Rasmussen Mental Health Exam 2

Anxiety: Describe Panic Attacks

Panic disorder (PD) consists of recurrent and unexpected "out of the blue" panic attacks. The *panic attack is the key feature of panic disorders (PDs)*. A panic attack is the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom: "I am going to die." Typically, panic attacks occur suddenly (not necessarily in response to stress), are extremely intense, and can last for 1 to 30 minutes before they subside. Panic attacks can happen at any time during the day or can occur while sleeping at night, causing a person to wake up terrified. The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur. Severe personality disorganization is evident. People experiencing panic attacks may believe that they are losing their minds or are having a heart attack; the attacks are often accompanied by highly uncomfortable physical symptoms. Some of the symptoms a person may experience are palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, feelings of choking, chills, hot flashes, and gastrointestinal symptoms. During the intervals between panic attacks, the person may experience low-level constant anxiousness and anticipatory anxiety. It is not uncommon for someone rushed to the emergency department (ED) with all the signs and symptoms of a heart attack (chest pain, difficulty breathing, dizziness, and excessive fatigue) to have an extensive medical workup that proves negative for cardiac problems. At that point the person needs to be referred to a counselor for potential diagnosis and treatment of an anxiety disorder. Major depression occurs in the majority of individuals with PD and complicates the course of the disorder considerably. Panic attacks are usually terrifying and painful for the person who is experiencing them. Some studies have demonstrated that people with panic attacks have an 18% higher rate of suicide attempts as well as a higher suicide rate in the general population The incidence of panic attacks over time may lead to complications such as persistent anxiety, phobic avoidance, depression, alcoholism, or other drug overuse. At times, people with panic disorder may also have agoraphobia. If agoraphobia is present, it is noted as a specifier on a DSM-5 diagnosis. the following pharmacological treatments as efficacious in the treatment of panic disorders: • High-potency benzodiazepines, such as alprazolam, clonazepam, and lorazepam usually used on a short-term basis. • Antidepressants such as tricyclics and SSRIs • Monoamine oxidase inhibitors (MAOIs) ch Know that a patient is at risk for hypertensive crisis when MAOIs and SSRIs are combined • Use of cognitive and behavioral therapy in conjunction with medications can help people learn skills to combat their panic, and is effective in the treatment among some individuals with panic attacks

Schizophrenia Treatment focus during different phases (Table 17-5)

(Table 17-5) pg.257 *Treatment Focus at Different Phases of Schizophrenia* tablet

15-8 Common Adverse Reactions to and Toxic Effects of Monoamine Oxidase Inhibitors

*Adverse Reactions* • Hypotension • Sedation, weakness, fatigue • Insomnia • Changes in cardiac rhythm • Muscle cramps • Anorgasmia or sexual impotence • Urinary hesitancy or constipation • Weight gain -comments Hypotension is the most critical side effect (10%); older adults, especially, may sustain injuries from falls. *Toxic Effects of Hypertensive crisis* • Severe headache • Stiff, sore neck • Flushing; cold, clammy skin • Tachycardia • Severe nosebleeds, dilated pupils • Chest pain, stroke, coma, death • Nausea and vomiting -comments 1. Patient should go to local emergency department immediately—blood pressure should be checked. 2. One of the following may be given to lower blood pressure: • 5 mg of intravenous phentolamine (Regitine) or • Oral chlorpromazine or • Nifedipine (Procardia) (calcium channel blocker), 10 mg sublingually ∗ Related to interaction with foodstuffs and cold medication.

Mood: Depression Physical Interventions (Table 15-5)

*Nutrition—Anorexia* 1. Offer small, high-calorie, and high-protein snacks frequently throughout the day and evening. 2. Offer high-protein and high-calorie fluids frequently throughout the day and evening. 3. When possible, encourage family or friends to remain with the patient during meals. 4. Ask the patient which foods or drinks he or she likes. Offer choices. Involve the dietitian. 5. Weigh the patient weekly and observe the patient's eating patterns. 1. Low weight and poor nutrition render the patient susceptible to illness. Small, frequent snacks are more easily tolerated than large plates of food when the patient is anorectic. 2. These fluids prevent dehydration and can minimize constipation. 3. This strategy reinforces the idea that someone cares, can raise the patient's self-esteem, and can serve as an incentive to eat. 4. The patient is more likely to eat the foods provided. 5. Monitoring the patient's status gives the information needed for revision of the intervention. *Sleep—Insomnia* 1. Provide periods of rest after activities. 2. Encourage the patient to get up and dress and to stay out of bed during the day. 3. Encourage the use of relaxation measures in the evening (e.g., tepid bath, warm milk). -If a patient refuses to eat solid foods, milk is a good source to offer as it offers protein, fat, carbohydrates, and vitamins. 4. Reduce environmental and physical stimulants in the evening—provide decaffeinated coffee, soft lights, soft music, quiet activities. 1. Fatigue can intensify feelings of depression. 2. Minimizing sleep during the day increases the likelihood of sleep at night. 3. These measures induce relaxation and sleep. 4. Decreasing caffeine and epinephrine levels increases the possibility of sleep. Playing relaxing music can help the patient sleep. *Self-Care Deficits* 1. Encourage the use of toothbrush, washcloth, soap, makeup, shaving equipment, and so forth. 2. When appropriate, give step-by-step reminders such as, "Wash the right side of your face, now the left." 1. Being clean and well groomed can temporarily increase self-esteem. 2. Slowed thinking and difficulty concentrating make organizing simple tasks difficult. *Elimination—Constipation* 1. Monitor intake and output, especially bowel movements. 2. Offer foods high in fiber and provide periods of exercise. 3. Encourage the intake of fluids. 4. Evaluate the need for laxatives and enemas. 1. Many depressed patients are constipated. If the condition is not checked, fecal impaction can occur. 2. Roughage and exercise stimulate peristalsis and help evacuation of fecal material. 3. Fluids help prevent constipation. 4. These measures prevent fecal impaction.

Anxiety: Outcomes for anxiety (Table 11-7) Short- and Long-Term Outcomes for Specific Anxiety Disorders

*Phobia* Patients will: • Develop skills at reframing anxiety-provoking situation (by date). • Work with nurse/clinician to desensitize self to feared object or situation (by date). • Demonstrate one new relaxation skill that works well for them (by date) *Generalized anxiety disorder* Patients will: • State increased ability to make decisions and problem solve. • Demonstrate ability to perform usual tasks even though still moderately anxious (by date). • Demonstrate one cognitive or behavioral coping skill that helps reduce anxious feelings (by date). *Obsessive-compulsive disorder* Patients will: • Demonstrate techniques that can distract and distance self from thoughts that are anxiety producing (by date). • Decrease time spent in ritualistic behaviors. • Demonstrate increased amount of time spent with family and friends and on pleasurable activities. • State they have more control over intrusive thoughts and rituals (by date).

Anxiety: Nursing Diagnosis associated with anxiety (Table 11-6)

*Potential Nursing Diagnoses for the Anxious Patient* Signs and Symptoms • Concern that a panic attack will occur Nursing Diagnoses Anxiety (moderate, severe, panic) ---- Signs and Symptoms • Exposure to phobic object or situation Nursing Diagnoses Fear ----- Signs and Symptoms • Presence of obsessive thoughts • Recurrent memories of traumatic event • Fear of panic attacks no Nursing Diagnoses ----- Signs and Symptoms • High levels of anxiety that interfere with the ability to work, disrupt relationships, and change ability to interact with others Nursing Diagnoses Ineffective coping Deficient diversional activity ------ Signs and Symptoms • Avoidance behaviors (phobia, agoraphobia) Social isolation ------- Signs and Symptoms Hypervigilance after a traumatic event Nursing Diagnoses Ineffective role performance -------- Signs and Symptoms • Inordinate time taken for obsession and compulsions Nursing Diagnoses Impaired social interaction-Ineffective relationship ------- Signs and Symptoms • Difficulty with concentration Nursing Diagnoses Post-trauma syndrome ------ Signs and Symptoms • Preoccupation with obsessive thoughts • Disorganization associated with exposure to phobic object • Intrusive thoughts and memories of traumatic event • Excessive use of reason and logic associated with overcautiousness and fear of making a mistake ------- Signs and Symptoms • Inability to go to sleep related to intrusive thoughts, worrying, replaying of a traumatic event, hypervigilance, fear Nursing Diagnoses Sleep deprivation Disturbed sleep pattern Fatigue ------ Signs and Symptoms • Feelings of hopelessness, inability to control one's life, low self-esteem related to inability to have some control in one's life Nursing Diagnoses Hopelessness Chronic low self-esteem Spiritual distress ----- Signs and Symptoms • Inability to perform self-care related to rituals Nursing Diagnoses Self-care deficit ------ Signs and Symptoms • Skin excoriation related to rituals of excessive washing or excessive picking at the skin Nursing Diagnoses Impaired skin integrity ------- Signs and Symptoms • Inability to eat because of constant ritual performance Nursing Diagnoses Imbalanced nutrition: less than body requirements -------- Signs and Symptoms • Feeling of anxiety or excessive worrying that overrides appetite and need to eat ------- Signs and Symptoms • Excessive overeating to appease intense worrying or high anxiety levels Nursing Diagnoses Imbalanced nutrition: more than body requirements

15-4 Symptoms and Interventions for Serotonin Syndrome ss: is a group of symptoms that may occur following use of certain serotonergic medications or drugs. The degree of symptoms can range from mild to severe. Symptoms include high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils, and diarrhea.

*Symptoms* • Hyperactivity or restlessness • Tachycardia → cardiovascular shock • Fever → hyperpyrexia • Elevated blood pressure • Altered mental status (e.g., delirium) • Irrationality, mood swings, hostility • Seizures → status epilepticus • Myoclonus, incoordination, tonic rigidity • Abdominal pain, diarrhea, bloating • Apnea → death *Emergency Measures * 1. Discontinue offending agent(s). 2. Initiate symptomatic treatment: • Serotonin receptor blockade: cyproheptadine, methysergide, propranolol • Cooling blankets, chlorpromazine for hyperthermia • Dantrolene, diazepam for muscle rigidity or rigors • Anticonvulsants • Artificial ventilation • Paralysis ch

Mood: Depression Nursing Diagnosis (Table 15-2)

-Disturbed sleep pattern -Constipation -Sexual dysfunction -Risk for loneliness - Ineffective role performance *Risk for suicide/ Risk for self-mutilation* Previous suicidal attempts, putting affairs in order, giving away prized possessions, suicidal ideation (has plan, ability to carry it out), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness *Decisional conflict Impaired memory Acute confusion* Lack of judgment, memory difficulty, poor concentration, inaccurate interpretation of environment, negative ruminations, cognitive distortions *Ineffective coping/ Interrupted family processes/ Risk for impaired parent/infant/child attachment* Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope *Decisional conflict* Difficulty making decisions, poor concentration, inability to take action *Hopelessness* Feelings of helplessness, hopelessness, powerlessness *Powerlessness Ineffective coping* Feelings of inability to make positive change in one's life or have a sense of control over one's destiny *Spiritual distress/Impaired religiosity/Risk for impaired religiosity* Questioning meaning of life and own existence, inability to participate in usual religious practices, conflict over spiritual beliefs, anger toward spiritual deity or religious representatives *Chronic low self-esteem/Situational low self-esteem* Feelings of worthlessness, poor self-image, negative sense of self, self-negating verbalizations, feeling of being a failure, expressions of shame or guilt, hypersensitivity to slights or criticism *Impaired social interaction/ Social isolation* Withdrawal, noncommunicativeness, speech that is only in monosyllables, avoidance of contact with others *Self-neglect (bathing/hygiene, dressing/grooming)/Imbalanced nutrition: less than body requirements* Vegetative signs of depression: changes in sleeping, eating, grooming and hygiene, elimination, sexual patterns

Mood: Depression Communication Interventions (Table 15-4)

1. Help the patient question underlying assumptions and beliefs and consider alternate explanations to problems. 1. Reconstructing a healthier and more hopeful attitude about the future can alter depressed mood. 2. Work with the patient to identify cognitive distortions that encourage negative self-appraisal. For example: a. Overgeneralizations b. Self-blame c. Mind reading d. Discounting of positive attributes 2. Cognitive distortions reinforce a negative, inaccurate perception of self and world. a. The patient takes one fact or event and makes a general rule out of it ("He always..."; "I never..."). b. The patient consistently blames self for everything perceived as negative. c. The patient assumes others do not like him or her, and so forth, without any real evidence that assumptions are correct. d. The patient focuses on the negative. 3. Encourage activities that can raise self-esteem. Identify need for (a) problem-solving skills, (b) coping skills, and (c) assertiveness skills. 3. Many depressed people, especially women, are not taught a range of problem-solving and coping skills. Increasing social, family, and job skills can change negative self-assessment. 4. Discuss physical activities the patient enjoys (e.g., running, weightlifting). Explain that initially 10 to 15 minutes a day 3 or 4 times a week has short-term benefits. 4. Exercise can help reduce tension, alleviate depression and anxiety, improve self-concept, and shift neurochemical balance. 5. Encourage formation of supportive relationships, such as through support groups, therapy, and peer support. 5. Such relationships reduce social isolation and enable the patient to work on personal goals and relationship needs among people who share similar experiences. 6. Provide information referrals, when needed, for spiritual/religious information (e.g., readings, programs, tapes, community resources). 6. Spiritual and existential issues may be heightened during depressive episodes—many people find strength and comfort in spirituality or religion.

Schizophrenia: Describe signs and symptoms (Box 17-2)

1. Positive symptoms: Psychotic symptoms are the most obvious (e.g., delusions, hallucinations, and perceptions that are not based on reality). ∗ 2. Negative symptoms: Include poverty of thought, loss of motivation, inability to experience pleasure or joy, feelings of emptiness, and blunted affect. ∗ 3. Cognitive symptoms: Include the inability to understand and process information, trouble focusing attention, and problems with working memory. The cognitive disturbances also account for the inability to use language appropriately (which is manifested by speech; e.g., looseness of association). These are the symptoms that most profoundly affect the individual's ability to engage in normal social/occupational experiences. ∗ 4. Mood symptoms: Depression, anxiety, dysphoria, suicide, and demoralization. ∗ 5. Grossly disorganized or catatonic behavior 6. Characterological symptoms: Most often people with schizophrenia are isolated or alienated from others. These patients have deep feelings of inadequacy and poorly developed social skills. look on chart pg. 250

a client who is delusional says to a nurse, the federal guards are out to kill me. the nurses best response is if someone tells you the federal guards/ mafia are out to kill them/ talking about them, THIS IS A DELUSION!. the pt is hearing the voices bc of there imbalance. the delusion is real for them this is called *persecutory delusion* someone might also say they're the queen of england, this is another kind of delusion acknowledge a delusion, but dont feed into it

1. i dont believe this is true 2. the guards are not out to kill you 3. what makes you think the guards were sent to hurt you? 4. i dont know anything about the guards, do you feel *afraid* people are trying to hurt you one thing about delusions, is delusions is about fear. when someone is afraid, and they are in a crisis. when someone tells you someone is out to kill them, you sense fright, fear, scared. it is the fear in there head thats making them talk about someone wanting to kill/ hurt them. ITS ALL ABOUT FEAR, so the trick to this question is anything that points to fear, fright/scared. *persecutory delusion IS ABOUT FEAR* *you are addressing fear in the answer and that points to the correct answer*

a client is admitted to a mental health unit w/ a dx of depression. The nurse dev. a plan of care for the ct, and includes which appr. activity in the plan? the question is really asking the appr. activity in the plan, the question is not asking for medication, so it's not MAOI one of the signs of depression is low activity, low energy, low concentration, so this guy is not going to read bc his concentration is poor. A depressed person would not make a decision unless they are doing better.

1. reading a writing most of the day 2. several activities in which the client can choose 3. nothing, until the ct has to participate in milieu 4. A structured program of activities in which a client can participate anslast

an adult client w/ depression has been tx with medication and (cbt) cognitive behavioral therapy c/b, the patient now verbalizes that being passive and letting others make decisions for her contributed to the depression, what referral could the nurse make to help this patient prevent recurrence of depression pt is depressed, and pt has been treated w/ medication, and (cbt) cognitive behavioral therapy, being passive is a sign of depression,and letting others make decisions for them is a sign of depression which contributes to high depression. question is what referrals? A suggestion of a service. eg. social work, nutrition factors. the answer would not be ssri, bc where not looking for medication.

1. social skills training 2. use of complementary therapy (relaxation)- homeopathic therapy... yoga, deep breathing exercises 3. relaxation training classes 4. learning desensitizing techniques- used for phobia, you know when you have fear of something to desensitize you, or take care of the phobia, when you have fear of something to desensitize you, or take care of the phobia they gradually introduce you that thing. you're being desensitize from the phobia by gradually introducing you to it. ansfirst

a pt with (Phenelzine maoi) for depression which behavior indicates that the pt has effectively implemented the info provided?

1. the pt monitors sodium intake and weight daily 2. the pt wears support stockings and elevates the legs while sitting *stockings are for edema 3. the pt can identify foods with high selenium content that should be reported 4. the pt checks with the pharmacist or md when selecting an otc med

Bipolar Medications- Lithium and other anticonvulsants *Make sure to know specific meds within each class

16-5 pg 236 *Lithium Side Effects and Signs of Lithium Toxicity* -Level <0.4 to 1 mEq/L (therapeutic level) -Signs Fine hand tremor, polyuria, and mild thirst Mild nausea and general discomfort Weight gain -Interventions Symptoms may persist throughout therapy. These symptoms often subside during treatment. Give with food to decrease nausea. Weight gain may be helped with diet, exercise, and nutritional management. ----- *Early Signs of Toxicity* -Level <1.5 mEq/L -Signs Nausea, vomiting, diarrhea, thirst, polyuria, slurred speech, muscle weakness -Interventions Medication should be withheld, blood lithium levels measured, and dosage re-evaluated. ----- *Advanced Signs of Toxicity* -Level 1.5 to 2 mEq/L -Signs Coarse hand tremor, persistent gastrointestinal upset, mental confusion, muscle hyperirritability, electroencephalographic (EEG) changes, incoordination -Interventions Interventions outlined above or below should be used, depending on severity of circumstances. -------- *Severe Toxicity* -Level 2 to 2.5 mEq/L -Signs Ataxia, serious EEG changes, blurred vision, clonic movements, large output of dilute urine, tinnitus, blurred vision, seizures, stupor, severe hypotension, coma; death is usually secondary to pulmonary complications -Interventions There is no known antidote for lithium poisoning. The drug is stopped, and excretion is hastened. If patient is alert, an emetic is administered. Otherwise, gastric lavage and treatment with urea, mannitol, and aminophylline hasten lithium excretion. -Level >2.5 mEq/L -Signs Symptoms may progress rapidly; coma, cardiac dysrhythmia, peripheral circulatory collapse, proteinuria, oliguria, and death -Interventions In addition to the interventions above, hemodialysis may be used in severe cases.

Bipolar Medications- Lithium and other anticonvulsants *Make sure to know specific meds within each class

16-6 pg 238 *Antiepileptic Drugs* -Drug Carbamazepine (Tegretol, Equerto, and others) FDA approved -Major Adverse Effects •Agranulocytosis and aplastic anemia are most serious adverse reactions • Blood levels should be monitored throughout first 8 weeks because drug induces liver enzymes that speed its own metabolism. Dosage may need to be adjusted to maintain serum level of 6-8 mg/L. • Immediate action when severe adverse reactions appear (e.g., confusion, difficulty breathing, irregular heartbeat, skin rash or hives, jaundice) • Best use is for treatment and prevention of manic episodes. It is less effective for treatment and prevention of depression ----- *Valproic acid* (Depakene) *Valproic acid delayed reaction* (Stavzor) *Divalproex delayed release* (Depakote) • *Baseline liver function tests should be performed and results monitored* at regular intervals • Bipolar disorder; bipolar depression ------- *Valproate injectable (Depacon) FDA approved* • Hepatitis, although rare, has been reported, with fatalities in children. Symptoms include fever, chills, right upper quadrant pain, dark urine, malaise, jaundice/confusion, significant drowsiness • Best use for men and older women. Can cause birth defects in pregnant women • Lithium is more effective in reducing the risk of suicide and at preventing relapses. Divalproex has a more rapid onset and efficacy and is often chosen for first-line treatment; however, divalproex is effective in rapid cyclers and in mixed mania ----- *Lamotrigine (Lamictal)* • *Life-threatening* rash reported in 3 out of every 1000 individuals (Stevens-Johnson syndrome) ------ *FDA approved* • *Rare but potential* aseptic meningitis risk with lamotrigine • Use caution when renal, hepatic, or cardiac function is impaired • Often used in combination with other mood-stabilizing drugs, it is a good drug for long-term maintenance therapy • Bipolar depression; pain ------ *Topiramate (Topamax)* • Used in acute mania or in combination with other drugs • Adverse effects include weight loss, cognitive side effects, fatigue, dizziness, and paresthesia • *Used off-label; not presently FDA approved* for bipolar disorder ----- *Oxcarbazepine (Trileptal)* • Structural variant of carbamazepine • Thought to have better side effect profile and more favorable drug interaction profiles • *Used off-label; not presently FDA approved* for bipolar disorder

Anxiety: Describe Agoraphobia

Agoraphobia is an intense, excessive anxiety about or fear of being in places or situations where help might not be available and escape might be either difficult or embarrassing. The feared places or situations are avoided by the individual in an effort to control anxiety. Examples of situations that are commonly avoided by patients with agoraphobia are being alone outside the home; using public transportation (e.g., traveling in a car, bus, or airplane); being in open spaces (e.g., bridges, marketplaces, or parking lots); being in an enclosed place (e.g., elevators, churches, or theaters); or being in a crowd (APA, 2013). A DSM-5 diagnosis is made when a person experiences fear or anxiety in at least two of the aforementioned situations. Avoidance behaviors can be debilitating and life constricting. Agoraphobia is perhaps the most limiting and debilitating of all of the phobias. In its most extreme form, patients may simply refuse to leave their homes, putting great strain on family and friends and resulting in problems in their marriages. Characteristically, individuals with agoraphobia experience overwhelming and crippling anxiety when they are faced with the provoking object or situation. Even thinking about or visualizing the object or situation can cause a person to become severely anxious. Consider the effects on a father whose avoidance renders him unable to leave home and who thus cannot work or participate in his children's school activities, such as attending school sports. Or consider the businesswoman whose avoidance of flying prevents her from attending business conferences or sales promotions. The life of a person with agoraphobia becomes even more restricted when the symptoms become more severe and activities are discontinued. When the fears and anxieties become too intense, an individual may not be able to leave home and must rely on others to help him or her meet basic needs and provide everyday services such as shopping, walking the dog, and so on. All too frequently, complications ensue when individuals attempt to decrease anxiety or depression through self-medication with alcohol or drugs. This disorder is thought to be primarily due to psychogenic causes that lead to a conditioned response of fear and anxiety. The disorder is chronic, although it responds well to cognitive behavioral therapy (CBT) and SSRI medications to help reduce the anxiety as well as treat the depression. Panic attacks may precede agoraphobia 30% to 50% of the time, depending on the specific source ch 6. Those with agoraphobia may feel it is silly not to go outside but are unable to go out of the door. 7. Understand symptoms and be able to relate to a scenario if presented for obsessive-compulsive disorder, generalized anxiety disorder, panic disorder with agoraphobia, and posttraumatic stress disorder. 9. Social skills training is needed if one verbalizes letting others make personal decisions while being treated for depression with medications and cognitive behavioral therapy. Social skills training is helpful in treating and preventing the recurrence of depression.

15-3 Patient and Family Teaching about Tricyclic

Antidepressants • The patient and family should be informed that improvement in mood may take from 7 to 28 days after initiation of treatment. Up to 6 to 8 weeks may be required for the full effect to be reached and for major depressive symptoms to subside. The family should reinforce this frequently to the depressed family member because depressed people have trouble remembering and respond to ongoing reassurance. • The patient should be reassured that drowsiness, dizziness, and hypotension usually subside after the first few weeks. • When the patient starts taking tricyclic antidepressants (TCAs), the patient should be cautioned to be careful working around machines, driving cars, and crossing streets because of possible altered reflexes, drowsiness, or dizziness. • Alcohol can block the effects of antidepressants. The patient should be told to refrain from drinking alcohol. • If possible, the patient should take the full dose at bedtime to reduce the experience of side effects during the day. • If the patient forgets the bedtime dose (or the once-a-day dose), the next dose should be taken within 3 hours; otherwise, the patient should wait until the usual medication time the next day. The patient should not double the dose. • Suddenly stopping TCAs can cause nausea, altered heartbeat, nightmares, and cold sweats in 2 to 4 days. The patient should call the physician or take one dose of TCA until the physician can be contacted.

Mood: Depression Beck's Cognitive Triad (p. 199)

Beck found that depressed people process information in negative ways, even in the midst of positive factors that affect the person's life. Beck believed that three automatic negative thoughts—called Beck's cognitive triad—are responsible for the development of depression: 1. A negative, self-deprecating view of self: "I really never do anything well; everyone else seems smarter." 2. A pessimistic view of the world: "Once you're down, you can't get up. Look around, poverty, homelessness, sickness, war, and despair are every place you look." 3. The belief that negative reinforcement (or no validation for the self) will continue: "It doesn't matter what you do; nothing ever gets better. I'll be in this stupid job the rest of my life." The phrase automatic negative thoughts refers to thoughts that are repetitive, unintended, and not readily controllable. This cognitive triad seems to be consistent in all types of depression, regardless of clinical subtype. The goal of CBT is to change the way a patient thinks, which will in turn help relieve the depressive syndrome. This is accomplished by assisting the patient in the following: 1. Identifying and testing negative cognition 2. Developing alternative thinking patterns 3. Rehearsing new cognitive and behavioral responses

Brain Stimulation Therapies Somatic Treatments Electroconvulsive therapy (ECT)

Brain imaging may help predict ECT response. New research demonstrates that brain scans can be predictive of those who will benefit most from ECT (Brooks, 2016). People with major depression who had been nonresponsive to at least two trials of medication were used in a controlled study. Those individuals with major depressive disorder who had reduced hippocampal volumes as shown on MRI scan showed significant change in the course of depression as well as in increased hippocampal and amygdalar volume after ECT. The hippocampus is involved with learning and memory, while the amygdala helps with emotional regulation, decision making, and memory. Electroconvulsive therapy remains one of the most effective treatments for major depression with psychotic symptoms and for treatment of patients with life-threatening psychiatric conditions (e.g., self-harm). Today ECT is mostly reserved for people with treatment-resistant (TR) 219depression, accounting for between 20% and 30% of depressed individuals. Treatment-resistant depression exists when pharmacological interventions fail or when the side effects are too uncomfortable. Although stigmatized for many years, ECT is safe and effective and can achieve a 70% to 90% remission rate in depressed patients within 1 to 2 weeks. The following list describes when ECT may be indicated: • There is a need for a rapid, definitive response when a patient is suicidal or homicidal. • The patient is in extreme agitation or stupor. • The patient develops a life-threatening illness because of refusal of foods and fluids. • The patient has a history of poor drug response, a history of good ECT response, or both. • Standard medical treatment has no effect. ECT is useful in treating patients with major depressive and bipolar depressive disorders, especially when psychotic symptoms are present (e.g., delusions of guilt, somatic delusions, or delusions of infidelity). Patients who have depression with marked psychomotor retardation and stupor also respond well. However, ECT is not necessarily effective in patients with chronic depression, atypical depression, personality disorders, drug dependence, or depression secondary to situational or social difficulties. The usual course of ECT for a depressed patient is 2 or 3 treatments per week to a total of 6 to 12 treatments. PROCEDURE The procedure is explained to the patient, and informed consent is obtained if the patient is being treated voluntarily. When informed consent cannot be obtained from a patient treated involuntarily, permission may be obtained from the next of kin, although in some states treatment must be court ordered. Use of a general anesthetic and muscle-paralyzing agents has revolutionized the comfort and safety of ECT. For an excellent article on ECT and thorough description of the procedure POTENTIAL ADVERSE EFFECTS On awakening from ECT, the patient may be confused and disoriented. The nurse and significant others may need to orient the patient frequently during the course of treatment. Many patients state that they have memory deficits for the first few weeks after treatment. Memory usually, although not always, recovers. ECT is not a permanent cure for depression, and maintenance treatment with TCAs or lithium decreases the relapse rate. Maintenance ECT (once a week to once a month) may also help to decrease relapse rates for patients with recurrent depression. It should be noted, however, that about 50% to 60% of patients will respond to treatment, which includes available pharmacotherapies, cognitive behavioral therapies, and ECT (Scicurious, 2012). Therefore other methods are desperately needed to treat the 40% to 50% of depressed individuals who do not respond to available therapies.

Light Therapy

Light therapy is the first-line treatment for seasonal affective disorder with or without medication (see Table 15-1). Full-spectrum wavelength light is the specific type of light used. People with seasonal affective disorder often live in climates in which there are marked seasonal differences in the amount of daylight. Seasonal variations in mood disorders in the Southern Hemisphere are the reverse of those in the Northern Hemisphere. Light therapy also may be useful as an adjunct to medications in treating chronic MDD or dysthymia PDD with seasonal exacerbations. Light therapy is thought to be effective because of the influence of light on melatonin. Melatonin is secreted by the pineal gland and is necessary for maintaining and shifting biological rhythms. Exposure to light suppresses the nocturnal secretion of melatonin, which seems to have a therapeutic effect on people with seasonal affective disorder. Treatments consist of exposure to light balanced to replicate the effects of sunlight for 30 to 60 minutes a day.

Bipolar Medications- Lithium and other anticonvulsants *Make sure to know specific meds within each class

Refer to Table 16-1 pg. 236 *Patient and Family Teaching about Lithium Therapy* The patient and the patient's family should receive the following teaching. (They should be encouraged to ask questions and given the material in written form as well.) • Lithium can treat your current emotional problem and helps prevent relapse. Therefore it is important to continue taking the drug after the current episode is over. • Because therapeutic and toxic dosage ranges are so close, it is important to monitor lithium blood levels very closely—more frequently at first, then once every several months after that. • Lithium is not addictive. • It is important to eat a normal diet with normal salt and fluid intake (1500-3000 mL/day or six 12-ounce glasses of fluid). Lithium decreases sodium reabsorption in the kidneys, which could lead to a sodium deficiency. • Watch sodium levels. A low sodium intake leads to a relative increase in lithium retention, which could produce toxicity. • You should stop taking lithium if you have excessive diarrhea, vomiting, or sweating. All of these symptoms can lead to dehydration. Dehydration can raise lithium levels in the blood to toxic levels. Inform your physician if you have any of these problems. • Do not take diuretics (water pills) while you are taking lithium. • Lithium is irritating to the lining in your stomach. It helps to take lithium with meals. • Lithium can cause renal damage. Kidney function should be assessed before treatment and once a year thereafter. • Lithium can promote goiter (thyroid enlargement) and frank hypothyroidism. Plasma levels of T3, T4, and thyroid-stimulating hormone (TSH) should be measured before treatment and yearly thereafter. • Do not take any over-the-counter medicines without checking first with your physician. • If you find that you are gaining a lot of weight, you may need to consult your physician or nutritionist. • Many self-help groups are available to provide support for people with bipolar disorder and their families. The local self-help group is (give name and telephone number). • You can find out more information by calling (give name and telephone number). • Keep a list of side effects and toxic effects handy (see Table 16-5), along with the name and number of a contact person. • If lithium is to be discontinued, your dosage will be tapered gradually to minimize risk of early relapse.

Bipolar Nursing Diagnosis related to disorder (Table 16-2)

Table 16-2 pg. 231 *Potential Nursing Diagnoses for Bipolar Disorders* -Signs and Symptoms Excessive and constant motor activity Poor judgment Lack of rest and sleep Poor nutritional intake (excessive or relentless mix of above behaviors can lead to cardiac collapse) -Nursing Diagnoses Risk for Injury Impaired mood regulation Imbalanced Nutrition: Less Than Body Requirements Deficient Fluid Volume ------ -Signs and Symptoms Loud, profane, hostile, combative, aggressive, demanding behaviors -Nursing Diagnoses Risk for Self-Directed Violence ------ -Signs and Symptoms Intrusive and taunting behaviors Inability to control behavior Rage reaction -Nursing Diagnoses Labile Emotional Control Risk for Suicide Interrupted Family Processes Ineffective Coping Ineffective Impulse Control ----- -Signs and Symptoms Manipulative, angry, or hostile verbal and physical behaviors Impulsive speech and actions Property destruction or lashing out at others in a rage reaction -Nursing Diagnoses Defensive Coping Ineffective Coping ----- -Signs and Symptoms Racing thoughts, grandiosity, poor judgment -Nursing Diagnoses -Disturbed Thought Processes -Ineffective Coping ------- -Signs and Symptoms Giving away valuables, neglecting family, making impulsive major life changes (divorce, career changes) -Nursing Diagnoses -Interrupted Family Processes -Caregiver Role Strain -------- -Signs and Symptoms Continuous pressured speech jumping from topic to topic (flights of ideas)- scizo -Nursing Diagnoses Impaired Verbal Communication ------ -Signs and Symptoms Constant motor activity, going from one person or event to another Annoyance or taunting of others; loud and crass speech Provocative behaviors -Nursing Diagnoses Impaired Social Interaction Risk for Injury ------- -Signs and Symptoms Failure to eat, groom, bathe, dress self because too distracted, agitated, and disorganized -Nursing Diagnoses Self-Care Deficit (bathing/hygiene, dressing/grooming) ----- -Signs and Symptoms Inability to sleep because too frantic and hyperactive (sleep deprivation can lead to exhaustion and death) -Nursing Diagnoses Disturbed Sleep Pattern Risk for Activity Intolerance Risk-Prone Health Behavior

Bipolar Nursing interventions for interactions (Table 16-3, 16-4)

Table 16-3 pg. 232 *Interventions for Acute Mania: Communication* Intervention 1. Use firm and calm approach: "John, come with me. Eat this sandwich." -Rationale Structure and control are provided for patient who is out of control. Feelings of security can result: "Someone is in control." 2. Use short and concise explanations or statements. -Rationale Short attention span limits comprehension to small bits of information. 3. Remain neutral; avoid power struggles and value judgments. -Rationale Patient can use inconsistencies and value judgments as justification for arguing and escalating mania. 4. Be consistent in approach and expectations. -Rationale Consistent limits and expectations minimize potential for patient's manipulation of staff. 5. Have frequent staff meetings to plan consistent approaches and to set agreed-on limits. -Rationale Consistency of all staff is needed to maintain controls and minimize manipulation by patient. 6. With other staff, decide on limits, tell patient in simple, concrete terms with consequences; for example, "John, do not yell at or hit Peter. If you cannot control yourself, we will help you" or "The seclusion room will help you feel less out of control and prevent harm to yourself and others." -Rationale Clear expectations help patient experience outside controls as well as understand reasons for medication, seclusion, or restraints (if unable to control behaviors). 7. Hear and act on legitimate complaints. -Rationale Underlying feelings of helplessness are reduced, and acting-out behaviors are minimized. 8. Firmly redirect energy into more appropriate and constructive channels. -Rationale Distractibility is the nurse's most effective tool during the patient's manic phase. --------> 16-4 pg. 232 *Interventions for Acute Mania: Safety and Physical Needs* -Intervention *Structure in a Safe Milieu* 1. Maintain low level of stimuli in patient's environment (e.g., away from bright lights, loud noises, and people). 2. Provide structured solitary activities with nurse or aide. 3. Provide frequent high-calorie fluids. 4. Provide frequent rest periods. 5. Redirect violent behavior through physical exercise (e.g., walking) 6. When warranted in acute mania, use antipsychotics and seclusion to minimize physical harm via physician's order. 7. Observe for signs of lithium toxicity. 8. Protect patient from giving away money and possessions. Hold valuables in hospital safe until rational judgment returns. -Rationale 1. Decreases escalating anxiety. 2. Structure provides security and focus. 3. Prevents dangerous levels of dehydration. 4. Prevents exhaustion. 5. Physical exercise can decrease tension and provide focus. 6. Exhaustion and death can result from dehydration, lack of sleep, and constant physical activity. 7. There is a small margin of safety between therapeutic and toxic doses. 8. Patient's "generosity" is in fact a symptom of the disease and can lead to catastrophic financial ruin for patient and family. -Intervention *Nutrition* 1. Monitor intake, output, and vital signs. 2. Offer frequent high-calorie protein drinks and finger foods (e.g., sandwiches, fruit, milkshakes). 3. Frequently remind patient to eat. "Tom, finish your milkshake." "Sally, eat this banana." -Rationale 1. Adequate fluid and caloric intakes are ensured; development of dehydration and cardiac collapse is minimized. 2. Constant fluid and calorie replacement are needed. Patient may be too active to sit at meals. Finger foods allow "eating on the run." 3. During mania the patient is unaware of bodily needs and is easily distracted. Needs supervision to eat. -Intervention *Sleep* 1. Encourage frequent rest periods during the day. 2. Keep patient in areas of low stimulation. 3. At night, provide warm baths, soothing music, and medication when indicated. Avoid giving patient caffeine. -Rationale 1. Lack of sleep can lead to exhaustion and death. 2. Relaxation is promoted and manic behavior is minimized. 3. Promotes relaxation, rest, and sleep. -Intervention *Hygiene* 1. Supervise choice of clothes; minimize flamboyant and bizarre dress (e.g., garish stripes or plaids and loud, unmatching colors). 2. Give simple step-by-step reminders for hygiene and dress. "Here is your razor. Shave the left side ... now the right side. Here is your toothbrush. Put the toothpaste on the brush." -Rationale 1. The potential is decreased for ridicule, which lowers self-esteem and increases the need for manic defense. The patient is helped to maintain dignity. 2. Distractibility and poor concentration are countered through simple, concrete instructions. -Intervention *Elimination* 1. Monitor bowel habits; offer fluids and foods that are high in fiber. Evaluate need for laxative. Encourage patient to go to the bathroom. -Rationale 1. Fecal impaction resulting from dehydration and decreased peristalsis is prevented.

Anxiety: Describe Post Traumatic Stress Syndrome- nursing diagnosis associated with PTSD (Box 10-2) (Ch. 10) ????

The diagnosis of posttraumatic stress disorder (PTSD) and its deleterious effects have received increased awareness over the past decade and more as active-duty military men and women return from war-torn Iraq and Afghanistan. However, PTSD is not limited to active-duty military personnel; it can occur in any individual who has had exposure to a trauma severe enough to be outside the range of normal 123human experience. Specific examples include childhood physical abuse, torture/kidnap, military combat, sexual assault, natural disasters (e.g., floods, tornados, earthquakes, tsunamis), human disasters (plane and train accidents, crime-related events, terrorist attacks, assault, mugging), and even the diagnosis of a severe illness. Posttraumatic stress disorder not only occurs in people who have experienced a traumatic event but also can occur in people who have witnessed an unbearable event (e.g., watching a friend die an atrocious death, first responders answering a call to a graphically violent event, or emergency room personnel and hospice nurses). Even those who have been repeatedly exposed to stories about a traumatic event in graphic terms can become traumatized. The common element in all these experiences is the individual's extraordinary helplessness or powerlessness in the face of overwhelming circumstances.

15-7 Drugs that Can Interact with Monoamine Oxidase Inhibitors

Use of the following drugs should be restricted in patients taking monoamine oxidase inhibitors (MAOIs): • Over-the-counter medications for colds, allergies, or congestion (any product containing ephedrine, phenylephrine hydrochloride, or phenylpropanolamine) • Tricyclic antidepressants (e.g., imipramine, amitriptyline) • Narcotics • Antihypertensives (e.g., methyldopa, guanethidine, reserpine) • Amine precursors (e.g., levodopa, L-tryptophan) • Sedatives (e.g., alcohol, barbiturates, benzodiazepines) • General anesthetics • Stimulants (e.g., amphetamines, cocaine)

Foods that Can Interact with Monoamine Oxidase Inhibitors

Vegetables Avocados, especially if overripe; fermented bean curd; fermented soybean; soybean paste; broad beans (fava bean pods); sauerkraut ----- Fruits Figs, especially if overripe; bananas in large amounts (banana peel is extremely high in tyramine) ------ Meats Meats that are fermented, smoked, cured, or otherwise aged; spoiled meats; liver, unless very fresh -------- Sausages Fermented varieties: bologna, pepperoni, salami, air-dried sausages, others --------- Fish Pickled herring and smoked salmon negligible; lungfish row, sliced schmaltz herring in oil, salmon mousse; dried, pickled, or cured fish; fish that is fermented, smoked, or otherwise aged; spoiled fish -------- Milk, milk products Practically all cheeses, especially hard cheeses -------- Foods with yeast Yeast extract (e.g., Marmite, Bovril) --------- Beer, wine Some imported beers, tap (draft) beers, some wines, Chianti ------- Other foods Protein dietary supplements; soups (may contain protein extract); shrimp paste; soy sauce *Foods that Contain Other Vasopressors* Chocolate Contains phenylethylamine, a pressor agent; large amounts can cause a reaction Fava beans Contain dopamine, a pressor agent; reactions are most likely with overripe beans Ginseng Headache, tremulousness, and mania-like reactions have occurred Caffeinated beverages Caffeine is a weak pressor agent; large amounts may cause a reaction *Safe Foods (Little or No Tyramine)* Most vegetables Most fruits Meats that are known to be fresh (exercise caution in restaurants; meats may not be fresh) Nonfermented varieties Fish that is known to be fresh; vacuum-packed fish, if eaten promptly or refrigerated only briefly after opening Milk, yogurt, cottage cheese, cream cheese Baked goods that contain yeast Major domestic brands of beer; most white wines

Anxiety: Medications for Anxiety *Make sure to know specific meds within each class Refer to Table 11-9 Refer to Box 11-1 Client education Nursing concerns??? pg. 132 11-2 on tablet

ch Buspirone is a better drug to prescribe for anxiety disorder because it does not cause dependence. Clozapine medication teaching. Know what it is for. For example, it is not for seizures. ---- Refer to Table 11-9 pg. 148 *Accepted Treatments for Selected Anxiety Disorders* *Panic disorder (PD)* SSRIs are treatment of choice; if patients do not respond to SSRIs, short-term treatment with a benzodiazepine may be used, or patients may switch to another type of antidepressant such as venlafaxine or tricyclics Therapeutic Modality CBT (cognitive behavioral therapy) • Relaxation techniques • Breathing techniques • Cognitive restructuring • Systematic desensitization • In vivo exposure aimed at eliminating avoidance behaviors Comments Benzodiazepines (short term) to reduce or eliminate panic attacks in initial phase of treatment Antidepressants may decrease panic episodes and treat underlying depression CBT teaches new coping skills and ways to reframe thinking ------- *Generalized anxiety disorder (GAD)* When medications are indicated: • Buspirone (BuSpar) reduces rumination and worry, not addictive • SSRI and TCA antidepressants are effective with chronic anxiety • Investigational drugs include pregabalin and other anticonvulsants -Therapeutic Modality Cognitive behavioral therapy or anxiety management therapy Anxiety management therapy involves education, relaxation training, and exposure to anxiety-provoking stimuli -Comments Many patients are helped with psychological approaches and may not need medications *Social phobia/social anxiety disorder (SAD)* SSRIs or venlafaxine are first-line drug treatments SSRIs may help lessen rejection sensitivity Beta-blockers target physical symptoms of anxiety (e.g., propranolol) Anticonvulsants such as gabapentin (Neurontin) and pregabalin (Lyrica) are being investigated -Therapeutic Modality Cognitive behavioral therapy can help improve symptoms after 6 to 12 weeks -Comments Benzodiazepines can be addictive over the long term and are not really a drug of choice for social anxiety disorder *Obsessive-compulsive disorder (OCD)* SSRIs reduce OCD symptoms directly (e.g., fluvoxamine [Luvox] and fluoxetine [Prozac]) TCAs (e.g., clomipramine [Anafranil]) -Therapeutic Modality Exposure and response prevention (ERP) emotionally difficult treatment for patients yet up to 75% to 80% successful SSRIs reduce OCD symptoms directly -Comments Effective and necessary in addition to serotonergic medications Exposure in vivo plus response prevention are the crucial essential factors Complete remission is not common ----- Refer to Box 11-1 pg. 148 *Patient and Family Medication Teaching: Anxiolytic Drugs* 1. Caution the patient and family: • Not to increase dose or frequency of ingestion without prior approval of therapist • That these medications reduce the ability to handle mechanical equipment (e.g., cars, saws, and other machinery) • Not to drink alcoholic beverages or take other antianxiety drugs because depressant effects of both would be potentiated • To avoid drinking beverages containing caffeine because they decrease the desired effects of the drug 2. Recommend that the patient taking benzodiazepines avoid becoming pregnant because these drugs increase the risk of congenital anomalies. 3. Advise the patient not to breast-feed because these drugs are excreted in the milk and would have adverse effects on the infant. 4. Teach a patient who is taking monoamine oxidase inhibitors about the details of a tyramine-restricted diet. 5. Teach the patient that: • Abrupt cessation of benzodiazepine use after 3 to 4 months of daily use may cause withdrawal symptoms such as insomnia, irritability, nervousness, dry mouth, tremors, convulsions, confusion, and even psychosis. • Medications should be taken with, or shortly after, meals or snacks to reduce gastrointestinal discomfort. • Drug interactions can occur: antacids may delay absorption; cimetidine interferes with metabolism of benzodiazepines, causing increased sedation; central nervous system depressants, such as alcohol and barbiturates, cause increased sedation; serum phenytoin concentration may become too high because of decreased metabolism.

Schizophrenia Nursing Diagnosis associated with schizophrenia- (Table 17-4)

look on page 254 tablet look at things that pertain to positive symptoms, hallucinations, delusions, things that affect the thought process. so if i ask a question asking for the dx for Schizophrenia, and it is talking about thought disorders, let ur dx reflect the clinical manifestations that is in ur scenario, ch 41. When working with a client with auditory hallucinations, asking the client to describe the hallucination is a therapeutic communication technique. 47. If a client has a history of violence, know that a nursing diagnosis of Risk of Violence should be noted.

Bipolarxl Medications- Lithium and other anticonvulsants *Make sure to know specific meds within each class Refer to Table 16-1, 16-5, 16-6

mrs a you cannot give a pt who has bipolar antidepressants bc bipolar is depression and manic, so today they're depressed and tomorrow they are manic mrs.s big thing is the medication called lithium, know normal range= 0.4, 0.8, 0.1-1.2...another txtbook might say 0.5-1.3 ANYTHING MORE THAN 1.3 is TOXIC!!!! 1.5, 1.6,1.7 and above is clear toxicity anything below 1.2 is therapeutic range our pt for lithium. we do lab work every month, if they're not in the hospital. The pharmist/pharmacist tech knows if u see lithium, then you have to get lab work so we check labs, and lab is done in the morning, if you're going to do a lithium level, make sure the last lithium was taken *12 hours before* as a nurse pay attention to the narrow margin once the patient eats, it is another factor bc lithium when your electrolytes are messed up for any reason, it can affect your lithium level. if youre vomiting and having diarrhea, it's going to affect ur lithium level. if you do agressive exercise it's going to effect your lithium level. if you have a pt on lithium- you have to be very careful as a nurse bc if ur not ur pt is going to end up with lithium toxicity and lithium toxicity is fatal. it is like in a 2nd ur pt is dead. ex pt decides been admitted into a mental health facility, and every morning she wants to exercise. 12 noon to 1pm she decides to go around the block and ride her bike 5 times. The nurse is taking care of her and she is on lithium. she starts sweating, as the nurse taking care of her what will be your counsel of pt education, what are you going to tell her? *she is losing sodium, water, so the concentration in the bv is going to be high, bc ur dehydrated*, so tell her not to do aggressive exercise it could also be someone vomiting bc ur losing water, diarrhea. *Someone who is eating 2 much salt, then ur going to over dilute and the meds is going to be sub therapeutic and its not going to work.* ex -trick- someone having diarrhea, vomiting, and we just talked about toxicity, pt is on lithium, we know when that happens they can become toxic, prof might add as an option hypokalemia (low k+). you wanna go w/ toxicity basically which one will kill you faster? diarrhea, vomiting and cardiac arrhythmias will give you hypokalemia, but it is not relevant to lithium, so the answer would be toxicity. lithium is toxic, know the narrow margin for therapeutic dose and toxic dose. the critical thing about lithium is its narrow margin, but you have to be careful. when your pt aggressively exercises, someone that loses fluids, they get dehydrated, there lithium level can go up bc of the concentration of lithium in there system from the aggressive exercise, to care for a pt on lithium, check to see when the pt is dehydrated, or anything that cause dehydration for ex one of your pt is on lithium and they're exercising aggressively, that means they're losing fluids, but they're also losing alot of salts., so what happens is they're dehydrated, WHICH CAUSES THE CONCENTRATION IN THERE BLD SYSTEM TO BE HIGH, so they're going to get toxic, despite the fact they're taking the normal dose. *any question that points to dehydration, you're going to think lithium toxicity, so things like diarrhea, vomiting, will lead to dehydration, so think lithium toxicity* in reference to sodium intake any individual with high sodium intake, that means they're taking a lot of salt. that means they retain fluids and dilute the concentration of lithium in there system, so they will be SUB THERAPEUTIC the lithium is not going to work the way its suppose to work, so if the sodium level is low, that means they do not have enough, thats going to concentrate there system and then, they are going to end up having high toxicity, so low sodium would lead to toxicity(high?). Dehydration will cause lithium toxicity!!!!! ch 29. Bipolar patients may be maintained on lithium indefinitely to prevent recurrences/relapses. Helping the patient understand this is important. 17. With one with bipolar disorder, set clear limits and provide distractions when the client is acting out. 30. During the continuation phase of treatment for bipolar disorder, a referral may be necessary if the patient finds it difficult to live down the odd behaviors that he/she may have experienced. Ongoing therapy may be needed. 31. When a client is having unrealistic thoughts such as all are out to destroy him/her, focus on the feelings and not the content. State something to the effect "Why would people be out to get you?" 21. Complications associated with Lithium include diaphoresis, nausea, and weakness. 18. Know the therapeutic lithium level. It typically between 0.4 and 1.3.

Anxiety: Describe Generalized Anxiety Disorder

mrs a it could come as an acute scenario for ex someone comes to the office, er, on triage they are pacing back and forth, they're saying they are having a bad feeling something is about to happen and have been having this feeling for months, this is GAD. acute- if patient is pacing, it is acute. has to be adressed immiesd. The management is to help them calm down, give them something to help them relax right away. ---> the key point is that it is chronic and has been going on for awhile, maybe a period for about 6 months, so this points to GAD book Generalized anxiety disorder (GAD) is a chronic psychiatric disorder associated with severe distress different from other anxiety disorders in that there is pervasive cognitive dysfunction, impaired functioning, and poor health-related outcomes. GAD is highly comorbid with other mental disorders in particular social phobia, specific phobia, panic disorder, and depression. Self-medication may lead to alcohol or substance use disorder GAD also differs from other anxiety disorders in that patients do not fear a specific external object or situation, and there is no distinct symptomatic reaction pattern. Basically, GAD is characterized by excessive, persistent, and uncontrollable anxiety, and by excessive and constant worrying. It is sometimes referred to as the "worry disease" (e.g., What if I'm late? ...What if I fail? ...What if I am fired?). A diagnosis of GAD is made if at least three of the following symptoms are present: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance chart A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children. 1. Restlessness or feeling keyed up or on edge 2. Being easily fatigued 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder). When medications are indicated: • Buspirone (BuSpar) reduces rumination and worry, not addictive • SSRI and TCA antidepressants are effective with chronic anxiety • Investigational drugs include pregabalin and other anticonvulsants Cognitive behavioral therapy or anxiety management therapy Anxiety management therapy involves education, relaxation training, and exposure to anxiety-provoking stimuli Many patients are helped with psychological approaches and may not need medications *Generalized anxiety disorder* Patients will: • State increased ability to make decisions and problem solve. • Demonstrate ability to perform usual tasks even though still moderately anxious (by date). • Demonstrate one cognitive or behavioral coping skill that helps reduce anxious feelings (by date). ch Lorazepam is the most appropriate medication to administer a patient with generalized anxiety disorder that is experiencing severe anxiety as a prn medication. A side effect of imipramine is urinary retention. Be aware of this when administering the medications. jargon

Anxiety: Describe OCD

mrs a mild anxiety is we have an exam, and ur asking to pee like five or six times, if it progresses to the point you start having diarrhea panic stress, chest pain, sob cronic over a period of time. 6 months. ongoing Obsessive-compulsive disorder (OCD) usually begins the late teens or early twenties and ranges from mild to severe. There is substantial evidence that OCD has biological origins and is thought by many to be a neurologically based disorder. OCD seems to occur more often in patients with other neurological disorders, such as in Huntington's chorea epilepsy, Sydenham's chorea, and brain trauma (Black & Andreasen, 2014). OCD is related to Tourette's disorder; there is a high frequency of one disorder co-occurring with the other. Other factors that support OCD as a neurological disorder include the following 1. Brain imaging studies show an increase in metabolic activity in patients with OCD, specifically hyperactivity in the prefrontal cortex and dysfunction in the basal ganglia and cingulum. Some researchers speculate that the basal ganglia dysfunction is responsible for the complex motor programs involved in OCD, whereas the tendency to worry and plan excessively is a result of the prefrontal cortex hyperactivity. 2. There is evidence that OCD has a significant genetic component based on family and twin studies. 3. The hypothesis is that dysregulation of serotonin levels is involved in the etiology of OCD. Clinical studies have shown that OCD patients are responsive to SSRIs whereas other antidepressants are ineffective, with the exception of the tricyclic antidepressant clomipramine that has proven especially effective in people with OCD. Obsessive-compulsive (OC) symptoms are common, but obsessive-compulsive disorders (OCDs) can be extremely disabling and painful. OCD is no longer considered uncommon. *Obsessions* are defined as thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. Obsessions often seem senseless to the individual who experiences them, although they still cause the individual to experience severe anxiety. Common obsessions include fear of hurting a loved one or fear of contamination. *Compulsions* are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. Common compulsions are repetitive hand washing and checking a door multiple times to make sure it is locked. Compulsions can include mental acts as well, such as counting, praying, or performing a compulsive act that temporarily reduces high levels of anxiety. The primary gain is achieved by compulsive rituals, but because the relief is only temporary, the compulsive act must be repeated many times. Although obsessions and compulsions can exist independently of each other, they almost always occur together as in *obsessive-compulsive disorder (OCD)*. OCD behavior exists along a continuum. "Normal" individuals may experience mildly obsessive-compulsive behavior. Nearly everyone has experienced having a song playing persistently through the mind, despite attempts to push it away. Many people have had nagging doubts as to whether a door is locked or the stove is turned off. These doubts require the person to go back to check the door or stove. Minor compulsions, such as touching a lucky charm, knocking on wood, and making the sign of the cross upon hearing disturbing news, are not harmful to the individual. Mild compulsions (timeliness, orderliness, and reliability) are valued traits in selective contexts in the U.S. society. At the more severe end of the continuum are obsessive-compulsive symptoms that typically center on dirtiness, contamination, and germs and occur with corresponding compulsions, such as cleaning and hand washing. A smaller number focus on safety issues and engage in repetitive checking rituals. At the most severe levels are persistent thoughts of sexuality, violence, illness, or death. These obsessions or compulsions cause marked distress to the individual. People often feel humiliation and shame regarding these behaviors. The rituals are time-consuming and interfere with normal routine, social activities, and relationships with others. Severe OCD consumes so much of the individual's mental processes that the performance of cognitive tasks may be impaired. Suicide can be a risk for these individuals, especially in the presence of a co-occurring depression. ch repetitive behavior.

severe anxiety/ panic

mrs a pt with mild, moderate, severe, panic or generalized anxiety a severe kinda anxiety vs. a panic kinda anxiety you want to look a the suttle differences in them if i asked you about a pt who has tachycardia, they came to the e.r, they're sweating profusely while talking to you, THIS IS A SEVERE FORM OF ANXIETY but if someone is actually having chest pain, sob, THIS IS A PANIC ANXIETY ch Maintain a calm manner, Remain with the client, Use clear and simple statements. 3. A nurse will encourage an anxious patient to talk about feelings as concerns spoken aloud are less overwhelming and help problem solving, anxiety can be reduced by focusing on and validating what is occurring, and encouraging patients to explore alternatives increases a sense of control. 4. A cruel and abusive person may rationalize the behavior by blaming the victim and state the victim provoked the situation.

Mood: Depression Medications- Classes: SSRI, TCA, MAOIs *Make sure to know specific meds within each class Refer to boxes 15-3, 15-4, 15-5, and 15-7 Refer to tables 15-6, 15-7,15-8, 15-9 Other Therapies (ECT, Light Therapy) pg. 218

mrs a maoixl MAOIs- for antidepressants can talk about food, otc medication, aged cheese, bacon is a tyramine agent and causes high blood pressure and has vasopressor leading to htn the key thing for MAOIs is you cannot combine with ssri's, when combine them you're going to have a problem. Do not mix them together. the other thing about MAOIs is when you combine them with tyramine, or tyramine agent, you're going to end up in *HYPERTENSIVE CRISIS* not only tyramine includes things like chocolate, otc medications, when you combine with MAOIs you're going to end up with HYPERTENSIVE CRISIS bc otc meds has pseudoephedrine, which is a component of vasopressin, it is a vasopressor agent meaning that is *constricts* your blood vessels and causes you to have high blood pressure, if you take that medication and combine it with MAOIs, youre going to have HYPERTENSIVE CRISIS psuedoephridrine and otc meds like cold medicine: they will cause you to have raise blood pressure. MAOIs HAS THE S/E OF RAISED BP, so if you take 2 of them 2getha you will end up having hypertensive crisis for ex what will tell you that your pt MAOIs understands pt teaching? if they ask you, i am going to ask my physician or pharmacists about otc meds, or im going to talk to my dr b4 i buy cold medicines... that implies that they understand bc if they buy cold medicines that have pseudo epherdrine they are going to end up w/ hypertensive crisis ch Be sure to tell a patient starting phenelzine for depression to check with pharmacist or physician before taking OTC meds.

manic person

mrs a: pacing all over the place, high energy, high metabolsim, they eat yet there skinny, FACTOR IN NUTRITION FOR A MANIC PERSON for ex. mrs. c 40yo female, she has bipolar in her manic phase, for someone like this, there nutrition would be (chicken nuggets, finger food) bc any food that requires you to be seated is the wrong option. manic pt is a grab and go, that answer that speaks to grab and go is the right answer. manic disorder goes with hyperactivity, they get belligerent, they are all over the place, you cannot stop them bc they have so much energy, for ex if i asked you about a depressed pt that doesn't come out of there room, and i ask you what kind of activities would you include in your plan of care for this patient, i am looking for an activity that the pt would participate in bc depressed pts dont take initiative, they dont make there own decisions, you want to have an activity that is structured, so they can participate. a depressed pt, you cannot give them a choice bc they wont make any choice, if you give them options for 10 different things, they will not be able to make that decision. for ex a manic person, if they want to eat, you dont give them something like spaghetti bc they dont have time to sit down and eat that food, bc the clinical manifestations, they are all over the place they are very active, they are up and down, you cannot slow them down, TEST if I ask you food options for a manic pt you want something that is grab and go. FINGER FOODS like hamburger. ch 19. When working with a patient with mania who is acting out, remain calm with the patient and offer a distraction. 20. One with controlled acute mania will function at an optimal level, use appropriate behavior, think without becoming overstimulated by activities. Manic patients do better in a simple, non-stimulating environment. Neutral colors for walls and furniture.

Schizophrenia Describe EPS vs NMS symptoms

mrs. a look for extrapyramidal symptoms and Neuroleptic malignant syndrome (NMS) EPS includes things like flapping of the toungue, Akathisia, dyskinesia NMS includes Hyperpyrexia is maliginant This blockage of D2 receptor sites in the motor areas of the brain is responsible for some of the most troubling side effects of the FGAs, namely the extrapyramidal symptoms *(EPS)* of akathisia, dystonia, parkinsonism, and tardive dyskinesia (TD). TD is perhaps the biggest concern of all the EPS since it is irreversible and can be socially isolating. Other adverse reactions include anticholinergic effects, orthostasis, and lowered seizure threshold. ch 42. Know the symptoms of Serotonin syndrome, tardive dyskinesia, pseudo-parkinsonism, and neuroleptic malignant syndrome. 39. Know extrapyramidal side effects of chlorpromazine. Akathisia, Acute dystonia, and dyskinesia---- If a patient experiences orthostatic hypotension when on chlorpromazine, promote sitting on the side of the bed before standing up. ---- Neuroleptic malignant syndrome (NMS) is estimated to occur in about 0.2% to 1% of patients who have taken antipsychotic agents. It is believed that the acute reduction in brain dopamine activity plays a role in the development of NMS, which is fatal in about 10% of cases. It usually occurs early in the course of therapy but has been reported in people after 20 years of treatment. Neuroleptic malignant syndrome is characterized by decreased level of consciousness; greatly increased muscle tone; and autonomic dysfunction, including hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling. Treatment consists of early detection, discontinuation of the antipsychotic agent, management of fluid balance, reduction of temperature, and monitoring for complications. Mild cases of neuroleptic malignant syndrome are treated with bromocriptine (Parlodel), whereas more severe cases are treated with intravenous dantrolene (Dantrium) and even with electroconvulsive therapy in some cases. See Table 17-10 for the side effects, onset, and nursing measures for EPS and NMS.

adhd in adults

mrs. a attention deficit hyperactivity disorder an adult can have adhd. they might tell you when i was young, middle school i was on meds, as an adult i still have some symptoms of hyperactivity this is ADHD!!! ------ Autism looking for a child who is not socializing. a child who does not want to hug anybody. a child that likes to play on there own bc a child who has autism, they kinda socialize w/ themselves, they want to be by themselves. they dont know how to socialize w/ other people.

Mood: Depression Define common symptoms

mrs. a: low energy, low or high appetite, general weakness, no initiating (hard to make decisions), introverted, not social, no pleasure in anything. book the following symptoms are most prevalent in all types of depression: • Mood of sadness, despair, emptiness • Negative, pessimistic thinking • Loss of ability to experience pleasure in life (anhedonia) • Low self-esteem • Apathy, low motivation, and social withdrawal • Excessive emotional sensitivity • Irritability and low frustration tolerance • Insomnia or hypersomnia • Disruption (mild to severe) in concentration or ability to make decisions • Suicidal ideation • Excessive guilt • Indecisiveness

Anxiety: Defense Mechanisms- understand examples how displayed (Table 11-4)

mrs.a someone who uses defense mechanisms all boils down to anxiety and there way to cope is to use defense mechanisms pay attention to denial, rationalization, reaction formation, projection, *denial* is straightforward, somebody who has lung cancer. then they come to the hospital and they're coughing, they may tell you it is a simple cold, i am going to be fine, that is denial *rationalization* making excuses for bad behavior, or unacceptable behavior. somebody that does something wrong and blame and make an excuse for it. for ex a husband that beats up his wife, makes excuses saying she caused it my dog ate my hwk, that why i didnt submit it someone who steals would say bc i am hungry. THE BIG THING!! about rationalization is ppl make excuses for bad behavior *reaction formation* a teacher you dont like but every time you bring them chocolate, donuts and coffee. *you dont like something, yet you want to asso. or act nice to the person/issue ex someone who doesn't like animals, yet they want to be a veterinary dr. nurse manager at work is always messing up the schedule, there way to cope is to bring them chocolate book *Defense Mechanisms* *Repression* --wnl Man forgets his wife's birthday after a marital fight. --Maladaptive Woman is unable to enjoy sex after having pushed out of awareness a traumatic sexual incident from childhood. *Sublimation* Woman who is angry with her boss writes a short story about a heroic woman. By definition, use of sublimation is always constructive. --Maladaptive- none *Regression* Four-year-old boy with a new baby brother starts sucking his thumb and wanting a bottle. --Maladaptive Man who loses a promotion starts complaining to others, does sloppy work, misses appointments, and arrives late for meetings. *Displacement* Patient criticizes a nurse after his family fails to visit. --Maladaptive Child who is unable to acknowledge fear of his father becomes fearful of animals. *Projection* Man who is unconsciously attracted to other women teases his wife about flirting. --Maladaptive Woman who has repressed an attraction toward other women refuses to socialize. She fears another woman will make homosexual advances toward her. *Compensation* Short man becomes assertively verbal and excels in business. --Maladaptive Individual drinks alcohol when self-esteem is low to diffuse discomfort temporarily. *Reaction formation* Recovering alcoholic constantly preaches about the evils of alcoholic beverages. --Maladaptive Mother who has an unconscious hostility toward her daughter is overprotective to protect daughter from harm, interfering with daughter's normal growth and development. *Denial* Man reacts to news of the death of a loved one by saying, "No, I don't believe you. The doctor said he was fine." --Maladaptive Woman whose husband died 3 years earlier still keeps his clothes in the closet and talks about him in the present tense. *Conversion* Student is unable to take a final examination because of a terrible headache. --Maladaptive Man becomes blind after seeing his wife flirt with other men. *Undoing* After flirting with her male secretary, a woman buys her husband tickets to a show. --Maladaptive Man with rigid and moralistic beliefs and repressed sexuality is driven to wash his hands to gain composure when around attractive women. *Rationalization* Employee says, "I didn't get the raise because the boss doesn't like me." --Maladaptive Father who thinks his son was fathered by another man excuses his malicious treatment of the boy by saying, "He is lazy and disobedient," when that is not the case. *Identification* Five-year-old girl dresses in her mother's shoes and dress and meets her father at the door. --Maladaptive Young boy thinks a neighborhood pimp with money and drugs is someone to emulate. *Introjection* After his wife's death, the husband has transient complaints of chest pains and difficulty breathing—the symptoms his wife had before she died. --Maladaptive Young child whose parents were overcritical and belittling grows up thinking that she is inferior. She has taken on her parents' evaluation of her as part of her self-image. *Suppression* Businessman who is preparing to make an important speech later in the day is told by his wife that morning that she wants a divorce. Although visibly upset, he puts the incident aside until after his speech, when he can give the matter his total concentration. --Maladaptive A woman who feels a lump in her breast shortly before leaving for a 3-week vacation puts the information in the back of her mind until after returning from her vacation.

Schizophrenia: Differentiate between positive and negative symptoms (Box 17-3)

mrs.a *positive signs* hallucinations, delusions, -positive signs are cardinal signs, signs that you dont miss in a Schizophrenic ind. do not feed into the delusions, you acknowledge the delusions, but you do not feed into it. *negative signs* signs you can see on a Schizophrenic ind. and also in other condiotions. thats why they are called negative signs. ex. flat affect (immobile facial expression or a blank look ch 38. Know what are considered negative symptoms of an antipsychotic. For example, a flat affect. book (Box 17-3) pg. 248 postive *Positive Symptoms* *Hallucinations* • Auditory • Voices commenting • Voices conversing • Voices commanding • Somatic-tactile • Olfactory • Visual • Gustatory *Delusions* • Persecutory delusions • Jealous delusions • Grandiose delusions • Religious delusions • Somatic delusions • Delusions of reference (events in the environment have special meaning) • Delusions of being controlled • Delusions of mind reading • Thought broadcasting, insertion, withdrawal *Bizarre Behavior* • Clothing, appearance • Social and sexual behavior • Aggressive, agitated behavior • Repetitive, stereotyped behavior *Positive Formal Thought Disorder and Speech Patterns* • Derailment • Tangentiality • Incoherence • Illogicality • Circumstantiality • Pressure of speech • Distractible speech • Clang associations (Box 17-3) pg.251 negative *Negative Symptoms* Affective Flattening • Unchanging facial expression • Decreased spontaneous movements • Paucity of expressive gestures • Poor eye contact • Inappropriate affect • Lack of vocal inflections *Alogia* • Poverty of speech • Poverty of content of speech • Blocking *Avolition, Apathy* • Impaired grooming and hygiene • Lack of persistence at work or school • Physical anergia *Anhedonia, Asociality* • Few recreational interests or activities • Little sexual interest or activity • Impaired intimacy and closeness • Few relationships with friends or peers *Attention Deficits* • Social inattentiveness

Mood: Depression Risk for suicide- Questions to ask High vs low risk (Ch 23)

mrs.a anytime you answer a question about depression, think suicide. for ex if she asked you about a pt dx with depression, and they stay indoors all the time, and all of a sudden the mood gets elated, that is the time to take caution, if i ask you about someone in this relm, know she is talking about someone who is deeply depressed, and as much as they elation came on that could be DECEPTIVE, that maybe a scenario where a pt can come and commit suicide. question: which pt is most likely to commit suicide Answer: someone who is lonely eg. divorced person Someone with alot of health problems that might overwhelm them to point they want to commit suicide. older person, age 70 white male who lives alone and divorced with alot of health problems is a candite for someone who can commit suicide CHOOSE THE ONE W/ LONELINESS, NO FAMILY/SOCIAL SUPPORT very likely to commit suicide not likely: church goer bc they have support book Risk for suicide is the most immediately important nursing diagnosis, and self-restraint from suicide is the ideal outcome. Other nursing diagnoses include Ineffective coping, Hopelessness, Social isolation, Spiritual distress, Chronic low self-esteem, Post-trauma syndrome, and Anxiety. Risk Factors Suicidal behavior: history of prior suicide attempts, aborted suicide attempts or self-injurious behavior • Current/past psychiatric disorders: especially mood disorders, psychotic disorders,alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity). Co-morbidity and recent onset of illness increase risk • Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, insomnia, command hallucinations • Family history: of suicide, attempts or psychiatric disorders requiring hospitalization •Precipitants/Stressors/Interpersonal: triggering events leading to humiliation, shame or despair (e.g., loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation. • Change in treatment: discharge from psychiatric hospital, provider or treatment change • Access to firearms *High* Psychiatric disorder with severe symptoms of acute precipitating event protective factors not relevant Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal Admission generally indicated unless a significant change reduces risk. Suicide precautions *Low* Modified risk factors, strong protective factors Thoughts of death, no plan, intent or behavior Outpatient referral, symptom reduction. Give emergency/ crisis numbers ch When caring for one with severe depression, careful observation around the clock is recommended. It should be unobtrusive. Many of those depressed contemplate suicide. When assessing a patient for suicide plans, the availability of a means to complete the task should be placed as the main priority. 24. Single, white older adults with co-occurring medical illnesses are *high risk factors for suicide.* 26. When one is placed on suicide precautions, maintain arm's-length distance, offer around the clock observation, allow no glass or metal on meal trays, and remove all potentially harmful objects form the area. 27. During an acute phase of major depression, the client may feel worthless and deserve bad things to happen personally.

Schizophrenia: Describe alternations in speech

mrs.a flight of ideas, saying random things things like *word salad*= they mumble and jumble alot of words together and different things together that doesnt connect. that is word salad. sometimes they will *pressure speech*, they talk like they're pressured, they sound is pressured, they *coin words.. new words* that no one else understands the meaning, they're the only one that knows what it means, they say words in sentences and you wonder what they are trying to say. NEOLOGISM book (e.g., frequent derailment or incoherence) *Associative looseness* Associations are the threads that tie one thought to another and one concept to another. In schizophrenia, these threads are missing, and connections are interrupted. In *associative looseness (or looseness of association [LOA]*), thinking becomes haphazard, illogical, and confused. Zelda Fitzgerald wrote her husband, the writer F. Scott Fitzgerald, an account of going mad: Then the world became embryonic in Africa—and there was no need for communication ... I have been living in vaporous places peopled with one-dimensional figures and tremulous buildings until I can no longer tell an optical illusion from a reality ... head and ears incessantly throb and roads disappear (Vidal, 1982). *Neologisms* Neologisms are made-up words that have special meaning for the person—for example, "I was going to tell him the mannerologies of his hospitality just won't do." "I want all the vetchkisses to leave the room and let me be." Children and creative 249writers often make up their own words, but their creation of neologisms is imaginative, constructive, and adaptive. Neologisms in people with schizophrenia represent a disruption in thought processes. ch 33. Understand neologism, concrete thinking, thought insertion, and idea of reference. Be able to relate to an example. If one talks about odd words, this would be a neologism for instance. 35. One who is homeless and experiencing a mental illness may experience the nursing diagnosis of chronic low self-esteem. 36. Be able to note when interventions such as yoga are effective for the stressed patient. Yoga decreases blood pressure and resting heart and increases flexibility. 37. Starting an exercise program and using cognitive behavioral therapy techniques demonstrate one utilizing positive coping strategies. *Echolalia* Echolalia is the pathological repeating of another's words by imitation and is often seen in people with catatonia. Echolalia is the counterpart of echopraxia, mimicking the movements of another, which is also seen in catatonia. *Clang association* Clang association is the meaningless rhyming of words, often in a forceful manner ("On the track ... have a Big Mac ... or get the sack"), in which the rhyming is often more important than the context of the word. This form of speech pattern may be seen in individuals with schizophrenia; however, it may also be seen in people in the manic phase of a bipolar disorder or in individuals with a cognitive disorder, such as Alzheimer's disease or HIV-related dementia. *Word salad* Word salad is a term used to identify a jumble of words that is meaningless to the listener and perhaps to the speaker as well. It may include a string of neologisms. For example, "I sang out for my mother ... for this to hell I went. How long is road? These little said three hills hop aboard, share the appetite of the Christmas mice spread ... within three round moons the devil will be washed away."

Schizophrenia schizoxl Patient education in regards to medication compliance- alternative forms Refer to Table 17-8, 17-9, 17-10 *Make sure to know specific meds within each class

mrs.a they have delusions,hallucinations mrs.a there is alot of non compliance w/ Schizophrenics. an alternative way is to give them inejectables, there are some meds you can do once a month instead of taking them everyday. an alternative form is injectables. look at the meds and know the classess look at reference in txt ch 32. A schizophrenic patients exhibits little spontaneous movement and flexibility, the physical needs must be placed first in Maslow's hierarchy of needs. 34. If a schizophrenia patient starts dialoguing about space issues, maintain at least an arm's length from the patient. 40. Disturbed thought processes may be an appropriate diagnosis for a schizophrenic who has unrealistic thoughts. 43. If a schizophrenic patient does not want to take oral medications, consider administering injectables.

15-7

pg. 213 Selective Serotonin Reuptake Inhibitors (SSRIs): Most Popular Type of Antidepressants *Citalopram/Celexa* Minimal interaction with other drugs, minimal weight gain, sedation====== Possible initial anxiety *Escitalopram/Lexapro* Minimal interaction, low sedation, and weight gain===== Possible initial anxiety 18 yr or older; 12-17 yr for MDD *Fluoxetine/Prozac* Activating (energizing)==== Possible interaction with other drugs, initial anxiety 8 yr or older *Fluvoxamine/Luvox* 8 yr or older for OCD only *Paroxetine/Paxil* Good antianxiety benefit==== Weight gain, interacts with other meds, contraindicated in pregnancy *Sertraline/Zolof* Not too sedating, nor prone to increased anxiety====Prone to gastrointestinal (GI) upset 6 yr and older only for OCD • Headache, which usually dissipates in a few days • Nausea, which usually dissipates in a few days • Sleeplessness and/or drowsiness during day, which usually dissipates in a few weeks • Tremors and/or dizziness • Sexual problems: reduces sexual drive, problems having and enjoying sex • Agitation, feeling jittery and nervous; rare serotonin syndrome; rare activation of suicidal ideation -------- Selective Serotonin Reuptake Inhibitor and Agonist (5-HT 1A receptor) Vilazodone Vibyrd Diarrhea, nausea, vomiting, insomnia, and sexual side effects Helps to target comorbid anxiety Caution in pregnancy, can cause weight gain, has withdrawal symptoms, and interacts with other drugs. ---------- Norepinephrine and Serotonin Specific Antidepressants (NASSA) Mirtazapine Remeron Dry mouth, abnormal dreams, confusion, sedation, influenza-like symptoms, hypotension Good for severe depression and elderly, less insomnia, less sexual dysfunction High weight gain and sedation Rare: induction of mania, suicidal thoughts or behaviors ------------- Norepinephrine Dopamine Reuptake Inhibitor (NDRI) Bupropion Wellbutrin Anxiety, insomnia, nausea, headache, dizziness, anorexia Energizing, few sexual side effects, less weight gain Rare seizures, doses over 400 mg; possible increased anxiety/insomnia ---------------- Serotonin Antagonist and Reuptake Inhibitors Nefazodone Serzone Nausea, headache, anxiety, sedation, dizziness Good at reducing anxiety, fewer sexual side effects Has been associated with liver toxicity and has been discontinued in some countries for this reason. It is associated with many drug interactions. *Serotonin Antagonist and Reuptake Inhibitors* Buspirone BuSpar Anxiety, nausea, headache, dizziness Mainly used in treatment of anxiety; can be antidepressant in higher doses Can act like an antidepressant in higher doses Plus side: very useful augmenting drug for antidepressants *Dual Action Reuptake Inhibitors (Serotonin and Norepinephrine) (SNRIs)* duloxetine Cymbalta Nausea, diarrhea, anorexia, sexual dysfunction, hypertension, palpitations, increased blood pressure, urinary frequency/retention, inappropriate antidiuretic hormone, hyponatremia, sedation Good for severe depression Liver toxicity is a concern Seizures, thrombophlebitis, supraventricular dysrhythmia have occurred Venlafaxine Effexor Headache, nervousness, insomnia, decreased appetite, sexual dysfunction, inappropriate secretion of antidiuretic hormone, hyponatremia Good for severe depression, social anxiety disorder, generalized anxiety disorder Possible high blood pressure, GI upset Rare: induction of hypomania Rare: activation of suicidal ideation Desvenlafaxine Pristiq Nausea, insomnia, dry mouth, nervousness, anorexia, constipation, and increased blood pressure Major depressive disorder (MDD) Rare: induction of hypomania Rare: activation of suicidal ideation or behavior Levomilnacipram Fetzima Nausea, constipation, increase heart rate, erectile dysfunction, tachycardia, hyperhidrosis Major depressive disorder (MDD) FDA-approved SNRI (July, 2013) Rare side effects too early to tell, dose-related adverse events include urinary hesitation and erectile dysfunction *Selective Norepinephrine Reuptake Inhibitors (Selective NRIs)* Atomoxetine Strattera Not yet FDA approved for depression Good for cognitive symptoms and anxiety, minimal sexual side effects Possible sedation and/or anxiety; not FDA approved for depression Reboxetine Vestra Not yet available in United States Effective in improving energy and cognition Is targeted for unipolar depression and anxiety (e.g., panic attack) Some U.S. studies do not find it useful in depression *Tricyclic Antidepressants (TCAs)* Amitriptyline/Elavil Clomipramine/Anafranil Desipramine/Norpramin Doxepin/Sinequan Imipramine/Tofranil Maprotiline/Ludiomil Nortriptyline/Pamelor Protriptyline/Vivactil Trimipramine/Surmontil Amoxapine/Asendin • Dry mouth • Constipation • Bladder problems (hard to empty bladder, weak urine stream, men with enlarged prostate may be more affected) • Sexual problems include reduced sex drive, problems having and enjoying sex • Blurred vision, which usually dissipates quickly • Drowsiness 10 yr or older only for OCD 12 yr and older 6 yr and older (for bedwetting) *Monoamine Oxidase Inhibitors (MAOIs)* Isocarboxazid/Marplan Most used Phenelzine/Nardil Most used Tranylcypromine/Parnate Selegiline/Eldepryl, EMSAM Transdermal Patch -Inhibits type B MAO -Used in Parkinson's patients and FDA approved for depression • MAOIs are always used as second-line treatment and only used in depressions that are resistant to other medications and treatments • MAOIs have high risk of hypertensive crisis • If taken with any foods high in tyramine or any sympathomimetic drugs can lead to cerebral hemorrhage or death

Schizophrenia Patient education in regards to medication compliance- alternative forms Refer to Table 17-8

pg. 266 tablet

Schizophrenia Patient education in regards to medication compliance- alternative forms Refer to Table 17-10

pg. 266 tablet

Schizophrenia Patient education in regards to medication compliance- alternative forms Refer to Table 17-9

pg. 266 tablet

15-5 Patient and Family Teaching about Selective Serotonin Reuptake Inhibitors

• Selective serotonin reuptake inhibitors (SSRIs) may cause sexual dysfunction or lack of sex drive. Inform nurse or physician. • SSRIs may cause insomnia, anxiety, and nervousness. Inform nurse or physician. • SSRIs may interact with other medications. Be sure physician knows other medications patient is taking (e.g., digoxin, warfarin). SSRIs should not be taken within 14 days of the last dose of a monoamine oxidase inhibitor (MAOI). • No over-the-counter drug should be taken without first notifying physician. • Common side effects include fatigue, nausea, diarrhea, dry mouth, dizziness, tremor, and sexual dysfunction or lack of sex drive. • Because of the potential for drowsiness and dizziness, patient should not drive or operate machinery until these side effects are ruled out. • Alcohol should be avoided. SSRIs may act synergistically, and people report increased effects of alcohol (e.g., one drink can seem like two). Alcohol is also a central nervous system (CNS) depressant that may work against the desired effect of the SSRI. • Liver and renal function tests should be performed and blood counts checked periodically. • Medication should not be discontinued abruptly. People report such effects as dizziness, nausea, diarrhea, muscle jerkiness, and tremors. If side effects from the SSRIs become bothersome, patient should ask physician about changing to a different drug. Abrupt cessation can lead to serotonin withdrawal. • SSRIs should be used with caution in the elderly and in pregnant women. The physician should take into account the benefits versus the risk in these populations, as well as all patients taking SSRIs or any kind of antidepressant. • Any of the following symptoms should be reported to a physician immediately: • Increase in depression or suicidal thoughts • Rash or hives • Rapid heartbeat • Sore throat • Difficulty urinating • Fever, malaise • Anorexia and weight loss • Unusual bleeding •Initiation of hyperactive behavior • Severe headache ch When educating on SSRI, ensure those being instructed to report any suicidal thoughts. Suicidal ideation may happen when starting antidepressants.

15-6 Patient and Family Teaching about Monoamine Oxidase Inhibitors

• Tell the patient and the patient's family to avoid certain foods and all medications (especially cold remedies) unless prescribed by and discussed with the patient's physician (see Table 15-9 and Box 15-7 for specific food and drug restrictions). • Give the patient a wallet card describing the monoamine oxidase inhibitor (MAOI) regimen. • Instruct the patient to avoid Chinese restaurants (where soy sauce, sherry, brewer's yeast, and other contraindicated products may be used). • Tell the patient to go to the emergency department immediately if he or she has a severe headache. • Ideally, monitor the patient's blood pressure during the first 6 weeks of treatment (for both hypotensive and hypertensive effects). • Instruct the patient that after the MAOI is stopped, dietary and drug restrictions should be maintained for 14 days.