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1 Bipolar Disorder
https://www.youtube.com/watch?v=vwpptgg8Sbw

3 Diagnostic & Statistical Manual of Mental Disorders (DSM)

• American Psychiatric Association.
• DSM first edition published in 1952 with 102 disorders
• Currently on DSM-5-TR (Text Revision) DSM 5 was published 2013 and the TR was
2022
• Bipolar disorder under the DSM-5, there are now seven possible diagnoses
4 What is Bipolar
1 Bipolar disorder (formerly called manic-depressive illness or manic depression) is a
mental disorder that causes unusual shifts in mood, energy, activity levels, concentration,
and the ability to carry out day-to-day tasks.

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
2 National Institute of Mental Health Definition

5 Bipolar
1 Manic Episode
2 • Decreased need for sleep (e.g., feeling energetic despite significantly less sleep than
usual
• Increased or faster speech
• Uncontrollable racing thoughts or quickly changing ideas or topics when speaking
• Distractibility
• Increased activity (e.g., restlessness, working on several projects at once)
• Increased risky behavior (e.g., reckless driving, spending sprees)
•
3 Hypomanic Episode
4 • A hypomanic episode is characterized by less severe manic symptoms that need to last
only four days in a row rather than a week. Hypomanic symptoms do not lead to the
major problems in daily functioning that manic symptoms commonly cause.
6

7 Epidemiology
• Gender- Equal
• Age-
– Bipolar I 18yo
– Bipolar II 22yo
• Social Class- Higher

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• Social Class- Higher

8 Bipolar Disorders: Types

• Bipolar I Disorder (Severe)
• Bipolar II Disorder
• Cyclothymic Disorder
• Substance/Medication-induced Bipolar and Related disorder
• Bipolar & Related Disorder Due to Another Medical Condition
• Other Specified Bipolar & Related Disorder
• Unspecified Bipolar & Related Disorder
• Dual Diagnosis
•
9 Bipolar Type I Disorder
Defined by manic episodes that last at least 7 days, or by manic symptoms that are so
severe that the person needs immediate hospital care. Usually, depressive episodes occur
as well, typically lasting at least 2 weeks. Episodes of depression with mixed features
(having depressive symptoms and manic symptoms at the same time) are also possible.
•

10 Bipolar II Disorder
Hypomanic episode with major depression;
no history of mania, but can have a history of
hypomania
11 Cyclothymic Disorder
Hypomanic and depressive symptoms that
do not meet bipolar II disorder criteria, no
major depressive episodes, occurring over two
years, with no more than two months free of
symptoms
12 Substance/Medication-induced Bipolar and Related disorder
• Direct result of physiological effects of a substance.
– Steroids, alcohol, cocaine, or prescription antidepressants
• Mood may be elevated, expansive, or irritable with inflated self-esteem
• Decreased need for sleep & distractibility
13 Bipolar & Related Disorder Due to Another Medical Condition
• Abnormally & persistently elevated, expansive, or irritable mood & excessive activity or
energy
• Directly related to another medical condition
– Thyroid disorders, stroke, traumatic brain injury, multiple sclerosis…
14 Dual Diagnosis
• Mental Health Disorder and Substance Abuse
• http://www.webmd.com/bipolar-disorder/video/treating-dual-disorders

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• Mental Health Disorder and Substance Abuse
• http://www.webmd.com/bipolar-disorder/video/treating-dual-disorders

15 Bipolar Predisposing Factors

• Biological Theories
– Genetics
• Twin Studies
• Family Studies
• Biochemical Influences
– Biogenic Amines
• Physiological Influences
– Neuroanatomical Factors
– Medication Side Effects
• Psychosocial Theories
16 Symptoms of bipolar disorder
1 Manic Phase
▪ Euphoria
▪ Poor Judgment
▪ Racing Thoughts
▪ Agitation/Irritation
▪ Spending Sprees
▪ Easily distracted
▪ Careless/dangerous use of drugs/alcohol
2 Depressive Phase
▪ Sadness
▪ Hopelessness
▪ Suicidal thoughts
▪ Anxiety
▪ Sleep problems
▪ Fatigue
▪ Loss of interest
▪ Chronic pain without a known cause
17 Developmental Implications
• Explosive temper
• Rapid mood shifts
• Reckless behavior
• Aggression

18 Adolescent mania
• Faster cycling (very labile)
• Fewer Psychotic features
• Fewer Delusions
• Increased Suicidality

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• Fewer Delusions
• Increased Suicidality
• Increased Depression
19 Elder Mania
• Confusion
• Disorientation
• Distractibility
• Neurologic Impairment
• Pressured Speech

20 Symptoms of bipolar
• Seasonal changes in mood
• Rapid cycling
• Psychosis
•

21 Symptoms of bipolar cont.

▪ Euphoric/expansive mood: extremely happy, silly, or giddy
▪ Irritable mood: hostility and rage, often over trivial matters
▪ Grandiosity: believes abilities to be better than everyone else’s
▪ Decreased need for sleep: may sleep for only 4 or 5 hours per night and wake up
feeling rested
▪ Pressured speech: loud, intrusive, difficult to interrupt
▪ Racing thoughts: rapid change of topics
▪ Distractibility: unable to focus on school lessons
▪ Increase in goal-directed activity/psychomotor agitation: activities become
obsessive; increased psychomotor agitation
▪ Excessive involvement in pleasurable or risky activities: exhibits behavior that has
an erotic, pleasure-seeking quality about it
▪ Psychosis: may experience hallucinations and delusions
▪ Suicidality: may exhibit suicidal behavior during a depressed or mixed episode or
when psychotic
•
•
22 Tests and diagnosis

• Physical exam
• Lab tests
• Psychological
evaluation
• Mood charting
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• Mood charting
23 Treatments for Bipolar disorder
Medication
Lithium

24 Nursing Implications for Clients Taking Lithium

• Works better in younger (many side effects with elderly)
• Therapeutic and toxic levels are very close.
• Clients should maintain fluid intake at 1.5-3L per day to avoid dehydration

25 Lithium - continued
• Taking with food reduces GI distress
• Alterations in sodium intake will alter lithium levels
• Many side effects – including diabetes insipidus and hypothyroidism- that may cause
clients to discontinue medication
• Avoid activities that cause heavy sweating

26 LITHIUM TOXICITY
Maintenance level Range- 0.6 to 1.2 mEq/L

See ATI RN Mental Health Nursing 11ed pg 130

27 Common Adverse Effects 1.2-1.4

• N/V/D, thirst, polyuria, muscle weakness, fine hand tremors, slurred speech, lethargy
Nursing
• Instruct pt that manifestations at low levels often improve over time.

28 Toxicity: Early Indications 1.5-2.0

• Mental confusion, sedation, poor coordination, coarse tremors, ongoing GI distress
(N/V/D)
Nursing
• Hold Lithium & contact provider
• Administer new dose based on blood lithium and Sodium levels
• Excretion can need to be promoted

29 Toxicity: Advanced indication 2.0-2.5

• Extreme polyuria of dilute urine, tinnitus, giddiness, jerking movements, blurred vision,
ataxia, seizures, severe hypotension & stupor leading to coma, & possible death from
respiratory complications
Nursing
• Administer emetic to alert pts or gastric lavage
• Urea, Mannitol or aminophylline may be prescribed to increase rate of excretion

30 Severe Toxicity: > 2.5

• Rapid progression of manifestations leading to coma & death
Nursing

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• Rapid progression of manifestations leading to coma & death
Nursing
• Hemodialysis can be warranted

31 Client teaching needs on Lithium

• Do not double doses
• Need to consume at least 1.5-3L of fluid to assist with kidney excretion
• Nausea helped by meds with food
• Dry mouth helped by water and hard candy
• Caffeine makes tremor worse
• Avoid excessive perspiration
• Severe diarrhea can cause toxicity
32 Treatments for Bipolar disorder
Medications (continued)-
• Anticonvulsant mood stabilizers-Depakote, Tegretol, Klonopin
• Antipsychotics (seroquel)
• Symbyax
– Combo- Fluoxentine & Olanzapine
• Benzodiazephines

33 Treatments for Bipolar disorder

• Psychotherapy-Individual, Family, Group
• Transcranial Magnetic Stimulation
• Electroconvulsive Therapy (ECT)
• Hospitalizations
• Herbal supplements
•

34 Patient and Family Education

• Mental Health Specialists
• Community Mental Health Centers
• Support Groups
• Internet resources
www.dbsalliance.org
https://childmind.org/guide/bipolar-disorder-in-kids-quick-guide/
35 Application of the Nursing Process

36 Nursing Diagnosis
• Disturbed thought processes
• Impaired social interaction
• Risk for injury
• Disturbed sleep pattern

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• Disturbed sleep pattern

37 Bipolar
• http://www.webmd.com/bipolar-disorder/video/challenges-of-living-with-bipolar

38 Bipolar
Depressive and Bipolar Disorders: Crash Course Psychology #30-
https://www.youtube.com/watch?feature=player_detailpage&v=ZwMlHkWKDwM

39 Bipolar Review Questions

40 42. The nurse manager is evaluating a primary nurse's ability to develop a

therapeutic relationship. A client with a bipolar mood disorder, manic phase, has
been hyperactive and sarcastic. This behavior has been decreasing and the client
states, “My husband and I have problems because we see things differently.” What
response indicates to the nurse manager that the primary nurse is not being
therapeutic?
1. “Do you know why you are feeling calmer today?”
2. “Not getting along with one's spouse is upsetting.”
3. “Can you explain what you mean by seeing things differently?”
4. “Tell me about a specific time when you have had problems with your husband.”

41 282. A male client with the diagnosis of a bipolar disorder, depressed episode, is
found lying on the floor in his room in the psychiatric unit. He states, “I don't
deserve a comfortable bed; give it to someone else.” The nurse's best response is:
1. “Everyone has a bed. This one is yours.”
2. “You are not allowed to sleep on the floor.”
3. “I don't understand why you are on the floor.”
4. “You're a valuable person. You don't need to lie on the floor.”

42 284. A client is admitted with a bipolar disorder, depressed episode. The nursing
history indicates a progressive increase in depression over the past month. What
should the nurse expect the client to display?
1. Elated affect related to reaction formation
2. Loose associations related to a thought disorder
3. Physical exhaustion related to decreased physical activity
4. Paucity of verbal expression related to slowed thought processes

43 291. A nurse is caring for a client with bipolar I disorder. What should the plan of
care for this client include? Select all that apply.

1. _____ Touching the client to provide reassurance

2. _____ Providing a structured environment for the client

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1. _____ Touching the client to provide reassurance

2. _____ Providing a structured environment for the client
3. _____ Ensuring that the client's nutritional needs are met
4. _____ Engaging the client in conversation about current affairs
5. _____ Designing activities that require the client to maintain contact with reality

44 The nurse is planning activities for a client who has bipolar disorder with
aggressive social behavior. Which of the following activities would be most
appropriate for this client?

1. chess
2. writing
3. ping pong
4. basketball

45 294. A 32-year-old woman is hospitalized with a diagnosis of a bipolar disorder,

manic episode. She becomes loud and vulgar and disturbs the other clients. What is
the nurse's best reaction to this situation?

1. State, “You are bothering the other clients.”

2. Ignore the vulgar talk because it is part of the illness
3. Segregate the client until this phase of her illness passes
4. Comment, “We don't like that kind of talk around here.”

46
A suicidal client, with a history of manic behavior, is admitted to the ED. The client’s
diagnosis is documented as bipolar I disorder: depressive state. What is the rationale
for this diagnosis versus a diagnosis of major depression?
A) The physician does not believe the client is suffering from major depression.
B) The client has experienced a manic episode in the past.
C) The client does not exhibit psychotic symptoms.
D) There is no history of major depression in the client's family.

47
A client, who is prescribed lithium carbonate, is being discharged from inpatient care.
Which medication information should the nurse teach this client?
A) Do not skimp on dietary sodium intake.
B) Have serum lithium levels checked every 6 months.
C) Limit fluid intake to 1,000 ml of fluid per day.
D) Adjust the dose if you feel out of control.