lithium Nursing Considerations & Management

Acute mania: 600 mg PO tid or 900 mg slow-release form PO bid to produce effective serum levels between 1 and 1.5 mEq/L. Serum levels should be determined twice per wk in samples drawn immediately before a dose (at least 8–12 hr after previous dose).
Long-term use: 300 mg PO tid–qid to produce a serum level of 0.6–1.2 mEq/L. Serum levels should be determined at least every 2 mo in samples drawn immediately before a dose (at least 8–12 hr after previous dose).
Conversion from conventional to slow-release dosage forms: Give the same total daily dose divided into two or three doses.

PEDIATRIC PATIENTS

Safety and efficacy for children < 12 yr not established.

GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

Reduced dosage may be necessary. Elderly patients often respond to reduced dosage and may exhibit signs of toxicity at serum levels tolerated by other patients. Plasma half-life is prolonged in renal impairment.

Therapeutic actions

Lithium’s exact mechanism is unclear but it alters intraneuronal metabolism of catecholamines and sodium transport in neurons and muscle cells.

Indications

Treatment of manic episodes of manic-depressive illness; maintenance therapy to prevent or diminish frequency and intensity of subsequent manic episodes
Unlabeled use: Improvement of neutrophil counts in patients with cancer chemotherapy–induced neutropenia and in children with chronic neutropenia and HIV patients on zidovudine therapy (doses of 300–1,000 mg/day, serum levels of 0.5 and 1 mEq/L); prophylaxis of cluster headache and cyclic migraine headache, treatment of SIADH, hypothyroidism (doses of 600–900 mg/day)

Adverse effects

Exacerbation of psoriasis, acne, rash; nausea, diarrhoea, vertigo, muscle weakness, dazed feeling; loss of concentration; tremors; hypothyroidism; wt gain, oedema; cardiac arrhythmias; exophthalmos; restlessness; electrolyte disturbances.
Potentially Fatal: Severe neurotoxicity, leucopenia.

Contraindications

Severe renal and cardiac disease; severe dehydration, sodium depletion, debilitation.

Nursing considerations

Assessment

History: Hypersensitivity to tartrazine; significant renal or CV disease; severe debilitation, dehydration; sodium depletion, patients on diuretics; protracted sweating, diarrhea; suicidal or impulsive patients; infection with fever; pregnancy; lactation
Physical: Weight and T; skin color, lesions; orientation, affect, reflexes; ophthalmic examination; P, BP, R, adventitious sounds; bowel sounds, normal output; normal fluid intake, normal output, voiding pattern; thyroid, renal glomerular and tubular function tests, urinalysis, CBC and differential, baseline ECG

Interventions

Give with caution and daily monitoring of serum lithium levels to patients with renal or CV disease, debilitation, or dehydration or life-threatening psychiatric disorders.
Give drug with food or milk or after meals.
BLACK BOX WARNING: Monitor clinical status closely, especially during initial stages of therapy; monitor for therapeutic serum levels of 0.6–1.2 mEq/L; toxicity is closely related to serum levels.
Individuals vary in their reponse to this drug; some patients may exhibit toxic signs at serum lithium levels considered within the therapeutic range.
Advise patient that this drug may cause serious fetal harm and cannot be used during pregnancy; urge use of barrier contraceptives.
Decrease dosage after the acute manic episode is controlled; lithium tolerance is greater during the acute manic phase and decreases when manic symptoms subside.
WARNING: Ensure that patient maintains adequate intake of salt and adequate intake of fluid (2,500–3,000 mL/day).

Teaching points

Take this drug exactly as prescribed, after meals or with food or milk. Swallow extended- or controlled-release tablets whole; do not chew or crush.
Eat a normal diet with normal salt intake; maintain adequate fluid intake (at least 2.5 quarts/day).
Arrange for frequent checkups, including blood tests. Keep all appointments for checkups to get the most benefits with the least toxicity.
Use contraception to avoid pregnancy. If you wish to become pregnant or believe that you have become pregnant, consult your health care provider.
Discontinue drug, and notify your health care provider if toxicity occurs—diarrhea, vomiting, ataxia, tremor, drowsiness, lack of coordination or muscular weakness.
You may experience these side effects: Drowsiness, dizziness (avoid driving or performing tasks that require alertness); GI upset (eat frequent small meals); mild thirst, greater than usual urine volume, fine hand tremor (may persist throughout therapy; notify your health care provider if severe).
Report diarrhea or fever.