Assessment of a client with a mood disorder focuses on both verbal and nonverbal assessments. People with a bipolar disorder experience periods of unusually intense emotion, grandiose delusions, changes in sleep patterns and activity levels, and impulsive behaviors, often without recognizing potential harmful effects. See Figure 8.3 for an artistic depiction of grandiose delusions when a cat looking in a mirror sees a lion. It is often helpful to interview family members or significant others of clients with mood disorders. Clients with mania, hypomania, or psychosis often have poor insight and may have difficulty providing an accurate history. Safety guidelines for assessing a client with a bipolar disorder include the following: Table 8.4a outlines typical assessment findings a nurse may observe in a client experiencing a manic episode. Typical findings relate to mood, behavior, thought processes, speech patterns, and cognitive function. Table 8.4a Typical Mental Status Examination Findings for a Client Experiencing a Manic Episode,, May exhibit inappropriate dress or grooming or dress provocatively, sloppily, flamboyantly, or bizarrely. May change clothes frequently throughout the day. May use excessive makeup or demonstrate little attention to grooming. May demonstrate risky behaviors with poor impulse control and poor judgment, such as eating and drinking excessively, spending or giving away a lot of money, or having reckless sex. Excessive spending can lead to financial hardship from credit card debt from buying items they don’t need. May feel as if they are unusually important, talented, or powerful. May describe hallucinations, illusions, or paranoia. May exhibit flight of ideas, loose associations, and clang associations. (See definitions of terms in the “Application of the Nursing Process in Mental Health Care” chapter.) May exhibit suicidal, homicidal, or violence ideation.
Many screening tools exist to assess mood disorders. Common examples include the following:
Initial medical evaluation of clients with a possible or established diagnosis of bipolar disorder typically includes the following:
Thereafter, routine laboratory testing for clients with bipolar disorders can include these items:
Reflective Question
Mental health disorders are diagnosed by trained mental health professionals using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Nurses create individualized nursing care plans using nursing diagnoses based on the client’s response to their mental health disorders. Examples of common nursing diagnoses associated with bipolar disorders are listed in Table 8.4b. Table 8.4b Common Nursing Diagnoses Related to Bipolar Disorder,
Outcome criteria are based on the phase of bipolar illness the client is experiencing, either acute or maintenance phase. During an acute manic episode, the overall goals are symptom management, achieving remission of symptoms, preventing injury, and supporting physiological integrity. Examples of goals during the acute phase include the following:
The maintenance phase occurs after acute symptoms have been controlled and the goals become focused on preventing future exacerbations of manic episodes through education, support, and problem-solving skills. The following are examples of goals during the maintenance phase:
SMART outcomes are Specific, Measurable, Attainable/Actionable, Relevant, and Timely. Read more about SMART outcomes in the “Application of the Nursing Process in Mental Health Care” chapter. The following are sample SMART outcomes for clients with bipolar disorders:
When a client is hospitalized during an acute manic episode, planning focuses on stabilizing the client while maintaining safety. Nursing care focuses on managing medications, decreasing physical activity, increasing food and fluid intake, reinforcing a minimum of 4 to 6 hours of sleep per night, and ensuring self-care needs are met. During the maintenance phase, planning focuses on preventing relapse and limiting the severity and duration of future episodes. During this period, individuals with bipolar disorders often face multiple hardships resulting from their behaviors during previous acute manic episodes. Interpersonal, occupational, educational, and financial consequences may occur. Clients need support as they recover from acute illness and repair their lives. Individuals are often ambivalent about treatment, but bipolar disorders typically require medications to be taken over long periods of time or for a lifetime to prevent relapse. Self-medication through alcohol or other substances often complicates recovery and treatment. Nurses must establish a therapeutic nurse-client relationship to support continued treatment. Individuals are typically referred to community resources and outpatient mental health care settings. In addition to medication management, outpatient services provide structure and decrease social isolation.
Common nursing interventions for clients experiencing acute manic episodes are described in the following tables. Table 8.4c describes interventions according to categories in the APNA Standard of Implementation. (Read more about the APNA Implementation Standard in the “Application of the Nursing Process in Mental Health Care” chapter.) Table 8.4d describes nursing interventions to promote physiological integrity. See the “Treatments for Bipolar Disorders” section of this chapter for additional collaborative mental health interventions, including medications and psychotherapy. Table 8.4c Nursing Interventions for Mania Based on the Categories of the APNA Implementation Standard
Table 8.4d Nursing Interventions to Promote Physiological Integrity
Effective Communication Tips for Clients with Bipolar Disorder
Patient Education: Bipolar Disorder Living with bipolar disorder can be challenging, but there are ways to control symptoms and enable oneself, a client, a friend, or a loved one to live a healthy life. The client may be resistant to teaching during the acute phase of a manic episode, so it is beneficial to wait until manic symptoms begin to resolve. Patient education regarding bipolar disorder includes the following guidelines:
Controlling escalating agitation during the acute phase of a manic episode may include immediate administration of a prescribed antipsychotic and benzodiazepine. A combination of haloperidol (Haldol) and lorazepam (Ativan) that can be injected for rapid onset of action is commonly used. The nurse must monitor for respiratory depression, hypotension, and oversedation after administering this type of medication. De-escalation techniques should be attempted at early signs of escalating agitation to avoid the need for seclusion or restraints. However, if a client is escalating out of control to a point where they pose an immediate risk of injury to themselves or others, the use of a seclusion room or restraints may become necessary to maintain a safe environment. Most state laws prevent the use of unnecessary restraint or seclusion, so their use is associated with complex ethical, legal, and therapeutic issues. Agency policy must be closely followed when implementing seclusion or restraints. Documentation is required that indicates the need for seclusion and/or restraint:
Each agency establishes a proper reporting procedure through the chain of command. For example, seclusion and restraint are only permitted with a written order from an authorized provider (e.g., physician, nurse practitioner, or physician assistant) and rewritten every 24 hours or more frequently according to hospital policy and state regulations. The order must include the type of restraint (e.g., physical or chemical) to be used. In an emergency, the charge nurse may place a client in seclusion or restraints and obtain a written order within a specified period of time (typically 15-30 minutes). Established agency protocols specify associated nursing responsibilities to maintain client safety while in seclusion or restraints, such as the following:
Evaluation occurs continuously throughout the treatment of bipolar disorders. The registered nurse individualizes assessments based on the established goals and SMART outcomes for each client. The effectiveness of nursing and collaborative interventions is evaluated and revised as needed. Questions used to guide the evaluation process include the following:
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