Bipolar Disorders

Bipolar Disorders

Case Study: Alex

  • Alex is a 24-year-old male who arrives at U of L EPS via EMS.

  • He was found wandering the streets, shouting about his invention.

  • Symptoms and behavior:

    • Has not slept in 3 days

    • Exhibits hyperverbal speech and pressured speech

    • Wears flamboyant clothing

    • Spent $5,000 impulsively

    • Intrusive with staff and other patients, attempts to hug strangers, and interrupts conversations

  • Medical history includes:

    • Diabetes

    • Peanut allergy

    • Asthma

  • History includes daily marijuana use.

Bipolar Disorders Overview

  • Characterized by mania or hypomania alternating with depression.

  • Types of Bipolar Disorders:

    • Bipolar I: Includes major depressive episodes, manic episodes, or mixed episodes.

    • Bipolar II: Characterized by major depressive episodes and hypomania.

    • Cyclothymic disorder: Features hypomania and depressive episodes that do not meet full criteria for major depressive episodes.

Mania

Manic Episode Criteria:

  • Defined as a distinct period of abnormally elevated, expansive, or irritable mood combined with abnormally increased goal-directed activity or energy.

  • Duration: at least 1 week (or any duration if hospitalization is necessary).

  • Accompanied by three (or more) of the following symptoms (four if irritability):

    • Inflated self-esteem or grandiosity (delusions of grandeur).

    • Decreased need for sleep (e.g., feels rested after only 3 hours).

    • More talkative than usual, or pressure to keep talking (pressured speech).

    • Flight of ideas or racing thoughts.

    • Distractibility (easily drawn to unimportant or irrelevant stimuli).

    • Increased goal-directed activity (social, work/school, sexual) or psychomotor agitation (purposeless activity).

    • Excessive involvement in activities with high potential for painful consequences (e.g., spending sprees, sexual indiscretions).

Epidemiology and Risk Factors

  • Lifetime prevalence: 1% to 4% (approximately 14.9 million people).

  • Symptom onset: Typically between ages 14 to 21; fewer cases arise after age 40.

  • Female patients: At greater risk for depression and rapid cycling.

  • Male patients: More likely to experience manic episodes.

  • Common comorbid conditions include anxiety disorders (e.g., panic disorder, social phobia) and substance use disorders.

Bipolar I Disorder Across the Life Span

  • Children and Adolescents:

    • Often experience depression first, marked by intense rage.

    • Symptoms are reflective of developmental levels.

  • Older Adults:

    • May exhibit greater neurologic abnormalities and cognitive disturbances.

    • Incidence of manic episodes decreases with advancing age.

Etiology of Bipolar Disorder

Biologic Theories

  • Chronobiologic theories.

  • Genetic factors.

  • Role of chronic stress, inflammation, and kindling.

Psychological and Social Theories

  • Emphasize reducing environmental stress and trauma, especially in genetically vulnerable individuals.

Characteristics of Bipolar I Disorder

  • A chronic, multisystemic cyclic disorder.

  • Earlier onset often correlates with more frequent episodes compared to later onset.

  • Progressive condition with prodromal, symptomatic, and residual states. It can be managed with early diagnosis and tailored treatment.

  • A family history and early onset are linked to increased episodes and persistent symptoms.

Impact of Bipolar I Disorder

  • Can cause severe functional impairment leading to alienation, job loss, indebtedness, and divorce.

  • Common symptoms: mood lability and rapid cycling.

  • Diagnosis requires at least one manic or mixed episode alongside a depressive episode.

Recovery-Oriented Care for Individuals with Bipolar Disorder

  • Emphasizes teamwork and collaboration in treatment efforts.

  • Treatment goals include:

    • Minimizing and preventing manic and depressive episodes.

    • Managing stress, medication adherence, and maintaining social rhythms.

    • Educating patients and families about the disorder for lifelong management.

Evidence-Based Nursing Care of Individuals with Bipolar Disorder

Assessments

  • Mental Health Nursing Assessment:

    • Evaluate physical health changes (activity, eating, sleep patterns).

    • Assess diet and body weight.

    • Laboratory testing (e.g., thyroid function).

    • Gather sexual practices history.

    • Assess past medication use (e.g., antidepressants).

    • Investigate discontinuation of mood stabilizers.

Case Study: Alex’s Assessment

  • Data Summary:

    • Wandering in streets, shouting about inventions, flamboyant clothing, spent $5,000.

    • Symptoms: sleeplessness, hyperverbal and pressured speech, impulsivity, intrusion, interruptions.

  • Physical Health History:

    • Diabetes, peanut allergy, asthma.

  • Substance Use History:

    • Daily marijuana use.

  • Nursing Assessment Steps:

    • Rule out medical causes and reconcile medication history.

    • Conduct a Mental Status Exam (MSE).

    • Perform a risk assessment (suicidal, self-harm, injury, safety).

    • Utilize rating scales for assessment.

    • Evaluate substance use and sleep/functioning.

Case Study: Alex’s Nursing Diagnosis

  • Diagnosis 1: Risk for injury due to impaired judgment and hyperactivity, evidenced by impulsive spending, unsafe wandering, and lack of sleep.

  • Diagnosis 2: Disturbed sleep pattern related to excessive energy and decreased sleep, evidenced by self-reported insomnia for 72 hours and physical restlessness.

  • Diagnosis 3: Impaired social interaction due to intrusive behavior and grandiosity, evidenced by interrupting, hugging strangers, and inappropriate speech.

Therapeutic Relationship with Patients

  • Engaging and exhausting: Important to provide refocusing while maintaining calm.

  • Nurses should avoid power struggles and confrontations.

  • Respect patients' personal space and meet them where they are in their mental state.

Mental Health Nursing Interventions

  • Focus on periods of stable mental health for:

    • Stress reduction strategies.

    • Illness management plans.

    • Relapse prevention strategies.

  • Recovery and Wellness Goals:

    • Ensure adequate rest, hydration, and nutrition.

    • Reestablish physical well-being.

Medication Interventions

Lithium

  • Classification: A mood stabilizer (salt).

  • Important balance between lithium levels, sodium, and fluid volume.

    • High sodium levels can lead to low lithium levels, and vice versa.

    • Decreased body fluid volume leads to increased lithium levels and potential toxicity.

  • Therapeutic Range for Lithium: 0.6-1.2 MEQ/L (maintenance).

  • Moderate Toxicity Symptoms: Confusion, dysarthria, nystagmus, myoclonic twitches, ECG changes.

  • Severe Toxicity Symptoms: Life-threatening conditions such as impaired consciousness, increased deep tendon reflexes, seizures, renal insufficiency, coma, or death.

  • Actions if toxicity is noted:

    • Withhold further doses of lithium.

    • Notify the provider.

    • Obtain lithium level for assessment.

    • Increase fluid intake.

Divalproex Sodium (Valproic Acid) (Depakote)

  • Classification: Anticonvulsant for mania, mixed mania, and rapid cycling.

  • Assessments Required:

    • Baseline and every 6 months CBC with differential and liver function tests.

    • Monitor Divalproex level weekly until therapeutic, then every 6 months.

  • Therapeutic Range: 50 to 120 ng/mL.

  • Symptoms of Toxicity: Dizziness, agitation, stupor, disorientation, tachycardia, hypotension/hypertension, nausea/vomiting, coma, shock, respiratory depression, nystagmus, neuromuscular disturbances.

  • Black Box Warning: Hepatotoxicity risk.

Carbamazepine

  • Classification: Anticonvulsant with mood stabilizing effects.

  • Laboratory Monitoring Required:

    • Baseline and at months 1 and 3, then yearly CBC with differential and liver function tests.

    • Carbamazepine level monitored monthly until therapeutic.

  • Therapeutic Range: 8-12 ng/mL.

  • Symptoms of Toxicity: Similar as above, including agitation, stupor, changes in heart rate, respiratory issues.

  • Black Box Warning: Aplastic anemia and agranulocytosis risk.

Lamotrigine

  • Focus on depressive episodes; approved for maintenance treatment of bipolar depression.

  • Dosing Caution: Requires slow dose titration and monitoring for potential risk of Stevens-Johnson Syndrome.

  • Important to assess for rashes as a potential side effect.

Antipsychotics

  • Known for broad efficacy in treating Bipolar Disorders.

  • Examples of Atypical Antipsychotics:

    • Aripiprazole (Abilify)

    • Asenapine (Saphris)

    • Cariprazine (Vraylar)

    • Lurasidone (Latuda)

    • Olanzapine (Zyprexa)

    • Quetiapine (Seroquel)

    • Risperidone (Risperdal)

    • Ziprasidone (Geodon)

    • Paliperidone (Invega)

Mental Health Nursing Interventions

Therapeutic Interactions

  • Focus on safety and milieu therapy, with interventions like:

    • Cognitive Behavioral Therapy (CBT)

    • Interpersonal Therapy

    • Adjunctive therapies for comprehensive care.

Psychosocial Interventions

  • Enhancing cognitive and behavioral functioning:

    • Teaching symptom management strategies.

    • Family education and incorporation of support groups.

    • Emphasis on psychoeducation and collaborative care, promoting an interdisciplinary approach.

Case Study: Alex’s Plan

  • Treatment plan includes:

    • Admission to inpatient unit.

    • Stabilization on medication for managing Bipolar Disorder I (current manic episode).

    • Frequent observation to ensure safety throughout treatment.

Case Study: Alex’s Implementation

  • Care steps include:

    • Placement in a private room to minimize stimuli and ensure therapeutic milieu.

    • Monitor for escalating behaviors to intervene early.

    • Set clear, consistent limits on behavior to create structure.

    • Encourage rest periods and meal breaks for physical recovery.

    • Maintain continuous evaluation of suicidal ideation/self-harm.

    • Collaborate with provider for effective medication management (e.g., mood stabilizers, atypical antipsychotics, monitor side effects and efficacy).

    • As stabilization occurs, reinforce medication adherence and encourage group and individual therapy participation.

Case Study: Alex’s Evaluation

  • After 8 days on the unit:

    • Alex remains adherent to medications: Olanzapine (Zyprexa) 10 mg daily and Lithium 450 mg BID.

    • Notable improvement: now able to sleep 6 hours per night.

    • Shows remorse over spending and prior behaviors, reducing hyperverbal and pressured speech.

    • Significant reduction in grandiosity.

    • Actively engages in discussions about his diagnosis, medication, and therapy.

Case Study: Alex’s Evaluation Indicators of Progress

  • Overall reduction in manic symptoms observed.

  • Improvement seen in sleep patterns, insight, judgment, and interpersonal skills.

  • Alex is ready to engage in psychoeducation and therapy.

If Outcomes Not Met

  • Steps to consider:

    • Reassess symptoms, barriers, and stressors affecting treatment.

    • Evaluate the need for medication adjustments with the healthcare team.

    • Collaborate with social worker for access to individual therapy services.


Priorities for nursing care in patients with bipolar disorder focus on ensuring safety, stabilization, and effective treatment management:

  1. Safety Assessment

    • Conduct a risk assessment to evaluate potential self-harm and suicidal ideation.

    • Monitor for escalating behaviors and intervene early to prevent harm.

  2. Medication Management

    • Collaborate with healthcare providers for effective medication management, including mood stabilizers and antipsychotics.

    • Regularly assess for medication adherence, side effects, and therapeutic response.

  3. Therapeutic Environment

    • Maintain a therapeutic milieu by creating a structured and supportive environment.

    • Limit environmental stimuli when necessary to minimize agitation and distractions.

  4. Physical Health Monitoring

    • Evaluate physical health changes, including sleep patterns, diet, and activity levels.

    • Ensure regular laboratory testing for monitoring medication levels and potential toxicity symptoms.

  5. Psychoeducation and Support

    • Educate patients and families about bipolar disorder for ongoing management and understanding of the disease.

    • Encourage participation in therapy and support groups to foster coping strategies and recovery.

  6. Crisis Intervention

    • Be prepared to manage acute manic or depressive episodes, ensuring rapid response to patient needs.

    • Take proactive measures to mitigate risks associated with impulsive behavior during manic episodes.

  7. Collaborative Care

    • Work within an interdisciplinary team to provide holistic care, ensuring the patient's needs are met across various domains of health.

    • Engage in open communication and share observations about the patient's condition with the healthcare team.

By prioritizing these nursing interventions, the aim is to stabilize the patient's condition, reduce symptoms, and foster recovery.