110 Unit 8 Unit 9 Exam

mania

-a mood disorder marked by a hyperactive, wildly optimistic state -When a hyperactive patient experiencing acute mania is hospitalized, initial nursing intervention that is a priority is Set limits on the patients behavior as necessary This intervention provides support through the nurses presence and provides structure as necessary while the patients control is tenuous. Acting out may lead to the loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective. -Mood -Overly joyous -Behavior Busy all day and night, constant activity and reduced need to sleep prevent proper rest. May not sleep for days in a row Verbally abusive towards friends Excessive spending Thought process Elaborate schemes to get rich/famous Flight of ideas Dress is outlandish, bizarre, colorful Clang associations Grandiosity ASSESSMENT A) Intro: Early treatment and diagnosis can help people avoid: -suicide attempts -aLcohol or substance abuse -Marital or work problems -Development of comorbidity B) Mood: patient states that he or she is feeling an intense state of well being - Euphoric mania- Overly joyous, out of proportion to what is going on, inappropriate to circumstances. Feels wonderful in the beginning. -Dysphoric mania- Mood may change quickly to dysphoric mania- irritable, angry, suicidal, hypersexual, experience panic attacks, pressured speech, agitation, severe insomnia, grandiosity or persecutory delusions or confusion. Health education -Patient families: chronic and highly recurrent nature -Warning signs and symptoms of impending episodes -Regularity in sleep pattern, meals, excercise and other activities -Expected side effects and toxic effects of medications -Use of alcohol, drug abuse, caffeine, and OTC medications can produce relapse -Importance of individual and group therapy and adherence with other treatment plan. Warning signs and symptoms of impending episodes Regularity in sleep pattern, meals, exercise and other activities Expected side effects and toxic effects of medications Use of alcohol, drug abuse, caffeine, and otc medications can produce relapse Importance of individual and group therapy and adherence with other treatment plan. Characteristics Elaborate schemes to get rich/famous and acquire unlimited power -Excessive phone calls and emails -Busy all day and night -Often gives away money , prized possessions, expensive gifts -Throw lavish parties -Excessive spending -Hyper sexuality Example of how they feel: The first time i was manic (goodwin and jamison 1990 p 27 C) Behavior Can lead to physical exhaustion and even death It is an emergency Can happen both in hypomania and mania Hypomania: constant activity and reduced need for sleep prevent proper rest. May not sleep for days in a row. Mania: Constantly goes from one place, activeity or project to another -Many are started few are completed D) Thought process and speech patterns Flight of ideas- continuous flow of accelerated speech with abrupt changes from topic to topic. Content of speech is often is often grossly inappropriate. Speech is often sexually explicit, profuse and loud Clang Associations-stringing words together becuase of their rhyming sounds, without regard to their meaning Grandiosity-Exaggerate their achievements or importance. They boast exceptional powers and status. Grandiose persecutory delusions are also common E) Congnitive Function- Poor judgment, decision making, planning and problem solving are affected. Poor concentration. Grandiose thoughts but very weak grasp of reality. May have hallucinations or delusions F) Assessment guidelines for nurses 1) Danger to self and other-exhaustion, lack of sleep, poor impulse control 2) Need for protection from uninhibited behavior- bankruptcy, giving away possessions 3) Need for hospitalization- to safe guard and stabilize the patient 4) Medical Status- May be due to general medical condition or substance induced or exposure to toxins 5) Coexisting medical condition 6) Patients and family's understanding of the disease, medications and support groups -Inactivity is impossible -Manipulative -Dress is outlandish, bizarre, colorful and inappropriate -Manipulative, profance, fault finding and adept at exploiting other Example: "for no reason" (seager, 1991, p 101) NURSING DIAGNOSIS applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: drink six servings of a high-calorie, high-protein drink each day. High-calorie, high-protein food supplements will provide the additional calories needed to offset the patients extreme hyperactivity. ENVIRONMENT The environment for a patient experiencing mania should be as simple and as nonstimulating as possible. Patients experiencing mania are highly sensitive to environmental distractions and stimulation. Draperies present a risk for injury.

Illusion

"I believe you want to poison me." An error in the perception of a sensory stimulus

DSM-5 DIAGNOSTIC CRITERIA for Anorexia Nervosa

A. Restrictions o energy intake relative to requirements, leading to a signi - cantly low body weight in the context o age, sex, developmental trajec- tory, and physical health. Signi cantly low weight is de ned as a weight that is less than minimally normal or, or children and adolescents, less than that minimally expected. B.Intense earo gainingweightorbecoming at,orpersistentbehaviorthat inter eres with weight gain, even though at a signi cantly low weight. C. Disturbance in the way in which one's body weight or shape is experi- enced, undue inf uence o body weight or shape on sel -evaluation, or persistent lack o recognition o the seriousness o the current low body weight.Coding note: The ICD-9-CM code or anorexia nervosa is 307.1, which is assignedregardlesso thesubtype.TheICD-10-CMcodedependsonthesub- type (see below). Specify whether:(F50.01) Restricting type: During the last 3 months, the individual has not engagedinrecurrentepisodeso bingeeatingorpurgingbehavior(i.e., sel -induced vomiting or the misuse o laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accom- plishedprimarilythroughdieting, asting,and/orexcessiveexercise. (F50.02) Binge-eating/purging type: During the last 3 months, the individual hasengagedinrecurrentepisodeso bingeeatingorpurgingbehavior(i.e., sel-inducedvomitingorthemisuseo laxatives,diuretics,orenemas). Specifyif:Inpartialremission:Ater ullcriteria oranorexianervosawerepreviously met.CriterionA(lowbodyweight)hasnotbeenmet orasustained period,buteitherCriterionB(intense earo gainingweightorbecoming at or behavior that inter eres with weight gain) or Criterion C (distur- bancesinsel-perceptiono weightandshape)isstillmet.In ull remission: Ater ull criteria or anorexia nervosa were previously met,noneo thecriteriahavebeenmet orasustainedperiodo time. Specify current severity: Theminimumlevelo severityisbased, oradults,oncurrentbodymassindex (BMI)(seebelow)or, orchildrenandadolescents,onBMIpercentile.The ranges below are derived rom World Health Organization categories or thinness in adults; or children and adolescents, corresponding BMI per- centilesshouldbeused.Thelevelo severitymaybeincreasedtorefect clinical symptoms, the degree o unctional disability, and the need or supervision. Mild: BMI ≥17 kg/m2 Moderate: BMI16-16.99 kg/m2 Severe: BMI15-15.99 kg/m2Extreme: BMI<15 kg/m2

SUICIDE STAFF FEELINGS .... Facility Patient feelings.... DEALING WITH a LOSS .... Dealing with no improvement NURSE RISK FOR FEELINGS OF

After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: ineffectiveness and frustration. Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patients progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Guilt and despair might be observed when the nurse experiences feelings about patients because of sympathy. Interest is possible but not the most likely result. The correct response is more global than overinvolvement. A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? Hold a staff meeting to express feelings and plan the care for other patients. > Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. > Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. > Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support.

Some Medical Complications of Anorexia Nervosa and Bulimia Nervosa

Anorexia Nervosa Bradycardia Orthostatic changes in pulse rate or blood pressure Cardiac murmur—one third with mitral valve prolapse Sudden cardiac arrest caused by pro ound electrolyte disturbances Prolonged QT interval on electrocardiogram Acrocyanosis Symptomatic hypotension Leukopenia Lymphocytosis Carotenemia (elevated carotene levels in blood), which produces skin with yellow pallor Hypokalemic alkalosis (with sel -induced vomiting or use o laxatives and diuretics) Elevated serum bicarbonate levels, hypochloremia, and hypokalemia Electrolyte imbalances, which lead to atigue, weakness, and lethargy Osteoporosis, indicated by low bone density Fatty degeneration o liver, indicated by elevation o serum enzyme levels Elevated cholesterol levels Amenorrhea Abnormal thyroid unctioning Hematuria Proteinuria Bulimia Nervosa Cardiomyopathy (rare occurrence due to diminished protein synthesis, mal- nutrition) Cardiac dysrhythmias Sinus bradycardia Sudden cardiac arrest as a result o pro ound electrolyte disturbances Orthostatic changes in pulse rate or blood pressure Cardiac murmur; mitral valve prolapse Electrolyte imbalances Elevated serum bicarbonate levels (although can be low, which indicates metabolic acidosis) Hypochloremia Hypokalemia Dehydration, which results in volume depletion, leading to stimulation o aldosterone production, which in turn stimulates urther potassium excretion rom kidneys; thus there can be an indirect renal loss o potas- sium as well as a direct loss through sel -induced vomiting Severe attrition and erosion o teeth producing irritating sensitivity and exposingthepulpo theteeth Loss o dental arch Diminished chewing ability Parotid gland enlargement associated with elevated serum amylase levels Esophageal tears caused by sel -induced vomiting Severe abdominal pain indicative o gastric dilation Russell's sign (callus on knuckles rom sel -induced vomiting)

Possible Signs and Symptoms of Anorexia Nervosa and Bulimia Nervosa

Anorexia Nervosa Terroro gainingweight Preoccupation with thoughts o ood View o sel as at even when emaciated Peculiar handling o ood: Cutting ood into small bits Pushing pieces o ood around plate Possible development o rigorous exercise regimen Possible sel -induced vomiting; use o laxatives and diuretics Cognition is so disturbed that the individual judges sel -worth by his or her weight Controls what he or she eats to eel power ul to overcome eelings o help- lessness Bulimia Nervosa Binge eating behaviors O ten sel -induced vomiting (or laxative or diuretic use) a ter bingeing History o anorexia nervosa in one ourth to one third o individuals Depressive signs and symptoms Problems with: Interpersonal relationships Sel -concept Impulsive behaviors Increased levels o anxiety and compulsivity Possible chemical dependency Possible impulsive stealing Controls/undoes weight a ter bingeing, which is motivated by eelings o emptines

Bipolar treatment

Antianxiety Drugs Electroconvulsive Therapy (ECT) Milieu management Support groups Health teaching and health promotion

Medications ( Meds Medicine Medication )

Anticonvulsants > divalproex (Depakote), (history of migraine headaches is diagnosed with bipolar disorder.) > carbamazepine (Tegretol), > gabapentin (Neurontin) > Lamotrigine anxiolytic ( Antianxiety Drugs ) Clonazepam ( Klonopin) Lorazepam ( Ativan ) <> Atypical Antipsychotics - Olanzapine (zypreza) - Risperidone ( Risperdal ) antipsychotic drugs aripiprazole and risperidone Q) A patient was started on escitalopram (Lexapro) 5 days ago and now says, This medicine isnt working. The nurses best intervention would be to: explain the time lag before antidepressants relieve symptoms. Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients. Paroxetine HCL (PAXIL) Q) The nurse is preparing to administer paroxetine HCl (Paxil) to a 70-year-old patient. The nurse understands that this patient may require a decreased dose. Q) A patient being treated with paroxetine (Paxil) 50 mg/day orally for major depressive disorder reports to the clinic nurse, I took a few extra tablets earlier in the day and now I feel bad. Which aspects of the nursing assessment are most critical? Select all that apply. > Vital signs > Presence of abdominal pain and diarrhea > Hyperactivity or feelings of restlessness headaches, nervousness, and poor appetite from Paroxetine (Paxil ) Reassure the patient that these side effects will decrease over time. The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. Although assessing for suicidal ideation is never inappropriate, in this situation physiologic symptoms should be the initial focus. The patient may have urinary retention, but frequency would not be expected. Venlafaxine ( Effexor) for Social Anxiety disorder should not take St Johns Wort ejaculation dysfunction and urinary retention side effects from Effexor ( reassure the patient that these are common side effects isocarboxazid (Marplan) Foods to avoid while taking this med : bannanas, red wine, sausage, yogurt. Corticosteroids Mood alterations and weight gain are possible adverse effects of corticosteroid use, but these are not life-threatening effects

Wellbutrin XL

Anxiety level may increase... Clients who suffer from anxiety may experience increased anxiety when taking this antidepressant Anorexia and bulimia are both contraindications for Wellbutrin XL because of a higher indigence of seizure experienced by clients treated for bulimia. Do not consume alcohol while taking this medication- Alcohol should not be consumed when taking the medication because it may increase the risk of seizures Headaches are a side effect and usually go away within a few days. Headaches can happen early in treatment, and clients must often be encouraged to continue taking their medication

Bulimia Nursing Process

Assessment ❖ Do not appear to be physically/emotionally ill often at ideal or close to body weight Inspections large parotid glands, dental caries/erosion Sensitive to the perception of others Outcome ❖ Based on diagnosis Planning ❖ Same as Anorexia ❖ Referrals for outpatient Treatment ❖ Therapy helps to examine the underlying conflicts and body dissatisfaction that sustain the illness (CBT) ❖ Antidepressants ❖ SSRI (Prozac) help prevent relapse ❖ Wellbutrin (contraindicated in pt who purge) Physical/Medical Complications ❖ obesity ❖ menstrual irregularities ❖ diabetes ❖ high blood pressure ❖ high cholesterol ❖ osteoarthritis ❖ decreased mobility ❖ shortness of breath ❖ heart disease ❖ liver and kidney problems ❖ cardiac arrest and/or death Assessment ❖ Obesity ❖ Have problems with heartburn, dysphagia, bloating, and abd pain, diarrhea, urgency, constipation and anal blockage ❖ Hx of quantity of food consumed during binging episodes and how often they occur Outcome ❖ Established to measure treatment results >>Nutrient intake >>Demonstrates coping >>Satisfaction with body appearance Planning ❖ Includes usual diet and exercise regimens ❖ Manage dysfunction of GI tract Treatment ❖ CBT and psychotherapy (the number and severity of binge eating) ❖ SSRI (short-term) Under investigation ❖ TCA ❖ Antiepileptic ❖ Appetite suppressants >>>Belviq >>>Fen-phen >>>Qsymia Outcomes/Evaluation ❖ Adequate fluid and nutritional intake ❖ Weight/muscle/fat congruent to height, frame, gender, and age ❖ Realistic perception of appearance and body function ❖ Vital signs within normal range ❖ Electrolyte balance ❖ Hope in future/will to live/set goals Prevention strategies ❖ Help children develop a positive self-image and sense of worth ❖ Avoid pressuring children to excel beyond their capabilities ❖ Recognize stressors & provide encouragement and support ❖ Teach children good nutrition & exercise can keep them healthy ❖ Give children the correct amount of independence, responsibility, and accountability for their age-group ❖ Discourage dieting ❖ Seek professional help if a child has S&S of an eating disorder

Manic Episode Symptoms

DIGFAST D DistractIbility, I irritability, G grandiosity, F flight of ideas, A activity increased, S sleep decreased, T talkative DO I SEE? CATS ARE RED GOING UP IN AND OUT

Implementation Evaluation of patient with suicidal thoughts and depression (outcomes)

Discloses plan for suicide if present Verbalizes need for assistance Expresses will to live Verbalizes feelings about self worth Willingness to call on others for help Interaction with others to share thoughts, feelings, and beliefs Q) patient being treated as an outpatient states, I am considering suicide. > Bringing this up is a very positive action on your part. > This response gives the patient reinforcement and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as, You have a lot to live for. It uses the patients ambivalence and sets the stage for more realistic problem- solving strategies.

Implementation Environmental guidelines for minimizing suicidal behaviors

Ensure that meal trays contain no glass or metal silverware, no soda cans Do not assign patient to a private room, and ensure the door remains open at all times Jump proof and hang proof the bathrooms by installing break away shower rods and recessed shower nozzle Keep electrical cords to a minimal length Install unbreakable glass. Keep all windows locked Lock all utility rooms, kitchen, adjacent stair wells, and offices. Take all potentially harmful gift from visitors before allowing them to see patients Go through personal belongings with patient present and remove all potentially harmful objects Ensure that visitors do not bring in or leave potentially harmful objects Search patients for harmful objects on return from pass Communication, encourage verbalization of feelings, suicide contract

Acute mania: Nursing interventions

Environment All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping balance activity and rest. Provide a subdued environment. nursing intervention will best assist the patient with energy conservation Communication -Use firm calm approach, -short concise explanations or statement -remain neutral, avoid power struggles and value judgments -be consistent in approach & expectations (limits), -Have frequent staff meetings to plan consistent approaches and set agreed on limits -Decide limits for patients with other staff members. Tell patients about it in simple, concrete terms with consequences -hear & act on legit complaints, -firmly redirect energy into more appropriate and constructive channels Structure in a Safe Milieu: -maintain low level stimuli in patients environment -Provide structured solitary activities with nurse or aide -Redirect violent behavior When warranted in acute mania, use phenothiazine and seclusion to minimize physical harm Observe for signs of lithium toxicity Protect patient from giving away money and possessions. Hold valuable in hospital safe until rational judgment returns. Physiological safety: Self care needs Nutrition -Monitor intake, output, and vital signs Offer frequent, high calorie, protein drinks and finger foods Frequently remind patient to eat finish the finger food -for the patient diagnosed with bipolar disorder experiencing acute mania Broiled chicken breast on a roll, an ear of corn, apple. The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive patient could eat on the run. Other foods cannot be eaten without utensils. Sleep Encourage frequent rest periods during the day Keep patients in areas of low stimulation At night, provide warm baths, soothing music, and medication when indicated Avoid giving patient caffeine Hygiene Supervise choice of clothes, minimize flamboyeant, and bizarre dress Giver step by step reminders for hygiene and dress Elimination: Monitor bowel habits; offer fluids and foods that are high in fiber. Evaluate need for laxative. Encourage/remind patient to go to the bathroom , freq. high calorie fluids, rest periods, admin antipsychotics PRN per MD, observe for lithium toxicity. Patient Acute Mania = defeat within staff (Hold a staff meeting to discuss consistency and limit-setting approaches.) When staff members are overwhelmed, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration. Nursing Intervention nurses first intervention for patient that is experiencing acute mania that undresses in the group room and dances. would be to: = put a blanket around the patient, and walk with the patient to a quiet room. Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff members to avoid argument and provide control is an effective approach. documentation indicates that the treatment plan for a patient experiencing acute mania has been effective Converses without interrupting; clothing matches; participates in activities. --The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. Q) patient experiencing acute mania has disrobed in the hall three times in 2 hours. The nurse should: arrange for one-on-one supervision. A patient who repeatedly disrobes, despite verbal limit setting, needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proved successful, considering the behavior has continued. Asking whether the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness. Q) A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, Ill throw the pool balls if anyone comes near me. The nurses first intervention is to: clear the room of all other patients. Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. A show of force is likely to frighten the patient and increase this risk for violence.

Depression Strategies for Working With Patients Who Have Hallucinations

Establish a Trusting, Interpersonal Relationship If the nurse is anxious or frightened, the patient will be anxious or frightened. Be patient, show acceptance, and use active listening skills. Assess for Symptoms of Hallucinations Including Duration, Intensity, and Frequency Observe for behavioral clues that indicate the presence of hallucinations. Observe for clues that identify the level of intensity and duration of the hallucination. Help the patient record the number of hallucinations that are experienced each day. Focus on the Symptom and Ask the Patient to Describe What Is Happening Empower the patient by helping him or her understand the symptoms experienced or demonstrated. Help the patient gain control of the hallucinations, seek helpful distractions, and minimize intensity. Identify Whether Drugs or Alcohol Have Been Used Determine whether the person is using alcohol or drugs (over-the-counter, prescription, or street drugs). Determine whether these may be responsible for or exacerbate the hallucinations. If Asked, Point Out Simply That You Are Not Experiencing the Same Stimuli Respond by letting the patient know what is actually happening in the environment. Do not argue with the patient about differences in perceptions. When an hallucination occurs, do not leave the person alone. Suggest and Reinforce the Use of Interpersonal Relationships as a Symptom Management Technique Encourage the patient to talk to someone trusted who will give supportive and corrective feedback. Help the patient in mobilizing social supports. Help the Patient Describe and Compare Current and Past Hallucinations Determine whether the patient's hallucinations have a pattern. Encourage the patient to remember when hallucinations first began. Pay attention to the content of the hallucination; it may provide clues for predicting behavior. Be especially alert for command hallucinations that may compel the patient to act in a certain way. Encourage the patient to describe past and present thoughts, feelings, and actions as they relate to hallucinations. Help the Patient Identify Needs That May Be Reflected in the Content of the Hallucination Identify needs that may trigger hallucinations. Focus on the patient's unmet needs and discuss the relationship between them and the presence of hallucinations. Determine the Impact of the Patient's Symptoms on Activities of Daily Living Provide feedback regarding the patient's general coping responses and activities of daily living. Help the patient recognize symptoms, symptom triggers, and symptom management strategies.

DSM-5 DIAGNOSTIC CRITERIA for Bipolar I Disorder

Foradiagnosiso bipolarIdisorder,itisnecessarytomeetthe ollowingcriteria or a manic episode. The manic episode may have been preceded by and may be ollowed by hypomanic or major depressive episodes. Manic Episode A. Adistinctperiodo abnormallyandpersistentlyelevated,expansive,orirri- table mood and abnormally and persistently increased goal-directed activity orenergy,lastingatleast1weekandpresentmosto theday,nearlyevery day(oranydurationi hospitalizationisnecessary).B. Duringtheperiodo mooddisturbanceandincreasedenergyoractivity,three(or more)o the ollowingsymptoms(ouri themoodisonlyirritable)arepresentto a signi cant degree and represent a noticeable change rom usual behavior:1. Infatedsel-esteemorgrandiosity.2. Decreasedneed orsleep(e.g., eelsrestedateronly3hour

What signs and symptoms should the nurse expect to assess if a client taking an MAO antidepressant ingests foods containing tyramine?

Headache and palpitations

What role do thyroid levels play in depression?

Hypothyroidism can lead to feeling sluggish and depressed

Nursing interventions ANOREXIA

Imbalanced Nutrition: Less than body requirement ANOREXIA +Spread calories across 6 meals +Encourage to keep a food diary to record all food ingested as well as thoughts and feelings associated with eating or not eating +Liquid supplements can be added by dietitian +Teach nutritional information about calories, food values and balanced diets +Begin diet low in fat and milk products +Nasogastric feeding in an inpatient setting-oral feeding with supplemental nighttime NG feeding for those who are seriously ill. +Weigh on a routine basis +Encourage client to plan meals

alterations of body image

Impact, Shock, Denial Despair Discouragement Withdrawal Anger Refusal to discuss change or loss Decrease self esteem Hostile/irritable Depression Insomnia Refusal to participate in self care Sadness Grief Normal reaction to loss Regression can and does occur Provide safe environment for expression of feelings Common in patients who have experienced mastectomy, amputation, burns, cancer, disfiguring surgery , or spinal cord injury. Adjustment: Acceptance and adaption Active participant in therapy/ care Planning for future Increase self esteem

When to take the Xanax

Measure your anxiety on a scale, then decide when to use Xanax, but do not exceed twice a day Self monitoring tools promote independence and teach the client to track symptoms

Major Depressive Disorder Responses to Anxiety

Mild Moderate Severe Panic

Major Depressive Disorder Levels of Anxiety

Mild +1 Moderate + 2 severe + 3 Panic +4

Low Self Esteem Non Verbal communication

Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness.

poor reality testing, grandiosity, denial of problems, poor concentration, inability to meet basic needs

Nursing diagnoses Defensive coping Ineffective coping Outcomes Reports an increase in concentration, Refrains from manipulation Uses effective coping strategies

Pressured speech, flight of ideas, going from one person or event to another, annoying or taunting others, loud and crass speech, provocative behaviors

Nursing diagnoses Impaired verbal communication Impaired social interaction Outcomes Initiates and maintains goal directed and mutually satisfying verbal exchange

anxiety, agitation, inability to concentrate, restlessness, prolonged periods of no sleep

Nursing diagnoses: Sleep deprivation Outcomes Sleeps 5-8 hours a night, reports feeling rejuvenated after sleep.

manic episode

Onset between 18-30 years old Mood: -Elevated -Exapnsive -Irritable Speech: -Loud. Rapid -Punning -Poor judgment -Clanging -Vulgar ? wt. loss Grandiose delusions Distracted Hyperactive Decrease need for sleep Inappropriate dress Flight of ideas. Poor Judgment and hyperactivity Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply. Disturbed thought processes Sleep deprivation People with mania are hyperactive and often do not take the time to eat and drink properly. Their high levels of activity consume calories; therefore deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

Cognitive Distortions Related to Eating Disorders

Overgeneralization:Asingleeventa ectsunrelatedsituations. "He didn't ask me out. It must be because I'm at." "I was happy when I wore a size 6. I must get back to that weight." All-or-nothing thinking: Reasoning is absolute and extreme, in mutually exclu- sivetermso blackorwhite,goodorbad. "I I have one Popsicle, I must eat ve." "I I allow mysel to gain weight, I'll blow up like a balloon." Catastrophizing: The consequences o an event are magni ed. "I I gain weight, my weekend will be ruined." "When people say I look better, I know they think I'm at." Personalization: Events are overinterpreted as having personal signi cance. "I know everybody is watching me eat." "People won't like me unless I'm thin." Emotional reasoning: Subjective emotions determine reality. "I know I'm at because I eel at." "When I'm thin, I eel power ul."

Euphoric mania

Patient is very happy but the emotion is inappropriate for what is going on

Criteria for Hospital Admission of Individuals with Eating Disorders

Physical Criteria Weight loss more than 30% over 6 months Rapid decline in weight Inability to gain weight with outpatient treatment Severe hypothermia caused by loss o subcutaneous tissue or dehydration (bodytemperature lowerthan36° Cor96.8° F) Heart rate less than 40 beats per minute Systolic blood pressure less than 70 mm Hg Hypokalemia (less than 3 mEq/L) or other electrolyte disturbances not corrected by oral supplementation Electrocardiographic changes (especially dysrhythmias) Psychiatric Criteria • • • • • • • • • • • Suicidal or severely irrepressible, sel -mutilating behaviors Uncontrollable use o laxatives, emetics, diuretics, or street drugs Failure to comply with treatment contractSevere depression PsychosisFamily crisis or dys unction

Since the client has decreased energy, which intervention is best?

Plan a scheduled rest period

When the nurse prepares a client for ECT, what should be expected?

Preparation is similar to brief surgical procedure

depressive episode

Previous manic episodes Feelings of worthlessness, guilt, hopelessness Increase anger and irritability decrease interest in pleasure Negative views Fatigue and decrease energy Decrease appetite Constipation Insomnia Decrease libido Suicidal preoccupation May be agitated or have movement retardation.

Implementation Suicide Prevention (national Strategies)

Promote awareness that suicide is a preventable public health problem Develop broad based support for suicide prevention Develop and implement strategies to reduce the stigma Promote efforts to reduce access to lethal means and methods of self harm Training for recognition of at risk behavior and delivery of effective treatment Promote and support research on suicide prevention

DSM-5 DIAGNOSTIC CRITERIA for Bulimia Nervosa

Recurrent episodes o binge eating. An episode o binge eating is charac- terizedbybotho the ollowing:1. Eating, in a discrete period o time (e.g., within any 2-hour period), an amount o ood that is de nitely larger than what most individuals wouldeatinasimilarperiodo timeundersimilarcircumstances. 2.Asenseo lacko controlovereatingduringtheepisode(e.g., eeling that one cannot stop eating or control what or how much one is eating). Recurrent inappropriate compensatory behavior in order to prevent weight gain,suchassel-inducedvomiting;misuseo laxatives,diureticsorother medications; asting;orexcessiveexercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week or 3 months. Sel -evaluation is unduly inf uenced by body shape and weight The disturbance does not occur exclusively during episodes o anorexia nervosa. Specifyif: Inpartialremission:Ater ullcriteria orbulimianervosawerepreviouslymet, some,butnotall,o thecriteriahavebeenmet orasustainedperiodo time. In ullremission:Ater ullcriteria orbulimianervosawerepreviouslymet, noneo thecriteriahavebeenmet orasustainedperiodo time. Specify current severity: The minimum level o severity is based on the requency o inappropri- ate compensatory behaviors (see below). The level o severity may be increased to ref ect other symptoms and the degree o unctional disability. Mild:Anaverageo 1to3episodeso inappropriatecompensatorybehav- iors per week. Moderate: An average o 4 to 7 episodes o inappropriate compensatory behaviors per week. Severe: An average o 8 to 13 episodes o inappropriate compensatory behaviors per week. Extreme:Anaverageo 14ormoreepisodeso inappropriatecompensatory behaviors per week.

Depression Assessment (SIG E CAPS)

S sleep disturbances I interest decreased in pleasure activities and sex G guilty feelings E energy decreased C concentration (decreased) A appetite (up or down) P psychomotor Function decrease S Suicidal ideations

In what classification of drugs is the antidepressant Fluoxetine ( Prozac)

SSRI selective serotonin reuptake inhibitor The action of an SSRI antidepressant is to increase availability of serotonin The nurse understands that SSRIs are now more widely prescribed than tricyclics for antidepressant therapy because tricyclics are more lethal in an overdose When the client receives fluoxetine (prozac) , the nurse must explain the purpose and when to expect therapeutic effectiveness which is in 1-3 weeks Gastrointestinal disturbances occur commonly in clients who are taking SSRI antidepressants SSRIs can "This medication will help you think more clearly."

Depression

Safety precautions -Remove harmful objects -Close observation -1 on 1 -Written contract Meaningful socialization Participation in -Activities -Hobbies -Group discussion Increase self esteem Provide for physical needs Assess weight Prevent constipation Encourage exercise Maintain hygiene Promote Expression of Feelings -Encourage expression Non-judgmental support -Kind- pleasant- interested approach -Frequent contact -Assist in decision making ANY AGE SIGNS AND SYMPTOMS. Cognitive -suicidal preoccupation -Crying -Poverty of ideas -Negative view -Self, World, Future Mood Dysphoric Depressive Despair decrease interest in pleasure Psychomotor -Agitation or retardation of movement -Fatigue -Decrease appetite -Constipation -Sleep disturbances -Decrease libido -NO SEX Medical TX Meds ECTS Assess Suicidal potential , Recognition of intent AT RISK -Adolescents and older adult -Recent crisis- stress- loss -Substance abuse -Chronic or painful illness -Previous suicide attempts -Identity crisis -Withdrawn -depressed - Hallucinating Sad Persons Scale -Sex (gender) increase in males -Age below 19 and above 45 -Depression -Previous suicide attempts -ETOH (alcohol) abuse -Rational thinking impaired -Social support -Organized plan -No spouse -Sickness (chronic) Neurotic (sad to Happy) Wakes up optimistic but worsens as day passes. Psychotic (happy to sad) Feels worse in a.m. but worsens as day passes. Depression Nursing interventions Meaningful socialization Participation in -activities -Hobbies -Group discussion Increase self esteem Safety precautions -Remove harmful objects -Close observation -1 on 1 -Written contract Provide for physical needs -Assess weight -Prevent constipation -Encourage exercise -Maintain hygiene

PatientandFamilyTeaching about Selective Serotonin Reuptake Inhibitors

Selective serotonin reuptake inhibitors (SSRIs) may cause sexual dys unc- tion or lack o sex drive. In orm nurse or physician. SSRIs may cause insomnia, anxiety, and nervousness. In orm nurse or physician. SSRIs may interact with other medications. Be sure physician knows other medications patient is taking (e.g., digoxin, war arin). SSRIs should not be taken within14dayso thelastdoseo amonoamineoxidaseinhibitor(MAOI). No over-the-counter drug should be taken without rst noti ying physician. Common side e ects include atigue, nausea, diarrhea, dry mouth, dizziness,tremor,andsexualdysunctionorlacko sexdrive. Because o the potential or drowsiness and dizziness, patient should not drive or operate machinery until these side e ects are ruled out. Alcohol should be avoided. SSRIs may act synergistically, and people report increasede ectso alcohol(e.g.,onedrinkcanseemliketwo).Alcoholis also a central nervous system (CNS) depressant that may work against the desirede ecto theSSRI. Liver and renal unction tests should be per ormed and blood counts checked periodically. Medication should not be discontinued abruptly. People report such e ects as dizziness, nausea, diarrhea, muscle jerkiness, and tremors. I side e ects rom the SSRIs become bothersome, patient should ask physician aboutchangingtoadi erentdrug.Abruptcessationcanleadtoserotonin withdrawal. SSRIs should be used with caution in the elderly and in pregnant women. The physician should take into account the bene ts versus the risk in these populations, as well as all patients taking SSRIs or any kind o antidepressant. Any o the ollowing symptoms should be reported to a physician immediately: Increase in depression or suicidal thoughts Rash or hives Rapid heartbeat Sore throat Di culty urinating Fever, malaise Anorexia and weight loss Unusual bleeding Initiationo hyperactivebehavior Severe headache

Suicide

Signs and symptoms Gives overt or covert cues, has psychiatric diagnosis Nurse Diagnoses Risk for suicide (A person intentionally overdoses on antidepressant drugs.) Risk for injury Risk for self directed/ Other directed violence Outcomes Remains free from injury, expresses will to live, discloses plan for suicide if present, refrained from attempting suicide. Signs and symptoms Overwhelmed with situational crises, relies heavily on drugs or alcohol, has few supportive systems, shows poor problem solving skills. Nurse Diagnoses Ineffective coping Disabled family coping Impaired family coping Impaired social interaction Outcomes Identifies coping mechanisms to assist with situational crisis, identifies social support within community Signs and symptoms Lacks hope for future, has no closes relationships Nurse Diagnoses Hopelessness Powerlessness Social isolation Spiritual distress Loneliness Chronic sorrow Outcomes Expresses willingness to call on others for help, identifies support systems within, community Signs and symptoms Believes that he or she is no good, worthless, ineffective, a burden to others, can't do anything right Nurse Diagnoses Situational low self esteem Chronic low self esteem Outcomes Describes feelings of self worth Signs and symptoms Does not understand age related crisis Nurse Diagnoses Deficient knowledge Outcomes Patient and family identify developmental crisis as age related and identify community resources. INTERVENTION FOR distressed family and friends of someone who has committed suicide > Attending a self-help group for survivors Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide.

Outcomes for Depression

Signs and Symptoms Previous suicidal, putting affairs in order, giving away prized possessions, suicidal ideation Nursing Diagnoses > Risk for self directed violence >Risk for suicide >Risk for self mutilation Outcomes Expresses feelings, verbalizes suicidal ideas, refrains from suicidal, attempts, plans for suture Signs and Symptoms Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalization of inability to cope Nursing Diagnoses Ineffective coping Outcomes Identifies ineffective and effective coping, engages in personal actions to manage stressors effectively. Signs and Symptoms Dull, sad affect, no eye contact, preoccupation with own thgouths, seeks to be alone, uncommunicative, withdrawn, feels rejected and not good enough Nursing Diagnoses Social isolation Outcomes Attends group meetings, interacts spontaneously with others, talks with nurse in 1:1. Demonstrates interest in engaging with family and others Signs and Symptoms Difficult making decisions, poor concentration, inability to take action Nursing Diagnoses Decisional conflict Outcomes Participates in health care decisions, makes judgments and chooses between alternatives Signs and Symptoms Feelings of helplessness, hopelessness, powerlessness Nursing Diagnoses Hopelessness Powerlessness Outcomes Expresses hope for a positive future Believes personal actions impact outcomes, has optimism Signs and Symptoms Questioning meaning of life and existence Feelings of worthlessness, poor self-image, negative sense of self Nursing Diagnoses Spiritual distess Impaired religiosity Risk for impaired religiosity Outcomes Shares feelings about spirituality Signs and Symptoms Feelings of worthlessness, poor self image Nursing Diagnoses Chronic low self esteem Situational low self- esteem (A patients employment is terminated and major depressive disorder results. The patient says to the nurse, Im not worth the time you spend with me. Im the most useless person in the world The patients statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Situational low self-esteem.) Outcomes Identifies strengths, verbalizes self acceptance, participate in groups Signs and Symptoms Vegetative signs of depression Nursing Diagnoses > Self care deficit > Imbalanced nutrition: less than body requirements > Sexual dysfunction > Insomnia Vegetative signs of depression are alterations in the body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than to diagnoses associated with feelings about self. Outcomes Increases baseline self care, reports adequate sleep, eating, elimination Q ) "I'm sorry that I'm still alive. My life will never be normal again." Nurse response should be "It's true that your life may be different. What concerns you the most?" This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. Q) A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Nurse response : "Can you tell me what it is that makes you think you will die so soon?" The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data.

Risk factors for eating disorders

Strong genetic liability for Eating Disorders Female athletes in gymnastics, ballet, figure skating, distance running....have increase in incidence; males in bodybuilding 50 - 75% of patients with Anorexia and Bulimia also have Major Depressive Disorder or Dysthymia Incidence of OCD in Bulimia Incidence of substance abuse associated with both Anorexia and Bulimia Comorbid Personality Disorder in 42-75% Sexual abuse reported in those with Anorexia and Bulimia Anorexia carries a significant risk of death and suicide Eating Disorders associated with Oppositional Defiant Disorder Tryptophan-essential to serotonin synthesis (diet)

SymptomsandInterventions or Serotonin Syndrome

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 o ending agent(s). 2. Initiate symptomatic treatment: Serotonin receptor blockade: cyproheptadine, methysergide, propranolol Cooling blankets, chlorpromazine or hyperthermia Dantrolene, diazepam or muscle rigidity or rigors Anticonvulsants Arti cial ventilation Paralysis

Patient and FamilyTeaching about Monoamine Oxidase Inhibitors

Tell the patient and the patient's amily to avoid certain oods and all medi- cations (especially cold remedies) unless prescribed by and discussed with the patient's physician (see Table 15-9 and Box 15-7 or speci c ood 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 i he or she has a severe headache.Ideally, monitor the patient's blood pressure during the rst 6 weeks o treatment(orbothhypotensiveandhypertensivee ects). Instruct the patient that a ter the MAOI is stopped, dietary and drug restric- tionsshouldbemaintained or14days.

Reality testing

The ability to evaluate the external world objectively and to differentiate adequately between it and the internal world

Cognition

The act process or result of knowing, learning or understanding

Clang association

The meaningless rhyming of words, often in a forceful manner. "The rat-a-tat-tat is a mat in the bat cat pit in a vat. That hat. Pat at."

PatientandFamilyTeaching about Tricyclic Antidepressants

The patient and amily should be in ormed that improvement in mood may take rom 7 to 28 days a ter initiation o treatment. Up to 6 to 8 weeks mayberequired orthe ulle ecttobereachedand ormajordepressive symptoms to subside. The amily should rein orce this requently to the depressed amilymemberbecausedepressedpeoplehavetroubleremem- bering and respond to ongoing reassurance. The patient should be reassured that drowsiness, dizziness, and hypoten- sion usually subside a ter the rst ew weeks. When the patient starts taking tricyclic antidepressants (TCAs), the patient should be cautioned to be care ul working around machines, driving cars, and crossingstreetsbecauseo possiblealteredrefexes,drowsiness,ordizziness. Alcohol can block the e ects o antidepressants. The patient should be told torerain romdrinkingalcohol. I possible, the patient should take the ull dose at bedtime to reduce the experience o side e ects during the day. I the patient orgets 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 onedoseo TCAuntilthephysiciancanbecontacted.

Labile Labile and euphoric

The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. (Euphoria refers to an elated mood.) Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile.

Drugs that Can Interact with Monoamine Oxidase Inhibitors

Use o the ollowing drugs should be restricted in patients taking mono- amine oxidase inhibitors (MAOIs): Over-the-counter medications or 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)

Since Anna is eating 50% of her meals, which priority nursing intervention should be included on the treatment plan?

Weigh weekly and document

Delusion of grandeur

an exaggerated belief about one's importance, wealth, power, or talents "I hear voices telling me I'm the next prophet."

Assessment of suicide potential - Assess for risk factors (See risk factor chart) ASK !

asking is the single most important assessment yet providers don't ask Relief for someone thinking about suicide to talk about it. --Provider "giver permission to talk" Relief to be able to talk about despair and loneliness. Asking does not "give a person ideas" It is a professional responsibility. Talking openly leads to a decrease in isolation and facilitates problem solving. People who contemplate suicide, attempt suicide and even regret failure are extremely receptive to talking about it.

Implementation A. Milieu Management Care of suicide patients

conduct one on one nursing observation and interaction 24 hours a day (never let the patient out of staffs sight) Maintain arms length at all time Document patients whereabouts, mood, verbatim statements, and behavior every 15 to 30 minutes per protocol During observation when patient is sleeping, hands should always be in view, not under the bedcovers Carefully observe patient swallow each dose of medication Nurse/Physician should explain to the patient what they will be doing and why. With patient input, create a suicide contract Environment: An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. > Supervise the patient 24 hours a day. > The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient is still a suicide risk; therefore, continuous supervision is indicated.

suicide contract

contract between the patient and nurse (or significant other) in which the patient will call the designated person when the patient has thoughts of suicide For the next 24 hours, I will not kill or harm myself in any way. Leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, I am not going to harm myself, I am going to kill myself, or I am not going to attempt suicide, I am going to commit suicide. A patient may call a therapist and leave the telephone to carry out the suicidal plan.

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?

each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patients physiologic safety. Hyperactivity and poor judgment place the patient at risk for injury. Risk for injury

When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others

limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient and threaten the patient with seclusion as punishment. Asking why does not provide for environmental safety. Do not hit anyone. If you are unable to control yourself, we will help you.

Electroconvulsive therapy

a biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient ECT is contraindicated in patients with __intracranial pressure____ and __pheochromocytoma_____ because ___heart rate can accelerate to 140's ECT Generalized grand mal seizure (30-60 seconds) Electrodes placed unilaterally or bilaterally 2-3 times/week for a total of 6-12 treatments Used for -Severe depression and or psychotic illness -Manic episodes of bipolar disorder and rapid cycling mania -Acute schizophrenia Indications -Suicidal and /or homicidal -Medication trials have failed -Catatonia -Drug resistant patients -Marked Vegetative symptoms -Marked agitation -Psychosis -Rapid cycler Higher Risk Cerebral Intracranial pressure from tumor Recent (3 months) CVA Cerebral aneurysm Brain Tumors Cardiac MI or arrhythmias Aortic aneurysm Severe underlying hypertension Congestive heart failure *Side effects: -temporary memory loss and confusion, headache *Risk of permanent memory loss; death r/t cv problems *Patient receives oxygen prior to treatment . Airway is placed *RN helps physicians and provides physical and emotional support to client Nursing care of patient undergoing ECT BEFORE : The correct interventions reflect routine electroconvulsive therapy preparation, which is similar to preoperative preparation: sedation and anticholinergic medication before anesthesia, maintaining nothing-by-mouth status to prevent aspiration during and after treatment, airway maintenance, and general safety by removing prosthetic devices. Restraint is not part of the pretreatment protocol. An advance directive is prepared independent of this treatment. > Check for signed consent > Check labs and EKG, xray > NPO for 6-8 hours. Withhold food and fluids for a minimum of 6 hours before treatment. > Have patient void and remove dentures, eyeglasses contact lenses, jewelry and hearing aids. > Anticipate the meds to be given to the patient ( general anesthetic and muscle relaxant) Administer pretreatment medication 30 to 45 minutes before treatment. DURING > Ensure patency of airway > Observe and record type and amount of movement induced by seizure. > Monitor vital signs and cardiac functioning > EKG/EEG AFTER > Position patient on side to prevent aspiration > Orient to time and place. > Monitor vital signs and cardiac functioning, BP, P, R, every 15 minutes for 1 hr > Remain in bed 1 hr > Describe what has occurred > Stay with patient until fully awake. (At least 15 minutes.) > Reassure patient memory loss is usually temporary > Oriented and able to perform self care without assistance Q) What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? Supporting physiologic stability During the immediate post-treatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiologic stability. Monitoring pupillary responses is not a priority. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused. Q) electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. Recent memory impairment or confusion or both are often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten and important details. The incorrect responses contain rationales that are untrue. The patient needing time to reorient himself or herself to a pressured work schedule is less relevant than the correct rationale.

Lithium

lithium (Lithibid) The nurse assesses the patient and notes tremors and confusion. The patient's latest serum lithium level was 2 mEq/L. Nurse should Hold the dose and notify the provider. Nurse notes a large output of clear, dilute urine from patient . The nurse should suspect Lithium toxicity A patient receiving lithium should be assessed for .Diaphoresis, weakness, and nausea. Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Evaluate renal and thyroid function, WBC w/ differential, serum electrolytes, and glucose. Patients on Lithium should should drink 2 to 3 liters of fluid each day. Monitor serum lithium levels twice weekly during initiation of therapy and every 2 month during chronic therapy. Draw blood samples in the morning immediately before next dose. Therapeutic levels range from 0.5 - 1.5 mEq/L for acute mania and 0.6-1.2 mEq/L for long term control. Serum concentrations should not exceed 2.0 mEq/L prior to administering the medication Assess mental status (orientation, mood, behavior) initially and periodically. Initiate suicide precautions if indicated. Monitor intake and output ratios. Report significant changes in totals. Unless contraindicated, fluid intake of at least 2000-3000 mL/day should be maintained. Weight should also be monitored at least every 3 mo. Evaluate renal and thyroid function, WBC with differential, serum electrolytes, and glucose periodically during therapy. I would worry about Toxicity Overdose: Monitor serum lithium levels twice weekly during initiation of therapy and every 2 mo during chronic therapy. Draw blood samples in the morning immediately before next dose. Therapeutic levels range from 0.5-1.5 mEq/L for acute mania and 0.6-1.2 mEq/L for long term control. Serum concentrations should not exceed 2.0 mEq/L. signs and symptoms of lithium toxicity (vomiting, nausea , anorexia, diarrhea, slurred speech, lightheadedness, decreased coordination, drowsiness, muscle weakness, tremor, or twitching). If these occur, report before administering next dose. Contact the provider to obtain an order for a serum lithium level. Patient teaching: Instruct patient to take medication as directed, even if feeling well. Take missed doses as soon as remembered unless within 2 hr of next dose (6 hr if extended release). Lithium may cause dizziness or drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Low sodium levels may predispose patient to toxicity. Advise patient to drink 2000-3000 mL fluid each day and eat a diet with consistent and moderate sodium intake. Excessive amounts of coffee, tea, and cola should be avoided because of diuretic effect. Avoid activities that cause excess sodium loss (heavy exertion, exercise in hot weather, saunas). Notify health care professional of fever, vomiting, and diarrhea, which also cause sodium loss. Advise patient that weight gain may occur. Review principles of a low-calorie diet. Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially NSAIDs. Review side effects and symptoms of toxicity with patient. Instruct patient to stop medication and report signs of toxicity to health care professional promptly. Advise patient to notify health care professional if fainting, irregular pulse, or difficulty breathing occurs. Lithium may be teratogenic. Advise female patients of reproductive potential to use contraception during therapy and to consult health care professional if pregnancy is planned or suspected, and to avoid breast feeding. Monitor breast-fed infants for signs and symptoms of lithium toxicity (hypertonia, hypothermia, cyanosis, ECG changes). Emphasize the importance of periodic lab tests to monitor for lithium toxicity. A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, Do I have to keep taking this lithium even though my mood is stable now? Select the nurses most appropriate response.: Taking the medication every day helps prevent relapses and recurrences. Patients diagnosed with bipolar disorder may be indefinitely maintained on lithium to prevent recurrences. Helping the patient understand this need promotes medication compliance. Q) A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, Ive had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do? The nurse should advise the patient: Have someone bring you to the clinic immediately. The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurologic symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not address the patients symptoms. Restricting oral fluids will make the situation worse. Q) Lithium is prescribed for a new patient. Which information from the patients history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? Congestive heart failure The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. Arthritis, epilepsy, and psoriasis do not directly involve fluid balance and kidney function.

Major Depressive Disorder Defense Mechanisms

repression denial Suppression rationalization intellectualization regression dissociation undoing conversion projection displacement sublimation reaction Compensation introjection identification formation

Suicide Precautions

secure room: -Windows locked -Breakproof Glass and mirrors -Plastic Flatware -Cords -Phone -Extension -Equipment -Curtains -Belts/ Shoelaces/ Drawstring pants -Matches or cigarettes -Sharps/ Razors Patient Care: -Frequent observation... Preferably 1 to 1 -Staff communication-Constant Risk assessment / Documentation -Develop therapeutic Relationship -Written behavior contract with pt. -Restraints as necessary -Medicine (medication) -Monitor and restrict visitors. I am feeling a lot better, so you can stop watching me. I have taken too much of your time already. Which is the nurses best response > Because we are concerned about your safety, we will continue with our plan. > When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. > Do not convey concern for the patient, or suggest that the patient is not a partner in the care process. ------------------------------ 1 > Allow no glass or metal on meal trays 2 > Remove all potentially harmful objects from the patients possession. 3 > Maintain arms length, one-on-one nursing observation around the clock. One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patients possession are measures included in any level of suicide precautions.

Flight of ideas

symptom of mania that involves an abruptly switching in conversation from one topic to another "Joe the crow is a bird. So is tweety. I love looney tunes. Do you play violin?"

Initial Aims of Treatment for Bulimia Nervosa Are to:

❖ Eliminate binge-purge patterns ❖ Establish good eating habits ❖ Eliminate the underlying cause of bulimic 0patterns ❖ Programs emphasize education as much as therapy

Delusion

"I have superpowers to save the world." A false belief held to be true even with evidence to the contrary

Hallucination

"Snakes are coming out of the TV." A sense perception for which no external stimulus exists

Interventions for patients with major depressive disorder D) Psychopharmacological interventions

(see pharmacology table)

Pharmacological interventions

-Lithium -ANticonvulsant -Atypical antipsychotics -Antianxiety agents

Suicide Protective Factors

-sense of responsibility to family -pregnancy -religious beliefs -satisfaction with life -positive social support -access to health care -effective coping skills -effective problem solving skills -intact reality testing

Assessment guidelines for nurses

1) Evaluate patients risk of harm to self or others. Over hostility is correlated with suicide. 2) A thorough medical and neurological assessment to determine if depression is primary or secondary to another disorder - Evaluate if the patient is psychotic -Patient has taken drugs or alcohol -If medical conditions are present -History of comorbid psychiatric disorder (eating disorder, borderline or anxiety disorder) 3) Past history of depression 4) Support system

Assessment of suicide potential Assess for risk factors (See risk factor chart) Assess for Lethality

1) Specific plan with details 2) How lethal? 3) Access to method. Q) When assessing a patients plan for suicide, Availability of means and lethality of method is PRIORITY..... > If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.

Serotonin deficiency

> Depression, eating disorders, alcoholism, aggression > R/t depression and suicide > Research suggests that low levels of serotonin may play a role in the decision to commit suicide.

Emotion

A complex pattern of changes, including physiological arousal, feelings, cognitive processes, and behavioral reactions, made in response to a situation perceived to be personally significant.

Health teaching and promotion

As the client approaches the goal weight, he she is encouraged to expand the behavior to include eating out, preparing a meal and eating forbidden foods Develop social skills Problem solving skills Decision making skills

Drugs for Bipolar: Mood Stabilizers

Mood stabilization in bipolar patients is accomplished with lithium and other drugs Drug Lithium ( Eskalith) Route and Adult Dose PO initial 600mg tid Maintenance 300 mg tid (max 2, 4 g/day) Remarks For treatment of mania and depressive symptoms. Must be used cautiously in epilepsy and in psychosis Antiseizure Drugs Drug Carbamazepine (Tegretol) Route and Adult Dose: PO 200 mg bid Gradually increased to 800 - 1200 mg/day in three to four divided doses Remarks for treatment of manic depressive and schizoaffective symptoms Used as anti seizure medication Drug lamotrigine ( Lamictal ) Route and Adult Dose PO 50 mg/day for 2 weeks Then 50 mg bid for 2 weeks May increase gradually up to 300-500 mg/day in two divided doses ( max 700 mg/day) Remarks Used as anti seizure medication Fatal rash has been reported in children less than 16. years old Drug valproic acid ( Depakene) ( see page 203 for the Drug Profile box) Route and Adult Dose PO 250 mg tid ( max: 60 mg/kg/day ) Remarks For treatment of mania and prevention of migraine headache Used as anti seizure medication Drug Route and Adult Dose Remarks

Insight

Understanding and awareness of the reasonds for and meaning behind ones motives and behavior

Who are my Idols/Role Models?

What TV shows do I watch? Which characters do I identify with? What magazines do I look at? What/who gets my attention? Who am I most attracted to or look at the most when I am out in public? Is/are there any type/s of persons that I am repulsed by? How does this affect my caring for similar clients in a health care setting?

Anorexia Nervosa There are two main subtypes: Restricting type <> Lose weight by restricting "bad" foods, eventually restricting nearly all food <> Show almost NO variability in diet Binge-eating/purging type <> Lose weight by vomiting after meals, abusing laxatives or diuretics, or engaging in excessive exercise <> May engage in eating binges

❖ Fear of obesity ❖. Feels fat when thin ❖ Food preparation and eating rituals ❖ Refusal to maintain minimal body weight ❖ Amenorrhea ❖ Excessive Exercise ❖ Cold intolerance Signs and Symptoms Noticeable weight loss Always cold Muscle weakness Amenorrhea Yellow skin Lanugo Impaired renal function Decreased bone density Peripheral edema Constipation Abnormal lab values EKG changes Bradycardia, Heart failure, decreased BP Cold hands and feet Electrolyte imbalances Assessments/characteristics low weight Amenorrhea Yellow skin Lanugo Cold Extremities Constipation Abnormal lab values (low T3, T4) Anemic pancytopenia Decreased bone density Rigidity, perfectionism ( Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients diagnosed with eating disorders.) Characteristics ❖ Restrict intake of food ❖ Decrease BMI (significant) ❖ Engage in binge eating, purging ❖ Intense fear of weight gain ❖ Distorted body image Medical Complications ❖ Fatigue and lack of energy ❖ Bradycardia (arrhythmias) ❖ Electrolyte imbalances ❖ Osteoarthritis ❖ Cardiac arrest and death ❖ Dizziness and HA ❖ Decreased metabolic rate ❖ Skin problems ❖ Hair loss ❖ Stomach pains ❖ Depression ❖ Insomnia ❖ Shortness of breath ❖ Infertility ❖ Cathartic colon(caused by laxative abuse) BRAIN ❖ can't think right ❖ Fear of weight gain ❖ Mood/ Depressed / Irritable ❖ Bad Memory ❖ Fainting Blood ❖ Anemia Intestines ❖ Bloating ❖ Constipation Hair ❖ Thins ❖ Becomes Brittle Heart ❖ Low Blood Pressure ❖ Slower heart rate ❖ Palpitations Kidneys ❖ Failure ❖ Kidney Stones ❖ Skin ❖ Bruise Easily ❖ Dry Skin ❖ Growth of fine hair ❖ All over body ❖ Cold easily ❖ Yellow Skin ❖ Nails get brittle Hormones ❖ Bone Loss ❖ Problems Growling In women ❖ Periods Stop ❖ Trouble getting pregnant Pregnancy ❖ Higher risk for miscarriage ❖ C-Section ❖ Low Birthweight baby ❖ Post Partum Depression Anorexia Nervosa: The Clinical Picture ❖ The key goal for people with anorexia nervosa is becoming thin The driving motivation is fear: 1) Of becoming obese 2) Of giving into the desire to eat 3) Of losing control of body shape and weight ❖ People with anorexia are preoccupied with food Anorexia Nervosa: Medical Problems Caused by starvation: ❖ Amenorrhea ❖ Low body temperature ❖ Hypotension ❖ Osteoporosis ❖ Bradycardia ❖ Cardiac arrhythmias ❖ Metabolic and electrolyte imbalances ❖ Dry skin, brittle nails ❖ Poor circulation ❖ Acrocyanosis ❖ Peripheral neuropathy ❖ Lymphocytosis ❖ Carotenemia ❖ Hematuria ❖ Proteinuria ❖ Leukopenia Similarities with Bulimia Nervosa: Cardiovascular abnormalities (low BP, low HR), electrolyte imbalance (Low K) Cardiac failure peripheral edema, Muscle weakening See page 346, table 18-1 Thoughts and behaviors REstricts calories to maintain body weight at or above minimally normal for age and height( less than 85% of expected) Preoccupation with thoughts of food View self as fat even when emaciated Peculiar handling of food, Cutting into small bits Pushing pieces of food around plate Possible development of rigorous exercise regimen Possible self induced vomitting use of laxatives and diuretics Self worth is judged by his/her weight See p/ 346. Box 18-3 Peripheral edema Decreased bone density Amenorrhea Lanugo Electrolyte imbalance Muscle weakness Anorexia Nervosa : Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, Describe what you think about your present weight and how you look. Which response by the patient is most consistent with the diagnosis? I am fat and ugly. >>>>>Patients diagnosed with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually disclose perceptions about self to others. The patient with anorexia will persist in trying to lose more weight. >>>>>>>>>Nursing Diagnosis : Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia >>>>> OUTCOME: gain 1 to 2 pounds. Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. WEIGHT GAIN IN PATIENTS WITH ANOREXIA NERVOSA Observe for adverse effects of re-feeding. The nursing intervention of observing for adverse effects of re-feeding most directly relates to weight gain and is a priority. When a nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: >>>>>According to our agreement, no exercising is permitted until you have gained a specific amount of weight. >>A matter-of-fact statement that the nurses perceptions are different helps avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. Peripheral edema, Constipation, Hypotension, Lanugo Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. >>>Adherence to a selected menu >>>Observation during and after meals >>>Monitoring during bathroom trips Priority milieu interventions support the restoration of weight and a normalization of eating patterns. These goals require close supervision of the patients eating habits and the prevention of exercise, purging, and other activities. Menus are strictly adhered to. Patients are observed during and after meals to prevent them from throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

Psychosis

A patient experiencing hallucinations, delusions, and dramatically disturbed thoughts. Hallucinations, delusions, dramatically disturbed thoughts.

Areas to Assess depression

A) Affect outward representation of a persons internal state of being B) Thought process: Judgment is poor, indecisive is common. Memory and concentration are poor. Delusional thinking may be seen in patients with major depression. C) Mood Subjective experience of the patient (Patient states how he or she feels. ) D) Feelings: -Guilt -Helplessness: Unable to carry out simple tasks such as grooming -Hopelessness: One of the core characteristics of depression and risk factors for suicide (Hopelessness is the characteristic common among people who attempt suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired.) -Anger & irritability- Destruction of property, verbal attacks, or physical aggression towards others. E. Physical behavior -Psychomotor retardation: Slowed and difficult movements can lead to complete inactivity and incontinence. Facial expressions decreased and gaze is fixed. ( When patients are unable to perform self-care activities, staff members must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.) -Psychomotor agitation: Patients are unable to relax. Is constantly pacing, bitting their nails, tap their fingers. -Grooming: Dressing and personal hygiene are neglected. Appears shabby, and unkempt -Vegetative signs: Alterations in activities necessary to support physical life and growth. -Changing in eating patters, -Change in sleep patterns Insomnia or wake frequently -Changes in bowel habits -Decreased libido F. Communication: may speak and comprehend slowly. G. Religious Beliefs & Spirituality: Patient might be concerned with the greater meaning of their experience. Assess how it has helped the patients in the past

Definitions for some terminologies used in depressive disorders Afftect

Affect-the external manifestation of feeling or emotion which is manifested in facial expression, tone of voice and body language. Anergia: Lack of energy Anhedonia: Loss of interest in and withdrawal from all regular and pleasurable activities. Often associated with depression. Anhedonia is a common finding in many types of depression and refers to feelings of a loss of pleasure in formerly pleasurable activities. Anhedonia refers to the inability to find pleasure or meaning in life; thus planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. > Instilling a sense of hopefulnessd. > Assisting with self-care activities > Accommodating psychomotor retardation NOTE: episodes of depression in bipolar are different from unipolar depression.

Nursing interventions Bulimia

Imbalanced Nutrition : More than body requirement- Bulimia Help Client differentiate between emotions and sensations of hunger +Help client assess situations that precede binging +Help client identify particular foods that trigger binge eating ( The binge eater is often overweight) +Help client solve ways to avoid privacy at usual times of binges Help client identify other positive behaviors (avoiding fast-food, shopping for food with a friend) +Teach clients to eat 3-6 meals a day and avoid periods of fasting +Teach client to include carbohydrates at each meals +Encourage delay in responding to urge to binge by trying alternative behaviors such as talking to a teacher, counselor or calling a friend. An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient to: avoid skipping meals or restricting food. >>>>>One goal of health teaching is the normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private. A nursing diagnosis for a patient diagnosed with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is, Within 2 weeks the patient will : identify two alternative methods of coping with loneliness. >>>>>>>The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. ( needs to be measurable ) Priority nursing intervention with bulimia nervosa Assist the patient to identify triggers to binge eating. For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge- purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority.

Other important interventions

Monitor clinical status (e.g. weight, intake, vital signs) Immediate medical stabilization is necessarry Monitor hydration and electrolytes, especially potassium Support efforts take responsibility for self Contract with client ANy acute psychiatric symptoms such as suicide are addressed immediately Lab test should be continued after discharge. A patient who is referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patients oral intake, the nurse should ask: What do you eat in a typical day? >>>>Although all the questions might be appropriate to ask, only What do you eat in a typical day? focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patients thoughts on present weight explores the patients feelings about weight.

Interventions for patients with major depressive disorder B) Physical interventions Interventions targeting the vegetative signs of depression Vegetative symptoms refer to somatic changes associated with depression.

Nursing Actions that should be implemented > Offer laxatives, if needed. > Monitor food and fluid intake. > Provide a quiet sleep environment. promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted. ANOREXIA... Nutrition.... Food > Offer small, high calorie and high protein snacks frequently throughout the day and evening > Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins. > Offer high protein, high calorie fluids frequently throughout the day and evening > Encourage family members of friends to remain with the patients during meals > Ask the patient which foods or drinks he or she likes. Offer choices. Involve the dietitian > Weigh the patient weekly and observe the patients eating patterns. Sleep: INSOMNIA > Provide periods of rest after activities > Encourage the patient to get up and dress and to stay out of bed during the day > Encourage the use of relaxation measures in the evening (bath, warm milk) > Reduce environmental and physical stimulants in the evening- Provide decaffeinated coffee, soft lights, soft music, and quiet activities Self care deficits: > Encourage the use of toothbrush, washcloth, soap, makeup, shaving equipment and so forth to increase self esteem > Give step by reminders such as "wash the right side of your face, no the left". Patients have slow thinking and difficulty concentrating so they are unable to organize simple tasks Elimination: CONSTIPATION > Monitor intake and output, especially bowel movements > Offer foods high in fiber, and provide periods of exercise > Encourage the intake of fluids > Evaluate the need for laxatives and enemas.

Giving away valuables neglect of family impulsive life changes stress and frustration of family

Nursing diagnoses Interrupted family process Caregiver role strain Outcomes Adequate resources for family, Family routines reestablished Giving Away Valuables student gives away several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? Giving away sweaters Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated.

Hospitalization for patients that Anorexia Nervosa Criteria for Hospitalization

Physical criteria for hospitalization include ❖weight loss of more than 30% of body weight within 6 months, ❖temperature below 36 C (hypothermia), ❖heart rate less than 40 beats/min, and ❖systolic blood pressure less than 70 mm Hg. ❖Many people without eating disorders have bradycardia (pulse less than 60 beats/min). ❖Urine output should be more than 30 ml/hr. ❖A potassium level of 3.4 mEq/L is within the normal range. ❖Weight loss over 30% over 6 months ❖Rapid decrease in weight ❖Inability to gain weight with outpatient treatment ❖Hyperthermia d/t loss of subcutaneous tissue/dehydration ❖HR less than 40bpm ❖SBP less than 70mm ❖Hypokalemia (less than 3mEq/L) ❖EKG changes **Due to life threatening effects of starvation

post partum depression

Risk for other-directed violence When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis.

Mood

Subjective data a patient reports about how they are feeling emotionally. A pervasive and sustained emotion that, when extreme can markedly color the way the individual perceives the world Mood is a persons self-reported emotional feeling state Q) During a psychiatric assessment, the nurse observes a patients facial expressions that are without emotion. The patient says, Life feels so hopeless to me. Ive been feeling sad for several months. How should the nurse document the patients affect and mood? Affect flat; mood depressed Mood is a persons self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others.

which of the following findings is a factor in the development of lithium toxicity?A. Hyponatremia

The client who is taking lithium needs an adequate intake of sodium and fluid to prevent the development of lithium toxicity

SAD persons scale: Suicide assessment tool Assessment of suicide potential Assess for risk factors (See risk factor chart) SAD persons scale assesses suicide potential. > The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed.

Uses 10 major risk factors to assess suicidal potential S sex (male) -1 if male A Age 25-44 or 65+years - 1 if 25 or 65+ D Depression- 1 if present P previous attempt 1 if present E Ethanol use 1 if present R Rational thinking loss 1 if psychotic for any reason S Social supports lacking or recent loss 1 if lacking O organized plan 1 if plan with lethal method N No spouse 1 if divorced, widowed, separated, single male S Sickness 1 if severe or chronic 0-2 send home with follow up 3-4 Closely follow up; consider hospitalization 5-6 Strongly consider hospitalization 7-10 Hospitalization or commit A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.

cachexia

weakness and wasting of the body due to severe chronic illness a condition of physical wasting away due to the loss of weight and muscle mass that occurs in patients with diseases such as advanced cancer or AIDS Imbalanced nutrition: less than body requirements, related to self-starvation The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patients self- starvation is the priority A patient diagnosed with anorexia nervosa has a body mass index (BMI) of 14.8 kg/m2. Which assessment finding is most likely to accompany this value? Cachexia The BMI value indicates extreme malnutrition. Cachexia is a hallmark of this problem. The patient would be expected to have leukopenia rather than leukocytosis. Hypothermia and hypotension are likely assessment findings.

medical complications of Anorexia nervosa that can occur

• atrophy of the cardiac muscle and cardiac dysrhythmias • alteration in thyroid metabolism • estrogen deficiencies (those with longstanding estrogen deficiencies may develop osteoporosis). • Refeeding may lead to slowed peristalsis, constipation, bloating, and fluid retention. • Amenorrhea 5 • Low body temperature • Hypotension • Osteoporosis (bone loss / problems growing) • Bradycardia • Cardiac arrhythmias • Metabolic and electrolyte imbalances • Dry skin, brittle nails • Poor circulation • Acrocyanosis • Peripheral neuropathy • Lymphocytosis • Carotenemia • Hematuria • Proteinuria • Leukopenia • Low Blood pressure • Palpitations • Kidney stones/ kidney failure • Bloating • Constipation • Anemia • Low potassium , magnesium and sodium Nursing diagnoses: A) imbalanced Nutrition: less than body requirements may be related to associated condition of physiological disorder (including restrictions of food intake or excessive activity, laxative abuse), possibly evidenced by weight loss, poor skin turgor and muscle tone, [denial of hunger, unusual hoarding or handling of food, amenorrhea, electrolyte imbalance, cardiac irregularities, hypotension]. B) risk for deficient Fluid Volume possibly evidenced by risk factors of inadequate intake of food and liquids, chronic or excessive laxative or diuretic use C) disturbed Body Image may be related to alteration in self-perception, cultural or spiritual incongruence possibly evidenced by verbalizations of feelings or perceptions (e.g., rejection by others, perceptual developmental changes), perceptions reflecting altered view of body appearance, refusal to verify actual change.

Three types of bipolar disorder

❖ Bipolar I ❖ Bipolar II ❖ Cyclothymia Epidemiology ❖ Lifetime prevalence of bipolar disorder in the United States is 3.9% ❖ Bipolar 1: more common in males ❖ Bipolar 11: more common in females ❖ Cyclothymia: usually begins in adolescence or early adulthood Etiology ❖ Biological factors <> Genetic <> Neurobiological <> Neuroendocrine ❖ Psychological factors ❖ Environmental factors

Bulimia Treatment options

❖ Family therapy : Family supported in playing an active, positive role ❖ Cognitive behavioral Therapy (CBT) Alters behavior by altering way we think about food/ Weight ❖ Dietary Counseling: Talking therapy w it the aim of developing a healthy diet ❖ Psychodynamic Therapy: Explore life experiences and their impact on behavior ❖ Medication: Antidepressants

Bipolar Mania Bipolar Manic

❖ Insomnia ❖ Activity for days without rest and without appearing tired ❖ Easy agitation and aggression ❖ Exaggerated confidence ❖ Attention seeking ❖ Drug abuse including alcohol, cocaine or sleeping medications Manic ❖ Onset before age 30 Mood: ❖ Elevated ❖ Expansive ❖ Irritable Speech ❖ Loud- Rapid ❖ Punning ❖ Rhyming ❖ Clanging ❖ Vulgar ❖ ? wt. Loss ❖ Grandiose ❖ Delusions ❖ Distracted ❖Hyperactive ❖Decrease beed for sleep ❖ Inappropriate ❖ Flight of Ideas ❖ Begins suddenly escalates over several days

Bulimia Nervosa vs. Anorexia Nervosa Similarities

❖ Onset after a period of dieting ❖ Fear of becoming obese ❖ Drive to become thin ❖ Preoccupation with food, weight, appearance ❖ Elevated risk of self-harm or attempts at suicide ❖ Feelings of anxiety, depression, perfectionism ❖ Substance abuse ❖ Disturbed attitudes toward eating

Bulimia Nervosa vs. Anorexia Nervosa Differences

❖ People with bulimia are more worried about pleasing others, being attractive to others, and having intimate relationships ❖ People with bulimia tend to be more sexually experienced ❖ People with bulimia display fewer of the obsessive qualities that drive restricting type anorexia ❖ People with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping ❖ People with bulimia tend to be controlled by emotion-change friendships easily ❖ People with bulimia are more likely to display characteristics of a personality disorder ❖ Only half of woman with bulimia experience amenorrhea ❖ People with bulimia suffer damage caused by purging ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖

Milieu Management

❖ Precise mealtimes and time limits are allotted to consume meals ❖ Adherence to selected menus, ❖ Observation during and after meals ❖ Regularly scheduled weighing -After voiding, early morning at same time, same type of clothing - Check for attempt to put on weights around body ❖ Close monitoring includes: all trips to the bathroom after eating, bathroom trips after seeing visitors and after any hospital pass to ensure they have not access to and ingested laxatived and diuretics ❖ Privileges are tied to weight gain and adherence to treatment plan ❖ Parents of teenagers are taught to continue the same approach at home ❖ Maintenance of appropriate exercise after reaching acceptable weight (90% at least) ❖ Precise meal times ❖ Adherence to the selected menu ❖ Observation during and after meals ❖ Monitoring all bathroom trips after eating, after seeing visitors and hospital pass ❖ Regularly scheduled weighing ❖ Maintenance of appropriate exercise after reaching acceptable weight at least 90% of IBW ❖ Privileges are tied to weight gain and adherence to treatment plan ❖ Parents of teenagers are taught to continue the same approach at home ❖ Discourage dieting

Suicide Risk Factors

> Mental health disorders ( Up to 10% of patients diagnosed with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness. Depressive symptoms are related to suicide among patients diagnosed with schizophrenia. Patients diagnosed with schizophrenia usually have auditory, not visual, hallucinations. Although the use of drugs and alcohol compounds the risk for suicide, it is independent of schizophrenia.) >Male Gender > Increasing age men >45, Women >55 > Race > Religion- Protestants and Jews have higher rates of suicide than Roman > Marital status -Divorced men > Professionals at higher risk if fall in status > Physical health > Genetics Genetics are associated with suicide risk. Monitoring and support are important. Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. hopelessness. hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide. Risk Factors > Recent stressful life event > Self-imposed isolation > Shame or humiliation >Shame and humiliation related to the failure can be hypothesized. The inability to contact parents can be seen as a recent lack of social support, as can the roommates absence from the dormitory. Terminating access to ones social networking site represents self imposed isolation. This is a highly lethal method with little opportunity for rescue. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night lower lethality methods with higher rescue potential > Turning on the oven and letting gas escape into the apartment during the night > Cutting the wrists in the bathroom while the spouse reads in the next room > Overdosing on aspirin with codeine while the spouse is out with friends. HIGH RISK FACTOR > A 79-year-old single white man with cancer of the prostate gland > High-risk factors include being an older adult, > single, > male > having a co-occurring medical illness. > Cancer is one of the somatic conditions associated with increased suicide risk. > Protective factors for African- American women and Hispanic individuals include strong religious and family ties. > Asian Americans have a suicide rate that increases with age. High level RISK for suicide I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. Im going to shoot myself in the heart. The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue. 82-year-old white manWhites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, 17-year-old white female adolescent 22-year-old man with traumatic brain injury > Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. > Other high risk groups include young African-American men, > Native-American men, > older Asian Americans, and > persons with traumatic brain injury. Traumatic brain injury and Post traumatic stress disorder in SOLDIERS A nurse assesses the health status of soldiers returning from Afghanistan. Screening for Traumatic brain injury and post-traumatic stress disorder as a priority because each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems.

Cognitive Therapy

A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? Being thin does not seem to solve your problems. You are thin now but still unhappy.

Psychopharmacology

Antidepressants 1. Selective serotonin reuptake inhibitors (SSRIs) First-line therapy Indications Adverse reactions Potential toxic effects 2. Tricyclic antidepressants (TCAs) Neurotransmitter effects Indications Adverse effects Contraindications 3. Monoamine oxidase inhibitors (MAOIs) Neurotransmitter effects Indications Adverse/toxic effects Interactions ✓Drug ✓Food Contraindications

Bulimia Nervosa ❖ Also known as "binge-purge syndrome," is characterized by binges: <> Bouts of uncontrolled overeating during a limited period <> Eats more than most people would/could eat in a similar period ❖The disorder is also characterized by compensatory behaviors, such as: <> Vomiting <> Misusing laxatives, diuretics, or enemas <> Fasting <> Exercising excessively

Engages in repeated episodes of binge eating followed by self-induced vomiting, use of laxatives, diuretics, other meds, fasting/exercise (compensatory behaviors) Bulimia <> Binge Eating (usually in solitude) <> Increase mood while eating <> Decreased mood when stopped. <> May vomit when binge is over <> Generally sleeps after eating <> Characteristics ❖ Rarely seen in children younger than 12 ❖ Disturbance in the perception of body shape and weight ❖ Hospitalization may be required if they have co-occurring depression and suicidal ideations Signs and Symptoms ❖ Peripheral edema ❖ Electrolyte imbalance ❖ Weight fluctuations (10-15 lbs.) ❖ Swollen glands (parotid) ❖ Muscle weakness ❖ Tooth decay ❖ Gastric dilation ❖ Russell signs (calluses, scars of hands) Blood ❖ Anemia Heart ❖ irregular heart beat ❖ heart muscle weakened ❖ heart failure ❖ Low pulse ❖ low blood pressure Body Fluids ❖ Dehydration ❖ Low potassium, magnesium, and sodium Intestines ❖ Constipation ❖ Irregular bowel movements (BMI) ❖ Bloating ❖ Diarrhea ❖ Abdominal cramping Hormones ❖ Irregular or absent period Brain ❖ Depression ❖ Fear of gaining weight ❖ Anxiety ❖ Dizziness ❖ Shame ❖ Low Self esteem Cheeks ❖ Swelling ❖ Soreness Mouth ❖ Cavities ❖ Tooth enamel erosion ❖ Gum disease ❖ Teeth sensitive to hot and cold foods Throat and Esophagus ❖ Sore ❖ Irritated ❖ Can tear and rupture ❖ Blood in vomit Muscles ❖ Fatigue Stomach ❖ Ulcers ❖ Pain ❖ Can rupture ❖ Delayed Emptying Skin ❖ Abrasion o knuckles ❖ Dry Skin ❖ ❖ Physical/Medical Complications ❖Arrhythmias (Irregular heartbeats, Sinus Bradycardia) ❖Orthostatic changes (BP and P) ❖Dehydration ❖Cardiac arrest and death ❖Headaches ❖Tears of the esophagus ❖Chronic Sour throat ❖Parotid gland enlargement ❖Chest pains ❖Development of peptic ulcers and pancreatitis ❖Gastric dilation and rupture ❖Anemias The individual with bulimia usually is near normal weight. Binge eating (usually in solitude) Increase mood while eating Decrease mood when stopped Generally sleeps after eating May purge (vomit, laxatives) when binge is over. Normal to slightly low weight Dental caries Tooth erosion Parotid swelling, gastric dilation Calluses Scar on hand (russells sign) Similarities with anorexia Nervosa Peripheral edema, muscle weakening, electrolyte imbalance (low K, Low Na) See page 352, table 18-3 Recurrent episodes of binge eating at least once a week Recurrent inappropriate compensatory behavior to prevent weight gain such as self induced vomiting, miss use of laxatives, diuretics, enemas, medicine, fasting or excessive exercise Depressive signs and symptoms Problems with: interpersonal relationships, self concept, impulsive behaviors Increased levels of anxxiety and compulsivity Possible chemical dependency Possible impulsive stealing See p 353, Box 18-6 Russell's sign >>>>Parotid gland swelling ( Physical assessment of a patient diagnosed with bulimia nervosa often reveals: prominent parotid glands Prominent parotid glands are associated with repeated vomiting.) >>>>Normal weight >>>>Electrolyte imbalance >>>>Muscle weakness >>>>Tooth erosion Anorexia nervosa (AN) is an eating disorder of complex and life-threatening proportions. It is an illness of starvation brought on by a severe disturbance of body image and a morbid fear of obesity. Individuals with anorexia nervosa have intense irrational beliefs about their shape and weight, and they engage in self starvation, express intense fear of gaining weight, and have a 2 disturbance in self evaluation of weight and its importance; Females with anorexia often experience amenorrhea, although this is no longer a criterion for diagnosis There are two main subtypes: • Restricting type • Lose weight by restricting "bad" foods, eventually restricting nearly all food • Show almost NO variability in diet • Binge-eating/purging type • Lose weight by vomiting after meals, abusing laxatives or diuretics, or engaging in excessive exercise • May engage in eating binges Bulimia nervosa (BN) is an eating disorder characterized by repeated episodes of binge eating. During binges, the individual rapidly consumes large amounts of high-caloric food (upward of 2,000-5,000 calories), usually in secrecy and accompanied by a sense of loss of control. The binge is followed by self-deprecating thoughts, guilt, and anxiety over fear of weight gain. The two major variants of BN are purging and nonpurging. Purging occurs with compensation for binges with self-induced vomiting and/or ingestion of laxatives. Nonpurging involves binge eating accompanied by excessive exercise, ingestion of stimulants, and/or fasting. SYMPTOMS AND SIGNS Common symptoms include episodes of overeating, followed by self-induced vomiting, and use of diuretics or laxatives. ➢ Also known as "binge-purge syndrome," is characterized by binges: ➢ Bouts of uncontrolled overeating during a limited period ➢ Eats more than most people would/could eat in a similar period ➢ The disorder is also characterized by compensatory behaviors, such as: ➢ Vomiting ➢ Misusing laxatives, diuretics, or enemas ➢ Fasting ➢ Exercising excessively

Behavior

the actions by which an organism adjusts to its environment

The Initial Aims of Treatment for Anorexia Nervosa Are To:

❖ Restore: restore proper weight leads to ❖ Recover: Recover from malnourishment leads to ❖ Restore: Restore proper eating

Suicide by overdose

(A person intentionally overdoses on antidepressant drugs. life-or-death ramifications and is therefore higher in priority.) BEST INITIAL OUTCOME FOR OVERDOSE IS PATIENT WILL = exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours. Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. Q) patient attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, There must be a mistake. This could not have happened. Weve given our child everything. The parents reaction reflects: > denial. > The parents statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. Q) friend threatened to take an overdose of pills. The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: > Do you have access to medications? >The nurse must assess the patients access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.

Suicide - Psychosocial risk factors

> Suicide ideation with intent > Lethal suicidal plan > History of suicide attempt > Co-Occurring psychiatric illness > Co-Occurring medical illness > History of childhood abuse > Family history of suicide > Lack of social support > Unemployment > Recent stressful life events > Panic attacks > Feelings of shame and /or humiliation > Impulsivity > Aggressiveness > Loss of cognitive function > Access to firearms/ other highly lethal means > Impending incarceration > Low frustration tolerance > Sexual orientation issues > Hopelessness Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.

DEPRESSION

A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, No one cares about me. Im not worth anything. Which response by the nurse would be the most helpful? Ill sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon. Spending time with the patient at intervals throughout the day shows acceptance by the nurse and helps the patient establish a relationship with the nurse. The therapeutic technique is called offering self. Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters the building of trust. The incorrect responses would be difficult for a person with profound depression to believe, provide trite reassurance, and are counterproductive. The patient is unable to say positive things at this point. Patients with depression usually see the negative side of things. The meaning of compliments may be altered to I didnt look nice yesterday or They didnt like my other shirt. Neutral comments such as an observation avoid negative interpretations. Saying You look nice or I like your shirt gives approval (nontherapeutic techniques). Saying You must be feeling better today is an assumption, which is nontherapeutic. Left-sided brain damage is associated with depression and distress about the disability. Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control, and asking the patient to stop will lead to embarrassment.

Implementation (general)

Acute phase: Depressive epidose Hospitalizations Medications Lithium Lamictal Atypical antipsychotics Manic Episode Hospitalization for safety Medications -Depakote or lithium - Atypical anti psychotic Establish a trusting relationship (Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.) Outcome Injury prevention -well hydrated stable cardiac status Tissue integrity Sufficient sleep Self control No self harm Continuation phase Community resources Continue medication regimen Outcome 4-9 months Education -Knowledge of disease -Knowledge of medication -Consequences of addiction -Early s/s of relapse Support group Communication/ problem solving Maintenance Phase prevent recurrence community resources Self help groups Outcome Focus on prevention -Interpersonal strategies -Psychotherapy Group therapy

Eating disorders

Anorexia Nervosa >>>Views self as fat- regardless of weight >>>Intense fear of becoming fat >>>Anxious about losing control ( Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment.A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of a too-rapid weight gain.) >>>WEight is below 85% of normal >>>Feels powerless >>>Associated with obsessive compulsive disorder Bulimia Recurrent binge eating followed by self-induced vomiting, misuse of laxatives and enemas Depressed mood following binge eating Increase anxiety and compulsivity PICA Persistent eating of non nutritive food and non food substances. Pica refers to eating nonfood items. Food-constarch, baking powder, coffee grounds Non-Food: clay soilds, laundry starch, paint chips More common in children, pregnant women, individuals with autism or cognitive impairment, patients in chronic renal failure. Influenced by cultural background Associated with iron and zinc deficiency.

carbamazepine (Tegretol) for rapid cycling and in Beverly paranoid , angry patients with manic episodes

Anticonvulsant patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Phenytoin is also an anticonvulsant but is not used for mood stabilization. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients with manic episodes.

. What questions would a nurse want to ask to learn about thoughts related to her body weight and eating habits?

Are you actively trying to lose weight? Would you describe your current eating habits? Can you discuss your feelings about your appearance ? Can you describe how you are feeling ? Do you have any thoughts of hurting your self? What is your relationship like with your family? Why are you trying to lose weight? Are you on a caloric restriction? Would you consider your self a perfectionist or someone that likes to have control ? Have you ever had anyone tease you about weight related issues? Are you using any type of diet pills ? Are you using any drugs or alcohol ? Have you lost more that 12-15 pounds in the last few months without actively trying to do so? Do you feel anxiety when you are around food? What are your thoughts about how you look and feel right now?

Anorexia Nursing proce

Assessment Severely underweight Lanugo (face and back) Mottled cool skin of extremities BP, P, T Physical Hx of dieting, Methods used for wt control Interpersonal and social functioning Value placed on specific shape and wt Outcomes Attainment of safe wt Patient centered-developed with patient Measure treatment results Planning Affected by patient's acuity Plan for medical stabilizations Be careful of Re-feeding Syndrome(complication(where metabolic alteration in lytes, vitamins, and Na retention) Once medically stable then address underlying issues of disorder Treatment Goal: 90% of ideal wt-able to menstruate SSRI (Prozac) obsessive-compulsive behavior Antipsychotics (Zyprexa) to improve mood, obsessive bx, Weight restoration program based on height and resistance to gain wt

Etiology : Depression: Psychological factors

Cognitive Theory: According to Beck, automatic, negative, repetitive, unintended and not readily controllable thoughts perpetuates depression. Becks Triad: 1) A negative self deprecating view of self "I don't know what I'm doing." " I always mess up" "No one likes me, Im no fun. I drag everyone down" 2) A pessimistic view of the world 3) Belief that negative reinforcement will continue in future Learned helplessness: A person believes that an undesired event is his or her fault and nothing can be done to change it. Associated with certain social groups including the older adults, people living in impoverished areas and women.

Ineffective Coping: Purging

Discuss how purging is used to cope with negative feelings Point out that purging began as a method of control and that not the purging is out of control If client continues to vomit, restrict bathroom use for 1-2 hours after meals unless accompanied by staff Encourage to talk to staff when they feel the urge. Have client list the pros and cons of eating disorder Help clients identify secondary gains that are ultimate, unconscious purpose the disorder serves e.g. -Ideal body weight will protect from all future pain -Gain a sense of control -Response to depression -Regress to a younger, safer time in life.

Disturbed body image

Discuss with clients how they perceive their bodies -Delusional distortions -See themselves as slightly larger -Do not argue with body perceptions Point out your perception and objective data about their bodies Discuss clients perceptions of other peoples bodies Assist to develop a self esteem that is compatible with a healthy body weight. Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. outcome most appropriate to monitor is Patient expresses satisfaction with body appearance. >>>>Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

Interventions for patients with major depressive disorder E. Nonpharmacological interventions for depression

Electroconvulsive therapy (please refer to previous pages in this handout) Transcranial Magnetic Stimulation -MRI strength magnetic impulses to stimulate focal areas. Outpatient treatment which lasts about 30 minutes, 5 days a week for 4-6 weeks. Teach patient that they will feel slight tapping or knocking on the head, contraction of scalp and tightening of the jaw. Side effects include headache, lightheadedness, scalp tingling and discomfort the the administration site. Vagus nerve stimulation Used in treatment resistant depression. Surgical procedure with a device in chest wall and a wire wrapped around the vagus nerve. Side effects include neck pain, cough, paresthesias, and dyspnea. Also other S/E of surgery. Deep brain stimulation Electrodes are placed in deep regions of the brain for stimulation Light Therapy Effective for seasonal affective disorder (SAD) and chronic major depressive disorder or dysphoric disorder with seasonal exacerbations. Thoughts to be effective because of influence or melatonin. St John's Wort ( St johns) ( St. John ) Thought to increase serotonin, norepinephrine, and dopamine. Generally found to be as effective as antidepressants in treatment of mild and moderate depression. However it is not regulated by the FDA and concentrations and active ingredients may vary. St. John's wort interferes with metabolism of medications that use the cytochrome P450 enzyme system, including many HIV medications. The health care provider will need to check for toxicity caused by the drug interactions. Teaching is needed about drug interactions. St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain. Exercise Substantial evidence that exercise can enhance mood and counteract symptoms of depression. Helps with biological, social , and psychological effects of depression. It is more easily accessed, less expensive, and has fewer side effects that antidepressants. 1.Electroconvulsive therapy (ECT) 2.Transcranial magnetic stimulation 3.Vagus nerve stimulation 4.Light therapy 5.St. John's wort 6.Exercise

Risk Factors of depression

Female gender Being unmarried Low socio economic class Early childhood trauma the presence of negative life event, especially loss and humiliation Family history of depression, especially in first degree relatives High levels of neuroticism (predisposition to respond to stress poorly Postpartum period Medical illness Absence of social support Alcohol or substance abuse.

Hyperactivity, pacing, poor judgment

Nursing diagnoses Wandering Risk for injury Outcomes; Remains in secure area. Can be redirected from unsafe activities

Affect

Objective data a nurse can observe about the emotional state of a patient. The external manifestation of feeling or emotion which is manifested in facial expression, tone of voice and body language

Interventions for patients with major depressive disorder A. Guidelines for communication with severely withdrawn persons

Observations-For mute patient use techniques of making observations. This redirects and reinforces reality. Be cautious with therapeutic silence. Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations on the patient for answers. . Acceptance and support are shown by the nurses presence. -Asking direct questions increase anxiety. Direct questions may make the patient feel that the encounter is an interrogation. -Use simple, concrete words -Allow time for the patient to respond -Listen for covert messages and ask about suicide plans -Avoid platitudes "things will look up" "Everyone gets down one in a while" (platitudes minimize patients feelings and increase feelings of guilt and worthlessness.) Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness. -Open- ended questions are preferable if the patient is able to participate in dialog.

Tyramine restriction

Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy. Patients taking MAOIs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and, in high levels, produces intense vasoconstriction, resulting in elevated blood pressure. Q) A nurse teaching a patient about a tyramine-restricted diet would approve which meal? Mashed potatoes, ground beef patty, corn, green beans, apple pie The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate. Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

social skills training

a therapy approach that helps people learn or improve social skills and assertiveness through role playing and rehearsing of desirable behaviors Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and the development of a patients support system. The use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity is a concern. Desensitization is used in the treatment of phobias.

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient:

consults the pharmacist when selecting over-the-counter medications. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation.

Interventions for patients with major depressive disorder C interventions for the depressed patient

priority nursing intervention for a patient diagnosed with major depressive disorder carefully and inconspicuously observing the patient around the clock. Approximately two thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regularly planned observations of the patient with depression may prevent a suicide attempt on the unit. cognitive behavioral therapy. When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using cognitive behavioral therapy. Cognitive behavioral therapy attempts to alter the patients dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections among nerve cells in the brain and that it is at least as effective as medication. Evidence does not support superior outcomes for the other psychotherapeutic modalities mentioned. +Help patient question underlying assumptions, consider alternate explanations - Overgeneralizations - Self Blame -Mind reading -Discounting positive attributes +Promote attendance in therapy groups that offer simple methods of accomplishment +Encourage activities that can raise self esteem +Encourage exercise +Encourage supportive relationships +Teach assertive techniques +Encourage independence in the performance of ADL's intervene if unable to perform +Help patient to identify areas of his or her life that can be controlled +Offer praise when able to complete tasks and showing participation in self care. Q) Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective? Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings.

Disturbed sleep pattern

nursing diagnosis for both a patient diagnosed with major depressive disorder (MDD) and for one experiencing acute mania Patients diagnosed with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients diagnosed with MDD. Defensive coping is more relevant for patients experiencing mania. Fluid volume excess is less relevant for patients diagnosed with mood disorders than is deficient fluid volume.

BINGE EATING DISORDER

Engage in repeated episodes of binge eating, after which they experience significant distress Characteristics ❖Do not use compensatory bx ❖Hospitalization not indicated ❖Have problems with heartburn, dysphagia, bloating, and abd pain, diarrhea, urgency, constipation and anal blockage Signs and Symptoms ❖ Sedentary lifestyle ❖ Low self-esteem ❖ Feelings of guilt and shame ❖ Frequent Dieting ❖ Avoidance of social situations where food will be present ❖ Secretive eating patterns ❖ Depression ❖ Suicidal thoughts

Etiology : Depression: Biological factors

Genetic factors: associated with early age of onset, greater rate of comorbidity and ( Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow.) Unintentional weight loss is not a normal finding for elderly patients and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. Biochemical factors- Serotonin, norepinephrine, dopamine, acetylcholine, GABA Alteration in hormonal regulation- Patients with major depression have elevated corticotrophin releasing hormone and increased urine cortisol level. Inflammation- Increased C-reactive protein and interleukin-6 may play a role in depression Diathesis stress model- Psychosocial stressors and interpersonal events trigger neurophysical and neurochemical changes in the brain

symptoms of hypokalemia. in Bulimia Nervosa

Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self- monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia.

Dysphoric mania

Irritable mood, angry, hypersexual, panic attacks.

Major Depressive Disorder (MDD)

<> History of one or more major depressive episodes <> No history of manic or hypomanic episodes <> Symptoms interfere with social or occupational functioning <> May include psychotic features Major Depressive Disorder Subtypes: Psychotic features Melancholic features Atypical features Catatonic features Postpartum onset Seasonal features-seasonal affective disorder (SAD) Proposed Subtypes: Premenstrual dysphoric disorder Mixed anxiety-depression Recurrent brief depression Minor depression Dysthymic Disorder: Chronic depressive syndrome Present for most of the day More days than not At least 2 years Epidemiology: Leading cause of disability in the United States Children and adolescents Older adults Comorbidity Etiology: Biological factors <> Genetic <> Biochemical <> Alterations in hormonal regulation Psychological factors <> Cognitive theory <> Learned helplessness Nursing Process: Assessment Self- assessment Unrealistic expectations of self Feeling what the patient is feeling Assessment tools Assessment of suicide potential Key assessment findings Outcomes Identification Recovery model Focus on patient's strengths Treatment goals mutually developed Based on patient's personal needs and values Planning Geared towards Patient's phase of depression Particular symptoms Patient's personal goals Basic Level Interventions Counseling and communication Health teaching and health promotion Promotion of self-care Milieu therapy Advanced Practice Interventions Psychotherapy Groups therapy

Bipolar disorder

Disturbances in how people feel. Marked by shifts in mood, energy, and ability to function. Many individuals experience chronic interpersonal or occupational difficulties even during remission. Suicide rate is high among people with bipolar bipolar 1 disorder Severe mania Week long episode Psychosis *severe depression Manic episodes may alternate with depression or a mixed state of agitation and depression. Patients often have difficulty maintaining social connections and employment Bipolar 2: Hypomania -euphoric Increased functioning -Excessive energy at least 4 days Severe Depression Particular suicide risk Psychosis is never present with hypomania. Psychosis may be present with depression. Usually does not cause severe impairment with social functioning or employment Cyclothymic Hypomania -Irritable hypomanic episodes Mild/ moderate depression Symptoms alternate from mild to moderate depression for at least 2 years in adults and one year in children. Symptoms cause occupational and social impairment. Rapid Cycling 4 or more episodes in 12 months. Cycling can occur over a month or a 24 hour period More severe symptoms -poorer global functioning -High recurrence risk -Resistance to conventional somatic treatments Carbamezeping (tegretol) May be candidate for ECT Etiology: Bipolar disorders are distinctly different from one another A) Biological Factors: Genetic- bipolar disorders- Strong heritability, likely that bipolar disorder is polygenic ( a number of genes contribute to it) Research 1) Connection between bipolar and gene that encodes for DGKH enzyme 2)Abnormal circadian genes- result in super fast biological clock, which manifests itself in extreme insomnia. 3) Bipolar and schizophrenia may have similar genetic origins and pathology- irregular chromosomes 13-15 4) Study of genetics will revolutionize understanding and Tx Neurobiological Neurotransmitters (norepinephrine, dopamine and serotonin) Structural and Functional Brain changes - Neuroimaging reveals structural changes seem to cause the disorder and some seem to be caused by the disorder Neuroendocrine- hypothyroid associated with depressed moods B) Psychological factors: Play a role in precipitating manic episodes in an individual. It is possible that an individuals with genetic predisposition and neurochemical imbalance may never experience symptoms of bipolar disorder without a stressful life event. C) environmental factors- More prevalent in upper socioeconomic classes. Higher levels of education and occupational status. CAUSE The cause of bipolar disorder has not been determined, but: several factors, including genetics, are implicated. At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances. A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder. Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. Nursing ACtions A patient diagnosed with bipolar disorder commands other patients, Get me a book. Take this stuff out of here, and other similar demands. The nurse wants to interrupt this behavior without entering into a power Distraction: Lets go to the dining room for a snack. The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger. Q) A patient experiencing acute mania waves a newspaper and says, I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes. Select the nurses most appropriate intervention. Invite the patient to sit with the nurse and look at new fashion magazines. ---Situations such as this offer an opportunity to use the patients distractibility to the staffs advantage. Patients become frustrated when staff members deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patients need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response. After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patients family? Psychoeducation During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, the treatment focuses on maintaining medication compliance and preventing a relapse, both of which are fostered by ongoing psychoeducation. A patient tells the nurse, I am so ashamed of being bipolar. When Im manic, my behavior embarrasses my family. Even if I take my medication, theres no guarantee I wont have a relapse. I am such a burden to my family. These statements support which nursing diagnoses? Powerlessness , Chronic low self-esteem, Chronic low self-esteem and powerlessness are interwoven in the patients statements.

Loud, profane, hostile, combative aggresive, demanding

Nursing diagnoses Risk for other directed violence Outcomes Refrains from harming others, controls Impulses, avoids violating others space.

minimal nutritional intake, poor hygience, clothing unclean

Nursing diagnoses Self care deficit Outcomes Returns to previous level of care VS, hydrated, eating, taking meds

Medication Generic drugs are approved by the FDA if they are proved to be bioequivalent to the brand-name drug. They tend to be less expensive because manufacturers of these drugs do not have to do the extensive testing required of brand-name drugs before marketing. They are not identical to brand-name drugs and often have different inert ingredients. USP designation is given to drugs that have met high standards for therapeutic use, patient safety, quality, purity, strength, packaging safety, and dosage form by the United States Pharmacopoeia National Formulary. The FDA classifies controlled substances with Roman numerals from I to V. The USP designation does not indicate FDA approval. The USP designation does not indicate generic availability. Nurse Practice Acts: law(s) govern all drug administration by nurses. Each states Nurse Practice Act identifies how nurses administer medications. The other acts govern how drugs are marketed and tested.

Lithium - Expected Side Effects: 0.4- 1.0 mEq/L Fine Hand Tremors Mild polyuria Mild Thirst Mild Nausea Lithium- Early S/S of toxicity < 1.5 mEq/L. Hold me / call pop Diarrhea Nausea , Vomitting Polyuria Thirst Drowsiness Lethargy Slurred Speech Muscle weakness / Lack of coordination Fine hand tremor Lithium - Late Sign and symptoms of Toxicity 1.5 - 2.5 mEq/L Coarse hand tremor Ataxia Confusion EkG Changes Large output of dilute urine Blurres vision Chronic movement Seizures Stupor Severe hypotension Coma ***Medical Emergency: Hold med call doctor for immediate intervention Lithium and olanzapine (zyprexa) -A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: -bring hyperactivity under rapid control. -Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithiums antimanic activity nor minimize the side effects. Lithium is used for long-term control. LITHIUM The normal range for a blood sample taken 8-12 hours after the last dose of lithium is 0.4 to 1 mEq/L lithium level 1 mEq/L. = within therapeutic limits Patient Teaching Lithium = maintain normal salt and fluids in the diet. Sodium depletion and dehydration increase the chance for developing lithium toxicity. The incorrect options offer inappropriate information. Q) A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: = meals. (Some patients find that taking lithium with meals diminishes nausea) Q) A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. Consider the need to check the lithium level. The patient may not be swallowing medications. The patient is continuing to exhibit manic symptoms. The lithium level may be low as a result of cheeking the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Q) A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. (TCA) The patient says, I dont think I can keep taking these pills. They make me so dizzy, especially when I stand up. The nurse should: explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks. Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing these facts may be enough to convince the patient to remain medication compliant. The minor inconvenience of side effects as compared with feelings of depression is a convincing reason to remain on the medication. Withholding the drug, forcing oral fluids, and having the health care provider examine the patient are unnecessary steps. Independent nursing action is appropriate. Pursed-lip breathing is irrelevant. TCA Tricyclic antidepressants (TCAs) decrease the transmission of pain impulses to the spinal cord and brain. TCAs also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by TCAs. Q) A patient diagnosed with major depressive disorder is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? Urinary retention All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues. Imipramine Tofranil is being used in this patient to manage chronic pain and improve functional ability. Although the medication is also prescribed for patients with depression, insomnia, and anxiety, varenicline (Chantix): Adverse effects of varenicline include depression and attempted suicide. The patient's symptoms require immediate assessment and discontinuation of the drug. Which information is most important for the nurse to report to the health care provider about a patient who has been using varenicline (Chantix)? The patient complains of new-onset sadness and depression. Q) A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to: report increased suicidal thoughts. Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. > MONITORING patients on antidepressants is VERY IMPORTANT SINCE : As depression lifts, physical energy becomes available to carry out suicide. Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. amitriptyline (Elavil) Q) A patient being treated for major depressive disorder has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares. The nurse should advise the patient: Take one dose of the antidepressant. Come to the clinic to see the health care provider. The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant (TCA) . Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing. ANTIDEPRESSANT The purpose of antidepressant drugs in the treatment of narcolepsy is the management of cataplexy, not to treat depression Q) A nurse performs a medication history on a newly admitted patient. The patient reports taking amitriptyline (Elavil) 75 mg at bedtime for 6 weeks to treat depression. The patient reports having continued fatigue, lack of energy, and depressed mood. The nurse will contact the provider to discuss which intervention? Beginning to taper the amitriptyline. The response to tricyclic antidepressants (TCAs) should occur after 2 to 4 weeks of therapy. If there is no improvement at this time, the TCA should be gradually withdrawn and an SSRI prescribed. TCAs should never be stopped abruptly. TCAs cause fatigue and drowsiness, so they should be given at bedtime. Changing the dose or the dosing schedule are not indicated. amitriptyline (Elavil) reports constipation and dry mouth. = Increase fluid intake. The nurse is teaching a patient who will begin taking doxepin (Sinequan) to treat depression. Which statement by the patient indicates a need for further teaching? "I will take the medication in the morning before breakfast." ( never take dose-in (sinequan is a history of Glaucoma) fluoxetine (Prozac) daily. The patient asks about the weekly dosing that a family member follows. What will the nurse tell the patient about a weekly dosing regimen? it can be used after daily maintenance dosing proves effective and safe. A patient who has a major depressive disorder has been taking fluoxetine (Prozac) 20 mg daily for 3 months and reports improved mood, less fatigue, and an increased ability to concentrate. The patient's side effects have diminished. patient can talk to provider about changing to once a week dosing A patient has been taking sertraline (Zoloft) 20 mg/mL oral concentrate, 1 mL daily for several weeks and reports being unable to sleep well. What will the nurse do next? Ask the patient what time of day the medication is taken. A patient who has been taking a monoamine oxidase (MAO) inhibitor for several months will begin taking amoxapine (Asendin) instead of the MAO inhibitor. The nurse will counsel the patient to begin taking the amoxapine. at least 14 days after discontinuing the MAO inhibitor. A patient who has been diagnosed with depression asks why the provider has not ordered a monoamine oxidase (MAO) inhibitor to treat the disorder. The nurse will explain to the patient that MAO inhibitors require strict dietary restrictions. AVOID over-the-counter medications to treat cold symptoms such as Pseudoephedrine while taking MAO Monoamine oxidase

Assessment of suicide potential Assess for risk factors (See risk factor chart) Assess for overt and covert statements related to suicide VERBAL CLUES TO SUICIDE

Overt Statement "I can't take it anymore" "Life isn't worth living anymore" "I wish I were dead" " Everyone would be better off if I died" Covert Statements "Its okay now. Soon everything will be fine" "Things will never work out" "I won't be a problem much longer" " Nothing feels good to me anymore and probably never will" "Do you have a plan? " "If so what is your plan for suicide? VERBAL CLUES TO SUICIDE: " I have a plan that will fix everything." > verbal clues to suicide may be overt or covert. It alludes to the patients suicide as being a way to fix everything but does not say it outright. "Nothing matters anymore." What is the most appropriate response by the nurse? > Are you having thoughts of suicide? > The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation. Suicidal Ideation nurses most therapeutic comment to suicidal ideation > Lets consider which problems are most important and which are less important. > The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

Other Self-InjuryAddictions

PICA ➢Eating of non-food items ➢Not part of any other mental illness ➢No cultural aspects ➢ ➢ Rumination ➢Regurgitation with re-chewing, re-swallowing, or spitting ➢No GI or medical reason ➢Not part of other mental illness or eating disorders Avoidant/Restrictive Food Intake ➢Avoiding/restricting foods starting in childhood ➢Significant in BMI ➢Dependent on enteral feeding or experiencing nutritional deficiencies ➢No distortion of body image ➢No medically explained/part of any other mental illness

A client receiving lithium for bipolar disorder would be at risk for increased lithium toxicity if it were prescribed with:

Sodium bicarbonate There are no drug interactions with lithium Potassium citrate Diuretics

Evaluation of patients with bipolar/ Mania

Stable vital signs Well hydrated Able to control personal behavior or respond to external controls Sleep for at least 4-5 hours a night or take few short rest periods during the day Patient adheres to treatment plan including medication Resume functioning in the community Achievement of stability in family, work and social relationships Stability in mood. Improved coping skills for reducing stress

A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of:

processing the heightened anxiety associated with eating. Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients concentration and attention is important, but not the primary purpose of the schedule.

Hypomania

suggestions nurse should provide to the family Provide structure Limit credit card access Monitor the patients sleep patterns A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is overstimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work is necessary to limit stimuli and to prevent problems associated with poor judgment and the inappropriate decision making that accompany hypomania.

refeeding syndrome re feeding re-feeding

• Fatigue • Weakness • Confusion • Difficulty breathing • High blood pressure • Seizures • Irregular heartbeat • Edema • Heart failure • Coma • Death Weight gain of more than 2 to 5 pounds weekly may overwhelm the hearts capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications. When starting re- feeding nurse should assess lung sounds and extremities. complications of re-feeding. Which body system should a nurse closely monitor for dysfunction? Cardiovascular: Re-feeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity.

Bipolar Depressive

❖ Sleep disturbances ❖ Fatigue ❖ Abnormal eating habits ❖ Vague physical symptoms ❖ Obsession with death ❖ Lack of interest in appearance or sex ❖ Inability to concentrate Depressive ❖ Previous Manic ❖ Episodes Mood ❖ Dysphoric ❖ Depressive ❖ Despairing ❖ Decrease interest in pleasure ❖ Negative views ❖ Fatigue ❖ Decrease appetite ❖ Constipation ❖ Insomnia ❖ Decrease libido ❖ Suicidal pre occupation ❖ May be agitated or have movement retardation ASSESSMENT ❖ Mood ❖ Behavior ❖ Thought processes and speech patterns - Flight of ideas - Clang associations - Grandiosity ❖ Cognitive functioning "Cinema I and II, last row. Row, row, row your boat. Don't be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote." Self-Assessment ❖ Manic patient - Manipulative - Aggressively demanding - Splitting ❖ Staff member actions -Frequent staff meetings to deal with patient behavior and staff response - Set limits consistently Assessment Guidelines Bipolar Disorder ➢Danger to self or others ➢Need for protection from uninhibited behaviors ➢Need for hospitalization ➢Medical status ➢Coexisting medical conditions ➢Family's understanding Implementation ➢ Acute phase: highest priority is always safety - Depressive episodes - Manic episodes ➢ Continuation phase Prevent relapse with follow-up care ➢ Maintenance phase