Chapter 7 Psychiatric Nursing - HESI

Kava (CAM) is_________________

hepatotoxic

somatic symptom disorder

history of diverse physical complaints which are psychological in origin and result in disruption in daily life pain- back, chest, head, pelvic area palpitations dizziness

What happens if you give a MAOI with a SSRI, tyramines, or medications that contain pseudoephedrine?

hypertensive crisis

When should carbamazepine be stopped?

if WBC drops below 3000 or neutrophils go below 1500 -also monitor hepatic and renal function

When should the nurse suspect an imminent suicide attempt?

if the depressed client becomes "better" (happy and elated) - a happy effect can signify that the client feels relieved that a plan has been made and is prepared for the suicide attempt

Leukocytosis

increase in the number of white blood cells

physiological responses to anxiety

increased heart rate increased blood pressure rapid shallow respirations dry mouth muscle tension tight feeling in the throat tremors muscle tension anorexia urinary frequency palmar sweating

lithium carbonate

indications: bipolar disorders (manic phase) Adverse: nausea, fatigue, thirst, polyuria, and find hand tremors weight gain, hypothyroidism

passive aggression (defense mechanism)

indirectly expressing aggression towards others Ex: an employee arrives late to a meeting and disrupts others after being reminded of the meeting earlier that day and promising to be on time

tardive dyskinesia

involuntary movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of antipsychotic drugs that target certain dopamine receptors

What do patients with bulimia often use to vomit?

ipecac to induce vomiting

Akasthisia

is an extrapyramidal side effect of antipsychotic medication characterized by inner restlessness and an inability to sit or stand in one position. Akathisia is frequently misdiagnosed because the restlessness is misinterpreted as worsening psychotic agitation.

MAO inhibitors

isocarboxazid phenelzine sulfate tranylcypromine sulfate selegiline used to treat depression, phobias, and anxiety adverse reactions: tachycardia, urinary hesitancy, impotence, dizzy, insomnia, muscle twitching, dry mouth , hypertensive crisis, confusion do not use with tricyclics (hypertensive crisis may arise) DO not eat foods high in tyramine do not use with SSRIs

Kava (CAM) is used to treat anxiety and is OTC. What medication does it inhibit?

levodopa in patients with Parkinson disease

What should the dose be for lamotrigine be and why?

low dose 20-50 mg/day initially then gradually increase to maintenance dose done to minimize risk of severe rash

psychological determinants of eating disorders

low self-esteem controlling families that emphasize perfection chaotic and emotionally expressive families

where should a manic client be place on the unit?

make every attempt to reduce stimuli in the environment, place client in quiet part of the unit

therapeutic communication with psychiatric patients

make sure to keep statements free from advice and reassurance state facts- no opinions allows patient to have autonomy to make choices

clarifying (therapeutic technique)

making sure you have understood the meaning of what was said

PTSD

may have flashbacks nightmares emotional detachment intrusive thoughts when anxiety occurs client may be shocked, anger, panic, or denial

antipsychotic drugs

medications that are used to treat schizophrenia and related psychotic disorders

Anorexia causes

mental disorder caused by a distorted body image, with an unwarranted fear of being overweight -genetic factors- 70% accordance of identical twins -20% accordance with fraternal twins

Degrees of mania

mild moderate severe must determine the level assess level of danger to self and others

malingering

Deliberate faking of a physical or psychological disorder motivated by gain to possibly miss work...

Nursing interventions for phobia and panic disorders

- assist client to recognize factors associated with feared stimuli that stimulate phobic response -teach coping strategies -expose client progressively to feared stimuli- with nurse presence (you do not do this initial with client- you wait until the interventions part so it is a progressive exposure)

displacement (defense mechanism)

- The transfer of feelings from one target to another that is considered less threatening or that is neutral. EX: A client is angry at his doctor, does not express it, but becomes verbally abusive with the nurse.

Introjection: Defense Mechanism

- Integrating the beliefs and values of another individual into ones own ego structure. EX: Children integrate their parents value system into the process of conscience formation. A young man deals with business clients in the same fashion his father deals with business clients

Repression (defense mechanism)

- Involuntary blocking of unpleasant feelings and experiences from ones awareness. (unconsciously blocking the feeling- that is why it is different from suppression- suppression consciously blocks the feeling) EX: An accident victim can remember nothing about the accident a young man who's mother died when he was 12 years old cannot tell you how old he was or the year she died

Denial (defense mechanism)

- Refusing to acknowledge the existence of a real situation or the feelings associated with it. EX: A women drinks alcohol every day and cannot stop, failing to acknowledge that she has a problem.

isolation (defense mechanism)

- Separate a thought or memory from the feeling tone or emotion associated with it. EX: Without showing any emotion, a young women describes being attacked and raped. a nursing working in the ER is able to care for seriously injured patients by isolating or separating her feelings and emotions related to the client's pain, injuries, or death

panic disorders and phobias

-Discrete periods of intense fear or discomfort that are unexpected and may be incapacitating -characterized by an irrational fear of an external object, activity or situation -chronic condition that has exacerbations and remissions -transfers anxiety or fear from its source to a symbolic object, idea, or situation -fear is excessive and unrealistic but can't help it

What should the nurse do with clients that have a diagnosis of PTSD?

-actively listen to client's stories of experiences surrounding the traumatic event -assess suicide risk -assist client to develop objectivity about the event and problem-solve regarding possible means of controlling anxiety related to the event -encourage group therapy with other clients who have experienced the same or related traumatic events

A client is in the middle of an extensive ritual that focuses on food during lunch. However, the client is scheduled for group therapy, which is about to start. What action should the nurse take?

-allow the client to complete the ritual -discuss with group leader about allowing the client to enter the group late -arrange for the client to begin lunch earlier so that the ritual can be completed before the scheduled activities

PTSD four symptom clusters

-avoidance of situations that are reminders -persistent negative alterations in cognitions and mood -numbing symptoms -persistent negative emotional distress -alterations in arousal and reactivity - including irritable or aggressive behavior and reckless or self-destructive behavior (suicide, substance abuse)

mild mania

-being on a high -well-being -minor alterations in habits -does not seek treatment b/c of pleasurable effect

moderate anxiety

-can focus on problem solving; however not at optimal level -client becomes hesitant -speech rate and volume increase -client becomes wordy -restless- body movements and gestures -may develop physical symptoms- diarrhea, tachycardia, nausea, etc.

What are the major warning signs that suicide is impending?

-client is giving away possessions -previously depressed client suddenly becomes happy

nursing interventions anxiety

-develop coping mechanisms -encourage exercise, deep-breathing, visualization, relaxation, and biofeedback -decrease stimuli -teach client to recognize anxiety

borderline personality disorder

-disturbances in self-image, and sexual and social roles -makes suicidal gestures -overly dependent on others -cannot problem solve or learn from experiences -whiny, manipulative, and argumentative -impulsive behaviors Ex: a teenage girl who threatens to commit suicide when her boyfriend leaves, but in 6 weeks has a new boyfriend and is clinging to him

binge eating disorder

-episodes of eating large amounts of food in a short period -describe feeling guilty or shameful after overindulging -No purging -Not obese -may have another psychiatric disorder

Nursing interventions for obsessive-compulsive and related disorders

-explore meaning and purpose of the behavior with client -avoid punishing or criticizing -avoid reinforcing compulsive behaviors -limit the amount of time for rituals -administer antianxiety medications -administer SSRis and tricyclic antidepressants as prescribed

Nursing interventions for depressed clients

-express concern "I am very concerned that you are feeling..." -tell client you will share information with staff "I need to share this with the staff so that we can provide for your safety until you are feeling better." -offer the client hope "you're feeling bad at this moment, but these feelings will pass." -stay with the client NEVER leave a suicidal client

Severe Mania

-extreme hyperactivity -flight of ideas -non-stop activity -sexually acting out -talkativeness -overresponsiveness to external stimuli -easily distracted -agitation and possibly explosiveness -severe sleep disturbance -delusions of grandeur or persecution

Describe the nurse's role in preparing clients for ECT

-give accurate, nonjudgmental information about the treatment -explore the client's concerns -check emergency equipment and make sure O2 is available

moderate mania

-grandiosity -talkativeness -pressured speech -impulsiveness -excessive spending -bizarre dress and grooming

signs and symptoms of somatic symptom disorders

-having pain or issue for 6 months -history of frequent "doctor shopping" -no emotional concern for the physical impairment -women may report excessive dysmenorrhea -with panic attack-vital signs elevated -fear of having a disease -drug abuse

CAM - Kava Kava

-herb -relieves anxiety -induce feelings of relaxation and contentment -elevate mood -could cause psychiatric symptoms -potential risk of liver failure -cannot take with anticonvulsants and antianxiety medications

traumatic and stressor related disorders

-include severe anxiety- comes from witnessing a traumatic event (war, rape, incest, etc.) -this can be a direct or an indirect experience

Signs and symptoms of personality disorders

-insensitivity to the needs of others -demanding and finding fault -inability to trust others -passive-aggressive traits -blurs boundaries between self and others -lack of individual accountability -spark interpersonal conflict -"get under the skin" of others -hard time forming relationships with others

Cardiotoxicity

-irregularities in cardiac rhythms and conduction, heart failure, damage to the myocardium -can cause fatal myocarditis and circulatory failure

Describe the nursing interventions used to care for a client during and after ECT

-maintain a patent airway -check vital signs every 15 minutes until client is alert -remain with the client after treatment until client is conscious -reorient if client is confused

interventions for mood disorders/depressive disorder

-must asks client about the thoughts are harming themselves or if any thoughts are present -implement suicide precautions -assists with ADLs -encourage client to participate in activities (do not give client a choice -observe for sudden mood elevation (may indicate risk of suicide) -sit in silence if needed -return to client when promised

What should nursing interventions be aimed at for eating disorders?

-nutritional support -increase self esteem -develop positive self image -family therapy is most effective therapy is usually long term

A veteran of the wars in Afghanistan and Iraq is plagued with nightmares and is found trying to strangle his roommate one night. List in order of priority the appropriate nursing interventions.

-protect the roommate from harm -stay with the client -if client is agitate- give antianxiety meds as prescribed -arrange for private room -place client on homicidal precautions at night

What interventions should the nurse use if a client becomes abusive?

-redirect negative behavior or verbal abuse in a calm, firm, nonjudgemental manner -suggest a walk or other physical activity -set limits on intrusive behavior ex. "when you interrupt, I cannot explain the procedure to the others; please wait your turn." -out of control clients- administer medications or use seclusion if the client is a danger to self or others -use compassion with clients

A client is standing on a table loudly singing "The Star-Spangled Banner" and is encircled by sheets, which have been set afire. In order of priority, describe appropriate nursing actions.

-remove client and other person in the vicinity to a safe area -have someone activate the hospital fire plan -when area is safe place client in safe environment with low stimulation and medicated as indicated

signs and symptoms of depressive disorder

-sadness -cannot concentrate -helpless feeling and powerlessness -decreased energy -sleep pattern disturbances -appetite and weight changes -slowed speech, thought, movement -could be hyperactive and agitated -negative feelings SEVERE: -hopeless, worthless, shame, and guilt -flat affect -indecisiveness -lack of motivation -change in physical appearance -delusions and hallucinations -suicidal thoughts -sleep and appetite changes -loss of interest in sexual activity -constipation

what is the advantage of group therapy

-socializing techniques -feeling of universality (not being alone-or only one) -feedback opportunities -alternative ways of analyzing and dealing with issues

A client displays a phobic response to flying. Describe the desensitization process that would probably be implemented.

-talk about planes -look at pictures of planes -make plans to accompany client to airport for a visit -accompany client onto plane -allow client to board plane alone -accompany client on a short flight while listening to a relaxation tape

Describe the clinical symptoms of anorexia nervosa.

-weight loss of at least 15% of ideal or original body -hair loss -dry skin -irregular heart -decreased pulse -decreased BP -amenorrhea -dehydration -electrolyte imbalance

2 subtypes of anorexia

1. Restricting type 2. Binge-eating/purging type

Lithium toxicity

1.5 mEq/L diaphoresis, weakness, nausea, diarrhea

How long should you wait between discontinuing an MAO and starting a S/NRIs

14 days

open ended questions (therapeutic technique)

questions that require more than a yes or no response

acknowledgment (therapeutic technique)

recognizing client's opinions and statements without imposing your own values and judgements

With cardiotoxicity

check for edema and listen to breath sounds

dependent personality disorder

a personality disorder characterized by helplessness; excessive need to be taken care of; submissive and clinging behavior; difficulty in making decisions -passive and does not accept responsibility -has low self esteem EX: an adult who exhibits adolescent type behavior, wants others to take care of him or her while at the same time declaring independence

antisocial personality disorder

a personality disorder in which a person exhibits a lack of conscience for wrongdoing, even toward friends and family members; may be aggressive and ruthless or a clever con artist verbal: humiliating and belligerent nonverbal: cold, callous, and insensitive to others ex: a prison inmate who tries to get special privileges is bribing the guards (acting out the role of a con artist)

When should lithium levels be drawn?

Draw 12 hours after last dose

avoidant personality disorder

a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation Ex: a man refuses to play on the employees' softball team because he is afraid his team members will make fun of him

A 66 year old woman is admitted to the psychiatric unit with agitated depression. She has not responded to antidepressants in the past. What would be the medical treatment of choice for this client?

ECT

What is the most significant risk factor for suicide?

a previous suicidal attempt -those with family members that have committed suicide are more at risk also

Benzodiazepines

chlordiazepoxide HCl diazepam clorazepate dipotassium lorazepam reduces anxiety muscle relaxation treat alcohol and drug withdrawal reactions: sedation, drowsy, ataxia, dizzy administer at bedtime do not drink alcohol avoid driving or operating equipment do NOT stop suddenly

With bulemia

clients purge, misuse laxatives, diuretics, and other medications- fast and excessive exercise

S/NRIs (serotonin/norepinephrine reuptake inhibitors)

duloxetine vanlafaxine desvenlafaxine treats depression anxiety panic disorder aggression disorder OCD manages diabetic neuropathic pain may cause nausea, dry mouth, insomnia, headache, depressed appetite, sexual dysfunction

long-acting antipsychotic drugs

Fluphenazine decanoate (Prolixin Decanoate) Haloperidol decanoate (Haldol Decanoate)

Munchausen syndrome by proxy

A factitious disorder in which parents make up or produce illnesses in their children. Also known as factitious disorder by proxy.

Agranulocytosis

A life-threatening drop in white blood cells. This condition is sometimes produced by the atypical antipsychotic drug clozapine.

depersonalization disorder

A person has a recurring or persistent feeling of being cut off or detached from his body or mental processes, as if observing themselves from the outside. May feel that the external world is unreal

Where should a nurse place an anxious client?

A place where there are reduced environmental stimuli - a quite area of the unit that is away from the nurse's station

Functional Neurological Symptom Disorder

A rare somatoform disorder in which a person experiences very specific genuine physical symptoms for which no physiological basis can be found

schizotypal personality disorder

a psychological disorder characterized by several traits that cause problems interpersonally, including constricted or inappropriate affect; magical or paranoid thinking; and odd beliefs, speech, behavior, appearance, and perceptions ex: a person who spends hours walking the streets dressed in all sorts of mismatched clothing while wearing a hat with all kinds of things hanging from it

Dissociative Amnesia and Fugue

a sudden loss of memory for important personal information that is too extensive to be due to normal forgetting cannot recall own identity rarely occurs person may assume new identity

medications for panic disorders and phobias

antianxiety medications selective serotonin reuptake inhibitors (SSRIs) teach to decrease intake of caffeine and nicotine

antidepressants

anticholinergic effects postural hypotension

What should you not take with kava kava?

anticonvulsant medications antianxiety medications

tricyclics

Amitriptyline despiramine imipramines nortriptyline protriptyline maprotiline used to treat depression may cause dry mouth, blurred vision, constipation, sedation, tachycardia, orthostatic hypotension, quinidinelike effects on the heart, GI, nausea, narrow therapeutic window give at bedtime may take 2-6 weeks to work wait 1-3 weeks if stopping tricyclics and starting MAO inhibitors do not drink alcohol

If a patient is taking fluoxetine (Prozac) what should they wait 5 weeks to take?

An MAO- the patient must wait a full 5 weeks however if the patient is taking a MAO, the patient must wait 14 days to start fluoxeine (Prozac)

Feelings of self importance and entitlement. May exploit others to get own needs met.

antisocial personality disorder

conversion reaction

anxiety is transformed into physical symptoms such as heart palpitations, paralysis, or blindness

obsessive-compulsive personality disorder

Attempts to control self through the control of others or environment; shows inattention to new facts or different viewpoints; cold and rigid toward others; perfectionist, inflexible and stubborn; acts with blind conformity and obedience to rules; excessively neat and clean; preoccupied with work efficiency and productivity; verbally and nonverbally expresses disapproval of those whose behaviors and standards are different from own Ex: a nurse who insists that all staff on the unit wear a freshly starched uniform every day and has no tolerance for staff that do not dress as professionally as this individual

Somatic Symptom and Related Disorders

Characterized by physical complaints about conditions that are caused by psychological factors. clients go from doctor to doctor seeking treatment for a psychological factor that is causing a physical complaint unnecessary tests are performed and health care costs are increased for these clients

factitious disorder

Condition in which a person acts as if he or she has a physical or mental illness when he or she is not really sick.

An air traffic controller suddenly develops blindness. All physical findings are negative. The client's history reveals increased anxiety about job performance and fear about job security. What type of disorder is this? What purpose is the blindness serving? What nursing interventions are indicated?

Conversion Reaction decrease anxiety about job assist with ADLs, encourage expression of anger, teach relaxation techniques

A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is discharged. What nursing interventions is appropriate in addressing this behavior?

Discuss activities that don't involve food that can take place after discharge. Discuss the cookbooks with the treatment team, and if the treatment plan so indicates, take the books from the client.

dissociative amnesia

Dissociative disorder characterized by the sudden and extensive inability to recall important personal information, usually of a traumatic or stressful nature -gaps in memory -usually occurs after a traumatic event (threat of death, injury, natural disaster)

panic

cannot differentiate from real and unreal cannot concentrate or problem solve may cause hallucinations Overwhelming feeling loss of control and inability to function may be angry and aggressive requires immediate intervention

What can happen if ipecac is not vomited and it is absorbed?

cardiotoxicity may occur

Name the components of a suicide assessment

Existence of a plan, existence of a method, availability of method chosen, lethality of method chosen, identified support system, and history of previous attempts

Bipolar or "Manic-Depressive" Disorder

Extreme mood swings between depression and extreme happiness or "mania" -in order to be diagnosed with bipolar disorder the client must have had at least one episode of major depression

When dealing with a depressed client the nurse should?

encourage independence -urge client to initiate grooming - the nurse can assists if needed

with S/NRIs you should not used with?

MAO inhibitors (hypertensive crisis)

Parsley (CAM) is a OTC treatment for mild depression. It should not be used in conjunction with?

MAOI inhibitors -increases the risk of serotonin syndrome

St. John's Wort (CAM) is a OTC treatment for mild depression. It should not be used in conjunction with?

MAOI inhibitors -increases the risk of serotonin syndrome

Phenothiazines

end in -zine chlorpromazine trifluoperazine thioridazine perphenazine triflupromazine loxapine

St. John's Wort

OTC medication (CAM) used to treat depression -may induce mania in bipolar clients and enhance photosensitivity -interacts with oral contraceptives, warfarin, and statins -will trigger serotonin syndrome if combined with SSRI or tricyclic antidepressants

What is a nonphenothiazine that is used only for Tourette syndrome?

Pimozide

hypertensive crisis

Severe Headache Palpitations Diaphoretic Stiff Neck

With SSRIs you should not use

St. John's Wort

anxiety

The condition of feeling uneasy or worried about what may happen

Group intervention

Used with 2 or more client's who develop interactive relationships and share at least one common goal or issue may be closed or open and group may be small or large common to have nurse-led intervention groups include those that focus on medications, symptom mgmt, anger mgmt and self care.

If a client is taking MAOI or SSRI and they change to either of these types of medications

a 2 week time lapse needs to occur EX: taking SSRI and physician changes medication to an MAOI- the patient must wait 2 weeks to start the MAOI

Munchausen syndrome

a condition in which the "patient" repeatedly makes up clinically convincing simulations of disease for the purpose of gaining medical attention

Dystonia

a condition of abnormal muscle tone that causes the impairment of voluntary muscle movement

obsessive compulsive and related disorders

a group of disorders in which obsessive-like concerns drive people to repeatedly and excessively perform specific patterns of behavior that greatly disrupt their lives

Phenothiazines

a group of drugs used to treat psychosis

narcissistic personality disorder

a personality disorder characterized by exaggerated ideas of self-importance and achievements; preoccupation with fantasies of success; arrogance -needs attention and admiration -preoccupied with power and appearance -talks about self and draws attention to self -lacks empathy EX: a star football plater whose success has gone to his head

blood dyscrasia

abnormal or pathologic condition of the blood

A client on your unit refuses to go to group therapy. What is the most appropriate nursing intervention?

accompany client to the group; do not give client option. Client needs to be mobilized

what should a nurse do if a patient confesses a phobia to the nurse?

acknowledge the fear and the feeling the client has; DO NOT expose client to the identified fear

acute dystonia

acute sustained contraction of muscles, usually of the head and neck

who is anorexia common in?

adolescent girls; coexists with depression females -male and female athletes

tyramine foods

aged cheese (cheddar, blue cheese, swiss cured meats (salami, sausages, pepperoni) sauerkraut, soy sauce, shrimp sauce yeast, fava beans, yogurt, liver, east, bananas, soy sauce

valerian (CAM)

alleviates insomnia -can also alleviate anxiety and psychological stress S/E: uneasiness, excitability, headaches, and insomnia

identification (defense mechanism)

an attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires example: a teenage boy dresses and behaves like his favorite singer

anorexia nervosa

an eating disorder in which an irrational fear of weight gain leads people to starve themselves

mileiu therapy

an environment that is controlled with resources to aid in safety and protection for the client uses people, resources, and activities to improve interpersonal skills, social functioning, and performing ADLs inpatient and outpatient settings (rehab facilities- weight loss centers)

DSM-5 Disorders

another name for obsessive compulsive and related disorders

A client who has been withdrawn and tearful comes to breakfast one morning smiling and interacting with peers. Before breakfast she gave her roommate her favorite necklace. What actions should the nurse take and why?

assess for suicidal ideation, plan, and means of carrying out plan. Place on precautions as indicated. A sudden change in mood and giving away possessions are two possible signs that a suicide plan has been developed

if a psychiatric patient complains of a physical problem (chest pain)

assess the client! blood pressure, pulse, etc. do not ignore physiological needs of the client

A 10 year old is admitted to the children's unit of the psychiatric facility after stabbing his sister. His behavior is extremely aggressive with the other children on the unit. Using a behavior modification approach with positive reinforcement, design a treatment plan for this child.

assess what activities the child enjoys. set up a token system; when he displays nonaggressive behavior, he earns a token good toward participating in the activity selected. He loses a token when he becomes aggressive.

focusing (therapeutic technique)

assisting the client to explore a specific topic - possible to share perceptions

When is the best time for interaction with a client that has obsessive compulsive disorders

at the end of the performed ritual that is when the client's anxiety is at it's lowest

project (defense mechanism)

attributing one's own thoughts or impulses to another person ex: a student who has sexual feelings towards her teacher tells her friends the teacher is "coming on to her"

Arpiprazole (Abilify)

atypical antipsychotic

Clozapine (Clozaril)

atypical antipsychotic superior effects with resistant clients Side Effects: agranulocytosis, drowsiness, GI symptoms, neuroleptic malignant syndrome

risperidone

atypical antipsychotic with lots of extrapyramidal SE

Needy, always in a crisis, self mutilating, unable to sustain relationships, splitting behavior

avoidant personality disorder

What should a nurse do when caring for a patient somatic symptom disorders?

be aware of own feelings and do not be judgmental the pain is real to the client nurse should: -acknowledge the symptom or complaint -reaffirm that diagnostic test results reveal no organic pathology -determine the secondary gain acquired by the client

Bulemia

bingeing & purging of food by various means

Lithium treats

bipolar disorder

What might the initial treatment include for a client admitted to the hospital with a diagnosis of bulimia nervosa?

blood work to evaluate electrolyte status; replenishment of electrolytes and fluids as indicated; careful monitoring for evidence of vomiting

Orderly rigid

borderline personality disorder

Nonbenzodiazepines

buspirone zolpidem (give with food 1 1/2 prior to bedtime) ramelteon reduces anxiety used for insomnia may cause dizziness, and daytime drowsiness

silence (therapeutic techniques)

can be therapeutic or can be used to control interaction; use carefully with paranoid client'; may be misinterpreted or could be used to support paranoid ideation

undoing (defense mechanism)

communication or behavior done to negate a previously unacceptable act example: a young man who used to hunt wild animals now chairs a committee for the protection of animals

nonverbal communication

communication using body movements, gestures, and facial expressions rather than speech

Nonphenothiazines

control psychotic behavior less sedative than phenothiazines may cause: sever extrapyramidal effects leukocytosis blurred vision dry mouth urinary retention

phenothiazines

controls psychotic behavior, hallucinations, delusions, and bizarre behavior may cause: drowsiness, orthostatic hypotension, weight gain, anticholinergic effects, extrapyramidal effects, photosensitivity, blood dycrasis, neuroleptic malignant syndrome KEEP client supine 1 hours after administration because of orthostatic hypotension effects NO alcohol or sedatives - NO antacids- reduce absorption of medication

symptoms of panic disorders and phobias

coping styles are used -displacement -projection -repression -sublimation autonomic hyperactivity -SOB -heart palpitations -dizzy -diaphoretic -frequent urination *panic attacks that usually peak at 10 minutes but can least up t 30 minutes *disruption in personal life and work life *possible use of alcohol and drugs to decrease anxiety

Signs and symptoms of obsessive-compulsive and related disorders

coping styles to control anxiety repression isolation undoing magical thinking (the belief that one's thoughts or wishes can control other people or events evidence of destructive, hostile, aggressive, and delusional thought content difficulty with interpersonal relationships interference with normal activities (ex. client must wash hands all morning and can't take her children to school) recurring repetitive behaviors that interfere with normal functioning

What could happen if bipolar patients take St. John's wort?

could enhance photosensitivity could induce mania

mild anxiety

daily life logical thoughts still transpire client still appears calm and in control

lab test for depression

decreased serotonin level decreased norepinephrine level

What are anxiety reducing strategies the nurse can teach?

deep-breathing techniques, visualization, relaxation techniques, exercise, biofeedback

What is the most important s/s of depression?

depressed mood with loss of interest in the pleasures of life ex: a mother that no longer wants to play with her children

signs and symptoms of dissociative disorders

depression mood swings insomnia potential for suicide anxiety drug/alcohol abuse

reaction formation (defense mechanism)

development of conscious attitudes and behaviors that are the opposite of what is really felt example: a person who dislikes animals does volunteer work for the humane society

sign and symptoms of bulimia

diarrhea constipation abdominal pain bloating dental damage from vomiting sore throat chronic inflammation of esophagus financial stressors related to food budget concerns with body shape and weight not usually underweight!

What are the early signs of toxicity with lithium?

diarrhea vomiting drowsiness muscle weakness lack of coordination renal impairment may cause coma, convulsions, or death

dissociative identity disorder

disorder occurring when a person seems to have two or more distinct personalities within one body -ex. if a child is being abused - he/she may take on an identity when abused and another when not being abused

dissociative disorders

disorders in which conscious awareness becomes separated (dissociated) from previous memories, thoughts, and feelings unconscious defense mechanism

mood disorders

disturbances in mood or prolonged emotional state -extreem sadness -extreem elation

What is contraindicated with lithium use?

diuretics loss of sodium can cause toxicity education: use salt consistently

nurse- client confidentiality

do not say you will not tell anyone about your discussion (if client request- there may be instances that the information may need to be shared) -what if patient is suicidal

antiaxiety drugs

drugs used to control anxiety and agitation benzodiazepines nonbenzodiazepines tricyclics MAO inhibitors SSRIs (selective serotonin reuptake inhibitors) atypical antidepressants S/NRIs NDRIs

Anticholinergic effects with antidepressant signs and symptoms

dry mouth constipation photophobia blurred vision Tachycardia

Anticholinergic effects

dry mouth, blurred vision, constipation, urinary retention

depressed clients have difficulty with?

hearing and accepting compliments -be sure to state things like- "I noticed you combed your hair today" NOT "you look nice today"

nursing interventions for personality disorders

establish trust be straight forward aid in helping client recognize behavior focus on clients strengths and accomplishments set limits on manipulative behaviors encourage socialization

basic communication skills

establish trust nonjudgemental attitude be empathetic (not sympathetic) use active listening accept and support client's feelings clarify and validate client's statements use matter of fact approach

phenothiazines can cause _____________ with long term treatment

extrapyramidal symptoms

thanatophobia

fear of death

claustrophobia

fear of enclosed or narrow spaces

acrophobia

fear of heights

signs and symptoms of obsessive compulsive and related disorders

fear of losing control hoarding excoriation (skin picking) trichotillomania (hair pulling disorder)

social anxiety

fear of not making a good impression on others

agoraphobia

fear of open spaces and crowds

hydrophobia

fear of water

information giving (therapeutic technique)

feedback about client's observed behavior

atypical antipsychotic drugs

fewer side effects -need to monitor WBC weekly for first 6 months and then biweekly

What should a nurse do if a client is anxious?

first assess the nurse's own anxiety and ensure the nurse remains calm anxiety can become contagious

SSRIs

fluoxetine paroxetine sertraline fluvoxamine citalopram escitalopram vilazodone used for depression, anxiety, panic disorder, aggression, anorexia, and OCD may cause drowsiness, dizziness, headache, insomnia, loss of appetite effect 2-+4 weeks after treatment should not use with MAO inhibitors - hypertensive crisis should wait at least 14 days between discontinuing MAO inhibitors and starting fluoxetine (Prozac) if the patient takes prozac they need to wait 5 weeks before initiating an MAO inhibitor monitor for serotonin syndrome do NOT use with St. John's wort

Behavior modiification

focuses on consequences of actions positive reinforcement aids in strengthening desired behavior (token, praise, etc.) negative reinforcement is used to decrease or eliminate inappropriate behavior (ignoring undesirable behavior, removing a token or privilege, giving a "time out" role modeling and teaching new behaviors- interventions that occur with behavior modification

crisis intervention

focuses on direct resolution of immediate crisis individual in state of disequilibrium (most of the time) goal- return individual to pre-crisis level (usually no longer than 6 weeks of treatment)

What should you administer with valporic acid?

food

MAO inhibitors should avoid

foods that have high tyramine

Complimentary and Alternative Medicine (CAM)

forms of treatment that are used in addition to or instead of standard treatment

post-traumatic stress disorder (PTSD)

four symptoms: -avoidance of events or situations that are reminders -persistent negative alterations in cognitions and mood -numbing symptoms - persistent negative emotional state -alterations in arousal and reactivity - including irritable or aggressive behavior and reckless or self destructive behavior

A 29 year old secretary, who is obese, has visited seven different doctors in the past year with a complaint of chest pain and SOB. This individual is certain she is having a heart attack in spite of the health care provider's reassurance that all tests are normal. What type of disorder is this? What nursing actions are indicated?

functional neurologic symptom disorder -clients display psychological stress in physical ways -emotion crisis can transfer into physical crisis -want to decrease anxiety -teach relaxation techniques

with patients that have dissociative disorders, what does the nurse want to avoid

giving too much information about past events at one time the various types of amnesia associated with these disorders are in place as a defense mechanism to protect the client from pain

what medications are considered nonphenothiazines

haloperidol thioxthixene pimozide

At an independent psychiatric unit, clients are expected to get up at a certain time, attend breakfast at a certain time, and arrive for their medications at the correct time. What form of therapy is incorporated into this unit?

milieu

Nursing interventions for clients with anorexia

monitor -weight -vitals -electrolytes set a time for eating be aware of client choosing low calorie foods monitor for vomiting monitor for excessive exercise use positive reinforcement provide snacks between meals assess for water loading before weighing

nursing interventions for bulimia

monitor weight/VS/electrolytes; structured/supportive environment; assist client to learn strategies for coping; encourage expression of anger; promote family therapy

Serotonin Syndrome

monitor with SSRI medications rapid onset agitation myoclonus hyperreflexia fever shivering diaphoresis ataxia diarrhea

depressive disorders

mood disorder -pathological grief reactions ranging from mild to severe states

nonverbal may be

more important than verbal communication

severe anxiety

motor: restless, fatigued quickly, shakiness, tension Autonomic Hyperactivity: SOB, heart palpitations, dizziness, diaphoresis, frequent urination Vigilance and scanning: difficulty concentration, sleep disturbance, irritable, quick to anger -on edge appearance and low self-esteem

Dramatic, flamboyant, needs to be the center of attention

narcissistic personality disorder

MAOI diet restrictions

no food that contains tyramines -raisins -red wine -aged cheese COULD cause hypertensive crisis

What activities are appropriate for a manic client?

noncompetitive physical activities that require the use of large muscle groups

Unable to conform to social norms

obsessive-compulsive personality disorder

suggesting (therapeutic techniques)

offering alternatives for example "have you ever considered....")

rationalization (defense mechanism)

offering an acceptable, logical explanation to make unacceptable feelings and behaviors acceptable example: a student who did not do well in a course says it was poorly taught and the course content was not important anyway

What can you not mix with St. John's wort?

oral contraceptives warfarin statins serotonin syndrome with- SSRIs tricyclic antidepressants

reflecting/restating (therapeutic techniques)

paraphrasing or repeating what the client has said (do not overuse this technique)

nursing care after electroconvulsive therapy (ECT)

patent airway check vitals every 15 minutes until client is alert reorient client (may be confused) Common Complaints: headache muscle soreness nausea retrograde amnesia

Fluphenazine (Prolixin)

phenothiazine that is given to non compliant patients because can be administered every 14 days through IM injection

antipsychotic medications

phenothiazines nonphenothiazines long-acting drugs atypical antipsychotic drugs

phenthiazines cause ___________so client needs to wear protective clothing and sunglasses

photosensitivity

Kava (CAM) has the ability to?

potentiate benzodiazepines

what is the difference between primary and secondary gain?

primary- decrease in anxiety secondary- an advantage something obtained from being sick-freedom from responsibilities, sympathy, etc.

What should the nurse not allow an anorexia patient to do?

provide food for others- they enjoy watching others eat and makes the client feel in control

extrapyramidal symptoms

pseudoparkinsonism acute dystonia akathisia tardive dyskinesia

Clients that are diagnosed with eating disorders are often also diagnosed with?

psychiatric disorders

What could kava kava cause?

psychiatric symptoms risk of liver failure

personality disorders

psychological disorders characterized by inflexible and enduring behavior patterns that impair social functioning schizotypal antisocial narcissistic avoidant obsessive-compulsive

Interventions for dissociative disorders

reduce stimuli stay with client during periods of depersonalization demonstrate acceptance of behavior document different personalities implement suicide precautions -identify coping patterns

regression (defense mechanism)

reverting to an earlier level of development when anxious or highly stressed example: after moving to a new home, a 6 year old starts wetting the bed

nursing interventions for bipolar disorder or manic depressive illness

safe environment maintain physical health decrease stimuli within the environment suicide precautions be consistent to minimize manipulative behavior do not give attention to bizarre behavior meet client needs ASAP to keep from becoming aggressive paise self-controlling behaviors administer lithium, sedatives, and antipsychotics as prescribed

Unable to make decisions for self. Allows others to assume responsibility for his or her life

schizotypal personality disorder

What are the side effects of antianxiety drugs

sedation and drowsiness

What does lithium require?

serum lithium levels and renal function assessment and monitoring

What are 5 autonomic responses to anxiety?

shortness of breath, heart palpitations, dizziness, diaphoresis, frequent urination

What is an important nursing intervention for the depressed client?

sit quietly with the client

Five years ago, a man was involved in a motor vehicle accident that killed the friend who was a passenger in the car he was driving. Since that time, he has been unable to work because of severe back pain. The pain is unrelieved by prescribed medications. What type of disorder is this? What are the contributing causes? Described the nursing care.

somatization disorder -unresolved grief, anxiety -evaluation pain medication for use and/or abuse -document duration and intensity of pain -assist client to identify precipitating factors related to request for medication

Suicide precautions

standard interventions to prevent a suicide attempt from occurring

severe anxiety

stimulates fight or flight disorganized sensory stimuli perceptions may be distorted impairs concentration and problem solving ability focuses only on one detail emotional pain is verbalized "i need help" tremors, pacing, etc.

sublimation (defense mechanism)

substitution of an unacceptable feeling with a more socially acceptable one example: a student who feels too small to play football becomes a champion marathon swimmer

The wife of a man killed in a motor vehicle accident has just arrived at the emergency department and is told of her husband's death. What nursing actions are appropriate for dealing with this crisis?

take her to a quiet room and ask her if there are family members, friends, or clergy that you can call for her. Assess her need for medication and discuss it with the health care provider. stay with her, be firm and directive, and assess previous coping strategies

norepinephrine dopamine reuptake inhibitors (NDRIs)

take if SSRI and SNRI are not effective used for anxiety and sleep disturbances may cause insomnia, tremors, weight loss, dry mouth, sexual dysfunction lowers seizure threshold; therefore, DO NOT use with patients that have seizure disorders or eating disorders do not use with EPHEDRA- may cause hypertensive crisis do not take with alcohol

How does a nurse know that a depressed client is improving?

takes an interest in their appearance or begin to perform self- care activities that were previously of little or no interest to them

nursing care before electroconvulsive therapy (ECT)

teach client about treatment do not say "shock" anticholinergic (atropine sulfate) give 30 minutes before treatment to dry oral secretions quick acting muscle relaxer or general anesthetic is given-helps prevent bone and muscle damage emergency care with suctioning needs to be present with O2

useful phrases in client interaction

tell me about... go on.... I'd like to discuss what you are thinking.... what are your thoughts... are you saying that.... what are you feeling.... it seems as if....

DSM-5

the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; a widely used system for classifying psychological disorders DSM-5 gives criteria for each disorder

The 10 year old sister, his mother, and the mother's live in boyfriend are asked to attend a therapy meeting. Who is the "client" who will be treated during this therapy meeting. (goes with question of 10 year old boy that stabbed his sister)

the entire family- remember that family (group_ therapy does not focus on one person, it focuses on the entire group

suppression (defense mechanism)

the intentional exclusion of feelings and ideas "I'll think about the cancer diagnosis after my birthday party."

cognitive therapy

therapy that teaches people new, more adaptive ways of thinking and acting; based on the assumption that thoughts intervene between events and our emotional reactions replaces irrational beliefs and distorted attitudes short term - 2-3 months

family therapy

therapy that treats the family as a system. Views an individual's unwanted behaviors as influenced by, or directed at, other family members focuses on entire family not just one individual life scripts- what parent's believe children should do is recognized goal- decrease family conflict and anxiety and to develop appropriate relationships

what is the main goal post op electroconvulsive therapy (ECT)?

to maintain patent airway patient may be nauseated after therapy and unconscious - ensure client is not aspirating and maintain airway

hepatotoxic

toxic to the liver

atypical antidepressants

trazodone used for depression effective 2-4 weeks after treatment is initiated

With MAOs do not give with?

tricyclics SSRIs could cause hypertensive crisis

Generalized Anxiety Disorder (GAD)

unrealistic, excessive, or persistent anxiety or worry about two or more life circumstances lasting longer than 6 months previously learned coping mechanism no longer aid the client in controlling anxiety

confrontation (therapeutic technique)

use judiciously- calling attention to inconsistent behavior

Intellectualization (Defense Mechanism)

use of excessive reasoning or logic to deal with situations rather than feeling their emotions Example: the wife of a substance abuser describes in detail the dynamics of enabling behavior yet continues to call her husband's place of work to report his monday-morning illness

lamotrigine

used: bipolar disorder (alone or with mood stabilizers) adverse reactions: headache, dizziness, double vision, rash(steven johnson syndrome)

Carbamazepine

used: bipolar disorder (alternative to lithium) adverse reactions: dizziness, ataxia, blood dyscrasia

Valporic Acid (Depakote)

used: bipolar disorder (may be used with lithium) Adverse reactions: Gi distress, nausea, anorexia, vomiting hepatotoxicity, neurological symptoms

electroconvulsive therapy (ECT)

uses electrically induced seizures for psychiatric purposes used with severely depressed patients who do not respond to medication treatment & therapy extremely suicidal patients may need because antidepressants take 2 weeks to work

People with personality disorders

usually are comfortable interacting with others and believe that they are right and the world is wrong -very little motivation to change

With PTSD what can trigger reaction?

visible reminders- scars, physical disability, etc.

Identify the physiological changes that commonly occur with depression

weight changes (loss or gain), constipation, fatigue, lack of sexual interest, somatic complaints, and sleep disturbances

judiciously

wisely

Should the nurse directly ask the client if they are suicidal?

yes, the nurse can state: "have you every thought about harming yourself?" if the answer is YES: -give them hope by telling them about medications treatments to help -identify the method of suicide the client has choosen "what is your plan for harming yourself?" -ask if the method is available- if shotgun- does the client state it is loaded and in his/her room

should the nurse allow obsessive compulsive acts

yes- do not interfere with ritual- this may enhance anxiety (as long as free from anxiety) DO NOT be judgmental

Forbidden phrases in client interaction

you should, you'll have to, you can't, if it were me I'd, why don't you, I think you, it's the policy on this unit, don't worry, everyone..., why?, just a second, I know...

signs and symptoms of anorexia

• Terror of gaining weight • Preoccupation with thoughts of food • View of self as fat even when emaciated • Peculiar handling of food: • Cutting food into small bits • Pushing pieces of food around plate • Possible development of rigorous exercise regimen • Possible self-induced vomiting; use of laxatives and diuretics • Cognition is so disturbed that the individual judges self-worth by his or her weight • Controls what he or she eats to feel powerful to overcome feelings of helplessness -weight loss of 15% -excessive exercise -skeletal appearance -distorted body image (sees self as fat) -hair loss and dry skin -irregular heart beat and decreased pulse and BP -dehydration