• Bipolar disorder, (also known as manic depressive disorder) is a
serious mental illness that causes unusual and severe mood changes.
The person may experience 'highs' (clinically known as mania) and 'lows'
(known as depression), which may persist for a few days or many
• Depression: a disorder that affects the mood leading to reduced
interests in activities causing severe impairment in functioning
• Mania:a mental illness marked by periods of great excitement and
euphoria, delusions and over activity
TYPES OF BIPOLAR DISORDER
1.Bipolar I Disorder: Manic or mixed episodes that
persist for at least seven days, or severe manic
symptoms that requires the person to be hospitalized
immediately. Also, depressive episodes occur that may
persist for at least two weeks.
2.Bipolar II Disorder: A combination of depressive
episodes and hypomanic episodes, but no predominant
manic or mixed episodes.
3.Cyclothymic Disorder or Cyclothymia: A mild form of
bipolar disorder where episodes of hypomania and mild
depression may persist for at least two years.
• A person affected by bipolar I disorder has had at
least one manic episode in their life. A manic
episode is a period of abnormally elevated or
irritable mood and high energy, accompanied by
abnormal behavior that disrupts life.
• Manic episodes are followed by episodes
• But mostly , patients in bipolar spend most of their
time in manic episodes. They last longer than
• Bipolar 1 disrupts normal life functioning and
• Abnormal behavior during manic episodes includes:
• Flying suddenly from one idea to the next
• Rapid, "pressured" (uninterruptible), and loud speech
• Increased energy, with hyperactivity and a decreased need for sleep
• Inflated self-image
• Excessive spending
• Substance abuse
• Excessive shopping/ shopaholics
• have sex with people they wouldn't otherwise, or pursue grandiose,
• In severe manic episodes, a person loses touch with reality. They may
become delusional and behave bizarrely.
• Depressive episodes in bipolar disorder are similar
to "regular" clinical depression, with depressed
mood, loss of pleasure, low energy and activity,
feelings of guilt or worthlessness, and thoughts
• Depressive symptoms of bipolar disorder can last
weeks or months, but rarely longer than one year.
• Depressive episode is of smaller duration than
• Bipolar 2 is characterised by hypomanic episodes(The
less-intense elevated/manic moods) and depression.
• A person affected by bipolar II disorder has had at least
one hypomanic episode in their life.
• Most people with bipolar II disorder suffer more often
from episodes of depression alternated with the
• During a hypomanic episode, elevated mood can
manifest itself as either euphoria (feeling "high") or as
• Bipolar has less severe symptoms and usually patient is
treated as outpatient, it doesn’t interfere with functioning
• Flying suddenly from one idea to the next
• Having exaggerated self confidence
• Rapid, "pressured" (uninterruptible) and loud
• Increased energy, with hyperactivity and a
decreased need for sleep
• People experiencing hypomanic episodes are often
quite pleasant to be around. They can often seem
like the "life of the party" making jokes, taking an
intense interest in other people and activities, and
infecting others with their positive mood.
• Depressive episodes in bipolar II disorder are
similar to "regular" clinical depression, with
depressed mood, loss of pleasure, low energy and
activity, feelings of guilt or worthlessness, and
thoughts of suicide.
• depressive episodes of bipolar II disorder are often
longer-lasting and may be even more severe than
in bipolar I disorder.
1. History taking psychiatric history taking
2. Mental State Examination (MSE)
3. Physical examination
4. Investigations The following are some of the investigations:
• DCT (HIV Testing)
• Thyroid hormone levels
• B/S for malaria parasite
Aims of treatment
The main purpose of the treatment is to:
• Reduce the frequency and severity of the disorder
• Enable the person to manage daily activities and enjoy
his/her life at home and at work
• Prevent self-harm and suicide
• Carbamazepine (Tegretol) mostly used to maintain a manic
• Lamotrigine (Lamictal)
• Sodium Valproate
• Olanzapine or risperidone
• diazepam (Valium)
• Prevent harm.
• Control disturbed behaviour.
• Reduce severity of psychosis and symptoms.
PROVISION OF A SAFE ENVIROMENT
• Nurse patient in a room that has high window / windows near the roof to prevent
patient from escaping.
• Nurse patient on a low bed to prevent falls and injury
• Nurse patient in a well lit room for easy observations
• Remove objects that can bring about injury to the patient ie drip stand
• Check patient pulse , temperature and respirations
• Check the mental state examination routinely
• Check for any injuries on the body to rough or abrupt movements
• Encourage patient to rest by providing a noise free environment.
Trolleys should be oiled, nurses should wear rubber shoes, phones
should be on silent. If necessary, give a sedative like diazepam to
NURSE PATIENT RELATIONSHIP
• Create a nurse client relationship to promote trust between nurse and
• Introduce yourself to patient to gain trust.
• Talk in a soft manner which doesn’t scare the patient.
• Do not act suspicious but always inform the patient of what
procedures are to be done and what is going on to maintain trust.
BEHAVIOUR MODIFICATION SKILLS
• Modify the patients behaviour by rewarding of behaviour with
positive or negative reinforcements.
• If patient does something good, a positive action such as praise or a
gift can be given to encourage such behaviours to continue.
• Bad behaviour can be rewarded by punishments such as putting
patient in time out.
SOCIAL SKILLS TRAINING
• Patient is taught some social skills like politeness, greetings and
how to react in certain social situations
• The nurse must observe for extra pyramidal side effects of
psychotropic drugs and monitor the patient’s willingness to
take the drugs. Patients may refuse to take medication,
pretend to take medication by palming it, or pretend to
swallow the medication while retaining the pill in the mouth
(only to get rid of it at the first possible moment).
• Encourage daily baths to promote comfort
• Mouth care to prevent halitosis
• Nail care to prevent harbouring of infections and hurting themselves
with long nails
• Skin care by applying Vaseline or lotion after bath to prevent skin
Provide high protein and caloric nutritious finger foods that can be
consumed on the run as client has difficulties sitting long enough to eat
• Keep snacks on the unit at all times to compensate for the increased
energy requirements due to hyperactivity.
• Maintain accurate records of intake and output caloric count to assess
• Walk or sit with client while he eats as the presence of nurse will
encourage client to eat
• Provide vitamins and minerals to improve patients nutritional status.
Set limits on manipulative behaviour. Explain to the client what is
expected and the consequences if limits are violated.
• Provide positive reinforcement for non-manipulative behaviour as
reinforcement enhances self-esteem and promotes repetition of desired
• Recognize manipulative behaviour and understand so as help patient
reduce feelings of insecurity and increasing feelings of power and control.
• Ignore client’s attempts to argue or bargain his/her way out of the limit
setting, lack of feedback may decrease these behaviours.
• Help client recognize that he/she must accept the consequences of own
behaviour and refrain from blaming it to others
RISK OF INJURY
Remove harmful objects and substances to prevent client from
harming self-due to impaired rationality.
• Reduce environmental stimuli by assigning client to a quiet unit and if
possible keep lighting and noise level low as client is easily distracted
even by any slightest stimuli
Client should be assigned a low bed to prevent falls.
Administer mood stabilizing and antipsychotics as per psychiatrist’s
orders to provide quick relief