Bipolar disorder (manic component)

96 Bipolar disorder (manic component)




Overview/pathophysiology


Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. (See the care plan on “Major Depression,” p. 698, for specifics regarding depression.) Mania is characterized by a period in which there is a dramatic change in mood; the individual is either elated and expansive or irritable. For the diagnosis to be made, this change in mood must last 1 wk (or any duration if hospitalization is required). At least three other symptoms from the following list must be present: inflated self-esteem or grandiosity; decreased need for sleep; pressured speech; flight of ideas; distractibility; increased involvement in goal-directed activities or psychomotor agitation; and overinvolvement in pleasurable activities with potentially damaging consequences, for example, hypersexuality, impulsive spending, and reckless and dangerous behavior.


Hypomania is characterized by at least 4 days of abnormally and persistently elevated, expansive, or irritable mood accompanied by at least three additional symptoms seen in a manic episode.


About 25% of the first episodes of bipolar disorder occur before age 20. In women, hormonal factors may account for a greater rate of rapid cycling (meaning highs and lows in a short period), but in general, women and men are equally affected with this disorder. There is no difference in prevalence rates by race or ethnicity. Bipolar disorder is a chronic, relapsing, and episodic disease. In individuals 40 yr of age or older who experience a first episode of mania, it is most likely related to medical conditions such as substance abuse or a cerebrovascular disorder. About 50% of bipolar patients have concurrent substance abuse disorders. Theories that explain causation of bipolar disorder include disorders in brain function or structure, sleep deprivation, and genetic factors.



Health care setting


Primary (outpatient) care for most patients, except for those who are at high risk for suicide, represent a danger to others, or are experiencing a psychotic mania. Acute care (inpatient) stays are brief and focus on restabilization. Patients with bipolar disorder require long-term medication management; intensive psychosocial support to function within the community; and possibly individual, group, and family therapy.



Assessment


Similar to depression, the assessment of mania involves much more than an assessment of mood. This is a holistic disorder that results in changes in self-attitude (feelings of self-worth), as well as vital sense (sense of physical well-being) and spiritual sense. Depression diminishes self-worth, self-attitude, and vital sense, whereas mania increases these perceptions.




Feelings, attitudes, and knowledge:


During manic episodes, patients express inflated views of themselves. Many manic patients state that they enjoyed being high and because of this refused medications. After the mania has subsided, the patient is confronted with the consequences of behaviors and actions engaged in while manic. Being faced with the reality of those behaviors and their consequences produces negative feelings expressed as shame, humiliation, denial, anger, fear of experiencing a relapse, fear of passing the disorder onto children, and fear of completing the bipolar cycle with an episode of depression.



Elevated mood or irritability:


Patients may be excessively cheerful and unusually elated or display irritability over the smallest matters. This irritability increases when others attempt to reason with them. A manic person may display a haughty or superior attitude toward others. He or she may display overt anger, particularly if his or her requests or behaviors are curtailed.



Increased self-attitude:


Patients may express and act in unusually optimistic fashion, engaging in behaviors that reflect poor judgment. The manic person is overconfident and energetic. Unfortunately the excess energy is channeled into inappropriate, dangerous, or indiscreet behaviors. A normally conservative person may engage in sexual indiscretions or speak in overly critical or judgmental terms, often at inappropriate times and about sensitive subjects.



Increased vital sense:


The person with mania has increased energy and may appear tireless in the face of physical and mental efforts that would greatly tax unaffected individuals. He or she may feel completely refreshed after only a few minutes or hours of sleep.



Spiritual issues:


Bipolar disorder mania carries with it many negative experiences—such as marital and family problems, divorce, legal difficulties, financial ruin, and unemployment—that contribute to the downward spiral of self-appraisals. Bipolar disorder can lead to a crisis in faith in self, others, life, and ultimately God. This loss of faith and hope contributes significantly to the risk of suicide.



Additional signs:


Manic individuals may experience a voracious appetite or may be too busy to eat. A change in sleep pattern is characteristic of mania, with many individuals feeling less need for sleep, so sleep is usually decreased. An increase in sexual interest and activity is characteristic of manic individuals.



Suicidality:


Suicide assessment is critical with manic patients. The presence of psychotic thinking, hyperactivity, impulsiveness, and possible substance abuse increases suicide risk significantly. It is important to ask questions to determine the presence of suicidal ideation and the lethality of any plan. Essential questions to ask include:


• Have you thought of hurting yourself?

• Are you presently thinking about hurting yourself?

• If you have been thinking about suicide, do you have a plan? What is the plan?

• Have you thought about what life would be like if you were no longer a part of it?

A previous history of suicide attempts places the patient at high risk for attempting suicide.



Diagnostic tests


There are no diagnostic tests to diagnose bipolar disorder mania. Diagnosis is made through history, interview of patient and family, and observation of verbal and nonverbal behaviors. The Young Mania Scale is an effective instrument to quantify the degree of mania.





Nursing diagnosis:



Risk for other-directed violence


related to impulsivity/agitation occurring with manic excitement


Desired Outcome: By the time of discharge from an inpatient setting, patient demonstrates self-control and decreased hyperactivity.



































































ASSESSMENT/INTERVENTIONS RATIONALES
Continually assess patient’s response to frustrations or difficult situations. This enables early intervention and helps patient manage situation independently, if possible.
Continually assess to ensure that patient’s environment is safe. Remove objects that could be dangerous and rearrange room to decrease environmental risks to prevent accidental/purposeful injury to self or others. Hyperactive behavior and grandiose thinking can lead to destructive actions with possible harm to self or others.
Decrease environmental stimuli, avoid exposure to situations of predictable high stimulation, and remove patient from area if he or she becomes agitated. Patient may be unable to focus attention on relevant stimuli and will be reacting/responding to all environmental stimuli.
Intervene at earliest signs of agitation. Use direct verbal interventions prompting appropriate behavior, redirect or remove patient from difficult situation, establish voluntary time-out or move to a quiet room, use physical control (e.g., hold patient). Early intervention assists patient in regaining control, defuses a difficult situation, prevents violence, and enables treatment to continue in the least-restrictive manner.
Until patient is calm, avoid analyzing or problem solving regarding prevention of violence or collecting information about precipitating events or provoking stimuli. Any questioning will only add to agitation. Analyze and problem solve when patient is calm.
Communicate rationale for taking action using a concrete, direct, and simple approach. People are unable to process complicated communication when they are agitated or upset.
When patient is ready to leave quiet area or time-out location, allow gradual reentry to area of greater stimulation. Patient has diminished tolerance for environmental stimuli; gradual reentry fosters coping skills.
Do not argue with patient who verbalizes put-downs or unrealistic or grandiose ideas. Arguing only increases agitation and reinforces undesirable behavior.
Ignore and minimize attention given to bizarre dress or use of profanity, while placing clear limits on destructive behavior. This avoids reinforcing negative behavior while providing controls for potentially dangerous behavior.
Avoid unnecessary delay of gratification when patient makes a request. If refusal is necessary, make sure that rationale is given in nonjudgmental and concrete manner. Patients in a hyperactive state do not tolerate waiting or delays that add to frustration or agitation level. Any unnecessary delays could trigger aggressive behavior.
Offer alternatives when available. This uses patient’s distractibility to decrease the frustration of having request refused. For example, “I don’t have any soda. Would you like a glass of juice?”
When patient is less agitated and labile, provide information about alternative problem-solving strategies. When calm, patient is able to hear and retain information.
When patient is calm, help to examine the antecedents/precipitants to agitation. This promotes early recognition of the developing problem, enabling patient to plan for alternative responses and intervene in a timely fashion.
Collaborate with patient to identify alternative behaviors that are acceptable to both patient and staff. Role-play how to use these behaviors if appropriate. Patient is more apt to follow through if the alternatives are mutually agreed on. This practice enables patient to “try on” new behaviors while calm and ready to learn.
Give positive reinforcement when patient attempts to deal with difficult situations without violence. Praise increases patient’s sense of success and increases likelihood that desired behaviors will be repeated.
Administer the following medications as prescribed:  
Antimanic medications: lithium carbonate (Lithobid, Eskalith), divalproex sodium (Depakote), valproic acid (Depakene), valproate (Depacon), carbamazepine (Tegretol), topiramate (Topamax), oxcarbazepine (Trileptal), topiramate (Topamax), tiagabine (Gabitril), and lamotrigine (Lamictal). Lithium is the drug of choice for mania and is indicated for alleviation of hyperactive symptoms. Some patients are lithium nonresponders and may need either divalproex, carbamazepine, topiramate, valproic acid, valproate, tiagabine or lamotrigine.
Atypical antipsychotics with mood-stabilizing effects: olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), clozapine (Clozaril), paliperidone (Invega), resperidone (Risperdal Consta, M-tabs), ziprasidone (Geodon) Olanzapine is better tolerated and prevents relapse more effectively than lithium. Quetiapine is also effective in treating the anxiety symptoms in bipolar depression. Each of the atypical antipsychotics is effective in managing mania.
Provide restraint or seclusion per agency policy. These measures may be necessary for brief periods to protect patient, staff, and others.
Prepare patient for electroconvulsive therapy (ECT) if indicated. In severely manic episode, ECT may be necessary.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Bipolar disorder (manic component)

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