Bipolar Disorders

1. Concepts and principles related to bipolar disorders:
   1. The psychodynamics of manic and depressive episodes are related to hostility and guilt.
   2. The struggle between unconscious impulses and moral conscience produces feelings of hostility, guilt, and anxiety.
   3. To relieve the internal discomfort of these reactions, the person projects long-retained hostile feelings onto others or onto objects in the environment during manic phase; during depressive phase, hostility and guilt are introjected toward self.
   4. Demands, irritability, sarcasm, profanity, destructiveness, and threats are signs of the projection of hostility; guilt is handled through persecutory delusions and accusations.
   5. Feelings of inferiority and fear of rejection are handled by being light and amusing.
   6. Both phases, though appearing distinctly different, have the same objective: to gain attention, approval, and emotional support. These objectives and behaviors are unconsciously determined by the client; this behavior may be either biochemically determined or both biochemically and unconsciously determined.
   
   
2. Assessment of bipolar disorders:
   1. Manic and depressed types are opposite sides of the same disorder.
      1. Both are disturbances of mood and self esteem.
      2. Both have underlying aggression and hostility.
      3. Both are intense.
      4. Both are self-limited in duration.
   2. Comparison of behaviors associated with mania and depression.
   
   
   Behaviors Associated with Mania and Depression
   
   

   Mania (Periods of Predominantly and Persistently Elevated, Expansive, or Irritable Mood)	Depression (Loss of Interest or Pleasure in Usual Activities)
   Affect Lack of shame or guilt; inflated self-esteem; euphoria; intolerance of criticism	Anger, anxiety, apathy, denial, delusions of guilt, helplessness, feelings of doom, hopelessness, loneliness, low self-esteem (self degradation)
   Physiology Insomnia; inadequate nutrition, weight loss	Insomnia; anorexia, constipation, indigestion, nausea, vomiting, weight loss
   Cognition Denial of realistic danger Thoughts: flight of ideas, loose associations; illusions, delusions of grandeur; lack of judgment; distractibility	Ambivalence, confusion, inability to concentrate, self-blame; loss of interest and motivation; self-destructive (preoccupied with suicide)
   Behavior Hyperactivity(social, sexual, work) irrationality, aggressiveness. sarcasm, exhibitionism, and acting out in behavior and dress Hostile, arrogant, argumentative, demanding, and controlling Speech: rapid, rhyming, punning, witty, pressured	Altered activity level, social isolation, substance abuse, overdependency, underachievement, inability to care for self, psychomotor retardation

   
   
3. Analysis/nursing diagnosis:
   1. Risk for violence directed at others/self related to poor judgment, impulsiveness, irritability, manic excitement.
   2. Altered nutrition, less than body requirements, related to inability to sit down long enough to eat, metabolic expenditures.
   3. Sleep pattern disturbance: lack of sleep and rest related to restlessness, hyperactivity, emotional dysfunctioning, lack of recognition of fatigue.
   4. Self-care deficits related to altered motor behavior due to anxiety.
   5. Sensory/perceptual alterations (overload) related to endogenous chemical alteration, sleep deprivation.
   6. Altered feeling state, judgment, thought content (magical thinking), thought processes (altered concentration and problem solving) related to disturbance in self-concept.
   7. Altered feeling processes (mood swings).
   8. Altered attention: hyperalertness.
   9. Impaired social interaction related to internal and external stimuli (overload, underload).
   
   
4. Nursing care plan/implementation:
   1. Manic:
      1. Prevent physical dangers stemming from suicide and exhaustion - promote rest, sleep, and intake of nourishment.
         1. Use suicide precautions.
         2. Reduce outside stimuli or remove to quieter area.
         3. Diet: provide high-calorie beverages, finger foods within sight and reach.
      2. Attend to client’s personal care.
      3. Absorb with understanding and without reproach behaviors such as talkativeness, provocativeness, criticism, sarcasm, dominance, profanity, and dramatic actions.
         1. Allow, postpone, or partially fulfill demands and freedom of expression within limits of ordinary social rules, comfort, and safety of client and others.
         2. Do not cut off manic stream of talk, because this increases anxiety and need for release of hostility.
      4. Constructively utilize excessive energies with activities that do not call for concentration or follow-through.
         1. Outdoor walks, gardening, putting, and ball tossing are therapeutic.
         2. Exciting, disturbing, and highly competitive activities should be avoided.
         3. Creative occupational therapy activities promote release of hostile impulses, as does creative writing.
      5. Give tranquilizers as ordered until lithium affects symptoms (3 weeks); then give lithium carbonate as ordered.
      6. Help client to recognize and express feelings (denial, hopelessness, anger, guilt, blame, helplessness).
      7. Encourage realistic self-concept.
      8. Health teaching: how to monitor effects of lithium; instructions regarding salt intake.
   2. Depressed:
      1. Take routine suicide precautions.
      2. Give attention to physical needs for food and sleep and to hygiene needs. Prepare warm baths and hot beverages to aid sleep.
      3. Initiate frequent contacts:
         1. Do not allow long periods of silence to develop or client to remain withdrawn.
         2. Use a kind, understanding, but emotionally neutral approach.
      4. Allow dependency in severe depressive phase. Because dependency is one of the underlying concerns with depressive persons, if nurse allows dependency to occur as an initial response, he or she must plan for resolution of the dependency toward himself or herself as an example for the client’s other dependent relationships.
      5. Slowly repeat simple, direct information.
      6. Assist in daily decision making until client regains self-confidence.
      7. Select mild exercise and diversionary activities instead of stimulating exercise and competitive games, because they may overtax physical and emotional endurance and lead to feelings of inadequacy and frustration.
      8. Give antidepressant drugs.
      9. Health teaching: how to make simple decisions related to health care.
      
      
5. Evaluation/outcome criteria:
   1. Manic: speech and activity are slowed down; affect is less hostile; able to sleep; able to eat with others at the table.
   2. Depressed: takes prescribed medications regularly. Does not engage in self-destructive activities. Able to express feelings of anger, helplessness, hopelessness.
   
   
6. Critical Pathway: Client Experiencing Manic Episode.