Perioperative Care of the Patient with Bipolar Disorder ... - AORN

August 2010 Vol 92 No 2 SAUNDERS
disorder lead healthy and productive lives, and, in
most cases, treatment can help reduce the frequency
and severity of episodes.
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.
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
214 AORN Journal
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