Bipolar disorder is a mental health condition characterized by very high moods (manic or hypomanic episodes) and depression. There are several types of bipolar disorder.
In this article:
- Types of Bipolar Disorder
- Nursing Process
- Nursing Care Plans
- Insomnia
- Risk for Injury
- Risk for Self-Mutilation
- Risk for Suicide
Types of Bipolar Disorder
Manic and hypomania (a less severe form of mania) include the following symptoms:
- Hyperactivity
- Euphoria
- Racing thoughts
- An exaggerated sense of grandiosity and self-importance
- Poor decision-making resulting in shopping sprees or inappropriate dress
- Manipulation
- Risk-taking behaviors such as driving vehicles at high speeds or participating in unprotected sex
- Socially inappropriate behavior affecting relationships and workplaces
Depressive episodes, on the other hand, affect day-to-day activities:
- Feelings of sadness or hopelessness
- Loss of interest or pleasure in activities
- Loss of energy
- Inability to concentrate
- Suicidal ideation
Bipolar disorder is a life-long mental illness and treatment focuses on managing symptoms through psychotherapy and mood stabilizers, antipsychotics, antidepressants, and anti-anxiety medications.
Nursing Process
Patients who require inpatient treatment for bipolar disorder are likely experiencing either a manic or depressive episode and need supervision and intervention by trained psychiatric nurses. Nurses may also interact with patients with bipolar disorder when treating subsequent disorders such as substance abuse disorders or general health conditions.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for bipolar disorder, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for bipolar disorder.
Disturbed Thought Processes
Patients with bipolar disorder may experience a range of disturbed thoughts.
Nursing Diagnosis: Disturbed Thought Processes
Related to:
- Sleep deprivation
- Psychotic process
- Substance abuse
As evidenced by:
- Distractibility
- Egocentricity
- Impaired decision-making
- Suspiciousness
- Delusional thinking
- Hypervigilance
- Hallucinations
Expected outcome:
- Patient will display reality-based thinking with an absence of delusions by discharge.
- Patient will recognize and verbalize when thoughts are not reality-based.
- Patient will verbalize an absence of hallucinations.
Assessment:
1. Determine alcohol or drug use.
Substances can increase delusional thoughts or impair judgment and have a cumulative effect on an already unstable mentality.
2. Assess for hallucinations.
Auditory hallucinations are most common in a psychotic state and cause delusions that range from believing someone is out to harm them to exaggeration about their ability to possess special powers.
3. Assess attention span and problem-solving.
In communication with the patient, assess their ability to maintain a train of thought, interpret information, and make appropriate decisions.
Interventions:
1. Reorient and focus on reality.
Reorient the patient to person, place, and time as needed. Focus on reality during conversation such as discussing current events to divert from false ideals.
2. Provide positive reinforcement.
When the patient differentiates between reality and delusions provide positive and supportive reinforcement.
3. Do not accept nor deny beliefs.
The nurse should not accept the patient’s delusions as facts as this only reinforces false thinking. The nurse should also not outwardly deny or argue beliefs as this will only alienate the patient and harm a therapeutic relationship.
4. Teach thought-stopping techniques.
Instruct the patient on techniques to stop intrusive thoughts such as yelling “stop!” or clapping the hands when the patient has an unwanted thought as this can prevent further harmful emotions and behaviors.
Insomnia
Bipolar disorder often causes insomnia as the patient experiences a decreased need for sleep.
Nursing Diagnosis: Insomnia
Related to:
- Hyperactivity
- Use of stimulants
- Disorder process
- Distractibility
As evidenced by:
- Difficulty falling asleep
- Decreased need for sleep
- Sleeping for only short periods
- Awakening very early
Expected outcomes:
- Patient will sleep at least 6-7 hours per night by discharge.
- Patient will apply two interventions to improve sleep.
- Patient will exhibit decreased restlessness and exhaustion due to adequate sleep.
Assessment:
1. Assess sleep patterns.
Assess a baseline understanding of the patient’s sleep patterns in order to institute scheduled naps and bedtimes.
2. Monitor for physical signs of exhaustion.
Patients with bipolar disorder may not feel a need for sleep and will go days without resting due to hyperactivity. They may not notice symptoms of fatigue such as tremors and increased blood pressure. The nurse can intervene before exhaustion occurs.
Interventions:
1. Administer benzodiazepines.
New research shows that clonazepam and lorazepam may be safer for sleep as they may improve symptoms of mania.
2. Trial dark therapy.
Dark therapy is a behavioral treatment that enhances melatonin naturally by keeping patients in a pitch-dark room during nighttime hours. Blue-light blocking glasses can improve circadian rhythms once insomnia has dissipated.
3. Promote relaxation.
Promote relaxation and improve sleep hygiene by instituting soft music, dim lighting, and non-caffeinated teas before bedtime.
4. Prohibit stimulants.
Caffeinated beverages should be prohibited for the patient with insomnia.
5. Recommend CBT for insomnia.
Cognitive behavioral therapy for insomnia for bipolar disorder has proven not only to improve sleep but also to lessen the number of days in a mood episode. Patients can utilize apps that can coach on CBT for insomnia.
Risk for Injury
Patients are at a risk for injury from participating in dangerous activities or potentially harming themselves.
Nursing Diagnosis: Risk For Injury
Related to:
- Extreme hyperactivity
- Destructive behaviors
- Disinhibition
- Poor judgment
- Risk-taking behavior
- Aggression
- Alcohol and drug use
- Delusional thinking
- Self-harm
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at preventing signs and symptoms.
Expected outcomes:
- Patient will not harm themselves or others during a manic episode.
- Patient will display a calm and subdued energy level before discharge.
- Patient will cooperate with unit rules without aggression or inappropriate behavior.
Assessment:
1. Distinguish between manic or depressive behavior.
Manic episodes often include hyperactive behavior with risk-taking due to a disillusioned belief of being invincible. Episodes of depression may include hearing voices and acting on dangerous behaviors or partaking in drugs or alcohol.
2. Assess safety/suicide risk.
Observe the patient’s behaviors for aggression, irritability, a lack of judgment, and socially inappropriate behavior. Ask the patient directly if they have thoughts of killing themselves. Interventions are aimed at keeping the patient and others safe.
3. Obtain information from family and friends.
Family members, spouses, and close friends are a valuable source of information and can help to understand a patient’s usual behaviors during acute episodes to determine risks.
Interventions:
1. Reduce stimuli.
Provide a private room if possible that is quiet with low lighting to reduce hyperactivity and distraction.
2. Remove dangerous objects.
Remove any objects that could be used as a weapon or to potentially harm themselves.
3. Provide physical activities.
Patients experiencing mania have endless energy. Offer exercise classes or housekeeping duties to help relieve hyperactivity as well as distract them from unsafe activities.
4. Administer tranquilizing medication.
Anti-psychotic medications are often prescribed to relieve symptoms of hyperactivity and agitation.
Risk for Self-Mutilation
Patients with bipolar disorder are at risk for self-mutilation when in a manic, depressive, or mixed state.
Nursing Diagnosis: Risk for Self-Mutilation
Related to:
- Disease process
- Dysfunctional thought processes
- Difficulty coping with stressful situations
- Difficulty expressing feelings
- Depressive symptoms
- Ineffective impulse control
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free from self-injury.
- Patient will utilize appropriate coping strategies to reduce the risk of self-mutilation.
Assessment:
1. Assess the patient’s mental state.
Bipolar disorder is characterized by manic and depressive episodes. Both states or even a mixed state, may cause the patient to participate in self-injurious behavior.
2. Assess for personality factors affecting emotions.
Poor emotional regulation and impulsivity are underlying features contributing to self-harm in patients with bipolar disorder. Patients who have difficulty managing their emotions are more likely to react inappropriately. Neuroticism, or the likelihood of experiencing negative emotions like anxiety, worry, or frustration, is also linked to self-harm.
Interventions:
1. Encourage the patient to verbalize feelings.
The patient must learn to verbally express their thoughts and emotions instead of acting out in a harmful manner to regulate their emotions.
2. Decrease social isolation.
Loneliness may be a cause of increased self-harm in some patients. Identify support persons that the patient can reach out to when feeling the urge to self-harm. This may also include mental health professionals.
3. Reinforce alternative ways to cope.
Patients in a manic state may need to find other outlets, such as exercise or cleaning, to cope with impulsive urges. If the patient is depressed, offer ways to distract from difficult emotions, like going for a walk. These activities encourage goal redirection for self-efficacy, promote coping, and reduce the risk of self-harm.
4. Remove harmful objects from the patient’s surroundings.
Family members may assist with removing sharp objects or lighters from the patient’s environment to dissuade self-mutilation.
Risk for Suicide
Bipolar disorder is a mood disorder that may increase the patient’s suicidal thoughts and risk for suicide. Suicide is a significant cause of death in patients with bipolar disorder.
Nursing Diagnosis: Risk for Suicide
Related to:
- Psychiatric disorder
- Dysfunctional thought processes
- Difficulty coping with stressful situations
- Depressive symptoms
- Ineffective impulse control
- Access to a weapon
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain safe and will not harm themself.
- Patient will express feelings, disclose suicidal ideations, and seek help when suicidal thoughts occur.
Assessment:
1. Assess the patient’s current mood and signs of psychotic symptoms.
Psychotic features may occur with manic or depressive episodes and correlate with an increase in suicidal thoughts. Assess for hallucinations, delusions, paranoia, and irrational thinking.
2. Assess for suicidal ideations.
The nurse should inquire directly if the patient is having thoughts of suicide. The nurse should remain aware of statements or an expression of feelings that may correlate to an increased risk.
3. Assess the patient’s support system.
A perceived lack of social support is correlated to a history of attempted suicide in patients with bipolar disorder.
Interventions:
1. Provide mental health resources.
Ensure the patient has ample access to counselors, support groups, and hotlines as needed in the event of suicidal ideation. Perceived loneliness is a risk factor for suicidal ideation, and enhanced support may be protective.
2. Ensure adherence to the medication regimen.
Lithium is a mood stabilizer commonly used to treat bipolar disorder and also has been shown to decrease the risk of suicidal thoughts.
3. Maintain close surveillance.
If a patient has expressed suicidal ideations or has a plan, it is imperative to increase surveillance to maintain the client’s safety. Inpatient admission may be necessary for continuous supervision.
4. Ensure the patient’s environment is safe.
Removing dangerous objects and weapons from the patient’s environment can reduce the risk of suicide and injuries.
References
- Aiken, C. (2022, February 24). New Directions for Insomnia and Bipolar Disorder. Psychiatric Times. Retrieved March 31, 2022, from https://www.psychiatrictimes.com/view/new-directions-for-insomnia-and-bipolar-disorder
- Bassett, D. L. (2010, August 16). Risk assessment and management in bipolar disorders. The Medical Journal of Australia. Retrieved March 31, 2022, from https://www.mja.com.au/journal/2010/193/4/risk-assessment-and-management-bipolar-disorders
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Katz, D. (2021, August 31). Psychosis and Suicidality in Patients with Bipolar Depression. MGH Psychiatry News. https://mghpsychnews.org/psychosis-and-sucidality-in-bipolar-depression/
- Mayo Clinic. (2021, February 16). Bipolar disorder – Symptoms and causes. Mayo Clinic. Retrieved March 31, 2022, from https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955
- Psychotic symptoms in bipolar disorder. (2021, October 17). NeuRA Library. Retrieved March 31, 2022, from https://library.neura.edu.au/bipolar-disorder/signs-and-symptoms-bipolar-disorder/general-signs-and-symptoms-bipolar-disorder/psychotic-symptoms/
- Townsend, M. C. (2011). Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychotropic Medications.
- Weintraub, M. J., Van de Loo, M. M., Gitlin, M. J., & Miklowitz, D. J. (2017). Self-Harm, Affective Traits, and Psychosocial Functioning in Adults With Depressive and Bipolar Disorders. The Journal of nervous and mental disease, 205(11), 896–899. https://doi.org/10.1097/NMD.0000000000000744
