Mental health midterm

alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants/tobacco, and other substances

10 classes of psychoactive substances in the DSM 5

schizophreniform disorder

2/3 progress to 5 symptoms are experienced for at least 1 month < 6 months does not have to have impaired social/occupational functioning (difficult to assess) essential features of this disorder are like those of schizophrenia except the symptoms last less than 6 months, occupational functioning may or may not be apparent, some individuals will return to previous functioning, some may have problems moving forward

1.Alzheimer's, the most common, with gradual onset of decline. 60-80% 2.Vascular dementia- from ischemia or stroke. ~10% 3.Dementia with Lewy bodies - fluctuating cognition. 10-15% 4. Frontotemporal dementia -behavioral disorder and affective symptoms. ~10%

4 main types of dementia"

LEAD: system wide culture change committed to reducing suicides TRAIN: a competent, confident, and caring work force IDENTIFY: individuals with suicide risk via comprehensive screening and assessment ENGAGE: all individuals at risk of suicide using a suicide care management plan TREAT: suicidal thoughts and behaviors directly using evidence based treatments TRANSITION: individuals through care with warm handoffs and supportive contacts IMPROVE: policies and procedures through continuous quality improvement

7 essential elements of zero suicide:

delirium

A disturbance of consciousness A change in cognition with acute onset Occurs Over a short period of time and may fluctuate Transient/fluctuates and when underlying cause corrected it resolves Always secondary to another condition A risk for all hospitalized patients Acute mental confusion- Temporary Highest in hospitalized older adults Increase risk for falls Can be confused with dementia Acute onset Easily distractible/Inattention Rambling conversation Disorganized thinking Altered LOC

Trauma centered caew

A framework developed by the national center for trauma informed care, a division of SAMHSA. Recognizes that trauma is almost universally found in the histories of mental health patients. Recognizes that trauma is a contributor to mental health issues, substance abuse, and contact with the criminal justice system

maintain a normal social interaction distance from the patient

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face disappears and appears in the mirror" While listening, the nurse should:

relapse

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3-4 hours per night, and has difficulty concentrating. The patient says, "Demons are in the basement and they can come through the floor." The nurse can correctly assess this information as an indication of

Olanzapine (Zyprexa) (positive and negative emotions)

A patient diagnosed with schizophrenia has taken a first generation antipsychotic medication for a year. Hallucinations are less intrusive but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication?

Risk for other directed violence

A patient diagnosed with schizophrenia is hospitalized after arguing with coworkers and threatening to harm them. The patient is aloof and suspicious says, "Two staff members I saw talking were plotting to assault me." Based on data gathered at this point, which nursing diagnoses relate?

Dangerous

A patient diagnosed with schizophrenia says, "my coworkers are out to get me. I also saw two doctors plotting to overdose me." How does this patient perceive the environment?

"I am having difficulty understanding what you are saying"

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response.

neuroleptic malignant syndrome, immediately notify the HCP

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00PM, vital signs are body temperature, 102.8, pulse 110bpm, 150/90mmhg. Select the nurse's best analysis and action.

parasympathetic branch

ANS, the part of the brain that helps maintain homeostasis and relaxation, takes over cortisol levels drop as the body returns to a more normal and healthier state that allows individuals to function as they did before the threat

Disulfiram intended effects: •Daily oral medication that is a type of aversion (behavioral) therapy •Used concurrently with alcohol will cause acetaldehyde syndrome to occur •Nausea, vomiting, weakness, sweating, palpitations, and hypotension •Acetaldehyde syndrome can progress to respiratory depression, cardiovascular suppression, seizures, and death NC: Inform the client of the potential dangers of drinking any alcohol •Advise the client to avoid any products that contain alcohol (cough syrup, aftershave lotion, mouthwash, hand sanitizer) •Encourage the client to wear a medical alert bracelet •Encourage the client to participate in a 12-step program •Advise the client that medication effects, such as the potential for acetaldehyde syndrome with alcohol ingestion, persist for 2 weeks following discontinuation of disulfiram Naltrexone Intended effects: Pure opioid antagonist that suppresses the craving and pleasurable effects of alcohol (also used for opioid withdrawal) NC: Assess the client's history to determine whether the client is also dependent on opioids, concurrent use increases the risk for a client to overdose on opiates •Suggest monthly IM injections of depot naltrexone for clients who have difficulty adhering to the medication regimen Acamprosate: intended effects •Taken orally thee times a day to reduce the unpleasant effects of abstinence (dysphoria, anxiety, restlessness) NC: Inform the client that diarrhea can result. Advise the client to maintain adequate fluid intake to prevent dehydration •Advise the client to avoid use in pregnancy

Alcohol abstinence maintenance meds

Sees environment accurately, understands consequences Vs Inaccurate perceptions of environment, hallucinations or delusions

Appraisal of reality continuum:

factitious disorder:

Artificially, deliberately, and dramatically fabricate symptoms or self-inflict injury Goal of assuming a sick role Compulsivity

cognitive theory

Beck; negative & self critical thinking causes depression cognitive behavior therapists assist in identifying negative thought patterns & replacing them with rational ones; often involves homework

one person has a need to communicate with another (stimulus) the person sending the message (sender) initiates interpersonal contact the message is information sent or expressed to another. the clearest messages are those that are well organized and expressed in a manner familiar to the receiver the message can be sent through a variety of media: auditory, visual, tactile, olfactory, or any combination person receiving the message (receiver) interprets the message and responds by providing feedback

Berlo's classic communication model (1960):

C—Have you ever felt you ought to Cut down on your drinking (or 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? AID—Adapted to Include Drugs

CAGE-AID screening tool

•Can produce physiological and psychological dependence •Can have cross-tolerance, cross-dependency, and an additive effect when taken concurrently •Examples: alcohol, benzodiazepines, minor tranquilizers, barbiturates, chloral hydrate

CNS depressants

Blood alcohol concentration (BAC) of 0.08% (80 g/dL) is considered legally intoxicated for adults operating automobiles in most U.S. states Death could occur from acute toxicity in levels greater than approximately 0.4% (400 g/dL) BAC depends on many factors: body weight, gender, concentration of alcohol in drinks, number of drinks, gastric absorption rate, and the individual's tolerance level Intended effects: Relaxation, decreases social anxiety, stress reduction

CNS depressants: alcohol

Examples: •Benzodiazepines like diazepam, barbiturates like phenobarbital, or club drugs like flunitrazepam ("date rape drug") •Can be taken orally or injected •Intended effects: •Decreased anxiety, sedation effects of intoxication: •Increased drowsiness and sedation, agitation, slurred speech, uncoordinated motor activity, nystagmus, disorientation, nausea, vomiting •Respiratory depression and decreased level of consciousness, can be fatal •An antidote, flumazenil, available for IV use for benzodiazepine toxicity •No antidote to reverse barbiturate toxicity withdrawal manifestations: •Anxiety, insomnia, diaphoresis, hypertension, possible psychotic reactions, hand tremors, nausea, vomiting, hallucinations or illusions, psychomotor agitation, and possible seizure activity

CNS depressants: sedatives/hypnotics/anxiolytics

Can be taken orally, injected intravenously, or smoked Intended effects: Increased energy, euphoria similar to cocaine Effects of Intoxication: •Impaired judgment, psychomotor agitation, hypervigilance, extreme irritability •Acute cardiovascular effects (tachycardia, elevated blood pressure) which could cause death Withdrawal manifestations: •Craving, depression, fatigue, sleeping •Not life-threatening

CNS stimulants: amphetamines

•Includes cola drinks, coffee, tea, chocolate, energy drinks •Intended effects: •Increased level of alertness and decreased fatigue Effects of Intoxication: •Intoxication commonly occurs with ingestion of greater than 250 mg (one 2 oz high-energy drink can contain 215 to 240 mg caffeine) •Tachycardia and arrhythmias, flushed face, muscle twitching, restlessness, diuresis, GI disturbances, anxiety, insomnia Withdrawal manifestations: •Can occur within 24 hr of last consumption •Headache, nausea, vomiting, muscle pain, irritability, inability to focus, drowsiness

CNS stimulants: caffeine

Can be injected, smoked or inhaled (snorted) Intended effects: •Rush of euphoria (extreme well-being) and pleasure, increased energy Effects of Intoxication: Mild toxicity: •Dizziness, irritability, tremor, blurred vision Severe effects: •Hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, possible cardiovascular collapse and death Withdrawal manifestations: •Depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation •Not life threatening, but possible occurrence of suicidal ideation Common signs of stimulant abuse •Dilation of the pupils •Dryness of the oronasal cavity •Excessive motor activity ØCocaine and crack ØMethamphetamine ØCaffeine and nicotine

CNS stimulants: cocaine

dementia

Chronic syndrome characterized by progressive, irreversible (more than 80%), cognitive deterioration, personality change, and a decline in functional abilities. It implies a global deterioration in a person's mental abilities: memory, judgment, ability to think abstractly, and orientation Progressive cognitive impairment (impaired ability to learn new information or recall previously learned information Characterized by gradual onset and continuing cognitive decline One or more of following cognitive disturbances: Aphasia (language disturbance) Apraxia (unable to perform motor activities even though physical ability is intact) Agnosia (unable to recognize objects with physical ability still intact) Executive function (unable to plan, organize, or think abstractly)

psychiatric mental health nursing

Committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and Comorbid conditions across the lifespan Art and science, employing a purposeful USE OF SELF as its art and a wide range of nursing, psychosocial, and neurobiological evidence to produce effective outcomes

Ability to recognize cues & act appropriately Vs Aggressive or violent behaviors

Control over behavior:

substance use

DSM 5 = a problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of 11 items, occurring within a 12 month period

use in larger amounts of over long period persistent or unsuccessful efforts at control excessive time spent in procurement, use, or recovery craving recurrent use results in failure to fulfill major roles (at work, school, or home) continued use despite persistent social problems loss of important activities due to use recurrent use despite physical hazards continued use despite knowledge of negative health effects tolerance (need for more, or diminished effect) withdrawal or continued use to avoid withdrawal

DSM 5 criteria for substance use disorder:

neuroleptic malignant syndrome (answer) (labile and schizophrenic...)

David is a schizophrenic, aged 24, is an ER patient presenting with the symptoms of delirium, muscle rigidity, temperature of 103, pulse rate of 126, pulse ox of 89% and a labile BP. What are you most concerned may be occurring?

milieu therapy health teaching health promotion psychotherapy CBT, dialetical behavioral therapy psychodynamic therapy group and family therapy

EBP in the optimum treatment of EDs

nigrostriatal pathway

EPS projections from the substantia nigra to striatum stimulation of purposeful movements D2 antagonism induces extrapyramidal symptoms

alcohol withdrawal

Early signs within a few hours Peaks within 24 to 48 hours Rapidly and dramatically disappears unless it progresses to delirium Irritability and "shaking inside" Grand mal seizures possible in 7 to 48 hours after cessation Illusions

Ability to problem solve and cope in ways that are not harmful (deep breathing, medication) Vs Poor coping that creates further dysfunction (substance abuse, self harm)

Effective coping strategies continuum:

Performs with abilities, recovery from minor failures Vs deterioration in work performance, inability to maintain steady employment

Effectiveness in work continuum:

somatization

Expression of stress through physical symptoms that are often manifestations of psychological and emotional distress Symptoms expressed in place of anxiety, depression, or irritability Holistic approach: multidimensional interplay of biological, psychological, and sociocultural needs and its effects on somatization

dissociative identity disorder (dissociative disorders)

Formerly known as multiple personality disorder, which is the presence of two or more distinct personality states that control behavior Most severe of the dissociative disorders Patients "lose time," they do not have memory of periods of time ranging from minutes to weeks Each alternate personality (alter) has its own pattern of personality, perception, affect, cognition, behavior, and memories The traumas that are overwhelming or intolerable are shared among the alters to protect the host Result of repetitive childhood abuse or trauma, with a mean duration of 10 years and beginning before the age of 6 years Scenario: The psychiatric nurse practitioner who visits a women's free health center notices that Taylor, 23, dresses, acts, writes, and speaks in extremely different ways at each visit and has lapses of memory in time, unable to remember the previous visits.

psychoanalytic theory

Freud; unconscious thoughts, psychosexual development psychoanalysis to learn unconscious thoughts; therapist is nondirective & interprets meaning

physiologic effects: amino acid that modulates other neurotransmitters relationship to mental health disorders: decreased in anxiety and schizophrenia

GABA

Finds life enjoyable, optimistic about needs being met Vs Loss of interest or pleasure, discouraged or hopeless mood

Happiness continuum:

call rapid response because it is likely neuroleptic malignant syndrome

Harry Potter is on the mental health unit because of hallucinations of Hogwarts, flying brooms and witches. he begins to become confused and disorientated, has decreasing loss of consciousness rapidly, holds himself stiff, and is very warm to touch. you take his vitals and he has a high bp, and temperature of 103.2. what are you most concerned he has?

Reasonable self confidence, resourcefulness Vs Lacks self confidence, inability to function independently

Healthy self concept continuum:

Attending

Intensity of presence, being there for the patient and in tune with the patient. results in a human connection behaviors include: active listening skills such as body posture & eye contact, touching, giving attentive physical care attending behaviors are learned are inherent in a true therapeutic relationship

Jessie, your BAL was 0.11%. that clearly indicates that you had alcohol intoxication

Jessie had a blood alcohol level (BAL) of 0.11% upon arrival to the ED. she is now your patient in the hospital psychiatric unit, day 4. She tells you "I wasn't drunk. I just had a few beers." What is an appropriate response?

"tell me about the last AA meeting you attended"

Jessie is now attending AA meetings three times a week for the past 6 weeks. she has been sober during this time and visits biweekly the community mental health outpatient clinic. Jessie's nurse counselor wants to talk with her about the AA meetings. Which initial question or statement is most appropriate?

mental illness

Medical conditions (dysfunctions of the brain and neurotransmitters) that affect a persons thinking, feeling, mood, ability to relate to others, and daily functioning. Result of a chain of events that include flawed biological, psychological, or social processes

withdrawal delirium

Medical emergency Possible death Peaks 2 to 3 days after cessation and reduction Autonomic hyperactivity Sensorial and perceptual disturbances Fluctuating loss of consciousness (LOC) Delusions (paranoid) Agitated behaviors Body temperature 100° F or higher

Recovery Model

More of a SOCIAL model of disability than a medical model of disability. Emphasis is on rehab and recovery. Assists with psychiatric disabilities to effectively manage symptoms, reduce psychosocial disability, and find a meaningful life in a community of their choosing

risk for suicide, imbalanced nutrition, anxiety, ineffective coping, hopelessness

ND for BSD:

Preoccupied with orderliness, stubbornness, perseverance, indecisiveness, and emotional constriction Pervasive pattern of perfection and inflexibility Cautious and consider all choices in a methodical and inflexible manner Obsessed with rules and details and follow them rigidly Rigid perfectionism: great difficulty incorporating new ideas or viewpoints Perseveration: persistent pursuit of tasks long after their actions have any consequence and even if the face of repeated failures High achievers; do well in the sciences; obtain their sense of worth from work and productivity Superficial, rigidly controlled intimacy Financially stingy

OCD personality disorder (cluster c)

similarity: can occur after the same kind of triggers that exist in PTSD, same or similar manifestations difference: acute stress disorder resolves within 1 month

PTSD vs Acute stress disorder

behavioral theory

Pavolv, Watson-Skinner; behavior is learned through conditioning behavioral modification addresses maladaptive behaviors by rewarding adaptive behavior

trauma informed care

Provides guidelines for integrating an understanding of how trauma affects patients into clinical programming. Changes from "what's wrong with you?" To "what has happened to you." a framework developed by the National Center for Trauma Informed Care, recognizes that trauma is almost universally found in the histories of mental health patients and is a contributor to mental health issues, substance abuse, chronic health conditions, and contact with the criminal justice system avoid retraumatizing through restraints or coercive practices, an open collaborative relationship between patient and provider, empowerment and cultural respect

Mental health care is to be consumer and family driven, with patients being partners in all aspects of care. Care must focus on increasing consumer success in coping with life's challenges and building resilience, not just managing symptoms An individual care plan is to be at the core of consumer centered recovery

Recovery model mandates:

depersonalization/derealization disorder: (dissociative disorders)

Recurrent periods of feeling unreal, detached, outside the body, numb, dreamlike, or a distorted sense of time or visual perception Reality testing remains intact Symptoms are not related to medical condition or substance use Scenario: Janet is admitted to the ED with a sensation of "floating" and "not feeling very real." Her ex-husband is with her and says "they were arguing over the deaths of their infant twins in a car accident last year, in which Janet was the driver at fault. This whole thing has led to our divorce," he says.

elderspeak

Refers to the unnecessary us of simple, childlike phrases; slow speech; high volume; and collective pronouns (do "we" want to take a bath?) when communicating with older adults Typically meant to create a sense of caring, but can inadvertently imply that the older adult is incompetent

Stable, strong relationships, variety of social supports Vs Unstable or intense relationships, lack of support

Satisfying relationships continuum:

Happiness Control over behavior Appraisal of reality Effectiveness in work Healthy self concept Satisfying relationships Effective coping strategies

Seven signs of mental health:

mental health

Successful performance of mental functions, resulting in the ability to engage in productive activities, enjoy fulfilling relationships, and change or cope with adversity. Foundation of thinking, communication skills, learning, emotional growth, RESILIENCE, and self esteem throughout the lifespan

Caring, attending, patient advocacy

The "art" of nursing care:

competent A nurse may be at a level of competence but is unable to demonstrate caring

The caring nurse is first and foremost _____________ nurse

Empathic understanding, actions, and patience on another's behalf. Being present leads to happiness and touches the heart. Giving of self while preserving the importance of self. first and foremost a competent nurse comforting

The caring nurse:

antipsychotic medications can cause amenorrhea, but ovulation still occurs

The nurse is discussing the side effects experienced by a female client taking antipsychotic medications. The client states, "I haven't had a period in 4 months." Which client teaching should the nurse include in the plan of care?

dissociative identity disorder

a college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later, and then sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered?

psychotic disorder

a constellation of symptoms including delusions, prominent hallucinations, disorganized speech, disorganized behavior or catatonia disorders: delusional, schizophreniform disorder, schizoaffective disorder, schizophrenia

group therapy

a gathering of two or more individuals who share a common purpose meet over a substantial time period in face to face interaction to achieve an identifiable goal therapeutic results: gaining new information or learning, gaining inspiration or hope, interacting with others, feeling acceptance and belonging, becoming aware that one is not alone and that others share the same problems, gaining insight into one's problems/behaviors and how they affect others, giving of oneself for the benefit of others (altruism)

maintain normal salt and fluids in the diet

a health teaching plan for a patient taking lithium should include instructions to:

ancient times: sickness represented displeasure of the gods, punishment for wrongdoing, witch hunts, treatments: starving, urging, torture, bloodletting period of enlightenment: 1790s: creation of asylums or safe havens Sigmund Freud: and others studied mental disorders scienticially by the 1900s shock therapies: insulin shock, ECT psychosurgery, psychotropic drugs (1950) deinstitutionalization: began in the late 1950s when the majority of care for persons with psychiatric illness began to shift away from hospitals toward community settings. contributing factors included the establishment of Medicare and Medicaid, changing rules governing involuntary confinment, and the passage of legislation supporting constriction of community health centers community centered care, self help support groups

a historical perspective of mental health treatment:

countertransference (answer)

a nurse assesses an older adult patient brought to the hospital emergency department by a neighbor who found the patient wandering confusedly in the front yard, saying "I can't find my way home." The nurse experiences sadness and reflects, "The patient is like one of my grandparents... so helpless." What feelings are being expressed by the nurse?

i've lost 60 pounds but i'm still a size 2. I want to be a size 0

a nurse assesses four adolescents diagnosed with various eating disorders. which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa?

"these clients are like living with my mother and aunt"

a nurse has worked on a mental health unit for an extended period of time. which statement is best associated with behaviors demonstrated as a result of burnout?

dependent

a nurse in the emergency department tells an adult, 'your mother had a serious stroke.' the adult tearfully says, 'who will take care of me now? my mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious.' which term best describes this behavior?

hallucinations and delusions

a nurse is assigned the care of four patients who are detoxifying from alcohol. the patient with which symptoms would be the nurse's highest priority?

confers with a pharmacist with selecting OTC meds

a nurse provided medication education for a patient diagnosed with major depressive disorder who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient...

within therapeutic limits

a nurse receives this lab result: lithium level 1 mEq/L. this result is...

verbal abuse of another patient

a nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verabally abuses a patient diagnosed with dementia, and flatters the primary nurse. the patient is detached and superficial during counseling sessions. which behavior most clearly warrants limit setting?

individual psychotherapy

a one to one relationship between the therapist and the client

report muscle stiffness

a patient begins therapy with a first generation antipsychotic medication. what teaching should a nurse provide related to the drug's strong dopaminergic effect?

external controls are necessary while internal controls are developed

a patient diagnosed with a personality disorder has used manipulation to get his or her needs met. the staff decides to apply limit setting interventions. what is the correct rationale for this action?

"taking the medication every day helps reduce the risk of a relapse"

a patient diagnosed with bipolar disorder is in the maintenance phase of treatment. the patient asks, "do I have to keep taking this lithium even though my mood is stable now?"

'it is disappointing when someone you love no longer recognizes you'

a patient diagnosed with dementia no longer recognizes family members. the family asks how long it will be before their family member recognizes them when they visit. what is the nurse's best reply?

explain the time lag before antidepressants relieve symptoms

a patient diagnosed with major depressive disorder began taking escitalopram 5 days ago. The patient now says, "this medicine isn't working." The nurse's best intervention would be to:

You're wearing a new shirt

a patient diagnosed with major depressive disorder says, "no one cares about me anymore. i'm not worth anything." today the patient is wearing a new shirt and has neat, clean hair. which remark by the nurse supports building a positive self-esteem for this patient?

relieving anxiety through the physical symptom

a patient has blindness related to a functional neurological (conversation) disorder but its unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? The patient is:

produce fewer motor side effects

a patient has taken many conventional antipsychotic drugs over the years. the health car provider who is concerned about early signs of tardive dyskinesia prescribes risperidone (Risperdal). A nurse planning care for this patient understands the second genderation antipsychotics:

has symptoms of alcohol withdrawal delirium

a patient was admitted 48 hours ago for injuries sustained while intoxicated. the patient is shaky, irritable, anxious, and diaphoretic. the pulse rate is 130 beats per minute. the patient shouts, 'snakes are crawling on my bed, i've got to get out of here.' what is the most accurate assessment of the situation? the patient:

january

a patient was diagnosed with seasonal affective disorder. during which month would this patient's symptoms be most acute?

between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)

a patient with a history of daily alcohol abuse was hospitalized at 0200 today. when would the nurse expect withdrawal symptoms to peak?

arrange for one on one supervision

a patient with acute mania has disrobed in the hall three times in 2 hours. the nurse should...

hypokalemia

a patient with bulimia nervosa has become dehydrated from self induced vomiting. this is most likely to result in:

explain how to manage hypotension and reassure the patient that side effects go away after several weeks

a patient with depression who is taking a tricyclic antidepressants tells the nurse, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should:

constricted

a person has recently abused morphine. the person's pupils would most likely be

"i get tired of being nagged. my spouse deserved the beating"

a person's spouse filed charges of battery. the person has a long history of acting-out behaviors and several arrests. which statement by the person suggests an antisocial personality disorder?

postpartum psychosis

a rare condition that develops within the first 6 weeks after delivery thoughts of harming self or baby, confusion and disorientation, command hallucinations and delusions that baby is possessed, paranoia, often have severe anxiety -- panic attacks

overgeneralization

a single event affects unrelated situations 'he didn't ask me out. it must be because i'm fat'

age discrimination

actions and outcomes that reflect the bias toward the elderly

acute: patient is admitted into an inpatient unit, CBT is highly effective, binge and purge cycle is interrupted, eating habits are normalized, underlying conflicts and distortions are examined, comorbid depression and substance abuse are treated longterm: on discharge, the patient is referred for long care to solidify goals and to address attitudes and percpetions that maintain the ED, patient and family benefit from connecting with the national network, psychotherapy is performed

acute and long term care for bulimia:

facial grimacing involuntary upward eye movement muscle spasms of the tongue, face, neck, and back (back muscle spasms cause trunk to arch forward) laryngeal spasms

acute dystonia:

managing medications decreasing physical activity increasing food and fluid intake ensuring at least 4-6 hours of sleep per night intervening so that self care needs are met

acute mania hospitilization:

perfectionism

addie's condition worsens and she collapses at home. she is admitted to your unit with anorexia. you have completed your physical and biopsychosocial assessment of her. which common personality trait is likely to present a particular challenge?

antidepressants are administered for severe depression lithium or other mood stabilizers reduce aggressive behavior benzodiazepine augmentation improved positive and negative symptoms clonazepam decreases anxiety, agitation, and possibly psychosis

adjuncts to antipsychotic drug therapy

Psychotherapy or consultation Holistic approach Biological, environmental, psychological, spiritual, and sociocultural needs Cognitive-behavioral therapy (CBT) Act as nurse consultant or liaison

advanced practice interventions for somatization

commitment to patient's health, well-being, and safety across the lifespan. alleviation of suffering. promotion of a peaceful, comfortable, and dignified death advise patients of their rights (including the right to refuse treatment), providing accurate and current information so patients can make informed decisions, support those decisions

advocacy in nursing includes:

children: consider developmental level of child, gather data through "play" and interviewing, parent present adolescents: adolescents are especially concerned with confidentiality, especially substance use, suicide, and sexual abuse, at least part of the interview should be completed without parent/caregiver present older adults: be aware of any physical limitations, clarify any sensory deficits. adjust pace of the interview if necessary

age considerations:

restless trouble standing still paces the floor feet in constant motion, rocking back and forth

akathisia

cause: poorly understood, hypothesis: abrupt and drastic reduction in dopaminergic activity, high mortality primary symptoms: muscle rigidity/mutism, hyperthermia, tachycardia, diaphoresis, labile BP, respiratory distress-hypoxia, renal failure interventions: emergency medical care

all about Neuroleptic malignant syndrome:

comorbidity: bipolar, depressive and anxiety disorders, OCD, substance abuse terror of gaining weight preoccupation about food see themselves as fat over exercise disturbed cognition weird food/eating behaviors assessment: severely underweight, lanugo (fine hair), amenorrhea, cold skin, pale, undernourished clinical: orthostatic changes, bradycardia, cardiac murmur, sudden cardiac arrest, prolonged QT interval, acrocyanosis, symptomatic hypotension, leukopenia, lymphocytosis, carotenemia, hypokalemic alkalosis, electrolyte imbalances, osteoporosis, fatty degeneration of liver, elevated cholesterol levels, amenorrhea, abnormal thyroid functioning, hematuria, protenuria nursing dx: imbalanced nutrition: less than body requirements, decrease CO, risk for injury, risk for imbalanced fluid volume, disturbed body image, anxiety and chronic low self esteem, deficient knowledge, ineffective coping, powerlessness, hopelessness

all about anorexia:

ex: depakote, lamictal, tegretol anticonvulsants are used as mood stabilizers to treat mania and depression in bipolar disorder. they are prescribed alone, with lithium, or with an antipsychotic drug to control mania. treatment of bipolar depression may include an atypical antipsychotic and antidepressant may require assessing blood levels notify MD immediately if skin rash (Tegretol & Lamictal), risk of steven-johnson syndrome

all about anticonvulsants:

uses: major depression, panic disorder and other anxiety disorders, psychotic depression mechanism of action: interact with the monoamine neurotransmitter systems in the brain, particularly the neurotransmitters NE and serotonin takes time to have a therapeutic effect (weeks)!!!

all about antidepressants:

most affect more than one NT the typical antipsychotics (first generation), ex: Thorazine, Haldol the atypical antipsychotics (second generation), ex: Risperidone, Abilify, Seroquel takes time to have a full therapeutic effect, however, the antipsychotics may be used for rapid sedation

all about antipsychotic drugs:

a narrow therapeutic index: 0.5-1.5 mEq 1.5-2 = mild to moderate toxic reactions. CNS: coarse hand tremor, mental confusion, hyperirritability of muscles, drowsiness, incoordination CV: ECG changes, GI: pesistent GI upset, gastritis, salivary gland swelling, abdominal pain, excessive salivation, flatulence, indigestion 2-2.5 = moderate to severe toxic reactions CNS: ataxia, giddiness, blurred vision, clonic movements, seizures, stupor, coma CV: serious ECG changes, severe hypotension with cardiac arryhtmias, GU: large output of dilute urine, Resp: fatalities secondary to pulmonary complications

all about lithium:

ex: Citalopram, Fluoxetine, Setraline MOA: block the re-uptake of serotonin and therefore increase the availability of that NT for use in the synpase most commonly used, initial drug choice for many patients interact with many other drugs - MAOIs (can cause death) serotonin syndrome is a potentially life threatening condition resulting from excess serotonin agonist activity

all about selective serotonin reuptake inhibitors (SSRIs)

cause: excessive serotoningeric activity (overdose, drug interaction, not informing other providers of meds) manifestations: confusion to coma, hyperthermia, hyperreflexia, labile BP & HR, myoclonus and tremor, sweating/diarrhea nursing interventions: prevention through education, stop medications, early diagnosis, supportive therapies, cooling blankets

all about serotonin syndrome

AXIS 1

all major psychiatric disorders

positive symptoms

alterations in thinking delusions: false fixed beliefs that cannot be corrected by reasoning, often loosely organized and may be bizarre concrete thinking: overemphasis on specific details and impairment in the ability to sue abstract concepts (what brought you to the hospital? a cab) alterations in speech: looseness of association, neologisms, echolalia, clang association, word salad hallucinations: sensory perceptions for which there is no external stimulus, auditory is most common, visual, olfactory, gustatory, tactile, command hallucinations must be carefully assessed depersonalization: a non specific feeling that a person has lost his or her identity derealization: the false perception by a person that the environment has changed extreme motor agitation, stereotyped behaviors, automatic obedience, waxy flexibility, stupor, negativism

1. Decline in memory and learning, 2. Progressive gradual decline in cognition-no plateaus 3. No evidence mixed etiology. Probable: causative gene Possible: All 3 above, but no causative gene. Irreversible Begins to damage the brain long before symptoms appear Buildup of beta amyloid protein that cause neuritic plaques. Deficiency in acetylcholine? Increased risk: ApoE gene variation Age is the biggest risk factor There may be a genetic link to Early-onset familial Alzheimer's disease (30-60 Years) Alzheimer's Disease accounts for 60 -80% of all dementias A.D. is the sixth leading cause of death in the U.S

alzheimer's

cognitive behavioral therapy

among the most useful therapies provides education, addresses cognitive distortions, and presents behavioral approaches in an attempt to reduce symptoms and increase involvement with others and the environment teaches people to restructure their thinking and examine their assumptions, problems, concerns, and or fears so that problems or concerns seem more amenable to change, and hold less negative impact therapist helps the patient correct their faulty conceptions and helps them change their 'self signals' or 'self talk' essentially challenges core beliefs that are causing a person distress

social skills training

an adult diagnosed with major depressive disorder was treated with medications and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?

avoid skipping meals or restricting food

an appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient to:

agnosia

an older adult was stopped by police for driving through a red light. when asked for a driver's license, the adult hands the police officer a pair of sunglasses. what sign of dementia is evident?

sublimation

an unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not acceptable in their original form often these impulses are sexual or aggressive

benzodiazepine: short acting and long acting uses: anxiety disorders, PTSD, alcohol withdrawal MOA: moderate the actions of GABA, increases the receptor responsivness to GABA risk of dependence, caution when driving, do not use with alcohol, do not stop abruptly

anti-anxiety medications:

can't see - blurred vision can't pee - urinary retention can't spit - dry mouth can't you know - constipation

anticholingergic effects

Persistent disregard for and violation of the rights of others with an absence of remorse for hurting others Sense of entitlement: believe they have the right to hurt others, take what they want, treat others unfairly, destroy the properties of others, and so on (callousness) Do not adhere to traditional values or standards of morality as boundaries for their actions No restraint on their behavior; do not feel any sense of responsibility for their actions Lack of regard for the law and the rights of others; history of persistent lying, use of aliases, conning others for personal profit or pleasure, and stealing (deceitfulness) Impulsiveness; risky behaviors to "feel alive"

antisocial personality disorder (cluster b)

highly co occurring: alcohol/drug abuse, major depressive disorder in up to half of people with anxiety disorders frequently co occurring: eating disorders, bipolar disorders, PDD co occurring medical conditions: cancer, heart disease, HTN, irritable bowel syndrome, renal or liver dysfunction, reduced immunity chronic anxiety: associated with increased risk for cardiovascular morbidity and mortality

anxiety disorders co morbidity:

respiratory: asthma, hypoxia, pulmonary edema, COPD, PE cardiovascular: cardiac dysrhythmias, such as torsades de pointes, angina, CHF, mitral valve prolapse, hypertension endocrine: hyperthyroidism, hypoglycemia, hypercortisolism, pheochromocytoma neurologic: parkinson disease, akathisia, postoconcussion syndrome, complex partial seizures metabolic: hypercalcemia, hyperkalemia, hyponatremia, porphyria

anxiety due to medical conditions:

Assessment and diagnosis •Determine if symptoms are conscious or unconscious •Avoid confrontation •Self-assessment: Frustrations related to countertransference Planning and implementation • Monitor for safety Prevent dangerous unnecessary treatments Evaluation •New coping strategies

application of the nursing process: somatization disorder

acute carer: ICU, critical care unit, ED unit, establishment of trust, monitoring of weight and eating, countering distorted ideas, milieu therapy, counseling, health teaching, and medications, patient privileges linked to treatment plan compliance long term: chronic illnesses, possible long term treatment: periodic brief hospital stays, outpatient psychotherapy, and medications, greatest success with a combination of individua, group, family, and couples therapy

appropriate interventions for acute and long term care for anorexia:

say to the pt, 'I must watch you take the medication. please take it now.'

as a nurse prepares to administer an oral medication to a patient diagnosed with a borderline personality disorder, the pt says, 'just leave it on the table. i'll take it when I finish combing my hair" what is the nurses best response?

don't assume they aren't the suicidal type ask directly 'are you having thoughts of suicide/killing youself' ask if they have a plan, the more detailed the plan the greater the risk don't have to solve all their problems but you must get help remain calm, non judgemental and understanding emphasize the temporary time frame of suicidal crisis emphasize the normality of suicidal thoughts help identify and suggest alternatives, encourage positive action

ask the question (suicide)

between 10-15% of depressed die by suicide interview should include current suicidal ideation, available means lethality of intended action contract for safety? substance abuse/impulsivity history of psychiatric disorder, previous attempt, or family history

assess for suicide potential:

physical/neurologic exam to determine whether anxiety is primary or secondary to another psychiatric disorder, a medical condition, or substance abuse assess for potential self harm and or suicide perform a psychosocial assessment assess cultural beliefs and background

assessment for anxiety

1.Clarify presenting signs 2.Assess for withdrawal 3.Assess for overdose 4.Assess for self-harm potential 5.Evaluate physiologic response 6.Explore individual's interest in taking action 7.Assess knowledge of community resources •History of substance use •Medical history Psychiatric history ØDepression? Personality or conduct disorder? Schizophrenia? ØMedications? Outcomes? ØAbuse? Family violence? Suicidal or homicidal ideation? Psychosocial issues ØPoor work record? ØHas substance use affected relationships? Family? Friends? Professional peers? ØSupport systems? Coping styles? ØPolice or criminal record? Legal problems?

assessment guidelines for addiction

•Assess suicidal and homicidal thoughts. •Determine whether the patient has a medical disorder or another psychiatric disorder. •View the assessment of personality functioning from within ethnic, cultural, and social backgrounds. •Ascertain recent and important losses. •Evaluate for changes in personality in middle adulthood or later: -May signal an unrecognized substance use disorder. •Be aware of strong negative emotions that patients evoke.

assessment guidelines for personality disorders;

speech patterns: pressured speech, cirumstantial speech, tangential speech, loose associations, flight of ideas, clang associations thought content: grandiose delusions, persectory delusions

assessment of BSD:

thought content

assessment of cognition; SUICIDE, morbid, despair, desire to end emotional pain, don't see any options for ways to solve their problems, judgement is poor, delusional thinking

thought process

assessment of cognition; usually organized but may be disorganized if psychosis present, slowing, memory and concentration are affected, rumination (dwell on and exaggerate how they view their own faults and failures)

Diagnostic tests: Computed tomography scan (CT) Positron emission tomography (PET) Mental status questionnaires Mini-Mental State Examination Complete physical and neurological exam Complete medical and psychiatric history Review of recent symptoms, meds, and nutrition Alzheimer's Assessment Confabulation Perseveration Cardinal symptoms observed in AD: Amnesia or memory impairment Aphasia Apraxia Agnosia Disturbances in executive functioning Alzheimer's planning: Gear the plan toward a person's immediate needs. Identify the level of functioning. Assess the caregivers' needs. Plan and identify appropriate community resources. Alzheimer's implementation Counseling and communication techniques Health teaching and health promotion Referral to community supports Pharmacologic interventions

assessment of dementia

psycho social assessment: focus on thought processes, content, alterations in reality, perception, and speech, alterations in behavior history of psychoitc episodes or dx of schizo previous and current suicidal ideation current support system, client's perception of current situation, dual diagnosis

assessment of shizo

Genetics: predisposition to developing a substance use disorder due to family history Chronic stress: socioeconomic factors History of trauma: abuse, combat experience Lowered self-esteem Lowered tolerance for pain and frustration Few meaningful personal relationships Few life successes Risk-taking tendencies

assessment: risk factors for addictions

presence of perceptual disturbances for at least 2 weeks in absence of mood related symptoms mood symptoms must be present for 50% of total duration of illness negative symptoms of similar to that of schizo are often present, usually less severe. they are a common symptom, but not a diagnostic criteria of schizoaffective disorder (flat affect, psychomotor retardation, loss of social function, etc)

associated features supporting dx for schizoaffective disorder:

inappropriate affect dysphoric mood (form of depression, anxiety, anger) disturbed sleep pattern lack of interest in eating food or refusal cognitive deficits common (vocational and functioning impairments) abnormalities in sensory processing social cognition deficits hostility and aggression

associated features supporting schizo diagnosis:

bipolar I disorder

at least one episode of mania and at least one clearly recognizable episode of major depression marked impairment in social and occupational functioning manic episode may be accompanied by psychosis

residual

at least one previous psychotic episode but not currently; social withdrawal, flat affect, loose associations

brief psychotic disorder

at least one psychotic symptom (delusions, hallucinations, disorganized speech or behavior) lasting 1 day < 1 month, may or may not have an identifiable stressor (childbirth)

uses: schizoprenia, acute psychosis, treatment of acute mania associated with bipolar disorder, some sues for augmentation of antidepressants MOA: these drugs are known as serotonin-dopamine antagonists. these drugs target the negative symptoms of schizophrenia as well as the positive and have fewer motor side effects they may also improve cognitive function

atypical antipsychotics:

target positive or negative symptoms aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone disadvantages: weight gain, dyslipidemia, altered glucose, risk of diabetes, HTN, atherosclerosis, and increase in heart disease is more expensive than conventional antipsychotics

atypical second gen antipsychotics

High levels of anxiety Feelings of low self-worth Hypersensitive to criticism or rejection Avoid situations requiring socialization; withdrawal Strong desire for affection but fearful of disappointment or ridicule Inhibited, reluctant to express irritation or anger, even when justified View themselves as personally unappealing or inferior to others Unable to feel empathy towards others since they are consumed with their own self-deprecation Social phobias

avoidant personality disorder: cluster c

modeling -- mimicking appropriate behaviors in situations systemic desensitization -- gradually exposing a person to the feared object or situation until the person is free of incapacitating anxiety response prevention -- starts with the therapist preventing the compulsion, such as hand washing, and gradually helping the patient limit the time between rituals until the urge dissipates thought stopping -- examples include snapping a rubber band on one's wrist to stop an obsession or negative thought

behavior modification therapy:

eustress

beneficial stress, motivates people to develop the skills they need to solve problems and meet personal goals

is a variant of compulsive overeating, is an eating pattern that resembles that of obesity recurrent episodes of thinking about and eating large amount of food occur in a short period feelings of disgust, depression, and guilt are expressed after binging binge eating disorder is now recognized as a specific disorder in the DSM 5 is noted as a symptom of depression high rates of mood disorders and personality disorders are found among binge eaters binge eaters report a history of major depression more often than nonbinge eaters binge eaters report that binge eating is soothing and helps regulate moods dieting is almost always an antecedent of binge eating in bulimia nervosa in approx 50% of obese binge eaters, no attempt to restrict dietary intake occurs before bingeing effective treatment for obese binge eaters integrates modification, improvement of depressive symptoms, and achievement of the appropriate weight effective program for BED integrates modification with noted association mood changed, working toward an appropriate weight

binge eating disorder

genetic factors: twin studies, adoptive studies, family studies neurobiological factors: mood disorders are most likely a result of complex interactions among numerous chemicals, including neurotransmitters and hormones neuroendocrine factors: hypothalamic-pituitary-adrenal axis, which modulates the stress response and is involved in maintaining homeostasis, has been implicated in mood disorders neuroanatomical factors: studies have identified ventricular enlargement, cortical atrophy, and suicidal widening

biological theories of bipolar spectrum disorders:

genetic predisposition, abnormalities of neurotransmitter function, neuroendocrine factors -- HPA dysfunction

biological theory of depression:

1. devastating on relationships and finances 2. suicide 11-15% 3. legal problems 4. school problems: drop out, trauncy 5. 60-70% smoke 6. incorrect, inappropriate, or partial treatment

bipolar patients effects:

group of brain diseases that are marked by recurring depressed and elevated/irritable moods associated with severe morbidity both physically and mentally chronic, recurrent, and life threatening illnesses that require a lifetime of monitoring increasingly diagnosed at younger ages, still not drop in mortality rates frequently undiagnosed less than half regain full occupational, interpersonal and or social functioning even during remission significant morbidity and mortality

bipolar spectrum disorders:

residential settings

board and care homes, adult foster homes, halfway homes, group homes, supervised apartment living these emphasize recovery go beyond symptom control and medication management to personal growth goals: reintegration to the community, empowerment, increased independence, improved quality of life

Unstable, intense relationships Instability of affect; unstable, frequent mood changes Emotional lability (shifting from anxiety, to irritability, etc.) Poor impulse control; self-mutilation and other self-destructive behaviors; suicide-prone Chronic depression Projected identification common primitive defense mechanism used by persons with BPD Emotional dysregulation: patterns of high emotional sensitivity, acute responsiveness, and slow return to normal Desperately seek relationships to avoid feelings of abandonment and chronic feelings of emptiness Frequent use of the defense splitting (the inability to integrate both the positive and the negative qualities of an individual into one person; thinks in extremes - all good or all bad, no middle ground)

borderline personality disorder (cluster b)

borderline: •Emotional instability •Separation insecurity •Depression (chronic) •Fear feelings of abandonment •Excessive demands, impulsive behavior, uncontrolled anger •Stormy relationships •Idealization and devaluation •Self-mutilation and prone to suicide •Splitting narcissistic: •Attention seeking •Antagonism •Grandiosity •Expectation of special treatment •Arrogant and haughty •Lack of empathy •Exploit, blame, and envy others •Shallow, superficial, and tantrums •Manipulation •Splitting

borderline vs narcissistic personality disorder:

repeated episodes of binge eating followed by inappropriate compensatory behaviors such as self induced vomiting, laxative misuse, diuretics, fasting, excessive exercise and other medications signficant disturbance in perception of body shape and weight most people experience at least 1 other psychiatric disorder but usually have multiple such as mood disorders, anxiety disorders, personality disorders, substance abuse may be predisposed based on differences in their brains.... have increase gray matter in the medial orbitofrontal cortex (reward response) many are predisposed to ADHD are impulsive and have poor emotional regulation, triggers may include stress, poor body image, food, restrictive dieting and boredom assessment: initially do not appear to be physically or emotionally ill, enlargement of parotid glands, dental erosion, family relationships are frequently chaotic and reflect lack of nurturing clinical: cardiomyopathy, cardiac dysrhythmias, sinus bradycardia, sudden cardiac arrest, orthostatic changes in pulse and BP, electrolyte imbalances, metabolic acidosis, hypochloremia, hypokalemia, dehydration and renal loss of potassium as a result of self induced vomiting, attrition and erosion of teeth, loss of dental arch, diminished chewing ability, parotid gland enlargement, esophageal tears as a result of self induced vomtiing, gastric dilation, russell sign nursing dx: decrease CO, disturbed body image, disturbed body image, powerlessness, chronic low self esteem, anxiety, ineffective coping

bulimia nervosa all abouttt:

posttraumatic stress disorder

can occur in any individual who has had exposure to trauma severe enough to be outside of the range of normal human experience childhood physical abuse, torture/kidnap, military combat, sexual assault, natural disasters, human disasters, and even the diagnosis of a severe illness can also occur in people who have witnessed an unbearable event even those who have been repeatedly exposed to stories about a traumatic event in graphic terms can be traumatized common element is the individual's extraordinary helplessness or powerlessness in the face of overwhelming circumstances

Marijuana or hashish (which is more potent) can be smoked or orally ingested •Intended effects: •Euphoria, sedation, hallucinations, decrease of nausea and vomiting secondary to chemotherapy, management of chronic pain Effects of intoxication •Chronic use: lung cancer, chronic bronchitis, and other respiratory effects •In high doses: occurrence of paranoia, such as delusions and hallucinations •Increased appetite, dry mouth, tachycardia Withdrawal manifestations: •Irritability, aggression, anxiety, insomnia, lack of appetite, restlessness, depressed mood, abdominal pain, tremors, diaphoresis, fever, headache

cannabis

physical changes: after childbirth, a dramatic drop in estrogen and progesterone may trigger depression. the hormones produced by the thyroid gland also may drop sharply -- feeling tired, sluggish, and depressed. changes in blood volume, blood pressure, immune system and metabolism can lead to fatigue and mood swings emotional factors: sleep deprived and overwhelmed. anxious about their ability to care for a newborn. feels less attractive or struggle with sense of identity. feels a loss of control over life lifestyle influences: a demanding baby or older siblings, difficulty breast feeding, exhaustion, financial problems, and lack of support from partner or other loved ones pre existing depression

causes of post partum depression: (there is no single cause of depression after birth)

distress

causes problems both mentally and physically may trigger depression, cause, confusion, instill helplessness/hopelessness, cause fatigue, etc

substance use and addictive disorders

characterized by loss of control due to the substance use or behavior, participation that continues despite continuing associated problems, and a tendency to relapse back into the substance use or behavior

schizophrenia

characterized by thought disorders that reflect a break between the cognitive and the emotional sides of one's personality etiology and patho: genetic predisposition, prenatal and perinatal vulnerability factors, neuroanatomic and neurotransmitters alterations positive and negative symptoms

severe and persistent mental illness may still require acute care community centered care involves medication management, transportation, shopping, food prep, hygiene, finances, social support, vocational referral ACT programs (assertive community treatment)

chronic care for mental illnesses:

generalized anxiety disorder

chronic psychiatric disorder severe distress with pervasive cognitive dysfunction, impaired functioning, and poor health related outcomes highly comorbid with other disorders (social phobia, specific phobia, panic disorder, and depression) patients do not fear a specific external object or situation no distinct symptomatic reaction pattern

substance addiction

chronic relapsing brain disease compulsive drug seeking motivated by cravings compulsion occurs despite harmful consequences results in long lasting brain changes

community outpatient treatment

clients can continue to work and can stay connected with family, friends, and other support systems while participation in therapy nursing goals: supportive milieu, client developing healing program, teach ADL self cares, facilitate groups, therapeutic communication, monitor meds and side effects individual psychotherapy

Impaired memory, judgment, attention span May vary during the day Sleep-wake cycle may be reversed Rapid, inappropriate, incoherent speech Altered level of consciousness Emotionally: fearful, anxious, suspicious, aggressive, hallucinations or delusions interventions: Reorient Clocks/calendars Reduce noise/light Personal contact Monitor skin 2 to immobility Treat the underlying cause.

clinical picture of delirium

Progressive deterioration of intellectual functioning Severe Memory loss is NOT a normal part of growing older Decline in ability to perform ADL Deterioration of personality Emotional changes: labile mood, acting out, depression There is more than one cause

clinical picture of dementia:

Intoxication: Only drug for which objective measures of intoxication exist Blood alcohol level (BAL): determines level of intoxication and tolerance Alcohol Withdrawal Alcohol Withdrawal Delirium (DTs) Medical emergency; potentially fatal Peaks in 2 to 3 days after cessation Hallucinations, delusions, agitation, fever, perceptual and autonomic disturbances; severe disturbance in sensorium; fluctuating levels of consciousness

clinical picture: alcohol

seen as odd or eccentric, have unusual beliefs, avoid interpersonal relationships, often indifferent

cluster a disorders

emotional reactivity, poor impulse control, manipulation, unclear sense of identity

cluster b disorders

high anxiety and outward signs of fear, inhibited, internalizing blame, even when not to blame

cluster c disorders

substance use disorders: more than 50% of individuals with schizo, associated with negative outcomes (incarceration, homelessness, violence, suicide) tobacco use disorder: more than 50% of persons with schizo depressive symptoms occur frequently suicide is the leading cause of premature death in this population, accounting for 6-10% of deaths anxiety disorders, OCD, and panic attacks are significantly higher in this population obesity: may be related to the antipsychotic medication, particularly atypical agents HIV infection double the rate for the general population

co morbidity with schizophrenia:

learning theories: anxiety is a learned response that can be unlearned with behavioral therapy cognitive therapies: anxiety disorders are a result of a distortions in an individual's thinking and perceiving -- CBT to learn and reframe one's thinking cultural considerations -- sociocultural variation in symptoms of anxiety

cognitivate, behavioral and cultural theories for anxiety:

perhaps the most debilitating symptoms include impairment in memory; disruption in social learning; and inability to reason, solve problems, and focus attention the greater the degree of negative and cognitive symptoms, the more likely it is that the person will be unable to function on a job, engage in social activities, and care for self adequately and safely

cognitive symptoms of schizo:

sleeping, eating, experience headache or back pain, lose interest in favorite activities, feel tense and become irritable, feel powerless

common symptoms of stress:

defense mechanism of denial

commonly used by clients who have problems with a substance use or addictive disorder prevents a client from obtaining help with a substance use or addictive behavior

compared with a pt with anorexia who is restricting food, the pt with bulimia more readily establishes a therapeutic alliance because the eating behaviors are ego dystonic or against what they want therapeutic alliance allows the nurse and other team members to provide counseling that gives useful feedback regarding distorted beliefs with bulimia, be aware that the patient is sensitive to the perceptions of others patient may feel shame and totally out of control therapeutic alliance empathizes with the feleings of low self esteem, unworthiness, and dysphoria nurse may suspect dishonesty when the patient does not report bingeing and or purging accepting, having a nonjudgemental approach, and understanding the subjective experience of the patient will help build trust

communication guidelines for EDs

delusions reflect the mispercpetion of cognitive stimuli when teh nurse attempts to see the world as it appears through the eyes of the patient, it is easier to understand the patient's delusional experience talking about the patient's feelings is helpful, talking about the delusional material is not it is never useful to argue or try to reason with the patient regarding the content of the delusion clarify misinterpretations of the environment

communication guidelines for delusions:

nurse should try to understand what the voices are saying or telling the person to do suicidal or homicidal messages necessitate initiation of safety measurse for all members of the health care team approach individuals who are hallucinating in a nonthreatening, nonjudgemental manner during the acute phase of the illness, the nurse should maintain eye contact, call the patient by name, and speak simply

communication guidelines for hallucinations:

a paranoid individual may make offensive yet accurate criticisms of the nurse or the unit policies it is important that the staff not react to these criticisims with anxiety or rejection of the patient approach a patient who is paranoid in a nonjudgemental, respectful manner use clear and simple language be honest and consistent with the patient regarding expectations and enforcing rules avoid laughing, whispering, or talking quietly when the patient cannot hear what is being said

communication guidelines for paranoia:

understand the patient may need more time to reply to communication silence/sitting with patient can be therapeutic, allow time for patient to respond make observations related to patient/situation or environment avoid platitudes listen carefully for covert messages and question directly about suicide

communication guidelines for patients with depression:

People with PDs are excessively dependent, demanding, manipulative, stubborn, or may self-destructively refuse treatment. Nurses greatly enhance their ability to be therapeutic when they combine: -Limit-setting -Trustworthiness -Dealing with manipulations -Authenticity with their own natural style

communication guidelines for personality disorders:

lowering the patients anxiety, decreasing defensive patterns, encouraging participation in therapeutic and social events, raising feelings of self worth, increasing medication compliance

communication guidelines for schizo:

firm and calm approach set limits in concert with other staff members short, concise explanations be neutral, avoid power struggles, value judgements redirect energy to constructive channels -- use distractibility to the nurse's advantage

communication in mania:

Always remember the needs of the family are crucial Communication guidelines for people with dementia often: Have difficulty finding the right words. Use familiar words repeatedly. uInvent new words to describe things (neologisms) . Lose their train of thought. Rely on nonverbal gestures. Alzheimer's: Always identify yourself. Call the person by his or her name at each meeting. Speak slowly. Use short, simple words and phrases. Maintain face-to-face contact. Be near the patient when talking, one or two arm-lengths' away. uHave the patient wear eyeglasses or a hearing aid. Keep the patient's room well lit. Have clocks, calendars, and personal items (e.g., family pictures, Bible) in clear view. Reinforce the patient's pictures, nonverbal gestures, X's on calendars, and other methods to present reality.

communication/care guidelines for dementia

substance use disorder, anxiety disorders, higher rates of obesity and DMII associated with long term antipsychotic use

comorbidities for schizoaffective disorder:

high rate of medical comorbidity especially cardiovascular, cerebrovascular, and metabolic diseases: endocrine disorders, type 2 DM, obesity

comorbidity + bipolar spectrum disorders:

anorexia: self induced vomiting, use of laxatives and diuretics, judges self worth by weight, controls what they eat to feel powerful to overcome feelings of helplessness, lanugao, cachetic, prominent parotid glands, if purging terror of gaining weight, preoccupartion with food, views self as fat even when emanciated, peculiar handling of food (cutting foof into small bits, pushing food around the plate, maintaining a rigorous exercise regimen) bulimia: self concept, impulsive and compulsive, anxiety, possible chemical dependency and shoplifting, undoes weight after bingeing, prominent parotid glands, if purging (binge eating, self induced vomiting, laxative and diuretic use, history of anorexia in one quarter to one third of individuals, depressive s/sx, problems with interpersonal relationships)

compare and contrast the s/sx of anorexia and bulimia:

undoing

compensates for an act or communication

the connection of groups (e.g. minority groups) to their cultural traditions and history connectedness and support can be enhanced through social programs directed at specific groups (such as older adults/lgbt youth) as well as through actvities that support the development of positive and supportive communities support the development of relationships between youth and positive adults in their lives build connections among co workers, connect with individuals who might be isolating themselves increase supportive connections in your social organizations create and sustain peer delivered services and support groups its important to remember that not all social connections are healthy suicide prevention programs should promote practices leading to positive and supportive relationships

connectedness matters (suicide)

hildegard peplau

considered the mother of psychiatric nursing interpersonal relations nursing 1952 interpersonal relations in nursing: a conceptual framework of reference for psychodynamic nursing 1991 speciality practice roles: introduced the concept of advanced nursing practice. promoted professional standards and regulation through credentialing multidisciplinary had a passion for clarifying and developing the art and science of professional nursing practice and believed that a scientific approach was essential to the practice of psychiatric nursing

verbal commuication

consists of all words a person speaks

rationaliziation

consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener, it is a form of well deception

target positive symptoms high potency: trifluoperazine, thiothixene, fluphenazine, haloperidol, pimozide low potency: cholopromazine, thioriadizine medium potency: loxapine, molidone, perphenazine AE: extrapyramidal symptoms: akathisia, acute dystonia, pseudoparkinsonism tardive dyskinesia, neuroleptic malignant syndrome, agranulocytosis, other adverse reactions: anticholingeric effects, orthostasis, lowered seizure threshold

conventional first gen antipsychotics:

Neurological symptoms in the absence of a neurological diagnosis Presence of deficits in voluntary motor or sensory functions Common symptoms—paralysis, blindness, movement and gait disorders, numbness, paresthesias, loss of vision or hearing, or episodes resembling epilepsy "La belle indifférence" versus distress

conversion disorder:

usually includes recurrent acute exacerbations of psychosis previous belief of schizophrenia as a disease with an unalterable advancement to progressive deterioration early and aggressive treatment with antipsychotics may alter teh course of schizophrenias when given at the time of the first psychotic break prevention of relapse can be more important than the risk of side effects from medications because most side effects are reversible, while the consequences of relapse may be irreversible with each relapse of psychosis, there is an increase in residual dysfunction and deterioration

course of schizo:

electroconvulsive therapy

course of treatment: 2-3 treatments/weeks for total of 6-12 treatments for patients not responding to antidepressants or for depression with psychosis potential adverse reactions: initial confusion and disorientation on awakening, memory deficits

may be more prevalent in upper SES among creative writers, artists, highly educated men and women, professional people

cultural considerations for BSD

AXIS 3

current medical conditions

DSM V

current official guidebook for categorizing and diagnosing psychiatric mental health disorders in the US and is published by APA it provides a standard language and criteria for the classification of mental disorders

Medications can be the underlying cause of delirium Recognize medication reactions before delirium starts Pharmacological management focuses on the treatment of the underlying disorder Antipsychotic or antianxiety medications may be prescribed

delirium medications

Neurodegenerative: Frontotemporal dementia: Frontal/temporal anterior lobes of brain shrink: Also known as Pick's Disease: Younger age Lewy body Age Family history Gradual Progressive AD most common More women than men May have delusions-false beliefs infections: Creutzfeldt-Jakob disease, Mad cow, Bovine spongiform encephalopathy, No treatment Vascular: Single or multiple strokes History Smoking A fib HTN DM May be abrupt More men

dementia types

Belief in inability to survive if left alone Excess need to be taken care of Solicit caretaking through clinging and submission Perversely, excessively submissive Intense fear of separation and being alone Tolerant of poor, even abusive relationships If relationship does end, the individual has an urgent need to get into another Inability to make decisions without excessive reassurance

dependent personality disorder (cluster c)

can remain undiagnosed 50% of the time suicide rates among elderly men are the highest of all age groups antidepressants in older adults linked to falls, strokes, seizures, and other adverse outcomes older adults taking SSRIs had more adverse events than those taking TCAs

depression in older adults:

sadness, emptiness, irritability, somatic (body) concerns, and impairment of thinking all impact a person's ability to function

depressive disorders all share symptoms of:

persistent feelings of sadness, anxiety, guilt or hopelessness disturbances in sleep and appetite fatigue and loss of interest in daily activities problems concentrating irritability chronic pain without a known cause recurring thoughts of suicide

depressive phase of BSD:

Depressed elderly vulnerable Lack of communication with health care workers Distrust, fear of losing autonomy Must preserve dignity Poor physical health, comorbidities Chronic pain Poor pain management Disability Memory loss thinking clearly Alcohol Increase risk for depression Thyroid Parkinsons Heart disease Cancer Stroke Side effects drugs Symptoms depression as occur part of dementia physical activity: lowers the risk of depression, decrease risk of dementia, increase quality of life for elders

determinants of health: depression in elderly

presence of perceptual disturbances common in schizo: hallucinations, delusions, paranoia presence of mood disorder symptoms such as major depressive episodes and/or mania: 2 subtypes (depressive and bipolar type)

diagnostic presentation symptoms for schizoaffective disorder:

hallucinations, delusions, disorganized speech, grossly disorganized behavior, negative symptoms (flat affect, avolition, alogia) level of functioning in 1 or more major areas such as work, relationships, family neuro symptoms such as impaired fine motor skills, abnormal movements, tics, grimacing

diagnostic presentation/symptoms of schizophrenia:

Primary focus: -Stabilizing patient, achieving behavioral control, regulating emotions, developing distress tolerance skills, and constantly using crisis interventions Target behaviors include decreasing: -Life-threatening suicidal behaviors -Therapy-interfering behaviors -Quality-of-life interfering behaviors Is extremely effective in helping patients gain hope and a quality of life

dialectical behavior therapy:

tyramine-free diet hypertensive crisis with excessive tyramine or sympathomimetic drugs (such as OTC cold meds), can lead to stroke no cheese, wine, pickled foods

dietary restrictions for patients on MAOIs

self worth and interpersonal functioning eventually become issues that are useful to target long term outpatient treatment helps patients: maintain healthy weight, with individual, family, group therapy, psychopharm, and nutrition counseling address depression, substance abuse, and or personality disorders that interfere with quality of life

differentiate between the long term prognosis of anorexia nervosa, bulimia nervosa, and binge eating disorder

pathological anxiety

differs from normal anxiety in terms of duration, intensity, and disturbance in a person's ability to function (dysfunctional behaviors, extreme withdrawal), is out of proportion to the threat, persists after the threat is resolved, becomes generalized to benign situations or occurs in a complete absence of a stressor

Sudden, unexpected travel from a customary locale, and the inability to recall one's identity after a traumatic event Patient flees from their normal life to another location and starts a new life Scenario: Lin, 19 years old, is admitted to the psychiatric unit after police found her wandering in a Louisiana shopping mall parking lot. Lin does not recall who she is or where she lives. It is later found that Lin lives in Oregon, where her fiancé had cancelled their wedding 2 weeks earlier.

dissociative amnesia with fugue: dissociative disorders

Psychologically induced memory loss and inability to recall important personal information after severe stressor Memory impairment may be selective for the traumatic event(s) or a particular time period, or generalized for the entire life history Symptoms are not a result of drugs or a medical condition Scenario: Bob's vehicle hits an improvised explosive device (IED). He and his friend are thrown onto the sand. Bob's friend dies. A convoy passes 2 hours later. Bob is sitting by his friend, staring into space, and is unable to state who or where he is. Bob states that he does not remember the explosion.

dissociative amnesia: dissociative disorders

Disturbance in the normally well-integrated continuum of consciousness, memory, identity, and perception Dissociation: an unconscious defense mechanism to protect the individual against overwhelming anxiety related to past trauma; ranges from minor to severe in presentation Patients with dissociative disorders have intact reality testing, meaning they are not delusional or hallucinating Includes amnesiac states

dissociative disorders:

PCP—1-(phenylcyclohexyl) piperidine ØAlso known as angel dust, horse tranquilizer, and peace pill •Ketamine •Salvia Effects •Desired: Separation from body and environment •Negative: Can cause anxiety, numbness, memory loss, nausea •Potential deadly effects

dissociative drugs:

the patient expresses satisfaction with body appearance

disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. which outcome indicator is most appropriate to monitor?

physiologic effects: sleep/wake cycle, signals muscles to become active relationship to mental health disorders: Increased in schizophrenia and mania, decreased in depression

dopamine

affect flat; mood depressed

during a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood?

confabulation

during morning care, a nursing assistant asks a patient diagnosed with dementia, 'how was your night?' the patient replies, 'it was lovely. I went out to dinner and a movie with my friend.' which term applies to the patient's response?

hypercarotenemia

earler we learned that addie's skin was slightly yellow and her skin showed signs of dehydration. what is yellow skin in anorexia nervosa linked to?

up to 1/3 of the deaths related to EDs are due to suicide a history of sexual abuse is more common in those with EDs than it is in the general population women with a history of EDs and sexual abuse have a higher rate of other comorbid psychiatric illnesses than women diagnosed solely with EDs

eating disorder facts:

Effects of excess: •Slurred speech, nystagmus, memory impairment, altered judgment, decreased motor skills, decreased level of consciousness (which can include stupor or coma), respiratory arrest, peripheral collapse, and death (with large doses) Chronic use: •Direct cardiovascular damage, liver damage (ranging from fatty liver to cirrhosis), erosive gastritis and gastrointestinal bleeding, acute pancreatitis, sexual dysfunction

effects of alcohol intoxication

altruism

emotional conflicts and stressors are addressed by meeting the needs of others. the person receives gratification either vicariously or from the response of others

idealization

emotional conflicts or stressors are addressed by attributing exaggerated positive qualities to others idealization is an important aspect of the development of self may be disappointed when the person turns out to be human, results in lowering of self esteem, then individual devalues and rejects the object of their affection to protect their own self esteem

bulimia nervosa

engage in repeated episodes of binge eating followed by inappropriate compensatory behaviors such as self induced vomiting, misuse of laxatives, diuretics, or other medications; fasting, or excessive exercise

binge eating disorder

engage in repeated episodes of binge eating, consuming large amounts of calories, after which they experience significant distress do not regularly use the compensatory behaviors seen in patients with bulimia nervosa

physical factors (background noise, lack of privacy, uncomfortable accommodations) social determinants (sociopolitical, historical, or economic factors; presence of others; expectations of others)

environmental factors that affect communication:

symmetrical relationship

equal: friends or colleagues

Exact cause - unknown Inadequate light during the day Low light and increase in shadows late in the day: Aggravate confusion Circadian rhythm disorders Sleep wake disorders Melatonin may be decreased in AD Shift change (hospitals) - more noise and chaos Wearing off of medications Theorize-drop in BP, change in blood glucose after eating

etiology for sundowning

biologic factors genetics psychological trauma environmental stressors brain defects or injury infection prenatal damage substance abuse poor nutrition and exposure to toxins

etiology of mental illness:

schizophrenia has a strong genetic component although most people with schizophrenia do not have family history of the disease eight genetically different types of schizophrenia have been identified new schizophrenia risk gene called c4: responsible for a biological process called synpatic pruning, elimination of weak or redudant connections between neurons in the area of the brain associated with thinking and planning skills as the brain matures, occurs naturally in the teen years, hypothesis is that these genes go into overdrive and cause excessive or inappropriate "pruning" of neural connections that lead to the cognitive symptoms seen in schizo

etiology of schizo: genetic factors:

dopamine hypothesis: concluded tehre was a hyperactivity of the neurotransmitter dopamine in the limbic regions of the brain first generation (typical) antipsychotics block the activity of dopamine and in doing so, reduce some of the symptoms of schizophrenia ampetamines, cocaine, Ritalin, and levodopa increase the activity of dopamine in the brain and can exacerbate the symptoms of schizophrenia in psychotic patients and stimulates symptoms of schizophrenia in a person without schizophrenia serotonin: second generation atypical antipsychotics block serotonin might also play a role in causing some of the symptoms of schizophreniayo

etiology of schizo: neurochemical factors

complicated matter brain chemistry and brain activity are different in a person with schizophrenia than in a person without schizophrenia the schizophrenias most likely occur as a result of a combination of inherited genetic factors and extreme nongenetic factors (e.g. virus infection, birth injuries, nutritional factors, head trauma in early life) neuroanatomical factors: neuroprogressive component -- tissue volume decrease in both gray and white matter, disruptions in communication pathways, plausible that structural cerebral abnormalities cause disruption to the entire circuitry of the brain brain imaging -- lower brain volume, larger lateral and third ventricles, atrophy in the frontal lobe, more cerebrospinal fluid in some nongenetic risk factors: prenatal risk factors, social, psychological, physical and environment stressors

etiology of schizophrenia:

Biological factors Genetic Psychological factors Psychodynamic theories Behavioral theories Cognitive theories Cultural considerations

etiology of somatic disorders:

personalization

events are overinterpreted as having personal signficance 'I know everyone is watching me eat' 'people won't lik eme unless i'm thin"

mania

exaggerated elevated, expansive, or irritable mood, accompanied by a persistent increase in activity and/ or energy

compulsive hoarding

excessive collection of items considered worthless individuals often feel shame for their failure to discard items extreme disruption in daily living and severe distress disabling and can result in self imposed social isolation unsafe living conditions

The nurse should use open-ended questions to obtain the following information for the nursing history: Type of substance or addictive behavior Pattern and frequency of substance use Amount of substance used Age at onset of substance use Changes in occupational or school performance Changes in use patterns Periods of abstinence in history Previous withdrawal manifestations Date of last substance use or addictive behavior

expected findings for addictions

major depressive disorder

experience substantial pain and suffering, as well as psychological, social and occupational disability unable to function normally patient presents with history of one or more episodes and no history of manic or hypomanic episodes many patients who are initially diagnosed with a major depressive disorder will later prove to have a bipolar disorder with psychotic symptoms: severe form of mood disorder characterized by delusions and/or hallucinations

pseudoparksonism acute dystonia akathisia tardive dyskinesia when you block dopamine receptors, it changes the balance = disrupts movements - parkinson's disease treatment: Congentin, Benadryl

extrapyramidal symptoms:

The senses of vision, hearing, touch, taste, and smell decline with age. Muscular strength decreases with age. Muscle fibers atrophy and decrease in number. Regular sexual expressions are important to maintain sexual capacity and effective sexual performance. At least 50% of restorative sleep is lost as a result of the aging process. Older adults are major consumers of prescription drugs because of the high incidence of chronic diseases in this population. Older adults have a high incidence of depression. Many individuals experience difficulty when they retire. Older adults are prone to become the victims of crime. Older widows appear to adjust better than younger ones.

facts about aging:

talking about suicide will not cause a person to think that suicide is an option for themselves few suicides happen without warning people with thoughts of suicide can help themselves depression, anxiety, mood disorders, substances abuse and conduct disorders are common factors found in individuals with thoughts of suicide suicide is preventable suicide is not painless, not an easy way out people who show marked and sudden improvement after a suicide attempt or depressive period may be in great danger people who talk about suicide may very well attempt or die by suicide suicidal behavior is not a way to get attention not every death is preventable there is strong evidence that sexual minority individuals are more at risk than their peers to think about and attempt suicide any concerned, caring individual can be a gatekeepter and may very well make the difference between life and death

facts you need to know about suicide:

risk for deficient fluid volume

family members of a client in acute mania report this client has not slept for four nights. the client also climbed up and down the stairs of the stadium for 6 hours without stopping. now the client has blisters on his feet and is sweating profusely. to which problem should the nurse give priority?

self care

feelings experienced by health care professionals when working with a person with a personality disorder. Patient's problems can overwhelm health care professionals. Intense feelings evoked in a nurse often mirrors the feelings of a patient: -For example, a patient might tell a nurse, "You're inadequate and incompetent!" •Health care professionals may feel confused, helpless, angry, and frustrated. Patients are abusive of authority and successful in splitting staff in an attempt to defend against the patient's own feelings of frustration and powerlessness. When staff members are split, the result is conflict. Untrained staff members may become vengeful in response to a sense of entitlement, manipulation, dependency, ingratitude, impulsivity, and rage. Nurses and other health care professionals should practice self-health management, which includes acknowledging and accepting their own emotional responses. Health care professionals should ensure personal well-being.

termination phase

final, integral phase of the nurse patient relationship termination is discussed in the first interview, and again during the working stage at appropriate times may occur when the patient is discharged or when the student's clinical rotation ends often awakens strong feelings in both the nurse and patient

1. major means of managing conflict and affect 2. relatively unconscious 3. discrete from one another 4. although they are hallmarks of major psychiatric syndromes, they are reversible 5. adaptive as well as pathological

five properties of the defense mechanisms:

traumatic brain injury

found in people involved in contact sports, accidents, and falls, and in patients diagnosed with shaken baby syndrome and Alzheimer dementia, war veterans

therapeutic milieu

french word for middle = surroundings or environment healthy environment, combined with a healthy social structure within an impatient setting or structured outpatient clinic is essential to supporting and treating those with mental illness small version of the larger society (test new behaviors, increase ability to interact adaptively within the outside community)

treatment: analysis of dreams and free association too lengthy, expensive, pioneered hypnosis three layers of mental activity: conscious, preconscious, unconscious later construct: between the id, ego, superego id: primitive, pleasure seeking part of our personalities that lurks in the unconscious mind ego: sense of self, acts as an intermediary between the id and the world using ego defense mechanisms (denial, repression, identification) superego: assigned to those processes that Freud referred to as our conscience; sense of what is right and wrong

freud's psychoanalytic theories:

transference

freud's psychoanalytic therapy: occurs as the patient projects intense feelings onto the therapist (nurse) related to unfinished work from previous relationships safe expression of those feelings is crucial to successful therapy

countertransference

freud's psychoanalytic therapy: therapists (nurse) have unconscious emotional responses to the patient which must be scrutinized in order to prevent damage to the therapeutic relationship

Second most common cause of early onset dementia, before age 65 Distinguished by frontal atrophy of the brain, primarily in the anterior temporal and posterior inferior areas of the frontal lobes Degeneration from neuronal loss, gliosis, and microvascular changes of the frontal, anterior temporal lobes and anterior cingulate cortex and insular cortex Accumulation of protein tau partly responsible, 36-50% frontotemporal lobar degeneration (Bang, Spina, & Miller, 2015, p. 1677) Different extent of involvement in lobes of the brain depend on the variant of the type of FTD Genetic risk factor - 40% having a family history of dementia Diabetes increases the risk FTD patients have a higher education compared to AD The younger the onset, the poorer the prognosis Behavioral: Look for personality change Apathy---common sign—mistaken for depression Abnormal social behaviors Has your mom/dad embarrassed you or said something embarrassing to others? Inappropriate sense of humor? New criminal behavior—like shoplifting—early manifestation of the disorder Blunting, poor impulse control, lack of empathy Disinhibition Inappropriate sexual advances Severe violation of personal boundaries Childish comments Hygiene neglect Change in food preferences—high intake sugar and carbohydrates Hyperorality Weight change Language - difficulty speaking, writing, word retrieval can have aphasia

frontotemporal dementia:

mental status examination

fundamental to overall patient assessment purpose is to evaluate the current cognitive processes aids in collecting and organizing objective data the nurse observes the patient's: physical behavior, nonverbal communication, appearance, speech patterns, mood and affect, thought content, perceptions, cognitive ability, and insight and judgement

'you seem concerned about how you are being treated here on this unit'

gale tells another nurse on the unit, ' you are the only decent person here. you really care and my nurse is really cold.' the nurse is new to the unit and does not know how to answer. what would be your best response to gale if you were in this position?

introduce yourself, and late Gale know that you will be her nurse during your shift

gale's medical hx (from previous admissions) indicates diagnosis of depressive disorder and borderline personalty disorder. based on these diagnoses, which of the following will be your best initial intervention as you begin your shift?

AXIS 5

global assessment of functioning (GAF) score

disorganized type

grossly inappropriate or flat affect, incoherence, loose associations, extremely disorganized behavior

substance abuse

habitual use falls outside medical necessity use falls outside social acceptance use is for single purpose of altering mood, emotion, or consciousness

loss of interest in normal daily activities depressed mood consider: periods of sadness are part of the human condition in everyone

hallmarks of depression:

Usually ingested orally, but can be injected or smoked •Examples: •Lysergic acid diethylamide (LSD), mescaline (peyote), Psilocybin (magic mushroom) and phencyclidine piperidine (PCP) •Intended effects: •Heightened sense of self and altered perceptions (colors being more vivid while under the influence) Effects of intoxication: •Anxiety, depression, paranoia, impaired judgment, impaired social functioning, pupil dilation, tachycardia, diaphoresis, palpitations, blurred vision, tremors, incoordination, and panic attacks Withdrawal manifestations: •Hallucinogen persisting perception disorder: Visual disturbances or flashback hallucinations can occur intermittently for years

hallucinogens:

interpersonal theory

harry stack sullivan; relationships as basis for mental health or illness therapy focuses on here & now & emphasizes relationships; therapist is an active participant focuses on what occurs between people, as opposed to psychoanalytic theory that is rooted in what occurs in the mind personality dynamics and disorders were caused primarily by social forces and interpersonal situation human beings are driven by the need for interaction viewed lonliness as the most painful human experience believed anxiety is an interpersonal phenomenon brought about by interaction

Dressing and Bathing Nutrition Bowel and Bladder Function Sleep Safety: Safe Environment Wandering Useful Activities Services: Community services Caregiver In home services

health maintenance for dementia:

normal anxiety

healthy life force necessary for survival, motivates people to make and survive change

specific phobias

high levels of anxiety or fear in response to specific objects or situations (dogs, spiders, heights, storms, water, blood, closed spaces)

Manipulative, insensitive Dramatic, rapidly shifting, charming, flamboyant, and sexually seductive behaviors Need to become and remain the center of attention, love, and admiration Constant, sudden emotional shifts and lability Superficial, shallow, short-lived relationships Lack insight about their role in the failure of relationships

histrionic personality disorder (cluster b)

personality

how we perceive and interact with the world, the style of how a person deals with the world stylistic pecularities that people bring to social relationships (shyness, seductiveness, rigidity, suspiciousness) in ordinary and nonpath states, personality traits are flexible and adaptive

peripheral edema

hypoalbuminemia in a patient with an eating disorder would produce which assessment finding?

Misinterpretation of physical sensations Preoccupation with having or acquiring serious illness for at least 6 months High anxiety about health Excessive health-related behaviors or maladaptive avoidance May be care-seeking or care-avoidant

illness anxiety disorder:

psychosocial assessment: HPI: clients perception or current situation social history past psychiatric history substance use other medical problems mental status exam: level of mood, thought processes/content, any psychotic symptoms, judgement

important features of assessment of bipolar disorder:

anhedonia

inability to experience any pleasure in activities that usually produce pleasurable feelings

nonsubstance related disorders (behavioral/process addiction)

include gambling, sexual activity, shopping, social media, and internet gaming

bipolar disorder unspecified

includes disorders with bipolar features that do not meet criteria for any of the previously specified disorders

acting out behaviors

individual addresses emotional conflicts or stressors by actions rather than by reflections or feelings by acting out at others, an individual can transfer the focus from personal doubts and insecurities to some other person or object

passive aggression

individual deals with emotional conflict or stressors by indirectly and unassertively expressing aggression toward others on the surface, there is an appearance of compliance that masks covert resistance, resentment, and hostility aggression towards others is expressed through procrastination, failure, inefficence, passivity, and illness that affect others more than oneself occurs especially in response to assigned tasks or demands for independent action, responsibilities, or obligations

Sniffed, huffed, or bagged, often by children or adolescents •Examples: •Amyl nitrate, nitrous oxide, solvents •Spray paint •Glue •Cigarette lighter fluid •Propellant gases used in aerosols •Intended effects: •Euphoria Effects of intoxication: •Depend on the substance, but generally can cause behavioral or psychological changes, dizziness, nystagmus, uncoordinated movements or gait, slurred speech, drowsiness, hyporeflexia, muscle weakness, diplopia, stupor or coma, respiratory depression, and possible death Withdrawal manifestations: •None

inhalants

anorexia nervosa

intense irrational beliefs about their shape and weight, engage in self starvation, express intense fear of gaining weight, and have a disturbance in self evaluation of wieght and its importance females often experience amenorrhea two subtypes: restricting subtype, binge eating/purging subtype

agorophobia

intense, excessive anxiety about or fear of being in places or situations where help might not be available and escape may be difficult or embarrassing (the feared places or situations are avoided by the individual in an effort to control anxiety)

Individual Psychotherapy •Cognitive Behavioral Therapy (CBT) can be used to decrease anxiety and change behavior •Motivational Incentives •Motivational Interviewing •Relapse prevention therapy Group Therapy Self-Help Groups/12-Step Programs •Alcoholics Anonymous (AA) •SMART Recovery (Self-Management and Recovery Training) Family Therapy •Identifies codependency, common behavior demonstrated by the significant other/family/friends of an individual with substance dependency, and assists the family to change that behavior

interprofessional care for addictions

increase the amount of light in your home, get outside, exercise regularly, find ways to relax, take a trip

interventions for SAD:

1. safety -- assessment for suicide potential 2. self care assistance 3. interaction -- group activity, 1 on 1s 4. exercise 5. counseling -- client goals, teaching, problem solving skills 6. expression of feelings -- journaling, positive affirmation, expressive art/crafts, assertiveness training 7. target the physical needs: nutrition -- anorexia, sleep -- insomnia, self care deficits, elimination -- constipation, exercise 8. medications 9. ECT

interventions for depression:

•Identify and discuss what precedes impulsive acts. •Explore effects on self and others. •Recognize cues. •Identify triggers. •Discuss alternative behaviors. •Teach or refer the patient for coping skills training (e.g., anger management, assertive skills).

interventions for impulsive behavior:

meds: antidepressants, antipsychotics hormone therapy, counseling, inpatient treatment (suicidal, ECT) positive affirmations use positive reinforcement on mothering role healthy lifestyle choices: rest as much as they can, exercise regularly, daily walks with baby, eat healthy foods, avoid alcohol set realistic expectations: don't pressure to do everything, scale back expectations for the perfect household, encourage family members to help with clients chores make time for self: get dressed, makeup, hair done, leave the house and visit a friend or run an errand, schedule time alone with partner avoid isolation

interventions for postpartum psychosis:

phase 1: psychopharm treatment, supportive/directive communications, limit setting (milieu management and counseling), psychiatric, medical, neurologic evaluation phase II and phase III: family psychoeducation/community support, health teaching (patient and family), disease, medication management, cognitive and social skills enhacement, stress and anxiety controls health promotion and maintenance: identify signs of relpase and take preventive steps, improve functional deficits (self care, social, work functioning), encourage participation in nonthreatening activities, encourage family and social interaction

interventions for schizo:

family needs to be included in: psychological strategies aimed at reducing psychotic symptoms, teaching patient and family about illness, recognizing effect of stress, psychosocial activities, identifying support sources, medication groups for patients and family

interventions: health teaching and health promotion

denial

involves escaping unpleasant realities by ignoring their existence

substance use disorder

involves repeated use of chemical substances leading to clinically significant impairment during a 12 month period substances include: ETOH, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, tobacco, and other substances

displacing feelings (answer)

jacob is a 13 year old who is in the school nurse's office with a black eye. the school nurse told by his teacher that he started a fight with another student this morning as soon as he arrived at school. Jacob shares with you that his parents told him this morning that they are separating

stay with Jessie, call the supervisor and arrange for continuous monitoring

jessie has missed three sessions at the mental health center and sporadically attends AA meetings. she is drinking heavily this weekend and has sustained a 2 inch gash in her forehead after swerving off the road and into a shallow ditch. She is taken by rescue to the ED. you are her nurse. she tells you "I hope I just go to sleep and never wake up." what is your best intervention?

anergia

lack of energy, passivity, lack of persistence at work or school

avolition

lack of motivation; inability to initiate tasks, such as social contacts, grooming, and other aspects of activities of daily living

1.Use of restraints Physical restraints include any manual methods, materials or equipment that inhibits free movement Chemical restraints are drugs given for the specific purpose of inhibiting a certain behaviour or movement and that are not part of the normal treatment plan 2.Decision making about health care Advance Directive -Living Will is a personal statement of how and where one wishes to die, and can be changed at any time by the individual. It is activated only when the person is terminally ill and incapacitated. -Durable Power of Attorney for Health Care differs from a living will in that a person is appointed to act as the patient's agent. The individual does not have o be terminally ill or incompetent to allow the empowered individual to act on their behalf. 3.Elder Abuse 4.End-of-life care

legal and ethical issues that affect mental health of older adults

persistent depressive disorder

less notably severe depression characterized by depressive symptoms that have been present for at least 2 years may suffer from social and occupational distress, but not usually severe enough to warrant hospitization unless the individual becomes suicidal major differences between MDDs and PDDs are the level of severity, duration, and persistence this is much less severe than an episode of MDD, but this can endure for years

mild anxiety: occurs in a normal experience of everyday living = feel focused mod anxiety: as anxiety escalates, the patient' perceptual field narrows and some details are excluded from observation = perceptual field is narrowed severe anxiety: the perceptual field of a person experiencing severe anxiety is greatly reduced = greatly reduced perceptual field, totally absorbed with self, distorted perceptions panic level of anxiety: most extreme form and results in markedly disturbed behavior = hallucinations, delusions, emotional paralysis

levels of anxiety: Hildegard Peplau

Discovered by Dr. Friederich Lewy in 1912 Protein that disrupts brain normal function Involves changes in thinking, movement, behavior and mood Lewy bodies in cortical location. Abnormal deposits of protein - alpha synuclein in the brain leads to dementia Deposits called Lewy bodies Affects ~ 1 million people in US Usually 50 or older Slightly more men than women Over time-similar to Parkinson's Insidious onset, gradual progression, Fluctuating cognition, pronounce variations in attention and alertness Recurrent visual hallucinations, well formed and detailed Spontaneous Parkinson features after cognitive decline Suggestive: REM sleep behavior disorder, Severe neuroleptic sensitivity

lewy bodies:

MOA: not fully understood, a salt; the ions alter sodium ion transport in nerve cells this alteration is what causes the side effects the most narrow therapeutic index of all psychotropics this medication takes effect in one to three weeks!!

lithium carbonate:

vagus nerve stimulation

long term implanted treatment device approved by FDA for patients with treatment resistant depression action: not well understood, affects neurotransmitters implicated in depression device implanted in upper chest that sends electrical signals to left vagus nerve in the neck at regular intervals

chronic anxiety

long term, thought to be associated with increased risk for cardiovascular morbidity, usually begins at a young age

Alzheimer's disease Frontotemporal dementia Dementia with Lewy bodies Vascular dementia Traumatic brain injury Substance-induced dementia HIV infection Prion disease Parkinson's disease Huntington's disease

major neurocognitive disorders:

Assess the patient for a short period before labeling him or her as manipulative. Set limits on manipulative behaviors: -Arguing or begging -Using flattery or seductiveness -Instilling guilt and clinging -Constantly seeking attention -Pitting one person, staff member, or group against another -Frequently disregarding the rules -Constant engaging in power struggles -Exhibiting angry, demanding behaviors Behaviors should be objectively documented (e.g., time, date, circumstances). Provide clear boundaries and consequences. Enforce consequences. Avoid: -Discussing yourself or other staff members with patient -Promising to keep a secret -Accepting gifts from patient -Doing special favors for patient

managing behaviors:

euphoria, extreme optimism and inflated self esteem rapid speech, racing thoughts, agitation and increased physical activity poor judgement recklessness or taking chances not normally taken difficulty sleeping tendency to be easily distracted inability to concentrate aggressiveness/irritability

manic phase of BSD:

catatonic type

marked psychomotor disturbance, motionaless or excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement (echolalia, echopraxia)

thought blocking

may be signaled when a patients stops talking in the middle of a sentence and remains silent

orientation phase

may last for a few meetings or can extend over a longer period first time the nurse and the patient meet, they are strangers to each other each person has their own unique frame of reference-need for self-awareness on the part of the nurse

not uncommon for the first med to not improve symptoms. meds may need to be changed for a treatment response may start out with SSRIs improvement in mood may take 2-4 weeks or longer

medications for depression:

Cholinesterase inhibitors: Examples: donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne) In some clients, these medications slow cognitive deterioration of Alzheimer's disease in the mild to moderate stages Adverse effects: GI effects: nausea, vomiting, and diarrhea Monitor for GI adverse effects and for fluid volume deficits Promote adequate fluid intake provider may titrate the dosage to reduce GI effects Bradycardia, syncope Teach the family to monitor pulse rate for the client who lives at home The client should be screened for underlying heart disease NMDA receptor antagonist Example: memantine (Namenda) Approved for moderate to severe stages of Alzheimer's Blocks the entry of calcium into nerve cells, thus slowing down brain-cell death Can be used concurrently with a cholinesterase inhibitor Administer with or without food Monitor for common adverse effects, including dizziness, headache, confusion, and constipation

medications neurocognitive disorders:

Bupropion: intended effects •Decreases nicotine craving and manifestations of withdrawal NC: To treat dry mouth, encourage client to chew sugarless gum, suck on hard candy, sip on small amounts of water, or suck on ice chips Nicotine replacement therapy (gum, patch, nasal spray, lozenges, inhaler): intended effects •Nicotine replacements are pharmaceutical product substitutes for the nicotine in cigarettes or chewing tobacco •The rate of tobacco use cessation is nearly doubled with the use of nicotine replacements NC: Nasal spray provides pleasurable effects of smoking due to rapid rise of the nicotine level in the client's blood •Nasal spray is not recommended for clients who have disorders affecting the upper respiratory system such as chronic sinus problems, allergies, or asthma •Gradually taper nicotine inhaler use over 2 to 3 months and then discontinue Varenicline: intended effects •Nicotine receptor agonist that promotes the release of dopamine to stimulate the pleasurable effects of nicotine •Reduces cravings for nicotine as well as the severity of withdrawal manifestations •Reduces the incidence of relapse by blocking the desired effects of nicotine NC: Instruct client to take medication after a meal •Monitor blood pressure during treatment •Monitor clients who have diabetes mellitus for loss of glycemic control •Follow instructions for titration to minimize adverse effects •Can cause neuropsychiatric effects such as unpredictable behavior, mood changes, and thoughts of suicide. Advise the client to notify the provider if nausea, vomiting, insomnia, new-onset depression, or suicidal thoughts occur •Due to potential adverse effects, varenicline is banned for use in clients who are commercial truck or bus drivers, air traffic controllers, or airplane pilots

meds for treatment of nicotine dependency:

Methadone substitution intended effects •Methadone substitution is an oral opioid agonist that replaces the opioid to which the client has a physical dependence •Methadone administration prevents abstinence syndrome from occurring and removes the need for the client to obtain illegal opioids •Methadone substitution is used for withdrawal and long-term maintenance •Dependence is transferred from the illegal opioid to methadone NC: Encourage the client to participate in a 12-step program •Inform clients that the methadone dose must be slowly tapered to produce detoxification •Inform the client that the medication must be administered from an approved treatment center Clonidine: intended effects •Assists with withdrawal effects related to autonomic hyperactivity (diarrhea, nausea, vomiting) •Clonidine therapy does not reduce the craving for opioids NC: Obtain baseline vital signs •Advise the client to avoid activities that require mental alertness until drowsiness subsides •Encourage the client to chew sugarless gum or suck on hard candy, and to sip on small amounts of water or suck on ice chips to treat dry mouth Buprenorphine intended effects •Agonist-antagonist opioid used for both withdrawal and maintenance •Decreases feelings of craving and can be effective in maintaining compliance NC: Unlike methadone, a primary care provider can prescribe and dispense buprenorphine •Administer the medication sublingually

meds for treatment of opioid dependency:

homeless population of persons with mental illness, including substance abuse most health care dollars still spent on inpatient psychiatric care; community services not adequately funded cultural considerations: diversity increasing in US in terms of ethnicity and changing family structures

mental illness in the 21st century:

presence of delusions of hallucinations for 2 weeks or more in the absence of mood symptoms: used to rule out mood disorder mood symptoms are present throughout the majority of total period of active and residual portions of illness: used to rule out schizophrenia symptoms are not better explained by substance use or another medical condition

method for differentiating schizo and schizoaffective:

Occurs more often in those with a history of 1.smoking, 2.hypertension, 3.sedentary lifestyle, 4.high cholesterol, and depression. 5.affects those who are not involved in activities that challenge their brain

mild cognitive impairment

be calm, recognize the anxious person's distress, be willing to listen evaluate effective past coping mechanisms help the patient consider alternatives to problem situations and offer activities to temporarily relieve feelings of inner tension communication techniques: open ended questions, broad openings, exploring, seeking clarification

mild to mod levels of anxiety

undifferentiated type

mixed schizophrenic symptoms along with disturbances of thought, affect, behavior

ex: Nardil, Parnate, Marplan (Not Popular Meds!!) block monoamine oxidase by binding to the enzyme and permanently inactivating it synthesis of replacement MAO requires about 2 weeks allows for levels of DA, NE, and 5HT to rise significant dietary restriction with these drugs that, if neglected, can contribute to lethal side effects

monoamine oxidase inhibitors (MAOIs)

ex: lithium carbonate, anticonvulsant medications: Tegretol, Depakote, Lamictal, Neurontin uses: bipolar disorder and helps prevent relapse

mood stabilizing drugs:

depression, anxiety, demoralization, dysphoria, and suicidology

mood symptoms of schizo:

variations in mood such as anxiety, suicidality, demoralization, and dysphoria co occurring depressive symptoms increase the suffering of patients with schizophrenia post psychotic depressive disorder occurs in up to 25% of patients after an acute psychotic episode and increases the risk of suicide depression, anxiety, demoralizaiton, suicidality, excitability, agitation

mood symptoms:

recovery model

more of a social model of disability than a medical model of disability. therefore the focus shifts from one of illness and disease to an emphasis on rehab and recovery 12 step program of Alcoholics Anonymous

anxiety

most basic of human emotions dysfunctional behaviors are often a defense against anxiety when the behavior is recognized as dysfunctional, interventions to reduce anxiety can be initiated by the nurse as anxiety decreases, dysfunction behavior with frequently decrease feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized

hospital inpatient treatment

most intensive care for acutely ill people, severely depressed or suicidal, severely psychotic, experiencing alcohol or drug withdrawal, exhibiting behaviors that require close supervision (unsafe) nursing goals: SAFETY to client and others; stabilize with medication, milieu, and interaction, develop a transition plan to outpatient, crisis work with family

pica

mr. anderson is found to be eating laundry powdered detergent on more than one occassion. this is most likely a sign of which feeding problem?

Grandiose sense of personal achievements Consider themselves special and expect special treatment Arrogant and haughty demeanor Lack empathy for the needs or feelings of others; exploit others to meet own needs Blame others for the problems they themselves have caused Increasing attention seeking over time Envious of others Use of splitting, tantrums Can be sadistic, with paranoid tendencies

narcissistic personality disorder: cluster b

QSEN

national initiative toward patient safety and quality, prepares future nurses who will have the knowledge, skills and attitudes necessary to continuously improve quality and safety of the health care systems in which they work patient centered care, teamwork and collaboration, evidence based practice, quality improvement, safety, informatics

mesocortical pathway

negative and cognitive symptoms projections from the ventral tegemntal area to the cortex cognition and executive emotions and affect hypofunction of this pathway might be related to cognitive and negative symptoms in schizophrenia

inconsistency unavailability mutual avoidance lack of self awareness

negative behaviors that impact the progression of nurse patient relationship:

e.g. apathy, lack of motivation, anhedonia, poor thought processes, persist and are extremely destructive because they render a person inert and unmotivated

negative symptoms of schizo:

absence of negative behaviors flat affect (no emotion showing in the face), reduced social interaction, anhedonia (no feeling of enjoyment) avolition (less motivation, initiative, focus on tasks) alogia (speaking less), catonia (moving less(

negative symptoms of schizophrenia:

the A's: anhendonia--without pleasure avolition -- without volition associality -- decreased desire for comfort social situation affective blunting alogia -- without speech (poverty of speech)

negative symptoms:

limbic system (emotional brain) three main neurotransmitters that regulate anxiety responses (serotonin 5HT thought to be decreased in anxiety disorders) NE -- when increased causes hyperarousal and increased anxiety GABA -- slows neurotransmission which has a calming effect-- abnormalities in receptors lead to unregulated anxiety levels genetic components are substantiated by numerous studies that find anxiety disorders tend to cluster in families

neurobiology + genetic theories for anxiety:

brainstem : basic functions limbic system: brain's 'reward circuit' cerebral cortex: information processing dopamine: NT active in all addictions, regulates emotions, cognition, pleasure, pain, becomes less effective so the individual needs more drug to raise dopamine levels vicious cycle of drug effects on dopamine: tolerance, dependence/addiction opioids: alcohol and other CNS depressants, act on GABA (NT that inhibits and protects receptor nerves), cross tolerance: developing tolerance for more than one drug in the same class: intense rush followed by intense lows

neurobiology theory of addictions

group of conditions characterized by the disruption of thinking, memory processing, and problem-solving Treatment of clients who have neurocognitive disorders requires a compassionate understanding of both the client and family Progressive deterioration of cognitive functioning and global impairment of intellect (dementia) No change in consciousness Difficulty with memory, problem solving, and complex attention Mild: Does not interfere with ADLs; does not necessarily progress Major: Interferes with daily functioning and independence

neurocognitive disorders:

preorientation phase

new health care professionals usually have many concerns and experience some anxiety on their first clinical day students new to the mental health setting are often concerned about being in situations that they may not know how to handle

decreasing or removing triggers can reduce anxiety symptoms: caffeine, nicotine, stimulants, dietary triggers, stress, improving sleep CAM has been shown to decrease anxiety yoga, relax training, mindful meditation, acupuncture digital support: telehealth strategies, web based applications, mobile apps, virtual reality applications, and even wearables show promise to decrease anxiety

non pharm treatment for anxiety:

asking excessive questions giving approval or disagreeing giving premature advice asking "why" questions minimizing feelings being falsely reassuring making value judgements changing the subject

nontherapeutic communication techniques:

physiologic effects: affects attention, learning, memory and regulation of mood, sleep, and wakefulness relationship to mental health disorders: decreased in depression, increased in schizophrenia, mania, and anxiety

norepinephrine

clinical interview

nurses uses communication skills and active listening to better understand a patient's situation nurse provides the opportunity for the patient to reach specific goals and to: feel understood and comfortable, identify and explore problems relating to others, discuss healthy ways of meeting emotional needs, experience a satisfying interpersonal relationship permit the patient to set the pace (preparing for the interview), enhance feelings of security (setting), ensure ease of communication (seating), making introductions, initiating the interview, offering leads, making statements of acceptance speak briefly, when you do not know what to say, say nothing. when in doubt, focus on feelings, avoid giving advice, avoid relying on questions, note nonverbal cues, keep the focus on the patient

screening tool is often used (Hamilton, PHQ-9, Beck Depression Inventory) assess for suicide potential!! complete a psychosocial history assess mood, physical changes, and cognition

nursing assessment of depression:

anxiety fear ineffective coping social isolation ineffective role performance impaired social interaction post trauma syndrome fatigue spiritual distress self care deficit

nursing diagnosis for anxiety

•Depending on therapeutic intent, effectiveness can be evidenced by the following: •Absence of injury •Ongoing abstinence from the substance •Regular attendance at a 12-step program •Decreased craving for substance •Improved coping skills to replace use of substance

nursing evaluation of medication effectiveness:

patient is primary focus professional attitude sets the tone use self disclosure only for therapeutic purposes- and cautiously this is not a social relationship confidentiality is essential use interventions based on evidence and theory keep a non judgmental perspective avoid giving advice give priority to nonverbal behavior and gestures

nursing principles of therapeutic communication:

outcome criteria will dictate the frequency of evaluation of short term and intermediate indicators if outcomes not achieved satisfactorily, preventing factors are analzyed care plan revised longer term outcomes include compliance with the medication regimen, resumption of functioning in community, etc

nursing process: evaluation BSD

1. assess patient's responses to treatment as well as an adverse responses 2. prevent health teaching for medication management, intended effects, ways to cope with side effects 3. direct interventions toward alleviating side effects 4. communicate observations about patient's responses to medications to other health care clinicians 5. apply current research findings to guide nursing actions r/t psychotropic medications

nursing responsibilities in regard to psychopharmacology:

obsessive compulsive disorder

obsession and compulsions can exist independently of each other, but they can almost always occur together behavior exists along a continuum "normal" individuals: may experience mild obsessive compulsive behaviors (touching a lucky charm, knocking on wood, making the sign of the cross upon hearing disturbing news) mild compulsion are valued traits in selected contexts in US society severe symptoms: center on dirtiness, contamination, and germs and occur with CORRESPONDING compulsions such as cleaning and hand washing most severe symptoms: include persistent thoughts of sexuality, violence, illness, and death usually begins in the late teens, early twenties ranges from mild to severe substantial evidence that there is biological origins brain imaging studies, genetic component based on family and twin studies, responsiveness of patients to SSRIs (hypothesis that dysregulation of serotonin levels involved in the etiology of OCD)

abstinence syndrome

occurs when a client abruptly withdraws from a substance on which he or she is physically dependent

somatiziation

occurs when anxiety is repressed to an unconscious level but is revealed on a physical level in the form of physical symptoms that have no organic cause

Older adults who use substances are especially prone to falls and other injuries, memory loss, somatic reports (headaches), and changes in sleep patterns Indications of alcohol use in older adults can include a decrease in ability for self-care (functional status), urinary incontinence, and manifestations of dementia Older adults can show effects of alcohol use at lower doses than younger adults Polypharmacy (the use of multiple medications), the potential interaction between substances and medications, and age-related physiological changes raise the likelihood of adverse effects, such as confusion and falls in older adult clients

older adults + addictions

haloperidol and an anxiolytic via an immediate IM injection

on day 4 of gale's inpatient stay, she is still refusing oral medications. she has another outburst and slaps another patient on the back of the head. she is placed in seclusion and medicated. which of the following medications would most likely be given?

delusional disorder

one or more non bizarre delusions exist at least 1 month with no impairment in psychosocial functioning types: persecutory, erotomanic, grandiose, jealous, somatic) late age onset delusions lasting one month or longer with a general then such as grandiose, persecutory, somatic, and referential low prevalence, type of personality disorder, may or may not impede occupational functioning

typical age of onset is early adulthood, although onset can occur any time from adolescence to late in life schizoaffective disorder is often diagnosed with another psychiatric illness initially (illness along with schizo or bipolar spectrum, diagnosis may be converted away from schizoaffective disorder if pattern of symptoms shift)

onset and time course for schizoaffective disorder:

late teens to mid 30s, child onset rate. peak early to mid 20s males, late 20s females course unpredictable, one of exacerbations and remissions

onset and time course of schizo:

•Morphine •Heroin •Codeine •Fentanyl •Methadone •Meperidine Intoxication Effects Constricted pupils Increased respiration Increased blood pressure Slurred speech Drowsiness Psychomotor retardation Initial: euphoria Later: dysphoria Impaired: •Concentration •Judgment •Memory Withdrawal Effects Yawning Insomnia Irritability Rhinorrhea Panic Diaphoresis Cramps Nausea and vomiting Muscle aches Chills and fever Lacrimation Diarrhea

opiates

•Can be injected, smoked, and inhaled •Examples: •Heroin, morphine, hydromorphone Effects of intoxication: •Slurred speech, impaired memory, pupillary changes •Decreased respirations and level of consciousness, which can cause death •Maladaptive behavioral or psychological changes, including impaired judgment or social functioning An antidote, naloxone (Narcan), available for IV use to relieve effects of overdose Withdrawal manifestations: •Occur within hours to several days after cessation of opioid use •Common findings include agitation, insomnia, flu-like manifestations, muscle aches, abdominal cramps, rhinorrhea, yawning, sweating, and diarrhea •Withdrawal is very unpleasant, but not life-threatening •Suicidal ideation can occur

opioids

substance/medication induced bipolar and related disorder bipolar and related disorder due to another medical condition other specified bipolar and related disorder unspecified bipolar and related disorder

other bipolar disorders:

outcomes identification: reflect patient values and ethical and environmental situations be culturally appropriate be documented as measurable goals include a team estimate of expected outcomes planning: usually patients with anxiety disorders do not require in patient admission, planning for care usually involves selecting interventions that can be implemented in a community setting individuals with anxiety disorders should be encouraged to participate actively in planning whenever possible implementation: ID community resources offering specialized treatment identify community support groups for people with specific anxiety disorders and their families use therapeutic communication, milieu therapy, promotion of self care activities, psychotherapy, and health teaching and health promotion as appropriate

outcomes ID, planning, and implementation nursing process guidelines for anxiety

phase 1: acute, patient safety, medical stabilization, refrain from acting on delusions/hallucinations phase II: stabilization, phase III: maintenance: medical adherence, understanding, and compliance, continual recovery and functional improvement, anxiety control and relapse prevention, enhancement of quality of life

outcomes identification for schizo:

outcomes can be similar to that of an episodic mood disorder and a chronic schizophrenic disorder outcomes more often resampled those of patients suffering from schizo than episodic mood disorders patients with predominantly mood symptoms have a better long term prognosis than those with predom schizophrenic like symptoms

outcomes of schizoaffective disorder:

Pervasive, persistent, and inappropriate suspiciousness and distrust of others without the slightest justification Present as hostile, irritable, angry, injustice collectors, pathologically jealous of their partner, and litigious cranks Constantly suspicious and believe others are lying, cheating, exploiting, or trying to harm them in some way Lack warmth, pat close attention to power and rank, and express disdain to those who are weak, sickly, or impaired May appear businesslike and efficient, but generate fear and conflict in others through hostile/sarcastic expressions Find hidden malicious meaning in benign comments and behaviors (ideas of reference)

paranoid personality disorder (PPD): (cluster a)

mania or hypomania with mixed features

patient in full bipolar mania or hypomanic mood displays depressive symptoms at the same time

cognitive distortion

people with eating disorders have cognitive distortions that are the result of processing errors in the brain determining which cognitive distortions were present before the ED and which ones are result of semistarvation is important EDs are connected to the underlying emotions of: anxiety, dysphoria, low self esteem, feelings of lack of control

paranoid type (schizo)

persecutory or grandiose delusions and hallucinations; sometimes excessive religiosity, hostile and aggressive behavior

phobias

persistent, intense 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 specific, social, agoraphobia

transference

person unconsciously and inappropriately displaces (transfers) those emotional reactions that originated form significant figures in childhood onto another individual the patient may say "you remind me of _____"

projection

person unconsciously rejects emotionally unacceptable personal features and attributes them to other people, objects, or situations through projection hallmark of blaming, scapegoating, prejudicial thinking, stigmatization

emotional factors (mood, response to stress, personal bias) social factors (previous experience, cultural differences, language differences, lifestyle differences) cognitive factors (problem-solving ability, knowledge level, language use)

personal factors that affect communication:

AXIS 2

personality disorders and mental retardation

personality disorder

personality traits are exaggerated and rigid to the point that they cause dysfunction in their relationships

improvement in weight gain and appetite is facilitated through the treatemnt of the underyling anxiety olanzapine (zyprexa) a second generation antipsychotic medication, affects weight gain and improves cognition and body iamge fluoxetine (prozac) a selective serotonin reuptake inhibitor has shown mixed results in maintaining weight and preventing relapse

pharm therapies for EDs

benzodiazepines (anxiolytics) -- prescribed for short term treatment only, not recommended for patients with substance abuse problems, can be highly addictive buspirone -- management of anxiety disorders, non addictive, excellent for long term relief of anxiety symptoms ssris -- first line treatment for all anxiety disorders, ocd, and bdd snris-- only venlafaxine is currently approved for panic, GAD, SAD. duloxetine for GAD tricyclic antidepressants -- second or third line use for PD, GAD, and SAD, clomipramine is effective in OCD MAOIs: reserved for treatment resistent conditions due to risk of life threatening hypertensive crisis. recently being used in people with social anxiety disorder and rejection sensitivty

pharm therapies for anxiety:

antipsychotic medications: alleviate symptoms of schizo but cannot cure underlying psychotic processes: psychotic symptoms return with medication noncompliance antipsychotic drugs are effective in: acute exacerbations of schizo, preventing or mitigating a relapse conventional antipyschotics: target positive symptoms atypical second gen antipsychotics: target positive and negative symptoms, atypical agents have fewer side effects, atypical agents treat anxiety, depression, and decrease suicidal behavior

pharm therapy for schizo:

Medications are not available for the treatment of PDs per se. Treating the symptoms is helpful. Benzodiazepines (maintenance dosing) for anxiety are not appropriate because of the potential for abuse and overdose; they may be used in emergency situations. Medications with low toxicity are appropriate. Selective serotonin reuptake inhibitors (SSRIs)—treat co-morbid depression and panic attacks. Trazodone and venlafaxine—have low toxicity in overdose. Carbamazepine—targets impulsivity and self-harm. Lithium, anticonvulsants, SSRIs—minimize aggression. Atypical antipsychotics—help with psychotic features.

pharmacologic therapies: personality disorders

Treat the symptoms and stage of disease! Mood-Depression (SSRI/SNRI, Celexa, Cymbalta) Psychosis-hallucinations, agitation, behavioral (2 generation anti-psychotics Seroquel, Risperdal, Zyprexa Sleep (Trazadone, Klonopin, Melatonin Vascular dementia (treat cardiac issues too!) Altered pharmacokinetics in the Elderly Decrease absorption and acid production Decrease muscle, body water, hepatic flow Decrease renal perfusion and GFR, decrease serum albumin with altered protein binding *May also forget to take their meds or can't afford them

pharmacology for depression in elderly

non verbal communication

physical appearance facial expressions body posture amount of eye contact eye cast (emotion expressed in the eyes) hand gestures sighs fidgeting yawning tone and pitch of a person's voice

Decreased blood flow and oxygenation Decreased cerebral blood flow, may take longer to learn new material but learning still takes place Brain mass decreases with age: by 80, gross brain weight has decreased by about 17% Crystallized intelligence remains the same, Fluid intelligence, complex multi-step tasks, may take longer. memory: - Long term memory - intact - Short term memory, especially memory that involves complex subjects, may decline. - Ability to transfer short term memory to long term memory also declines.

physiological changes in the brain:

withdrawal

physiological manifestations that occur when the concentration of the substance in the client's bloodstream declines withdrawing from a substance that has the potential to cause abstinence syndrome can cause the client to experience distressing manifestations that are potentially life threatening

phase II (continuation of treatment, BSD)

planning focuses on maintaining compliance with the medication regimen and preventing relapse education for patient and family is a priority community resources, medication adherence, health teaching and health promotion

phase 1 (acute mania, BSD)

planning focuses on medically stabilizing the patient while maintaining safety, during this, hospitilization is usually safest communication guidelines, milieu therapy, medications, ECT

phase III (maintenance treatment, BSD)

planning focuses on preventing relapse and limiting the severity and duration of episodes psychosocial interventions, psychotherapy, support groups

consistency pacing (patient sets pace) listening initial impressions comfort balancing control

positive behaviors that impact progression of nurse patient relationship:

mesolimbic pathway

positive symptoms of schizo projections from the ventral tegmental area to the nucleus accumbens motivation, emotions, reward, positive symptoms of schizophrenia D2 antagonists, reduce positive symptoms of schizophrenia

hallucinations, delusions, bizarre behavior, paranoia. referred to as florid psychotic symptoms

positive symptoms of schizo:

presence of problematic behaviors hallucinations, illusory perception, especially auditory delusions (illusory beliefs), especially persecutory disorganized thought and nonsenscial speech, bizarre behaviors

positive symptoms of schizophrenia:

anxiety sadness -- lack of joy in life irritability, crying, headaches a sense of inadequancy exhaustion -- constant fatigue a sense of emotional numbness or failure withdrawal from family and friends lack of concern for self or baby excessive concern for your baby less interest in sex severe mood swings impaired thinking or concentration insomnia

postpartum depression:

acute anxiety

precipitated by an imminent loss or change that threatens an individual's sense of security acute anxiety is a normal and expected response to stress

body dysmortphic disorder

preoccupation with an imagined 'defective body part' obsessional thinking (thinking they are ugly or deformed) compulsive behaviors (mirror checking, skin picking, excessive grooming) impairment of normal social activities related to academic or occupational functioning usually feels shame, hides or withdraws from others, may alter appearance through plastic surgery

cyclothymic disorder

presents with hypomanic episodes alternating with persistent depressive episodes (dysthymia) for at least 2 years duration, 1 year in children individuals with with tend to have irritable hypomanic episodes

actual number of individuals with EDs is not known because disorders may exist for a long time before the person seeks help EDs are culturally influenced with varying prevalence, depending on the culture and social norms female and male athletes demonstrate an increased incidence of EDs anoreixa - appears in early to middle adolescence bulimia - appears in late adolescence women aged 35-65 = changes in appearance and role potentially increase the risk of ED ED's are almost always co morbid with other psychiatric illnesses more than 50% of people with anorexia and 95% of those with bulimia have one other psychiatric disorder significant co morbidity with: mood and anxiety disorders, substance abuse, body dysmorphic disorders, impulse control disorders, personality disorders especially borderline and OCD always assess for psychiatric risk, including suicidal and self harm thoughts, plans, and or intent

prevalence and comorbidity of eating disorders

Engage in physical activity. Avoid obesity Mental stimulation-Puzzles, reading, learn a new language, go to school. Don't Smoke Keep diabetes under control. HTN - keep controlled Avoid excessive alcohol May promote cell growth through increased blood flow. Increases the risk for cardiovascular disease Increased prevalence of AD in poorly educated people. Increases the risk of AD

primary prevention for dementia

•Emerges from hope •Person-driven •Many pathways •Holistic •Supported by peers/allies •Supported through relationships/social networks •Culturally based •Supported by addressing trauma •Involves individual, family, community •Based on respect

principles in the recovery paradigm

decade of the brain (1990s)

prior to this mental illness was perceived as a lack in character or spiritual flaw

therapeutic communication

professional relationship goal directed: focus on patient's problems and needs, boundaries and roles are firm and clear scientifically based (Peplau's theories) values: respect for the individual/nonjudgemental, desire to work with patients to help with problems, It isn't just the words we use!

tuberoinfundibular pathway

prolactin release hypothalamus to infundibular region dopamine is released into the portal circulation connecting the median eminence with the anterior pituitary gland dopamine tonically inhibits prolactin release D2 antagonism increases prolactin levels

working phase

promotion of a strong working relationship develops over time allows for the patient to experience increased levels of anxiety and demonstrate dysfunctional behaviors in a safe setting while experimenting with new and more adaptive coping behaviors

defense mechanisms

protect people from painful awareness of feelings and memories that can provoke overwhelming anxiety adaptive use of defense mechanisms helps people lower anxiety levels to achieve goals in acceptable ways

receiving effective mental health care the skills and abilities to solve problems connectedness - positive connections with family, peers, community, and social institutions that foster resilience reduced access to lethal means

protective factors for suicide:

stooped posture shuffling gait rigidity bradykinesia tremors at rest pill rolling motion of the hand

pseudoparkinsonism:

biological theory

psychiatric disorders are heavily influenced by &/or cause changes to the brain &/or neurotransmitter resulting in changes in thinking and behavior neurochemical imbalances are corrected through medication and talk therapy (e.g. cognitive behavioral therapy)

establish rapport obtain an understanding of the current problem or chief complaint review physical status and obtain baseline vital signs assess for risk factors affecting the safety of the patient or others (suicide/homicide) perform a mental status exam assess psychosocial status ID mutual goals for treatment formulate a plan of care that prioritizes the patient's immediate condition and needs document data in a retrievable format

psychiatric nursing assessment goals:

address emotional distress, symptom management, address barriers to treatment/recovery for those suffering from substance abuse/dependence. address physical symptoms that occur along with altered psychological status address behaviors and mental states that indicate potential danger to self or others help with communications problems due to psychiatric disorders psychological symptoms that occur along with altered physiological status

psychiatric nursing:

psychologic: lack of tolerance for pain/frustration, lack of impulse control, meaningful work, and relationships, lack of self esteem, strong tendency toward risk taking, self medicating societal/cultural: lack of bonding, support/role models for values, peer influences

psycho/societal and cultural influences for addictions

Psychological factors that increase risk for medical diseases, magnify them, or interfere with their treatment Depression Cardiovascular diseases and cancer Stress

psychological factors affecting medical condition:

AXIS 4

psychosocial and environmental problems, including problems with primary support group, social environment, education, occupation, housing, economics, access to health care, legal system

central or chief complaint (in the patient's own words) history of violent, suicidal, or self mutilating behaviors alcohol and/or substance abuse family psychiatric history personal psychiatric treatment including medications and complementary therapies stressors and coping methods quality of activities of daily living personal background social background including support systems weaknesses, strengths, and goals for treatment racial, ethnic, and cultural beliefs and practices spiritual beliefs or religious practices

psychosocial assessment:

although increasing evidence for genetic and biological vulnerabilities in the etiology of the mood disorders, stressful life events can trigger symptoms of bipolar disorder persons with BSDs who suffered abuse as children have earlier onset of bipolar disorder, faster cycling frequencies, increase in comorbid conditions such as substance abuse and addiction

psychosocial theories of BSDs:

psychotherapy is the treatment of choice for individuals with PTSD: cognitive behavioral therapy, group therapy with others who have had traumatic experiences, family therapy, vocational rehab when target symptoms arise and become serious, medications can be used and may serve to help the patient gain emotional control

psychotherapeutic treatment strategies

do NOT CURE mental illness should be used in combo with counseling and therapy have side effects most have a lag period drug and food interactions are common should be tapered off

psychotropic medications...

QT interval is a measurement of ventricular repolarization risk of re-entrance tachycardia such as torsades de pointe

qt prolongation

bipolar disorders with rapid cycling features

rapid cycling consists of two or more distinct episodes of alternating episodes of both mania and depression in a 12 month period depression - mania - depression - mania

refeeding syndrome

rare but can be lifethreatening shifts in electrolytes and minerals, can result in CHF, arrhythmias, resp failure, metabolic acidosis, seizures, encephalopathy, possibly death

global assessment of functioning

rates the patient's level of function in work, social skills, and psychological ability normal = 80-100 moderate problems = 60-80 serious mental disability, functional impairments = <40 present and past GAF scores are compared

fear

reaction to a specific danger

all or nothing thinking

reasoning is absolute and extreme, in mutually exclusive terms or black or white, good or bad 'if I have one popsicle, I must eat five' 'if I allow myself to gain weight, i'll blow up like a balloon'

bipolar II disorder

recent severe and prolonged periods of depression that alternate with brief periods of hypomanic episodes brief periods of hypomania may be missed hypomania is essentially a less severe and less intense form of mania and may only last 2-4 days in most cases periods of hypomania alternate with depressive episodes that are more prolonged psychosis is not present

panic disorders

recurrent and expected panic attacks feeling of terror, suspension of normal functioning, severely limited percpetual field, misinterpretation of reality, often accompanied by highly uncomfortable physical symptoms (palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing frequency, nausea, feelings of choking, chills, hot flashes, GI symptoms

relationship factors

refer to whether the participants are equal or unequal

ageism

refers to deeply rooted negative attitudes or bias toward people because of their age

dopamine

regulates pleasure and pain and plays a major role in all addictions. Drugs of abuse affect the limbic (reward) system. First-time use releases a large amount of dopamine. Intense pleasure results. Neurons are unable to regulate dopamine. Dopamine is unable to stimulate the reward center. More of a drug is used to increase dopamine levels. Cycle of tolerance begins. Dependence and addiction occurs

medication compliance: teach, even if feeling unwell, resist the temptation to skip medications. if they stop, s/sx of the disorder may recur pay attention to warning signs: help them identify a pattern to the episodes of bipolar disorder and what triggers them. involve family members or friends in watching for warning signs avoid drugs and alcohol. drugs especially stimulants including diets, drugs, and alcohol may be part of what triggers episodes of bipolar disorder

relapse prevention interventions: BSD

burnout

related to emotional exhaustion and withdrawal associated with increased workload and instituional stress

stabilized

remember: we want to treat the symptoms while getting their mood ______

tolerance

requiring increased amounts of the substance to achieve the desired effect

poverty of speech (alogia)

restriction in the amount of speech; answers range from brief to monosyllabic one-word answers

Blackout or loss of consciousness Changes in bowel movements Weight loss or weight gain Experience of stressful situation Sleep problems Chronic pain Concern over substance use Cutting down on consumption or behavior

review of systems for addictions

More women than men have dementia 2/3 AD - women Less education = Greater risk of dementia Medicare payments in 2004 - three times higher for those over 65 with dementia Advancing Age: Possible decreased brain reserves Sex-Women: Live longer, loss of neuroprotective effects of estrogen Family History: Possible gene mutations Depression: May decrease brain reserves/transmitters High-fat, cholesterol diet: Increased neuroinflammation CRP: Increased neuroinflammation Homocysteine: Increased oxidative stress, free radical toxicity, increased atherosclerotic sequelae Smoking: Accelerated cerebral atrophy, perfusional decline, and white matter lesions Diabetes mellitus: Impaired glucose uptake in neuronal cells, decreased blood supply due to small-vessel disease Hypertension: Decreased blood flow/cerebral ischemia, white matter lesions Head trauma: Possible blood brain barrier disruption. Obesity: Hyperlipidemia and hypertension

risk factors for dementia

a highly stressful life event such as losing someone close, financial loss, or trouble with the law prolonged stress due to adversities such as unemployment, serious relationship conflict, harassment or bullying exposure to another person's suicide, or to graphic or sensationalized accounts of suicide (contagion) access to lethal methods of suicide during a time of increased risk

risk factors for suicide:

compulsions

ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety common: repetitive hand washing, checking a door multiple times to make sure it is locked can include mental acts such as counting or praying relief is only temporary therefore the compulsive act must be repeated many times

when stress is prolonged, chemicals produced by the stress response (cortisol, adrenaline, and other catecholamines) can have damaging effects on the body

role of HPA AXIS (hypothalamus, pituitary gland and adrenal glands) in chronic stress

acute stress disorder

same triggers as PTSD, same or similar manifestations, difference is it resolves within 1 month

stabilization phase

schizo; period in which acute symptoms, particularly the positive symptoms, decrease in severity

maintenance phase

schizo; period in which symptoms are in remission, although there might be milder persistent symptoms (residual symptoms)

acute phase

schizo; periods of florid positive symptoms (more fully developed and flagrant) e.g. hallucinations, delusions) as well as negative symptoms (e.g. apathy, withdrawal, lack of motivation) and cognitive symptoms

prodromal phase

schizo; signs and symptoms that precede the acute, fully manifested signs and symptoms of disease occur in up to 80-90% of people with schizo before the emergence of frank psychosis include social withdrawal and deterioration in function and depressive mood, followed by perceptual disturbances, magical thinking, and peculiar behavior anxiety and sleep disturbances if recognized as possible: early treatment may help prevent full blown psychosis and help diminish chronic symptoms

Inability to establish relationships with others and restricted range of emotions in interpersonal settings Seen by others as eccentric, isolated, or lonely Affect is usually flat, which projects emotional coldness Appear indifferent to praise or criticism by others Invest no interest or energy into human relationships of any kind, but may invest enormous energy into nonhuman interests such as mathematics or astronomy Often connect more with animals Often creative, original thinkers

schizoid personality: (cluster a)

devastating brain diseases that target young people in their teens or early twenties at the beginning of their productive lives rarely evidenced in childhood profoundly disrupts an individual's ability to perceive reality accurately, to think clearly, to use language appropriately, to experience normal emotions, or to engage in normal social/occupational experiences schizophrenia spectrum disorders are a group of psychotic disorders psychosis is not a diagnosis but a symptom psychosis refers to a total inability to recognize reality (delusions and hallucinations) schizophrenia is treatable but not curable

schizophrenia spectrum disorders:

resembles schizophrernia but with no psychosis, odd, eccentric behavior and speech, cognitive perceptual distortions without psychosis, may display magical thinking and rituals, have bizarre fantasies or preoccupations that are not consistent with cultural norms, give and take conversations difficult, genuinely unhappy about lack of relationships, social anxiety and unhappiness may increase over time

schizotypal personality disorder: (cluster a)

depression and other signs and symptoms of SAD for at least 2 consecutive years, during the same season periods of depression have been followed by non depressed seaseons no other explanations for the changes in mood or behavior

screening for SAD

Cognitive Stimulation therapy for mild-moderate dementia. Group sessions to stimulate thinking and socialization Sessions involve: Exercises Food Word games Number games, current affairs Famous faces Found to be effective in improving: memory judgment language reasoning Written cues and reminders Minimize choices Avoid open ended questions Establish routines Adequate lighting Well lit halls

secondary prevention for dementia:

nurses may find it difficult to appreciate the force of illness, regarding it as trivial and incorrectly believing that weight restriction, bingeing, and purging are self imposed nurses may believe that a patient chooses risky behavior and blame the patient personality traits and conflicts pose challenges avoid authoritarianism and coerction terror of weight gain and resistance cause frustration

self care: discussion:

physiologic effects: affects sleep and wakefulness, especially falling asleep. affects mood and thought process relationship to mental health disorders: thought to play a role in thought disorders of schizophrenia, decreased in depression, possibly decreased in anxiety and obsessive compulsive disoder

serotonin

ex: Venlafaxine, Duloxetine increase the levels of both serotonin and NE by inhibiting their reuptake into the cells in the brain because of the addition of the NE neurotransmitters, these drugs are lethal in overdose diabetic neuropathy

serotonin-NE reuptake inhibitors (SNRIs)

hospital (inpatient), community (outpatient), individual psychotherapy and treatment, residential settings, chronic care

setting for psychiatric care:

social anxiety disorder

severe anxiety or fear provoked by exposure to a social situation or a performance situation, resulting in humiliation or embarrassment (fear of public speaking is the most common)

affective blunting

severe reduction in the expression of emotions on the contact, bland intonation of speech, often referred to as flat affect

physical needs must be met to prevent exhaustion patient's safety and the safety of others must be addressed move the patient to a quiet environment with minimal stimulation provide gross motor activities to drain some of the tension communication techniques: firm, short, simple statements, reinforcing commonalities in the environment and recognition of reality when there are distortions

severe to panic levels of anxiety:

codependence

shortly before treatment, after crying and begging him to get help, harry's girlfriend stayed home from a planned night out with her friends to pour all of the alcohol in his apartment down the drain. what type of behavior is evident?

reach out: show them you truly care share observations and concerns concern and counter their sense of hopelessness don't worry about doing or saying the right thing. your genuine interest and concern is what is the most important

show you care (suicide)

mask depression through sulking, being negative or grouchy, getting into trouble at school, feeling misunderstood, withdrawing from others, running away girls more vulnerable even before adolescence

signs of depression in adolescents:

complain of feeling unwell refuse to go to school vague physical complaints show aggression act clingy

signs of depression in children

1.Provide continuity of care. 2.Avoid unnecessary procedures. 3.Provide frequent, brief, and regular visits. 4.Always conduct a physical exam. 5.Avoid disparaging comments. 6.Set reasonable therapeutic goals.

six key elements for effective treatment:

nursing process

six step, problem solving care approach (assessment, diagnosis, outcomes ID, implementation, evaluation) facilitates care that is: appropriate, safe, culturally competent, developmentally relevant, high quality foundation for the standards of practice

One or more distressing symptoms Excessive thoughts, anxiety and behaviors around symptoms, or health concerns Without significant physical findings and medical diagnosis Suffering is authentic High level of functional impairment

somatic symptom disorder:

patient advocate

speaks up for another's cause. helps others by defensive actions, especially when the other person lacks knowledge, skills, ability or status to speak for himself or herself not a legal role but rather an ethical one when they advise patients of their rights, provide accurate and current information so patients can make informed decisions, and support those decisions demonstrates respect and value for human life while saving lives or bringing comfort to those who are dying also function as this when they engage in public speaking, write articles, and lobby congressional representatives to help improve and expand mental health care

clinical/critical pathways

specific to the institution using them. these pathways serve as a map for specified treatments and interventions to occur within specific time frames that have been shown to improve clinical outcomes

poverty of content of speech

speech that is adequate in amount but conveys little information because of vagueness, empty repetitions, or use of stereotypes or obscure phrases

Stage 1 Mild: Forgetfulness loses things, forgets, aware of the problem, depression common Stage 2 Moderate: Confusion Continued, progressive memory problems, Withdrawn from social act. Declines in ADL's Needs daycare or in-home assistance Stage 3 Moderate to Severe: Ambulatory Dementia Loss of reasoning, more ADL losses, loss of language, institutional care needed Stage 4 Late End Stage Non-ambulatory, forgets how to eat, return of primitive reflexes

stages of alzheimer's disease:

"the psychiatric mental health RN collects and synthesizes comprehensive health data that are pertinent to the health care consumer's health and/or situation" use holistic, evidence based assessment technique primary source: patient, secondary sources (others) health insurance portability and accountability act (HIPAA) document relevant data in retrievable format assessment considerations: age, language barriers

standard 1: assessment

formulating a nursing diagnosis standard nursing diagnosis: the problem (unmet need), the etiology (probable cause), the supporting data (signs and symptoms) risk diagnosis: high probability of a future negative event for a vulnerable individual health promotion diagnoses: willingness to enhance specific health behaviors

standard 2: diagnosis

"the psychiatric mental health RN identifies expected outcomes and the health care consumer's goals were planned individualized to the health care consumer or to the situation" outcomes criteria: goal outcomes reflect maximal patient health that can be realistically achieved through evidence based interventions provide direction for continuity of care patient centered and culturally appropriate

standard 3: outcomes identification

"the psychiatric-mental health RN develops a plan that prescribes strategies and alternatives to assist the health care consumer in attainment of expected outcomes" outcomes: are variable and measurable, are a reflection of patient's actual state goals: are measurable, indicate the desired patient behaviors, include a set time for achievement, are short and specific planning interventions to achieve outcomes includes the use of specific principles. the plan should be: safe, Evidenced based whenever possible, realistic, compatible with other therapies nursing interventions classification (NIC) provides nurses with standardized interventions nursing outcomes classifications (NOC) provides standardized outcomes

standard 4: planning

"the psychiatric-mental health RN implements the identified plan" basic level: PMH-RN Role standard 5A: coordination of care standard 5B: health teaching and health promotion standard 5E: pharm, biological, and integrative therapies "the psychiatric mental health RN incorporates knowledge of pharm, biological, complementary interventions with applied clinical skills to restore health and prevent further disability" standard 5F: therapeutic relationsihp and counseling advanced practice: PMH-APRN ROle prescriptive authority and treatment, psychotherapy, consultation

standard 5: implementation

"the psychiatric-mental health RN enhances progress toward attainment of expected outcomes" systematic, ongoing, criterion-based include supporting data, enables revisions to diagnoses, outcomes, and interventions

standard 6: evaluation

clinical algorithms

step by step guidelines prepared in a flowchart or decision tree format.

CNS stimulants used for ADD, ADHD ex: Ritalin, Concerta, dextroamphetamine MOA: stimulate brain function, increasing release of NTs (NE & dopamine) and blocking re-uptake reduces action of GABA stimulants are not used in situations where drugs may be "diverted" or in cases where family history reveals "sudden death" phenomena

stimulants:

eliciting the relaxation response (meditation, prayer, mindfulness) physical activity -- deepens breathing relieves muscle tension, and can elevate levels of the body's own endorphins (yoga, tai chi, running, walking briskly) seek social support (eg close family ties, acquaintances, spouses, friends)

stress reduction techniques

emotional reasoning

subjective emotions determine relaity I kow im fat because I feel fat when I feel thin, I feel powerful

Alcohol •Most toxic teratogen for fetuses •Fetal alcohol syndrome (FAS) or effects Nicotine: •Risks of low birth weight and developmental issues (cerebral palsy, etc.)

substance use in pregnancy

psychotic features: hallucinations and delusions catatonic features, melancholic features, post partum onset, seasonal pattern, atypical features

subtypes of depression:

always screen! at every encounter, be alert for subtle signs often under screened in the geriatric population screening instruments, use one consistently on every visit if it all possible will assit in indentifying response and remission in various categorites (sleep, work) ex: PHQ 9, beck depression inventory

suicide prevention:

anxiety, insomnia, irritability, weight loss, decreased appetite, increased libido

summer SAD:

self care for nurses

supervision and support for staff in challenging and frightening situations from more experienced nurses and staff skills for responding to hallucinations and delusions, avoiding transferable anxiety, use of group supervision, peer group supervision for experience staff

intrusive re experiencing of the initial trauma (flashbacks, nightmares, unwanted distressing memories of the event, feelings of unreality) avoidance: avoid all memories and feelings as well as people or places that might recall the event persistent negative alterations in cognitions and mood: distorted cognitions about themselves and others and feelings of detachment alteration and arousal and activity: irritability, angry outbursts, self destructive behavior, exaggerated startle response, hypervigilance, sleep difficulties

symptoms of PTSD:

feeling overwhelmed physically and mentally exhausted interferes with ability to function, intrusive thoughts/images of another's critical experience difficulty separating work from personal life, becoming pessimistic, critical, irritable, prone to danger dread of working with certain individuals depression ineffective and or destructive self soothing behaviors, withdrawing socially and becoming emotionally disconnected from others becoming demoralizing questioning one's professional competence and effectiveness becoming easily frustrated insomnia lowered self esteem in nonprofessional situations, loss of hope

symptoms of compassion fatigue:

schizoaffective disorder

symptoms of psychosis and thought disorder along with all the features of a mood disorder (depressive or bipolar) social and occupational dysfunction symptoms not substance related or other medical disorder

clinical practice guidelines

systematically developed statements based on literature review that appraise and summarize the best evidence to guide clinicians in making informed decisions about specific health problems

protrusion and rolling of the tongue sucking and smacking movements of the lips chewing motion facial dyskinesia involuntary movements of the body and extremities

tardive dyskinesia

countertransference

tendency of the nurse to displace feelings related to people in his or her past onto a patient frequently, the patient's transference to the nurse evokes this feelings in the nurse

NON-PHARMACOLOGICAL Calm, quiet environment Maintain nutrition Assess potential causes of agitation Reorientation is not recommended Therapeutic activities Current events Reminiscence Art therapy-play dough Music therapy-old songs Games-checkers Patient safety paramount importance Pharmacological treatment Aim-Improve cognition, mood and behavior. Increase quality of life

tertiary prevention for dementia:

craving: a powerful desire to use control: loss of control of amount or frequency of use compulsion: the need to have the substance in the system, without this the individual cannot function consequences: continued use despote negative consequences

the 4 C's of addiction:

younger

the ____ onset of schizophrenia, the more discouraging the prognosis

nurse patient relationship

the basis of all psychiatric nursing treatments the first connections between the nurse and the patient are to establish an understanding that the nurse: is safe, confidential, reliable, and consistent maintains clear and appropriate boundaries each person brings his or her own uniqueness to the nurse patient relationship historically referred to as the therapeutic use of self develop your own style "use of self", find the techniques and phrases that work for you

not injury himself/herself independently carry out ADLs establish a balance of rest, sleep, and activity establish a balance of adequate nutrition, hydration, and elimination evaluate self attributes realistically socialize with staff, peers, and family/friends return to occupation or school activities comply with medication regimen verbalize symptoms of a recurrence

the client will .... acute treatment BSD goals

suppression

the conscious denial of a disturbing situation or feeling

catastrophizing

the consequences of an event are magnified 'if I gain weight, my weekend will be ruined'

compassion fatigue/secondary traumatic stress

the emotional effect that nurses and other health care workers may experience by being indirectly traumatized when helping or trying to help a person who has experienced primary traumatic stress

several factors, including genetics, are implicated

the exact cause of bipolar disorder has not been determined, however, for most patients:

repression

the exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness

mood of sadness, despair, emptiness negative, pessimistic thinking loss of ability to experience pleasure in life (anhedonia) low self esteem apathy, low motivation, and social withdrawal excessive emotional sensitivity irritability and low frustration tolerance insomnia or hypersomnia disruption (mild to severe) in concentration or ability to make decisions suicidal ideation excessive guilt indecisiveness

the following symptoms are most prevalent in all types of depression:

splitting

the inability to integrate the positive and negative qualities of oneself or others into a cohesive image aspects of the self and of others tend to alternate between opposite poles

report the lab results to the HCP

the laboratory report for a patient taking clozapine (Clozaril) shows a WBC of 3000mm^3 and a granulocyte count of 1500 mm^3. the nurse should:

depression in adults can be missed especially if there are also medical problems depression in children and adolescents can be missed when attention is focused on behavioral problems (just a "stage!") racial disparities in health care can contribute to underdiagnosis in minorities

the presence of depression can be missed:

orientation phase working phase termination phase phases often overlap preorientation phase: nurse may have many thoughts and feelings before the first clinical session

the three phases of the nurse patient relationship are:

consider each disorder primary and provide simultaneous treatment

the treatment team plans care for a person diagnosed with schizophreniaand cannabis abuse. the person has recently used cannabis daily and is experiencing increased hallucinations and delusions. which principle applies to care planning?

varied and complex cause, EDs include a biological vulnerability or predisposition that is activated by psychologic, environmental, and cultural factors neurobiological/neuroendocrine: abnormalities are of the 'the chicken or the egg' quality because we are not certain whether they cause the ED or if they ED causes them genetic model: individuals with EDs have a characteristic phenotype: constellation of personality traits that have been shown to be mod heritable female relatives of people with EDs are up to 12 times more likely to develop them as well psychologic models: core psychopathologic characteristics of EDs are thought to be low self esteem and self doubts about personal worth family theorists long believed that specific dynamics converge to create individuals with EDs. the Academy for Eating Disordres strongly opposes the theoretical model that states that family dynamics are the primary cause of EDs

theory of eating disorders:

no single cause due to combination of hereditary and temperamental traits, as well as environmental and developmental events personality traits thought to be present from infancy disorder emerges in adolescence genetic factors: PDs are historically considered to be environmentally mediated, research supports a more dominant role of genetics, neurobiologic factors childhood neglect is particularly damaging, childhood trauma: excessively harsh and erratic discipiline, alcoholic parents and abusive and chaotic home life are risk factors for borderline PDs and antisocial PDs in particular sexual abuse is a risk factor for BPD

theory of personality disorders:

using silence active listening clarifying techniques: paraphrasing, restating (content), reflecting (feelings), exploring, projective questions: the what if, presupposition questions: the miracle question broad opening statements general lead

therapeutic communication techniques:

narrow therapeutic index: 0.5-1.5 mEq/L 1.5-2 = mild to moderate toxic reactions CNS: coarse hand tremor, mental confusion, hyperirritability of muscles, drowsiness, and incoordination CV: ECG changes GI: persistent GI upset, gastritis, salivary gland swelling, abdominal pain, excessive salivation, flatulence, indigestion 2-2.5 - moderate to severe toxic reactions CNS: ataxia, giddiness, tinnitus, blurred vision, clonic movements, seizures, stupor, coma CV: serious ECG changes, severe hypotension with cardiac arythmias GU: large output of dilute urine resp: fatalities secondary to pulmonary complications

therapeutic levels for lithium:

attending behavior open ended invitation to talk minimal encourages to talk reflection of feelings summary statements

therapeutic techniques accomplish:

interpersonal therapy

therapists actively guide and challenge maladaptive behaviors and distorted views premise: if people are aware of their dysfunctional patterns & unrealistic expectations, they can modify them focus is on "here and now" emphasizes the patient's life and relationships at home, at work, and in the social realm

•Creating a therapeutic relationship is difficult. •Most health care providers have experienced interrupted therapeutic alliances. •Suspiciousness, aloofness, and hostility will set up failure. •Guarded and secretive style produces an atmosphere of combativeness. •When patients blame or attack others, the nurse needs to understand the context of the complaints. •Attacks spring from a feeling of being threatened. The more intense the complaints, the greater the fear of potential harm and loss. •Psychotherapy •Psychodynamic psychotherapy •Cognitive-behavioral therapy • Systems training for emotional predictability and problem solving (STEPPS)

therapy for personality disorders:

in reality in speech in perception in behavior

think alterations:

suppression (answer)

this is your first holiday schedule as a graduate RN. you are scheduled to work christmas eve and christmas day and you are disappointed. you wanted to work thanksgiving but you have that holiday off. you say to yourself, i'm sure ill get those days off next year

obsessions

thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind often seem senseless to the individual that experiences them, although they still cause the individual to experience severe anxiety common: fear of hurting a loved one or fear of contamination

1. genuineness: self awareness of one's feelings occurs; what is displayed on the outside of the person is congruent with the internal processes 2. empathy: is temporarily living in another's life empathy = we understand the feelings of others sympathy = we feel the feelings of others, objectivity is lost and the ability to assist the patient in solving a personal problem ceases 3. positive regard: implies respect, has the ability to view another person as being worthy of caring about and as someone who has strengths and achievement potential

three characteristics that promote change and growth in patients:

stable and realistic sense of self, system for interpreting social situations and understanding of relational motives and actions of others, capacity to serve self and others

three qualities are needed to guide a person toward effective social and interpersonal functioning:

when was your last menstrual period?

to further assess for anorexia nervosa, the school nurse should ask:

•Cigarettes and cigars are inhaled •Smokeless tobacco is snuffed or chewed Intended effects: •Relaxation, decreased anxiety Effects of intoxication: •Highly toxic, but acute toxicity seen only in children or when exposure is to nicotine in pesticides •Also contains other harmful chemicals that are highly toxic and have long-term effects •Long term-effects: •Cardiovascular disease (hypertension, stroke), respiratory disease (emphysema, lung cancer) •With smokeless tobacco (snuff or chew): irritation to oral mucous membranes and cancer Withdrawal manifestations: •Abstinence syndrome evidenced by irritability, craving, nervousness, restlessness, anxiety, insomnia, increased appetite, difficulty concentrating, anger, and depressed mood

tobacco (nicotine)

positive symptoms (answer)

too much dopamine is responsible for:

displacement

transfer of emotions associated with a particular person, object, or situation to another person, object or situation that is nonthreatening

light therapy: 30 or more minutes each day 70% reduction of their symptoms, 50% remission medication: antidepressants, Paxil, Zoloft, Prozac

treatment for SAD:

stages for treatment: acute to continuation to maintenance treatment: medications: lithium, anti seizure, antipsychotics, anxiolytics education, therapy, social supports, relapse planning, family needs information structure in a safe environment, nutrition, SLEEP, hygiene, elimination

treatment for bipolar:

Benzodiazepines •Chlordiazepoxide •Diazepam •Lorazepam •Oxazepam Intended effects: Maintenance of vital signs within expected reference ranges •Decrease in the risk of seizures •Decrease in the intensity of withdrawal manifestations •Substitution therapy during alcohol withdrawal NC: Administer around-the-clock or PRN •Obtain baseline vital signs •Monitor vital signs and neurological status on an ongoing basis •Provide for seizure precautions adjunct medications: •Carbamazepine •Clonidine •Propranolol •Atenolol Intended effects: Decrease in seizures: Carbamazepine •Depression of autonomic response (decrease in blood pressure, heart rate): Clonidine, propranolol, atenolol •Decrease in craving: Propranolol, atenolol NC: Provide seizure precautions •Obtain baseline vital signs, and continue to monitor on an ongoing basis •Check heart rate prior to administration of propranolol, and withhold if less than 60 bpm nursing care and pharm therapy: •Safely and comfortably help achieve detoxification. •Enhance motivation for abstinence and recovery. •Medications include: •benzodiazepines •anticonvulsants •beta-blockers •magnesium sulfate, folic acid, and multivitamins •thiamine (vitamin B1), --(Wernicke's Korsakoff syndrome)

treatment of alcohol withdrawal:

Non pharmacological interventions include: CBT, skills training, support groups, reminiscence therapy, psychotherapy Complementary interventions: exercise, massage, environmental modifications, nutrition, activities to promote cognition Treat concurrent diseases Interdisciplinary team: Speech, occupational, PT, case workers

treatment of dementia always depends on stage and symptoms:

side effects often appear early in therapy and can be minimized with treatment treatment usually consists of: lowering the dose, prescribing antiparkinsonian drugs: trihexphynidyl, benztropine (congentin), benadryl, biperiden (akineton)

treatment of extrapyramidal symptoms:

antipsychotics combined with psycho therapy, other therapies such as art and vocational, support groups living support treatment for acute symptoms, comorbidities, hospitalization for stabilization and diagnosis, safety

treatment planning for schizo:

mood stabilizers are first line, often in conjunction with antipsychotics (mood stabilizer treatment should be aggressive if patient is manic, and reduced as pt enters maintenance phase, accompanied lab monitoring for mood stabilizer) antidepressants can be used for patients experiencing MDE (should be monitored closely as not to trigger mania) ECT often used in cases of mania, hospitalization for treatment of acute exasperations, family therapy and social skills traning, education of illness course and prognosis, living support

treatment planning for schizoaffective:

ex: Amitriptyline, Doxepin, Nortriptyline nonselective NE-serotonin reuptake inhibitors have high side effect profile, not considered first line side effects: sedation, orthostatic hypotension, anticholingeric effects, cardiac dysrhythmias can be deadly in overdose discontinuation must be slow

tricyclic antidepressants (TCAs)

separate and distract the patients. take one to the day room and the other to the activities area

two patients in a residential care facility are diagnoed with dementia. one shouts to the other 'move along, you're blocking the road.' the other patient turns, shakes a fist, and shouts, 'I know what you're up to; you're trying to steal my car.' what ist the nurse's best action?

Factitious disorder imposed on self Factitious disorder imposed on another Malingering •Condition related to factitious disorders •Conscious fabrication of illness or exaggerating symptoms for secondary gain such as insurance fraud, prescription medication, avoidance of prison or military service

types of factitious disorder:

education, support, self help, psychotherapy, family therapy, family education

types of grousp:

schizophrenia (+ symptoms), acute mania, psychotic depression, drug induced psychosis, other psychotic symptoms these are the drugs often used for controlling aggression in violent patients (Haloperidol + Lorazepam in combination) MOA: treat psychotic symptoms, such as delusions and hallucinations high potency vs low potency

typical antipsychotics:

reaction formation

unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion, also termed overcompensation

complementary relationship

unequal: difference in status and power, such as between a nurse and patient or between a teacher and student relationship is characterized by inequality (one participant is superior to the other)

Cerebrovascular disease dominant pathology; Large vessel stroke to microvascular disease Partly reversible, partial improvement from acute onset to progressive decline with fluctuations Onset temporarily related to >1 cerebrovascular events Evidence for decline prominent in: complex attention, frontal-executive function

vascular dementia:

withdrawal, misinterpreting, poor concentration, and preoccupation with religion

what assessment findings mark the prodromal stage of schizophrenia?

involves complex disturbances in relationships and marked disruption in sleep patterns links environmental and genetic influences, neural systems and behaviors, and high rates of certain psychological and medical comorbidities

what causes bipolar spectrum disorders?

effective diagnosis of anxiety is dependent on an awareness of cultural norms

what is the foundational principle to consider when assessing clients from varying ethnic cultures for behaviors associated with anxiety disorders?

maintenance of nutrition and hydration

what is the priority nursing need for a patient diagnosed with late-stage dementia?

ms munini frequently calls or comes to the clinic in a panic, believing she is ill. her suffering is genuine, but she never has any concrete signs of any illness

which is an example of illness anxiety disorder?

mr. harris injures his foot to avoid military service

which is an example of malingering?

observe for adverse effects of refeeding

which nursing intervention has priority as a patient diagnosed with anorexia nervosa begins to gain weight?

"if I allow myself to gain weight, i'll be huge"

which of the following is an example of an all or nothing thinking, which is the frequent cognitive distortion of patients with an ED?

establishing disciplined eating through the nurse's AUTHORITARIAN approach with the patient

which of the following is least likely to contribute to building an effective therapeutic alliance between the nurse and a patient with anorexia?

too preoccupied to respond when unit fire alarm is tested

which patient behavior noted by the nurse supports the diagnosis of a severe level panic?

"I deserve to be this way" patients with depression feel worthless and often believe they deserve to have bad things happen, usually feel hopeless

which statement indicates the most likely attitude towards the illness for a patient with depression?

a chronic, relapsing brain disease associated with craving and a lack of control over use of a substance

which statement most accurately describes substance addiction?

depression, anxiety, loss of energy, social withdrawal, increased sleep and sleepiness, loss of interest in activities you once enjoyed, including sex. overeating, especially foods high in carbs weight gain, difficulty concentrating and processing information

winter SAD

avoid TCA's and MAOIs

with high suicide risk patients, avoid prescribing these medications:

cause: abrupt cessation manifestations: 24-48 hours cholingergic rebound: dizziness, flu like, parathesias, myalgia, insomnia, chills, tearfulness, sensory perceptual tx: drug tapering depends on half life

withdrawal emergent syndrome from SSRI's and other antidepressants

Early symptoms of withdrawal appear 7 to 48 hours after cessation of alcohol intake and continue for 5 to 7 days Abdominal cramping; vomiting; tremors; restlessness and insomnia; increased heart rate, blood pressure, respiratory rate, and temperature; transient hallucinations or illusions; anxiety; tonic-clonic seizures Alcohol withdrawal delirium (Delirium tremens or DTs) •Usually peaks 2 to 3 days after cessation of alcohol intake (can occur later) and lasts 2 to 3 days •Considered a medical emergency •Manifestations include severe disorientation, psychotic manifestations (hallucinations), severe hypertension, cardiac dysrhythmias, and delirium •Alcohol withdrawal delirium (DTs) can progress to death

withdrawal manifestations of alcohol:

dissociation (answer)

you are a nurse in the ER. your patient is a 30 year old female brought in after an auto accident. her husband died in the accident. the police told you she was sitting up holding him in her arms when they arrived. when you begin to interact with her, she doesn't remember when she has been brought to the hospital

"yes, if you use it correctly"

your patient asks, 'will antabuse really help me with my drinking problem?" what is your most appropriate response?