King Saud University

College Of Nursing

NUR.472

Community & Mental Health Nursing

Prepared By:
Hatem ALsrour

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Introduction
Every person has feelings of happiness and
sadness once in a while. Feeling high and feeling
low are parts of life. We all experience changes in
moods from time to time depending on events we
go through in life.
But when these mood swings become more
dramatic and severe, and impair a person’s ability
to function as usual at work, school, or in
relationships, it may indicate the presence of a
serious mood disorder. Exactly it is called bipolar
disorders.

Definition
Bipolar disorder(manic depression) simply can be
defined as:
a mental disorder that is characterized by severe
mood swings cycling between periods of intense
“highs” (mania or hypomania) and periods of
intense “downs” (depression).

TYPES OF MOOD EPISODES :

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In bipolar disorder each mood swing is called an
“episode.” There are 4 main types of mood
episodes that people with bipolar disorder can
have:
1. Depression: is when people with bipolar disorder
feel very sad. Sometimes this can go on for a
long period of time. They may not even want to
get out of bed or eat. They don’t enjoy doing
things they used to do.

With all types of extreme moodepisodes,

peopleare at risk for suicide.

Mania & Hypomania

Mania
•

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 • Affect on the relationship of person with social &\or family.

• Affect on person’s work.

• It is a problem.

• Need hospitalization.

• Hallucination.

• Delusion.

Hypomania
•

• May not affect on the relationship of person with social&\ or

family .

• May not affect on person’s work.

• It is sometimes not even noticed as a problem.

• May not need hospitalization.

• No hallucination.

• No delusion.

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Types of bipolar disorder
Bipolar disorder is divided into two main subtypes:

1. Bipolar I disorder:
You've had at least one manic episode,
with or without previous episodes of
depression.
2. Bipolar II disorder:
You've had at least one episode of
depression and at least one hypomanic
episode. In bipolar II disorder, the periods
of depression are typically much longer
than the periods of hypomania.
3.Cyclothymia:
is a mild form of bipolar disorder. Cyclothymia
includes mood swings but the highs and lows are
not as severe as those of full-blown bipolar
disorder.

Causes
 Scientists don’t really know what causes bipolar
disorder

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 (unknown causes)

 Genetic factors
 Hormones are chemicals in the body
 Other illnesses

Triggers and risk factors for

bipolar disorder
1)Severe stress or emotional trauma
○ Stress can also worsen a bipolar mood
episode or extend its duration.
2)Substance Abuse
○ Drugs such as cocaine, ecstasy, and
amphetamines can trigger mania
○ alcohol and tranquilizers can trigger
depression.

3)Medication
○ Antidepressant drugs, over-the-counter
cold medicine, appetite suppressants,
caffeine,, and thyroid medication can
trigger mania
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 4) Sleep Deprivation

5) Seasonal Changes
○ Manic episodes are more common during
the summer.
○ Depressive episodes more common during
the fall, winter, and spring.
6)Major life changes, such as the death of a
loved one
7) Having other biological family members with
bipolar disorder

Diagnosis
Bipolar disorder can be hard to detect because
the symptoms can be similar to other mood
disorders. Some people have the condition for
10 years or more before a healthcare provider
diagnoses it.
When people are feeling manic or hypomanic,
they are full of energy. They usually feel good.
They feel "high on life" and don’t always seek
help.

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On the other hand, people are more likely to
seek help when they fall into depression.
When people feel depressed, they are likely to
describe only depression symptoms to their
healthcare provider. They may not mention the
times when they are feeling “high on life,”
since depression is what they are feeling at
the time. Therefore, it’s common for a person
to be incorrectly diagnosed with major
depression instead of bipolar disorder. That’s
why it’s important for people to say how
they’ve been feeling weeks and even months
before the day they talk to their healthcare
provider in order to make it easier for the right
diagnosis.
Many of the signs and symptoms of bipolar
disorder can also be associated with other
illnesses, such as anxiety disorders and
schizophrenia. This can make it even harder
for a healthcare provider to make a correct
diagnosis.
Unfortunately, there is no laboratory test can
detect bipolar disorder. However, a simple
questionnaire can help a doctor determine if
someone has common symptoms of bipolar
disorder. This questionnaire is called the Mood
Disorder Questionnaire( MDQ).

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 The MDQ is a checklist that helps a doctor
identify bipolar-related symptoms. Remember,
only a doctor can provide an accurate
diagnosis.

 A manic episode is diagnosed if elevated mood

occurs with three or more of the other symptoms
most of the day, nearly every day, for 1 week or
longer. If the mood is irritable, four additional
symptoms must be present.

 A depressive episode is diagnosed if five or more of

these symptoms last most of the day, nearly every
day, for a period of 2 weeks or longer.

What does a diagnostic exam for

bipolar disorder consist of?
1. A complete psychiatric history
• current and past symptoms

• symptoms of immediate family members and

relatives.

• family history(there may be genetic factors).

Etc…

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 2. A complete medical history and physical
exam
• Any physical illnesses(may be producing the
symptoms of bipolar disorder).

• AIDS, a brain tumor or head injury, diabetes,

epilepsy, Lupus, Multiple Sclerosis, a salt
imbalance or thyroid disorder can produce
bipolar-like symptoms.

3. Drug Screen:

○ Rule out possibility that symptoms are drug-

induced.

4. Electrolytes:

○ Excess of sodium within the nerve cells may be

noted.

If no physical cause is found, if no other

psychiatric disorder better accounts for symptoms,
if the current symptoms have been of significant
duration a patient may then be diagnosed with
bipolar disorder. It is important to note here that if
there is no previous history of mania or
hypomania, the current symptoms must be those
of mania or hypomania for a diagnosis of bipolar
disorders.

Medicines

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Treatment for bipolar disorder can vary. What
works for one person may not work for someone
else. There are 3 basic parts of treatment for
bipolar disorder. They are:
1. Medicine.

2. Therapy .

3. Self care.

Goal Of Bipolar Disorders Treatment

1. To control symptoms of depression and mania.

2. To reduce the number of times that moods go up and

down.

3. To help people with bipolar disorder feel as good as

they can.

4. To reduce lesser bipolar symptoms that still could be

a problem.

5. To reduce side effects of bipolar disorder treatment.

Bipolar disorder medicines may be used alone or

with others. Some medicines may take time to
start working. Types of bipolar disorder medicines
include:
1. Mood stabilizers: These may delay or relieve
episodes of mania (highs) or depression (lows). e.g.:
• Lithium (Eskalith or Lithobid): has long been used as a
first line treatment for acute mania in people with
bipolar disorder

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• sodium (Depakote)

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2. Antidepressants:
These are often used with a mood stabilizer in people
with depressive episodes. If used alone,
antidepressants may increase the chances of a
person with bipolar disorder switching into mania.
e.g.:
• Olanzapine (Zyprexa), which is FDA approved for the
treatment of acute mania.

3. Antipsychotics:
These are medicines that are mostly used to treat
mania. They may also be used to treat psychosis that
can occur during severe episodes of mania or
depression. Antipsychotics may be used alone or with
other medicines for treating bipolar disorder, e.g.:
 CLOZAPINE (CLOZARIL)

 QUETIAPINE (SEROQUEL)

 ZIPRASIDONE (GEODON)

3. Other medicines:
Might be suggested by the healthcare provider when
a person with bipolar disorder cannot sleep or feels
nervous.

4. Anticonvulsant medications:

such as carbamazepine (Tegretol), also can have

mood-stabilizing effects and may be especially useful
for difficult-to-treat bipolar episodes.

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 • Newer anticonvulsant medications,
including lamotrigine (Lamictal), gabapentin
(Neurontin), and topiramate (Topamax), are
being studied to determine how well they
work in stabilizing mood cycles.

• Anticonvulsant medications may be

combined with lithium, or with each other,
for maximum effect.

Therapy (psychotherapy)
1. Cognitive behavioral therapy:
This is a common form of individual therapy for
bipolar disorder. The focus of cognitive
behavioral therapy is identifying unhealthy,
negative beliefs and behaviors and replacing
them with healthy, positive ones. In addition,
you can learn about bipolar disorder and its
treatment and what may trigger your bipolar
episodes. You also learn effective strategies to
manage stress and to cope with upsetting
situations.

2. Family therapy:
Family therapy involves you and your family
members. Family therapy can help identify and
reduce stressors within your family. It can help
your family improve its communication style and
problem-solving skills and resolve conflicts.

3. Hospitalization

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 In some cases, people with bipolar disorder may
benefit from inpatient hospitalization.
Hospitalization for psychiatric treatment can
help stabilize your mood, whether you're in a
full-blown manic episode or a deep depression.
Partial hospitalization or day treatment
programs also are options to consider.

4. Group therapy:
Group therapy provides a forum to communicate
with and learn from others in a similar situation.
It may also help build better relationship skills.

Lithium
 INDICATIONS
i. Treatment of bipolar affective disorders
(treatment of manic episodes).

 Therapeutic Effects:
i. Prevents/decreases incidence of manic episodes

 Contraindicated in:
i. Severe cardiovascular or renal disease

ii. Dehydrated or debilitated patients

iii.Should be used only where therapy, including

lithium blood levels, may be closely monitored

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 iv.Pregnancy or lactation.

 Use Cautiously in:

i. Geriatric patients (initial dosage reduction
recommended)

ii. Any degree of cardiac, renal, or thyroid disease

iii.Diabetes mellitus

iv.Children.

 NURSING PROCESS
• ASSESSMENT
 Assess mood, ideation, and behaviors frequently.
Initiate suicide precautions if indicated.

 Monitor intake and output ratios. Report significant

changes in totals. Weight should also be monitored
at least every 3 mo.

 Lab Test Considerations: Renal and thyroid

function, WBC with differential, serum electrolytes,
and glucose should be evaluated periodically
throughout therapy.

 Toxicity and Overdose: Serum lithium levels should

be monitored twice weekly during initiation of
therapy and every 2–3 mo during chronic therapy.
Blood samples should be drawn in the morning
immediately before next dose. Therapeutic levels
range from 0.5 to 1.5 mEq/liter.

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Assess patient for signs and symptoms of
lithium toxicity (vomiting, diarrhea, slurred
speech, decreased coordination, drowsiness,
muscle weakness, or twitching). If these occur,
report before administering next dose.

Range Lithium level name

(0.6—1.2) mmol/L Normal level

(1.2—2.5)mmol/L Warning level

(1.5—2.5)mmol/L Mild toxicities level

(2.5—3.5)mmol/L Severe toxicities level

>2.5 mmol/L Fatal level

• POTENTIAL NURSING DIAGNOSES

i. Thought process, altered .

ii. Violence, [actual] risk for self-directed .

iii. Violence, [actual] risk for directed at others

.

iv.Noncompliance.

• IMPLEMENTATION
✔ PO: Administer with food or milk to minimize
GI irritation. Extended-release preparations
should be swallowed whole; do not break,
crush, or chew.

PATIENT/FAMILY TEACHING
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 ✔ Instruct patient to take medication exactly as
directed, even if feeling well.

✔ Medication may cause dizziness or drowsiness.

Caution patient to avoid driving or other
activities requiring alertness until response to
medication is known.

✔ Advise patient to drink 2000–3000 ml fluid

each day and eat a diet with moderate sodium
intake. Excessive amounts of coffee, tea, and
cola should be avoided because of diuretic
effect.

✔ Advise patient that weight gain may occur.

Review principles of a low-calorie diet.

Conclusion
Bipolar disorder is a lifelong condition. It
can be hard for healthcare providers to
diagnose. But it's nothing to be embarrassed
about. Learning more about how to manage
the condition can help.

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REFERENCES
1. Psychiatric-Mental Health Nursing

2. Brunner & Suddarth’s Textbook Of Medical Surgical Nursing

3. www.nursing-center.com

4. www.who.com

5. www.helpguide.org

6. www.nlm.nih.gov/medlineplus/

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