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Bipolar Disorders Care Plan Nursing Care Plan (NCP)

Bipolar disorders are characterized by recurrent mood swings of varying degree from depression to elation with intervening periods of normalcy. Milder mood swings such as cyclothymia may be manifested or viewed as everyday creativity rather than an illness requiring treatment. Hypomania can actually enhance artistic creativity and creative thinking/ problem-solving.

This plan of care focuses on treatment of the manic phase. (Note: Bipolar II disorder is characterized by periods of depression and hypomania, but without manic episodes.)

DSM-IV
296.xx Bipolar I disorder
296.0x Single manic episode
296.40 Most recent episode hypomanic
296.4x Most recent episode manic
296.6x Most recent episode mixed
296.7 Most recent episode unspecified
296.5x Most recent episode depressed
296.89 Bipolar II disorder (recurrent major depressive episodes with hypomania)
301.13 Cyclothymic disorder
296.80 Bipolar disorder NOS

ETIOLOGICAL THEORIES
Psychodynamics
Psychoanalytical theory explains the cyclic behaviors of mania and depression as a response to conditional love from the primary caregiver. The child is maintained in a dependent position, and ego development is disrupted. This gives way to the development of a punitive superego (anger turned inward or depression) or a strong id (uncontrollable impulsive behavior or mania). In the psychoanalytical model, mania is viewed as the mirror image of depression, a “denial of depression.”

Biological
There is increasing evidence to indicate that genetics plays a strong role in the predisposition to bipolar disorder. Research suggests a combination of genes may create this predisposition. Incidence among relatives of affected individuals is higher than in the general population. Biochemically there appear to be increased levels of the biogenic amine norepinephrine in the brain, which may account for the increased activity of the manic individual.

Family Dynamics
Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned by a significant other during the first 6 months of life. The bonding process is interrupted and the child withdraws from people and the environment. Rejection by parents in childhood or spending formative years with a family that sees life as hopeless and has a chronic expectation of failure makes it difficult for the individual to be optimistic. The mother may be distant and unloving, the father a less powerful person, and the child expected to achieve high social and academic success.

NURSING PRIORITIES
1. Protect client/others from the consequences of hyperactive behavior.
2. Provide for client’s basic needs.
3. Promote reality orientation, realistic problem-solving, and foster autonomy.
4. Support client/family participation in follow-up care/community treatment.

DISCHARGE GOALS
1. Remains free of injury with decreased occurrence of manic behavior(s).
2. Balance between activity and rest restored.
3. Meeting basic self-care needs.
4. Communicating logically and clearly.
5. Client/family participating in ongoing treatment and understands importance of drug
therapy/monitoring.
6. Plan in place to meet needs after discharge.

Nursing diagnosis of Bipolar Disorders: TRAUMA, risk for/VIOLENCE, risk for directed at others may be related to Emotional difficulties; irritability and impulsive behavior; delusional thinking; angry response when ideas are refuted/wishes denied; Manic excitement; History of assaultive behavior possibly evidenced by Body language, increased motor activity; Difficulty evaluating the consequences of own actions; Overt and aggressive acts; hostile, threatening verbalizations.

Desired Outcome:

1. Demonstrate self-control with decreased hyperactivity.
2. Acknowledge why behavior occurs.
3. Verbalize feelings (anger, etc.) in an appropriate manner.
4. Use problem-solving techniques instead of violent behavior/threats or intimidation.

Nursing intervention and rationale:
1. Decrease environmental stimuli, avoiding exposure to areas or situations of predictable high stimulation and removing stimulation from area if client becomes agitated.
Rationale: Client may be unable to focus attention on only relevant stimuli and will be reacting/responding to all environmental stimuli.

2. Continually reevaluate client’s ability to tolerate frustration and/or individual situations.
Rationale: Facilitates early intervention and assists client to manage situation independently, if possible.

3. Provide safe environment, removing objects and rearranging room to prevent accidental/purposeful injury to self or others.
Rationale: Grandiose thinking (e.g., “I am Superman”) and hyperactive behavior can lead to destructive actions such as trying to run through the wall/into others.

4. Intervene when agitation begins to develop, with strategies such as being verbally direct, prompting more effective behavior, redirecting or removing from the provoking situation, voluntary “Time out” in room or a quiet place, physical control (e.g.,holding).
Rationale: Intervention at earliest sign of agitation can assist client in regaining control, preventing escalation to violence and allowing treatment in least restrictive manner.

5. Defer problem-solving regarding prevention of violence and information collection about precipitating or provoking stimuli until agitation/ irritability is diminished (e.g., no “why,” analytical questions).
Rationale: Questions regarding prevention increase frustration because agitation decreases ability to analyze situation.

6. Communicate rationale for staff action in a concrete manner.
Rationale: Agitated persons are unable to process complicated communication.

7. Provide information regarding more independent and alternative problem-solving strategies when client is not labile or irritable.
Rationale: Improves retention, as agitated person will not be able to recall or use strategies discussed.

8. Analyze any violent incidents with involved staff/ observers, identifying antecedents or provoking situations, client indicators of increasing agitation, client response(s) to intervention attempted, etc.
Rationale: Information is used to develop individualized and proactive interventions based on experience.

9. Provide seclusion and/or restraint (according to agency policy).
Rationale: May be required for brief period when other measures fail to protect client, staff, or others.

10. Prepare for electroconvulsive therapy as indicated.
Rationale: ECT may be required in presence of severe manic decompensation, when client does not tolerate/fails to respond to lithium or other drug treatments.
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