Please enable JavaScript.

Coggle requires JavaScript to display documents.

Bipolar I Disorder - Coggle Diagram

- - - - Patient Teaching:
        Instruct patient to take oxcarbazepine in equally spaced doses, as directed. Take missed doses as soon as possible but not just before next dose; do not double dose. Notify health care professional if more than 1 dose is missed.
        Medication should be gradually discontinued to prevent seizures. Instruct patient to read the Medication Guide before starting and with each Rx refill.
        May cause dizziness, drowsiness, or CNS changes. Advise patients to avoid driving or other activities requiring alertness. Do not resume driving until physician gives clearance based on control of seizure disorder.
        Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
        Advise patient not to take alcohol or other CNS depressants concurrently with this medication.
        Advise patient and family to notify health care professional if thoughts about suicide or dying, attempts to commit suicide; new or worse depression; new or worse anxiety; feeling very agitated or restless; panic attacks; trouble sleeping; new or worse irritability; acting aggressive; being angry or violent; acting on dangerous impulses; an extreme increase in activity and talking, other unusual changes in behavior or mood occur.
        Instruct patient to notify health care professional of medication regimen before treatment or surgery.
        Advise patients to carry identification describing disease and medication regimen at all times.
    - - Dose Availability: Extended-release tablets, Oral suspension, Tablets
        (Immediate-release tablets and oral suspension can be interchanged at equal doses.)
        Oral (Adults):
        Adjunctive therapy (immediate-release)—300 mg twice daily, may ↑ by up to 600 mg/day at weekly intervals up to 1200 mg/day (up to 2400 mg/day may be needed);
        Conversion to monotherapy (immediate-release)—300 mg twice daily; may ↑ by 600 mg/day at weekly intervals, while other antiepileptic drugs are tapered over 3–6 wk; a dose of oxcarbazepine should be ↑ up to 2400 mg/day throughout 2–4 wk;
        Initiation of monotherapy (immediate-release)—300 mg twice daily, ↑ by 300 mg/day every 3rd day, up to 1200 mg/day. The maximum maintenance dose should be achieved over 2–4 wk;
        Adjunctive therapy or monotherapy (extended-release)—600 mg once daily for 1 wk; may ↑ by 600 mg/day at weekly intervals up to 1200–2400 mg once daily; Concurrent use of strong CYP3A4 inducer (carbamazepine, phenobarbital, phenytoin, rifampin) (extended-release)—consider initiating therapy with 900 mg once daily
        .
        Oral (Children 2–16 yr): Adjunctive therapy (immediate release)—4–5 mg/kg twice daily (up to 600 mg/day), ↑ over 2 wk to achieve 900 mg/day in patients 20–29 kg, 1200 mg/day in patients 29.1–39 kg and 1800 mg/day in patients >39 kg (range 6–51 mg/kg/day). In patients <20 kg, initial dose of 16–20 mg/kg/day may be used not to exceed 60 mg/kg/day.
        Conversion to monotherapy (immediate-release)—8–10 mg/kg/day given twice daily; may ↑ by 10 mg/kg/day at weekly intervals, whereas other antiepileptic drugs are tapered over 3–6 wk; a dose of oxcarbazepine should be ↑ up to 600–900 mg/day in patients ≤20 kg, 900–1200 mg/day in patients 25–30 kg, 900–1500 mg/day in patients 35–40 kg. 1200–1500 mg/day in patients 45 kg, 1200–1800 mg/day in patients 50–55 kg, 1200–2100 mg/day in patients 60–65 kg, and 1500–2100 mg/day in patients 70 kg. The maximum maintenance dose should be achieved over 2–4 wk.
        Oral (Children 6–17 yr): Adjunctive therapy or monotherapy (extended-release)—8–10 mg/kg once daily (up to 600 mg/day) for 1 wk; may ↑ by 8–10 mg/kg/day at weekly intervals over 2–3 wk to achieve 900 mg/day in patients 20–29 kg, 1200 mg/day in patients 29.1–39 kg and 1800 mg/day in patients >39 kg; Concurrent use of strong CYP3A4 inducer (carbamazepine, phenobarbital, phenytoin, rifampin) (extended–release)—consider initiating therapy with 12–15 mg/kg (max dose = 900 mg) once daily.
        
        Renal Impairment Oral (Adults): CCr<30 mL/min (immediate and extended-release). Initiate therapy at 300 mg/day and ↑ slowly to achieve the desired response.
  - - - Patient Teaching
        Consult health care professionals before stopping quetiapine; it should be discontinued gradually. Stopping abruptly may cause insomnia, nausea, and vomiting.
        It should not be given to elderly patients with dementia-related psychosis; it may ↑ risk of death.
        Possibility of extrapyramidal symptoms. Instruct patient to report symptoms immediately to a health care professional.
        Change positions slowly to minimize orthostatic hypotension. Protect from falls.
        May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness.
        Avoid extremes in temperature; this drug impairs body temperature regulation.
        Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult with a health care professional before taking other drugs and alcohol, especially other CNS depressants.
        Advise patient and family to notify health care professional if thoughts about suicide or dying, attempts to commit suicide; new or worse depression; new or worse anxiety; feeling very agitated or restless; panic attacks; trouble sleeping; new or worse irritability; acting aggressively; being angry or violent; acting on dangerous impulses; an extreme increase in activity and talking; other unusual changes in behavior or mood occur.
        Refer a patient for nutritional, weight, or medical management of dyslipidemia.
        Instruct patient to notify health care professional promptly if sore throat, fever, unusual bleeding or bruising, constipation, or rash.
        Emphasize the importance of routine follow-up exams to monitor side effects and continued participation in psychotherapy as indicated to improve coping skills.
    - - Interactions
        Drug-Drug:
        Concurrent use of macrolide antibiotics (erythromycin, clarithromycin), dofetilide, sotalol, quinidine, disopyramide, procainamide, thioridazine, chlorpromazine, droperidol, gemifloxacin, moxifloxacin, mefloquine, pentamidine, arsenic trioxide, citalopram, escitalopram, tacrolimus, and ziprasidone ↑ the risk of serious ventricular arrhythmias and should be avoided.
        ↑ CNS depression may occur with alcohol, antihistamines, opioid analgesics, and sedative/hypnotics.
        ↑ risk of hypotension with acute ingestion of alcohol or antihypertensives.
        Phenytoin and thioridazine ↑ clearance and ↓ effectiveness of quetiapine (dose change may be necessary); similar effects may occur with carbamazepine, barbiturates, rifampin, or corticosteroids.
        Effects may be ↑ by ketoconazole, itraconazole, fluconazole, protease inhibitors, or erythromycin, as well as by other agents that inhibit the cytochrome P450 CYP3A4 enzyme.
        Concurrent use of anticholinergic medications may ↑ risk of anticholinergic adverse reactions.
        
        Contraindications/Precautions
        Contraindicated in:
        Concurrent use of agents that prolong the QT interval; ↑ risk of serious arrhythmias
        History of arrhythmias, including bradycardia; Hypokalemia or hypomagnesemia (↑ risk of serious arrhythmias);
        Congenital long QT syndrome (↑ risk of serious arrhythmias).
        
        Use Cautiously in:
        Cardiovascular disease, cerebrovascular disease, dehydration or hypovolemia (↑ risk of hypotension)
        History of seizures or Alzheimer’s dementia
        Diabetes (may ↑ risk of hyperglycemia)
        Patients at risk for aspiration pneumonia or falls
        Hepatic impairment (dose ↓ may be necessary)
        Hypothyroidism (may be exacerbated)
        History of suicide attempt
        Low white blood cell count or history of drug-induced leukopenia/neutropenia (↑ risk of leukopenia/neutropenia)
        Urinary retention, prostatic hypertrophy, constipation, or ↑ intraocular pressure
        Obstetric: Neonates at ↑ risk for extrapyramidal symptoms and withdrawal after delivery when exposed during the 3rd trimester; use only if potential maternal benefit justifies potential fetal risk
        Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant
        Pediatric: May ↑ risk of suicide attempt/ideation especially during early treatment or dose adjustment; risk may be greater in children or adolescents
        Geriatric: Older adults may require ↓ doses; ↑ risk of mortality and stroke in older adults treated for dementia-related psychosis.
  - - - Side Effects
        CV: bradycardia, hf, pulmonary edema.
        Derm: stevens-johnson syndrome, toxic epidermal necrolysis, itching, rashes, urticaria.
        EENT: blurred vision, dry eyes, intraoperative floppy iris syndrome, nasal stuffiness.
        Endo: hyperglycemia, hypoglycemia.
        GI: diarrhea, constipation, nausea.
        GU: erectile dysfunction, ↓ libido.
        MS: arthralgia, back pain, muscle cramps.
        Neuro: paresthesia, dizziness, fatigue, weakness, anxiety, depression, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares.
        Resp: bronchospasm, wheezing.
        Misc: hypersensitivity reactions (including anaphylaxis and angioedema), drug-induced lupus syndrome.
      - **Interactions
        Drug-Drug:**
        General anesthetics, IV phenytoin, diltiazem, and verapamil may cause ↑ myocardial depression.
        ↑ risk of bradycardia with digoxin.
        Amiodarone or fluconazolemay ↑ levels.
        ↑ hypotension may occur with other antihypertensives, acute ingestion of alcohol, or nitrates.
        Concurrent use with clonidine↑ hypotension and bradycardia.
        May ↑ withdrawal phenomenon from clonidine(discontinue carvedilol first).
        Concurrent administration of thyroid preparations may ↓ effectiveness.
        May alter the effectiveness of insulins or oral hypoglycemic agents(dose adjustments may be necessary).
        May ↓ effectiveness of theophylline.
        May ↓ beneficial beta1-cardiovascular effects of dopamine or dobutamine.
        Use cautiously within 14 days of MAO inhibitor therapy (may result in hypotension/bradycardia).
        Cimetidine may ↑ toxicity from carvedilol.
        Concurrent NSAIDs may ↓ antihypertensive action.
        Effectiveness may ↓ by rifampin. May ↑ serum digoxinlevels. May ↑ blood levels of cyclosporine(monitor blood levels)
        Contraindications/Precautions
        Contraindicated in:
        History of severe hypersensitivity reaction (Stevens-Johnson syndrome, angioedema, anaphylaxis);
        Pulmonary edema; Cardiogenic shock; Bradycardia, heart block, or sick sinus syndrome. Decompensated HF requiring IV inotropic agents (wean before starting carvedilol). Severe hepatic impairment; Asthma or other bronchospastic disorders.
        Use Cautiously in:
        HF (condition may deteriorate during initial therapy)
        Diabetes mellitus (may mask signs of hypoglycemia)
        Thyrotoxicosis (may mask symptoms); Peripheral vascular disease; History of severe allergic reactions (intensity of reactions may ↑); Patients undergoing cataract surgery (↑ risk of intraoperative floppy iris syndrome)
        Obstetrics: Crosses placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression
        Lactation: Use while breastfeeding only if the potential maternal benefit justifies the potential risk to the infant
        Pediatric: Safety and effectiveness not established; Geriatric: ↑ sensitivity to beta-blockers; initial dose ↓ recommended.
    - - Nurse Assessment:
        Oral: Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify health care professional. Administer with food to minimize orthostatic hypotension., Administer extended-release capsules in the morning
        Monitor BP and pulse frequently during the dose adjustment period and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position. If heart rate decreases below 55 beats/min, decrease dose
        .
        Monitor intake and output ratios and daily weight. Assess the patient routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, jugular venous distention). Patients may experience a worsening of symptoms during the initiation of therapy for HF.
        
        Hypertension: Check frequency of refills to determine adherence
        
        Lab Test Considerations:
        May cause ↑ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
        May cause ↑ ANA titers.
        May cause ↑ blood glucose levels.
        Toxicity and Overdose: Monitor patients receiving beta-blockers for signs of overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails, or palms, seizures). Notify health care professionals immediately if these signs occur.
      - Patient Teaching:
        Swallow whole; do not crush or chew. Extended-release capsules may be opened and sprinkled on cold applesauce and taken immediately; do not store the mixture.
        Take medication as directed, at the same time each day, even if you are feeling well. Do not skip or double up on missed doses. Take missed doses as soon as possible, up to 4 hr before the next dose.
        
        Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia. Discontinue carvedilol slowly over 1–2 wk. Advise patient to read Patient Information before starting therapy and with each Rx refill in case of changes.
        Teach patient and family how to check pulse and BP.hold dose and contact health care professional if the pulse is <50 bpm or BP changes significantly
        May cause drowsiness or dizziness. Caution patients to avoid driving or other activities that require alertness
        Change positions slowly to minimize orthostatic hypotension.
        May increase sensitivity to cold
        Advise patients with diabetes to monitor blood glucose closely, especially if weakness, malaise, irritability, or fatigue occurs. Medication may mask some signs of hypoglycemia.
        Advise patient to notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occur.
        Obstetrics: If carvedilol is taken during the third trimester, monitor the newborn for symptoms of hypotension, bradycardia, hypoglycemia, and respiratory depression and manage accordingly
        Reinforce the need to continue additional therapies for hypertension (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation)
- - - - Nursing Interventions:
        Develop a therapeutic relationship with the patient
        Assess the patient's limitations to performing self-care by asking open-ended questions.
        Observe the patient's cognitive and functional ability to perform self-care activities
        Ensure self-care goals that are set in place for the patient to perform are realistic and attainable in their current state
        Give the patient gentle reminders, re-direct, and provide step-by-step instructions to complete self-care activities if the patient seems forgetful or distracted.
        
        Provide sufficient/realistic amount of time for the patient to perform self-care activities without interrupting or rushing
        Give praise and encouragement when the patient performs self-care activities, even when the patient is only partially able to complete activities.
        
        Evaluation: The patient performed three self-care activities: brushing teeth, hair and getting dressed after the first 4 hours of being awake.
    - - Nursing Interventions:
        Develop a therapeutic relationship with the patient
        Provide high caloric and fiber-rich foods, patients experiencing severe depression episodes and altered cognition have insufficient nutritional intake due to a lack of desire or forgetfulness to eat and drink
        Talk with the patient regarding the types of foods they like to eat.
        Encourage the patient to increase fluid and food intake.
        Emphasize the importance of eating meals to maintain physical health
        If possible, assess the patient's ability to obtain/access and the types of food in the group home that patient lives in
        Assess the patient's thoughts and feelings toward eating
        Monitor patient's intake and output
        Assess for signs of malnutrition
        Review laboratory values periodically if malnutrition is suspected: Serum albumin
        Transferrin
        RBC
        WBC
        Serum electrolyte values
        
        Evaluation: The patient expressed a verbal understanding of the importance of eating after 12 hours of nursing interventions.
        The patient ate three meals in the dining room during my 12- hour shift.
  - - - Nursing Interventions:
        Develop a therapeutic relationship with the patient
        Maintain low levels of stimuli in the patient's room (lights, noises, etc.)
        Ensure all personal items that can be potentially harmful (shoelaces, scarves, belts, etc.) are removed from the patient's body and room to ensure the patient's safety and others.
        Assess the patient frequently for any alterations in behavior, mood, disturbed thoughts, anxiety, paranoia, etc
        If the patient is overly stimulated, have them go to their room to avoid any possible outbursts or incidences from overstimulation.
        Have the patient sit by the nurses' station if they display unsafe behavior towards themselves or others and remind the patient of the unit rules.
        
        Continually assess whether the potential for self-harm or the desire to harm others is present. Assess for the presence of suicidal or homicidal thoughts. If so, evaluate whether the patient has a plan to carry out their ideas. If so, notify the provider immediately and take necessary precautions to keep the patient and others on the unit safe.
        Provide patient with adequate rest periods throughout the day to avoid overstimulation and exhaustion
        Provide patient with adequate nutrition and hydration
        Ensure the patient is adhering to the medication regimen to prevent worsening symptoms.
        
        Evaluation: Patient remained free from injury during my 12-hour shift.
    - - Nursing Interventions:
        Develop a therapeutic relationship with the patient
        Emphasize the importance of unit rules to keep the patient and others safe using short and concise explanations
        Inform patients of unit rules daily to increase remembrance and adherence-be consistent with expectations
        Give praise when patients make good decisions and keep track of good behavior (points & reward system)
        Encourage patients regarding their progress and growth while at the facility.
        Assess clients routinely for any changes in behavior and moods to possibly avoid negative outbursts and escalated situations
        
        Evaluation: Patient expressed verbal understanding of the unit rules during the first 2 hours of being on the unit.