Bipolar disorders are characterized by recurrent mood swings of varying degree from depression to

elation with intervening periods of normalcy. Milder mood swings such as cyclothymia may be manifested
or viewed as everyday creativity rather than an illness requiring treatment. Hypomania can actually
enhance artistic creativity and creative thinking/ problem-solving.

This plan of care focuses on treatment of the manic phase. (Note:Bipolar II disorder is characterized by
periods of depression and hypomania, but without manic episodes.) Refer to CP: Depressive Disorders for
care of depressive episode.

ETIOLOGICAL THEORIES

Psychodynamics

Psychoanalytical theory explains the cyclic behaviors of mania and depression as a response to
conditional love from the primary caregiver. The child is maintained in a dependent position, and ego
development is disrupted. This gives way to the development of a punitive superego (anger turned
inward or depression) or a strong id (uncontrollable impulsive behavior or mania). In the psychoanalytical
model, mania is viewed as the mirror image of depression, a “denial of depression.”

Biological

There is increasing evidence to indicate that genetics plays a strong role in the predisposition to bipolar
disorder. Research suggests a combination of genes may create this predisposition. Incidence among
relatives of affected individuals is higher than in the general population. Biochemically there appear to be
increased levels of the biogenic amine norepinephrine in the brain, which may account for the increased
activity of the manic individual.

Family Dynamics

Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned
by a significant other during the first 6 months of life. The bonding process is interrupted and the child
withdraws from people and the environment. Rejection by parents in childhood or spending formative
years with a family that sees life as hopeless and has a chronic expectation of failure makes it difficult for
the individual to be optimistic. The mother may be distant and unloving, the father a less-powerful
person, and the child expected to achieve high social and academic success.

CLIENT ASSESSMENT DATA BASE (MANIC EPISODE)

Activity/Rest

Disrupted sleep pattern or extended periods without sleep/decreased need for sleep (e.g., feels well
rested with 3 hours of sleep)

Physically hyperactive, eventual exhaustion

Ego Integrity

Inflated/exalted self perception, with unrealistic self-confidence

Grandiosity may be expressed in a range from unrealistic planning and persistent offering of unsolicited
advice (when no expertise exists) to grandiose delusions of a special relationship to important persons,
including God, or persecution because of “specialness”

Humor attitude may be caustic/hostile

Food/Fluid

Weight loss often noted

Hygiene

Inattention to ADLs common

Grooming and clothing choices may be inappropriate, flamboyant, and bizarre; excessive use of makeup
and jewelry

Neurosensory

Prevailing mood is remarkably expansive, “high,” or irritable

Reports of activities that are disorganized and flamboyant or bizarre, denial of probable outcome,
perception of mood as desirable and potential as limitless

Mental Status: Concentration/attention poor (responds to multiple irrelevant stimuli in the

environment), leading to rapid changes in topics (flight of ideas) in conversation and inability to complete
activities

Mood: labile, predominantly euphoric, but easily changed to anger or despair with slightest provocation;
mood swings may be profound with intervening periods of normalcy

Delusions: paranoid and grandiose, psychotic phenomena (illusions /hallucinations)

Judgment: poor, irritability common

Speech: rapid and pressured (loquaciousness), with abrupt changes of topic; can progress to
disorganized and incoherent

Psychomotor agitation

Safety

May demonstrate a degree of dangerousness to self and others; acting on misperceptions

Sexuality

Increased libido; behavior may be uninhibited

Social Interactions
May be described or viewed as very extroverted/sociable (numerous acquaintances)

History of overinvolvement with other people and with activities; ambitious, unrealistic planning; acts of
poor judgment regarding social consequences (uncontrolled spending, reckless driving, problematic or
unusual sexual behavior)

Marked impairment in social activities, relationship with others (lack of close relationships),
school/occupational functioning, periodic changes in employment/frequent moves

Teaching/Learning

First full episode usually occurs between ages 15 and 24 years, with symptoms lasting at least 1 week

May have been hospitalized for previous episodes of manic behavior

Periodic alcohol or other drug abuse

DIAGNOSTIC STUDIES

Drug Screen: Rule out possibility that symptoms are drug-induced.

Electrolytes: Excess of sodium within the nerve cells may be noted.

Lithium Level: Done when client is receiving this medication to ensure therapeutic range between 0.5
and 1.5 mEq/liter.

NURSING PRIORITIES

1. Protect client/others from the consequences of hyperactive behavior.

2. Provide for client’s basic needs.

3. Promote reality orientation, realistic problem-solving, and foster autonomy.

4. Support client/family participation in follow-up care/community treatment.

DISCHARGE GOALS

1. Remains free of injury with decreased occurrence of manic behavior(s).

2. Balance between activity and rest restored.

3. Meeting basic self-care needs.

4. Communicating logically and clearly.

5. Client/family participating in ongoing treatment and understands importance of drug

therapy/monitoring.

6. Plan in place to meet needs after discharge.