Question

You are working in a clinic where a 24 year old female is being seen for suspected lithium (Eskalith) toxicity. She reports feeling nauseated, shaky, weak and has had episodes of diarrhea. She takes Lithium (Eskalith )600 mg po tid. She reports taking the medicine as prescribed.
Upon further discussion, she reports feeling “down” recently so she has been running extensively to try and lift her spirits. She asks you if her feelings of depression mean her bipolar disorder is out of control and she asks you “what exactly is bipolar disorder?”. Her serum lithium level is 1.9 mEq/L.
Explain how you will respond to her questions.
Develop a detailed teaching plan for this patient. Be sure to include details about bipolar disorder.
Provide all necessary information regarding Lithium (Eskalith)- including classification, action, side effects, nursing considerations/interventions.
What is a therapeutic serum level?

Answer 1

BIPOLAR DISORDER:

A bipolar disorder is also known as manic depressive illness. It is a disorder which causes unusual shift in mood,energy, activity level and ability to carry out day to day activities. These mood changes varies from extremely high called the manic episode to very low called depressive episode. The bipolar disorder is classified into four subgroups:

• Bipolar 1 disorder: If manic, the episode occures for a week and requires immediate hospitalization. If depressive, episode occurs for two weeks. Mixed features may also be present.
• Bipolar 2 disorder : Mainly have depressive and hypomanic episodes.
• Cyclothymic disorder: Have numerous periods of hpomania and numerous periods of depressive episode for about two years but not full blown manic episode.
• Other unspecified disorder: the symptoms do not match the manic or depressive episode.

Clinical features:

Manic episode: Agitated, irritated, talks lot of things at a time, more active than usual,Thought is disturbed, thinks lot of things at a time, activity levels are high, difficulty in sleeping, involve in risky activities.

Depressive episode: Feels very sad, hopeless, have decreased energy and activity levels, worried and can't enjoy anything,trouble in concentrating, sleep disturbances,forgetfulness, posses sucidial ideation.

Teaching plan:

In every case of a psychiatry, family participation is very important. The cooperation will help to deal with the manic and depressive episodes of the bipolar disorders. The patient and family should be aware how to identify the clinical pattern of the disease. Teaching paln is stated below:

Objective	Content	Teaching strategies	Time	Person involved	Resources	Evaluation
At the end of the teaching session, the group of audience will be able to: Know about bipolar disorder	A bipolar disorder is also known as manic depressive illness. It is a disorder which causes unusual shift in mood,energy, activity level and ability to carry out day to day activities. These mood changes varies from extremely high called the manic episode to very low called depressive episode. Clinical features: Manic episode: Agitated, irritated, talks lot of things at a time, more active than usual,Thought is disturbed, thinks lot of things at a time, activity levels are high, difficulty in sleeping, involve in risky activities. Depressive episode: Feels very sad, hopeless, have decreased energy and activity levels, worried and can't enjoy anything,trouble in concentrating, sleep disturbances,forgetfulness, posses sucidial ideation.	Lecture group discussion Demonstration	10 mins	Nurse Patient Patient family	Manpower visual aids
Show ways to manage bipolar disorder,adherence to treatment and how to avoid risk behaviour	1)Manage bipolar disorder: Ensure safety Watch drug responses Set limit to partcular behavior Use simple ways to communicate Foods high in calorie and protein Promote rest and sleep 2)Avoid risk behaviors like: Suicide, drug or alcohol abuse,violence 3)Contact the physician if: you are unable to manage bipolar disorder, eat less, unable to make it for next morning, feeling very low, feels dizzy or stomach upset, sleeps less or more than usual, and if you have concerns. 4)Adhere to the treatment and medications prescibed and contact the physician if medications seems to be uneffective. 5)If patient have forgetfulness then place reminders may be in your phone or text messages in order to take medications timely. 6) Follow up with the psychaitrist.	Explaination Modelling Demonstration	20 mins	Nurses Patients patient's family	Manpower Role play visual aids

LITHIUM:

Lithium is a significant psychiatric medication used in the treatment of bipolar disorder.

Drug classification: Mood stabilizers

Actions: After ingestion the lithium reaches to the central nervous system where it acts upon number of neurotransmitters causing decreased epinephrine and increased serotonin synthesis. Lithium is also believed to have neuroprotective properities by preventing apoptosis and increasing cell longitivity.

Side effects:

• Increased urination
• shakiness of hand
• increased thirst
• hypothyroidism
• diabetes insipidous
• lithium toxicity
• Diahhorea vomiting
• poor coordination
• ringing in ears

Nursing interventions:

• Assess the patient's mental status initially and periodically.
• Initate suicidal precautions if needed.
• Monitor intake and output and report any changes.
• Keep patient hydrated, encouarge adequate fluid intake.
• Monitor patients weight.
• Check renal and thyroid functions.
• Check patient's WBC, differential count and glucose level.
• Monitor lithium levels twice weekly during actue phase
• Watch for signs of lithium toxicity.

Drug range in blood: The therapeutic drug range of lithium in blood is 0.6 - 1.2 mmol/L. If the lithium level is below then it means the patient is not receiving adequate amount of drug and if more than this range then it indicates lithium toxicity.