Bipolar disorder

Bipolar disorder ]
involves periods of excitability (mania)alternating [right]with periods of depression. The "mood swings" between mania and depression can be very abrupt.


Alternative Names

Manic depression; Bipolar affective disorder

Causes

Bipolar disorder affects men and women equally. It usually appears between ages 15 - 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.
Bipolar disorder results from disturbances in the areas of the brain that regulate mood.
There are two primary types of bipolar disorder. People with bipolar disorder I have had at least one fully manic episode with periods of major depression. In the past, bipolar disorder I was called manic depression.

People with bipolar disorder II seldom experience full-fledged mania. Instead they experience periods of hypomania (elevated levels of energy and impulsiveness that are not as extreme as the symptoms of mania). These hypomanic periods alternate with episodes of major depression.

A mild form of bipolar disorder called cyclothymia involves periods of hypomania and mild depression, with less severe mood swings. People with bipolar disorder II or cyclothymia may be misdiagnosed as having depression alone.



Symptoms

The manic phase may last from days to months and can include the following symptoms:
• Agitation or irritation
• Elevated mood
o Hyperactivity
o Increased energy
o Lack of self-control
o Racing thoughts
• Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
• Little need for sleep
• Over-involvement in activities
• Poor temper control
• Reckless behavior
o Binge eating, drinking, and/or drug use
o Impaired judgment
o Sexual promiscuity
o Spending sprees
• Tendency to be easily distracted
These symptoms of mania are seen with bipolar disorder I. In people with bipolar disorder II, hypomanic episodes involve similar symptoms that are less intense.
The depressed phase of both types of bipolar disorder involves very serious symptoms of major depression:
• Difficulty concentrating, remembering, or making decisions
• Eating disturbances
o Loss of appetite and weight loss
o Overeating and weight gain
• Fatigue or listlessness
• Feelings of worthlessness, hopelessness and/or guilt
• Loss of self-esteem
• Persistent sadness
• Persistent thoughts of death
• Sleep disturbances
o Excessive sleepiness
o Inability to sleep
• Suicidal thoughts
• Withdrawal from activities that were once enjoyed
• Withdrawal from friends
There is a high risk of suicide with bipolar disorder. While in either phase, patients may abuse alcohol or other substances, which can worsen the symptoms.
Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur simultaneously or in quick succession in what is called a mixed state.

Exams and Tests
A diagnosis of bipolar disorder involves consideration of many factors. The health care provider may do some or all of the following:
• Ask about your family medical history, particularly whether anyone has or had bipolar disorder
• Ask about your recent mood swings and for how long you've experienced them
• Observe your behavior and mood
• Perform a thorough examination to identify or rule out physical causes for the symptoms
• Request laboratory tests to check for thyroid problems or drug levels
• Speak with your family members to discuss their observations about your behavior
• Take a medical history, including any medical problems you have and any medications you take
Note: Use of recreational drugs may be responsible for some symptoms, though this does not rule out bipolar affective disorder. Drug abuse may itself be a symptom of bipolar disorder.
Treatment
For the manic phase of bipolar disorder, antipsychotic medications, lithium, and mood stabilizers are typically used. For the depressive phase, antidepressants are sometimes used, with or without the manic phase treatment.
There is very little long-term evidence suggesting that any medication has great success in the maintenance phase. However, in studies that followed patients for 2 years, lithium and some antipsychotics were found to be moderately successful.
Antipsychotic drugs can help a person who has lost touch with reality. Anti-anxiety drugs, such as benzodiazepines, may also help. The patient may need to stay in a hospital until his or her mood has stabilized and symptoms are under control.
Electroconvulsive therapy (ECT) may be used to treat bipolar disorder. ECT is a psychiatric treatment that uses an electrical current to cause a brief seizure of the central nervous system while the patient is under anesthesia. Studies have repeatedly found that ECT is the most effective treatment for depression that is not relieved with medications.
Getting enough sleep helps keep a stable mood in some patients. Psychotherapy may be a useful option during the depressive phase. Joining a support group may be particularly helpful for bipolar disorder patients and their loved ones.
Outlook (Prognosis)

Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to ensure that any episodes of mania and depression are treated as early as possible.
Some people stop taking the medication as soon as they feel better or because they want to experience the productivity and creativity associated with mania. Although these early manic states may feel good, discontinuing medication may have very negative consequences.
Suicide is a very real risk during both mania and depression. Suicidal thoughts, ideas, and gestures in people with bipolar affective disorder require immediate emergency attention.
Possible Complications
Stopping or improperly taking medication can cause your symptoms to come back, and lead to the following complications:
• Alcohol and/or drug abuse as a strategy to "self-medicate"
• Personal relationships, work, and finances suffer
• Suicidal thoughts and behaviors
This illness is challenging to treat. Patients and their friends and family must be aware of the risks of neglecting to treat bipolar disorder.
Nursing care
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 over involvement 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 diagnosis
(a.) risk for suicide related to depression associated with bipolar disorder as evidenced by feelings that his family can’t deal with him anymore and he feels like “everyone is shitting on me”,

(b.) risk for violence directed at others related to manic excitement as evidenced by agitated behaviors,

(c.) defensive coping related to an inadequate level of perception of control as evidenced by grandiosity and argumentative behavior,

(d.) chronic low self-esteem related to shame and impaired self-appraisal as evidenced by hypersensitivity to slights of criticism, and

(e.) impaired memory related to neurologic disturbance as evidenced by incidences of forgetting information caused by Electroconvulsive Therapy.


Nursing Interventions
1. Initiate a nurse-patient relationship by demonstrating an acceptance of JR as a worthwhile human being through the use of nonjudgmental statements and behavior. Suicide precautions per hospital policy.
2. Self-care assistance- list of hygiene tasks and the steps, times
3. Suicide prevention-assess command hallucinations and teach client what to do
4. Observe the client every 15 minutes while suicidal, remove all dangerous, sharp objects from room.
• Violence prevention encourage to talk rather than act out feelings, identify triggers, give personal space to client who is escalating,verbally set limits on aggressive behavior, avoid touching client who is scared

4. Reinforce that she is worth while,
a.) Assist the client in evaluating the positive as well as the negative aspects of her life
b.) Encourage the appropriate expression of angry feelings.
c.) Schedule regular periods of time throughout the day for recreational/occupational therapy, encourage client to groom self, offer praise for completing grooming.
d.) Ensure client's participation in taking mood stabilizing medications. Watch client swallow medication.
6. Engage client in interpersonal therapies, cognitive-behavioral therapy,
7. Encourage client to attend group therapy, and journal episodes.
8.Teach family-convey message they are not the cause, teach signs of relapse, medications, how to deal with active symptoms, role play with them, teach about keeping a moderate level of expressed emotion, establish family rules,support groups, and family therapy

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 re[/justify]stored.
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.[/justify]
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