nursing management of patient with mood disorder

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1 : Nursing management of patient with Mood Disorders Mr. Vinodkumar Patil Principal Smt. Sushiladevi Nagur Memorial Nursing School Bijapur. 586101
2 : Introduction A Definition of Mood Prolonged emotional state that influences the person’s whole personality and life functioning
3 : Mood Disorders Mood disorders are characterized by a disturbance of mood, accompanied by a full or partial manic or depressive syndrome, which is not due to any other physical or mental disorder. The prevalence rate of mood disorders is 1.5 percent, and it is uniform throughout the world
4 : Classification of Mood Disorders F30 – F39 Mood (affective) disorders F30 Manic Episode F31 Bipolar affective disorder F32 Depressive Episode F33 Recurrent depressive disorder F34 Persistent mood disorder F38 Other mood disorders F39 Unspecified mood disorder
5 : Manic Episode Manic episode refers to a syndrome in which the central features are over activity, mood change and self important ideas. The lifetime risk of manic episode is about 0.8-1%. The one episode last usually for 3 to 4 month.
6 : Classification of mania F30 Manic episode F30.0 Hypomania F30.1 Mania without psychotic symptoms F30.2 Mania with psychotic symptoms F30.8 Other manic episodes F30.9 Manic episode unspecified
7 : Etiology Neurotransmitter and structural Hypotheses Excessive level of Nor epinephrine and dopamine Imbalance between Cholinergic and noradrenergic or Deficiency in serotonin Biological findings suggest that lesions are more common in areas of the brain such as Right hemisphere or Bilateral sub cortical and periventricular gray matter.
8 : Genetic consideration First degree relative: 5-10% chance Identical twins about 40-70% chance Psychodynamic theories Developmental theorist Faulty family dynamics during early life Another theory explains that As a defense against or denial of depression
9 : Clinical features Elevated, expansive or irritable mood Four stages of elevated mood Euphoria (stage 1) Elation (stage 2) Exaltation (stage 3) Ecstasy (stage 4) Psychomotor activity Increased psychomotor activity Over activeness Restlessness
10 : Speech and thought Flight of ideas Pressure of speech Delusion of grandeur Delusion of persecution Distractibility Other features Increased sociabilities Impulsive behavior disinhibition
11 : hypersexuality Poor judgement High-risk activities Decreased need for sleep (< 3 hrs) Decreased food intake due to over-activity Decreased attention and concentration Absent insight
12 : Diagnosis
13 : Treatment modalities Pharmacotherapy Lithium 900-2100mg/day Carbamazepine 600-1800mg/day Sodium valproate 600-2600 mg/day Other drugs Clonazepam Calcium channel blockers etc….
14 : Treatment modalities Electroconvulsive therapy Acute manic excitement Psychosocial treatment Family therapy Marital therapy
15 : Nursing management for mania Nursing assessment History collection Mental status examination Physical examination Process recording Laboratory investigation Other health worker
16 : Nursing diagnosis I High-risk for injury related to extreme hyperactivity evidenced by lack of control over purposeless and potential injurious movements Objective Patient will not injure self
17 : Nursing interventions Keep environmental stimuli to a minimum. Assign single room; limit interaction with others; keep lighting and noise level low. Remove hazardous objects and substances, caution the patient when there is possibility of an accident Assist patient to engage in activities, such as writing, drawing and other physical exercise Stay with patient as hyperactivity increases Administer medication as prescribed by physician
18 : High-risk for violence, self directed or directed at others related to manic excitement, delusional thinking and hallucination Objective: patient will not harm self or others Nursing diagnosis II
19 : The following are some guidelines for self protection when handling an aggressive patient. Never see a potentially violent person alone. Keep a comfortable distance away from the patient Be prepared to move, violent patient can strike out suddenly Maintain a clear exit route for both the staff and patient.
20 : Nursing interventions Maintain low level of stimuli in patient’s environment, provide unchallenging environment. Ensure that all sharp objects, glass or mirror items, belts, ties, matchboxes have been removed from patient’s environment.
21 : Evaluation Patient Outcome/Goal Patient will be emotionally responsive and return to pre-illness level of functioning Nursing Evaluation Was nursing care adequate, effective, appropriate, efficient, and flexible?
22 : Depressive episode
23 :
24 : Definition Depression is a mood disturbance characterized by sadness, despair and discouragement, emptiness, hopelessness. The depressive episode may be caused by a personal loss or tragedy or may have no real cause such as occurs in bipolar sufferers A disturbance of mood, characterized by a full or partial depressive syndrome, or loss of interest or pleasure in usual activities and pastimes with evidence of interference in social/occupational functioning.  
25 : Risk for Depression Lifetime risk for major depression is 7% to 12% for men Risk for women 20-30% Depression occurs twice as frequently in women as in men Rates peak between adolescence and early adulthood
26 : Classification of depression F32 Depressive episode F32.0 Mild depressive episode .00 Without somatic syndrome .01 With somatic syndrome F32.1 Moderate depressive episode .10 Without somatic syndrome .11 With somatic syndrome F32.2 Severe depressive episode without psychotic symptoms F32.3 Severe depressive episode with psychotic symptoms F32.8 Other depressive episodes F32.9 Depressive episode, unspecified F33 Recurrent depressive disorder
27 : ETIOLOGICAL THEORIES Biological theories Neurochemical Decreased levels of Norepinephrine and serotonin Dysregulation of Acetylcholine and GABA Genetic theories More often in first degree relative Identical twin > 70%
28 : Conti… Endocrine theories Malfunctioning of Hypothalamic-pitutary-adrenal axis Creates cortisol, thyroid and other hormonal abnormalities
29 : Conti… Circadian rhythm theories Circadian rhythms are responsible for the daily regulation of Wake-sleep cycles, activity pattern and hormonal secretion Change in circadian rhythm result in development of depressive and mood symptoms. Change in brain anatomy Loss of neurons in the frontal lobes, cerebellum and basal ganglia.
30 : Conti… Psychological theories Psychoanalytic theory : According to Freud Loss of “loved object” and Fixation in oral sadistic phase Behavioral theory: Depression is conditioned by repeated losses in the past.
31 : Conti… Cognitive theory: Depression is due to negative cognition which includes: Negative expectation of environment Negative expectation of self Negative expectation of the future. Sociological theory Stressful life events like Death, marriage, financial loss before the onset of the disease
32 : Clinical features Depressed mood Sadness of mood or loss of interest and loss of pleasure in all most all activity, and present throughout the day. Depressive cognition Hopelessness, helplessness, worthlessness Unreasonable guilt and self-blame over trivial matters in the past.
33 : Conti… Suicidal thoughts Hopelessness leads to preoccupation of thoughts and plan for suicide. Psychomotor activity Retarded psychomotor activity Walk and act, and think slowly Questions are often answered after a long delay and in a monotonous voice. Marked anxiety, restlessness and feeling of uneasiness.
34 : Conti… Psychotic features About 15-20% of patient may have delusion and hallucinations Somatic symptoms of depression Significant decrease in appetite or weight Early morning awakening Diurnal variation, with depression being worst in the morning Anhedonia Poor memory Menstrual and /or sexual disturbance
35 : Conti… Biological functioning Insomnia Loss of appetite and weight Loss of sexual drive
36 : Diagnosis Psychological tests Beck depression inventory Hamilton rating scale for depression Based on ICD 10 criteria
37 : Treatment Pharmacotherapy- Antidepressants Tricyclic antidepressant (TCAs) – Imipramine 75-300mg/day OR Monoamino reuptake inhibitors Amitriptyline 75-300mg/day c;lomipramine 75-80% mg/day Selective serotonin reuptake inhibitors (SSRIs) Fluoxetine 10-80mg/day
38 : Conti… Atypical antidepressants Amineptine 100-400 mg/day Monoaminooxidase inhibitors (MAO) Isocarboxazid 10-30 mg/day
39 : Mechanism of action Increase catacholamine level in the brain TCAs block the reuptake of norepinephrine or serotonin at the nerve terminals and increase its level at the receptor site. MAOs degrade the catacholamine after reuptake and increase brain amine level. SSRIs act by inhibiting the reuptake of serotonin and increase its level at receptor site.
40 : Side effects Anticholenergic reaction: Dry mouth, constipation, distress, urinary retention, blurred vision, delirium Sexual dysfunction: Impaired ejaculation, importance CNS effects Fine tremors, sedation, extra pyramidal symptoms, withdrawal syndromes, sizures.
41 : Conti… Cardiovascular effects Orthostatic hypotension, palpitation, arrhythmias, ECG changes, myocardial depression In IHD cases AV block, sudden death may occur Hypertensive crisis with MAOs
42 : ELECTRO CONVULSIVE THERAPY ECT is indicated to have rapid action and remission of symptoms. In major depression cases it will be given as initial treatment and fosters antidepressant action.
43 : Psychotherapeutic approach Supportive psychotherapy Various technique are employed to support the patient. They are reassurance, ventilation, occupational therapy, relaxation and other activity therapies. Psychotherapy Emphasizes helping patient gain insight into the cause of their depression
44 : Conti… Cognitive therapy Aims to correct the depressive negative cognition Group therapy negative feelings such as anxiety, anger, guilt etc.. Family therapy Behavioral therapy
45 : Nursing management of major depressive episode Nursing assessment: Nursing assessment should focus on judging the severity of the disorder including the risk of suicide. Identifying the possible cause. Social resources available to the patient, and effect of the disorder on other people.
46 : Nursing diagnosis I High-risk of self directed violence related to depressed mood, feeling of worthlessness evidenced by expression of suicidal thoughts. Patient will not harm self.
47 : Nursing interventions Ask the patient directly “have you thought about harming your self in any way? If so, what do you plan to do? Do you have the means to carry out this plan? Create a safe environment for the patient. Remove all potential harmful objects from patients vicinity Formulate a short term verbal or written contract that the patient will not harm self. Secure a promise that the patient will seek out staff when feeling suicidal.
48 : Conti… It may be desirable to place the patient near the nursing station. Do not leave the patient alone. Observe for passive suicide- the patient may starve or fall asleep in the bath tub or sink. Do not allow the patient to put the bolt on his side of the door of the bathroom or toilet If the patient suddenly becomes unusually happy or gives any other clues of suicide, special observation may be necessary. Encourage the patient to express his feelings including anger.
49 : Nursing diagnosis II Dysfunctional grieving related to real or perceived loss evidenced by denial of loss, inability to carry out activities of daily living. Objective: patient will be able to verbalize normal behavior associated with grieving
50 : Nursing interventions Assess stage of fixation in grief process Be accepting of patient and spend time with him. Show empathy, care and unconditional, positive regard Explore feelings of anger and help patient direct them towards the intended object or person Provide simple activities which can be easily and quickly accomplished. Gradually increase the amount and complexity of activities.
51 : Nursing diagnosis III Self-esteem disturbed related to learned helplessness evidenced by expression of negative and pessimistic outlook Objective: patient will be able to verbalize positive aspects about self and attempt new activities without fear of failure.
52 : Nursing interventions Be accepting of patient and spend time with him, even though pessimism and negativism may seem objectionable. Focus on strengths and accomplishments and minimize failures Provide him simple and easily achievable activity. Encourage the patient to perform his activities without assistance Encourage patient to recognize areas of change and provide assistance toward this effort
53 :
54 : BIPOLAR MOOD DISORDER (bipolar affective disorder, manic depressive disorder
55 : Definition This is characterized by recurrent episodes of mania and depression in the same patient at different times. Typically, the patient experience extreme high (mania or hypomania) alternating with extreme lows (depression). Onset : between age of 20-30
56 : F31 Bipolar affective disorder F31.0 Bipolar affective disorder, current episode hypomanic F31.1 Bipolar affective disorder, current episode manic without psychotic symptoms F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms F31.3Bipolar affective disorder, current episode mild or moderate depression .30 Without somatic syndrome .31 With somatic syndrome Classification
57 : F31.4 Bipolar affective disorder, current episode severe depression without psychotic symptoms F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms F31.6 Bipolar affective disorder, current episode mixed F31.7 Bipolar affective disorder, currently in remission F31.8 Other bipolar affective disorders F31.9 Bipolar affective disorder, unspecified Conti…
58 : Etiology Precise cause unknown Genetic, biochemical and psychological factors may play a role May be triggered by stressful events, antidepressant use Sleep deprivation and hypothyroidism
59 : Signs and symptoms of bipolar disorder
60 : Based on the signs and symptoms ICD 10 criteria Diagnosis
61 : Treatment Lithium Valporic acid Carbamazepine Antidepressants course and prognosis of mood disorder An average manic episode lasts for 3-4 months Depressive episode lasts for 4-9 months
62 :


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