Nursing Interventions in the Diagnosis of Bipolar Disorder

Diagnosis Bipolar Disorder: "Bipolar disorder is a severe biologic illness characterized by recurrent fluctuations in mood. Typically, patients experience alternating episodes in which mood is abnormally elevated or abnormally depressed-separated by periods in which mood is relatively normal." (Lehne, 2004, p. 321)

The following is a short synopsis according to the DSM-IV-TR, "Criteria for Bipolar Disorder" includes a distinct period of abnormality and persistently elevated, expansive, or irritable mood for at least:
- 4 days for hypomania
- week for mania

During the period of mood disturbance, at least three or more of the following symptoms have persisted and have been present to a significant degree:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Excessive involvement in pleasurable activities that have a high potential for painful consequences." (American Psychiatric Association [APA], 2000).

Psychodynamics of the Disease The onset of the disease usually occurs during late adolescence or in the mid twenties. However, the disease has been known to occur up into the fifth decade of life. The mood swings that accompany this disorder are of several types. They are as follows: the Pure Manic Episode, evidenced by hyperactivity, excessive enthusiasm, and flight of ideas, constant wakefulness without sleep,

Impairment in normal social functioning usually requiring hospitalization; Hypomanic Episode, evidenced by a milder form of the Pure Mania, without the loss of normal functioning that would require hospitalization; Major Depressive Episode, characterized by depressed mood consisting of symptoms such as anhedonia, avolition, alogia, affective flattening and thoughts of suicide and death; the last episode associated with Bipolar disorders is the Mixed Episode in which, "patients experience symptoms of mania and depression simultaneously. The combination of high energy and depression puts them at significant risk of suicide." (Lehne, 2004, p. 321)

Case Presentation
A Caucasian woman in her mid twenties presented signs and symptoms of self mutilation with a straight edge razor inflicted gash across her lower abdomen approximately six inches below the umbilicus. The depth of the gash just stopped at the abdominal fascia. The patient was sent from the emergency room to the psychiatric floor. Upon meeting the patient one day after her admission to E.R., she appeared dressed in pajama bottoms and a t-shirt, shuffling down the hall in her socks. She was holding her abdomen with one hand and appeared in some discomfort. Her black hair was short and disheveled. When the patient arrived at her room she sat down on her bed. She acknowledged with blunted affect that she cannot stop self mutilation, and described how she cut herself through the muscles in her abdomen almost down to the fascia. Her voice was tremulous and fast paced. This could be due to the fact that she had just been given her first dose of Clozaril. She stated that her mouth was dry and that she needed to drink some water. She then went on to say that she was getting very sleepy. The client felt comfortable with the interview.

She shared personal information in regards to being sexually abused by her bother beginning at the age of seven until the age of fifteen. Her brother was two years older than her and died in an automobile accident at the age of eighteen. She went on to say that her mother never knew or acknowledged the sexual abuse and that she could not tell her because the mother idolized the son. The client was receptive to cognitive reframing; however she was very critical of herself and stated that she felt worthless and ashamed. She appeared very tired and stated that she wanted to sleep.

Table 1
Textbook characteristics of Bipolar disorder versus client characteristics observed

Textbook Characteristics:
Pure Manic Episode
Hypomanic Episode
Major Depressive Episode-
Affective Flattening
Alogia
Avolition-apathy
Anhedonia
Mixed Episode
Rapid-Cycling Bipolar Disorder- Patients experience four or Client

Characteristics Observed:
No current symptoms
Rapid breathing, rapid speech, however due to medication a client was concurrently exhibiting lethargy
Client acknowledged sadness/ worthlessness
Facial expression flat
Thoughts of dying, hard to focus
Hair/clothes unkempt
Expressed no interest in children or own

Client's Symptoms
1. Hypomania
2. Depression
a.) Affective Flattening
b.) Alogia
c.) Avolition & Apathy
d.) Anhedonia
3. Mixed Episode
4. Rapid Cycling
(Varcarolis, 2004, p. 485)

Nursing Interventions

1. Observe the client every 15 minutes while suicidal, remove all dangerous, sharp objects from room.

2. Reinforce that she is worth while,
a.) Assist the client in evaluating the positive as well as the negative aspects of her life
b.) Encourage the appropriate expression of angry feelings.
c.) Schedule regular periods of time throughout the day for recreational/occupational therapy, encourage client to groom self, offer praise for completing grooming.
d.) Ensure client's participation in taking mood stabilizing medications. Watch client swallow medication.
3. Engage client in interpersonal therapies, cognitive-behavioral therapy,
4. Encourage client to attend group therapy, and journal episodes.

Table 2
Medical Interventions, Bipolar Disorder
Drug therapy using
Mood stabilizer
Antidepressants
Antipsychotics
Education and Psychotherapy
ECT
(Varcarolis, 2002, p. 483)

Clients Medical Interventions
Drug therapy includes
Lithium 300mg every h.s.
Not taking any Clozaril
Client is receiving psychotherapy, family counseling, group therapy while in hospital, and cognitive restructuring.
None