DHS: SENIORS AND PEOPLE WITH DISABILITIES DIVISION Nurse to Nurse Oregon’s community-based care newsletter

Vol. 5 No. 2. 2008 Summer 2008

In this issue Bipolar Bipolar disorder ...... 1 disorder Bipolar disorder is a Nine strategies for brain fi tness ...... 4 category of mood disorders characterized by episodes of Megacolon and mania. Formerly referred to megarectum ...... 7 as manic-depression, bipolar disorder or Continuing education bipolar affective disorder includes bipolar for community-based I, bipolar II, cyclothymia and bipolar NOS. nurses ...... 9 According to the American Psychiatric Restraint review ...... 10 Association, bipolar disorder affects 1.2 percent of the general population. It can typically be well managed with Attention all nurses ...... 13 appropriate treatment. Home and community We need your feedback! .13 nurses can make a signifi cant contribution toward the success of such treatment.

Bipolar I Mania According to the DSM IV-R, one or more episodes of mania or mixed episode is required for a diagnosis of bipolar I disorder. Mania is characterized by an elevated, expansive or irritable mood over a distinct period of time. Individuals in a manic state often display increased energy and less need for sleep. They may be irritable and easily distracted.

Independent. Healthy. Safe. Bipolar disorder — continued

Some people become overconfi dent or Depression often leads to changes in an grandiose. If severe, individuals can develop individual’s eating or sleeping patterns. delusions or suffer from other forms of Many individuals report ongoing psychosis. Judgment and inhibition are restlessness. Others report a lack of energy often impaired. despite an increase in sleep. Some people experience suicidal ideation. If severe, a Individuals experiencing mania may engage person can become psychotic. in self-destructive behavior, such as going on shopping sprees Mixed affective with disregard episodes or a for fi nances. mixed state is an Others experience episode in which increased sex-drive an individual and may engage experiences both in risky sexual symptoms of mania behavior. Those and depression with psychosis, simultaneously. extreme anxiety An example of this or irritability would be someone may become who reports feeling combative. hopeless and sad yet displays To meet the DSM-IV-R criteria for mania, increased energy. an individual must exhibit symptoms of mania for at least one week, or with such severity to require hospitalization. Bipolar II Hypomania Depression Bipolar II disorder is characterized by There is no requirement for the presence hypomanic episodes and at least one major of depression for a diagnosis of bipolar depressive episode. I disorder. That said, many people with Bipolar I disorder do experience major Hypomania shares some characteristics depressive episodes. Symptoms of major with mania but to a lesser degree. depression include persistent feelings of Individuals experiencing hypomania also hopelessness and helplessness. Individuals experience fewer symptoms than those in a depressive phase of bipolar disorder in a full-blown manic state. People in often express feeling empty and apathetic. hypomanic states report an increase in Others report anxiety, anger, or guilt. energy and confi dence. The negative social and functional effects of mania are typically absent in hypomanic episodes. Hypomania

2 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Bipolar disorder — continued

should be monitored, however, as it can Common comorbid conditions for children become worse leading to full-blown mania. such as depression or ADHD, can be Another concern is the risk of a major misdiagnosed as bipolar disorder. Also, depressive episode. developmental factors, such as hormonal changes, should always be considered. Cyclothymia Such factors can produce signs that look like symptoms of bipolar disorder. Cyclothymia is characterized by both episodes of hypomania and periods of depression. For this diagnsosis, however, Treatment the depression is not characterized as The emphasis of treatment for these major in severity. This is a low-grade cycle disorders is typically on the management of moods which can impact functioning and prevention of acute episodes. but to a lesser extent than what might Lithium has been the best known and occur with Bipolar I and II disorders. An most commonly used mood stabilizing individual with cyclothymia may experience medications for years. The therapeutic some diffi culties with relationships or work, range for lithium is narrow, with adverse but would generally be able to maintain effects if exceeded. Lithium levels, social supports and employment despite therefore, require monitoring. High plasma experiencing symptoms. lithium levels can cause gastrointestinal problems and fatigue. Lithium toxicity can Etiology lead to cardiac arrhythmia, seizures and even coma. Long-term use of lithium can As with most major psychiatric disorders, lead to kidney changes or renal failure. For the cause of bipolar disorder is unknown. this reason, kidney functions should also be Current research, however, attributes the monitored. disorder to various potential factors. There is an established genetic factor to the Anticonvulsants, such as carbamazepine condition. There is also good evidence to are also used to stabilize moods. link environmental stressors to the disorder. Antipsychotics can be helpful in managing Most mental health practitioners agree agitation during acute episodes of mania. that there is likely a genetic predisposition Likewise, antidepressants are used to treat to the disorder that may be triggered by episodes of depression. Their use, however, external factors. has been debated, as some researchers have associated antidepressant use with The onset of bipolar disorder typically the onset of manic or mixed state episodes. occurs in adolescence or young adulthood. Children and young adolescents are Research indicates that specifi c factors increasingly being diagnosed with bipolar increase the likelihood of recurrent disorder. This has been somewhat symptoms. Decreased sleep, caffeine controversial, particularly for children. consumption, and other kinds of substance

3 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Bipolar disorder — continued

use have been linked to increased and you can help to protect your by more severe manic episodes. Other monitoring for risk, offering support, and substances, increased stress, and abrupt with your patient’s consent, communicating changes in medication may trigger episodes with other service providers. This is of both mania and depression. particularly true if your patient has a history of suicidal ideation or attempts. Considerations Some individuals have developed a crisis plan with their psychiatrist or other mental There is a high rate of substance abuse . As a nurse, you associated with these disorders. Substances should be informed of any plan for crisis are often used as a way to self-medicate that has been developed. If your patient or to quell the symptoms related to bipolar expresses suicidal thoughts or a plan to disorder. Unfortunately, many substances hurt herself, take it seriously. If necessary, can have adverse reactions when paired she should be assessed by a psychiatrist or with medications that your patient may a designated mental health professional for have been prescribed. Commonly used hospitalization. substances, such as alcohol, can also increase the severity of symptoms as well Individuals with bipolar disorder can live full as risk of dangerous or impulsive behaviors. and independent lives. As a nurse, you may As a nurse, you can educate your patient play an important role in supporting the about the risks of substance abuse. ongoing symptom management necessary to do so. This can entail ensuring good The risk of suicide for people diagnosed communication and collaboration between with bipolar disorder is also of concern. other service providers in your patient’s The American Psychiatric Association life. It may include providing ongoing reports that 10-15 percent of individuals education to both your patient and to with bipolar I disorders complete suicide. her family about symptoms, treatment, The suicide rate for people diagnosed with adverse side effects of medications, and bipolar is 10-20 percent greater than that their precautions. Monitoring symptoms of the general population. as well as changes in diet, sleep, and other Individuals are at the greatest risk for behaviors, will allow you to work with your suicide when fi rst emerging from a major patient to intervene prior to the onset of an depressive episode. During this time, your acute episode. patient may continue to express suicidal feelings and may have an increase in energy to act on such feelings. As a nurse,

4 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Nine strategies for brain fi tness by Roger Anunsen While everyone hopes that cures for Alzheimer’s disease and other dementia will be announced in the near future, it is now very clear that we can (and should) do much more than just worry and wait. Find a variety of challenges that you enjoy Roger Anunsen, neuroscience researcher and regularly engage your brain. numbers 8 and 9). from and host of the new Brain Wellness Series, Oxygen and fuel recommends that anyone concerned about food are carried by your blood and a memory decline (their own and/or their healthy brain MUST have regular and loved ones) consider some or all of the adequate supplies of these raw materials. following evidence-based suggestions: Learn what your brain and your body need to thrive and then do what you need to do 1. Exercise your mind: Without regular to maintain your personal balance. and adequate mental activity, brain cells deteriorate. With mental activity, brain Hydration: Get enough liquids because cells thrive and only then can memory be your brain MUST have enough liquids and dehydration can put your brain health at improved. Use your BrainTime. Find a variety of challenges that you enjoy and risk. regularly engage your brain. 4. Socialize with others: Recent studies 2. Get regular sleep: Memory problems found that regular, meaningful interaction cannot be successfully managed without with others adds something to the brain fi rst establishing the amount of sleep your that appears to build a barrier of protection brain (and body) needs.. and then doing against the symptoms of memory loss. all you can to maintain your regular sleep Tomorrow’s prescription for cognitive pattern. You should identify the source improvement just might be: Enjoy one of a sleep disturbance and then consider another’s company! some of the many recent advances in sleep 5. Take a deep breath: Oxygen is therapies. New studies on naps reveal the delivered to the brain as a fuel necessary brain health value of a 20 to 90 minute nap for good brain health, especially your and rejects the myth of a nap interrupting a hippocampus. Your three-pound brain good nights sleep. consumes a huge amount of your oxygen 3. Feed and hydrate your brain: Our intake and will thank you when you take brains receive nutrition from two sources: those deep breaths. That deep breath can oxygen (see number 5) and food (see also reduce your stress. (See number 7).

5 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 6. Add even a little more physical such as olive oil, walnuts, fl ax seed, tofu activity: Make a move toward a healthier and other soy products and certain fi sh brain. Moving any part of your body will, including salmon. Fish oil supplements in fact, increase, even if could help, but fresh is only slightly, the fl ow of best. blood needed to keep 9. Lower stress every your brain fresh. More day: Stress, especially blood fl ow generated long-term chronic from each extra physical stress, has been directly movement will cause linked to memory more blood fl ow into the decline. Purposefully brain, so…. interrupt stress several Just move it! times each day. Harvard 7. Eat antioxidants: recently urged 1-minute, Your mother was right: 2-minute and 3-minute Eat your fruits and stress therapies. Try vegetables especially the reducing stress for a Eat your fruits and vegetables. brightly colored ones that few seconds at a time are full of brain-healthy antioxidants. Think by learning how to take a mindful deep raspberries, blueberries, red beans, dried breath. Try doing and fi nishing one thing plums, strawberries, concord grape juice before you even think of doing the next and green tea. thing. Completely enjoy focusing on something or someone you love for a 8. Eat Omega 3 fats: Get a weekly supply moment or two….every day. of good brain fats, high in Omega-3 fatty acids. These are reported to be especially Roger Anunsen is the creator of MemAerobics important for myelination, the process that and host of the new Brain Wellness Series as well creates the myelin needed to “insulate” as a cognitive wellness program consultant. Mr. our brain’s neurons thus protecting its Anunsen was appointed as a voting delegate effi ciency and transmission speed. Our to the 2005 White House Conference on Aging and has presented at the national ASA/NCoA brains are 60 percent fat, so eat good fats conferences since 2006. For more information, call 503-636-7400.

6 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Megacolon and Megarectum Megacolon is a descriptive term for an enlarged and fl accid colon where feces accumulation no longer triggers peristalsis and bowel movements. Normally, feces in the colon is moved along the intestinal track by muscle contractions. However, Megarectum is not an uncommon a person with a megacolon lacks or condition in persons with developmental has inadequate muscle contractions to disabilities who can’t communicate the move intestinal contents through the need or recognize the need to use the toilet. gastrointestinal track. Overtime the colon Megarectum is a descriptive term for an dilates to accumulate large amounts of enlarged and fl accid rectal vault where stool and an impaction can occur. For a fecal matter no longer triggers muscle few individuals bowel care can become contractions and bowel evacuation. so unmanageable that a colonostomy or The normal function of the rectal vault ilieostomy is the only treatment. is to collect feces until the pressure The most common cause of fl accid of accumulating feces triggers muscle colon is Hirshsprung’s disease. In this contractions and a bowel movement. disease there is a lack of or disruption If for some reason a bowel movement of certain nerve fi bers in the colon. does not occur, more feces will enter the Hirshsprung’s is a congenital disease vault, water will be reabsorbed making and is usually recognized within the fi rst the feces hard and diffi cult to force three months of life, depending on the through the anal sphincter. If this process severity. Occasionally an adult will be occurs frequently, the rectal vault will lose diagnosed with a variation of the disease. muscle tone, become fl accid and enlarge. Hirshsprung’s disease occurs in about Once the rectal vault expands, it can one in 5000 births and is four times more hold large amounts of stool and regular common in males than females. Treatment bowel movements become impossible. is to surgically remove the diseased, Megarectum can lead to megacolon and be nonfunctioning segment of the bowel, life threatening if an impaction, perforation anastomose the normal two portions to and sepsis occurs. The goal in managing restore bowel function. Most surgical these two conditions is to encourage outcomes are successful but if there is a as normal bowel elimination pattern as lingering problem with feces retention, possible. bacteria can overgrow causing enterocolitis and sepsis.

7 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Megacolon and Megarectum — continued

Nurses may care for individuals with Megarectum is not an uncommon megarectum and megacolon due condition in persons with developmental to congenital conditions, such as disabilities who can’t communicate the myelomeningocele or spina bifi da. In both need or recognize the need to use the of these conditions there is an impairment toilet. Other factors include hypotonia, of the sensation of rectal fi lling and rectal lack of skeletal muscle coordination with fullness. Individuals cannot recognize skeletal deformities, prolonged immobility when they need to need to have a bowel and poor toileting habits. Also, poor movement. Careful bowel management is chewing and swallowing skills frequently an essential intervention starting in infancy. lead families and caregivers to offer soft Many other children with developmental foods low in fi ber. Chronic dehydration disabilities and compounds neurological the problem. In impairment never addition, many attain voluntary individuals take control of their medications bowels. They that slow GI may suffer from motility, such as obstipation which anticholinergics usually goes and opiates. unrecognized One of these because contributing they cannot conditions may communicate not be diffi cult their needs to overcome but Many other children with developmental disabilities and of discomfort neurological impairment never attain voluntary control some individuals and other life of their bowels. have all of these threatening factors from birth medical conditions which makes their may take higher priority. In the past it was chances of developing megacolon/rectum not uncommon for parents and caregivers very high. to start giving enemas and suppositories during infancy thinking that this was the Management of constipation is important only way to manage constipation. for all individuals but for persons with megacolon/rectum it is essential that it be Today, developmental professional managed diligently. Bowel care requires encourage establishing a bowel routine keeping a bowel diary, having a protocol, that is more normal even if is does involve daily dietary fi ber, good hydration, stool medication intervention. softeners, laxatives and occasional use of enemas/suppositories. Once a bowel

8 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Megacolon and Megarectum — continued care pattern has been established (fi ber, is unrealistic. Even with an established hydration, stool softeners, laxatives, pattern of evacuation, any change in etc.) nurses should encourage caregivers routine may cause an impaction and need to follow the regimen carefully as for hospitalization. reestablishing a normal pattern of evacuation without these interventions

Continuing education for community-based nurses The Offi ce of Licensing and Quality SPD, 500 Summer Street NE E-13, Salem, of Care is pleased to announce its fi rst OR 97301. Please be sure to write clearly. self-study continuing education course for Upon completion of the course you can community-based nurses. The course, “Self apply for 2.0 contact hours of nursing directed learning series: Registered Nurse continuing education (CE). The cost of Delegation in Oregon,” is available at no CE hours is $20. Instructions to apply for charge for down load at the DHS Web CE hours are contained in the self-study site www.oregon.gov/DHS/spd/provtools/ course. We thank you for taking the time You can also e-mail your request nursing/. ro complete this RN self-study course for the course to [email protected]. that demonstrates your commitment to If you do not have a computer and would professional nursing excellence within like the course mailed to you, please send Oregon’s long-term care system. your written request to Bernadette Murphy,

9 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Restraint use review Providing safe care for residents with physical and cognitive impairments is a high priority for health care providers. For ten plus years, there has been increased concern surrounding the use of restraints to prevent falls, control agitated residents and prevent wandering. Studies have shown that restraints are more likely to Physical restraint cause harm then prevent it. Bed rails, A physical intervention (24 Hour vest and waist restraints have caused Residential Services OAR) or restraint (Adult various injuries including death. According Foster Homes OAR) is inappropriate or to a report by the U.S, Food and Drug unauthorized if: Administration (FDA), there are an estimated 100 or more deaths that occur • It is applied without a functional annually in care setting in the United States assessment of the behavior justifying the as a result of restraint use. Reducing the need for the restraint; or use of restraints, and ensuring that any • It is used for behaviors not addressed in restraint in use is necessary has become a a behavior support plan ;or national goal. • It uses procedures outside the A restraint is any method, device or parameters described in a behavior chemical substance which restricts the support plan; or freedom of movement or normal access to the body. • It does not use procedures consistent with the Oregon Intervention System It is important to note that each (OIS). care facility is bound by an Oregon Administrative Rule (OAR) rule that is A restraint or physical intervention is not established for their different care setting. appropriate if: The following language is taken from both the 24 Hour Residential Services • There is not a physician’s order when for Children and Adults OAR and the the restraint is used as a health related Adult Foster Homes for Individuals with procedure: or Developmental Disabilities OAR. • It is applied without ISP team approval as identifi ed on the ISP and is described in a formal written behavior plan.

10 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Restraints — continued

It is not abuse if it is used as an emergency Chemical restraints measure, if absolutely necessary to protect are any medication the individual or others from immediate (psychotropic or injury and only used for the least amount otherwise) which of time necessary. is given to alter or control one’s Mechanical restraints include, but are not behavior. limited to, posey vest, soft ties or vests, Here are some things to keep in mind straight jackets, wheelchair seatbelt, locked when reviewing restraint use: chairs, safety bars, lap trays, Lap Buddy, hand mitts, helmets, restrictive clothing, 1. Prior to the use of a restraint there Geri chairs or any specialized chair that must be an assessment that includes prevents rising, body positioning which consideration of all other alternatives. limits free access in a home or community. 2. The least restrictive restraint must be It is important to take into consideration used and as infrequently as possible. the intent of the use of a device. For 3. Check to determine what program example the use of a seatbelt to protect an rule(s) require a physicians order and/ individual from falling out of a wheelchair or consent from the resident or legal is a safety device, however, if the intent of representative. the seatbelt is to stop a client from getting up to walk it becomes a restraint. Another 4. Ensure that all caregivers have been example would be brakes on a wheelchair. instructed on the correct use and If the intent is to stop the individual from precaution related to the use of the harm it is a safety device however, if the restraint. intent is to not allow the individual to leave 5. Ensure that any restraint use is the area it is a restraint. reassessed on a regular basis to determine Chemical restraints are any medication whether or not their continued use is (psychotropic or otherwise) which is given necessary. to alter or control one’s behavior. And 6. Restraints are never to be used for example of a chemical restraint could be discipline and/or for the convenience of the Tylenol given for agitation vs. Tylenol given staff. for pain which would not be considered a chemical restraint. Please refer to each setting specifi c rules regarding restraints for further guidance. As nurses, who provide oversight, we have the perfect opportunity to ensure that if As nurses out in the community, you have a restraint of any kind is being used, it is the ability to ensure that any use of a being used appropriately and with the restraint is necessary and in the resident’s proper intent. best interest.

11 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 * Attention fi rst time readers* Date:______Nurse to Nurse: Oregon’s Community-Based Care Nursing Newsletter To subscribe to this newsletter, please complete and return the following subscription survey.

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12 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008 Attention all nurses Seniors and People with Disabilities will be holding a one day conference for nurses working in the SPD contract nurse program and others who work in community based care settings. These conferences will be one day and will include such topics as: delegation; running a small business and documentation. Registration is open to everyone but contract nurses will get fi rst preference. A registration fl yer will be sent out prior to each conference. To request a fl yer, if you did not receive one, please email Bernadette Murphy at Bernadette.J.Murphy@state. or.us. Locations: July 8th Redmond — Deschutes Fair July 15th Wilsonville — Clackamas & Expo Community College July 10th Baker City — Geiser Grand Hotel July 17th Roseburg — Douglas County Fairgrounds

We need your feedback! A survey was sent out to SPD Contract RNs to determine what health related training topics they were interested in learning more about. The survey also inquired as to what additional training they felt was needed in order to do their job better. For those that have turned in their surveys, thank you!! For those that haven’t, please mail them in by June 10th. If you didn’t receive a survey, or need a new one, please contact Bernadette Murphy at [email protected].

Nurse-to-Nurse is published by Seniors and People with Disabilities, Offi ce of Licensing and Quality of Care, Oregon Department of Human Services, 500 Summer Street NE, E-13, Salem, OR 97301-1074 Editorial Team: Deborah Cateora, Health Service Unit Manager and Bernadette Murphy, Health Service Unit. Design and layout by Becki-Trachsel- Hesedahl, Web and Publication Design Team, DHS Offi ce of Communications.

To contact the editorial team with a suggestion call 1-800-232-3020, ask for Bernadette Murphy. 13 Oregon Department of Human Services — Seniors and People with Disabilities Vol. 5 No. 2 2008