pn bipolar case study quiz

RN Bipolar Case Study Quiz: Enhancing Nursing Knowledge Through ATI Video Case Studies

Bipolar disorder is a complex mental health condition that requires a deep understanding and specialized care from healthcare professionals. For nursing students and practicing nurses, developing a comprehensive knowledge of this disorder is crucial for providing effective patient care. One of the most valuable tools in nursing education is the use of case studies, particularly video case studies, which offer a unique and immersive learning experience. The RN Bipolar Case Study Quiz, based on ATI video case studies, serves as an excellent resource for enhancing nursing knowledge and skills in managing bipolar disorder.

Understanding the RN Bipolar Case Study Quiz

The RN Bipolar Case Study Quiz is designed to assess and reinforce nursing students’ understanding of bipolar disorder and its management. This quiz is structured to evaluate key aspects of bipolar disorder care, including symptom recognition, treatment options, and patient assessment techniques. By incorporating real-world scenarios, the quiz helps bridge the gap between theoretical knowledge and practical application in clinical settings.

The purpose of this quiz extends beyond mere assessment; it serves as a learning tool that encourages critical thinking and decision-making skills essential for nursing practice. As students engage with the quiz, they are challenged to apply their knowledge to realistic patient scenarios, mirroring the complexities they may encounter in their future careers.

Key components assessed in the quiz typically include:

1. Identification of manic and depressive symptoms 2. Understanding of medication management 3. Recognition of potential triggers and warning signs 4. Knowledge of appropriate nursing interventions 5. Familiarity with patient education strategies

By focusing on these areas, the quiz ensures that nursing students are well-prepared to provide comprehensive care to patients with bipolar disorder. It’s worth noting that understanding mental health conditions like bipolar disorder is crucial not only for psychiatric nurses but for all healthcare professionals. For instance, understanding bipolar disorder can be beneficial even in professions like firefighting , where mental health awareness is increasingly important.

ATI Video Case Study on Bipolar Disorder: A Comprehensive Overview

ATI (Assessment Technologies Institute) video case studies are innovative educational tools that provide a visual and interactive approach to learning about various health conditions, including bipolar disorder. These case studies offer a unique opportunity for nursing students to observe patient interactions, clinical presentations, and treatment approaches in a controlled, educational environment.

The ATI video case study on bipolar disorder typically features:

1. Realistic patient scenarios depicting various stages of the disorder 2. Demonstrations of proper assessment techniques 3. Examples of effective communication with patients and their families 4. Illustrations of appropriate nursing interventions

One of the significant benefits of using video case studies for learning about mental health disorders is the ability to observe subtle behavioral cues and nonverbal communication that might be difficult to convey through text alone. This visual learning approach can be particularly beneficial when studying complex conditions like bipolar disorder, where mood changes and behavioral patterns play a crucial role in diagnosis and treatment.

Moreover, these video case studies can help students develop empathy and understanding for patients with bipolar disorder. This empathetic approach is crucial in mental health nursing and can extend to various healthcare roles. For example, EMTs with bipolar disorder or those treating patients with the condition can benefit from this deeper understanding and empathy.

Key Concepts Covered in the Bipolar Disorder Case Study

The bipolar disorder case study delves into several crucial aspects of the condition, providing a comprehensive overview for nursing students. Some of the key concepts covered include:

1. Symptoms and diagnostic criteria of bipolar disorder: – Manic episodes: elevated mood, increased energy, decreased need for sleep – Depressive episodes: persistent sadness, loss of interest, fatigue – Mixed episodes and rapid cycling

2. Treatment options and nursing interventions: – Pharmacological treatments: mood stabilizers, antipsychotics, antidepressants – Psychotherapy approaches: cognitive-behavioral therapy, interpersonal therapy – Electroconvulsive therapy (ECT) in severe cases

3. Patient assessment and monitoring techniques: – Use of standardized assessment tools – Monitoring for medication side effects – Recognizing warning signs of mood episodes

Understanding these concepts is crucial for providing effective care to patients with bipolar disorder. It’s also important to note that managing bipolar disorder often involves a holistic approach. For instance, using a wellness tracker can be beneficial for managing bipolar disorder , helping patients and healthcare providers monitor mood patterns and identify triggers.

Preparing for the RN Bipolar Case Study Quiz

Effective preparation for the RN Bipolar Case Study Quiz involves a combination of strategic studying and practical application of knowledge. Here are some effective study strategies for nursing students:

1. Review core concepts: Ensure a solid understanding of bipolar disorder, its symptoms, and treatment options. 2. Utilize ATI video case studies: Watch and re-watch the video case studies, taking notes on key observations and interventions. 3. Practice critical thinking: Analyze the scenarios presented in the case studies and consider how you would respond in similar situations. 4. Engage in group discussions: Share insights and perspectives with fellow students to broaden your understanding. 5. Use practice questions: Familiarize yourself with the quiz format and types of questions you might encounter.

Self-assessment techniques, such as creating mock scenarios or quizzing yourself on key concepts, can also be valuable in preparing for the quiz. Remember, the goal is not just to pass the quiz but to develop a deep understanding that will translate into effective patient care in your future nursing career.

Applying Knowledge from the Case Study to Clinical Practice

The ultimate goal of studying bipolar disorder through case studies and quizzes is to apply this knowledge effectively in clinical practice. Translating theoretical knowledge to practical nursing skills involves:

1. Recognizing symptoms: Being able to identify signs of manic, depressive, or mixed episodes in patients. 2. Implementing interventions: Knowing when and how to apply appropriate nursing interventions. 3. Educating patients and families: Providing clear, accurate information about bipolar disorder and its management. 4. Collaborating with the healthcare team: Working effectively with psychiatrists, therapists, and other healthcare professionals.

It’s important to recognize that bipolar disorder can manifest differently in various healthcare settings. Nurses may encounter patients with bipolar disorder in psychiatric units, general medical floors, or even in emergency departments. Therefore, a broad understanding of the condition and its impact on overall health is crucial.

Continuous learning and staying updated on mental health nursing is essential in providing the best care for patients with bipolar disorder. This includes keeping abreast of new treatment options, understanding emerging research, and being aware of the latest guidelines in bipolar disorder management.

The RN Bipolar Case Study Quiz, based on ATI video case studies, is an invaluable tool in nursing education. It not only assesses knowledge but also enhances understanding and prepares future nurses for the complexities of managing bipolar disorder in clinical settings. The use of video case studies provides a unique, immersive learning experience that bridges the gap between theory and practice.

As mental health awareness continues to grow, the importance of comprehensive education on disorders like bipolar cannot be overstated. Nurses play a crucial role in the care and management of patients with bipolar disorder, and tools like these case studies and quizzes are essential in preparing them for this responsibility.

It’s worth noting that the impact of bipolar disorder extends beyond the clinical setting. Understanding this condition can be beneficial in various aspects of life and healthcare. For instance, understanding the link between bipolar disorder and sexual behavior can help healthcare providers offer more comprehensive care. Similarly, alternative therapies like yoga can be beneficial for managing bipolar disorder , highlighting the importance of a holistic approach to treatment.

Ultimately, the journey of learning about bipolar disorder doesn’t end with passing a quiz or completing a case study. It’s an ongoing process of growth, empathy, and skill development. As future healthcare providers, nursing students are encouraged to continually enhance their knowledge and skills in mental health care, always striving to provide the best possible care for their patients.

The importance of education and empathy in understanding bipolar disorder cannot be overstated. It’s these qualities, combined with clinical knowledge and skills, that will make a real difference in the lives of patients living with bipolar disorder.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 2. National Institute of Mental Health. (2020). Bipolar Disorder. 3. Vieta, E., et al. (2018). Bipolar disorders. Nature Reviews Disease Primers, 4(1), 18008. 4. Goodwin, G. M., et al. (2016). Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 30(6), 495-553. 5. Malhi, G. S., et al. (2015). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian & New Zealand Journal of Psychiatry, 49(12), 1087-1206. 6. Grande, I., et al. (2016). Bipolar disorder. The Lancet, 387(10027), 1561-1572.

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Nursing Case Study for Bipolar Disorder

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Kelli is a 20-year-old patient brought to the ER after being reported by neighbors in her apartment complex for disruptive behavior. Law enforcement and emergency medical services were called, and, as a team, decided she needed a higher level of medical care.

The patient says she is” on a break from art college” but works at a local restaurant as a server and occasionally cleans houses as well. She has also sold her paintings and drawings in the past as well. She denies taking any medication. She also says, “I don’t understand why I am here. I was working on my art projects, and I guess I played my music too loud or something. I said I’d come here so I would not be arrested.”

What are some questions that should be included in the initial assessment?

• Ask about drug and alcohol consumption and previous episodes. Make sure she does not intend to harm herself or others. Check to see why the patient does not understand coming to a medical treatment facility (make sure she is lucid). Ask about trauma or accidents.

What interventions do you anticipate being ordered by the provider?

• Obtain old medical charts (there may be a pattern). Screen for drugs and alcohol. Assess for trauma (especially head injury, so neuro checks). Complete a thorough medical history to rule out medical reasons for behavior. Conduct a medical examination including labs (eg. thyroid-stimulating hormone, complete blood count, chemistries)

Kelli’s drug and alcohol tests are negative. Her roommate is now at the bedside and asks to speak to staff privately. She expresses concern that Kelli can be emotional at times as well as going days without sleep then not being able to get out of bed. The nurse returns to further evaluate the patient.

With this new information, what might the nurse ask Kelli?

• Ask about “periods of unusually intense emotion, changes in sleep patterns and activity levels, and uncharacteristic behavior—often without recognizing their likely harmful or undesirable effects” (from NIH). Dig deeper to find if these “episodes” last for long or short periods. Specifically, ask about extreme highs and lows, change in appetite, racing thoughts vs concentration difficulty, risky behaviors (eg gambling, extreme shopping sprees, sexual promiscuity), anxiety, excessive talking, thoughts of death/dying.

Kelli admits to being able to stay awake for what seems like entire weekends without being tired, but that is when she says her creativity is best. When she was attending college and living in the dorms, she says she had lots of friends but worried about what she calls “all the partying.” This is because she liked to “hook up” with strangers because it was fun, but she worries about possible sexually transmitted infections now that she is older. She says she was extremely popular, and her talent was at its peak. But there are times she could not pay attention in class or even get out of bed, so she dropped out of school. Sometimes, she cannot even touch her art supplies, but says she is probably the “most talented artist around.”

What signs and symptoms indicate Kelli may have bipolar disorder?

• Sleep disturbances, cycling between being creative and not being able to concentrate, sexual promiscuity, feelings of grandiosity, loss of pleasure of usual activities

Are there risk factors for this condition?

• The exact cause of bipolar disorder is not clear. The problem may be related to an imbalance of chemicals in the brain such as norepinephrine, serotonin, or dopamine. These chemicals allow cells to communicate with each other and play an essential role in all brain functions, including movement, sensation, memory, and emotions.
• Approximately one to three percent of people worldwide have bipolar disorder. People with a family history of bipolar disorder are at increased risk of developing the condition. Most people develop the first symptoms of bipolar disorder between age 15 to 30 years.

Kelli’s medical records have arrived, and the provider advises nursing staff she has a history of being brought to the ER for similar episodes. The provider says, “This patient is a schizophrenic. We don’t have time for this.”

What is the best response to the provider’s statement?

• As the patient’s advocate, the nurse should advise the provider this is inappropriate. First, it is a disparaging remark. Second, if he means schizophrenic, that is not accurate and as an ER physician should refer the patient for further psychiatric screening and evaluation.
• It is never wrong to stand up to providers or colleagues, but it should be done respectfully and NOT in front of the patient when at all possible.

What should the nurse screen Kelli for at this point?

• Suicidal ideations include whether she has a plan or has attempted suicide in the past. Suicide screening is an ongoing process and not just a few questions at admission. Per UpToDate, “A review estimated that approximately 10 to 15 percent of bipolar patients die by suicide and many studies indicate that the rate of suicide deaths in patients is greater than the rate in the general population.”

How can the nurse address Kelli’s question about help?

• Something like (from uptodate), “Treatment of mania focuses on managing symptoms and keeping you safe. In the early phase of mania (called the acute phase), you may be psychotic (having false, fixed beliefs or hearing voices or seeing things others cannot see or hear). You may not be able to make good decisions and you may be at risk of hurting yourself or others. You may need to be treated in a hospital temporarily, until your medicine begins to work.”
• Also, “Once the worst symptoms of mania or depression are under control, treatment focuses on preventing a recurrence. People who have suffered a manic episode are often advised to continue taking medicine(s) to control bipolar disorder. Although medicines are the treatment of choice for bipolar disorder, counseling and talk therapy also have an important role in treatment. This is especially true after an acute episode has passed. Psychotherapy may include individual counseling as well as education, marital and family therapy, or treatment of alcohol and/or drug abuse. Therapy can help you to stick with your medicine, which can decrease the risk of relapse and the need for hospitalization.”

Kelli is amenable to being held for the state’s required psychological hold. She says she wants to be able to live her life as “normally” as possible. She asks about medications that may be available to help.

What patient education about medications should the nurse provide at this time?

• While it is beyond the scope of the RN to prescribe medications, generalized education on pharmaceutical options is acceptable. Saying something like, “Treatments with medications is recommended for people with bipolar disorder, and studies show starting it early and maintaining it is best.” Point out there may be multiple medications needed and they may need to be changed and/or adjusted for her individual responses.

The nurse knows which medications may be prescribed for long-term management of this condition?

• Mood stabilizers (examples: lithium, valproic acid, divalproex sodium, carbamazepine,and lamotrigine). Antipsychotics. [examples: olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris)] Antidepressants or antidepressant-antipsychotic combo like Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine Anti-anxiety medications (example: benzodiazepines)

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This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Mental Health > Test 2 (case study quiz) - Chapter 26 - Bipolar and related disorders > Flashcards

Test 2 (case study quiz) - Chapter 26 - Bipolar and related disorders Flashcards

Bipolar disorders is characerized by….

mood swings from profound depression to extreme euphoria (mania)

delusions or hallucinations may be present onset of symptoms reflect a seasonal pattern.

What is the difference between mania and hypomania?

hypomania does not impair social or occupational functioning or require hospitalization like mania does

Bipolar dx can be labeled as I or II. What is the difference between the two?

(UPDATE AFTER LECTURE)

Bipolar I includes at least one MANIA or mixed episode + major depressive episodes

Bipolar II includes at least one major depressive episode + at least 1 hypomanic episode with normal moods in between.

What is a manic episode like?

Distinct period of persistently elevated, expansive or irritable mood and abnormally focused/persistent goal directed activity or energy last at least 1 week.

Inflated self esteem/grandiosity

decreased need for sleep.

more talkative

flight of ideas (racing thoughts)

distractibility

engaged in reckless behavior (buying srees, sexual indiscretion, foolish investments, etc)

mood distrubance that severely impairs socially/occupationally

What is a HYPOmanic episode like?

exactly like above EXCEPT mood disturbance DOES NOT impair the person socially/occupationally

Degrees of mania

See slide for more details

hypomania, acute, delirious

This disorder is a chronic mood disturbance of at least 2 years’ duration. The elevated period does not meed hypomania criteria and the depressed mood is not as severe as bipolar. What is the DO?

cyclothymic disorder

the individual is never without the symptoms for more than 2 months.

A person gets intoxicated on drugs, alcohol or medications which cause mood disturbances. This is known as

substance/medication induced bipolar disorder

How can bipolar be caused by another medical condition?

deficiency (depression) or increase (mania) in DA and NE (5ht remains low in both)

right sided lesions in limbic system is another example

see page 502 in ch 26

Medication for bipolar

_______ is antimanic, mood stabilizer. It requires an ekg and intake of salt and water. It is used to treat mania.

Lithium (considered the gold standard)

Remember to check the blood lithium levels daily!

T or F: The calcium channel blocker Verapamil can be used to treat Bipolar depression.

_________ is an anticonvulsant used to treat bipolar disease. it is good for rapid cyclers.

Carbamazpine (Tegretol, Equetro)

Know TEGRETOL acronym

T - Trigeminal neurolgia = tonic clonic seizures (do not stop abruptly)

E - Evaluate for UE: anorexia, nausea, dizziness, sedation, heart attack, sore throat, blood dyscrasias.

G - Give with food, milk to reduce GI upset

R - Review levels, maintain between 4-12

E - Evaluate hepatic and renal function (and for anorexia - sign for toxicity)

T - Tablet = chewable, do not swallow whole! Or take extended release

O - Open and mis with food (extended release)

L - Look for many drug/drug interactions (toxic with lithium)

T or F: 2nd and 3rd generation antipsychotics and atypicals may be used to treat bipolar disorder.

approved for mania and may also be effective against depressive symptoms. Most atypicals can lead to weight gain and increase the incidence of type II diabetes.

________ ( ______ ) works well in patients with bipolar 2.

aripiprazole (Abilify)

Two i’s - bipolar 2

Hip hip hurray, I have the ability 2 feel better

Paroxetine (Paxil) is what type of med? How does it effect bipolar disorder patients?

Works well, decreases switching to other antidepressants.

Which group of antidepressants should be avoided in bipolar treatment?

There are three stages of mania ranging from hypomania to delirious mania. explain MOOD we expect to see in each stage.

Stage I: Hypomania - Cheerful and expansive (with underlying irritability that surfaces rapidly when desires unfulfilled); volatile and fluctuating.

Stage II: Acute Mania - characterized by euphoria and elation. Appears to be on continuous high. Always subject to frequent variation.

Stage III: Delirious Mania - very labile. Might go from despair to urestrained merriment and ectasy. Might be irritable or indifferent. Panic anxiety may be evident.

There are three stages of mania ranging from hypomania to delirious mania. explain COGNITION AND PERCEPTION we expect to see in each stage.

Stage I: Hypomania - perception of self is exalted. Easily distracted by irrelevant stimuli.

Stage II: Acute Mania - flight of ideas (fragmented, psychotic, disjointed); abrupt topic changes.

Stage III: Delirious Mania - clouding of consciousness + confusion, disorientation and sometimes stupor.

There are three stages of mania ranging from hypomania to delirious mania. explain ACTIVITY AND BEHAVIOR we expect to see in each stage.

Stage I: Hypomania - extroverted, sociable, talk loudly and inappropriately. increased libido.

Stage II: Acute Mania - xcessive activity. excessive spending poor impulse control. manipulate others. energy seems inexhaustible. no need for sleep. Dress may be disorganized, flamboyant, bizarre and excessive.

Stage III: Delirious Mania - purposeless movements, frenzied, agitated. Intervention or death.

T or F: bipolar persons should be treated by someone of the same sex

True. Consistent person of same sex.

What type of foods should you have available to bipolar DO pts?

things that can be eaten on the run; finger foods.

A person in the manic phase will have a short attention span. What can we do to communicate?

Walk and talk with patient.

Reduce stimuli

SECLUSION (away from nurses station - too much noise)

Use short simple sentences

T or F: You should be strict with rules when it comes to bipolar patients.

True. no special favors or privileges. Patient may try to charm you to fulfill their own desires.

Patient may try to make sexual advances - set boundaries verbally and physically (ask colleague to help. Do not go “off-site” for sessions). redefine your role as a reminder!

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• Test 2 (Case study quiz) Chapter 25 - Depressive disorders
• Test 2 (case study quiz) - Chapter 26 - Bipolar and related disorders
• Test 2 (Case Study QUiz) - Chapter 27 - Anxiety, OCD, and related DO's AND Chapter 13 - crisis
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Bipolar Disorder

Bipolar disorder , also known as manic- depressive illness, is a mental health condition characterized by extreme shifts in mood, energy levels, and activity patterns. Individuals with bipolar disorder experience episodes of intense highs, known as manic or hypomanic episodes, where they might feel overly energetic, euphoric, or impulsive. These episodes alternate with periods of deep lows, or depressive episodes, during which they might feel extremely sad, hopeless, and lethargic. The disorder can disrupt daily life, relationships, and decision-making .

Understanding its varied manifestations, potential causes, nursing interventions , and available treatments is important in supporting those affected by this challenging condition.

What is Bipolar Disorder?

Bipolar disorders are mood disorders characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy.

• These disorders are linked to early death , primarily due to cardiovascular disease-related fatalities being the prevailing reason.
• Bipolar disorders stand apart from other affective disorders due to recurring manic or hypomanic episodes alternating with depressive episodes. Bipolar I involves overt manic episodes with symptoms like grandiosity and decreased need for sleep , often accompanied by psychotic features. Bipolar II is marked by depression alternating with hypomania.

Types of Bipolar Disorder

• Bipolar I disorder is the diagnosis given to an individual who is experiencing, or has experienced, a full syndrome of manic or mixed symptoms; the client may also have experienced periods of depression.
• Bipolar II disorder. Bipolar II disorder is characterized by recurrent bouts of major depression with the episodic occurrence of hypomania; this individual has never experienced a full syndrome of manic or mixed symptoms.
• Cyclothymic disorder. The essential feature is a chronic mood disturbance of at least 2 years duration, involving numerous periods of depression and hypomania, but not of sufficient severity and duration to meet the criteria for either bipolar I or bipolar II disorder.
• Bipolar disorder due to general medical condition. This disorder is characterized by a prominent and persistent disturbance in mood (bipolar symptomatology) that is judged to be the direct result of the physiological effects of a general medical condition (APA, 2000).
• Substance-induced bipolar disorder. The bipolar symptoms associated with this disorder are considered to be the direct result of the physiological effects of a substance (e.g., use or abuse of a drug or medication , or toxin exposure).

Pathophysiology

The pathophysiology of bipolar disorder, or manic-depressive illness (MDI), has not been determined, and no objective biologic markers correspond definitively with the disease state.

• The genetic component of bipolar disorder appears to be complex; the condition is likely to be caused by multiple different common disease alleles, each of which contributes a relatively low degree of risk on its own.
• Many loci are now known to be associated with the development of bipolar disorder.
• These loci are grouped as major affective disorder (MAFD) loci and numbered in the order of their discovery.

Statistics and Incidences

Globally, the life-long prevalence rate of bipolar disorder is 0.3 to 1.5%.

• The life-long prevalence of bipolar disorder in the United States has been noted to range from 0.9 to 2.1%.
• For both bipolar I and bipolar II, the age range is from childhood to 50 years, with a mean age of approximately 21 years.
• BPI occurs equally in both sexes; however, rapid-cycling bipolar disorder is more common in women than in men.

Predisposing factors to bipolar disorder include:

• Biological. Twin studies have indicated a concordance rate for bipolar disorder among monozygotic twins at 60% to 80% compared to 10% to 20% in dizygotic twins.
• Biochemical. Just as there is an indication of lowered levels of norepinephrine and dopamine during an episode of depression, the opposite appears to be true of an individual experiencing a manic episode.
• Physiological. Right-sided lesions in the limbic system, temporobasal areas, basal ganglia, and thalamus have been shown to induce secondary mania.
• Medication side effects. Certain medications used to treat somatic illnesses have been known to trigger a manic response; the most common of these are the steroids frequently used to treat chronic illnesses such as multiple sclerosis and systemic lupus erythematosus .

Clinical Manifestations

These are the symptoms of bipolar disorder:

• Heightened, grandiose, or agitated mood. The affect of a manic individual is one of elation and euphoria- a continuous “high”.
• Exaggerated self-esteem . Usual inhibitions are discarded in favor of sexual and behavioral indiscretions.
• Sleeplessness. Sleep patterns are disturbed; the client becomes oblivious to feelings of fatigue , and rest and sleep are abandoned for days or weeks.
• Pressured speech. Loquaciousness, or pressured speech, is so forceful and strong that it is difficult to interrupt maladaptive thought processes.
• Flight of ideas. There is a continuous, rapid shift from one topic to another.
• Reduced ability to filter out extraneous stimuli; easily distractible. There is inability to concentrate because of a limited attention span; the individual is easily distracted by even the slightest stimulus in the environment.
• Increased number of activities with increased energy. Motor activity is constant; the individual is literally moving at all times.
• Multiple, grandiose, high risk activities , using poor judgement; with severe consequences.

Assessment and Diagnostic Findings

A number of reasons exist for obtaining selected laboratory studies in patients with bipolar disorder; an extensive range of tests is indicated, because bipolar disorder encompasses both depression and mania and because a significant number of medical causes for each state exist.

• Complete blood count . A complete blood count with differential is used to rule out anemia as a cause of depression in bipolar disorder.
• Erythrocyte sedimentation rate. The erythrocyte sedimentation rate (ESR) is determined to look for underlying disease processes such as lupus or an infection ; an elevated ESR often indicates an underlying disease process.
• Fasting glucose . In some cases, a fasting glucose level is indicated to rule out diabetes .
• Electrolytes . Serum electrolyte concentrations are measured to help diagnose electrolyte problems, especially with sodium , that are related to depression.
• Proteins. Low serum protein levels found in patients who are depressed may be a result of not eating.
• Thyroid hormones. Thyroid tests are performed to rule out hyperthyroidism (mania) and hypothyroidism (depression).
• Creatinine and blood urea nitrogen. Kidney failure can present as depression; treatment with lithium can affect urinary clearances, and serum creatinine and blood urea nitrogen (BUN) levels can increase.
• Substance and alcohol screening. Alcohol abuse and abuse of a wide variety of drugs can present as either mania or depression.
• MRI. The total value of performing an MRI in a patient with bipolar disorder remains unclear; however, a couple of reasons do exist for performing an imaging study.
• Electrocardiography. Many of the antidepressants , especially the tricyclic agents and some of the antipsychotics can affect the heart and cause conduction problems.

Medical Management of Bipolar Disorder

The treatment of bipolar disorder is directly related to the phase of the episode (i.e. depression or mania) and the severity of that phase.

• Psychotherapy. Psychotherapy helps patients with bipolar disorder but does not cure the disorder itself; when Schottle and colleagues looked at psychotherapy for patients, family, and caregivers , they found that although results were heterogeneous, most studies demonstrated relevant positive results in regard to decreased relapse rates, improved quality of life, increased functioning, or more favorable symptom improvement.
• Electroconvulsive therapy. Electroconvulsive therapy (ECT) is useful in a number of instances in patients with bipolar disorder, such as when rapid, definitive medical/psychiatric treatment is needed; when the risks of ECT are less than that of other treatments; when the bipolar disorder is refractory to an adequate trial with other treatment strategies; and when the patient prefers this treatment modality.
• Diet. Patients should be advised not to make significant changes in their salt intake, because increased salt intake may lead to reduced serum lithium levels and reduced efficacy, and reduced intake may lead to increased levels and toxicity.
• Activity. Patients in a depressed state are encouraged to exercise; these individuals should try to develop a regular daily schedule of major activities, especially times of going to bed and waking up.

Pharmacological Management

Appropriate medication for managing bipolar disorder depends on the stage the patient is experiencing.

• Anxiolytics, benzodiazepines . By binding to specific receptor sites, benzodiazepines appear to potentiate the effects of gamma-aminobutyric acid (GABA) and facilitate inhibitory GABA neurotransmission and the action of other inhibitory neurotransmitters.
• Mood stabilizers. Lithium is the drug commonly used for prophylaxis and treatment of manic episodes.
• Anticonvulsants . Anticonvulsants have been effective in preventing mood swings associated with bipolar disorder, especially in those patients known as rapid cyclers.
• Antipsychotics, 2nd generation. Second-generation, or atypical, antipsychotics are increasingly being used for the treatment of both acute mania and mood stabilization in patients with bipolar I disease.
• Antipsychotics, 1st generation. First-generation antipsychotics, also known as conventional or typical antipsychotics, are efficacious in treating both psychotic and nonpsychotic manic and mixed episodes, as well as hypomania.
• Antipsychotics, phenothiazine. Phenothiazine antipsychotics, which are classified as first-generation antipsychotics, are efficacious in treating both psychotic and nonpsychotic manic and mixed episodes, as well as hypomania.
• Antiparkinsons agents, dopamine agonists. Dopamine agonists are non-errgot agents that bind to D2 and D3 dopamine receptors in the striatum and substantia nigra.

Nursing Management for Bipolar Disorder

Nursing management of a patient with bipolar disorder includes the following:

Nursing Assessment

Assessment of a patient with bipolar disorder includes:

• History. Taking a history with a client in a manic phase often proves difficult; obtaining data in several short sessions, as well as talking to family members , may be necessary.
• General appearance and motor behavior. Clients with mania experience psychomotor agitation and seem to be in perpetual motion; sitting still is difficult; this continual movement has many ramifications; clients can be exhausted or injure themselves.
• Mood and affect. Mania is reflected in periods of euphoria, exuberant activity, grandiosity, and a false sense of well-being.
• Thought process and content. Cognitive ability or thinking is confused and jumbled with thoughts racing one after another, which is often referred to as a flight of ideas; clients cannot connect concepts, and they jump from one subject to another.

Nursing Diagnosis for Bipolar Disorder

Nursing diagnoses commonly established for clients in the manic phase are as follows:

• Risk for other-directed violence related to manic excitement, suspicion of others, paranoid ideation.
• Risk for injury related to extreme hyperactivity , destructive behaviors.
• Imbalanced nutrition : less than body requirements related to refusal or inability to sit still long enough to eat meals.
• Disturbed thought processes related to psychotic process.
• Disturbed sensory perception related to sleep deprivation , psychotic process.

Nursing Care Planning and Goals

Main Article: 6 Bipolar Disorders Nursing Care Plans

Nursing care planning goals for bipolar disorders are:

• Client will no longer exhibit potentially injurious movements after 24 hours with administration of tranquilizing medications.
• Client will experience no physical injury.
• Client’s agitation will be maintained at a manageable level with the administration of tranquilizing medications during first week of treatment.
• Client will not harm self or others.
• Client will consume sufficient finger foods and between-meal snacks to meet recommended daily allowances of nutrients.
• Within one week, client will be able to recognize and verbalize when thinking is non-reality based.
• Client will be able to recognize and verbalize when he or she is interpreting the environment inaccurately.

Nursing Interventions

Nursing interventions for bipolar disorder clients are:

• Providing for safety. A primary nursing responsibility is to provide a safe environment for clients and others; for clients who feel out of control, the nurse must establish external controls emphatically and non judgementally.
• Meeting physiologic needs. Decreasing environmental stimulation may assist clients to relax; the nurse must provide a quiet environment without noise, television, and other distractions; finger foods or things a client can eat while moving around are the best options to improve nutrition.
• Providing therapeutic communication . Clients with mania have short attention spans, so the nurse uses simple, clear sentences when communicating; they may not be able to handle a lot of information at once, so the nurse breaks information into many small segments.
• Promoting appropriate behavior. The nurse can direct their need for movement into socially acceptable, large motor activities such as arranging chairs for a community meeting or walking .
• Managing medications. Periodic serum lithium levels are used to monitor the client’s safety and to ensure that the dose given has increased the serum lithium level to a treatment level or reduced it to a maintenance level.

The goals are met as evidenced by:

• Client is able to differentiate between reality and unrealistic events or situations.
• Client is able to recognize thoughts that are not based in reality and intervene to stop their progression.
• Client has gained or maintained weight during hospitalization.
• There is no evidence of violent behavior to self and others.
• Client is no longer exhibiting signs of physical agitation.

Documentation Guidelines

Documentation in a patient with bipolar disorder include:

• Individual findings include factors affecting, interactions, the nature of social exchanges, and specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

References and Sources

Interesting resources for further reading about bipolar disorder:

• Bartels, S. J., Mueser, K. T., & Miles, K. M. (1997). A comparative study of elderly patients with schizophrenia and bipolar disorder in nursing homes and the community.  Schizophrenia Research ,  27 (2-3), 181-190. [ Link ]
• Black, J. M., & Hawks, J. H. (2005).  Medical- surgical nursing . Elsevier Saunders,.
• Boyd, M. A. (Ed.). (2008).  Psychiatric nursing: Contemporary practice . lippincott Williams & wilkins.
• Keltner, N. L. (2013).  Psychiatric nursing . Elsevier Health Sciences.
• Videbeck, S. L. (2010).  Psychiatric-mental health nursing . Lippincott Williams & Wilkins.

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Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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Understanding the Effects of Pharmacotherapy Through Passive Data Collection

Four Myths About Lamotrigine

Revisiting Modafinil/Armodafinil for the Treatment of Bipolar Disorder

Securing the Future of Lithium Research

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