BIPOLAR DISORDER

NURSING ASSESSMENT PT
2

PSYCHOTIC DISORDER
SHMN
Nurse Self-Assessment

• Witnessing mania can bring about intense emotions in a nurse

• The patient may use humor, manipulation, power struggles , or
demanding behavior to prevent or minimize the staff’s ability to set
limits on and control dangerous behavior.
• People with mania have the ability to split/divide staff into either
good or bad nurse:
• “The nurse on the day shift is always late with my medications and
never talks to me. You are the only one who seems to care”
Nurse Self-Assessment

• Devise tactics are used to pit one staff member or group against
another by undermining a unified front and consistent plan of care.
• Frequent staff meetings to deal with the behaviors can help minimize
staff working against each other, feelings of anger and frustration.
• Limit setting (lights out at 11PM) is the main theme in treating
someone with mania:
• Consistency among staff is imperative if limit setting is to be
carried out effectively.
Nurse Self-Assessment

• Patients can become aggressively demanding which often

triggers frustration, worry and exasperation in healthcare
professionals
• The behavior of a client experiencing mania is often aimed at
decreasing the effectiveness of staff control, which could be
accomplished by getting involved in power plays:
• E.g The patient might taunt the staff by pointing out faults
or oversights and drawing negative attention to one or
more staff members. Usually this is done in a loud and
disruptive manner which provokes staff to become
defensive, escalating the environmental tension and
patient’s degree of mania.
Nurse Self-Assessment
cont’d

• As a nurse working with a client experiencing mania, you may find yourself
feeling helpless, confused and even angry.
• Understanding, acknowledging, and sharing these responses and
countertransference reactions will enhance your professional ability to care for
the patient and perhaps promote your personal development as well.
• Collaborating with the multidisciplinary team, accessing supervision with your
nurse team and sharing your experiences with your peers at handover or
conferences maybe helpful or even essential.
Nurse Diagnosis

• A primary consideration for a client in acute mania is

the prevention of exhaustion and death from cardiac
collapse.
• Due to the client’s poor judgement, excessive and
constant motor activity, probable dehydration, and
difficulty evaluating reality; Risk for injury is a likely
and appropriate diagnosis.

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Nursing Outcomes

• Interventions will vary based on the phase of the

client (Acute, Continuation and Maintenance)
• Acute Phase:
• The primary focus is on preventing injury on both
physical and psychological (hydration, sleep &
rest, no self-harm, self-control)
Nursing Outcome: Continuation phase

• Can last for 4-9 months

• While goals are aimed at preventing relapse, other
outcomes must also be considered – knowledge of disease,
medication, impact of substance abuse and addiction,
awareness of signs & symptoms, triggers, support groups,
problem-solving
Nursing outcomes: Maintenance phase

• Focus is on continuing prevention of relapse and limiting

the severity and duration of future episodes
• Psychotherapy, group or other ongoing supportive therapy
• Focus on learning interpersonal strategies: work, social,
family problems
Planning

• When planning care for an individual with bipolar, it is

usually geared toward the particular phase of mania
the client is in (acute, continuation & maintenance) as
well as co-occurring issues identified in the
assessment.
• E.g.: Risk of suicide, risk of violence to person or
property, family crisis, legal crisis, substance
abuse, risk-taking behaviors

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Planning: Acute

• Focus is on medically stabilizing patient while maintaining safety

• Decreasing physical activity
• Increasing food & fluid intake
• Ensuring & encouraging at least 4-6 hours of sleep / night
• Allowing client to meet self-care needs 9 (ADL, urinating, bowel
movements)
• Some clients may need isolation or electroconvulsive therapy (CBT)
Planning: Continuation phase

• Focus is on maintaining medication adherence an prevention of relapse.

• Interventions are planned based on your assessment findings regarding
interpersonal and stress-reduction skills, cognitive functioning, employment
status, any substance-abuse related problems
• Client and family education is key
• Referral to community-based programs, support groups for co-occurring
disorders is evaluated
• Communication skills and problem-solving skills are important
Planning: Continuation phase

• Repair of residual problems during manic phase (violent, risky, bizarre

behavior)
• Cognitive Behavioral Therapy (CBT):
• An evidence-based therapeutic modality for children, adolescents,
and adults that seek to identify negative and irrational patterns of
thought and challenge them based on rational evidence and
thoughts.
• Combination of medication with CBT may be useful in addressing
interpersonal issues.
Planning: Maintenance phase

• Focus is on preventing relapse and limiting the severity and duration of

future episodes.
• Clients with bipolar disorder require medication over long periods of time;
even their lifetime.
• Psychotherapy:
• A therapeutic modality based on classical psychoanalysis but with less
focus on the early development of pathology. It uses free association,
dream analysis, transference and countertransference. The therapist is
actively involved and interacts with the client in the here and now.
Implementation

The minimize the Some are reluctant to give

Clients with bipolar
destructive consequences up the increased energy,
disorder are often
of their behaviors or deny euphoria, and heightened
ambivalent about
the seriousness of the sense of self-esteem of
treatment
disease hypomania.

Non-adherence to
treatment plan
(medication) of mood-
stabilizers is a major cause
of relapse.
Implementation: Acute phase (depressive
episode)

Depressive episodes of bipolar disorder have the same symptoms and risks as
major depression; but occurs more often and more intense.

Hospitalization may be required if suicidal ideation, psychosis or catatonia is

present.

Treatment with antidepressants is not recommended (for bipolar I disorder) as

their CNS may become overactive, and antidepressants may result in hypomania
or mania.
Implementation: Acute phase (Manic episode)

Hospitalization provides safety for a patient experiencing acute

mania (bipolar I disorder) as it imposes external controls on
destructive behaviors, and provides for medication stabilization.

Staff members continuously set limits in a firm, nonthreatening,

and neutral manner to prevent further escalation of mania and
provide safe boundaries for the patient and others.
Implementation: Continuation phase

Crucial for patients and their families.

The outcome here is preventing relapse, and community resourses based on

patient needs.

Medication adherence is most importance.

Follow-up as out-patient
Implementation: Maintenance phase

The goal is to prevent recurrence of an

episode

Community resources for both patient,

family & friends (support systems)