Q6E4

Panic level of anxiety

-behavior may be angry, withdrawn or aggressive with clinging and/or crying -unable to concentrate problem-solve. No longer rational or thinking logically -pt has loss of control and ability to function. Feels overwhelmed and helpless -grossly disoriented perceptions. Patient is unable to tell the difference between real and unreal -requires immediate attention

Which drugs can you die form during withdrawals if not managed

-benzos -alcohol

Sedative, Hypnotic or Anxiolytics

-benzos -zolpidem

Risk Factors for AD

-biggest risk factor is age: with each decade of life the risk increases -family Hx -head injuries

Antipsychotics and Dementia

-black label warning -increased mortality rate -increased vardiovascular disease and pneumonia -if they are put on one there needs to be a good reason for it (risk vs benefit)

Milieu therapy, or therapeutic community, is defined as

-"a scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual" -Within the therapeutic community setting, the client is expected to learn adaptive coping and interaction and relationship skills that can be generalized to other aspects of his or her life.

CMS (Center for medicare/medicaid studies) Interpretive Guidelines for Restraint & Seclusion

-According to federal law, all patients have the right to be free from physical or mental abuse, and corporal punishment - Restraint and seclusion cannot be imposed to coerce, discipline or retaliate against a patient by staff. -The only way restraint and seclusion can be imposed is to ensure the immediate physical safety of the patient, staff or others. -Provider must see patient within an hour of imposing restraint

AD Family Education

-chronic and progressive; they are not going to get better -meds slow progression they do not cure -will require more assistance overtime and eventually will be fully dependent on the caregiver -advanced directives -additional support -long term care facilites -social interaction is as effective as meds: encourage social interaction

Alzheimer's Disease

-chronic, progressive, may result in death -problem with thinking and memory -Alzheimer's disease (AD) accounts for 50 to 60 percent of all cases of NCD

Delirium

-common -life-threatening -potentially preventable -multi-factorial -elderly highly vulnerable

Validation Therapy

-communicating with a disoriented elderly person by validating and respecting their feelings in whatever time or place is real to them at the time, even though this may not correspond with our "here and now" reality -validation therapy validates the feelings and emotions of a person with NCD -it often integrates redirection techniques -the key is to agree with what they want, but by conversation and steering get them to do something without them realizing they are actually being redirected "that lady stole my watch" "that watch must be very important to you. Have you tried looking for it?"

Mild AD Sx

-confusion & memory loss -disorientation, getting lost in familiar places -problems with routine tasks -changes in personality & judgement

General Attitude

-cooperative / uncooperative -friendly /; hostile / defensive -uninterested / apathetic -attentive / interested -guarded / suspicious

Dopamine Mild Excess

-creativity -improved problem solving

Dopamine Action

-decision making -reward seeking -integrate thoughts & emotions -fine muscle control

Psychotic

-delusions -hallucinations

Positive Schizophrenia Sx

-delusions -hallucinations -thought disorder -disorganized speech -bizarre behavior -inappropriate affect -people are often diagnosed only after the positive symptoms start to manifest -antipsychotics only treat the positive Sx

Moderate AD Sx

-difficulty with ADLs -anxiety, suspiciousness, agitation -sleep disturbance -wandering and pacing -difficulty recognizing family and friends

Dopamine Severe Excess

-disorganized thoughts -loose associations -disabling compulsions -psychosis agitation -psychomotor activation

Common Delirium Signs & Symptoms

-disturbed attention and awareness -reduced level of alertness or arousal -acute onset and fluctuating course -fragmented sleep -disordered thought process -disorientation to time and place -executive dysfunction -memory impairment -visuospatial deficits -abnormalities of language -abnormalities of language -psychomotor agitation or retardation -illusions, hallucinations, delusions -labile affect -asterixis -frontal release signs

Mood Schizophrenia Sx

-dysphoria (a state of unease or generalized dissatisfaction with life) -suicidality -hopelessness

The pediatric clinic nurse is counseling a female teenage client that regularly uses marijuana. The client was recently in a car accident and is struggling in school. What would the nurse want to include in teaching?

-effects concentration, memory, coordination

Sedative, Hypnotic or Anxiolytics Withdrawal

-essentially s/s of anxiety -typically s/s of withdrawal correspond to the reasons why they got it in the first place -autonomic hyperactivity -increased hand tremor -insomnia -N or V -hallucinations -psychomotor agitation -grand mal seizures

Stimulant Intoxication

-euphoria -hypervigilance -changes in sociability -anxiety or tension -impaired judgement -chest pains, arrythmias (risk for MI/death) -muscle twitching -psychomotor agitation

Cannabis Action

-euphoria -sedation -impairment of short term memory (moderate dose) -slowed reaction times -hallucinations -amotivational syndrome (lazy)

Stimulant Withdrawal

-fatigue -depression -nightmares -profuse sweating -muscle cramps -hunger

Course of Schizophrenia

-first noticed age range: teens to mid 20s -Premorbid phase: -Prodromal phase: -Schizophrenia -Residual phase - periods of remission/exacerbation

Nursing Interventions: Hallucinations

-Observe for signs -Avoid touching: may be mispercieved -Convey acceptance -Do not reinforce: I do not see them but I know that you do -Help the client connect increased anxiety with hallucinations: know what precipitates them to increases self awareness -May need to teach distraction or voice dismissal: learn how to live with voices

Neurocognitive Disorder Primary vs Secondary

-Primary NCDs are those in which the disorder itself is the major sign of some organic brain disease not directly related to any other organic illness (e.g., Alzheimer's disease) -Secondary NCDs are caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma)

Care plan for the client with a cognitive disorder is aimed at

-Protection of self and others -Maintaining orientation to reality to the best of client's ability -Minimizing confusion -Fulfilling basic needs -Assisting and educating prospective caregivers about appropriate care for their loved one

Thought Process (form of thought)

-flight of ideas -associative looseness (talks about one unrelated topic after another) -circumstantiality (verbalizations are long and tedious and because of numerous details take the pt forever to get to the point) -tangentially (verbalization are long and tedious and never get to a point) -neoglisms (the individual is making up nonsensical sounds which only have meaning to them -concrete thinking -clang associations (speaking in puns and rhymes; using words that sound alike but have different meanings) -word salad -perseveration (persistently repeating the last word of a sentence sentence sentence -echolia (persistently repeating what another person says) -Mutism (does not speak either cannot or will not) -poverty of speech (doesn't talk much) -ability to concentrate and disturbance of attention

Risk Factors

-genetics -for the most part we dont really know -probably results from a combination of influences including biological, psychological, and environmental factors -if genetics are a factor using marijuana increases the risk of developing schizophrenia

Appearance

-grooming -hygiene -posture -height and weight -level of eye contact -hair color and texture -evidence of scars, tattoos, or other distinguishing skin marks -evaluation of clients appearance compared with chronological age

Quesitons to ask when doing a drug history

-how much -how long -how often -route -do you use any non prescription drugs -mode of use -when was the last use: withdrawals

Judgment and Insight

-ability to solve problems and make decisions -knowledge about self (awareness of limitations / consequences of actions / illness) -adaptive / maladaptive use of coping strategies

Benztropin

-acetylcholine and dopamine need to be in balance -if antipsychotics are used we need to also use benztropine to maintain this balance to decrease risk of EPS

Battery

-actually touching the person -meds against their will

IV Heroin Withdrawal

-acute abstinence

Negative Schizophrenia Sx

-affective flattening -alogia -avolition/apathy -anhedonia/associality -attention defecit -antipsychotics do not help with the negative Sx

Education tidbit

-aging alone normally does not cause memory impairment

Random Wendy tidbit

-all antipsychotics are lipid soluble and tend to build up the elderly due to higher fat content

Prodromal Syndrome s/s often observed before violence

-anxiety and tension, verbal abuse and profanity and increasing hyperactivity

Cognitive Schizophrenia Sx

-attention -memory -executive function: abstraction, concept formation, problem solving, decision making

Projection

-attributing unacceptable desires to others -Chris often cheats on her boyfriend because she suspects he is already cheating on her

Sedative, Hypnotic or Anxiolytics Intoxication

-inappropriate sexual or aggressive behavior -mood lability -impaired judgement -slurred speech -incoordination -stupor -coma

Alcohol Withdrawal s/s

-tremor of hands, tongue, eyelids -N or V -tachycardia -elevated BP -depressed mood or lability -transient hallucinations -insomnia -may progress to delirium -severe dependence-*seizures and death*

Motor Activity

-tremors -tics or other stereotypical movements -mannerisms and gestures -hyperactivity -restlessness or agitation -aggressiveness -rigidity -gait pattern -echopraxia -psychomotor retardation -ROM

Twin Studies

-twins have a 4x higher rate of schizophrenia

Severe ANxiety

-verbalization of emotional pain "I need help" -pt has impaired concentration and problem solving ability. Selective attention and uni-focused -pt has tremors, increased motor activity such as spacing or wringing of hands -perception may be distorted -stimulated fight-or-flight response

Premorbid phase:

-very shy and withdrawn -poor peer relationships -doing poorly in school -antisocial behavior -may be asymptomatic

Alcohol OD s/s

-vomiting -coma -Resp depression -hypotension

Least Restrictive Alternative

-way back when people used to get committed for almost anything -nowadays people have rights lol and because of that they have the right to be treated in the least restrictive way in the least in the least restrictive enviroment

Schizophrenia Social / Occupational Dysfunction

-work -relationships -self-care -mortality

anhedonia

inability to feel pleasure

Opioid Treatment Center

methadone clinic

Side Effects of atypical antipsychotics

most common -weight gain -DM -Hyperlipidemia less common -cataracts -Prolonged QT interval -myocarditis -sexual side effects -EPS -sedation overall atypicals work very well and are the 1st line Tx -usually take 2-4 weeks to work -AE are usually seen before the drug starts to work

Neuroleptic Malignant Syndrome

rare but life threatening -similar to malignant hyperthermia -FEVER -tachycardia -labile BP -tachypnea -immeidately stop antipsychotics -cool the patient -rehydration -dopamine agonist -dantrolene

Tolerance

reduced drug responsiveness that develops over course of drug use -may require more pain meds to stop pain in the hospital

Nursing Role in the Psychiatric Setting

-Therapeutic use of self is the instrument for delivery of care to clients in need of psychosocial intervention. -Interpersonal communication techniques are the "tools" of psychosocial intervention.

ADDICTION

-Addiction is a brain disease -Relapse is a part of the disease, not (necessarily) a sign of failure -Addiction is a treatable disease -The sooner an addict gets treatment, the better. -The longer an addict stays in treatment, the greater the chances that treatment will be effective -chronic illness -Addiction is NOT a moral failure -Drugs and alcohol can "hijack" the brain's reward system and pleasure pathways -The risk factors for addiction may include genetic and environmental factors such as stress and availability -Drug and alcohol abuse usually begins in adolescence, when the brain is still undergoing dramatic changes in both structure and function -The younger one starts abusing drugs or alcohol, the greater the changes they will become addicted -Adolescents with drug or alcohol problems may require a different type of treatment than adults -Many addicts have one or more-co-occurring mental disorders (such as depression or ADHD) that need to be addressed and treated at the same time as a substance abuse disorder (dual diagnosis treatment) -There are medical treatments available to help treat addiction to opioids (methadone, suboxone) -Evidence-based behavioral therapies are the best available treatment for treating addiction to stimulants (learning to manage thoughts, Inpatient: 4-5 hrs a day in group sessions, lots of independent work, one on one counceling sessions, bring in 12 step groups into facility) -Treatments for addiction are as effective as treatments for other chronic, relapsing diseases such as diabetes, hypertension or asthma -Treatment does not have to be voluntary to be effective, but ultimately the addict must take personal responsibility for his or her recovery -AA and other 12-step programs are mutual support groups and alone are not considered treatment. They help many people, but do not work for everyone -If one type of treatment does not seem to work for the addict, he or she should keep at it until they find the treatment that is right for them -Addiction should be viewed as a chronic illness, one that may require continuing care, also known as "aftercare, which increases the changes of prolonged recovery

Psychological Responses

-Anxiety and grief have been described as two major, primary psychological response patterns to stress. -A variety of thoughts, feelings, and behaviors are associated with each of these response patterns. -Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individual's functioning.

Standards of Psychiatric-Mental Health Nursing Practice: Interventions - Notes

-Basis of all is therapeutic relationship: requires self awareness, knowledge of services, interpersonal skills, non-judgmental attitude -Counseling to assist clients in improving coping skills and preventing mental illness and disability -Mileau therapy to provide and maintain a therapeutic environment for the client -Self-care activities to foster independence and mental and physical well-being -Psychobiological interventions to restore the clients health and prevent further disability -Health Teaching to assist clients in achieving satisfying, productive, and healthy patterns of living. -Case management to coordinate comprehensive health services and ensure continuity of care. -Health promotion and maintenance- implements strategies with clients to promote and maintain mental health and prevent mental illness.

FDA controlled substances

-C1: ecstasy, heorin, LSD, marijuana, peyote -C2: hydromorphone, methadone, oxycodone, fentanyl, morphine, opium, codeine, cocaine, amphetamine, methamphetamine -C3: vicodin, tylenol w/codeine, ketamine, anabolic steroids -C4: benzos -C5: robitussin AC, phenergan w/codeine -controlled to reduce risk for dependence -C1 is the highest risk for potential abuse and dependence

Ethical/Legal Issues in Psychiatric Nursing: the right to the least restrictive alternative (LRA)

-Continuum of setting: outpatient (may get released if they agree to take their meds and show up to outpatient counseling sessions), inpatient (eastern state is a last resort) -Type: voluntary versus involuntary (cant protect themselves or are a danger to others), open or closed unit -Intervention: verbal techniques, chemical intervention, physical restraint, seclusion

Characteristics of a Crisis

-Crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology. -Crises are precipitated by specific identifiable events. -Crises are personal by nature. -Crises are acute, not chronic, and are resolved in one way or another within a brief period. -A crisis situation contains the potential for psychological growth or deterioration.

Factors that Can Precipitate Delirium

-Demographic Characteristics -Cognitive Status -Environmental -Functional Status -Sensory -Decreased Oral Intake -Drugs -Coexisting medical Conditions -Surgery

Motivational Approaches to Change

-Express empathy through reflective listening -Develop discrepancy between patients' goals or values and their current behavior -Avoid argument or direct confrontation -Roll with resistance -Support self efficacy HCP are coaches -help pt identify their goal and how we can help them achieve that

Heroin

-IV heroin "rush", euphoria •Route: IV injection (preference), smoking, and nasal inhalation (known as sniffing or snorting) •IV-effects w/greatest intensity and fastest onset (7-8sec) •Smoked or snore-effects develop more slowly (10-15 min) •When heroin is administered orally or subcutaneously, as opposed to IV, its effects can not be distinguished from those of morphine or other opioids. oOnce in the brain, heroin is rapidly converted into morphine, its active form.

What Causes Delirium

-Infection: sepsis, encephalitis, meningitis, syphilis, CNS abscess -Withdrawal: alcohol, barbiturates, sedative hypnotics -Acute Metabolic: acidosis, electrolyte imbalances, hepatic/renal failure, hypo/hyperglycemia -Trauma: head, burns - CNS Disease: hemorrhage, CV accident, seizures, tumor -Hypoxia: acute hypoxia, chronic lung disease, hypotension -Deficiencies: B12, niacin, thiamine -Environmental: hypo/hyperthermia, endocrinopathies, DM, adrenal, thyroid -Acute Vascular: HTN emergency, SAH, -Toxins/Drugs: meds, street drugs, alchol, pesticides, industrial posions, carbon monoxide, cyanide, solvents -Heavy Metals: lead, mercury, Metallica

Sensorium and Cognitive Ability

-LOC / consciousness -orientation -memory -capacity for abstract thought

Methadone

-Maintenance and suppressive therapy -Prevents euphoria inducing effects of opioids -Dispensing confined to FDA approved clinics: long waiting list to get in due to limited facilities, have to go to facility every day to get dose

Heroin AE

-N/V -resp depression sedation -ortho hypo -constipation -urinary retention

Neurocognitive Disorder Classification

-Neurocognitive disorder (NCD) may be classified as mild or major, depending on severity of symptoms. -Mild NCD has also been called Mild Cognitive Impairment. -Major NCD constitutes what was previously described in the DSM as dementia.

Positive Sx Notes

-Psychosis is a disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization. Psychotic states are periods of high risk for agitation, aggression, impulsivity, and other forms of behavioral dysfunction. -Hallucinations are false sensory perceptions occurring in any of the five sensory modalities. Auditory hallucinations are the most common, followed by visual, tactile, olfactory, and gustatory. -Delusions: False beliefs that are firmly held despite obvious evidence to the contrary, and not typical of the patient's culture, faith, or family, are classified as delusions. Thought disorganization - Disruption of the logical process of thought may be represented by loose associations, nonsensical speech, or bizarre behavior. These symptoms are typically accompanied by a high level of functional impairment and high risk for agitated and aggressive behavior. -Agitation - agitation is an acute state of anxiety, heightened emotional arousal, and increased motor activity. Agitation is common in a variety of psychiatric and medical conditions, and frequently accompanies psychosis. When anxiety presents in the context of a psychosis, it must be treated concurrently. -Aggression - acts or threats of violence are common in acute psychotic states, especially in patients with persecutory delusions, thought disorganization, and poor impulse control. Antipsychotic medications do not reduce the likelihood of violence in the general population. However, medications that reduce active psychotic symptoms are effective in reducing the risk of violence occurring in the context of psychosis

Conditions Essential to Development of a Therapeutic Relationship

-Rapport: this is a must for any theraeputic relationship -Trust -Respect -Genuineness -Empathy

Here are the 10 warning signs of Alzheimer's

-Recent memory loss that affects job skills -Difficulty performing familiar tasks -Problems with language -disorientation to time and place -Poor or decreased judgment -Misplacing items -Changes in mood or behavior -Changes in personality -Loss of initiative -Problems with abstract thinking

Nursing Diagnosis/Outcome Identification

-Risk for trauma -Disturbed thought processes -Impaired memory -Disturbed sensory perception -Risk for other-directed violence -Impaired verbal communication -Self-care deficit -Situational low self-esteem -Grieving

-JG, 49‐year‐old, seen in ED 2 days ago and diagnosed with alcohol and released after 8 hours in his brother's care. Brought back to ED 12 hours ago with active GI bleed & alcohol intoxication. According to ED notes: -84/50, 110, 26 vomiting bright red blood. -Labs: Hct 23%, ALT 69, AST 111, serum ETOH 271 -He was given fluids & 6 units PRBCs in ED. -You note that JG's provider has not diagnosed JG as having an alcohol use disorder and his orders do not include treatment for alcohol withdrawal. 1) What action is necessary before you continue to care for JG? 2) What standard assessment tool would be helpful?

-S/S alcohol overdose: respiratory depression, mental confusion, unconsicious Withdrawal: CNS irritability, anxiety, increased vital signs, tremors, ataxia, diaphoresis, slurred speech, GI disturbance, disorientation, hallucinations, seizures, death 1) Alcohol withdrawal protocol CIWA Replace B1 vitamins (Thiamine, folate, riboflavin) Alcohol dependence: Tolerance, withdrawal and compulsive use Alcohol abuse: maladaptie pattern of substance use despite adverse outcomes 2) CAGE Tool: Cut down, Annoyed, Guilt, Eye opener

The most common client diagnoses associated with violence include

-Schizophrenia (most are non-viloent) -Major depression -Bipolar disorder -Substance use disorders -Neurocognitive disorders -Antisocial, borderline, and intermittent explosive personality disorders

Schizophrenia Risk Factor Notes

-Schizophrenia is considered a developmental brain disorder, a disorder of brain circuits, with genetic and environmental predisposing factors. -Common co-occurring conditions: Drug abuse, Diabetes, Heart disease Genetic factors are important (50% in monozygotic twins), but not sufficient, to precipitate the disorder. A variety of environmental factors have been identified in the etiology of schizophrenia, most of them with at least plausible connections to neurodevelopment. Advanced paternal age is more prevalent in schizophrenia patients than the general population -First and second trimester insults to fetal development, including viral infection, starvation, and toxic exposure are correlated with an increased risk of schizophrenia. Vulnerability is heightened in the perinatal period, during which anoxia, birth trauma, and toxic exposure are known risk factors -Exposure to psychoactive drugs in adolescence and young adulthood is also associated with greater risk Most cases start in early 20s. Research on "prodromal" stage, which precedes the first psychotic episode, has identified factors that may predict schizophrenia in up to 80% of youth

Developmental Theories & Mental Health

-Stages are identified by age. However, personality is influenced by temperament (inborn personality characteristics) and the environment. -It is possible for behaviors from an unsuccessfully completed stage to be modified and corrected in a later stage. -Stages overlap, and individuals may be working on tasks from more than one stage at a time. -Individuals may become fixed in a certain stage and remain developmentally delayed. This can be the result of drug abuse or trauma among other things

Other Causes of Psychotic Disorders

-Substance use or medication -Another medical condition -Schizoaffective disorder (thought and mood disorder combined)

Important Areas for Ongoing Monitoring

-Suicidality -MSE -Homicidality - MSE -Psychosis - MSE -Mood - MSE -Anxiety - MSE -Sleep (often over/under sleep with stress) -Appetite/Dietary intake -Activity/ability to function -Social Interaction

Extrapyramidal Symptoms

-TD does not go away with d/c of the meds -Td less common

Whether individuals experience a crisis in response to a stressful situation depends on three factors

-The individual's perception of the event -The availability of situational supports -The availability of adequate coping mechanisms

Crisis Intervention

-The minimum therapeutic goal of crisis intervention is psychological resolution of the individual's immediate crisis and restoration to at least the level of functioning that existed before the crisis period. -getting through the immediate crisis is key -A maximum goal is improvement in functioning above the pre-crisis level.

Countertransference

-The reaction of the nurse to the client that may interfere with objectivity -Tendency of the nurse to displace feelings related to people in his or her past onto a patient

The involuntary admission process

-involuntary admission is the civil court process by which a petition is filed to initiate involuntary psychiatric Tx for a person who need care but is unwilling, or incapable of volunteering for Tx -the petition is adjudicated by a judge or special justice at a formal court hearing -due process protectio0ns are important, but balancing rights of individuals with community interests and public safety can often be difficult. Tx resources are limited and controversies abound -procedures seem simple, but effective implementation is a complex task under best circumstances

Cannabis Withdrawal

-irritability, aggression -nervousness, anxiety -sleep difficulty, disturbing dreams -decreased appetite -restlessness -despressed mood

Rationalization

-justifying behaviors by substituting acceptable reasons for less-acceptable real reasons -Kim failed his history course because he did not study or attend class, but he told his roommates that he failed because the professor didn't like him

Severe AD Sx

-loss of speech -loss of appetite and weight loss -loss of bladder and bowel control -total dependence on caregiver

Mini Mental State Exam

-memory and concentration test -clock drawing test 90% accuracy

Levels of anxiety

-mild -moderate -severe -panic

AD Meds

-only slow progression of disease -they do not cure -chronic, progressive, may be fatal

Mild anxiety

-patterns and thoughts are logical, and is able to concentrate or problem solve -patients appears calm and in control -produces an increase in the level of awareness and alertness -motivates learning and is associated with daily life -is considered a helpful adaptive response to stress

Addiction Tx

-peer groups and environment -all you have to change is everything... -people, places, and things

Moderate Anxiety

-pts speech rate and volume is increased. Pt becomes wordy -pt can still focus and problem solve -pt becomes restless with frequent body movements and gestures -sensory stimuli perceptions is dulled and client becomes hesitant -can still do motivated learning

Sublimation

-redirecting unacceptable desires through socially acceptable channels -Jerome's desire for revenge on the drunk driver who killed his son is channeled into a community support group for people who've lost loved ones to drunk driving

Reaction Formation

-reducing anxiety by adopting beliefs contrary to your own opinion -Nadia is angry with her coworker Beth for always arriving late to work after a night of partying, but she is nice and agreeable to Beth and affirms partying is "cool" -essentially her reaction is opposite of how the person is feeling

Denial

-refusing to accept real events because they are unpleasant -Kaila refuses to admit she has an alcohol problem although she is unable to go a single day without drinking excessively

IV Heroin Intoxication

-resp depression -coma -pinpoint pupils

Regression

-returning to coping strategies from less mature stages of development -After failing to pass his doctoral exams, Giorgio spends days in bed cuddling his favorite childhood toy

Speech Patterns

-slowness or rapidity of speech -pressure of speech -intonation (are words spoken with appropriate emphasis, are words spoken in monotone/without emphasis -volume -stuttering or other speech impairments -aphasia

Prodromal phase:

-substantial functional impairment -sleep disturbance -anxiety -irritability -depressed mood -poor concentration -fatigue -behavioral defecits

Delirium Characteristics

-sudden onset -temporary -common in ICU -usually has medical cause

The Dopamine Hypothesis

-suggests that schizophrenia is caused by an excess of dopamine-dependent neuronal activity in the brain -antipsychotics reduce neuronal transmission of dopamine pathways

Repression

-suppresing painful memories and thoughts -LaShea cannot remember her grandfather's fatal heart attack, although she was present

Cannabis Intoxication

-tachycardia -impaired motor coordination -sensation of slowed time -conjuctival injection -delusions -hallucinations -paranoia -panic (rare)

Caregiving and Alzheimers

-the nurse spends a significant portion of the time on interventions helping the caregiver if the pt is still in the house educate about options: -at home with unpaid care: friends and family coming over to give them a break -at home paid care -respite care -specialized assisted living communities

Restraints

-the physician must reissue a new order for restraints Q4hr for adults and Q1-2 for children -restraints should be used as a last resort after all other interventions have been unsuccessful and the client is clearly at risk to self or others

Random fact while searching for LRA in the back of the book

-the term lesbianism, used to identify female homosexuality, is traced to the Greek poet Sappho who lived on the island of Lesbos and is famous for the love poems she wrote to other women -beginning in the late 1800s, homosexuality was classified as a mental illness. This remained the case until 1973 when the APA removed the classification from the DSM

CIWA Protocol

-this isnt the same picture she showed in class which had the drugs below on it -chlordiazepoxide -lorazepam -Assists clinical personnel to recognize the process of withdrawal before it progresses to more advance stages; directs pharmacotherapy intervention

Displacement

-transferring inappropriate urges or behaviors onto a more acceptable or less threatening target -During lunch at a restaurant, Mark is angry at his older brother, but does not express it and instead is verbally abusive to the server

Stimulants Action

-tremor -restlessness -agitation -insomnia -increased mental agility -paranoia -compulsive behavior -hallucinations -constipation -increased orgasms

Confusion Assessment Method (CAM) Diagnostic Algorithm

1&2 + either 3 or 4 Feature 1 Acute Onset & Fluctuating Course -Is there evidence of an acute change in mental status from patient baseline? -Did the(abnormal) behavior fluctuate during the day? Feature 2 Inattention -Did the patient have difficulty focusing attention? -spell WORLD forwards and backwards -serial 7s: start at 100 and subtract by 7s Feature 3 Disorganized Thinking -Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversions or unpredictable switching topics? Feature 4 Altered Level of Consciousness -Overall, how would you rate this patient's LOC? (alert, vigilant, lethargic, stuporous, comatose) 1 Acute onset & fluctuating course 2 inattention 3 Disorganized Thinking 4 altered LOC

30 year old female 24 hours post admission for pneumonia. Vital signs: 170/90, 125, 20, 99 F. Lung sounds diminished on right side. Grinding teeth, difficulty paying attention, rapid speech. Mother arrived for a visit one hour ago. 1) What is causing these vital signs and symptoms? 2) What actions should the nurse take?

1) Amphetamines produce arousal and elevation of mood with euphoria and talkativeness, sense of increased physical strength andmental capacity, self confidence increased, little or no need for food or sleep, organsm delayed and intensified 2) Nurse can notify MD, arrange for transfer, prepare to pharmacologically treat symptoms Adverse: psychotic state with hallucinations and paranoid ideation, can be triggered by a single dose but usually long term use; Sympathomimetic: vasocontriction and excessive heart stimulation causing hypertension, angina and dysrhythmias. OD: Cerebral and systemic vasculitis and renal failure leading to stroke Withdrawal:Dysphoriaand strong sense of craving plus fatigue, prolonged sleep, excessive eating and depression which can persist for months.

75-year-old Caucasian male with sadness, tearfulness, lack of appetite, weight loss for 2 months since the death of his wife of 50 years. Patient goes to church weekly, continues in weekly poker club and has breakfast with friends on the weekend. 1) Is there any indication of mental illness?

1) No indication of mental illness. The person is showing sings of mourning but there is no indication that is impairing him in any way

20 year old female admitted to ED with RR 9, BP 100/60, pulse 68. Pinpoint pupils. She withdraws to pain. PMH: Asthma, one child age 1, normal vaginal delivery, chronic pain from back injury, bipolar disorder (not currently medicated) 1) What commonly abused substances may be causing her symptoms? 2) What physical assessment might give cues to the abused drug? 3) What drug might be given to reverse the overdose?

1) Opioids (Morphine and semi synthetics - methadone, meperidine, oxycodone, codeine, heroin) AEB Decreased respirations, pinpoint pupils, sedation 2) track marks 3) naloxone

Anger/Aggression Management: Interventions

1) Remain calm: anger expressed by the nurse will most likely incite increased anger in the client 2) Set verbal limits on behavior: consistency in enforcing the consequences is essential if positive outcomes are to be achieved 3) Have the client keep a diary of angry feelings, what triggered them, and how they handled them: provides objective measure of the problem 4) Avoid touching the client: the client may view the touch as threatenting and become violent 5) Help determine source of anger: many times anger is being displaced onto a safer object or person. If resolution is to occur, the first step is to identify the source of the problem 6) Ignore derogatory remarks: lack of feeback often distinguishes an undesirable behavior 7) Help find alternative ways of releasing tension, sucha s physical outlets, and more appropriate ways of expressing anger, sucha s seeking out staff when feelings emerge: client will lkiely need assistance to problem solve more appropriate wats to behave 8) Role-model appropriate ways of expressing anger assertively, such as, "I dislike being called names. I get angry when I hear you saying those things about me": role modeling is one of the strongest methods of learning 1) Observe for escalation of anger (the prodromal stage): increased motor activity, pounding, slamming, tense posture, defiant affect, clenched teetha dn fists, arguing, demanding, and challenging or threatening staff: violence may be prevented if risks are identified in time 2) When behaviors are observed, first ensure that sufficient staff is available. Attempt to defuse the anger with the least restrictive means: the initial consideration must be having enough help to diffuse the potentially violent situation. Client rights must be honored, while preventing harm to client and others

Phases in the Development of a Crisis

1) The individual is exposed to a precipitating stressor. 2) When previous problem-solving techniques do not relieve the stressor, anxiety increases further. 3) All possible resources, both internal and external, are called on to resolve the problem and relieve the discomfort. 4) If resolution does not occur in previous phases, the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the individual occurs, often with drastic results.

30-year-old Hispanic female feeling hopeless, helpless, sleeps 2-3 hours per night, lost 15 pounds in the last month, unable to care for children 2 and 4 years old, lost her spouse of 10 years to an accident at work 7 months ago. Has been unable to work since husband's death. 1) Any indication of mental health?

1) Yes, her sleep is disrupted, lost 15 lbs last month, unable to care for children, unable to work since her husbands death.

-73-year-old AF admitted with left trochanter fracture (tripped over Chihuahua while trying to get to door). Niece was at door and called 911. -Never married, lives alone, drives, has dinner every Sunday with family, plays cards with friends. -Medical History: Diabetes (Metformin), no cognitive impairment -116/80 92, 20, 95% Afebrile -Delirium screen: speaks clearly, socially appropriate, concisely describes how he was hospitalized and past. Oriented to time and place and reports his age and birthdate. Asks about impending surgery. Attentive. Able to spell world backward. -Pain 7/10. Given Dilaudid 2 mg IV for pain and methocarbamol (Robaxin) for spasm. -Niece calls nurse, she is worried about his behavior. Mr. F. says, "What am I doing here? It's time to feed the dog. Where's Wilma?" 1) Is there a distinct change in mental status from baseline? Can you spell the word "world" backward? He is unable to 2) Is he positive for inattention?

1) Yes: went from no impairment to "What am I doing here? It's time to feed the dog. Where's Wilma?" 2) Yes: previosuly was able to spell world backwards and then upon Sx onset was unable to do it

Impaired Verbal COmmunication R/T panic anxiety, withdrawal, disordered, unrealistic thinking AEB loose association of ideas, neoglisms, word salad, clang association, echolalia, verbalization that reflect concrete thinking, poor eye contact Interventions & Rationale

1) attempt to decode incomprehensible communication patterns. Seek validation and clarification by stating "Is it that you mean...?" or "I dont understand what you mean by that. Would you please explain it to me?": these techniques reveal how the client is being perceived by others, while the responsibility for not understanding is accepted by the nurse 2) maintain staff assignments as consistently as possible: this facilitates trust and understanding between client and nurse 3) the technique of verbalizing the implied is used with the client who is mute (unable or unwilling to speak). Example - "that must have been very difficult for you when your mother left. You must have felt alone": this approach conveys empathy and may encourage the client to disclose painful issues 4) anticipate and fulfill clients needs until functional communication pattern returns : client safety and comfort are nursing priorities 5) orient client to reality as required. Call the client by name. Validate those aspects of communication that help differentiate between what is real and what is not: these techniques may facilitate restoration of functional communication patterns in the client 6) explanations must be provided at the clients level of comprehension. Example - "pick up the spoon, scoop some mashed potatoes into it, and put it in your mouth": because concrete thinking prevails, abstract phrases and cliches must be avoided, as they are likely to be misinterpreted

Distrubed THought Porcesses R/T inability to trust, panic anxiety, possibel hereditary or biochemical factors AEB delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract or conceptualize; extreme suspiciousness of others Interventions & Rationale

1) convey acceptance of clients need for the false belief, but indicate that you do not share the belief: client must understand that you do not view the idea as real 2) DO NOT ARGUE*** or deny the belief. Use "reasonable doubt: as a therapeutic technique "I understand that you belief this is true, but I personally find it hard to accept": arguing with the client or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded 3) reinforce and focus on reality. Discourage long ruminations about irrational thinking. Talk about real events and real people: discussions that focus on the false ideas are purposeless and useless, and may even aggravate the psychosis

Social Isolation R/T inability to trust, panic anxiety, weak ego development, delusional thinking, regression AEB withdrawal, sad, dull affect, need-fear dilemma, preoccupation with thoughts, expression of feelings of rejection or of aloneness imposed by others Interventions & Rationale

1) convey an accepting attitude by making brief, frequent contacts: an accepting attitude increases feeling of self worth and facilitates trust 2) show unconditional positive reward: this conveys a belief in the client as a worthwhile human being 3) offer to be with client during group activities that he or she finds frightening or difficult: the presence of a trusted individual provides emotional security for the client 4) give recognition and positive reinforcement for clients voluntary interactions with others: positive reinforcement enhances self esteem and encourages repetition of acceptable behaviors

Distrubed Sensory Perception R/T panic anxiety, extreme loneliness and withdrawal into the self AEB inappropraite responses, disordered thought sequencing, rapid mood swings, poor concentration, disorientation Interventions & Rationale

1) observe clinet for s/s of hallucinations (listening pose, laughing or talking to self, stopping midsentence): early intervention may prevent aggressive response to command hallucinations 2) avoid touching the client without warning them that you are about to do so: pt may perceive touch as threatening and may respond in aggressive manner 3) an attitude of acceptance will encourage the pt to share the content of the hallucination with you: this is important to prevent possible injury to the client or others from command hallucinations 4) DO NOT reinforce the hallucination. Use "the voices" instead of words like "they: that imply validation. Let client know that you do not share the perception. Say, "even though I realize the voices are real to you, I do not hear any voices speaking": it is important for the nurse to be honest, and the client must accept perception as unreal before hallucinations can be eliminated 5) Help the client understand the connection between increased anxiety and the presence of hallucinations: if client can learn to interrupt escalating anxiety, hallucinations may be prevented 6) try to distract the client form the hallucination involvement in interpersonal activities and explanation of the actual situation will help bring the client back to reality 7) for some client auditory hallucinations persist after the acute psychotic episode has subsided. Listening to the radio or watching TV helps distract some clients from attention to voices. Others have benefited from an intervention called voice dismissal. With this technique, the client is taught to say loudly, "go away" or "leave me alone" in a conscious effort to dismiss the auditory perception: these activities assist the client to exert some conscious control over the hallucination

Disturbed Sensory Perception r/t cerebral degeneration AEB auditory and visual hallucinations Nursing Interventions & Rationale

1) do not ignore hallucinations when it is clear that the pt is experiencing them. It is important for the nurse to hear an explanation of the hallucination form the pt: these perceptions are very real and often frightening to the pt. Unless they are appropriately managed, hallucinations can escalate into disturbing and even hostile behaviors 2) rule out the disturbed sensory perception as a possible side effect of certain physical conditions or meds: physical changes in the elderly result in less ability to metabolize meds, causing an increased risk of side effects. Some infections are also known to cause hallucinations in the elderly 3) check to ensure that hearing aid is properly working and that faulty sounds are not being emitted: faulty sounds could be misinterpreted for auditory hallucinations 4) check eyeglasses to ensure that the individual is indeed wearing their own glasses: wearing the wrong prescription could cause the individual to misinterpret visual perceptions 5) try to determine from where the visual hallucination is emanating, and correct the situation by moving or covering the item: clients often see faces in patterns on fabrics or in pictures on the wall. A mirror can also be the culprit of false perceptions 6) distract the pt. Focus on real situations and people: hallucinations are less likely to occur when the person is occupied or involved in what is going on around them 7) depending on the situation, it may be better at times to go along with the client rather than attempting to distract them: not all hallucinations are upsetting, and there are times when trying to distract the person from hallucination may incur increased stress and agitation in the individual

Disturbed Thought Processes; Impaired Memory r/t cerebral degeneration AEB disorientation, confusion, memory deficits, and inaccurate interpretation of the environment Nursing Interventions & Rationale

1) frequently orient pt to reality. Use clocks and calendars with large numbers that are easy to read. Notes and large, bold signs may be useful as reminders. Allow client to have personal belongings: all of these items serve to maintain orientation and aid in memory recognition 2) keep explanations simple. Use face to face interaction. Speak slowly and do not shout: facilitates comprehension. Shouting may create discomfort, and possibly provoke anger 3) discourage rumination of delusional thinking. Talk about real events and real people. But remember that the clients level of reality is different from the nurses. Do not lie to the client. May need to use validation therapy and redirection: rumination promotes disorientation. Reality orientation and validation therapy increase a sense of self worth and personal dignity 4) monitor for med side effects: physiological changes in the elderly can alter the bodys response to certain meds. Toxic effects may intensify altered thought processes 5) encourage client to view old photo albums and utilize reminiscence therapy: these are excellent ways to promote self esteem and provide orientation to reality

Hypothalamic Pituitary Axis: Short Term Stress Response

1) glycogen breaks down to glucose; increased blood glucose 2) increased BP 3) increased breathing rate 4) increased metabolic rate 5) changes in blood flow patterns leading to increased alertness and decreased digestive and kidney activity -all of these are adaptive responses due to stress which allow us to be able to be more alert in order to protect ourselves

Risk for Violence R/T extreme suspiciousness, panic anxiety, catatonic excitement, rage reactions, command hallucinations, overt and aggressive acts, goal directed destruction of objects in the environment, self destructive behavior or active aggressive suicidal acts Interventions & Rationale

1) maintain low level of stimuli in pts environment (low lighting, few people, simple decor, low noise level): anxiety level rises in a stimulating environment. A suspicious agitated client may perceive individuals as threatening 2) observe clients behavior frequently. Do this while carrying out routine activities: observation during routine activities avoids creating suspiciousness on the part of the client. Close observation is necessary so that intervention can occur if required to ensure client and others safety 3) remove all dangerous objects from the clients environment: prevents client, in an agitated, confused state, from using them to harm self or others 4) intervene at the first sign of anxiety, agitation or verbal or behavioral aggression. Offer empathetic response to the clients feelings "you seem anxious (or frustrated or angry) about this situation. How can I help?": validation of the clients feelings conveys a caring attitude and offering assistance reinforces trust 5) it is important to maintain a calm attitude toward the client. As the clients increases, offer some alternatives <participating in physical activity (punching bag, exercise), talking about the situation, taking some anxiety meds>: offering alternatives to the client gives them a feeling of some control over the situation 6) have sufficient staff available to indicate a show of strength to the client if it becomes necessary: this shows the client evidence of control over the situation and provides physical security for staff 7) if client is not calmed down by :talking down" or by meds, use of mechanical restraints may be necessary: LRA must be selected when planning interventions for a violent client. Restraints should be used only as a last resort after all other interventions have been unsuccessful and the client is at risk of harm to self or others 8) if restraints are deemed necessary make sure sufficient staff is available to help. Must be evaluated by physician within 1hour of restraints or seclusion. Must reissue new order Q4 (adults) and Q1-2 (children): these interventions are necessary for the protection of client and staff 10) 1:1 for one hour then can be monitored via video and audio. Circulatory checks Q15. Keep hydrated and fed, and manage elimination. Position client for comfort and prevention of aspiration: client safety is a priority 11) as agitation decreases, assess the clients readiness for restraint removal or reduction. Remove one restraint at a time while assessing clients response: this minimizes the risk of injury to client and staff.

A 72-year-old man who is still managing investments at a brokerage firm seeks consultation at the urging of his wife for increasing difficulty with memory over the past 2 years. Clients have expressed concern about his occasional lapses in memory. His wife reports that he frequently repeats questions about social appointments and becomes angry when she points this out. The physical examination is normal, but the patient has difficulty remembering elements of a brief story and adding a small amount of change. He has a score of 28 out of 30 on the Mini-Mental State Examination, indicating slightly impaired cognitive function. Early Alzheimer's disease is suspected. 1) What collaborative care should the nurse expect? 2) What should the nurse teach the family about the progression of the disease? 3) What are some of the nursing problems that this patient may develop? 4) The family asks what causes Alzheimer's disease, what should the nurse say? 5) What medications should the nurse expect? 6) What are some other causes of temporary dementia?

1) meds, impact assessment, education 2) chronic progressive disease, med compliance important, meds only slow progression does not cure, AE of meds, stay connected and socialize to help prevent progression, keep pt in familiar surroundings, assistance options, advanced directives, long term care, support groups 3) depends on the state of progression, see nursing Dx for AD 4) we dont really know, we do know that the risk increases with age, link to head injury 5) Donezepil, Memantine, antidepressants if depressed, antipsychotics if he becomes aggressive 6) infection, meds, drugs, toxins, trauma, CNS disease, hypoxia

JG is a 40 year old woman with schizoaffective disorder. She has recently been involuntarily admitted to the inpatient psychiatry unit with grave related to delusions and paranoia. She stopped risperidone 1 week ago. This is her seventh hospital admission for similar symptoms. She is stabilized on risperidone. Prior to discharge she is started on depot injection risperidone. 1) What does the patient need to know about the injections? 2) What is the advantage of injectable antpsychotic medication?

1) must come to clinic monthly for a shot, AE 2) dont have to worry about taking pills daily not on test

55-year-old woman, taken to ER after hotel manager where she was living called authorities because hotel room smelled like urine and feces, mattress and couch were covered with urine ad feces. Empty food containers, dirty dishes and clothing everywhere. No delusions and psychosis. Throughout hospital stay, patient refused to shower or wear Attends, although she was incontinent in both bowel and bladder. 1) Can this patient be legally detained? 2) If so, why? 3) Who has the authority to detain a mentally ill client? 4) What process is followed after the detention?

1) possibly 2) if her behaviors were affecting her health then yes she could 3) DMHP 4) -thorough mental health assessment - court hearing within 48-72hr to see if she is fit to reenter society or if there is a justified reason for her to stay longer

Self Care Defect r/t disorientation, confusion, and memory deficits AEB inability to fulfill ADLs Nursing Interventions & Rationale

1) provide a simple structure environment: to minimize confusion a) identify self care deficits and provide assistance as required. Promote independent actions as able b) allow plenty of time for client to perform tasks c) provide guidance and support for independent actions by talking the client through the task one step at a time d) provide a structured schedule of activities that does not change from day to day e) ADLs should follow usual routine as closely as possible f) provide for consistency in assignment of daily caregivers 2) perform ongoing assessments of pts ability to fulfill nutritional needs, ensure personal safety, follow med regimen, and communicate need for assistance with activities that he or she cannot accomplish independently: pt safety and security are nursing priorities 3) assess prospective caregivers ability to anticipate and fulfill clients unmet needs. Provide info to assist caregivers with this responsibility. Ensure that caregivers are aware of available support systems from which they may seek assistance when required. Examples include adult day care centers, housekeeping and homemaker services, respite care services, or the local chapter of the national support organization: to ensure provision and continuity of client care

Self Care Defecit R/T withdrawal, regression, panic anxiety, perceptual or cognitive impairment, inability to trust AEB difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, toileting Interventions & Rationale

1) provide assistance with self care as required. Some clients who are severely withdrawn may require total care: client safety and comfort are nursing priorities 2) encourage client to perform as many activities independently as possible. Provide positive reinforcement for independent accomplishments: enhance self esteem and promote repetition of desirable behaviors 3) use concrete communication to show client what is expected. Provide step by step instructions for assistance with ADLS: because concrete thinking prevails, explanations must be provided at the clients level of comprehension 4) ceative approaches may need to be taken with the client who is not eating, such as allowing the client to open own canned or packaged foods; family style serving may also be an option: these techniques may be helpful with the client who is paranoid and may be suspicious that they are being poisoned 5) if toileting needs are not being met, establish a structured schedule for client: will help client establish a pattern so that they can develop a habit of toileting

-Mrs. Livingstone has lived alone for the past several years, doing her own cooking and caring for herself. Her daughter, Judy, who lives in another city, calls Mrs. Livingstone each week although she has not seen her mother for about 6 months. -During the last phone call, Judy became concerned. Her mother seemed distracted, frequently interrupted the conversation and repeatedly said that she was "so worried." When asked what worried her, Mrs. Livingstone said, "I just don't know." She repeatedly asked the same question. -Alarmed, Judy drove to her mother's home six hours away. When she arrived, Judy was shocked to see how thin her mother had become. There was little in the house to eat except tapioca pudding, gelatin and applesauce. Judy was able to figure out that Mrs. Livingstone had broken her dentures and was having difficulty chewing. Her skin turgor is sluggish. -Mrs. Livingstone said the coffeemaker and the TV did not work. The daughter used both and found them to be working. Mrs. Livingstone often started tasks but did not finish them, she seemingly forgot what she was doing. Often could not think of words, such as the name of the dresser in her bedroom -As evening approached Mrs. Livingstone became more agitated and was unable to sleep. She said she had to "see about the children." -Judy brought her mother home with her the following day and made an urgent appointment with her family doctor to evaluate Mrs. Livingstone's condition. -During the examination, Mrs. Livingstone was unable to focus on the nurse's questions and instructions. She knew her own identity, was unsure of her exact location and did not know the current date. She became visibly agitated with the questions and said she didn't want to answer or says 'I don't know, well I do know but I am not going to answer." (probably because she was unable to answer). -Mrs. Livingstone thought the physician was the son of one of her friends from home and asked him several times about his mother. She complained of fatigue and epigastric tenderness. She was 20 pounds under her ideal body weight and she was pale. Lab tests revealed iron deficiency anemia, low albumin, and dehydration. 1) List the signs of confusion seen in this case. Which stage of Alzheimer's disease would you assign Mrs. Livingstone? 2) Why do you think the daughter failed to recognize Mrs. Livingstone's problems. 3) What are appropriate nursing problems for Mrs. Livingstone? 4) What collaborative interventions are needed? 5) What nursing interventions are appropriate? 6) What patient/family teaching is needed at this time?

1) see next card, stage 2 2) doesnt see her often 3) see nursing Dx 4) she needs a caregiver 5) based on problems 6) chronic and progressive, etc

The inpatient psychiatric nurse is caring for an obese patient that is hallucinating that has grabbed a female patient around the neck and is threatening to strangle her. Which of the following actions would be most appropriate? Select all that apply: -Tell the patient to let go -Call a code grey -Request the prescribed PRN haloperidol -Put the patient in seclusion -Distract the patient

1) setting verbal limits: Tell the patient to let go: 2) medication: Request the prescribed PRN haloperidol 3) call for assistance: Call a code grey 4) Restraints: Put the patient in seclusion not sure where distraction comes in to play but the others are in correct order -restraints are always a last measure

-RB has just been admitted to the inpatient psychiatric unit with the diagnosis Schizophrenia: paranoid type. He is 22 years old and has been attending the local university and living at home with his parents. He has always been a good student and has been active socially. Last semester his grades began declining, and he became very withdrawn He spends most of his time along in his room. His grooming has deteriorated; he may go days without bathing. For several weeks before admission, he insisted on keeping all of the blinds and curtains in the house closed. - For the past 2 days he has refused to eat, saying, "they have contaminated the food." As you approach RB, you note that he appears to be carrying on conversation with someone, but there is no one there. When you talk to him, he looks around and answers in a whisper but gives you little information. 1) What are the negative symptoms of schizophrenia that RB may be experiencing? You should be able to identify at least three (DSM-IV-TR). 2) Identify one positive symptom of schizophrenia that RB is experiencing? 3) What are delusions of grandeur? 4) What symptoms would indicate that RB has paranoid schizophrenia? 5) Why is it important to know RB's history before he is diagnosed with schizophrenia? 6) What diagnostic screening would be important in evaluating RB? 7) What meds are commonly used to treat SZ? Organize according to atypical antipsychotics and typical antipsychotics.

1) withdrawn, isolating, refusal to eat, blinds closed, decreased grooming and showering 2) voices 3) think they are more powerful than they actually are "I am God" 4) 5) substance abuse? 6) H&P, lab work 7)

A 70-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep track of appointments and recent telephone calls, but the process has been insidious. She lives independently in the community; she drives a car, pays her bills, and is normal in appearance. A mental status examination revealed slight difficulty on delayed recall of four words, but the results were otherwise normal. 1) Does the patient have mild cognitive impairment? 2) What collaborative care should the nurse expect?

1) yes this is a classic example 2) frequent visits with HCP for monitoring of progression -also anyone can call the DOL and suggest that someone needs to take a driving test to see if they are safe to drive, including us

RB goes is discharged and, after living at home for six months, he is able to start taking classes again part-time. 11) What types of psychosocial treatments may be used to support RB and his family? 12) What are important indicators of relapse in schizophrenia that the nurse can teach the family?

11) individual therapy, psychoeducation, 1:1 counseling, support groups 12) changes in sleep and behavior are the most common. This is true for most mental health disorders

Addiction Risk Factors

Biology/genes -genetics -gender -mental disorders Environment -chaotic home and abuse -parents use and attitude -peer influences - community attitudes poor social achievement Drug -route -effect of drug itself -early use -availability -cost

Which client should the nurse see first? 1) Client with delusions that FBI is following him 2) Elderly client with neurocognitive disorder stabbed visitor with a fork 3) Client withdrawing from methamphetamine 4) Client with hallucinations of a man's voice criticizing her

2) Elderly client with neurocognitive disorder stabbed visitor with a fork -danger to self and others

3) What would be helpful for JG's provider to know regarding JG's substance abuse history? 4) What medications are commonly prescribed for patients withdrawing from alcohol? 5) What other medical problems will JG's physician need to be aware of as he provides care. 6) What phase of treatment is JG ending? 7) What types of education and referral should be done prior to JGs discharge from the hospital? 8) What are the goals of chemical dependency treatment?

3) Pattern of use:age started; legal history;physical injuries; withdrawal symptoms; social costs; 4) Benzodiazepines treat acute withdrawal 5) watch for s/s of dysrythmias and MI Other medical problems caused by alcohol: GI -gastritis, bleeding (gastric distress, nausea, vomiting, black stools, abd dist) Alcoholic hepatitis, ascites, cirrhosis CV - cardiomyopathy, heart failure, dysrhythmias, hypertension Blackouts Wernicke's - alcoholic encephalopathy(pataxia, paralysisof eye muscles, nystagmus, ental confusion) Korsakoff's - amnesia, disorientation, severe peripheral neuropaty, confabulation Infertility FAS Osteoporosis and myopathy 6) detox 7) ask if they want to stop, Tx options 8) Goals: complete cessaton of use (abstinence) or change in pattern from compulsive to moderate (Risk reduction)

Do you know today's date? He seems confused and asks where the dogfood is. -He demonstrates ongoing vigilance and anxiety (change in LOC) 3) What actions can the team take to decrease the delirium? 4) Would it be a good idea to give the patient lorazepam or risperidone for the symptoms?

3) determine cause and implement interventions: D/C dilaudid, reorient, hydration, family close by, limit stimuli 4) -No, they would only be ordered if the pt was unable to stay safe, -also his precipitating factor was likely due to meds so more meds is probably not the solution

-The patient's drug screen comes back positive for heroin, as does her pregnancy test -After the patient has stabilized and is ready for discharge, the hospital social worker approaches her about chemical dependency treatment using motivational interviewing. 4) What is this? The patient asks about how to find out about outpatient treatment and what to ask. 5) What should the social worker tell her? 6) What are co-occurring disorders? 7) Why is this relevant this patient? 8) To her child?

4) a short assessment done by a social worker designed to identify and help pts with drug/alcohol abuse issues to get Tx 5) give her info on whats available??? 6) mental health and abuse disorders co-occurring 7) bipolar + heroin addict 8) teratogenic effects?

RB is started on Risperidone and prn haloperidol. You inform RB and his family about the common side effects of the typical antipsychotics. 8) What routes can risperidone and haloperidol be administered? 9) Identify at least four adverse effects of each drug? 10) What would be the most important initial interventions in treating RB?

8) Risperdone: PO, IM; Haloperidol IM, IV, PO 9) Typicals: anticolergic effects, ortho changes, sedation, EPS, photophobia, Atypicals: weight gain, DM, hyperlipidemia, EPS 10) meds, sleeping eating, psychotherapy

cross-tolerance

A condition in which the development of tolerance for one drug causes an individual to develop tolerance for another drug. -in the hospital they will require stronger doses of opioids to achieve desired levels of pain relief

Alzheimer's Disease Stages

AD can be described in stages -Stage 1. No apparent symptoms: this stage can be going for 10-20 years before becoming symptomatic -Stage 2. Forgetfulness: progressive -Stage 3. Mild cognitive decline -Stages 4-7 up to severe cognitive decline: incontinent, lose ability to speak

Delirium Tx

Institute supportive measures -maintain hydration -avoid restraints -mobilize pt -reduce noise -reassurance -bedside sitters Does pt behavior interfere with care or safety? -Yes: low dose antipsychotics and/or benzos-> continue eval and Tx -No: continue eval and Tx Pt discharged to appropriate postacute setting

Transference

Transference The client reacts to the nurse as she did to an earlier significant other -This allows the client to experience feelings that would otherwise be inaccessible -Analysis of transference - allows client to gain insight into the influence of the past -the patient may have reactions toward the therapist that are actually based on feelings toward someone from the past

Impulse Control

Ability control impulses -aggression -hostility -fear -guilt -affection -sexual feelings

Collaborative Care

Acute -Physical and pharmacologic stabilization Long Term -Ongoing individual and/or group counseling -Pharmacologic therapy adjustment -Case management services, depending on severity and social system -Psychoeducation

Alogia

Alogia is the inability to speak because of mental defect, mental confusion, or aphasia. It is a speech disturbance that can be seen in people with dementia. However, it is often associated with the negative symptoms of schizophrenia. Alogia has been called a poverty of speech, or a reduction in the amount of speech.

Psychiatric Assessment

Always Send Mail Through the Post Office Appearance Speech Memory/Mood Perception Orientation she said these were the key ones but to also include judgement

Pharmacotherapy

Alzheimer's Dementia -Donepezil: N/D bradycardia, falls -Memantine -slows the progression, do not cure Depression: often 1st sign of AD -Antidepressants Behaviors -Antipsychotics: usually really low doses due to higher mortality rates when used for AD, risk vs benefit assessments, die from pneumonia or stroke

Key Typical Antipsychotic Common Adverse Effects

Anticholinergic Orthostatic changes Sedation Dermatologic photophobia Increased prolactin Extrapyramidal symptoms: -Early/Reversible: dystonia, akathesia, Parkinsonism -Late/Irreversible: tardive dyskinesia

Key Typical Antipsychotic Common Adverse Effects Notes

Anticholinergic effects (dry mouth, blurred vision, photophobia, urinary hesitancy, consitpation, tachycardia) Orthostatic hypotension Sedation EPS..various movement disorders suffered as a result of taking dopamine antagonists. 3 types: Dystonia (muscular spasms of neck, eyes, tongue or jaw) Dyskinesia (Pseudoparkinsonism)-stiffness, tremors, shuffling gait Akathesia inability to sit still commonly treated with Benztropine (Cogentin) or Benadryl Tardive dyskinesia SEE POSTED U-TUBE VIDEO- Late onset, permanent movement disorder (involuntary, irregular mm movements, usually in the face) Neuroendocrine-increased prolactin, gynecomastia, sexual dysfunction, photophobia

Pharmacotherapy

Antipsychotics -Atypical -Typical Antidepressants Antianxiety Agents

One proposed mechanism leading to Alzheimer's Disease

As alzheimers disease progress, neurofibrillary tangles spread throughout the brain. Plaques also spread throughout the brain, starting in the neurocortex. By the final stage, damage is widespread and brain tissue has shrunk significantly

Asociality

Asociality refers to the lack of motivation to engage in social interaction, or a preference for solitary activities.

Avolition

Avolition means a severe lack of initiative or motivation

Alcohol

CNS depressant and reward circuit stimulus Chronic effects -Cardiovascular- damages myocardium, increases BP -Depresses respiration: decreased resp & LOC increase risk of death form aspiration -Causes hepatic cirrhosis -Gastritis -Diuretic -Pancreatitis -Decreased sexual function -Increased cancer risk -Increases risk for fetal alcohol syndrome in pregnancy

The Marijuana Plant

Cannabis Sativa and Cannabis Indica • Over 100 described cannabinoid compounds and over 500 noncannabinoid constituents which vary widely between plants (not all marijuana is the same, relating to strength) • Most compounds found in the marijuana plant not well characterized or studied • Main psychoactive ingredient = Δ-9 tetrahydrocannabinol (THC) • Cannabidiol (CBD) also occurs in plant and is being studied • Many studies done with pharmaceutical THC or CBD, not with botanical form

Labile

Changing rapidly and often

Cognitive Sx Notes

Cognitive symptoms are subtle. Like negative symptoms, cognitive symptoms may be difficult to recognize as part of the disorder. Often, they are detected only when other tests are performed. Cognitive symptoms include the following: Poor "executive functioning" (the ability to understand information and use it to make decisions) Trouble focusing or paying attention Problems with "working memory" (the ability to use information immediately after learning it). Cognitive symptoms often make it hard to lead a normal life and earn a living. They can cause great emotional distress.

Crisis, Defined

Crisis is defined as a sudden event in one's life, during which usual coping mechanisms cannot resolve the problem; the crisis disturbs homeostasis.

The nurse is teaching a young person recently diagnosed with schizophrenia about the disorder. Which of the following points should the nurse include? A. "You'll likely need to be hospitalized in an inpatient mental health unit regularly." B. "Once hallucinations are controlled you'll be back to normal." C. "You probably won't be able to return to school." D. "There is a genetic transmission element to the disease."

D. "There is a genetic transmission element to the disease."

Who is responsible for deciding whether or not someone needs to be involuntarily committed?

DMHP Designated Mental Health Professional -they are licensed clinical social workers (LCSW) -they admit pts not the physician -their job is to protect the patient and only involuntarilky commit if there is a reason and do so using the LRA -hospital staff often gets frustrated with the DMHP because they dont commit the pt when the staff believes that they should be committed. -the pt has rights too -they are not trained in med management

Case 1 Notes

Diagnosis of Mental Illness: Clinically significant behavioral or psychological syndrome or pattern Causes present distress or Disability -impairment in one or more areas of function Is not a culturally sanctioned event DSM-IV definition: a clinical significant behavioral or psychological syndrome or pattern that occurs in a person and that Is associated with present distress or disability (impairment in one or more important areas of fx, or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom, and is not merely a culturally sanctioned response to a particular event (e.g. death of a loved one). Look for DSM V: six disorder categories: substance use, mood, major psychoses, anxiety, externalizing child, and personality disorders. Inability to accurately interpret the consequences of one's behavior

Perceptual Disturbances

Hallucinations -auditory -visual -tactile -olfactory -gustatory -illusions -depersonalization (out of body experiences) -derealization (altered perception of enviroment)

Thought Disorders: Psychosis (Positive Symptoms Schizophrenia)

Hallucinations Delusions Thought disorganization Agitation Aggression Goal: Help patient recognize psychosis develop strategies

PHYSICAL AND PSYCHOLOGIAL RESPONSES TO STRESS

Hypothalamic Pituitary Axis: Stress Response -stress triggers the release of CRH by the hypothalmus triggering the release of ACTH triggering the release of cortisol in the system

Neurocognitive Disorder

Impairment in the cognitive functions of thinking, reasoning, memory, learning, and speaking

Diagnosis - Identifying Needs & Selecting Goals of Care: Common Diagnoses

In mental health "risk for" are important nursing Dx -Risk for suicide -Risk for self or other directed violence -Disturbed thought process -Disturbed sensory perception:audio/visual -Risk for injury related to...... -Risk for self mutilation -Impaired nutrition: less than body requirement -Insomnia (often 1st indicator of changes in mental health is sleep changes) -Self care deficit -Social isolation -Ineffective coping -Chronic low self esteem -Anxiety (moderate to severe) -Impaired social interaction -Impaired verbal communication

Validation Therapy

Keep calm and validate -dont argue with them -agree with where they are at -empathize with feelings -it is the emotional content of what is said that is more important than the persons orientation to the president

Delirium Med FART

MED (Medical Cause) F (Fluctuating Course) A (Attentional Impairment) R (Recent Onset) T (Thinking Impairment) she had it as MED FRAT but I prefer this version

Ego Defense Mechanisms

MEMORIZE -the person is usually not conscious that they are doing them

Mental Illness

Maladaptive responses to stressors from the internal or external environment, evidenced by thought, feeling, and behaviors that are incongruent with the local & cultural norms, and interfere with the individual's social, occupational and/or physical functioning." -the important part here is that it interferes with the individual's social, occupational and/or physical functioning."

Role of the Nurse

Manage the therapeutic environment on a 24-hour basis. Ensure that the client's physiological and psychological needs are met, including: -Medication administration -Development of a one-to-one relationship -Setting limits on unacceptable behavior -Client education

The patient is interested in methadone maintenance treatment. What should the nurse tell her about methadone maintenance treatment? The patient is admitted to a methadone program after several months. She is readmitted to hospital for skin grafts from infected veins. What is cross-tolerance and why is it important for the hospital nurse to know about?

Methadone Maintenance Treatment transfers patient from abused opioid to methadone, thus avoiding withdrawing and the need to procure illegal drugs. Most effective when linked with non-drug treatment directed at alternating patterns of drug use Suppression prevents reinforcing effects of opioid induced euphoria. Because of cross tolerance, even opioid based street drugs produce less euphoric effect Methadone can only be prescribed/dispensed at an FDA approved agency. Methadone: QT interval prolongation Cross tolerance to several drugs in the same classification

Mild Cognitive Impairment Case Notes

Mild cognitive impairment represents an intermediate state of cognitive function between the changes seen in aging and those fulfilling the criteria for dementia and often Alzheimer's disease.1 Most people undergo a gradual cognitive decline, typically with regard to memory, over their life span; the decline is usually minor, and although it may be a nuisance, it does not compromise the ability to function. A minority of people, perhaps 1 in 100, go through life with virtually no cognitive decline and are regarded as aging successfully. However, another trajectory of aging is characterized by a decline in cognitive function beyond that associated with typical aging; the decline is often recognized by those experiencing it and occasionally by those around them Mild cognitive impairment is classified into two subtypes: amnestic and nonamnestic.3 Amnestic mild cognitive impairment is clinically significant memory impairment that does not meet the criteria for dementia. Typically, patients and their families are aware of the increasing forgetfulness. However, other cognitive capacities, such as executive function, use of language, and visuospatial skills, are relatively preserved, and functional activities are intact, except perhaps for some mild inefficiencies. Nonamnestic mild cognitive impairment is characterized by a subtle decline in functions not related to memory, affecting attention, use of language, or visuospatial skills The estimated prevalence of mild cognitive impairment in population-based studies ranges from 10 to 20% in persons older than 65 years of ages compared with the incidence of dementia in the general U.S. population, which is 1 to 2% per year, the incidence among patients with mild cognitive impairment is significantly higher, with an annual rate of 5 to 10% in community-based populations12 and 10 to 15% among those in specialty clinics

Hypothalamic Pituitary Axis: Long Term Stress Response

Mineralcorticoids 1) retention of sodium and water by kidneys 2) increased blood volume and BP Glucocorticoids 1) protein and fats broken down and converted to glucose, leading to increased blood glucose 2) immune system may be suppressed effects the whole body in response to physical or psychological stress

Case 1 Notes

Motivational interviewing: The approach attempts to increase the client's awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Alternately, therapists help clients envisage a better future, and become increasingly motivated to achieve it. Either way, the strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change. 1-Express empathy 2-Develop discrepancy 3-Roll with resistance - patient is primary resource for deaing with it. Resistance is a signal of the need to reframe 4-Self efficacy A person's belief in the possibility of change Is an important motivator See Addiction slides for key points

Negative Sx Notes

Negative symptoms are associated with disruptions to normal emotions and behaviors. These symptoms are harder to recognize as part of the disorder and can be mistaken for depression or other conditions. These symptoms include the following: "Flat affect" (a person's face does not move or he or she talks in a dull or monotonous voice) Lack of pleasure in everyday life Lack of ability to begin and sustain planned activities Speaking little, even when forced to interact. People with negative symptoms need help with everyday tasks. They often neglect basic personal hygiene. This may make them seem lazy or unwilling to help themselves, but the problems are symptoms caused by the schizophrenia.

Legal Issues in Psychiatric/Mental Health Nursing: Categories of Restraints

Patient with non-violent, non-self destructive behavior -E.g. unsteady gait, confusion, agitation, dementia Patient with violent, self-destructive behavior -E.g. Violent, aggressive, threatening other staff

Mental Status Examination

Point in time check not a history evaluation -always want to comment if pt has expressed suicidal or homicidal thoughts - highest priority -Appearance -Motor Activity -Speech Pattern -General attitude -Mood -Affect -Thought Processes (Form, content) -Perceptual Disturbances -Sensorium and Cognitive Ability -Impulse Control -Judgment and Insight (see Townsend, Appendix C)

Assessing risk factors for aggression

Prevention is the key issue in management of aggressive or violent behavior. Three factors are important considerations in identifying extent of risks -Past history of violence -Client diagnosis -Current behaviors Past history of violence is considered the most widely recognized risk factor for violence in a treatment setting.

Mental Health: Assessment

Psychosocial History: -Reason for admission -Past psychiatric history/mediation -Current medical problems (always be sure to ask them if they are taking their meds, a lot of hospitalizations are related to med noncompliance) -Substance Use (drug induced psychoses and/or withdrawal) -Social History/Support -Systems/Spirituality -Coping skills Mental Status Exam

Reversible NCD

Reversible NCD may be more appropriately termed temporary dementia. It can occur as a result of: -Stroke -Depression -Side effects of medications -Nutritional deficiencies -Metabolic disorders

Delirium Cuases

Review Meds; H&P; labs (CBC, glucose, electrolytes, creat, BUN, Ca, UA, pulse Ox, EKG) Offending drug? Yes: D/C ->Trauma or focal finding? No: Trauma or focal finding? Yes: CT scan brain -> focus of infection? No: Focus of infection? Yes: begin ABX -> Unexplained fever/nuchal rigidity? No: Unexplained fever/nuchal rigidity? Yes: perfrom lumbar puncture -> no obvious etiology? No: No obvious etiology? Yes: consider B12/folate, thyroid tests, EKG, MRI, toxicology report, toxin screen: -> patient improves? No: patient improves? Yes: reassess patient; consider prolonged delirium syndrome -> patient discharged to appropriate postacute setting No: patient discharged to appropriate postacute setting

Schizophrenia Notes

Schizophrenia is a chronic, severe, and disabling brain disorder that affects 2.4 million Americans.. About 1 percent of Americans have this illness.1 People with the disorder may hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated. People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking. Families and society are affected by schizophrenia too. Many people with schizophrenia have difficulty holding a job or caring for themselves, so they rely on others for help.

Distrubed THought Porcesses R/T inability to trust, panic anxiety, possibel hereditary or biochemical factors AEB delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract or conceptualize; extreme suspiciousness of others Short & Long Term Goals

Short Term Goal -by the end of 2 weeks, client will recognize and verbalize that false ideas occur at times of increased anxiety Long Term Goals -by time of discharge from treatment, client verbalizations will reflect reality based thinking with no evidence of delusional ideation -by time of discharge from Tx, the pt will be able to differentiate between delusional thinking and reality

Impaired Verbal COmmunication R/T panic anxiety, withdrawal, disordered, unrealistic thinking AEB loose association of ideas, neoglisms, word salad, clang association, echolalia, verbalization that reflect concrete thinking, poor eye contact Short & Long Term Goals

Short Term Goal -client will demonstrated the ability to remain on one topic, using appropriate, intermittent eye contact for 5 minutes with the nurse or therapist Long Term Goal -by time of discharge from treatment, the client will demonstrate ability to carry on a verbal communication in a socially acceptable manner with HCPs and peers

Disturbed Sensory Perception r/t cerebral degeneration AEB auditory and visual hallucinations Short and Long Term Goals

Short Term Goal -client will exhibit fewer manifestations of disturbed sensory perception Long Term Goal -client will maintain reality orientation to the best of their ability

Self Care Defect r/t disorientation, confusion, and memory deficits AEB inability to fulfill ADLs Short And Long Term Goals

Short Term Goal -client will participate in ADLs with the assistance from caregiver Long Term Goals -client will accomplish ADLs to the best of their ability -unfulfilled needs will be met by caregivers

Self Care Defecit R/T withdrawal, regression, panic anxiety, perceptual or cognitive impairment, inability to trust AEB difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, toileting Short & Long Term Goals

Short Term Goal -client will verbalize a desire to perform ADLs by the end of 1 week Long Term Goal -client will be able to perform ADLs in an independent manner and demonstrate a willingness to do so by the time of discharge

Social Isolation R/T inability to trust, panic anxiety, weak ego development, delusional thinking, regression AEB withdrawal, sad, dull affect, need-fear dilemma, preoccupation with thoughts, expression of feelings of rejection or of aloneness imposed by others Short & Long Term Goals

Short Term Goal -client will willingly attend therapy activities accompanied by trusted staff member within 1 week Long Term Goal -client will voluntarily spend time with other clients and staff members in group therapeutic activities

Risk for Trauma R/T impairments in cognitive and psychomotor functioning Short and Long Term Goals

Short Term Goals -client will call for assistance when ambulating or carrying out other activities (if it is within their cognitive ability) -client will maintain a calm demeanor, with minimal agitated behavior -client will not experience physical injury Long Term Goals -client will not experience physical injury

Distrubed Sensory Perception R/T panic anxiety, extreme loneliness and withdrawal into the self AEB inappropraite responses, disordered thought sequencing, rapid mood swings, poor concentration, disorientation Short & Long Term Goals

Short Term Goals -client will discuss content of hallucinatinos with nurse or therapist within 1 week Long Term Goals -client will be able to define and test reality, reducing or eliminating the occurence of hallucinations (this goal may not be realistic of for the individual with severe and persistent illness who has experienced auditory hallucinations for many years -client will verbalize understanding that the voices are a result of his or her illness and demonstrate ways to interrupt the hallucination

Disturbed Thought Processes; Impaired Memory r/t cerebral degeneration AEB disorientation, confusion, memory deficits, and inaccurate interpretation of the environment Short and Long Term Goals

Short Term Goals -pt will utilize measures provided (clocks, calendars, room identification) to maintain reality orientation -pt will experience fewer episodes of acute confusion Long Term Goal -pt will maintain reality orientation to the best of their cognitive ability

Risk for Violence R/T extreme suspiciousness, panic anxiety, catatonic excitement, rage reactions, command hallucinations, overt and aggressive acts, goal directed destruction of objects in the environment, self destructive behavior or active aggressive suicidal acts SHort and Long Term Goals

Short Term Goals -within (a specified time), client will recognize signs of increasing anxiety and agitation and report to staff (or other care provider) for assistance with intervention -client will not harm self or others Long Term Goal -client will not harm self or others

List the signs of confusion seen in this case. Which stage of Alzheimer's disease would you assign Mrs. Livingstone?

Signs of Confusion -Mrs. Livingstone is showing moderate signs of confusion. -She is oriented to person, but not to place and time. -She does still know her daughter. -She repeatedly asks the same question. (amnesia: loss of ability to learn new information or recall old information, often appears as forgetfulness) -Her judgment is poor as reflected in not making good decisions about eating. She may be cognitively unable to take action to get her dentures repaired. -She is showing signs of "sundowning". She is more agitated in the evening and is unable to sleep. These symptoms are consistent with stage II Alzheimer's Disease. -apraxia: unable to use TV and coffee pot. This could also be agnosia, that is, simply not recognizing the use of a common object. forgets the name of common objects. (aphasia)

Methadone

Substitution: long acting pain med with no euphoria Maintenance therapy: take daily Suppressive therapy; dont go through withdrawal Key concepts: cross-tolerance, Opioid Treatment Center

Withdrawal

Symptoms occur when body has adapted to substance and the substance is removed

Risk for Trauma R/T impairments in cognitive and psychomotor functioning Nursing Interventions & Rationale

The following measures may be taken to ensure client safety a) arrange furniture and other items in the room to accomodate pts disability b) store frequently used items with easy access c) do not keep bed in an elevated position. Pad siderails and headboard if pt has Hx os seizures. Keep bedrails up when pt is in bed (if regulations permit) d) assign room near nurses station; observe frequently e) assist client with ambulation f) keep a dim light on at night g) if pt is a smoker, cigarettes and lighter should be kept at nurses station and dispensed only when someone is available to stay with pt while they are smoking h) frequently orient to place, time, and situation i) if client is prone to wander, provide an area within which wandering can be carried out safely j) soft restraints may be required if pt is very disoriented and hyperactive

The Nurse's Role on the Team in the Inpatient Psychiatric Setting

The psychiatric-mental health nurse provides structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other health care clinicians.

Mental Health

The successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local norms and cultures."

3) Techniques for dealing with aggression include

a) Talking down. Say, "John, you seem very angry. Lets go to your room and talk about it": promtoes a trusting relationship and may prevent the pts anxiety form escalating b) Physical outlets. "Maybe it would help if you punched your pillow": provides effective way for client to release tnesion with high levels of anger c) Medications/ If agitation continues to escalate, offer client choice of taking meds voluntarily. If he or she refuses, reassess the situation to determine if harm to self or others is imminent: tranquilizing meds may calm client and prevent violence form escalating d) Call for assistance. Remove self and others from immediate area. Call code grey. Sufficient staff to indicate a show of strneght may be enough to deescalate the situation, and client may agree to take meds: client and staff safety are of primary concern e) Restraints. If client is not calmed by talking down or meds, restraints may be necessary: clients who do not have internal control over their own behavior may require external controls, such as mechanical restraints in oprder to prevent harm to self and others

4) if client is highly suspicious, the following interventions may be helpful

a) use same staff as much as possible; be honest and keep all promises: familiar staff and honesty promote trust b) avoid physical contact; warn client before touching to perform a procedure, such as taking BP: suspicious pts often perceive touch as threatening and may respond in an aggressive or defensive manner c) avoid laughing, whispering, or talking quietly where client can see but not hear what is being said: client may believe they are being talked about d) provide canned food with can opener or serve food family style: pt may believe food is being poisoned and refuse to eat food from an individually prepared tray e) mouth checks for cheeking: may believe they are being poisoned with their meds and attempt to discard their meds f) provide activites that encourage a 1:1 relationship with teh nurse or therapist: competitive activities are very threatening to suspicious pts g) maintain an assertive, matter of fact, ye genuine approach with suspicious pts: suspicious pts do not have the capacity to relate to, and therefore often feel threatened by a friendly or overly cheerful attitude

Anger and Aggression Signs

anger -frowning, clenched fists, low pitched voice, yelling, intesnse eye contact or avoidance, easily offended, defensive, passive-aggressive aggression -mild: sarcasm -mod: slamming doors -sev: pacing, threats, misinterpreting environment, paranoia

Two students fail their introductory nursing course. One student plans to seek tutoring and retake the course next fall. The second student attempts suicide. Which of the following factors would have been influential in the development of the second student's crisis? a) The time of year in which the event occurred b) The presence of support systems c) A lack of adequate coping mechanisms d) The individual's family birth order

c) A lack of adequate coping mechanisms

A client, diagnosed with borderline personality disorder, approaches the nursing station often with various requests. The nurse intervenes by stating, "You may approach the nurse's station only once an hour." Which nursing intervention has been employed? a) Providing reality orientation b) Ensuring physical need fulfillment c) Setting limits on behavior d) Providing client education

c) Setting limits on behavior

The ED nurse is caring for an a combative client with suspected schizophrenia. Which of the following actions should be taken first? a. Get vital signs b. Collect UA c. Administer prescribed ziprasidone d. Ask about medication adherence

c. Administer prescribed ziprasidone -combative

Substance Use and Substance-Induced Disorders

commonly developed between 18-25 -brians not fully mature until mid 20s -if you get through these years without developing a disorder your chance of getting one significantly decreases

Physical Dependence

continued use is required to avoid abstinence symptoms

The nurse is performing a mental status assessment on a newly admitted client. Which of the following questions should be included? a. What are your coping mechanisms? b. When did you last use alcohol? c. How many hours did you sleep last night? d. How would you describe your mood?

d. How would you describe your mood? -mood is a component of MSE -sleep is an important factor for ongoing monitoring -a&b are part of the mental health assesment which is more historical in nature -D is a point in time eval that is directly part of the MSE

Thought Process (Content of THought)

delusions -persecutory -gandiose -reference -control or influence -somatic -nihilistic -suicidal or homicidal ideas -obsessions -paranoia / suspiciousness -magical thinking (step on a crack and you break your mothers back) -religiousity -phobias -poverty of content (little info conveyed/ vague)

Mechanism of Addiction

drugs of abuse target the brains pleasure center -drugs of abuse increase dopamine -once you experience this level of pleasure everyday life is not satisfying -cocaine causes 3-4x more dopamine to be released and blocks reuptake

Interventions Continued

f) Observation and documentation. The client in restraints should be observed on a 1-1 basis the first hour which can progress to audio and visual monitoring after the first hour. Q15 minutes circulation checks should be performed (temp, color, pulses). Assist client with needs r/t nutrition, hydration, and elimination. Position for comfort and to prevent aspiration. Document all observations: client well being is a nursing priority g) Ongoing assessment. As agitation decreases, assess clients readiness for restraint removal or reduction. With assistance remove one restraint at a time while assessing pts response. This minimizes risk of injury to client and staff: gradual removal of the restraints allows for testing of the clients self control. Client and staff safety are of primary concern. h) Staff debriefing. It is important when a client loses control for staff to follow up with a discussion about the situation. What happened, what would have prevented it, why seclusion or restraints was used, and how client or staff felt in terms of using seclusion and restraint. It is also important to discuss the situation with other pts who witnessed the episode. It is important that they understand what happened. Some clients may fear that they could be secluded or restrained at some time for no apparent reason: debriefing helps to diminish the emotional impact of the intervention. Mutual feedback is shared, and staff has the opportunity to process and learn from the event.

Duty to Warn AKA Tarasoff Duty

if someone makes a threat against someones life and they have a plan we have an obligation to report it to the police and/or person -this overrules patient confidentiality

Assault

threatening -we can explain but we can never threaten

Schizophrenia

two or more of the following, each present for a significant portion of time during a 1-month period -delusions -hallucinations -disorganized speech -grossly disorganized or catatonic behavior -negative Sx (diminished emotional expression or avolition)

Involuntary psychiatric admissions

typically, pts in inpatient psychiatric settings are admitted involuntarily under a legal hold for assessment and Tx. They're deemed either dangerous to themselves or others or unable to feed clothe, or shelter themselves (gravely disabled). Their s/s stem from an acute phase of mental illness and arent related to brain injury, organic brain changes, cognitive disabilities, medical problems, intoxication, or criminal Behavior. Some also have substance abuse issues. Generally, theyre expected to respond to Tx. Length of stay averages 5-14 days. Examples of events and conditions that can lead to involuntary admission include: -deliberate self-harm with significant injury (cutters - cut themselves not to kill themselves but get attention) -acute suicidal ideation with or without an actual suicide attempt -psychosis leading to risky behavior (for instance, hearing voices commanding the patient to kill himself or others) -grossly disorganized behavior and inability to take care of self -refusal to eat in the belief that food is poisoned

Mood

what they say -depressed; despairing -irritable -anxious -elated -euphoric -guilty -labile

Affect

what you observe -congruence with mood -constricted or blunted -flat -appropriate -inappropriate

Cannabinoids

• Endocannabinoids = neurotransmitters produced naturally in body - Play role in cognition, emotion, memory • Phytocannabinoids or cannabinoids = compounds produced by cannabis plant • Pharmaceutical cannabinoids = produced in lab - Dronabinol (THC) - Nabilone (THC analog) - Nabiximols (Combined THC and CBD) • Synthetic cannabinoids (e.g. SPICE)