Bipolar

Once known as manic depression.

Bipolar disorder is a chronic, recurrent illness that must be
carefully managed throughout a persons life.
Marked by shifts in mood, energy, and ability to function.**
Course ranges from severe mania, an exaggerated euphoria or
irritability to severe depression.
Periods of normal functioning may alternate with periods of
illness (highs, lows or a combination of both).
May individuals continue to experience chronic interpersonal or
occupational difficulties even during remission.
25% to 60% of individuals with bipolar disorder will make a
suicide attempt at least once in their lifetime, an nearly 20% of
all deaths among this population are from suicide.

Bipolar Spectrum

Acute phase
Injury prevention reflects both physiological and psychiatric
issues. Example hydration, cardiac status, skin integrity, sleep,
self-control, and no self-harm.
Continuation phase
Last 4-9 months. Relapse prevention psycoeducational classes
for patient and family. Knowing the disease process, know
medications, early signs and symptoms of relapse, support
groups or therapy and communication and problem solving skills
training.
Maintenance phase
Planning focuses on preventing relapse and limiting the severity
and duration of further episodes. Patients with bipolar require
medications for their entire lifetime.
Bipolar disorders, Bipolar 1
At least one episode of mania alternates with major depression
Psychosis may accompany the manic episode
Bipolar disorder, Bipolar 2
Hypomanic episode(s) alternate with major depression.
Hypomanic is low level symptomatology
Psychosis is not present

Hypomania of bipolar II disorder tends to be euphoric and often

increases functioning and the depression tends to put people at
particular risk for suicide.
Bipolar II disorder is under diagnosed and often mistaken for
major depression or personality disorders, when it actually may
be the most common form of bipolar disorder.
Clinicians may downplay bipolar II and consider it to simply be
the milder version of bipolar disorders. However, it is a source of
significant morbidity and mortality, particularly due to the
occurrence of severe depression.
One out of two people with depression may have bipolar II.

Bipolar disorder, Cyclothymia

Hypomanic episodes alternate with minor depressive episodes
(at least 2 years in duration).
Individuals with cyclothymia tend to have irritable hypomanic
episodes. cyclothymia usually begins in adolescence or early
adulthood. There is a 15% to 50% risk that an individual with
cyclothymia will subsequently develop bipolar I or bipolar II
disorder.
Mood swings involving hypomania and dysthymia of 2 years'
duration. The mood swings are not severe enough to prompt
hospitalization.
Rapid Cycling
Four or more mood episodes in a 12 month period
Used to indicate more severe symptoms, such as poorer global
functioning, high recurrence risk, and resistance to conventional
treatments.
Bipolar disorder, Male vs. Female
Bipolar seems to be somewhat more common among males.
Bipolar 2 disorder (characterized by the milder form of maniahypomania and increased depression is more common among
females.
Women with bipolar disorders are likely to abuse alcohol, commit
suicide and develop thyroid disorders.
Men with bipolar disorders are more likely to have legal problems
and commit acts of violence.
Comorbidity
More than half of people with bipolar disorder have another Axis I
psychiatric disorder
Within a lifetime, the most commonly co-occurring disorders for
all bipolar disorders were panic attacks (62%), alcohol abuse

(39%), social phobia (38%), oppositional defiant disorder (37%),

specific phobia (35%), and seasonal affective disorder (35%).
Substance use disorders were much higher in bipolar I than in
bipolar II disorders.
Treatment for substance abuse and bipolar disorder should
proceed concurrently whenever possible
The incidence of borderline personality disorder occurring along
with bipolar disorder is high. Patients who have borderline
personality disorder have a 19.4% higher rate of bipolar disorder
than do people with other personality disorders
The rates of the following disorders were significantly higher in
patients with Bipolar disorder: chronic fatigue syndrome, asthma,
migraine, chemical sensitivity, hypertension, bronchitis, and
gastric ulcers.

Genetic Factors
Bipolar disorders have a strong heritability (i.e., the influence of
genetic factors is much greater than the influence of external
factors).
Bipolar disorders are 80% to greater than 90% heritable, whereas
Parkinson's disease, for example, is only 13% to 30% heritable
Rate of bipolar disorders may be as much as 5 to 10 times higher
for people who have a relative with bipolar disorder than the
rates found in the general population.
Likely that bipolar disorder is a polygenic disease, which means
that a number of genes contribute to its expression.
Researchers have found a connection between bipolar disorder
and a genome that encodes an enzyme called diacylglycerol
kinase eta (DGKH).
Lithium is the first-line therapy for bipolar disorder, and DGKH is
a crucial part of a lithium-sensitive pathway
Other research has focused on abnormal circadian genes that
may result in a superfast biological clock, which manifests itself
in extreme insomnia
Bipolar disorders and schizophrenia may have similar genetic
origins and pathology both disorders exhibit irregularities on
chromosomes 13 and 15
Neurobiological
Neurotransmitters (norepinephrine, dopamine, and serotonin)
have been studied since the 1960s as causal factors in mania
and depression.
Proportions of neurotransmitters in relation to one another may
be more important

Receptor site insensitivity could also be a causal factor

Brain pathways implicated in the pathophysiology of bipolar
disorder are located in subregions of the prefrontal cortex (PFC)
and medial temporal lobe (MTL).
Prefrontal cortical changes are evident in the early stages of the
illness, whereas lateral ventricle abnormalities develop with
repeated episodes of mania and/or depression
Functional imaging also reveals differences in the anterior limbic
regions of the brain, which are associated with emotion,
motivation, memory, and fearthe areas most deeply affected
by bipolar disorder.

Environmental factors
Bipolar disorder is a worldwide problem that generally affects all
races and ethnic groups equally
Some evidence suggests that bipolar disorders may be more
prevalent in upper socioeconomic classes.
People with bipolar disorders appear to achieve higher levels of
education and higher occupational status than individuals with
unipolar depression.
The proportion of patients with bipolar disorders among creative
writers, artists, highly educated men and women, and
professional people is higher than in the general population.
Application of the nursing process
Early diagnosis and proper treatment can help people avoid:
suicide attempts, alcohol or substances abuse, martial or work
problems, and development of medical comorbidity.
General Assessment
Mood
Behavior
Thought processes and speech pattern
Cognitive function
Diagnosis
Primary consideration for a patient in acute mania is the
prevention of exhaustion and death from cardiac collapse.
Because the patinets poor judgment, excessive and constant
motor activity, probable dehydration and difficulty evaluating
reality RISK for Injury is an appropriate diagnosis.

ASSESSMENT GUIDELINES: Bipolar

Disorder pg. 234

1. Assess whether the patient is a danger to self and others:

Patients experiencing mania can exhaust themselves to

the point of death.

Patients may not eat or sleep, often for days at a time.

Poor impulse control may result in harm to others or self.

Uncontrolled spending may occur.

2. Assess the need for protection from uninhibited behaviors.

External control may be needed to protect the patient from such
consequences as bankruptcy, because patients experiencing mania
may give away all of their money or possessions.

3. Assess the need for hospitalization to safeguard and stabilize

the patient.

4. Assess medical status. A thorough medical examination helps

to determine whether mania is primary (a mood disorderbipolar
disorder or cyclothymic disorder) or secondary to another condition.
Mania may be secondary to a general medical condition.

Mania may be substance-induced (caused by use or

abuse of a drug or substance or by toxin exposure).

5. Assess for any coexisting medical condition or other situation

that warrants special intervention (e.g., substance abuse, anxiety
disorder, legal or financial crises).

6. Assess the patients and family understands of bipolar

disorder, knowledge of medications, and knowledge of support
groups and organizations that provide information on bipolar
disorder.

Mood

Euphoric mood associated with mania is unstable.

During euphoria, the patient may state that he or she is
experiencing an intense feeling of well-being, is "cheerful in a
beautiful world," or is becoming "one with God."
The overly joyous mood may seem out of proportion to what is
going on, and cheerfulness may be inappropriate for the
circumstances.

Mood may change quickly to irritation and anger when the

person is thwarted.
The irritability and belligerence may be short-lived, or it may
become the prominent feature of the manic phase of bipolar
disorder.
People experiencing a manic state may laugh, joke, and talk in a
continuous stream, with uninhibited familiarity. They often
demonstrate boundless enthusiasm, treat others with
confidential friendliness, and incorporate everyone into their
plans and activities. They know no strangers, and energy and
self-confidence seem boundless.
Elaborate schemes to get rich and famous and acquire unlimited
power may be frantically pursued, despite objections and
realistic constraints.
Excessive phone calls and e-mails are made, often to famous and
influential people all over the world.
People in the manic phase are busy during all hours of the day
and night, furthering their grandiose plans.
To the person experiencing mania, no aspirations are too high,
and no distances are too far. No boundaries exist to curtail them.
In the manic state, a person often gives away money, prized
possessions, and expensive gifts. The person experiencing a
manic episode may throw lavish parties, frequent expensive
nightclubs and restaurants, and spend money freely on friends
and strangers alike.
This excessive spending, use of credit cards, and high living
continue even in the face of bankruptcy.
As the clinical course progresses from hypomania to mania,
sociability and euphoria are replaced by a stage of hostility,
irritability, and paranoia. The following is a patient's description
of the painful transition from hypomania to mania

Behavior
When people experience hypomania, they have voracious
appetites for social engagement, spending, and activity, even
indiscriminate sex. Constant activity and a reduced need for
sleep prevent proper rest. Although short periods of sleep are
possible, some patients may not sleep for several days in a row.
This nonstop physical activity and the lack of sleep and food can
lead to physical exhaustion and even death if not treated; it
therefore constitutes an emergency.
When in full-blown mania, a person constantly goes from one
activity, place, or project to another. Many projects may be

started, but few if any are completed. Inactivity is impossible,

even for the shortest period of time. Hyperactivity may range
from mild, constant motion to frenetic, wild activity. Flowery and
lengthy letters are written, and excessive phone calls are made.
Individuals become involved in pleasurable activities that can
have painful consequences. For example, spending large sums of
money on frivolous items, giving money
Lithium
Mood stabilizer, is the first-line drug for use in treating bipolar
disorder.
Not a cure
Effective in controlling hypersexuality and feelings of anxiety,
elation, grandiosity, and expansiveness. It takes 7 to 14 days and
sometimes longer to reach therapeutic levels in the patient's
blood.
Major long-term risks of lithium therapy: hypothyroidism and
impairment of the kidney's ability to concentrate urine
Chemical name: LiCO or abbreviated as Li
Effective in the treatment of bipolar I acute and recurrent manic
and depressive episodes.
Lithium inhibits about 80% of acute manic and hypomanic
episodes within 10 to 21 days
Less effective in people with mixed mania (elation and
depression), those with rapid cycling, and those with atypical
features.
Particularly effective in reducing elation, grandiosity,
expansiveness, flight of ideas, irritability and manipulation and
anxiety
Controls to a lesser extent insomnia, psychomotor agitation,
threatening or assaultive behavior, distractibility, hypersexuality,
paranoia
Must reach therapeutic levels in the patient's blood to be
effective.
An antipsychotic or benzodiazepine can be used to prevent
exhaustion, coronary collapse, and death until lithium reaches
therapeutic levels.
Antipsychotics act promptly to slow speech, inhibit aggression,
and decrease psychomotor activity. As lithium becomes effective
in reducing manic behavior, the antipsychotic drugs are usually
discontinued.
Many patients receive lithium for maintenance indefinitely and
experience manic and depressive episodes if the drug is
discontinued

Thought process and speech pattern

Flight of ideas: continuous flow of accelerated speech with
abrupt changes from topic to topics that are usually based on
understandable associations or play on words. Speech is rapid,
verbose and circumstantial ( including minute and unnecessary
details).
Clang association: stringing together words because of their
rhyming sounds without regard to their meaning.
Grandiosity: exaggerated belief in ones own importance,
identity, or capabilities.
Lithium
First line for bipolar depression
Recommended for acute mania
First line for maintenance treatment of bipolar disorder
Lithium is effective in reducing:
Elation, grandiosity and expansiveness
Flight od ideas
Irritability and manipulation
Anxiety
Lithium can also control the following: insomnia, psychomotor
agitation, threatening or assaultive behavior, distractibility,
hyper sexuality and paranoia.
Lithium, Therapeutic levels
During the active phase, 300 mg to 600 mg is given 2 or 3 times
a day by mouth to reach a clear therapeutic result or a lithium
level of 0.8 to 1.4 mEq/L.
Maintenance blood levels should range between 0.4 and 1.3
mEq/L.
To avoid serious toxicity, lithium levels should not exceed 1.5
mEq/L**
At levels < 0.4-1.0 mEq/L (therapeutic level) side effects include
fine hand tremor, polyuria, and mild thirst; mild nausea and
general discomfort; weight gain
Symptoms may persist throughout therapy, but often subside
during treatment.
Weight gain may be helped with diet, exercise, and nutritional
management.

Lithium, Early Sign if Toxicity

At serum levels < 1.5 mEq/L
Nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred
speech, muscle weakness, and fine hand tremor
Medication should be withheld, blood lithium levels measured,
and dosage reevaluated. Dehydration, if present, should be
addressed
Lithium, Advanced Sign of Toxicity
1.5-2.0 mEq/L
Coarse hand tremor, persistent gastrointestinal upset, mental
confusion, muscle hyperirritability, electroencephalographic
changes, incoordination, sedation

Lithium, Severe Signs of Toxicity

2.0-2.5 mEq/L
Ataxia, confusion, large output of dilute urine, serious
electroencephalographic changes, blurred vision, clonic
movements, seizures, stupor, severe hypotension, coma;
Death is usually secondary to pulmonary complications.
Hospitalization is indicated. The drug is stopped, and excretion is
hastened. If patient is alert, an emetic is administered.
Gastric lavage and treatment with urea, mannitol, and
aminophylline can hasten lithium excretion
Lithium, Lethal Dose
> 2.5 mEq/l
Convulsion, oliguria and death can occur
In addition to the intervention above, hemodialysis may be used
in severe cases.
Lithium, Maintenance
After therapeutic levels have been reached, blood levels are
determined every month.
After 6 months to a year of stability, measurement of blood
levels every 3 months may suffice.
Blood should be drawn in the morning, 8 to 12 hours after the
last dose of lithium is taken.
Patient and family should also be advised that suddenly stopping
lithium can lead to relapse and recurrence of mania.
Lithium, Patient Teaching
1. Lithium is not addictive.
2. Sodium It is important to eat a normal diet with normal salt and
fluid intake (1500-3000 mL/day or six 12-oz glasses of fluid). Lithium
decreases sodium reabsorption in the kidneys, which could lead to a
deficiency of sodium. A low sodium intake leads to a relative increase
in lithium retention, which could produce toxicity.
3. You should stop taking lithium if you have excessive diarrhea,
vomiting, or sweating. All of these symptoms can lead to dehydration.
Dehydration can raise lithium levels in the blood to toxic levels. Inform
your physician if you have any of these problems.
4. Do not take diuretics (water pills) while you are taking lithium.
5. Lithium is irritating to the lining of your stomach. Take lithium with
meals.
6. It is important to have your kidneys and thyroid checked

periodically, especially if you are taking lithium over a long period. Talk
to your doctor about this follow-up.
7. Do not take any over-the-counter medicines without checking first
with your doctor.
8. If you find that you are gaining a lot of weight, you may need to talk
this over with your doctor or nutritionist.
9. If lithium is to be discontinued, your dosage will be tapered
gradually to minimize the risk of relapse.
Lithium, Contradictions
Baseline physical and laboratory examinations should include
assessment of renal function; determination of thyroid status,
including levels of thyroxine and thyroid-stimulating hormone;
and evaluation for dementia or neurological disorders, which
presage a poor response to lithium.
Lithium therapy is generally contraindicated in patients with
cardiovascular disease, brain damage, renal disease, thyroid
disease, or myasthenia gravis.
Whenever possible, lithium is not given to women who are
pregnant
Lithium use is also contraindicated in mothers who are breastfeeding and in children younger than 12 years of age.
Anticonvulsant Drugs
Three anticonvulsant drugs have demonstrated efficacy and been
approved for the treatment of mood disorders: valproate (Depakote),
carbamazepine (Tegretol), and lamotrigine (Lamictal)
Anticonvulsant drugs are thought to be:
Superior for continuously cycling patients
More effective when there is no family history of bipolar disease
Effective at dampening affective swings in schizoaffective patients
Effective at diminishing impulsive and aggressive behavior in some
nonpsychotic patients
Helpful in cases of alcohol and benzodiazepine withdrawal
Beneficial in controlling mania (within 2 weeks) and depression
(within 3 weeks or longer)
Valproate (Depakote)
Is useful in treating lithium non responders who are in acute
mania, experience rapid cycles, are in dysphoric mania, or have
not responded to carbamazepine.
Also helpful in preventing future manic episodes
Important to monitor liver function and platelet count
periodically, although serious complications are rare.

Milieu management and seclusion and restraints

When a patient is dangerously out of control, use of the seclusion
room or restraints may also be indicated.

The seclusion room provides comfort and relief to many patients

who can no longer control their own behavior.
Seclusion serves the following purposes:

Reduces overwhelming environmental stimuli

Protects a patient from injuring self, others, or staff

Prevents destruction of personal property or property of others

Seclusion is warranted when documented data collected by the
nursing and medical staff reflect the following points:
Substantial risk of harm to others or self is clear.
The patient is unable to control his or her actions.
Problematic behavior has been sustained (continues or
escalates despite other measures).
Other measures have failed (e.g., setting limits beginning with
verbal de-escalation or using chemical restraints).
Use of seclusion and restraint is permitted only on the written
order of a physician, which must be reviewed and rewritten every
24 hours.

The order must include the type of restraint to be used.

Only in an emergency may the charge nurse place a patient in

seclusion or restraint; under these circumstances, a written
physician's order must be obtained within a specified period of
time (15 to 30 minutes).

Patient should be observed every 15 minutes

Patient is to be offered food and fluids every 30 to 60 minutes

and toileted every 1 to 2 hours

Because phenothiazines are often administered to patients in

seclusion, vital signs should be measured frequently (e.g., every
1 to 2 hours).

Intervention for the patient in

acute mania pg. 237

RATIONALE
INTERVENTION
Communication
Structure and control are
provided for patient who is
Use firm and calm approach: John, come
out of control. Feelings of
with me. Eat this sandwich.
security can result:
Someone is in control.

Use short and concise explanations or

statements.

Short attention span limits

comprehension to small bits
of information.

Remain neutral; avoid power struggles

and value judgments.

Patient can use

inconsistencies and value
judgments as justification for
arguing and escalating
mania.

Intervention for the patient in

acute mania pg. 237

RATIONALE
INTERVENTION

Be consistent in approach and

expectations.

Consistent limits and

expectations minimize
potential for patients
manipulation of staff.

Consistency of all staff is

Have frequent staff meetings to plan
needed to maintain controls
consistent approaches and set agreed-on
and minimize manipulation
limits.
by patient.
With other staff, decide on limits and tell
patient in simple, concrete terms with
consequences. Example: John, do not
yell at or hit Peter. If you cannot control
yourself, we will help you. Or The
seclusion room will help you feel less out
of control and prevent harm to yourself
and others.

Clear expectations help

patient experience outside
controls, as well as
understand reasons for
medication, seclusion, or
restraints (if he or she is not
able to control behaviors).

Hear and act on legitimate complaints.

Underlying feelings of
helplessness are reduced,
and acting-out behaviors are
minimized.

Intervention for the patient in

acute mania pg. 237

RATIONALE
INTERVENTION

Firmly redirect energy into more

appropriate and constructive channels.

Distractibility is the nurses

most effective tool with the
patient experiencing mania.

Structure in a Safe Milieu

Maintain low level of stimuli in patients
environment (e.g., away from bright
lights, loud noises, and people).

Escalation of anxiety can be

decreased.

Provide structured solitary activities with Structure provides security

nurse or aide.
and focus.

Provide frequent high-calorie fluids.

Serious dehydration is
prevented.

Provide frequent rest periods.

Exhaustion is prevented.

Redirect violent behavior.

Physical exercise can

decrease tension and provide
focus.

Intervention for the patient in

acute mania pg. 237

RATIONALE
INTERVENTION
Exhaustion and death can
When warranted in acute mania, use
result from dehydration, lack
phenothiazines and seclusion to minimize
of sleep, and constant
physical harm.
physical activity.

Observe for signs of lithium toxicity.

There is a small margin of

safety between therapeutic
and toxic doses.

Protect patient from giving away money

and possessions. Hold valuables in
hospital safe until rational judgment
returns.

Patients generosity is a
manic defense that is
consistent with irrational,
grandiose thinking.

Physiological Safety: Self-Care Needs

Nutrition
Monitor intake, output, and vital signs.

Adequate fluid and caloric

intake are ensured;
development of dehydration
and cardiac collapse is

Intervention for the patient in

acute mania pg. 237

RATIONALE
INTERVENTION
minimized.
Constant fluid and calorie
Offer frequent, high-calorie protein drinks replacement are needed.
and finger foods (e.g., sandwiches, fruit, Patient may be too active to
milkshakes).
sit at meals. Finger foods
allow eating on the run.

Frequently remind patient to eat. Tom,

finish your milkshake. Sally, eat this
banana.

The patient experiencing

mania is unaware of bodily
needs and is easily
distracted. Needs supervision
to eat.

Sleep
Encourage frequent rest periods during
the day.

Lack of sleep can lead to

exhaustion and death.

Keep patient in areas of low stimulation.

Relaxation is promoted, and

manic behavior is minimized.

Intervention for the patient in

acute mania pg. 237

RATIONALE
INTERVENTION
At night, provide warm baths, soothing
music, and medication when indicated.
Avoid giving patient caffeine.

Relaxation, rest, and sleep

are promoted.

Hygiene
The potential is decreased
Supervise choice of clothes; minimize
for ridicule, which lowers
flamboyant and bizarre dress (e.g., garish self-esteem and increases
stripes or plaids and loud, unmatching
the need for manic defense.
colors).
The patient is helped to
maintain dignity.
Give simple step-by-step reminders for
hygiene and dress. Here is your razor.
Shave the left side . now the right side.
Here is your toothbrush. Put the
toothpaste on the brush.

Distractibility and poor

concentration are countered
through simple, concrete
instructions.

Elimination
Monitor bowel habits; offer fluids and
Fecal impaction resulting
foods that are high in fiber. Evaluate need from dehydration and

Intervention for the patient in

acute mania pg. 237

RATIONALE
INTERVENTION
for laxative. Encourage patient to go to
the bathroom.

decreased peristalsis is
prevented.