MOOD AND MOOD DISORDERS

8/7/2019 MOOD AND MOOD DISORDERS

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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

MOOD AND MOOD DISORDERS

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