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Chapter 15
Mood Disorders
Part II
Bipolar Disorder (Mania)
Etiological implications
 Biological theories: Strong hereditary
implications
 Biochemical influences: Possible excess of
norepinephrine, serotonin, and/or
dopamine
Bipolar Disorder (Mania) (cont.)
Physiological influences
 Alterations in electrolyte transfer resulting
in increased levels of intracellular sodium
and calcium
 Brain lesions
 Medication side effects
 Steroids
 Amphetamines
 Antidepressants
Bipolar Disorders (Mania) (cont.)
 Psychosocial theories
 Credibility of psychosocial theories has
declined in recent years
 Bipolar disorder viewed as brain disorder
Development Implications
 Childhood & Adolescence
 CABF group.
 The use of FIND (frequency, intensity,
number, and duration).
Mania in Children; symptoms
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Euophoria
Irritable mood
Grandiosity
Decreased need
for sleep
 Pressured speech
 Racing thoughts
 Distractibility
 Increased
psychomotor
agitation
 Psychosis
 suicidality
Nursing Process/Assessment
 Symptoms may be categorized by degree of
severity
 Stage I—Hypomania: Symptoms not sufficiently
severe to cause marked impairment in social or
occupational functioning or to require
hospitalization
 Mood: cheerful and expansive
 Cognition and perception: self-exaltation; easily
distracted
 Activity and behavior: increased
motor activity; extroverted; superficial
Assessment
 Stage II—Acute mania: intensification of
hypomanic symptoms; requires
hospitalization
 Mood: euphoria and elation
 Cognition and perception: fragmented,
disjointed thinking; pressured speech; flight of
ideas; hallucinations and delusions
 Activity and behavior: excessive
psychomotor behavior; increased
sexual interest; inexhaustible
energy; goes without sleep;
bizarre dress and make-up
Assessment (cont.)
 Stage III—Delirious mania: A grave form of
the disorder, characterized by severe
clouding of consciousness and representing
an intensification of the symptoms associated
with acute mania
 Mood: labile, from ecstasy to despair
 Cognition and perception: confusion,
disorientation, hallucinations, delusions
 Activity and behavior: frenzied
psychomotor activity; agitated,
purposeless movements; exhaustion
and death can occur without
intervention
Nursing Diagnosis
 Risk for Injury related to:
 Extreme hyperactivity evidenced by
increased agitation and lack of control over
purposeless and potentially injurious
movements
Nursing Diagnosis (cont.)
 Risk for violence: Self-directed or
other-directed related to:
 Manic excitement
 Delusional thinking
 Hallucinations
Nursing Diagnosis (cont.)
 Imbalanced Nutrition less than body
requirements related to:
 Refusal or inability to sit still long enough to
eat evidenced by loss of weight,
amenorrhea
Nursing Diagnosis (cont.)
 Disturbed thought processes related to:
 Biochemical alterations in the brain evidenced
by delusions of grandeur and persecution
Nursing Diagnosis (cont.)
 Disturbed sensory perception related to:
 Biochemical alterations in the brain and to
possible sleep deprivation, evidenced by
auditory and visual hallucinations
Nursing Diagnosis (cont.)
 Impaired Social Interaction related to:
 Egocentric and narcissistic behavior
 Disturbed sleep pattern related to:
 Excessive hyperactivity and agitation
Criteria for Measuring Outcomes
 The client
 Exhibits no evidence of physical injury
 Has not harmed self or others
 Is no longer exhibiting signs of physical
agitation
Criteria for Measuring Outcomes (cont.)
 The client (cont.)
 Eats a well-balanced diet with snacks to
prevent weight loss and maintain nutritional
status
 Verbalizes an accurate interpretation of the
environment
 Verbalizes that hallucinatory activity has
ceased and demonstrates no outward
behavior indicating hallucinations
Criteria for Measuring Outcomes (cont.)
 The client (cont.)
 Accepts responsibility for own behaviors
 Does not manipulate others for gratification
of own needs
 Interacts appropriately with others
Planning/Implementation
 Nursing interventions are aimed at:
 Maintaining safety of client and others
 Restoring client nutritional status
 Encouraging appropriate client interaction
with others
 Assisting client to define and test reality
 Meeting client’s self-care needs
Client/Family Education
 Nature of illness
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Causes of bipolar disorder
Cyclic nature of the illness
Symptoms of depression
Symptoms of mania
Client/Family Education (cont.)
 Management of illness
 Medication management
 Assertive techniques
 Anger management
Client/Family Education (cont.)
 Support services
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Crisis hotline
Support groups
Individual psychotherapy
Legal/financial assistance
Evaluation
 Evaluation of the effectiveness of the
nursing interventions is measured by
fulfillment of the outcome criteria.
Evaluation (cont.)
 Has the client avoided personal injury?
 Has violence to client or others been
prevented?
 Has agitation subsided?
Evaluation (cont.)
 Have nutritional status and weight been
stabilized?
 Have delusions and hallucinations
ceased?
Treatment Modalities for Mood Disorders
 Psychological treatment
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Individual psychotherapy
Group therapy
Family therapy
Cognitive therapy
Treatment Modalities for Mood Disorders (cont.)
 Organic Treatments
 Psychopharmacology
 For Depression
 Tricyclic antidepressants
 MAO Inhibitors
 SSRIs
 Others
* Maprotiline
* Mirtazapine
* Amoxapine
* Serzone
* Trazodone
* Effexor
* Bupropion
Treatment Modalities for Mood Disorders (cont.)
 Psychopharmacology (cont.)
 For mania:
 Lithium carbonate
 Anticonvulsants
 Verapamil
 Olanzapine
Treatment Modalities for Mood Disorders (cont.)
 Electroconvulsive Therapy
 For depression and mania
 Mechanism of action: thought to increase levels of
biogenic amines
 Side effects: temporary memory loss and confusion
 Risks: mortality; permanent memory loss;
brain damage
 Medications: pretreatment medication; muscle
relaxant; short-acting anesthetic
Nursing Process: Suicide Assessment
 Epidemiological factors
 Marital status: Suicide rate for single
people twice that of married people
 Single, divorced, and widowed people
have rates four to five times greater than
those who are married
Nursing Process: Suicide Assessment (cont.)
 Epidemiological factors (cont.)
 Gender: Women attempt suicide more
often; more men succeed
 Age: Suicide highest in persons older than
50 years; adolescents also at high risk
Nursing Process: Suicide Assessment (cont.)
 Epidemiological factors (cont.)
 Religion: Protestants have significantly
higher rates of suicide than Catholics and
Jews. A strong feeling of cohesiveness
within a religious organization seems to be
an important factor.
Nursing Process: Suicide Assessment (cont.)
 Epidemiological factors (cont.)
 Socioeconomic status: People in the
highest and lowest social classes have
higher suicide rates than those in the
middle classes.
 Professionals: Professional healthcare
personnel and business executives are at
the highest risk.
Nursing Process: Suicide Assessment (cont.)
 Epidemiological factors (cont.)
 Ethnicity: Whites are at highest risk for
suicide, followed by Native Americans,
then by African Americans.
Nursing Process: Suicide Assessment (cont.)
 Presenting symptoms/Medicalpsychiatric diagnosis
 Mood disorders (major depression and
bipolar disorders) are the most common
disorders that precede suicide.
 Other disorders include
 Anxiety disorders
 Schizophrenia
 Borderline personality disorder
 Antisocial personality disorder
Nursing Process: Suicide Assessment
 Suicidal ideas or acts
 Assess: Intent; plan; means; lethality of
means; previous attempts
 Verbal clues:
 Direct statements: “I want to die.”
 Indirect statements: “I don’t have
anything to live for anymore.”
(cont.)
Nursing Process: Suicide Assessment (cont.)
 Interpersonal support system
 Analysis of the suicidal crisis
 The precipitating stressor
 Relevant history
 Life-stage issues
 Psychiatric/medical/family history
 Coping strategies
Nursing Process
 Diagnosis/Outcome Identification
 Risk for suicide related to feelings of
hopelessness and desperation
 Outcome: The client has experienced no
physical harm to self
Nursing Process (cont.)
Diagnosis/Outcome Identification
(cont.)
 Hopelessness related to absence of support
systems and perception of worthlessness
 Outcome: Expresses some optimism and
hope for the future
Nursing Process (cont.)
 Planning/Implementation
 Establish a therapeutic relationship to
convey acceptance of the person.
 Communicate the potential for suicide to
team members.
 Stay with the person to convey support
throughout the current crisis.
Planning/Implementation
 Accept the person, which will show
unconditional positive regard.
 Listen to the person.
 Secure a no-suicide contract (verbally
or in writing) for a specified amount of
time.
Intervention with the Outpatient Suicidal
Client
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Do not leave the person alone.
Establish a no-suicide contract.
Enlist help of family and friends.
Schedule daily appointments.
Establish trusting relationship.
Talk directly about client’s plans for suicide.
Discuss current crisis situation.
Identify areas of client control.
Antidepressant medication.
Information for Family/Friends of Suicidal
Client
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Take any hint of suicide seriously.
Report threats of suicide immediately.
Be a good listener; stay with the person.
Express concern about the person’s welfare.
Be aware of resources for assistance.
Restrict access to firearms or other means of
self-harm.
 Instill hope. Express love for the person.
 Encourage professional help.
 Be nonjudgmental.
Intervention with Families and Friends of
Suicide Victims
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Encourage them to talk about the suicide.
Be aware of blaming or scapegoating.
Listen to feelings of guilt.
Encourage discussion of relationship with lost
loved one.
 Encourage grieving at own personal pace.
 Discuss coping strategies.
 Identify resources that provide support.
Nursing Process/Evaluation
 Evaluation of the suicidal client is an
ongoing process accomplished through
continuous reassessment of the client
as well as determination of the goal
achievement.
Nursing Process/Evaluation (cont.)
 Long-term goals for the suicidal client
would be to:
 Develop and maintain a more positive selfconcept
 Learn more effective ways to express feelings
to others
 Achieve successful interpersonal
relationships
 Feel accepted by others and achieve a sense
of belonging