6 Bipolar Disorders Nursing Care Plans

Risk For Injury

Clients with bipolar disorder are at risk for injury due to a combination of affective, cognitive, and psychomotor factors that can affect their judgment, impulsivity, and coordination. Furthermore, bipolar disorder is associated with neurologic imbalances, which can further increase the risk of injury. Exhaustion, dehydration, and rage may also contribute to the risk of injury in clients with bipolar disorder. The main complications of bipolar disorder, or manic-depressive illness (MDI) are suicide, homicide, and addictions (Soreff & Xiong, 2022).

Nursing Diagnosis

• Risk for Injury

Risk factors

• Affective, cognitive, and psychomotor factors
• Biochemical/neurologic imbalances
• Exhaustion and dehydration
• Extreme hyperactivity/physical agitation
• Rage reaction

Possibly evidenced by

• Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• The client will respond to the medication within the therapeutic levels.
• The client will sustain optimum health through medication management and a therapeutic regimen.
• The client will drink 8 oz of fluid every hour throughout the day while in the acutely manic stage.
• The client will remain free from falls and abrasions every day while in the hospital.
• The client will be free of dangerous levels of hyperactive motor behavior with the aid of medications and nursing interventions within the first 24 hours.
• The client will spend time with the nurse in a quiet environment three to four times a day between 7 am and 11 pm with the aid of nursing guidance.
• The client will take short voluntary rest periods during the day.
• The client will be free of excessive physical agitation and purposeless motor activity within two weeks.
• The client will be free of injury within two to three weeks:
  • Stable cardiac status.
  • Skin free of abrasions and scrapes.
  • Well-dehydrated.

Nursing Assessment and Rationales

1. Assess the client’s current mood and behavior, observe for signs of a manic or depressive episode, as well as any impulsive or reckless behavior that may increase the risk of injury.
This is to determine whether the client is currently experiencing a manic, depressive, or stable state. This information will identify potential risks for injury and take measures to prevent harm to the client or others. Clients emerging from depression are thought to be at an increased risk of suicide. The risk of self-destructive behavior and death is lifelong (Soreff & Xiong, 2022).

2. Assess the client’s cognitive function, including attention, memory, and decision-making skills.
The client’s cognitive function will identify any deficits or impairments that may increase their risk of injury. Symptoms of mania may include reckless behavior without regard for consequences and severe thought disturbances. Clients in the manic phase can become homicidal by acting on delusions (Soreff & Xiong, 2022).

3. Assess the client’s use of substances, including alcohol and drugs.
Some substances can worsen the symptoms of bipolar disorder or trigger mood episodes such as depression or mania. Substance use can also lead to further complications and increase the risk of harm, including accidents, injuries, or even overdose. One major area of concern is the relationship between violent crime and bipolar disorder. This danger is particularly present and prominent with clients who have a substance abuse problem (Soreff & Xiong, 2022). 

4. Observe for signs of lithium toxicity (e.g., nausea, vomiting, diarrhea, drowsiness, muscle weakness, tremor, lack of coordination, blurred vision, or ringing in the ears).
There is a small margin of safety between therapeutic and toxic doses. Symptoms of intoxication include coarse tremors, hyperreflexia, nystagmus, and ataxia. Clients often show varying levels of consciousness, ranging from mild confusion to delirium. Gastrointestinal effects typically occur within one hour of ingestion (Hedya et al., 2023).

5. Observe the client for indications for inpatient management.
Clients diagnosed with bipolar mania or depression and severe symptoms must be referred for urgent/emergent mental health intervention. The indications for inpatient treatment in a person with bipolar disorder, include the danger to self, danger to others, delirium, marked psychotic symptoms, total inability to function, total loss of control, and medical conditions that warrant medication monitoring (Soreff & Xiong, 2022).

Nursing Interventions and Rationales

1. Provide structured solitary activities with the assistance of a nurse or aide.
The structure provides focus and security. Clients with bipolar disorder are especially sensitive to the disruption of routines. A malfunctioning body clock is a prime suspect in the causes of the dramatic mood shifts that define the bipolar disorder, according to research published in Current Psychiatry Reports. A routine also allows the client to feel some sense of control in their life (McMillen, 2021). 

2. Provide frequent rest periods.
This prevents exhaustion. Sleep deprivation may be associated with poor eating habits in bipolar clients, given the association of sleep deprivation with certain hormonally influenced responses that lead to enhanced caloric intake. Furthermore, sleep disturbances in bipolar disorder are linked to reduced energy levels and thus, a lessened likelihood of engaging in other healthy behaviors (Gold & Sylvia, 2016).

3. Encourage the client to communicate openly about their feelings and concerns, and provide a nonjudgmental and supportive environment.
This can help the client develop coping strategies and problem-solving skills to manage their symptoms and minimizes the risk of impulsive or risky behaviors. Clients with bipolar disorder may need to take medications and attend therapy sessions to manage their condition. Open communication helps clients feel more comfortable talking to their healthcare providers about their symptoms and any concerns they may have about their treatment. Open communication can help identify triggers and warning signs of mood episodes. This helps them take action early to prevent or lessen the severity of mood episodes.

4. Maintain a low level of stimuli in the client’s environment (e.g., loud noises, bright light, low-temperature ventilation).
This helps minimize the escalation of anxiety. A highly-stimulating environment can trigger symptoms of mania or hypomania in clients with bipolar disorder. Overstimulation, such as loud noise, bright lights, or a fast-paced environment, can disrupt sleep patterns, increase irritability and anxiety, and trigger racing thoughts and impulsive behavior.

5. Encourage the client to engage in activities that are safe and structured, such as exercise or creative activities.
Exercise has been shown to have mood-stabilizing effects and can help minimize the severity and frequency of mood swings in clients with bipolar disorder. Clients in the depressed phase are encouraged to exercise. These individuals should try to develop a regular daily schedule of major activities, especially times of going to bed and waking up. A regular exercise schedule should be proposed for all clients, especially those with bipolar disorder. Both exercise and a regular schedule are keys to surviving this illness (Soreff & Xiong, 2022). 

6. Provide a safe and supportive environment for the client, including ensuring that the client’s room is free from potential hazards and that safety measures are in place (such as bed rails or padded walls).
Clients with bipolar disorder may experience symptoms that can impair their judgment, increase impulsivity, and heighten the risk of accidents or self-harm. Therefore, it is essential to reduce potential hazards in the client’s environment and provide safety measures as needed. Homicidal clients, often in the manic phase, can be very demanding and grandiose. In this context, they are angered if others do not immediately comply with their wishes, and they can turn dramatically violent (Soreff & Xiong, 2022).

7. Administer phenothiazines for acute mania and enforce seclusions to decrease any physical harm.
Exhaustion and death result from dehydration, lack of sleep, and constant physical activity. Phenothiazine antipsychotics, which are classified as first-generation antipsychotics, are efficacious for treating both psychotic and non-psychotic manic and mixed episodes, as well as hypomania (Soreff & Xiong, 2022).

8. Redirect violent behavior.
Physical exercise can decrease tension and provide focus. If the client diagnosed with bipolar disorder does not have strategies to cope with irritability, it can lead to angry outbursts. Many clients with bipolar disorder experience anger, which can appear out of character for them. (Legg, 2019)

9. Protect the client from giving away money and possessions. Hold valuables in a hospital safe until rational judgment returns.
The client’s “generosity” is a manic defense that is consistent with irrational, grandiose thinking. In some cases, extreme grandiosity can take the form of delusions or fixed beliefs unsupported by facts and reality. For example, the client may run through their savings buying expensive gifts for loved ones because they feel convinced that they are about to get a promotion and significant raise (Saripalli & Raypole, 2021).

10. Work with the client to develop a safety plan that includes methods to manage mood swings and prevent injury, as well as emergency contacts and resources.
The safety plan can help clients recognize when they are at risk for injury and take steps to prevent it. It also ensures a rapid response in case of a crisis. Therefore preventing harm to the client and others. Clients with a possible diagnosis of bipolar depression must also be referred for urgent/emergent mental health intervention if they present with serious delusion, visual/auditory hallucinations, confusion, catatonic behavior, extreme negativism/mutism, and/or inappropriate affect of a bizarre or odd quality (Soreff & Xiong, 2022).

11. Assist in transferring the client to the appropriate facility or with the admission process.
The treatment of bipolar disorder is directly related to the phase of the episode and the severity of that phase. For example, a person who is extremely depressed and exhibits suicidal behavior requires inpatient treatment. If the client is in a short-term inpatient care unit and has not made significant progress, reevaluate the management strategy. Transfer to a long-term inpatient care unit might also be considered (Soreff & Xiong, 2022).

12. Place the client in suicide precautions.
A client with bipolar disorder, especially one in a depressive episode, may present with a significant risk for suicide, especially those with an early onset of symptoms. Serious suicide attempts and specific ideation with plans to constitute clear evidence of the need for constant observation and preventive protection; consider referring these individuals to mental health specialty care (Soreff & Xiong, 2022). A sign on the door indicating visitors need to report to the nurse’s station prior to entering the room. All sharp objects and unnecessary cables, cords, shoe laces, and equipment should be removed from the client’s room. Linens should be limited. A designated suicide watcher may be appointed as appropriate (Upstate University Hospital, 2019).