BIPOLAR DISORDER

1
BIPOLAR DISORDER

• Chapter 14

2
Clinical Picture

• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymia

3
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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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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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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Mania continued

• Delusions (grandeur)
• Hallucinations
• Mood swings
• Aggressive
• Denial (nothing is wrong)
• Irritability, intrusive
• Cant sit still

8
Mania continued

• Euphoric mood
• Poor judgment, Provocative behavior
• Increased sexual interest
• Substance abuse
• Omnipotent feelings
• Endless energy

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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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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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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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Etiology

• Biological factors
• Genetic
• Neurobiological
• Neuroendocrine
• Psychological factors
• Environmental factors

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Assessment

• Mood
• Behavior
• Thought processes and speech patterns
• Flight of ideas
• Clag associations
• Grandiosity
• Cognitive functioning

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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
• Familys understanding

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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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Outcomes Identification

• Acute phase
• Prevent injury
• Continuation phase
• Relapse prevention
• Maintenance phase

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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 patients 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 DisorderDIG
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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Care Plan
Gordons Functional Health Pattern based on your clients 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) Rationale (Use APA citations) Evaluation Goal Met Goal not Met (If not met, what revisions would you make?)
Disrupted Nutritional-Metabolic 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 intake, output and vital signs daily. 2. Encourage frequent high calorie protein drinks and finger food such as 6 times a day. 3. Frequently remind patient on a daily basis to eat every meal and snacks 1. Minimize dehydration and electrolyte imbalance 2. Constant fluid and calorie are needed. Patient may be too active to sit during meals. 3. Unaware of nutritional needs and easily distracted. 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.
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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 gt 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
  clients hospitalization
• Give instructions verbally and in writing
• Include family members or significant others if
  they will supervise home administration

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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