Psych Exam #4 (Ch 11-19, 21-24, 32-35)
Maintenance Phase
(1 year or more) prevention of further episodes of depression; possible medication
What are the 11 therapeutic factors that are common to all groups
(1) Instillation of hope (2) Universality (3) Imparting of information (4) Altruism (5) Corrective recapitulation of primary family group (6) Development of socializing techniques (7) Imitative behavior (8) Interpersonal learning (9) Group cohesiveness (10) Catharsis (11) Existential resolutio
What are the 3 phases of group development?
(1) Orientation phase (2) Working phase (3) Termination phase
Acute Phase
(6-12 weeks) Goal: - reduction of depressive symptoms - restoration of psychosocial and work function; - may require hospitalization and medication
Doxepin
(Adapin, Sinequan) TCA
Clomipramine
(Anafranil) TCA
Amoxapine
(Asendin) TCA
Lorazopam
(Ativan) Antianxiety
Nortriptyline
(Aventyl, Pamelor) TCA
Citalorpram
(Celexa) SSRI
Duloxetine
(Cymbalta) SSRI
Valproate sodium
(Depacon) Anticonvulsant
Valproic acid
(Depakene, Stavzor) Anticonvulsant
Divalproex sodium
(Depakote) Anticonvulsant
Trazodone
(Desyrel, Oleptro) Serotonin Antagonist and SSRI
Venlafaxine
(Effexor) SSRI
Amitriptyline
(Elavil) TCA
Selegiline
(Emsam) a patch MAOI
Lithium
(Eskalith, Eskalith CR, Lithobid) First line treamtment
Haloperidol
(Haldol) First generation antipsychotic
Clonazepam
(Klonopin) Antianxiety
Lomotrigine
(Lamictal) Anticonvulsant
Escitalopram
(Lexapro) SSRI
Maprotiline
(Ludiomil) Antidepressant
Maprotiline
(Ludiomil) TCA
Fluvoxamine
(Luvox) SSRI
Isocarboxazid
(Marplan) MAOI
Thioridazine
(Mellaril) First generation antipsychotic
Phenelzine
(Nardil) MAOI
Gabapentin
(Neurotin) Anticonvulsant
Desipramine
(Norpramin) TCA
Tranylcypromine
(Parnate) MAOI
Paroxetine
(Paxil) SSRI
Desvenlafaxine
(Pristiq) SSRI?
Fluoxetine
(Prozac) SSRI
Mirtazapine
(Remeron) TCA
Risperidone
(Risperdal) Second generation antipsychotic
Nefazodone
(Serzone) Serotonin Antagonist and SSRI
Trifluoperazine
(Stelazine) First generation antipsychotic
Trimipramine
(Surmontil) TCA
Carbamazepine
(Tegretol, Carbatrol, Equetro) Anticonvulsant
Chlorpromazine
(Thorazine) First generation antipsychotic
Imipramine
(Tofranil) TCA
Topiramate
(Topamax) Anticonvulsant
Oxcarbazepine
(Trileptal) Anticonvulsant
Vilazodone
(Viibryd) SSRI and Serotonin Receptor Agonist
Protriptyline
(Vivactil) TCA
Sertraline
(Zoloft) SSRI
Olanzapine
(Zyprexa) Second generation antipsychotic
Psychomotor agitation
(constant pacing and wringing of hands)
Journaling
(particularly teenager), this is a tangible way of recording and viewing emotions, setting effective goals and evaluating processes
Alcohol withdrawal Tx
*Benzos*: Stabilize vitals, prevent seizures, avoid DTs, decrease withdrawal symptoms (see Anxiolytics ppt slides for more info on this med class) -(LIBrium) Chlordiazepoxide - LorazePAM (Ativan) Clonidine (CataPRES): helps with autonomic symptoms of withdrawal (ex: hypertension) Remember: Pam is liberated from the pressure of DTs (with LorazepAM, Librium, and Catapres) Naltrexone (Revia) -can be used for treatment of both alcoholism and opioid addiction Acamprosate (Campral)
SSRI's
*First line* -block repute of serotonin -relatively low side effects comparatively -they DO NOT cause anticholinergic effects Therapeutic uses: -major depression -OCD -Bulimia -Premenstrual dysphoric disorder -Panic disorder -PTSD
Thought Process and Speech Patterns
*Flight of Ideas* *Clang Associations* *Grandiosity* (inflated self-regard)
Screening, Brief Intervention, Referral to Treatment (SBIRT)
A public health approach that seeks to intervene early and provide treatment for people with substance use disorders and for those at risk of developing these disorders.
Fear
A reaction to a specific danger, whereas anxiety is a vague sense of dread related to an unspecified or unknown danger.
Impaired impulse control
A reduced ability to resist ones impulses. Example interrupting, throwing unwanted food on the floor.
tardive dyskinesia
A serious and irreversible side effect of phenothiazines and related drugs; consists of involuntary tonic muscle spasms typically involving the tongue, fingers, toes, neck, trunk, or pelvis. persistent EPS symptoms after prolong txd even after discontinued; involuntary movements of jaw, tongue, face
Delirium tremens
A severe reaction that can be part of alcohol withdrawl, characterized by sweating, trembling, anxiety, and hallucinations
Sleep deprivation
A state that occurs from a discrepancy between hours of sleep obtained and hours of sleep required for optimal functioning.
Excessive sleepiness
A subjective report of difficulty staying awake that is serious enough to impact social and vocational functioning and increase the risk for accident or injury.
Sleep architecture
A term that refers to the structure and pattern of sleep.
Planning: Borderline Personality Disorder
A therapeutic relationship is essential with patients who have this disorder. The more intense the patients complaints are, the greater their fear of potential harm or loss is. Be aware of manipulative behaviors such as flattery, seductiveness, and instilling guilt.
Psychodrama
A type of group therapy in which real life experiences are acted out to gain insight
A client reports symptomatology that supports the diagnosis of sleep paralysis. The nurse effectively assesses the client by asking, A. "Do you ever have nighmares?" B. "Have you ever fallen asleep while driving?" C. "Do you have a history of obsessive compulsive behavior?" D. "Is it difficult for you to fall asleep?"
B. "Have you ever fallen asleep while driving?" Clients with sleep paralysis can often also exhibit symptoms of narcolepsy such as extreme sleepiness resulting in falling asleep at inappropriate times.
A slightly obese client reports falling asleep during the daytime even though she has slept all night. Her husband says she snores, and her blood pressure is noted to be in the low hypertensive range. The nurse anticipates that the client will be scheduled for which diagnostic test? A. Hypertension screening B. Polysomnography C. Glycosylated hemoglobin D. Positron emission tomography
B. Polysomnography Positron emission tomography Polysomnography consists of an electroencephalogram that records respirations, eye movements, and muscle tone during sleep. Sleep apnea becomes apparent if respirations cease frequently during sleep.
Cluster C
Behaviors described as anxious or fearful. -Avoidant -Dependent -Obsessive-Compulsive
Cluster B
Behaviors described as dramatic, emotional, or erratic. -Borderline personality disorder -Narcissistic personality disorder -Historic personality disorder -Antisocial personality disorder
Cluster A
Behaviors described as odd or eccentric. -Personality paranoid disorder -Schizoid personality disorder -Schizotypal personality disorder
Binge eating disorder
Binge eat no purging
bulimia nervosa
Binge eat then purge
Opioid Intoxication
Bradycardia Hypotension Hypothermia Sedation Meiosis (Pinpoint pupils) Hypokinesis Slurred speech Head nodding Euphoria Analgesia Calmness
Norepinephrine Dopamine Reuptake Inhibitor:
Bupropion (WELLbutrin) ↑ NE and DA (norepinephrine-dopamine reuptake inhibitor) *No sexual side effects* Seizure risk Used for smoking cessation (Zyban)
A client tells the nurse, "I just don't sleep more than 5 hours at night." The nurse responds best by asking A. "Are you aware that some people require less sleep than others?" B. "When did this pattern of sleep start for you?" C. "Do you usually feel rested and alert when you get up?" D. "Are you taking any medication that could affect your sleep?"
C. "Do you usually feel rested and alert when you get up?" The most accurate way to determine an individual's sleep requirements is to ask if the person feels fully awake and functions effectively on the sleep he or she is getting.
Sleep efficiency
Ratio of sleep duration to time spent in bed.
Group work
Recognizing what is happening on the surface and what is going on underneath.
Severe Mental Illness (SMI)
Refers to a group of psychiatric disorders, most of which are primarily biological in origin, that can significantly affect functioning and one's quality of life, especially if they go untreated.
Opioid withdraw tx
Relapse Prevention: -Naltrexone (Revia) Heroin Withdrawal: -Clonidine (Catapres)-lowers blood pressure Detoxification Maintenance -Methadone (Dolophine) -Buprenorphine-Naloxone (Suboxone) 1. Sublingual administration 2. Pt needs teaching regarding safety issues, adverse reactions, & interactions with other meds!!!
Individual roles
Relate to specific personalities, personal agendas, and desires for having personal needs met. do not usually move the group forward in a positive way; best interest of the group is not at heart
delusions
False; fixed beliefs cannot be fixed with reasoning A false belief held to be true even with evidence to the contrary (e.g., a false belief that one is being singled out for harm by others).
Planning for Continuation Phase
Focus on *maintaining adherence to meds and prevent relapse* - Psychoeducational teaching necessary for patient and family - Referrals to community programs, groups, and support for co-occurring disorders or problems - Community and problem solving skills training - *Cognitive behavioral therapy*
15
For child who is secluded, vital signs and range of motion in extremities must be monitored every _____ minutes.
Circadian drive
Functions as part of the circadian rhythm that comes into play during the day to promote wakefulness. The circadian drive is balanced by the homeostatic mechanism of sleep drives.
Risk factors for personality disorders
Genetics Neurobiological Psychological Environmental Diathesis-stress model
Biological risk factors
Genetics- common in family that has history of eating disorders Neurobiological- Hypothalamic, hormonal, or biochemical imbalance.
Psychoeducational groups
Groups used to increase knowledge/skills regarding a specific somatic or psychological topic
80% of the population of people with SMI's
Have a nicotine addiction
Symptom-management groups
Help patients cope with the symptoms of mental illness in spite of medication
MAOIs
Remember NAR-PAR and Emsam Phenelzine (NARdil) Tranylcypromine (PARnate) Selegiline (Emsam patch) Nar-Par is a depressed pirate on a diet (on-slim-fast).His parrot's name is Emsam.
MAOIs: Foods to avoid
Remember: Nar-Par is "On Slim Fast" diet - *O*verripe figs/avocados - *N*othing fermented - *S*ausage, Sauerkraut, Soups/Supplements with protein extract - *L*iver, lots of bananas, lots of chocolate - *I*mported beer, Chianti - *M*eats that are aged, smoked - *F*ava beans, Fish that is dried or pickled - *A*ll cheeses except cottage and cream cheese - *S*oybean, soy sauce, shrimp paste - *T*oo much caffeine; TYRAMINE
Group phases
Represent distinct periods or stages in the process of group development.
Terminating - group leader responsibility
The leader ensures that each members summarized accomplishments and gives positive and negative feedback regarding the group experience
Maintaining - group leader responsibility
The leader facilitates communication, ensures that the meetings begin and end on time, and encourages members to solve group problems instead of the leader
Instillation of hope
The leader shared optimism about success of group treatment, and members share their improvements. Ex: You got better, maybe I can too."
How should a demoralizing member be dealt with?
The leader should listen to what the member has to say but may have to speak to him/her in private
Agnosia
The loss of sensory ability to recognize objects
Deinstitutionalization
The mass shift of patients from state hospitals into the community, began in the 1960s and has continued since.
Clang Associations
The meaningless rhyming of words, often in a forceful manner. 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.
medical comorbidity
The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV, and pulmonary disorders The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and complications from the route of administration of substances
neglect
The most prevalent form of child abuse in the US is _______
Withdrawal
The negative physiological and psychological reactions that occur when a drug taken for a long period is reduced in dosage or no longer taken
Neurobiology and personality disorders
The neurotransmitter theory proposes that certain neurotransmitters, including neurohormones, may regulate and influence temperament. Research in brain imaging has also revealed some differences in the size and function of specific structures of the brain in people with some personality disorders
Stigma
The perception that an individual is flawed.
diathesis
The physiological vulnerabilities such as genetic predispositions, biochemical makeup, and personality structure
Teamwork and Safety when working with patients with Borderline Personality Disorder
The primary goal is management of the patient's affect in a group context. Community meetings, coping skills groups, and socializing groups are all helpful for these patients. They have the opportunity to interact with peers and staff to discuss goals and learn problem-solving skills.
Planning when taking care of patients with Antisocial Personality Disorder
The role of the nurse will be to provide consistency, support, boundaries, and limits. Providing realistic choices.
restructuring
changing an activity in a way that will decrease the stimulation or frustration (shorten the 1:1 session or change to a physical activity) this requires flexibility and planning to have an alternative in mind in case the activity is not going well.
What is the possible cause of conversion disorder?
channeling of emotional conflicts or stressors into physical symptoms
Contraindications of Lithium
cardiovascular disease brain damage renal disease thyroid disease myasthenia gravis pregnant women breastfeeding
second generation antipsychotics
cause metabolic syndrome such as weight gain, dyslipidemia and insulin resistance, increase risk of diabetes, hypertension and atherosclerosis
extrapyramidal side effects
caused by 1st-gen anti-psychotics blockage of D2 receptor A variety of signs and symptoms that are often side effects of the use of certain psychotropic drugs, particularly phenothiazines. Three reversible extrapyramidal side effects are acute dystonia, akathisia, and pseudoparkinsonism. A fourth, tardive dyskinesia, is the most serious and is not reversible.
Vegetative signs of depression
change in : - bowel movements - eating habits, - sleep disturbances, - disinterest in sex - chronic pain
action
changing
Intellectual development disorder (IDD)
disorders marked by deficits in intellectual functioning, social functioning, and managing age-appropriate ADL's and must be evident during childhood development. previously called mental retardation
psychological risk factors
distorted body image. Feelings of helplessness, ineffectiveness and depression
therapeutic games
drawings, puppets, etc are used for younger children who cannot respond to a direst approach
drug use disorder
drug use, craving, and seeking regardless of consequences.
Terminal insomnia
early morning awakening
Etiology
early onset is more severe; young people have more mood switches, mixed episodes, sick more often, and greater risk of suicide attempts; theories of development are focused on biological, psychological, and environmental factors
Deep Brain Stimulation
electrodes are implanted straight into the brain and is attached to a pulsation device in the chest risk for hemorrhage used for treatment resistant depression
Transcranial Magnetic Stimulation
magnetic pulses stimulate the prefrontal cortex and make neurons fire effective stand alone treatment Usual course is 5 days a week for 4 to 6 weeks headache and lightheadedness and tingling of the scalp
Conventional Antipsychotics
maintenance mania
american psychiatric association
major disorders that may not be diagnosed until adulthood are: - oppositional defiant disorder (childhood), i - intermittent explosive disorder (> 18 year of age), - conduct disorder
flashbacks, avoidance, hyper vigilance, alterations in mood
major features of PTSD include
all eating disorders
manifestations: Hypokalemia (especially Bulimia Nervosa) Dehydration stimulates increased aldosterone production, leading to Na and H2O retention and K+ excretion Anemia Hypoalbuminemia- due to protein loss Abnormal Thyroid Function Tests ECG Changes (prolonged QT interval) Decreased bone density- osteoparosis
roles of forensic psychiatric nurse
psychotherapist, forensic nurse examiner, competency evaluator, fact or expert witness, consultant to law, hostage negotiator, or criminal profiler
-two problems seen in these three impulse conduct disorders are:
pyromania- repeated deliberate fire setting, kleptomania- repeated failure to resist urge to steal objects not needed for personal use or monetary value
expert witness
recognized as having a certain level of skill or expertise in a designated area and possesses superior knowledge because of education
blunted
reduced or minimal emotional response
alogia
reduced verbalization
simple resitution
refers to a procedure in which an *individual is required or expected to correct the adverse environmental or relational effects of his or her misbehavior by restoring the environment to its prior state*, making a plan to correct his or her actions with the nurse, and implementing the plan (apologizing to the persons harmed, fixing the chairs that are upturned) simple restitution is not punitive in nature, and there are typically additional activities (counseling)
disruptive mood dysregulation disorder
relating to children ages 6-18 and refers to situations in which a person has frequent tamper tantrums resulting in verbal or behavioral outbursts out of proportion to the situation this diagnosis is given for the first time only to children between ages of 6-18 who do NOT have other medical or mental health diagnoses that old account for the tantrums
stereotyped behaviors
repeated movement that does not serve a purpose. A motor pattern that originally had meaning to the person (e.g., sweeping the floor, washing windows) but has become mechanical and lacks purpose.
glutamate
this neurotransmitter increases the ability of nerve fiber to transmit information; a lack of this interferes with normal neuron transmission in areas affective mood, attention and cognition
serotonin
this neurotransmitter is an important regulator of sleep, appetite, and libido.
Norepinephrine
this neurotransmitter modulates attention and behavior, is stimulated by stressful situations, and can be depleted or imbalanced
maintenance phase
this phase of the treatment and recovery from major depression id directed at prevention of further episodes of depression. Depending on the risk factors for relapse, medication may be phased out or continued. takes 1 or more years
continuation phase
this phase of the treatment and recovery from major depression is directed at prevention of relapse through pharmacotherapy, education, and depression-specific psychotherapy. takes 4-9 months
acute phase
this phase of treatment and recovery from major depression is directed at reduction of depressive symptoms and restoration of psychosocial and work function. Hospitalization may be required, and medication of tore biological treatments may be initiated. take 6-12 weeks
Behavioral therapy
this type of therapy uses conditioning to shape a client's behaviors in the desired direction using "principle of least restrictive intervention" to manage behavior
guilty but mentally ill
those who plead guilty and are sent to the correctional system where they receive treatment then sent to the parole decisions
Why do people have factitious disorders?
to get emotional needs met and attain the status of "patient"
posits
to set, to state (another word)
forensic nursing
traditional nursing and forensic knowledge to better serve victims and perpetrators of violence
Vagus Nerve Stimulation
treatment for epilepsy and depression boosts levels of neurotransmitters and improving mood surgically implant a pacemaker like device into the left chest wall and wire goes through the vagus nerve on the left side of the neck; infrared magnetic wand turns the device on Pulses are delivered for 30 seconds every 5 minutes for 24 hours a day voice alterations normally occur; other side effects are neck pain, cough, paresthesia, and dyspnea turned off with magnet during public speaking or exercise
debriefing
treatment of ASD, and typically occurs within 12-48 hours after the traumatic event as is often offered as a group intervention
Antianxiety Drugs
treatment of acute mania managing psychomotor agitation do not give to patients with substance abuse
labile
unstable; undergoing rapid emotional change
Therapeutic drawing
use of art and drawing provides a non verbal means of expressing difficult or confusing emotions
Epidemiology
usually begins with depressive episode; women with postpartum psychosis within 2 weeks of giving birth have 4 times the chance of conversion to bipolar disorder; - women are likely to abuse alcohol, commit suicide, and develop thyroid disease; - men are likely to have legal problems and commit acts of violence; - Bipolar1 may get confused with ADHD in kids; Bipolar II is under diagnosed and confused with major depression or personality disorders; - Cyclothymic disorder usually begins in adolescence or early adulthood and 15% to 50% risk that they will develop bipolar disorder
counseling
verbal interactions teach, coach, or maintain adaptive behavior and provide positive reinforcement. it is most effective for motivated patients and those with well-developed communication and self-reflective skills
Clonidine
Opiates, Hypertension= Heroin withdrawal
neologisms
made up words "mannerologies" "macnabs"
Broad based mental illness
Any commonly accepted mental health diagnosis
Therapeutic group
Any group of people who meet together for personal development and psychotherapeutic growth.
Buprenorphine (Subutex)
Opiates= Detoxification and maintenance
Methadone hydrochloride
Opiates= Detoxification maintenance
Levo-alpha-acetylmethadol
Opiates= Withdrawal and maintenance
Other housing
Opportunities for *community reintegration* are also available in supportive housing units that are not part of treatment. Three-quarter-way houses, therapeutic communities, and housing programs offer *drug-free living environments, peer support, and classes to assist or remediate skills* needed for daily living. Residents usually attend some type of outpatient substance use treatment to continue in their recovery program.
Peer support specialists
Other consumers who are in recovery, may provide some of the services and are referred to as...
Imparting of information
Participants receive formal teaching by the leader or advice from peers. Ex: Here is how to rake your medication."
Victims of violence
Patient's with SMI's are more likely to become
Who is at risk for over-diagnosis of a personality disorder?
Patients who differ from the majority culture or the culture of the clinician.
Psycho-social Interventions for patients with Borderline Personality Disorder
Patients with this personality disorder are impulsive and may be suicidal, self-mutilating, aggressive, manipulative, and even psychotic during periods of stress. Provide clear and consistent boundaries and limits. Use straightforward communication. When behavioral problems emerge, calmly review the therapeutic goals. When responding to superficial self-destructive behaviors. The nurse remains neutral and dresses the wound in a matter-of-fact manner. Then the patient is instructed to write down the sequence of events leading up to the injury, as well as the consequences, before staff will discuss the event.
Histrionic Personality Disorder
People with this disorder are excitable and dramatic yet are often high functioning. They may be referred to in terms of "drama queen" or "drama major." Classic characteristics of this population include extroversion, flamboyancy, and colorful personalities. Despite this bold exterior, they tend to have limited ability to develop meaningful relationships. Tends to be diagnosed more commonly in women. Inborn character traits such as emotional expressiveness and egocentricity have also been identified as predisposing an individual to this disorder. This disorder is characterized by emotional attention-seeking behaviors including self-centeredness, low frustration tolerance, and excessive emotionality. Is often impulsive and may act flirtatiously or provocatively.
Psychopharmacology
the study of drug effects on psychological states and symptoms medicating children typically works best when combines with another treatment such as cognitive-behavioral therapy
temperament
the style of behavior a child habitually uses to cope with the demands and expectations of the environment
learned helplessness
the thought that an undesired event is his or her fault and nothing can be done to change it a person believes she/he has no control of the situation
Bibliotherapy
the use of literature to help the child express feelings in a supportive environment, gain insight into feelings and behavior, and learn new ways to cope with difficult situations ensure book used does not violate family's belief system
contemplation
they may still not be ready to commit to addressing it.
Guilt
thinking about the past failings
Catatonia
A pronounced increase or decrease in the rate and amount of movement; the most common form is stuporous behavior in which the person moves little or not at all.
Patient and Family Teaching
*Know about the disease and it's processes *Alcohol, drugs, caffeine, and OTC's can cause relapse *Good sleep and hygiene is important *Psychosocial strategies *Group and individual psychotherapy for relapse prevention *Increased risk for diabetes, high blood pressure, dyslipidemia, cardiac problems
Outcomes Identification for caring for patients with antisocial personality disorder
*abusive behavior self-restraint *aggression self-restraint *coping *social interaction *social isolation *health promotion knowledge *health promoting behavior Successfully achieving these outcomes when working with this population is extremely difficult, but maintaining safety is the priority. Small, incremental changes and progress will likely be the best outcomes.
Types of mental illnesses SMIs include:
*major depressive disorder *bipolar disorder *schizophrenia *schizoaffective disorder *panic disorder *posttraumatic stress disorder *borderline *antisocial personality disorder *obsessive-compulsive disorder
Interventions for Continuation Phase
*prevention of relapse*, community resources, referrals, *medication adherence* - Day hospitals, psychiatric home care
Acute Phase Outcomes ISH The Stupid TeNtion
*primary outcome = injury prevention* 1.) Injury prevention** 2.) Hydrated 3.) Stable cardiac status 4.) Tissue integrity 5.) Sleep and Rest 6.) Thought self-control 7.) No attempt at self-harm
family assessment
+ Codependence
Continuation Phase
- (4-9 months) - prevention of relapse through psychotherapy, - education, and depression-specific psychotherapy
Detoxification
- (also known as detox) is warranted when the individual quits using a psychoactive substance that is known to cause withdrawal or when the individual is already in withdrawal. This is a medically managed inpatient program with 24-hour medical coverage while the patient's body clears itself of drugs. This process is accompanied by uncomfortable and even fatal side effects caused by withdrawal. Detoxification is also available as a medically monitored program with 24-hour professional supervision based on the severity of symptomatology and the presence of comorbid conditions
Biochemical Factors
- *Serotonin*( regulator of sleep, appetite, and libido) and *norepinephrine*(attention and behavior); - depression results from dysregulation of a neurotransmitters (serotonin, NE, dopamine, AcH, GABA, and glutamate); -Stressful events trigger NE, serotonin, and AcH (overused and depleted supply and reduction in neurogenesis)
Key Assessment Findings
- *depressed mood* - *anhedonia* - *anergia* - *anxiety* - thinking is slow - memory and concentration are negatively effected - dwell on and exaggerate perceived faults and failures - persecutory delusions - feelings of worthlessness, hopelessness, guilt, anger, and helplessness - *Psychomotor agitation* - *psychomotor retardation* (slowing of movements)=more common - *somatic complaints* (headache, malaise, backaches) - *Vegetative signs of depression*
Neurobiological
- *norepinephrine, dopamine, and serotonin*; ------too few= depression; ------too many= mania; - could also be receptor site insensitivity; brain pathways include: subregions of the prefrontal cortex and median temporal lobe; - structural and functional brain changes: prefrontal cortex changes are evident in early stages and lateral ventricle abnormalities develop with repeated episodes; - differences in anterior limbic regions which control emotion, memory, motivation, and fear (These are most deeply effected)
Cognitive Theory
- *person's thoughts will result in emotions*. If a person looks at life in a positive way, the person will experience positive emotions, but negative interpretation of life events can result in sorrow, anger, and hopelessness people may acquire a psychological predisposition to depression due to early life experiences that contribute to negative, illogical and irrational thought processes; perceive information in a negative way even in the midst of positive factors (Beck) - *Beck's Cognitive Triad*:
Depression in children
- 13 - 18 yrs = 11.2% prevalence - If the first episode of depression occurs in childhood or adolescence, the likelihood of recurrence is high
Genetics
- 80%-90% heritable; - polygenetic disease; - connection between BPD and *diacylglycerol kinase eta (DGKH)* - enzyme ; - lithium is first line therapy because DGKH is crucial part of lithium-sensitive pathway; - abnormal circadian genes which leads to insomnia; *Circadian clock gene (CRY2)* associated with rapid cycling; - bipolar and schizophrenia exhibit irregularities on *chromosomes 13 and 15*
Assessment Tools
- Beck Depression Inventory, - Hamilton Depression Scale, - Zung Depression Scale, -Geriatric Depression Scale, -Patient Health Questionairre-9
The substance-related and addictive disorders include - Alcohol
- Caffeine - Cannabis - hallucinogen - Inhalant - Opioid - Sedative, hypnotic, anxiolytic - Stimulant - Tobacco.
Depression in old
- Depression is the leading cause of disability; - not a normal result of aging; - increases as health deteriorates; - many older adults suffer from subsyndromal depression (experience many, but not all symptoms of major depression); - many older adults are likely to commit suicide
Mania
- Extreme drive and energy - Inflated sense of self-importance - Drastically reduced sleep requirements - Excessive talking combined with pressured speech - Personal feeling of racing thoughts - Distraction by environmental events - Unusually obsessed with and over focused on goals - Purposeless arousal and movement - Dangerous activities: indiscriminate spending, reckless sexual encounters, risky investments - Euphoric or Dysphoric
Planning for Maintenance Phase
- Focus on *preventing relapse and limiting severity and duration of future episodes* - Require medication for life - Need support groups and periodic evaluations
Assessing Feelings
- Guilt - hopelessness - helplessness, - physical aggression, - destruction of property, or directed toward self as suicide or self destructive behaviors (alcohol, substance abuse, overeating, smoking) low self esteem
motor retardation
A pronounced slowing of movement
Interventions for Acute Phase : Manic episode
- Hospitalization provides safety - Use *calm voice* - use *short statements* - remain neutral - be consistent in expectations - *frequent staff meetings* --> consistent approach + limit setting - *redirect energy* - maintain *low level stimuli* - structured solitary activities - *high calorie fluids* - frequent rest periods - redirect violent behavior via exercise - use phenothiazines and seclusion to minimize physical harm - observe for lithium toxicity - don't let them give away money or possessions - monitor intake and output and vitals - *finger foods* - remind them to eat - provide warm baths, soothing music, and medication to sleep - No caffeine - supervise clothing choice give simple step by step reminders for hygiene and dress - Monitor bowel habits
Assessing Physical Behaviors
- Lethargy - Fatigue - psychomotor retardation (slow movements, - decreased facial expressions, - fixed gaze, - or no movement at all and incontinence) - Psychomotor agitation - grooming, dress, and personal hygiene neglect - change in sleep patterns; insomnia or hypersomnia - change in bowel habits; constipation - disinterest in sex - vegetative signs of depression; anorexia, overeating, weight gain
Depressive Disorders
- Major depressive disorder, -disruptive mood dysregulation disorder, - dysthymic disorder, - premenstrual dysphoric disorder, - substance-induced depressive disorder, - depressive disorder associated with another medical condition
stressful life events
- Norepinephrine, serotonin, and acetylcholine play a role in stress regulation. - When these neurotransmitters become overtaxed through stressful events, neurotransmitter depletion may occur. - Research indicates that stress is associated with a reduction in neurogenesis, which is the ability of the brain to produce new brain cells
Alterations in Hormonal Regulation
- People with depression have increase urine cortisol levels and elevated corticotropin-releasing hormone; - use the dexamethasone suppression test to check for depression (dexamethasone represses cortisol , so if there in no suppression of cortisol in the test, they have depression); is also seen with OCD - Estrogen is associated with mood regulation; menopausal women lose this and are at the same risk level as men
Major Depressive Disorder
- Persistently depressed mood lasting for a minimum of *two weeks*; - lack of interest in previously pleasurable activities (*anhedonia*), - *fatigue*, - *sleep disturbances*, - *changes in appetite*, - feelings of *hopelessness or worthlessness*, - persistent *thoughts of death or suicide*, - *inability to concentrate* or make decisions, - *change in physical activity*, - *psychomotor agitation* (figeting and changing position often); *must have depression or anhedonia and 5 of the other 8 symptoms*
Anticonvulsant Drugs
- Superior for rapid cycling patients* - more effective when there is no family history - dampening affective swings in schizoaffective patients - diminish impulsive and aggressive behavior - indicated for alcohol and benzo withdrawal - controlling mania and depression* slows inference of sodium and calcium back into the neuron makes GABA more inhibitory inhibits glutamate and suppresses the CNS --ADVERSE EFFECTS-- *CNS effects: (Nystagmus, Double vison, Vertigo, Staggering gait, Headache) *Blood dycrasias: (Leukopenia, Anemia, Thrombocytopenia) *Teratogenesis *Hypo-osmolarity *Skin disorders (Dermatitis, Stevens-Johnson Syndrome) *nausea *vomiting *hepatotoxicity *pancreatitis --DONT USE IF-- *pregnant *bone marrow suppression or bleeding disorders *liver disorders --DONT USE WITH-- *oral contraceptives *warfarin *grapefruit juice *Phenytoin, phenobarbital *Each other*
Nursing Diagnoses for Bipolar Disorder
- Wandering (hyperactivity) - Risk for injury - Risk for other-directed violence - Sleep deprivation - Defense coping - Ineffective coping - Self-care deficit - Interrupted family processes - Caregiver role strain - Impaired verbal communication - Impaired social interaction
Assessing Thought Processes
- ability to solve problems and think clearly is negatively affected - poor judgment - indecisiveness - claim their mind is slowing down - memory and concentration are poor - intrusive negative thoughts - delusional thinking
Disruptive Mood Dysregulation Disorder
- children between the ages of *6 to 18* - and refers to situations in which a person has frequent *temper tantrums resulting in verbal or behavioral outbursts* out of proportion to the situation; - only given if they do not have another medical condition which causes temper tantrums (autism)
Premenstrual Dysphoric Disorder
- cluster of symptoms that occur within the *last week prior to onset of a woman's period*; - physical discomfort and emotional symptoms severe enough to interfere with work and social life; - decrease or disappear with onset of period
Assessment in Children and Adolescents
- core symptoms are the same: sadness and loss of pleasure - crying - withdraw - irritable - negativity - isolation - loss of energy - refuse to go to school - substance abuse or sexual promiscuity - preoccupied with death or suicide - anxiety and anger
Comorbidity
- depression frequently accompanies many other psychiatric disorders (anxiety, borderline personality disorders); - 70% of people with anxiety also have depression; - depression increases with the presence of a medical condition, especially if chronic; - common in substance abuse (alcohol, cocaine, marijuana, heroin, and anxiolytics and prescription medicines); - unlikely that there is a single cause of depression
Assessing Religious Beliefs and Spirituality
- depression prevented by engaging in spiritual activities --> helped with negative thoughts and other symptoms of depression *support spirituality in depressed patients
psychological Comorbidity
- dopamine may be associated with addictive behavior 1. The physiological response to certain drugs of abuse presents a cluster of symptoms similar to the symptoms of other mental health disorders (e.g., psychosis, and schizophrenia). 2. Subclinical symptoms from one mental health disorder may result in medication of those symptoms with a psychoactive drug (social anxiety and alcohol or marijuana). 3. Psychiatric illnesses and substance use disorders have common risk factors.
Primary Risk Factors for Depression
- female - unmarried - low socioeconomic class - early childhood trauma - presence of negative life event - family history of depression - ineffective coping ability - postpartum time period - medical illness - absence of social support - alcohol or substance abuse
Diathesis-Stress Model
- genetically predisposed people with early life trauma may result in long term hyperactivity of the CNS *corticotropin-releasing factor* and *NE systems* ---> neurotoxin effect on the hippocampus ---> cause sensitization to CRF circuits ---> exaggerated stress response (even mild stress can act as a trigger)
Interventions for Acute Phase : Depressive episode
- hospitalization is required for suicidal ideation, psychosis, or catatonia - *Lithium if first line treatment (takes 7-14 days to get right level)* - *Antidepressants are not recommended* since CNS may become overactive and result in hypomania or mania - *Second generation antipsychotic* may be added to medication if psychotic features are present
Genetic Factors
- increased heritability is associated with early onset, greater rate of comorbidity, and increased risk of current illness; - multiple genes involved; - There is a genetic marker associated with depression in the context of stressful life events.
self assessment
- keep in mind that BiPOlar pt can be manipulative - Frequent staff meetings to deal with the behaviors of the patient and the nurses' responses to these behaviors can help minimize staff splitting and feelings of anger and isolation. - set limits : consistency among staff
Dysphoric Mania
- mixed state or agitated depression, with depressive symptoms along with mania; 1) irritable, 2) angry, 3) suicidal, 4) *hypersexual*; 5) panic attacks, 6) *pressured speech*, 7) agitation, 8) insomnia, 9) *grandiosity*, 10) *persecutory delusions* 11) confusion.
Hopelessness Attributes
- negative expectations for the future - loss of control over future outcomes - passive acceptance of the uselessness of planning to achieve goals emotional negativism, as expressed in despair, despondency, or depression
Assessment in Older Adults
- often overlooked because they are more likely to complain of p physical illness rather than emotional and -have comorbid issues that cause the same symptoms - Use Geriatric Depression Scale
Cognitive Function
- often preceded by high cognitive functioning - cognitive impairment is more common in bipolar I but is also present in bipolar II - Potential cognitive dysfunction implications: 1) affects overall function 2) correlate with greater number of manic episodes, psychosis, chronic illness, and poor functional outcomes 3) Early diagnosis and treatment are crucial prevent illnessess 4) Medication selection should consider not only efficacy in reducing symptoms but cognitive impact of the drug
Alcoholics Anonymous (AA) -
- oldest and best known of the 12-step fellowships. - Anyone with the desire to quit drinking or using substances is welcome to attend meetings - Individuals learn how to be sober through the support of other members and the 12 steps. In most suburban and urban areas, meetings can be found every day and around the clock; they are even available online and are structured for confidentiality and anonymity. Family members and other support are often welcome. -The 12-step model has been adopted worldwide. Specific groups may focus on specific addictions and include specific populations. The size of meetings ranges from small (around 15) to large (more than 50). There are also meetings to address the special needs of family and significant others, such as Al-Anon for friends and family members of alcohol abusers, Alateen for teenage relatives of alcohol abusers, and Nar-Anon for family and friends of drug abusers. Gamblers Anonymous is for individuals with significant gambling problems.
Assessing Mood
- only assessed by asking a person how they feel - frequent responses: anxiety, worthlessness, guilt, helplessness, hopelessness, and anger - feel they are no good or won't amount to anything
Assessing Affect
- poor posture - look older than they are - sad facial expression - frequent bouts of crying - no eye contact - monotone - little or no expression (flat affect) - only yes or no responses - frequent sighing
Depressive Disorder Associated with Another Medical Condition
- result of changes that are directly related to certain illnesses such as kidney failure, Parkinson's disease, and Alzheimer's disease
Assessing Communication
- speak and comprehend very slowly - in extreme cases, may become mute
Electroconvulsive Therapy
- subdue severe manic behavior for treatment resistant people and rapid cyclers - Monitor vitals every 15 minutes for 1 hour; - they will have high blood pressure cause short term memory loss
Substance-induced Depressive Disorder
- symptoms of major depression arise as a result of prolonged drug or alcohol intoxication or as a result of withdrawal; - S&S would not be experience in the absence of drugs, alcohol, or withdrawal
oppositional defiant disorder
-*angry and irritable mood*: - losing temper or becoming easily annoyed -*defiant behaviors*: arguing with adults, refusing tot comply with adults' requests or rules -*vindictive behavior*: spiteful, malicious -experience: social difficulties, conflicts with authority figures, academic problems -individual usually shows a pattern of deliberately annoying people -blaming other for his or her mistakes or misbehaviors -more prevalent in boys than girls -boys are more likely to annoy and blame others -girls argue more -child shows a preference for large rewards and pays little attention to increasing penalties
types of therapy
-*cognitive-behavioral therapy*- talk therapy focused on patient's feelings, thoughts, and behaviors -*psychodynamic psychotherapy*- focused on underlying feelings and motivations and explores conscious and unconscious thought process -*dialectical behavioral therapy*- specific type of cognitive-behavior treatment that has a focus on impulse control (used in prisons to help decrease physical aggression) -*parent-child interaction therapy*- APRN's/ advanced practice provider sit behind a one way mirror helping parents interact with their child. -*parent management training*- focus is on parent, not child. teaches reinforcement of positive and prosocial behavior, and on brief, negative consequences of bed behavior -*multisystemic therapy (MST)* *most extensive*- intensive family and community based program that takes into consideration all of the environment of violent juvenile offenders
Maintenance Therapy for Lithium
--not addictive --eat a normal diet with normal salt and fluid intake (1500-3000 mL/day or six 12 oz glasses of fluid) --take with meals --stop taking if you have excessive diarrhea, vomiting, or sweating --do not take diuretics -- have your kidneys and thyroid checked for hypothyroidism and inability to make urine -- do not take over the counter medications --talk about weight gain with doctor -- self help groups -- taper dose to discontinue to prevent relapse of mania
GABA
-An inhibitory neurotransmitter that puts a brake on excitatory neurotransmitters is the common focus of pharmacological therapy for anxiety symptoms. -Too little can cause anxiety disorder. -Benzos help
Delirium meds
-Antipsychotics -Antianxiety agents
Coping enhancement
-Assisting a pt to adapt to perceived stressors, changes, or threats that interfere with meeting life demand and roles. -Prove an atmosphere of acceptance -Encourage verbalization of feelings, perceptions, and fears. -Discourage decision making with pts with severe stress
Self-esteem enhancement
-Assisting a pt to increase his or her personal judgement of self worth -Make positive statements about the pt. -Monitor frequency of self negating verbalizations -Explore previous achievements
Defense mechanisms
-Automatic coping styles that protect people from anxiety and maintain self image by blocking feelings, conflict, and memories.
Other classes
-B blockers, antihystamines, and anticolnvulsants are often added if the first course of tx is ineffective.
Separation anxiety disorder
-Begins around 8-18 months and declines after that. -Exhibit developmentally inappropriate levels of concern over being away from a significant other. Fear of something horrible happening to the other person resulting in permanent separation. -Adults wit this disorder are weary of romantic relationships and are more likely to be unmarried. Characteristics include: harm avoidance, worry, shyness, uncertainty, fatiguability, and lack of self direction.
MAOIs ADVERSE EFFECTS--
-CNS stimulation -orthostatic hypotension -Hypertensive crisis with tyramine (hypertension, headache, nausea, increased heart rate) -Local Rash
Social anxiety disorder
-Characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that could be evaluated negatively by others. -Fear of saying something that sounds foolish in public, not being able to answer questions in a classroom, looking awkward in public, and performing badly on stage. -Small children may be mute, nervous, and hide behind their parents. -Older children and adolescents may be paralyzed by fear of speaking in class or interacting with other children, the fear immobilizes them. -Younger people may act out to compensate for this fear making an accurate diagnosis more difficult. -May result in physical complaints to avoid social situations
Alzheimer's meds
-Cholinesterase inhibitors -NMDA receptor antagonist
patient history
-Clients perception of issue -History of dieting -Method of weight control -Value attached to shape/weight -interpersonal / social functioning -Impulsivity/compulsivity -Relationships (family, interpersonal)
Moderate Alzheimer's (Middle Stage)
-Confuses words -Gets frustrated or angry -Symptoms noticeable to others -Forget events or own history -Confused about where they are or day -Need help dressing -Problems with elimination -Changes in sleep -Risk for wandering
Substance induced obsessive compulsive and related disorder
-Develop with the use of a substance or within a month of stopping used of the substance. -Drugs that treat movement lie Parkinson's disorder
401-800 mg % BAL
-Difficulty waking the patient (coma) -Serious decrease in pulse, temperature, blood pressure, and rate of breathing -Urinary and bowel incontinence -Death
Delirium S&S
-Disturbance in attention -Develops over a short period of time -Disorganized thinking -Disorientation -Anxiety -Agitation -Poor memory -Delusional thinking
binge eating
-Eat large quantities of food over a short period of time- usually 2 hours- no purging -Food consumption leads the person feeling out of control -Must binge at least once a week for 3 months to be diagnosed -Occurs mostly in females -Between binges the person will restrict diet to low calorie or diet foods
Hope instillation
-Enhancing he belief in one's capacity to initiate and sustain actions -Assist the pt to identify areas of hope in life. Demonstrate hope by recognizing the pats intrinsic worth and viewing the pats illness as only one facet of the individual -Avoid masking the truth
Severe to panic levels of anxiety care
-Extreme regression and running about aimlessly are behavioral manifestations of a persons intense psychic pain. -Provide for the safety of the patient and others and to meet physical needs to prevent exhaustion. -Anxiety reduction: Removing the person to a quiet environment with minimal stimulation and providing gross motor activities to drain some of the tension. -Feeling understood can decrease the overwhelming sense of isolation and reduce anxiety. -Pts feel out of control so they need to know they are safe from their own impulses. -Firm, short and simple statements are useful. -Reinforcing commonalities in the environment and pointing out reality when there are distortions can also be useful interventions.
Most Extreme Forms of Severe Alcohol Withdrawal
-Grand mal seizures -Occurs 3-10 days of last drink (Delirium tremens)
Sever anxiety
-Greatly reduced and distorted perceptual field. Focuses on details or one specific detail. Attention is scattered. -Problem solving feels impossible. Unable to see connections between events or details. Prevent problem solving. -Feelings of dread, confusion, purposeless activity, sense of impending doom, more intense somatic complaints (chest discomfort, dizziness), diaphoresis, withdrawal, loud and rapid speech, threats and demands.
What types of groups/treatments require an Advanced Practice Nurse to be the leader?
-Group psychotherapy -Psychodrama -Dialectical behavior treatment
Therapeutic factors
Are aspects of the group experience that leaders and members have identified as curative and crucial for therapeutic change.
Mild anxiety
-Heightened perceptual field. Focus is flexible and is aware of the anxiety. -Able to work effectively toward a goal and examine alternatives. Can alert the person that something is wrong and can stimulate appropriate action. -Slight discomfort, attention-seeking behavior, restlessness, easily startled, irritability or impatience, mild tension-relieving behavior (foot or finger tapping)
Care plan for panic disorders
-Help the patient connect feelings before attack with onset of attack: "What were you thinking/feeling before the attack?" -Help the pt recognize symptoms from anxiety -Cognitive behavioral treatment is highly effective (I can control my anxiety) -ABD breathing = focus away from anxiety
Severe Alzheimer's (Late Stage)
-Inability to respond to own environment -Can't carry on own conversation -Repetitive behavior -Requires full-time care -Unaware of surroundings -Changes in physical abilities -Vulnerable to infections
Medical Complications of Alcohol Withdrawal
-Infections -Hypoglycemia -Gastrointestinal bleeding -Undetected trauma -Hepatic failure -Cardiomyopathy with ineffective pumping -Encephalopathy
What are the 3 group leader responsibilities?
-Initiating -Maintaining -Terminating
Agoraphobia
-Intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available. -Feared places are avoided to avoid anxiety -I.e. being alone outside, trailing in a car, bus, or plane, riding in an elevator. -Situations can be made tolerable by the addition of a friend.
Generalized anxiety disorder
-Key = excessive worry -Persons anticipate disaster and are restless irritable, and experience muscle tension. Decision making is difficult d/t poor concentration and dread of making a mistake. -Huge amounts of time are spent preparing for an activity. -Key symptoms = putting things off and avoidance that may result in lateness or absence and overall social isolation. -Family members and friends are overtaxed as the person with this disorder seeks continual reassurance and perseverates about meaningless details. -Sleep disturbance is common d/t worry > fatigue.
Panic disorders
-Key feature = Panic attacks...so sever that normal functioning is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur. -Uncomfortable physical symptoms: palpitations, chest pain, breathing difficulties, nausea, and feeling of choking, chills, and hot flashes -Upredictability is a key aspect of panic disorders in children and adolescents. Attacks of panic seem to come out of nowhere and last about 10 minutes then subside. They may become avoidant ofsituatios where help is not available, may develop feeling of hopelessness in controlling these attacks, and may become depressed. -People begin to "fear the fear". They become so preoccupied about future episodes that they avoid what could be pleasurable and adaptive activities.
--DONT TAKE SSRI WITH--
-MAOI (SS*)- discontinue at least 14 days prior -TCA (SS) -St. John' Wart (SS) -Warfarin (increased warfarin levels)- monitor prothrombin levels -Lithium (increased levels of lithium) -NSAIDs and anticoagulants (risk of bleeding)
--DO NOT TAKE WITH--
-MAOI (hypertension) -Antihistamines (added AcH effects) -Direct or indirect acting sympathomimetics -CNS depressants (alcohol, benzos, opioids)
201-300 mg % BAL
-Marked impairment of thinking, memory, and coordination -Marked reduction in level of alertness -Memory blackouts -Nausea and vomiting
Silent member
-May be observing and listening intently until he/she feels safe -He/she cannot benefit from feedback of others and others cannot benefit from this member's silence
Complaining member who rejects help
-May take pride in the insolubility of his problems -Believes his problems are unique - his situation is different and worse than anyone else's -Plays the "Yes, but..." game
Mild Alzheimer's (Early Stage)
-Memory lapses; still able to function independently -Difficulty performing tasks -Losing/misplacing objects -Trouble planning/organizing -Problems retrieving words/names
Delirium interventions
-Mental and neuro exams -Reorient -Recognize drug reactions -Vitals -Safety
20-100 mg % BAL
-Mood and behavioral changes -Reduced coordination -Impairment of ability to drive a car or operate machinery
Moderate anxiety
-Narrowed perceptual field; grasps less of what is going on. Focuses on the source of the anxiety; less able to pay attention. -Able to solve problems but not at optimal ability. Can alert the person that something is wrong and can stimulate appropriate action. -Voice tremors, change in voice pitch, poor concentration, shakiness, something complaints (urinary frequency/headache), increased RR, HR, and muscle tension, more tension-relieving behavior (pacing)
Severe Alcohol Withdrawal
-Obvious trembling of the hands and arms -Sweating -Elevation of pulse and blood pressure -Nausea -Hypersensitivity to noises and light -Brief periods of hearing and seeing things that are not present -Fever greater than 101 also may be seen
TCA ADVERSE EFFECTS--
-Orthostatic hypotension -*Anticholinergic effects* (urinary retention and constipation warrant immediate medical attention) -Sedation - *Cardiac Toxicity* (dysrhythmias, tachycardia, MI, heart block) - mental confusion, agitation, seizures, coma, death) -Decreased seizure threshold -Excessive sweating
nursing care eating disorders
-Perform Self Assessment -Highly structured milieu on unit -Use positive approach -Encourage client decision making -Establish realistic goal for weight -Promote Cognitive Behavioral Therapies -Monitor vitals/ I&O/weight -Monitor after meals -Consult dietitian for controlled rate of nutritional support
Specific Phobias
-Persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance of the object, activity, or situation. _Characterized by the experience of high levels of anxiety or fear in response to specific objects or situations. -Daily functioning is compromised, and phobic people go to great lengths to avoid the feared object. The life of a phobic person becomes more restricted as activities are given up so that the phobia is avoided.
Body dysmorphic disorder
-Preoccupation with an imagined defective body part results in obsessional thinking and compulsive behavior, such as mirror checking and camouflaging. -False assumptions about the importace of appearance, fear of rejection by others, perfectionism, and conviction of being disfigured lead to overwhelming emotions of disgust, shame, and depression. -Does not respond to reassurance
101-200 mg % BAL
-Reduced coordination of most activities -Speech impairment -Trouble walking -General impairment of thinking and judgment
Uncomplicated or Mild to Moderate Alcohol Withdrawal
-Restlessness -Irritability -Anorexia -Tremor -Insomnia -Impaired cognitive functions -Mild perceptual changes
Antidepressants
-SSRI's - 1st line of defense. Paroxetine (paxil), *fluoxetine (prozac)*, escitalopram (lexapro), fluvoxamine (luvox), and sertraline (zoloft). Zoloft and Paxil have the most calming effect. -Serotonin norepinephrine reuptake inhibitor (SNRI) - venlafaxine (effexor) and duloxetine (cymbalta) -MAOIs - reserved for treatment resistant conditions because of the risk of life threatening hypertensive crisis if the pt does not follow dietary restrictions.
Demoralizing member
-Self-centered, angry, or depressed -Lack empathy -Refuse to take responsibility and often challenge the leader
SSRI adverse effects
-Sexual dysfunction -CNS stimulation -Weight loss followed by *weight gain* long term -*Serotonin Syndrome* -Withdrawal syndrome (headache, nausea, visual disturbances, anxiety, dizziness, tremors) -Hypotnatremia (when taking diuretic) -Rash -Sleepiness, faintness, lightheadedness -GI Bleeding -Bruxism
Give examples of characteristics that influence a group
-Size -Defined purpose -Degree of similarity among members -Rules -Boundaries -Content (what is said) -Process (underlying dynamics among members)
Care plan for generalized anxiety disorder
-Stay with pt -Speak slowly and calmly -Assure pt that you are in control and can assist them. -Provide quiet environment -Encourage pt to discuss preceding events. -Link puts behavior to feelings -Teach cognitive therapy: Anxiety is the result of automatic thinking with a dysfunction appraisal of a situation -Ask ?'s that clarify and dispute illogical thinking: "What evidence do you have? Explain the logic in that. Are you basing that conclusion on fact or feeling?" -Have pt write an assessment of strengths
Obsessive Compulsive Disorder
-Symptoms that occur on a daily basis. -Pathological obsessions or compulsions cause marked distress to individuals, who often feel humiliating and shame regarding these behaviors. -The rituals are time consuming and interfere with normal routines. Can impair performance of cognitive tasks. -Can be present as early as age 3
DO NOT TAKE WITH--
-TCA -SSRI -antihypertensives -meperidine (demerol) -*Tyramine* (aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein, dietary supplements, beers, red wine, milk) -vasopressors
Monopolizing member
-Tends to talk over other members and not allow others to have a chance to speak -May be attempting to deal with anxiety -Will speak even more when group tension increases
Hoarding disorder
-The accumulation of belongings that may have little or no value is an obsession that pretense some people form leading normal lives. _Can progress to the point where the home is uninhabitable. -Individuals may be aware of the problem and how the quest to collect has consumed their lives and alienated others.
How should a monopolizing member be dealt with?
-The entire group should be reminded that each member should have an equal chance to express -Leader can request a response from someone other than the monopolizing member -The member may have to be confronted directly
How should a silent member be dealt with?
-The group leader must not assume that the silence means the member is not engaged -The silence MUST be addressed at some point because it is hindering to both the silent member and others
Working phase
-The leader encourages focus on problem solving; also supports conflict resolution -As group members feel safe, they may open up more, which can also lead to conflict; they are also empowered to solve their own problems and even group problems
Termination phase
-The leader helps members reflect on their progress and identify post-termination goals -Ideas for how to maintain progress after group termination should be discussed -Members should openly address feelings such as loss, anger, fear, etc, and help each other prepare for separation
Orientation phase
-The leader structures the atmosphere or climate of the group to ensure respect, trust, and confidentiality -The purpose and contract expectations are stated and members are encouraged to get to know each other
Mild to moderate anxiety care
-The pt is still able to solve problems, just has difficult concentrating. -Can help focusing by asking open ended ?s, giving broad openings, and exploring and seeking clarification. -Provide a calm presence, recognizing the anxious person's distress, and be willing to listen. -Evaluation of previous coping methods
Characteristics of a mentally healthy child or adolescent
-Trust others -Self-determined -Developmentally appropriate behavior without violating social norms -Has a positive, realistic self-concept and developing identity -Adapts to and copes with anxiety and stress using age appropriate behavior -Can learn and master developmental tasks and new situations -Expresses self in spontaneous and creative ways -Develops and maintains satisfying relationships
Panic
-Unable to attend to the environment. Focus is lost; may feel unreal (depersonalization) or that the world is unreal (derealization). -Completely unable to process what is happening; disorganized or irrational reasoning. No problem solving. -Experience of terror, immobility or sever hyperactivity or flight, unintelligible communication or inability to speak, something complaints increase (numbness or tingling, SOB, dizziness), severe withdrawal, hallucinations or delusions.
Relaxation Therapy
-Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety. -Demonstrate and practice the relaxation technique with the pt -Provide written information about preparing and engaging in relaxation techniques.
Antianxiety
-Used to treat somatic and psychological symptoms of anxiety disorders -Benzodiazipines are most commonly used because of the quick onset. Should only be used short term d/t addiction.
Bulimia nervosa
-Watch for hypokalemia, because vomiting causes K+ loss -Dehydration stimulates Aldosterone production which leads to NA and H2O retention and potassium excretion -Hypoalbuminemia- caused by loss of protein Abnormal thyroid function tests -ECG changes from K+ and Mag loss (prolonged QT Interval) -calluses or scars on hands "russels sign"; enlargment of parotid glands (gastric rupture possible)
301-400 mg % BAL
-Worsening of above symptoms with reduction of body temperature and blood pressure -Excessive sleepiness -Amnesia
intermittent explosive disorders
-adults 18 years or older -*inability to control aggressive impulses* ---verbal or physical -----targeted towards animals, property, or themselves -----punching wall/glass -----destroy room/ furniture -----sporting event/driving -leads to problems with: interpersonal relationships, occupational difficulties, criminal difficulties, physical health (hypertension and diabetes have been linked to this disorder, correlation may be due to the individual begin in a heightened state of stress and agitation for a prolonged period of time.
Rehabilitation
-are available as medically managed and *medically monitored inpatient programs*. - The medically managed programs usually employ *24-hour medical staff* and provide *intensive and specialized care for those individuals with either biomedical or psychiatric comorbid conditions*. Medically monitored programs are also available for individuals with less complex conditions. They offer professionally directed evaluation and treatment in *short-term settings* for those with acute distress and moderate impairment and *long-term settings* for those with chronic distress or severe impairment. *Short-term rehabilitation aids in the recovery of lost skills and function*, while *long-term rehabilitation helps to improve functioning that never developed and may have led to addictions*
assessment guidelines: intermittent explosive disorder
-assess the history, frequency and triggers for violent outbursts. -identify times in which the patient was able to maintain control despite being in a situation which the patient might normally lose control of emotions. -explore actual and potential sources of support at home and socially -assess for substance use: past and present
assessment guidelines: conduct disorder
-assess the seriousness, types and initiation of disruptive behavior and how it has been managed -assess anxiety, aggression and anger levels, motivation and the ability to control impulses -assess moral development, problem solving, belief system, and spirituality for the ability to understand the impact of hurtful behavior on others, to empathize with others, and to feel remorse -assess the ability to form a therapeutic relationship and engage in honest and committed therapeutic work leading to observable behavioral change: signing a behavioral contract, drug testing, living according to "home rules" -assess for substance use: past and present
etiology
-biologic factors: ---genetics: oppositional defiant disorder (family history of mental illness), intermittent explosive disorder (runs in families- learned from generation to generation), conduct disorder (more common in children and adolescents whose parents were similarly afflicted) ---psychological factors: children with conduct disorders tend to utilize more immature style of coping and problem solving, compensating/ covering for low self-esteem, respond impulsively at times due to childhood trauma (consciously or unconsciously) ---environmental factors: main context is FAMILY, abusive, rejecting or overly controlling parents are more apt to produce a child with same characteristics
Cholinesterase inhibitors
-donepezil (Aricept) -rivastigmine (Exelon) -galantamin (Razadyne) -Action: Inhibit acetylcholinesterase, thereby increasing available acetylcholine -Side effects dose related: N&V, diarrhea, insomnia, fatigue, muscle cramps, incontinence, bradycardia
nursing interventions
-explore the impact of the child's behaviors on family life and of the other member's behavior of the child -assist the immediate and extended family to access available and supportive individuals and systems -discuss how to make home a safe environment, especially in regard to weapons and drugs; attempt to talk separately to members whenever possible -discuss realistic behavioral goals and how to set them: problem solve potential problems -teach behavior modification techniques. role-play them with the parents in different problem situations that might arise with their child -give support and encouragement as parents learn to apply new techniques -provide education about medications -refer parents or caregivers to a local self-help group - advocate with the educational system if special-education services are needed
reality testing
A process by which a person is objectively able to evaluate the external world and adequately distinguish it from the internal world (the self). ability to recognize distortion of reality as internal, rather than external
nursing process: diagnosis
-focus is on protection of others and self from impulsive and premeditated acts, improving coping skills, and addressing the family. -children with these disorders display: disruptive behavior that are impulsive, angry/ aggression, often dangerous -children are in: conflict with others, noncompliant, do not follow age-appropriate social norms, have inappropriate ways of meeting their needs
childhood-onset conduct disorder
-found mainly in who are: physically aggressive, poor peer relationships, show little concern for others, lack feelings of guilt or remorse, feel actions are justified, project a strong image but they actually have low self-esteem -hallmark signs: limited frustration tolerance, irritability, temper outbursts
Interventions for Vegetative Signs
-high calorie and high protein finger foods (small portions & frequent) -high calorie and high protein fluids -family to remain with them during meals -ask what foods they like -weigh them weekly -periods of rest -encourage getting up and dressed all day -relaxation in the evening -reduce environmental and physical stimuli (no caffeine) -encourage oral and body hygiene -step by step reminders when needed -monitor intake and output, especially bowels -high fiber foods and exercise -encourage intake of fluids -evaluate need for laxatives and enemas
assessment guidelines: oppositional defiant disorder
-identify issues that result in power struggles and *triggers* for outbursts- when they begin and how they are handled -assess the child's or adolescent's *view of his/her behavior and its impact on others*- at home, school and with peers -explore *feelings of empathy and remorse* -explore how the child or adolescent can exercise *control and take responsibility, problem solve* for situations that occur, and plan to handle things differently in the future- *assess barriers and motivation* to change and potential rewards to engage patient
evaluation
-impulse control disorder patients exhibit an inability to self-regulate -care is aimed at a safe environment and setting boundaries -goal is for the patient to: consider the rights of others, display appropriate controlled behaviors
MAOIs
-inactivate or break down MAOs that break down monoamines (NE, serotonin, dopamine, and tyramine) --Therapeutic uses-- -depression -bulimia nervosa -OCD -GAD -PTSD -Panic disorder -Social phobia
Tricyclic Antidepressants
-inhibit the reuptake of NE and serotonin -also block histamine receptors which causes sedation --Therapeutic uses-- -Depressive Disorders -Neuropathic pain -Fibromyalgia -Anxiety disorders -Insomnia
application of the nursing process: assessment
-interview parents along with the child alone and then separately will enrich the assessment ---*suicide risk*: important for nurse to listen carefully and explore the following areas: past suicidal thoughts, threats, and attempts, existence of plan, and accessibility of the methods for carrying out the plan, feelings of hopelessness, changes in level of energy, circumstances, state of mind, and motivation, viewpoints about suicide and death (any family member or friend attempted suicide?), depression and other moods or feeling (anger, guilt, rejection), history of impulsivity, poor judgment or decreased decision making, drug or alcohol use, prescribed medications and any recent adherence issues, an assessment of protective factors and coping skills
teamwork and safety
-low expressed emotions and calm communication -communication with a potentially hostile patient should include: using nonthreatening body posture and a flat, neutral tone of voice when correcting behavior-- never an angry tone of voice --using matter-of-fact, easy to understand words --avoiding personal terms when setting a limit-- such as "i" or "you" --consistently setting limits
NMDA receptor antagonist
-memantine (Namenda) -Action: Regulates glutamate activity by blocking NMDA receptors, thereby decreasing excitatory neurotoxicity caused by over stimulation of NMDA receptors by glutamate -Side effects: Dizziness, agitation, headache, constipation, confusion
self assessment
-nurses and caregivers have a ethical and professional responsibility to provide equal care to all people/patients -an empathetic view of people/patient with these disorders is necessary keeping in mind: enviroments and history
Halfway houses
-offer *residential treatment* in a substance-free communal or family environment that provides opportunities for independent growth. Individuals come to continue the work that was begun in other treatment programs, usually that of a long-term or short-term residential rehab. Focus is on extending the period of sobriety, getting case management assistance in *addressing educational, economic and social needs, and integrating new life skills* into a solid, modeled recovery program. Most residents will live there but work outside
conduct disorder- comorbidity
-oppositional defiant disorder is related to: ADHD, anxiety, depression, suicide, bipolar disorder, substance abuse -intermittent explosive disorder are associated with: mood disorders, anxiety disorders, eating disorders, substance-use disorders, impulse-control disorders -conduct disorders are associated with: ADHD, substance use disorders, learning disabilities
pharmacological interventions
-oppositional defiant disorder: medication not recommended -*intermittent explosive disorder*: -----serotonin reuptake inhibitor- fluoxetine, -----lithium (mood stabilizer), --------clozapine and haloperidol calming effect, -------- beta blocker (calming effect- slows heart rate and decreases BP) -conduct disorder: antipsychotic- risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole
conduct disorder: most frequently diagnosed
-persistent pattern of behavior in which the *rights of others are violated and societal norms or rules are disregarded* -behavior is usually abnormally aggressive- destruction of property, physical injury (fights/bullying) -complications- academic failure, school suspensions and dropouts, juvenile delinquency, drug and alcohol abuse, and juvenile court involvement
health teaching and health promotion
-positive outcomes ---families are actively engaged and given support is using parental skills to provide nurturance and set consistent limits ---behavior modifications ---monitoring medications for effects ---collaborating with teachers to foster academic success ---home environment allows for successful achievement of developmental milestones
--DO NOT TAKE MAOI IF--
-pregnant -pheochromocytoma -heart failure -heart disease -renal insufficiency -diabetes -seizure disorder -younger than 16
--DO NOT TAKE TCAs IF--
-pregnant -seizure disorder -coronary heart disease -diabetes -liver, kidney, or respiratory disorders -urinary retention -angle closure glaucoma -bengin prostatic hypertrophy -hyperthyroidism
--DONT TAKE SSRI IF--
-pregnant -taking MAOI or TCA -liver or renal dysfunction, cardiac disease, seizure disorder, diabetes, ulcers, history of GI bleeding
nursing process: implementation
-psychosocial interventions ----focus on correcting the faulty personality development- blaming others, denial of responsibility for personal actions ----generate more mature and adaptive coping mechanisms and goals ----interventions should include: promote a climate of safety for the patient and others, establish a rapport with the patient (helps establish a sense of security), set limits and expectations, consistently follow through with consequences of rule-breaking, provide structure and boundaries, provide activities and opportunities for achievement of goals to promote a sense of purpose
seclusion and retraint
-seclusion ---goal is to try reduce the stimuli of the environment - quiet room, time out -restraint- last resort
Disruptive Behavior Management
-seclusion and restraints (seclusion less restrictive than restraint) -time out -quiet room
Choosing an Antidepressant
-symptom profile -side effect profile -ease of administration -history of past response -safety and medical considerations
adolescent-onset conduct disorder
-tend to act out misconduct with their peer group: early onset of secual behavior, substance abuse, risk-taking behaviors -males more likely to: fight, steal, vandalize, school discipline problems -females more likely to: lie, be truant, run away, abuse substances, engage in prostitution, become more aggressive during this period of development -some are referred to as being callous and unemotional: callous is characterized by lack of empathy ----disregarding or being unconcerned about the feelings of others, lack of remorse or guilt except when facing punishment, unconcerned about meeting school and family obligations, unemotional traits; *shallow, unexpressive, superficial affect*
Lithium Carbonate
-treats bipolar I acute and recurrent manic and depressive episodes - takes about 7-14 days to reach therapeutic levels -less effective with mixed mania, rapid cycling, and atypical features -Particularly effective for: --elation, grandiosity --flight of ideas -- irritability --anxiety -Less effective for: --insomnia --psychomotor agitation --assaultive behavior --distractibility --hypersexuality --paranoia -Is not a cure -Must stay on it for life
conduct disorder
-two types of conduct disorder: 1) childhood-onset conduct disorder- occurs prior to age 10, 2) adolescent- onset conduct disorder- no symptoms until after 10 years of age -classified as: mild, moderate, severe
conduct disorder- epidemiology
-up to 16 million american or about 7% of all adults may be affected by this disorder sometime in their life -rates are higher in males, but generally even out after puberty
neuroleptic malignant syndrome (NMS)
0.2%-1% of patients on 1st generation antipsychotics; can occur with 2nd generation as well; excess D2 receptor blocker and is life threatening Emergency; symptoms: reduced consciousness, increased muscle tone, tachycardia, diaphoresis, drooling
Implementation of Phases
1) Acute Phase 2) Continuation Phase: 3) Maintenance Phase
Characteristics of a resilient child
1) adaptability to changes in the environment 2) ability to form nurturing relationships with other adults when the parent is not available 3) ability to distance self from emotional chaos 4) good social intelligence 5) good problem-solving skills 6) ability to perceive a long-term future
general assessment
1) mood 2) Behavior 3) Thought process and speech 4) cognitive function
Nursing Assessment guidelines for patients with Antisocial Personality Disorder
1. Assess current life stressors. 2. Assess for criminal history. 3. Assess for suicidal, violent, and/or homicidal thoughts. 4. Assess anxiety, aggression, and anger levels. 5. Assess motivation for maintaining control. 6. Assess for substance misuse (past and present).
Assessment Guidelines for Borderline Personality Disorder
1. Assess for suicidal or violent thoughts toward others. If these are present, the patient will need immediate attention. 2. Determine whether the patient has a medical disorder or another psychiatric disorder (especially a substance use disorder) that may be responsible for the symptoms. 3. View the assessment about personality functioning from within the person's ethnic, cultural, and social background. 4. Has the patient experienced a recent important loss? This personality disorder is often exacerbated after the loss of significant supporting people or in a disruptive social situation. 5. Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized substance use disorder.
The three essential therapies for borderline personality disorder:
1. Cognitive-behavioral therapy (CBT) 2. Dialectical behavior therapy (DBT) 3. Schema-focused therapy
Assessment Guidelines
1.) *Danger to self or others* - mania --> exhaustion --> death - no sleeping / eating for days - poor impulse control --> harm - uncontrolled spending 2.) *Need for protection from uninhibited behaviors* 3.) Need for hospitalization 4.) Medical Status- is mania primary or secondary to another disorder 5.) Coexisting medical condition 6.) Patient and family understanding of the illness
Beck's Cognitive Triad
1.) A negative, self-deprecating view of self 2.) A pessimistic view of the world 3.) The belief that negative reinforcement will continue in the future
5 A's for Alcohol Misuse Intervention
1.) Assess alcohol consumption 2.) Advise about effects of alcohol 3.) Agree on goals 4.) Assist in developing motivation, skills, and supports 5.) Arrange follow up, counseling, and referrals
Health Teaching
1.) Depression is involuntary 2.) Can be managed 3) management depends on understanding S&S of relapse 4.) role of Medications 5.) Psychotherapy 6.) Coping skills
Counseling and Communication Guidelines
1.) Help them question underlying assumptions and beliefs and consider alternate explanations to problems 2.) Work with patient to identify distortions that encourage negative self-appraisal 3.) Encourage activities that raise self-esteem; need for problem solving skills, coping skills, and assertiveness 4.) Encourage exercise 5.) Encourage formation of supportive relationships 6.) Provide information for referrals and religious information
Maintenance Phase Outcomes
1.) Primary :*Prevention of relapse* 2.) limitation of severity and duration of future episodes 3.) Learning interpersonal strategies R/T work, personal, family probs 4.) Participation in psychotherapy, group, or other supportive therapy
Self Assessment (for nurse)
1.) Recognize unrealistic expectations for yourself or patient 2.) Identify feelings the patient may be feeling 3.) Understand biology and genetics 4.) Be empathetic 5.) Use supervision
Assessment Guidelines
1.) Risk of harm to self or others 2.) Psychotic? Drugs? Medical conditions? Comorbid? 3.) History of depression or suicide? 4.) Support systems
According to the American Psychiatric Association how many personality disorders are there?
10; These 10 behaviors are grouped into clusters
Inflammatory Process
2 blood components : *C-reactive protein* and *interleukin-6* may be associated with psychological probs induced inflammation; - these are elevated in people who experienced adversity in childhood; adversity may compromise resilience and place children at risk for depression; - inflammatory diseases and people treated with cytokines for cancer are at higher risk for depression
group
2 or more people who develop an interactive relationship and share a common goal or interest
Blood alcohol levels (BAL)
20-100 mg% 101-200 mg % 201-300 mg % 301-400 mg % 401-800 mg %
Personality disorders are present in what percentage of patients with mental state disorders?
50%
Prevalence of personality disorders
6% of global population. 10% of the US population.
hopelessness
=suicidal ideation
Stimulus control
A behavioral intervention that involves adherence to five basic principles that decrease the negative associations between the bed and bedroom and strengthen the stimulus for sleep.
Dementia
A broad term used to describe progressive deterioration of cognitive functioning and global impairment of intellect
Hypersomnolence
A condition associated with excessive daytime sleepiness and excessive sleep but is not experienced as restful or refreshing.
Flight of Ideas
A continuous flow of speech in which the person jumps rapidly from one topic to another. - rapid, verbose, and circumstantial - may be disorganized and incoherent sexually explicit and vulgar loud or screaming
pseudoparkinsonism
A medication-induced temporary constellation of symptoms associated with Parkinson's disease, including tremor, reduced accessory movements, impaired gait, and stiffening of muscles.
group work
A method whereby people with a common purpose come together and benefit by giving and receiving feedback from each other
word salad
A mixture of words meaningless to the listen and to the speaker as well. (schizophasia) jumble of words "throat hoarse strength of policy dreadfully essential Brazilian highlighters on a boat ringing supreme!"
recovery model
A model that is patient/consumer-centered, is hopeful and empowering, and emphasizes the person and the future rather than the illness and the present.
DSM-5 Criteria For Borderline Personality Disorder
A pervasive pattern of instability of interpersonal relationships, self-image, affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbances: Markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideations or severe dissociative symptoms.
depersonalization
A phenomenon whereby a person experiences a sense of unreality of or estrangement from the self. For example, one may feel that limbs or extremities have changed, that one is seeing self and events from a distance, or that one is in a dream.
Which statement by Kyla, a patient you are educating in the sleep disorders clinic, indicates that she needs further teaching? A. "I will be sure to try to get 8 hours of sleep every night, and 9 or 10 hours of sleep if I can." B. "Getting less than 6 hours of sleep at night may increase my risk for medical problems." C. "Getting enough sleep will increase my productivity at work." D. "Since I have to drive for my job, getting enough sleep will help me avoid accidents."
A. "I will be sure to try to get 8 hours of sleep every night, and 9 or 10 hours of sleep if I can." Sleeping more than 8 hours per night is associated with up to a twofold increased risk of obesity, diabetes, hypertension, incident cardiovascular disease, stroke, depression, and substance abuse. The other options are all true.
One criterion for the diagnosis of primary insomnia is met when the client reports A. "I've actually missed work because I'm too tired to go." B. "I was diagnosed with depression 2 months ago." C. "I've had problems falling asleep for 3 weeks now." D. "I have these terrible nightmares when I fall asleep."
A. "I've actually missed work because I'm too tired to go." A criterion for primary insomnia listed in the DSM-5 is disruption of the normal routine as a result of the sleep disturbance.
A client reports to the nurse that falling asleep can often take hours. An appropriate intervention would be to A. teach the client how to do progressive relaxation. B. advise the client to drink an ounce or two of brandy at bedtime. C. suggest that the client seek a referral for polysomnography. D. point out that reducing stress at work would be advisable.
A. teach the client how to do progressive relaxation. Progressive relaxation relaxes muscle groups sequentially and generates a state of pleasant comfort and ease, a natural prelude to sleep.
DSM-5 Criteria for Anti-Social Personality Disorder
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others. 6. Consistent irresponsibility as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. Lack of remorse as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. The individual is at least age 18 years. C. There is evidence of conduct disorder with onset before age 15 years. D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.
The most effective nursing intervention regarding the accurate assessment of sleep disorders involves A. a sleep diary. B. information regarding sleep cycles. C. client description of the symptomatology. D. assessment for substance abuse.
A. a sleep diary. Self-reported sleep patterns may be biased, and so clinical tools such as a sleep diary are helpful in accurately estimating total sleep time.
A depressed client is likely to report a sleep disorder that includes A. frequent awakenings during the night. B. nightmares. C. difficulty falling asleep. D. sleepwalking.
A. frequent awakenings during the night. Depressed clients often report normal sleep onset, followed by repeated awakenings during the second half of the night
When providing possible interventions to promote the safety of a client reporting symptoms of somnambulism, the nurse includes A. gating the stairways. B. sleeping on a mattress placed on the floor. C. regular bedtime dose of a benzodiazepine. D. avoiding the use of serotonergic medications.
A. gating the stairways. Somnambulism or sleep walking can result in falls; gating the stairways may minimize that risk.
predisposing factors of conduct disorder
ADHD, oppositional child behaviors, parental rejection, inconsistent parenting with harsh discipline, early institutional living, chaotic home life, large family size, absent or alcoholic father, antisocial and drug-dependent family members, association with delinquent peers
nursing interventions : ETOH withdrawal
Assess and promote sleep Assess nutritional status: Pts with history of alcohol dependence may need Thiamine (vitamin B-1) supplement for prevention of Wernicke-Korsakoff Encourage self-care Teaching points include: coping skills, health promotion, relapse prevention strategies Goal: stabilization (for patients in withdrawal), abstinence, motivation for treatment, pursuit of recovery lifestyle
Assessment
Assess for signs/symptoms of intoxication and withdrawal of common drugs. Know the signs! Know BAL (blood alcohol level) & expected behaviors: Inspect patient's clothing for drug paraphernalia Check UDS (urine drug screen)
Screening tools
AUDIT: Alcohol Use disorders Identification Test CAGE: 4-items asked
What side effects of anti psychotic medication is generally reversible?
Anticholinergic effects, pseudoparkinsonism, dystonic reaction, ften appear early in therapy and can be minimized with treatment.
third-generation antipsychotics
Abilify ( aripiprazole) improves positive and negative symptoms and cognitive function less risk of EPS (and TDK (tardive dyskinesia) A newer classification of anti-psychotics includes aripiprazole (Abilify), a unique anti-psychotic known for 681 682 dopamine system stabilization. In areas of the brain with excess dopamine, it lowers the dopamine level by acting as a receptor antagonist; however, in regions with low dopamine, it stimulates receptors to raise the dopamine level. Side effects include insomnia and akathisia.
Therapeutic Levels of Lithium
Active Phase= 300 mg to 600 mg 2-3 times a day by mouth Therapeutic level= 0.8 to 1.4 mEq/L Maintenance Levels= 0.4 to 1.3 mEq/L Lithium should be measured at least 5 days after starting and after dose changes until therapeutic levels have been reached Once reached, levels are checked every month; after 6 months they are checked every year Blood is drawn in the morning 8-12 hours after dose
Alcohol Acute Effects/ Health Risks
Acute Effects: - Low doses= euphoria, mild stimulation, relaxation, lowered inhibitions -High doses= drowsiness, slurred speech, nausea, emotional volatility, loss of consciousness Health Risks: -Increased risk of injuries, violence, fetal damage, depression, neurologic deficits, hypertension, liver and heart disease, addiction & fatal overdose
Opioids (Heroin, Opium) Acute Effects/ Health Risks
Acute Effects: -Euphoria, drowsiness, impaired coordination, dizziness, confusion, nausea, sedation, feeling of heaviness in the body, slowed or arrested breathing Health Risks: -Constipation, endocarditis, hepatitis, HIV, addiction, fatal overdose
Cannabinoids (Marijuana, Hashish) Acute Effects/ Health Risks
Acute Effects: -Euphoria, relaxation, slowed reaction rime, distorted sensory perception, impaired balance and coordination, increased heart rate and appetite, impaired learning, memory, anxiety, panic attacks, psychosis/cough Health Risks: -Respiratory infections, possible mental health decline, addiction
Stimulants (Cocaine, Amphetamine, Methamphetamine) Acute Effects/ Health Risks
Acute Effects: -Increased heart rate, blood pressure, body temperature, metabolism; feelings of exhilaration, increased energy, mental alertness, tremors, reduced appetite, irritability, anxiety, panic, paranoia, violent behavior, psychosis Health Risks: -Weight loss, insomnia, cardiac or cardiovascular complications, stroke, seizures, addiction -COCAINE= nasal damage -METH= severe dental carries
Dissociative Drugs (Ketamine, PCP, Salvia divinorum, Dextromethorphan) Acute Effects/ Health Risks
Acute Effects: -Ketamine= Feelings of being separate from ones body and environment, impaired motor function, analgesia, impaired memory, delirium, respiratory depression and arrest, death -PCP= Feelings of being separate from ones body and environment, impaired motor function, analgesia, psychosis, aggression, violence, slurred speech, loss of coordination, hallucinations -Salvia= Feelings of being separate from one's body and environment, impaired motor function -Dextromethorphan= Feelings of being separate from one's body and environment, impaired motor function, euphoria, slurred speech, confusion, dizziness, distorted visual perceptions Health Risks: -Ketamine= Anxiety, tremors, numbness, memory loss, nausea -PCP= Anxiety, tremors, numbness, memory loss, nausea -Salvia= Anxiety, tremors, numbness, memory loss, nausea -Dextromethorphan= Anxiety, tremors, numbness, memory loss, nausea
Hallucinogens (LSD, Mescaline, Psilocybin) Acute Effects/ Health Risks
Acute Effects: -LSD= Altered states of perception and feeling, hallucinations, nausea, increased body temperature, heart rate, blood pressure, loss of appetite, sweating, sleeplessness, numbness, dizziness, weakness, tremors, impulsive behavior, rapid shifts in emotion -Mescaline=Altered states of perception and feeling, hallucinations, nausea, increased body temperature, heart rate, blood pressure, loss of appetite, sweating, sleeplessness, numbness, dizziness, weakness, tremors, impulsive behavior, rapid shifts in emotion -Psilocybin= Altered states of perception and feeling, hallucinations, nausea, nervousness, paranoia, panic Health Risks: -Flashback Hallucinogen Persisting Perception Disorder
Club Drugs (MDMA, Flunitrazepam, GHB) Acute Effects/ Health Risks
Acute Effects: -MDMA= mild hallucinogen, increased tactile sensitivity, empathetic feelings, lowered inhibition, anxiety, chills, sweating, teeth clenching, muscle cramping -Flunitrazepam= Sedation, muscle relaxation, confusion, memory loss, dizziness, impaired coordination -GHB= Drowsiness, nausea, headache, disorientation, loss of coordination, memory loss Health Risks: -MDMA= Sleep disturbance, depression, impaired memory, hyperthermia, addiction -Flunitrazepam= Addiction -GHB= Unconsciousness, seizures, coma
Anabolic Steroids Acute Effects/ Health Risks
Acute Effects: -No Intoxication Effects Health Risks: -Hypertension, blood clotting and cholesterol changes, liver cysts, hostility and aggression, acne, premature stoppage of growth in adolescents -Prostate cancer, reduced sperm production, shrunken testicles, breast enlargement (MALES) -menstrual irregularities, beard, masculine characteristics (FEMALES)
Inhalants Acute Effects/ Health Risks
Acute Effects: -Stimulation, loss of inhibition, headache, nausea, vomiting, slurred speech, loss of motor coordination, wheezing Health Risks: -Cramps, muscle weakness, depression, memory impairment, damage to cardiovascular and nervous systems, unconsciousness, sudden death
Tobacco (Nicotine) Acute Effects/ Health Risks
Acute Effects: -Increased blood pressure -Increased heart rate Health Risks: -Chronic lung disease, cardiovascular disease, stroke, cancers, adverse pregnancy outcomes, addiction
binge eating disorder
Acute care -Psychosocial interventions -Pharmacological interventions -Health teaching and health promotion -Teamwork and Safety Advanced practice interventions -Cognitive Behavioral Therapies ===>Cognitive reframing ===>Relaxation Techniques ===>Journal writing ===>Desensitization exercises Individual therapy Support Group therapy
bulimia nervosa
Acute care -Teamwork and safety -Pharmacological interventions -Counseling -Health teaching and health promotion Advanced practice interventions -Cognitive Behavioral Therapies, SSRI's and treat medical issues that may arise
Black Box Warning
Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of Major Depressive Disorder and other psychiatric disorder
anorexia nervosa
Acute care- inpatient hospitalization Cognitive Behavioral Therapy:Cognitive Reframing, Relaxation Techniques, Journal Writing, Desensitization exercises Pharmacological interventions- SSRI's to treat. Provide health teaching and health promotion- important for nurses to always do this --Safety and teamwork- staff must communicate Work with Dietitian to provide education to include: -Correcting misinformation of regarding food, meal planning and food selection -Every time they weigh, must clean out pockets (coins, heavy things), wear the same thing
Negativism
Akin to resistance but may not be intentional. The patient does the opposite of what he or she is told to do(active neg or fails to do what is requested (passive negativism)
Naltrexone
Alcohol & Opiates= Withdrawal, relapse prevention, decreased cravings
Disulfram (Antabuse)
Alcohol deterrent For patients motivated to stay sober Strong adverse reaction when patient takes, eats, uses, applies anything with alcohol Pt teaching is essential DON'T *abuse* or *use* any type of alcohol while taking Ant*abuse*
Quetiapine fumarate (Seroquel)
Alcohol= Detoxification with reduced craving
Chlordiazepoxide (Librium)
Alcohol= Increase seizure threshold, reduce withdrawal agitation
Disulfram (Antabuse)
Alcohol= Maintenance
Acamprosate calcium (Campral)
Alcohol= Relapse prevention; rebalance of neurotransmitters
Carbamazepine (Atretol, Tegretol)
Alcohol= Withdrawal
Diazepam (Valium)
Alcohol= Withdrawal
Phenobarbital
Alcohol= Withdrawal
Laissez-faire leader
Allows group members to behave in any way they choose and does not attempt to control the direction of the group; not very effective unless the group is very mature and high-functioning
TCAs
AmiTRIPTYLINE (Elavil) NorTRIPTYLINE (Pamelor) IMIPRAMINE (Tofranil) CloMIPRAMINE (Anafranil) Triptyline and Mipramine are very hard to mention But in the past these TCAs were used to treat depression
Basil sleep requirement
Amount of sleep required to feel fully awake and able to sustain normal levels of performance during periods of wakefulness
Intensive outpatient
An *alternative to partial hospitalization* is an intensive outpatient program (IOP). This is a *nonresidential program*, highly structured with scheduled treatment groups and at least one individual session regularly. Medication oversight is usually available, but it will not be monitored or managed by a healthcare professional. Participants will attend at least *3 days a week for between 5 and 10 hours per week*
Delirium
An acute cognitive disturbance and often reversible condition that is common in hospitalized patients, especially older patients
Etiology of Antisocial Personality Disorder: Neurobiological
An alteration in serotonin transmission has been implicated with the aggression and impulsivity that frequently accompany this disorder. Lower levels of serotonin along with dopamine hyper-function may contribute to aggression, dis-inhibition, and comorbid substance use.
Dialectical Behavioral Therapy (DBT): For Borderline Personality Disorder
An evidence-based therapy developed by Linehan (1993) to treat chronically suicidal individuals with borderline personality disorder. This combines cognitive and behavioral techniques with mindfulness, which emphasizes being aware of thoughts and actively shaping them.
boundary impairment
An impaired ability to sense where one's body or influence ends and another's begins. Exp. standing to close to others , drink another's beverage, believing that because it is near him it is his.
Borderline Personality Disorder
Another Cluster B diagnosis, the disorder is the most well known and dramatic of the personality disorders. Borderline personality disorder is characterized by severe impairments in functioning. The major features of this disorder are patterns of marked instability in emotional control or regulation, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. One of the primary features of this disorder is emotional lability, that is, rapidly moving from one emotional extreme to another Impulsivity is manifested in acting quickly in response to emotions without considering the consequences. This impulsivity results in damaged relationships and even in suicide attempts. Ineffective and often harmful self-soothing habits such as cutting, promiscuous sexual behavior, and numbing with substances are common and may result in unintentional death. An unusual feature of this disorder is the use of splitting as a primary defense or coping style. Splitting refers to the inability to view both positive and negative aspects of others as part of a whole. This inability results in viewing someone as either a wonderful person or a horrible person.
self assesment
Assess personal thoughts, opinions, and feelings as the first step to remaining objective and establishing a therapeutic relationship with a person with a substance use disorder non punitive alternatives to discipline programs in the form of peer assistance. Diversion legislation allows addicted nurses to attend a treatment or recovery program, have their progress monitored, meet specific criteria to return to work, and be spared revocation or suspension of their licenses if they follow the recommendations of their programs.
bulimia nervosa
Assessment -Binge eating and inappropriate compensatory behavior both occur on average of once a week for at least 3 months -Clients have a lack of control over what they are eating -Consumes large amounts of food over a short period of time followed by self induced vomiting (purging) to rid the excess calories -Maintains BMI 18.5-30 -Most common in females, late teens early adulthood. -Between binges utilizes a low calorie diet.
anorexia nervosa
Assessment- Usually females in adolescence or early adulthood Onset can be triggered by a stressful life event Restricts food intake, does not binge or purge Criteria- less than 85% of expected normal weight
gesturing or posturing
Assuming unusual and illogical expressions (often grimaces) or positions.
According to the National Sleep Foundation, which condition is an example of a social problem that may be a result of sleepiness? A. Narcolepsy B. Road rage C. Alcohol abuse D. Insomnia
B. Road rage Social problems such as road rage may be caused, in part, by a national epidemic of sleepiness.
An older adult who reports taking a late afternoon nap every day to make up for his disrupted sleep at night still feels tired. The nurse explains that A. an afternoon nap includes a great deal of REM sleep. B. a late afternoon nap does not compensate for a lack of nighttime sleep. C. a noontime nap includes very little REM sleep. D. the elderly always need fewer than 6 hours of sleep each night.
B. a late afternoon nap does not compensate for a lack of nighttime sleep. Daytime naps do not compensate for a lack of nighttime sleep. Daytime naps differ in structure from normal nighttime sleeping as a result of a circadian cycle.
Ellie, a 38-year-old patient referred for sleep studies, reports frequent daytime lethargy, unintended lapses into sleep, and never feeling rested on awakening in the morning. Ellie's symptoms describe: A. circadian rhythm disorder. B. hypersomnolence. C. rapid eye movement (REM) sleep behavior disorder. D. breathing-related sleep disorder.
B. hypersomnolence. The patient with hypersomnolence reports recurrent periods of sleep or unintended lapses into sleep, frequent napping, nonrefreshing nonrestorative sleep regardless of the amount of time slept, and difficulty with full alertness during the wake period. Circadian rhythm sleep disorders occur when there is a misalignment between the timing of the individual's normal circadian rhythm and external factors that affect the timing or duration of sleep. Patients with REM sleep disorder display elaborate motor activity associated with dream mentation. Breathing-related sleep disorder is characterized by frequent upper airway obstruction.
A non-habit-forming melatonin receptor agonist often prescribed for insomnia is A. zolpidem (Ambien). B. ramelteon (Rozerem). C. eszopiclone (Lunesta). D. zaleplon (Sonata).
B. ramelteon (Rozerem). Ramelteon (Rozerem) is a short-acting melatonin receptor agonist that has been approved by the FDA for insomnia and is not habit forming.
A recovering alcoholic client is being treated for a sleep disorder. Research has shown that a successful sleep treatment plan is vital to support the client's A. ability to work and support himself. B. sustaining his continued sobriety. C. re-integration into positive interpersonal relationships. D. general health and wellness.
B. sustaining his continued sobriety. Targeting sleep disturbances during recovery may support continued abstinence by addressing a distracting and common disorder in recovering alcoholic clients.
Bipolar I Disorder
BIG mania , little Depression at least 1 week long manic episode that results in excessive activity and energy and alternate with depression or mixed state of agitation and depression; may be symptom free at times; difficulty maintaining social connections and employment and may experience psychosis during manic episodes; more common in males
Environmental Factors and personality disorders
Behavioral genetics research has shown that about half of the variance accounting for personality traits emerges from the environment. These findings suggest that, while the family environment is influential on development, there are other environmental factors besides family upbringing that shape an individual's personality. Childhood neglect or trauma has been established as a risk factor for personality disorders This association has been linked to possible biological mechanisms involving corticotropin-releasing hormones in response to early life stress and emotional reactivity.
Kyla asks you to explain what basal sleep requirement is. Your best response is: A. "The basal temperature of your body needed to induce the best sleep." B. "The sleep time by your body needed to repair cellular damage." C. "The amount of sleep needed to be fully awake and perform well in the daytime." D. "The amount of sleep needed to transition to REM sleep."
C. "The amount of sleep needed to be fully awake and perform well in the daytime." Basal sleep requirement is the amount of sleep required to feel fully awake and able to sustain normal levels of performance during the periods of wakefulness. The other options do not describe basal sleep requirement.
Ellie asks what medication may help her condition. Your response is based on the knowledge that: A. there is no effective medication treatment for hypersomnolence disorder. B. medication therapy with benzodiazepines may be initiated. C. Ellie may be prescribed a stimulant. D. Ellie will be started on an anticholinesterase inhibitor for increased cognition.
C. Ellie may be prescribed a stimulant. Pharmacotherapy with long-acting amphetamine-based stimulants such as methylphenidate and non-amphetamine-based stimulants such as modafinil are helpful in hypersomnolence disorder. The other options are incorrect because there is effective medication treatment; benzodiazepines are sedating and addictive; and anticholinesterase inhibitors are used for the treatment of dementia.
Factors that consistently increase the risk for sleep disturbance include A. gender and race. B. diet and exercise. C. alcohol and tobacco. D. income and education.
C. alcohol and tobacco. There is a strong correlation between alcohol and tobacco use with sleep latency and efficiency problems.
A client who travels often and therefore experiences jet lag regularly reports the use of over-the-counter (OTC) melatonin supplements. The nurse responds by informing the client that A. melatonin is a naturally secreted hormone and thus is a safe supplement. B. research has supported the effectiveness of using melatonin supplements for jet lag. C. currently, no standardized, safe therapeutic dosage range for melatonin supplements has been established. D. hypertension is a common side effect of melatonin supplement therapy.
C. currently, no standardized, safe therapeutic dosage range for melatonin supplements has been established. Because melatonin is an OTC product, the FDA has no input on the identification of effective dosage ranges or standardization of nutraceutical ingredients.
A client tells the nurse that when she was younger, she slept 8 to 10 hours nightly, whereas now she sleeps only 6 or 7 hours and has to take a nap each afternoon. The nurse can assess that the client A. has a primary sleep disorder. B. is suffering from sleep apnea. C. has an age-related sleep pattern change. D. is displaying signs of sleep deprivation.
C. has an age-related sleep pattern change. The older a person gets, the more likely he or she is to have decreased total time sleeping, even though time in bed is increased. REM sleep is also reduced, and wakefulness during the night is increased.
A client reports insomnia and shares that a friend has recommended a nonprescription hormone product that can be purchased at the local health food store. The nurse suspects that the medication is A. a benzodiazepine. B. a tranquilizer. C. melatonin. D. lithium.
C. melatonin. The use of melatonin appears to be helpful in treating sleep problems in the elderly. However, this practice is not without risk. Melatonin products are not approved by the U.S. Food and Drug Administration; therefore, variation may exist in the purity, safety, and effectiveness of the products.
Cognitive-Behavioral Therapy (CBT): For Borderline Personality Disorder
Can help individuals to identify and change inaccurate core perceptions of themselves and others and relationship problems. May result in a reduction of mood and anxiety symptoms and reduce the number of self-harming or suicidal behaviors.
Marked by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs.
Characterization of Schizophrenia
Substance induced anxiety disorder
Characterized by symptoms of anxiety, panic attacks, obsessions, and compulsions that develop with the use of a substance
Treatment for Schizotypal Personality Disorder
Clinicians should be aware that these patients may also be actively involved in groups such as cults, unusual religious groups, and engage in occult activities. While there is no specific medication for this disorder, associated conditions may be treated. Patients do benefit from low-dose anti-psychotic agents for psychotic-like symptoms and day-to-day functioning. These agents help with such symptoms as ideas of reference or illusions. Depression and anxiety may be treated with antidepressants and antianxiety agents.
Integrative Therapy
Cod liver oil- omega 3 good for mood stabilization and depression Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) important in CNS functioning and mood stabilization
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.
Sleep hygiene
Conditions and practices that promote continues and effective sleep.
Cultural considerations when working with culturally different patients and assessing/planning care
Consider age, ethnicity, gender, sexual orientation, worldview, religiosity, and socioeconomic status
Clubhouse model
Consumers run the programing. Consumer-run businesses, such as a coffee shop or housekeeping service, teach all members to perform a job in the business.
circumstantiality
Conversation is derailed by unnecessary and tedious details
What influences the rate of diagnosing personality disorders?
Culture
CAGE
C—Have you ever felt you ought to *Cut down* on your drinking (drug use)? A—Have people *Annoyed* you by criticizing your drinking (drug use)? G—Have you ever felt bad or *Guilty* about your drinking (drug use)? E—Have you ever had a drink (used drugs) first thing in the morning (*Eye-opener*) to steady your nerves or get rid of a hangover?
The nurse appropriately assesses an obese, hypertensive, Type 2 diabetic client when asking, A. "Do you regularly have nightmares?" B. "Is getting to sleep a problem for you?" C. "Do you snooze when you sleep?" D. "How much sleep do you usually get each night?"
D. "How much sleep do you usually get each night?" Short sleep duration has been associated with obesity, cardiovascular disease, hypertension, and diabetes.
As you are talking with Ellie, she begins to cry and states, "I can't keep going like this! I work in a bank and if I can't function correctly I'll lose my job. I just don't think I'll get better." A therapeutic response would be: A. "Don't worry! I'm sure with treatment everything will get better." B. "You are not alone. Many people who come for sleep studies are going through the same thing." C. "You seem so sad. May I ask if something else is troubling you?" D. "There is much hope for improvement through treatment. Let's talk about some strategies for your problems at work."
D. "There is much hope for improvement through treatment. Let's talk about some strategies for your problems at work." This response instills hope regarding the ability of the patient to improve and suggests positive strategies for daily functioning. The other responses are nontherapeutic.
Medications to treat insomnia are usually prescribed for no longer than A. 1 to 2 days. B. 1 to 2 months. C. 3 weeks. D. 2 weeks.
D. 2 weeks. Nurses frequently provide education about the benefits of a particular sleep medication, the side effects, untoward effects, and the fact that medications are usually prescribed for no longer than 2 weeks because tolerance and withdrawal may result
An older adult client is reporting symptomatology that suggests REM sleep behavior disorder (RSBD). The nurse is correct in recognizing that this client is at risk for developing A. lymphoma. B. hypertension. C. acute renal failure. D. Parkinson's disease.
D. Parkinson's disease. RSBD is seen in elderly males as they begin to develop neurological pathologies such as Parkinson's disease.
When providing sleep hygiene information to a client reporting difficulty falling asleep, the nurse includes A. drinking a small amount of alcohol to relax just before bedtime. B. taking a short nap after lunch whenever possible. C. keeping the bedroom warm to induce coziness. D. taking a 20-minute walk after dinner.
D. taking a 20-minute walk after dinner. Light, daily exercise often promotes sleep; however, the exercise should not be done right before bedtime.
Delirium complications
Delirium is associated with increased morbidity and mortality and can have long-term consequences such as permanent cognitive decline
Stimulant Withdrawal
Depression Hypersomnia Fatigue Anxiety Irritability Poor concentration Psychomotor retardation Increased appetite Paranoia Drug craving
Comorbidities to Eating Disorders
Depression Personality disorders Substance abuse disorder anxiety
Schizophrenia is best characterized as
Deteriorating personality
Nursing Diagnosis for patients with antisocial personality disorder
Diagnoses and nursing care plans should be geared toward maintaining safety and providing structure. Nursing diagnoses are focused on the protection of the patient and others from impulsive and premeditated acts and on improving coping skills. *Risk for other-directed violence *Defensive coping *Impaired social interaction *Ineffective health maintenance.
Psychological Factors
Diathesis-stress model
Health education groups
Discuss health-related topics such as STDs or heart disease
Sleep fragmentation
Disruption of sleep stages as indicated by excessive amounts of stage one sleep, multiple brief arousals, and frequent shifts in sleep staging.
Positive symptom Nursing diagnosis
Disturbed sensory perception: auditory/visual Risk for self-directed/other directed violence Impaired verbal communication
Assessment
Early diagnosis and treatment can prevent - suicide attempts, - alcohol or substance abuse, - marital or work problems, - development of medical comorbidity; - can use Mood Disorder Questionnaire
terminal insomnia
Early morning awakening or waking up at least 2 hours before planning to wake up
standardized screening tools
Eating Disorder Inventory Body Attitude Test Diagnostic Survey for Eating Disorders Eating Attitudes Test
Dual-diagnosis groups
Education focused on management of two mental health problems at once such as mental illness + substance abuse
Personality disorders tend to amplify what?
Emotional dysregulation; describes poorly modulated mood characterized by mood swings. Individuals with emotion regulation problems have ongoing difficulty managing painful emotions in ways that are healthy and effective.
Nursing diagnosis of patients with Borderline Personality Disorder
Emotions such as anxiety, rage, and depression, and behaviors such as withdrawal, paranoia, and manipulation are among the most frequent that healthcare workers must address. The nursing diagnosis Self-mutilation is most often associated with this disorder. Defined as "deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension" Characteristics Include: • Disturbed interpersonal relationships • Feels threatened with loss of significant relationship • History of self-directed violence • Impulsivity • Irresistible urge to cut self • Labile behavior • Mounting tension that is intolerable • Use of manipulation to obtain nurturing relationship with others Other Nursing Diagnosis: *Risk for suicide *Risk for self-directed violence *Risk for other-directed violence *Social isolation *Impaired social interaction *Disturbed personal identity Ineffective coping
What is an important principle to remember for dealing with challenging group members?
Encourage the group to solve its own problems
Group norms
Established expectation or assumptions help by members of a group regarding what kind of behavior is acceptable, good or bad, allowed or not allowed.
Group content
Ex: tape record a group's interactions, type up what everyone says, and print it out, you would have a transcript of the content.
Support and self-help groups
Examples include: -Bereavement -Suicide Survivor Support -Cancer Support -Alcoholic's Anonymous -Narcotics' Anonymous -Overeater's Anonymous -Gambler's Anonymous
motor agitation
Excited behavior such as running or pacing rapidly, often in response to internal or external stimuli; it can ose a risk to the patient(exhaustion, collapse, and even death) or others (being knocked down).
Autocratic leader
Exerts control over the group and does not encourage much interaction among members
Toxic Levels of Lithium
Expected side effects= 0.4-1.0 mEq/L (hand tremor, polyuria, mild thirst, mild nausea, weight gain) Early signs of toxicity= 1.5 mEq/L (nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, fine hand tremor) Advanced signs of toxicity= 1.5-2.0 mEq/L (course hand tremor, persistent gastrointestinal upset, mental confusion, muscle hyperirritabliliy, electroencephalographic changes, incoordination, sedation) Severe toxicity= 2.0-2.5 mEq/L (ataxia, giddiness, blurred vision, clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, coma, death > 2.5 mEq/L= (convulsions, oliguria, death)
Naltrexone hydrochloride (Trexan)
Heroin, Opiates, Pathological gambling= Detoxification, maintenance, reduction of impulsive and compulsive behaviors
eating disorders
High Mortality Rate Potential Suicide Risk Treatment focus' on normalizing eating patterns and addressing issues raised by the illness
Patient history of a patient with borderline personality disorder
History of suicidal or aggressive ideation or actions, treatment history, and medication (prescribed and illicit) use. Significant areas about which further details must be obtained include current or past physical, sexual, or emotional abuse and level of current risk of harm from self or others. Information regarding prior use of any medication, including psychopharmacological agents, is important.
The co-occuring illnesses people with SMI are at a greater risk of having.
Hypertension Obesity Cardiovascular disease Diabetes
Neuroendocrine
Hypothalmic-pituitary-thyroid-adrenal axis and BPD are connected; hypothyroidism is known to be associated with depressed mood and is seen inpatients experiencing rapid cycling - treatment-resistant bipolar disorder is treated with high-dose thyroxine
Biologically based mental illness
Illnesses that have been determined to be due to biological differences in the brain
Flat affect
Immoble or blank facial expression
Nursing care of patients with SMI: Assessment Strategies
Important aspects of assessment include: • Intentional risk to self or others: Suicidality or homicidality • Unintentional risk: Inadequate nutrition, clothing inadequate for the weather, neglect of medical needs, or carelessness while driving, smoking, or cooking • Depression or hopelessness • Anxiety • Signs of impending relapse: Decreased sleep, increased impulsivity or paranoia, diminished reality testing, increased delusional thinking, or command hallucinations • Physical health problems that can cause psychiatric symptoms and be mistaken for mental illness or relapse (e.g., brain tumors or drug toxicity) • Comorbid illnesses: To ensure that the patient provides appropriate self-care and receives adequate healthcare • Treatment nonadherence: Signs such as worsening of symptoms, unused medications, missed appointments, or reluctance to discuss these issues.
Pharmacological Interventions for patients with Antisocial Personality Disorder
In the United States, there are no FDA-approved medications specifically for treating this disorder. Patients with this personality disorder respond to mood-stabilizing medications such as lithium or valproic acid (Depakote) to help with aggression, depression, and impulsivity. SSRIs such as fluoxetine (Prozac) and sertraline (Zoloft) may be used to decrease irritability and help with anxiety and depression. Benzodiazepines may help with anxiety but should be used with caution because they are addictive agents. Methylphenidate (Ritalin) may help if there is a comorbidity of attention-deficit/hyperactivity disorder.
MAOIs: General Info
Many adverse effects Many drug interactions Toxic Effect: *hypertensive crisis* Pt. teaching is critical regarding foods and meds to avoid
Family therapy
In this type of therapy, specific goals are defined for each member, identifying ways to improve and work to achieve the goals for the entire family or subunits within the family. Homework assignments are given so family can practice skills outside of therapeutic environment
Agraphia
Inability to read or write
Individual and group psychotherapy
Includes counseling and therapy based on a variety of models, usually provided by independently licensed mental health professionals (e.g., licensed independent social workers or APRNs).
Etiology of Antisocial Personality Disorder: Environmental
Inconsistent parenting and discipline, significant abuse, and extreme neglect are associated with this disorder. Virtually all individuals who eventually develop this disorder have a history of impulse control and conduct problems as children and adolescents.
Treatment for patients with Avoidant Personality Disorder
Individual and group therapy is useful in processing anxiety-provoking symptoms and in planning methods to approach and handle anxiety-provoking situations. Psychotherapy focuses on trust and assertiveness training. Antianxiety agents can be helpful. Beta-adrenergic receptor antagonists (e.g., atenolol) help reduce autonomic nervous system hyperactivity. Antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs) like citalopram (Celexa) Serotonin norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor) may reduce social anxiety. Serotonergic agents may help individuals feel less sensitive to rejection.
Treatment of Patients with Paranoid Personality Disorder
Individuals with this disorder tend to reject treatment. Psychotherapy is the first line of treatment. Individual therapy focuses on the development of a professional and trusting relationship. Due to their fears, patients may behave in a threatening manner. Therapists should respond by setting limits and dealing with delusional accusations in a realistic manner without humiliating the patients. Group therapy is threatening to people with paranoid personality disorder. However, the group setting may be useful in improving social skills. Role playing and group feedback can help reduce suspiciousness. An antianxiety agent such as diazepam (Valium) may be used to reduce anxiety and agitation. More severe agitation and delusions may be treated with antipsychotic medication such as haloperidol (Haldol) in small doses for brief periods of time to manage the mildly delusional thinking or severe agitation. The first-generation antipsychotic medication pimozide (Orap) may be useful in reducing paranoid ideation.
Interpersonal Relationship risk factors
Influenced by parental pressure and the need to succeed.
Feedback
Information that group members get from other members about how they affect one another.
A personality is considered unhealthy when...
Interpersonal and social relationships and functioning are consistently maladaptive, complicated, or dysphoric.
finger foods
Interventions for the patient experiencing mania include encouraging patients to eat high-calorie finger foods to help maintain nutrition during states where the patient may not want to sit down to consume a meal(
Atypicals-Novel Antidepressants
Make a NOVEL connection to the receptors: -Give depression a *zap* from *faxine* *dulo* -Get *well* from the *dopamine* in *Wellbutrin* -Depression hurts...*Cymbalta*...(remember the commercial?) Mirta*ZAP*ine [another way to remember Mirtazapine is by the brand name *Rem*eron. It is very sedating; therefore, given before bedtime. You can associate R.E.M. sleep with the name: R.E.M.eron] Venla*FAXINE* & Desvenla*FAXINE* Cymbalta [*Dulo*xetine is generic] *WELL*butrin [generic=Bupropion]
Assertive Community Treatment (ACT)
Involves consumers working with a multidisciplinary team that provides a comprehensive array of services. This team approach eliminates the need for multiple departments or agencies to provide services. Research supports this model for improving the quality of life and reducing inpatient admissions, incarceration, and homelessness among people with SMI. At least one member of the team is available 24 hours a day for crisis care. The emphasis is on treating the patient within his or her own environment.
paranoia
Irrational fear of others A state characterized by the presence of intense and strongly defended irrational suspicions. These ideas cannot be corrected by experience and cannot be modified by facts or reality.
hypervigilance
Is an enhanced state of awareness or "being on guard" that impedes one's ability to relax and disengage from a stressful situation
Personality
Is an individual's characteristic pattern of relatively permanent thoughts, feelings, and behaviors that define his or her quality of experiences and relationships.
Cognitive enhancement therapy (CET)
Is based on the principle of neuroplasticity, that healthier areas of the brain can assume neurological functions for the compromised areas of the brain. Is a lengthy process of structured computer-based drills and group exercises that incrementally challenge and strengthen functions such as focusing attention and processing and recalling information.
Epidemiology and Comorbidity For Borderline Personality Disorder
It carries a high mortality rate—nearly 10%— primarily from suicide. This disorder results in extensive utilization of services from the healthcare system. This personality disorder seems to decrease with age. Patients with this disorder experience high rates of remission and low rates of relapse. About 85% of individuals with borderline personality disorder also meet the diagnostic criteria for another psychiatric disorder. Substance use in individuals with borderline personality disorder is extremely common. Nonpsychiatric diagnoses are also associated with borderline personality disorder. They include diabetes, high blood pressure, chronic back pain, fibromyalgia, and arthritis.
Epidemiology of Antisocial Personality Disorder
It is the most researched personality disorder probably due to its marked impact on society in the form of criminal activity. The prevalence of this disorder is about 1.1% in community studies Women may be under-diagnosed due to the traditional close association of this disorder with males.
Task roles
Keep the group focused on its main purpose and get the work done.
Maintenance roles
Keep the group together, help each person feel worthwhile and included, and create a sense of group cohesion. helps members learn to care about each other
Bipolar II Disorder
LITTLE Mania , BIG depression low level mania (hypomania) alternates with profound depression; mania tends to be *euphoric (mania)* and increases functioning; high energy lasts for at least *4 days* and involves at least 3 symptoms of mania; *psychosis is never present with hypomania but may be present with the depressive stage*; does not cause much impairment and hospitalization is rare; depressive symptoms put people at risk for suicide
Dysthymic Disorder
LOW LEVEL DEPRESSION - feelings of depression persist consistently for at least *2 years*; - symptoms *cause social and occupational problems* but not severe enough to require hospitalization; - usually in teenagers; - not uncommon to have episodes of major depression along with the low level depression
Sleep restriction
Limiting the total sleep time, which creates a temporary, mild state of sleep deprivation and strengthens the sleep homeostatic drive.
Cyclothymic Disorder
Little Mania, little depression hypomania alternates with mild to moderate depression for at least *2 years* in adults and 1 year in children; aren't severe enough for bipolar diagnosis, but enough to disturb social and occupational functioning; difficult to distinguish from Bipolar II; *have irritable hypomanic episodes*
Apraxia
Loss of purposeful movement in the absence of motor or sensory impairment
Psychology of Borderline Personality Disorder
Margaret Mahler (1895-1985), a Hungarian-born child psychologist who worked with emotionally disturbed children, developed a framework for this disorder. She believed that psychological problems are a result of the disruption of the normal separation-individuation of the child from the mother.
Planning for Acute Phase
Medically stabilizing the patient while maintaining *safety* (usually in the hospital) Nurses should: - manage meds - decreased physical activity - increase food and fluid intake - ensure at least 4-6 hours of sleep per night - alleviate bowel or bladder problems - make sure self-care needs are met - Some may require seclusion or electroconvulsive therapy
Who should be doing the talking in the group?
Members are encouraged to talk to each other and not to the leader
Imitative behavior
Members can copy behavior from the leader or peers and can adopt healthier habits. "I like the way you answered that question, maybe I can try that next time."
Existential resolution
Members examine aspects of life (e.g., loneliness, mortality, responsibility) that affect everyone in constructing meaning. Ex: "I understand that all of us struggle with the inevitable loss."
Interpersonal learning
Members gain insight into themselves based on the feedback from others during later group phases. Ex: "When you speak to me that way, I feel intimidated."
Altruism
Members gain or profit from giving support to others, leading to improved self-value. Ex: "I'm sorry that happened to you. I can help you."
Socializing techniques
Members learn new social skills based on other' feedback and modeling. "You took that criticism really well. You didn't appear to become upset. Maybe I can try that."
Universality
Members realize that they are not alone with their problems, feelings, or thoughts. Ex: "You feel that way too? Wow! I am not alone."
Corrective recapitulation of the primary family group
Members repeat patterns of behavior in the group that they learned in their families; with feedback from the leader and peers, they learn about their own behavior. "Is this the way you speak to your wife at home?"
Norepinephrine and Serotonin Specific Antidepressant
Mirta*ZAP*ine (*R.E.M.*emeron) ↑ 5-HT and NE Less sexual dysfunction than other antidepressants ↑ sedation (take at bedtime) Weight gain
illusions
Misinterpretation of a real experience. Errors in the perception of a sensory stimulus. For example, a person may mistake polka dots on a pillow for hairy spiders.
Personality disorders tend to co-occur with what disorders?
Mood Eating Anxiety Substance misuse
Factitious disorder is also known as
Munchhausen's syndrome
tangential
Only slightly relevant, going off-topic
Tolerance
Needing increased amounts of a substance in order to receive the desired result to become intoxicated or finding that using the same amount over time results in a much-diminished effect.
Is Anhedonia a positive or negative symptom of schizophrenia?
Negative symptoms refer to deficits that characterize schizoprenia. They include the crippling symptoms of affective blunting, anergia, anhedonia, avolition, poverty of content of speech, poverty of speech, and thought blocking
Rimonabant (Zimulti)
Nicotine, Obesity= Maintenance of body weight, smoking cessation
Varenicline (Chantix)
Nicotine= Reduction of craving and withdrawal
Bupropion (Zyban)
Nicotine= Withdrawal from smoking
Bizarre
Odd, illogical grossly inappropriate, or unfounded; includes grimacing and giggling
Schizotypal Personality Disorder
People with this disorder do not blend in with the crowd. Their symptoms are strikingly strange and unusual. Magical thinking, odd beliefs, strange speech patterns, and inappropriate affect are hallmarks of this disorder. Abnormalities in brain structure, physiology, chemistry, and functioning are similar to schizophrenia. For example, both disorders share reduced cortical volume. They experience extreme anxiety in social situations. Contributions to conversations tend to ramble with lengthy, unclear, overly detailed, and abstract content. An additional feature of this disorder is paranoia. Individuals with schizotypal personality disorder are overly suspicious and anxious. They tend to misinterpret the motivations of others as being out to get them and blame others for their social isolation. Odd beliefs (e.g., being overly superstitious) or magical thinking (e.g., "He caught a cold because I wished he would") are also common.
Schizoid Personality Disorder
People with this disorder exhibit a lifelong pattern of social withdrawal. They are somewhat expressionless and operate with a restricted range of emotional expression. People with this disorder do not seek out or enjoy close relationships. If trust is established, the person may divulge numerous imaginary friends and fantasies.
Avoidant Personality Disorder
People with this personality disorder are extremely sensitive to rejection, feel inadequate, and are socially inhibited. They avoid interpersonal contact due to fears of rejection or criticism. It is found equally among men and women. Symptoms are noticeable in early childhood. These symptoms include shyness and avoidance that, unlike common shyness, increase during adolescence and early adulthood. Some can function in a protective environment. However, if their support system fails, they can suffer from depression, anxiety, and anger.
Nursing Assessment for patients with Anti-social Personality Disorder
People with this personality disorder do not enter the healthcare system for treatment of this disorder unless they have been court-ordered to do so. Psychiatric admissions may be initiated for anxiety and depression. Keep in mind that questions asked during the assessment phase may not always result in accurate responses because the patient may become defensive or simply not tell the truth. Entering treatment may also be a way to avoid or address legal, financial, occupational, or other circumstances.
Assessment
Perform neuro checks (rule-out brain injury) Evaluate mental status (MSE) Check UDS (urine drug screen) Review Labs (rule-out medical conditions) Review pt's medical history Review pt's psychiatric history
Preservation
Persistant repetition of a word, phrase, or gesture
Personality comes from the Latin word...
Persona; which means mask and it may refer to what other people see.
Outcomes Identification: Borderline Personality Disorder
Personality change occurs with one behavioral solution and one learned skill at a time. In the acute-care setting, the focus is on the presenting problem, which may be depression or severe anxiety.
florid symptoms
Positive symptoms are those symptoms that should not be present, but are. They include hallucinations, delusions, bizarre behavior, and paranoia and are referred to as florid symptoms.
Refeeding syndrome
Potentially fatal complication that occurs when fluids, electrolytes, and carbohydrates are introduced to a severely malnourished client. (overloading the patient with nutrients and electrolytes too quickly- can lead arrhythmias) Nursing Actions: -Inpatient treatment -Consult with the provider and dietitian to develop a controlled rate of nutritional support during initial treatment. -Monitor serum electrolytes, and administer fluid replacement.
Medication education groups
Prepares patients for self-management of medications
Interventions for Maintenance Phase
Prevent recurrence of episodes Community resources
Electroconvulsive Therapy
Primary treatment for: -suicidal or homicidal thoughts -medication fails -marked agitation, vegetative signs, catatonia -major depression with psychotic symptoms -manic patients -rapid cycling patients Usual course is 2 to 3 treatments per week to a total of 6 to 12 treatments Carefully measure for hypertension, congestive heart failure, cardiac arrhythmia, increased cerebral oxygenation, blood flow, and intracranial pressure
Alzheimer's disease
Progressive deterioration in other cognitive functions such as problem-solving and learning new skills and a decline in the ability to perform activities of daily living
Sleep Drive
Promotes sleep and is known as the homeostatic process. The longer the period Of wakefulness, the stronger the sleep Drive.
Teamwork and Safety
Protect against self harm control hyperactivity seclusion or restraints may be needed Seclusion for: reducing overwhelming stimuli protect from self harm and injuring others prevents destruction of personal property
Insurance Parity
Providing mental healthcare coverage equal to that for physical healthcare
Psychological Factors and personality disorders
Psychoanalytic theory focuses on the use of primitive defense mechanisms by individuals with personality disorders. Defense mechanisms such as: *repression *suppression *regression *undoing *splitting Learning theory emphasizes that children learn maladaptive responses based on modeling or reinforcement by significant others. Cognitive theories emphasize the role of beliefs and assumptions in creating emotional and behavioral responses that influence one's experiences within the family environment.
Treatment of patients with Schizoid Personality Disorder
Psychotherapy can help improve sensitivity to others' social cues. Group therapy may also be helpful even though the patient may frequently be silent. Group therapy provides experience in practicing interactions and feedback from others. Antidepressants such as bupropion (Wellbutrin) may help increase pleasure in life. Second-generation antipsychotics, such as risperidone (Risperdal) or olanzapine (Zyprexa), are used to improve emotional expressiveness.
Treatment for patients with Dependent Personality Disorder
Psychotherapy is the treatment of choice. Cognitive-behavioral therapy can help patients develop more healthy and accurate thinking by examining and challenging automatic thoughts that result in fearful behavior. This process can help in developing new perspectives and attitudes about the need for other people. Symptoms of depression and anxiety may be treated with the appropriate antidepressant and antianxiety agents. Panic attacks can be helped with the tricyclic antidepressant imipramine (Tofranil).
Treatment for patients with histrionic personality disorder
Psychotherapy may promote clarification of inner feelings and appropriate expression. Group therapy may be useful in this population, although distracting symptoms may be disruptive to group functioning. There are no specific pharmacological treatments available for people with histrionic personality disorder. Medications such as antidepressants can be used for depressive or somatic symptoms. Antianxiety agents may be helpful in treating anxiety. Antipsychotics may be used if the patient exhibits derealization or illusions.
Psychopharmacological Interventions
Require multiple medications Severe manic episodes: Lithium or Valproate and a second generation antipsychotic such as Olanzapine (Zyprexa) or Risperidone (Risperdal) Less severe: only one Benzodiazepines may be used at times
Compulsions
Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety or prevent an imagined calamity. Performing the ritualistic behavior decreases anxiety.
What is the treatment for illness anxiety disorder?
SSRI, pos. underlying depression/anxiety
Antidepressants in Older Adults
SSRIs are first line "start low and go slow" prone to more side effects risk for falls due to sedation do not discontinue abruptly or get *discontinuation syndrome* (anxiety, dysphoria, flulike symptoms, dizziness, excessive sweating, and insomnia)
SSRI's
SSRIs: General Info - Uses: Depression, Anxiety Disorders - 5-HT reuptake inhibition ↑ 5-HT ↓ depression - 5-HT reuptake inhibition → *GI issues*, *sexual dysfunction* - Better side effect profile than older antidepressants - Less muscarinic and Ach receptor blockage than TCAs - Discontinuation Syndrome: taper slowly - Toxic Effects: Serotonin Syndrome
Teamwork and Safety
Safety is priority with depression due to suicide Suicide precautions: -removal of sharps, strangulation risks, and medications -check on them every 15 minutes or even 1 on 1 all the time -no harm contracts
Screening
Screening is essential for early detection and intervention Ask about type of substance used, patterns of use, and amounts Provide a nonjudgmental attitude If screening is positive, a complete assessment is needed
Second Generation Antipsychotics
Sedative properties mood stabilizing properties
Assessment tools for patients with Borderline Personality Disorder
Self-report inventories such as Minnesota Multi-phasic Personality Inventory (MMPI), are useful because they have built-in validity and reliability scales for the clinician to refer to when interpreting test results. Areas of assessment that are typically included on questionnaires and rating scales related to borderline personality disorder include the following: • Feelings of emptiness • An inclination to engage in risky behaviors such as reckless driving, unsafe sex, substance use, binge eating, gambling, or overspending • Intense feelings of abandonment that result in paranoia or feeling spaced out • Idealization of others and becoming close quickly • A tendency toward anger, sarcasm, and bitterness • Self-mutilation and self-harm • Suicidal behaviors, gestures, or threats • Sudden shifts in self-evaluation that result in changing goals, values, and career focus • Extreme mood shifts that occur in a matter of hours or days • Intense, unstable romantic relationships
SSRI's
Sertraline (Zoloft) *remember SERoTonin Fluoxetine (Prozac) *remember Fluox Fluvoxamine (Luvox) *remember Fluvox Paroxetine (Paxil) *remember Parox Escitalopram (Lexapro) *remember -pram Citalopram (Celexa) *remember -pram FluOX FluvOX ParOX PRAM
Stimulant Intoxication
Short Term: Increased energy Decreased Appetite Mental alertness Increased heart rate/pressure Dilated pupils Long Term: Irregular heartbeat Chest pains Increased risk of heart attack Panic attacks Depression Delusions/hallucinations "Cocaine bugs"
Wellness and recovery action plans
Similar programs are psycho-educational programs that empower and train consumers in skills that promote recovery and prepare them to deal with stressors and crises. These programs help individuals to identify and manage triggers that could provoke a relapse, early identification of impending relapse, and crisis plans for managing crises or impending relapse.
Severe and persistent mental illness (SPMI)
Similar to SMI, but emphasizing chronicity
Depression assessment
Sleep Interest (decreased) = anhedonia Guilt Energy (fatigue; anergia) Concentration Appetite Psychomotor Function Suicidal Ideations (monitor especially when meds are started and adjusted)
Etiology of Antisocial Personality Disorder: Cultural Factors
Some studies have found a higher prevalence rate of this personality disorder in African Americans and in individuals with co-occurring substance dependence.
why would a structured med group benefit a schizophrenic patient
Structured med group ~ schizophrenia patients have concrete thinking processes and will repond best to structured activities
nursing interventions: ETOH withdrawal
Substance overdose and withdrawal can be fatal and requires immediate attention: SAFETY is first Frequent monitoring of vitals Low stimulus environment Close observation of patient Seizure precautions may be needed Monitor for hallucinations, illusions, delusional thinking, confusion
Panic attacks
Suddent onset of extreme apprehension or fear, usually associated with feelings of impending doom.
Democratic leader
Supports extensive group interaction toward problem solving
parkinsonism
Symptoms of parkinsonism include fine tremors, cogwheel rigidity, and shuffling gait.
Opioid Withdrawal
Tachycardia Hypertension Hyperthermia Insomnia Mydriasis (Dilated pupils) Hyperreflexia Diaphoresis Piloerection Increased respiratory rate Lacrimation Yawning Rhinorrhea Muscle Spasm Abdominal cramps Nausea Vomiting Diarrhea Bone and muscle pain Anxiety
Which side effect of antipsychotic medication is generally nonreversible?
Tardive dyskinesia
Antidepressant Drugs
Target symptoms: -sleep disturbance -appetite disturbance -fatigue -decreased sex drive -psychomotor retardation or agitation -diurnal variations -impaired concentration or forgetfulness -anhedonia take 1-3 weeks to be therapeutic; goal is complete remission of symptoms; usually trial runs for 3 months and then reevaluate; may precipitate a psychotic episode in a person with schizophrenia or manic episode; bipolar people get a mood stabilizer also
Stress management groups
Teach strategies such as relaxation techniques or mindfulness
la belle indifference
Term used to describe the lack of concern over physical illness; seen in conversion reactions
Outpatient treatment
The *least-intensive form* of substance use treatment is outpatient. Treatment may be a *mix of individual sessions and educational or psychotherapy groups* as determined by the individuals' needs and their treatment goals. It is structured, drug-free, and non-residential. Programming consists of *not more than 5 contact hours a week*. Web-based interventions are also available for self-paced, anonymous collective participation in treatment efforts
negative symptoms
The absence of something that should be there e.g. lack of motivation, poor thought processes, hygiene, apathy, anhedonia ( inability to experience pleasure) social withdrawal, dysfunction, reduced affect. Responds less well to Anti-psychotic therapy
Confabulation
The creation of stories or answers in place of actual memories to maintain self-esteem (unconscious)
Genetics and personality disorders
The disorders themselves are not inherited. It is the personality traits. Personality disorders may represent extreme variations of normal personality traits in four areas: 1) anxious-dependency traits 2) psychopathy-antisocial 3) social withdrawal 4) compulsivity
sleep continuity
The distribution of sleep and wakefulness across the sleep period.
Waxy flexibility
The extended maintenance of posture, usually seen in catatonia. For exp. the nurse raises the patient's arm, and the patient continues to hold this position in a statue like manner.
somatic delusions
The false belief that the body is changing in an unusual way (rotting inside)
Anosognosia
The inability to recognize one's illness due to illness itself
Anxiety d/t medical condition
The individuals symptoms of anxiety are a direct physiological result of a medical condition. I.e. hyperthyroidism, PE, dysrhytmias.
Obsessive compulsive or related disorders d/t medical condition
The individuals symptoms of obsessions and compulsions are a direct physiological result of a medical condition, such as a traumatic brain injury, seizures.
Teamwork and safety when taking care of a patient with Antisocial Personality Disorder
The safety of patients and staff is a prime consideration in working with individuals in this population. To promote safety, the entire treatment team should follow a solid treatment plan that emphasizes realistic limits on specific behavior, consistency in responses, and consequences for actions. Careful documentation of behaviors will aid in providing effective interventions and in promoting teamwork. Simply noting that the patient truly feels hurt. Showing empathy may also decrease aggressive outbursts if the patient feels that staff members are trying to understand feelings of frustration.
Etiology, Neurobiology of Borderline Personality Disorder
The serotonin transporter gene 5-HTT may have shorter alleles, which have been associated with lower levels of serotonin and increased impulsive aggression. Abnormalities in the prefrontal cortex and limbic regions. The frontal region is implicated in regulatory control processes and the limbic region is essential for emotional processing.
neurobiological process that occurs in the brain and neurotransmitters involved with substance use
The structures most identified with the *reward system or pleasure center* are the nucleus accumbens and the ventral tegmental area. *The neural pathways between these areas are activated by the neurotransmitter dopamine*. Normal activities such as eating, nurturing, and sexual activity are associated with pleasant feelings and cue the amygdala and hippocampus for memories of the experiences. *The frontal cortex is stimulated, releasing glutamate and closing the circuit* -Psychoactive substances and certain behaviors can *hijack this reward pathway circuit*, releasing as much as 10 times the amount of dopamine as usual. Over time, the release of dopamine becomes more important than the reward of pleasure, and the *increased importance of the addictive process cancels the inhibitory function of the frontal cortex*, leading to *craving*. The brain responds to this imbalance by resetting the pleasure threshold, producing transporter chemicals, and decreasing or down regulating the number of receptors attempting to reach homeostasis. This is the mechanism that is responsible for drug tolerance.
Hyerorality
The tendency to taste, chew, and put everything in mouth
Stigma of patients with SMI's
The thought that patients with SMI's are often violent. When in reality violence is rare.
Sleep latency
The time it takes to go to sleep.
Hypermetamorphosis
The urge to touch everything
Pharmacological Interventions for patients with Borderline Personality Disorder
There are no medications specifically approved by the FDA for treating this disorder. Psychotropic medications geared toward maintaining patients' cognitive function, symptom relief, and improved quality of life are available. People with this disorder respond to antidepressants such as SSRIs, anti-convulsants, and lithium for mood and emotional dysregulation symptoms. Naltrexone (Revia, Vivitrol), an opioid receptor antagonist, has been found to reduce self-injurious behaviors. Second-generation anti-psychotics may control anger and brief psychosis.
Psychiatric advance directives
These are legal documents that allow an individual whose disorder is in remission to direct how to manage treatment if judgment becomes impaired during a relapse.
Treatment for patients with Narcissistic Personality Disorder
These patients are more likely to be involved in couples or family therapy than individual treatment. They are likely to deflect suggestions that they contribute to family problems, and will instead blame others. If a person with this personality disorder somehow seeks treatment, individual cognitive-behavioral therapy is helpful for deconstructing faulty thinking. Group therapy can also assist the person in sharing with others, seeing their own qualities in others, and learning empathy. Lithium (Eskalith, Lithobid) has been used in patients who demonstrate mood swings. Antidepressants can also be used if the person has symptoms of depression.
Day Programs
These programs provide structure and therapeutic activities to patients who attend the program 1 or more days a week. Services often include: Education regarding social skills, ADLs, and prevocational skills (the fundamentals needed before one can be successfully employed [e.g., interviewing, dressing for work]). These programs also provide social contact and peer support.
Antisocial Personality Disorder
This disorder is a pattern of disregard for, and violation of, the rights of others. People with this disorder may be more commonly referred to as sociopaths. The main pathological traits that characterize antisocial personality disorder are antagonistic behaviors such as being deceitful and manipulative for personal gain or hostile if needs are blocked. The disorder is also characterized by dis- inhibited behaviors such as high risk taking, disregard for responsibility, and impulsivity. Criminal misconduct and substance misuse are common in this population. One of the most disturbing qualities associated with this disorder is a profound lack of empathy, also known as callousness. These individuals tend to exhibit a shallow, un-expressive, and superficial affect. They may also be adept at portraying themselves as concerned and caring if these attributes help them to manipulate and exploit others.
Dependent Personality Disorder
This disorder is characterized by a pattern of submissive and clinging behavior related to an overwhelming need to be cared for. This need results in intense fears of separation. This may be the result of chronic physical illness or punishment for independent behavior in childhood. The inherited trait of submissiveness may also be a factor.
Obsessive-Compulsive Personality Disorder
This disorder is characterized by limited emotional expression, stubbornness, perseverance, and indecisiveness. Preoccupation with orderliness, perfectionism, and control are the hallmarks of this disorder. It is one of the most prevalent personality disorders. Has been associated with increased relapse rates of depression and an increase in suicidal risks in people with co-occurring depression. The main pathological personality traits are rigidity and inflexible standards of self and others. They rehearse over and over how they will respond in social situations.
Etiology of Antisocial Personality Disorder: Genetics
This disorder is genetically linked. There are two main dimensions of genetic risk. One is the trait of aggressive-disregard, which refers to violent tendencies without concern for others, and the trait of dis-inhibition, which is a lack of concern for consequences.
Etiology, Genetics of Borderline Personality Disorder
This disorder is highly associated with genetic factors such as hypersensitivity, impulsivity, and emotional dysregulation. The role of genetic vulnerability is at approximately 40%.
Guardianship
This involves the appointment of a person (guardian) to make decisions for the consumer during times when judgment is impaired or is disabled with anosognosia. They may be significant others or attorneys.
Social skills training
This is an evidence-based practice that focuses on teaching a wide variety of social and ADL skills.
Partial hospitalization
This is an intensive form of *outpatient* programming *for those individuals who do not need 24-hour residential programming* but who benefit from a combination of *multidisciplinary treatment on at least 3 days a week for at least 10 hours per week of planned programming*. This combination of psychotherapy and educational groups *does not require the individual to have previous treatment experience*. Participants may live in some type of supportive housing program or at an independent home. Medication management is available but it is not usually medically monitored or managed
Group cohesiveness
This powerful factor arises in a mature group when each member feels connected to the other members, the leader, and the group as a whole; members can accept positive feedback and constructive criticism. " This group has helped me to see that when I complain to my daughter about her father that I am triangulating her by truing to get her on my side. Now I see how unfair this is to her."
Schema-Focused Therapy: For Borderline Personality Disorder
This therapy combines parts of CBT with other forms of therapy that focus on the ways that individuals view themselves. This reframing of "schemas" is based on the notion that borderline personality disorder is the result of a dysfunctional self-image, probably brought about by a dysfunctional childhood. This dysfunctional self-image affects how individuals respond to stress, react to their environment, and interact with others.
Cognitive behavioral therapy
This therapy is based on the premise that negative and self-defeating thoughts lead to psychiatric pathology and that learning to replace these thoughts with more realistic and accurate appraisals results in improved functioning
Cognitive-behavioral therapy (CBT)
This type of therapy has been effective in helping individuals with SMI reduce and cope with symptoms such as delusions and impaired social functioning. Focuses on patterns of thinking and "self-talk" (i.e., what one says to oneself internally). It identifies distorted thinking and negative self-talk and guides patients to substitute more effective ways of thinking. Uses natural consequences and positive reinforcers (rewards) to shape the person's behavior in a more positive or adaptive manner.
Group therapy
This type of therapy is specific to a group... (for younger children) uses play to introduce ideas and work through issues (for grade school children) combines play, learning skills, and talking about the activity so they can learn social skills by taking turn and sharing with peers (for adolescents) learning skills and talking focusing largely on peer relationships and working through specific problems.
Obsessions
Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind even thought the individual attempts to do so.
Catharsis
Through experiencing and expressing feelings, therapeutic discharge of emotions is shared. Ex: "This experience allowed me to get in touch with my sadness."
People with SMI's are 12 Times more likely
To commit suicide
derogatory hallucinations
are an extension of the strong feelings of rejection and lack of self-respect experienced by the individual during the prodromal period.
first generation antipsychotics
Treat positive symptoms, D2 receptor blockers,
Antidepressants: General Info
Treatment choice based on different factors Symptom relief can take weeks SSRIs are usually first-line Side effects relate to the blockage or activation of neurotransmitters
Hair pulling and skin picking disorders
Trichotillomania = hair pulling Trichophagia = swallowing the hair > Rapunzel syndrome Dermotillomania = skin picking -Occurs more often in children than adults -A means to deal with the stress.
Implementation when taking care of patients with Antisocial Personality Disorder
Try to prevent or reduce untoward effects of manipulation (flattery, seductiveness, instilling of guilt). Set clear and realistic boundaries and consequences and ensure that all staff follow limits. Carefully document behaviors and signs of manipulation. Be aware that these patients can manipulate with feelings of guilt when they are not getting what they want.
Dialectical behavior treatment
Type of psychotherapy which focuses on improving interpersonal behavioral, cognitive, and emotional skills and reducing self destructive behaviors
Treatment for patients with Obsessive Compulsive Personality Disorder
Typically, patients with this disorder seek help on their own as they are aware of their own suffering. They may also seek treatment for anxiety or depression. Both group therapy and behavioral therapy can be helpful so that patients can learn new coping skills for their anxiety and see direct benefits for change from feedback within the group. Clomipramine (Anafranil) may help reduce the obsessions, anxiety, and depression associated with this disorder. Other serotonergic agents such as fluoxetine (Prozac) may also be effective.
Anxiety
Universal human experience and is the most basic of emotions. Feelings of apprehension, uneasiness, uncertainty, or dread. Effects us on a deep level, invades our core. Woman are effected more than men Most common form of psychiatric disorder
Group process
Used to describe everything else that goes on in the group. Way that group members interact with one another.
MAOIs: General Info
Uses: Atypical depression and treatment-resistant anxiety disorders Not first-line treatment due to side effect profile Monoamine is destroyed by MAO Inhibiting MAO ↑ monoamine neurotransmitters (NE, 5-HT, DA) Inhibiting MAO ↑ monoamine (tyramine) in foods/drugs Tyramine can produce hypertensive crisis...strict diet restriction is needed
TCAs: General Info
Uses: Depression, Anxiety Disorders *5-HT reuptake inhibition* ↑ 5-HT ↓ depression Not first-line treatment due to side effect profile *H1 receptor blockage* → Sedation *Ach receptor blockage* → Anticholinergic effects Other Common Adverse Effects: orthostatic hypotension, tachycardia. See chapter 22 manual; Table 14-6 textbook. Toxic Effects: *Cardiac Toxicity*, Drug-Drug Interactions, LETHAL in Overdose
Serotonin Nprepinephrone Reuptake Inhibitors
VenlaFAXINE (Effexor) DesvenlaFAXINE (Pristiq) Duloxetine (Cymbalta) ↑ 5-HT and NE *↑ BP* can occur with Venlafaxine and Desvenlafaxine *Cymbalta* can help *↓ neuropathic pain* (remember the TV commercial) Discontinuation syndrome with Venlafaxine: taper slowly Useful for anxiety disorders
metabolic syndrome
Weight gain, dyslipidemia, and altered glucose metabolism caused by atypical antipsychotic drugs. Increase risk of diabetes, hypertension and atherosclerosis often caused by second gen anti-psychotics except ziprasidone and aripiprazole
anhedonia (inability to feel happy) and 5/8 of the other symptoms
What entails a true diagnosis of depression?
Intoxication : -
When people are in the process of using a substance to excess, they are experiencing intoxication
Initiating - group leader responsibility
When the structure, size, composition, purpose, and timing of the group is defined; task and maintenance functions may be discussed and demonstrated
Therapeutic community meeting groups
Where unit member behavior is processed and integrated into treatment; patient governance and advocacy issues are managed
relapse
Without continuing action the individual will likely return to previous behavior
Elimination Disorders
______________(bowel movement) - after has been potty trained may go back (above age of 6) to having BM's in unusual places, may smear it if serious sexual or other) abuse Enuresis (urine)- after has been potty trained above age of 6 will still frequently wet the bed at night, or urinate in their pants- may indicate sexual abuse
Codependence
a cluster of over responsible behavior—doing for others what others could just as well do for themselves. They have a constellation of maladaptive thoughts, feelings, behaviors, and attitudes that effectively prevent them from living full and satisfying lives. Symptomatic of codependence is valuing oneself by what one does, what one looks like, and what one has, rather than by who one is. *People who are codependent often define their self-worth in terms of caring for others to the exclusion of their own needs.* Nurses are at risk for codependency since the very nature of the profession can lead to viewing oneself exclusively as a provider of care
factitious disorder imposed on another
a condition in which one person induces illness symptoms in someone else
role playing
a counseling technique in which the nurse, the patient, or a group of patients acts out a specified script or role to enhance their understanding of that role. learn and practice new behaviors or skills, and practice specific situations. it requires well-developed expressive and receptive language skills.
Tourette's Disorder
a disorder characterized by motor and verbal tics appearing between ages 2 and 7 that cause marked distress and significant impairment in social and occupational functioning usually involve head but can involve torso or limbs Ex: motor tics: tongue protrusion, touching, squatting, hopping, skipping, retracing steps, twirling when walking verbal tics: spontaneous production words and sounds
Schizophrenia is usually...
a disorder marked by an initial episode followed by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs.
Autism Spectrum Disorder (ASD)
a disorder occurring typically within the first three years of life, yielding deficits in social interaction and communication skills children with this disorder are referred to EARLY INTERVENTION PROGRAMS and continue to receive school-based services as they enter the public education system
social communication disorder
a disorder where children have problems using verbal and nonverbal means for interacting socially with others (Autism needs to be ruled out first)
Diathesis-Stress Model
a general theory that explains psychopathology using a systems approach. Diathesis refers to genetic and biological vulnerabilities and includes personality traits and temperament. Temperament is our tendency to respond to challenges in predictable ways. stress refers to immediate influences on personality such as the physical, social, psychological, and emotional environment. Under conditions of stress, the diathesis-stress model proposes that personality development becomes maladaptive for some people, resulting in the emergence of a personality disorder.
Motor Disorders
a group of disorders characterized by motor symptoms such as tics, stereotypic movements, or dyscoordination
advanced practice forensic nurse
a master's level in forensic nursing that has completed graduate education with a comprehensive focus in forensic nursing
modeling
a method of learning behaviors or skills by observation and imitation that can be used in a wide variety of situations. it is enhanced when the modeler is perceived to be similar (age interests) and attending to the task is required
stereotypic movement disorder
a motor disorder characterized by repetitive, purposeless movement Ex: hand waving, rocking, head banging, nail biting, teeth grinding more common in boys than girls other disorders such as Tourette's, tic disorder, autism spectrum disorder, or stimulant abuse needs to be ruled out first
behavior contract
a patient-centered verbal or written agreement between the patient and nurse or other parties (family, treatment team, teacher) about behaviors, expectations, and needs. the contract is periodically evaluated and reviewed and typically coupled with rewards and other contingencies, positive and negative
major depressive disorder
a persistently depressed mood lasting for a minimum of two weeks accompanied by: 1) lack of interest in previously pleasurable activity (anhedonia), 2) fatigue, 3) sleep disturbances; 4) changes in appetite, 5) hopelessness and/or worthlessness, 6) suicidal ideations, 7) inability to concentrate, and 8) change in physical activity.
Learned Helplessness
a person who believes that an undesired event is his or her own fault and that nothing can be done to change it is prone to depression
addiction
a primary, chronic disease of brain reward, motivation, memory, and related circuitry. - s/s: loss of behavioral control with craving and ability to abstain, loss of emotional regulation, and loss of ability to identify problematic behaviors and relationships.
attention-deficit/hyperactivity disorder (ADHD)
a psychological disorder marked by extreme inattention and/or hyperactivity and impulsivity diagnostic criteria: needs to occur before age 12
forensic nurse generalist
a registered nurse with a baccalaureate, associate degree, or diploma level proficient in assessment and treatment of victims and perpetrators of violence
catatonia
a state of unresponsiveness to one's outside environment, usually including muscle rigidity, staring, and inability to communicate
redirection
a technique used following an undesirable or inappropriate behavior to engage or re-engage an individual in an appropriate activity. it may involve the use of verbal directive (setting firm limits), gestures, or physical prompts
cognitive behavioral therapy
a therapy that incorporates techniques from behavioral therapy and cognitive therapy to correct faulty thinking and change maladaptive behaviors
point and level system
a type of behavior modification program in which points are awarded for desired behaviors and increasing levels of privileges can be earned
Acute Dystonia
acute sustained contraction of muscles, usually head, neck
Vegetative Signs of Depression
alterations in those activities necessary to support physical life and growth
Play therapy
an approach to treating childhood disorders that helps children express their conflicts and feelings indirectly by drawing, playing with toys, and making up stories
Suicidal thoughts, especially those in which the patient has a plan and the means to carry it out, represent
an emergency requiring immediate intervention by the nurse
Group
an interconnected and interdependent set of individuals who come together for a shared purpose.
ameliorate
another word for "improve"
phenothiazines
antipsychotic (neuroleptic) drugs. all end in 'zine Ex: Thorazine, Compazine, they are major tranquilizers so think safety
Rapid Cycling
at least 4 mood episodes in a 12 month period; can occur within a month period or throughout a 24 hour period; associated with more severe symptoms
Cognitive theoriest believe that patients with somatic symptoms focus on...
body sensation, misinterprets their meaning, and may become excessively alarmed by them
Paranoid Personality Disorder
characterized by a longstanding distrust and suspiciousness of others based on the belief, which is unsupported by evidence, that others want to exploit, harm, or deceive the person. These individuals are hypervigilant, anticipate hostility, and may provoke hostile responses by initiating a counterattack. As adults, relationships are difficult due to jealousy, controlling behaviors, and unwillingness to forgive. Projection is the dominant defense mechanism whereby people attribute their own unacknowledged feelings to others. For example, they may accuse their partner of being hypercritical when they themselves are attentively fault finding.
social functioning
characterized by ability in communication and language, interpreting and acting on social cues, and regulating emotions
intellectual functioning
characterized by ability in reasoning, problem solving, planning, judgment, abstract thinking, and academic ability
reactive attachment disorder
children with which disorder will have a consistent pattern of inhibited, emotionally withdrawn behavior, and the child rarely directs attachtment behaviors towards and adult caregivers. This is caused by a lack of bonding experiences with a primary caregiver by the age of eight months.
clang associations
choosing words on sound rather than meaning, rhyming click, clack, clutch, close
First degree biological relatives of individuals with chronic pain disorders are more likely to have...
chronic pain, depressive disorder, and alcohol dependence
forensic psychiatric nursing
collecting evidence by carefully evaluating the perpetrator's intent or determining if the perpetrator had diminished capacity
Somatic symptom disorder
combination of distressing symptoms and an excessive or maladaptive response or associated health concerns w/o sign. physical findings & med dx
Somatic Symptoms may be initiated, exacerbated or maintained by....
combinations of bio,psycho, and sociocultural factors
Behavioral theorists suggested that people with somatic symptoms learn methods of....
communication helplessness and these methods aid in manipulation
illness anxiety disorder
condition marked by intense preoccupation with the possibility of a serious undiagnosed illness
Malingering
consciously motivated act to deceive based on the desire for material gain
Patients with conversion disorder will have symptoms like...
deficits in voluntary motor or sensory functions (can't talk, move, hear, see, etc.)
Antidepressants
depression
competence to proceed
determined by the defendant's mental condition at the time of the trial
nurse coroner/death investigator
determining how and why people die
dyslexia
difficulty reading
language disorder
difficulty understanding or using words in context and appropriately Ex: unable to follow directions
dyscalculia
difficulty with math
dysgraphia
difficulty writing
command hallucinations
direct a person to take an action
disinhibited social engagement disorder
disorder seen in children who demonstrate no normal fear of strangers and seem unfazed in response to separation from a primary caregiver. They are usually willing to go off with unknown people.
acute stress disorder
disorder that may develop after exposure to a high traumatic event such as those in PTSD
Communication disorders
disorders characterized by a deficit in language skills acquisition that creates impairments in academic achievement, socialization, or self-care
positive feedback
emotional support and positive feedback are good for anyone, but they are particularly helpful for individuals who rarely receive such attention
Nursing interventions for somatic disorders should focus on...
establishing a helping relationship with the patient
hypersomnia
excessive exhaustion and sleep as many as 12-16 hours per day
derealization
false perception the environment has changed For example, everything may seem bigger or smaller, or familiar objects may appear strange and unfamiliar
pica
feeding disorder has lack of nutrients in system so will eat unusual things like chalk and dirt, occurs mostly in children but can be seen in adults
Worthlessness
feeling inadequate to having unrealistically negative evaluation of self worth
Light Therapy
first line treatment for seasonal affective depression influences melatonin which regulates circadian rhythm and ability to process dopamine and NE morning exposure is best; 30 to 45 minutes of light exposure side effects include headache and jitteriness
eye movement desensitization and reprocessing
first line treatment of traumatized children, processes traumatic memories through a specific eight phase protocol that allows the person to think about the traumatic event while attending to other stimulation, such as eye movements, audio tones, or tapping.
Although controversial, a diagnosis of depression can now be given in the
first two months following death of a loved one or other loss.
physical restraint
for you persons, therapeutic holding may be used to protect the child from impulses to act out and hurt self or others. for stronger adolescents and adults, seclusion and restraint may be necessary
sexual assault nurse examiner
forensic nurse generalists who seek training in the care of adult and pediatric victims of sexual assault
Planning
geared towards the patient's phase of depression, particular symptoms, and personal goals must be aware of potential for suicide assessment for suicide and harm is ongoing *SAFETY IS ALWAYS PRIORITY*
Preparation
getting ready
ideas of reference
giving personal significance to unrelated or trial events; perceiving events as related to you. The false impression that outside events have special meaning for oneself.
Group psychotherapy
group therapy.
anhedonic
having difficulty experiencing positive emotions, a risk factor for depression
Recovery Model Outcome
healing is possible and attainable though partnerships focused on patient strengths, patient centered care, and based on patient's values and personal needs Outcomes should be concrete, measurable, short-term, and long-term goals
Negative symptoms impede one's ability to do the following?
initiate and maintain conversations and relationships, Obtain and maintain employment, make decisions and follow through on plans, maintain adequate hygiene and grooming.
anorexia nervosa
intake restriction
symptoms and behaviors of ADHD
hyperactivity difficulty taking turns difficulty maintaining social relationships high levels of impulsivity poor social boundaries intrusive behaviors frequently interrupting others distractibility and disorganization unable to complete challenging or tedious task
People with illness anxiety disorder are also known as...
hypochondriacs
roles of forensic nursing
identification of victims, creation of appropriate treatment plans, collection/documentation/preservation of evidence
executive functioning
impaired abilities to make decisions, or set priorities
concrete thinking
impaired ability to think abstractly Thinking grounded in immediate experience rather than abstraction. There is an overemphasis on specific detail as opposed to general and abstract concepts.
diminished capacity
impaired mental functioning
Developmental Assessment purpose
in provides information about the child or adolescent's maturational level. Info is reviewed in relation to the child's chronological age to identify developmental strengths or deficits.
helplessness
inability to carry out simple tasks - anger and irritability=verbal attacks,
speech disorder
inability to produce sounds effectively for speaking Ex: "no" for "snow" "little" for "yellow"
anosognosia
inability to realize they are ill
Mood Assessment
inappropriately euphoric mood; may change quickly to irritation or anger when thwarted (plan is derailed); overly friendly spend lots of money; have irrational plans to get rich; busy all day and night; very self-confident; then they become hostile, irritable, and paranoid
inappropriate
incongruent with the actual emotional sate or situaltion (a man laughs when a peer threatens him)
St. John's Wort
increase serotonin, NE, and dopamine good for mild to moderate depression not FDA approved adverse reactions when taken with other medications
Exercise
increases serotonin and dampens hypothalamic-pituitary-adrenocorticoid axis
Grandiosity
inflated self-regard - exaggerate their importance and achievements -*Grandiose persecutory delusions* (EX: god speaking to pt, FBI out to get pt) - Sensory perceptions may become altered - Hallucinations may occur - Delusions and hallucinations are not present with hypomania
limit setting
involves giving direction, stating an expectation, or telling the patient what is required. this should be done firmly, calmly, without judgement or anger, preferably in advance of any problem behavior occurring, and consistently when in a treatment setting among multiple staff
McNaughton rules
irresistible impulse, guilty but mentally ill
dissociation
is a result following exposure to violence and trauma, the parasympathetic response triggers a hypoaroused state with dysregulation of the hypothalamic pituaitary adrenal axis
Pressured speech
is a tendency to speak rapidly and frenziedly,(excited) as if motivated by an urgency not apparent to the listener
dissociation
is an unconscious defense mechanism that protects the individual against overwhelming anxiety through an emotional separation but results in disturbances in memory, consciousness, self identity, and perception
Narcissistic Personality Disorder
is characterized by feelings of entitlement, an exaggerated belief in one's own importance, and a lack of empathy. In reality, people with this disorder suffer from a weak self-esteem and hypersensitivity to criticism. This disorder is associated with less impairment in individual functioning and quality of life than the other personality-based disorders. There may be a familial tendency for this disorder as parents with this disorder may attribute an unrealistic sense of talent, importance, and beauty to their children. These attributions put the children at higher risk. Underneath the surface of arrogance, people with this personality disorder feel intense shame and have a fear of abandonment. The main pathological personality trait is antagonism, represented by the grandiosity and attention-seeking behaviors.
dissociative fugue
is characterized by sudden, unexpected travel away from the customary locale and inability to recall ones identity and information about some or all of the past
dissociative amnesia
is marked by the inability to recall important personal information, often of a traumatic or stressful nature; this lack of memory is too pervasive to be explained by ordinary forgetfulness
anergia
lack of energy
affective blunting
lack of facial expression
Anhedonia
lack of interest in previously pleasurable activities
avolition
lack of motivation
Continuation Phase Outcomes
lasts for 4-9 months 1.) Primary :*Relapse prevention* 2.) Knowledge of disease 3.) Knowledge of medication 4.) Consequences of substance addictions 5.) Knowledge of early signs and symptoms of relapse 6.) Support groups 7.) Communication and problem solving
Behavioral Assessment
like social engagement, spending, and activity; even indiscriminate sex; reduced need for sleep prevent proper rest; *nonstop physical activity and lack of sleep and food can lead to exhaustion and death and is an emergency*; constantly go from one place to another; many projects get started, but never get finished; religious preoccupation is common; they are manipulative, profane, fault finding, and good at exploiting other's vulnerabilities; constantly push the limits; dress in outlandish way, colorful, and inappropriate; highly distractible; concentration is poor; judgement is poor
associative looseness
logical thoughts not tied together, illogical, disjointed
anorexia nervosa
manifestations: Low blood pressure, possible orthostatic hypotension, Decreased pulse and temp Fine, downy hair (lanugo) on the face, arms, and back, Yellowed skin, cool extremities, poor skin turgor, Amenorrhea- irregular or non existent menses
Environmental risk factors-
media influence and pressure from society to be thin
echopraxia
mimicking (echoing) of anothers movements
ambivalence
mixed feelings or ideas about something or someone
Environmental Factors
more prevalent in upper socioeconomic classes because people with bipolar disorder appear to achieve higher levels of education and higher occupational status that people with unipolar depression
Comorbidity
more than half have another psychiatric disorder; panic attacks, alcohol abuse, social phobia, oppositional defiant disorder, specific phobia, and seasonal affective disorder; substance abuse is more common in bipolar I and should be treated at the same time; borderline personality disorder is high; physical disorders associated: chronic fatigue, asthma, migraine, chemical sensitivity, hypertension, bronchitis, and gastric ulcers
precontemplation
need assistance in admitting there is a problem
Conversion disorder manifests as...
neurological symptoms in the absence of a neuro dx
Bereavement exclusion
not diagnosed with depression in the first 2 months following significant loss
dysrhythmic disorders
occurs when feelings of depression persist consistently for at least two years may be present in children, adolescents, and adults onset of this is usually in teen years in which, when they become adults, will express that they've always felt this way
Affective flattening is
one of the negative symptoms that contribute to rendering the person inert and unmotivated.
forensic psychiatric nursing
one who is prepared as a generalist or at the advanced practice level who combines medical and psychiatric nursing with an understanding of the criminal justice
affect
outward expression of emotion
affect
outward representation of person's internal state of being ad is an OBJECTIVE finding based once nurse's assessment
advance practice interventions
overall goals are to: help patients maintain control of their thoughts and behaviors, assist families to function more adaptively
hallucinations
perceiving a sensory experience in which no external stimulus exists, hearing a voice; seeing a vision
the diathesis stress model
physiological vulnerabilities such as genetic predispositions, biochemical makeup, and personality structure PLUS the life events that impact individual vulnerabilities explains why two persons exposed to relatively similar events may respond differently explains how early life trauma may result in long-term hyperactivity of CNS corticotropin-releasing factor and norepinephrine systems causing a neurotoxic effect on the hippocampus leading to neuronal loss. Sensitization of CRF circuits to even mild stress in adulthood leads to an exaggerated stress response.
Music Therapy
prescribed use of music by qualified person, usually a therapist, to guide the patient in exploring images and feelings inspired by the music selection shone by the therapist. Mommy Guided Imagery Method
positive symptoms
presence of something NOT normally present (e.g. hallucinations, delusions, bizarre behavior, paranoia)
Seclusion Protocol
proper reporting through the chain of command physicians order must be reviewed and rewritten every 24 hours - include type and restraint with order - In an emergency, must get order within 30 minutes after - behavior must be observed and documented every 15 minutes - offered food and fluids every 30 to 60 minutes - use the bathroom every 1 to 2 hours - vitals measured every 1 to 2 hours
forensic nursing
provides direct services to crime victims and perpetrators of crime, consultation services to colleagues, medicine, social work, rehabilitation and law
Mental Status Exam purpose
provides information about the mental state at the time of the examination and identifies problems with thinking, filing, and behaving
akathisia
psycho-motor restlessness, pacing , fidgeting, Regular rhythmic movements, usually of the lower limbs, with constant pacing sometimes seen; often noticed in people taking anti-psychotic medication.
echolalia
repeating (echoing) of another words
Psychoanalytic theorists believes that psychogenic complaints of pain, illness, or loss of physical function are related to....
repression of a conflict
depressive disorder associate with another medical condition
results from changes that are directly related to certain illnesses such as Parkinson's or Alzheimer's. symptoms of this diagnosis is not considered major depressive disorder
Antidepressants and Children
risk of suicide goes up if depressed children do not take antidepressants; to reduce risk, closely monitor by health care professional and patient/care giver education
Bipolar disorder
shifts in mood, energy, and ability to function ranges from severe mania to severe depression
Assessment of Suicide Potential
should be an ongoing assessment for suicidal or homicidal ideation
Negative symptoms
social isolation, impaired social interaction, risk for loneliness, chronic low self-esteem, Risk of rself directed violence, ineffective coping, self-care deficit (bathing/hygiene, dressing/grooming) Constipation. FAMILY and SIG Other....compromised family coping, caregiver role strain, drficent knowlege, nonadherence,
Somatic disorders include...
somatic symptom disorder, illness anxiety disorder, conversion disorder, psychological factors affecting medical condition, factitious disorder
clarification as intervention
sometime misunderstandings are the source of frustration and potential loss of control. helping the patient to understand the environment and what is happening can reduce feelings of vulnerability and the urge to strike out
Group psychotherapy or group therapy
specialized treatment intervention led by an advanced mental health professional. Focus more on general topics such as improving social skills, shyness, anger, or grieving.
Euphoric Mania
starts out as wonderful feeling then turns scary and dark as euphoria moves toward confusion and loss of control
Pregnant Women
studies show they are relatively safe increase in preterm birth congenital malformations for MAOI, TCA, and SSRI irritability and tremors in neonates preeclampsia, diabetes, and hypertension associated with maternal depression low birth weight, preterm birth, small size associated with maternal depression
cognitive symptoms
subtle changes in memory, attention and thinking
Evaluation
suicide sleep pattern thought processes self esteem social interactions If these have not been met, need to go back and try again
affective symptoms
symptoms involving emotion and their expression
legal insanity
the presence of a major mental disorder that prevents an individual to distinguish right from wrong
resilience
term that refers to positive adaptation or the ability to maintain or regain mental health despite adversity
fact witness
testifies what was personally seen or heard, performed, or documented patient's care and testifies first hand experiences only
forensic nursing
the application of nursing science to public or legal proceedings
forensic nursing
the application of the forensic aspects of healthcare combined with the biopsychosocial education of the registered nurse in the scientific investigation and treatment
correctional nursing
the care of incarcerated patients and presents challenges to the way nurses think about patients
depersonalization
the focus is on oneself, it is an extremely uncomfortable feeeling of being an observer of ones own body or mental processes
derealization
the focus is on the outside world, it is the recurring feeling that ones surroundings are unreal or distant. the person may feel mechanical, dreamy, or detached from the body
legal sanity
the individual's ability to distinguish right from wrong with reference to the act with which he or she is charged
The maintenance stage
the ongoing commitment to a recovery program
Affect is...
the outward expression of a persons internal emotional state. Affect may not always coincide with inner emotions. (Flat, Blunted, inappropriate, bizarre)
affect
the outward representation of internal state and is an objective finding
mood
the patient's SUBJECTIVE experience of sustained emotions or feelings
irresistible impulse
the person may have known that the criminal act was wrong but could not control their behavior
resilience
the personal strength that helps most people cope with stress and recover from adversity and even trauma the relationship between a child's inborn strengths and that child's success in handling stressful environmental factors
planned ignoring
when the staff determines behaviors not to be safe and only attention seeking, they may be ignored. additional interventions may be used in conjunction-- positive reinforcement for on-task actions
vagus or tenth
which nerve governs the sympathetic and parasympathetic system
myelinated ventral vagal
which responses of the vagus nerve are activated during social or intelligent engagement when the individual is "on" in a pleasant state, not overwhelming, arousal.
unmyelinated ventral vagal
which responses of the vagus nerve are activated when we percieve a threat
dorsal vagal response
which vagal response occurs to dampen down the sympathetic nervous system and is the parasympathetic response
physical distance and touch control
while touching and closeness may have a positive effect on many patients, patients with oppositional defiant, intermittent explosive, and conduct disorders may need increased personal space and feel threatened by touch
Do somatix disorders run in families?
yes; increased risk in monozygotic twin pairs
Serotonin Syndrome
• *Hyperactivity* or restlessness • *Tachycardia* → cardiovascular shock • *Fever* → hyperpyrexia • Elevated blood pressure • Altered mental states (*delirium*) • Irrationality, mood swings, hostility • *Seizures* → status epilepticus • Myoclonus, incoordination, tonic rigidity • Abdominal pain, diarrhea, bloating • *Apnea* → death
Guidelines for Nursing Care for patients with Paranoid Personality Disorder
• Considering the degree of mistrust, promises, appointments, and schedules should be strictly adhered to. • Being too nice or friendly may be met with suspicion. Instead, give clear and straightforward explanations of tests and procedures beforehand. • Use simple language and project a neutral but kind affect. • Limit setting is essential when threatening behaviors are present.
Intervention Strategies
• Involve the patient in goal-setting and treatment planning. This increases treatment adherence and improves treatment outcomes. • Emphasize quality of life rather than simply focusing on symptoms as this conveys an interest in the person rather than the illness and promotes recovery. • Maintain sustained therapeutic relationships; trust in providers is key to overcoming anosognosia and achieving treatment adherence. People with SMI often require extended periods to form these connections. • Focus on coping with current issues rather than past difficulties. • Encourage reality testing to enable consumers to recognize and counter hallucinations and delusional thinking. For instance, if a person experiences frightening hallucinations while in public, he can learn to scan the room and determine if others seem frightened. If not, he can learn to attribute his experience to his illness and to ignore the hallucinations. • Enable consumers to recognize and respond to stigma. Stigma predisposes SMI people to isolation and social discomfort. The resulting isolation contributes to loneliness and reduces access to support. • Promote social skills and provide opportunities for socialization, especially with positive role models, such as other patients who are further along in recovery. • Involve consumers in support groups such as NAMI that expose them to members who "have been there." Such groups provide support, socialization opportunities, and practical suggestions for issues and problems facing patients and significant others. Peer support specialists are another excellent resource for this purpose. • Educate consumers about their illness and recovery. Understanding the illness enhances coping, treatment adherence, and quality of life. • Care for the whole person. SMI patients have more physical illness; poorer hygiene and health practices; less access to effective medical treatment; increased risk for victimization, STDs, and undesired pregnancies. They also have more premature mortality than the general population. Avoiding obesity through exercise and good nutritional practices can reduce the risk of comorbidities such as metabolic syndrome. Sound physical health conserves energy and resources for use in coping with SMI. • Involving individuals with co-occurring substance use disorders in Alcoholics Anonymous and Narcotics Anonymous (AA/NA) and other dual-diagnosis services. Substance use disorder rates are high in SMI populations. They increase relapse and interfere with recovery. Achieving sobriety is most associated with AA and integrated treatment programs.
The Recovery Model
• Is patient/consumer-centered. • Is hopeful and empowering. • Emphasizes the person and the future rather than the illness and the present. • Involves an active partnership between patient and care providers. • Focuses on strengths and abilities rather than dysfunction and disability. • Encourages independence and self-determination. • Focuses on achieving goals of the patient's choosing (not staff's). • Emphasizes staff working collaboratively with consumers, building on strengths to help consumers achieve the highest possible quality of life. • Aims for increasingly productive and meaningful lives for those with SMI.
Guidelines for caring for a patient with Dependent Personality Disorder
• Nurses can help the patient identify and address current stressors. • Be aware that strong countertransference may develop because of patient's demands for extra time and crisis states. • The therapeutic nurse-patient relationship can provide a testing ground for increased assertiveness through role modeling and teaching of assertive skills.
Nursing Care for a patient with Schizoid Personality Disorder
• Nurses should avoid being too "nice" or "friendly." • Do not try to increase socialization. • Patients may be open to discussing topics such as coping and anxiety. • Conduct a thorough assessment to identify symptoms the patient is reluctant to discuss. • Protect against ridicule from group members due to patient's distinctive interests or ideas.
Guidelines for Nursing Care of Patients with Obsessive Compulsive Personality Disorder
• Nurses should guard against power struggles with these patients as their need for control is very high. • Patients with this disorder have difficulty dealing with unexpected changes. • Provide structure, yet allow patients extra time to complete habitual behavior. • Assist patients to identify ineffective coping and to develop effective coping techniques.
Guidelines for Nursing care for patients with Narcissistic Personality Disorder
• Nurses should remain neutral and recognize the source of narcissistic behavior—shame and fear of abandonment. • Use the therapeutic nurse-patient relationship as an opportunity to practice how to engage in meaningful interaction. • Avoid engaging in power struggles or becoming defensive in response to the patient's disparaging remarks. • Role model empathy.
Guidelines for nursing care for patients with Avoidant Personality Disorder
• Nurses should use a friendly, accepting, and reassuring approach. • Remember that being pushed into social situations can cause severe anxiety for these patients. • Convey an attitude of acceptance toward patient fears. • Provide the patient exercises to enhance new social skills but use with caution because any failure can increase feelings of poor self-worth. • Assertiveness training can assist the person to learn to express needs.
Guidelines for Nursing Care of patients with Histrionic Personality Disorder
• Nursing care should reflect an understanding that seductive behavior is a response to distress. • Keep communication and interactions professional. • Patients may exaggerate symptoms and have difficulty in functioning. • Encourage and model the use of concrete and descriptive rather than vague and impressionistic language. • Assist the patient to clarify feelings because they often have difficulty identifying them. • Teach and role model assertiveness. • Assess for suicidal ideation. What was intended as a suicide gesture may inadvertently result in death.
Serotonin Syndrome Interventions
• Remove offending agent(s) • Initiate symptomatic treatment: • Serotonin-receptor blockade with *cyproheptadine, methysergide, propranolol* • Cooling blankets, chlorpromazine for hyperthermia • Dantrolene, *diazepam* for muscle rigidity or rigors • Anticonvulsants • Artificial ventilation • Induction of paralysis
Nursing care guidelines for Schizotypal Personality Disorder
• Respect patient's need for social isolation. • Nurses should be aware of patient's suspiciousness and employ appropriate interventions. • Perform careful assessment as needed to uncover any other medical or psychological symptoms that may need intervention (e.g., suicidal thoughts). • Be aware that strange beliefs and activities, like strange religious practices or peculiar thoughts, may be part of the patient's life.
