MH WK 4 pt 2 Nursing Management of Bipolar Disorder and Mania

Multi-Phase Clinical Goals: Safety, Control, and Stabilization

• Acute Phase Goals:

  • The primary objectives for a patient experiencing a manic episode are safety, behavioral control, and medication stabilization.
  • Destructive behaviors must be identified and managed immediately.
  • Stabilization involves adjusting pharmacological interventions to achieve a baseline mood state.

• Maintenance Phase Goals:

  • The focus shifts to relapse prevention.
  • Strategies include medication adherence education, establishing regular sleep cycles, ensuring proper nutrition, and utilizing community support resources.
  • The end goal is to restore the patient's ability to function within the community, even if the baseline functioning is lower than pre-morbid levels.

• Continued Evaluation:

  • The nursing process requires constant re-evaluation of outcomes and care plans.
  • For unstable patients (e.g., those requiring injections multiple times a day or displaying inappropriate public exposure), care plans may require revision multiple times within a single shift.

• Post-Hospitalization Transitions:

  • Patients may transition to lower levels of care such as an IOP (Intensive Outpatient Program) or a PHP (Partial Hospitalization Program) to maintain stability.
  • Discharge plans may be canceled if significant life stressors occur (e.g., a death in the family), as the stress can trigger a relapse of mania.

Environmental Management and Safety Interventions

• Managing Manipulative and Manic Behaviors:

  • Patients in a manic state may engage in destructive "industrial" behaviors, such as flushing towels, blankets, or excess linen to clog toilets and cause floods.
  • Nurses must monitor the use of hygiene products (ADLs). Manic patients may use excessive amounts of supplies (e.g., four cups of shampoo or conditioner) or misuse them specifically to cause overflow or bubbles in toilets.
  • Roommate assignments should be flexible; roommates are often moved if there is a high risk of theft or property destruction.

• Redirection and Task-Based Interventions:

  • Provide patients with tasks to utilize their hands and focus energy, such as folding laundry or sorting newspaper clippings.
  • Exercise serves as a natural antidepressant. If a patient is hyperactive, allowing they to use a gym or play basketball (e.g., for $5$ to $10$ minutes) with a 1:1 staff escort can help dissipate manic energy.

• Adolescent Unit Vulnerabilities (Ridgeview Case Study):

  • Co-ed environments in adolescent units present high risks for sexual socialization and assault, particularly during idle times or "nap times."
  • Cases of incest or past trauma must be carefully managed by ensuring siblings or involved parties are not placed on the same unit or in the same rooms.
  • Locked bathrooms and constant supervision are necessary to prevent clandestine sexual encounters between patients.

Communication Techniques for the Manic Patient

• The "Firm and Calm" Approach:

  • Communication must be clear, concise, and direct.
  • Limit instructions to short sentences ($3$ to $5$ words), as patients in high-arousal states often cannot process lengthy explanations.

• Consistency and Limit Setting:

  • Minimize splitting behaviors and manipulation by maintaining a unified front among staff.
  • Expectations must be identified in simple, concrete terms (e.g., "You must put on clothes before receiving your meal tray").

• Addressing Complaints:

  • Always listen to and act on legitimate complaints. Even in mania, there is often a grain of truth in patient grievances that must be addressed to maintain therapeutic rapport.

Ethical and Legal Standards for Seclusion and Restraint

• Indication and Criteria:

  • Seclusion and restraint are only permitted when a patient is an immediate harm to themselves or others and all other measures have failed.
  • Aggravating behaviors (e.g., flushing clothes) are not sufficient reasons for restraint; interventions like moves to a quiet room or medication should be prioritized first.

• Documentation and Monitoring:

  • Documentation must be strictly factual and include specific times: e.g., $10:21$ hands-on, $10:24$ medication administration ($Ativan$, $Benadryl$, $Haldol$), $10:25$ four-point restraints applied.
  • Checks must occur every $15$ minutes (some facilities require every $5$ minutes). A staff member must remain at the door at all times.
  • Range of Motion (ROM) must be provided every $1$ to $2$ hours.
  • Patients must be offered biological needs: fluids, food, and bathroom access.

• Legal Orders:

  • Standing orders or PRN (as-needed) orders for seclusion and restraint are illegal.
  • Orders must be renewed frequently (every $1$ to $2$ hours for acute phases, though some facility policies differ).

Pharmacotherapy for Bipolar Disorder

• Lithium Therapy:

  • Requires careful monitoring of hydration. Excessive water or caffeine can disrupt levels.
  • Patients may engage in "water loading" or drinking excessive decaf coffee in an attempt to flush the medication from their system.

• Anticonvulsants (Mood Stabilizers):

  • Depakote (Divalproex): Available in liquid form for patients who attempt to "cheek" pills. The liquid has a strong, unpleasant odor and can be mixed with juice. Look for "red lips" as a clinical sign of liquid medication retention.
  • Lamictal (Lamotrigine): High risk for Stevens-Johnson Syndrome ($SJS$). Patients must be monitored for the development of any rash, as this condition causes severe skin sloughing and can be fatal.
  • Equetro: An extended-release carbamazepine used for mood stabilization.

• Second-Generation Antipsychotics:

  • Zyprexa (Olanzapine): Should not be administered within $30$ to $60$ minutes of $Ativan$ due to risks of cardiac or respiratory depression.
  • Geodon (Ziprasidone): Reconstitution is difficult as the powder is a hard crystal; it requiring vigorous, prolonged shaking with normal saline before injection.
  • Abilify (Aripiprazole): Preferred by many patients because it is weight-neutral and has fewer impacts on sexual functioning.
  • Seroquel (Quetiapine) & Risperdal (Risperidone): Carry black box warnings for usage in the elderly population (increased mortality risk).
  • Saphris (Asenapine): Administered sublingually (melts under the tongue).
  • Vraylar (Cariprazine): A newer medication often used for both mania and depression.

Integrative and Somatic Therapies

• ECT (Electroconvulsive Therapy):

  • Involves inducing a controlled seizure to treat severe levels of depression, catatonia, or chronic suicidal ideation in bipolar patients.

• RTMS (Repetitive Transcranial Magnetic Stimulation):

  • Utilizes magnets to interact with and activate neurons in the brain.

• Therapeutic Modalities:

  • CBT (Cognitive Behavioral Therapy): Primary talk therapy used as an adjunct to medication.
  • Interpersonal and Social Rhythm Therapy: Helps patients build routines, manage social cues, and regulate sleep-wake cycles to prevent relapse.
  • Family-Focused Therapy: Involves the family unit in the rehabilitation process, even if the family was a source of past trauma.

• Support Resources:

  • NAMI (National Alliance on Mental Illness).
  • DBSA (Depression and Bipolar Support Alliance).
  • Mental Health America.