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<h2>1. MEDICAL MANAGEMENT</h2>

<h3>Aims</h3>
<p>The main aims of medical management of mania include:</p>
<ul>
  <li>To reduce the severity of manic symptoms such as hyperactivity, agitation, and irritability in order to stabilize the patient's mood.</li>
  <li>To protect the patient and others from harm since manic patients may engage in impulsive or risky behaviours.</li>
  <li>To restore normal sleep patterns and reduce excessive activity so that the patient can regain physical and mental stability.</li>
  <li>To treat the underlying mood disorder and correct neurochemical imbalances associated with mania.</li>
  <li>To prevent complications such as exhaustion, injury, substance abuse, or financial problems.</li>
  <li>To prevent relapse and recurrence of manic episodes through continuous treatment and follow-up care.</li>
</ul>

<h3>Assessment</h3>
<p>Assessment is essential in the management of mania because it helps determine the severity of the condition and guides appropriate treatment.</p>

<p><strong>History Taking</strong> — The health worker should obtain a detailed history including previous episodes of mania or depression, family history of mood disorders, substance use, medication history, and recent stressful life events.</p>

<p><strong>Mental Status Examination</strong> — The clinician should assess mood and affect (elevated, irritable, or labile), speech pattern (pressured or rapid speech), thought processes (flight of ideas or grandiose thoughts), level of activity (hyperactivity or restlessness), and insight and judgment.</p>

<p><strong>Risk Assessment</strong> — Evaluate the risk of harm to self or others, risk of impulsive behaviours such as excessive spending or risky sexual behaviour, and possibility of suicidal thoughts, especially if mixed features are present.</p>

<p><strong>Physical Examination</strong> — A general physical examination is necessary to rule out medical conditions that may mimic mania and to assess the patient's nutritional status, hydration, and level of exhaustion.</p>

<h3>Laboratory Investigations</h3>
<p>Investigations confirm the diagnosis, identify underlying medical causes, and ensure safe use of psychiatric medications. These include: Full Blood Count (FBC), Urea and Electrolytes (U&E), Liver Function Tests (LFT), Kidney Function Tests (KFT), Thyroid Stimulating Hormone (TSH) — to exclude hyperthyroidism, Rapid Plasma Reagin (RPR) — to screen for syphilis, HIV test, Hepatitis B and C, Vitamin B12 levels, Pregnancy test in women of childbearing age, Drug of Abuse Screen (DOA6), Electrocardiogram (ECG) — for baseline cardiac status before starting medications, Electroencephalogram (EEG) — if seizure disorder is suspected, MRI or CT scan of the brain if structural abnormalities are suspected.</p>

<h3>Drug Therapy</h3>
<p>Drug therapy is the mainstay of treatment in mania and aims to stabilize mood and control symptoms.</p>

<p><strong>Mood Stabilizers</strong> — Lithium is one of the most commonly used drugs for treating mania. It helps stabilize mood and reduce manic symptoms. Regular monitoring of blood lithium levels is required to prevent toxicity.</p>

<p><strong>Antipsychotic Drugs</strong> — These are often used to control agitation, psychotic symptoms, and severe mania. Examples include Haloperidol, Olanzapine, and Risperidone. These drugs help reduce hallucinations, delusions, and excessive excitement.</p>

<p><strong>Anticonvulsants (Mood Stabilizers)</strong> — Sodium Valproate and Carbamazepine help control mood swings and reduce manic symptoms.</p>

<p><strong>Sedatives / Benzodiazepines</strong> — Used short-term to reduce agitation and promote sleep. Example: Diazepam.</p>

<h3>Treatment Protocol</h3>
<p>Treatment is immediate and long-term, aimed at reducing self-harm, harm to others, and destruction of property. If the patient is violent, refer to the general management of aggressive and violent patients.</p>

<p><strong>1. Immediate Treatment (Pharmacotherapy)</strong></p>
<p>Immediate treatment focuses on controlling agitation, aggression, and manic symptoms.</p>

<p><strong>i. Haloperidol</strong> — Dose: 2.5 mg – 5 mg | Route: Oral (PO) or Intramuscular (IM) | Indication: Used when the patient is aggressive or violent. | MOA: Blocks post-synaptic dopamine receptors in the brain, reducing agitation and psychotic symptoms. | Side effects: Dizziness, constipation. | Nursing implications: Advise the patient to rise slowly to prevent dizziness; encourage fibre intake; monitor vital signs before and after administration.</p>

<p><strong>OR ii. Diazepam</strong> — Dose: 5 mg – 10 mg | Route: Oral (PO) or Intravenous (IV) | Indication: Used for aggressive or violent patients. | May be repeated every 6 hours, maximum 40 mg/day.</p>

<p><strong>PLUS iii. Sodium Valproate</strong> — Dose: 500 mg OD orally, may be increased to BD. | MOA: Increases GABA levels in the brain, stabilizing mood. | Side effects: Dry mouth, black tarry stools, drowsiness. | Nursing implications: Educate about side effects; perform LFTs before and during treatment.</p>

<p><strong>OR iv. Sodium Divalproex</strong> — Dose: 500 mg OD orally, increase to BD.</p>

<p><strong>v. Carbamazepine</strong> — Dose: 200 mg BD orally, may be increased to 400 mg BD.</p>

<p><strong>2. Maintenance Treatment (Long-Term Pharmacotherapy)</strong></p>
<p>Aims to prevent relapse. Continue with ONE of: Sodium Valproate 500 mg – 1 g orally; OR Carbamazepine 200 mg – 400 mg orally BD; OR Sodium Divalproex 500 mg – 1 g OD or BD.</p>

<p><strong>3. Management of Persistent Psychotic Symptoms</strong></p>
<p><em>First Line:</em> Haloperidol 2.5–5 mg OD orally OR Chlorpromazine 50–100 mg OD orally.<br>
<em>Second Line:</em> Risperidone 2 mg OD orally.</p>
<p>Continue with sodium valproate/divalproex or carbamazepine. Wean off benzodiazepines within 5–7 days and consider weaning off antipsychotics within 4 weeks. Monitor Hb levels as carbamazepine causes anaemia — check Hb monthly and FBC every 6 months.</p>

<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">💡 Exam Tip — Drug Protocol Summary <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body">Immediate: Haloperidol OR Diazepam PLUS Sodium Valproate / Divalproex / Carbamazepine. Maintenance: Continue one mood stabiliser. Persistent psychosis: Add Haloperidol or Chlorpromazine (first line) or Risperidone (second line). Wean benzodiazepines within 5–7 days.</div></div>

<h2>2. NURSING MANAGEMENT</h2>

<h3>Aims of Nursing Care</h3>
<ul>
  <li>To promote quick recovery and patient comfort.</li>
  <li>To prevent suicide ideation and injury to self or others.</li>
  <li>To promote good nutritional status and nurse-patient relationship.</li>
  <li>To prevent further complications.</li>
</ul>

<h3>1. Environment</h3>
<p>A calm and structured environment is important because manic patients are easily overstimulated and distracted. Reducing noise and maintaining order helps the patient remain calm and focused.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — Environment <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will place the patient in a quiet, low-stimulus room because this helps reduce overstimulation and agitation.</li><li>I will limit the number of visitors interacting with the patient because too many people can increase excitement and worsen manic symptoms.</li><li>I will maintain a structured daily routine for the patient because routine helps reduce confusion and promotes organised behaviour.</li><li>I will reduce bright lights and loud sounds in the patient's surroundings because a calm environment promotes relaxation and emotional stability.</li></ul></div></div>

<h3>2. Maintaining Safety</h3>
<p>Patients experiencing mania often have poor judgment and may act impulsively. Ensuring safety protects the patient and others from potential harm.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — Safety <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will closely observe the patient for impulsive or aggressive behaviour because continuous monitoring helps prevent injury.</li><li>I will remove sharp or harmful objects from the patient's environment because this reduces the risk of accidental harm.</li><li>I will set clear and firm limits on inappropriate behaviour because limit setting helps the patient understand acceptable actions.</li><li>I will prevent the patient from engaging in exhausting physical activities because excessive activity may lead to fatigue or injury.</li></ul></div></div>

<h3>3. Building Rapport</h3>
<p>Building rapport helps establish trust between the nurse and the patient, making it easier to provide care and encourage cooperation.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — Rapport <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will approach the patient with a calm and non-judgmental attitude because this promotes trust and cooperation.</li><li>I will communicate using short and simple sentences because manic patients may have difficulty concentrating on long explanations.</li><li>I will listen actively to the patient's concerns because this helps the patient feel understood and supported.</li><li>I will maintain consistency in communication among healthcare staff because consistency prevents confusion and builds confidence in care.</li></ul></div></div>

<h3>4. Promoting Rest and Sleep</h3>
<p>Patients with mania often sleep very little, which can worsen their symptoms. Promoting rest helps restore physical and mental balance.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — Rest & Sleep <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will encourage scheduled rest periods during the day because rest helps reduce fatigue from continuous activity.</li><li>I will establish a regular bedtime routine because routine promotes better sleep patterns.</li><li>I will provide a quiet and comfortable sleeping environment because reduced noise and distractions promote relaxation.</li><li>I will administer prescribed medication when necessary because medication may help stabilize mood and improve sleep.</li></ul></div></div>

<h3>5. Assisting with Activities of Daily Living (ADLs)</h3>
<p>Manic patients may neglect personal hygiene, nutrition, and other daily needs due to excessive activity and distractibility.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — ADLs <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will assist the patient with bathing, grooming, and dressing because manic patients may neglect personal hygiene.</li><li>I will provide high-calorie finger foods because the patient may not sit long enough to eat regular meals.</li><li>I will encourage adequate fluid intake because excessive activity may lead to dehydration.</li><li>I will monitor the patient's weight and nutritional status because this helps detect weight loss caused by poor eating habits.</li></ul></div></div>

<h3>6. Behaviour Therapy</h3>
<p>Behaviour therapy focuses on reinforcing positive behaviours and discouraging disruptive or harmful actions.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — Behaviour Therapy <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will reinforce appropriate behaviour through praise and encouragement because positive reinforcement increases desirable behaviour.</li><li>I will redirect the patient when inappropriate behaviour occurs because redirection helps control behaviour without confrontation.</li><li>I will set clear and consistent behavioural limits because consistency helps maintain discipline and order.</li><li>I will encourage participation in simple structured activities because these activities help channel excess energy constructively.</li></ul></div></div>

<h3>7. Cognitive Behavioural Therapy (CBT)</h3>
<p>CBT helps patients identify and change unrealistic thoughts that influence their behaviour.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — CBT <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will help the patient identify unrealistic thoughts because mania often involves exaggerated or distorted thinking.</li><li>I will encourage the patient to consider the consequences of impulsive behaviour because this promotes better judgment and decision-making.</li><li>I will teach coping strategies for managing stress because effective coping reduces triggers for manic episodes.</li><li>I will assist the patient in setting realistic goals because goal setting improves focus and self-control.</li></ul></div></div>

<h3>8. Managing Medication</h3>
<p>Medication is essential in controlling manic symptoms and stabilizing mood. Common medications include mood stabilizers such as Lithium and antipsychotics like Haloperidol.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — Medication <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will administer medications as prescribed because they help stabilize mood and control manic symptoms.</li><li>I will monitor the patient for medication side effects because early detection helps prevent complications.</li><li>I will observe and document the patient's response to medication because this helps evaluate treatment effectiveness.</li><li>I will educate the patient about the importance of medication adherence because consistent medication prevents relapse.</li></ul></div></div>

<h3>9. Social Therapy</h3>
<p>Social therapy helps improve interpersonal relationships and assists the patient in adjusting to social environments.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — Social Therapy <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will encourage participation in supervised group activities because social interaction improves communication skills.</li><li>I will teach the patient appropriate social behaviour and boundaries because manic patients may behave in socially inappropriate ways.</li><li>I will support gradual reintegration into normal social roles because this promotes independence and confidence.</li><li>I will encourage involvement in productive activities because meaningful activities help channel excess energy positively.</li></ul></div></div>

<h3>10. Family Therapy</h3>
<p>Family therapy focuses on involving family members in the treatment process and providing them with knowledge and support.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — Family Therapy <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will educate family members about mania and its symptoms because understanding the illness helps them support the patient effectively.</li><li>I will encourage family participation in the treatment plan because family involvement improves recovery outcomes.</li><li>I will teach family members to recognise early warning signs of relapse because early detection allows timely intervention.</li><li>I will provide emotional support and counselling to family members because caring for a manic patient can be stressful.</li></ul></div></div>

<h3>11. Information, Education and Communication (IEC)</h3>
<p>IEC involves providing health education to the patient and family to improve understanding of the illness and promote long-term management.</p>
<div class="exam-tip-wrap"><button class="exam-tip-btn" onclick="this.classList.toggle('open');this.nextElementSibling.classList.toggle('show')">📝 Exam Points — IEC <span class="exam-tip-arrow">›</span></button><div class="exam-tip-body"><ul><li>I will educate the patient about the causes and symptoms of mania because knowledge helps the patient understand their condition.</li><li>I will teach the importance of medication adherence because regular medication use prevents relapse.</li><li>I will provide information on stress management techniques because stress can trigger manic episodes.</li><li>I will encourage healthy lifestyle practices such as adequate sleep and a balanced diet because healthy habits support long-term mental stability.</li></ul></div></div>