Mania

Bipolar: Assessment/Clinical Manifestations

• Rapid cycling bipolar illness occurs when there are more than 4 episodes of mood disturbance in a year.

• Bipolar I has more severe mood swings than Bipolar II (full mania and depression)

• Bipolar II has hypomania and depression

• These can be all manic episodes or mixed manic and depressive episodes.

• It can also refer to people who go from mania to depression (or depression to mania) with little time spent in a stable mood.

• Some individuals cycle at slower rates.

Positive Bipolar Symptoms

• Hallucinations

• Delusions

• Disorganized speech (associative looseness)

• Bizarre behavior

Negative Bipolar Symptoms

• Blunted affect

• Poverty of thought (alogia)

• Loss of motivation (avolition)

• Inability to experience pleasure or joy (anhedonia)

Cognitive Bipolar Symptoms

• Inattention, easily distracted

• Impaired memory

• Poor problem-solving skills

• Poor decision-making skills

• Illogical thinking

• Impaired judgment

Affective Bipolar Symptoms

• Dysphoria

• Suicidality

• Hopelessness

Mania Affect Clinical Manifestations

• Extroverted

• Irritable/Brittle

• Overly optimistic

• Euphoric/ High

• Labile

• Lack of shame or guilt

• Overly humorous

• Low intimacy

Cognition Mania Clinical Manifestations

• Poor insight

• Impulsive/Poor Judgment

• No introspection

• Poor concentration

• Flight of ideas

• Loose association

• Poor realty testing

• Very distractible

• Grandiose & Persecutory delusions

• Weak ego boundaries

Mania Physiological Clinical Manifestations

• Weight loss

• Dehydration

• Poor nutrition

• Lack of sleep

• Does not feel tired

Mania Behavioral Clinical Manifestations

• Pressured speech

• Increased libido

• Spending sprees

• Restlessness

• Wastes energy

• Legal troubles

• Aggressive

• Irresponsible

• Inappropriate attire

• Socially intrusive

Mania Nursing Diagnoses

Risk for violence self or other directed

Risk for injury

Self-care deficit

Altered thought process

Impaired social interaction

Ineffective role performance

Sexual dysfunction

Dysfunctional family process

Disturbed sleep patterns

Ineffective health maintenance

Ineffective coping

Noncompliance

Imbalanced nutrition

Impaired verbal communication

Knowledge deficit

Mania Goals

Patient will sleep at least 6-8 hours each night.

Patient will not lose weight.

Patient will not harm self or others.

Patient will dress appropriately.

Patient will not have pressured speech.

Patient will not be socially intrusive.

Patient’s verbalize thoughts will be organized and reality

based.

Patient will follow medical regimen and treatment plan.

Mania Interventions

• Psychopharmacology:

  • mood stabilizers

  • antipsychotic medication

  • sedatives

  • hypnotics

  • anti-anxiety agents

  • antidepressants

Most patients will need to remain on a mood stabilizer to prevent further manic episodes.

Mood Stabilizer

Lithium & Anticonvulsants

• Acute mania

• Bipolar Disorder

• Non psychiatric (anticonvulsants) uses:

  • anti-seizure

  • chronic pain

Lithium Medications

• Carbolith

• Cibalith-S

• Duralith

• Eskalith

• Lithane

• Lithizine

• Lithobid

• Lithonate

• Lithotabs

Acute mania doses:1800-2400mg/day

Maintenance doses: 300-1200mg/day

Acute Mania Doses For Lithium

1800-2400mg/day

Maintenance Mania Doses For Lithium

300-1200mg/day

Lithium

• Used to treat manic phase of bipolar illness and keep mood stable

• May take several days to get to therapeutic level and may need to give patient antipsychotic to help sedate

• It is excreted un-metabolized by the kidney. Need good renal function and adequate sodium and water (2.5-3L) intake.

• Normal side effects include: fine hand tremors, polyuria, headache, weight gain, drowsiness (care with driving)

• Long term use may cause hypothyroidism

• May be taken with food or milk if it irritates stomach

Nursing Considerations for Lithium (Signs)

• Check for signs of lithium toxicity:

blurred vision

nausea & vomiting

diarrhea

ataxia

tinnitus

drowsiness

• Lithium toxicity can lead to death from:

renal failure

cardiac dysrhythmias

CNS disturbances: seizures, blackouts, vertigo

Nursing Considerations for Lithium (Labs/Range)

• Lithium serum levels should be drawn in AM prior to first AM dose.

• BUN and Creatinine blood levels should initially be drawn weekly

• During initial treatment lithium levels may be taken several times a week. On maintenance: once a month.

• Lithium levels:

maintenance — 0.5-1.0 (0.6-1.2) mEq/l

acute treatment -- 0.5- 1.5

toxicity—above 1.5

If lithium level is too high or signs of toxicity are present, DO NOT ADMINISTER LITHIUM AND CALL PHYSICIAN

Maintenance Lithium Levels

0.5 - 1.0 (0.6 - 1.2) mEq/l

Acute Treatment Lithium Levels

0.5 - 1.5 mEq/l

Lithium Toxicity

> 1.5 mEq/l

Nursing Consideration for Lithium (Thyroid Gland)

Thyroid function tests should be done on admission and periodically

Abnormal results should be reported immediately

Check for development of goiter

Anticonvulsants

• Gabapentin (Neurontin)

• Lamotrigine (Lamictal)

• Carbamazepine (Carbatrol, Tegretol)

• Topiramate (Topamax)

• Valproic acid (Depakene, Depakote)

Regular blood serum levels are done to prevent toxicity and insure therapeutic levels.

Mania: Interventions

• Safe structured environment

• Consistent clear limit setting

• Avoid environmental over-stimulation

• Prevent social intrusiveness—private room, limit group activities, avoid competitive activities

• Channel excess energy into safe activity

• Help to dress appropriately—do not allow patient to lose dignity

• Monitor eating and weight—finger foods, high calorie foods, extra fluids, small frequent servings

• Assist with sleep rituals, hypnotic medications, if stays awake keep busy with quiet activities

• Monitor hygiene and physical status as patient my ignore

Mania (Delusions): Interventions

Initially explore then briefly reassess

Refocus to reality based activity

Distract through activity

Discuss underlying feelings (ex. fear or anger)

Acknowledge their perspective but state it is not shared; do not say “It is all in your head.”

Inform that clinical manifestations are part of the illness Explore the relationship between stress and adaptation

Do not try to argue, prove wrong, demean or ridicule

More Mania Interventions

Patient & family education: What is bipolar illness?

Medication: Know therapeutic and side effects, take as prescribed, need for monitoring blood levels

Interventions: Keep regular sleeping hours, use debit cards & limit access to funds

Support groups www.dbsalliance.org - Depression and Bipolar Support Alliance www.bpso.org - BPSO (Bipolar Significant Other)

Signs of escalating mood:

• excess energy

• irritability

• impulsivity

• increased sexuality

• racing ideas and rapid speech

Mania: Evaluations

Patient sleeps at least 6-8 hours each night.

Patient weight has remained stable.

Patient has not harmed self or others.

Patient dresses appropriately.

Patient speech is of a normal rate and volume.

Patient is not socially intrusive.

Patient’s verbalize thoughts are organized and reality

based.

Patient follows medical regimen and treatment plan.