Chapter 14
BIPOLAR DISORDER
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1
Clinical Picture
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymia
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2
Bipolar Disorder Characteristics
• Symptoms of at least one episodes of mania,
often accompanied by major depressive episodes
• Bipolar Disorders are a group of mood disorders
that include manic episodes, hypomanic
episodes, mixed episodes, depressed episodes,
and cyclothymic disorder
• Clients with bipolar disorder experience the
elevated mood symptoms seen in mania and
hypomania
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Epidemiology
Lifetime prevalence of bipolar disorder
in the United States is 3.9%
• Bipolar I – more common in males
• Bipolar II – more common in females
• Cyclothymia – usually begins in
adolescence or early adulthood
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4
Characteristics
• Bipolar I disorder, manic: characterized by elation or
irritability with excessive motor activity
• Bipolar I disorder, mixed: characterized by mood swings
ranging from depression to euphoria, with intervening
periods of normal behavior
• Bipolar II disorder: characterized by no manic or mixed
episode but at least one hypomanic episode
• Cyclothymic disorder: characterized by a chronic,
fluctuating mood disturbance with frequent periods of
hypomania and depression
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5
Mania
• Inflated self-esteem or grandiosity
• Decrease need for sleep
• Pressured speech
• Flight of ideas
• Distractibility
• Psychomotor agitation
• Involvement in pleasurable activities
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6
Mania continued
• Delusions (grandeur)
• Hallucinations
• Mood swings
• Aggressive
• Denial (nothing is wrong)
• Irritability, intrusive
• Can’t sit still
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Mania continued
• Euphoric mood
• Poor judgment, Provocative behavior
• Increased sexual interest
• Substance abuse
• Omnipotent feelings
• Endless energy
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8
Hypomania
• Less extreme form of mania
• Euphoric, feel wonderful, “on top of the
world”
• No psychotic features
• Overly enthusiastic involvement in
projects of an interpersonal, political,
religious, or occupational nature.
• Labile mood (euphoria to irritability)
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Hypomania continued
• Increased sexual behaviors (flirting,
making sexual overtures, multiple
sexual relationships)
• Dress flashy or seductive manner
• Wear heavy make up
• Pressured speech
• Racing thoughts or flight of ideas
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10
Mixed Episodes
• Both mania and depression are present
are present nearly every day in rapidly
alternating succession over a period of
at least a week.
• Irritability and Agitation
• Insomnia and appetite disturbance
• Suicidal and psychotic thoughts
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11
Cyclothymic Disorder
• Chronic, fluctuating mood disturbance
involving numerous periods of hypomanic
symptoms and numerous periods of
depressive symptoms
• Begins in adolescence or early adulthood.
• Free of severe symptoms that qualify for the
diagnosis of manic disorder or major
depressive disorder.
• Moody, unpredictable, temperamental
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12
Etiology
• Biological factors
– Genetic
– Neurobiological
– Neuroendocrine
• Psychological factors
• Environmental factors
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13
Assessment
• Mood
• Behavior
• Thought processes and speech
patterns
– Flight of ideas
– Clag associations
– Grandiosity
• Cognitive functioning
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14
Self-Assessment
• Manic patient
– Manipulative
– Aggressively demanding
– Splitting
• Staff member actions
– Frequent staff meetings to deal with
patient behavior and staff response
– Set limits consistently
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Assessment Guidelines
Bipolar Disorder
• Danger to self or others
• Need for protection from uninhibited
behaviors
• Need for hospitalization
• Medical status
• Coexisting medical conditions
• Family’s understanding
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16
Nursing Diagnosis
• Risk for injury
• Risk for violence (Other-directed or
Self-directed)
• Risk for suicide
• Ineffective health maintenance
related to hyperactivity
• Disturbed sleep pattern
• Disturbed thought process
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17
Outcomes Identification
• Acute phase
– Prevent injury
• Continuation phase
– Relapse prevention
• Maintenance phase
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18
Planning
• Acute phase
– Medical stabilization
– Maintaining safety
– Self-care needs
• Continuation phase
– Maintain medication adherence
– Psychoeducational teaching
– Referrals
• Maintenance phase
– Prevent relapse
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Implementation
• Acute phase – highest priority is
safety
– Depressive episodes
– Manic episodes
• Continuation phase
– Prevent relapse with follow-up care
• Maintenance phase
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Nursing Interventions
• Reduce environmental stimuli
• Limit patient’s participation in group activities
• Create a safe environment
• Provide physical exercise as a substitute for
increased motor activity
• Avoid arguments or confrontations with the patient
• Restrict caffeine intake
• Limit the selection of clothing available
• Keep the patient oriented to reality
• Assist patient in focusing on a single task
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A Mnemonic for Symptoms of Bipolar Disorder
“DIG FAST”
• Distractability (unimportant things can easily divert
your attention)
• Indiscretion (impulsive pleasurable acts with
painful consequences)
• Grandiosity (or inflated ego)
• Flight of ideas
• Activity increase toward goals
• Sleep deficits (less need for sleep)
• Talkativeness (or feels pressured to keep on
talking)
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22
Gordon’s
Functional
Health Pattern
based on your
client’s
symptoms
Nursing
Diagnosis
(NANDA)
(Actual and/or
potential)
Include etiology
and sign and
symptoms
Nursing
Outcome Criteria
(NOC)
Measureable
Goal during your
shift
Implementation
(Independent
and collaborative
nursing
intervention
include further
assessment,
intervention and
teaching)
Disrupted
NutritionalMetabolic
Pattern of food
and fluid
consumption
relative to
increased
metabolic
need and
pattern;
indicators of
lack of nutrient
supply due
hyperactivity
and inattention
Ineffective
health
maintenance
related to
hyperactivity
as evidence by
decrease
need for
food/fluid
intake
Patient will eat
50% to 75% of
each meal,
drink 4 to 6
glasses of
fluids, plus
snacks
between
meals with the
aid of nursing
interventions
by (date)
1. Monitor
Care Plan
Rationale
(Use APA
citations)
1. Minimize
intake, output
dehydration
and vital signs and electrolyte
daily.
imbalance
2. Encourage
2. Constant
frequent high
fluid and
calorie protein calorie are
drinks and
needed.
finger food
Patient may
such as … 6
be too active
times a day.
to sit during
3. Frequently
meals.
remind patient 3. Unaware of
on a daily
nutritional
basis to eat
needs and
every meal
easily
and
snacksan imprint
distracted.
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Saunders,
of Elsevier Inc.
Evaluation
Goal Met
Goal not Met
(If not met, what
revisions would
you make?)
Goal met:
Patient ate
75% of lunch
today. Drinking
fluids with
reminders. Ate
a few bites of
snacks, then
started
preaching to
other patients
and pacing the
unit.
23
Pharmacological Interventions
• Lithium carbonate
– Indications
– Therapeutic and toxic levels
• Therapeutic blood level 0.8 to 1.4 mEq/L
• Maintenance blood level 0.4 to 1.3 mEq/L
• Toxic blood level: 1.5 to 2.0 mEq/L
– Maintenance therapy
– Contraindications
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Lithium Toxicity
– Symptoms of Li Toxicity
• Levels 1.3 to 1.5 mEq/L - Fine hand tremors, nausea, vomiting,
diarrhea, confusion, ataxia, slurred speech, lethargy, thirst and
polyuria, muscle weakness.
• Nursing Consideration: Medication should be withheld, Assess
patient for toxicity symptoms, blood levels measured, and
evaluate dosage. Dehydration should be addressed.
• Levels 1.6 to 2.0 Course hand tremors, GI upset, mental confusion,
muscle hyperirritability, incoordination, sedation.
• Nursing Consideration: See above
• Levels > 2.1 to 3.0 mEq/L – Ataxia, Confusion, blurred vision,
hypotension, Profound CNS depression, arrythmia, seizures,
coma, death due to pulmonary complications
• Hemodialysis may be used in severe cases.
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Anticonvulsant Drugs
• Valproate (Depakote)
• Carbamazepine (Tegretol)
• Lamotrigine (Lamictal)
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Valproic Acid
• Divalproex Sodium - Depakote® - (enteric coated)
• Valproic Acid Syrup – Depakene® syrup
• Valproic Acid – Depakene® (250 - 1,500 mg/d)
Therapeutic Range: (50 – 125 µg/mL) for Mania
– Side effects:
• GI distress N/V/D - give with food
• Drowsiness -give at bedtime
• Tremor
• Alopecia - zinc and selenium supplements
• Weight gain - diet and regular exercise
– Black box warnings: Hepatoxity, pancreatitis,
teratogenicity
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Mood Stabilizers continued
• Carbamazepine - Tegretol® (200 - 1,60o mg/d)
– Therapeutic Range: (4 – 12 mL)
– Anticonvulsant, bipolar disorder, trigeminal neuralgia
– Side effects: sedation, dizziness, anticholinergic, rash,
weight gain, hepatic dysfunction, leukopenia (rare)
• Lamotrigine - Lamictal® (50 - 500 mg/d)
– Anticonvulsant
– Side effects: rash, dizziness, headache, sedation
• Oxcarbazepine - Trileptal® (600 - 2,400 mg/d)
– Anticonvulsant
– Side effects: sedation, dizziness, headache, nausea and
vomiting
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Antianxiety Drugs
• Clonazepam (Klonopin)
• Lorazepam (Ativan)
Atypical Antipsychotics
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
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Other Treatments
• Electroconvulsive therapy (ECT)
• Milieu management
• Support groups
• Health teaching and health promotion
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Medication Teaching
• Proper client education enhances the
effectiveness of medication therapy and
can improve client adherence and
diminish non-adherence
• Client education begins when medication
therapy begins and is repeated during the
course of the client’s hospitalization
• Give instructions verbally and in writing
• Include family members or significant
others if they will supervise home
administration
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31
Advanced Practice
Interventions
• Psychotherapy
– Cognitive-behavioral therapy (CBT)
– Interpersonal and social rhythm
therapy
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Evaluation
• Evaluate outcome criteria
• Care plan reassessed
• Care plan revised if indicated
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