NCP Bipolar Disorders

DSM-IV

296.xx Bipolar I disorder

296.0x Single manic episode

296.40 Most recent episode hypomanic

296.4x Most recent episode manic

296.6x Most recent episode mixed

296.7 Most recent episode unspecified

296.5x Most recent episode depressed

296.89 Bipolar II disorder (recurrent major depressive episodes with hypomania)

301.13 Cyclothymic disorder

296.80 Bipolar disorder NOS

Bipolar disorders are characterized by recurrent mood swings of varying degree from depression to elation with intervening periods of normalcy. Milder mood swings such as cyclothymia may be manifested or viewed as everyday creativity rather than an illness requiring treatment. Hypomania can actually enhance artistic creativity and creative thinking/ problem-solving.

This plan of care focuses on treatment of the manic phase. (Note: Bipolar II disorder is characterized by periods of depression and hypomania, but without manic episodes.) Refer to CP: Depressive Disorders for care of depressive episode.

ETIOLOGICAL THEORIES

Psychodynamics

Psychoanalytical theory explains the cyclic behaviors of mania and depression as a response to conditional love from the primary caregiver. The child is maintained in a dependent position, and ego development is disrupted. This gives way to the development of a punitive superego (anger turned inward or depression) or a strong id (uncontrollable impulsive behavior or mania). In the psychoanalytical model, mania is viewed as the mirror image of depression, a “denial of depression.”

Biological

There is increasing evidence to indicate that genetics plays a strong role in the predisposition to bipolar disorder. Research suggests a combination of genes may create this predisposition. Incidence among relatives of affected individuals is higher than in the general population. Biochemically there appear to be increased levels of the biogenic amine norepinephrine in the brain, which may account for the increased activity of the manic individual.

Family Dynamics

Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned by a significant other during the first 6 months of life. The bonding process is interrupted and the child withdraws from people and the environment. Rejection by parents in childhood or spending formative years with a family that sees life as hopeless and has a chronic expectation of failure makes it difficult for the individual to be optimistic. The mother may be distant and unloving, the father a less-powerful person, and the child expected to achieve high social and academic success.

CLIENT ASSESSMENT DATA BASE (MANIC EPISODE)

Activity/Rest

Disrupted sleep pattern or extended periods without sleep/decreased need for sleep (e.g., feels well rested with 3 hours of sleep)

Physically hyperactive, eventual exhaustion

Ego Integrity

Inflated/exalted self perception, with unrealistic self-confidence

Grandiosity may be expressed in a range from unrealistic planning and persistent offering of unsolicited advice (when no expertise exists) to grandiose delusions of a special relationship to important persons, including God, or persecution because of “specialness”

Humor attitude may be caustic/hostile

Food/Fluid

Weight loss often noted

Hygiene

Inattention to ADLs common

Grooming and clothing choices may be inappropriate, flamboyant, and bizarre; excessive use of makeup and jewelry

Neurosensory

Prevailing mood is remarkably expansive, “high,” or irritable

Reports of activities that are disorganized and flamboyant or bizarre, denial of probable outcome, perception of mood as desirable and potential as limitless

Mental Status: Concentration/attention poor (responds to multiple irrelevant stimuli in the environment), leading to rapid changes in topics (flight of ideas) in conversation and inability to complete activities

Mood: labile, predominantly euphoric, but easily changed to anger or despair with slightest provocation; mood swings may be profound with intervening periods of normalcy

Delusions: paranoid and grandiose, psychotic phenomena (illusions/hallucinations)

Judgment: poor, irritability common

Speech: rapid and pressured (loquaciousness), with abrupt changes of topic; can progress to disorganized and incoherent

Psychomotor agitation

Safety

May demonstrate a degree of dangerousness to self and others; acting on misperceptions

Sexuality

Increased libido; behavior may be uninhibited

Social Interactions

May be described or viewed as very extroverted/sociable (numerous acquaintances)

History of overinvolvement with other people and with activities; ambitious, unrealistic planning; acts of poor judgment regarding social consequences (uncontrolled spending, reckless driving, problematic or unusual sexual behavior)

Marked impairment in social activities, relationship with others (lack of close relationships), school/occupational functioning, periodic changes in employment/frequent moves

Teaching/Learning

First full episode usually occurs between ages 15 and 24 years, with symptoms lasting at least 1 week

May have been hospitalized for previous episodes of manic behavior

Periodic alcohol or other drug abuse

DIAGNOSTIC STUDIES

Drug Screen: Rule out possibility that symptoms are drug-induced.

Electrolytes: Excess of sodium within the nerve cells may be noted.

Lithium Level: Done when client is receiving this medication to ensure therapeutic range between 0.5 and 1.5 mEq/liter.

NURSING PRIORITIES

1. Protect client/others from the consequences of hyperactive behavior.

2. Provide for client’s basic needs.

3. Promote reality orientation, realistic problem-solving, and foster autonomy.

4. Support client/family participation in follow-up care/community treatment.

DISCHARGE GOALS

1. Remains free of injury with decreased occurrence of manic behavior(s).

2. Balance between activity and rest restored.

3. Meeting basic self-care needs.

4. Communicating logically and clearly.

5. Client/family participating in ongoing treatment and understands importance of drug therapy/monitoring.

6. Plan in place to meet needs after discharge.