0133427269 Module28 MoodandAffect LectureOutline

Concept 28 Mood and Affect The Concept of Mood and Affect Emotions are feeling responses to a wide variety of stimuli Positive emotion ( stimulates individual to stay in situation Negative emotion ( stimulates individual to avoid or withdraw from situation Mood ( sustained emotional state and how one feels subjectively Affect ( immediate emotional expression of emotional state Immediate, observable emotional expression of mood that people communicate verbally, nonverbally Verbal clues ( elation, happiness, pleasure, anger, frustration Nonverbal cues ( facial expressions, motor activities, physiological responses Normal mood and affect Definitions of affect descriptors to facilitate communication among healthcare professionals ( See Table 281 DESCRIPTORS OF AFFECT, p. 1776 Genetic and lifespan considerations Study of genetic influences on mood is new Mood intensity and lability seems to be strongly linked to genetic influences Environmental influences have a strong influence on ability to self-regulate mood intensity and shifts See CONCEPTS RELATED TO MOOD AND AFFECT, p. 1777 Alterations to mood and affect When alterations to mood and affect become significant enough to impair functioning, they may rise to the level of mood disorder as defined by the APA Mood disorders ( syndromes with core clusters of symptoms, categorized into several subtypes Depressive disorders ( feelings of sadness, discouragement, hopelessness, anhedonia, fatigue, sleep disturbances, somatic complaints, irritability Bipolar disorders ( alternating periods of depressive episodes and mania or hypomania Anxious distress ( can be found with both depressive and bipolar disorders Alterations and manifestations Depression ( major depressive disorder (MDD) unipolar disorder Person experiences depressed mood that moves from mild to severe Severe phase lasts at least 2 weeks Often chronic course with incomplete remission between episodes Persistent depressive disorder (dysthymic disorder) ( chronic disorder in which periods of depressed mood are interspersed with normal mood Less severe Fewer physiological symptoms Double depression ( dysthymic disorder and one or more episode of MDD More severe symptoms than MDD Note a bona fide diagnosis Adjustment disorder with depressed mood (adjustment disorder) Dramatic life changes ( losses due to death, relocation, loss of autonomy, illness, financial stress Essential feature is maladaptive reaction to an identifiable psychosocial stressor Bipolar disorders Persons mood alters between extremes of depression and elation, interspersing periods of normal mood Bipolar I disorder ( one or more manic and one or more depressive episodes Bipolar II disorder ( one or more hypomanic and one or more depressive episodes Mixed ( rapidly alternating moods Rapid cycling ( four or more episodes of illness within 12 month period Postpartum mood disorders Mood disorder after delivery fairly common Continuum Postpartum blues ( within first 10 days postpartum, lasts few day to 2 weeks ( disappears spontaneously May be hormonal fluctuations Depressive disorder with peripartum onset (postpartum depression) ( severe form of depression Begins within 3 months of delivery Multiple children, preterm, higher risk Insomnia, loss of energy, inability to concentrate Untreated ( affects ability to parent Longer than 2 weeks depression Postpartum psychosis ( medical emergency Usually within 26 weeks of delivery Symptoms develop rapidly See ALTERATIONS AND THERAPIES Mood and Affect, p. 1780 Theories of depression Currently considered to be caused by an interaction of individual genetic, biological, environmental, and psychosocial factors Considered spectrum disorders ranging from mild to severe, with most cases falling in the middle Look at factors interacted in past and in present Many factors increase or decrease risk of mood disorders Biological rhythms Regular fluctuations of a variety of physiological factors over a period of time Internal desynchronization may result in depression ( tendency may be inherited Seasonal affective disorder (SAD) ( individual typically experiences depression during fall, winter, returning to normal mood in spring, summer Majority of SAD sufferers women with family history of mood disorders Symptoms of SAD ( increased appetite, carbohydrate craving, weight gain Intrapersonal factors Focuses on theme of loss May be person, relationship, object, self-esteem, security Normal feeling with loss is anger ( taught anger inappropriate to express ( turned inward Unusually sensitive to loss, abandonment issues ( dependent traits Unusually sensitive to failure ( self-critical Learning theory People learn to be depressed in response to an external locus of control ( perceive themselves lacking control over their life experiences Repeated failures teach them that what they do has no effect on final outcome Believe they have no control ( no will or energy to cope with life Cognitive theory Those who are depressed focus on negative messages in environment ( ignore positive experiences Present viewed as negative In manic phase ( all present viewed as positive Sociocultural factors Variety of sociocultural conditions may contribute to feelings of powerlessness, hopelessness, low self-esteem Ageism, racism, sexism, classism, homophobia Higher rate of depression among women than men Occurrence of stressful life events Expansion of family, reduction of family Factors that influence degrees of stress that accompanies significant life events Strong network support Adaptive coping mechanisms Low vulnerability See Figure 281 THE RELATIONSHIP BETWEEN LIFE EVENTS AND DEPRESSION, p. 1781 Childhood sexual abuse ( significant risk factor for depression during childhood and adulthood Onset earlier More likely to self-mutilate and attempt suicide Gender bias theory Women experience more depression than men ( throughout the world Cross-cultural similarities Gender socialization differences may be factor in higher depression rates Rigid expectations about gender roles linger ( homemaker, employed outside the home Employed outside the home ( decreased depression rates Applies to older adults Value on youth Older adult may feel useless, unimportant See Table 282 CAUSATIVE THEORIES OF MOOD DISORDERS, p. 1782 Prevalence Major depressive disorder ( lifetime prevalence rate 16.6 Dysthmia ( lifetime prevalence 2.5 Bipolar disorders ( approximately 5.7 million in U.S. (2.6 of population) Postpartum depression ( 8 19 of women report postpartum depression symptoms Genetic considerations and nonmodifiable risk factors Genetics Genetic predisposition ( more severe the depression, stronger genetic link Children of depressed parents have increased risk Parents of depressed children also have increased risk Bipolar disorders ( 85 appear to be inherited Studies suggest complex mode of inheritance exists Neurobiology Prefrontal cortex ( lower than normal activity, low glucose metabolism, decreased blood flow Neurotransmission hypothesis specifically concerned with levels of serotonin, dopamine, norepinephrine, and acetylcholine in the CNS Most likely combination of problems in neurotransmitter systems Principal neurotransmitter for mood states is serotonin ( associated with anxiety, aggression Imbalance may occur through action of enzyme monoamine oxidase (MAO) Responsible for deactivating neurotransmitters after they have been released May explain higher incidence of depression in women, older people ( have consistently higher MAO levels than men, younger people Sensitivity of receptors to neurotransmitters Thyroid hormone levels in CNS may be low ( transthyretin, protein important for transporting thyroid hormones in the brain Limbic system in brain is major site of stress adaptation Stress ( neurotransmitter production in limbic system Chronic stress results in shortage of neurotransmitters Case Study Part 1 ( Jason is a 22-year-old college student who has missed several classes and did not turn in a major paper, p. 1784 Prevention There is no definitive way to prevent depression Some strategies can be useful for modifying stressors and environmental factors that contribute to depressive illnesses Teaching healthy coping mechanisms Proper diet, exercise and rest Abstaining from using illegal drugs and using alcohol only in moderation Teaching clients to recognize signs of depression Awareness of individual risk factors such as family history, low self-esteem Prevention programs May be useful for children and adolescents Those delivered by professional interventionists have greater effects Screenings No diagnostic tests are available to screen for mood disorders Several self-report scales can assist in screening for depression Reynolds Child Depression scale PHQ-2 Assessment Establish a therapeutic relationship Ask open-ended questions and allow adequate time for response See Table 283 CHARACTERISTICS OF MOOD DISORDERS, p. 1786 Self-report scales Adults Beck Depression Inventory Center for Epidemiological Studies Depression Scale-Revised (CESD-R) Mood Disorder Questionnaire (MDQ) Children Center for Epidemiological Studies Depression Scale for Children (CES-DC) Childrens Depression Inventory 2 (CDI-2) Older adults Geriatric Depression Scale (GDS) Cornell Depression Scale (CDS) Postpartum depression Edinburgh Postnatal Depression Scale Becks Postpartum Depression Predictors Inventory-Revised (PDPI-R) Lifespan and cultural considerations Older, single White men have highest rate of suicide in U.S. Many have seen their primary care provider in the month before completing suicide Nurses need to assess for risk in all clinical settings Appropriate expressions of mood largely culturally determined Situations in which people expected to feel a certain way How expected to behave in certain situation Western interpretation is that emotions intrapersonal Other cultures (interpersonal Emotions viewed and expressed in somatic terms Emotions of suffering, depression different meanings, forms of expression in different cultures Unexpected, unacceptable, tragedy, martyrdom, positive feature of life Western culture considers depression a mental disorder Nurses must understand expression of depression culturally determined Immigrants at higher risk for depression ( many stressors African Americans, Latinos often look to family, faith for help Less likely to be treated Diagnostic tests Thorough workup is necessary to rule out underlying conditions Diagnostic and laboratory tests include Thyroid function tests Electrolyte panel, urinalysis, toxicology Liver function tests Other tests based on individual symptoms Differentiating depression from grief Depression and grief may present similarly See Table 28-4 DIFFERENCES BETWEEN DEPRESSION AND GRIEF, p. 1788 Case Study Part 2 ( Following a clinical interview and administration of Beck Depression Inventory, the healthcare provider at the campus health center diagnosed Jason with major depressive disorder , p. 1788 Interventions and therapies Independent Preventing suicide and promoting safety Client safety always takes priority over other nursing care concerns Severe depression ( high risk for suicide, violent behaviors Encourage client to discuss all of their feelings Having feeling always acceptable Acting on feeling may be problematic Use calm, reassuring approach, teach calming measures such as time outs, controlled breathing Collaborate with clients to identify community resource to which they can turn if suicidal thought recur outside treatment setting See Box 281 PREVENTING INPATIENT SUICIDE AND PROMOTING SAFETY, p. 1789 Teaching assertive behavior Assertiveness is learned behavior People learn patterns of communicating ( can unlearn ineffective patterns, learn new effective patterns Aggressive behavior is directed toward getting what one wants without considering feelings of others, at any cost Passive behavior consists of avoiding conflict at any cost, even at expense of own happiness Passive communicators hold feelings, anger builds up Explosion Passiveaggressive behavior Assertive behavior ( expressing ones wishes and opinions ( taking care of self ( not at expense of others Minimizing maladaptive dependence Hopeless clients have tendency to form dependent relationships Strategies to minimize maladaptive dependence include Emphasize short-term nature of relationship Recognize that a client who singles out one staff member exclusively and refuses to relate to others is developing dependence Avoid giving dependent clients the hope that the nurseclient relationship can continue after therapy has ended Refuse requests for your address or telephone number Remind clients that social contact will not be allowed Essential for nurse (student) to separate professional life from social life Collaborative Pharmacologic therapy for depression Antidepressants ( treat major depression by enhancing mood Sometimes used to treat anxiety disorders Black box warning monitor for signs of suicide especially when treatment begins, when doses changed Medication may reduce depressive symptoms associated with dysfunction of neurotransmitters Exert effect through action on certain neurotransmitters in brain Four primary classes Tricyclic antidepressants (TCAs) Named for three-ring chemical structure Act by inhibiting reuptake of norepinephrine and serotonin into presynaptic nerve terminals Most common side effect ( orthostatic hypotension TCAs can accumulate in cardiac tissue ( dysrhythmias Sedation reported at initiation of therapy Long half-life Anticholinergic effect ( dry mouth, constipation, urinary retention Nursing considerations Careful monitoring of condition, providing about treatment May take 26 weeks for therapeutic effects Previous health history assessment Contraindications Drug interactions Drug interactions Significant drug interactions may occur Demerol can cause seizures, delirium death Oral contraceptives may have decreased effectiveness Some drugs increase rate of TCA metabolism Client education May take several weeks or more to achieve full therapeutic effect of drug Keep all scheduled follow-up appointments with healthcare provider Sweating, along with other anticholinergic side effects, may occur Take medication exactly as prescribed, report any side effects Do not take other drugs, over-the-counter (OTC) medications, herbal remedies without notifying healthcare provider Avoid alcohol and other CNS depressants Change positions slowly to avoid dizziness Do not drive or engage in hazardous activities until the drugs sedative effect known Take drug at bedtime if sedation occurs Immediately discuss with healthcare provider intention or desire to become pregnant ( drugs must be withdrawn over several weeks, not discontinued abruptly Selective serotonin reuptake inhibitors (SSRIs) Slow reuptake of serotonin into presynaptic nerve terminals Favorable side effect profile Serotonin ( natural neurotransmitter in CNS found in high concentrations in certain neurons Lack of serotonin can lead to depression TCAs inhibit both norepinephrine ( SSRIs selectively target serotonin Presynaptic receptors less sensitive, postsynaptic receptors more sensitive Nursing considerations Careful monitoring of condition, education as relates to prescribed drug treatment Assess need for antidepressant therapy ( note intensity, duration of symptoms, identifying factors that led to depression Drug history CNS depressants Alcohol Other antidepressants Hypersensitivity to SSRIs Ask client about suicidal ideation ( several weeks before full therapeutic benefit Sexual side effects ( history of disorders of sexual function History of eating disorders Baseline liver function tests Baseline body weight Client teaching Goals of therapy Reason for baseline data Know that SSRIs may take up to 5 weeks to reach maximum therapeutic effectiveness Do not take any prescription drugs, OTC drugs, herbal products without notifying healthcare provider Keep all follow-up appointments with healthcare provider Report side effects, including nausea, vomiting, diarrhea, sexual dysfunction, fatigue Do not drive or engage in hazardous activities until drugs sedative effect is known Do not stop taking the dug suddenly after long-term use because withdrawal symptoms can occur Take most SSRIs in morning with food to avoid GI upset and insomnia Lexapro and Zoloft may be taken a.m. or p.m. Remeron at bedtime Exercise and restrict caloric intake to avoid weight gain Monoamine oxidase inhibitors (MAOIs) Inhibit monoamine oxidase ( enzyme that terminates the actions of neurotransmitters Low safety margin ( reserved for clients who have not responded to TCAs or SSRIs Drugdrug and fooddrug interactions, hepatotoxicity Adverse effects Orthostatic hypotension headache, insomnia, diarrhea Interact with large number of foods, other medications SSRIs ( serotonin syndrome Antihypertensives ( excessive hypotension Potentiate hypoglycemic effects of insulin, oral antidiabetics Demerol ( hyperpyrexia Tyramine containing foods ( hypertensive crisis within minutes Nursing considerations Monitoring and education related to prescribed drug treatment Refrain from foods that contain tyramine CBC Assess for possibility of pregnancy May lower threshold for seizures in epilepsy Careful drug history May take 48 weeks for full therapeutic benefits Client education Goals of therapy Reasons for obtaining baseline data Possible side effects Strictly observe dietary restrictions for foods containing tyramine Do not take any prescription, OTC drugs or herbal products without notifying healthcare provider Avoid caffeine Wear medic alert bracelet identifying MAOI medication Be aware it may take several weeks or more to obtain full therapeutic effect of drug Keep all follow-up appointments with healthcare provider Do not drive or engage in hazardous activities until drugs sedative effect is known Observe for and report signs of impending stroke or myocardial infarction (MI) Atypical antidepressants, including serotoninnorepinephrine reuptake inhibitors (SNRIs) and others Duloxetine (Cymbalta), venlafaxine (Effexor) ( inhibit reabsorption of serotonin and norepinephrine and elevate mood by increasing levels of serotonin, norepinephrine, and dopamine in the CNS Bupropion (Wellbutrin) inhibits reuptake of serotonin, affects activity of norepinephrine and dopamine Mirtazapine (Remeron) blocks presynaptic serotonin and norepinephrine receptors ( enhances release of neurotransmitters from nerve terminals Nefazodone (Serzone) ( similar to Remeron Pharmacologic therapy for bipolar disorders Called mood stabilizers ( moderate extreme shifts between mania and depression Nursing considerations Monitor clients condition and provide education as it relates to prescribed drug treatment Monitor for and report increased signs of suicidality Monitor for and report changes in cardiovascular status Monitor for and report signs of extrapyramidal symptoms or neuroleptic malignant syndrome Monitor neurological and neuromuscular status in older adults Lithium therapy Carefully monitor clients condition and provide education as it relates to drug treatment Clients frequently experience dehydration and sodium depletion Assess for signs and symptoms of lithium toxicity Client teaching Goals of therapy Reasons for obtaining baseline data Possible side effects Take medication as ordered because compliance is key to successful treatment Keep all scheduled laboratory visits to monitor lithium levels Do not change diet or decrease fluid intake because any changes in diet and fluid status can affect therapeutic drug levels Avoid alcohol use Do not take other prescription medications, OTC drugs, or herbal products without notifying your healthcare provider Nonpharmacologic therapy Cognitive-behavioral therapy Combination therapy Helps people identify habitual reactions to troublesome situations AND teaches them how to relax and calm bodies Cognitive aspect ( focuses on distorted thinking patterns Goal is accurate rational thinking based on logic, available facts Initially identify troubling problems in lives Therapist helps problem solve by asking questions Techniques used by therapists Cognitive modification of negative thoughts, maladaptive schemas Automatic thoughts that have a theme are called schemas Help identify patterns of irrational thinking, replace with logical, fact-based patterns of thinking Mindfulness ( art of conscious living by focusing ones full attention on the activity at hand Learn to identify destructive thought patterns, label them, watch them pass by whenever they come to mind Cognitive-behavioral group therapy often treatment of choice ( opportunity to practice new ways of interacting with others Electroconvulsive therapy (ECT) Electric current passed through the brain ( several times/week for 12 treatments May be useful for variety of clients Safer alternative for highly suicidal, medically deteriorated, psychotic depression Safe for children, adolescents, all trimesters of pregnancy Often treatment of choice for older clients Transient short-term memory loss expected Transcranial magnetic stimulation use of magnetic field passing through skull ( causes cells in cerebral cortex to fire In depression ( target area is left prefrontal cortex In manic episodes ( target area is right prefrontal cortex Rapid onset of action ( 12 weeks Same effectiveness in depression without psychosis as ECT Complementary and alternative therapy Exercise ( short periods of vigorous aerobic exercise, longer periods of nonaerobic exercise for at least several weeks Most helpful for mild to moderate depression Yoga found to improve wellness, prevent depression St. Johns wort Mild to moderate depression Should not be combined with prescription antidepressants May interfere with action of anticonvulsants SAMe Used for depression, arthritis in Europe Effective treating depression, postpartum depression postmenopausal depression May worsen bipolar depression Used successfully as augmentation of antidepressants Best taken 30 minutes before meals Vitamin B Necessary for production of dopamine, serotonin, norepinephrine, as well as natural synthesis of SAMe Significant vitamin B deficiency ( twice the risk of depression Tyrosine Precursor for dopamine and norepinephrine Acts as a mood elevator Combined with B6 and vitamin C will be absorbed better Melatonin Insomnia frequent in depression Melatonin effective in inducing sleep with no notable side effects Omega-3 fatty acids Thought to act on cells similar to lithium Appeared to be an antidepressant, antimanic, mood stabilizer Acupuncture Helpful in relieving feelings of depression, anxiety ( likely related to endorphin rise Electrostimulation with acupuncture needles usually increases effectiveness of treatment Animal-assisted therapy Companionship with animals associated with people experiencing less depression and loneliness Music therapy Meaningful clinical improvement following music therapy in a small study Review The Concept of Mood and Affect Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( Jason was admitted to the short-term acute care psychiatric unit of the local hospital, p. 1797 Exemplar 28.1 Depression Overview Disorder characterized by sad, despondent mood Many symptoms associated with depression Lack of energy Sleep disturbances Abnormal eating patterns Feelings of despair, guilt, hopelessness Most common mental health disorder of older adults Majority of depressed clients in mainstream everyday settings Risk factors for depression include History of child abuse or neglect, spousal abuse, loss of a close family member or intimate friend, other significant loss Dysfunctional family relationships, with or without presence of substance abuse Family history of mental illness or substance abuse Prevention No definitive way to prevent depression Strategies to modify stressors can help Exercise Proper diet and rest Avoiding alcohol and illicit drugs Clinical manifestations Major depressive disorder (MDD) Characterized by a change in several aspects of an individuals life and emotional state consistently over a period of 14 days or longer May describe feelings of sadness, discouragement, hopelessness May report vague somatic complaints May consist of a single episode, or may recur See Box 283 DSM-5 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER, p. 1799 Activities that previous gave pleasure are no longer enjoyed ( anhedonia Changes in appetite, sleep disturbances Insomnia Middle insomnia ( waking up in middle of night and having difficulty falling asleep again Terminal insomnia ( waking at end of night, unable to return to sleep Hypersomnia( sleeps for prolonged periods of time, wakes up tired or fatigued Fatigue, decreased energy ( anergy Psychomotor retardation ( thinking, body movements noticeably slowed, speech slowed or absent Feelings of guilt, worthlessness, self-blame, impaired concentration and decision-making ability, suicidal ideation See Figure 284 CHARACTERISTICS OF MAJOR DEPRESSION, p. 1800 Persistent depressive disorder Also known as dysthmic disorder Chronic depression for the majority of most days for at least 2 years No more than 2 months can be described as symptom free Symptoms tend to be less severe than MDD Often occurs in childhood, adolescence, early adulthood Tends to be chronic Symptoms similar to those of chronic MDD Seasonal affective disorder (SAD) Depressive disorder that occurs in relation to the seasons Usually in winter months Natural light may help modulate daily rhythms that influence sleep, activity patterns One medication indicated for SAD ( bupropion extended release (Wellbutrin ER) May prevent major depressive episode in people with SAD Research exploring light therapy indicate reduction of fatigue, depression, increased alertness See CLINICAL MANIFESTATIONS AND THERAPIES Depressive Disorders, p. 1800 See LIFESPAN CONSIDERATIONS Symptoms of Depression, p. 1801 Collaboration Diagnostic tests No diagnostic tests available Clinicians use complete medical history and physical exam to rule out underlying causes Diagnosis determined by licensed mental health provider Pharmacologic therapy Antidepressant medications May be period of trial and error to determine effective medication, dosage Maintenance until client symptom free for 412 months ( slowly discontinue medication Black box warning ( link between medications and increased suicidal thoughts in children, youth Psychotherapy Usually used in addition to medication Help client learn to live with chronic depressive disorder, manage specific symptoms, promote coping skills Cognitive-behavioral therapy (CBT) Most effective psychotherapeutic approach for depression Objective Reduce symptoms by identifying, correcting clients distorted, negative thinking Determine which behaviors the client needs to change Interpersonal psychotherapy Involves identifying, resolving clients interpersonal difficulties Difficulties that lead to depression may be social isolation, prolonged grief, early development of dysfunctional social behavior Electroconvulsive therapy (ECT) Application of electrical current to brain while client under general anesthesia ( produces generalized seizure Mechanism not known Increases circulating levels of brain neurotransmitters Not a first treatment ( prolonged unresponsiveness to medications Respond more quickly than to medication therapy Nursing process Assessment Clients may express Feelings of sadness Fatigue Lack of interest in relationships, activities previously pleasurable Feelings of worthlessness or guilt Impaired concentration Anxious distress Sleep disturbances or excessive sleep Appetite changes weight loss or gain Withdrawal/social isolation Suicide assessment Assess all clients for suicide risk Ask whether client has thoughts of self-harm, how often these occur, and whether the client would act on those thoughts Ask whether client has a plan to carry out suicide If client has a plan, assess the lethality of it Determine whether client has a family history of suicide Assess for comorbidities Assess for presence of medical illness Some illnesses may trigger depression Chronic illnesses are associated with increased risk of depression Use of alcohol or illicit drugs can cause depression Certain medications are associated with increased risk of depression Assessment of the older adult Geriatric Depression Scale (GDS) Can be used with older adults with cognitive impairment Cornell Depression Scale ( use in older adults with severe cognitive impairment Assessment of children Need to rule out physical illness that could be linked to depressive symptoms Initial psychiatric assessment by child psychologist or psychiatrist Diagnosis Risk for Self-Directed Violence Situational Low Self-Esteem or Chronic Low Self-Esteem Hopelessness Social Isolation Ineffective Health Maintenance Planning Client will remain free of injury Client will refrain from attempts to injure self or others Client will participate in recreational activities Client will articulate steps to feeling better, before beginning to feel better Client will protect personal rights while respecting those of others Client will comply with medication regimens Implementation Nurse adopts emotionally neutral attitude ( not trivializing clients feelings Nurse should be aware of personal feelings, risk of emotional contagion Improve self-esteem Provide distraction from self-absorption by involving client in recreational activities, pleasant pastimes Dispel notion that clients often have that when they feel better they will want to engage in activities Must begin doing things in order to feel better Recognize accomplishment, do not use flattery or excessive praise Be accepting of clients negative feelings, but set limits on time spent discussing accounts of past failures Teach assertiveness techniques Instill hope Help client identify their personal strength Engage clients in setting goals for themselves Help clients weigh and choose alternatives Explore problem-solving models with client Help clients to identify resources who can provide support and encouragement in overcoming problems they identify Discharge planning begins with first client contact Evaluation Client meets daily functional needs appropriately Client does not demonstrate or express suicidal ideation Client describes hopefulness for the future Client is able to resume normal activity patterns such as returning to work or school Review Depression Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 28.2 Adjustment Disorder with Depressed Mood Overview Also called situational depression Generally begin 3 months after the event ( typically lasting no more than 6 months Response to a situation or stressor that is greater than what is usually expected Risk factors Any life-altering event can create risk ( further increased by several preexisting conditions Older adults at high risk, especially when experiencing two or more life-altering events in close proximity Resilience factors Capacity to respond to stressors successfully called resilience( encompasses biological and psychological characteristics intrinsic to an individual Individuals with no history of mental illness can experience situation depression following major event ( resilience factors make difference in whether adjustment disorder with depressed mood becomes depressive disorder Clinical manifestations Symptoms similar to those of other depressive disorders See CLINICAL MANIFESTATIONS AND THERAPIES Adjustment Disorder with Depressed Mood, p. 1806 Collaboration CBT often sufficient to assist client to return to normal state Pharmacologic therapy Antidepressant or antianxiety medication may be prescribed May take several weeks to take full effect Client at high risk for self-medicating with alcohol or other drugs Exercise Depression, chronic stress may affect persons desire to move Lack of visible energy noted in posture Role of exercise in elevating mood, relieving stress, anxiety being supported Elicits relaxation response Emphasis on exhalation Positive effects of exercise on cognitive functioning Exercise, muscle relaxation particularly helpful for adjustment disorder with depressed mood Nursing process Assessment Nursing history Precipitating stressor Symptoms Risk for depression Presence of resilience factors Physical exam In particular if stressor was assault or motor vehicle crash Depression scales, inventories Diagnosis Helplessness Disturbed Sleep Pattern Disrupted Family Processes Situational Low Self-esteem Ineffective Coping Planning Client will obtain adequate sleep and rest Client will refrain from reckless or irresponsible behaviors Client will return to normal daily routines Client will remain free of injury Implementation Promote hope Explore clients previous achievements of success Encourage client to identify strengths Facilitate evaluation of behavior Encourage client to believe in self Inform client of rights Help client clarify needs and wants by setting clear goals Provide client with accurate information, preferably in writing Help client strategize by using problem-solving process Help identify resources ( friends, family, self-help groups, advocacy groups Encourage client to identify best person to assist with this problem Foster effective communication so they can get their message across Promote firmness and persistence so clients needs are met Support family function Provide information about clients condition in accordance with client preferences, remembering confidentiality Support family by referring referrals to outside resources Assist with plan to support family processes while other family member unable to participate Encourage family members to resolve disagreements in a healthy manner Review Adjustment Disorder with Depressed Mood Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 28.3 Bipolar Disorders Overview Group of mood disorders that include manic episodes, hypomanic episodes, mixed episodes, depressed episodes, cyclothymic disorder Pathophysiology and etiology No definitive cause or specific pathophysiology has been identified Bipolar disoders thought to arise from a complex combination of genetic, psychological, environmental, and psychosocial factors Bipolar I ( one or more manic and one or more depressive episodes Bipolar II ( one or more hypomanic and one or more depressive episodes Tend to be recurrent, increase in frequency as individual ages Majority of bipolar I disorder clients do not experience baseline moodeuthymic major depressive episode quickly follows Bipolar disorders typically appear between 15 and 30 years of age Clinical manifestations See Box 286 DSM-5 DIAGNOSTIC CRITERIA FOR BIPOLAR I DISORDER, p. 1810 Mania and hypomania Mania characterized by abnormal, persistently elevated, expansive or irritable mood lasting at least 1 week Significantly impairs social or occupational functioning, generally requires hospitalization Must be accompanied by at least three additional symptoms Inflated self-esteem or grandiosity Decreased need for sleep Pressure of speech Flight of ideas Distractibility Increased involvement in goal-directed activities or psychomotor agitation Excessive involvement in pleasurable activities with high potential for painful consequences Psychotic symptoms may be a feature of severe mania Hypomania Less extreme form ( does not impair functioning, require hospitalization Feel on top of the world Onset of manic episodes usually occurs in early 20s Often follows severe disappointment, embarrassment, psychic stress Behavior excessive, overly enthusiastic Increased sexual behaviors are often seen Clients with mania rarely believe they are sick See Figure 285 CHARACTERISTICS OF A MANIC EPISODE, p. 1811 Depressive episodes Similar to depression, with history of manic or hypomanic episodes Treatment similar to depression ( adds mood stabilizer Clinicians struggle with clients unresponsive to antidepressant pharmacotherapy Recent study ( those with major depression plus anxiety, tendency to experience people as unfriendly, family history of bipolar disorder, recent diagnosis of depression and legal problems ( bipolar disorder rather than depression Many with bipolar disorder not correctly diagnosed in timely manner Mixed features DSM-5 recognizes specifier of with mixed features Symptoms of both mania and depression present nearly every day Rapidly alternating succession of at least a week Can resemble depression, with energy and animation behind sadness Rapid cycling Individuals with bipolar I or II may exhibit rapid cycling ( four mood episodes occurring within a year with periods of partial or full remission of 2 months or more OR with immediate alternate periods of mania/hypomania and depression Individuals can experience episodes more than once a week and even more than once a day Cyclothymic disorder Chronic, fluctuating mood disturbances involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms for at least 2 years Considered moody, unpredictable, temperamental See Figure 286 COMPARISON OF AFFECT (MOOD) IN MAJOR DEPRESSIVE DISORDER, BIPOLOR DISORDER, DYSTHYMIA, AND CYCLOTHYMIA, p.1811 Begins usually in adolescence or early adulthood Lifespan considerations Children with bipolar disorders Often present with irritability or hyperactivity High rate of attempted suicide, as well as co-occurrence or other disorders ( attention-deficit/hyperactivity disorder (ADHD), anxiety, substance abuse Parents, close relatives affected ( child more likely to have disorder Manic characterized by hyperactivity, high energy, irritability, aggressions, sometimes hallucinations Depressive phase characterized by sadness, alterations in sleep and eating patterns, feels worthless, lacks energy, socially withdrawn See CLINICAL MANIFESTATIONS AND THERAPIES Bipolar Disorders, p. 1812 Collaboration Diagnostic tests No diagnostic tests to determine bipolar and related disorders Diagnosis is made from clinical manifestations and client history Physical exam helps rule out underlying conditions Pharmacologic therapy Hyperactive, agitated behavior ( responds rapidly to antipsychotic mood stabilizers Risperidone (Risperdal) Olanzapine (Zyprexa) Nursing interventions Monitoring clients for side effects Lithium carbonate Effective in long-term treatment of mania Alters neurotransmission in CNS Not recommended in pregnancy, breastfeeding, impaired renal function, congestive heart failure, sodium-restricted diets, organic brain disease, impaired CNS functioning Administered orally ( onset of action 13 weeks Dose gradually increased until therapeutic blood level achieved ( 1.01.5 mEq/L Dosage adjusted downward once desired effect achieved Asian descent ( toxic reactions at lower doses (0.6 mEq/L) Toxic symptoms begin at blood levels above 1.5 mEq/L Monitor serum levels closely until stabilized Anticonvulsants Used in mania therapy Valproic acid (Depakote, Depakene) Lamotrigine (Lamictal) Topiramate (Topamax) Carbamazepine (Tegretol) Cannot be discontinued abruptly ( may precipitate seizure Atypical antipsychotics Work to quickly calm clients Becoming first line therapy Aripiprazole (Abilify) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Nursing process Assessment Onset may be gradual or dramatic Subjective data Changes in clients thought processes, evidenced by statements such as I feel like my thoughts are racing Inflated self-esteem, sometimes to extent of having delusions of grandeur Clients ignore fatigue, hunger, even hygiene, being too involved in activity to focus on physiological sensations Distractibility Hallucinations Surprising sense of well-being ( do not understand why people are upset with their behavior Objective data First mania most likely to be in 20s Initial episode likely manic in males, depressive in females Constant motor activity in mania Do not eat, rest Manic communications manifested by flight of ideas, pressured speech Poor judgment as reported by family members ( spending sprees, sexual activity that are completely out of character Unusual appearance Impairment in occupational functioning Interpersonal chaos due to manipulative behavior, testing limits Become irritable, hostile if attempts at manipulation fail Not usually cooperative in assessment process Diagnosis Risk for Injury Disturbed Thought Processes Impaired Social Interaction Self-Care Deficit Sleep Deprivation Risk for Suicide Planning Client will remain free of injury Client will remain oriented Client will be able to focus on a specific stimulus for more than 10 minutes at a time Client will be able to choose between two or more alternatives Client will use appropriate behaviors in a variety of social settings Client will maintain self-care Client will no longer experience sleep disturbances Implementation Promote client safety Provide a safe environment by reducing environmental stimuli Remove or prohibit smoking materials Monitor activities Set and enforce limits on unsafe or socially inappropriate behavior when clients are unable to control their impulses Promote reality-based thinking Spend time with clients Orient to person, place, time as needed Establish consistency by following schedule to help clients understand what is expected of them Communicate acceptance of their need for false beliefs while clearly stating that nurse does not share perceptions Not therapeutic to argue I find it hard to believe or That is extremely unusual Reflect statement back to client for validation Enhance socialization Identify needed behavior changes Assign tasks that will improve clients interactions with others Encourage and demonstrate honesty and respect for others rights Setting limits promotes client security ( enable clients to curb manipulative behavior or give it up Provide client opportunities to be in control when appropriate Set limits Staff members must agree on limits and enforce consistently Violations of limits must have established consequences Clients must know what behaviors are expected and what consequences will result Inconsistent application of consequences will cause failure in efforts to decrease manipulative behavior Client will give explanations of why limit exceeded ( another form of manipulation Promote improved self-care Monitor intake and output Offer frequent small snacks Work with dietitian to ensure high-calorie finger foods, nutritious foods available Assist client with personal hygiene, toileting Allow clients to do as much as possible with verbal encouragement Reinforce attempts at self-care with recognition Incontinence occasionally seen ( establish schedule of frequent, regular toileting Constipation common ( frequent fluid intake, high-fiber diet Enhance rest and sleep Design nursing activities to facilitate regular sleepwake cycles Monitor clients closely for signs of fatigue, make provisions for rest periods Promote nighttime sleeping by limiting extended daytime naps Prior to bedtime, decrease light, noise, encourage quiet activities, presleep routines Medications that do not suppress REM sleep as prescribed Encourage client to stay in darkened room with expectation that they will fall asleep Assign monotonous task such as folding towels to encourage drowsiness Allow for sleep cycles of at least 90 minutes Evaluation Specific client behaviors indicate that nursing interventions have been successful Review Bipolar Disorders Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 28.4 Postpartum Depression Overview Postpartal period time for adjustment New family member Postpartum discomforts Changes in body image End of pregnancy Puerperium ( changes of pregnancy begin to return to normal Postpartum blues ( common occurrence after childbirth Postpartum depression ( major depressive order with peripartum onset Normal presentation First 2448 hours after birth ( passive, somewhat dependent ( taking-in period Talk through perceptions of labor, birth Major needs food and sleep Second, third day ( ready to resume control ( taking-hold period Anxiety ( breastfeeding, unsure of self in child care Maternal role attainment (MRA) ( process by which a woman learns mothering behaviors, becomes comfortable with identity as a mother Four stages Anticipatory stage ( during pregnancy Formal stage ( begins when child born Informal stage ( begins when mother starts making her own choices about mothering Personal stage ( final stage of maternal role attainment Usually occurs within 310 months after birth Challenges of new role Finding time for themselves Feeling incompetent due to not mastering all aspects of mothering role Fatigue resulting from sleep deprivation Feeling of responsibility, loss of freedom Finding time for older children Infant behavior may be challenging MRA ( BAM ( Becoming a mother Long-term adjustments and stresses face family ( nurses can provide anticipatory guidance Development of family attachment First interaction with infant influenced by many factors Family of origin, relationships, stability of home environment, communication patterns, degree of nurturing she received as a child Personal characteristics Level of trust Level of self-esteem Capacity for enjoying herself Adequacy of knowledge about childbearing and childrearing Prevailing mood or usual feeling tone Reactions to the present pregnancy Initial maternal attachment behavior Fairly regular pattern of maternal behaviors Fingertip exploration of newborns extremities Palmar contact with larger body areas Enfolding infant with whole hand and arm Takes from minutes to days Increases time spent in en face position Relies heavily on senses of sight, touch, hearing ( getting to know what baby is like May experience shock, disbelief, denial Acquaintance phase Mother to infant Infant to mothering Phase of mutual recognition Balance sought between needs of mother and infant Both should enjoy Negative maternal feelings likely to surface, intensify ( normal Fatherinfant interactions Similar feelings to mothers feeling of attachment Engrossment Siblings and others Infants can form strong attachments to several people Cultural influence in the postpartal period Western culture emphasizes birth ( other cultures emphasize postpartum period Beliefs about postpartal care, rest, support, and so on influenced by beliefs and values of family, cultural group Nurses come from a particular ethnoculture, as well as culture of health care Need to recognize own preferences ( individualize care for mother/familys preferences Cultural examples European heritage ( full meal, iced fluids after birth Ambulate, shower, wash hair, fresh gown Short hospital stay May or may not want classes Islamic faith may have specific modesty requirements Completely covered No man other than husband, family member may be alone with her Hotcold balance Hispanic, Asian, African cultures may avoid cold after birth Mexican culture may avoid hot foods Extended family role Grandmother involvement Adjust visiting hours Model mothering skills of older female relatives Religious customs, requirements Shabbat, diet Postpartum blues Transient period of depression ( adjustment reaction to depressed mood Manifested by mood swings, anger, weepiness, anorexia, difficulty sleeping, feeling of letdown Frequently occurs in hospital, may occur at home Usually resolve within 1014 days If symptoms persist, worsen ( evaluate for depression Assess woman for predisposing factors during labor and postpartum stay Edinburgh Postnatal Depression Scale or Postpartum Depression Predictor Inventory, Revised Key feature is episodic tearfulness without identifiable cause Several factors may contribute to the blues Emotional letdown that follows labor and childbirth Physical discomfort typical in the early postpartum period Fatigue Anxiety about caring for the newborn after discharge Fears about physical attractiveness Providing reassurance as a normal adjustment reaction can offer measure of relief Partner should be encouraged to watch, report for signs mother slipping into deeper depression Importance of social support Family relationships become more important ( can lead to more stress Attention infant receives is source of satisfaction to new parents Improved in-law relationships Postpartum doula ( professional trained to help new mother after birth of baby Postpartum mood disorders Postpartum depression Refers to mjor depression that occurs during or in the first 4 weeks following birth Overall prevalence rate of 3 6 of women during pregnancy or first 4 weeks after birth Symptoms are similar to serious depression at other times in life Sadness Frequent crying Insomnia or excessive sleeping Appetite change Difficulty concentrating or making decisions Feelings of worthlessness Obsessive thoughts of inadequacy Lack of interest in usual activities associated with pleasure Lack of concern about personal appearance Risk factors Primiparity Ambivalence about maintaining pregnancy History of postpartum depression or bipolar illness Lack of social support Lack of a stable supportive relationship with parents or partner Womans lack of a supportive relationship with her parents, especially father, as a child Womans dissatisfaction with herself, including body image problems and eating disorders Women with postpartum depression at risk for suicide ( as enter or exit deeply depressed state Genetic considerations There is increasing support for theory of gene and environment interaction Several studies implicate a serotonin-related transporter genotype to postpartum depression Postpartum psychosis Postpartum mood episodes with psychotic features Occurs in 1 in every 500 1000 deliveries Increased risk in First deliveries Women with prior postpartum depression Women with history of depressive or bipolar disorder Evident within 13 months following birth Symptoms include agitation, hyperactivity, insomnia, mood lability, confusion, irrationality, difficulty remembering or concentrating, poor judgment, delusions, hallucinations related to infant Emergency ( risk of suicide, infanticide See CLINICAL MANIFESTATIONS AND THERAPIES Postpartum Depression, p. 1822 Collaboration Women with history of postpartum psychosis or depression ( refer to mental health professional for counseling between second and sixth week postpartum Diagnostic tests Routine use of screening tool significantly improves diagnosis See Box 28-8 EDINBURGH POSTNATAL DEPRESSION SCALE, p. 1822 See Box 28-9 POSTPARTUM DEPRESSION PREDICTORS INVENTORY-REVISED, p. 1823 Pharmacologic therapy Breastfeeding ( sertraline (Zoloft) first-line treatment for postpartum depression Parozetine (Paxil) alternative Combination of antidepressant and psychosocial interventions Support groups Successful adjuncts to treatment Not alone in experience Forum for exchanging information, learning stress reduction measures Other therapy Directed at specific type of psychotic symptoms displayed Removal of infant Social support Nursing process Priority is to maintain safety of client and family Assess for risk of harm to self or others Assessment History Factors predisposing to postpartum depression Personal/family history of psychiatric disease Depression scale for postpartum depression Edinburgh Postnatal Depression Scale Listen to womans feeling about transition to maternal role, statements of feelings of failure, self-accusation Observation for objective signs of depression Note severity and duration of symptoms Be specific, objective, carefully document Fatigue level at 2 weeks postpartum Family input, observations Diagnosis Ineffective Individual Coping Risk for Altered Parenting Risk for Violence Planning Maintain safety for mother and family Appropriate care for the newborn is provided by family, support persons Encourage client to express feelings and concerns Promote compliance with the agreed-upon plan of care Assist client to integrate newborn into family Implementation Alert mother, spouse, other family members to possibility of postpartum blues in early days after birth, reassure of short-term nature of condition Describe symptoms of postpartum depression, encourage mother to call healthcare provider if symptoms become severe, fail to subside quickly, if at any time she feels unable to function Encourage mother to plan how she will manage at home Community-based nursing care Telephone follow-up 23 weeks post partum Presence of three symptoms of depression on 1 day, or one symptom for 3 days, may signal serious depression ( make immediate referral if rejection of infant, threatened or actual aggression against the infant has occurred Symptoms difficult for family Difficulty understanding Worry, confusion Practical matter of running household Integration of newborn into family, care of newborn and other children ( further compromised if concurrent paternal postpartum depression Information Emotional support Assistance in providing or obtaining care for infant Identify community resources Referrals to public health nursing services, social services Evaluation Clients signs of depression are identified, receive prompt intervention Newborn is effectively cared for by father or other support persons until mother is able to provide care Mother and newborn remain safe Newborn is successfully integrated into family unit Review Postpartum Depression Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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