Bipolar Disorder Nursing Care Management Guide

Bipolar disorder, once called manic-depressive illness, swings mood, energy, and activity between extremes: manic or hypomanic highs (energized, euphoric, impulsive) and depressive lows (sad, hopeless, lethargic), with stretches of normalcy between. On the unit the manic phase is what tests you, because the patient is in constant motion, makes high-risk decisions, and can exhaust or injure themselves before the medication takes hold. The illness also carries early mortality, mostly from cardiovascular disease.

What is Bipolar Disorder?

Bipolar disorders are mood disorders that swing from profound depression to extreme euphoria (mania) with intervening normalcy. What sets them apart from other affective disorders is recurring manic or hypomanic episodes alternating with depression. Bipolar I has overt manic episodes (grandiosity, decreased need for sleep, often psychotic features). Bipolar II is depression alternating with hypomania.

Types of Bipolar Disorder

• Bipolar I disorder. A full syndrome of manic or mixed symptoms, current or past; the patient may also have had depressive periods.
• Bipolar II disorder. Recurrent major depression with episodic hypomania, never a full manic or mixed syndrome.
• Cyclothymic disorder. A chronic mood disturbance of at least 2 years with numerous periods of depression and hypomania, but not severe or long enough to meet criteria for bipolar I or II.
• Bipolar disorder due to a general medical condition. A prominent, persistent mood disturbance judged to be the direct physiological result of a medical condition (APA, 2000).
• Substance-induced bipolar disorder. Bipolar symptoms considered the direct physiological result of a substance (drug use or abuse, medication, or toxin exposure).

Pathophysiology

The pathophysiology of bipolar disorder is not settled, and no objective biologic marker defines the disease state. The genetic component is complex, likely driven by multiple common disease alleles, each adding a small amount of risk. Many loci are now linked to it, grouped as major affective disorder (MAFD) loci and numbered in the order of discovery.

Statistics and Incidences

Global life-long prevalence is 0.3 to 1.5%. In the United States it runs 0.9 to 2.1%. For both bipolar I and II, age range runs from childhood to 50 years, with a mean of about 21 years. Bipolar I hits both sexes equally, but rapid-cycling bipolar disorder is more common in women.

Causes

• Biological. Twin studies show a concordance rate of 60% to 80% in monozygotic twins versus 10% to 20% in dizygotic twins.
• Biochemical. Norepinephrine and dopamine run low in depression; the reverse appears true in mania.
• Physiological. Right-sided lesions in the limbic system, temporobasal areas, basal ganglia, and thalamus can induce secondary mania.
• Medication side effects. Some drugs trigger mania, most commonly the steroids used for chronic illnesses like multiple sclerosis and systemic lupus erythematosus.

Clinical Manifestations

Heightened, grandiose, or agitated mood, a continuous high of elation and euphoria. Exaggerated self-esteem with discarded inhibitions and sexual or behavioral indiscretions. Sleeplessness, with rest abandoned for days or weeks. Pressured speech that is hard to interrupt. Flight of ideas, rapidly shifting from topic to topic. Distractibility and a short attention span. Constant motor activity. Multiple grandiose, high-risk activities with poor judgment and severe consequences.

Assessment and Diagnostic Findings

Bipolar disorder spans both depression and mania, and many medical conditions can mimic either, so the workup is broad:

• Complete blood count. With differential, to rule out anemia as a cause of depression.
• Erythrocyte sedimentation rate. An elevated ESR points to an underlying disease process such as lupus or infection.
• Fasting glucose. To rule out diabetes.
• Electrolytes. Especially sodium, which ties to depression.
• Proteins. Low serum protein in depressed patients may reflect poor eating.
• Thyroid hormones. To rule out hyperthyroidism (mania) and hypothyroidism (depression).
• Creatinine and BUN. Kidney failure can present as depression, and lithium can affect urinary clearance, raising serum creatinine and blood urea nitrogen.
• Substance and alcohol screening. Alcohol and many drugs can present as mania or depression.
• MRI. Value is unclear, but it is sometimes performed.
• Electrocardiography. Many antidepressants (especially tricyclics) and some antipsychotics affect cardiac conduction.

Medical Management of Bipolar Disorder

Treatment tracks the phase (depression or mania) and its severity. Psychotherapy helps but does not cure; studies show lower relapse rates, better quality of life, improved functioning, and symptom improvement. Electroconvulsive therapy (ECT) fits when rapid definitive treatment is needed, when its risks beat the alternatives, when the disorder is refractory to adequate trials, or when the patient prefers it. On diet, warn patients against changing salt intake: more salt lowers serum lithium (less effect), less salt raises it (toxicity). Patients in a depressed state are encouraged to exercise and keep a regular daily schedule, especially sleep and wake times.

Pharmacological Management

• Anxiolytics, benzodiazepines. Potentiate GABA and facilitate inhibitory neurotransmission.
• Mood stabilizers. Lithium is the standard for prophylaxis and treatment of manic episodes.
• Anticonvulsants. Prevent mood swings, especially in rapid cyclers.
• Antipsychotics, 2nd generation. Atypicals are increasingly used for acute mania and mood stabilization in bipolar I.
• Antipsychotics, 1st generation. Conventional or typical agents treat psychotic and nonpsychotic manic and mixed episodes and hypomania.
• Antipsychotics, phenothiazine. Classed as first-generation, with the same range of efficacy.
• Antiparkinson agents, dopamine agonists. Non-ergot agents that bind D2 and D3 dopamine receptors in the striatum and substantia nigra.

Nursing Management for Bipolar Disorder

Nursing Assessment

• History. Hard to take during a manic phase; use several short sessions and family input.
• General appearance and motor behavior. Psychomotor agitation and near-perpetual motion; sitting still is difficult, and patients can exhaust or injure themselves.
• Mood and affect. Euphoria, exuberant activity, grandiosity, false sense of well-being.
• Thought process and content. Confused and jumbled, racing thoughts and flight of ideas, jumping subject to subject.

Nursing Diagnosis for Bipolar Disorder

Risk for other-directed violence related to manic excitement, suspicion, paranoid ideation. Risk for injury related to extreme hyperactivity and destructive behavior. Imbalanced nutrition, less than body requirements, related to inability to sit still long enough to eat. Disturbed thought processes related to psychotic process. Disturbed sensory perception related to sleep deprivation and psychotic process.

Nursing Care Planning and Goals

After 24 hours with tranquilizing medication the patient will no longer make potentially injurious movements and will sustain no physical injury. Agitation will stay manageable with tranquilizing medication during the first week of treatment. The patient will not harm self or others, will consume enough finger foods and between-meal snacks to meet recommended daily nutrient allowances, and within one week will recognize and verbalize when thinking is not reality-based or when the environment is being misinterpreted.

Nursing Interventions

• Provide safety. Establish external controls emphatically and nonjudgmentally for patients who feel out of control.
• Meet physiologic needs. Cut environmental stimulation (no noise, TV, distractions); finger foods the patient can eat on the move improve nutrition.
• Provide therapeutic communication. Use simple, clear sentences and break information into small segments, since attention spans are short.
• Promote appropriate behavior. Channel the need for movement into acceptable large-motor activity like arranging chairs or walking.
• Manage medications. Use periodic serum lithium levels to keep the dose at a treatment or maintenance level and to protect the patient.

Evaluation

The patient distinguishes reality from unreality, intervenes to stop non-reality-based thoughts, gains or maintains weight during hospitalization, shows no violent behavior, and no longer shows physical agitation.

Documentation Guidelines

Document individual findings (affecting factors, interactions, nature of social exchanges, specific behaviors), cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and progress toward the desired outcome.