BACHELOR OF SCIENCE IN NURSING

NCMB 317- Care of Clients with Maladaptive Patterns of Behavior

(Acute & Chronic)
COURSE MODULE COURSE UNIT WEEK
6 6 7
Care of Clients with Bipolar and Related Disorders

 Read course and unit objectives

 Read study guide prior to class attendance
 Read required learning resources; refer to unit terminologies for jargons
 Proactively participate in classroom/online discussions
 Participate in weekly discussion board (Canvas)
Answer and submit course unit tasks

Videbeck, Sheila L. (2017) Psychiatric-Mental Health Nursing 7th edition. Wolters

Kluwer/Lippincott Williams and Wilkins
Kozier, Barbara, (2017) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and
Practice 10th edition Upper Saddle River, N.J.:Pearson Prentice Hall

At the end of the course unit (CM), learners will:

Cognitive
 Discuss etiologic theories of depression and bipolar disorder.
 Describe the risk factors for and characteristics of bipolar and other related disorders
 Identify populations at risk for suicide.
Psychomotor.
 Apply the nursing process to the care of clients and families with bipolar disorders.
  Provide education to clients, families, caregivers, and community members to increase
knowledge and understanding of bipolar disorders.
 Apply the nursing process to the care of a suicidal client
Affective
 Develop empathy to patients with bipolar and other related disorders through effective
communication
 Evaluate your feelings, beliefs, and attitudes in caring patients with bipolar and other related
disorders.

Attitude therapy. An orientation organized through experiences which respond consistently

to an object, person, or situation. It aimed to modify a patient's patterns of behavior which is
viewed as a group of symptoms, rather than one specific symptom.
Behavioral therapy. A form of therapy that seeks to identify and help change potentially self-
destructive or unhealthy behaviors of patient. The focus of treatment is often on current
problems and how to change them
Bipolar I disorder. The patient may had at least one manic episode that may be preceded or
followed by hypomanic or major depressive episodes. In some cases, mania may trigger a break
from reality (psychosis). Bipolar I disorder can be severe and dangerous
Bipolar II disorder. The patient had at least one major depressive episode and at least one
hypomanic episode, but never had a manic episode. Bipolar II disorder is not a milder form of
bipolar I disorder, but a separate diagnosis. An individual with bipolar II disorder can be
depressed for longer periods, which can cause significant impairment Cyclothymic disorder.
The patient had at least two years for adult or one year in children and teenagers of many
periods of hypomania symptoms and periods of depressive symptoms (though less severe than
major depression).
Hypomania. A mild form of mania, marked by elation and hyperactivity.
Mania. A mental illness marked by periods of great excitement or euphoria, delusions, and
overactivity
Suicide. The act or an instance of taking one's own life voluntarily and intentionally

BIPOLAR AND RELATED DISORDERS

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme
mood swings that include emotional highs (mania or hypomania) and lows (depression). When a person
become depressed, he or she may feel sad or hopeless and lose interest or pleasure in most activities.
When his or her mood shifts to mania or hypomania (less extreme than mania), he or she may feel
euphoric, full of energy or unusually irritable.
These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think
clearly.
Episodes of mood swings may occur rarely or multiple times a year. While most people will experience
some emotional symptoms between episodes, some may not experience any. Although bipolar disorder
is a lifelong condition, mood swings and other symptoms can be manage by medications and
psychological counseling (psychotherapy).

There are several types of bipolar and related disorders. They may include mania or hypomania and
depression. Symptoms can cause unpredictable changes in mood and behavior, resulting in significant
distress and difficulty in life.
1. Bipolar I disorder. The patient may had at least one manic episode that may be preceded or
followed by hypomanic or major depressive episodes. In some cases, mania may trigger a break
from reality (psychosis). Bipolar I disorder can be severe and dangerous
2. Bipolar II disorder. The patient had at least one major depressive episode and at least one
hypomanic episode, but never had a manic episode. Bipolar II disorder is not a milder form of
bipolar I disorder, but a separate diagnosis. An individual with bipolar II disorder can be
depressed for longer periods, which can cause significant impairment
3. Cyclothymic disorder. The patient had at least two years for adult or one year in children and
teenagers of many periods of hypomania symptoms and periods of depressive symptoms (though
less severe than major depression).
4. Other types. These include, for example, bipolar and related disorders induced by certain
drugs or alcohol or due to a medical condition, such as Cushing's disease, multiple
sclerosis or stroke.
Although bipolar disorder can occur at any age, typically it's diagnosed in the teenage years or early
20s. Symptoms can vary from person to person, and symptoms may vary over time.

Diagnostic Criteria
Mania and hypomania are two distinct types of episodes, but they have the same symptoms. Mania is
more severe than hypomania and causes more noticeable problems at work, school and social activities,
as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require
hospitalization.
Both a manic and a hypomanic episode include three or more of these symptoms:
1. Abnormally upbeat, jumpy or wired
2. Increased activity, energy or agitation
3. Exaggerated sense of well-being and self-confidence (euphoria)
4. Decreased need for sleep
5. Unusual talkativeness
6. Racing thoughts
7. Distractibility
8. Poor decision-making — for example, going on buying sprees, taking sexual risks or
making foolish investments
Major depressive episode
A major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in
day-to-day activities, such as work, school, social activities or relationships. An episode includes five
or more of these symptoms:
1. Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens,
depressed mood can appear as irritability)
 2. Marked loss of interest or feeling no pleasure in all — or almost all — activities
3. Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in
children, failure to gain weight as expected can be a sign of depression)
4. Either insomnia or sleeping too much
5. Either restlessness or slowed behavior
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Decreased ability to think or concentrate, or indecisiveness
9. Thinking about, planning or attempting suicide
Other features of bipolar disorder
1. Signs and symptoms of bipolar I and bipolar II disorders may include other features, such as
anxious distress, melancholy, psychosis or others. The timing of symptoms may include
diagnostic labels such as mixed or rapid cycling. In addition, bipolar symptoms may occur
during pregnancy or change with the seasons.
2. Symptoms in children and teens
Symptoms of bipolar disorder can be difficult to identify in children and teens. It's often hard to
tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental
health problem other than bipolar disorder.
3. Children and teens may have distinct major depressive or manic or hypomanic episodes, but
the pattern can vary from that of adults with bipolar disorder. And moods can rapidly shift
during episodes. Some children may have periods without mood symptoms between episodes.
The most prominent signs of bipolar disorder in children and teenagers may include severe
mood swings that are different from their usual mood swings.
4. Despite the mood extremes, people with bipolar disorder often don't recognize how much their
emotional instability disrupts their lives and the lives of their loved ones and don't get the
treatment they need.

Behaviors considered appropriate can mask depression

1. Children – cranky, school phobia, hyperactivity, learning disorders, failing grades,
antisocial behaviors
2. Adolescence – substance abusers, joining gangs, engage in risky behavior, under
achiever, drop outs
3. Adults – substance abuse, eating disorders, compulsive behavior (gambling,
workaholism), hypochondriasis
4. Older adult – argumentative, cranky, somatic ailments

Theories of Etiology
Factors Depression Bipolar (Mania)
Genetic Factor - Higher among family with - Higher among family with
depressive disorder than in general mania and hypomanic disorder than
population in general population
Neurochemical - Decrease serotonin and - Increase serotonin,
Factors norepinephrine norepinephrine, acetylcholine,
dopamine
 Neurostructural factor - Ex: Limbic system hypometabolism - Limbic system dysfunction

Individual Factor - imagined or real Loss of a loved - Mask for depression

person or object
Psychosocial Factor - Faulty family interaction - Faulty family interaction

SAD PERSONS’ Scale is a tool for assessing a person at risk for suicide S – Sex
- gender
A – Age – <19 and >45
D – Depression is a good prediction

P – Previous attempt is a major indicator E –

Ethanol (alcohol) used
R – Rational thinking is impaired
S – Social support is absent
O – Organized plan on how to carry the plan N –
No spouse or single
S – Sickness

Behavioral cues of impending suicide

W- Withdraws social activities and plans H-
Has death plan/ Leaves a note
- Finalizes business or personal affairs
- Gives away valuable possessions
I - Improved mood 10 – 14 days after taking antidepressant C -
Change in patient’s behavior
H - He/she makes direct or indirect statements (“I
may not be around then”)
(“I will not be needing it where I am going”)

Contributory factors of suicide in adolescence (USED PILL) U –

Used of drugs
S – Social problems with peers E –
Emotional isolation
D - Dysfunctional family interaction/depression

P – Poor judgment/ poor impulse control I –

immature coping skills
L – Low self-esteem
L – Lack of self-integration & identity

Contributory factors of suicide in adults (DOLL)

D – Drug addiction and alcoholism/ depression O –
Occupational related risks
L – Lack of personal and financial resources
 L – Loss of significant relationships

Contributory factors of suicide in elderly (PERCIeVeD)

P – Passive suicide (refusing to eat, drink, cooperate with care E –
Exhaustion
R – Retirement
C – Chronic medical condition
I – incidence of suicide increases with age
V – View self as useless (desperate, frustrated) D –
Dependent

Psychiatric conditions with high incidence of suicide (MAD PALS) M –

Major depression
A – Alcoholism
D – Drug addiction

P – Panic disorder/post traumatic disorder A –

Anorexia nervosa
L – Low impulse control behavior
S – Schizophrenia & Schizoaffective disorder

Treatment and management

1. Biological therapy
- Psychopharmacology
- ECT
2. Interpersonal therapy
- Help client establish a successful relationship
- Help client learn to trust others
3. Behavioral therapy
-Reinforcing behavioral change through positive feedback and decreasing negative interactions
-Focus on improving social & coping skills and
4. Cognitive Therapy
-Changing negative thinking into positive thinking
5. Attitude therapy

Application of the nursing process in the care of patient with bipolar and other related disorders

Area of Concern Depression Mania

Physical Need - Provide adequate nutrition and - Provide adequate nutrition
hydration and hydration
- Assess weight - Prevent exhaustion
- Prevent constipation - Encourage rest
- Increase activity and exercise > short naps
- Promote personal hygiene >sedation PRN
 Emotional Need Allow client express feeling - Set limit on patients
unacceptable behavior while
showing his or her
innate worth
Environment - Stimulating - non-stimulating
- Safety (remove harmful objects or - safety (remove excess
things) furniture
- institute suicide precaution
Activity Repetitive, menial task - Gross physical activities Ex:
Ex: folding laundry – promote brisk walking
completion of ADL by providing
enough time and assisting client
when necessary
Attitude therapy - Kind firmness (ADL and therapy - Matter of fact (setting limit,
participation follow rules and regulations
- Watchfulness (24hr observation or
1:1)

Boyd (2017), Essentials of Psychiatric Nursing, Wolters/Kluwer

Holland (2018), The Nurses Guide to Mental Health Medicines Elsevier/Mosby Keltner
(2019), Psychiatric Nursing 8th edition, St. Louis, Mo.: Elsevier/Mosby.
Kozier, Barbara, (2017) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and
Practice 10th edition Upper Saddle River, N.J.:Pearson Prentice Hall
Pullen, Richard (2010) Nursing Made Incredibly Easy. Varcarolis (2015), Manual of Psychiatric
Nursing Care Planning 5th edition, Elsevier/Mosby
Videbeck, Sheila L. (2017) Psychiatric-Mental Health Nursing 7th edition. Wolters
Kluwer/Lippincott Williams and Wilkins

Smith Kathleen, PhD. The Difference between Bipolar Disorder 1 and 2.

https://www.psycom.net/depression.cemtral.bipolar.html

Emanuel Severus & Michael Bauer (2013) International Journal of Bipolar Disorders
https://journalbipolardisorders.springeropen.com/articles/10.1186/2194-7511-1-14

1. Diagnosing Bipolar and related disorders

2. Treatment of Bipolar and related disorders
3. Application of nursing process to client with Bipolar and related disorders.
Case Vignette
VM, a 56 year old, single, male client, is admitted in the acute care service of the National
Center for Mental Health for the first time because of having recurrent thoughts of suicide. He
has an old scar round her neck from a previous attempt by hanging self but was seen and
prevented by loved ones. During assessment he is seen lethargic, withdrawn and irritable. He
has also difficulty falling asleep and decreased appetite. During the interview with the nurse, he
stated "I killed my nephew. I am a worthless person. I'm better off dead and be with John."
According to his family, John as the client's favorite nephew who died of a car accident which
was drove by him.
1. Enumerate at least five (5) symptoms presented by the client.
2. The action of the nurse that would be most therapeutic with the above
statement of the client is to institute suicidal precaution.
3. Enumerate the 3 precautionary measures for suicidal patient.
4. When do you think the client will carry out his plan of suicide? Explain the
rationale.
5. As part of your assessment, the nurse should be aware of the behavioral cues
of impending suicide. Enumerate at least five (5) cues.
6. Based from the SAD PERSONS Scale of suicide, identify at least five
(5) risk factors applicable to VM.
7. Based from the case vignette, identify at least five (5) nursing diagnosis.
8. From question # 6 choose two (2) nursing diagnosis. Enumerate at least 5
nursing interventions for each nursing diagnosis.
9. Enumerate at least five (5) psychiatric conditions with high incidence of
suicide. Explain