This document provides information about bipolar disorder, including: - The characteristics and symptoms of mania including overactivity, mood changes, and feelings of grandeur. - The diagnostic evaluation process including a mental status examination assessing appearance, speech, mood, thought processes, intellect, judgment, and insight. - Treatment options like pharmacotherapy using mood stabilizers, antipsychotics, and sedatives/hypnotics. Psychosocial interventions like CBT and psychoeducation are also used. - Nursing management involves assessment, developing nursing diagnoses related to risks of injury, violence, nutrition, social interaction and self-esteem, and implementing interventions to address each diagnosis.

1. Presented By: Mrs Bemina Ja
Assistant Professor
Esic College Of Nursing
Kalaburagi

2.  The word is derives from the Greek (mania) meaning
"madness, frenzy"

3.  It refers to a syndrome in which the central features are
 Overactivity
 Mood Changes [Irritability Or Elation]
 Self Important Ideas
It occurs in episodes last for 3-4 months and complete
recovery

4.  Hypomania
 Mania without psychotic symptoms
 Mania without psychotic symptoms
 Manic episode unspecified

5. 1.UNKNOWN
2.BIOLOGICAL THEORIES
 Genetic Hypothesis First Degree Relatives Of Patient
With Bipolar Disorder
 Life Time Risk For Children Of One Parent With Mood
Disorder Is 74%
 Monozygotic Turns Is 65%
 Dizygotic Turns Is 15%
 Identical twins with bipolar disorders about 40-70%
chance

6. 3.BIOCHEMICAL THEORIES
 Neurotransmitter and structural hypothesis
 Excessive level of nor epinephrine and dopamine
 Imbalance between cholinergic and nor adrenergic
system
 Deficiency of serotonin
4.PSYCHOLOGICAL THEORIES
According to Freud
 Mania is viewed as denial of depression
 Faulty family dynamics during during early life are
responsible for manic behaviors

7. 5.TRANSACTIONAL MODEL
 Precipitating Factors
 Family History Of Mania
 Past Episode Of Mania
 Possible Elecrolyte Imbalance
 Possible Cerebral Lesions
 Possible Medication Side Effects
6.COGNITIVE APPRAISAL
 Primary-threat To Loss Of Self Esteem
 Secondary-inability To Use Coping Mechanisms
 Quality Of Response Adaptive Maladaptive
 Uncomplicated Denial Of Depression
 Bereavement Symptoms Of Mania

8.  The underlined characteristics are:-
 AFFECTIVE SYMPTOMS
 BEHAVIORAL SYMPTOMS
 COGNITIVE SYMPTOMS
 PHYSIOLOGICAL SYMPTOMS

9. AFFECTIVE SYMPTOMS
 Elevated mood: it has 4 stages depending on severity
of manic episodes
 EUPHORIA (stage-I) : increased sense of
psychological well being & happiness not in keeping
with ongoing events
 ELATION (stage-II) : moderate elevation of mood
with increased psychomotor activity
 EXALTATION (stage-III) : intense elation of mood
with Delusions of Grandeur.
 ECSTASY (stage-IV) : severe elevation of mood ,
intense sense of rapture or blissfullness seen in
delirious or stuporous mania

10. AFFECTIVE SYMPTOMS
 Elevated mood
 Expensiveness [unceasing and unselective enthusiasm]
 Humorousness
 Inflated self esteem
 Intolerance of criticism
 Lack of shame or guilt
 Sometimes irritable mood is predominant
 May shift from Euphoria to Depression or Anger

11. BEHAVIORAL SYMPTOMS
 • Aggressiveness
 • Grandiose acts
 • Hyperactivity
 • Increased motor activity
 • Irresponsibility
 • Irritability
 • Argumentativeness
 • Poor personal grooming
 • Provocativeness
 • Increased social activity
 • Dressed up in gaudy or flamboyant clothes
 • Sexual hyperactivity

12. COGNITIVE SYMPTOMS
 • Ambitiousness
 • Denial of realistic danger
 • Easily distracted
 • Flight of ideas
 • Uses playful language
 • Speaks loudly
 • Delusions of grandeur
 • Delusion of persecution
 • Lack of judgment
 • Distractibility

13. PHYSIOLOGICAL SYMPTOMS
 • Dehydration
 • Inadequate nutrition (due to over-activity)
 • Little need of sleep
 • Weight loss
Others
Reckless driving
Foolish business invesment
Distributing money articles to unknown persons
Decreased food intake
Increased socialisation
Hypersexuality

14.  Self-concept
 • Exaggerated self-esteem—believes they can accomplish
anything
 • A false sense of well being
Roles and Relationships
 Rarely can fulfill role & responsibilities.
 Have trouble at work or school--- too distracted and hyperactive
to pay attention to children or ADLs.
 Begins many tasks or projects but completes few.
Physiologic and self-care considerations
 Can go days w/o sleep or food and not even realize they are
hungry or tired
 Unwilling to stop or unable to rest or sleep
 Ignores personal hygiene
 destroy valued items
 May physically injure themselves
 Tend to ignore or be unaware of health needs

15. DIAGNOSTIC EVALUATION
MENTAL STATUS EXAMINATION
GENERALAPPEARANCE & BEHAVIOR
 Psychomotor agitation ; sitting still is difficult
 may wear clothes that reflect elevated mood---brightly
colored clothes, flamboyant, attention- getting,
Speech
 Pressured speech [Forceful and strong,
 Playful language with pinning rhyming joking, teasing
speaks loudly
 Interrupts and cannot listen to others

16. Mood & affect
 Euphoric, grandiosity, and false sense of well-being.
 Mood is quite labile.
Thought process and content
 flight of ideas
 Cannot connect concepts and jump from one subject to
another
 Circumstantiality and Tangentiality
 Do not consider risks or personal experience, abilities or
resources.
 Some experience psychotic features– grandiose delusions

17. Sensorium and intellectual processes
 Oriented to person and place but rarely to time
 Intellectual function is difficult to assess during the manic
phase
 Claims to have many abilities that they do not possess
 Impaired ability to concentrate or pay attention
 If psychotic—may experience hallucination
Judgment and insight
 Easily angered and irritated
 Poor judgment
 Impulsive and rarely think before acting or speaking
 Insight is limited---believes they are ―fine‖ and have no
problems
 Blames any difficulties on others

18.  Pharmacotherapy
 Electro-convulsive therapy
 Psychosocial treatment
 Nursing management

19. PSYCHOPHARMACOLOGY
MOOD STABILIZERS
Antimanic –
 Lithium
 Maintenance level 0.5-1mEq/L
 Treatment level 0.8-1.5mEq/L
 Toxic level 1.5mEq/L and above
ANTICONVULSANT
 Carbamazepine (tegretol) therapeutic level 4-12ug/ml
 Valproic acid therapeutic level 50-125 ug/ml
 Clonazepam, [less frequently used]
 Gabapentin
Calcium channel blocker
Verapamil
ANTIPSYCHOTICS
 Olanzapine,
 Risperidone,
 Quetiapine Chlorpromazine,
 Haloperidol
SEDTIVES/HYPNOTICS
 Benzodiazepines

20. PSYCHO SOCIAL INTERVENTIONS
 Cognitive behaviour therapy
 Interpersonal therapy milieu therapy sel care activities
 Psychoeducation

21. NURSING MANAGEMENT
ASSESSMENT
 • Severity of disorder.
 • Knowing the causes.
 • Resources available.
 • Judging the effect of patient’s behavior on other
people.
 • MSE

22. Nursing Diagnosis
 Risk for injury related to extreme hyperactivity
 Risk for violence self directed or to others r/t manic excitement,
delusional thinking and hallucination
 Imbalanced nutrition less than body requirement related to refusal or
inability to sit still long enough to eat
 Impaired social interaction r/t egocentric behaviour and narcissistic
behaviour
 Self esteem disturbance retated to unmet dependency needs, lack of
positive feed back, unrealistic self expectations
 Altered family process related to euphoric mood and grandiose ideas ,
manipulative behaviour refusal to accept responsibility for own actions
 Ineffective coping skills related to poor impulsive control as evidenced
by acting out behaviour
 Impaired social interaction related to short attention span ,high level of
distractibility and labile mood as evidenced by insuffcient or excessive
quality or ineffective quality of social exchange

23. Assessment Nursing
diagnosis
Objective Interventions Evaluatio
n
Asess for
• Severity of
disorder.
• Knowing the
causes.
• Resources
available.
• Judging the
effect of
patient’s
behavior on
other people.
• MSE
Risk for
injury
related to
extreme
hyperactivit
y and
impulsive
behavior
Client will
not injure
self
-Keep environment
stimuli to a minimum
-Assign single room with
minimal furniture
-Keep light and noise level
low
-Remove hazardous
objects
-Keep patient engaged in
activities such as drawing
and other physical exercise
-Stay with patient when
hyperactivity increases
-Administer medication as
prescribed by physicians
Client is
safe

24. Assessmen
t
Nursing
diagnosis
Objecti
ves
Nursing interventions Eva
luat
ion
Asess for
• Severity of
disorder.
• Knowing
the causes.
• Resources
available.
• Judging the
effect of
patient’s
behavior on
other people.
• MSE
Risk for
violence self
directed or to
others r/t
manic
excitement,
delusional
thinking and
hallucination
Patient
will not
harm
self and
others
Maintain low level stimuli
Observe patients behaviour at least
every 15 minutes
Ensure that all sharp objects are
been removed
Encourage verbal expression of
feelings
Engage him in physical activities
Maintain a calm attitude to the
patient
Have sufficient staff
State limitations and expectations
Following application of restraints
observe patient every 15minutes
Remove restraints gradually once at
a time
Keep a comfortable distance away
from patient
Maintain a clear exit route
Pati
ent
is
safe

25. Assessment Nursing
diagnosis
Objectives Nursing
intervention
Evaluati
on
Asess for
• Severity of
disorder.
• Knowing the
causes.
• Resources
available.
• Judging the
effect of
patient’s
behavior on
other people.
• MSE
Imbalanced
nutrition less
than body
requirement
related to
refusal or
inability to sit
still long
enough to eat
Patient will not
exhibit signs
and symptoms
of malnutrition
Provide high
calorie ,protien
nutritious finger food
and drinks that can be
consumed on the run
Find out clients
likes and dislikes
Provide 6-8 glasses
of fluids per day
Maintain intake
output and calorie
count
Weigh the patient
regularly
Supplement diet
with vitamins and
minerals
Walk and sit with
patient while he eats
Patient
nutrition
al status
improved
/maintain
ed

26. Assessment Nursing
diagnosis
Objecte
asives
Intervention Evaluation
Asess for
• Severity of
disorder.
• Knowing the
causes.
• Resources
available.
• Judging the
effect of
patient’s
behavior on
other people.
• MSE
Impaired social
interaction r/t
egocentric
behaviour and
narcissistic
behaviour as
evidenced by
inability to
develop
satisfying
relationships
and
manipulation of
others for own
desires
Patient will
interact with
others in an
appropriate
manner
Recognise the
manipulative behaviour
Set limits on the
manipulating behaviour
Terms of limits must
be agreed by all the
staff working with the
patient
Give positive
reinforcement for non
manupilative behaviour
Help patient to
identify the positive
aspects about self
recognize
accomplishments and
feel good about them
Patient
social
interaction
im
proved

27. Assessment Nursing
diagnosis
Objectives Intervention Evaluati
on
Asess for
• Severity of
disorder.
• Knowing the
causes.
• Resources
available.
• Judging the
effect of patient’s
behavior on other
people.
• MSE
Self esteem
disturbance
retated to
unmet
dependency
needs, lack of
positive feed
back,
unrealistic
self
expectations
Patient will
have
realistic
expectations
about self
Ask how client would like to
addressed
Explain the rationale for request
by staff unit routine etc adhere to
courteous approaches ,matter of
fact style and friendly attitudes
Encourage verbalisation and
identification of feelings related to
issues of chronicity lack of control
over self
Offer matter of fact feed back
regarding unrealistic plans
Help him to set realistic goals
himself
Encourage client to view life
after discharge and identity aspects
over which control is possible
Through role play practice how
he will demonstrate that control
Patient
develops
realistic
expectati
ons about
self

28. Assessment Nursing
diagnosis
Objective
/expected
outcome
Intervention Evaluat
ion
Assess for
• Severity of
disorder.
• Knowing the
causes.
• Resources
available.
• Judging the
effect of
patient’s
behavior on
other people.
• MSE
Altered family
process related
to euphoric
mood and
grandiose ideas ,
manipulative
behavior refusal
to accept
responsibility for
own actions
The family
members will
demonstrate
coping ability
in dealing with
patient
Determine individual
situation and feelings of
individual family members
like guilt anger
powerlessness despair and
alienation
Assess patterns of
communication
Determine patterns of
behaviour displayed by
patient in his relationship
with others
Assess role of patients
in the family like provider
Provide information
about behaviour patterns
and expected course of the
illness
The
family
member
s coping
ability
in
dealing
with
patient
improve
s