Bipolar Disease

Understanding Bipolar Disorder

  • Definition: Bipolar disorder is a mood disorder characterized by recurring cycles of extreme lows (depression) and extreme highs (mania).

Mood Cycling

  • Depressive Phase:

    • Characteristics: Very low mood, low energy, low motivation.

    • Risk: High risk for suicide.

  • Manic Phase:

    • Characteristics: High energy, hyperactivity, elevated mood, potential aggression, and violence.

  • Memory Aid: "Bipolar like a bicycle" - two wheels for two moods (highs and lows) cycling like a bicycle.

    • Depression: Declined mood.

    • Mania: Elevated mood (think "maniac" for more energy).

Types of Bipolar Disorder

  • Bipolar I Disorder:

    • Characterized by at least one episode of mania lasting more than one week or the need for hospitalization.

  • Bipolar II Disorder:

    • Involves two episodes of milder hypomania, which may last longer than those in Bipolar I.

  • Cyclothymia:

    • Persistent mild lows and mild highs over a two-year cycle.

  • Rapid Cycling:

    • Diagnosed when cycling occurs four or more times within a twelve-month period (Hesi) or five times as per ATI.

Causes and Risk Factors

  • Unknown Cause: The precise cause of bipolar disorder is not known but genetics play a significant role.

    • Family History: Having a family member with bipolar disorder increases the likelihood by tenfold for Bipolar II.

  • Triggers: Selective Serotonin Reuptake Inhibitors (SSRIs) can induce a manic episode in patients during depressive phases.

    • Definition of SSRIs: A class of antidepressants typically prescribed for treating depression.

Signs and Symptoms of Mania

  • Acronym Memory Aids:

    • M stands for More Energy and Mood Swings (Euphoric energy).

    • Clients may show impulsivity and grandiosity, experiencing hallucinations and delusions of grandeur, like believing they possess supernatural powers.

    • A for Agitation: Setting limits and creating a structured environment helps manage agitation.

    • N for Nonstop Talking and Flight of Ideas: Patients exhibit rapid speech and varied thoughts.

    • I for Insomnia: High energy results in the inability to sleep for extended periods.

    • A for Attention Span: Clients are often easily distracted, necessitating reduced stimuli in their environment.

Manic Behavior Symptoms (as per ATI and Hesi)

  • More talkative than usual.

  • Easily distracted.

  • Intense need for activity.

  • Quick anger and flight of ideas.

  • Colorful or outlandish clothing.

Nursing Interventions for Acute Mania

  • Environment Management:

    • Provide a private room near the nurse's station to observe the patient closely while minimizing stimuli.

    • Avoid: Group contact, dining areas, and group activities; prefer one-on-one interactions.

    • Encourage physical activities like aerobic exercises to help manage excess energy.

  • Setting Limits: Establish clear consequences for aggressive behavior; for example, a one-hour room stay if rules are broken.

  • Dietary Considerations:

    • Increased caloric and fluid requirements during manic episodes; aim for high-calorie and high-protein foods that can be eaten without utensils.

    • Suggested Foods: Handheld options like hamburgers, sandwiches, burritos, milkshakes, protein shakes, fruits, and veggies.

    • Big No-No: Avoid caffeine as it may exacerbate mania.

  • Education on Medications:

    • For mania, anxiolytics (e.g., benzodiazepines like clozapine, alprazolam) are utilized

    • For depression, antidepressants should always be combined with mood stabilizers to mitigate the risk of triggering mania.

Medication Overview

  • Three Main Mood Stabilizers:

    1. Carbamazepine:

    • Indications: Treatment for bipolar disorder and seizures, also for trigeminal neuralgia.

    • Side Effects: Risk of leukopenia (low white blood cell count) leading to infection; report fever and sore throat. Risk of accidental pregnancy (oral contraceptives may be ineffective).

    1. Valproic Acid:

    • Indication: Prescribed for bipolar disorder and epilepsy.

    • Side Effects: Liver toxicity, thrombocytopenia (low platelets leading to bleeding risks); monitor for jaundice and liver lab values (ALT, AST). Also contraindicated in pregnancy and should not be stopped abruptly.

    1. Lithium:

    • Long-term treatment for both bipolar and schizoaffective disorders; known for its long-lasting effects.

    • Therapeutic Range: Normal range is 0.6 to 1.2; toxicity occurs above 1.5.

      • Risk of Toxicity: Increased risk in patients with renal dysfunction, report signs like tinnitus, nephrotoxic effects (creatinine > 1.3, urine < 30mls/hour).

      • Acronym for Lithium: LIFT (Levels > 1.5; Increase fluid and sodium; Toxic signs; Hold NSAIDs).

  • Fluid and Sodium Management:

    • Increase fluids to prevent dehydration (1-3 liters per day).

    • Avoid sodium restriction to prevent toxicity.

    • Educate patients on signs of dehydration like excessive urination, extreme thirst, tremors, confusion.

Common Side Effects of Medications

  • Dry mouth and thirst: Manage with ice chips, gum, and oral hygiene.

  • Drowsiness and fatigue: Caution patients against driving.

  • Weight gain: Encourage proper diet and exercise, address any decreased appetite.

  • Gastrointestinal upset: Minor disturbances may occur.

Key Exam Tips

  • Focus on medication combinations for treating bipolar disorder, especially the critical role of mood stabilizers in conjunction with antidepressants.

  • For NCLEX questions regarding lithium toxicity, remember high-risk conditions, signs to report, and fluid management protocols.

  • No NSAIDs should be prescribed due to their adverse effects on kidney function in patients on lithium.