Which is the priority of care for a patient experiencing hyperactive mania
Assessment of a client with a mood disorder focuses on both verbal and nonverbal assessments. People with a bipolar disorder experience periods of unusually intense emotion, grandiose delusions, changes in sleep patterns and activity levels, and impulsive behaviors, often without recognizing potential harmful effects. See Figure 8.3 for an artistic depiction of grandiose delusions when a cat looking in a mirror sees a lion. Show
It is often helpful to interview family members or significant others of clients with mood disorders. Clients with mania, hypomania, or psychosis often have poor insight and may have difficulty providing an accurate history. Safety guidelines for assessing a client with a bipolar disorder include the following:
Mental Status ExaminationTable 8.4a outlines typical assessment findings a nurse may observe in a client experiencing a manic episode. Typical findings relate to mood, behavior, thought processes, speech patterns, and cognitive function. Table 8.4a Typical Mental Status Examination Findings for a Client Experiencing a Manic Episode,, Assessment Typical Findings During a Manic EpisodeLevel of Consciousness and OrientationMay be disoriented/confused, but can be oriented to person, place, and time.Mood and AffectExhibits an unstable, euphoric mood. Client may state they feel “up,” “high,” “jumpy,” or “wired,” but mood can quickly change to irritation and anger.Appearance and General BehaviorTypically exhibits a decreased need for sleep and a loss of appetite that may result in dehydration or poor nutritional status. May exhibit inappropriate dress or grooming or dress provocatively, sloppily, flamboyantly, or bizarrely. May change clothes frequently throughout the day. May use excessive makeup or demonstrate little attention to grooming. May demonstrate risky behaviors with poor impulse control and poor judgment, such as eating and drinking excessively, spending or giving away a lot of money, or having reckless sex. Excessive spending can lead to financial hardship from credit card debt from buying items they don’t need. SpeechTypically talk very fast (e.g., pressured speech) about many different topics (hyperverbal). May have difficulty in accurately communicating needs due to flight of ideas or slurred or garbled speech.Motor ActivityTypically hyperactive with an inability to recognize need for rest or sleep.Thought and PerceptionClient may state they feel as if their “thoughts are racing.”May feel as if they are unusually important, talented, or powerful. May describe hallucinations, illusions, or paranoia. May exhibit flight of ideas, loose associations, and clang associations. (See definitions of terms in the “Application of the Nursing Process in Mental Health Care” chapter.) May exhibit suicidal, homicidal, or violence ideation. Attitude and InsightTypically exhibit limited insight with an inability to make sound decisions impacting their adherence to taking prescribed medications.Cognitive AbilitiesTypically exhibit decreased attention span, distraction, and impaired judgement.Screening ToolsMany screening tools exist to assess mood disorders. Common examples include the following:
Laboratory TestingInitial medical evaluation of clients with a possible or established diagnosis of bipolar disorder typically includes the following:
Thereafter, routine laboratory testing for clients with bipolar disorders can include these items:
Reflective Question
DiagnosesMental health disorders are diagnosed by trained mental health professionals using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Nurses create individualized nursing care plans using nursing diagnoses based on the client’s response to their mental health disorders. Examples of common nursing diagnoses associated with bipolar disorders are listed in Table 8.4b. Table 8.4b Common Nursing Diagnoses Related to Bipolar Disorder, Nursing DiagnosisAssociated Behaviors and CharacteristicsSafety: Outcomes IdentificationOutcome criteria are based on the phase of bipolar illness the client is experiencing, either acute or maintenance phase. During an acute manic episode, the overall goals are symptom management, achieving remission of symptoms, preventing injury, and supporting physiological integrity. Examples of goals during the acute phase include the following:
The maintenance phase occurs after acute symptoms have been controlled and the goals become focused on preventing future exacerbations of manic episodes through education, support, and problem-solving skills. The following are examples of goals during the maintenance phase:
SMART outcomes are Specific, Measurable, Attainable/Actionable, Relevant, and Timely. Read more about SMART outcomes in the “Application of the Nursing Process in Mental Health Care” chapter. The following are sample SMART outcomes for clients with bipolar disorders:
Planning InterventionsWhen a client is hospitalized during an acute manic episode, planning focuses on stabilizing the client while maintaining safety. Nursing care focuses on managing medications, decreasing physical activity, increasing food and fluid intake, reinforcing a minimum of 4 to 6 hours of sleep per night, and ensuring self-care needs are met. During the maintenance phase, planning focuses on preventing relapse and limiting the severity and duration of future episodes. During this period, individuals with bipolar disorders often face multiple hardships resulting from their behaviors during previous acute manic episodes. Interpersonal, occupational, educational, and financial consequences may occur. Clients need support as they recover from acute illness and repair their lives. Individuals are often ambivalent about treatment, but bipolar disorders typically require medications to be taken over long periods of time or for a lifetime to prevent relapse. Self-medication through alcohol or other substances often complicates recovery and treatment. Nurses must establish a therapeutic nurse-client relationship to support continued treatment. Individuals are typically referred to community resources and outpatient mental health care settings. In addition to medication management, outpatient services provide structure and decrease social isolation. ImplementationCommon nursing interventions for clients experiencing acute manic episodes are described in the following tables. Table 8.4c describes interventions according to categories in the APNA Standard of Implementation. (Read more about the APNA Implementation Standard in the “Application of the Nursing Process in Mental Health Care” chapter.) Table 8.4d describes nursing interventions to promote physiological integrity. See the “Treatments for Bipolar Disorders” section of this chapter for additional collaborative mental health interventions, including medications and psychotherapy. Table 8.4c Nursing Interventions for Mania Based on the Categories of the APNA Implementation Standard Categories of Interventions Based on the APNA Standard of ImplementationWhat the nurse will do…RationaleCoordination of carePlan for quality of life, independence, and optimal recovery. Refer to community resources and outpatient mental health care settings. Maintain safety by communicating safety precautions with interprofessional team members as needed to prevent self-harm, suicide, or homicide risks. Ensure consistency of behavioral expectations among all staff on the unit by including expectations in the nursing care plan. The nurse coordinates care delivery during inpatient care and for after discharge.The client may exhibit high risk or impulsive behaviors that could pose a risk of harm to self/others. They may experience altered thought processes with poor insight and judgment. Consistent expectations help prevent manipulative behaviors and pushing of limits. Health TeachingCreate, adapt, and deliver health teaching to clients, including self-care, self-awareness activities, and milieu group therapy topics. See “Patient Education” topics for bipolar disorder in the box following these tables.Nurses encourage resilience by promoting adaptive coping strategies.Pharmacological, Biological, and Integrative TherapiesDeliver patient education about mood stabilizers and other medications with expected time frames for improvement.Open all medications in front of the client. Observe for signs of medication toxicity, such as lithium. The client’s understanding of their medications and potential side effects can increase medication adherence.Opening all medications in front of the client may decrease paranoia. There is a small margin of safety between therapeutic and toxic doses of lithium. Milieu TherapyManage the milieu by reducing environmental stimuli and excess noise. The client may require a private room.Provide structured 1:1 activities with the nurse or other staff. Avoid competitive activities or games. Encourage frequent rest periods and “down time.” Promote physical exercise to redirect aggressive behavior. During acute mania, use prescribed medications, seclusion, or restraint to minimize physical harm. Store valuables in the hospital safe until safe judgment returns. Encourage participation in group therapy after acute manic episode has resolved addressing social skills, personal grooming, mindfulness, and stress management. Reducing stimuli may prevent escalation of anxiety and agitation.Structured activities provide security and focus. However, avoid group and/or competitive activities because they may be too stimulating and can cause escalation of anxiety and agitation. Resting can prevent exhaustion that can result from constant physical activity. Physical exercise can decrease tension and provide focus. The nurse’s priority is to protect the patient and others from harm. Storing valued items protects the patient from giving away money and possessions. Group therapy can encourage effective coping skills. Therapeutic Relationship and CounselingUse a firm and calm approach with short and concise statements. For example, “John, come with me. Eat this sandwich.”Be consistent in approach and expectations. Identify expectations in simple, concrete terms with consequences. For example, “John, do not yell at or hit Peter. If you cannot control your behaviors, you will be escorted to the seclusion room to prevent harm to yourself and others.” Listen to and act on legitimate complaints. Redirect energy into appropriate and constructive channels. Set limits with personal boundaries. See additional “Communication Tips” in the box below. Structure and control can improve feelings of security for a client who is feeling out of control.Consistent limits and expectations minimize the potential for the client’s manipulation of staff and provide feelings of security. Clear expectations help the patient experience outside controls and understand reasons for medication, seclusion, or restraints if they are not able to control their behaviors. Listening to legitimate complaints can reduce underlying feelings of helplessness and can minimize acting-out behaviors. Distraction is an effective tool with clients experiencing mania. Clients may be impulsive and hyperverbal and interrupt, blame, ridicule, or manipulate others. Table 8.4d Nursing Interventions to Promote Physiological Integrity Problem/ InterventionRationaleNutrition
Effective Communication Tips for Clients with Bipolar Disorder
Patient Education: Bipolar Disorder Living with bipolar disorder can be challenging, but there are ways to control symptoms and enable oneself, a client, a friend, or a loved one to live a healthy life. The client may be resistant to teaching during the acute phase of a manic episode, so it is beneficial to wait until manic symptoms begin to resolve. Patient education regarding bipolar disorder includes the following guidelines:
Implementing Seclusion or RestraintsControlling escalating agitation during the acute phase of a manic episode may include immediate administration of a prescribed antipsychotic and benzodiazepine. A combination of haloperidol (Haldol) and lorazepam (Ativan) that can be injected for rapid onset of action is commonly used. The nurse must monitor for respiratory depression, hypotension, and oversedation after administering this type of medication. De-escalation techniques should be attempted at early signs of escalating agitation to avoid the need for seclusion or restraints. However, if a client is escalating out of control to a point where they pose an immediate risk of injury to themselves or others, the use of a seclusion room or restraints may become necessary to maintain a safe environment. Most state laws prevent the use of unnecessary restraint or seclusion, so their use is associated with complex ethical, legal, and therapeutic issues. Agency policy must be closely followed when implementing seclusion or restraints. Documentation is required that indicates the need for seclusion and/or restraint:
Each agency establishes a proper reporting procedure through the chain of command. For example, seclusion and restraint are only permitted with a written order from an authorized provider (e.g., physician, nurse practitioner, or physician assistant) and rewritten every 24 hours or more frequently according to hospital policy and state regulations. The order must include the type of restraint (e.g., physical or chemical) to be used. In an emergency, the charge nurse may place a client in seclusion or restraints and obtain a written order within a specified period of time (typically 15-30 minutes). Established agency protocols specify associated nursing responsibilities to maintain client safety while in seclusion or restraints, such as the following:
Read more details about the legal implications of seclusion and restraints in the “Legal and Ethical Considerations in Mental Health Care” chapter. EvaluationEvaluation occurs continuously throughout the treatment of bipolar disorders. The registered nurse individualizes assessments based on the established goals and SMART outcomes for each client. The effectiveness of nursing and collaborative interventions is evaluated and revised as needed. Questions used to guide the evaluation process include the following: What nursing intervention should be implemented when a client is in the manic phase?Clients with bipolar disorders are at a high risk for suicide. Although clients in the manic phase are briefly agitated, energized and elated, their underlying depression makes them likely to inflict self-injury.
...
Desired Outcomes.. Which of the following is the first line treatment for acute mania?Lithium remains a highly effective pharmacological treatment for acute mania. For patients with classic mania, which refers to the presence of euphoria, grandiosity and hyperactivity in a person with a stable episodic course, many experts prefer lithium as a first-line medication.
What is the treatment for hypomania?If you are experiencing mania or hypomania, you will normally be offered one of these antipsychotics: haloperidol. olanzapine (Zyprexa) quetiapine (Seroquel)
What helps the most when a patient is in a manic phase?Medications, talk therapy and support groups as well as support from your family and friends can help manage your mania. Stay in close contact with all your healthcare providers, especially during times of manic episodes. Your provider will want to see you and may need changes to your medications or dose.
|