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With the increasing incidence and prevalence of mental disabilities like bipolar disorders in Australia (Geller. B, DelBello. M, 2008). the nursing profession will have to attain the knowledge and skills required to care for individuals who have bipolar disorder via a multidisciplinary approach across all nursing settings; acute care, aged care, specialist mental health and community settings.
The World Health Organization (WHO) defines disability as “The inability to engage in any substantial, gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death, or has lasted or can be expected to last for a continuous period of not less than 12 months” (World Health Organization, 2010). The term disability is such a broad term, where generally an individual suffering from a disability is known to suffer either mentally or physically. Bipolar disorder is a mental disorder that affects an individual’s psychological or behavioural patterns and is known to have a long-term affect upon an individual.
The Australian Psychology Society, a leader in providing information in regards to mental health issues to the public, defines “Bipolar disorder, previously known as manic depression, [as] a mental illness that seriously affects the way a person acts, thinks and feels. It is generally characterised by a cycle of mood swings between elation and depression, varying from mild to extreme. Extreme elation is called ‘mania’ ” (The Australian Psychology Society, 2010).
Bipolar is the sixth leading cause of disability among illnesses and is associated with both high mortality and morbidity costs (Geller. B, DelBello. M, 2008). It affects one in fifty Australians, where gender and age characteristics do not influence the disorder to predominantly affect one of these specific groups (Better Health Channel, 2010). There are a range of factors that contribute to the disorder, where genetics, biology, lifestyle and environmental factors can all play a role in the development of the disorder (The Australian Psychology Society, 2010). Some of which are explored below:
Although the underlying mechanisms have not been extensively researched and proven, research has identified that there is a strong genetic predisposition (Better Health Channel, 2010). Research has shown that “relatives of people suffering from bipolar illness are 10 to 20 times more likely to develop either depression or manic-depressive illness than the general population” (Bipolar Genetics Collaboration, 2005).
One biological theory that has originated suggests that “brain chemicals (neurotransmitters) that help regulate mood, called serotonin and nor-epinephrine are thrown out of balance”, therefore it can trigger and cause an episode of mania followed by depression (Better Health Channel, 2010).
Research has shown that environmental factors can also have an impact on an individual’s susceptibility of developing the disorder. Some evidence suggests that “this disorder varies seasonally, with mania being more common in spring and depression more prevalent in winter” (The Australian Psychology Society, 2010). Other literature suggests that childhood trauma can contribute to an individual obtaining bipolar disorder (Etain et al, 2008).
Lifestyle factors can also exacerbate bipolar disorder and cause an individual to be more susceptible to developing it later in life. Bipolar disorder events of mania and depression can be triggered by the stressors in one’s life where each individual has their own triggers for such events (The Australian Psychology Society, 2010)
Bipolar is a mental disorder not an illness and is commonly stumbled upon throughout a wide range of settings in the health sector. Bipolar is universally recognised across the world and is generally dealt with within hospitals, Aged Care facilities, specialist mental health facilities and in some cases through home care (Berk et al, 2008)
Bipolar can be obtained by anyone at any age and does not necessarily mean that you acquire the disorder just because you begin to age. Research has shown that “the onset of the disorder in children and adolescence has been reported to be not so rare”, (Maj, et al, 2002) where “most of those affected are aged in their 20’s when first diagnosed” (Better Health Channel, 2010) with the mood disorder. Due to the number of cases evident within the “younger” population it is vital that the health sector especially nurses take into account all age groups when providing information and assessing individuals health needs so there is not just a focus on the elderly.
There are two types of the disorder; Bipolar I and Bipolar II, where both classes differ from one another (Bipolar Spectrum) in that the symptoms and affects upon the individual suffering each are different.
Bipolar I disorder is diagnosed when the individual experiences more manic or mixed episodes than depressive episodes, often resulting individual’s to become more agitated and hyperactive than they normally would be (Black Dog Institute, 2009). The severity and duration of these episodes are often severe as behaviours displayed during these episodes put the individual in danger thus resulting in hospitalisation (Black Dog Institute, 2009).
Bipolar II or commonly known as “unipolar” (Maj, et al, 2002) is described as having more “episodes of hypomania and one or more episodes of depression where mania is not illustrated” (Berk et al, 2008). An individual who suffers from this type of Bipolar, often experiences more depressive feelings and displays negative emotions.
Individuals who suffer from the disorder often have no control over their actions, where it seems as though someone has taken over their body. They can have distinct patches lasting a few weeks at a time, where during one week they may be much more confident than normal but in the next they may feel empty and exhausted struggling to cope with everyday life situations. It is often hard to control the behaviours displayed by the individual as depending on the age of the individual suffering, they may not understand what is happening to them at that particular point in time. Thus nurses need to act as a friend to these individuals and actively listen to their concerns and needs on a regular basis. They can in turn relay this to the multidisciplinary team that cares for the patient in order for everyone to be on the same level and have common treatment goals and care plans (Portsmouth, L., Coyle, J. & Trede, F., 2008).
Mood stabiliser medications are often used to manage the disorder where health professionals such as, psychologists and psychiatrists in particular, use techniques of counselling, Cognitive Behaviour Therapy (CBT) and Interpersonal therapy to help treat the disorder (Bipolar Disorder, n.d). Techniques of counselling such as Cognitive Behaviour Therapy (CBT) are used to help change thinking patterns and behaviour of the individual. This approach reduces stress and enables individuals to take back control of their life, where families also benefit by thoroughly understanding the illness and gain strategies to use to reduce the severity of the disorder (The Australian Psychology Association, 2010).
Medications such as Lithium, olanzapine and valproate are used in cases of severe long-term treatments, where a number of guidelines are followed before distributing the medication. Distribution of the medication only occurs if the response to previous treatments has not worked and the individual’s physical risk factors are monitored (eg. Weight and other illness’s and diseases such as diabetes and renal disease) and also taking into account gender as valproate “should not be prescribed for women of child-bearing potential” (National Institute for Health and Clinical Excellence, 2006). The nurse’s role in treatment is to be able to deliver such medication on the order of doctors or psychiatrists alike and to support any cognitive behavioural therapy that has been conducted as advised and trained by psychologists or psychiatrists.
Other non-medicine approaches to managing the Bipolar disorder consist of using the techniques of Electroconvulsive Therapy (ECT), Complementary Medicines (not prescribed) such as omega-3 fatty acids and hospitalisation in cases of emergency (Bipolar Disorder, n.d). Electroconvulsive Therapy (ECT) has been proven effective as it provides a rapid and short-term improvement in an individual, although it is only used in extreme cases as it can have many negative impacts (Bauer et al, 2006). Some nurses may be involved in the delivery or care of a patient post ECT.
During the management of mental disorders nurses are commonly referred to as Nurse care coordinators, where “they facilitate information flow to the psychiatrist by providing patient assessments, implementing reminders, and tracking laboratory values” (Bauer et al, 2006). Nurses also perform common nurse duties such as showering and other personal care needs when looking after patients with bipolar disorder.
Due to the symptoms of the disorder the ‘stop-start’ phenomenon is largely widespread making the consequences of taking medication very detrimental, as there is an increased rate of relapse (Black Dog Institute, 2009). It is therefore vital that the nurse build a good relationship with the individual as relapse, will have many negative impacts upon the individual’s recovery as the process will become slower thus causing episodes to become more prevalent and worse.
It is important for nursing staff to allow the individual to learn about their disorder and take some responsibility for their actions and disorder in general. This will prompt the individual to increase their motivation to take on rehabilitation and manage their own medications so they can return to a near-normal life and enable the recovery process quicker and a shorter duration.
Healthcare professionals including nurses should develop therapeutic liaison with the patients suffering from Bipolar disorder. Patients should be advised to regularly monitor their behaviours throughout the week, so they can self regulate symptoms and identify triggers and early warning signs. Observing and recording their behaviours during the week, such as sleep patterns, eating habits and scaling how they are coping with everyday activities, (Basco, M, 2006) will compel the individual to take responsibility for their behaviours thus allowing them to realise what can be done to manage their behaviours (National Institute for Health and Clinical Excellence, 2006).
Nurse care coordinators provide care for patients by regularly monitoring the individual’s clinical status. The nurse’s can use a manual consisting of three types of contacts as a guideline in the recovery phase as has been used in a number of facilities. These include the “backbone scheduled care”, “Demand-responsive services” and “outreach and in reach contacts”. The “backbone scheduled care”, are regular scheduled appointments for the management and monitoring of the individuals changes and improvements regardless of the patients clinical status. “Demand-responsive services” are there for patients who cannot wait until the next day to deal with specific problems they may be encountering. For example, “to alleviate side effects, address non response to a change in medication, or to help with crisis management” (Bauer et al, 2006). Outreach and in reach contacts” follow up on the missed appointments due to the patient either forgetting or being too aggressive due to their disorder. During these appointments liaison with other healthcare professionals is undertaken where collaborating mental health and medical-surgery providers will build a stronger connection with the patient and support care coordination (Bauer et al, 2006).
Nurses should also liaise with family and friends of the individuals suffering from bipolar disorder to gain extra information required for care or to update them on their patient’s process. They can also be involved in patient-family-health professional case conferencing in order to update not only the patient but family, friends and health professional team members of the patient’s progress. (Goulburn Valley Health, 2010).
A nurse’s involvement in the care of an individual with bipolar disorder is vital to ensure optimal outcomes and compliance to medication. It also enables each individual to have a ‘friend’ to talk to within the hospital and/or community setting that can understand where they are coming from due to their previous training other than just talking to family and friends who may like the knowledge and advice to help the patient. It is also important that they work well in a multidisciplinary team to ensure such optimal care is provided (Portsmouth, Coyle and Trede, 2008).
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