Perioperative Care of the Patient with Bipolar Disorder ... - AORN

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August 2010 Vol 92 No 2 SAUNDERS Online Resources* Depression and Bipolar Support Alliance http://www.dbsalliance.org National Alliance on Mental Illness http://www.nami.org National Institute of Mental Health http://www.nimh.nih.gov/health/topics/ bipolar-disorder/index.shtml Mental Health America http://www.mentalhealthamerica.net/go/ information/get-info/bipolar-disorder *Access verified April 29, 2010 to run in families, there is a strong genetic component; therefore, scientists continue to study this disorder to locate the genes that cause bipolar disorder. Significantly high or low levels of neurotransmitters, specifically epinephrine, norepinephrine, dopamine, and serotonin, have been associated with both mania and depression. It is likely that many different genes combined with a person’s environmental and neurobiological factors may interact to cause the disorder. SYMPTOMS Unlike the normal ups and downs that everybody experiences in life, the symptoms of bipolar disorder are severe and can be described as unusually intense emotional states, called “mood episodes.” 6 An overly joyful or overexcited mood that seems out of proportion or inappropriate to the circumstance is called a manic episode. Mania may present as anger, belligerence, and irritability instead of elation and euphoria in some individuals. The characteristic symptoms of a manic episode are � lability (eg, changing quickly from happiness to anger or depression); � inappropriate demanding of other’s attention; � manipulative, profane, or sexually explicit language or behavior; � grossly inappropriate or loud, rapid speech; 212 AORN Journal � stringing words together that rhyme (ie, clang associations); � thoughts that race from topic to topic (ie, flight of ideas); � disorganized thoughts; � grandiosity (eg, believing oneself to be a prominent businessman or religious figure); � restlessness; � disorganized or aggressive behavior; � poor concentration and distractibility; � poor judgment; � psychomotor agitation; and � disorientation, incoherence, delusions, and hallucinations. 3 An extremely sad or hopeless mood is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression; this is called a mixed episode. Extreme changes in activity, behavior, energy, and sleep accompany these changes in mood. An individual may be diagnosed with bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one to two weeks. 1 Sometimes symptoms are so severe that the individual cannot function normally at work, school, or home. TREATMENT: MOOD STABILIZERS Individuals with bipolar disorder often need several medications. Anti-anxiety, antidepressant, and atypical antipsychotic medications may be used in addition to mood stabilizers, which are considered lifetime maintenance therapy for individuals with bipolar disorder. 7 Most often, lithium carbonate is the first choice of mood stabilizer for the acute treatment of mania and the prevention of recurrent manic episodes. To avoid toxicity, lithium maintenance blood levels should range between 0.4 mEq/L and 1.3 mEq/L, and not exceed 1.5 mEq/L. 3 Lithium is usually contraindicated in individuals with cardiovascular, renal, or thyroid disease, or myasthenia gravis; those who are pregnant or breastfeeding; and children younger than 12 years.
SPECIAL NEEDS POPULATIONS www.aornjournal.org Approximately 20% to 40% of individuals with bipolar disorder may not respond to lithium, so the next choice of medications prescribed are antiepileptics, such as carbamazepine, divalproex, lamotrigine, gabapentin, and topiramate. 3 Because these medications may have major adverse effects, patients who are taking them should be monitored carefully: � Carbamazepine can cause agranulocytoses, aplastic anemia, sedation, diplopia, and incoordination. � Divalproex can cause fever, chills, right upper quadrant pain, Because bipolar disorder is a chronic and episodic disorder, continual maintenance treatment consists of medications, psychoeducational classes, support groups, and psychotherapy for both the individual and family members. dark-colored urine, jaundice, malaise, tremors, gastrointestinal upset, and weight gain. Nurses who have patients who are taking this medication also should monitor their liver function tests. � Lamotrigine can cause rash, dizziness, diplopia, headache, ataxia, and sedation. � Gabapentin can cause breathing difficulty, swelling of lips, rash, slurred speech, fatigue, sedation, dizziness, ataxia diplopia, and hypertension. � Topiramate can cause cognitive adverse effects, fatigue, dizziness, and paresthesia. Nurses who have patients who are taking this medication should perform a complete physical assessment before surgery to check the patient’s white blood cell, red blood cell, and platelet counts; liver, renal, and thyroid function tests; urinalysis results; weight; blood pressure; and blood glucose. Individuals with bipolar disease may not disclose their disease. Therefore, when the nurse sees these medications listed on the patient’s chart or if the patient displays an overjoyous, elated mood, or an irritable, belligerent mood that does not match the circumstances, or changes moods quickly, then bipolar disorder is a potential diagnosis. LENGTH OF TREATMENT Because bipolar disorder is a chronic and episodic disorder, continual maintenance treatment that consists of medications,psychoeducational classes, support groups, and psychotherapy for both the individual and family members is needed. Problems that result from angry, impulsive, hyperactive, hostile, or demanding behavior that occurs during a manic episode often leads to interpersonal problems that affect the patient’s friends, family members, and classmates or colleagues. The focus of care for the individual living in the community is maintaining compliance with the medications, preventing relapse, and limiting the severity and duration of episodes. Relapses occur most often when individuals stop taking their mood-stabilizing medication because they feel better or only take the medication occasionally because they forget or do not think that taking the medication regularly is important. It is essential for individuals with bipolar disorder to take their medication on a regular basis and for as long as their physicians recommend, which will result in fewer and less-severe mood episodes. It is important to note that no moodstabilizing medication should be discontinued without a discusssion with the physician who prescribed it, and the medication always should be tapered off under a physician’s supervision rather than being stopped all at once. Bipolar disorder tends to worsen if it is not treated. 8 Proper diagnosis and treatment help individuals with bipolar AORN Journal 213
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