PMH Bundle NSG 329
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This 52 page Bundle was uploaded by Brieanna Phipps on Monday May 2, 2016. The Bundle belongs to NSG 329 at University of North Carolina - Wilmington taught by Dr. Mechling in Spring 2016. Since its upload, it has received 17 views. For similar materials see Psychology and Mental Health in Nursing and Health Sciences at University of North Carolina - Wilmington.
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Date Created: 05/02/16
Psych Test 1 Study Guide: 50 questions (3 med Calc, 4 alternative) Medications and Alternative Therapies: 30% Takes at least 3 weeks to really take affect. Side effects happen sooner. (9 out of 10 meds should not be stopped abruptly) Antidepressents: TCA’s (Tricyclics) - Elavil, Norpramin, Tofranil, Aventyl -↑ Side effects: Sedation, Orthostatic hypotension, Anticholinergic crisis: Cant pee(urinary retention) cant see cant spit cant shit( constipation) can’t think through (confusion), cant cool (hot dry skin) , Cardiotoxicity- cant take with cardiac history - add fiber and plenty of food to diet MAOI’s Nardil, Parnate, Marplan -Side effects: Hypertensive crisis, Seizures, Dietary restrictions! -Block the breakdown of tyramine (a catylist of dopamine). Tyramine is in many aged foods and fermented with lots of preservatives (pickles, cheese, wine, avocado, beer, meat) SSRI’s (selective serotonin reuptake inhibitor) -Paxil, Prozac, Zoloft, Celexa, Luvox, Lexapro, & Vybrid -most popular - SE: headache, drowsiness, insomnia, GI upset (usually subsides in 3 weeks) -Long term SE: weight gain, sexual dysfunction, decreased libido (after off drug can have anger) SNRI’s (norepinephrine) -Effexor, Cymbalta, Pristiq SE- orthostatic hypotention “Heterocyclics” -Wellbutrin, Remeron, Serzone, Trazadone,& Deplin -deplin acts on seratonin, norepinephrin, and dopamine General SE: headache, drowsiness, Anticholinergic s/s Serotonin Syndrome: serious. Overload of serotonin. CARL- confusion, agitation, restlessness, and lethargy + nausea and vomiting, diarrhea, fever, tremors, (carl has the flu) -TX: IV fluids, (IV BENZO-Ativan) anipyretics, muscle relaxors, cyproheptadine ( counteracts against serotonin) , nitopress (MORE LIKELY IF OVERLAP IN MEDS OR HERBAL SUPPS ADDED) Benzodiazepines - Xanax, Ativan, Klonopin, Serax, Valium, Librium - Extremely addictive. Klonogpin is least addictive - SE: Respiratory depression, drowsiness - Do not mix with alcohol. Elderly not a good population for this. - Buspar: if someone has general anxiety disorder Mood Stabilizers Pts could have a seizure if discontinue quickly. Need to go in for lab work- drug levels drawn every 3-6 months Anti-seizure meds -Depakote, Tegretol, Trileptal, Keppra, Neurotonin -Therapeutic range for Tegretol: 6-12 mcg/mL - Toxicity causes ataxia, drowsiness, and blurred vision -Therapeutic range for Depakote: 50-100 mcg/mL - Complain of headache, nausea, vomiting, indigestion Lamictal: safe for mood swings Risk for steven johnsons, drowsiness, dizziness Topamax: treat migrains, fibromialgai. Used more for offlabel Lithium -Most frequently RX medication for Bipolar D/O -Must draw levels every 6 mos. -Also obtain UA, CBC, TSH, Free T4, - Therapeutic Range: 0.6-1.2 mEQ/L -S/S of Toxicity: Polydipsia, Polyuria, N&V, Diarrhea, Headache, Muscle pain, Rash - monitor BUN and Creatinine, Hydration important especially in summer Anti psychotics SE: tend to gain weight, metabolism slows, HTN, obesity, type 2 diabetes, metabolic syndrome Clozaril and syprexa are more risky for metabolic syndrome Least amount of weight gain: Geodon and abilify Conventional: “old school” -Thorazine, Haldol, prolixin, Navane, Moban -Tx of positive symptoms of schizophrenia: hallucinations, paranoia, delusional thinking, agitation, impulsivity ect.. blocks dopamine. -↑ Side effects: NMS, EPS, Disordered water balance, metabolic syndrome Atypical newer -Risperdal, Zyprexa, Abilify, Geodon,Seroquel, Clozaril, Newer ones: Invega, Saphris, & Latuda -Tx of negative symptoms of schizophrenia: withdrawal, apathy, social isolation, flat affect, chronic sadness -Side effects still an issue… but less likely than a conventional more weight gain than Abilify and Geodon) -Rule is that a doc is going to prescribe atypical before conventional -clozaril: start on low does. Lab work done often even for REFILLS - SE: agranulocytosis: destruction of WBC, increase infection, Disordered water balance - NSG: monitor for fever, thrush, infections Side effects: Disordered water balance: more common with typical than atypical -Often etiology is unknown: Suspect a decrease in renal function -Outcome:Seizures, Coma, and/or death Nsg. Interventions (preventative): Encourage hydration, Teach about adequate fiber intake, Assess I & O and weigh regularly st NMS: Neuroleptic malignant syndrome(TX 1 stop med) S/S: Cardinal sign: elevated temperature,(100.4) Tachycardia, Hypertension, Diaphoresis, Changes in LOC, Muscle rigidity -hard to narrow down, most seen with “Haldol” - can die from if not treated in time - Different from anticholinergic crises (diaphoresis) EPS: extraperamital side effects -Treat with Cogentin, Benadryl, Artane (more common) (anticholinergics) -Generally will see 1 : Acute Dystonia, Muscle rigidity, Torticollis (stiff neck), Oculogyric crisis (eyes roll back in head. mecical emergency), Jaw pain, tongue protrusion -2 : Pseudoparkinsonism, Tremor (worst at rest), Slowed movement, Rigidity, Loss of facial expression, Drooling, moon face rd -3 : Akathesia (can’t sit still), Motor restlessness, Agitation, Hyperverbal/difficulty communicating. - Reduce dose of antipsychotic. - Treat with a -blocker (e.g. propranolol). - Might treat with Benadryl. -Chronic: Tardive Dyskinesia, Permanent movement disorder, Lip smacking, tongue protrusion, puckering, blinking, Persistent, but symptoms can be minimized - Occurs 6-8+ months following initiation of antipsychotics - Facial-buccal area -- lip smacking, sucking, etc. - Movements in trunk, rocking - No real treatment; Might decrease dosage, change med, or add Cogentin Med adherence is 58% with a reported range of 24%-90%. - Alternative Somatic Therapy (Last resorts after medications) ECT: Electro convulsive therapy: rewiring of neuro pathways -indices seizures and helps increase neurotransmission -mainly for depression but also bipolar psychotic d/o - lasts 25sec-1 min actual tx person is hooked up to monitor - 6-12 tx 2-3 times per week depending on toleration -ADR hypotension, HTN, brady or tachy cardia -usually confusion subsides -NSG: pt has anxiety about being alone (even though they won’t be), need informed consent, NPO anesthesia, muscle relaxers -D/C antiseizure meds 2 weeks prior -contraindicated: CHF, recent MI, recent CVA, increased ICP, mass tumor, Head injury, sever pulmonary disease, severe Osteoporosis, High risk pregnancy VNS: Vagal Nerve Stimulator -implant with wire like pace maker, placed in upper chest wired to neck and brain -mainly for depression. Maybe parkinsons -acts on serotonin, norpeinephrin, Gaba TMS: Transcranial magnetic stimulation (less invasive) -Treats depression, anxiety, and parkinsons -Acts like anticonvulsents like mood stabilizers -Lasts 40 minutes up to 6 weeks $500 per session -SE: Headache, lightheadedness, tingling at site Therapeutic communication: 20% Using silence Accepting (“yes I understand what you said”) Giving recognition ( “I see you made your bed”) Offering self (“I’ll stay with you a while”) Giving broad openings ( “ tell me what you are thinking”) Offering general leads (“and after that?” “yes go on”) Placing the event in time or sequence (what seemed to lead up to..?) Making observations (“you seem tense”) Encouraging the description of perceptions (“what do the voices seem to be saying”?) Encouraging comparison ( “what was your response the last time this occurred?”) Restating (I can’t study my mind keeps wondering… “you have trouble concentrating?”) Reflecting (What do you think I should do?.. “What do you think you should do?”) Focusing (“ This point seems worth looking at more closely” Exploring (“please explain the situation in more detail”) Seeking clarification and validation (“Tell me if my understanding agrees with yours”) Presenting reality (“I understand the voices seem real to you, but I do not hear any voices”) Voicing doubt (“I find that hard to believe or accept”) Verbalizing the implied (putting into words what the client has only implied or said indirectly) Attempting to translate words into feelings (“ you must be feeling very lonely right now”) Formulating a plan of action (“next time this comes up what is a good way to handle it?”) Non therapeutic communication techniques: Giving reassurance (“Everything will be all right”) Rejecting (“Let’s not discuss…”) Approving or disapproving (“that’s good I’m glad you…”) Agreeing or disagreeing (“that’s right I agree”) Giving advice (“I think you should..”) Probing (“Tell me how your mother abused you”) Defending ( “No one here would lie to you”) Requesting and explanation (“why do you think that”) Indicating the existence of an external source of power (“what makes you say that?”) Belittling feelings expressed ( “everyone gets down the dumps sometimes”) Making stereotyped comments (“keep your chin up”) Using denial ( Im nothing… “of course you’re something everybody is somebody”) Interpreting (“what you really mean is…”) Introducing an unrelated topic Assessment: 15% (legalities, thought content) Legalities: -clients have same rights as anyone ethically can refuse care -use nursing judgment to see if they are unsafe or harming themselves -they have right to confidentiality, least restrictive means, right to receive visitors, freedom from harm r/t physical or pharmalogical restraint Tort-wrongful act or injury committed against another person -Ex. Assault, battery, rape, unlawful imprisonment -Psych pts area vulnerable population Involuntary admit: licensed medical health care provider evaluate them 72 hour hold Voluntary committal: can leave AMA DSM 5 Axis 1- primary psych dx Axis 2- intellectual disability. (mentally retarded) Axis 3- general medical conditions (diabetes or htn) Axis 4- environmental stressor (divorce, homeless, unemployed) Axis 5- GAF score 1-100 (global assessment function score) Assessment: Psychiatric Nursing Assessment Physical appearance: Grooming, dress, height, weight, nutritional status, appearance relative to age, unusual characteristics or markings Behavior/Psychomotor Excessive or limited movement relative to reported symptoms, eye contact, activity/Physical movement: posture, odd or repeated gestures, paucity of movement, lack of expression Attitude/Interpersonal Is behavior unusual or statistically infrequent? Relations: Is behavior disturbing to client or others, at home or at work? Is behavior maladaptive, contributing to client’s difficulty? Affect and Mood: Example: Depressed Sad, tearful, hopelessness, slow or retarded psychomotor activity (Affect: prevailing emotional Constricted (range and duration) narrow band of affective expression over tone, content or type, range and time duration, appropriateness and Appropriate with respect to speech content and life situation depth or intensity) Profound Example: Mania (Mood: client selfreport of Euphoric (content or type), agitation, increased psychomotor activity, current state when asked “How exaggerated gestures, claims of omnipotence are you feeling?” This is Labile (range and duration), wide band of affective expression over a short recorded verbatim) period of time Inappropriate (with respect to speech content and life situation) Speech and Thought: Rate, volume, speed, loudness. Both can be High (fast, loud) Medium (normal or average) or Low (slow or soft) Is speech pressured? Loud? Slow? Halting? Soft? Inaudible? Does patient have poor or distorted enunciation Does patient have dysarthria? (slurring of articulation) Thought Process: Thought blocking (sudden cessation of speech in the midst of a stream of talk with no clear explainable reason) (How patient expresses self) Circumstantiality (excessive, unnecessary detail. Eventually the patient gets to the point.) Tangentiality (just as above, rambles without ever returning to the original question. Patient indicates a greater thought disturbance and disorganization) Loose associations (lack of logical relationship between thoughts and idea, but a slight relationship may exist or be interpreted.) Flight of ideas (continuous overproductive speed with fragmented ideas. The relationship between ideas may be weak or unclear, but perceivable. The original questions is never answered. The patient may seem overstimulated with excessive energy) Mutism (Patient is totally unexpressive.) Neologisms (Patient “makes up” or invents words. Words are spontaneously created) Perseveration (Involuntary repetition of a single response or idea) Clang association (Patient combines unrelated words or phrases with similar sounds. Speech has a repetitive or rhyming quality) Word salad (This is the highest level of disorganized thought. The patient is grossly incoherent) Thought content: Does patient have delusions? Obsessions? Suicidal or homicidal thoughts? Phobias, Preoccupation with particular emotions such as guilt? Does the patient have perceptual disturbances including hallucinations or illusions? Orientation: Does patient know name, place, date, time? Consciousness: Alert? Confused? Clouded? Stuporous? Memory: Can patient recall the distant past (remote memory)? Does patient have recent memory? Immediate memory (ability to recall serial 7’s on mental status exam) Does patient use confabulation or distortion during recall of events? Intelligence: Is patient able to demonstrate academic problem solving? What is education level? Language comprehension? Ability to demonstrate abstract thinking? Reliability: Is patient credible or trustworthy regarding the history he/she provides? Judgment: Does patient demonstrate adaptive decision making? Is decision making constructive? Insight: Does patient have an understanding about the nature of his/her illness (absent, poor, partial, good)? Schizoprenia spectrums: 15% Positive Symptoms: Excess of Normal Functions - Delusions (fixed, false beliefs) - Grandiose - Nihilistic: very morbid, preoccupied with death, might even think they are dead - Persecutory: plotting against me - Somatic: constantly think they are sick - Hallucinations (perceptual experiences) - Thought disorder - Disorganized speech - Disorganized or catatonic behavior - Catatonia: can mold them (catalepsy), waxy flexibility, mutism, agitated, echolalia or echopraxia ( echoing what they say, or copying behavior), stupor, facial grimicing. Positive (beyond the norm increased. Negative Symptoms: Less Than Normal Functioning - Alogia: reduced fluency and productivity of language and thought - Affective blunting: reduced range of emotion - Avolition: withdrawal and inability to initiate and persist in goal-directed behavior - Anhedonia: inability to experience pleasure - Ambivalence: concurrent experience of opposite feelings, making it impossible to make a decision -One of the most severe mental illnesses -Men diagnosed earlier -EOS: Diagnosed late adolescence -LOS: Diagnosed > 45 years -Hyperactive limbic area (r/t + symptoms), Hypofrontality or hypoactivity of the pre- frontal & neo-cortical areas (both + & - s/s). -Risks: Low birth weight, Short gestation, Early dev difficulties, CNS infections -Diagnosis: During a one-month period at least two of the following: Delusions, Hallucinations, Disorganized speech, grossly abnormal psychomotor behavior, Negative s/s (alogia, anhedonia, flat affect, avolition). *its not a result of just one neurotransmitter. -Pre morbid phase: poor social skills, odd kid, funny looking kid -Prodromal phase: psychotic break during schizo. See impairment in functioning, indications of hallucinations, thought disturbances, ect -Schizophrenia (acute phase): actual disease acute. You have delusions, hallucinations, parinoia ect. Full on disease -Residual phase: can still have some symptoms but they aren't prominent or they are absent. If there -is any symptoms left over they are negative ones. Generally on medication during this phase *even on medications there is a 50% chance of relapse. * Inappropriate Affect, Loose Association, Autistic thinking (very concrete), Ambivalence The spectrum -Delusional: don’t see progression, they experience delusions for at least one month. Categories: grandiose, erotomanic (consistent delusional pattern about romance), persecutory (someone's after me, plotting against me) jealous (preoccupation, thinking they are having an affair) mixed ( combo of some of the d/o) -Brief psychotic: s/s can last a day maybe but last less than a month, occur in people who have personality disorders. Can occur chemically, medically (thyroid d/o, dehydration, diabetes, ect) -Schizophreniform D/O -Schizophrenia -Schizoaffective: blended with mood d/o. (most manageable) -Schizotypal/ schizoid: the typical mimics more of schizophrenia, but with schizoid don’t see delusions ect Psych Nursing (origins, roles, ethics, legalities) 10% chpt 5 and ppt Safety and Milieu management 10% chpt 12 PSYCH STUDY GUIDE TEST 2!!!! Anxiety— ATI P.88 Mild anxiety is normal, the difference in other levels of anxiety: the manifestations change and the big one is that it narrows. o Increased alertness o The perceptional field widens o Insight or awareness of the anxiety Moderate anxiety: increased pulse, increased BP, increased respirations, increased GI motility, sweating, etc. o Perceptual field narrows o Difficulty concentrating o Can still follow direction. o Nursing Interventions: Remove the stimuli Keep your sentences very plain and simple. Simple directions Do not touch them o *** TEST QUESTION: We have a client who is new to the unit but has had various psych admins, has a history of violence and acting out. Which place would be best to put the client: put hands on their own private patient room with a roommate secluded area off to the side of the nursing station (because he is unpredictable) Severe Anxiety: o Selective Inattention (don’t see what’s going on around them) o Increased pulse, increased or decreased BP, Increased respirations o Sweating, pacing, GI system (butterflies in stomach), N&V Panic: o This equals terror o They are in survival mode o Scattered o Feeling fear and dread o Very confused o Self absorbed (only think of themselves- survival) o Dissociation o May develop chest pain, SOB, can mirror a heart attack o RULE OUT MEDICAL PROBLEMS General Anxiety Disorder: a three month window, the client exhibits may usually see: Agoraphobia (fear of public open spaces, too many people around, not having an escape route) Manifestations of GAD include the following: o Restlessness, Muscle tension, Avoidance of stressful activities or events, Increased time and effort required to prepare for stressful activities or events, Procrastination in decision-making, Seeks repeated reassurance MEDS- Benzos -don’t use with addiction SSRIs -first line -Luvox helps a lot with OCD Busbar Sedative Hypnotics -anxiety is related to bedtime and sleeping hx of trauma that happened at night Ambien (highly addictive), Lunesta -address sleep hygiene Trazadone Beta blockers -propanolol -clonidine Depakote -PTSD for military o Long term effects: hypoglycemia Heart: more prone to issues with their heart increased risk of MI GI system: GERD, gastro-esophageal disorder, IBS Tend to be at a higher risk to seizure disorders Women are at a higher risk for anxiety Have to rule out any medical things (below) before saying it’s anxiety -MI -post-menopausal issues Nursing Care: A structured environment for physical safety and predictability -Monitoring for, and protection from, self-harm or suicide Daily activities that encourage the client to share and be cooperative Use of therapeutic communication skills, such as open-ended questions, to help the client express feelings of anxiety, and to validate and acknowledge those feelings Client participation in decision making regarding care -Use relaxation techniques with the client as needed for relief of pain, muscle tension, and feelings of anxiety. -Instill hope for positive outcomes (but avoid false reassurance). -Enhance client self-esteem by encouraging positive statements and discussing past achievements. -Assist the client to identify defense mechanisms that interfere with recovery. OCD (Obsessive Compulsive Disorder) ** a lot of test questions on this. Obsession: persistent reoccurring thoughts that drive a need for some kind of behavior. Compulsion- the act Examples: toe tapping, washing hands, It is interfering with your daily life (that is when it is pathological) Underlying: control, fear, anxiety Give them CONTROL! o ***TEST QUESTION: patient who has an issue with germs and is an OCD of washing hands. He needs to go to group but is washing his hands. What not to do: tell him he can’t do it, the anxiety is going to go up, stress. CHECK TO SEE IF IT IS PLACED INTO TREATMENT- let him do it and finish it. 5-6 DAYS INTO TREATMENT: on treatment plan maybe he used to wash for 10 seconds but now limit the time. We can give him an amount of tissues per day to use if he didn’t like touching the door. o Nursing Interventions- educate them on what is happening with their skin break down, encourage lotion, as part of treatment plan- use cold water instead of hot water. Medications: o SSRI’s: Luvox** (helps a lot with individuals who have OCD) o Buspar o Benzos o Mood stabilizers o Beta blockers- propanolol is often used with people with anxiety disorders, adrenergic receptors (sympathetic nervous system) o Clonidine- antihypertensive (S/E= hypotension) HOARDING SHOW (a form of OCD)- 46 yo o Physical health- fall risk, respiratory (mold, spores, dampness in the air. More susceptible to colds, flu, allergies, asthma), nutrition (can’t get to the stove, doesn’t have a functional kitchen, outdated, bugs, rats, roaches in it), fire hazard, sleep, o Social health- shame/guilt, crazy, well liked, involved in church, has a girlfriend, shops (doesn’t use the stuff he buys), retired Navy, boy scouts as a child o Pleasure out of buying stuff, if he used the stuff he bought that he would mess it up, wanting to have control, anxiety. (know what is at the root of this- usually a recent major loss) o Fire marshal tells him he has to get the house cleaned by 30 days: if they throw things out his anxiety goes up because he is giving away his control- that is not therapeutic (outcome: they will start doing it again) o Therapeutic way: involve them in decision making process, getting them support, educating the family, telling him what is going to happen – we have 30 days and this week lets work on this shelf and then I will come back, give him that control) o MEDS- same as OCD. (SSRI’s and anti-anxiety) ■ Hoarding disorder – Client has obsessive desire to save items regardless of value. Experiences extreme stress with thoughts of discarding or getting rid of items. Client’s hoarding behavior results in social and occupational impairment and often leads to an unsafe living environment. PTSD: doesn’t fall into anxiety disorders anymore, The new category is traumatic and stress related disorders.. (attachment and adjustment disorder in kids) Has to have witnessed a traumatic event Had the traumatic event happen to them They weren’t there to witness the traumatic event but it happened to someone very close to them. Signs and Symptoms: Mood: labile, irritable, anger, aggression, depression agitation Cognition: paranoia, hypersensitive to certain things, have unreasonable beliefs to what is going on around them. Behavior: aggressive, acting out, sleep disturbance is hard for them, they are very reactive to certain triggers. Relationships suffer greatly and it’s very stressful. Reckless behavior (self medicating, driving fast, etc), they are hyper-aroused and may also avoid things that can trigger the event. (flashbacks) Very vigilant and they have these flash backs. It is all about re- experiencing that event for them. ** The one symptom they will confess to is not getting enough sleep. o Part of the assessment: rule out depression, anything medical that is going on by doing a complete physical, neurological examination, TBI’s are very frequent, psychotherapy (individual group therapy can be really effective but they want to be conclusive) psychopharm: **(Depokote is one of the main medications given to the military population)** Eye movement desensitation and reprocessing (EMDR) Personality disorders It is more about environment than it is with genetics. It is very difficult to treat especially with cluster B. * S/S | Meds (Action, S.E) | Communication skills | Patient/family teaching Not a lot of evidence that there is something chemically going on with the brain. Has to do more with environment and how we are raised. Ingrained behaviors that become a part of the person’s personalities. -age 3 or 4. -difficult to change. -learned behavior. Generally lack insight. -I don’t have a problem, it’s everyone else. -what prompts them to change is losing something important to them (relationship) Medications treat symptoms and behaviors, not the actual D/O There is an impairment of relationships with other people. Develop personality d/o to get their needs met. -if someone grew up with a parent with borderline, the parent is focused on themselves and the kid needs to find a way to protect themselves and cope Tend to be more takers than givers -needy, -self-serving Hard time accepting consequences Cluster A (odd, aloof, eccentric) - commonalities for all of them: They often lack insight, -the personal relationships really suffer (they are very inner focused), -there is no definitive medications but the meds treat the symptoms that fall into the different clusters, etc, -it usually takes a major event or threat (losing something significant to them) that forces that change. -antipsychotics atypicals -anti-depressant SSRI and SNRI Paranoid Medications: antipsychotics (second generations) o Reclusive o Skeptical o Suspicious o Major distrust of others o Hostile o Defensive o Issues with control o -very suspicious, o -trust is hard for them (distrustful) o -defensive o -argumentative o -guarded o -fears that they will be exploited or degraded in some way o -avoid people and relationships o -controlling o Nursing Interventions: Presenting reality Acknowledge what they are thinking and feeling Knock on door, explain what you are doing, pick up on nonverbal cues, etc. Needs a lot of reinforcement Encourage interaction with other people If you say you are going to do it, do it. announce presence Schizoid- social deficits -***reality is not impaired (no delusions or hallucinations)*** -have difficulty the most under stress -very poor social skills -isolative (avoid people) -flat affect -decreased ability to experience joy -not a wide range of emotion -co-occurring symptoms with avoidant PD o Social withdrawal o Poor social skills o Tend to have a flat affect o Difficulty expressing anger o They will choose job where they don’t have to interact with people (solitary), ex: stocking shelves at night o Have a hard time experiencing joy -NI: focused on helping them with social skills, -expressing emotions -find things that are joyful for them Schizotypal- less of social more of cognitive thoughts -***reality is impaired (delusions and hallucinations)*** -mirrors schizophrenia -inappropriate mood and affect -avolition, autistic thinking, loose associations, flat affect, -disturbed thoughts o Inappropriate mood o Disordered thoughts o Referential thinking o Talk in metaphors o Peculiar appearance o Increased social anxiety o *** We see parallels with schizophrenia o -NI: bring them back to reality Cluster B (dramatic, impulsive, erratic) p.694 -THERAPY IS MOST HELPFUL -MOOD STABILIZERS, antidepresants, antispsychotics (atypicals) and antianxiety Antisocial PD o Predominantly male o -grew up in a chaotic environment o -parent died or abandoned them, abused o -as kids, they have ADHD, oppositional defiant d/o (ODD) o -as teenagers they have conduct d/o o -have trouble with the law (lawbreaking) o -disregard for social norms o -vandalism o -spousal abuse o -theft o -involvement with drugs (selling, using) o -guns o -little to no regard for other people o -charming and cunning o -very manipulative o -short fused o -labile (moody) o -anger management o Don’t have a regard for the rights of others o Violence toward others o Wife beaters o Cheating, lying, stealing o Trouble with the law o Drug dealing or self substance abuse o Can usually be traced back to childhood o Smooth talkers, cunning, charming, manipulative o Nursing Diagnosis: risk for others: directed violence o Nursing Considerations: Safety (violence toward others) set very strong boundaries o Engage him in exercise o Gentle confrontation o ** Often sexually inappropriate (don’t give any wiggle room, cut and dry NO- you’re the client and I’m the nurse) o Medications: Mood stabilizers ** nd Antipsychotic (2 generation) ** Betablocker and antihypertensives Borderline PD o Predominantly female o **TWO KEY FEATURES: some form of self harm (predominantly **cutting) and history of child abuse (sexual) o -hx of abuse (sexual) & engage in self-mutilation (cutting) o -engage in splitting (go to someone for something, they say no and they go to someone else and try to turn the people against eachother) o -thrive on chaos o -attention seeking o -NI: set consistent limits with all staff o -see things in black and white o -hard for them to feel fulfilled o -push and pull people o -safety is an issue o -accidentally commit suicide o -dialectical behavior therapy (DBT) works well o -mindfulness, coping skills, o -they may dissociate o Labile mood and behavior o Dramatic o Tend to see the world in black and white and also as all good and bad o **SPLITTING: you want to go out to a party and you ask mom to borrow car and she says no and you go ask dad. On the unit if the patient is focused on an extra cookie and one nurse said no but another nurse doesn’t realize the other nurse said no and gives it so now the one nurse is BAD, and the other is GOOD. Don’t let them split, best to assign to one staff person but as treatment persists add more staff members. Communication within staff is very important. BE CONSISTENT! o Attention seeking o Nursing considerations: Safety (violence toward self) o Medications: SSRI’s SNRI’s Mood stabilizers 2ndgeneration antipsychotics Therapy-DBT-emotional regulation skills and mindfulness. Cutting: is a coping skill, MAJOR SAFETY ISSUE. they tend to get reality out of it (it makes them know that they are here really in life when they see the blood, they feel a rush, it is possible to become addicted to this because it releases dopamine) NURSING INTERVENTIONS: o Chief priority would be to stop the bleeding and skin integrity o Don’t give too much attention to that behavior o They tend to cut places like their wrists but then wear a lot of bangles or bracelets. o Sometimes it won’t be appropriate for season (they will wear long pants and long sleeve shirts in hot weather) o Sexual abuse Narcisstic PD o Blend of female and male o -in childhood as form of protection o -cannot take criticism get defensive o -point out other people’s flaws o -cannot take self criticism o -insult other people b/c they are insecure o -deep down sad and lonely o Insult other people or point out other people’s flaws o Can’t take negative feedback o Self focused o Manipulative- think they deserve special treatment (the rules don’t apply to them) o Nursing Interventions: Enforcing the rules Getting them to be kind to others and recognizing that everyone has feelings Gently confront and redirecting them Give them positive praise if they did something nice help them to see how their behaviors affect other people set limits Histrionic PD o Usually female o -DRAMA QUEEN o -dramatic flair o -center of attention o -if they aren’t they will create attention o -very flamboyant o -rocky relationships with opposite sex o -very somatic (whiney) to garner attention o -NI: limit setting o -meds: mood stabilizers o Have to be the center or attention o Dramatic o Very rocky relationships especially with men. CLUSTER C- (Anxious or fearful traits; insecurity and inadequacy ) Avoidant › Characterized by social inhibition and avoidance of all situations that require interpersonal contact, despite wanting close relationships, due to extreme fear of rejection; often very anxious in social situations Dependent › Characterized by extreme dependency in a close relationship with an urgent search to find a replacement when one relationship ends Obsessivecompulsive › Characterized by perfectionism with a focus on orderliness and control to the extent that the individual may not be able to accomplish a given task MOOD DISORDERS Depression( see pic handout & see handout on suicide) (movie patch adams) Major Depressive D/O -5 or more symptoms in the same 2-week period or longer that inflicts a change from their previous fxning. -At least 1 of 5 of those symptoms has to be a depressed mood or anhedonia (enjoyed something and now you don’t). Persistent Depressive D/O -dysthymia -all day most days for 2 years or better -can get a family report as well S-sleep C-concentration I-interest A-appetite G-guilt P-psychomotor E-energy S-suicide tendancy 20 million people suffer from depression. (more women than men because they seek help). Risk Factors -family tendencies -young adults -tragedies Neurotransmitters and Depression -serotonin -increased estrogen, decreases serotonin, which causes the ovaries to not produce as much estrogen -dopamine -norepinephrine -GABA -estrogen -having fluctuating estrogen levels, it decreases serotonin -women have more incidences of depression -women tend to takes on a lot -women are more likely to attempt suicide -men are more likely to complete suicide MEDICATIONS -TCA’s -MAOI’s -SSRI’s -SNRI’s -HETEROCYCLICS -Beta Blockers-Propanolol Suicide Assessment 1. Are you considering suicide, or have you ever attempted in the past? -mental illness increases the rate of suicide 2. Do you have a plan? -do you have the means? (what they are going to use to do it; know what means that they have available) -contract for safety -do you promise me that you will not harm yourself while you are in our care? -gives us a false sense of assurance I: Ideations S: Substance Abuse (adds irrational thinking & risk taking to the picture) P: Purposelessness A: Anxiety (feel restless, “feel like I can jump out of my skin”) T: Trapped (feeling trapped) H: Hopelessness (“It’s never going to get better”) W: Withdrawal (social) A: Anger R: Recklessness M: Mood changes (when they take an antidepressant & their mood starts to lift, this is the most dangerous, because now they have the energy and can act on their suicidal impulses) BIPOLAR (see handout) out of two weeks, they must have symptoms most of the days. Depression ---------------------------------------------------------------------- Mania -includes depressive episodes and manic episodes (Bipolar I) -depressive episodes and hypomania (Bipolar II) Mania -inflated sense of self -risky bx (shopping spree, gambling, promiscuity, drug abuse) -hypersexual -flight of ideas (hyperverbal) -decreased need for sleep -to meet nutritional needs give them on the go foods and finger foods -give them anti-depressants it will increase the mania -hypomania is not as intense and not as frequently; less of a danger issue BIPOLAR 1 more mania, depressive episodes (psychosis symptoms) maniano sleep, flight of ideas, hyperverbal, risky behavior, hypersexual, drugs, drinking, impaired judgement, reckless behavior, grandiose behavior. POSITIVE things patients say about mania excited, feeling good about themselves, grandiose, creative, and artistic talents come out. PROBLEM is they don’t adhere to medications when manic. BIPOLAR 11 depressive episodes, more hypomania hypomania irritability, excess energy, flight of ideas, (not so much risky behavior) trouble relaxing, and hyperverbal. CYCLOTHYMIC Disorder pattern extending long term of mood swings. (milder form of bipolar disorder) Periods of hypomania symptoms alternating with mild to moderate periods of depression. MEDICATIONS (Won’t generally see antidepressants with Bipolar 1) Lithium mood stabilizers (DEPACOTE and TEGRATOL) antiseizure antipsychotics (ABILIFY and CLOZARIL) EATING D/O ati know BMIs PMH Final INTENLECTUAL DISABILITY (MENTAL RETARDATION) Diagnosis o Mild: IQ 50-70 o Moderate: IQ 35-49 o Severe: IQ 20-34 o Profound: IQ below 20 o Also take into consideration level of independence, social skills, and meeting milestones Promote safety, encourage independence but intervene when necessary, use positive reinforcement, consistent staffing, trusted caregiver should be present May be able to grow out of this disorder AUTISM SPECTRUM DISORDER Consistent staffing with person they like the most Keep in room that will decrease stimulation with little furniture** Severity based on o Social communication impairments o Restricted, repetitive patterns of behavior Characteristics o Diagnosed by age 3 o Easily agitated o Difficulty staying still o Sometimes nonverbal o Trouble following directions o **dangerous behaviors- promote safety** o self soothing repetitive actions o problems with texture o **routine is key o self injurious (banging head against wall) **high pain tolerance may need one to one obs ADHD Meds o Stimulants: Concerta, vyvance, ritallin, adderall, focalin, quillivant (liquid) o non stim: Strattera, wellbutrin, intunive, clonidine o Don’t give stimulants past 4:00 or 6 hours before bed to prevent insomnia o Weekend breaks/summer breaks are common Safety, increase self esteem, aversion reinforcement, establish goals, tasks, assist one on one Characteristics o **Impulsivity o Trouble in school Disruptive o Cant focus/concentration issues/**inattention o Restlessness/**hyperactivity o Intellectual disability o Comorbidity common ODD (oppositional defiance d/o)-most common Depression Conduct disorder Anxiety ODD (OPPOSITIONAL DEFIANT DISORDER) Characteristics o Anger o Defiance/argumentative o Younger age o Temper tantrums o Problems with authority Ensure structure, use positive and aversive reinforcement, role play to help cope with certain situations, peer group, explain how behavior affects others, develop trusting relationship CONDUCT DISORDER Meds: o Mood stabilizers Lithium Depakote, Tegretol, Trileptal, Keppra, Neurontin Lamitcal Topamax o Atypical antipsychotics Observe signs of escalating behaviors, redirect negative behaviors through physical activity, establish trusting relationship, group situations, aversion reinforcement, discuss how behavior affects others, role play, Characteristics o Violation of social norms o Infringe on rights of others o Rules don’t apply to them o Aggression toward people or animals o Bullying, theft, violation of curfew, swearing, vandalism, drug use o Results in antisocial d/o when older (males) ANXIETY DISORDERS Types o Separation** (early school years) o Generalized o OCD o PTSD** (7-8 yo) Flashbacks Nightmares Anxious/acting out Aggression with playing Grades drop Causes Abuse/neglect Whitness domestic violence Sexual encounter at young age Meds: o SSRIs** Paxil, Prozac, Zoloft, Celexa, Luvox, Lexapro, & Vybrid Serotonin syndrome (CARL has the flu) o Antipsychotics o Beta blockers o Benzos Xanax, Ativan, Klonopin, Serax, Valium, Librium SE: Respiratory depression, Drowsiness, Dizziness, Highly addictive! Ensure trust, positive reinforcement, identify adaptive coping strategies, encourage group sessions, small personal goals Behavior therapy, family therapy, group therapy MOOD DISREGULATION DISORDER Depression o Labile moods o Acting out o Somatic complaints to avoid school o Difficulty coping (SIB) o Tell parents to look for changes in friends, involvement o **giving away prized possessions o meds: MAOI’s: Nardil, Parnate, Marplan Avoid ages foods and drinks (cheese, alcohol) to prevent hypertensive crisis Seizure precaution SSRI’s: Paxil, Prozac, Zoloft, Celexa, Luvox, Lexapro, & Vybrid Serotonin syndrome TCA’s: Elavil, Norpramin, Tofranil, Aventyl Orthostatic hypotension Sedation Cardiotoxcity SNRI’s: Effexor, Cymbalta, Pristiq All can cause Anticolenergic crisis: cant pee, cant see, cant spit, cant shit, cant see through (confused), cant cool Bipolar (DMDD – under 16) o anger, irritability, crying spells o Gets confused with ADHD o Avoid antidepressants b/c can increase mania and avoid stimulants o Meds: mood stabilizers/anti-seizure o prozac and lithium 5f Alcohol screening: 2 or more “yes” probable alcohol abuse o C- cut down on drinking? o A- have you been annoyed by something criticizing your drinking o G- have you felt guilty after drinking o E- do you drink every morning to calm nerves 5-6 drinks 0.1 impaired driving ADDICTION: brain disease expressed by compulsive behavior DEPENDENCE: physiological need, when body doesn’t have it, withdrawal symptoms ABUSE: use beyond prescription or to point of intoxication alcohol is hardest/most dangerous drug to detox from Stages of alc withdrawal o Stage 1 (12 hours after first drink will see withdrawal symptoms) *mild tremors *anxiety *↑ blood pressure *headache *nausea *diaphoresis *Oriented, no confusion, no hallucinations. ambulating directs energy and decreases anxiety** o Stage 2 visible tremulousness motor restlessness, insomnia ↑ pulse, BP, & temp nausea, vomiting obvious diaphoresis Intermittent confusion Transient visual hallucinations & illusions **ambulating directs energy and decreases anxiety** o Stage 3 uncontrollable tremors agitation, extreme restlessness, to panic unable to sleep marked disorientation and confusion disturbing visual and auditory hallucinations DT’s (Delerium Tremens) could lead to a seizure seizure precautions Alc Withdrawal Treatment: o Benzodiazepines Librium, Ativan, Serax, Valium first line Tapered up to 5 days o Beta blockers and antipsychotics (Conventional) o Multivitamins Mg and folic acid Thiamine (Vit B) prevents wernikes encephalopathy alc induced amnesia (first sign: ataxia and diplopia) o Safe detox is key; stay with patient Koricoff syndrome o Organic brain damage o Severe and permanent Abstinence Treatment: could be on these drugs for the rest of their lives o Naltrexone (Vivitral): Injectable opioid blocker Very expensive Increases incidence of kidney disease, CHF, Type II diabetes, increase of opp sex characterisitics, impetigo, hypogomatism o Antabuse: vomiting common Opioid Withdrawal symptoms o Antidote for opioids: narcan o Rhinorrhea (runny nose) o Pupils constricted o Fever o Chills o Body aches o N&V o Diarrhea o Sweating o Yawning Drug Under the Withdrawal other influence symptoms Benzos Mood lability Anxiety returns, -depressant, Unsteady, agitation, Path to abuse uncoordinated tremors, myalgia, and will resort Slurred speech insomnia, ↑ VS to other drugs (*respiratory -anitidote: depression*) flumazenil (romazicon) Crack/cocaine Euphoria Irritability stimulant Psychomotor Paranoia agitation Fatigue Hypervigilenc Insomnia to e hypersomnia Grandiosity Anxiety Insomnia Depression ↑ T,P,R, & BP Suicidality Dilated pupils Sweating ↓ appetite May also see N&V, hallucinations, & delirium Methampheta Cocaine Stimulant, mine symptoms + Sudafed (dries Wt. loss / mouthcandy emaciated. ), household Sores on the skin chemicals, (scratching and battery acid; picking). tripping could Rotted teeth happen out of (candy). blue if taken Ammonia breath one month ago Bath Salts: ↑ VS Stimulant, meth and Sweating Excited cocaine Acidosis delirium Impaired renal syndrome function Dizziness, N&V Abnormal LFT’s EKG ∆’s Psychosis Restlessness Impulsivity Agitation & Aggression Suicidality Nose irritation Marijuana Euphoria Restless, depressant Relaxation irritability, and Drowsiness loss of appetite Time distortion Hunger Tachycardia Conjuctival redness Inhalants Fainting, Similar to alc Depressant, euphoria (20-30 withdrawals Can cause mins), throat permanent and nostril brain damage irritation, mouth and sudden ulcers common, death teens and syndrome preteens Relapse not a failure, just an opportunity to learn Direct/matter of fact communication is best o Acknowledge and then ways to fix o *encouraging comparisons* codependency: taking care of person with substance abuse o spouse likes to feel needed; need spouse to feel like they have a purpose Methadone full opioid agonists (naturally occurring neurotransmitter or mimic) replaces and/or mimics neurotransmitter increases risk for abuse, OD, and respiratory depression prolonged QT interval Suboxone (NALAXONE & BUPRENORPHINE) partial AGONIST/antagonist LESS ADDICTIVE POTENTIAL LESS RISK OF OD decreases cravings, addiction, and OD Subutex (buprenorphine) partial ANTAGONIST/agonist generic does nothing to minimize cravings LONGTERM, some SHORTER IT IS THE BUPRENORPHINE THAT HAS ANALGESIC PROPERTIES time lag between methadone (start withdrawal) OD: repiratory, pupils, slurred speech, drowsiness, chest pain 6b ABUSE: (notes also) Do interviews together first, then separate to see if stories match up Circled welts in a uniform line could be chinese medicine o Don’t jump gun and assume it is abuse Documentation is key o Color o Pattern o Depth Sexual abuse o hallmark sign: Enuresis (bed wetting) and encopresis (pooping pants) o Fast development o Bleeding/burning in perineal area Two most dangerous signs of homicide in abusive relationship o When she becomes more independent o When she becomes pregnant because she will have something else to keep her occupied Arm women with RESOURCES if being abused Thinking about “good times” makes the women more reluctant to leave Some safe houses don’t allow pets or male children RESTRAINTS: Avoid words in documentation: refused to follow directions, uncooperative o Document exact reason for; must state facts De-escalate patient before chemical and physical restraint o Talk with pt o Acknowledge feelings o Find out what triggered them o Allow for explanation of feelings o Use coping skills (counting) Document staff injury Can only restrain for 1 hr, need doc for reorder Nursing assessment after restraint o LOC o Vitals o Emotional state o Process o Triggers o What she wished staff did differently o Any injuries o Have they calmed down o Will they contract for safety Mental Health Exam 3 Study Guide 1. Substance Abuse Disorders: related to alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics, stimulants, and tobacco. A substance use disorder involves a repeated use of chemical substances, leading to clinically significant impairment during a 12month period, and at least two of the following criteria: a. Uses substances in larger amounts or over a longer period of time than intended. b. Has continued desire or unsuccessful attempt to control substance use. c. Spends a considerable amount of time obtaining, using, or recovering from effects of substance. d. Continues substance regardless of social or interpersonal problems associated with substance use. e. Reduces or quits participation is social, occupational, or recreational activities because of substance use. f. Uses substance repeatedly in physically hazardous situations, such as driving impaired. g. Continues to use substance regardless of physical or psychological problems associated with substance use. h. Develops a tolerance to substance i. Requires additional amounts of substance to achieve the desired effect j. Exhibits manifestation of withdrawal k. Feels a strong urge to use the substance. l. 01 criteria: no diagnosis of substance use disorder m. 23 criteria: mild substance use disorder n. 45 criteria: moderate substance use disorder o. 6+: severe substance use disorder. i. Defense mechanism: 1. Altruism: dealing with anxiety by reaching out to others 2. Sublimation: deal with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression. 3. Suppression: voluntarily denying unpleasant thoughts and feelings 4. Repression: Putting unacceptable ideas, thoughts, and emotions out of conscious awareness 5. Displacement: shifting feelings related to an object, person, or situation to another less threatening object, person or situation. 6. Reaction formation: overcompensating or demonstrating the opposite behavior of what is felt. 7. Undoing: preforming an act to make up for prior behavior 8. Rationalization: creating reasonable and acceptable explanations for unacceptable behavior. 9. Dissociation: temporarily blocking memories or perceptions from consciousness. 10. Splitting: demonstrating an inability to reconcile negative and positive attributes of self or others. 11. Projection: blaming others for unacceptable thoughts and feelings 12. Denial: pretending the truth is not reality to manage the anxiety of acknowledging what is real. **common is substance use disorders. Prevents a client from obtaining help. 13. Regression: demonstrating behavior from an earlier developmental level. Often exhibited as childlike or immature behavior. ii. Prevalence: 1. The U.S. has one of the highest levels of substance abuse in the world. 2. 92% of people in the U.S. over the age of 12 have used alcohol sometime in their lives. 3. If substance use begins before the age of 15, the individual is 4X more likely to have abuse problems as an adult, compared with individuals who begin using alcohol after the age of 21. 4. Men are 4X more likely to be heavy drinkers. 5. At least ½ of adults arrested for major crimes (theft, assault, & homicide) test + for drugs. 6. **ALCOHOL MOST DANGEROUS THING TO DETOX OFF! a. Go into Delirium tremensseize, cardiac respiratory arrest. iii. Dual Diagnosis: 1. Over ½ of persons with serious mental illness are also addicted to alcohol or illicit drugs. a. Persons with schizophrenia 4X more likely b. Persons with bipolar disorder 5X more likely (relapse during manic phase) 2. Substance use & abuse frequently goes undetected. 3. Remember, when 1 present, always r/o a medical cause for s/s or manifestations. p. Screening for Alcohol Abuse: Intended effects: relaxation, decreased social anxiety, stress reduction 1. CAGE questionnaire a. Have you ever felt that you ought to cut down on your drinking? b. Have people annoyed you by criticizing your drinking? c. Have you ever felt guilt about your drinking? d. Have you ever had a drink first thing in the morning to steady your nerves? e. Scoring: Two “yes” answers indicates probable alcohol use. 2. Blood Alcohol Levels: 0.8% considered legally intoxicated. a. 0.05 g/dl – 12 drinks; giddy, impaired judgment b. 0.10 g/dl – 56 drinks; ↓ coordination, trouble driving c. 0.20 g/dl – 1012 drinks; severely impaired motor function d. 0.30 g/dl – 1520 drinks; confusion, disoriented to stupor (greater than 0.35% could result in death) e. 0.40 g/dl – 2024 drinks; coma f. 0.50 g/dl – 25+ drinks; respiratory arrest, death g. Go down the line, respiratory arrest a
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