AORN Journal
Volume 92, Issue 2 , Pages 211-219, August 2010

Perioperative Care of the Patient with Bipolar Disorder

Article Outline

 

Bipolar disorder, also known as manic-depressive illness, is a chronic, recurrent illness characterized by changes in a person's mood, energy, and ability to function. Mood episodes may alternate between mania, hypomania, depression, or a combination of depression and mania. The person may have periods of normal functioning that alternates with periods of illness. According to the American Psychiatric Association, bipolar disorder is a mood disorder that consists of “one or more manic or hypomanic episodes (elevated, expansive, or irritable mood) and usually one or more depressive episodes.”1(p168) For perioperative nurses who care for the patient with bipolar disorder, it is important to be aware of medications that the patient may be taking, be prepared for escalation of the patient's mood and/or behavior, and understand techniques that can be used to help de-escalate situations that involve the patient.

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Epidemiology 

Bipolar disorder affects approximately 5.7 million US adults, or about 2.6% of US adults ages 18 and older, in a given year.2 Bipolar disorder occurs between the ages of 18 and 30 years, with at least half of all cases starting before age 25 years. The first episode occurs earlier for individuals with a family history of the disease. An individual who experiences a manic episode at age 40 years or older is more likely to have mania secondary to a medical condition or substance abuse. The first episode in men is more often manic, whereas the first episode in women is usually depression. As the illness progresses, the episodes increase in number and severity.3

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Comorbidity 

Even though substance abuse disorders are very common in individuals with bipolar disorder, the reasons remain unclear. Individuals may be trying to treat their symptoms with alcohol or drugs, or the behavior control problems associated with mania may cause individuals to drink too much.4 Attention deficit hyperactivity disorder and anxiety disorders, such as post-traumatic stress disorder and social phobia, are common in individuals with bipolar disorder. These individuals also may be at a higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses because these illnesses may cause symptoms of mania or depression.5

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Etiology 

Results of research indicate that there is no one single cause of bipolar disorder; instead, many factors act together to produce the illness or increase the risk.6 Because bipolar disorder tends to run in families, there is a strong genetic component; therefore, scientists continue to study this disorder to locate the genes that cause bipolar disorder. Significantly high or low levels of neurotransmitters, specifically epinephrine, norepinephrine, dopamine, and serotonin, have been associated with both mania and depression. It is likely that many different genes combined with a person's environmental and neurobiological factors may interact to cause the disorder.

Online Resources⁎

 

Depression and Bipolar Support Alliance

http://www.dbsalliance.org

National Alliance on Mental Illness

http://www.nami.org

National Institute of Mental Health

http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Mental Health America

http://www.mentalhealthamerica.net/go/information/get-info/bipolar-disorder

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Symptoms 

Unlike the normal ups and downs that everybody experiences in life, the symptoms of bipolar disorder are severe and can be described as unusually intense emotional states, called “mood episodes.”6 An overly joyful or overexcited mood that seems out of proportion or inappropriate to the circumstance is called a manic episode. Mania may present as anger, belligerence, and irritability instead of elation and euphoria in some individuals. The characteristic symptoms of a manic episode are

■lability (eg, changing quickly from happiness to anger or depression);

■inappropriate demanding of other's attention;

■manipulative, profane, or sexually explicit language or behavior;

■grossly inappropriate or loud, rapid speech;

■stringing words together that rhyme (ie, clang associations);

■thoughts that race from topic to topic (ie, flight of ideas);

■disorganized thoughts;

■grandiosity (eg, believing oneself to be a prominent businessman or religious figure);

■restlessness;

■disorganized or aggressive behavior;

■poor concentration and distractibility;

■poor judgment;

■psychomotor agitation; and

■disorientation, incoherence, delusions, and hallucinations.3

An extremely sad or hopeless mood is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression; this is called a mixed episode. Extreme changes in activity, behavior, energy, and sleep accompany these changes in mood. An individual may be diagnosed with bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one to two weeks.1 Sometimes symptoms are so severe that the individual cannot function normally at work, school, or home.

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Treatment: Mood Stabilizers 

Individuals with bipolar disorder often need several medications. Anti-anxiety, antidepressant, and atypical antipsychotic medications may be used in addition to mood stabilizers, which are considered lifetime maintenance therapy for individuals with bipolar disorder.7 Most often, lithium carbonate is the first choice of mood stabilizer for the acute treatment of mania and the prevention of recurrent manic episodes. To avoid toxicity, lithium maintenance blood levels should range between 0.4 mEq/L and 1.3 mEq/L, and not exceed 1.5 mEq/L.3 Lithium is usually contraindicated in individuals with cardiovascular, renal, or thyroid disease, or myasthenia gravis; those who are pregnant or breastfeeding; and children younger than 12 years.

Approximately 20% to 40% of individuals with bipolar disorder may not respond to lithium, so the next choice of medications prescribed are antiepileptics, such as carbamazepine, divalproex, lamotrigine, gabapentin, and topiramate.3 Because these medications may have major adverse effects, patients who are taking them should be monitored carefully:

■Carbamazepine can cause agranulocytoses, aplastic anemia, sedation, diplopia, and incoordination.

■Divalproex can cause fever, chills, right upper quadrant pain, dark-colored urine, jaundice, malaise, tremors, gastrointestinal upset, and weight gain. Nurses who have patients who are taking this medication also should monitor their liver function tests.

■Lamotrigine can cause rash, dizziness, diplopia, headache, ataxia, and sedation.

■Gabapentin can cause breathing difficulty, swelling of lips, rash, slurred speech, fatigue, sedation, dizziness, ataxia diplopia, and hypertension.

■Topiramate can cause cognitive adverse effects, fatigue, dizziness, and paresthesia. Nurses who have patients who are taking this medication should perform a complete physical assessment before surgery to check the patient's white blood cell, red blood cell, and platelet counts; liver, renal, and thyroid function tests; urinalysis results; weight; blood pressure; and blood glucose.

Individuals with bipolar disease may not disclose their disease. Therefore, when the nurse sees these medications listed on the patient's chart or if the patient displays an overjoyous, elated mood, or an irritable, belligerent mood that does not match the circumstances, or changes moods quickly, then bipolar disorder is a potential diagnosis.

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Length of Treatment 

Because bipolar disorder is a chronic and episodic disorder, continual maintenance treatment that consists of medications, psychoeducational classes, support groups, and psychotherapy for both the individual and family members is needed. Problems that result from angry, impulsive, hyperactive, hostile, or demanding behavior that occurs during a manic episode often leads to interpersonal problems that affect the patient's friends, family members, and classmates or colleagues. The focus of care for the individual living in the community is maintaining compliance with the medications, preventing relapse, and limiting the severity and duration of episodes.

Relapses occur most often when individuals stop taking their mood-stabilizing medication because they feel better or only take the medication occasionally because they forget or do not think that taking the medication regularly is important. It is essential for individuals with bipolar disorder to take their medication on a regular basis and for as long as their physicians recommend, which will result in fewer and less-severe mood episodes. It is important to note that no mood-stabilizing medication should be discontinued without a discusssion with the physician who prescribed it, and the medication always should be tapered off under a physician's supervision rather than being stopped all at once. Bipolar disorder tends to worsen if it is not treated.8 Proper diagnosis and treatment help individuals with bipolar disorder lead healthy and productive lives, and, in most cases, treatment can help reduce the frequency and severity of episodes.

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Nursing Implications 

Individuals with bipolar disorder may have frequent crises in their lives as a result of their problems with interpersonal relationships, stress, ineffective coping and problem-solving skills, fluctuating employment status and social support systems, substance-related problems, and possible legal problems.3 What may seem like a small stressor to the nurse (eg, a minor surgical procedure) may be interpreted as a major stressor by the patient. Perioperative nursing implications for nurses who care for patients with bipolar disorder are provided in Table 1. The nurse should perform an accurate and early mood assessment because a prevailing mood of increased anxiety or quick shifts of mood must be identified before the mood escalates to excessive overactivity, impulsivity, distractibility, inability to control behavior, anger, and/or aggression. A family member may be able to provide insight into the patient's psychiatric history.

TABLE 1. Perioperative Implications for the Patient with Bipolar Disorder
Preoperative care
•Establish rapport with the patient.

•Assess the patient's mood, level of anxiety, and ability to cooperate.

•Assess the patient's mental status by observing the patient's
•facial expression,

•behavior (eg, excessive or reduced body movements, abnormal movements, eye contact),

•orientation level,

•speech, and

•vocal expressions (eg, disorganized thoughts, delusions, hallucinations, insight, judgment, memory).


•Perform a psychosocial assessment, including
•identifying the patient's social support system (eg, friends, family members, caregivers, roommates) and whether someone is at the hospital with the patient;

•asking a family member of the patient, if possible, to provide insight into the patient's history;

•assessing substance use and abuse (ie, alcohol, illicit drugs), as well as current use of medications such as psychotropic medications (eg, antipsychotic, antidepressant, antianxiety, mood stabilizer); and

•assessing coping abilities, including what the patient does when he or she gets upset, to whom can the patient talk, and what usually helps the patient relieve stress.


•Ask about previous hospitalizations and surgery experiences.

•Document a thorough medication history.

•Evaluate the patient's white blood cell, red blood cell, and platelet counts; liver, renal, and thyroid function; urinalysis; weight; blood pressure; and blood glucose levels. Communicate to the surgeon and/or anesthesia care provider if any abnormalities are present.

•Initiate seizure precautions.

•Review the preoperative assessment and note any mental status changes.

Intraoperative care
•Monitor the patient's blood pressure and blood glucose levels.

•Monitor the patient's mental status frequently while he or she is awake.

•Be aware that the stress of surgery may exacerbate the patient's symptoms of anxiety, depression, or mania.

•Discourage local sedation if the patient's mental status is extremely labile.

•Be at the bedside during induction of and emergence from anesthesia.

•Have additional personnel available as needed.

Postoperative care
•Monitor the patient's intake, output, and vital signs.

•Monitor the patient's mental status frequently.

•Assess for increased anxiety, agitation, rapid mood swings, or psychosis.

•If the patient becomes agitated,
•move him or her to a quiet place (ie, with a low level of environmental stimuli);

•stay with the patient or have a staff member, friend of the patient, or one of the patient's family members stay with the patient;

•observe and reassure the patient frequently;

•use a firm, neutral, and calm approach when speaking with the patient;

•set patient behavioral limits to maintain safety;

•use verbal de-escalation techniques as necessary;

•administer anti-anxiety and/or antipsychotic medications as necessary; and

•use restraints as a last alternative and only by the physician's orders.


To decrease the patient's anxiety and possible paranoia, the nurse should not wear a surgical hat and mask when first meeting the patient. To make the patient feel safe, the nurse should provide structure and control by

■using a firm and calm approach;

■giving short and concise explanations;

■remaining neutral and avoiding power struggles;

■staying consistent in approach and expectations;

■setting limits in a firm, nonthreatening and neutral manner; and

■redirecting the patient's energy into more appropriate and constructive avenues.

If the patient becomes overwhelmed with feelings of insecurity and anxiety, he or she may be prone to self-harm or violence toward others. Therefore, crisis intervention by the nurse has two basic initial goals: ensuring the patient's safety and reducing the patient's anxiety to prevent further escalation of mania to help provide safe boundaries for the patient and others.

If the patient is becoming increasingly manic (eg, anxious, agitated, distractible, excitable), then the nurse should move the patient to a quiet place to maintain a low level of stimuli away from bright lights, loud noises, and people. The patient should be within view of staff members or, if the patient is not visible to staff members, then it is important that someone stay with him or her. This could be a staff member or a family member or friend, because family members and friends have been identified as major support systems for individuals with severe mental illness.9 Frequent observation by the nurse, however, is still needed. The nurse's presence provides support, and, if needed, the nurse can direct the patient's energy into nonstimulating and calming solitary activities (eg, listening to soft music, drawing or writing, walking slowly in the room) to help minimize excitability. The structure that the nurse creates provides the patient with security and focus. The nurse can demonstrate respect for the patient's personal space by keeping at least 1.5 feet to 3 feet between himself or herself and the patient, so that the patient does not perceive the nurse as being intrusive. To maintain reduced environmental stimuli, it is ideal to have only one nurse interacting with the patient, but other staff members need to maintain an unobtrusive presence in case the patient's mood and/or behavior escalates.

To help calm a patient who becomes overexcited or angry, the nurse can use de-escalation techniques to help diffuse the situation. For example, speaking in a calm, nonthreatening, and caring manner can help the patient feel less anxious. Although it may be difficult for the nurse to remain calm when faced with an angry patient, it is important to maintain a calm demeanor because the nurse's anxiety can cause the patient to become more anxious or angry. Confrontations also can increase the patient's anger or anxiety, so it is important to avoid verbal confrontation with the patient, and security personnel should remain in the background unless they are needed.

If low environmental stimuli and the verbal de-escalation techniques prove ineffective and the patient's mood and/or behavior continues to escalate, then anti-anxiety medications can help reduce agitation or anxiety, and antipsychotic medications can reduce psychomotor activity and delusions or hallucinations. Because the patient is likely to be NPO, medication should be administered by IV. If the patient's behavior escalates to psychosis (eg, the patient experiences delusions or hallucinations; exhibits disorganized, incoherent speech), then nursing interventions should focus on protecting the patient from self-harm or harming others. Restraints may need to be used; however, these should only be used after the previously identified, less-restrictive interventions have been tried and then only with a physician's order.

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Conclusion 

Working with patients with bipolar disorder can be challenging, particularly if the patient becomes manic or the nurse has limited or no experience in psychiatric-mental health nursing. Because individuals with bipolar disorder can be very demanding and manipulative, the nurse may begin to feel frustrated by the patient's behavior. In responding to the patient, it is important that the nurse set limits in a firm, calm manner and use therapeutic communication techniques as well as nursing interventions to maintain safety for both the patient and others. Being able to redirect and distract the patient who is manic are the nurse's most effective tools. Remaining neutral and being consistent without tolerating dangerous or inappropriate behavior is a helpful way to approach the patient with bipolar disorder.2

The focus of nursing interventions for a patient with bipolar disorder may be varied, depending on the patient, but may involve crisis intervention, acute symptom stabilization (eg, medication), and safety measures. A nurse who is able to assess the patient's level of mood, behavior, and thought processes will help the patient have a more positive perioperative experience.

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Examination. Continuing Education Program 

1.4 

Perioperative Nursing Care of the Patient with Bipolar Disorder 

PURPOSE/GOAL

To educate perioperative nurses about caring for the patient with bipolar disorder.

OBJECTIVES

1.Describe the characteristics of bipolar disorder.

2.Describe the etiology of bipolar disorder.

3.Explain how to assess a manic patient's with mood, behavior, and thought processes.

4.Discuss the pharmaceutical treatments for bipolar disorder.

5.Discuss the perioperative nursing implications of caring for the patient with bipolar disorder.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

Questions 


1.An individual with bipolar disorder can have mood episodes that alternate between mania, depression, or a combination of depression and mania.
a.true

b.false


2.As the bipolar disorder progresses, the episodes
a.decrease in number and severity.

b.increase in number and severity.

c.decrease in number and increase in severity.

d.increase in number and decrease in severity.


3.Evidence suggests that bipolar disorders may be linked to
a.family violence.

b.genetic factors.

c.infections.

d.nutritional deficiencies.


4.Characteristic symptoms of mania are
1.amnesia.

2.grandiosity.

3.lability.

4.manipulative behavior.

5.restlessness.
a.1 and 3

b.1, 2, and 5

c.2, 3, 4, and 5

d.1, 2, 3, 4, and 5



5.Symptoms of bipolar disorder may be so severe that the individual cannot function normally at work, school, or home.
a.true

b.false


6.The first choice of mood stabilizer for the acute treatment of mania and the prevention of recurrent manic episodes is often
a.clonazepam.

b.lamotrigine.

c.lithium carbonate.

d.topiramate.


7.The nurse can provide structure and control for the bipolar patient by
1.avoiding power struggles.

2.giving short and concise explanations.

3.providing stimulating activities.

4.staying consistent in approach and expectations.
a.1 and 2

b.3 and 4

c.1, 2, and 4

d.1, 2, 3, and 4



8.Preoperative nursing care of a patient with bipolar disorder should include
1.assessing the patient's mood, anxiety, and ability to cooperate.

2.assessing substance use and abuse.

3.establishing rapport with the patient.

4.performing a psychosocial assessment.
a.1 and 2

b.3 and 4

c.1, 2, and 3

d.1, 2, 3, and 4



9.Nursing care of a patient with bipolar disorder who becomes agitated after surgery may include
1.maintaining the patient's safety by setting behavioral limits.

2.ensuring that someone stays with the patient.

3.administering anti-anxiety or antipsychotic medications as necessary.

4.placing the patient in restraints as a last resort.

5.using verbal de-escalation techniques as needed.
a.1 and 3

b.2, 4, and 5

c.1, 2, 4, and 5

d.1, 2, 3, 4, and 5



10.If the patient is becoming increasingly manic, then the nurse can
a.direct the patient's energy into nonstimulating and calming solitary activities.

b.ensure the patient's room is brightly lit to provide security.

c.move the patient to a quiet place where he or she can be alone and out of sight of others.

d.observe the patient as infrequently as possible to remain unobtrusive.


The behavioral objectives and examination for this program were prepared by Jana Saunders, PhD, RN, CNS, and Kimberly Retzlaff, editor, with consultation from Rebecca Holm, RN, MSN, CNOR, clinical editor, and Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Dr Saunders, Ms Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

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Learner Evaluation. Continuing Education Program 

1.4 

Perioperative Care of the Patient with Bipolar Disorder 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

1.Describe the characteristics of bipolar disorder.Low 1. 2. 3. 4. 5. High

2.Describe the etiology of bipolar disorder.Low 1. 2. 3. 4. 5. High

3.Explain how to assess a manic patient's mood, behavior, and thought processes.Low 1. 2. 3. 4. 5. High

4.Discuss the pharmaceutical treatments for bipolar disorder.Low 1. 2. 3. 4. 5. High

5.Discuss the perioperative nursing implications of caring for the patient with bipolar disorder.Low 1. 2. 3. 4. 5. High

Content 


6.To what extent did this article increase your knowledge of the subject matter?Low 1. 2. 3. 4. 5. High

7.To what extent were your individual objectives met?Low 1. 2. 3. 4. 5. High

8.Will you be able to use the information from this article in your work setting?1. Yes 2. No

9.Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.)

9A.How will you change your practice? (Select all that apply)

1.I will provide education to my team regarding why change is needed.

2.I will work with management to change/implement a policy and procedure.

3.I will plan an informational meeting with physicians to seek their input and acceptance of the need for change.

4.I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.

5.Other: ________________________

9B.If you will not change your practice as a result of reading this article, why? (Select all that apply)
1.The content of the article is not relevant to my practice.

2.I do not have enough time to teach others about the purpose of the needed change.

3.I do not have management support to make a change.

4.Other: ________________________


10.Our accrediting body requires that we verify the time you needed to complete the 1.4 continuing education contact hour (84-minute) program: ________________________

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Event: #10054; Session: #4018 Fee: Members $7, Nonmembers $14

The deadline for this program is August 31, 2013.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.

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References 

  1. Mood disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. rev.. Washington, DC: American Psychiatric Publishing, Inc; 2000;p. 167–208
  2. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–627
  3. Mood disorders: bipolar. In:  Varcarolis EM,  Carson VB,  Shoemaker NC editor. Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. 5th ed.. St Louis, MO: Saunders; 2006;p. 359–383
  4. Bizzarri JV, Sbrana A, Rucci P, et al. The spectrum of substance abuse in bipolar disorder: reasons for use, sensation seeking and substance sensitivity. Bipolar Disord. 2007;9(3):213–220
  5. Krishnan KR. Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med. 2005;67(1):1–8
  6. Bipolar disorder (National Institute of Mental Health). http://www.nimh.nih.gov/health/publications/bipolar-disorder/index.shtmlAccessed April 29, 2010
  7. Bipolar disorders. In:  Preston JD,  O'Neal JH,  Talaga MC editor. Handbook of Clinical Psychopharmacology for Therapists. 6th ed.. Oakland, CA: New Harbinger Publications; 2010;p. 89–100
  8. Fundamentals of treatment. In:  Goodwin FK,  Jamison KR editor. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression. 2nd ed.. New York, NY: Oxford University Press; 2007;p. 699–719
  9. Saunders JC. Families living with severe mental illness: a literature review. Issues Ment Health Nurs. 2003;24(2):175–198

Jana Saunders, PhD, RN, CNS, is a professor at the Anita Thigpen Perry School of Nursing, Texas Tech University Health Sciences Center, Lubbock. Dr Saunders has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

  • ⁎ Access verified April 29, 2010

  indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire August 31, 2013.

PII: S0001-2092(10)00549-1

doi:10.1016/j.aorn.2010.04.014

AORN Journal
Volume 92, Issue 2 , Pages 211-219, August 2010

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