PSYCHE FINALS : TRANS 2 BEHAVIORS COMMONLY ASSOCIATED WITH DEPRESSION

a. Affective: Anger, anxiety, apathy, bitterness, hopelessness,

AFFECTIVE / MOOD DISORDERS helplessness, sense of worthlessness, low self-esteem, denial of
MODELS OF CAUSATION: Genetic; Aggression turned inward; Objects loss; feelings
Personality disorganization; Cognitive: Hopelessness; Learned b. Physiological: Fatigue, backache, anorexia, vomiting, headache,
helplessness - hopelessness; dizziness, insomnia, chest pain, constipation, weight change,
Behavioral: Loss of positive reinforcement; abdominal pains*
Biological: Decreased serotonin and norepinephrine *; Life stressors; and c. Cognitive: Confusion, indecisiveness, ambivalence, inability to
Integrative: chemical, experiential, behavioral variables concentrate, pessimism, loss of interest, self-blame
DEPRESSION d. Behavioral: Altered activity level, over-dependency, psychomotor
Definition: retardation, withdrawal, poor hygiene, agitation, irritability,
An abnormal extension or over elaboration of sadness and grief; oldest and tearfulness
most frequently described psychiatric illness; a pathologic grief reaction
experienced by an individual who does not mourn In a depressed patient, hostility is turned towards the self, while in manic
 The term depression is used in varied ways: a sign, patient, hostility is turned towards the environment.
symptom, syndrome, emotional state, reaction, disease or
Depression in children results to anhedonia (energy loss & fatigue,
clinical entity.
decreased interest in previously enjoyed activities) like playing alone during
 May be mild, moderate, severe, with (uncommon) or
recess.
without psychotic features
TYPES: DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION:
1. Depressive Disorders At least five of the following, most of the day, nearly daily, for 2 weeks:
2. Manic-Depressive (Bipolar) Disorders 1. Early morning depression
3. Suicidal Behavior 2. Loss of interest or pleasure (ANHEDONIA)*
3. Insomnia*
A.DEPRESSIVE DISORDERS 4. Psychomotor retardation (slow mov’t)
Depressive episode with no manic episodes 5. Fatigue or loss of energy (anemia)
1. Major depression, single episode 6. Feelings of worthlessness & ambivalence (fear of death vs. fear
2. Major depression, recurrent: Repeated episodes of major sadness or living) *
depression separated by long intervals, occurring in clusters or increasing 7. Self care deficit*
with age* 8. History of suicide*
3. Dysthymia: Chronic depressive mood problems occurring in the absence 9. Weight loss or gain
of a major depressive or organic or psychotic diagnosis. 10. Flat affect*
DIFFERENTIATION/CATEGORY: 11. Constipation*
*Moderate Depression – crying at night PREDISPOSING FACTORS:
- Dysthymia – painful
depression for 2 years 1. Single, Annulled & Divorced
*Severe Depression – Crying at early morning, depression less than 2weeks 2. Loss of loved one (situational crisis)
*Major Depression – Severe depression for more than 2 weeks 3. SAD – Seasonal Affective Disorder – common on winter season
* - both of them have the same characteristics (Nov.-Feb.) or intimate months
Seasonal depression occurs during winter and fall this is due to abnormal 4. Suicidal attempt – a strong and desperate call for help involving a
melatonin metabolism. definite risk.
5. Alcoholics/Drug addicts* Cognitive styles of suicidal patients:
A 66 y/o American men, no hobby, no friend, retired 6 yrs ago, no money & 1. Ambivalence. They have 2 conflicting desires at the same time: To
has history of alcohol abuse is at risk for suicide live and to die. Ambivalence accounts for the fact that a suicidal person
6. Protestants often takes lethal or near-lethal action but leaves open the possibility for
7. Incurable Illness* rescue.
8. Post partum depression 2. Communication. Some, people cannot express their needs or
9. Schizophrenia* feelings to others, or when they do, they do not obtain the results they
Prone: Male hope for. For them, suicide becomes a clear and direct, if violent, form of
Age bracket prone for suicide communication.
#1. Adolescent (identity crisis) Demographic Variables – suicide rates are higher among the following:
2. Elderly (ego-despair) 1. Single people
3. Middle age men (45 y.o. above) 2. Divorced, separated or widowed
4. Post partum depression (7 days/2-4 weeks) 3. People who are confused about their sexual orientation
4. People who have experienced a recent loss: divorce, loss of job,
Suicide and Self-destructive Behavior
loss of prestige, loss of social status or who are facing the threat of criminal
Suicide is never a random act. Whether committed impulsively or
exposure
after painstaking consideration the act has both a message and a purpose.
5. Caucasians, Eskimos and Native Americans
In general the purpose or reason for suicide is to escape; to get away or end
6. Protestants or those who profess no religious affiliation
an intolerable situation, crisis, difficulty, or relationship, e.g., escaping a
Clinical variables:
terminal illness, avoiding being a burden to others, resolving an untenable
1. People who have attempted suicide before
family situation, or to avoid punishment or exposure of socially or
2. People who have experienced the loss of an important
personally unacceptable behavior.
person at some time in the past or the loss of both parents early in
Self-destructive behavior is action by which people emotionally,
life, or the loss of or threat of their spouse, job, money or social
socially and physically damage or end their lives. Typical behavior are biting
position
one’s nails, pulling one’s hair scratching or cutting one’s wrist. A complete
3. People who are depressed or recovering from depression
suicide is the most violent self-destructive behavior.
or a psychotic episode
Levels of self-destructive behavior:
4. Those with physical illness, particularly when the illness
1.Chronic self-destructive behavior – e.g. smoking, gambling, self-
involves an alteration of body images or lifestyle
mutilation
5. Those who abuse alcohol or drugs
2.Suicidal threat – a threat more serious than a casual statement of
6. Those who are recovering from a thought disorder combined
suicidal intent and accompanied by behavioral changes, e.g., mood swings,
with depressed mood and / or suicidal ideation ( hallucinations that tell
temper outbursts, decline in school or work performance
them to kill or harm themselves)
3. Suicidal gesture – more serious warning signal than a threat that
Management – people bent on suicide almost always give either verbal or
maybe followed a suicidal act that is carefully planned to attract attention
nonverbal clues of their intent. They actually make a powerful attempt to
without seriously injuring the subject
communicate to others their hurt ad desperation. They are crying out for 4 High risk of immediate Has current high lethal
help. suicide plan, obtainable
1. A lethality assessment scale (Table 2) is an attempt to predict the means, history of
likelihood of suicide. previous attempts, has
a close friend but is
Table 2: Lethality Assessment Scale unable to
communicate with him
Key to Scale Danger to Self Typical Indicators or her a drinking
1 No predictable risk of Has no notion of problem; is depressed
immediate suicide suicide or history of and wants to die
attempts, has
satisfactorily social 5 Very high risk of Has current high lethal
support network, and immediate suicide plan with available
is in close contact with means, history of high
significant others lethal suicide
attempts, is cut off
2 Low risk of immediate Person has considered from resources; is
suicide suicide with low lethal depressed and uses
method; no history of alcohol to excess, and
attempts or recent is threatened with a
serious loss; has serious loss, such as
satisfactorily support unemployment or
network; no alcohol divorce or failure in
problems; basically school age more in
wants to live elderly and
adolescents
3 Moderate risk of Has considered suicide
immediate suicide with high lethal General guidelines – the general task of the nurse is to work with the client
method but no specific to stop the constricted processing of suicidal thinking long enough to allow
plan or threats; or has the client and the family to consider alternatives to suicide.
plan with low lethal a. Take only threat seriously
method , history of b. Talk about suicide openly and directly
low lethal attempts, c. Implement basic suicide precautions:
with dysfunctional
1. Check on the client at least every 15 minutes or require the
family history and
client to remain in public place
reliance on Valium or
other drugs for stress 2. Stay with the client while all medications are taken
relief; is weighing the 3. Search the client’s belongings for potentially harmful
odds between life and objects. Make the search in the client’s presence and ask for
death the client’s assistance while doing so
 4. Check articles brought in by visitors R. Monitor your personal feelings about the client and decide how they may
5. Allow the client to have regular food tray but check whether the glass be influencing your clinical work
or any utensils are missing when collecting the tray S. Work with other team members to evaluate the issues fully
6. Allow visitors and telephone calls unless the client wishes otherwise T. Do a body examination
7. Check that visitors do not potentially dangerous objects in the room U. Recognize that people can and have hanged or strangled themselves with
d. In addition to the above, maximum suicide precautions mean: shoelaces, brassiere straps, pantyhose, robe belts, etc.
 Provide one-to-one nursing supervision. The nurse must
be in the room with the client at all times 2 LETHAL METHODS OF SUICIDE:
 Maintain the client’s safety in the least restrictive 1. Low-risk = slashing of the radial
manner possible pulse (more o females)
 Do not allow the client to leave the unit for test or 2. High-risk = drowning, gun shot,
procedures hanging, jumping from a very high place/building, overdose of
 Serve the client’s meals in an isolation tray that contains tranquilizer (Midazolam & Dormicum)
no glass or metal silverware SUICIDAL BEHAVIORS:
e. Expect that the client will be experiencing shame, and work to assists the a) SUICIDAL GESTURE: Directed toward the goal of receiving attention
client toward self- acceptance rather than actual self-destruction;
f. Relieve the client’s obvious immediate distress b) SUICIDAL THREAT: Occurs before the overt suicidal activity takes
g. Find out what, in the client’s view, the most pressing need is place: “Will you remember me when I am gone,” “Take care of my
h. Assume a nonjudgmental, caring attitude that does not engender self-pity children”;
in the client c) SUICIDAL ATTEMPTS: Any self-directed actions taken by the
i. Ask why the client chose to attempt suicide at this particular moment. The individual that will lead to death if not interrupted. A most suicidal
answer will shed light on the meaning suicide has for this patient and may person has made a specific plan, and has the means readily
provide information that can lead to other helpful interventions available.
j. Decide if a no-harm, no suicide contract will be used Best question to be asked after a patient who recovers from an overdose of
k. Be careful not to encourage staff behaviors that give clients or staff pills includes asking “Do you still want to end your life?”
members a false sense of security IMPENDING SIGNS OF SUICIDE:
L. Do not make unrealistic promises 1. Sudden elevation of mood/sudden mood swings*
When a depressed patient suddenly becomes cheerful, it means that
M. Encouraged the client to continue daily activities and self-care as much
the patient is recovering from depression and is in danger of committing
as possible
suicide.
N. Decide with the client which family members and friends are to be 2. Giving away of prized possessions*
contact and by whom 3. Delusion of Omnipotence (divine
O. Be prepared to deal with family members who may be confused, angry or powers)
uninterested Used by SS (Suicidal, Schizophrenia)
P. Evaluate the client’s need for medication 4. When the patient verbalizes that the 2nd Gen TCA is
Q. Evaluate the plan developed in collaboration with the client and arrange working. ( telling a lie)
for appropriate follow-up Suicidal attempts are common when client is strong enough to carry out a
suicidal plan, usually 10-14 days after start of medication, and after ECT
 USUAL TIME FOR SUICIDE: 2nd Second Gen. TCA
1. Early in the morning RATIONALE: The depression at this time is 3rd MAOI
HIGH 4th ECT (last resort)
2. In between nursing shifts RATIONALE: Nurses at this time are very 15. Meet physical needs:
busy Promote eating, rest, elimination
NURSING DIAGNOSIS: (common) Risk/Potential for Injury Promote self-care whenever appropriate possible
Directed to Self 16. Support self-esteem:
STEP BY STEP PRIORITIZE NURSING INTERVENTIONS: Warm and consistent care
1. One-on-one nursing monitoring/intervention (never leave the Being patient with client’s slowness
client)* Simple tasks that increase success and self- esteem and
2. Do not leave the patient for the 1st 24 hrs. (No suicide contract)* imply confidence in capabilities
3. Offering of self (best therapeutic communication)* Example: Self care activities that will not easily tire the
4. No metallic objects patient. Rationale: Depressed patients have fatigue.
5. No sharp objects 17. Decrease social withdrawal: Sit with client during quiet times; introduce
6. Needs stimulus – bright room Rationale: to see suicidal acts to others when ready
7. Avoid religious music (increases guilt) and love songs = non-suggestive The priority focus for a suicidal patient in the ER with a slash in her
song is needed wrist is her physiologic homeostasis.
8. Check for impending signs of suicide Assess attempt for suicide in a 16 y/o girl who is eating & sleeping
= sudden elevation of mood; poorly since break-up
#1 – sudden mood swings and saying,” My life is ruined now.”
A female patient who becomes euphoric for no apparent reason shows a ANTIDEPRESSANTS or THYMOLEPTICS
behavior that indicates recovery from depression, which increases the risk I. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
for suicide.
Usually the FIRST LINE of drug. RATIONALE: FEWER SIDE EFFECTS
9. Activities focus on self-care
Action: Balance Serotonin – gradual effect (usually 2 weeks)
10. Join group therapy
Effect: 2 wks.
Depressed patients usually turn their hostile feelings
Code: XETINE/ODONE
towards themselves. Providing an activity that serves as an outlet for these
Fluoxetine HCl (Prozac) – dry mouth (xerostomia)
aggressive feelings will make the patient feel less guilty.
Paroxetine HCl (Paxil)
During family therapy, a mother asks, “How long will my daughters
Trazodone (Desyrel)) – adverse effect: Priapism (prolonged use)
have suicidal thoughts?” appropriate response of the RN- ‘’ Your daughter
Nefazodone (Serzone)
will go on to view suicide as a way of coping.”
Fluvoxamine (Luvox)
11. Monitor in giving medication – do not leave patient after giving
Sertraline (Zoloft) – causes GI upset (diarrhea, insomnia): always
medication for 30 minutes. Check under the tongue & pillow
with meals
12. Monitor patient in CR, between shift & during endorsement
Venlafaxine (Effexor)
13. #1 Attitude Therapy: Kind Firmness
Citalopram (Celexia)
14. Step by step Tx: ANTIDEPRESSANT another word is THYMOLEPTICS
1st SSRI (Selective Serotonin Reuptake Inhibitor) A
Common Side Effects:
1. Weight Loss # 1 adverse effect – cardiac dysrhythmias
2. Insomnia (single am dose) #1 screening test before taking TCA – ECG
When a depressed client taking TCA shows no improvement in the
Nursing Considerations: symptoms, the nurse must anticipate the physician to discontinue TCA after
1. For insomnia: two weeks and start on Parnate.
a. Induce sleep thru: Nursing intervention before giving the drug includes checking the BP.
1. Warm bath (systemic effect)
2. Warm milk/banana (active MAOI – MONO AMINE OXIDESE INHIBITOR
substance: tryptophan) ACTION: Psychomotor stimulator or psychic energizers; block
3. Massage oxidative deamination of naturally occurring monoamines
b. Give meds in single AM dose (epinephrine, NOREPINEPHRINE, serotonin) → CNS stimulation
Antidepressants are best taken after meals Effect: 2 weeks
CODE: PAMMANA
II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT Parnate (tranylcypromine)
Action: Increases norepinephrine and/or serotonin levels in CNS by blocking Marplan (Isocarboxacid)
their uptake by presynaptic neurons or it balances Serotonin & Epinephrine Mannerix (Moclobemide) *the newest MAOI
levels. Nardil (Phenelzine SO4)
Effect: 2-4 wks. CONTAINDICATIONS: TYRAMINE + MAOI = HYPERTENSIVE CRISIS
Code: PRAMINE/TRYPTILLINE 1. Tyramine rich-food, high in Na & cholesterol Hypertensive Crisis
Clomipramine HCl (Anaframil) #1 for OCD* 1. Aged cheese (except cottage cheese, cream cheese),
Imipramine (Tofranil)* the best drug for enuresis Cheddar cheese and Swiss cheese are high in tyramine and
Amitryptilline (Elavil) should be avoided.
Protryphilline (Vivactil) 2. Canned foods such as sardines, soy sauce & catsup
Maprotilline (Ludiomil) 3. Organ meats (chicken gizzard & liver) &
Norpramine (Desipramine) #1 antidepressant for elderly process foods (salami/bacon) ↑ Na
depression. 3. Red wine (alcohol)
RATIONALE: Fewer anticholinergic S/E 4. Soy sauce
Nortryptilline (Pamelor, Aventyl) 5. Cheese burger
Trimipramine ( Surmontil) 6. Banana, papaya, avocado, raisins (all over ripe
Buproprion (Wellbutrin) 400 mg/day*(ceiling dose) EXCESS INTAKE: fruits except apricot)
Grand mal seizure 7. Yogurt, sour cream, margarine;
Doxepine (Sinequan) 8. Mayonnaise
Amoxapine (Asendin) 9. OTC decongestants
Common Side Effects: 1. Sedation (at night) 10. Pickled foods, Pickled herring
2. Weight gain Foods contraindicated in MAOI therapy includes figs, bologna, chicken liver,
Nursing Consideration: 1. Give meds at night meat tenderizer, , sausage, chocolate, licorice, yeast, sauerkrauts, Food safe
to give includes fresh fish, Cream, Yogurt, Coffee, Chocolate , Italian green Legal/Pre-Nursing Responsibilities: Preparation: Similar to preparing a
beans, sausage, yeast, client for surgery:
1. Informed Consent – if client is coherent, if not a guardian
Antidote: CALCIUM CHANNEL-BLOCKERS (-DIPINE) may sign the consent forms.
1. Verapamil (Calan) 2. No metallic objects
2. Phentolamine (Regitine)  also the #1drug for 3. No nail polish to check peripheral circulation
Pheochromocytoma (tumor in 4. No contact lenses it may adhere to the cornea
IV. ELECTROCONVULSIVE THERAPY (ECT) 5. Wash & dry hair
ECT is passing of an electric current through electrodes applied to one or 6. Give following medications BEFORE ECT:
both temples to artificially induce a grand mal seizure for the safe and a. Atropine sulfate – anticholinergic
effective treatment of depression. PRIMARY purpose – to dry secretions and prevent
ECT’s mechanism of action is unclear at present aspiration
Advantages: SECONDARY purpose – to prevent bradycardia
Quicker effects than antidepressants; Safer for elderly; 80 % (vagolytic)
improvement rate of major depressive episode with vegetative aspects b. Phenobarbital (Luminal), Methohexital
- Best therapy for major depression (last resort) (barbiturate Na)- minor tranquilizer also an anticonvulsant
- Invasive c. Succinylcholine (Anectine) – muscle relaxant
- Induction of 70-150 volts of electricity in).5-2secs. Then, it is followed by a 7. Priority vs. to focus ABC; check RR 12 less; LOC
grand-mal seizure lasting 30-60 secs. 8. Before ECT - supine position; after ECT- side-lying
- 6-12 treatments, “every other day” 9. Have patient VOID before giving ECT
- Before ECT a major depressed client undergo the ff meds: Nursing Diagnosis:
1. SSRi (Selective Serotonin Reuptake Inhibitor inhibitor) –2 wks 1. Risk for Airway Obstruction/aspiration
2. Antidepressants  TCA 2nd Generation – 2-4 wks 2. Risk for Injury
3. MAOi – 2 wks 3. Impaired/Altered Cognition/LOC
4. ECT (last resort) Nursing Intervention
Side Effects: 5 S in Seizure
1. Temporary RECENT Memory Loss – 1. Safety (#1 objective)
ANTEROGRADE amnesia 2. Side-lying (#1 Position)
Intervention: Re-orient client to 3 spheres 3. Side rails up
2. confusion/disorientation – (usually 24 hours) 4. Stimulus ↓ (no noise & bright lights)
3. Headache  ↑ 02 demand, ↑ cerebral hypoxia 5. Support the head with a pillow AFTER the seizure
4. Muscle spasm  FIRST & TOP priority: Ensure a patent airway. Side-lying after
5. Wt. gain (stimulate thalamic/limbic  appetite) removal of airway. Observe for respiratory problems
Contraindicated:  Remain with client until alert. VS q 5 min until stable.
1. PPPP – Post MI, Post CVA, pacemaker, pregnant women  REORIENT: Time, place (unit), person (nurse); Reassure regarding
2. Neurologic problem  Alzheimer’s, degenerative disorder confusion and memory loss. Same RN before & after.
3. Brain tumor, weakness of lumbosacral spine
B. BIPOLAR DISORDERS: With one or more manic episodes, with or without 5. Flight of ideas – talkative/pressured speech/pressure to keep
a major depressive episode talking
1. Bipolar, depressive: Most recent or current behavior displaying Tell manic pt to speak more slowly to make a sense if he keeps on moving
major depression one subject to another.
2. Bipolar, manic: Most recent or current behavior displaying 6. Hyperactive & Distractibility
overactive, agitated behavior 7. Easily Agitated
3. Bipolar, mixed: Rapid intermingling of depressed and manic 8. Manipulative
behavior 9. Increased Metabolism
4. Cyclothymania: Numerous occurrences of abnormally depressed 10. Poor impulse control – impulsive
moods over a period of at least 2 years 11. Violent/aggressive/hypersexual
12. Pressured speech
MANIA NURSING DIAGNOSIS:
Mood that is elevated, expansive, or irritable 1. Risk/ Potential for Injury directed to others /or to self
Manic behavior is a defense against depression since the 2. Fluid & Electrolytes Imbalances
individual attempts to deny feelings of unworthiness and helplessness. 3. Fluid Volume Deficit
MANIC EPISODE: NURSING INTERVENTIONS:
Neurotransmitter imbalance: 1. Accept client; reject behavior
• 1. Norepinephrine* 2. Provide consistent care
• 2. Serotonin 3. Set limits of behavior/external controls
BEHAVIORS COMMONLY ASSOCIATED WITH MANIA *One staff to provide controls
A. Affective: Elation/ euphoria, lack of shame, lack of guilt, humorous, *Do not leave alone in room when hyperactivity is escalating
intolerance of criticism, expansiveness, inflated self-esteem* *Explain restrictions on behavior
B. Physiological: Dehydration, inadequate nutrition, needs little sleep, *Do not encourage performance/jokes
weight loss* *Approach in a calm, collected, non-argumentative manner
C. Cognitive: Ambitiousness, denial of realistic danger, distractibility, 4. Distract and redirect energy: Choose physical activities using large
grandiosity, flight of ideas, lack of judgment. * movements until acute mania subsides (dancing, walking with staff)
D. Behavioral: Aggressiveness, provocativeness, excessive spending, Meet nutritional needs: High-calorie FINGER FOODS and fluids to be
hyperactivity, poor grooming, irritability, argumentative* carried while moving. Prone to become fatigue, so, give finger foods: potato
DIAGNOSTIC CRITERIA FOR A MANIC EPISODE: chips, bread, raisin, and sandwich. SHORTCUT: ALL HIGH CALORIC & HIGH
At least 3 of the following for at least 1 week: CARBOHYDRATE DIET or ALL BAKERY PRODUCTS!!!
1. Delusion of Grandeur – over self-worth, inflated self-esteem Tuna sandwich & apple are appropriate food for bipolar manic
RATIONALE: A defense to mask feelings of depression & A Husband of 36 y/o bipolar manic type says, “My wife hasn’t eaten or
inadequacies slept for days.” The RN should place a priority focus on physical condition.
2. Insomnia Encourage rest: Sedation PRN, short PM naps
3. Flight of ideas 7. Avoid ACTIVITIES that increases attention span such as chess, bingo,
4.Excessive involvement in pleasurable activities without regard for scrabble...
negative consequences
8. Avoid CONTACT SPORTS: Basketball, gym, strenuous activities & Increase adrenergic neurotransmitter levels in cerebral tissue through alteration
perspiration!! of sodium transport → affects a shift in intraneural metabolism of
ACCEPTABLE ACTIVITIES: Brisk walking, punching bag, raking leaves, NOREPINEPHRINE
tearing newspaper Action: ↓ hyperactivity and balance or stabilize the mood
9. Productive activities: Gardening, finger painting, household chores, Effect: 1 wk.
Activity for Manic Bipolar includes raking leaves (quiet physical, CODE: LITH
constructive, productive) to increase self-esteem; competitive is not safe. Lithium CO3 – Eskalith, Lithane, Lithobid
10. Less environmental stimulus: No bright lights, do not touch Lithium Citrate – Cibalith - S
11. Encourage OFI: Because of Lithium and increased metabolism
12. Check Lithium intoxication Therapeutic Serum Level:
SELECTED SITUATIONS AND INTERVENTIONS: = 0.5-1.5 mEq (local/CGFNS)
A. Disturbing the Group Session = 0.6 – 1.2 mEq (NCLEX)
1. Separate the patient from the group, A. Early in therapy: Serum levels measured q 2-3 times per week; 12 hours
REMEMBER don’t touch the patient. after the last dose. Long-term: q 2-3 months. Before lithium is begun
Touching the patient may increase AGITATION. baseline RENAL, CARDIAC, and THYROID status obtained.
2. Setting of limits – “matter of fact” (#1 Attitude therapy for Antidote:
manipulative patients) 1. DIAMOX (ACETAZOLAMIDE) carbonic anhydrase inhibitor (for open
Patient in acute manic phase begins to disrobe, appropriate nursing angle glaucoma)
action includes removing patient from group meeting & accompany him to 2. MANNITOL (Osmitrol) osmotic diuretics  Action to ↑ urine output,
his room ↓ cerebral edema
B. Aggressive Reaction 3. MNGT. OF OVERDOSE: Induce emesis / lavage; airway; dialysis for
1. Decrease environmental stimulation severe intoxication
A pt who is pt watching TV suddenly throws the pillows & chair, 4. If patient forgets a dose, he may take it if he missed dosing time by 2
immediate action is to place pt in seclusion. hours; if longer than 2 hours, skip the dose and take the next dose. NEVER
“Staff 1st used a lesser means of control for less success.” Shows a DOUBLE A DOSE!!!
documentation that indicates a pt’s right is being safeguarded during Nursing Considerations:
aggressive reactions. 1. Before extracting Lithium serum level  Lithium fasting 12 hrs 
C. Violent Patients check vital signs
1. Move to the door fast and call the crisis management team 2. Avoid diuretics to prevent hyponatremia
D. Swearing 3. Avoid strenuous exercise/activities  gym works
1. Setting of Limits 4. Avoid sauna baths
2. Give avenues for verbalization/expression vs. Physical 5. Avoid caffeine  because it is a diuretic
violence 6. For hypernatremia  AVOID Na CO3
MOOD STABILIZERS (ANTIMANIC DRUGS): LITHIUM 7. Avoid taking soda and/or soda drinks
For: (Mood disorder specifically Mania (Bipolar Disorder) 8. ↑ OFI – 3 L /day; ↑ Na – 3mg/day
USES: Elevate mood when client is depressed; dampen mood when client is
in manic; used in acute manic, bipolar prophylaxis; ACTS by reducing
 A patient who is talking lithium must be placed in a normal
sodium (3 gms.) , high fluid diet (3 L of water). This is done to facilitate
excretion of lithium from the body.
A. Increase Na = ↓ Lithium effect
For hypernatremia  AVOID Na CO3
Avoid taking soda and/or soda drinks
When the lithium level falls below 0.5, the patient will manifest signs
and symptoms of mania.
B. Decrease Na = ↑ Lithium intoxication  MORE dangerous!!!!
AVOID the 2 dangerous “D”: diuretics & dehydration
Avoid diuretics to prevent hyponatremia
Avoid strenuous exercise/activities  gym works
Avoid sauna baths (EXCESSIVE PERSPIRATION)
Avoid caffeine  because it is a diuretic
Stages in Lithium Intoxication
I. Early/Initial/Mild: 1.5 mEq
- Nausea, vomiting & anorexia
- Diarrhea
- Gross hand tremors
- Abdominal cramps  hypocalcemia  metabolic alkalosis
(Prolong vomiting  metabolic acidosis)
II. Moderate: 1.6 – 2.4 mEq
Symptoms are 2x the initial signs

III. Severe: ↑ 2.5 mEq

1. Nystagmus, tactile, olfactory & visual hallucination
2. POA (Polyuria, Oliguria, Anuria)  ARF (Kidney
problem)
Lithium is nephrotoxic & teratogenic
3. Grand Mal Seizure  Cerebral hypoxia  ↓LOC
 COMA  death