Health and Illness 2: Final Exam content

Beware

-Patient may appear to feel better before making an attempt -Increased risk when medications begin to take effect -Take all suicidal gestures seriously -Legal responsibility: danger to self

Suicide and Bipolar

-15x higher risk then genial public -May account 1/4 of all completed suicides -Past history of suicide attempts increase risk for completed -number depression increased risk for completed suicides

Palliative vs hospice

-Palliative allows a person to simultaneously receive curative and palliative treatment -Hospice is provided once a person decides to forego curative treatment and the prognosis is generally< 6 months to live

Role of the nurse

-Patient assessment -Alleviate suffering -Safety of patient and others -Therapeutic communication Administer and monitor medication response -Patient advocate -Patient/community education

A registered nurse teaches a client about precautions to be taken before initiating lithium therapy. Which statements made by the client indicates effective learning? "I will take the medication with meals or milk." I will increase the sodium in my diet "I will notify my prescriber about the signs and symptoms without terminating the therapy." "I will discontinue therapy if I experience any signs of diarrhea."

"I will take the medication with meals or milk."

MDD across the span

-(children) irritable, weight loss, may hide crying, thoughts -(adolescence) prodromal symptoms: first symptoms -(older adults) health care providers often over look depressive symptoms thinking it is part of chronic disease pg 245 Criteria for MDD 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, it can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate or indecisiveness nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

Completed suicide

-10th leading cause of death in the US -Incidence of suicide varies among cultural groups for example -Suicide for Indians/ Alaskan natives age 15-34 is the 2nd leading cause of death

Helping children grieve

-Act natural -Show genuine care and concern -Make it clear that you are there to listen -Talk openly and directly about the person who died -Keep in mind that evenings, weekends, anniversaries, and holidays can be extra challenging times -Find a way to help children symbolize and represent the death -Pay attention to the way a child plays; this is one of the main ways that children communicate -Say that you are sorry about the loss -Sit next to a child that wants closeness

Grief

-Actual -Delayed -Anticipated -Dysfunctional -How can you support -Everyone responds in a. different manner

Loss

-An actual or potential situation in which something that is valued is changed, no longer available or gone Types of loss -Actual loss -Perceived loss -Anticiplonary loss

Interrelated concepts

-Anxiety -Family -Cognition -Nutrition -stress and coping

Palliative care

-Any form of care of treatment that focuses on reducing the severity of disease symptoms rather trying to delay or reverse the progression of the disease itself or provide a cure -active care of patient whose disease is not response to curative treatment -control of pain, others symptoms and of psychological, social, and spiritual problems -Impact of chronic disease on physical functioning and how palliative care can support the patient and family through a life limited illness

Mental status exam

-Appearance -Observation -Speech -Mood activity -Affect -Perception -Though content -Though process -Memory -Insight

Suicide Assessment

-Asking a patient if he or she has suicidal thoughts and plans does not cause the patient to take suicidal -Do you have a plan -What is the plan -What is the means readily available -History of other suicidal attempts -Substance abuse

Coping

-Attending support groups -Journaling -Eating well -Exercising -getting enough rest -Antidepressants can be effective to those who become clinically depressed

Bipolar and related disorders

-Bipolar 1 (with psychosis) -Bipolar 2 (with psychosis) -Cyclothymic disorder -Substance/ medicino induced bipolar and related disorders -bipolar and related due to another medical condition

Disruptive mood dysregulation disorder

-Children or adolescent experience ongoing irritability, anger, and frequent, intense temper outburst

Major Depressive disorder

-Depression mood (flat affect= no sadness or anger) -Diminished interest or pleasure -Significant weight loss or gain -Insomnia/hypersomnia-sleep -Fatigue. loss of energy -Diminished ability to think/ concentrate/ indecisiveness -Recurrent thoughts of death, fear of dying, suicidal ideations (with or without a plan) -Psychomotor retardation or agitation.

Depression anxiety

-Depression or Anxiety on down phase -Feelings of worthlessness -Inability to participate in ADI's

Depression disorders

-Disruptive mood dysregulation disorder -Major depress disorder -Persistent depressive disorder -Postpartum disorder -People who are put on antidepressants are at a high risk for suicide (formulating)

Bipolar risk factors

-Environmental: more common in high income than low income countries, separated, divorce -Genetic/physiological: family history strongest risk factor -After a person has a maniac episode, subsequent episodes are more likely to have psychotic features

A primary healthcare provider prescribes an antidepressant for a hospitalized patient who has been severely depressed. Eight days later the nurse notes that the patient is neatly dressed and well groomed. The patient smiles at the nurse and says, "Things sure look better today." What nursing response is appropriate in light of the patient's statement?

-Formal suicide plans increase the risk of actual suicide

MDD prevalence

-High morality -children 14% will experience an episode of MDD before age 15

Palliative goals

-Improve quality of life for pt with serious, life limiting illness -prevent and relive suffering, including pain -affirm life, never hasten or postpone death

ER assessment tool

-In the past week have you wished you were dead -In the past few weeks have you felt that you or your family would be better off if you were dead -In the past week have you been having thoughts about killing yourself -have you ever tried to fill yourself -how -when

What is grief

-Individual -Loss stemming from affliction, violence, accidents, sudden change, and death

Mania (not substance abuse)

-Inflated self-esteem or grandiosity -Decreased need for sleep (rest only 3 hours) -Not eating/ drinking "on the go"-risk for dehydration/malnutrition -Pressures speech, increased talking -Racing thoughts, flight of ideas -Distractibility -Increased goal oriented activity -Psychomotor activity -Excessive involvement in high risk activities- high risk for painful consequences -Irritable agitation

Risk factors

-MDD -Bipolar disorder -Substance abuse -Schizophrenia -Command auditory hallucinations; are they hearing voices -anxiety disorders Psychosocial Physical illness

Categories

-Mania: significant impairment -Hypomania: do not require hospitalization, symptoms last 4 days -Euthymic: normal mood -Dysthymia: chronic low grade depression

What is Mood and Affect

-Mood is defined how a person feel (subjective) -Affect is defined as the observed response to their own feeling (objective)

Depression

-More in 1 than 2 -Depression in. 1 occurs during diagnosis; they don t see mania as an issue since they are really productive -depression can lead to loss of pleasure -Children can expression in a more subtle way than adults; can be masked since they can't express it; they will say their bored or irritated -teens have hormonal shifts which can be an issue when differentiating mental health issues and horses adults: a lot of depression in older adults that is not diagnosed

Bipolar assessment

-Not in touch with reality -Gathering information -Obtain collaborative information from family members - present during interview, or receive permission -caution about violating HIPPA -You can ask, you cannot tell

Hospice criteria

-Patient must desire the services and agree in writing that only hospice care (not curative care) can be used to treat the terminal illness -Pt can withdraw from hospice at any time or the pt family can take them out -The opt must be considered for hospice -terminal prognosis< 6 months to live -medicare, medicaid insures require a physician to certify the<6 months prognosis

Bipolar prevalence

-Pediatric prevalence difficult to establish -Can begin in late adolescence -Average late 20s -Illness typically begins with depressive episode (may be several)

Nursing assessment

-Precipitating stressors -Appraisal of stressor -Coping resources -Coping mechanism

Nursing Interventions

-Protecting the patient -Objects removed -Stay with the patient -one on one -Ongoing assessment -Increasing self esteem -Regulating emotions and behavior -Have patient tell you when thoughts of suicide -triggers -groups -monitor responser to medications -support system -psychosocial educations -support groups -Interdisciplinary care

Bipolar nursing

-Stress mangement -Eat a healthy diet -exercise -manage sleep: lack of sleep exacerbate- trigger mania -take meds as prescribed -Individual therapy -diary of mood -avoid caffeine, alcohol, OTD, substance abuse

Risk facts

-Temperamental: negative affectivity -environment: adverse childhood experiences, stressful life events, daily hassles, loneliness -chronic illness: cardiovascular disease, diabetes, cancer, stroke -children/ adolescents: bully/ teasing

Bipolar collaborative care

-Therapeutic -Mental status exam -Pharmacology -Patient safety -Suicidal assessment -Diet -Sleep

Collaborative care

-Therapeutic communications -Mental status exam -Pharmacology (SSRI, triycyclics, MAOs_ -patient safety -suicide assessment -diet -sleep

Supporting griefs

-avoiding or minimizing emotions -using alcohol or drugs to self-medicate -using work to avoid feelings

bipolar disorder

-includes mania and depression -there is a familiar link (higher number is families) not genetic link yet

Grief and Loss

-pending death: if they are suffering it can mean a sense of relief when they die -Young: its' unfair -Survivor guild -Blaming themselves or think they could have done something to stop the death

Suicide and MDD

-possibility existing during the entire course -most consistent risk factors is history of attempts or threats -Increased risk of completed suicide in males -living alone or being single -permanent feeling of hopelessness -If co-morbidity of personality disorder, risks is increased

Greif vs depression

Grief -Experiences in waves -Diminished in intensity over time -healthy self image -hopelessness -response to support -overt expression of anger -preoccupied with deceased Depression -Moods and feelings are static -consistent sense of depletion -sense of worthlessness and disturbed self-image -pervasive hopelessness -anger not as pronounces -preoccupied with self

A patient confides to the nurse, "I've been thinking about suicide lately." What conclusion should the nurse make about the client? The patient wants to frighten the nurse The patient wants to gain more attention from staff The patient feels safe in sharing with the nurse The patient is fearful of their potential actions and wants help/protection

The patient is fearful of their potential actions and wants help/protection

Stages of grief

5 stages -denial -anger -bargaining -depression -acceptance

A primary healthcare provider prescribes an antidepressant for a hospitalized patient who has been severely depressed. Eight days later the nurse notes that the patient is neatly dressed and well groomed. The patient smiles at the nurse and says, "Things sure look better today." What nursing response is appropriate in light of the patient's statement? Complimenting the client's appearance Starting preparations for the client's discharge Arranging for constant supervision of the client Adding privileges to the client's plan of care as a reward

Arranging for constant supervision of the client

Exemplar Bipolar Disorder

Bipolar 1 -Mania-highs -Depression-lows Bipolar 2 -Hypomania -Often still functioning -Manic phase may make them more productive - Severe depression phases

Types of fried

Conventional -Abbreviated -Anticipatory -Adaptive grief Dysfunctional -Prolonged grief disorder -Inhibited

Bipolar Pharmacology

Depression: antidepressants -Mood stabilizers -(valproate (Depakote), carbamazepine (Tegretol) lamotrigine (lamictal) -Lithium -Antipsychotics- risperidone, olanzapine

Lithium

Drug of choice for the treatment of mania -Narrow therapeutic range: acute mania —lithium serum level of 1 to 1.5 mEq/L; -maintenance serum levels should range between 0.6 and 1.2 mEq/L -Levels exceeding 1.5 to 2.5 mEq/L begin to produce toxicity, including gastrointestinal (GI) discomfort, tremor, confusion, somnolence, seizures, and possibly death. -Keeping the sodium level in the normal range (135 to 145 mEq/L) helps to maintain therapeutic lithium levels. Contraindicated: -Dehydration -Known Sodium imbalance -Cardiovascular disease -Renal dysfunction Adverse effects -Serious effects: cardiac dysrhythmias, hyponatreamia Others: GI discomfort, tremor, somnolence, seizures

Disturbed vegetative functioning is defined as an unconscious patient in a vegetative state and the depression they will experience once the wake up.

False

SSRI's are the first choice in antidepressants because of the positive response and low incidence of side effects and improvement can be seen after a week True False

False

Monoamine Oxidase Inhibitors (MAOIs): phenelzine

Four MAOI'S Nonselective: isocarboxazid, phenelzine, and tranylcypromine Selective: selegiline -Rarely used for depression -Used for Parkinson's disease Disadvantage of MAOI use: potential to cause hypertensive crisis -Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death Avoid foods that contain tyramine! -Aged, mature cheeses (cheddar, bleu, Swiss) -Smoked, pickled, or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, pâté) -Yeast extracts Red wines (Chianti, burgundy, sherry, vermouth) -Italian broad beans (fava beans)

Tricyclic Antidepressants (TCAs)

Have largely been replaced by SSRIs as first-line antidepressant drugs Considered second line -For patients who fail with SSRIs or other newer generation antidepressants -As adjunct therapy with newer generation antidepressants Mechanism of Action -Block reuptake of neurotransmitters, causing accumulation at the nerve endings -It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression Indications -Depression -enuresis: bed wetting -OCD -Adjuntive analgesics for chronic pain condition, such as trinomial neuralgia Adverse Effects -Sedation -Impotence -Orthostatic hypo -Older patients: dizziness, postural hypotension, constipation, delays micturition, edema, muscle tremors Overdose -CNS and cardiovascular systems are mainly affected. -Death results from seizures or dysrhythmias No specific antidote -Decrease drug absorption with activated charcoal. -Speed elimination by alkalinizing urine. -Manage seizures and dysrhythmias. -Provide basic life support.

Review Pharmacology

Lithium -Levels -Care -Side Effects -Toxicity SSRI's -side effects MAOIs -side effects -diet

Mania vs Hypomania

Mania -diagnosed with bipolar disease -need medications -Mania lasting weeks -Bipolar 1 Hypomania: is less extreme and can go undiagnostic -are still functioning -Bipolar 2

Second Geration Antidepressants: venlafaxine: SNRI and Fluoxetine SSRI

Mechanism of Action: -SSRI- Selective serotonin reuptake inhibitor -SNRI- Selective norepinephrine and dopamine reuptake inhibitor -Fewer adverse effects than TCAs and MAOIs - Very few drug-drug or drug-food interactions -Allow 4 to 6 weeks to reach maximum clinical effectiveness (same as TCA & MAOI) Indications: -Depression -Bipolar disorder, obesity, eating disorders, OCD, panic attacks or disorders, social anxiety disorder, PTSD, premenstrual dysphoric disorder, the neurologic disorder myoclonus, and substance abuse Adverse Effects: Insomnia, weight gain, and sexual dysfunction Contraindications: -Known drug allergy -MAOI use in the previous 14 days -Concurrent use of the herbal product St. John's Wart must be avoided Implementation Patient teaching- similar to other anti-depressants Evaluation -suicide risk -serotonin syndrome: -Delirium -Agitation -Tachycardia -Sweating -Tremors or spasms -Hyperthermia -Renal failure -Dysrhythmias

TCA (amitriptyline)

Oldest and most widely used of all the TCAs -Commonly used to treat insomnia and neuropathic pain -Contraindications: known drug allergy, pregnancy, and recent myocardial infarction Adverse effects: dry mouth, constipation, blurred vision, urinary retention, and dysrhythmias Classification - Tricyclic Anti-Depressant Pharmacokinetics Onset - 2-3 weeks Peak - 2-6 weeks Duration - days, weeks Routes - PO, IM Pharmacodynamics - Blocks serotonin, norepinephrine reuptake Adverse effects - greater incidence in higher doses -QT prolongation -Confusion -Sedation -NMS -Fractures Safety -Black Box warning - all anti-depressants Suicide risk increased with patients < 24 years old -Usual dose - 50 - 100 mg Developmental concerns -Pregnancy Category C -Elders at greater risk for ADRs, especially CV -Not studied in children < 12

Grief response

Psychological response -anger -guilt -anxiety -sadness -depression -despair Physiological response -sleep disturbances -changes in appetite -physical problems -Illness

Hospice

Relies on the belief that each of us has the right to die pain free and with dignity -holsiitc care

Lithium therapy is initiated for a patient diagnosed with manic episodes. Laboratory testing shows that the client's lithium level is 1.2 mEq/L (1.2 mmol/L). Why would the healthcare provider reduce the client's lithium dosage? To promote the drug excretion To reduce the risk of drug accumulation To maintain the serum drug level To reduce the risk of side effects

To maintain the serum drug level

A patient with mania is described as having grandiose delusions, racing ideas and are often reckless and have difficulty concentrating True False

True

Functional Impairment in relation to mood and affect is defined as the inability to solve problems of ordinary daily living.

True

The nurse assesses a patient with the diagnosis of bipolar disorder, manic episode. They are extremely talkative and have grandiose ideas. This would support the diagnosis? True False

True

Don'ts

Try to shelter children from the reality of death; it can be a learning experience -Give false or confusing messages ("Grandma is sleeping now.") -Tell a child to stop crying because others might get upset -Try to cheer the person up or distract from the emotional intensity ("At least he's no longer in pain." "She's in a better place now.") -Offer advice or quick solutions ("I know how you feel." "Time heals all wounds.") -Pry into personal matters Ask questions about the circumstances of the death

When

When diagnosis of a life limiting illness is made -can be provided either in acute care or end of life

Advanced directives

written documents that provide information about the patient wishes and his/her spokesmen -Resuscitation -DNR -Full code -Allow natural death -Comfort measures only