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SMAD. Revista eletrônica saúde mental álcool e drogas

versão On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.8 no.1 Ribeirão Preto abr. 2012




The role of the nurse in the adherence to treatment of people with bipolar affective disorder: what do the records say?1


El papel del enfermero en la adhesión al tratamiento de personas con trastorno afectivo bipolar: ¿qué los registros dicen?



Beatriz PedreiraI; Marcos Hirata SoaresII; Anaísa Cristina PintoI

INursing undergraduate students in Nursing, Departamento de Enfermagem, Centro de Ciências da Saúde, Universidade Estadual de Londrina, PR, Brazil. E-mail: Beatriz -, Anaísa -
IIRN, M.Sc. in Nursing, Assistant Professor, Departamento de Enfermagem, Centro de Ciências da Saúde, Universidade Estadual de Londrina, PR, Brazil. E-mail:





Descriptive-exploratory study that described the role of the nurse in the adherence to treatment of the person with bipolar affective disorder (BAD), through the survey of records made by students and nurses in their charts, and application of a scale in a community service of mental healthcare. The clinical-qualitative methodology was used, and as collection instrument, a field log. The scale was applied in the first and last contact with five subjects from the country side of Paraná, in a period of one month in 2010. We observed a more significant evolution in adherence to treatment in only one of the patients. The records do not report the conduct of the nursing staff most of the times and they have aspects of organist psychiatry in their description. The nurses must record their interventions and results adequately.

Descriptors: Psychiatric Nursing; Nursing Records; Bipolar Disorder; Qualitative Research.


Se trata de estudio descriptivo-exploratorio que describe el papel del enfermero en la adhesión al tratamiento de la persona con trastorno afectivo bipolar (TAB), a través del levantamiento de registros hechos por estudiantes y enfermeras en los prontuarios, y aplicación de una escala en un servicio comunitario de salud mental. Se utilizó la metodología clínico-cualitativa y, como instrumento de colecta, un diario de campo. La escala fue aplicada en el primero y último contacto con cinco sujetos del interior paranaense, en el período de un mes, en 2010. Se percibió una evolución más significativa en la adhesión al tratamiento en solamente una de los pacientes. Los registros no relatan conducta de enfermería en la mayoría de las veces y poseen aspectos de la psiquiatría organicista en su descripción. El enfermero debe registrar sus intervenciones y resultados adecuadamente.

Descriptores: Enfermería Psiquiatrica; Registros de Enfermería; Trastorno Bipolar; Investigación Cualitativa.




Bipolar affective disorder (BAD) is characterized by mood alterations that manifest themselves as depressive episodes, alternating with episodes of euphoria (also called mania), in several degrees of intensity(1). Among the potential risk factors for the development of BAD are the environmental stress, somatic and personality disorders, positive history of BAD in the family, unsound social-financial situation etc.(2).

One of the greater challenges in treating someone with BAD is to promote treatment adherence. Several factors contributes to the difficult in adhering like the lack of information regarding the clinical status and psychopharmacological and psychosocial treatment, lack of family support and adequate therapeutic bond with the professionals of mental healthcare, among many others(2-4).

In relation to the interaction with the user, in a study on the satisfaction and adherence to the BAD treatment, the results showed that most patients did not adhere to the treatment with medicine by "non-intentional behavior". Most of the subjects affirm satisfaction with the effectiveness of the medication and with the information received about it; however, reports of side effects were seen, doubts and lack of motivation to continue the treatment(4).

In this context, the nurse is the key-member to collaborate with the adherence and improvement in the quality of life of the person with BAD, since they spend most of their time close to the patients, having opportunities for education in health, emotional support and space for the practice of care of psychiatric nursing, which includes among other interventions, the therapeutic interpersonal relationship, considered the steppingstone to other interventions(5) .

Under an ethical-legal perspective, the nursing records, as well as the execution of the nursing process are fundamental resources that collaborate to the execution of a quality nursing assistance, which in this case, has as one of the objectives to motivate the adherence to treatment, must be set in modern scientific principles and stimulate the involvement of the professional in the practice of assistance of qualified nursing.

The studies on the nursing records are usually made in the areas of Nursing Fundaments and Medical-Surgical Nursing, where one example is the study made in a teaching hospital(6), which concluded that there was a need to improve the quality of the nursing records made in the charts. A research in the LILACS data base, in the month of November-2010, with the words "nursing records" and "psychiatric nursing", only 8 papers were found, indicating that there are still few papers on this issue.

Therefore, this study had the objective of describing the role of the nurse in the adherence to treatment of people with BAD, through a raising of records made by students and the nurse, in the charts of the respective patients, and the application of an adhesion scale for the BAD treatment.


Material and Methods

It is a qualitative study, having as base the clinical-qualitative methodology, applied constructively in healthcare scenarios, which allows the possibility of articulation of a set of techniques and adequate procedures, typical to the qualitative method of research, to described and understand the relations of feelings and meanings of human phenomenon, referred in this field. It is conceived as a scientific means to know and interpret meanings of psychological and psychosocial nature, in which the individuals give phenomenon of the health/disease field(7).

Data collection tools

We used as data collection tool the field logs, and also a scale to predict the adherence to treatment for a carrier of BAD, elaborated and validated(8), been applied in the first and last contact of the research's interview. Such scale was built as a way to make a prognostic of the adherence to treatment of the person with BAD, and it is called adherence scale to treatment for bipolar affective disorder (ECPAT-TBH)(8), having a summarized version, with 21 items and Cronbach alpha coefficient of 0.79.

The options of these items have a score that varies from 0 to 4, been that, the lower the score, higher the probability that the patient will not adhere to the treatment. The total score of the scale reaches a value of 72 points and a minimum of zero. Factor 1 (questions from 1 to 10 and 14) correspond to a proportion of 40.6% in the explanation of the adherence phenomenon. Factor 2 (questions 15 to 18), on the other hand, presents 29.1% of the explanations proportion, while factor 3 (question 19) correspond to 12.3%; and for factors 4 (question 20) and 5 (question 21), the proportion of explanation is 10.7 and 10%, respectively(8).

In the field log, between the months of July and August/2010, at least one or more weekly copies were recorded, of the logs made by the nursing students and by nurses, in the charts of the subjects, during a period of one month observation, for considering this deadline enough for the relation between adherence and the role of the nurse to be perceived.

Subjects and Location

Five subjects were evaluated that had a BAD diagnosis, in an interval of one month. They were attended at the Center for Psychosocial Care (CAPS) level III, in a city located in the countryside of Paraná. These CAPS has a service of emergency psychiatrics aggregated to the structure, which enables the brief admittance in the service itself.

The subjects were selected according to the acceptance criteria of the ethical regulations in human research, that is: have a BAD diagnosis, have enough education to understand the questions, period and treatment regime at CAPS (admittance, intensive, semi-intensive and non-intensive), not been under guidance or represented by realer and been in a clinical state that would enable communication with the interviewer.

Ethical research regulations

Following the criteria above, it was requested to the higher education professionals to indicate the names of probable research subjects. The research project was approved by the Ethics Committee in Human Research of the University of Londrina, under Protocol nº 053/10.



The data analysis obtained by applying the scale (ECPAT-TBH) and by accessing the patients' charts, in a period of one month, we were able to organize the information collected into 3 figures, the common characteristics in the patients' history are the scores of the scale applied in the first and last day of contact and the content in the notes made by the nursing students and nurses. The names of the patients were represented by their initials and letters were attributed to the students and nurses. All of the interviewees are female (100%) with ages between 21 and 40 years old. The five patients are separated, divorced or single and have only attended elementary school.

In Figure 3, due to the impossibility of presenting all of the notes, for been tôo extensive, will be placed, in the first subject, and example of the notes so it becomes comparison parameters, when the discussions are made, so that the readers understand the meaning given, when attributing a characteristic to the evolution of nursing as deficient and/or only the description of the adequate mental state exam (EEM).



Adhesion to the treatment is defined as the extension in which the patients follow the recommendations of the healthcare professionals. Many people in ambulatory clinics, or even a hospital wing, have difficulty to adhere to treatment. Studies suggest that approximately 50% of bipolar patients interrupt treatment at least once, while 30% of them have the treatment at least twice(9).

As seen in Figure 2, all of the patients followed for one month presented a positive evolution, even if discreet, in adhering to treatment, based on the results of the scale applied in the 1st day, and compared to the last. The SEJ patient had the most noteworthy evolution, with thirteen points in the scale and the other received from 2 to 4 points. Although studies with a wider scope is needed, the hypothesis can be made that the brief admittance made by CAPS has been an important resource in the strengthening of treatment adherence, besides preventing involuntary admittance(10).

Although the scales have a good role in the assessment of adherence to treatment, therapeutic interpersonal relations are still considered the best predictors of good prognosis. The education towards the disease, the identification and management of comorbidities, as well as the stimulus to positive changes in the life style of the patients and their family, are important roles performed by the multidisciplinary team in the treatment of patients mood disorders(11).

Thinking in the sense that one of the objectives reached throughout the interpersonal relation is the promotion of self-esteem(5), in a meta-analysis study(12), involving a total of 1,838 patients, suggested that the self-esteem of patients with BAD, in remission, can fluctuate throughout the remission of the symptoms: is significantly lower than in the control-group, is significantly higher in comparison to the patients with larger depressive disorder in remission from the symptoms. This strongly indicates that the promotion of therapeutic interpersonal relation is very important as adherence factor to treatment, and the item relationship and bond comprises exclusively to 3 items of the scale of adherence to treatment of BAD(8).

Common factors among patients according to the raised history

It is noticed, in Figure 1, that in the subject's history, there is the presence of suicidal tendencies. it is estimated that up to 50% of the carriers have tendency to suicide at least once in their lifetimes and 15% effectively commit them(13). Attempted suicide was present in the speech of most of them, when observing the historical item of the patients, for example, patients 1, 2, 3 and 5. A study suggest that bipolar disorder is a psychiatric disorder with greater risk throughout life for suicide attempts and complete suicide(14). Regarding depression, another mood disorder, a study of bibliographical review suggest that depression is present in 70% of suicide attempts(15).

According to the history raise in Chart 1, all of them suffered some kind of family abandonment, physical aggression from the parents or former-spouses, before or after presenting the first symptoms of BAD. In this study(8), 95.5% reported losses throughout life in relation to work, 88% in relation to family, 86.6% in social relations and 85% in conjugal relationship. This data coincides with the ones found in the history of the subjects in the study in question.

In relation to stressing events that triggered the reoccurrences, 53.7% reported the existence of such events, been related to the family category, with greater proportion (47.8%). Despite not knowing the causal basis of BAD, there is a complex interaction among the biological, genetic and psychosocial factors to try and explain the disorder.

The age the symptoms started to appear predominated from 20 to 29 years old, and despite the difficulty to obtain the correct diagnosis, this result matches with an author(16), that affirms that BAD frequently stricken individuals in the beginning of their professional lives, with the mean age of the first symptoms of BAD, 20 years old. The same literature also states that 69% of the patients are diagnosed wrongly, been unipolar depression the most frequent diagnosis.

Corroborating the prevalence of BAD in early age, a Canadian study with about 36,984 teenagers and young adults (15 to 24 years old) presented a prevalence, throughout life, of 3% and 56% of them already had medical attention in the last year; seeing, in average, four doctors before receiving the proper diagnosis, and more than one third of the patients wait 10 years or more to receive the correct diagnosis, bringing consequences like: lower probability of been treated with the currently recommended medication as first line of treatment, more frequent use of anti-depressants, with their associated risks, besides higher suicide and hospitalization rates, which reflects in the outcomes and costs(17).

The role of nursing from the notes of the nurses and the nursing students

A quoted in the introduction of this study, from the papers found in the research made in the month of November of 2010, two were related to the issue. A study made in a psychiatric emergency service reported that the content of notes contributed a little for the evaluation of the patient's status(18), and in a doctorate thesis(19), that researched the efficacy of a brochure for recording the nursing notes, concluded that the students who used the brochure provided by the researcher were capable to supply all of the needed information, and the that students were making notes directly on the chart, made them without providing all the complete information.

We noticed, by the nursing records presented in Figure 3, which most of the times, the information describes the mental state of the patients with a lot of properties (considering the fact that they are undergraduate students), when we observe the notes made by students, for example, the one made about patient SEJ. In some situations, describe conducts taken, like the medicine instruction and administration of medications, like for example, patients FALP and SEJ. The practice of interpersonal relation as strategy for nursing care, can be considered the steppingstone for assistance practice, does not appear in any of the records.

The notes do not provide a good assessment parameter of the provided care, the ones made by the nurses, as well as the one made by the students, once that there is the presence of several terms that give a moral judgment, for example, "extravagant clothes, strong make-up", made for patient SEJ. The moral judgment is something complex to be overcome and requires constant self-monitoring, for your own ethical and moral standards, since it is with them that clinical evaluations in mental healthcare are made(20).

Reflecting on the findings obtained in both studies cited here(18-19), and analyzing the records made by the students in Figure 3, an improvement was seen in the quality of information, when the quality of the description is analyzed of the mental state exam made by the students, a source of fundamental data to trace the plan of the nursing interventions. However, the conducts are not described facing the needs of the patients, most of the times.

We noticed a characteristic look in the care of the organist psychiatric nursing, in which the role of the nurse id to make rigorous observations of the patient's state, based in the knowledge of psychopathology, administrating medication to control behavior, and inform the doctor of any problems that might come up with the patient, without describing or considering the interpersonal relation as the main therapeutic resource(5,21).

The notes made by the nurse are important records that describe the quality of assistance given by the nursing. That is, in cases of evaluations or ethical-moral judgments, regarding the type of assistance given, the records show how the practice works and is articulated, they serve as legal document to prove imprudence or malpractice, if it focused only in the supply of medication and descriptions based in psychopathology or present other proposals that show more involvement from the professional for a more humanized care, or yet, other several explicative possibilities.

Considering the importance of knowledge in the process of therapeutic communication in nursing and this as base for the application of the nursing process, according to Resolution COFEn nº 358/2009, art.6o(22), the execution of the nursing process must be recorded formally, involving a summary of the data collected on the person, family or human collectiveness, in a given moment of the process of health and disease, like: the nursing diagnosis around the person's answer, family or human collectiveness in a given moment of the health and disease process, the actions or interventions of nursing made facing the diagnosis of nursing identified and the results attained as consequences of such actions or interventions made by the nursing staff.

In the notes described in Figure 3, the built-in valor judgment, decreasing significantly the quality of the notes. Some examples are the criteria of the nursing records, which it is believed that they approach fundamental aspects to describe the data related to the patient in the chart, as for the form, presentation and specificity of the content made objectively, with no prejudices, values, judgments or personal opinion. For this author(23), the records must avoid generalizations, including vague terms, like "god", "regular", "common", "normal", since these declarations become open to multiple interpretations, based on the reader's reference point.

The notes made by the nurse and students show only detailed reports from facts that happened in the healthcare service, but do not describe the active participation of the nursing in most of the reports, since in only a few reports it is possible to see the description of attitudes of interventions made by the nursing interns as well as by the nurse.

In Figure 3, only for 2 patients, we can see the description of interventions made, when you read "(...) worker the importance to adhere to the treatment(...)" and "(...) Oriented to eat less and have regular physical activity, after leaving CAPS". Therefore, it is not possible to affirm if the interventions are been made, but not written down, or if, actually, the notes show with fidelity the scenario of the nursing care.

That is why, one question still remains for future studies, since it was not possible to see if the interventions were made, although not written down, or if they are actually not written down, most of the time because they do not take place, most of the time, as seen in Figure 3, reports of interventions made with the patients, even if limited.


Final Considerations

From the analyses made in the patients' charts it was possible to identify flaws in the records of nursing assistance made to the BAD carrier, allowing to understand that it is possible to care omission of care, lack of interest to record the assistance given facing the clinical scenario presented by the patients, or still, simply lack of habit.

The results of this study point out that the records made by the nurses and the students do not provide the necessary data to ensure the existence of a quality nursing process, since most of them, the records presented the use of terms of a moral coin of phrase and there are not diagnosis, interventions nor evolution of nursing been reported.

Relating these reflections to the role of the nurse in the adherence to treatment, we saw that only one patient that remained admitted presented improvement in the adherence compared to the other patients. This supports even more hypothesis that need further study. Meanwhile, we conclude that the brief admission configured itself as differential in the adherence to treatment, once the patient with brief admittance obtained a higher score in relation to the other patients in treatment at CAPS.

The reports made by students and nurses do not consist in systematic instruments of communication of and for the quality of nursing care. Therefore we highlight the need for these professionals to be conscious about the importance and quality of these records, besides considering that the systematization of the nursing assistance is a task that belongs to the nurse, giving them legal authority in performing the job.

In recording the charts, the role of the CAPS nurses, will have greater visibility of their work, which seeks the promotion of mental healthcare in the everyday treatment of these people, as well as enable the patients to expose their doubts, anxieties, difficulties, opinions and experience related to the treatment, seeking to improve the adherence to treatment of the BAD person.



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Marcos Hirata Soares
Universidade Estadual de Londrina. Centro de Ciências da Saúde
Departamento de Enfermagem
Av. Robert Koch, 60
Vila Operária
CEP: 86038-350, Londrina, PR, Brasil

Received: Dec. 13th 2010
Accepted: Jan. 5th 2012



1 Paper extracted from course conclusion monograph "Cotidiano e Adesão ao Tratamento de Pessoas Portadoras de Transtorno Afetivo Bipolar: Estudo de Caso" presented to Centro de Ciências da Saúde, Universidade Estadual de Londrina, PR, Brazil.