exam 4 nursing 3

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exam 4 nursing : mood disordered meds
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1

Crises are universal experiences
Crisis represents struggle for equilibrium and adjustment when problems seem unsolvable
Presents both danger to personality organization as well as opportunity for personal growth

Concept of Crisis

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acute, time-limited event experienced as overwhelming emotional reaction

CRISIS

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: assistance in coping for those in crisis. Interventions used are broad, creative and flexible

CRISIS INTERVENTION

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Higher level of functioning
Same level of functioning
Lower level of functioning

Crisis is self-limiting (4 to 6 weeks)
Resolution of crisis: person will emerge at

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return individual to previous level of functioning
Deal with person’s present problems: “here and now”
Nurse takes active, directive role when intervening
Important to set realistic goals

Goal of crisis intervention

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Related to identified developmental stages occurring throughout life
Each new stage requires new coping mechanisms
Examples
Marriage, birth of a child, retirement

Maturational: TYPES OF CRISIS

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Arises from external rather than internal source; usually unanticipated
Examples
Loss of job, death of loved one, change in financial status, divorce

Situational: TYPES OF CRISIS

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Crisis or disaster not part of everyday life
Arise from
Natural disaster (floods, fires, earthquakes)
National disaster (acts of terrorism, war, riots, airplane crashes)
Crime of violence (rape, assault, murder in workplace/school, bombing in crowded areas, abuse)
U.S.: 460 major disasters from 1990-2000

Adventitious : TYPES OF CRISIS

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person is confronted by conflict or problem that threatens self-concept and causes anxiety

PHASE 1 OF CRISIS

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if usual defensive response fails and threat persists, anxiety continues to rise

PHASE 2 OF CRISIS

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if trial-and-error attempts fail, anxiety can escalate to panic levels

PHASE 3 OF CRISIS

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if problem is not solved and new coping skills are ineffective, anxiety can overwhelm person
Serious personality disorganization, depression, confusion, violence against self/other can occur

PHASE 4 OF CRISIS

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Patient’s perception of precipitating event
Perception critical: one person’s minor irritation can be another’s major problem
Assess patient’s situational supports
Does stressful event also affect patient’s family/support systems?
Assess patient’s personal coping skills
Evaluate patient’s anxiety level and use of defense mechanisms

Nursing Process: Assessment Guidelines

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Risk for self- or other-directed violence, Spiritual distress, Hopelessness, Anxiety (moderate, severe, panic), Disturbed thought processes, Ineffective coping, Risk for post-trauma syndrome

Outcomes identification
Outcomes need to realistic
Patient and family need to be involved in identifying outcomes
Outcomes need to be congruent with patient’s values, cultural expectations

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Planning
Nurse plans interventions via variety of modalities
Disaster nursing, mobile crisis units, group work, health education and crisis prevention, victim outreach programs, telephone hotlines

Implementation
Nurse can intervene for individual, group, or community
Questions important
How much has crisis affected person’s life?
How is state of disequilibrium affecting patient’s significant others?
Goals of intervention: patient safety, anxiety reduction

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Assess for suicidal or homicidal thoughts
Ensure patient safety
Listen carefully to patient’s perceptions of problem
Use directive and creative approaches in intervening

Common Nursing Interventions for Patient in Crisis

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Identify patient support systems and mobilize these
Plan with patient interventions acceptable
Plan regular follow-up to assess patient’s progress toward established goals

Common Nursing Interventions for Patient in Crisis

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Primary
Promote mental health and decrease incidence of crisis
Secondary
Interventions to prevent prolonged anxiety and personality disorganization
Tertiary
Support for those who have experienced severe crisis and are recovering
Goal: facilitate optimal level of functioning

Levels of Nursing Care for Crisis Intervention

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used in following situations
Debrief staff following patient suicide
Help staff/students following incident of school violence
Debrief rescue personnel who responded to disaster

Critical Incident Stress Debriefing (CISD)

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Performed 4-8 weeks after initial interview
Successful intervention characterized by:
Patient’s anxiety and ability to function has returned to pre-crisis level
Questions to ask
Is patient safe?
Has patient developed adaptive coping?
Has patient maintained optimum level of function?

Nursing Process: Evaluation

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Individuals with depression experience great personal pain and suffering
Depression common to all ages, races, and both sexes
Vulnerability to depression can be related to genetics and life stressors

Concept of Depression

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Fourth leading cause of disability in U.S.
Lifetime prevalence of major depressive disorder is 16.6%
More common in women

Prevalence

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Frequently with other psychiatric disorders
Anxiety disorders, schizophrenia, substance abuse, and eating disorders
Increases with presence of medical disorder

Comorbidity

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Children as young as age 3 have been diagnosed with depression
Adolescents have increased incidence
Often associated with substance abuse and antisocial behaviors
Older adults (>65) increased incidence
Increased suicide rate occurs with depression in this age group

Depressive Disorders: Developmental Aspects

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Genetics
Twin and adoptive studies point to genetic factors
Biochemical factors: multiple neurotransmitters (NT) may be involved
Monoamine NT (serotonin, noradrenaline)
Research focused on role of dopamine, acetylcholine, and GABA receptors
Stressful life events can deplete NTs

Biological Theories Related to Depressive Disorders

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Neuroendocrine factors
Hyperactivity of hypothalamic-pituitary-adrenal cortex axis implicated
Increased cortisol secretion
Dexamethasone suppression test (DST) helps determine cortisol oversecretion
Imaging results
CT and MRI scans show ventricle enlargement, cortical atrophy, sulcal widening

Biological Theories Related to Depressive Disorders

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Psychodynamic factors: stress-diathesis model
Early life trauma sensitizes stress pathways in brain, increasing vulnerability to depression
Cognitive theory: Aaron Beck
Automatic negative thoughts (of self, future and the world) related to depression
Learned helplessness: Martin Seligman
Individual’s perception of lack of control over stressful life events leads to depression

Other Theories Related to Depressive Disorders

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Manifested by emotional, cognitive, physical, and behavioral symptoms occurring nearly every day for at least a 2-week period
Symptoms represent a change in functioning

Major Depressive Disorder (MDD)

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DSM-IV-TR diagnosis can include specifiers
Psychotic features; catatonic features; melancholic features; postpartum onset; seasonal affective disorder (SAD); atypical features

Major Depressive Disorder (MDD)

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Emotional and cognitive symptoms: depressed mood,
feelings of worthlessness and guilt,
anhedonia, hopelessness,
decreased concentration,
recurrent thoughts of death/suicide

PHYSICAL

weight gain or loss,
insomnia or hypersomnia,
increased or decreased motor activity,
anergia,
constipation

Major Depressive Disorder: Common Symptoms

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Characterized by chronic depressive syndrome usually present for most of day, more days than not, for at least a 2-year period (APA, 2000b)
Not usually severe enough for hospitalization unless person becomes suicidal
Onset is usually early childhood, teenage years, or early adulthood

Dysthymic Disorder: DD

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Use any of the multiple standardized depression screening tools available
Evaluate patient for suicidal ideation
Determine presence of emotional, cognitive, and physical symptoms of depression
Determine presence of other medical conditions contributing to depression

Nursing Process: Assessment Guidelines: DEPRESSION

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Determine history/current support system
Ascertain recent “triggering event” related to loss
Determine cultural beliefs/spiritual practices related to mental health treatment

Nursing Process: Assessment Guidelines: DEPRESSION

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Common nursing diagnoses assigned
Risk for suicide, Hopelessness, Ineffective coping, Social isolation, Self-care deficit
Outcomes identification
Important to include specific goals for patient safety and outcomes related to vegetative/physical signs of depression

Nursing Process: Diagnosis and Outcomes Identification: DEPRESSION

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Planning
Geared toward specific phase of depression and particular symptoms exhibited
Implementation
Focus interventions on specific symptoms with priority related to suicide prevention
Teach patient and family about symptoms of depression, treatment, and medication
Focus on predischarge counseling to alleviate tension on family system

Nursing Process: Planning and Implementation: DEPRESSION

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Understand that patient may need more time to reply to communication
Silence/sitting with patient can be therapeutic
Allow time for patient to respond
Make observations related to patient/situation or environment
Avoid platitudes
Listen carefully for covert messages and question directly about suicide

Communication Guidelines for Patient with Depression

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Milieu therapy
Structured hospital environment helpful
Follow protocol for suicide prevention
Psychotherapy
Cognitive-behavioral (CBT) and interpersonal (IPT) therapies used
Group therapy
Helps decrease feelings of isolation, hopelessness, helplessness and alienation

TREATMENT FOR DEPRESSION

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Advantage
Can help alter withdrawal, vegetative symptoms, activity level; improve self-concept
Drawback
Can take 1-3+ weeks to note improvement
Safety considerations
Concerns about relationship between use of antidepressant drugs and suicide; however, no conclusive evidence to support this

Treatment for Depression: Antidepressant Medications

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Action: inhibit reuptake of norepinephrine and serotonin by presynaptic neurons
Dose: start low and gradually increase
Common adverse reactions
Dry mouth, blurred vision, constipation, and urinary retention
Sedation
Potential dysrhythmias, hypotension, myocardial infarction

Treatment for Depression: Tricyclic Antidepressants (TCAs)

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Action: selectively block neuronal uptake of serotonin
Common adverse reactions
Agitation, anxiety, sleep disturbance, tremor, sexual dysfunction, headache, weight changes, nausea, diarrhea, dry mouth
Potential toxic effect
Serotonin syndrome (SS): potentially fatal reaction when more than one antidepressant used

Treatment for Depression: Selective Serotonin Reuptake Inhibitors (SSRIs)

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Symptoms
Hyperactivity, severe muscle spasms, tachycardia leading to cardiovascular shock, hyperpyrexia, hypertension, delirium, seizures, coma, death
Treatment
Stop offending agents
Provide respiratory, circulatory support in intensive care environment
Use medications to reverse excess serotonin: cyproheptadine, methysergide, propranolol

Symptoms and Treatment of Serotonin Syndrome (SS)

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Action: affect variety of NTs including those affecting serotonin and norepinephrine
Advantage
Can target unique populations of depressed individuals
Can be used to treat other conditions

Treatment for Depression: Newer Atypical Agents

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Action: enhance NTs at synapse by preventing the enzyme monoamine oxidase from breaking them down
Common adverse reactions
Hypotension, sedation, insomnia, changes in cardiac rhythm, muscle cramps, sexual impotence, anticholinergic effects, weight gain
Potential toxic reaction
Hypertensive crisis

Treatment for Depression: Monoamine Oxidase Inhibitors (MAOIs)

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Can occur when monoamine oxidase inhibition prevents the breakdown of tyramine, which is used by the body to make norepinephrine
Preventing hypertensive crisis involves maintaining a special diet (low tyramine) and avoiding medications that contain ephedrine/other psychoactive substances

Hypertensive Crisis and MAOIs

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Electroconvulsive therapy (ECT)
Course of treatment: 2 or 3 treatments/week for total of 6 to 12 treatments
For patients not responding to antidepressants or for depression with psychosis
Potential adverse reactions
Initial confusion and disorientation on awakening from treatment
Memory deficits

Treatment for Depression: Somatic Treatments

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Vagus nerve stimulation: long-term implanted treatment device approved by FDA for patients with treatment-resistant depression
Action: not well understood, affects neurotransmitters implicated in depression
Device implanted in upper chest that sends electrical signals to left vagus nerve in the neck at regular intervals

Treatment for Depression: Somatic Treatments

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Light therapy
First-line treatment for seasonal affective disorder (SAD)
Action: suppresses nocturnal secretion of melatonin, which seems to have beneficial effect on depression

Treatment for Depression: Integrative Therapies

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Plant with antidepressant properties
Not regulated by FDA
Research suggests effective in mild depression

ST JOHNS WART

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Research indicates mood elevation and decreased depression occurs with moderate exercise

EXCERSISE

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Evaluate short-term indicators and outcome criteria
Reduction in suicidal thoughts
Able to state alternatives to suicide
Decrease in severity of emotional, cognitive and vegetative/physical symptoms of depression

Nursing Process: Evaluation; DEPRESSION

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M- Meds = Nitroprusside, Morphine
A - Airway
D - Decrease preload ( nitroglycerin IV)
D - Diuretics ( Lasix)
O - Oxygen
G - Blood Gases (ABGs)

PULMONARY EDEMA - MADDOG

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Formerly called manic-depressive illness
Characterized by two opposite poles
Euphoria
Depression
Chronic, recurring, life-threatening illness
Individuals experience interpersonal, occupational difficulties even during remission
Associated with highest lifetime suicide rate among psychiatric disorders

Concept of Mood Disorders: Bipolar Disorder

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At least one episode of mania alternating with major depression
Psychosis may accompany manic episode

Bipolar I

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Hypomanic episode(s) alternating with major depression
Not accompanied by psychosis

Bipolar II

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Hypomanic episodes alternating with minor depressive episodes

TYPES OF BI POLAR DISORDER : Cyclothymia

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Rapid cycling (four or more episodes in 12-month period

TYPE OF BI POLAR DISORDER : Specifier from DSM-IV-TR

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Lifetime prevalence in U.S. estimated at 3.9%
First episode commonly occurs between ages 18 and 30

Prevalence

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Substance use disorders, personality disorders, anxiety disorders, attention deficit hyperactivity disorder
Medical conditions: cardiovascular, cerebrovascular, metabolic disorders

Comorbidity

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Genetics
Twin, family, and adoptive studies support strong genetic component
Specific genes identified on chromosome 13 associated with bipolar disorder

Biological Theories Related to Bipolar Disorders

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Neurobiological factors
Hypothalamic-pituitary-thyroid-adrenal axis dysfunction implicated
Neuroanatomical factors
Dysregulation in prefrontal cortex and medial temporal lobe implicated

Biological Theories Related to Bipolar Disorders

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Psychological influences
Stressful life events
Families characterized by high expressed emotion most associated with relapse
Cultural considerations
More prevalent in higher socioeconomic classes
Higher rates noted among creative writers, artists, highly educated men and women

Other Theories Related to Bipolar Disorders

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Periods of abnormal and persistently elevated mood for at leas:
4 days for hypomania
1 week for mania
Hypomania
Episode associated with decreased function
Hospitalization not required

BI POLAR DISORDER

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Episode associated with marked impairment in function
Hospitalization necessary

BI POLAR MANIA

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Mood symptoms
Unstable euphoric mood, intense feeling of well-being, mood may change to irritation and anger when thwarted
Behavioral symptoms
Excessive hyperactivity, involved in pleasurable activities with painful consequences, sexual indiscretion, excessive spending of money, mode of dress/makeup may be outlandish, bizarre

Bipolar Disorder: Common Symptoms

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Physical symptoms
Nonstop activity, minimal food intake, little or no sleep
Can lead to exhaustion and even death

Cognitive symptoms (thought processes)
Poor concentration, problems with verbal memory, sustained attention and executive functioning (may persist even in remission)
Flight of ideas: continuous flow of accelerated speech with abrupt changes from topic to topic usually based on understandable associations

Disorganized and incoherent speech with content often sexually explicit and grossly inappropriate
Clang associations: stringing together of words because of rhyming sounds
Grandiose persecutory delusions

Bipolar Disorder: Common Symptoms

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Determine if patient dangerous to self or others
Presence of physical exhaustion
Poor impulse control
Uncontrolled spending of money
Determine medical symptoms
Dehydration, infections

Nursing Process: Assessment Guidelines ; BI POLAR

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Determine presence of other medical/psychiatric conditions
Determine if hospitalization is necessary
Determine patient’s and family’s understanding of disorder, treatment, medications, support groups

Nursing Process: Assessment Guidelines: BIPOLAR

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Common nursing diagnoses
Risk for injury, Risk for self- or other-directed violence, Risk for suicide, Ineffective coping, Disturbed thought processes, Interrupted family processes, Impaired verbal communication, Imbalanced nutrition: less than body requirements

Nursing Process: Diagnosis and Outcomes Identification: BIPOLAR

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Outcomes identification
Acute phase: goal is prevention of physical injury and decrease in symptoms manifested
Continuation of treatment phase: goal is relapse prevention
Maintenance phase: goal is relapse prevention and limiting severity of future episodes

Nursing Process: Diagnosis and Outcomes Identification

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Planning
Geared toward particular phase of mania as well as other co-occurring issues (e.g., risk of suicide, risk of violence, family/legal crisis, substance abuse, risk-taking behaviors, medical compliance)

Nursing Process: Planning and Implementation: BI POLAR

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Implementation
Directed toward establishing therapeutic alliance
Acute phase implementations related to safety in hospital environment, establishment of controls and medical stabilization

Nursing Process: Planning and Implementation : BIPOLAR

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Use firm, calm approach
Use short, concise statements
Remain neutral; avoid power struggles
Be consistent
Important with firm limit setting
Hear and act on legitimate complaints
Firmly redirect energy into appropriate channels

Nursing Communication Guidelines for Patient with Bipolar Disorder

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Seclusion and restraints may be used if patient becomes dangerously out of control and other least restrictive measures failed
Purposes: reduces overwhelming stimuli, protects patient and others from injury, prevents destruction of property

Use of seclusion/restraint associated with complex legal, ethical, and therapeutic issues
Follow well-established institutional protocols for use of these measures

Treatment for Bipolar Disorders: Milieu Therapy

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Used for lifetime maintenance therapy
Lithium carbonate: first-line treatment for mania
Therapeutic blood level must be reached for drug to be effective (usually takes 7-14 days)
Maintenance/therapeutic blood levels between 0.4 and 1.3 mEq/L
Used in combination with antipsychotics or antianxiety medications in initial acute mania

Treatment for Bipolar Disorders: Mood Stabilizers

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Adverse reactions
Related to lithium toxicity—fine line between therapeutic and toxic levels
Lithium toxicity ranges from mild to moderate and severe symptoms depending on blood level
Severe symptoms include ataxia, ECG changes, clonic movements, seizures, coma, and death

Major long-term risks include hypothyroidism and kidney impairment
Necessity for periodic thyroid and renal function tests

Treatment for Bipolar Disorders: Lithium Carbonate

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Patient and family teaching important
Continue drug therapy to prevent relapse
Maintenance of normal diet with normal salt and fluid intake (1500-3000 mL/day)
Lithium decreases sodium absorption and low sodium levels/dehydration cause lithium toxicity
Stop taking lithium and call physician if symptoms of dehydration develop from sweating and/or nausea, vomiting, diarrhea

Treatment for Bipolar Disorders: Lithium Carbonate

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Adjunct to lithium as well as treatment for patients not responsive to lithium
Commonly used drugs
Carbamazepine (Tegretol), divalproex (Depakote), lamotrigine (Lamictal)
Adverse effects of individual antiepileptic drugs vary but include such problems as sedation, agranulocytosis, hepatitis, life-threatening rash

Treatment for Bipolar Disorders: Antiepileptic Medications

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Can be used to subdue severe manic behavior in patients who are treatment resistant to usual medications
May also be used in patients who are suicidal

Treatment for Bipolar Disorders: Electroconvulsive (ECT) Therapy

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Cognitive-behavioral therapy
Cognitive restructuring effective in decreasing affective symptoms, increasing social functioning, and reducing relapse
Interpersonal and social rhythm therapy (IPSRT)
Focuses on resolution of interpersonal problems and prevention of further disputes

Treatment for Bipolar Disorders: Psychotherapy

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Family-focused therapy
Treatment approach focusing on communication within family, communication skills, and education to prevent relapse

Treatment for Bipolar Disorders: Psychotherapy

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Short-term and intermediate evaluation focused on goal attainment such as:
Are patient’s vital signs stable?
Is patient well hydrated ?
Is patient able to control behavior or respond to external controls?
Does patient sleep at least 5 hours per night?
Does family have understanding of illness and treatment?

Nursing Process: Evaluation: BIPOLAR

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Long-term evaluation focused on goal attainment such as compliance with medication regimen, resumption of functioning in community, and family

Nursing Process: Evaluation; BIPOLAR

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complete or incomplete disruption in the continuity of bone structure
Complete: a break across the entire cross section of the bone, can be displaced
Incomplete: break through only a part of the cross section
Comminuted: several bone fragments
Closed: simple, no break in the skin
Open: compound, complex; skin or mucous membranes compromised

Fractures

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Pain: continuous, increase in severity until mobilized, muscle spasms
Loss of function: unable to function properly, abnormal movement
Deformity: displacement
Shortening: long bones, extremity appears shorten compared to other extremity
Crepitus
Localized edema and ecchymosis

Abnormalities: Fractures: ASSESSMENTS

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First immobilize the body part, splinting; assess neurovascular status before and after splinting
Open fracture: cover wound with sterile dressing to prevent further contamination
Reduction: restoration of the fracture fragments
Closed: manipulation and manual traction
Open: surgical approach
Immobilization: after reduction, bone fragments are immobilized by external or internal fixation/cast/traction

Abnormalities: Fractures: Management

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Nursing Management
Closed: Education, page 1163 Chart 43-1
Cast Care Page 1109 Chart 41-4
Open: Prevent infection of the wound, soft tissue, and bone and promote healing
Risk for osteomyelitis, tetanus, gas gangrene
External fixation: elevation, neurovascular assessment, pin care

Abnormalities: Fractures

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Shock: hypovolemic shock from hemorrhage
Fat embolism: fracture of long or pelvic bones, crush injuries; fat gobules may diffuse from the marrow into the vascular compartment, can occlude vessels
Onset is rapid: Hypoxemia, neurologic compromise, petechial rash
Management: respiratory support
Compartment Syndrome: a sudden and severe decrease in blood flow to the tissue distal to an area of injury; ischemic necrosis
Report of severe, unrelenting pain, worse with ROM, pallor, pulselessness, paresthesia, paralysis
Emergency: measures to restore tissue perfusion (fasciotomy)

Complications:

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DVT/PE
Delayed union, malunion, nonunion
Avascular Necrosis of bone: bone loses its blood supply and dies
Complex Regional Pain Syndrome: painful sympathetic nervous system problem: severe burning pain, local edema, stiffness
Heterotopic Ossification: abnormal formation of bone

Abnormalities: Fractures: Complications

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uses a pulling force to promote and maintain alignment to an injured part of the body
Must be continuous to be effective
Skeletal traction is never interrupted
Weights are not removed unless intermittent traction is ordered
Any factor that can reduce the effective pull or alter is eliminated
Patient must be in good body alignment in the center of the bed
Ropes must be unobstructed
Weights must hang freely and not rest on the bed
Knots in the rope or the footplate must not touch the pulley or foot of the bed

TRACTION

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Skin: pulling force is applied by weights that are attached to the client with Velcro, tape, straps, boots, cuffs, 2-3.5kg
Buck’s
Skeletal: continuous traction, passing a metal pin or wire through the bone, ropes and weights are attached the end of the pin
Nursing Management:
Maintain traction
Maintain Position
Prevent skin breakdown
Assess Neurovascular

TRACTION

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Concept of Mood Disorders: Bipolar Disorder
• Formerly called manic-depressive illness
• Characterized by two opposite poles
• Euphoria
• Depression
• Chronic, recurring, life-threatening illness
• Individuals experience interpersonal, occupational difficulties even during remission
• Associated with highest lifetime suicide rate among psychiatric disorders
Types of Bipolar Disorders
**Know this
• Bipolar I
• At least one episode of mania alternating with major depression
• Psychosis may accompany manic episode
• One episode
• Bipolar II
• Hypomanic episode(s) alternating with major depression
• No psychosis
• Cyclothymia
• Hypomanic episodes alternating with minor depressive episodes
• Duration 2 years, pt is very irritable, mind raises, thought are so quickly
• Specifier from DSM-IV-TR
• Rapid cycling (four or more episodes in 12-month period)

Bipolar Disorders: Prevalence and Comorbidity
• Prevalence
• Lifetime prevalence in U.S. estimated at 3.9%
• First episode commonly occurs between ages 18 and 30
**A lot of people are suffering with this disorder**
• Comorbidity
• Substance use disorders, personality disorders, anxiety disorders, attention deficit hyperactivity disorder
• Medical conditions: cardiovascular, cerebrovascular, metabolic disorders

Biological Theories Related to Bipolar Disorders
• What are some reasons?
• Genetics
• Twin, family, and adoptive studies support strong genetic component
• Specific genes identified on chromosome 13 associated with bipolar disorder
• Substance abuse
• Metabolic disorder: electrolyte imbalance
• What is going on in this phase
• Neurobiological factors
• Hypothalamic-pituitary-thyroid-adrenal axis dysfunction implicated
• Neuroanatomical factors
• Dysregulation in prefrontal cortex and medial temporal lobe implicated

Other Theories Related to Bipolar Disorders
• Psychological influences
• Stressful life events
• Families characterized by high expressed emotion most associated with relapse
• Hyperactive, can’t sleep
• Poor nutrition
• Cultural considerations
• More prevalent in higher socioeconomic classes
• Higher rates noted among creative writers, artists, highly educated men and women

Bipolar Disorder
• Periods of abnormal and persistently elevated mood for at leas:
• 4 days for hypomania
• 1 week for mania
• Hypomania
• Episode associated with decreased function
• Hospitalization not required
• Mania
• Episode associated with marked impairment in function
• Hospitalization necessary
Bipolar Disorder: Common Symptoms
• Mood symptoms
• Unstable euphoric mood, intense feeling of well-being, mood may change to irritation and anger when thwarted
• Behavioral symptoms
• Excessive hyperactivity, involved in pleasurable activities with painful consequences, sexual indiscretion, excessive spending of money, mode of dress/makeup may be outlandish, bizarre
• Physical symptoms
• Nonstop activity, minimal food intake, little or no sleep
• Can lead to exhaustion and even death
• Cognitive symptoms (thought processes)
• Poor concentration, problems with verbal memory, sustained attention and executive functioning (may persist even in remission)
• Flight of ideas:
• continuous flow of accelerated speech with abrupt changes from topic to topic usually based on understandable associations
• Disorganized and incoherent speech with content often sexually explicit and grossly inappropriate
• Clang associations: stringing together of words because of rhyming sounds
• ”like a rapper”
• Grandiose persecutory delusions
• **We bring them back to reality**
• I’m god, I’m the king of England, believe he is Michael Jackson

Nursing Process: Assessment Guidelines
• Determine if patient dangerous to self or others
• Presence of physical exhaustion
• Poor impulse control
• Agitation
• Uncontrolled spending of money
• impulsiveness
• Determine medical symptoms
• Dehydration, infections
• Determine presence of other medical/psychiatric conditions
• Determine if hospitalization is necessary
• Determine patient’s and family’s understanding of disorder, treatment, medications, support groups

Nursing Process: Diagnosis and Outcomes Identification
• Common nursing diagnoses
• Risk for injury, Risk for self- or other-directed violence, Risk for suicide, Ineffective coping, Disturbed thought processes, Interrupted family processes, Impaired verbal communication, Imbalanced nutrition: less than body requirements
• Outcomes identification
• Acute phase: goal is prevention of physical injury and decrease in symptoms manifested
• Continuation of treatment phase: goal is relapse prevention
• Maintenance phase: goal is relapse prevention and limiting severity of future episodes
• Planning
• Geared toward particular phase of mania as well as other co-occurring issues (e.g., risk of suicide, risk of violence, family/legal crisis, substance abuse, risk-taking behaviors, medical compliance)
• Implementation
• Directed toward establishing therapeutic alliance
• Acute phase implementations related to safety in hospital environment, establishment of controls and medical stabilization
Nursing Communication Guidelines for Patient with Bipolar Disorder
• Use firm, calm approach
• Use short, concise statements
• Tell them what they are doing wrong
• Remain neutral; avoid power struggles
• Don’t fight/argue with them
• Be consistent
• Important with firm limit setting
• Neutralize the situation
• Hear and act on legitimate complaints
• Address their problems
• Firmly redirect energy into appropriate channels
• In manic phase: give them to do an exercise/activity/to neutralize them

Treatment for Bipolar Disorders: Milieu Therapy
• Seclusion and restraints may be used if patient becomes dangerously out of control and other least restrictive measures failed
• Purposes: reduces overwhelming stimuli, protects patient and others from injury, prevents destruction of property
• Use of seclusion/restraint associated with complex legal, ethical, and therapeutic issues
• Follow well-established institutional protocols for use of these measures

Treatment for Bipolar Disorders: Mood Stabilizers
• Used for lifetime maintenance therapy
• Lithium carbonate: (Adam book)
• first-line treatment for mania
• Given once they reach the Therapeutic blood level must be reached for drug to be effective (usually takes 7-14 days)
• 0.4 and 1.3 Normal Maintenance/therapeutic blood levels between
• > 1.5 Early toxicity: N &V, diarrhea, thirst
• 1.5to 2.0 Advance toxicity: EKG changes, mental confusion
• 2 to 2.5 life threatening: severe EKG changes, seizures, death, use carbamazepine
• Hepatotoxic and heart
• Make sure pt. is getting adequate salt diet and monitor labs/ Lithium is a salt
• Used in combination with antipsychotics or antianxiety medications in initial acute mania
Treatment
• **know the changes in toxicity
• Adverse reactions
• Related to lithium toxicity—fine line between therapeutic and toxic levels
• Lithium toxicity ranges from mild to moderate and severe symptoms depending on blood level:
• Severe symptoms include ataxia, ECG changes, clonic movements, seizures, coma, and death
• Major long-term risks include hypothyroidism and kidney impairment
• Necessity for periodic thyroid and renal function tests
Patient and family teaching important
• Continue drug therapy to prevent relapse
• Maintenance of normal diet with normal salt and fluid intake (1500-3000 mL/day)
• Lithium decreases sodium absorption and low sodium levels/dehydration cause lithium toxicity
• Stop taking lithium and call physician if symptoms of dehydration develop from sweating and/or nausea, vomiting, diarrhea

Treatment for Bipolar Disorders: Antiepileptic Medications
• Adjunct to lithium as well as treatment for patients not responsive to lithium
• Commonly used drugs
Carbamazepine (Tegretol), divalproex (Depakote), lamotrigine (Lamictal)
o Adverse effects of individual antiepileptic drugs vary but include such problems as sedation, agranulocytosis, hepatitis, life-threatening rash

Electroconvulsive (ECT) Therapy
• Can be used to subdue severe manic behavior in patients who are treatment resistant to usual medications
• May also be used in patients who are suicidal

Psychotherapy
• Cognitive-behavioral therapy
• Cognitive restructuring effective in decreasing affective symptoms, increasing social functioning, and reducing relapse
• Interpersonal and social rhythm therapy (IPSRT)
• Focuses on resolution of interpersonal problems and prevention of further disputes
• Family-focused therapy
• Treatment approach focusing on communication within family, communication skills, and education to pre

Fractures
complete or incomplete disruption in the continuity of bone structure
1. Complete: a break across the entire cross section of the bone, can be displaced
2. Incomplete: break through only a part of the cross section, most common in children (greenstick fracture)
3. Comminuted: several bone fragments
4. Closed: simple, no break in the skin
5. Open:
• Immobilization: after reduction, bone fragment is immobilized by external or internal fixation/cast
• compound, complex; skin or mucous membranes compromised
• A cast can’t be put until the inflammation is gone/goes down
Grade I: clean wound less than 1 cm long
Grade II: larger wound w/o extensive soft soft tissue damage or avulsions
Grade III: Highly contaminated

Hip Fracture
Expected finding:
• Shortening and Displacement, reports pain in the hip and groin or in the medial side of the knee
• adducted, and externally rotated
Pain
• in the hip and groin or in the medial side of the knee.
**high mortality rate (die from complications)

Abnormal findings
• Neurovascular, venous thromboembolism
• Pulmonary complications:
o atelectasis, pneumonia
• skin breakdown, and loss of bladder control (incontinence or retention
Late complications include infection, nonunion, and AVN.

Management
• First immobilize the body part, splining: keeping stable
• Buck’s extension traction, a type of temporary skin traction
• Displaced femoral neck fracture is an emergency and must be repaired within 24 hours
• GOAL: manage pain during first 24 to 48 hrs, prevention secondary problems
• Deep breathing every 1 to 2 hrs
• Thigh-high anti-embolism stockings or pneumatic compression devices
• REPOSITION: to the uninjured side, placing pillow b/w legs (abducted/separated), proper alignment and supported while turning
• PROMOTE EXERCISE: use overbed trapeze, on first day of postop transfer pt. to chair, physical therapy, the safe use of assisted device

Assess neurovascular status before and after splinting
• Capillary refill
• Pulses
• Color
• Temperature

• **This will tell me if I got a complication of the fracture

Pelvic Fracture:
Expected finding;
• ecchymosis; tenderness over the symphysis pubis, anterior iliac spines, iliac crest, sacrum, or coccyx; local edema; numbness or tingling of the pubis; and inability to bear weight without discomfort
Pain
• Continuous, increase in severity until mobilized, muscle spasms (begin within 20 minutes after the injury)

Abnormal findings:
• Hemorrhage and shock
• Absence of pulses (dorsalis pedis and peripheral pulses)
Stable: treated with few days of bed rest
• Fluids, dietary fiber, ankle and leg exercises, deep breathing and skin care educe the risk of complications
• RISK: Paralysis of the ileus, bowel sounds
Unstable “open book”
• Immediate treatment in the emergency department
• stabilizing the pelvic bones and compressing bleeding vessels with a pelvic girdle
• an external binding and stabilizing device

Assessment
• Loss of function: unable to function properly, abnormal movement (pain contributes)
• Deformity: displacement, angulation, or rotation (when compare with the uninjured extremity)
• Shortening: long bones, extremity appears shorten compared to other extremity
• Crepitus: crumbling sensation (can be feel or heard)
• Localized edema and ecchymosis: as a result of trauma and bleeding into the tissues
• may develop within an hour, depending on the severity of the fracture
Management
• First immobilize the body part, splinting; assess neurovascular status before and after splinting
• Open fracture: cover wound with sterile dressing to prevent further contamination
• Reduction: restoration of the fracture fragments
• Closed: manipulation and manual traction
• Open: surgical approach
• Immobilization: after reduction, bone fragments are immobilized by external or internal fixation/cast/traction

Nursing Management
Closed: Education, page 1163 Chart 43-1
1. Describe approaches to control swelling and pain:
o elevate extremity to heart level; take analgesics as prescribed
2. Report pain uncontrolled by elevation and analgesics
o (may be an indicator of impaired tissue perfusion or compartment syndrome)
3. Describe management of immobilizing device or care of incision
4. Consume diet to promote bone healing
5. Demonstrate ability to transfer
6. Use mobility aids and assistive devices safely
7. Avoid excessive use of injured extremity; observe prescribed weight-bearing limits
8. State indicators of complications to report promptly to primary provider
o uncontrolled swelling and pain; cool, pale fingers or toes
o paresthesia; paralysis
o signs of local and systemic infection
o signs of venous thromboembolism
o problems with immobilization device
9. State possible delayed complications of fractures
o delayed union; nonunion; avascular necrosis
o complex regional pain syndrome, formally called reflex sympathetic dystrophy syndrome
o heterotopic ossification
10. Describe gradual resumption of normal activities when medically cleared, and discuss how to protect fracture site from undue stresses

Cast Care Page 1109 Chart 41-4
1. Describe techniques to promote cast drying
o do not cover cast; expose cast to circulating air
o handle damp plaster cast with palms of hands
o do not rest the cast on hard surfaces or sharp edges that can dent soft cast
2. Describe approaches to controlling swelling and pain
o elevate immobilized extremity to heart level, apply intermittent ice bag if prescribed, take analgesic agents as prescribed
3. Report pain uncontrolled by elevating the immobilized limb and by analgesic agents
o may be an indicator of impaired tissue perfusion—compartment syndrome or pressure ulcer
4. Demonstrate ability to transfer
o from a bed to a chair
5. State indicators of complications to report promptly to primary provider (e.g., uncontrolled swelling and pain; cool, pale fingers or toes; paresthesia; paralysis; purulent drainage staining cast; signs of systemic infection; cast, splint, or brace breaks)
6. Describe care of extremity following cast, splint, or brace removal
o skin care, gradual resumption of normal activities to protect limb from undue stresses, management of swelling

Open: Prevent infection of the wound, soft tissue, and bone and promote healing
• Risk for osteomyelitis, tetanus, gas gangrene
• External fixation: elevation, neurovascular assessment, pin care

ORIF VS OREF

Open Reduction with Internal Fixation (ORIF)
Priorities
o Elevation
o The keep the pt. leg in abducted position
o open surgical procedure to repair and stabilize a fracture
o Pin care/keep it nice and clean
o Internal fixation devices
 metallic pins, wires, screws, plates, nails, or rods
Open Reduction External Fixation (OREF)
o Elevate and Ice
o Keep the swelling down
o Support the extremities
o Immobilization is accomplished by external fixation
 bandages, casts, splints, continuous traction, and external fixators) or internal fixation.

Complications:
• Shock: hypovolemic shock from hemorrhage
• Fat embolism: 02 FIRST PRIORITY
o fracture of long or pelvic bones, crush injuries; fat globules
o may diffuse from the marrow into the vascular compartment, can occlude vessels
Onset is rapid: Hypoxemia, neurologic compromise, petechial rash, hypoxia and tachypnea
headache and mild agitation to delirium and coma
Management: respiratory support
• Compartment Syndrome: 5 p’s
o Pain, pallor, pulseless, paresthesia, paralysis
o a sudden and severe decrease in blood flow to the tissue distal to an area of injury; ischemic necrosis
• Report of severe, unrelenting pain,
o worse with ROM (hallmark sign) intensifies with dorsiflexion of the wrist of the affected extremity
o pallor, pulselessness, paresthesia, paralysis
• IF complications: splint may be loosened or removed (cut in half longitudinally)
• maintaining limb alignment, and the extremity must then be elevated no higher than heart level to maintain arterial perfusion

Emergency: measures to restore tissue perfusion (fasciotomy)

DVT/PE
• Delayed union, malunion, nonunion
• Avascular Necrosis of bone: bone loses its blood supply and dies
Infections: Always is a late sign
• Complex Regional Pain Syndrome: painful sympathetic nervous system problem: severe burning pain, local edema, stiffness
• Heterotopic Ossification: abnormal formation of bone

Traction
• Traction: uses a pulling force to promote and maintain alignment to an injured part of the body
• Must be continuous to be effective
• Skeletal traction is never interrupted
• Weights are not removed unless intermittent traction is ordered
• Any factor that can reduce the effective pull or alter is eliminated
• Patient must be in good body alignment in the center of the bed