most severe form with at least 1 episode of mania; alternates with major depression;

psychosis may accompany manic episode

(median age of onset is 18 years, more common among males)

hypomania episodes alternating with major depression (risk for suicide);

psychosis NOT present

(age of onset: 20 yrs; more common to females)

voracious appetites for social engagement, spending, activity, indiscriminate sex;

characterized by constant activity, decreased need for sleep;

may lead to physical exhaustion, even death

(mild - moderate mania)

hypomanic episodes alternating with minor depressive episodes;

at least 2 years in duration;

tendency toward irritable hypomanic episodes;

usually begins in adolescence/early adulthood

4 or more episodes in a 12 month period;

poorer global functioning;

high recurrence risk;

resistance to conventional somatic tx

a nearly continuous flow of accelerated speech w/abrupt changes from topic to topic that are usually based on understandable association or plays on words, i.e., "How are you doing, kid, no kidding around, I'm going home...home sweet home...home is where the heart is..." ---thoughts racing, abrupt change of topic

the stringing together of words because of their rhyming sounds, w/out regard to meaning

• Firm, calm approach (low voice, slow approach to pt, be direct/firm); 
• Short explanations (concise); 
• Avoid power struggles (stay neutral); 
• Consistency (imperative among staff if limit setting is to be carried out effectively)

• Lower physical activity, 
• increase food/fluids, 
• ensure sleep, 
• ensure no bowel/elimination problems, 
• assess self-care needs, 
• may need seclusion (occasionally ECT); 
• medical stabilization; 
• maintaining safety

Assess pt & family problem-solving skills:

Maintain medication adherence;

psychoeducational teaching (family);

referrals

prevent relapse;

maintain tx/results;

limit duration/severity of future episodes

"mood stabilizer" (drug of choice)

- effective in tx of bipolar I acute & recurrent manic & depressive episodes (less effective in people w/mixed mania (elation & depression), rapid cyclers, & atypical features);

C/I in CV disease, renal, or thyroid disease.

Decreases elation, grandiosity; may help w/destructive behavior; watch w/use of diuretics, cardiac meds.

fine hand tremor, polyuria, mild thirst, mild nausea, discomfort, wt gain

300 - 600 mg TID;

takes 10 - 21 days to reach therapeutic levels

N&V, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, fine hand tremor

• w/hold med, 
• measure blood lithium levels, 
• reevaluate dose, 
• address dehydration

coarse hand tremor, persistent GI upset, mental confusion, incoordination, sedation

ataxia, confusion, large output of dilute urine, serious electroencephalographic changes, blurred vision, clonic movements, seizures, stupor, severe hypotension, coma, death secondary to pulmonary complications, convulsions, oliguria, death

NSG: hospitalization, stop drug, excretion is hastened.

If pt is alert, administer emetic; hemodialysis in severe cases.

hypothyroidism & impairment of the kidney's ability to concentrate urine: must have periodic follow-ups to assess thyroid & renal function

valproate

(divalproax sodium (Depakote);

valpriod acid (Depakene))

anticonvulsant: for TX of lithium nonresponders in acute mania, who experience rapid cycles, are in dysphoric mania, or have not responded to carbamazepine; prevents future manic episodes;

monitor liver function, platelet count

anticonvulsant: seems to work better for rapid cyclers & severely paranoid, angry pts (manic) & dysphoric pts (manic); monitor liver function & platelet count, blood levels of drug;

s/e: dizzy, drowsy, N&V

***titrate up slowly for decreased s/e

*****If presence of skin rash occurs, notify MD & d/c drug

anticonvulsant: 1st line TX for bipolar depression, approved for acute & maintenance therapy

***potentially life-threatening rash could occur (serious, but rare: skin dries & sheds off)***

an acute disruption of psychological homeostasis in which one's usual coping mechanisms fail. This is usually an acute & time-limited occurrence (lasting 4-6 weeks). Outcomes depend on realistic perception of the event, adequate situational supports & adequate coping mechanisms.

a critical period of increased vulnerability and heightened potential - a turning point (new developmental stage is reached; old coping skills no longer helpful, ineffective defense mechanisms until new coping skills develop)

i.e., leaving for college, having a baby

arises from events that are extraordinary, external rather than internal, & often unanticipated, i.e., job loss/change, death of a loved one, abortion, divorce, severe mental or physical illness

not a part of everyday life; results from events that are unplanned & may be accidental, caused by nature, or human-made. This type of crisis results from

1.) a natural disaster (flood, fire, earthquake)

2.) a national disaster (acts of terrorism, war, riots, airplane crashes), or

3) a crime of violence (rape, assault, murder in the workplace or school, bombing in crowded areas, spousal or child abuse)

***strong need for psychological 1st aid***

In this phase of Caplan's 4 phases of crisis: conflict or problem -> self concept threatened -> increased anxiety

-> use of problem solving techniques & defense mechanisms -> resolve conflict or problem -> reduce anxiety

In this phase of Caplan's 4 phases: Problem-solving techniques & defense mechanisms fail -> threat persists

-> anxiety increases -> feelings of extreme discomfort produced -> functioning disorganized -> trial & error attempt to solve problem & restore normal balance

Trial & error attempts fail -> anxiety can escalate to severe & panic levels -> automatic relief behaviors mobilized (i.e., withdrawal and flight) -> some form of resolution may be made (i.e., compromising needs or redefining situation)

problem not solved & coping skills ineffective -> overwhelming anxiety -> possible serious personality disorganization, depression, confusion, violence against others, or suicidal behavior

1) Nurse needs to be needed

2) Nurse sets unrealistic goals for pt

3) Nurse has difficulty dealing w/issue of suicide

4) Nurse has difficulty terminating the nurse-patient relationship

promotes mental health & reduces mental illness to decrease the incidence of crisis;

proactive, preventative

establishes intervention during an acute crisis to prevent prolonged anxiety from diminishing personal effectiveness & personality organization, i.e., clinics, mental health ctrs, emergency rooms.

Primary focus is patient safety. Pt problem, support system, & coping styles are assessed; desired goals are explored & interventions planned.

provides support for those who have experienced a severe crisis and are now recovering from a disabling mental state, i.e., day hospitals, rehabilitation centers, sheltered workshops, & outpatient clinics

psychological 1st aid: consists of a 7 phase group meeting that offers individuals the opportunity to share their thoughts and feelings in a safe and controlled environment, i.e., for a group on a psych unit after someone has committed suicide; for staff in a nursery after an infant has died

1) Introductory,

2) Fact,

3) Thought,

4) Reaction,

5) Symptom,

6) Teaching,

7) Reentry

phase of CISD in which meeting purpose is explained; overview of debriefing process

phase of CISD in which facts of incident are discussed; participants introduce themselves, tell their involvement in the incident, describe the event from their perspective

phases of CISD in which participants discuss 1st thoughts of the incident

Phase of CISD in which participants talk about the worst thing about the incident - what they'd like to forget; what was most painful

Phase of CISD in which participants describe their cognitive, physical, emotional, or behavioral experiences at the incident scene & describe any symptoms they felt following the initial exp.

Phase of CISD in which normality of expressed symptoms is acknowledged/affirmed; guidance re: future symptoms is offered; stress mgmt techniques

Phase of CISD in which review material discussed, introduce new topics, questions, closure to debriefing; written material provided; encouragement/support given

*Clarify the message. Get straight to the point (concise but thorough);

*Personal space (watch client's comfort level);

*Body position (look at client's body language);

*Verbal expression (allow pt to talk);

*Limits (set/enforce reasonable boundaries);

*Don't overreact;

*Physical techniques (as a last resort);

*Nonverbal cues - make sure nonverbal cues are non-threatening

chronic mood disturbance of at least 2 years duration w/the recurrent experience of some of the symptoms of hypomania alternating with dysthymic depression. Do not have severe impairment of social or occupational functioning, nor do they experience psychotic symptoms such as delusions.

Consists of 1 or more episodes of major depression & 1 or more periods of clear-cut mania

Consists of 1 or more episodes of major depression plus at least one hypomanic episode

episode is assoc. w/change in functioning that is uncharacteristic of person when not symptomatic; absence of marked impairment in social or occupational functioning,; delusions are never present; hospitalization is NOT indicated.

1) severe enough to cause marked impairment in occupational activities, usual activities or relationships...OR...

2) hospitalization is needed to protect pt & others from irresponsible or aggressive behavior...OR...

3) There are psychotic features (grandiose and/or paranoid delusions)

check blood levels every 3 - 7 days for the 1st few weeks. Once pt is stable, check every 1 - 3 months. Initially, levels should be 1.0 - 1.2.

Maintenance levels range from 0.6 - 1.2.

Toxicity levels are >1.5.

An antipsychotic (like Olanzapine - an atypical antipsychotic) will help to decrease psychomotor activity, aggressive behavors & prevent exhaustion, coronary collapse, & death until this drug reaches therapeutic levels. C/I in pregnancy, brain damage, CVD, renal or thyroid disease.

particularly useful in mixed state and rapid cycling bipolar pts; must monitor blood levels; risk of hepatotoxicity

devastating brain disease affecting thinking, language, emotions, social behavior and reality perception; usually develops during late teens/20's; treatable, but not curable

refers to experiencing such phenomena as delusions, hallucinations, disorganized speech or behavior

communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation.

communication disorder in which the focus of a conversation drifts, but often comes back to the point.

the outward manifestation of a person's feelings and emotions. Schizophrenia may cause flat, blunted, inappropriate or bizarre _______.

disorganized thinking, manifested as jumbled and illogical speech and impaired reasoning.

thinking is not bound to reality but reflects the private perceptual world of the individual. Delusions, hallucinations, & neologisms are examples of this.

simultaneously holding two opposing emotions, attitudes, ideas, or wishes toward the same person, situation, or object.

the presence of something that is not normally present (e.g. hallucinations, delusions, bizarre behaviour, paranoia)

the absence of something that should be present but is not (e.g., apathy, lack of motivation, anhedonia, and poor thought processes)

List the 4 A's of schizophrenia (Bleuler):

4 areas of deficit/hallmarks of schizophrenia

• Positive symptoms, 
• Negative symptoms, 
• Cognitive symptoms, 
• Affective Symptoms

made-up words (or idiosyncratic uses of existing words) that have meaning for the pt but a different or nonexistent meaning to others, i.e., "I was going to tell him the mannerologies of his hospitality won't do." This eccentric use of words represents disorganized thinking & interferes w/communication.

the pathological repeating of another's words, often seen in catatonia:

Nurse: "Mary, come get your medication."

Mary: "Come get your medication."

the choice of words based on their sound rather than their meaning, often rhyming and sometimes having a similar beginning sound ("on the track...have a Big Mac;" "click, clack, clutch, close") ---may also be seen in neurological disorders

a jumble of words that is meaningless to the listener - and perhaps to the speaker as well - because of an extreme level of disorganization

sensory perceptions for which no external stimulus exists (auditory, visual, olfactory, tactile)

extreme motor agitation, stereotyped behaviors, automatic obedience, waxy flexibility, stupor, negativism

affective blunting, anergia, anhedonia, avolition, poverty of content of speech, thought blocking, flat affct/inappropriate affect

emotional response incongruent to situation (e.g., man laughs when told his father has died)

grimacing, giggling, mum; odd, illogical emotional state (grossly inappropriate)

inattention, easily distracted; impaired memory; poor problem-solving skills; poor decision-making skills; illogical thinking; impaired judgement

Focuses on symptoms, coping, functioning, & safety. Interviewing the client & observing behavior & other outward manifestations of the disorder;

Includes mental status, spiritual, cultural, biological, psychological, social, environmental elements.

Review medical workup to R/O medical cause & use of abusive substances;

Assess for command hallucinations (voices telling pt to harm self or others);

determine pt's belief system (delusions, paranoid beliefs)

*Never argue a delusion.

*Try to get an understanding of the client's experience.

the mimicking of movements of another

(also seen in catotonia)

a nonspecific feeling that a person has lost his/her identity & that the self is different or unreal. People may feel that body parts do not belong to them or may suddenly sense that their body has drastically changed (i.e., pt sees fingers as snakes, or arms as rotting wood)

false perception that the environment has changed (i.e., everything seems bigger or smaller, or familiar surroundings have somehow become strange & unfamiliar)

misperceptions of misinterpretations of a real experience, i.e., a man sees his coat on a coat rack and believes it is a bear about to attack. He does see something real but misinterprets what it is.

a pronounced increase or decrease in the rate and amount of movement; most common form is stuporous behavior in which the person moves little or not at all.

the extended maintenance of posture, usually seen in catatonia, i.e., nurse raises the pt's arm, & the pt continues to hold this position in a statue-like manner

symptoms that develop slowly and are those that most interfere w/a person's adjustment and ability to cope; these symptoms impede one's ability to initiate & maintain conversations and relationships, obtain & maintain a job, make decisions & follow through on plans, maintain adequate hygiene/grooming - contribute to poor social functioning & social w/drawal

patient/consumer-centered;

involves active partnership with care providers;

hopeful, empowering, strengths-focused model wherein staff assist the consumer in using strengths to achieve the highest quality of life possible. Encourages a high degree of pt independence & self-determination & focuses on achieving goals of the pt's choosing & leading increasingly productive & meaningful lives. Emphasis is on the person & the future rather than on the illness and the present.

*be aware/respectful of personal space;

*eye contact can be viewed as aggressive;

*be where you say you will be, when you say you be; *Don't probe;

*Don't argue delusion

>Consistent, repeated approaches by the nurse.

>Address physiological needs;

>Facilitate communication: patience, sit in silence, use open-ended statements, wait;

>Avoid excessive detail and the introduction of many topics;

>Give proposed length of time for the interaction;

>Ask for description of action and events, rather and thoughts & feelings;

>Avoid making client's behavior part of a power struggle;

>Be aware of nonverbal communication;

>Facilitate social participation: 1:1 at first, gradually expand to others;

>Be aware of family: refer to family therapy. Help them understand the client's illness & the client's needs. Teaching is very important.

>Termination may be very difficult.

Impaired social interaction R/T Fear or anxiety -

NSG Interventions

>Nurse must be reliable; follow through on commitments;

> Avoid physical contact & too much eye contact.

> Several brief interactions.

> Maintain physiological needs: nightlight, sleep med, antipsychotic. Have family bring food. Give food from unopened packages.

> Respect privacy - Don't probe.

> Assign 1 or 2 staff

> Open and honest approach - e.g., tell when plan to meet family and include in mtg.

> "Need-Fear dilemma" - client should set the pace for the closeness/relationship

> Gradually transfer trust to others.

> Don't argue delusion or nurse becomes a part of it. Convey your acceptance while letting the client know you do not agree w/the delusion.

>Don't argue. Point out your reality but don't try to rob client of his.

>Assess the need that is being met by the hallucination. >Establish a trusting nurse/client relationship.

>Be link to reality for the client.

>Encourage reality-based talk.

>Teach ways to deal with when alone, e.g. competing stimuli

>Approach client in nonthreatening/nonjudgmental manner.

>Assess if messages are suicidal/homicidal.

>Initiate safety measures if needed.

>Be alert to signs of anxiety in pt, which may indicate hallucinations are increasing.

reduced motivation; inability to initiate tasks such as social contacts, grooming, & other ADLs

Affective blunting (reduction in the expression, range, & intensity of affect), anergia, anhedonia, avolition, poverty of content of speech, poverty of speech, thought blocking.

a sudden interruption in the thought process, usually due to internal stimuli. Example: A pt abruptly stops talking mid-sentence and remains silent.

Nurse: "What happened just now?"

Pt: "I forgot what I was saying. Something took my thoughts away."

>Do not pretend that you understand.

>Place difficulty of understanding on yourself.

>Look for reoccurring topics & themes.

>Emphasize what is going on in the client's environment. >Involve client in simple, reality-based activities. >Reinforce clear communication of needs, feelings, and thoughts.

>Be open, honest, matter-of-fact, and calm.

>Have client describe delusion.

>Avoid arguing about content.

>Interject doubt.

>Validate part of delusion that is real.

>Observe for events that trigger delusions.

Action: serotonin & dopamine antagonist; treats symptoms AND improves quality of life.

Advantages: Alleviate positive AND negative symptoms; produce minimal extrapyramidal symptoms; help improve cognitive deficits & decrease anxiety and depression. Disadvantages: Tend to cause wt gain assoc. w/ additional metabolic s/e, increasing risk for diabetes, cardiovascular disease, and hypertension. More expensive than conventional antipsychotics.

Atypical antipsychotic (2nd generation) Use: TX of severe schizophrenia that is unresponsive to standard antipsychotic regimens; decreases recurrent suicidal behavior

S/E: tachycardia, agranulocytosis, transient fever, neuroleptic malignant syndrome (rare)

NSG: Lab: baseline WBC (weekly counts for 1st 6 months, then frequent monitoring thereafter), Monitor diabetics for loss of glycemic control, monitor CV and Resp status; daily temp (report fever); report flulike symptoms: fever, sore throat, lethargy, malaise, unexplained fatigue (esp. with activity), shortness of breath, sudden wt gain or edema of LE. Rise slowly to avoid orthostatic hypotensoin.

***Pt must be registered when taking; obtain regular CBCs to measure for neutropenia as this drug causes agranulocytosis in up to 1% of pts.***

sudden drop in leukocyte count; often followed by a severe infection manifested by high fever, chills, prostration, and ulcerations of mucous membranes (such as mouth, rectum, or vagina)

New antipsychotic: need to titrate slowly to avoid orthostatic hypotension. Should consider it's ability to prolong the QT interval.

New antipsychotic: extended release injectable suspension. Can cause PDSS (post injection delirium/sedation syndrome)

Must be monitored for 3 hrs. post injection.

Action: dopamine antagonist at D2 receptor sites in limbic & motor areas of brain

Disadvantage: severe s/e profile: extrapyramidal side effects, TD, anticholinergic effects, decreased seizure threshhold, orthostasis, photo sensitivity

tongue movements, lip smacking w/uncontrollable biting, chewing, or sucking movements

Neuroleptic Malignant Syndrom (NMS);

Nsg interventions: Discontinue antipsychotic drug; treat symptomatically in intensive care environment (management of fluid balance, temperature reduction, monitor for complications); mild cases treated w/bromocriptine (Parlodel); more severe cases treated w/dantrolene (Dantrium) & even with ECT

occurs from dopamine blockage; produces decreased level of consciousness, increased muscle tone, high fever, htn, sweating tachycardia, drooling...

NSG interventions are...

symptoms include sore throat, fever, malaise, and mouth sores; evaluate any flu-like symptoms. Occurs suddenly during 1st 12 wks. of therapy.

*A potentially dangerous blood dyscrasia: bloodwork ordered every week for 6 months, then every 2 months. *If positive for leukopenia or agranulocytosis, drug is discontinued & reverse isolation may be initiated.

*Use abnormal Involuntary Movement Scale (AIMS) for early recognition of EPS.

*Use anticholinergic meds as TX for EPS.

*Monitor pt for S&S of agranulocytosis.

*Monitor pt for S&S of NMS & intervene early.

Strong antagonists at the D2 dopamine receptors; dopamine blockage can lead to motor abnormalities (EPS) such as parkinsonism, akinesia, dyskinesia, TD; *AIMS scale is used to monitor for involuntary movements;

*Women may have amenorrhea (absence of the menses) or galactorrhea (breast milk flow).

*Men may develop gynecomastia (male mammary glands).

*ACH s/e: blurred vision, dry mouth, constipation, & urinary hesitancy; also impaired memory. S/E also include sedation, substantial wt. gain, failure to ejaculate, and orthostatic hypotension.

produce fewer EPS and target both neg & pos symptoms of schizophrenia.

*Increased risk of metabolic syndrome (increased weight, blood glucose & triglycerides), increased appetite -> wt gain, insulin resistance -> hyperglycemia;

Clozapine & Olanzapine carry the highest risk of causing metabolic syndrome. Aripiprazole & Ziprasidone carry the lowest risk. Clozapine has the potential to suppress bone marrow and induce agranulocytosis, reg. measure of WBC's required. Most common s/e are: drowsiness sedation, hypersalivation, wt gain, reflex tachycardia, constipation, dizziness.

very low potential for inducing convulsions or agranulocytosis; may lead to motor difficulties (highest risk of EPS among atypical antipsychotics), may lead to sexual dysfunction. Can cause orthostatic hypotension (can lead to falls)

A/E = wt gain, sedation, sexual dysfunction

leads to wt gain, moderate risk of metabolic syndrome; low risk for EPS or prolactin elevation

s/e: sedation, wt gain, hyperglycemia w/new onset type 2 diabetes and higher risk for metabolic syndrome.

s/e: dizziness, moderate sedation

*C/I: known hx of QT interval prolongation, recent acute MI, or uncompensated HF

little sedation & wt gain

s/e: insomnia and akathesia