Care of Clients with Bipolar Disorders
out of nowhere without context or warning.
Let us put ourselves in the holy presense of God, as we
adore His holy name.
Let us pray, th
Most gracious and Heavenly father,
We honor and acknowledge your presence with us
today. We thank you for this new day that you have
given to us and we thank you for all the blessings that
you have showered upon us and for waking us up early
this morning to another new day of learning. Lord, we
are sorry for all the sins that we have committed and for
all the bad words and misdeeds that we have said and
committed against other people and to people we love.
As we begin our class with our classmates and teacher
in NCM 56 this morning, may you guide our teacher and
reporters who will be sharing their topics for today and
may you bless our classmates the knowledge and
strength that they will need in order to learn something
new today. May you protect all of our friends, families,
and loved ones from harm. And please bless those who
are in need of your warmth and mercy especially those
who are struggling with extreme hardships in their lives
today and in the coming days to come. May all of the
things that we are going to do and accomplish today
bring honor to your mighty name and All this we ask in
the name of Jesus, your son and our Lord and Savior
=====
Good morning Ma’am Bustillo and Good morning fellow
classmates. My name is Shirnyl Hannah Magos, and
together with my groupmates, Sushmita Oracion, and
Cheska Pileo, we will be presenting to you our topic on
the Care of Patients with Bipolar Disorder. So without
any further adeieu lets begin.
So maybe from time to time we may find ourselves
hearing other people use the term bipolar in regular
conversations to describe someone who is moody or
unpredictable. Kung sa ato pa, in other cases bipolar or
mga “tulukaron”. Probably the first thing that comes to
mind when you hear the word bipolar kay kanang tawo
na kanang mangisog niya mukalit lang hilak or katawa
But in this presentation, the colloquial term bipolar is
actually different from bipolar disorder, that which our
report is being centered over.
Bipolar disorder, formerly known as manic-depression
or manic depressive illness, is a mental health illness
that is classified as a mood disorder, or a disturbance to
how a person feels, that is manifested in patients by
cycles or episodes of mania and depression ; causing
marked shifts, mood, enery, and ability to function
At some points of our life, we experience periods of
high and lows in. And that is normal, especially as
normal response to certain stimulus in the environment
and they don’t usually persist or cause significant
impairments to our normal day to day functioning. we
feel happy in response to achievements or
accomplishments, and sad or down in response to
depressing situations. However, for people with bipolar
disorders, they experience dramatic shifts from extreme
lows and extreme highs. And in contrast to our initial
belief, these shifts in mood don’t happen moment to
moment. They usually happen over several days, and
weeks, sometimes with periods of euthymia (or normal
mood), depending of the type of bipolar disorder .
- Bipolar disorder or BPD is a chronic and
recurrent mood disorder, and people having
this mental disorder often periods of normal
functioning which may alternate with periods of
feelings of highs and lows, and sometimes even
both; which could lead to chronic interpersonal,
occupational, and sometimes functional
difficulties even after remission
- During manic phases, clients often express
feelings of elation, inflated self-esteem,
grandiosity, hyperactivivity, agitation, and
accelerated thinking or flight of ideas. Because
of these feelings, they are always on the go, to
the point that they would never feel tired even
when they do, have lowered inhibitions, and
would do things to the extremes like
overspending, over dressing, and so on; Even
though they persistently feel high during a
manic phase, patients with bipolar disorder
 however, have very labile affect; meaning they
may quickly change to hostility or sadness
especially in response to attempts of forcing
them to do something that they don’t want or
when ruminating on past failuers
- During depressive episodes or phases, patients
moods, behavior, thoughts, actions, and speech
are the same as those in people diagnosed with
major depression;
- so, if a persons’ first episode of bipolar illness
started or first identified on its depressed
phase, patients are often misdiagnosed with
MDD and the diagnosis of bipolar disorder will
be made only when a manic episode emerges.
To tell if a person with BPD is experiencing a Manic
episode, the following DSM V diagnostic criteria must
be met.
A. A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood and abnormally and persistently
increased goal-directed activity or energy,
lasting at least 1 week and present most of
the day, nearly every day (or any duration if
hospitalization is necessary).
B. During the period of mood disturbance and
increased energy or activity, three (or more)
of the following symptoms (four if the mood
is only irritable) are present to a significant
degree and represent a noticeable change
from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g.,
feels rested after only 3 hours of
sleep).  the day, nearly every day.
3. More talkative than usual or
pressure to keep talking.  increased energy and activity, three (or
4. Flight of ideas or subjective
experience that thoughts are racing.  mood is only irritable) have persisted,
5. Distractibility (i.e., attention too
easily drawn to unimportant or
irrelevant external stimuli), as
reported or observed.  1.  Inflated self-esteem or grandiosity.
6. Increase in goal-directed activity
(either socially, at work or school, or
sexually) or psychomotor agitation
(i.e., puφoseless non-goal-directed
activity).
7. Excessive involvement in activities
that have a high potential for painful
consequences (e.g., engaging in
unrestrained buying sprees, sexual
indiscretions, or foolish business
investments).
C. The mood disturbance is sufficiently severe
to cause marked impairment in social or
occupational functioning or to necessitate
hospitalization to prevent harm to self or
others, or there are psychotic features. 
D. The episode is not attributable to the
physiological effects of a substance (e.g., a
drug of abuse, a medication, other
treatment) or to another medical condition.
In the lesser or milder extremes; instead of a
manic episode, some patients would experience
hypomanic episodes instead of the full blown
mania. Just like mania
Hypomanic Episode
- in some cases, during hypomanic episodes,
people with bPD are usually attributed with
increased and enhanced functioning,
creativity, and productivity unlike mania.
- as appealing as it may seem at first glance,
hypomanic episodes should still be treated
seriously as other bipolar episodes because
hypomania can easily progress to mania or
decline to a major depressive episode,
which further puts patients at risk of
harm/injuries not only to themselves but
also to others
A. A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood and abnormally and persistently
increased activity or energy, lasting at least
4 consecutive days and present most of
B. During the period of mood disturbance and
more) of the following symptoms (four if the
represent a noticeable change from usual
behavior, and have been present to a
significant degree:
 
2. Decreased need for sleep (e.g.,
feels rested after only 3 hours of
sleep). 
3. More talkative than usual or
pressure to keep talking. 
4. Flight of ideas or subjective
experience that thoughts are racing. 
 5. Distractibility (i.e., attention too 5. Psychomotor agitation or retardation
easily drawn to unimportant or nearly every day (observable by
irrelevant external stimuli), as others; not merely subjective
reported or observed.  feelings of restlessness or being
6. Increase in goal-directed activity slowed down). 
(either socially, at work or school, or 6. Fatigue or loss of energy nearly
sexually) or psychomotor agitation.  every day. 
7. Excessive involvement in activities 7. Feelings of worthlessness or
that have a high potential for painful excessive or inappropriate guilt
consequences (e.g., engaging in (which may be delusional) nearly
unrestrained buying sprees, sexual every day (not merely self-reproach
indiscretions, or foolish business or guilt about being sick). 
investments).  8. Diminished ability to think or
C. The episode is associated with an concentrate, or indecisiveness,
unequivocal change in functioning that is nearly every day (either by
uncharacteristic of the individual when not subjective account or as observed
symptomatic.  by others). 
D. The disturbance in mood and the change in 9. Recurrent thoughts of death (not just
functioning are observable by others.  fear of dying), recurrent suicidal
E. The episode is not severe enough to cause ideation without a specific plan, or a
marked impairment in social or occupational suicide attempt or a specific plan for
functioning or to necessitate hospitalization. committing suicide. 
If there are psychotic features, the episode B. The symptoms cause clinically significant
is, by definition, manic.  distress or impairment in social,
F. The episode is not attributable to the occupational, or other important areas of
physiological effects of a substance (e.g., a functioning. 
drug of abuse, a medication, other C. The episode is not attributable to the
treatment). physiological effects of a substance or
another medical condition
Major Depressive Episode

A. Five (or more) of the following symptoms

have been present during the same 2-week Now you might be wondering, why does this
period and represent a change from happen? Like how and why do people end up
previous functioning; at least one of the getting bipolar disorders?
symptoms is either (1) depressed mood or
(2) loss of interest or pleasure.  Unfortunately, just like other mental health
1. Depressed mood most of the day, disorders, the exact etiology of BPD is still
nearly every day, as indicated by unknown, however there are several theories and
either subjective report (e.g., feels predisposing factors that can help us explain the
sad, empty, or hopeless) or development of BPD.
observation made by others (e.g.,
appears tearful).  Biological Factors
2. Markedly diminished interest or
pleasure in all, or almost all, 1. Genetics
activities most of the day, nearly
every day (as indicated by either - The bipolar disorders have a strong
subjective account or observation).  heritability (i.e., the influence of genetic
3. Significant weight loss when not factors is much greater than the influence of
dieting or weight gain (e.g., a external factors).
change of more than 5% of body - Incidence is 5-10 times higher for people
weight in a month), or decrease or with a  relative with bipolar disorder than in
increase in appetite nearly every the general population
day. - Associated with the genome that encodes
4. Insomnia or hypersomnia nearly DGKH (diacylglycerol kinase eta)
every day. 
- Abnormal circadian genes (CRY2), resulting
in a superfast biologic clock that manifests
as insomnia
- Irregularities in chromosomes 13 and 15
2. Neurobiological
Mania: ↑ norepinephrine, dopamine and
serotonin
Depression: ↓ norepinephrine, dopamine
and serotonin
 Receptor insensitivity despite having
adequate amounts of these
neurotransmitters
 Dysregulation in the neurocircuits
surrounding the medial temporal
lobe and prefrontal cortex due to
structural changes in these areas
3. Neuroendocrine
The hypothalamic-pituitary-thyroid-adrenal
(HPTA) axis has been closely scrutinized in
people with mood disorders. Hypothyroidism is
known to be associated with depressed moods
and is seen in some patients experiencing rapid
cycling. In patients with treatment-resistant
bipolar disorder, a high-dose thyroxine may be
considered
Physiological Factors
. Neuroanatomical:
- Right-sided lesions in the limbic system,
temporobasal areas, basal ganglia, and
thalamus have been shown to induce
secondary mania. Magnetic resonance
imaging studies have revealed enlarged third
ventricles and subcortical white matter and
periventricular hyperintensities in clients
with bipolar disorder (Dubovsky, Davies, &
Dubovsky, 2003).
- b. Medication Side Effects: Certain
medications used to treat somatic illnesses
have been known to trigger a manic
response. The most common of these are the
steroids frequently used to treat chronic
illnesses such as multiple sclerosis and
systemic lupus erythematosus. Some clients
whose first episode of mania occurred
during steroid therapy have reported
spontaneous recurrence of manic symptoms
years later. Amphetamines, antidepressants,
and high doses of anticonvulsants and
narcotics also have the potential for
initiating a manic episode (Dubovsky,
Davies, & Dubovsky, 2003).
- c. Substance Intoxication and Withdrawal:
Mood disturbances may be associated with
intoxication from substances such as
alcohol, amphetamines, cocaine,
hallucinogens, inhalants, opioids,
phencyclidine, sedatives, hypnotics, and
anxiolytics. Symptoms can occur with
withdrawal from substances such as alcohol,
amphetamines, cocaine, sedatives,
hypnotics, and anxiolytics.
Psychological Factors
 perceived stressful events (e.g. loss of a
relationship, financial difficulties, failing an
exam, being accepted to a highly desirable
graduate school, etc. 
Environmental Factors (pg. 277)
 Prevalent in upper socio-economic classic
 Higher among creative writers, artists,
highly educated men and women, and
professionals than the general population,
however, the exact reason is unclear
 stressful family environments, and adverse
life events increase vulnerability among
children
Types of Bipolar Disorders
1.   Bipolar I disorder
-          characterized by at least one week-long
manic episode that results in excessive activity and
energy
-          manic episodes may alternate with
depression or a mixed state of agitation and
depression
-          patients may have symptom-free periods,
but because it is a severe disorder, patients end to
have difficulty maintaining social connections and
employment
-          psychosis (hallucination, delusions, and
dramatically disturbed thoughts) may occur during
manic episodes
 
2.   Bipolar II disorder
-          not usually severe enough to cause serious
impairments in occupational or social functioning;
hospitalization is rare
-          low-level mania or hypomania alternates
with profound depressions
-          hypomania tends to be euphoric and often
increases functioning
-          accompanied by excessive activity and
energy for at least 4 days and involves at least 3 of
the behaviors listed in mania
-          psychosis is never present; depressive side
of the disorder puts the patient at risk for suicide
 
3.   Cyclothymic disorder
-          difficult to distinguish from bipolar II disorder
-          symptoms of hypomania alternate with
symptoms of mild to moderate depression for at
least 2 years in adults and one year in children
-          neither symptoms constitutes an actual
diagnosis of either disorder, yet symptoms are
disturbing enough to cause social and occupational
impairment
-          individuals tend to have irritable hypomanic
episodes; marked by sleep disturbances and
irritability in children
-          some persons experience rapid cycling and
may have at least 4 mood disorders in a 12-month
period; rapid cycling is associated with more severe
symptoms (e.g. poorer global functioning, high
recurrence risk, and resistance to conventional
somatic treatments)
Signs and Symptoms
1. The affect of an individual experiencing a manic
episode is one of elation and euphoria—a continuous
“high.” However, the affect is very labile and may
change quickly to hostility (particularly in response to
attempts at limit setting) or to sadness, ruminating
about past failures.
2. Alterations in thought processes and communication
patterns are manifested by the following:
a. Flight of Ideas. There is a continuous, rapid shift
from one topic to another.
b. Loquaciousness. The pressure of the speech is so
forceful and strong that it is difficult to interrupt
maladaptive thought processes.
c. Delusions of Grandeur. The individual believes he
or she is all important, all powerful, with feelings of
greatness and magnificence.
d. Delusions of Persecution. The individual believes
someone or something desires to harm or violate him
or her in some way.
3. Motor activity is constant. The individual is literally
moving at all times.
4. Dress is often inappropriate: bright colors that do not
match; clothing inappropriate for age or stature;
excessive makeup and jewelry.
5. The individual has a meager appetite, despite
excessive activity level. He or she is unable or unwilling
to stop moving in order to eat.
6. Sleep patterns are disturbed. Client becomes
oblivious to feelings of fatigue, and rest and sleep are
abandoned for days or weeks.
7. Spending sprees are common. The individual spends
large amounts of money, which is not available, on
numerous items, which are not needed.
8. Usual inhibitions are discarded in favor of sexual and
behavioral indiscretions.
9. Manipulative behavior and limit testing are common
in the attempt to fulfill personal desires. Verbal or
physical hostility may follow failure in these attempts.
10. Projection is a major defense mechanism. The
individual refuses to accept responsibility for the
negative consequences of personal behavior.
11. There is an inability to concentrate because of a
limited attention span. The individual is easily distracted
by even the slightest stimulus in the environment.
12. Alterations in sensory perception may occur, and
the individual may experience hallucinations.
13. As agitation increases, symptoms intensify. Unless
the client is placed in a protective environment, death
can occur from exhaustion or injury
1. Risk for injury r/t dehydration and faulty
judgment as evidenced by inability to
meet own physiological needs and set
limits on own behavior
Independent
a. Monitor vital signs frequently q2h.
Rationale: Monitor cardiac status and other
related complications brought about by
dehydration, fatigue, electrolyte imbalances,
etc.
b. Provide a safe and quiet
environment for the patient free of
any hazardous items and
environmental stimulants. If possible
provide them in a private room.
Rationale: Environmental stimulants
escalates mania and distractibility.
Removing hazards in the
environment prevents accidental
injuries since client’s rationality is
impaired during a manic episode. .
c. Offer presence/ stay with the patient
and divert him/her from stimulating
situations.
` Rationale: Nurse’s presence
provides support to the patient. Patients with
bipolar mania have impaired interactions with
others. One-on-one interactions provides patients a
feeling of security, espeially one that is consistent.  nonstimulating and relaxing mood that can help the
d. Offer high-calorie, high-protein,
nutritious finger foods  j.
Rationale: Clients in an hyperactive
state have difficulty sitting still long
enough for a meal. 
e. Have nutritious drinks and snacks
available in the unit all the time.
Rationale: Nutritious intake is
required on a regular basis to
compensate for increased caloric
requirement with hyperactivity.
f. Regularly remind patient to drink.
Offer decaffeinated drinks only.
Rationale: Patients concentration is
poor and can easily get distracted to
the point that they might forget to
drink water when thirsty. Constantly
reminding and encouraging the
patient to drink promotes adequate
fluid intake and hydration. Avoiding
caffeine-containing drinks such as
coffee prevents excessive
hyperactive as caffeine is a CNS
stimulant that could worsen
symptoms of mania. :
g. Monitor intake and output.
Rationale: To help monitor and ensure adequate
fluid and nutritional intake necessary for
maintaining health and preventing diseases and
complications. 
h. Encourage the patient to take short
rest periods (e.g. 3-5 minutes every
hour) throughout the day whenever
possible
Rationale: Patients are unaware of feelings of
fatigue and lethargy. Providing short and frequent
rest periods throughout the day prevents sudden
collapse from hyperactivity and over exhaustion.
i. Employ nursing measures to
promote sleep and rest such as
warm milk, soft music, backrub,
warm bath,  etc.
Rationale: Such measures promote a
patient fall asleep.
Direct the patient’s energy into
productive and calming activities
such as pacing to slow, soft music,
 drawing alone, writing in a quiet
area, etc.

Rationale: Redirecting energy to nonstimulating

activities helps control hyperactivity and minimize
exciteability.

k. Weigh the patient daily.

Rationale: To help assess and monitor patients

nutritional status

Dependent

a. Administer sedative medications as

ordered.

Rationale: To assist the patient to sleep until

normal sleep patterns are restored

b. Administer Lithium (Eskalith) as

ordered

Rationale: Lithium is a mood stabilizer used to treat

acute mania and is useful in reducing manic
symptoms such as anxiety, elation, gradiosity,
expansiveness, irritability, manipulative behaviors,
and flight of ideas.

c. Administer second-generation
antipsychotics

Rationale: Provide sendative properties

during acute phase of treatment; help
with insombia, anxiety, and agitaition
such as olanzapine or risperidone;