Bipolar disorder is a chronic psychiatric condition marked by episodes of depression and mania. While depressive phases are characterized by low mood and energy, acute manic episodes are often more challenging due to hyperactivity, impulsivity, aggression, and poor judgment.
This second part of our bipolar disorder series focuses on acute manic episode management, nursing interventions, pharmacological treatments, dietary considerations, and exam-style clinical questions. Understanding these details is critical for healthcare providers, nursing students, and patients’ families to ensure safety and recovery.
Interventions for Acute Manic Episodes
When a patient is experiencing an acute manic episode, the top priority is safety — for both the patient and those around them. Nursing interventions focus on reducing stimulation, maintaining structure, managing aggression, and ensuring nutrition and hydration.
1. Reduce Stimulation
- Place the client in a quiet, private room near the nurse’s station. (NCLEX TIP)
- Avoid large groups or dining areas (to limit overstimulation).
- Encourage 1-on-1 activities instead of group activities.
- Keep the environment calm with low lighting and minimal noise.
2. Encourage Physical Activity
- Provide structured, supervised exercise (e.g., walking with staff, sweeping floors).
- Alternate aerobic activity with rest periods. (ATI, HESI tested)
- Channel excess energy into safe and repetitive tasks.
3. Manage Aggression with Structure
- Set clear, consistent limits on unacceptable behaviors like profanity or aggression.
- Provide choices in small matters (e.g., choosing clothes) to avoid power struggles. (NCLEX TIP)
- Always follow through with consequences calmly and consistently.
4. Diet and Nutrition
- Provide high-calorie, high-protein meals to meet increased energy demands.
- Use finger foods and snacks "on the go" (sandwiches, protein bars, fruit).
- Encourage high fluid intake (to prevent dehydration).
- Avoid caffeine (coffee, soda, tea) as it worsens agitation.
Top Missed NCLEX Question (Acute Mania)
Interventions for a client hospitalized with acute mania: Select all that apply
- Encourage physical activity (safe, supervised).
- Place client in a private room near nurses’ station.
- Allow choices in clothing (to reduce conflict).
- Avoid group activities (overstimulation risk).
- Avoid dining with other patients (risk of disruption).
Pharmacological Management
1. For Mania
- Anxiolytics: Clonazepam, Alprazolam (for acute agitation).
- Mood Stabilizers: Carbamazepine, Valproic acid, Lithium.
- Antipsychotics: Used in severe mania or psychosis.
2. For Depression (in Bipolar)
- Antidepressants: Used cautiously, usually with a mood stabilizer.
Valproic Acid (Depakote)
- Effective as a mood stabilizer in bipolar disorder.
- Requires liver function monitoring.
- Can cause hepatotoxicity and gastrointestinal side effects.
ATI Question Example:
Which test is most important to monitor with Valproic Acid therapy?
Liver function tests.Lithium Therapy
Lithium remains the gold standard treatment for bipolar disorder.
Therapeutic Levels
- Normal: 0.6–1.2 mEq/L
- Toxic: >1.5 mEq/L
Signs of Lithium Toxicity
- Nausea, vomiting, diarrhea
- Tremors, muscle weakness
- Polyuria (excess urination)
- Severe toxicity → confusion, seizures, coma
Mnemonic: LITH
- L: Level over 1.5 = Toxic
- I: Increase fluids, sodium diet
- T: Toxic signs = GI upset, tremors
- H: Hold NSAIDs & diuretics (contraindicated)
Contraindications
- Diuretics (increase risk of toxicity).
- NSAIDs (reduce renal clearance of lithium).
Nursing Considerations
- Teach patients to stay hydrated and maintain consistent salt intake.
- Monitor renal function regularly.
- Report symptoms like persistent diarrhea or vomiting.
Clinical Exam Questions
HESI Question
Lithium level = 1.8 mEq/L. What should the nurse do?
- Withhold the medication and notify the provider.
Kaplan Question
Lithium carbonate + diuretic → Is this safe?
- No, diuretics are contraindicated with lithium therapy.
ATI Question
Patient scheduled for lithium therapy reports taking furosemide (a diuretic). What should the nurse do?
- Contact the healthcare provider (risk of toxicity).
Dietary Tips for Bipolar Patients in Mania
- Provide portable, calorie-dense foods (sandwiches, burritos, protein bars).
- Offer protein shakes, milk, fruits, and veggies for balance.
- Avoid caffeine, which worsens hyperactivity.
- Encourage hydration with water and electrolyte drinks.
Quick Reference Table: Acute Mania Interventions
| Intervention Area | Key Nursing Action |
|---|---|
| Environment | Quiet, private room near nurses’ station |
| Group Contact | Avoid group meals/activities |
| Activity | Supervised exercise, safe tasks |
| Aggression | Clear limits, consistent consequences |
| Nutrition | High-calorie, high-protein, finger foods |
| Hydration | Encourage fluids, no caffeine |
FAQs
Q1. What is the first priority during an acute manic episode?
Ensuring safety by reducing stimulation and placing the client in a quiet room near the nurse’s station.
Q2. Why is diet important in mania?
Patients often burn excessive calories due to hyperactivity and may neglect eating. High-calorie, easy-to-eat foods prevent malnutrition.
Q3. Why are diuretics avoided with lithium?
They lower sodium levels, increasing lithium toxicity risk.
Q4. What labs are critical for valproic acid monitoring?
Liver function tests (AST, ALT) due to risk of hepatotoxicity.
Q5. Can lithium therapy be lifelong?
Yes, many patients require long-term lithium therapy with regular blood monitoring for safe, effective mood stabilization.
