Mercedes A' PerezMillan ARNP, MSN

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BIPOLAR DISORDER
Mercedes A. Perez-Millan ARNP, MSN
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DEFINITION

• Bipolar disorder is a chronic mood syndrome that
  manifests as alternating and recurring mood
  episodes throughout a persons life.
• Alternating mood episodes are characterized by
  mania, hypomania, depression, and concurrent
  mania and depression (mixed episodes) alternating
  with periods of normal functioning.

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Predisposing Factors

• Genetics
• Biochemical influences NE and DA
• Electrolytes intracellular Na and Ca
• Psychosocial theories

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BIPOLAR DISORDERSTypes

• Bipolar, manic
• Bipolar, depressed
• Bipolar, mixed
• Cyclothymia

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BIPOLAR DISORDERSTypes (cont)

• Bipolar I- Mania alternating with depression.
• Bipolar II- Hypomanic episodes alternating with
  depression.
• Cyclothymia- Hypomanic episodes alternating with
  dysthemia.

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Assessment- Hypomania

• Talks and jokes incessantly, life of the party
  demands constant attention.
• Treats everyone with familiarity often crude.
• Sexual talk often inappropriate and obscene,
  proposes to strangers.
• Talk is fresh flits from topic to topic.
• Full of pep and humor euphoria and sociability.
• Inflated self-confidence and enthusiasm. Many
  plans to become rich and famous.
• Poor judgment involved with schemes in which
  job, financial, or marriage is destroyed.
• High degree of involvement with the rich and
  famous world-wide phone calls.

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Assessment- Hypomania (cont)

• Decreased attention span, overactive.
• Busily preoccupied with grandiose plans (not
  delusions) goes from one action to the next.
• Increase sexual appetite sexually irresponsible
  and indiscreet, illegitimate pregnancies,
  increased incidences if venereal disease. Sex
  used for escape not for relating.
• Voracious appetite, gobbles food, eats on the
  run.
• May go without sleeping, unaware of fatigue.
• Financially extravagant, buying sprees, gives
  money and gifts freely. Goes into debt easily.
• Wears extravagant often inappropriate clothes and
  jewelry.

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Assessment- Mania

• Labile moods
• Inappropriate and intrusive behavior.
• Speech profane and crude sexual remarks.
• Flight of ideas may have clan associations.
• Good humor turns into rage and hostility
  specially when not getting his way, or controls
  are set. Quick shifts in moods, hostile to
  docility.
• Grandiose delusions.
• Judgment extremely poor.
• Decreased attention span and distractibility
  intensify.

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Assessment- Mania cont

• Restless, disorganized and chaotic. Behavior
  difficult to control, frequent outbursts and
  briefly assaultive when crossed.
• Too busy for sex.
• No time to eat or sleep. Too distracted and
  disorganized.
• Severe hyperactive and restless. Can result in
  exhaustion and death.
• Same as hypomanic with finances but extreme.

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Assessment- Depressed

• Symptoms for the depressed cycle of the
  Bipolar Disorder- Depressed are the same as the
  symptoms of Major Depression. The difference is
  that the bipolar patient has the history of at
  least one manic episode.

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Nursing Diagnosis

• Risk for other-directed violence
• Risk for self-directed violence
• Risk for injury
• Disturbed thought process
• Imbalanced nutrition, less than
• Disturbed sleep pattern
• Self care deficit
• Impaired social interaction
• (see chapter for additional nursing diagnosis)

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Goals

• The client
• Exhibits no evidence of physical injury
• Has not harmed self or others
• Is no longer exhibiting signs of physical
  agitation
• Eats a well-balanced diet with snacks to prevent
  weight loss and maintain nutritional status

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Goals (cont)

• The client (cont)
• Verbalizes an accurate interpretation of the
  environment
• Accepts responsibility for own behaviors
• Does not manipulate others for gratification of
  own needs
• Interacts appropriately with others

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BIPOLAR DISORDERS NURSING INTERVENTION

• Firm and calm approach.
• Short and concise explanations.
• Remain neutral, avoid power struggles.
• Be consistent in approach.
• Have frequent staff meetings to plan consistent
  approach.
• Set limits and tell in concrete terms
  consequences of inappropriate behavior.

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BIPOLAR DISORDERS NURSING INTERVENTION cont

• Firmly redirect energy into appropriate channels.
  Redirect violent behavior
• Hear and act on legitimate complaints.
• Low level of stimulation in environment.
• Structured solitary activities with staff.
• High- calorie protein finger foods snacks and
  drinks. Avoid caffeine.
• Provide frequent rest periods.
• Make sure patient takes prescribed meds.

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BIPOLAR DISORDERS NURSING INTERVENTION cont

• When violent or extreme agitation use
  antipsychotics and seclusion.
• Protect client from giving away money and
  possessions.
• Monitor lithium levels and observe for signs of
  toxicity.
• Supervise hygiene and choice of clothing.
• Give simple step-by-step directions.
• When able to learn teach about disorder,
  medication and community agencies.

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PSYCHOPHARMACOLOGY

• ANTIPSYCHOTICS
• BENZODIAZEPINES
• MOOD STABILIZERS
• LITHIUM CARBONATE
• Eskalith
• Lithane
• Lithobid
• ANTICONVULSANTS
• Carbamazepine (Tegretol)
• Valproic acid (Depakote)
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Oxcarbazepine (Trileptal)
• Tiagabine (Gabitril)
• Topiramate (Topomax)

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LITHIUM

• NOT METABOLIZED IN BODY
• 80 REABSORBED IN BODY AND EXCRETED BY KIDNEYS
• LEVELS OUT NEUROTRANSMITTERS

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LITHIUM

• SIDE EFFECTS
• METALLIC TASTE
• FINE HAND TREMORS
• WEIGHT GAIN
• NAUSEA
• POLYDIPSIA POLYURIA
• EDEMA
• TOXICITY
• DROWSINESS
• SLURRED SPEECH
• ATAXIA, MUSCLE SPASMS
• DIZZINESS, STUPOR
• CONVULSIONS DEATH

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NURSING IMPLICATIONS OF LITHIUM

• ADMINISTER WITH MEALS
• SERUM LITHIUM LEVELS AT LEAST TWICE WEEKLY THEN
  MONTHLY
• THERAPEUTIC LEVELS - 0.5 1.5 mEq/L
• TEACH PATIENT TO
• MAINTAIN A NORMAL SALT INTAKE
• DRINK 8 GLASSES OF FLUIDS/DAY

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Client/Family Education

• Nature of illness
• Causes of bipolar disorder
• Cyclic nature of the illness
• Symptoms of depression
• Symptoms of mania

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Client/Family Education (cont.)

• Support services
• Crisis hotline
• Support groups
• Individual psychotherapy
• Legal/financial assistance