CASE ANALYSIS OF BIPOLAR

1. What are the most important considerations w/ which the nurse

who is taking care of Alice should be concerned about?
 Providing for safety. A primary nursing responsibility is to
provide a safe environment for client and others; for clients
who feel out of control, the nurse must establish external
controls emphatically and non-judgementally.
 Meeting physiologic needs. Decreasing environmental
stimulation may assist client to relax; the nurse must provide
a quiet environment without noise, television, and other
distractions; finger foods or things client can eat while
moving around are the best options to improve nutrition.
 Providing therapeutic communication. Clients with mania
have short attention spans, so the nurse uses simple, clear
sentences when communicating; they may not be able to
handle a lot of information at once, so the nurse breaks
information into many small segments.
 Promoting appropriate behavior. The nurse can direct
their need for movement into socially acceptable, large motor
activities such as arranging chairs for a community meeting
or walking.
 Managing medications. Periodic serum lithium levels are
used to monitor the client’s safety and to ensure that the dose
given has increased the serum lithium level to a treatment
level or reduced it to a maintenance level.
2. Why was Alice given the dx of bipolar disorder?
 When Alice starting work her co- workers and friends
noticed that Alice look lethargic and work long hours, speak
loudly and rapidly and also irritable, less sleep but not looks
tired and also shouting and scream when her roommate asked
for rent, that’s why Alice diagnosed bipolar I disorder.
3. The physician should order a lithium level drawn after 4 - 6 days.
For what symptoms should the nurse be on alert?
 Acute and Chronic Toxicity Early signs of lithium toxicity
include diarrhea, vomiting, drowsiness, muscular weakness,
tremors, and lack of coordination. More severe symptoms
include confusion, agitation, giddiness, tinnitus (ringing in
the ears), blurred vision, and a large output of dilute urine.
4. Why did the doctor order olanzapine in addition to lithium
carbonate?
 Using lithium together with olanzapine may increase side
effects such as dizziness, drowsiness, confusion, and
difficulty concentrating. Some people, especially the elderly,
may also experience impairment in thinking, judgment, and
motor coordination.
5. Give at least nursing diagnosis & the nursing implication / nursing
intervention for that nursing dx.
 Risk For Violence: Self-Directed or Other Directed
*Frequently assess client’s behavior for signs of increased
agitation and hyperactivity.
Early detection and intervention of escalating mania will
prevent the possibility of harm to self or others, and decrease
the need for seclusions.
*Use a calm and firm approach.
Provides structure and control for a client who is out of
control.
* Remain neutral as possible; Do not argue with the client
Client can use inconsistencies and value judgments as
justification for arguing and escalating mania.
* Redirect agitation and potentially violent behaviors
with physical outlets in an area of low stimulation (e.g.,
punching bag).
Can help to relieve pent-up hostility and relieve muscle
tension.
 * Chart, in nurse’s notes, behaviors; interventions; what
seemed to escalate agitation; what helped to calm
agitation; when as-needed (PRN) medications were given
and their effect; and what proved most helpful.
Staff will begin to recognize potential signals for escalating
manic behaviors and have a guideline for what might work
best for the individual client.
 Ineffective Individual Coping
* Assess and recognize early signs of manipulative
behavior, and intervene appropriately
Setting limits is an important step in the intervention of
bipolar clients, especially when intervening in manipulative
behaviors. Staff agreement on limits set and consistency is
imperative if the limits are to be carried out effectively.
* Observe for destructive behavior toward self or others.
Intervene in the early phases of escalation of manic
behavior.
Hostile verbal behaviors, poor impulse control, provocative
behaviors, and violent acting out against others or property
are some of the symptoms of this disease and are seen in
extreme and/or acute mania. Early detection and intervention
can prevent harm to client or others in the environment.
* Maintain a firm, calm, and neutral approach at all
times. Avoid:
Arguing with the client.
Getting involved in power struggles.
Joking or “clever” repartee in response and other clients.
to client’s “cheerful and humorous” mood.
These behaviors by the staff can escalate environmental
stimulation and, consequently, manic activity. Once the
manic client is out of control, seclusion might be required,
which can be traumatic to the manic individual as well as the
staff.
* Provide hospital legal service when and if the client is
involved in making or signing important legal documents
during an acute manic phase.
Judgement and reality testing are both impaired during acute
mania. Client might need legal advice and protection against
making important decisions that are not in their best interest.
* Administer an anti-manic medication and PRN
tranquilizers, as ordered, and evaluate for efficacy, and
side and toxic effects.
Bipolar disorder is caused by biochemical/neurologic
imbalances in the brain. Appropriate anti-manic medications
allow psychosocial and nursing interventions to be effective.