Care of Clients with Maladaptive Patterns of
Behavior, Acute and Chronic
INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR
Session # 17
LESSON TITLE: DEPRESSIVE AND BIPOLAR DISORDERS Materials:
Textbook, Notebook, Bondpaper, Pen, and Paper
LEARNING OUTCOMES:
At the end of the lesson, the nursing student can: References
1. Accurately identify and differentiate between the various American Psychological Association. (2014).
mood disorders [Link]. accessed May 21,
2. Demonstrate the ability to create comprehensive care 2020.
plans for patients with mood disorders
3. Critically assess the outcomes of various treatments Corvell, C. (2020). MSD Manual Professional
for mood disorders and Version. Depressive Disorders. Retrieved from
4. Evaluate how mood disorders affect a patient’s daily life [Link] com/
5. Practice and apply therapeutic communication skills to professional/psychiatric-disorders/mood-
effectively engage with and support patients with mood disorders/depressive-disorders#v1028038
disorders
Howland, M., & Sehamy A.E. (2021). American
Psychiatric Association. What is Bipolar Disorder?
Retrieved from [Link]
families/bipolar-disorders/what-are-bipolar-disorders
Videbeck, S. L. (2014). Mental and Psychiatric
Health Nursing. 6th Edition. Lippincott, Williams
and Wilkins. Philadelphia, PA.
LESSON REVIEW / PREVIEW & HOOK ACTIVITY (15 minutes)
Instruction: The instructor will be showing 2 pictures to the class. Right after each picture is shown, you are to write a brief
reflection comprising 3-4 sentences regarding the photo. Write your answers on the space provided below.
MAIN LESSON (1 hour)
Depression
➢ According to the American Psychological Association, it is a negative affective state, ranging from unhappiness
and discontent to an extreme feeling of sadness, pessimism, and despondency that interferes with daily life.
➢ Various physical, cognitive, and social changes also tend to co-occur, including altered eating or sleeping habits,
lack of energy or motivation, difficulty concentrating or making decisions, and withdrawal from social activities.
➢ It is symptomatic of a number of mental health disorders.
Risk Factors for Depression
• Genetics: depression can run in families; if one twin is diagnosed with depression, there is a 70% probability the
other twin will also develop depression
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• Personality: people with low self-esteem, who are easily overwhelmed with stress, or who are generally
pessimistic appear to be more likely to experience depression
• Environment: continuous exposure to violence, neglect, or poverty may make some people prone to developing
depression
• Neurotransmitters: imbalances in serotonin, norepinephrine and dopamine; Biologic Amine Theory
General Symptoms of Depression
1. Feeling sad or having a depressed mood
2. Loss of interest or pleasure in activities previously enjoyed
3. Changes in appetite leading to weight loss or gain depending on eating habits
4. Trouble sleeping or sleeping too much
5. Loss of energy or increased fatigue
6. Increase in purposeless activity (such as pacing or hand movements) or slowed movement and speech
7. Feeling worthless or guilty
8. Difficulty thinking, concentrating, or making decisions
9. Thoughts of death or suicide
Types of Depressive Disorders
A. Major Depressive Disorder (Clinical Depression)
➢ Major depressive disorder typically involves 2 or more weeks of a sad mood or lack of interest in life
activities with at least four other symptoms of depression such as anhedonia (inability to feel pleasure) and
changes in weight, sleep, energy, concentration, decision-making, self-esteem, and goals.
➢ Major depression is twice as common in women and has a 1.5 to 3 times greater incidence in first-degree
relatives than in the general population.
➢ Incidence of depression decreases with age in women and increases with age in men.
➢ Single and divorced people have the highest incidence.
B. Persistent depressive disorder
➢ Depressive symptoms that persist for ≥ 2 years without remission are classified as persistent depressive
disorder (PDD), a category that consolidates disorders formerly termed chronic major depressive
disorder and dysthymic disorder.
➢ Symptoms typically begin insidiously during adolescence and may persist for many years or decades.
➢ The number of symptoms often fluctuates above and below the threshold for major depressive episodes.
➢ Affected patients may be habitually gloomy, pessimistic, humorless, passive, lethargic, introverted,
hypercritical of self and others, and complaining.
➢ Patients with PDD are also more likely to have underlying anxiety disorders, substance use disorders, or
personality (i.e. borderline personality) disorders
C. Premenstrual dysphoric disorder
➢ Premenstrual dysphoric disorder involves mood and anxiety symptoms that are clearly related to the
menstrual cycle, with onset during the premenstrual phase and a symptom-free interval after
menstruation.
➢ Symptoms must be present during most menstrual cycles during the past year.
➢ Manifestations are similar to those of premenstrual syndrome but are more severe, causing clinically
significant distress and/or marked impairment of social or occupational functioning.
➢ The disorder may begin any time after menarche; it may worsen as menopause approaches but ceases
after menopause.
➢ Prevalence is estimated at 2 to 6% of menstruating women in a given 12-month interval.
➢ For diagnosis of premenstrual dysphoric disorder, patients must have ≥ 5 symptoms during the week
before menstruation. Symptoms must begin to remit within a few days after onset of menses and
become minimal or absent in the week after menstruation. Symptoms must include ≥ 1 of the following:
• Marked mood swings (e.g. suddenly feeling sad or tearful)
• Marked irritability or anger or increased interpersonal conflicts
• Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
• Marked anxiety, tension, or an on-edge feeling
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In addition, ≥ 1 of the following must be present:
• Decreased interest in usual activities
• Difficulty concentrating
• Low energy or fatigue
• Marked change in appetite, overeating, or specific food cravings
• Hypersomnia or insomnia
• Feeling overwhelmed or out of control
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a feeling of being
bloated, and weight gain
Treatment
1. Medications: Antidepressants (See previous lesson)
2. Psychotherapy: Cognitive Behavioral Therapy – focused on problem solving and helps the person recognize
distorted thinking and change behaviors and thought patterns
3. Electroconvulsive Therapy
Nursing Interventions
• Provide for the safety of the client and others.
• Institute suicide precautions if indicated.
• Begin a therapeutic relationship by spending non-demanding time with the client.
• Promote completion of activities of daily living by assisting the client only as necessary.
• Establish adequate nutrition and hydration.
• Promote sleep and rest.
• Engage the client in activities.
• Encourage the client to verbalize and describe emotions.
• Work with the client to manage medications and side effects.
Bipolar Disorder
➢ Mental disorder that causes changes in a person's mood, energy, and ability to function.
➢ People with bipolar disorder experience intense emotional states that typically occur during distinct
periods of days to weeks, called mood episodes.
➢ These mood episodes are categorized as manic/hypomanic (abnormally happy or irritable mood) or
depressive (sad mood).
➢ People with bipolar disorder generally have periods of neutral mood as well.
➢ Bipolar disorder commonly runs in families: 80% to 90% of individuals with bipolar disorder have a
relative with bipolar disorder or depression.
➢ Bipolar disorder is a category that includes three different diagnoses: bipolar I, bipolar II, and
cyclothymic disorder.
Types of Bipolar Disorder
1. Bipolar I
➢ A disorder diagnosed when a person experiences a manic episode.
➢ During a manic episode, people with bipolar I disorder experience an extreme increase in energy and
may feel on top of the world or uncomfortably irritable in mood.
➢ Some people with bipolar I disorder also experience depressive or hypomanic episodes, and most
people with bipolar I disorder also have periods of neutral mood.
➢ A manic episode is a period of at least one week when a person is extremely high-spirited or irritable
most of the day for most days, possesses more energy than usual, and experiences at least three of the
following changes in behavior:
o Decreased need for sleep (e.g. feeling energetic despite significantly less sleep
than usual
o Increased or faster speech
o Uncontrollable racing thoughts or quickly changing ideas or topics when speaking
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o Distractibility
o Increased activity (e.g. restlessness, working on several projects at once)
o Increased risky behavior (e.g. reckless driving, spending sprees)
➢ A hypomanic episode is characterized by less severe manic symptoms that need to last only four days in
a row rather than a week. Hypomanic symptoms do not lead to the major problems in daily functioning
that manic symptoms commonly cause.
2. Bipolar II
➢ A disorder that requires someone to have at least one major depressive episode and at least one
hypomanic episode.
➢ People return to their usual functioning between episodes.
➢ People with bipolar II disorder frequently have other mental illnesses such as an anxiety disorder or
substance use disorder, the latter of which can exacerbate symptoms of depression or hypomania.
3. Cyclothymic disorder
➢ A milder form of bipolar disorder involving many "mood swings," with hypomania and depressive
symptoms that occur frequently.
➢ People with cyclothymia experience emotional ups and downs but with less severe symptoms than
bipolar I or II disorder.
➢ Cyclothymic disorder symptoms include the following:
a. For at least two years, many periods of hypomanic and depressive symptoms, but the symptoms do
not meet the criteria for hypomanic or depressive episode.
b. During the two-year period, the symptoms (mood swings) have lasted for at least half the time and
have never stopped for more than two months.
Treatment
A. Lithium: reduces manic behavior and prevents cycles of depression
• Treatment Level: 0.8-1.4 mEq/L
• Maintenance Level: 0.5-1 mEq/L
• Toxic Levels: 1.5 mEq/L and above
• Antipsychotic and antidepressive drugs are used in combination
• Lithium Toxicity Signs and Symptoms
o Nausea, vomiting, diarrhea
o Drowsiness, slurred speech, muscle weakness
o Blurred vision, hypotension, cardiac arrhythmias, seizures, coma
• Immediate Interventions Upon Detection of Lithium Toxicity
✓ Mild Toxicity: stop taking lithium and increase fluid intake
✓ Moderate to Severe Toxicity: vital signs monitoring, start IV fluids, gastric suctioning, whole bowel
irrigation, hemodialysis
B. Anticonvulsants: stabilize mood swings of bipolar patients
• Carbamazepine (Tegretol)
• Valproic Acid (Depakote)
• Gabapentin (Neurontin)
• Clonazepam (Klonopin)
C. Psychotherapy
• Effective only during depressive phase or normal mood
• When combined with medication, it can reduce the risk for suicide and injury
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CASELET: Bipolar I Disorder
Background
A 30-year-old man named Carlo lives with his wife and two young children somewhere in Dumaguete City. Carlo works as
an IT professional in a corporate office and is known for his dedication and technical skills. However, Carlo has been
struggling with Bipolar I Disorder for several years, a condition that significantly impacts his life and the lives of those
around him.
The Case of Carlo
Carlo’s experience with Bipolar 1 Disorder involves alternating periods of manic and depressive episodes. His behavior
and experiences are influenced by various factors:
• Manic Episodes: During his manic episodes, Carlo exhibits excessive energy, grandiosity, and hyperactivity. He
stays up all night working on ambitious projects and making extravagant purchases, such as the time he bought a
brand-new car without consulting his wife. He often compares himself to successful Filipino celebrities like Manny
Pacquiao, believing he is destined for similar fame and success.
• Depressive Episodes: In contrast, Carlo’s depressive episodes are marked by severe lethargy, feelings of
worthlessness, and an inability to function. He often calls in sick to work, isolates himself from his family, and
experiences profound sadness. During these times, Carlo finds solace in watching old movies starring Nora Aunor,
a reflection of his longing for simpler, happier times.
• Cultural Expectations: The Filipino value of "hiya" (shame) influences how Carlo and his family cope with his
disorder. They are reluctant to seek help from mental health professionals due to the stigma associated with
mental illness. Instead, they initially turned to faith healers and prayers.
• Community Support: Despite the challenges, Carlo receives strong support from his extended family and close-
knit neighborhood. His barangay captain has even offered to help connect him with community resources,
recognizing the importance of addressing mental health.
• Employment Challenges: Carlo’s unpredictable behavior has led to several conflicts at work. His boss is
supportive but is growing increasingly concerned about his reliability and productivity. Carlo fears losing his job,
which would significantly impact his family’s financial stability.
Questions
1. What actions can nurses do to educate Carlo and his family about Bipolar 1 Disorder and the importance
of consistent medical treatment?
2. How can nurses help Carlo manage the side effects of his medication while encouraging adherence to his
treatment plan?
3. How can nurses collaborate with Carlo’s employer to create a supportive work environment that
accommodates his condition?
CHECK FOR UNDERSTANDING (20 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to the correct
answer and another one (1) point for the correct rationale. Superimpositions or erasures in your answer/rationale are not
allowed. You are given 20 minutes for this activity:
Multiple Choice
1. Using cognitive-behavioral therapy, which treatment would be appropriate for a client with depression?
A. Challenging negative thinking
B. Encouraging analysis of dreams
C. Prescribing antidepressant medications
D. Using ultraviolet light therapy
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
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2. Nurse Alvin teaches the family of a client with major depressive disorder. Which of the following information should be
included in the teaching? Select all that apply.
A. Depression is characterized by sadness, feelings of hopelessness, and decreased self-worth
B. It is common for a pressed individual to have thoughts of suicide.
C. Attempts to cheer up a person with depression are often helpful.
D. Talk therapy, along with antidepressant medications, is usually the treatment.
E. Someone with depression may be preoccupied with spending money and too busy to sleep.
F. Encourage a person with depression to keep a regular routine of activity and rest.
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
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3. Which of the following would best indicate to the nurse that a depressed client is improving?
A. Reduced levels of anxiety.
B. Changes in vegetative signs such as insomnia, anorexia
C. Compliance with medications.
D. Requests to talk to the nurse.
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
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4. A client is diagnosed with major depressive disorder is withdrawn and rarely communicates with others. Which nursing
diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder?
A. Altered communication R/T feelings of worthlessness AEB anhedonia
B. Social isolation R/T poor self-esteem AEB secluding self in room
C. Altered thought processes R/T hopelessness AEB persecutory delusions
D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
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5. A nurse assesses a client suspected of having major depressive disorder. Which client symptom does not support this
diagnosis?
A. The client is disheveled and malodorous.
B. The client refuses to interact with others.
C. The client is unable to feel any pleasure.
D. The client has maxed-out charge cards and exhibits promiscuous behaviors.
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
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6. Kathleen, 68 years of age, is a widow of 6 months. Since her husband died, her sister reports that Kathleen has become
socially withdrawn, has lost weight, and does little more each day other than visit the cemetery where her husband was
buried. She told her sister today that she "didn't have anything more to live for." She has been hospitalized with major
depressive disorder. The PRIORITY nursing diagnosis for Kathleen would be:
A. Altered Thought Process
B. Complicated Grieving
C. Risk for Suicide
D. Social Isolation
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ANSWER: _____
RATIONALE: ______________________________________________________________________________________
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7. A patient diagnosed with bipolar disorder is dressed in a red leotard & brightly colored scarves. The patient says, "I'll
punch you, munch you, crunch you" while twirling & shadowboxing. Then the patient says gaily, “Do you like my scarves?
Here, they are my gift to you.” How should the nurse document the patient’s mood?
A. Labile and euphoric
B. Irritable and belligerent
C. Highly suspicious and arrogant
D. Excessively happy and confident
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
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8. A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency
department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?
A. Symptoms indicate consumption of foods high in tyramine.
B. Symptoms indicate lithium carbonate discontinuation syndrome.
C. Symptoms indicate the development of lithium carbonate tolerance.
D. Symptoms indicate lithium carbonate toxicity.
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
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9. A client is diagnosed with bipolar disorder: manic phase. Which nursing intervention would be implemented to achieve
the outcome of "Client will gain 2 lbs by the end of the week"?
A. Provide client with high-calorie finger foods throughout the day.
B. Accompany client to cafeteria to encourage adequate dietary consumption.
C. Initiate total parenteral nutrition to meet dietary needs.
D. Teach the importance of a varied diet to meet nutritional needs.
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
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10. A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for
this client?
A. The client will accomplish activities of daily living independently by discharge.
B. The client will verbalize feelings during group sessions by discharge.
C. The client will remain safe throughout hospitalization.
D. The client will use problem solving to cope adequately after discharge.
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE-TO-FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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2. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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3. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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4. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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5. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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6. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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7. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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8. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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9. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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10. ANSWER: _____
RATIONALE: __________________________________________________________________________________
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LESSON WRAP-UP (25 Minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
AL Strategy: NURSING CARE PLAN- BIPOLAR 1
Instructions:
1. You are to create a care plan for a client with Bipolar 1 using the format below:
Assessment Nursing Diagnosis Goal/Plan of Care Nursing Interventions
Subjective: Short – Term: Independent:
Objective: Long – Term: Collaborative:
at least 10 interventions
Source:
2. The care plan must be written at the back of the SAS using the required format. You can refer to your books or any
online source for additional reference.
3. You are to submit your care plan before the session ends.
.
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