Manic and hypomania (a less severe form of mania) include the following symptoms:
- Racing thoughts
- An exaggerated sense of grandiosity and self-importance
- Poor decision-making resulting in shopping sprees or inappropriate dress
- 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.
The 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 Related to Bipolar Disorder
Risk For Injury Care Plan
Patients are at a risk for injury from participating in dangerous activities or potentially harming themselves.
Nursing Diagnosis: Risk For Injury
- Extreme hyperactivity
- Destructive behaviors
- Poor judgment
- Risk-taking behavior
- Alcohol and drug use
- Delusional thinking
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
- 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
Risk For Injury 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.
Risk For injury 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.
Disturbed Thought Processes Care Plan
Patients with bipolar disorder may experience a range of disturbed thoughts.
Nursing Diagnosis: Disturbed Thought Processes
- Sleep deprivation
- Psychotic process
- Substance abuse
As evidenced by:
- Impaired decision-making
- Delusional thinking
- 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
Disturbed Thought Processes 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.
Disturbed Thought Processes 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 Care Plan
Bipolar disorder often causes insomnia as the patient experiences a decreased need for sleep.
Nursing Diagnosis: Insomnia
- Use of stimulants
- Disorder process
As evidenced by:
- Difficulty falling asleep
- Decreased need for sleep
- Sleeping for only short periods
- Awakening very early
- 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
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.
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.
References and Sources
- 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. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- 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. From https://images.template.net/wp-content/uploads/2016/04/04060256/Psychotropic-Medication-Nursing-Care-Plan-Free-PDF.pdf