50-100 TO BE THERAPEUTIC O NEURONTIN  NEWER ANTICONVULSANT  DOES NOT NEED A BLOOD LEVEL O TOPAMAX O LAMICTAL O TRILEPTAL ANTIANXIETY MEDICATIONS O KLONOPIN – SEDATES PATIENT, O ATIVAN – PRN TO CALM IS AGITATED CHILDREN CAN BE PUT ON LITHIUM, TEGRETOL, AND DEPAKOTE O O

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TYPES OF THERAPY PSYCHOLOGICAL THERAPY • MAY NEED INDIVIDUAL THERAPY TO MAKE SENSE OF THE CONFUSION OF THE MANIC STATE • WHEN THEY GET BACK TO THEIR NORMAL SELF AND SEE THEIR LIFE IN SHATTERS. GROUP THERAPY • POOR CANDIDATES IN THE ACUTE STAGE FAMILY THERAPY • IS NEEDED TO HEAL THE DISRUPTIONS O EXTRAMARITAL AFFAIRS • FAMILY NEEDS A LOT OF EDUCATION ON SYMPTOMS • NEED TO BE AWARE THAT ONE NIGHT OF MISSED SLEEP COULD BE A SYMPTOM OF AN UPCOMING MANIC EPISODE. • IF THAT HAPPENS THEY NEED TO SEE IF THE PERSON HAS BEEN ON MEDS OR GO TO PHYSICIAN OCCUPATIONAL THERAPY / RECREATIONAL THERAPY • NEED SUPERVISED NON COMPETITIVE ACTIVITIES – COMPETITION ESCALATES THEM • SOLITARY THINGS THEY CAN DO WITH A SHORT ATTENTION SPAN WITH MILD PHYSICAL EXERTION • WALKING, SHOOTING FREE THROWS ALONE, WRITING – CREATIVE AND LIKE TO EXPRESS FEELINGS MILIEU THERAPY • NON STIMULATING ENVIRONMENT O SPECIAL TREATMENT IS NECESSARY • PROTECT FROM IMPAIRED JUDGMENT • DON’T TAKE COMMENTS PERSONALLY • DON’T GET DEFENSIVE • MAKE SURE THEY DON’T GIVE AWAY THEIR VALUABLES AXIS IV – PSYCHOSOCIAL – ENVIRONMENT (ANY PROBLEM THAT WILL IMPACT PATIENT) GAP SCALE – LEVEL OF FUNCTION FROM 0-100

EX: how would you care for a post-op client who is showing signs of manic behavior. client has an IV, NG tube, cath and abd incision. ans:

ativan, distraction, monitor closely

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