360 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS
contacted if the client has diarrhea, fever, flu, or any
condition that leads to dehydration.
Thyroid function tests usually are ordered as a
baseline and every 6 months during treatment with
lithium. In 6 to 18 months, one-third of clients taking
lithium have an increased level of thyroid-stimulating
hormone, which can cause anxiety, labile emotions,
and sleeping difficulty. Decreased levels are impli-
cated in fatigue and depression.
Because most lithium is excreted in the urine,
baseline and periodic assessments of renal status are
necessary to assess renal function. The reduced renal
function in older adults necessitates lower doses.
Lithium is contraindicated in people with compro-
mised renal function or urinary retention and those
taking low-salt diets or diuretics. Lithium also is con-
traindicated in people with brain or cardiovascular
damage.
PROVIDING CLIENT AND FAMILY TEACHING
Educating clients about the dangers of risky behav-
ior is necessary; however, clients with acute mania
largely fail to heed such teaching because they have
little patience or capacity to listen, understand, and
see the relevance of this information. Clients with
euphoria may not see why the behavior is a problem
because they believe they can do anything without
impunity. As they begin to cycle toward normalcy,
however, risky behavior lessens and clients become
ready and able for teaching.
Manic clients start many tasks, create many
goals, and try to carry them out all at once. The result
is that they cannot complete any. They move readily
between these goals while sometimes obsessing about
the importance of one over another, but the goals can
quickly change. Clients may invest in a business in
which they have no knowledge or experience, go on
spending sprees, impulsively travel, speed, make new
“best friends,” and take the center of attention in any
group. They are egocentric and have little concern
for others except as listeners, sexual partners, or the
means to achieve one of their poorly conceived goals.
Education about the cause of bipolar disorder,
medication management, ways to deal with behav-
iors, and potential problems that manic people can
encounter is important for family members. Educa-
tion reduces the guilt, blame, and shame that accom-
pany mental illness, increases client safety, enlarges
the support system for clients and the family mem-
bers, and promotes compliance. Education takes the
“mystery” out of treatment for mental illness by pro-
viding a proactive view: this is what we know, this is
what can be done, and this is what you can do to help.
Family members often say they know clients have
stopped taking their medication when, for example,
clients become more argumentative, talk about buying
expensive items that they cannot afford, hotly deny
anything is wrong, or demonstrate any other signs of
escalating mania. People sometimes need permission
to act on their observations, so a family education ses-
sion is an appropriate place to give this permission and
to set up interventions for various behaviors.
Clients should learn to adhere to the established
dosage of lithium and not to omit doses or change
dosage intervals; unprescribed dosage alterationsTable 15-8
SYMPTOMS ANDINTERVENTIONS OFLITHIUMTOXICITY
Serum Lithium Level Symptoms of Lithium Toxicity Interventions1.5–2 mEq/L2–3 mEq/L3.0 and aboveNausea and vomiting, diarrhea, reduced
coordination, drowsiness, slurred
speech, muscle weaknessAtaxia, agitation, blurred vision, tinnitus,
giddiness, choreoathetoid movements,
confusion, muscle fasciculation, hyper-
reflexia, hypertonic muscles, myoclonic
twitches, pruritus, maculopapular rash,
movement of limbs, slurred speech,
large output of dilute urine, incontinence
of bladder of bowel, vertigo
Cardiac arrhythmia, hypotension, pe-
ripheral vascular collapse, focal or
generalized seizures, reduced levels of
consciousness from stupor to coma,
myoclonic jerks of muscle groups, and
spasticity of musclesWithhold next dose; call physician. Serum
lithium levels are ordered and doses of
lithium are usually suspended for a few
days or the dose is reduced.
Withhold future doses, call physician, stat
serum lithium level. Gastric lavage may
be used to remove oral lithium; IV con-
taining saline and electrolytes used to
ensure fluid and electrolyte function
and maintain renal function.All of preceding interventions plus lithium
ion excretion is augmented with use of
aminophylline, mannitol, or urea. He-
modialysis may also be used to remove
lithium from the body. Respiratory, cir-
culatory, thyroid, and immune systems
are monitored and assisted as needed.