Bipolar disorder is a mental health condition characterized by very high moods (manic or hypomanic episodes) and depression. There are several types of bipolar disorder.
Manic and hypomania (a less severe form of mania) include the following symptoms:
- Hyperactivity
- Euphoria
- Racing thoughts
- An exaggerated sense of grandiosity and self-importance
- Poor decision-making resulting in shopping sprees or inappropriate dress
- Manipulation
- Risk-taking behaviors such as driving vehicles at high speeds or participating in unprotected sex
- Socially inappropriate behavior affecting relationships and workplaces
Depressive episodes, on the other hand, affect day-to-day activities:
- Feelings of sadness or hopelessness
- Loss of interest or pleasure in activities
- Loss of energy
- Inability to concentrate
- Suicidal ideation
Bipolar disorder is a life-long mental illness and treatment focuses on managing symptoms through psychotherapy and mood stabilizers, antipsychotics, antidepressants, and anti-anxiety medications.
Nursing Process
Patients who require inpatient treatment for bipolar disorder are likely experiencing either a manic or depressive episode and need supervision and intervention by trained psychiatric nurses. Nurses may also interact with patients with bipolar disorder when treating subsequent disorders such as substance abuse disorders or general health conditions.
Nursing Assessment
Effective nursing assessment and intervention are essential to managing bipolar disorder, promoting patient well-being, and preventing complications.
Initial Evaluation
The initial evaluation of a patient with suspected bipolar disorder involves a thorough medical history, mental status examination, and diagnostic tests. Key aspects to assess include:
Medical History
Review the patient’s history for risk factors such as family history of bipolar disorder, previous episodes of mood swings, substance abuse, and significant life stressors. Inquire about symptoms such as periods of elevated mood, increased energy, decreased need for sleep, racing thoughts, impulsivity, depression, and suicidal ideation.
Mental Status Examination
Conduct a comprehensive mental status examination to evaluate the patient’s mood, affect, thought processes, speech patterns, and cognitive function. Observe for signs of mania or hypomania, such as grandiosity, distractibility, and hyperactivity, as well as symptoms of depression, such as hopelessness, fatigue, and anhedonia.
Diagnostic Tests
Utilize standardized screening tools and questionnaires to assess the severity and frequency of mood episodes. Collaborate with other healthcare professionals to conduct laboratory tests and imaging studies to rule out medical conditions that may mimic bipolar disorder.
Nursing Intervention
Effective nursing care for bipolar disorder patients revolves around creating and implementing tailored nursing care plans based on accurate nursing interventions.
Acute Management
Addressing acute episodes of mania or depression requires prompt and effective intervention. Key strategies include:
- Medication Management: Administer mood stabilizers, antipsychotics, and antidepressants as prescribed to stabilize mood and prevent relapse.
- Safety Measures: Implement measures to ensure the patient’s safety, including supervision and a safe environment, to prevent self-harm or harm to others.
- Therapeutic Communication: Provide support and reassurance to help the patient cope with distressing symptoms and encourage adherence to treatment.
Long-term Management
Preventing recurrent episodes and minimizing complications requires addressing underlying causes and educating the patient on long-term strategies. Key interventions include:
Follow-up Care
- Schedule regular follow-up appointments to monitor the patient’s progress, adjust treatment plans, and address any emerging symptoms or complications.
- Encourage the patient to maintain a mood diary, recording mood changes, medication usage, and any side effects, to facilitate ongoing evaluation and adjustment of interventions.
Patient Education
- Provide comprehensive education on the importance of adherence to medication and other prescribed treatments.
- Educate patients and their families about the potential health risks associated with untreated bipolar disorder and the benefits of effective management.
Supportive Interventions
- Encourage participation in psychotherapy, such as cognitive-behavioral therapy (CBT), to develop coping skills and manage triggers.
- Promote a healthy lifestyle, including regular exercise, a balanced diet, and adequate sleep, to support overall mental health and well-being.
- Foster a strong support network, including family, friends, and support groups, to provide emotional support and encouragement.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a bipolar disorder, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for bipolar disorder.
Disturbed Thought Processes
Patients with bipolar disorder may experience a range of disturbed thoughts.
Nursing Diagnosis: Disturbed Thought Processes
Related to:
- Sleep deprivation
- Psychotic process
- Substance abuse
As evidenced by:
- Distractibility
- Egocentricity
- Impaired decision-making
- Suspiciousness
- Delusional thinking
- Hypervigilance
- Hallucinations
Expected Outcome:
- Patient will display reality-based thinking with an absence of delusions by discharge
- Patient will recognize and verbalize when thoughts are not reality-based
- Patient will verbalize an absence of hallucinations
Assessment:
1. Determine alcohol or drug use.
Substances can increase delusional thoughts or impair judgment and have a cumulative effect on an already unstable mentality.
2. Assess for hallucinations.
Auditory hallucinations are most common in a psychotic state and cause delusions that range from believing someone is out to harm them to exaggeration about their ability to possess special powers.
3. Assess attention span and problem-solving.
In communication with the patient, assess their ability to maintain a train of thought, interpret information, and make appropriate decisions.
Interventions:
1. Reorient and focus on reality.
Reorient the patient to person, place, and time as needed. Focus on reality during conversation such as discussing current events to divert from false ideals.
2. Provide positive reinforcement.
When the patient differentiates between reality and delusions provide positive and supportive reinforcement.
3. Do not accept nor deny beliefs.
The nurse should not accept the patient’s delusions as facts as this only reinforces false thinking. The nurse should also not outwardly deny or argue beliefs as this will only alienate the patient and harm a therapeutic relationship.
4. Teach thought-stopping techniques.
Instruct the patient on techniques to stop intrusive thoughts such as yelling “stop!” or clapping the hands when the patient has an unwanted thought as this can prevent further harmful emotions and behaviors.
Insomnia
Bipolar disorder often causes insomnia as the patient experiences a decreased need for sleep.
Nursing Diagnosis: Insomnia
Related to:
- Hyperactivity
- Use of stimulants
- Disorder process
- Distractibility
As evidenced by:
- Difficulty falling asleep
- Decreased need for sleep
- Sleeping for only short periods
- Awakening very early
Expected Outcomes:
- Patient will sleep at least 6-7 hours per night by discharge
- Patient will apply two interventions to improve sleep
- Patient will exhibit decreased restlessness and exhaustion due to adequate sleep
Assessment:
1. Assess sleep patterns.
Assess a baseline understanding of the patient’s sleep patterns in order to institute scheduled naps and bedtimes.
2. Monitor for physical signs of exhaustion.
Patients with bipolar disorder may not feel a need for sleep and will go days without resting due to hyperactivity. They may not notice symptoms of fatigue such as tremors and increased blood pressure. The nurse can intervene before exhaustion occurs.
Interventions:
1. Administer benzodiazepines.
New research shows that clonazepam and lorazepam may be safer for sleep as they may improve symptoms of mania.
2. Trial dark therapy.
Dark therapy is a behavioral treatment that enhances melatonin naturally by keeping patients in a pitch-dark room during nighttime hours. Blue-light blocking glasses can improve circadian rhythms once insomnia has dissipated.
3. Promote relaxation.
Promote relaxation and improve sleep hygiene by instituting soft music, dim lighting, and non-caffeinated teas before bedtime.
4. Prohibit stimulants.
Caffeinated beverages should be prohibited for the patient with insomnia.
5. Recommend CBT for insomnia.
Cognitive behavioral therapy for insomnia for bipolar disorder has proven not only to improve sleep but also to lessen the number of days in a mood episode. Patients can utilize apps that can coach on CBT for insomnia.
Risk For Injury
Patients are at a risk for injury from participating in dangerous activities or potentially harming themselves.
Nursing Diagnosis: Risk For Injury
Related to:
- Extreme hyperactivity
- Destructive behaviors
- Disinhibition
- Poor judgment
- Risk-taking behavior
- Aggression
- Alcohol and drug use
- Delusional thinking
- Self-harm
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
Expected Outcomes:
- Patient will not harm themselves or others during a manic episode
- Patient will display a calm and subdued energy level before discharge
- Patient will cooperate with unit rules without aggression or inappropriate behavior
Assessment:
1. Distinguish between manic or depressive behavior.
Manic episodes often include hyperactive behavior with risk-taking due to a disillusioned belief of being invincible. Episodes of depression may include hearing voices and acting on dangerous behaviors or partaking in drugs or alcohol.
2. Assess safety/suicide risk.
Observe the patient’s behaviors for aggression, irritability, a lack of judgment, and socially inappropriate behavior. Ask the patient directly if they have thoughts of killing themselves. Interventions are aimed at keeping the patient and others safe.
3. Obtain information from family and friends.
Family members, spouses, and close friends are a valuable source of information and can help to understand a patient’s usual behaviors during acute episodes to determine risks.
Interventions:
1. Reduce stimuli.
Provide a private room if possible that is quiet with low lighting to reduce hyperactivity and distraction.
2. Remove dangerous objects.
Remove any objects that could be used as a weapon or to potentially harm themselves.
3. Provide physical activities.
Patients experiencing mania have endless energy. Offer exercise classes or housekeeping duties to help relieve hyperactivity as well as distract them from unsafe activities.
4. Administer tranquilizing medication.
Anti-psychotic medications are often prescribed to relieve symptoms of hyperactivity and agitation.
Nursing Diagnoses and Rationales for Bipolar Disorder
1. Risk for Injury
Rationale: Patients with bipolar disorder, especially during manic or depressive episodes, are at a heightened risk of self-harm or accidental injury due to impulsiveness, poor judgment, or psychomotor agitation. Monitoring for signs of self-destructive behavior, ensuring a safe environment, and establishing a supportive relationship can help mitigate these risks. Providing close supervision and involving the patient in safety planning are crucial steps.
2. Disturbed Thought Processes
Rationale: Bipolar disorder can lead to distorted thinking patterns, including grandiosity, paranoia, or hallucinations during manic phases, and pessimism or suicidal ideation during depressive phases. Regular assessments of cognitive function, therapeutic communication, and medication management are essential. Encouraging reality orientation and cognitive-behavioral strategies can support thought process stabilization.
3. Impaired Social Interaction
Rationale: Fluctuations between manic and depressive episodes can impair a patient’s ability to maintain healthy social relationships. Manic episodes may cause inappropriate social behaviors, while depressive episodes can lead to withdrawal and isolation. Encouraging participation in group therapy, social skills training, and maintaining a routine can enhance social interactions. Involving family and friends in the care plan can also provide a support network.
4. Ineffective Coping
Rationale: The chronic and episodic nature of bipolar disorder can overwhelm the patient’s coping mechanisms, leading to maladaptive behaviors such as substance abuse or denial. Assessing the patient’s coping strategies, providing psychological support, and involving mental health professionals can address coping issues. Encouraging the patient to express their feelings and offering support groups or counseling services can be beneficial.
5. Risk for Imbalanced Nutrition: Less Than Body Requirements
Rationale: Bipolar disorder may cause changes in appetite and eating patterns, leading to nutritional imbalances. Manic episodes can result in hyperactivity and neglect of nutritional needs, while depressive episodes may cause loss of appetite. Monitoring nutritional intake, providing small, frequent meals, and offering high-calorie, nutrient-dense foods can help manage nutritional needs. Consulting a dietitian and involving the patient in meal planning can also support adequate nutrition.
6. Risk for Deficient Knowledge
Rationale: Patients and their families may lack sufficient knowledge about bipolar disorder, its management, and prevention of complications. Providing comprehensive education about the disease, treatment options, medication adherence, and lifestyle modifications can empower patients and their families. Using teaching aids and ensuring understanding through return demonstrations or verbal feedback can enhance knowledge retention.
7. Risk for Decreased Fluid Volume
Rationale: Patients with bipolar disorder, particularly during manic episodes, may neglect fluid intake leading to dehydration. Monitoring fluid intake and output, encouraging adequate hydration, and administering intravenous fluids if necessary can help maintain fluid balance. Educating the patient and their family about the importance of fluid intake is also essential.
8. Risk for Anxiety
Rationale: The unpredictable nature of bipolar disorder and its potential complications can cause significant anxiety for patients and their families. Monitoring for signs of anxiety, providing reassurance, and offering psychological support can help manage anxiety. Involving mental health professionals and encouraging relaxation techniques, such as deep breathing exercises and mindfulness, can also be beneficial.
9. Risk for Noncompliance
Rationale: Patients with bipolar disorder may struggle with adherence to treatment regimens due to side effects, denial of illness, or cognitive impairments during mood episodes. Educating patients about the importance of medication adherence, simplifying medication schedules, and involving them in decision-making can improve compliance. Regular follow-ups and the use of reminder tools can also support adherence.
10. Chronic Low Self-Esteem
Rationale: Bipolar disorder can lead to feelings of worthlessness and low self-esteem, especially during depressive episodes. Providing positive reinforcement, setting achievable goals, and encouraging participation in therapeutic activities can help boost self-esteem. Offering individual and group therapy sessions can also support the patient’s self-worth and personal growth.
11. Sleep Pattern Disturbance
Rationale: Bipolar disorder often disrupts normal sleep patterns, with insomnia during manic episodes and hypersomnia during depressive episodes. Monitoring sleep patterns, creating a restful environment, and establishing a regular sleep routine can help manage sleep disturbances. Administering sleep aids or mood stabilizers as prescribed and encouraging relaxation techniques before bedtime can also be effective.
12. Ineffective Role Performance
Rationale: The symptoms of bipolar disorder can impair the patient’s ability to fulfill their roles in family, work, or social settings. Assessing the impact of the disorder on role performance, providing role-specific support, and involving occupational therapy can help patients regain functionality. Encouraging gradual reintegration into daily roles and responsibilities can promote a sense of normalcy and purpose.
REFERENCES
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