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Bipolar Affective

Jessica Stoefen, MN, RN, CCRN
Bipolar Disorder
• Lifetime rate in US is 4.4%

• Chronic, recurrent, life threatening

• Highest rate of suicide over the lifetime compared with

any other mental illness (11%)

• Affects men and women equally

• Younger initial onset than depression

• Physical exhaustion can lead to death

Bipolar Disorder
• Comorbidities

• Substance use disorders, personality disorders, anxiety

disorders, attention deficit disorder

• Cardiovascular disorders, cerebrovascular disorders,

metabolic disorders

• 2 poles

• Depression

• Mania - exaggerated euphoria or exaggerated irritability

Types of Bipolar Disorder

• Bipolar I Disorder

• Bipolar II Disorder

• Cyclothymia

• Rapid Cycling

• Bipolar NOS (Not

Otherwise Specified)
Bipolar II Disorder
Bipolar I Disorder
• Hypomanic episode(s)
• At
least 1 episode of alternating with major
mania alternating with depression
major depression • NO psychosis
• Psychosis
may • Hypomania = a mild form
accompany the manic of mania, marked by
episode elation and hyperactivity
• Higher
risk of suicide
during depression than
Bipolar I
Rapid Cycling Bipolar Disorder
• Hypomanic episodes
alternating with minor • 4 or more mood episodes in a
depression episodes 12 month period

• Irritable hypomanic episodes • Poorer global functioning,

higher recurrence risk
• Symptoms for 2 years to meet
diagnostic criteria Bipolar Disorder NOS

• Generally considered less • Bipolar features that do not

severe meet criteria for any Bipolar
Bipolar Disorder Symptoms
Cognitive Symptoms "Look at the sun, sun, sun,
• poor concentration bun, bun, honey bun, bunny
hon, bun in the oven.”
• problems with verbal memory

• poor attention span and poor “I don’t know what I’m going
executive functioning to do about Tony. Well
there’s the neighbor’s dog
• Flight of Ideas
barking again. Did you
• continuous flow of accelerated realize there are three weeks
speech left until June? Man it’s hot in
• jumps from topic to topic here. There’s a sale down at
the mall I just can’t miss.”
• usually does not make sense
Bipolar Disorder Symptoms

Disorganized Speech
“that boat
• typically incoherent and pressured
hope floats”
• content sexually explicit

• Clang Associations - stringing words

together because of rhyming sounds
“the train
• Grandiose or persecutory delusions
brain rained
on me.”
Causes of Bipolar Disorders
• Involves disturbances in relationships & disruptions in

• Environmental and genetic influences

• High rate of psychological and biological comorbidities

• No known set pathophysiology or specific biological or

genetic markers

• May be undiagnosed in different cultures

Biologic Theories of Bipolar
• Genetic Theories

• Twin and adoption studies support genetic component

• Neurobiological Factors

• Interactions between hormones and neurotransmitters

(NE, Serotonin, Dopamine) may be involved

• May be result of over sensitized neuroreceptors, may

have more neurotransmitters in the brain, or may have
different brain structure
Psychosocial Theories of Bipolar

• Stressful life events may trigger symptoms

• Family atmosphere may play role in relapse

Treatment of Bipolar
• Early diagnosis and treatment prevent
“No pill can help
• illness progression
me deal with the
• permanent cognitive deficits problem of not
wanting to take
• improve long term outcomes
pills, but no
• Milieu Therapy amount of therapy
alone can prevent
• Drug Treatment my manias and
• Psychotherapy depressions. I
need both.”
Drug Treatment for Bipolar

• During acute phase, medications essential to keep

patient safe

• During maintenance phase, medications essential to

maintain wellness

• many patients require multiple medications

• many patients require medication throughout their

Mood Stabilizers
• Lithium Carbonate is FIRST line treatment

• Lifetime maintenance therapy - NOT a cure

• Treats initial symptoms and prevents relapse

• 7-14 days to reach therapeutic levels (0.4-1.3mEq/L)

• Adverse Reactions: symptoms dependent on blood levels

• ECG changes, ataxia, clonic movements, seizures, coma,

• Dehydration can lead to lithium toxicity
Additional Drug Treatment
• Anticonvulsants (e.g. Depakote, Tegretol, Lamictal)

• Adjunct to Lithium or for patients who do not respond well

to Lithium

• Anxiolytics (e.g. Klonopin, Ativan)

• Treat acute mania and treatment-resistant mania

• Second-Generation Antipsychotics (e.g. Zyprexa, Risperdal,

Abilify, Geodone, Seroquel)

• Adjunctive treatment in initial phase of mania

Quick Question
A patient has a Lithium level of 1.1 mEq/L. This level

a: below therapeutic level

b: above therapeutic level

c: within the therapeutic range

d: potentially life threatening

Quick Question Answer
A patient has a Lithium level of 1.1 mEq/L. This level

a: below therapeutic level

b: above therapeutic level

c: within the therapeutic range

d: potentially life threatening

Communication Guidelines for
Patients with Bipolar Disorder
• Use firm, calm approach
• Use short, concise statements
• Remain neutral; avoid power struggles
• Be consistent (with yourself and other
• Important with firm limit setting
• Hear and act on legitimate complaints
• Firmly redirect energy into appropriate
The Nursing Process

Determine if patient dangerous to self or others
Presence of physical exhaustion
Poor impulse control
Uncontrolled spending of money

Determine medical symptom

Dehydration, infections
Remember Pathophysiology:

The nonstop activity, minimal food

intake, little or no sleep can lead to
exhaustion and even death.
The Nursing Process
Nursing diagnoses can be numerous. Individuals with bipolar
disorder are always evaluated for the risk of injury or risk of
self or other directed violence.

Other common diagnosis:

• Risk for suicide
• Ineffective coping
• Disturbed thought processes, acute confusion
• Interrupted family processes
• Imbalanced nutrition: less than body requirements
• Sleep deprivation
• Anxiety
The Nursing Process
Outcomes Identification
Acute phase: goal is prevention of
physical injury and decrease in
symptoms manifested
Continuation of treatment phase: goal
is relapse prevention
Maintenance phase: goal is relapse
prevention and limiting severity of
future episodes
The Nursing Process


• Acute phase focus is on physical safety and

medical stabilization in the hospital

• Work towards developing a therapeutic alliance

(while setting limits)
Milieu Therapy for Bipolar Disorder

safe milieu
• Seclusion and restraints may be
used if patient becomes
dangerously out of control and
other least restrictive
hydration measures failed
• Purposes: reduces
sleep overwhelming stimuli,
protects patient and others
hygiene from injury, prevents
destruction of property
Drug Therapy for Bipolar Disorder

• Includes Mood stabilizers, anxiolytics,

antipsychotics, and anti-seizure medications.

• Review on your own

• Varcarolis pp. 297

• ATI Chapter 21 - update

Lithium Patient Teaching
• Continue drug therapy to prevent relapse
• Maintenance of normal diet with normal salt and
fluid intake (1500-3000 mL/day)
• Lithium decreases sodium absorption and low
sodium levels/dehydration cause lithium toxicity
• Take Lithium with food to prevent GI upset
• Stop taking lithium and call physician if symptoms
of dehydration develop from sweating and/or
nausea, vomiting, diarrhea
• Lithium is NOT addictive
• Keep appointments for Lithium Level checks
Review Varcarolis Box 16-1 p 296
Quick Question
What is likely to occur when a patient,
taking lithium carbonate, has low sodium
A. Lithium toxicity
B. Low serum lithium levels
C. Increase in mania
D. Decrease in mania
Quick Question Answer
What is likely to occur when a patient,
taking lithium carbonate, has low sodium
A. Lithium toxicity
B. Low serum lithium levels
C. Increase in mania
D. Decrease in mania
Lithium Toxicity

All Elsevier items and derived items 2013, 2009 by

Saunders, an imprint of Elsevier Inc.
Lithium Toxicity
Early signs of Advanced signs of Lithium
Lithium Toxicity Toxicity
• (<1.5 mEq/L) • (1.5 to 2.0 mEq/l)
• Nausea, • Coarse hand tremor,
vomiting, persistent gastrointestinal
diarrhea, thirst, upset, mental confusion,
polyuria, slurred muscle hyperirritability,
speech and electroencephalographic
muscle (EEG) changes,
weakness. incoordination.
Lithium Toxicity
Severe Toxicity (2 to 2.5 mEq/L)
• Ataxia, serious EEG changes, blurred vision, clonic
movements, large output of dilute urine, tinnitus,
blurred vision, seizures, stupor, severe
hypotension, coma; death is usually secondary to
pulmonary complications.

>2.5 mEq/L
• Symptoms may progress rapidly; coma, cardiac
dysrhythmia, peripheral circulatory collapse,
proteiniuria, oliguria, and death.