NUR 412B Midterm FYI

What symptoms would you assess in opioid withdrawal? Amphetamine withdrawal? Alcohol withdrawal?

*Alcohol Withdrawal Symptoms:* Occurs within 4-12 hrs of last drink -Abdominal cramping, vomiting, tremors, restlessness, and inability to sleep, increased HR, transient hallucinations or illusions, anxiety, increased BP, increased RR, increased temperature, and tonic-clonic seizures -Alcohol withdrawal delirium can occur 2-3 days (48-72 hrs) after cessation of alcohol. This is considered a medical emergency. Manifestations include severe disorientation, psychotic manifestations (hallucinations), severe hypertension, cardiac dysrhythmias, and delirium. Alcohol withdrawal delirium can progress to death. *Opioid Withdrawal:* -Cravings for the substance produces a specific syndrome of withdrawal -Happens within minutes to several days following use Symptoms -Dysphoric mood -Nausea & vomiting -muscle aches -Lacrimation or rhinorrhea -pupillary dilation -sweating -abdominal cramping: can give dicyclomine (bentyl) for this -diarrhea -yawning -fever -insomnia -not life threatening *Amphetamine Withdrawal:* -Symptoms begin within a few hours to several days Symptoms: -fatigue -vivid unpleasant dreams -insomnia/hypersomnia (excessive sleepiness) -increased appetite -psychomotor (retardation/agitation) -Dysphoria -Cravings -Depression *Not life threatening

In the nursing process, assessment is priority action when taking the nursing process approach to client care. Please review what would provide important information about a client's psychosocial history? See your ATI book

*Important information about a client's psychosocial history:* -Perception of own health, beliefs about illness and wellness -Activity/leisure activities, how the client passes time -Use of substances/substance use disorder -Stress level and coping abilities: usual coping strategies, support systems

Selective Serotonin Reuptake Inibitors(SSRIs) (meds for depression)

*LEADING TREATMENT FOR DEPRESSION 6 SSRIs: 1. Sertraline (Zoloft) 2. Escitalopram (Lexapro) 3. Fluoxetine (Prozac) 4. Paroxetine (Paxil) 5. Citalopram (Celexa) 6. Fluvoxamine (Luvox) *Client Education:* -Advise the client that adverse effects can include *nausea, headache, and CNS stimulation (agitation, insomnia, anxiety)* -Instruct the client that *sexual dysfunction* can occur and to notify provider if effects are intolerable -Advise the client to observe for manifestations of serotonin syndrome. If any occur instruct the client to withhold the medication and notify the provider -Instruct the client to *avoid the concurrent use of St. John's wort* which can increase the risk of serotonin syndrome. -Instruct the client to follow a healthy diet and exercise regimen because *weight gain* can occur with long term use -Also possible side effects/complications of hyponatremia, rash, sleepiness, faintness, lightheadedness, GI bleeding, Bruxism (grinding teeth) **Contraindicated in Clients taking MAOIs and TCAs (increases risk of serotonin syndrome) *SSRI Notes from Class:* -SSRIs are first line for depression so always look for these drugs in questions -All SSRIs have a black box warning for suicide (can increase suicidal thoughts/ideas) -lexapro and celexa are very close -SSRIs + St. Jon's wort = serious risk for serotonin syndrome. -Celexa came out first (called "dirty drug" back then) -(Citalopram) Celexa max dose is 40 mg b/c can cause QT prolongation especially if also on an antipsychotic, so will get a baseline *EKG* first -Sertraline (Zoloft) is a go to drug, so is Fluoxetine (Prozac) -Some drugs are given during pregnancy if its what is best for the mom such as fluoxetine (prozac); however drugs like depakote and lithium def not given during 1st trimester -Prozac: 6 week washout (takes 6 weeks for prozac to leave body so have to be careful w/ other meds being added) -Paroxetine (Paxil) is great for depression and general anxiety disorder but issue is some people can gain up to 30 lbs. -When pts dont want to gain weight or lose their sex drive can prescribe other type of drug Wellbutrin (an atypical antidepressant) but can't drink alcohol & it lowers the seizure threshhold and it can cause an increase in anxiety, so probably need an anxiety med too. -Fluvoxamine (Luvox) usually seen with OCD

What meds are used in detox of alcohol? Opioids?

*Meds for Alcohol Withdrawal:* -Diazepam (Valium) -Carbamazapine (Tegretol) -Clonidine -Chlordiazepoxide (Librium) -Phenobarbital -Naltrexone (Vivitrol) *Meds for Opioid Withdrawal:* -Methadone substitution -Clonidine -Buprenorphine (Suboxone) -Naltrexone (Vivitrol) -Levo-alpha-acetylmethadol

What meds are used in maintenance of substances such as opioids and alcohol?

*Meds for alcohol abstinence:* -Disulfiram (Antabuse) -Naltrexone (Vivitrol) -Acamprosate *Meds for opioid abstinence/maintenance:* -Methadone substitution -Burprenorphine (Suboxone) -Naltrexone (Vivitrol)

Review all Sections: Section 12B

*Section 12B:* -Involuntary commitment of a person following a 12A examination. The facility must offer, upon admission, to contact the committee for Public Counsel Services (CPCS) who shall appoint an attorney upon request. Also provides for an emergency hearing in the district court for a person who who believes that his/her admission is the result of an "abuse or misuse" of the civil commitment law. -Authorization for Temporary Involuntary Admission to a DMH-licensed inpatient facility -Page 2 of "pink paper": 12A has been accepted and signed by MD on psych unit for involuntary psych hospitalization (less than or equal to 3 business days) -May be canceled if pt no longer meets 12A criteria -Duration: Up to 3 days (do not count weekends or holidays in this) -Time Frame: Accept CV, file for commitment before 3 days expire, or discharge.

Restraints What does a nurse document about restraints? The law requires the nurse to document what and how often?

*Patients Rights Regarding Seclusion & Restraints:* -Seclusion/Restraints ordered for short period of time -Only if less restrictive measures are not sufficient -Restraints are physical or chemical NEVER use restraints/seclusion for: -Convenience of staff -Punishment -Extremely physical or mentally unstable -On those who cannot tolerate the decreased stimulation of a seclusion room *When less restrictive measures have been tried to prevent harm to self or others:* -Obtain an order for seclusion or restraint -Orders obtained from provider -Order must specify duration of treatment -Provider must rewrite the order every 24 hrs *Less Restrictive Measures (Before Seclusion/Restraints)* -Verbal interventions such as telling the client to calm down -Diversion or redirection -Providing a calm, quiet environment -Offering a PRN medication (though technically a chemical restraint, medications are considered less restrictive then a mechanical restraint) *Nursing Responsibilities with respect to Seclusion/Restraints:* -Assess safety/physical needs & behaviors -Offer food and fluids -Toilet the pt -Monitor vital signs *When the nurse has tried all other less restrictive means to prevent a client from harming self or others the following must occur in order use seclusion or restraint:* -The provider must prescribe the seclusion or restraint in writing -Time limits for seclusion/restraints are based upon the age of the client (Age 18 yrs and older: 4 hr, Age 9-17 yrs: 2 hr, Age 8 yrs and younger: 1 hr) -If need for restraint/seclusion continues the provider must reassess the client and rewrite the prescription, specifying the type of restraint, every 24 hr or the frequency of time specified by facility policy Facility protocol should identify the nursing responsibilities, including how often to: -Assess (for safety and physical needs), and the client's behavior documented -Offered food and fluid -Toileted -Monitored for vital signs -Monitored for pain Complete documentation every 15 to 30 min including a description of the following: -Precipitating events and behavior of the client prior to seclusion or restraint -Alternative actions taken to avoid seclusion or restraint -The time treatment began -The client's current behavior, what foods or fluids have been offered and taken, needs provided for, and vital signs -Medication administration -Time released from restraints (The nurse can use seclusion/restraints without an order if it is an emergency situation, but must obtain an order within a specified period of time usually 15-30 min) *Important to document information related to violent or other unusual episodes. The nurse should clearly and objectively document the following: Client behavior, Staff Response, Time the nurse notified the provider

How is client safety on a locked psychiatric unit maintained? What are some responsibilities of health care members on a locked psychiatric unit?

*Physical Safety:* -The nurse's station and other areas should be placed to allow for easy observation of clients by staff and access to staff by clients -Special safety features, such as bathroom bars and wheel chair accessibility for clients who are disabled, should be addressed. Set up the following provisions to prevent client self harm or harm by others: -No access to sharp or otherwise harmful objects -Restriction of client access to restricted or locked areas -Monitoring of visitors -Restriction of alcohol or illegal substance access or use -Restriction of sexual activity among clients -Deterrence of elopement from facility -Rapid de-escalation of disruptive and potentially violent behaviors through planned interventions by trained staff -Seclusion rooms and restraints should be set up for safety and used only after all less-restrictive measures have been exhausted. When used, facility policies and procedures must be followed. -Plan for safe access to recreational areas, occupational therapy and meeting rooms -Teach fire, evacuation, and other safety rules to all staff: Provide clear plans for keeping clients and staff safe in emergencies; Maintain staff skills such as CPR -Considerations of room assignments on a 24 hr care unit should include: personalities of each roommate, the likelihood of nighttime disruptions for a roommate if one client has difficulty sleeping, mental health and medical diagnoses (such as how two clients who have severe paranoia might interact with each other) *Health Care Member Responsibilities:* -Promote independence for self-care and individual growth in clients -Treat clients as individuals -Allow choices for clients within the daily routine and within individual treatment plans -Apply rules of fair treatment for all clients -Model good social behavior for clients, such as respect for the rights of others -Work cooperatively as a team to provide care -Maintain boundaries with clients -Maintain a professional appearance and demeanor -Promote safe and satisfying peer interactions among clients -Practice open communication techniques with health team members and clients -Promote feelings of self worth and hope for the future

Phases of Therapeutic Nurse-Client Relationship

*Preinteraction Phase:* -Nurse explores self-perceptions *Orientation (Introductory) Phase:* -Establish trust and formulate contract for intervention -Nurse: Introduces self to the client and state purpose. Set the contract including meeting time, place, frequency, duration, and date of termination. Discuss confidentiality, Build trust by establishing expectations and boundaries. Set goals with the client. Explore the client's ideas, issues, and needs. Explore the meaning of testing behaviors. Enforce limits on testing or other inappropriate behaviors -Client: Meet with the nurse. Agree to the contract. Understand the limits of confidentiality. Understand the expectations and limits of the relationship. Participate in setting goals. Begin to explore own thoughts, experiences, and feelings. Explore the meaning of own behaviors *Working Phase:* -Promote client Change -Nurse: Maintain relationship according to the contract. Perform ongoing assessment to plan and evaluate therapeutic measures. Facilitate the client's expression of needs and issues. Encourage the client to problem solve. Promote the client's self esteem. Foster positive behavioral changes. Explore and deal with resistance and other defense mechanisms. Recognize transference and countertransferance issues. Reassess the client's problems and goals, and revise plans as necessary. Support the client's adaptive alternatives and use of new coping skills. Remind the client about the date of termination -Client: Explore problematic areas of life. Reconsider usual coping behaviors. Examine own world view and self-concept. Describe major conflicts and various defenses. Experience intense feelings and learn to cope with anxiety reactions. Test new behaviors. Begin to develop awareness of transference situations. Try alternative solutions. *Termination Phase:* -Evaluate goal attainment and ensure therapeutic closure -Nurse: Provide opportunity for the client to discuss thoughts and feelings about termination and loss. Discuss the client's previous experience with separations and loss. Elicit the client's feelings about the therapeutic work in the nurse-client relationship. Summarize goals and achievements. Review memories of work in the sessions. Express own feelings about sessions to validate the experience with the client. Discuss ways for the client to incorporate new healthy behaviors into life. Maintain limits of final termination -Client: Discuss thoughts and feelings about termination. Examine previous separation and loss experiences. Explore the meaning of the therapeutic relationship. Review goals and achievements. Discuss plans to continue new behaviors. Express any feelings of loss related to termination. Make plans for the future. Accept termination as final -Transference: occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client's personal life. -Countertransference: occurs when a health care team member displaces characteristics of people in her past onto a client

Review all the sections: Section 10 & 11 (CV)

*Section 10 & 11 (Conditional Voluntary- CV)* -Conditional Voluntary (CV) admission allow a patient to sign out of the facility as long as their mental status exam and the provider determine that they are not a danger to themselves or others; 3 day note -Admission to a suitable facility of an individual in need of care & treatment -Duration: length of treatment varies according to individual's assessed needs; terminated by 3 day notice given by individual, or discharge by facility -Time frame: Periodic Review- Assess for competence to remain on CV. -3 day: file for commitment before 3 days expires or discharge. Do not count weekends or holidays in the 3 days -Page 1 of CV: Pt has applied for voluntary admission to inpatient psych & agrees to certain admission conditions -Page 2 of CV: Application has been accepted & signed by MD on psych unit (cannot be accepted on non-psych unit)

Review all Sections: Section 12A

*Section 12A:* -Emergency admission ("pink paper"): A physician, qualified psych nurse, mental health clinical specialist, qualified court psychologist, or police officer may apply to hospitalize person against will -Application for temporary involuntary hospitalization to a DMH licensed inpatient facility -Page 1 of "pink paper": Application for involuntary psych hospitalization due to actual or potential danger to self or others, or inability to care for self, in setting of serious and symptomatic mental illness (aka 3 day psychiatric hold) -Duration: Up to 3 days (not counting weekends or holidays in that time); actually time limit for 12A itself not defined in statue (up to 3 days for 12B?) -Time Frame: Accept CV, file for commitment before 3 days expire, or discharge. -Section 12A & 12B: Temporary emergency admission initiated when an individual's behavior is imminently dangerous to himself or others: up to 72 hrs

What are the DT's? Symptoms of the DT's

Alcohol withdrawal delirium can occur 2-3 days after cessation of alcohol. -This is considered a medical emergency. -Manifestations include severe disorientation, psychotic manifestations (hallucinations), severe hypertension, cardiac dysrhythmias, and delirium -Alcohol withdrawal delirium can progress to death

Review all sections: Section 15 evaluations & commitments

*Section 15:* -Competency to stand trial: does this individual understand what's going on? -Criminal Responsibility: Did the defendant have a mental illness at the time the crime was committed? -Section 15A: Courthouse evaluation by DMH forensic Division -Section 15B: inpatient commitment at DMH facility or Bridgewater State Hospital (DOC) -Aid in sentencing: what kind of sentence is appropriate for this individual? -Section 15E: Inpatient Commitment Notes on 15B & 15E: -Eval for competence to stand trial or criminal responsibility (15B); Aid to sentencing (15E) -Duration: 20 days, may be extended an additional 20 days (15B) Up to 40 days (15E) -Prepare report of evaluation and assessment of need for further hospitalization for return to court on expiration of 20 days.

Review of all sections: Section 18A

*Section 18A:* -Forensic Commitment for evaluation of an inmate for need of hospitalization; subsequent order of treatment -Duration: Initial evaluation: up to 30 days; Initial treatment order up to 6 months, up to 12 months thereafter -Prepare report of assessment and petition for commitment for return to court on expiration of assessment. File subsequent petitions before orders or sentence expire

Review all Sections: Section 21

*Section 21:* -Authorization for Transport of Hospitalized Mentally Ill person from a (DMH-licensed) Facility -Allows transport from and back to DMH Inpatient Facility: Outside non-psych, another psych facility (including State Hospital), Court -Pt must already have a legal admission status from inpatient psych unit: Section 12B, CV, Civil Commitment -Required for transport if pt needs transfer to outside facility

Review all Sections: Section 7 & 8

*Section 7 & 8 (Civil Commitment):* -Involuntary commitment to a facility of an individual who is mentally ill and for whom discharge from such a facility would create a likelihood of serious harm -Involuntary DMH facility admission ordered by judge at commitment hearing -Duration: Up to 6 months for first order, up to 12 months thereafter -Time Frame: File for recommitment on or before expiration of current order or discharge

Review all the sections: Section 8B (Rogers)

*Section 8B Authorization to Treat (Rogers):* -An order of a district court made after entry of an order for involuntary commitment and a finding by the court that the client is incapable of giving informed consent (incompetent) to the administration of antipsychotic medication or other medical treatment for mental illness -Allows hospital to give specified antipsychotics and other specified treatments or procedures without pt consent. (If pt refuses PO formulation, may give IM/IV or by feeding tube if compatible -Duration: coincides with underlying commitment. Dissolves upon the client's discharge from the facility or upon conversion of the client's legal status to voluntary while at the facility -File for new 8B with petition for recommitment

What is Tarasoff Warning, LAMB, 3 days?

*Tarasoff Warning:* -A duty to warn/protect (Protection of a 3rd party) -"The protective privilege ends where the public peril begins" -Most states now recognize that therapists have ethical and legal obligations to prevent their clients from harming themselves or others; In most cases courts have outlined the following guidelines for therapists to follow in determining their obligation to take protective measures: 1. Assessment of a threat of violence by a client toward another individual, 2. Identification of the intended victim, 3. Ability to intervene in a feasible, meaningful way to protect the intended victim. -In psych mental health nursing it is the duty of the nurse to report to the psychiatrist or other team members if pt confides in the nurse the potential for harm to an intended victim. Doing so is not a breach of confidentiality and the nurse may be considered negligent for failure to do so. -When these guidelines apply to a specific situation, it is reasonable for the therapist to notify the victim, law enforcement authorities and/or relatives of the intended victim. The therapist may also consider initiating voluntary or involuntary commitment of the client in an effort to prevent potential violence. *Lamb Warning:* -Two reasons clinician can breach confidentiality (talk about pt without their permission) 1. The whole team at the hospital (can talk about pt with OT, Physicians, RNs, PT, etc to plan pt's care) 2. If have to go to court can talk about pt in front of judge *have to give pt the Lamb warning and document it *3 days:* If pt wants to leave on a CV they sign a 3-day note which gives the provider 3 days to observe and assess them to determine if they are safe to leave. If provider wants them to stay for care/treatment has to file for commitment before the 3 days is over and take them to court. Provider needs to provide proof that they are incompetent to make the decision to leave. Judge decides if they are. (Weekends and holidays are not included in the 3 days; needs to be 3 business days)

Member Roles within Groups

*Task Roles:* -Coordinator: clarifies ideas and suggestions that have been made within the group; brings relationships together to pursue common goals -Evaluator: examines group plans and performance, measuring against group standards and goals -Elaborator: explains and expands upon group plans and ideas -Energizer: encourages and motivates group to perform at its maximum potential -Initiator: outlines the task at hand for the group and proposes methods for solution -Orienter: maintains direction within the group *Maintenance Roles:* -Compromiser: Relieves conflict within the group by assisting members to reach a compromise agreeable to all -Encourager: Offers recognition and acceptance of other's ideas and contributions -Follower: Listens attentively to group interaction; is a passive participant -Gatekeeper: Encourages acceptance of and participation by all members of the group -Harmonizer: Minimizes tension within the group by intervening when disagreements produce conflict *Maintenance (Personal Roles):* -Agressor: expresses negativism and hostility toward other members; may use sarcasm in effort to degrade the status of others -Blocker: Resists group efforts; demonstrates rigid and sometimes irrational behaviors that impede group progress -Dominator: Manipulates others to gain control; behaves in authoritarian manner -Help seeker: Uses the group to gain sympathy from others; seeks to increase self-confidence from group feed-back; lacks concern for others or for the group as a whole -Monopolizer: Maintains control of the group by dominating the conversation -Mute or silent member: Does not participate verbally; remains silent for a variety of reasons- may feel uncomfortable with self-disclosure or may be seeking attention through silence -Recognition-seeker: Talks about personal accomplishments in an effort to gain attention for self -Seducer: Shares intimate details about self with group; is the least reluctant of the group to do so; may frighten others int he group and inhibit group progress with excessive premature self disclosure

What does psychobiological intervention mean? Using your ATI book, review an example of a psychobiological intervention

*What does psychobiological interventions mean?* -Psychobiology is the study of the biological foundations of cognitive, emotional, and behavioral processeses -So interventions that are related to this *Examples of psychobiological interventions:* -Administering prescribed medications -Providing teaching to the client/family about medications -Monitoring for adverse effects and effectiveness of pharmacological therapy

Review in the ATI book "mental status exam." What does the mental status exam (MSE) assess? What is remote memory?

*What does the Mental Status Exam (MSE) Assess?* 1. Level of Consciousness -*Alert:* the client is responsive and able to fully respond by opening her eyes and attending to a normal tone of voice and speech. She answers questions spontaneously and appropriately. -*Lethargic:* The client is able to open her eyes and respond but is drowsy and falls asleep readily -*Stuporous:* The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. She might not be able to respond verbally -*Comatose:* The client is unconscious and does not respond to painful stimuli. Abnormal posturing can occur in the client who is comatose- *Decorticate rigidity:* flexion and internal rotation of upper extremity joints and legs; *Decerebrate rigidity:* neck and elbow extension, wrist and finger flexion 2. Physical Appearance -Examination includes assessment of personal hygiene, grooming, and clothing choice. Expected findings with regard to this assessment are that the client is well-kept, clean, and dresses appropriately for the given environment 3. Behavior -Examination includes assessment of voluntary and involuntary body movements, and eye contact -*Mood:* A client's mood provides information about the emotion that she is feeling -*Affect:* A client's affect is an objective expression of mood, such as a flat affect, or a lack of facial expression 4. Cognitive and Intellectual abilities -Assess the client's orientation to time, person, and place -Assess the client's memory, both recent and remote -*Immediate Memory:* Ask the client to repeat a series of numbers or a list of objects -*Recent Memory:* Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission -*Remote Memory:* Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother's maiden name -Assess the client's level of knowledge. For ex, ask him what he knows about his current illness or hospitalization -Assess the client's ability to calculate. For ex, can he count backward from 100 in serials of 7 -Assess the client's ability to think abstractly. For ex, can he interpret a cliche such as "A bird in the hand is worth two in the bush"? The ability to interpret this demonstrates a higher level thought process -Perform an objective assessment of the client's perception of his illness -Assess the client's judgement based on his answer to a hypothetical question. For ex, how would he answer the question, "What would you do if there were a fire in your room?" The client should provide a logical response -Assess the client's rate and volume of speech, as well as the quality of his language. His speech should be articulate and his responses meaningful and appropriate (More specific info about MSE in other quizlet) *What is Remote Memory?* -Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother's maiden name

Defense Mechanisms

-Adaptive use of defense mechanisms helps people to achieve their goals (deal with stress) in acceptable ways -Defense mechanisms become maladaptive when they interfere with functioning, relationships, and orientation to reality. It is important that the defense mechanism used is appropriate to the situation and that an individual uses a variety of defense mechanisms, rather than having the same reaction to every stressful situation

Meds for Depression: Tricyclic Antidepressants

-Amitriptyline (Elavil) -Imipramine (Tofranil) -Doxepin (Sinequan) -Nortriptyline (Pamelor) -Amoxapine (Asendin) -Trimipramine (Surmontil) *Client Education:* -Advise the client to change positions slowly to minimize dizziness from *orthostatic hypotension* -To minimize *anticholinergic effects*, advise client to chew sugarless gum, eat foods high in fiber, and increase fluid intake to 2-3 L/day from food and beverage sources -Also possible side effects of sedation, toxicity (seen as dysrhythmias, mental confusion, and agitation, followed by seizures, coma, and possible death), decreased seizure threshold, excessive sweating, increased appetite so risk of *weight gain* **Concurrent use with MAOIs can cause severe hypertension **Concurrent use with alcohol, benzodiazepines, opioids, and antihistamines can result in additive CNS depression

Barriers to effective communication:

-Asking irrelevant personal questions -Offering personal opinions -Giving advice -Giving false reassurance -Minimizing feelings -Changing the topic -Asking "why" questions -Offering value judgements -Excessive questioning -Responding approvingly or disapprovingly

Atypical Antidepressants (meds for depression)

-Bupropion (Wellbutrin) -Alternative treatment for depression when pt's are unable to tolerate the sexual dysfunction side effects -It also suppresses appetite resulting in weight loss (so helpful when pts can't take the weight gain from SSRIs) *Client education:* -Advise the client to observe for headache, dry mouth, GI distress, constipation, Increased HR, nausea, restlessness, or insomnia and to notify the provider if they become intolerable -Monitor the client's food intake and weight due to appetite suppression -Avoid administering to clients at risk for seizures (b/c lowers seizure threshold) **Contraindicated in clients taking MAOIs and those with seizure disorders (also an increased risk of seziures with concurrent use of SSRIs)

Serotonin Syndrome

-Can begin 2 to 72 hrs after the start of treatment and it can be lethal *Manifestations:* -Mental confusion, difficulty concentrating -Abdominal pain -Diarrhea -Agitation -Fever -Anxiety -Hallucinations -Hyperreflexia, incoordination -Diaphoresis -Tremors

Identification (Defense Mechanism)

-Conscious or unconscious assumption of the characteristics of another individual or group; An attempt to increase self worth by acquiring certain attributes/characteristics of an individual one admires -Adaptive use: A girl who has a chronic illness pretends to be a nurse for her dolls; A teenage boy who required lengthy rehab after an injury decides to become a physical therapist as a result of his experiences -Maladaptive use: A child who observes his father be abusive towards his mother becomes a bully at school

Altruism (defense mechanism)

-Dealing with anxiety by reaching out to others -Adaptive use: A nurse who lost a family member in a fire is a volunteer firefighter -Maladaptive use: N/a (always healthy)

Sublimation (defense mechanism)

-Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression (Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive) -Adaptive use: A person who has feelings of anger and hostility toward his work supervisor sublimates those feelings by working out vigorously at the gym during his lunch period -Another example: A mother whose son was killed by a drunk driver channels her anger and energy into being the president of the local chapter of Mothers Against Drunk Drivers -Maladaptive use: N/a (always healthy)

Alterations in speech

-Flight of ideas: Associative looseness. The client might say sentence after sentence, but each sentence can relate to a different topic, and the listener is unable to follow the client's thoughts -Neologisms: Made-up words that have meaning only to the client, such as, "I tranged and flitted" -Echolalia: The client repeats the words spoken to him -Clang association: Meaningless rhyming of words, often forceful such as, "Oh fox, box, and lox" -Word salad: Words jumbled together with little meaning or significance to the listener, such as, "Hip hooray, the flip is cast and wide-sprinting in the forest"

Review of all sections: Section 16 Commitments

-Incompetent to stand trial: MUST BE MENTALLY ILL & DANGEROUS -Purpose of hospitalization is to restore the individual to COMPETENCY -When individual is competent , criminal case will be resumed -Criminal charges may be dismissed, facility cannot hold individual longer than the usual sentence -Not Guilty by Reason of Insanity: Purpose of hospitalization is to provide treatment to individual -District Attorney may oppose discharge Notes: -Section 16A: evaluation of incompetent or NGRI pt, for purposes of further commitment; Duration: period not to exceed 50 days combined with 15B; Prepare report of assessment for return to court on or before expiration of commitment period -Section 16B & 16C: Forensic commitment of defendant found incompetent to stand trial or NGRI; Duration: Up to 6 months for first order (16B); up to 12 months thereafter (16C). 30-day notice of intent to discharge to DA & Court, Notice to Court upon restoration of competence (17A); File for recommtment on or before expiration of current order

Mood Stabilizers:

-Lithium as well as many anticonvulsants: -Valproic Acid (Depakote) (Therapeutic serum level: 50-100, 50-125 for acute mania) -Gabapentin (Neurontin) -Carbazepine (Tegetrol) -Oxcarbamezapine (Trileptal) -Lamotrigine (Lamictal) -Topiramate (Topamax) *Side Effects of Mood stablizers:* -Anemia -Thrombocytopenia (low platelets) -Hepatotoxicity -Cardiac arrhythmias -Lethargy -Headaches/Migraines -Ataxia -GI upset -Serious skin rashes (Stevens-Johnson Syndrome) *Labs that need to be checked for Mood Stabilizers:* -Serum electrolytes (sodium) -LFTs (LDH, AST, ALT, Bilirubin) -CBC, platelet count, and bleeding time

Lithium

-Medication used to treat bipolar disorder it is a mood stabilizer that controls episodes of acute mania, helps to prevent the return of mania or depression, and decreases the incidence of suicide Side effects: -GI distress (nausea, diarrhea, abdominal pain-administer meds with milk/meals to avoid) -Fine hand tremors (adjust dosage/administer beta blockers) -Polyuria & mild thirst (instruct client to maintain adequate fluid intake) -Weight gain (encourage healthy diet and exercise) -Renal toxicity (keep dose at lowest level necessary, assess baseline BUN/Creatinine, and monitor kidney function) -Goiter and hypothyroidism (w/ long term treatment) -Bradydysrhythmias, hypotension, and electrolyte imbalances (important for pt to maintain adequate fluid and sodium intake) -Ataxia: significant side effect! *Therapeutic level: 0.6-1.2 mEq/L* (for acute mania: want closer to 1.0, for maintenance closer to 0.7/0.8) -During initial treatment of a manic episode levels should be 0.8-1.4 -Maintenance level range is 0.4-1.0 -Plasma levels greater than 1.5 can result in toxicity -Older adult clients at higher risk for toxicity -Lithium levels should be obtained in the morning 8-12 hrs after last dose Contraindications: -Shouldn't use during pregnancy (teratogenic) or breastfeeding -Contraindicated in clients with hepatic disease, severe renal or cardiac disease, hypovolemia, and schizophrenia -Use cautiously in older adult clients and clients who have thyroid disease, seizure disorder, or diabetes Interactions: -Diuretics: sodium is excreted with the use of diuretics. With decreased serum sodium, lithium excretion is decreased, which can lead to toxicity (which is why client needs adequate sodium and fluid intake-1.5-3 L/day) -NSAIDs: concurrent use increases renal absorption of lithium leading to toxicity (use aspirin for mild pain instead) -Anticholinergics: Abdominal discomfort can result from anticholinergic-induced urinary retention and polyuria Lithium Toxicity Symptoms: -Early indications: less than 1.5 mEq/L manifestations include: diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremors, slurred speech, lethargy (Hold med and notify provider) -Advanced indications: 1.5-2.0 mEq/L manifestations include: mental confusion, sedation, poor coordination, coarse tremors, and ongoing GI distress, including nausea, vomiting, and diarrhea (Hold med and notify provider, excretion may need to be promoted) -Severe toxicity: 2.0-2.5 mEq/L manifestations include: extreme polyuria of dilute urine, tinnitus, giddiness, jerking movements, blurred vision, ataxia, seziures, severe hypotension and stupor leading to coma, and possible death from resp complications (Administer an emetic, or gastric lavage; urea, mannitol, or aminophylline may be prescribed to increase the rate of excretion) -Greater than 2.5 mEq/L Manifestations: rapid progression of manifestations leading to coma or death (Hemodialysis can be warranted) *Lab Tests for Lithium:* -Evaluate renal and thyroid function -WBC w/ differential -Serum electrolytes (sodium) -Glucose -Monitor serum lithium levels (twice weekly during initiation of therapy and every 2 months during chronic therapy) *ECG

Exploring (effective therapeutic communication skills and techniques)

Allows the nurse to gather more information regarding important topics mentioned by the client; Delving further into a subject, idea, experience, or relationship is especially helpful in clients who tend to remain on a superficial level of communication -"Please explain that situation in more detail" -"Tell me more about that particular situation"

Encouraging comparison (effective therapeutic communication skills and techniques)

Asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships helps client recognize life experiences that tend to recur and those aspects of life that are changeable. -"Was this something like...?" -"How does this compare with the time when...?" -"What was your response the last time this situation occurred?"

Monoamine Oxidase Inhibitors (MAOIs) (meds for depression)

-Phenelzine (Nardil) -Isocarboxazid (Marplan) -Tranylcypromine (Parnate) -Selegiline (Emsam) *transdermal patch *Client Education:* -Due to the risk for hypertensive crisis advise the client to avoid foods with tyramine (ripe avocados or figs, fermented or smoked meats, liver, dried or cured fish, most cheeses, some beer and wine, and protein dietary supplements) -Due to the risk of medication interactions, instruct the client to avoid all medications including OTC meds without first talking with provider about them. Complications/Side Effects: -CNS stimulation (anxiety, agitation, hypomania, mania) -Orthostatic hypotension -Hypertensive crisis (resulting from intake of dietary tyramine; manifestations include: headache, nausea & vomiting, increased HR, increased BP, Diaphoresis, change in LOC)- administer IV phentolamine -Local rash associated with transdermal application (Choose a clean, dry area for each application, apply a topical glucocorticoid on the affected area) **Contraindicated in clients taking SSRIs **Transdermal Selegiline is contraindicated in clients taking carbamazepine or oxcarbazepine **Concurrent use with TCAs can lead to hypertensive crisis **Concurrent use with Meperidine can lead to hyperpyrexia

Denial (Defense mechanism)

-Pretending the truth is not reality to manage the anxiety of acknowledging what is real; Refusing to acknowledge the existence of a real situation or the feelings associated with it ( A woman drinks every day and cannot stop, failing to acknowledge that she has a problem) -Adaptive use: A person initially says, "No, that can't be true" when told they have cancer -Maladaptive use: A parent who is informed that his son was killed in combat tells everyone one month later that he is coming home for the holidays

Eating disorders: review last class and all chapters in both ATI and townsend What would be in a treatment plan for those suffering from eating disorders?

-Provide a highly structured milieu in an acute care unit for the client requiring intensive therapy. -Develop and maintain a trusting nurse/client relationship through consistency and therapeutic communication -Use a positive approach and support to promote client self-esteem and positive self-image -Encourage client decision making and participation in the plan of care to allow for a sense of control -Establish realistic goals for weight loss or gain -Promote cognitive behavioral therapies: Cognitive reframing, relaxation techniques, journal writing, desensitization exercises. -Monitor the client's vital signs, intake and output, and weight (2-3 lbs/week is medically acceptable) -Use behavioral contracts to modify client behaviors -Reward the client for positive behaviors such as completing meals or consuming a set number of calories. -Closely monitor the client during and after meals to prevent purging, which can necessitate accompanying the client to the bathroom. -Monitor the client for maintenance of appropriate exercise -Teach and encourage self care activities. -Incorporate the family when appropriate in client education and discharge planning. -Work with a dietitian to provide nutrition education to include correcting misinformation regarding food, meal planning, and food selection. -Consider the client's food preferences and ability to consume food when developing the initial eating plan. -A structured and inflexible eating schedule at the start of therapy, only permitting food during scheduled times, promotes new eating habits and discourages binge or binge-purging behavior. -Provide small, frequent meals which are better tolerated and will help prevent the client from feeling overwhelmed. -Provide liquid supplement as prescribed -Provide a diet high in fiber to prevent constipation. -Provide a diet low in sodium to prevent fluid retention. -Limit high-fat and gassy foods during the start of treatment. -Administer a multivitamin and mineral supplement -Instruct the client to avoid caffeine to reduce the risk for increased energy, resulting in difficulty controlling eating disorder behaviors. Caffeine also can be used by clients as a substitute for healthy eating. -Make arrangements for the client to attend individual, group, and family therapy to assist in resolving personal issues contributing to the eating disorder. -Meds: Fluoxetine (Prozac)

Schizophrenia

-Schizophrenia spectrum and other psychotic disorders affect thinking, behavior, emotions, and the ability to perceive reality -Schizophrenia probably results from a combination of genetic, neurobiological, and nongenetic (injury at birth, viral infection, and nutritional) factors. -The typical age at onset is late teens and early 20s, but schizophrenia has occurred in young children and can begin in later adulthood. Psychotic disorders become problematic when manifestations interfere with interpersonal relationships, self-care, and ability to work -With schizophrenia: the client has psychotic thinking or behavior present for at least 6 months. Areas of functioning, including school or work, self care, and interpersonal relationships, are significantly impaired. *Positive Symptoms:* Manifestations of things that are not normally present; usually the most easily identified: -Hallucinations -Delusions -Alterations in speech: flight of ideas, neologisms, echolalia, clang associations, word salad -Bizarre behavior, such as walking backward constantly *Negative Symptoms:* Absence of things that are normally present. These manifestations are more difficult to treat successfully than positive symptoms: -Affect: usually blunted (narrow range or expression) or flat (facial expression never changes) -Alogia: poverty of thought or speech. The client might sit with a visitor but only mumble or respond vaguely to questions -Anergia: lack of energy -Anhedonia: Lack of pleasure or joy. The client is indifferent to things that often make others happy, such as looking at beautiful scenery -Avolition: lack of motivation in activities and hygiene. For ex, the client completes an assigned task, such as making his bed, but is unable to start the next common chore without prompting *Cognitive Symptoms:* Problems with thinking make it very difficult for the client to live independently -Disordered thinking -Inability to make decisions -Poor problem solving ability -Difficulty concentrating to perform tasks -Memory deficits -Long-term memory -Working memory, such as inability to follow directions to find an address *Affective Symptoms:* Manifestations involving emotions: -Hopelessness -Suicidal ideation

Intellectualization (Defense mechanism)

-Separation of emotions and logical facts when analyzing or coping with a situation or event; An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis (Susan's husband is being transferred with his job to a new city far away from her parents. She hides anxiety by explaining to her parents the advantages associated with the move) -Adaptive use: A law enforcement officer blocks out the emotional aspect of a crime so he can objectively focus on the investigation -Maladaptive use: A person who learns he has a terminal illness focuses on creating a will and financial matters rather than acknowledging his grief

Review the DSM-5 a diagnostic tool for diagnosis information in ATI. What would the nurse use this for?

-THE DSM-5 is used as a diagnostic tool to identify mental health diagnoses. It is used by mental health professionals for clients who have mental health disorders -Nurses use the DSM-5 in the mental health setting to identify diagnoses and diagnostic criteria to guide assessment; to identify nursing diagnoses; and to plan, implement, and evaluate care

Encouraging description of perceptions (effective therapeutic communication skills and techniques)

Asking client to verbalize what is being perceived is a technique often used with clients experiencing hallucinations -"Tell me what is happening now" -"Are you hearing the voices again?" -"What do the voices seem to be saying?"

Projection (Defense mechanism)

Attributing one's unacceptable thoughts and feelings onto another who does not have them -Adaptive use: N/a -Maladaptive use: A married woman who is attracted to another man accuses her husband of having an affair

Psychotic or catatonic disorder not otherwise specified (Catatonic Schizophrenia)

-The client exhibits psychotic features such as impaired reality testing or bizarre behavior (psychotic) or a significant change in motor activity behavior (catatonic) but does not meet criteria for diagnosis with another specific psychotic disorder Symptoms (need 3 or more for diagnosis): -Stupor(no psychomotor activity) -Catalepsy (passive induction of a posture held against gravity) -Waxy flexibility (slight, even resistance to positioning by examiner) -Mutism (no, or very little, verbal response) -Negativism (opposition or no response to instructions or external stimuli) -Posturing (spontaneous and active maintenance of a posture against gravity) -Mannerism (odd, circumstantial caricature of normal actions) -Stereotypy (repetitive, abnormally frequent, non-goal-directed movements) -Agitation (not influenced by external stimuli) -Grimacing -Echolalia (mimicking another's speech) -Echopraxia (Mimicking another's movements) -This diagnosis is made when the symptomatology is evidenced from medical history, physical exams, or lab findings to be directly attributable to the physiological consequences of another medical condition such as metabolic disorders (hepatic encephalopathy, hypo/hyperthyroidism, hypo/hyperadrenalism, and vitamin b12 deficiency) and neurological conditions (epilepsy, tumors, cerebrovascular disease, head trauma, and encephalitis) *Nursing Interventions*

Offering general leads, broad opening statements (effective therapeutic communication skills and techniques)

-This encourages the client to determine where the communication can start and to continue talking *Giving Broad Openings:* Allows the client to take the initiative in introducing the topic; emphasizes the importance of client's role in the interaction. -"What would you like to talk about today?" -"Tell me what you are thinking" *Offering general leads:* General leads offer client encouragement to continue -"Yes, I see" "Go on" -"And after that?"

Essential Components of Therapeutic Communication

-Time: plan for and allow adequate time to communicate; some pts can require a longer period of time to respond to questions -Attending behaviors or active listening: nonverbal means of conveying interest in another. Eye contact, body language and posture, vocal quality, verbal tracking provides feedback by restating or summarizing a client's statements -Caring attitude: show concern and facilitate an emotional connection with the client and the client's family. -Honesty: Be open, direct, truthful, and sincere -Trust: demonstrate reliability w/o doubt or question -Empathy: convey an objective awareness and understanding of the feelings, emotions, and behaviors of others, including trying to envision what it must be like to be in the position of the client and the client's family. -Nonjudgmental attitude: this is a display of acceptance that will encourage open, honest communication -Genuineness: pt's can tell if you are not genuine!

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (meds for depression)

-Venlafaxine (Effexor) -Duloxetine (Cymbalta) *Client education:* -Adverse effects include nausea, insomnia, weight gain, diaphoresis, headahce, agitation, anxiety, dry mouth, and sexual dysfunction -Caution in administering to clients who have a history of hypertension Notes: -2nd line treatment if SSRI resistant depression -Duloxetine (Cymbalta) also used for diabetic neuropathy -Duloxetine cannot be used in pts who have hepatic disorder or who consume large amounts of alcohol

Suppression (defense mechanism)

-Voluntarily denying unpleasant thoughts and feelings -Adaptive use: A student puts off thinking about a fight she had with her friend so she can focus on a test -Maladaptive use: A person who has lost his job states he will worry about paying his bills next week

Accepting (effective therapeutic communication skills and techniques)

Acceptance conveys an attitude of reception and regard (acknowledge's nurse's interest and non judgmental attitude) -"Yes I understand what you said" -Eye contact & nodding

Giving recognition (effective therapeutic communication skills and techniques)

Acknowledging and indicating awareness is better than complimenting, which reflects the nurse's judgement. (acknowledges nurse's interest and non judgmental attitude) -"Hello, Mr. J I noticed that you made a ceramic ash tray in OT" -"I see you made your bed"

Review all sections: Section 35

Admission for alcohol or substance abuse

Paraphrasing (effective therapeutic communication skills and techniques)

Restates the client's feelings and thoughts for the client to confirm what has been communicated

Placing the event in time or sequence (effective therapeutic communication skills and techniques)

Clarifying the relationship of events in time help nurse and client to view them in perspective -"What seemed to lead up to...?" -"Was this before or after...?" -"When did this happen?"

What is cognitive reframing? When would it be used?

Cognitive reframing: -Changing cognitive distortions can decrease anxiety. -Cognitive reframing assists clients to identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self talk -For ex, a client who has a depressive disorder might say he is "a bad person" who has "never done anything good" in his life. Through therapy, this client can change his thinking to realize that he might have made some bad choices, but that he is not "a bad person" Involves: -Priority restructuring: Assists clients to identify what requires priority, such as devoting energy to pleasurable activities -Journal keeping: helps clients write down stressful thoughtsand has a positive effect on well-being -Assertiveness training: teaches clients to express feelings, and solve problems in a non-aggressive manner -Monitoring thoughts: Helps clients to be aware of negative thinking -Cognitive reframing can be used to decrease anxiety and change behavior in clients with substance use and addictive disorders -Also used in therapy for eating disorders

Dissociation (Defense mechanism)

Creating a temporary compartmentalization or lack of connection b/w the person's identity, memory, or how they perceive the environment -Adaptive use: A parent blocks out the distracting noise of her children in order to focus while driving in traffic -Maladaptive use: A woman forgets who she is following a sexual assault

Rationalization (defense mechanism)

Creating reasonable and acceptable explanations for unacceptable behavior;Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors (John tells the rehab nurse, "I drink because its the only way I can deal with my bad marriage and my worse job") -Adaptive use: An adolescent boy says "she must already have a boyfriend" when rejected by a girl -Maladaptive use: A young adult explains he had to drive home from a party after drinking b/c he had to feed his dog

Isolation (Defense mechanism)

Separating a thought or memory from the feeling, tone, or emotion associated with it -Without showing any emotion, a young woman describes being attacked and raped

Delusions Name the different types of delusions

Delusions: alterations in thought are false fixed beliefs that cannot be corrected by reasoning and are usually bizarre. These include the following: *-Ideas/Delusions of Reference:* Misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about him (ideas of reference); All events within the environment are referred by the psychotic person to himself or herself (ex of delusion of reference-someone is trying to get a message to me through the articles in this newspaper or through this tv show) *-Persecution:* Feels singled out for harm by others (e.g. being hunted down by the FBI); common in elderly patients; Most common type, the individual believes they are being persecuted or malevolently treated in some way (being plotted against, cheated or defrauded, followed and spied on, poisoned, or drugged) *-Grandeur/Grandiose:* Believes that she is all powerful and important, like a god; Individuals with grandiose delusions have irrational ideas regarding their own worth, talent, knowledge, or power (May believe they have a special relationship w/ famous person or that they are a famous person *-Somatic delusions:* Believes that his body is changing in an unusual way, such as growing a third arm; Believe they have some type of general medical condition *-Jealousy:* Believes that her partner is sexually involved with another individual even though there is not any factual basis for this beleif *-Erotomantic type:* the individual believes tat someone, usually of a higher status, is in love with him or her. Famous people are often the subjects *-Being Controlled:* Believes that a force outside his body is controlling him *-Thought Broadcasting:* Believes that her thoughts are heard by others *-Thought Insertion:* Believes that others' thoughts are being inserted into his mind *-Thought Withdrawal:* Believes that her thoughts have been removed from her mind by an outside agency *-Religiosity:* Is obsessed with religious beliefs *-Magical thinking:* Believes his actions or thoughts are able to control a situation or affect others, such as wearing a certain hat makes him invisible to others *-Nihilistic delusions:* the individual has a false idea that the self, a part of the self, others, or the world is nonexistent (ex. "The world no longer exists" or "I have no heart") *-Mixed type:* When the disorder is mixed, delusions are prominent, but no single theme is predominant.

Splitting (Defense mechanism)

Demonstrating an inability to reconcile negative and positive attributes of self or others -Adaptive use: N/a -Maladaptive use: A client tells a nurse that she is the only one who cares about her, yet the following day, the same client refuses to talk to the nurse

Reflecting (effective therapeutic communication skills and techniques)

Directs the focus back to the client in order for the client to examine his feelings; Questions and feelings are referred back to client so that they may be recognized and accepted adn so that client may recognize that his or her point of view has value- a good technique to use when client asks the nurse for advice -Client: "What do you think I should do about my wife's drinking problem?" -Nurse: "What do you think you should do? -Client: "My sister won't help a bit toward my mother's care. I have to do it all" -Nurse: "You feel angry when she doesn't help"

ECT review: Prep for this procedure? How often given and how? What would the nurse teach a client about to receive this procedure? What meds would be given?

ECT can be useful for some clients who have a depressive disorder and are unresponsive to other treatments -Anesthesia first (pre-op and post-op meds), muscle relaxant, anticholinergic, etc. -Maybe altropine first b/c dries people up (Dries up secretions) to prevent aspiration and respiratory concerns during treatment -MAO inibitors, depakote, and some other drugs have to be stopped a few weeks ahead of ECT b/c ECT induces seizures and these drugs have anticonvulsant effects so they would interfere with this treatment -ECT is given every other day for series of 12 treatments, if meds haven;t worked. Causes a 45 sec seizure. Causes short term amnesia, so have to educate pt ahead of time, so they aren't scared that they can't remember -ECT is only used for resistant treatment if meds haven't worked *Prep for this procedure & meds:* -informed consent -30 min prior to procedure IM injection of atropine sulfate given to decrease secretions that could cause aspiration and to counteract any vagal stimulation effects, such as bradycardia. -At the time of the procedure, an anesthesia provider administers a short acting anesthetic, such as methohexital or propofol, via IV bolus -A muscle relaxant such as succinylcholine is then administered to paralyze the client's muscles during the seizure activity, which decreases risk of injury -Severe hypertension needs to be controlled because immediately after procedure hypertension may occur for a short period -Any cardiac conditions (such as dysrhythmias or hypertension should be monitored and treated before the procedure) -IV line inserted and maintained until full recovery -Nurse monitor vitals and mental status before and after the procedure -Electrodes are applied to the scalp for electroencephalogram (EEG) monitoring -Client receives 100% O2 during and after ECT procedure until the return of spontaneous respirations -Ongoing cardiac monitoring is provided, including blood pressure, ECG, and O2 saturation -Clients are expected to become alert about 15 min following procedure *What would the nurse teach the client about to receive this procedure?* -Teach them the basics of what the procedure involves -Explain that the meds given before (muscle relaxant, anesthesia, and anticholinergics) will keep pt from feeling any pain and will keep pt safe -Teach pt that short term memory loss, confusion, and disorientation are common immediately after procedure. memory loss could last several hours to weeks (but very unlikely that it is permanent memory loss) -Assess the client and family's understanding and knowledge of the procedure and provides teaching as necessary. Many clients and fam have misconceptions about ECT due to media portrayals of the procedure. Due to the use of anesthesia and muscle relaxants, the tonic-clonic seizure activity associated with the procedure in the past is no longer an effect of the treatment. Complications: -Short term memory loss, confusion, disorientation immediately following procedure-could persist for several hours to weeks (provide a safe environment to prevent injury, and provide frequent orientation) -Reactions to anesthesia -Cardiovascular changes -Headache, muscle soreness, and nausea (administer antiemetic and analgesic as necessary) -Relapse of depression: not a permanent cure, maintenance ECT (weekly or monthly) can decrease the incidence of relapse Contraindications for ECT: no absolute contraindications but some medical conditions put pt at higher risk for adverse effects: Cardiovascular disorders and cerebrovascular disorders

Compensation (Defense mechanism)

Emphasizing strengths to make up for weaknesses -Adaptive use: An adolescent who is physically unable to play contact sports excels in academic competitions -Maladaptive use: A person who is shy works at computer skills to avoid socialization

Presupposition Questions (effective therapeutic communication skills and techniques)

Explores the client's life goals or motivations by presenting a hypothetical situation in which the client no longer has the mental health disorder

Voicing Doubt (effective therapeutic communication skills and techniques)

Expressing uncertainty as to the reality of a client's perceptions is a technique often used with clients experiencing delusional thinking -"I understand that you believe that to be true, but I see the situation differently" -" I find that hard to believe (or accept)" -"That seems rather doubtful to me"

Open-ended Questions (effective therapeutic communication skills and techniques)

Facilitates spontaneous responses and interactive discussions

Group Therapy

Focus of group therapy: -Helping individuls develop more functional and satisfying relations within a group setting Goals of group therapy: Goals vary depending on type of group, but clients generally: -Discover that members share some common feelings, experiences, and thoughts -Experience positive behavior changes as a result of group interaction and feedback -Sharing common feelings and concerns -Sharing stories and experiences -Diminishing feelings of isolation -Creating a community of healing and restoration -Providing a more cost-effective environment than that of individual therapy Examples of group therapy include: -Stress management -Substance use disorders -Medication and Education -Understanding mental illness -Dual diagnosis groups -Democratic leadership: supports group interaction and decision making to solve problems -Laissez-faire leadership: progresses without any attempt by the leader to control the direction -Autocratic leadership: the leader completely controls the direction and structure of the group without allowing group interaction or decision making to solve problems *Group Process:* is the verbal and nonverbal communication that occurs during group sessions, including how the work progresses *Group norm:* Is the way the group behaves during sessions, and over time, it provides structure for the group. For ex, a group norm could be that members raise their hand to be recognized by the leader before they speak. Another norm could be that all members sit in the same places for each session. *Hidden Agenda:* Some group members (or the leader) might have goals different from the stated group goals that may disrupt group processes. For ex, three members might try to embarrass another member whom they dislike *A subgroup:* Is a small number of people within a larger group who function separately from the group -Groups can be open (new members join as old members leave) or closed (no new members join after formation of the group) *Homogeneous group:* Is one in which all members share a certain chosen characteristic, such as diagnosis or gender. Membership of heterogenous groups is not based on a shared chosen characteristic. An ex of a heterogenous group is all clients on a unit, including a mixture of men and women who have a wide range of diagnoses *PHASES OF GROUP DEVELOPMENT:* 1. Orientation Phase -Primary focus: define the purpose and goals of the group Responsibilities: The group leader sets a tone of respect, and confidentiality among members -Members get to know each other and the group leader -There is a discussion about termination 2. Working Phase -Primary focus: Promote problem-solving skills to facilitate behavioral changes. Power and control issues may dominate this phase Responsibilities: -The group leader uses therapeutic communication to encourage group work toward meeting goals -Members take informal roles withing the group, which may interfere with, or favor, group progress toward goals 3. Termination Phase -Primary Focus: This marks the end of group sessions Responsibilities: -Group members discuss termination issues -The leader summarizes work of the group and individual contributions -Members of a group can take on any of a number of roles *Roles:* -Maintenance roles: Members who take on these roles tend to help maintain the purpose and process of the group. For ex. the harmonizer attempts to prevent conflict in the group -Task Roles: Members take on various tasks within the group process: An ex is the recorder, who takes notes and records what occurs during each session -Individual Roles: These roles tend to prevent teamwork, because individuals take on roles to promote their own agenda. Examples include the dominator, who tries to control other members, and the recognition seeker, who boasts about personal achievements

Displacement (defense mechanism)

Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation; The transfer of feelings from one target to another that is considered less threatening or that is neutral (A client is angry at his doctor, does not express it, but becomes verbally abusive with the nurse) -Adaptive use: An adolescent angrily punches a punching bag after losing a game -Maladaptive use: A person who is angry about losing his job destroys his child's favorite toy

Silence (effective therapeutic communication skills and techniques)

Silence allows time for meaningful reflection & allows the client to collect and organize thoughts

Closed-ended Questions (effective therapeutic communication skills and techniques)

Helpful if used sparingly during the initial interaction to obtain specific data. The nurse should avoid using repeated closed-ended questions which can block further communication

Touch (effective therapeutic communication skills and techniques)

If appropriate, therapeutic touch communicates caring and can provide comfort to the client (Not usually a good idea with psych patients)

Introjection (Defense mechnanism)

Integrating the beliefs and values of another individual into one's own ego structure -Children integrate their parents' value system into the process of conscience formation. A child says to his friend, "Don't cheat. it's wrong"

Antipsychotics (Name some & what would the side effects be such as EPS?

Look in schizophrenia quizlet

Polysubstance abuse: What is the alcohol screening tool used for older adults called?

MAST-G -Older adults who use substances are especially prone to falls and other injuries, memory loss, somatic reports (headaches), and changes in sleep pattern -Indications of alcohol use in older adults can include a decrease in ability for self-care (functional status), urinary incontinence, and manifestations of dementia -Older adults can show effects of alcohol use at lower doses than younger adults -Polypharmacy (the use of multiple medications), the potential interaction between substances and medications, and age-related physiological changes raise the likelihood of adverse effects such as confusion and falls in older adult clients

Countertransference

Occurs when a health care team member displaces characteristics of people in her past onto a client Behaviors: -Nurse overly identifies with client -Nurse competes with client -Nurse argues with client Ex. A nurse may feel defensive and angry with a client for no apparent reason if the client reminds her of a friend who often elicited those feelings Nursing Implications: A nurse should be aware that clients who induce very strong personal feelings may become objects of countertransference

Transference

Occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client's personal life Behaviors: -Client expects exclusive services from the nurse (e.g. extra session time) -Client demonstrates jealousy of the nurse's time or attention -Client compares the nurse to a former authority figure Ex. A client may see a nurse as being like his mother and thus may demonstrate some of the same behaviors with the nurse as he demonstrated with his mother Nursing Implications: A nurse should be aware that transference by a client is more likely to occur with a person in authority

Reaction Formation (Defense mechanism)

Overcompensating or demonstrating the opposite behavior of what is felt; Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors (Jane hates nursing, she attended nursing school to please her parents. During career day, she speaks to prospective students about the excellence of nursing as a career) -Adaptive use: A man who is trying to quit smoking repeatedly talks to adolescents about the dangers of nicotine -Maladaptive use: A person who dislikes her neighbor tells others what a great neighbor she is

Offering Self (effective therapeutic communication skills and techniques)

Use of this technique demonstrates a willingness to spend time with the client. Indicates to the client that the nurse has genuine concern; increases client's feelings of self worth. -"I'll stay with you awhile" -"We can eat our lunch together" -"I'm interested in talking with you"

Projective Questions (effective therapeutic communication skills and techniques)

Uses "what if" or similar questions to assist clients in exploring feelings and to gain greater understanding of problems and possible solutions

Undoing (defense mechanism)

Performing an act to make up for prior behavior; Symbolically negating or cancelling out an experience that one finds intolerable -Adaptive use: An adolescent completes his chores without being prompted after having an argument with his parent -Maladaptive use: A man buys his wife flowers and gifts following an incident of domestic abuse

Verbalizing the implied (effective therapeutic communication skills and techniques)

Putting into words what client has only implied or said indirectly is a technique that can also be used with clients who are mute or are otherwise experiencing impaired verbal communication. This technique clarifies that which is implicit rather than explicit -Client: "It's a waste of time to be here. I can't talk to you or anyone -Nurse: Are you feeling that no one understands?" -Client: (mute) -Nurse: "It must have been very difficult for you when your husband died in the fire"

Questions (effective therapeutic communication skills and techniques)

Questions allow the nurse to obtain specific or additional information from the client

Conversion (Defense mechanism)

Responding to stress through the unconscious development of physical manifestations not caused by physical illness -Adaptive use: N/a -Maladaptive use: A person experiences deafness after his partner tells him she wants a divorce

Regression (defense mechanism)

Sudden use of childlike or primitive behaviors that do not correlate with the person's current developmental level; Responding to stress by retreating to an earlier level of development and the comfort measures associated with that level of functioning -Adaptive use: A young child temporarily wets the bed when she learns that her pet died; When 2 yr old Jay is hospitalized for tonsillitis he will drink only from a bottle although his mother states he has been drinking from a cup for 6 months. -Maladaptive use: A person who has a disagreement with a co-worker begins throwing things at her office

Summarizing (effective therapeutic communication skills and techniques)

Summarizing emphasizes important points and reviews what has been discussed

Brief psychotic episode

The client has psychotic manifestations that last 1 day to 1 month (30 days) in duration and their is an eventual full return to the premorbid level of functioning -Sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. -The individual experiences emotional turmoil or overwhelming perplexity or confusion -Evidence of impaired reality testing may include incoherent speech, delusions, hallucinations, bizarre behavior, and disorientation -Individuals with preexisting personality disorders appear to be susceptible to brief psychotic disorder -Catatonic features can also be associated with this disorder

Restating (effective therapeutic communication skills and techniques)

Uses the client's exact words/main idea to determine if the message received was accurate; gives them the opportunity to continue, or to clarify if necessary. -Client "I can't study. My mind keeps wandering" -Nurse: "You have trouble concentrating" -Client: "I can't take that new job. What if I can't do it?" -Nurse: "You're afraid you will fail in this new position"

Active listening (effective therapeutic communication skills and techniques)

The nurse is able to hear, observe, and understand what the client communicates and to provide feedback

Making Observations (effective therapeutic communication skills and techniques)

Verbalizing what is observed or perceived encourages client to recognize specific behaviors and compare perceptions with the nurse -"You seem tense" -"I notice you are pacing a lot" -"You seem uncomfortable when you..."

Focusing (effective therapeutic communication skills and techniques)

This technique helps the client to concentrate on what is important; Taking notice of a single idea or even a single word works especially well with clients who are moving rapidly from one thought to another (not therapeutic with clients who are very anxious) -"This point seems worth looking at more closely. Perhaps you and I can discuss it together"

Clarifying techniques (effective therapeutic communication skills and techniques)

This technique is used to determine if the message received was accurate. Includes: restating, reflecting, paraphrasing, exploring Striving to explain that which is vague or incomprehensible and searching for mutual understanding facilitates and increases understanding for both client and nurse -"I'm not sure that I understand. Would you please explain?" -"Tell me if my understanding agrees with yours" -"Do I understand correctly that you said...?"

Presenting reality (effective therapeutic communication skills and techniques)

This technique is used to help the client focus on what is actually happening and to dispel delusions, hallucinations, or faulty beliefs -"I understand that the voices seem real to you, but I do not hear any voices" -"There is no one else in the room but you and me"

Giving information (effective therapeutic communication skills and techniques)

This technique provides details that the client might need for decision making

Repression (defense mechanism)

Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness (ex. an accident victim can remember nothing about the accident) -Adaptive use: A person preparing to give a speech unconsciously forgets about the time when he was young and kids laughed at him while on stage -Maladaptive use: A person who has a fear of the dentist continually forgets to go to his dentist appointments

Formulating a plan of action (effective therapeutic communication skills and techniques)

When client has a plan in mind for dealing with what is considered to be a stressful situation, it may serve to prevent anger or anxiety from escalating to an unmanageable level. -"What could you do to let your anger out harmlessly?" -"Next time this comes up, what might you do to handle it more appropriately?"

Attempting to translate words into feelings (effective therapeutic communication skills and techniques)

When feelings are expressed indirectly the nurse tries to "desymbolize" what has been said and to find clues to the underlying true feelings -Client: "I'm way out in the ocean" -Nurse: "You must be feeling very lonely right now"

SADS person scale

is a tool for medical professionals to screen for suicide risk it is a mneumonic -10 yes or no questions, and each affirmative answer is 1 pt S: Male sex A: Age (<19 or >45 years) D: Depression P: Previous attempt E: Excess alcohol or substance use R: Rational thinking loss S: Social supports lacking O: Organized plan N: No spouse S: Sickness This score is then mapped onto a risk assessment scale as follows: 0-4: Low 5-6: Medium 7-10: High Modified SAD Persons Scale: The score is calculated from ten yes/no questions, with points given for each affirmative answer as follows: S: Male sex → 1 A: Age 15-25 or 59+ years → 1 D: Depression or hopelessness → 2 P: Previous suicidal attempts or psychiatric care → 1 E: Excessive ethanol or drug use → 1 R: Rational thinking loss (psychotic or organic illness) → 2 S: Single, widowed or divorced → 1 O: Organized or serious attempt → 2 N: No social support → 1 S: Stated future intent (determined to repeat or ambivalent) → 2 This score is then mapped onto a risk assessment scale as follows: 0-5: May be safe to discharge (depending upon circumstances) 6-8: Probably requires psychiatric consultation >8: Probably requires hospital admission