Lithium ward bundle

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Lithium key facts

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

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
Lithium care plan elements

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

Lithium MDT checklist

Consider the pertinent elements of the checklist at each MDT meeting

Element Action
Pre- treatment checks ECG (if clinically indicated), U&Es, renal function, thyroid function, weight.
Medicines reconciliation Has the correct dose and brand been identified on admission?
Prescribed correctly on the prescription sheet? Both brand and approved name e.g. PRIADEL (Lithium Carbonate)
Review potential drug interactions Prescription reviewed for relevant drug interactions
Education

Has appropriate education been provided to patients, carers and staff?

Lithium level monitoring Is there a clear plan in place for monitoring lithium levels?
Care planning Does the care plan include lithium as a need?
Side effect monitoring Is there a systematic plan in place to monitor and report side effects?
Lithium clinical factors considered Are relevant clinical factors being considered before lithium is administered?
Physical health Are the patients physical health needs being monitored and addressed?
Discharge/transfer plan Is there a clear discharge/transfer plan in place?
Factors to consider before giving a dose of Lithium

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 (ibuprofen), ACE inhibitors (e.g. ramipril), angiotensin-2 receptor antagonists (e.g. candesartan).

Editorial Information

Last reviewed: 31 May 2019

Next review: 01 July 2021

Author(s): Lithium Short Life Working Group

Version: 1.0

Approved By: Prescribing Management Group - Mental Health

Reviewer Name(s): Andrew Walker, Suzanne Burke