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Nursing care for a patient with bipolar I disorder

Table of Contents

Introduction 

Description of the disorder 

Signs and Symptoms of the disorder 

Pathophysiology 

Contemporary treatment for bipolar I disorder 

Pharmacological treatment approach 

Non pharmacological treatment 

Nursing Management within the multidisciplinary team

Expected treatment outcome 

Introduction

Bipolar disorder is a form of a mental disorder that is also known as “manic-depressive illness or manic depression” that results in the uncommon mood swings, fluctuations in energy level, difficulty in concentrating on work and inability to perform daily tasks (National Institute of Mental Health, n.d.). The bipolar disorder can be divided into three types that are Bipolar I and II disorder. Additionally, the third type of bipolar disorder is known as Cyclothymic Disorder. All three are identified with different characteristics. Among the three types, type I is the most common and severe form of bipolar disorder (Leonard, 2019).  The report focuses on the study of a person suffering from bipolar I disorder.

The report describes the common facts and figures present for the disorder that is followed by the signs and symptoms of bipolar I disorder. Afterwards, the report describes the pathophysiology of the disorder. The report further describes both the type of contemporary treatment i.e. pharmacological and Non-pharmacological treatment available for the disorder. Afterwards, the nursing management along with other teams cumulatively has been described in the treatment and at last, the report describes the expected outcome of the treatment given to the patient suffering from type I disorder. 

Description of the disorder

The Bipolar I disorder involves the severe lunatic episodes that continue for a minimum of 7 days and the episodes are so intense that the patient might even require immediate hospital attention. Generally, the patient also bears the symptoms of depression and the can continue for a minimum of 2 weeks (National Institute of Mental Health, n.d.). The patient can also bear mixed features that include the combined episodes of depression and lunatic episodes. The disorder is commonly observed among children in their late adolescence or can even persist in early childhood.  According to Rowland and Marwaha (2018), the bipolar I disorder has multiple components that involve severe episodes of mood swings, changes at the immunological and physiological level and disturbance in the normal functioning of the body. The bipolar disorder is one of the major reasons for the disability throughout the world and has increased the premature mortality rate that could either be due to medical comorbidity or the cause could be suicide.

The epidemiology of type I disorder identified that the prevalence of the bipolar disorder is 1% and in that 0.6% is contributed by bipolar type I disorder (Rowland & Marwaha, 2018).  As per the Depression and Data Support Alliance report (2020) the disorder has some heritable component associated with it and it has been observed that more than two-thirds of the patients with bipolar disorder have minimum one close relative with the similar illness or unipolar disorder.  The disorder is affecting more than 45 million people throughout the world (WHO, 2019).

Signs and Symptoms of the disorder

The patient suffering from the disorder can show multiple symptoms like the patient is unable to stay rigid with one thought, the patient keeps on jumping from one thought to another. Furthermore, the patient might feel unwanted pressure, the patient can panic easily and unwontedly increases the pitch of his voice.  The patient can experience heavy fluctuations in their energy level at one the patient can be seen hyperactive with high energy with sleeplessness condition. During the manic episodes of the disorder, the patient may become sexually hyperactive and can fall victim for substantial abuse. Additionally, the patient might lose touch with the reality and can become delusional that is the patient may feel abnormally important, excessive talented or powerful and shows bizarre behaviour (Ahmed et al., 2017). The patient feels a loss of appetite. The judgemental ability of the patient also differs and the patient bears the substandard quality of judgements such as eat or drink more than required, give away money in a reckless way. According to Trindade, Amorim and Toledo (2019), the patient suffering from bipolar disorder can include cognitive impairment and perambulation as well. 

Pathophysiology

The pathophysiology of the disorder is associated with the part of the brain that is responsible for the regulation of the emotions that is the limbic system. The disorder is correlated with the neurological and psychological variables that can trigger negative emotions like traumatic condition, any bad influence, and any negative life events and so on. These events pose a major influence on the disorder. The cause of bipolar 1 disorder is associated with the mutual interaction of genes, neurological pathways and socio-environmental factors. The individuals who lack any form of social support or face insecurities with the people to whom they are attached are likely to develop bipolar disorder (Greenberg, et al. 2014). The researchers Pishva, et al. (2014), identified that the environmental factors strongly influence the gene expression and regulation that are associated with the development of the disorder. Bipolar disorder is associated with genetic regulation. The genes CACNA1C, ODZ4 and NCAN were found to be some of the potent genes that might be responsible for the development of the disorder (Kerner, 2014). Another gene group MAFD has been identified to be responsible for the development of bipolar 1 disorder.

The genes are strongly influenced by environmental factors. The calcium signalling pathway has been prominent among all the genetic risk pathways for the development of the disorder. The ex vivo studies conducted by the researchers Harrison et al. (2018) concluded that the dysregulation in the calcium signalling pathway can result in the development of the disorder. The findings suggested that an increase in calcium signalling results in the development of the disorder. The pathophysiology of the bipolar 1 disorder can be further illuminated by understanding the gene expression inside the human body.

The studies of gene expression found that the genes that were responsible for the formation of oligodendrocyte-myelin sheath were found to be down-regulated that resulted in the poor deposition of the myelin sheath over the neurons. This result in the poor nerve impulse transportation and additionally the poor functioning of the calcium gated channel can result in the development of the bipolar disorder. All three factors including the socio-environmental factors, genetic factors and neurological factors collaboratively develop the bipolar 1 disorder. The socio-environmental factor affects the emotions of the person. The emotions affect the limbic system of the brain particularly the hippocampus region. The hippocampus neurons get affected by it along with it some factors are released that affects the genes associated with the bipolar 1 disorder that results in the dysregulation of the gene expression and leads to irregular myelin deposition onto the neurons. This results in the disturbance in the nerve impulse conduction and thereby, contributing to the development of the disorder (Soreff, 2019). 

Contemporary treatment for bipolar I disorder

The mood disorders have known to be a major contributor to the morbidity and mortality rate and the reason for that is non-adherence of the drugs by the patients (John & Antai-Otong, 2016).  The treatment approach for the disorder could either be pharmacological or non-pharmacological. 

Pharmacological treatment approach

The researchers Baldessarini, et al. (2018) described that an effective pharmacological treatment for the disorder is still an area under research. However, the administration drugs like some newly identified antipsychotics and anticonvulsants like Divalproex and carbamazepine are have proved to be effective against the bipolar 1 disorder. Furthermore, the use of lithium salts is also under the trend of treating the disorder as the lithium has proved to have some anti-suicidal properties. Additionally, the treatment of mania involves the administration of some sedatives like benzodiazepines. Currently, second-generation drugs like paliperidone and ziprasidone are being used in the treatment. The placebo drugs are also used for the treatment of the disorder. There are different phases of bipolar 1 disorder starting from the hyper-active stage and later the depressive stages come that is difficult to manage (Mohammed & Grunze, 2016). The symptoms of type 1 bipolar disorder resemble with the unipolar disorder that makes the diagnosis part difficult. While dealing with the acute case of bipolar disorder, monotherapy can be considered as an option for the treatment. The administration of drugs like lamotrigine, quetiapine and olanzapine can be effective while dealing with an acute patient.

Furthermore, valproate and aripiprazole can also be administered for getting the outcome. Anti-depressant drugs can provide promising outcomes in the long term treatment program and are not suggested in acute cases. The use of Non-steroidal anti-inflammatory drugs has also been introduced in the trend of treatment of bipolar disorder. The NSAIDs have proven to be effective against minor cases. 

Non-pharmacological treatment

There are various non-pharmacological therapies available for the treatment of bipolar 1 disorder. Therapies under psychotherapy such as interpersonal and social rhythm therapy (IPSRT) and Cognitive behavioural therapy (CBT) are found to be effective in treating the maniac condition. Additionally, therapies like Psychoeducation and Family-focused therapy are also effective for improving the conditions. Furthermore, other treatment options available those are Electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) is also a measure for the people who are not responding to the medications. The CBT includes the identification of any ill-feeling or thoughts that are brewing inside the patient and replacing those thoughts with positive and healthy beliefs. The therapy focuses on identifying the factors that are responsible for triggering bipolar episodes.

Effective stress management strategies are also included in CBT for dealing with the situation (Naik, 2015). The IPSRT aims to stabilize the daily routine like adequate and timely sleeping, walking and time of meals. The consistency in the routine is effective for managing the number of maniac episodes. The IPSRT helps in the normal functioning of the patient but does not pose any impact on the symptoms of the disease and can be included in adjunctive therapy (Lam & Chung, 2019). Psychoeducation therapy involves educating about the signs and symptoms of the disorder and how they cause variation in the behaviour during the developmental stage. Psychoeducation is one of the most commonly used interventions for the treatment of bipolar 1 disorder. The psychoeducation promotes self-management that includes recognizing and accepting the evaluation from the authorized psychiatrist and enables the patient to self examine the changes (Wilson et al., 2017).

Nursing Management within the multidisciplinary team

The nursing management in patients suffering from bipolar 1 disorder is a challenging process. The mental health differs in the severity and could be due to different causes. The mild cases can be helped by understanding the problem and providing support to the patient (Healthdirect, n.d.). To provide effective nursing care the nurses are required to establish a relationship with the patient that has to be built on trust and empathy. Meanwhile, nurses should ensure that the patient remains safe from any form of injury. The nurses are required to assist the patient in decreasing their agitation and their hyperactivity. Furthermore, the nurses shall promote the psychoeducation by making the patient understand the mania and its effective management using strategies for managing the mood. The nurses should promote positive health and healthy lifestyle for the patient. The nurses are required to conduct a psychiatric assessment for the initial follow up (Queensland mind essentials, n.d.). The way a patient is responding during a manic episode can also be influenced by the cultural background of the patient. Therefore, knowing the cultural background becomes essential for effective management. The nurses shall work effectively work with psychologists, physiatrists for getting effective treatment outcome. Additionally, the nurses shall monitor the recovery, response to the medication and the overall health of the patient. 

Expected treatment outcome

Bipolar 1 disorder has multiple stages starting from the exceptionally high energy level to the depressive symptoms. The decreased need for rest and loss of appetite further intensifies the situation. The heavy fluctuations in the mood are also observed in the disorder. The treatment involves the administration of pharmacological drugs like antipsychotics and anticonvulsants are found to be effective in the treatment of the disorder. Furthermore, the use of NSAIDs, anti-depressant drugs, sedatives and drugs consisting of lithium salt is effective in treating the condition. However, the use of pharmacological drugs is partially effective and cannot cure the condition. The use of non-pharmacological interventions like CBT, IPSRT, psychoeducation along with the pharmacological treatment can effectively deal with the condition. The patient outcomes will improve with the cumulative treatment.

The immediate outcomes of the treatment will include controlling the mood fluctuations, depressive thoughts, increase in appetite and immediate management of the episodes. The long term outcomes will include a reduction in the number of episodes and the establishment of a healthy lifestyle. The patient will be able to perform daily activities effectively and increased concentration level. The negative thoughts will be replaced by positive beliefs and the person will be able to move on from any past event that was responsible for triggering the mood fluctuations.

References

Ahmed et al. (2017). Pseudocyesis presenting in a case of bipolar 1 disorder, maniac with psychosis. Western Michigan University, Available at https://scholarworks.wmich.edu/medicine_research_day/54/

Baldessarini, R. J., Tondo, L., & Vazquez, G. H. (2018). Pharmacological treatment of adult bipolar disorder. Molecular Psychiatry, 51(2), 335-351. doi: 10.1016/j.cnur.2016.01.015.

Borges, S. Q., Correa, T. X., & Trindade, I. O. A. (2019). Cognitive impairment in bipolar disorder neuroprogression or behavioural variant frontotemporal dementia?.Dementia &Neuropsychologia, 13(4), 475-480. https://doi.org/10.1590/1980-57642018dn13-040016

Depression and Bipolar Alliance. (2020). Bipolar disorder statistics. Available at: https://www.dbsalliance.org/education/bipolar-disorder/bipolar-disorder-statistics/

Greenberg, S., Rosenblum, K. L., Mclnnis, M. G., &Muzik, M. (2014). The role of social relationships in bipolar disorder: A review. Psychiatry Research, 219(2), 248-254. https://doi.org/10.1016/j.psychres.2014.05.047

Harrison, P. J., Geddes, J. R., & Tunbridge, E. M. (2018).The emerging neurobiology of bipolar disorder.Trends in Nursing, 41(1), 18-30. doi: 10.1016/j.tins.2017.10.006

Healthdirect. (n.d.). Caring for someone with a mental disorder. Available at https://www.healthdirect.gov.au/caring-for-someone-with-a-mental-health-disorder

John, R. L., & Antai-Otong, D. (2016). Contemporary approaches to major depression and bipolar disorders. Nursing Clinics of North America, 51(2), 335-351. doi: 10.1016/j.cnur.2016.01.015.

Kerner, B. (2014).Genetics of bipolar disorder.The Application of Clinical Genetics, 7, 33-42. doi: 10.2147/TACG.S39297

Lam, C., & Chung, M. (2019). A meta-Analysis of the effect of interpersonal and social rhythm therapy on symptom and functioning improvement in patients with bipolar disorders. Applied Research Quality Life. https://doi.org/10.1007/s11482-019-09740-1 

Leonard, J. (2019). Bipolar type definitions.Medical News Today, Available at https://www.medicalnewstoday.com/articles/324437

Mohammed, Z., & Grunze H. (2016). Acute pharmacological treatment strategies for bipolar depression. Neuropsychiatry, 6(3), 96-111. Available at http://www.jneuropsychiatry.org/peer-review/acute-pharmacological-treatment-strategies-for-bipolar-depression.pdf

Naik, S. K. (2015). Management of bipolar disorders in women by non pharmacological methods. Indian Journal of Psychiatry, 57(2), 264-374. doi: 10.4103/0019-5545.161490

National Institute of Mental Health. (n.d.).Bipolar disorder. Available at: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Pishva, E., Kenis, G., van den Hove, D., Lesch, K.-P., Boks, M. P. M., van Os, J., & Rutten, B. P. F. (2014). The epigenome and postnatal environmental influences in psychotic disorders. Social Psychiatry and Psychiatric Epidemiology, 49(3), 337–348. DOI: 10.1007/s00127-014-0831-2 

Queensland mind essentials. (n.d.). Caring for a person experiencing mania. Available at https://www.health.qld.gov.au/__data/assets/pdf_file/0028/444466/mania.pdf

Rowland, T. A., &Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251-269. doi: 10.1177/2045125318769235

Soreff, S. (2019). Bipolar disorder. Available at: https://emedicine.medscape.com/article/286342-overview#a3

WHO.(2019). Mental disorders. Available at: https://www.who.int/news-room/fact-sheets/detail/mental-disorders

Wilson, L., Crowe, M., Scott, A., Lacey, C. (2017). Psychoeducation for bipolar disorder: A discourse analysis. International Journal of Mental Health and Nursing, 27(1). https://doi.org/10.1111/inm.12328

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