Lithium ward bundle

Indications

• Treatment & prophylaxis of mania & bipolar disorder
• Treatment & prophylaxis of recurrent depression
• Treatment & prophylaxis of aggressive or self-harming behaviour

Prescribing

• Brands are not interchangeable
• Write the brand and approved name on the prescription sheet i.e. PRIADEL (Lithium carbonate)

Monitoring  lithium levels (see Lithium Standards)

• On admission to hospital
• 5 - 7 days after a dose change
• If patient becomes physically unwell
• Take level 12 hours after last dose
• Target range 0.4 - 1.0 mmol/L
• Immediately if toxicity suspected

On-going monitoring

• Lithium levels every 3 months once treatment established
• Renal and thyroid function every 6 months
• Calcium annually
• ECG annually if clinically indicated

Causes of toxicity

• Dehydration
• Deterioration of kidney function (Renal drug database)
• Infection
• Interacting medicines (Stockley's Drug Interactions)

Signs of toxicity

• Vomiting/diarrhoea
• Loss of appetite
• Confusion, slurred speech, drowsiness, sluggishness
• Severe tremor or twitching
• Muscle weakness
• Blurred vision, ringing in the ear
• Dizziness/loss of balance, clumsiness

All patients on lithium will have safe use of the drug identified as a need in their care plan. The following elements should be considered

Staff education

• All staff should be familiar with the key facts

Preventing & managing toxicity

• Staff should be vigilant for the signs and symptoms of toxicity
• Staff should be aware of the causes of toxicity
• Consider relevant clinical factors before administering a dose (see later)

Routine monitoring

• The care plan should contain details of the monitoring schedule
• The ward should have a system for reporting levels to the MDT

Communication of information at transition points e.g. discharge

Patient and carer education

Consider the pertinent elements of the checklist at each MDT meeting

Nurses should consider the following factors before giving a dose of lithium.

In the last 24 hours has the patient experienced any of the following

• Increasing gastrointestinal disturbance
• Inadequate fluid intake or excessive fluid loss
• Muscle weakness/lack of co-ordination
• Slurring of speech
• Severe tremor
• Blurred vision
• Confusion
• Unusual drowsiness
• Been prescribed a medicine that may interact with lithium¹

If yes seek medical advice before giving the dose.

¹Thiazide diuretics, other diuretics (furosemide, spironolactone), NSAIDs including COX-2 inhibitors (ibuprofen, celexoxib), ACE inhibitors (e.g. ramipril), angiotensin-2 receptor antagonists (e.g. candesartan).