Bipolar disorder is a complex mental health condition marked by dramatic shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. These shifts range between periods of extremely elevated mood known as mania or hypomania, and periods of profound depression. Understanding and managing bipolar disorder is crucial, and nurses play a vital role in patient care. This article delves into the essential nursing diagnoses for bipolar disorder, aligned with NANDA (North American Nursing Diagnosis Association) terminology, providing a comprehensive guide for healthcare professionals.
Types of Bipolar Disorder: Understanding the Spectrum
Bipolar disorder is not a monolithic condition; it encompasses several types, each with unique characteristics. Recognizing these variations is important for accurate nursing assessment and intervention.
Bipolar I Disorder: Defined by manic episodes that last at least 7 days, or by manic symptoms so severe that the person needs immediate hospital care. Depressive episodes, typically lasting at least 2 weeks, also commonly occur. It is possible to have episodes of mania and depression simultaneously (mixed features).
Bipolar II Disorder: Characterized by patterns of depressive episodes and hypomanic episodes, but not the full-blown manic episodes of Bipolar I Disorder. Hypomania is a less severe form of mania.
Cyclothymic Disorder (Cyclothymia): A milder form of bipolar disorder characterized by numerous periods of hypomanic symptoms as well as numerous periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic criteria for hypomanic or depressive episodes.
Unspecified Bipolar and Related Disorders: This category is used when symptoms characteristic of a bipolar disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning but do not meet the full criteria for any of the above categories.
Manic and hypomanic episodes share similar symptoms, although hypomania is less severe and does not cause significant impairment in social or occupational functioning, nor does it require hospitalization. Common symptoms include:
- Elevated Mood: Euphoria, excessive happiness, or irritability.
- Increased Activity and Energy: Restlessness, hyperactivity.
- Racing Thoughts: Rapid speech, flight of ideas.
- Inflated Self-Esteem: Grandiosity, unrealistic beliefs in one’s abilities.
- Impulsivity: Poor judgment, risk-taking behaviors such as excessive spending, reckless driving, or inappropriate sexual behavior.
- Decreased Need for Sleep: Feeling rested after only a few hours of sleep.
- Distractibility: Difficulty concentrating, easily diverted attention.
- Socially Intrusive Behavior: Overly talkative, demanding, or manipulative.
Depressive episodes in bipolar disorder are characterized by:
- Persistent Sadness: Feelings of hopelessness, emptiness, or despair.
- Loss of Interest or Pleasure: Anhedonia, lack of enjoyment in previously pleasurable activities.
- Fatigue or Loss of Energy: Feeling tired all the time.
- Sleep Disturbances: Insomnia or excessive sleepiness.
- Changes in Appetite or Weight: Significant weight loss or gain, or changes in appetite.
- Difficulty Concentrating: Indecisiveness, impaired memory.
- Feelings of Worthlessness or Guilt: Excessive or inappropriate guilt.
- Thoughts of Death or Suicide: Suicidal ideation or attempts.
Bipolar disorder is a chronic condition, and treatment is focused on long-term management of symptoms. This typically involves a combination of psychotherapy, medication, and lifestyle adjustments. Medications often include mood stabilizers, antipsychotics, antidepressants, and anti-anxiety medications.
The Nursing Process and Bipolar Disorder
For patients with bipolar disorder, especially those requiring inpatient care, the nursing process is crucial. These individuals often present during acute manic or depressive episodes, requiring careful monitoring, intervention, and a therapeutic environment provided by skilled psychiatric nurses. Nurses are also integral in managing co-occurring conditions like substance abuse or other health issues in patients with bipolar disorder.
Effective nursing care begins with accurate nursing diagnoses. These diagnoses, based on NANDA-I classifications, provide a framework for developing individualized nursing care plans. These plans prioritize assessments and interventions, setting both short-term and long-term goals for patient care. Below are examples of key nursing diagnoses relevant to bipolar disorder.
Disturbed Thought Processes
Nursing Diagnosis: Disturbed Thought Processes
This NANDA nursing diagnosis (00130) is defined as “a disruption in cognitive operations and activities.” In bipolar disorder, disturbed thought processes are frequently observed during manic and psychotic episodes.
Related Factors:
- Sleep deprivation
- Psychotic process
- Substance abuse
- Physiological changes (imbalance of neurotransmitters)
- Psychological conflicts
- Situational crises
As Evidenced By:
- Distractibility
- Egocentricity
- Impaired decision-making
- Suspiciousness
- Delusional thinking
- Hypervigilance
- Hallucinations
- Loose associations
- Tangentiality
- Circumstantiality
Desired Outcomes:
- Patient will demonstrate reality-based thinking and an absence of delusions by discharge.
- Patient will recognize and verbalize when thoughts are not reality-based.
- Patient will verbalize an absence of hallucinations.
- Patient will demonstrate improved decision-making and problem-solving abilities.
Nursing Assessments:
- Assess for substance use: Alcohol and drugs can exacerbate psychotic symptoms and impair judgment, compounding pre-existing mental instability.
- Evaluate for hallucinations: Auditory hallucinations are common in psychosis and can fuel delusions, ranging from paranoia to grandiose beliefs.
- Assess attention span and problem-solving skills: Observe the patient’s ability to maintain focus, process information, and make sound decisions during interactions.
- Monitor thought content and thought process: Assess for delusions, paranoia, flight of ideas, and disorganized thinking patterns.
Nursing Interventions:
- Reorient to reality: Regularly reorient the patient to person, place, and time. Engage in reality-focused conversations about current events to redirect from false beliefs.
- Provide positive reinforcement for reality-based thinking: Acknowledge and praise the patient when they differentiate between reality and delusions, offering positive support.
- Avoid reinforcing delusions: Do not agree with or validate delusions as factual, as this can strengthen false beliefs. However, avoid direct confrontation or arguing, which can damage the therapeutic relationship.
- Teach thought-stopping techniques: Educate the patient on techniques to interrupt intrusive thoughts, such as saying “stop” or using a physical action like clapping, to manage unwanted thoughts and prevent escalating emotional distress.
- Promote a calm and structured environment: Reduce environmental stimuli to minimize agitation and confusion.
Insomnia
Nursing Diagnosis: Insomnia
Insomnia (NANDA 00095) is defined as “a disruption in amount and quality of sleep that impairs functioning.” It’s a common complaint in bipolar disorder, particularly during manic episodes, where individuals experience a decreased need for sleep.
Related Factors:
- Hyperactivity
- Use of stimulants
- Disorder process (bipolar disorder itself)
- Distractibility
- Anxiety
- Fear
- Changes in routines
As Evidenced By:
- Difficulty falling asleep
- Decreased need for sleep
- Sleeping for only short periods
- Awakening very early
- Daytime fatigue
- Irritability
- Difficulty concentrating
Desired Outcomes:
- Patient will sleep at least 6-7 hours per night by discharge.
- Patient will implement two interventions to improve sleep hygiene.
- Patient will report decreased restlessness and fatigue due to improved sleep.
- Patient will demonstrate improved daytime functioning.
Nursing Assessments:
- Assess sleep patterns: Establish a baseline understanding of the patient’s typical sleep habits to guide the implementation of structured sleep schedules and nap times.
- Monitor for physical signs of exhaustion: Patients in manic states may not perceive their need for sleep and can go days without rest. Observe for physical manifestations of fatigue such as tremors and elevated blood pressure, allowing for timely intervention before exhaustion sets in.
- Assess for factors contributing to insomnia: Identify potential contributing factors like anxiety, medication side effects, or poor sleep hygiene practices.
Nursing Interventions:
- Administer prescribed medications: Benzodiazepines like clonazepam and lorazepam may be used cautiously for short-term management of insomnia, as some research suggests they might also have mood-stabilizing effects in mania.
- Implement dark therapy: Dark therapy, involving maintaining a pitch-dark room during nighttime hours, can naturally boost melatonin production. Blue-light blocking glasses may be beneficial in regulating circadian rhythms once acute insomnia improves.
- Promote relaxation and sleep hygiene: Encourage relaxation techniques and good sleep hygiene practices, such as playing soft music, dimming lights, and offering caffeine-free herbal teas before bedtime.
- Restrict stimulants: Advise against caffeinated beverages, especially in the evening, for patients experiencing insomnia.
- Recommend Cognitive Behavioral Therapy for Insomnia (CBT-I): CBT-I, tailored for bipolar disorder, has shown promise in improving sleep and potentially reducing mood episode frequency. Encourage patients to explore CBT-I resources, including mobile apps.
- Establish a regular sleep schedule: Promote consistency in bedtime and wake-up times, even on weekends, to regulate the body’s natural sleep-wake cycle.
Risk for Injury
Nursing Diagnosis: Risk for Injury
This NANDA diagnosis (00035) is defined as “vulnerable to physical damage due to environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.” In bipolar disorder, the risk for injury is elevated due to impulsivity, poor judgment, and hyperactivity, particularly during manic episodes.
Related Factors:
- Extreme hyperactivity
- Destructive behaviors
- Disinhibition
- Poor judgment
- Risk-taking behavior
- Aggression
- Alcohol and drug use
- Delusional thinking
- Self-harm ideations
- Impaired cognitive function
As Evidenced By:
A risk diagnosis is not evidenced by actual signs and symptoms because the problem has not yet occurred. Nursing interventions are focused on prevention.
Desired Outcomes:
- Patient will remain free from injury to self and others during manic episodes.
- Patient will demonstrate a calm and manageable energy level by discharge.
- Patient will cooperate with unit rules and boundaries without aggression or inappropriate behavior.
- Patient will verbalize an understanding of risk factors for injury and safety precautions.
Nursing Assessments:
- Differentiate between manic and depressive behaviors: Manic episodes often involve hyperactive, risk-taking behavior fueled by a sense of invincibility. Depressive episodes may involve suicidal ideation or substance abuse, both posing injury risks.
- Assess safety and suicide risk: Observe for aggression, irritability, impaired judgment, and socially inappropriate behavior. Directly inquire about suicidal thoughts. Interventions are aimed at ensuring the safety of the patient and others.
- Gather information from family and friends: Family, spouses, and close friends can offer valuable insights into the patient’s typical behavior during acute episodes, aiding in risk assessment.
- Evaluate the environment for safety hazards: Identify and remove potential hazards in the patient’s environment.
Nursing Interventions:
- Reduce environmental stimuli: Provide a private room if possible, with quiet surroundings and dimmed lighting to minimize hyperactivity and distraction.
- Remove dangerous objects: Eliminate any objects that could be used as weapons or for self-harm.
- Offer structured physical activities: Channel manic energy into safe outlets like exercise classes or structured tasks to reduce hyperactivity and divert from unsafe activities.
- Administer prescribed tranquilizing medications: Antipsychotic medications are often prescribed to manage hyperactivity, agitation, and impulsivity.
- Implement close observation: Maintain close observation of the patient, especially during acute episodes, to prevent impulsive actions.
- Set clear and consistent limits: Establish and enforce clear boundaries and unit rules to provide structure and safety.
Risk for Self-Mutilation
Nursing Diagnosis: Risk for Self-Mutilation
Risk for Self-Mutilation (NANDA 00151) is defined as “vulnerable to deliberate self-injurious behavior causing tissue damage with intent to cause nonfatal injury to attain relief of tension.” Patients with bipolar disorder can be at risk for self-mutilation in manic, depressive, or mixed states.
Related Factors:
- Disease process (bipolar disorder)
- Dysfunctional thought processes
- Difficulty coping with stressful situations
- Difficulty expressing feelings
- Depressive symptoms
- Ineffective impulse control
- History of self-harm
- Emotional dysregulation
As Evidenced By:
A risk diagnosis is not evidenced by actual signs and symptoms because the problem has not yet occurred. Nursing interventions are focused on prevention.
Desired Outcomes:
- Patient will remain free from self-inflicted injury.
- Patient will utilize appropriate coping strategies to manage urges for self-mutilation.
- Patient will verbalize feelings and needs instead of resorting to self-harm.
- Patient will demonstrate improved impulse control.
Nursing Assessments:
- Assess mental state: Evaluate the patient’s current mood state (manic, depressive, mixed) as each state can increase the risk of self-injurious behavior.
- Assess personality factors affecting emotions: Identify factors like poor emotional regulation, impulsivity, and neuroticism (tendency to experience negative emotions like anxiety and worry), which are linked to self-harm.
- History of self-harm: Inquire about any past episodes of self-harm, including methods and triggers.
- Identify triggers and coping mechanisms: Explore situations, thoughts, or feelings that trigger urges to self-harm and the patient’s current coping strategies.
Nursing Interventions:
- Encourage verbalization of feelings: Help the patient learn to express thoughts and emotions verbally as a healthier way to regulate emotions instead of acting out through self-harm.
- Reduce social isolation: Address potential loneliness, which can exacerbate self-harm risk. Identify supportive individuals and mental health professionals the patient can contact when experiencing urges to self-harm.
- Reinforce alternative coping mechanisms: Suggest and encourage alternative coping strategies. For manic patients, physical outlets like exercise or cleaning can help manage impulsive urges. For depressed patients, distraction techniques like walks can help manage difficult emotions. These activities promote self-efficacy and reduce self-harm risk.
- Remove harmful objects: Advise family members to remove sharp objects or lighters from the patient’s environment to reduce access to self-harm tools.
- Develop a safety plan: Collaborate with the patient to create a personalized safety plan that includes coping strategies, support contacts, and steps to take during a crisis.
- Monitor for warning signs: Be vigilant for behavioral cues indicating increased risk, such as increased anxiety, withdrawal, or preoccupation with self-harm.
Risk for Suicide
Nursing Diagnosis: Risk for Suicide
Risk for Suicide (NANDA 00150) is defined as “vulnerable to self-inflicted, life-threatening injury.” Suicide is a significant concern in bipolar disorder and a leading cause of death among individuals with this condition.
Related Factors:
- Psychiatric disorder (bipolar disorder)
- Dysfunctional thought processes
- Difficulty coping with stressful situations
- Depressive symptoms
- Ineffective impulse control
- Access to lethal means (weapons, medications)
- Hopelessness
- Social isolation
- History of suicide attempts
As Evidenced By:
A risk diagnosis is not evidenced by actual signs and symptoms because the problem has not yet occurred. Nursing interventions are focused on prevention.
Desired Outcomes:
- Patient will remain safe and free from self-harm.
- Patient will express feelings, disclose suicidal ideation, and seek help when suicidal thoughts occur.
- Patient will identify and utilize mental health resources.
- Patient will demonstrate improved coping skills and problem-solving abilities.
Nursing Assessments:
- Assess current mood and psychotic symptoms: Psychotic features in manic or depressive episodes can significantly increase suicidal risk. Assess for hallucinations, delusions, paranoia, and irrational thinking.
- Assess for suicidal ideation: Directly inquire about suicidal thoughts, plans, and intent. Be alert to verbal and nonverbal cues suggesting increased risk.
- Assess support system: A perceived lack of social support is linked to a higher risk of suicide attempts in bipolar disorder patients.
- Evaluate access to lethal means: Assess the patient’s access to firearms, medications, or other potential means of suicide.
- Assess for hopelessness: Hopelessness is a strong predictor of suicidal ideation and behavior.
Nursing Interventions:
- Provide mental health resources: Ensure the patient has access to counselors, support groups, crisis hotlines, and emergency services. Perceived loneliness is a risk factor, and enhanced support is protective.
- Promote medication adherence: Emphasize the importance of medication adherence, particularly with mood stabilizers like lithium, which has demonstrated effectiveness in reducing suicide risk in bipolar disorder.
- Maintain close surveillance: If suicidal ideation or a plan is identified, implement close observation and monitoring to ensure patient safety. Inpatient hospitalization may be necessary for continuous supervision.
- Ensure environmental safety: Remove dangerous objects and weapons from the patient’s environment to minimize access to lethal means.
- Develop a crisis plan: Collaborate with the patient to create a detailed crisis plan that outlines steps to take if suicidal thoughts escalate, including contact information for support and emergency services.
- Encourage hope and positive thinking: Help the patient identify strengths and positive aspects of their life to counter feelings of hopelessness.
References
- Butcher, H.K., Bulechek, G.M., Dochterman, J.M., & Wagner, C.M. (2018). Nursing Interventions Classification (NIC). Elsevier.
- Herdman, T.H., & Kamitsuru, S. (Eds.). (2018). NANDA International, Inc. nursing diagnoses: Definitions & classification 2018-2020. Thieme.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
- National Institute of Mental Health (NIMH). (n.d.). Bipolar Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder
