DEPRESSION

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

TWO MOST COMMON PRIMARY DEPRESSVIE DISORDERS

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

EPIDEMIOLOGY
• AT ANY GIVEN TIME15 % OF THE GENERAL POPULATION ARE DEPRESSED
• WOMEN HAVE A GREATER RISK OF DEVELOPING DEPRESSION THAN DO MEN
• ADOLESCENTS - SUICIDE IS A FACTOR – IT IS THE 3 LEADING CAUSE OF DEATH IN ADOLESCENTS
RD

• ELDERLY – HIGHEST SUICIDE RATE

• ONLY ONE IN FOUR PEOPLE THAT HAVE DEPRESSION GET TREATMENT

CAUSES OF DEPRESSION
• BIOLOGICAL THEORIES
O GENETICS
 IF YOU HAVE TWINS – ONE HAS DEPRESSION, OTHER HAS 60% CHANCE TO DEVELOP DEPRESSION
O BIOCHEMICAL FACTORS
 NEUROTRANSMITTERS; IN RELATION TO STRESS. IF UNDER A LOT OF STRESS THEY  THE # OF NEUROTRANSMITTERS
O NEUROENDOCRINE DISTURBANCES
 ABNORMAL HIGH HORMONE LEVELS
• PSYCHOSOCIAL FACTORS
O COGNITIVE THEORY
 DEPRESSION RESULTS VERY NEGATIVELY; FEEL NEGATIVE ABOUT EVERYTHING
O LOSS
 REACTION TO GRIEF – IF GRIEF IS NOT RESOLVED IT MAY  DEPRESSION; REAL OR SYMBOLIC LOSS
O LEARNED HELPLESSNESS
 HIGH LEVELS OF STRESS  TO ANXIETY THEN  DEPRESSION, THEY BLAME THEMSELVES
 FEEL HELPLESS
 AGED, THOSE LIVING IN GETTOS, AND WOMEN

CLINICAL MANIFESTATIONS
• SAD MOOD
O LOOK AT THE WORLD THROUGH GRAY COLORED GLASSES
O ALMOST TEARFUL

• SLEEP DISTURBANCE
O TERMINAL INSOMNIA / HYPOSOMINIA – WORST AT 2-3AM LOWEST POINT IN THEIR MOOD (USUALLY THE TIME TO COMMIT SUICIDE)

• INTERESTS DECREASE
O ANHEDONIA – CANNOT FEEL PLEASURE
• GUILT, WORTHLESSNESS
O EXCESSIVE INAPPROPRIATE GUILT; USUALLY FROM AN ACT THAT HAPPENED OVER 20 YEARS AGO THAT IS INSIGNIFICANT. THINK ABOUT THIS OVER
AND OVER. DELUSIONS ARE FOCUSED ON THIS; BELIEVE BEING PUNISHED
• ENERGY DECREASED
O NO “GET UP AND GO”
O HAVE TO PUSH THEMSELVES TO DO WHAT THEY NEED
O MAY NOT DO ANYTHING AT ALL AND STAY IN BED ALL DAY
• COGNITION DECREASED
O SLOWED SPEECH, DECREASED AMOUNTS OF SPEECH. AFFECTS THE ABILITY TO SOLVE PROBLEMS. DO NOT ANSWER FOR THE CLIENT
• APPETITE DISTURBANCE - SIGNIFICANT WEIGHT LOSS; MAY LOOSE 5% OF BODY WEIGHT IN A MONTH

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 • PSYCHOMOTOR RETARDATION, AGITATION
O EVERY FUNCTION OF THE BODY IS SLOW; EFFECTS PERISTALSIS; CONSTIPATION
O MOVEMENT IS VERY SLOW
O SOME CAN GET VERY AGITATED – MAY PACE, RING THEIR HANDS, OR BE VERY IRRITABLE, COMPLAIN OR CRY
• SOMATIZATION – HAVE PHYSICAL SYMTOMS THAT MASK DEPRESSION
O SOMETIMES DEPRESSION IS EXPRESSED THROUGH PHYSICAL SYMPTOMS.
O CAN BECOME DELUSIONAL ABOUT THE PHYSICAL SYMPTOMS.
• SUICIDE
O RECURRENT THOUGHTS OF DEATH WITH A PLAN OR ATTEMPT
o THE ULTIMATE RESPONSE TO FEELINGS OF HOPELESSNESS; AN AMBIVALENT ACT; SO YOU MAY BE ABLE TO CHANGE THEIR MINDS
O THOUGHTS = EXTREME, SEVERE EMOTIONAL PAIN
O AGGRESSION TURNED TOWARD SELF
O 72% OF SUICIDES ARE COMMITTED BY WHITE MALES; WOMEN ATTEMPT MORE THAN MALES
O SEEN IN PROFESSIONAL MEN, LAWYERS, MD’S
o LOSSES OF ELDERLY THAT MAY TRIGGER DEPRESSION:
 LOSS OF STATUS RELATED TO RETIREMENT; LOSS OF IDENTITY
 TERMINAL ILLNESS, CHRONIC ILLNESS, PAIN
 LOSS OF SPOUSE OR SOME TYPE OF PERSONAL LOSS
 LOSS OF FRIENDS AND FAMILY

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

NURSING PLAN OF CARE

RISK FOR SELF DIRECTED VIOLENCE
• GOAL: KEEP THE PERSON SAFE
• IF YOU ASK THE PERSON ABOUT SUICIDE THAT DOESN’T MEAN YOU ARE PUTTING THE IDEA IN THEIR HEAD. BECAUSE YOU HAVE TO ASSESS IF THE PERSON
IS SUICIDAL
O ASK IF THEY HAVE EVER THOUGHT ABOUT TAKING THEIR OWN LIFE; IF YES
O ASK WHAT PLANS, IF ANY, HAVE THEY MADE
O ASSESS:
 S – SPECIFY (HOW SPECIFIC ARE THE DETAILS OF THE PLAN)
 L – LETHALITY (HOW QUICKLY CAN DEATH BE ACCOMPLISHED BY THAT METHOD)
 A – AVAILABILITY (WHAT ARE THE AVAILABILITIES OF THE PROPOSED WEAPON)
 P – PROXIMITY (LIVING ARRANGEMENTS)
• NURSING PLAN OF CARE
O ONE ON ONE OBSERVATION - DO NOT LET THEM OUT OF THEIR SIGHT
O IRREGULAR SCHEDULE OF OBSERVATION - CHECK ON THEM IN SPORADIC TIMES
O REMOVE ENVIRONMENTAL HAZARDS
 GLASS, BELTS, RAZORS, SHOE LACES, MEDICATION, CORDS, SCISSORS, NAIL FILES
O CONTRACT – WILL NOT COMMIT SUICIDE
O SEEK OUT STAFF WHEN THOUGHTS EMERGE OF SUICIDE
O WHEN THEY ARE FEELING BETTER, DISCUSS ALTERNATE SOLUTIONS AND NETWORK OF SUPPORT SYSTEMS
 MORE LIKELY TO COMMIT SUICIDE EARLY IN THE MORNING
 BE AWARE OF SUDDEN CHANGE IN PERSONALITY OR BEHAVIOR
 BE AWARE IF THEY BEGIN TO GIVE THINGS AWAY OR MAKE A WILL

SELF ESTEEM DISTURBANCE – PG 585

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

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

ALTERATION IN THOUGHT PROCESSES

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

INEFFECTIVE INDIVIDUAL COPING

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

SOCIAL ISOLATION / IMPAIRED SOCIAL INTERACTION – PG 565

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

TOTAL SELF CARE DEFICIT

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

MEDICAL PLAN OF CARE

VERY TREATABLE WITH MEDICATIONS
• TRICYLIC (ANTIDEPRESSANTS)
O BLOCKS REUPTAKE OF NEUROTRANSMITTERS- MAKES MORE RECEPTORS SO MORE NERVE IMPULSES CAN GET THROUGH
O TAKES 1-3 WEEKS BEFORE THEY START TO WORK
O ELAVIL, ASCENDIN, PAMELOR
O SIDE EFFECTS: ANTICHOLINERGIC – CAN’T SEE, CAN’T PEE, CAN’T SPIT, CAN’T SHIT
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  DRY MOUTH, CONSTIPATION, URINARY RETENTION, HYPERTENSION, CAN HAVE CARDIOVASCULAR SIDE EFFECTS.
 IF AN OVERDOSE OCCURS IT IS LETHAL
 BETTER IF TAKEN AT BEDTIME DO TO SLEEPY SIDE EFFECT
O IF SEVERELY ILL THEY MAY ONLY BE GIVEN A WEEK SUPPLY AT A TIME
O DRUG INTERACTIONS: CNS, MAOI’S, COUMADIN (DO NOT GIVE WITH THESE DRUGS)
O ELDERLY AT MOST RISK FOR THE ANTICHOLINERGIC SIDE EFFECTS

O TEACHING
 GIVE AT BEDTIME WITH FOOD
 ELDERLY – SAFETY
 INCREASE FLUIDS
 OBSERVE FOR URINARY AND CONSTIPATION – MEDICAL EMERGENCY
 OBSERVE FOR SUICIDE
• THERAPEUTIC EFFECTS WILL NOT TAKE AFFECT FOR ABOUT 3 WEEKS
• START SLEEPING BETTER  MORE ACTIVITY  (AT HIGH RISK FOR SUICIDE BECAUSE THEY FEEL GOOD ENOUGH TO GO
THROUGH WITH IT) – THE LAST THING TO LIFT WILL BE THE MOOD.
• BE PATIENT, THE MOOD WILL GET BETTER
 TAKE AS PRESCRIBED – DO NOT STOP ABRUPTLY
 NO ALCOHOL OR CNS DEPRESSANTS
 DO NOT SMOKE – REDUCES AFFECTIVENESS
 TIME TO TAKE AFFECT – 3 WEEKS
• 2 GENERATION ANTIDEPRESSANTS - SSRI
ND

O BLOCK REUPTAKE OF SEROTONIN

o 1 LINE THERAPY FOR DEPRESSION
ST

O PROZAC, ZOLOFT, PAXIL, CELEXA

O SIDE EFFECTS: NOT AS BAD AS TRICYLIC
 AGITATION, ANXIETY, TREMORS, HA, SEXUAL DYSFUNCTION, INSOMNIA
 BEST TAKE IN THE MORNING
O CENTRAL SEROTONIN SYNDROME
 GETS TOO MUCH SEROTONIN – IF THE PERSON IS TAKING 2 ANTIDEPRESSANTS – NOT ENOUGH TIME HAS PASSED BETWEEN STOPPING
ONE AND STARTING ANOTHER.
 SHOULD NEVER BE GIVEN WITHIN 2 WEEKS OF AN MAOI
 IF PROZAC YOU SHOULD WAIT 5 WEEKS BEFORE YOU START AN MAOI
 ELEVATED BP, TACHYCARDIA, CV SHOCK AND DEATH SERIOUS
 USE INDERAL TO TREAT SYMPTOMS
O SINGLE DOSE IN THE AM – DO NOT HAVE SEDATIVE SIDE EFFECT
o THERAPEUTIC AFFECTS MAY NOT WORK FOR 4-5 WEEKS
O ELDERLY THE DOSES ARE DECREASED; CAN AGITATE THE ELDERLY
O CHILDREN THAT ARE DEPRESSED ARE USUALLY PUT ON THESE TYPE OF ANTIDEPRESSANTS
• OTHER ANTIDEPRESSANTS
O SELECTIVE SEROTONIN / NOREPINEPHERINE REUPTAKE INHIBITORS
 SERZONE, EFFEXOR, LEXAPRO, CYMBALTA
 SIDE EFFECTS
• NAUSEA, SLEEPINESS, DRY MOUTH, DIZZINESS
O DO NOT SEE THAT OFTEN – THEY ARE PUT ON THE SSRI’S FIRST ONLY IF THEY DO NOT WORK ARE THEY PUT ON THESE MEDICATIONS.
• ATYPICAL – MISC
O DESYREL (TRAZODONE)
 GIVEN FOR MILD TO MODERATE DEPRESSION
 OFTEN USED AS A SLEEPING AID
 CAN CAUSE PRIAPISM (WITHHOLD MEDICATION, NOTIFY MD IMMEDIATELY) EMERGENCY
O WELBUTRIN (BUPROPION) - ZYBAN
 EFFECTIVE FOR PEOPLE THAT CANNOT TAKE THE TRICYLIC ANTIDEPRESSANTS
 HAS A DOSE LIMIT – NO MORE THAN 150MG AT A TIME AND A TOTAL DOSE OF 450MG PER DAY
 MAY CAUSE SEIZURES
• MAOI’S
O HAS AN ENZYME THAT DISSOLVES THE NEUROTRANSMITTERS. STOP THE ENZYME FROM WORKING SO THEREFORE YOU HAVE MORE
NEUROTRANSMITTERS IN THAT GAP???
O NARDIL & PARNATE
O SIDE EFFECTS
 ORTHOSTATIC HYPOTENSION
O HAVE BAD DRUG INTERACTIONS AND FOOD INTERACTIONS
o NO FOODS WITH TYRAMINE ( CHEESE, WINE, SAUSAGE, BEER, SMOKED OR PICKLED FISH, OTHER PICKLED FOODS, BEEF OR CHOPPED LIVER,
AVOCADOS OR FIGS, CHINESE FOOD)
O NO OTC MEDS, OR OTHER ANTIDEPRESSANTS, NARCOTICS (DEMEROL – FATAL REACTION)
O NO GINSENG OR ST JOHNS WART
O CAN HAVE A HYPERTENSIVE CRISIS IF COMBINED WITH ANY OF THESE OR TOO MUCH TYRAMINE (CAN BE FATAL)
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  BP INCREASE, HA, STIFF OR SORE NECK, MAY HAVE TO GIVE MEDICATION TO RELIEVE THAT – PROCARDIA, THORAZINE. CAN TREAT
THE HYPERTENSIVE CRISIS
O MUST BE VERY COMPLIANT
O USED FOR ATYPICAL DEPRESSION THAT IS NOT RESPONDING TO OTHER DRUGS
O MUST START DIET 2 WEEKS BEFORE STARTING THE DRUG; STAY ON DIET 2 WEEKS AFTER STOPPING THE DRUG.
• ST. JOHNS WART
O CAREFUL OF SUNLIGHT – MAY GET BAD BURN
O DO NOT TAKE WITH MAOI’S OR ANY OTHER ANTIDEPRESSANT OR ANY OTHER CRITICAL MEDICATIONS SUCH AS: COUMADIN, CLOZARIL,
THEOPHYOLINE, ORAL CONTRACEPTIVES.
O DO NOT TAKE ANY OTHER DRUGS UNTIL OK’D BY PHYSICIAN
• ANTIPSYCHOTIC
O IF DEPRESSED AND DELUSIONAL
o CAUTION: IF CLIENT IS BIPOLAR AND THERE IS A DEPRESSED – BE CAREFUL BECAUSE ANY OF THESE MEDICATIONS CAN PUSH THE CLIENT INTO
THE MANIC PHASE
ECT – ELECTROCONVULSIVE THERAPY
• GRAND MAL SEIZURE ARTIFICIALLY INDUCED BY PASSING AN ELECTRIC CURRENT THROUGH THE BRAIN.
• ACTION IS UNKNOWN
O MAY INCREASE NEUROTRANSMITTERS
• USED IN CLIENTS THAT THEY NEED A RAPID RESPONSE
O IF SUICIDAL, IF THEY HAVE A HISTORY OF RESPONDING POORLY TO DRUGS
O IF SEVERE PSYCHOLOGICAL RETARDATION AND THEY ARE NOT EATING OR DRINKING AND THEIR PHYSICAL HEALTH IS IN DANGER
 (SO DEPRESSED THEY ARE STARVING THEMSELVES)
• CONTRAINDICATIONS
O RECENT MI, CVA, OR BRAIN TUMOR
• 6-12 TREATMENTS
• 2-3 TIMES PER WEEK
• MAINTENANCE ONCE A WEEK OR ONCE A MONTH

NURSING CARE
• PRE ECT
O INFORMED CONSENT – SPECIAL FOR ECT
O NPO FOR 6-8 HOURS
O VITAL SIGNS
O DENTURES, CONTACTS, HAIRPINS ARE REMOVED
O VOID BEFORE PROCEDURE
O GIVE ROBINUL OR ATROPINE - HELPS DRY SECRETIONS OR MINIMIZE BRADYCARDIA
O PROCESS
 THEY ARE GIVEN A MUSCLE RELAXER
 OXYGENATE THEM
 AN ORAL AIRWAY
 THEN THEY ARE SHOCKED
 WANT SEIZURES TO LAST AT LEAST 30 SECONDS
O IF THEY ARE HYPERTENSIVE THEY WILL BE GIVEN AN ANTIHYPERTENSIVE MED PRIOR TO THE SHOCK
• POST ECT
O RESPIRATIONS AND CARDIAC STATUS - MAKE SURE HAVE AN OPEN AIRWAY
O CHECK VS
O ORIENT DUE TO CONFUSION
O CHECK GAG REFLEX
O MEMORY LOSS GETS WORSE THE MORE TREATMENTS THEY HAVE

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

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

GROUP THERAPY
• INITIALLY MAY NOT BE A GOOD CANDIDATE BECAUSE THEY ARE NOT REACTING TO ONE TO ONE BUT MAY ATTEND GROUP AFTER GETTING COMFORTABLE
WITH ONE TO ONE
• INCREASE SOCIALIZATION
• SHARE COMMON FEELINGS AND CONCERNS
• DECREASE FEELINGS OF ISOLATION
• SUPPORT FORM OTHER MEMBERS AND FEELING PART OF A GROUP
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FAMILY THERAPY
• OPEN AND HONEST COMMUNICATION
• REINFORCE NON DEPRESSIVE BEHAVIOR
• PROBLEM SOLVING

BEHAVIOR THERAPY
• TRY TO DECREASE THE NUMBER OF NEGATIVE INTERACTIONS THE CLIENT HAS
• THEY WILL GET A MORE POSITIVE REINFORCEMENT FROM OTHER PEOPLE
• TEACHES COPING AND SOCIAL SKILLS
OCCUPATIONAL / RECREATIONAL THERAPY
• NON COMPETITIVE; ONE-TO-ONE ACTIVITY – SOMETHING THEY CAN DO THEMSELVES AND NOT FAIL
• SOMETHING SIMPLE AND MONOTONOUS – SOMETHING THEY DON’T HAVE TO THINK ABOUT
O JIGSAW PUZZLE, HOOKING A RUG, NEEDLE WORK, IF THEY ALREADY KNOW HOW TO DO IT.
O LOOKING AT A MAGAZINE, FOLDING LINEN
• YOU WANT THE ACTIVITIES TO BE A POSITIVE EXPERIENCE
MILIEU / ENVIRONMENT THERAPY
• PREVENTION OF SUICIDE; SAFETY
• STRUCTURED ROUTINE – KNOWING WHAT TO EXPECT DAY AFTER DAY
• POSITIVE SELF ATTITUDE – CAN FEEL HOPE THAT THEY CAN DO BETTER
YOU CAN SIT QUIETLY WITH A CLIENT IF THEY DO NOT FEEL LIKE TALKING

BIPOLAR I - MAJOR DEPRESSION AND MANIA

BIPOLAR II - MAJOR DEPRESSION AND HYPOMANIA
CYCLOTHYMIC DISORDER –

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

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

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

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

CLINICAL MANIFESTATIONS
• ELEVATED MOOD
O HIGH, EUPHORIC, BUT CAN BE IRRITABLE, AND UNSTABLE
O CAN TURN FROM SOCIABLE TO IRRITABLE AND DEMANDING
O MAY BECOME ARGUMENTATIVE AND COMBATIVE ESPECIALLY WHEN YOU TRY TO SET LIMITS
• INFLATED SELF-ESTEEM OR GRANDIOSITY
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 O FROM DELUSIONS
O GIVE ADVICE ON MATTERS THEY KNOW NOTHING ABOUT
O SUPREME SELF CONFIDENCE
O CAN DO NO WRONG
• CAN HAVE HALLUCINATIONS AND PERSECURITY DELUSIONS
• MARKED IMPAIRMENT OF JUDGMENT
O BUYING SPREES
O SEXUAL INDISCRETIONS
O BAD INVESTMENTS
• SLEEP DISTURBANCE
O DECREASED NEED FOR SLEEP
O TO BUSY TO SLEEP
O NOT AWARE OF NEED TO SLEEP
O CAN LEAD TO PHYSICAL EXHAUSTION
• PRESSURED SPEECH
• FLIGHT OF IDEAS
O IDEAS ARE COMING SO FAST, THEY CANNOT COMPLETE A THOUGHT
O THEY HAVE TO EXPRESS ANOTHER IDEA BEFORE THEY CAN COMPLETELY RESOLVE ANOTHER IDEA
O CAN BE CRUDE, IN A SEXUAL CONNOTATION
• DISTRACTIBILITY
O SHORT ATTENTION SPAN
O IF THEY ARE ARGUING ABOUT SOMETHING THEY CAN EASILY BE DISTRACTED
• PSYCHOMOTOR AGITATION
O INTRUSIVE IN OTHER PEOPLES BUSINESS
O POORLY GROOMED
O CONSTIPATED BECAUSE THEY DO NOT TAKE TIME TO GO TO THE BATHROOM
• COLORFUL AND BIZARRE DRESS

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

MEDICATION
• CP: MEDICATION TOXICITY
O MEDICATIONS NEED A BLOOD LEVEL
O NEED TO MONITOR BLOOD LEVEL AND MONITOR FOR SIGNS OF TOXICITY.
• ANTIPSYCHOTIC MEDS ARE GIVEN TO SLOW THEM DOWN TO PREVENT EXHAUSTION. AND ALSO IF THEY ARE HAVING DELUSIONS, IT WILL
HELP CLEAR THAT UP.
• LITHIUM
O ANTIMANIC DRUG
O NOT SURE HOW IT WORKS – POSSIBLE ALTERS SODIUM TRANSPORT…….
O ACUTE MAINTENANCE
 1 – 1.5MEQ/L
 WHEN THE PERSON IS IN AN ACUTE MANIC STATE – THEIR BLOOD LEVEL HAS TO BE HIGHER TO WORK MORE
AFFECTIVELY.
O ONCE THEY HAVE CALMED DOWN THEY CAN BE REDUCED TO A MAINTENANCE LEVEL
 .6 – 1.2 MEQ/L
 ANYTHING OVER 1.5 IS CONSIDERED TO BE TOXIC
O IN ORDER FOR LITHIUM TO WORK IT MUST REACH THESE LEVELS TO BE AFFECTIVE, SO IT WILL TAKE A WHILE. THAT IS WHY
TAKING LITHIUM IS NOT AFFECTIVE RIGHT AWAY THAT IS WHY YOU HAVE TO ADD AN EXTRA NARCOTIC. MIGHT TAKE 7-14 DAYS
BEFORE GETTING TO THE THERAPEUTIC BLOOD LEVEL.
O MONITORED WEEKLY OR BIWEEKLY
O BLOOD SHOULD BE DRAWN 8 – 12 HOURS AFTER A DOSE OF LITHIUM
 GIVE EVENING DOSE THEN DRAW BLOOD IN THE MORNING BEFORE A.M. DOSE
O A MEDICAL WORKUP IS DONE BEFORE A CLIENT IS STARTED ON LITHIUM
O HAVE TO LOOK AT RENAL AND THYROID FUNCTION. ALSO CHECK ECG OF HEART
O CONTRAINDICATED IN PREGNANCY, BRAIN DAMAGE, CARDIOVASCULAR OR THYROID DISEASE.
O WILL CAUSE FETAL DAMAGE.
O TEACHING ABOUT LITHIUM
 TAKE FOR AN INDEFINITE PERIOD OF TIME EVEN AFTER THEIR MOOD HAS STABILIZED
 NEED TO KNOW WHAT LITHIUM LEVEL IS AND HOW OFTEN IT IS MONITORED.
 THEY NEED TO BE ON A NORMAL OR REGULAR DIET.
 NO LOW SODIUM DIETS
 GOOD FLUID INTAKE – 1500 TO 3000CC PER DAY
 MAY CAUSE NAUSEA – GIVE WITH FOOD
 COMMON SYMPTOMS: HAND TREMOR, POLYURIA, MILD THIRST.
O S/S OF TOXICITY
 NAUSEA, VOMITING, DIARRHEA, SLURRED SPEECH, MUSCLE WEAKNESS, COARSE TREMORS, SEIZURES.
 LONG TERM AFFECTS OF LITHIUM – CAN CAUSE HYPERTHYROIDISM, IMPAIRS KIDNEYS ABILITY TO MAKE URINE.
• ANTIPSYCHOTIC MEDICATIONS – IF DELUSIONS OR HALLUCINATIONS
• ANTICONVULSIVE MEDICATIONS
O BEING USED AS MOOD STABILIZERS
O MAIN ONE IS DEPAKOTE, TEGRETOL, NEURONTIN

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

TYPES OF THERAPY
PSYCHOLOGICAL THERAPY
• MAY NEED INDIVIDUAL THERAPY TO MAKE SENSE OF THE CONFUSION OF THE MANIC STATE
• WHEN THEY GET BACK TO THEIR NORMAL SELF AND SEE THEIR LIFE IN SHATTERS.

GROUP THERAPY
• POOR CANDIDATES IN THE ACUTE STAGE

FAMILY THERAPY
• IS NEEDED TO HEAL THE DISRUPTIONS
O EXTRAMARITAL AFFAIRS
• FAMILY NEEDS A LOT OF EDUCATION ON SYMPTOMS
• NEED TO BE AWARE THAT ONE NIGHT OF MISSED SLEEP COULD BE A SYMPTOM OF AN UPCOMING MANIC EPISODE.
• IF THAT HAPPENS THEY NEED TO SEE IF THE PERSON HAS BEEN ON MEDS OR GO TO PHYSICIAN

OCCUPATIONAL THERAPY / RECREATIONAL THERAPY

• NEED SUPERVISED NON COMPETITIVE ACTIVITIES – COMPETITION ESCALATES THEM
• SOLITARY THINGS THEY CAN DO WITH A SHORT ATTENTION SPAN WITH MILD PHYSICAL EXERTION
• WALKING, SHOOTING FREE THROWS ALONE, WRITING – CREATIVE AND LIKE TO EXPRESS FEELINGS

MILIEU THERAPY
• NON STIMULATING ENVIRONMENT
O SPECIAL TREATMENT IS NECESSARY
• PROTECT FROM IMPAIRED JUDGMENT
• DON’T TAKE COMMENTS PERSONALLY
• DON’T GET DEFENSIVE
• MAKE SURE THEY DON’T GIVE AWAY THEIR VALUABLES

AXIS IV – PSYCHOSOCIAL – ENVIRONMENT (ANY PROBLEM THAT WILL IMPACT PATIENT)

GAP SCALE – LEVEL OF FUNCTION FROM 0-100

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

ans: ativan, distraction, monitor closely