1 of 28

Course: Mental Health Nursing

Topic: Mood Disorder: Bipolar Disorders Part II

The Nurses International Community

Contact info: info@nursesinternational.org

2 of 28

COPYRIGHT

NI Privacy Policy and Terms of Use.

Contact info: info@nursesinternational.org

3 of 28

Module Goals

Learners will be able to

Discuss evidence-based management of bipolar disorder.
Identify the appropriate nursing interventions for bipolar disorders.

Contact info: info@nursesinternational.org

4 of 28

Treatment of Bipolar Disorder

Key components of all psychotherapies (including psychoeducation)

Monitor moods and early warning signs
Recognize and manage stress triggers and interpersonal conflicts
Develop relapse prevention plans
Stabilize sleep/wake rhythms and daily routines
Encourage medication adherence
Reduce self-stigmatization
Reduce alcohol or drug use (including caffeine)

Goodwin et al., 2016

Contact info: info@nursesinternational.org

5 of 28

Treatment of Bipolar Disorder

Treatment is directed at managing symptoms

Medications
Continued treatment

Lifelong treatment with medications, even during periods when feeling better

Day treatment programs

Provide support and counseling while symptoms under control

Substance abuse treatment

Problems with alcohol or drugs

Hospitalization

Mayoclinic, 2021

Contact info: info@nursesinternational.org

6 of 28

Treatment of Different Phases

Acute Manic Episode
Initially: short-term treatment with medication in an appropriate clinical setting.
Long-term treatment:

Severe manic episodes: dopamine antagonist
Haloperidol, Olanzapine, Risperidone, and Quetiapine are effective in short-term reduction of symptoms
Valproate as an alternative
Carbamazepine and lithium are optional

Goodwin et al., 2016

Contact info: info@nursesinternational.org

7 of 28

Treatment of Different Phases

Acute Manic Episode

During long term treatment

Ensure that the highest well-tolerated dose is prescribed. (For a dopamine antagonist or partial agonist, or valproate, raising the dose may be sufficient to control manic symptoms)
Regarding lithium, maintain serum concentrations within the target range (0.6 - 0.8 mmol/l (or mEq/l)

Goodwin et al., 2016

Contact info: info@nursesinternational.org

8 of 28

Treatment of Different Phases

Acute Depressive Episode

During long term treatment:

May consider Quetiapine, Lurasidone or Olanzapine.
May consider ECT for clients with high suicidal risk, treatment resistance, psychosis, severe depression during pregnancy.
Less severe symptoms may indicate Lithium.

Goodwin et al., 2016

Contact info: info@nursesinternational.org

9 of 28

Treatment of Different Phases

Long-term Treatment

After successful maintenance therapy, advise client to continue medication indefinitely due to high relapse risk
Choice of long term treatment

May consider lithium as initial monotherapy.
Lithium monotherapy is effective against both manic, depressive, and mixed relapse.

Goodwin et al., 2016

Contact info: info@nursesinternational.org

10 of 28

What Would the Nurse Do?

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which symptom requires immediate attention?

Outlandish behaviors and inappropriate dress
Grandiose delusions of being a royal descendant of King Arthur
Nonstop physical activity and poor nutritional intake
Constant, incessant talking that includes sexual innuendoes and teasing the staff

Contact info: info@nursesinternational.org

11 of 28

Specific Psychological Interventions

Psychoeducation:

Group and individual psychoeducation is ‘first line’ psychological intervention.
Educate client and family/support system as appropriate.
Understanding symptoms help the client to seek the best support, identify issues, make a plan to prevent relapse, and adhere to treatment.

Goodwin et al., 2016

Contact info: info@nursesinternational.org

12 of 28

Specific Psychological Interventions

Cognitive Behavior Therapy (CBT):

Focus on identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones.
Assists in identification of triggers.
Teach stress management strategies and how to cope with upsetting situations.

Goodwin et al., 2016

Contact info: info@nursesinternational.org

13 of 28

Specific Psychological Interventions

Interpersonal and Social Rhythm Therapy (IPSRT):

Emphasis on preserving sleep and partaking in regular daily activities.
A consistent routine (for sleep, diet, and exercise) allows for better mood management.

Goodwin et al., 2016

Contact info: info@nursesinternational.org

14 of 28

Specific Psychological Interventions

Family/Caregivers interventions

Effective in short and long-term treatment
Most effective in younger clients
Key components:

Psychoeducation
Communication skills training
Problem-solving skills training

Cognitive and functional remediation

Helpful to improve interpersonal and occupational functioning.

Goodwin et al., 2016

Contact info: info@nursesinternational.org

15 of 28

Medications

Mood stabilizers (manic episode): Lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).

Antipsychotics: Olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris).

Mayoclinic, 2021

Contact info: info@nursesinternational.org

16 of 28

Medications

Antidepressants: Commonly prescribed along with a mood stabilizer and antipsychotics.

Antidepressant-antipsychotic: Combines the antidepressant fluoxetine and the antipsychotic olanzapine.

Anti-anxiety medications: Short term option of benzodiazepines to assist with anxiety and to improve sleep patterns.

Mayoclinic, 2021

Contact info: info@nursesinternational.org

17 of 28

Other Treatment Options

Electroconvulsive therapy (ECT)

Offered when:

Clients do not respond to medication.
Displays a high risk of suicide
Mania is particularly severe or treatment-resistant.
Client preference.
Clients with severe mania during pregnancy who can not take antidepressants.

Mayoclinic, 2021

Contact info: info@nursesinternational.org

18 of 28

Critical Thinking Question

Which of the following are the indications for Electroconvulsive Therapy in Bipolar Disorder? (Select all that apply)

Suicidal risk
Mania during pregnancy
Resistant to medication
Preferences over medication

Contact info: info@nursesinternational.org

19 of 28

Nurse’s Role in Treatment of Bipolar Disorder

Critical role: Detection of symptoms
Thorough mental status examination and screening
Assess signs of mania/hypomania
Obtain a detailed history:

Mood instability and mood swings
Stress factors
Life events
Alcohol and drug use
Money-spending patterns
Promiscuous behavior

Goossens et al., 2007

Contact info: info@nursesinternational.org

20 of 28

Nurse’s Role in Treatment of Bipolar Disorder

Safety Interventions
Protection of the client is the highest priority.
Limit external and internal stimuli

Reduce environmental stimuli
Promote the establishment of a quiet, controlled, and structured environment.
Nursing approach in the stage of acute (hypo)mania:

Calm, supportive, and neutral but firm.

Goossens et al., 2007

Contact info: info@nursesinternational.org

21 of 28

Nurse’s Role in Treatment of Bipolar Disorder

Safety Interventions

In cases of active or perceived danger to or from the client, implement the following recommended interventions to reduce safety risks:

Protection
Constant observation
Isolation or even seclusion

Goossens et al., 2007

Contact info: info@nursesinternational.org

22 of 28

Nurse’s Role in Treatment of Bipolar Disorder

Pharmacological Intervention

Medication considerations

Treatment effectiveness
Side-effects
Education and supervision of medication use

Interventions related to the prevention of lithium toxicity.
Monitor lithium blood levels (the target range is 0.6-0.8 mmol/l).

Above 0.8 mmol/l is associated with an increased risk of renal impairment especially in women

Daily weights
Observation for adequate fluid intake.

Goossens et al., 2007

Contact info: info@nursesinternational.org

23 of 28

Nurse’s Role in Bipolar Disorder

Self Management Interventions

For clients and family
Education

Impact of illness and the treatment options.
Use of pharmacology.
Identification of a symptoms profile.
Identification of vulnerability factors.
identification and anticipation of triggers.
life stressors, potential relapse patterns.
Alternative coping strategies.

Goossens et al., 2007

Contact info: info@nursesinternational.org

24 of 28

Nurse’s Role in Treatment of Manic Episode

Client too active to eat

Maintain the client’s body weight.
Provide foods that may be eaten on the move (finger foods) because some clients can not sit long enough to eat.
Provide high calorie and high protein foods.
Vitamin supplements may be indicated
Check weight daily.

Contact info: info@nursesinternational.org

25 of 28

Nurse’s Role inTeatment of Manic Episode

Sleeplessness

Provide a quiet environment.
Structure client’s days to minimize stimulating activities before bedtime.
Avoid caffeine before bedtime.
Assess the amount of rest the client is getting throughout the day.

Hygiene

Reinforce appropriate hygiene and dress
Shower
Dental Hygiene
Appropriate clothes

Contact info: info@nursesinternational.org

26 of 28

Critical Thinking Question

In a day treatment program, a manic client is creating considerable chaos, behaving in a dominating and manipulative way. Which nursing intervention is most appropriate?

Allow the peer group to intervene.
Describe acceptable behavior and set realistic limits with the client.
Recommend that the client is hospitalized for treatment.
Tell the client that his behavior is inappropriate.

Contact info: info@nursesinternational.org

27 of 28

References

Goodwin, G. M., et, al. (2016). Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. Journal of psychopharmacology (Oxford, England), 30(6), 495–553. https://doi.org/10.1177/0269881116636545

Mayoclinic. ( 2021). Bipolar Disorders. https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/diagnosis-treatment/drc-20355961

Goossens, P., Achterberg, TV., & Klein, E. (2007). Nursing processes used in the treatment of patients with bipolar disorder. International Journal of Mental Health Nursing. 16, 3. https://onlinelibrary.wiley.com/doi/10.1111/j.1447-0349.2007.00464.x

Contact info: info@nursesinternational.org

28 of 28

Please go to

My Learning Experience

to provide feedback on your experience.

Thank you, and come back soon!

Contact info: info@nursesinternational.org