Disease Description

Bipolar Disorder is a mental health condition that causes extreme mood

swings that include emotional highs (mania or hypomania) and lows
(depression). People who have bipolar disorder can have periods in which
they feel overly happy and energized and other periods of feeling very sad,
hopeless, and sluggish. In between those periods, they usually feel normal
which is known as euthymia. You can think of the highs and the lows as two
"poles" of mood, which is why it's called "bipolar" disorder. These shifts
can last for hours, days, weeks or months and interrupt your ability to
carry out day-to-day tasks.

 The word "manic" describes the times when someone with bipolar disorder feels overly
excited and confident. These feelings can also involve irritability and impulsive or reckless
decision-making. About half of people during mania can also have delusions (believing things
that aren't true and that they can't be talked out of) or hallucinations (seeing or hearing
things that aren't there).
 "Hypomania" describes milder symptoms of mania, in which someone does not have
delusions or hallucinations, and their high symptoms do not interfere with their everyday
life.
 The word "depressive" describes the times when the person feels very sad or depressed.

Types

There are a few types of bipolar disorder, which involve experiencing significant fluctuations in mood
referred to as hypomanic/manic and depressive episodes. However, people with bipolar disorder
aren’t always in a hypomanic/manic or depressive state.

1. A key feature of bipolar I disorder is manic episodes.

2. People with certain types of bipolar such as bipolar II disorder experience hypomania.
3. Involving numerous periods of depression and hypomania, but not of sufficient severity and
duration to meet the criteria for either bipolar I or bipolar II disorder. People with
cyclothymia experience emotional ups and downs but with less severe symptoms than
bipolar I or II disorder.

Etiology

 Genetics – But genes are not the only factor. Studies of identical twins have shown that one
twin can develop bipolar disorder while the other does not. Though people with a parent or
sibling with bipolar disorder are more likely to develop it, most people with a family history
of bipolar disorder will not. Twin studies have indicated a concordance rate for bipolar
disorder among monozygotic twins (identical) at 60% to 80% compared to 10% to 20% in
dizygotic twins (fraternal).

 The chemicals responsible for controlling the brain's functions are called neurotransmitters,
and include norepinephrine, serotonin and dopamine.

 Environmental Factors – A stressful circumstance or situation often triggers the symptoms of

bipolar disorder. Examples of stressful triggers include:

 the breakdown of a relationship

  physical, sexual or emotional abuse

 the death of a close family member or loved one

 These types of life-altering events can cause episodes of depression at any time in a person's
life.

 Bipolar disorder may also be triggered by:

 physical illness

 sleep disturbances

 overwhelming problems in everyday life, such as problems with money, work or

relationships

Signs & Symptoms

Manic Phase

Flight of ideas – excessive amount and rate of speech composed of fragmented or unrelated ideas;
racing, often unconnected, thoughts. Flight of Ideas: Example: My father sent me here. He drove me
in a car. The car is yellow in color. Yellow color looks good on me.

Grandiosity – characterized by the client’s claim to association with famous people or celebrities, or
the client’s belief that he or she is famous or capable of great feats.

Delusion - a fixed false belief not based in reality; (believing things that aren't true and that they
can't be talked out of). Ex. any belief relating to having special powers, relationships with someone
important or famous, or having exceptional talents or abilities.

Hallucination – seeing, hearing, or feeling things that aren't really there. Ex: A crawling feeling on the
skin

Impulsivity – for example, going on buying sprees, taking sexual risks or making foolish investments

Elevated Activity – Motor activity is constant; the individual is literally moving at all times.

Nursing Interventions

INTERVENTIONS RATIONALE
Provide a safe environment. provide a safe environment for client and
others; for clients who feel out of control, the
nurse must establish external controls
emphatically and nonjudgmentally.
Remove harmful objects from the room. Remove any objects that could be used as a
weapon or to potentially harm themselves.
Provide finger foods & fluids. High-calorie High-calorie protein drinks help in the
protein drinks help in the replacement of replacement of calories for the hyperactive,
calories for the hyperactive, manic patient. manic patient. Such as: hamburgers,
Finger foods provide nourishment in patients sandwiches, fruit juices, granola bars, and
who are always on the go. shakes
Re-channel energy on physical activity Patients experiencing mania have endless
energy. Offer exercise classes or housekeeping
duties to help relieve hyperactivity as well as
distract them from unsafe activities.
 Decrease stimuli.
- Turn off or turn down the TV & music.
- Keep away from other clients if they are
bothersome.
Regularly monitor for the patient’s manic
episodes manifested through hyperactivity and
increased agitation
Be calm and firm when dealing with the patient.
Providing therapeutic communication
Set and maintain limits on behavior that is
destructive or adversely affects others.
Reorient the client to person, place, and time as
indicated (call the client by name, tell the client
your name, tell the client where he or she is,
etc.)
Provide a consistent, structured environment.
Let the client know what is expected of him or
her. Set goals with the client as soon as
possible.
Limit the size and frequency of group activities
based on the client’s level of tolerance. Help the
client plan activities within his or her scope of
achievement.
The patient may be encouraged to involve
themselves in activities that require social
interaction when less manic.
Observe for behaviors that may indicate an
onset of a manic episode such as self- and
other-destructive behavior.
Medical Management
 Psychotherapy “Talk Therapy” – Psychotherapy helps patients with bipolar disorder but does
not cure the disorder itself; when Schottle and colleagues looked at psychotherapy for patients,
family, and caregivers, they found that although results were heterogeneous, most studies
Calming and relaxation will be encouraged for
the patient and manic episodes will be avoided.
Fewer stimuli mean lesser distractibility and
lesser trigger for manic episodes.
Prompt management (i.e., the patient is a
threat to others and to self can be avoided) can
be given as early as possible if the patient’s
manic episodes are detected early.
The patient is out of control – calmness and
firmness help in properly managing him/her.
Clients with mania have short attention spans,
so the nurse uses simple, clear sentences when
communicating; they may not be able to handle
a lot of information at once, so the nurse
breaks information into many small segments.
Limits must be established by others when the
client is unable to use internal controls
effectively. The physical safety and emotional
needs of other clients are important.
Repeated presentation of reality is concrete
reinforcement for the client.
Consistency and structure can reassure the
client. The client must know what is expected
before he or she can work toward meeting
those expectations.
The client’s attention span is short, and his or
her ability to deal with complex stimuli is
impaired.
When less manic, exposing patients to social
situations helps develop his/her social skills.
However, this should be done non-
competitively as competition stimulates
aggressive behavior and may trigger manic
episodes.
Extreme or acute mania may be manifested
through provocative behavior and
aggressiveness. Early detection leads to faster
and prompt management of the patient’s
manic episode before the patient becomes a
threat against himself/herself and his/her
environment.
 demonstrated relevant positive results in regard to decreased relapse rates, improved quality of
life, increased functioning, or more favorable symptom improvement.
 Electroconvulsive therapy. Electroconvulsive therapy (ECT) is useful in a number of instances in
patients with bipolar disorder, such as when rapid, definitive medical/psychiatric treatment is
needed; when the risks of ECT are less than that of other treatments; when the bipolar disorder
is refractory to an adequate trial with other treatment strategies; and when the patient prefers
this treatment modality.

Medication

Lithium

Adverse reaction: Client Teaching:

 Nausea Clients should drink adequate water (approximately 2
 Vomiting L/day) and continue with the usual amount of dietary
 Thirst table salt. Having too much salt in the diet because of
 Polyuria unusually salty foods or the ingestion of salt containing
 Tremors antacids can reduce receptor availability for lithium and
 Weight gain increase lithium excretion, so the lithium level will be
too low.
Watch out for Lithium Toxicity! –
If there is too much water, lithium is diluted, and the
S/s for Lithium Toxicity:
lithium level will be too low to be therapeutic. Drinking
 Confusion too little water or losing fluid through excessive
 Blurred vision sweating, vomiting, or diarrhea increases the lithium
 Diarrhea level, which may result in toxicity.
 Tinnitus
 Slurred speech
 Coma
 Convulsions
1. Antidepressants
 Selective Serotonin Reuptake Inhibitor (SSRI’s) – Inhibits uptake of serotonin. Used
for depression, anxiety, OCD, and eating disorders. First line drug for depression and
anxiety. At risk for suicidal ideation

 Serotonin/Norepinephrine (SNRI’s) / (DNRI’s) Dopamine/Norepinephrine Reuptake

Inhibitor – Inhibits uptake of serotonin, norepinephrine, and dopamine. Used for
depressive episodes, anxiety disorders, fibromyalgia, diabetic neuropathy pain
 Tricyclic Antidepressant (TCA’s) – Blocks reuptake of serotonin and norepinephrine
in the brain. Used for depressive episodes, bipolar disorder, OCD, Neuropathy, and
Enuresis. Causes heart problems in patients with pre-existing condition or elderly
clients (Cardiotoxic)
 Monoamine Oxidase Inhibitors (MAOI’s) – Blocks monoamine oxidase which causes
increase in epinephrine, norepinephrine, dopamine, and serotonin, which causes
stimulation of the CNS. - At risk for hypertensive crisis. (headache, stiff neck,
nausea/vomiting, fever, dilated pupils). Clients should Avoid foods with tyramine
(aged cheese, fermented meats, chocolate, caffeinated beverages, sour cream, and
yogurt)
Antipsychotic Drugs

First Generation Antipsychotics (FGA’s) Second Generation Antipsychotics

(SGA’s)
Typical/ Conventional Atypical
Blocks /inhibits dopamine from being Acts on both serotonin and dopamine in the
released in the brain. brain.
Higher risk of: lower risk of TD, EPS, and NMS
a) Tardive Dyskinesia (TD)
- Involuntary movements of  Weight gain
the face, tongue, or limbs  Increase of cholesterol
that are irreversible.  Increase of triglyceride
b) Extrapyramidal Syndrome (EPS)  Increase of blood sugar levels
- Parkinson’s like symptoms
such as akathisia
(restlessness) and dystonia
(muscle twitching)
c) Neuroleptic Malignant Syndrome
(NMS)
- Combination of EPS, high
fever, and autonomic
disturbance
d) Orthostatic hypotension

Side effect of both:

 Anticholinergic effect (Dry mouth, constipation, urinary retention, bowel obstruction,
dilated pupils, blurred vision, increased heart rate, and decreased sweating)
 Photophobia
 Photosensitivity
 Sedation/lethargy
May take 6-10 weeks to take effects

2. Anxiolytics
 Benzodiazepines – Binds to cell receptors enhancing the effects of GABA an inhibitory
neurotransmitter which slows/calms the activity of the nerves in the brain. Sedates,
therefore take at night and advice not to drive or operate heavy machinery. Withdrawals
happen when medication is stopped abruptly. Therefore, taper the dosage and never stop
abruptly.
o Signs and symptoms of withdrawals includes:
 increased anxiety
 increased heart rate
 increased blood pressure
 increased temperature and sweating
 decreased memory
 agitation
 seizures
 insomnia
  vomiting
 muscle aches
- Contraindicated for pregnant, laboring, & lactating women, elderly patients due to
high chance of dementia, and patients with impaired liver and kidney function.
- Suffixes: zolam, zepam