ATI Mental Health Ch. 21-33

Expected findings of shaken baby syndrome

Respiratory distress Retinal hemorrhage Altered level of consciousness Increase in head circumfrence

Steps to Handle Aggressive Behavior

Responding quickly, remaining calm and in control Encourage the client to express feelings verbally, using therapeutic communication techniques Allow the client as much personal space as possible Mainting eye contact and sitting or standing at the client's eye level Reassuring client Tell the client calmly and direct what he must do in a particular situation Use pharmacological interventions if the client does not respond to calm limit-setting Plan for 4-6 staff members to be available and in sight of the client as a show of force

Medications for Autism spectrum disorders

SSRIs & antipsychotic medications (risperidone, olanzapine, quetiapine, and aripiprazole)

Medications to treat trauma and stressor related disorders

SSRIs: paroxetine, sertraline, fluoxetine SNRI: venlafaxine Tricyclic antidepressants: amitriptyline, imipramine. MAOI: phenelzine

Postassaultive

Staff reviews the incident with the client during this stage

Olanzapine, Ziprasidone

Atypical Antipsychotics Used to control aggressive and impulsive behaviors. these are used more commonly than haloperidol because of the severity of adverse effects of haloperidol

Serotonin syndrome

agitation, confusion, disorientation, difficulty concentrating, anxiety, hallucinations, hyperreflexia, fever, diaphoresis, incoordination, tremors. Notify doctor, hold the med.

second generation anti psychotics (nursing) adverse effects

agitation, dizziness, sedation, sleep disturbances - report to provider

Buprenorphine (Subutex) intended effects

agonist antagonist opioid use for both detoxification and maintenance decreases feelings of craving and may be effective in maintaining compliance

contraindicated in client to have bone marrow suppression or bleeding disorders

carbamazepine

adjunct medications for detoxification

carbamazepine Tegretol Clonidine(Catapres) Propanolol (Inderal)

therapeutic uses of tricyclic antidepressants in children

-depression -autism spectrum disorder -ADHD -panic disorder, separation anxiety disorder -social phobia, school phobia -OCD

mental health disorders: compound rape reaction (2)

-depression -substance use disorder

Medications for oppositional defiant disorder

Medications not generally prescribed

Medications for PTSD

Medications prescribed to target specific problem areas associated with the disorder such as depression and ADHD

Honeymoon phase

Situation is defused after a violent episode Abuser becomes loving, promises to change, is sorry Vulnerable person wants to believe this and hopes for change

Disequilibrium (Bowlby)

The client focuses on the loss and has an intense desire to regain what was lost

Denial (Kubler-Ross)

The client has difficulty believing a terminal diagnosis or loss

Teaching with Buprenorphine (Subutex)

inform the client of the medication must be administered from an approved treatment center and administer the medication sublingually

blocks MAO in brain, increasing amount of norepinephrine, dopamine, and serotonin

pharmacological action of monoamine oxidase inhibitors

blocks reuptake of serotonin (intensified effect of serotonin)

pharmacological action of selective serotonin reuptake inhibitors

moderate selective blockade of serotonin receptors

pharmacological action of trazodone

block reuptake of norepinephrine and serotonin (intensified effect of these neurotransmitters)

pharmacological action of tricyclic antidepressants

increase amount of norepinephrine available

pharmacological action of venlafaxine, duloxetine, desvenlafaxine, and levomilnacipran (SNRIs)

Example of maturational/internal crisis

A child going off to college for the first time

overt saying

"There is just no reason for me to go on living."

Medications for ADHD

-Psychostimulant drugs (methylphenidate & amphetamine salts) -Nonstimulant SNRIs (atomoxetine)

Neglect

Failure to provide physical care, emotional care, education or necessary health or dental care

Task II (Worden)

Processing the pain of grief. The client uses coping mechanisms to deal with the emotional pain of the loss

Serotonin norepinphrine reuptake inhibitora (SNRI)

Venlafaxine

Expected Pharmacological Action of First Generation?

- block Dopamine D2 Acetylcholine Histamine Norepinephrine receptors in brain and periphery - inhibition of psychotic symptoms due to D2 receptor blockage

alcohol and other substances

these produce a sedative and amnesiac effect on the vulnerable person

covert saying

"Everything is looking pretty grim for me."

Risk Factors for Maladaptive Grieving

- Being dependent upon deceased - Unexpected death at a young age, through violence, or by a socially unacceptable manner - Inadequate coping skills or lack of social support - Pre-existing mental health issues, such as depression or substance use disorder

Maladaptive Grief: Delayed or Inhibited Grief

- Client does not demonstrate the expected behaviors of the normal grief process - Cultural expectations can influence this grief - Clients can remain in the denial stage of grief for an extended period of time - Subsequent minor loss can trigger the grief response

Maladaptive Grief: Distorted or Exaggerated Grief Response

- Client experiences the feelings and somatic manifestations associated with normal grief but to an exaggerated level - Client is unable to perform activities of daily living - Client can remain in the anger stage of the grief process and can direct the anger towards himself - Client can develop clinical depression

Maladaptive Grief: Chronic or Prolonged Grief

- Difficult to identify due to the varying lengths of time required by clients to work through the stages/tasks of grief - Client's can remain in the denial stage of grief and remain unable to accept the reality of the loss - Can result in the client's inability to perform ADLs

Task IV (Worden)

- Finding an enduring connection with the lost entity in the midst of embarking on a new life - Client finds a way to keep the lost entity a part of their life while at the same time moving forward with life and establishing new relationships

Anticipatory Grief

- Grief implies the "letting go" of an object or person before the loss, as in the case of a terminal illness - Individuals have the opportunity to grieve before the actual loss

Normal Grief

- Grief is considered uncomplicated - Emotions can include anger, resentment, withdrawal, hopelessness, and guilt but should change to acceptance with time - Client should achieve some acceptance by 6 months after the loss - Somatic manifestations: Chest pain, Palpitations, Headaches, Nausea, Changes in sleep patterns, or fatigue - The nurse should assess the client to identify a normal vs maladaptive grief response

emotional risk factors

- access to lethal methods such as firearms -lack of access to adequate mental health care - unemployment

expected finding

- assess carefully for verbal and nonverbal clues - suicidal comments are made to someone that the pt perceives as supportive - assess for potential suicidal risk - assess the pt suicide plan

sedative hypnotic anxiolytics (benzodiazepines) - diazepam - lorazepam

- avoid CNS depressant --> alcohol - avoid hazardous activities - caffeine interferes with the desired effects of the medication - should not abruptly discontinue

antidepressants: SSRI's (nursing consideration) -citalopram -fluoxetine -sertraline

- decreased risk for OD - Do not stop taking medications suddenly - 1-3 weeks for therapeutic effect for initial - 2 m for maximal response - avoid hazardous activities - sexual dysfunction can occur - follow a healthy diet --> weight gain can occur - monitor for indications of increased depression and intent of suicide

biological risk factors

- family history of suicide -physical disorders ( aids, cancer, stroke etc)

protective factors

- feelings of responsibility toward partner and children - current pregnancy - religious and cultural beliefs - overall satisfaction with life - presence of adequate social support - effective coping and problem-solving skills - access to adequate medical care

suicide precaution

- initiate one on one constant supervision around the clock - always have the pt on sight and close - document which staff member is accountable for the pt - search the pt belonging with the pt present - use only one plastic eating utensils - check the environment for possible hazards - ensure that the pts hands are always visible, even when sleeping - keep door open at all times - ensure that the pt swallows all medications- pt can hoard medications until there is enough for suicide attempt - identify if medications are lethal for overdose

Myths regarding suicide

- ppl who talk about suicide never commit it - there is no way to help someone who really wants to kill themselves -mention of the word suicide will cause the individual to commit suicide -ignoring verbal threats of suicide or challenging a person to carry out suicide plans will reduce the individual use of these behaviors

second generation anti psychotics (nursing) - risperidone - olanzapine

- preferred over first generation anti-psychotics due to decreased adverse effects - causes weight gain

psycho-social risk factors

- sense of hopelessness - intense emotions --> rage, anger or guilt - poor interpersonal relationships at home, school, and work - developmental stressors such as those experiences by adolescents

mood stabilizers (nursing considerations) - lithium

- take with food or milk - causes weight gain - increase fluid intake of 2-3 l/day - maintain adequate sodium intake -monitor lithium effectiveness and adverse e ects.

Therapeutic Use of First Generation?

- treat acute/chronic psychotic disorders - schiz. spectrum disorders - bipolar disorder= primarily manic phase - Tourette disorder - agitation (& positive symptoms of schiz.) - prevention of nausea/vomit through block of dopamine in chemoreceptor trigger zone of medulla

Types of ADHD

-ADHD predominantly inattentive -ADHD predominantly hyperactive-impulsive -Combined type: Client exhibits both inattentive and hyperactive-impulsive behaviors

interactions of alpha2-adrenergic agonists

-CNS depressants, including alcohol: increase CNS effects -antihypertensives: worsen hypotension -foods with high fat-content: increase guanfacine absorption

complications of alpha2-adrenergic agonists

-CNS effects (sedation, drowsiness, fatigue) -cardiovascular effects (hypotension, bradycardia) -weight gain -GI effects (N, V, constipation, dry mouth)

complications of CNS stimulants

-CNS stimulation (insomnia, restlessness) -weight loss related to reduced appetite; growth suppression -cardiovascular effects (dysrhythmias, chest pain, high BP) - development of psychotic manifestations, such as hallucinations and paranoia - withdrawal reaction (avoid abrupt cessation) hypersensitivity skin reaction to transdermal methylphenidate: hives, papules

interactions of atypical antipsychotics

-CNS suppressants: additive CNS depression with concurrent use of alcohol, opioids, antihistamines -levodopa: counteracts effects of antipsychotic agents -TCAs, amiodarone, and clarithromycin prolong QT interval, thereby increasing the risk of cardiac dysrhythmias -barbiturates and phenytoin promote hepatic drug-metabolizing enzymes, thereby decreasing drug levels of quetiapine -fluconazole inhibits hepatic drug-metabolizing enzymes, thereby increasing drug levels of aripiprazole, quetiapine, and ziprasidone

Psychotherapeutic Interventions: Primary care

-Collaborate w/ client to identify potential problems -Instruct on coping mechanisms -Assist in lifestyle changes

Manifestations of conduct disorder?

-Demonstrates a lack of remorse/care for feelings of others -Bullies, threatens, and intimidates others -Believes that aggression is justified -Exhibits low self-esteem, irritability, temper outbursts, reckless behavior -Demonstrate signs of suicidal ideation -Can have concurrent learning disorders or impairments in cognitive functioning -Demonstrates physical cruelty to others and/or animals -Used a weapon that could cause serious injuries -Destroys property of others -Has run away from home -Often lies, shoplifts, and is truant from school

Expected findings for depressive disorders

-Feelings of sadness -Loss of appetite -Nonspecific complaints related to health -Engaging in solitary play or work -Changes in appetite, resulting in weight changes, sleeping patterns -Crying -Loss of energy -Irritability, aggression, high-risk behavior -Poor school performance and/or dropping out of school -Feelings of hopelessness about the future -Suicidal ideation or suicide attempts

What are the characteristics of ADHD?

-Inattention -Hyperactivity -Impulsivity

Interventions for autism spectrum disorder

-Initiate a referral for early intervention -Provide a structured environment -Consult parents to provide consistent & individualized care -Encourage parents to participate in the child's care & treatment plan -Use short, concise, and developmentally appropriate communication -Identify desired behaviors & reward them -Role-model social skills -Role-play situations that involve conflict & conflict resolution strategies -Encourage verbal communication -Limit self-stimulating & ritualistic behaviors by providing alternative play activities -Determine emotional & situational triggers -Give plenty of notice before changing routines -Carefully monitor behaviors to ensure safety

Intellectual developmental disorder

-Intellectual deficits with mental abilities such as reasoning, abstract thinking, academic learning, and learning from prior experiences -Impaired ability to maintain personal independence and social responsibility, including activities of daily living, social participation, and the need for ongoing support at school

interactions of CNS stimulants

-MAOIs: hypertensive crisis -caffeine: increase CNS stimulant effects -phenytoin warfarin and phenobarbital: inhibits metabolism of these drugs -OTC cold and decongestant medications: increased CNS stimulation

interactions of SRNIs

-MAOIs: hypertensive crisis -paroxetine, fluoxetine, or quinidine gluconate: inhibit metabolizing enzymes, increasing levels of atomoxetine

interactions of tricyclic antidepressants

-MAOIs: severe HTN -antihistamines and other anticholinergic agents: additive anticholinergic effects -epinephrine and dopamine (direct-acting sympathomimetics): hypertensive effect -alcohol, benzodiazepines, opioids, and antihistamines: additive CNS depression

Specific learning disorder

-Persistent difficulty in acquiring reading, writing, or mathematical skills -Performance in one or more academic areas is significantly lower than the expected range for the client's age, level of intelligence, or educational level

Interventions for trauma & stressor disorders

-Providing assistance with working through traumatic events or losses to reach acceptance -Encouraging group therapy

Interventions for anxiety disorders

-Providing emotional support that is accepting of regression and other defense mechanisms -Offering protection during panic levels of anxiety by providing for needs -Implementing methods to increase client self-esteem and feelings of achievement

Medications for intermittent explosive disorder

-SSRIs (fluoxetine) -Mood stabilizers (lithium) -Antipsychotics (clozapine and haloperidol) -Beta blockers

What disorders associated with genetic links?

-Schizophrenia -Bipolar -Autism spectrum -ADHD -Intellectual developmental disorder

Common crisis characteristics

-Sudden event with little or no time to prepare -Perception of event as overwhelming/life-threatening -Loss or decrease in communication w/ significant others -An actual or perceived loss

rape-trauma syndrome: following the initial emotional response (8)

-clients can experience a variety of emotional reactions that can persist & become sustained and maladaptive -embarrassment -a desire for revenge -guilt -anger -fear -anxiety -denial

sexual assault evidence collection kits (6)

-collect blood -oral swabs -hair samples -nail swabs -scrapings -genital, anal, penile swabs

nursing care: obtain informed consent to collect data (3)

-data that can be used for legal evidence (photos, pelvic exam) -rape survivor has the right to refuse either a medical examination or a legal exam -legal exams provides forensic evidence for the police

Interventions for disruptive, impulse control, and conduct disorders, and ADHD

-Use a calm, firm, respectful approach with child -Modeling to show acceptable behavior -Obtain the child's attention before giving directions. Provide short and clear explanations -Set clear limits on unacceptable behaviors & be consistent -Plan physical activities through which the child can use energy and obtain success -Assist parents to develop a reward system using methods, such as a wall chart or tokens. Encourage the child to participate -Focus on family & child's strengths, not just problems -Support parents' efforts to remain hopeful -Provide safe environment for child & others -Provide the child w/ specific positive feedback when expectations are met -Identify issues that result in power struggles -Assist the child in developing effective coping mechanisms -Encourage the child to participate in group, individual, and family therapy

Autism spectrum disorder

-Wide spectrum of behaviors affecting an individual's ability to communicate and interact with others -Cognitive and language development are typically delayed -Characteristic behaviors include: Inability to maintain eye contact, repetitive actions, and strict observance of routines

silent rape reaction examples (6)

-abrupt changes in relationships with partners -nightmares -increased anxiety during interview -marked changes in sexual behavior -sudden onset of phobic reactions -no verbalization of the occurrence of sexual assault

complications of SSRIs

-agitation, anxiety, sleep disturbance, tremors, and tension headache -weight loss -GI effects (N, constipation or diarrhea, dry mouth)

complications of SNRIs

-appetite/growth suppression, weight loss -GI effects (N, V, upper abdominal pain) - suicidal ideation (in children and adolescents) -hepatotoxicity -CNS effects (headache, insomnia, irritability)

nursing care: perform an initial and ongoing assessment (2)

-assess the clients level of anxiety, coping mechanism, and available support systems -assess for indications of emotional and/or physical trauma

nursing care: support the client while legal evidence is being collected (3)

-avoid minimizing the clients level of emotional suffering -psychological responses can be subtle or not easily identifiable -refrain from asking "Why" questions

contraindications/precautions of atypical antipsychotics

-avoid use of alcohol -cardiovascular disease, seizures, or diabetes

First Generation Anti psychotics- mechanism of action

-block dopamine D2, ACh, histamine, nor-epinephrine receptors -blockage of D2 results in the inhibition of positive psychotic symptoms **due to the mechanism of activating dopamine receptors, levodopa therefore counteracts effects of anti psychotic agents, advise to AVOID concurrent use**

somatic reaction (6)

-can occur later in which the client can have a variety of physical manifestations -muscle tension -headaches -sleep disturbances -gastrointestinal manifestations (N, anorexia, D, abdominal pain) -genitourinary manifestations (vaginal pain or discomfort)

contraindications/precautions of SNRIs

-cardiovascular disorder -suicidal ideation

contraindications/precautions of tricyclic antidepressants

-desipramine and clomipramine are pregnancy risk category C -imipramine is pregnancy risk category D -seizure disorders -CAD, diabetes; liver, kidney, and respiratory disorders; urinary retention and obstruction; angle closure glaucoma; BPH; hyperthyroidism -TCAs can increase suicide risk

complications of atypical antipsychotics

-diabetes mellitus -weight gain -hypercholesterolemia -orthostatic hypotension -anticholinergic effects -agitation, dizziness, sedation, and sleep disruption -mild extrapyramidal side effects, such as tremor

documentation (3)

-document physical injuries in narrative and pictorial form -use body maps or photographs -document subjective data, using the clients verbatim statements

initial emotional (or impact) reaction (2)

-expressed reaction -controlled reaction

contraindications/precautions of alpha2-adrenergic agonists

-extended-release clonidine is contraindicated for under 6 years -cardiac disease

risk factors

-females -adolescents, middle, and older adult males are more likely to complete suicide -active military personnel/veterans - lesbians, gay, bisexual, or transgender -comorbid mental illness --> depression, substance use disorder, schizophrenia, bipolar disorder, personality disorder

specific substances (3)

-gamma hydroxybutyrate ("G" or "liquid ecstasy) -flunitrazepam ("roofies", "club drug, & "roaches") -ketamine ("black hole", "kit kat", & "special K")

First Generation Anti psychotics (Conventional) HIGH potency

-high potency= high EPS low sedation low anticholinergic adverse effects

contraindications/precautions of CNS stimulants

-history of substance use disorder, cardiovascular disorders, severe anxiety, and psychosis -pregnancy risk category C

nursing care: follow national protocol (5)

-includes client information -examination -documentation of biological and physical findings -collection of evidence -follow up as needed to document additional evidence

contraindications/precautions of SSRIs

-increase suicidal ideation in children and adolescents -dose should be tapered -- abrupt withdrawal of med can lead to discontinuation syndrome (dizziness, insomnia, nervousness, irritability, agitation)

controlled reaction (3)

-is ambiguous -survivor can appear clam and have blunted affect but can also be confused -can have difficulty making decisions and feel numb

rape (3)

-is defined as nonconsensual sexual activity involving any penetration of the vagina or anus with any body part or object -oral penetration by a sex organ of someone else -it is a crime of violence, aggression, anger, or power

sexual assault (7)

-is defined as pressured or forced sexual contact -sexually stimulated talk or actions -inappropriate touching or intercourse -insest -human sex trafficking -female genital mutilation -rape (forced sexual penetration)

expressed reaction (6)

-is overt and consists of emotional outbursts -crying -laughing -hysteria -anger -incoherence

nursing care: perform a self assessment (2)

-it is vital that the nurse who works w/ the client be empathetic, objective, and nonjudgemental -if the nurse feels emotional about the assault due to some event or person in their own past, it can be better to allow another nurse to care for the client

First Generation Anti psychotics (Conventional) LOW potency

-low potency = low EPS high sedation high anticholinergic adverse effects

First Generation Anti psychotics (Conventional) MEDIUM potency

-medium potency= moderate EPS moderate sedation low anticholinergic adverse effects

laboratory tests (2)

-obtain blood for lab tests (HIV, hepatitis B and C) -collect samples for legal evidence (hair, skin, semen)

complications of tricyclic antidepressants

-orthostatic hypotension -anticholinergic effects: dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia -weight gain related to increased appetite -sedation -toxicity -decreased seizure threshold -excessive sweating

nursing care (16)

-perform self assessment -perform an initial and ongoing assessment of the clients level of anxiety, coping mechanisms, and available support systems -assess for indications of emotional and/or physical trauma -provide a private environment for an examination with a specially trained nurse advocate -follow national standard protocol for the assessment -provide client safety -provide nonjudgemental and empathetic care -obtain informed consent to collect data that can be used as legal evidence -the rape survivor has the right to refuse either a medical examination or a legal exam -treat any injuries, and document care given -avoid minimizing the clients level of emotional suffering -refrain from asking "Why" questions -assess for suicidal ideation -administer prophylactic treatment for STD's -evaluate for pregnancy risk and provide protection -call clients available personal support system, if given permission -assist the client during the acute phase of rape trauma syndrome

therapeutic uses of atypical antipsychotics

-persuasive development disorders, including autism spectrum disorder -conduct disorder -OCD -relief of psychotic manifestations

nursing care: assist the client during the acute phase of rape trauma syndrome (6)

-prepare for thoughts -prepare for manifestations -prepare for emotions that can occur during the long term phase of the syndrome -encourage the client to verbalize her story and emotions -listen and let the client talk -use therapeutic techniques of reflection, open-ended questions, and active listening

nursing care: provide a private environment and a SANE (2)

-private environment for an examination with a specially trained nurse advocate -SANE is a sexual assault nurse examiner who performs such examinations and collects forensic evidence

client education: care after discharge (8)

-provide phone number for 24 hr hotlines -promote self care activities -give follow up instructions in writing, bc the client might be unable to comprehend or remember verbal instructions -initiate referrals for needed resources and support services -individual psychotherapy can be helpful to increase coping skills and precent long erm disability (depression or suicide) -schedule follow up calls or visits at prescribed intervals after assault -emphasize importance of after care -sexual assault clients have a pro compliance rate w/ follow up visits

sexual violence (3)

-refers to the denial of emergency contraception or measures to prevent sexually transmitted infections -organized rape during war or conflict -sexual homicide

long term psychological effects of sexual assault include (5)

-reliving the event (flashbacks, recurrent dreams, other intrusive thoughts) -increased activity, such as visiting friends frequently or moving residence, due to the fear that the assault will reoccur -hyperarousal and increased emotional responses (easily startled, anxiety, angry outbursts, difficulty falling asleep or concentrating) -avoidance, fears, phobias (fear of being alone, fear of sexual encounters, avoiding triggers of the event, memory problems, emotional numbness, guilt, depression) -difficulties with daily functioning, low self esteem, depression, sexual dysfunction, & somatic reports

Medications for conduct disorder

-second-and third-generation antipsychotic medications (risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole) -TCAs -Antianxiety medications -Mood stabilizers -Antipsychotic medications are used to manage aggression

types of rape (5)

-stranger -marital -date and acquaintance -majority of perpetrators are known to the person who is raped -alcohol & other substances are often associated with date or acquaintance rape

risk factors (4)

-there is no typical description of a person who is vulnerable to rape -individuals of all ages are affected by sexual assault and can be male or female -there is no "typical" rape survivor -individuals can experience a variety of physical and emotional injuries and effects

nursing care: administer prophylactic treatment (6)

-this is for STD's outlined by the CDC -prophylactic treatment of syphilis -prophylactic treatment of chlamydia -prophylactic treatment of gonorrhea -prophylactic treatment of HIV -prophylactic treatment of hepatitis exposure

First Generation Anti psychotics (Conventional)

-used mainly to control positive symptoms= hallucinations, delusions, bizarre behavior, flight of ideas, agitation, loose associations - because of presence of adverse effects these are for clients: 1. that use them successfully 2. can tolerate adverse effects 3. or are concerned about cost of second generation anti psych meds. -there are different potency levels depending on association with EPS, level of sedation, and anticholinergic adverse effects

maintenance level range of lithium is between

.4 to 1.0

initial treatment of manic episode levels of lithium should be between

.8 - 1.4

Categories of conduct disorder include what?

1. Aggression to people & animals 2. Destruction of property 3. Deceitfulness or theft 4. Serious violation of rules

Engel: Five Stages of Grief

1. Shock and Disbelief 2. Developing awareness 3. Restitution 4. Resolution of the loss 5. Recovery

Phases of the cycle of violence in a family

1. Tension-building phase 2. Acute battering phase 3. Honeymoon phase 4. Periods of escalation and deescalation

lithium plasma levels that can result in toxicity are greater than

1.5

Medications for disruptive mood dysregulation disorder

Antidepressant therapy

immediate, can take several weeks or longer

Advise clients starting antidepressant medication therapy that relief is not _____________

therapeutic uses of alpha2-adrenergic agonists

ADHD

therapeutic use of SNRIs

ADHD in children and adults

therapeutic uses of CNS stimulants

ADHD in children and adults

Complications

Agranulocytosis AntiCholinergic effects EPS - acute dystonia - psudeopakinsonism - akathisia - Tardive dyskinesia - Neuroendocrine effects (weight gain, menstrual irregularities) NMS Orthostatic hypotension Sedation Seizures Severe dysrhythmias Sexual dysfunction Skin effects (photosensitivity, etc) Liver impairments

Tension-building phase

Abuser has minor episodes of anger - can be verbally abuse and responsible for osme physical violence Vulnerable person is tense and tends to accept blame

Task I (Worden)

Accepting the reality of the loss

Maturational/internal crisis

Achieving new developmental stages, which requires learning additional coping mechanisms

Task III (Worden)

Adjusting to a world without the lost entity. The client changes the environment to accommodate the absence of the deceased

Treatment for fine hand tremors in lithium

Admin a beta adrenergic blocking agent like propranolol

Interactions

Advise Pt to Avoid concurrent use of OTC meds that have anticholinergic agents like sleep aids and antihistamines Advise to avoid alcohol and driving Avoid use of levodopa

Benzodiazepine Sedative hypnotic anxiolytics

Alprazolam Diazepam Lorazepam Chlordiazepoxide Clorazepate Oxazepam Clonazepam

cultural risk factors

American Indian and Alaskan Native ethnic groups

Risperidone (Risperdal)

Atypical Antipsychotic Class: benzisoxazoles 1-2mg/day

Haloperidol

Antipsychotic Agent Haloperidol is used to control aggressive and impulsive behavior Nursing Considerations: Monitor for clinical findings of parkinsonian and anticholinergic adverse effects Keep client hydrated, check vital signs, and test for muscle rigidity due to the risk of neuroleptic malignant syndrome

Phases of a crisis: Phase 2

Anxiety continues escalating as defense responses fail Functioning becomes disorganized Client resorts to trial-and-error attempts to resolve anxiety

Perceived Loss

Any loss defined by a client that is not obvious to others

Actual Loss

Any loss of a valued person or item

It is essential to ask the client if he is thinking of suicide.

Assess carefully for verbal and nonverbal clues. This will not give the client the idea to commit suicide.

Nursing Assessments for child/older adult abuse

Assess for any bruises, lacerations, abraisons or fractures in which the physical appearance does not match the history or mechanism of injury

Clonidine(Catapres) intended effects

Assists with withdrawal effects - non-addicting and serves as a bridge to enable the client to stay opiate free long enough to facilitate termination of methadone maintenance.

Iloperidone (Fanapt)

Atypical Antipsychotic Class: Benzisoxazoles 12-24 mg/day Nursing Considerations: ALL HIGH RISK!!!!! Weight GAIN PROLONGED QT INTERVAL!!!!!! Orthostatic Hypotension Low Risk Diabetes Dyslipidemia EPS Adverse Effects: Sedation Fatigue Dry mouth nasal congestion

Clozapine (Clozaril)

Atypical Antipsychotic Class: N/A Doses depend on time period but roughly 12.5-50 mg/day Nursing Considerations: Risk for fatal agranulocytosis (notify provider of any infections) Low risk EPS High risk weight gain, diabetes, dyslipidemia Adverse Effects: Sedation Orthostatic Hypotension HYPERSALIVATION Anticholinergic Effects

Asenapine (Saphris)

Atypical Antipsychotic Class: dibenzo-oxepino pyrroles Sublingual Tablets 10-20mg/day Nursing Considerations: ALL LOW RISK!!!!! Diabetes weight gain dyslipidemia anticholinergic effects Adverse Effects: Drowziness PROLONGED QT INTERVAL!!!!!!!!!!!!!!! EPS (in higher doses) causes temporary numbing of mouh

Nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (select all that apply.) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam

B- SSRIs may be prescribed to decrease the anxiety & depression E- Benzodiazepines may be prescribed to decrease anxiety

Patient education regarding violence

Based on normal growth and development Teach clients self-care and empowerment Teach ways to manage stress Safety plan Encourage participation in support groups Crisis intervention techniques to help family

Emotional Violence

Behavior that minimizes and individual's feelings of self-worth or humiliates, threatens, or intimidates a family member

Requirements for diagnoses of ADHD?

Behaviors must be present prior to age 12 Must be present in more than one setting to be diagnosed

Medications for anxiety

Benzodiazepine Sedative hypnotic anxiolytics: Lorazepam, alprazolam, clonazepam, diazepam Atypical anxiolytic/nonbarbiturate anxiolytics: Buspirone SSRIs: Paroxetine, sertraline, fluoxetine, citalopram, escitalopram, fluvoxamine. SNRIs: Venlafaxine, duloxetine, desvenlafaxine. other antidepressants- TCAs: amtitriptyline, imipramine, clomipramine. MAOIs: phenelzine, mirtazapine, trazodone. Antihistamines Beta blockers- propranolol centrally acting alpha blockers- prazosin Anticonvulsants- Gabapentin

Interactions with Benzos

CNS depressants such as alcohol, barbiturates, and opioids. can cause respiratory depression

sedative hypnotic anxiolytics (benzodiazepines) adverse effects

CNS depression - sedation, lightheartedness, ataxia and decreased cognitive function

Second Generation- Atypical Antipsychotics Pharmacological Action?

Block serotonin and dopamine receptors Also Block Acetylcholine Histamine Norepinephrine

Bereavement

Both grief and mourning (the outward display of loss) as a person deals with the death of a significant individual

CARE AFTER DISCHARGE

CARE AFTER DISCHARGE Ask the client to agree to a no-suicide contract, which is a verbal or written agreement that the client makes to not harm himself, but instead to seek help. ● A no-suicide contract is not legally binding and should only be used according to facility policy. ● A no-suicide contract can be bene cial, but it should not replace other suicide prevention strategies. ● A no-suicide contract can be used as a tool to develop and maintain trust between the nurse and the client. ● A no-suicide contract is discouraged for clients who are in crisis, under the in uence of substances, psychotic, very impulsive, and/or very angry/agitated.

Complications from Benzodiazepine Sedative hypnotic anxiolytics

CNS depression- sedation, lightheadedness, ataxia, decreased cognitive function Advise client to avoid hazardous activities (driving) Don't use alcohol w this med. Anterograde amnesia- difficultly recalling events after dosing notify the doc when this occurs. and withhold med. Acute toxicity- Oral: drowsiness, lethargy, confusion Gastric lavage is used followed by administration of activated charcoal or saline cathartics. Iv: respiratory depression, severe hypotension, cardiac arrest. (diazepam, lorazepam) *Flumazenil is the ANTIDOTE. paradoxical response- insomnia, excitation, euphoria, anxiety, rage Withdrawal effects- anxiety, insomnia, diaphoresis, tremors, and lightheadedness, delirium and seizures. TAPER DOSE.

mood stabilizing antiepileptic drugs prototype medications

Carbamazepine (Tegretol) Lamotrigine (Lamictal)

Interactions of lamotrigine

Carbamazepine, phenytoin and phenobarbital=decreased effectiveness of lamotrigine valproic acid increases 1/2 life of lamotrigine

Oppositional defiant disorder

Characterized by a recurrent pattern of antisocial behavior: -Negativity -Disobedience -Hostility -Defiant behaviors (especially toward authority figures) -Stubbornness, argumentativeness, limit testing -Unwillingness to compromise -Refusal to accept responsibility for misbehavior

Separation anxiety disorder

Characterized by excessive anxiety when a child is separated from or anticipating separation from home or parents Can develop into a school phobia or phobia of being left alone

Risk factors for abuse of a child

Child is under 3 years old Perpetrator sees child as different (unwanted pregnancy, disability)

PTSD

Children & adolescents exhibit psychological indications of anxiety, depression, phobia, or conversion reactions

Benzodiazepines used for detoxification

Chlordiazepoxide Librium diazepam Valium lorazepam Ativan oxazepam Serax

Preassultive

Client begins to become angry and exhibits increasing anxiety, hyperactivity, and verbal abuse

Phases of a crisis: Phase 4

Client experiences overwhelming anxiety that can lead to: -Anguish & apprehension -Feelings of powerlessness & being overwhelmed -Dissociative symptoms (depersonalization, detachment from reality) -Depression -Confusion -Violence against others/self

Kubler-Ross: Five Stages of Grief

Clients might not experience the stages in order, length of stage varies 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

hospitalization, close observation, and suicide precautions

Clients with major depression can require _____________, ____________, and ___________ until antidepressant medications reach peak effect

Anxiolytics

Clonazepam and Lorazepam can be useful in treating acute mania and managing the psychomotor agitation often seen in mania

Psychotherapeutic Interventions: Secondary care

Collaborate w/ client to identify interventions while in an acute crisis that promote safety

Psychotherapeutic Interventions: Tertiary care

Collaborate w/ client to provide support during recovery from a severe crisis that include outpatient clinics, rehabilitation centers, and workshops

Critical Incident Stress Debriefing

Crisis intervention strategy that assists individuals who have experienced a traumatic event, usually involving violence, in a safe environment Facilitator helps with safe expression of thoughts and feelings, acknowledges reactions, teaches stress management and provides referrals

What can influence whether nursing assessment data is valid and how a client responds to interventions regarding violence?

Cultural differences

Example of a situational/external loss

Death of a loved one

Conduct disorder (Childhood or adolescent onset)

Demonstrate a persistent pattern of behavior that violates the rights of others or rules and norms of society

Comorbidities

Depressive Disorders Post-traumatic Stress Disorders Alzheimer's disease Personality and Psychotic Disorders

Refer to chapter 24 for nursing considerations for each complication.

Did you really do it?

Who does violence affect?

Directed toward family, stranger or aquaintance Mass-casuality incident Natural disasters Violence against someone with a mental illness

Anger (Kubler-Ross)

Directed toward self, others, or objects

Following an Aggressive/Violent Episode

Discuss ways for the client to keep control during the aggression cycle Encourage the client to talk about the incident, and what triggered and escalated the aggression from the client's perspective Document the entire incident completely by including the following

Complications of Atypical anxiolytic

Dizziness, nausea, headache, lightheadedness, agitation the med does not interfere with activities b/c does not cause sedation

Assess the client's suicide plan.

Does the client have a plan? ◯ How lethal is the plan? ◯ Can the client describe the plan exactly? ◯ Does the client have access to the intended method? ◯ Has the client's mood changed? A sudden change in mood from sad and depressed to happy and peaceful can indicate a client's intention to commit suicide.

Electroconvulsive therapy (ECT)

ECT is e ective in decreasing suicidal ideation in clients who have a depressive or psychotic disorder.

Complications from SSRI's

Early adverse effects- nausea, diaphoresis, tremor, fatigue, drowsiness. Later effects- after 5 to 6 weeks: sexual dysfunction, weight gain, headache (client should report sexual problems, dose can be adjusted) weight changes- weight loss early, weight gain long term. GI bleeding- use med cautious in patients who have a history of GI bleed, ulcers, and those taking meds for blood coagulation (report dark stools, emesis like coffee grounds) Hyponatremia- more likely in older adults taking anti diuretics Serotonin syndrome Bruxism- grinding and clenching of teeth. (mouth guard, diff med, give low dose buspirone for it) withdrawal syndrome- nausea, sensory disturbances, anxiety, tremor, malaise, unease. TAPER MED.

interactions with Atypical anxiolytic

Erythromycin, ketoconazole, st. john's wort, and grapefruit juice can increase effects of buspirone.

Phases of a crisis: Phase 1

Escalating anxiety from a threat activates increased defense responses

Inattention

Evidenced by a difficulty in paying attention, listening, and focusing

Impulsivity

Evidenced by: -Difficulty waiting for turns -Constantly interrupting others -Acting without consideration of consequences

Hyperactivity

Evidenced by: -Fidgeting -Inability to sit still, running & climbing inappropriately -Difficulty with playing quietly -Talking excessively

Neurodevelopmental disorders

Ex: ADHD, autism spectrum, intellectual developmental disorder, specific learning disorder

Substance use disorders

Ex: Alcohol, tobacco, and cannabis use disorder

Feeding and eating disorders

Ex: Anorexia, bulimia, and binge eating disorder

Impulse control disorders

Ex: Intermittent explosive disorder

Depressive disorders

Ex: Major depressive disorder & dysthymic disorder

Disruptive, impulse control, and conduct disorders

Ex: Oppositional defiant disorder, disruptive mood dysregulation disorder, and conduct disorder

Trauma- and stressor-related disorders

Ex: PTSD

Anxiety disorder

Ex: Separation anxiety disorder & panic disorder

Intermittent explosive disorder

Exhibit recurrent episodic violent and aggressive behavior with the possibility of hurting people, property, or animals

Disruptive mood dysregulation disorder

Exhibit recurrent temper outbursts that are severe and don't correlate with the situation Onset is usually age 6-18

Economic maltreatment

Failure to provide for the needs of a vulnerable person when the funds are available Unpaid bills, resulting in disconnection of heat or electricity

Complications from SNRI

Headache, nausea, agitation, anxiety, dry mouth, and sleep disturbances. hyponatremia, especially in older clients taking antidiuretic. Anorexia resulting in weight loss. HTN Sexual dysfunction

Vulnerable populations for violence

Female partner Partner trying to leave relationship Pregnancy Older adults (poor health, disruptive behavior, dependent on caregiver)

adverse effects of lithium carbonate

G.I. distress find hand tremors polyuria mild thirst weight gain renal toxicity goiter and hypothyroidism with long-term treatment Brady dysrhythmias, hypotension, electrolyte imbalances

Escitalopram

GAD OCD

Paroxetine

GAD Panic disorder: decreases frequency and intensity of panic attacks & anticipatory anxiety about attacks OCD: reduces symptoms by increasing serotonin Social anxiety disorder trauma depressive disorders adjustment disorders associated symptoms of dissociative disorders

Expected Findings

Hyperactivity such as pacing, restlessness Defensive response when criticized, easily offended Eye contact that is intense, or no eye contact at all Facial expressions, such as frowning or grimacing Body language, such as clenching fists, waving arms Rapid breathing Aggressive Posture, such as leaning forward and appearing tense Verbal cues, loud, rapid talking Drug or alcohol intoxication

Bowlby: Four Stages of Grief

Identifies behaviors that are observed in clients who are grieving 1. Numbness or Protest 2. Disequilibrium 3. Disorganized and Despair 4. Reorganization

Attention deficit hyperactivity disorder (ADHD)

Involves the inability of a person to control behaviors requiring sustained attention

Anger

It can be positive if there is truly an unfair or wrong situation that needs to be righted. Anger becomes negative when it is denied. Denied or suppressed anger can manifest as physical or psychological findings, such as headaches, CAD, hypertension, gastric ulcers, depression, or low self-esteem

Maturational Loss

Losses normally expected due to the developmental processing of life

Characteristics of vulnerable people

Low self-esteen and feelings of helplessness, hopelessness, powerlessness, guilt or shame Try to protect perpetrator and accept responsibility for abuse Denial of the severity of the situation - feelings of anger or terror

Interactions with SNRI

MAOI and st. John's Wort can cause serotonin syndrome CNS depression with alcohol, opioids, antihistamines use of NSAIDS and anticoagulants increase risk bleeding

Nursing interventions for child/vulnerable adult abuse

Mandatory reporting or suspected or actual cases Complete & accurate documentation of all data Patient history Basic care to treat injuries Appropriate referrals

What factor is most likely to predict violence between strangers?

Past history of violence Criminal activity

Complications

Metabolic Syndrome (new onset of diabetes mellitus, dyslipidemia, weight gain) Orthostatic Hypotension Anticholineric Effects Agitation, Dizziness, Sedation, Sleep disruption MILD EPS -tremor Elevated Prolactin Levels Sexual dysfunction

Example of an adventitious crisis

Natural disaster

Manifestations of alcohol withdrawal

Nausea vomiting tremors restlessness insomnia depressed mood irritability increased heart rate, blood pressure, respiratory rate, and temperature and tonic clonic seizures

Therapeutic Use of Atypical Antipsych?

Negative and Positive symptoms of schiz. spectrum disorders Psychosis induced by levodopa therapy Relief of psychotic manifestations in other disorders such as bipolar disorder Impulse control Disorder

Medications for anxiety disorder

No FDA approved antianxiety medications for children -SSRIs may be prescribed

Nursing interventions for community violence

Psychological first aid safety Reduce stress-related manifestations (Re: Anxiety/panic) interventions to restore rest and sleep Links to social support and referrals

Situational/external crisis

Often unanticipated loss or change experienced in everyday, often unanticipated, life events

Other Medications

Other meds may be used to prevent violent behavior by treating the underlying disorder Includes antidepressants, selective serotonin reuptake inhibitors, mood stabilizers, lithium, and sedative/hypnotic medications (benzodiazepines)

SSRIs

Paroxetine others- sertraline citalopram escitalopram fluoxetine fluvoxamine

Contraindications for SSRI's

Paroxetine not safe for pregnancy but others may be don't give MAOIs or TCAs with this med avoid alcohol cautious with patients w bipolar b/c risk for mania.

Necessary Loss

Part of the cycle of life; anticipated but can still be intensely felt

Types of violence

Physical violence Sexual violence Emotional violence Neglect

What is the initial task of the nurse during crisis intervention?

Promote a sense of safety by assessing the client's potential for suicide or homicide

Purpose for Benzodiazepine Sedative hypnotic anxiolytics

Relief from anxiety occurs RAPIDLY. first line treatment for generalized anxiety disorder and panic disorder other uses: seizure disorder insomnia muscle spasm alcohol withdrawal induction of anesthesia amnesic prior to surgery or procedures

Assessments for violence - infants

Shaken baby syndrome - Intracranial hemorrhage - respiratory distress - bulging fontanels - Increase in head circumfrence - Retinal hemorrhage Any bruising before 6 months

Seclusion and Restraints

Should be used as last resort. Keep individuals safe during a violent outburst, but the use of restraint itself can be dangerous and lead to death of clients Intramuscular medication can need to be given Remove client immediately when crisis is over

Acute battering phase

Tension becomes too much to bear - serious abuse takes place Vulnerable person tries to cover up injury or try to get help

Acceptance (Kubler-Ross)

The client accepts what is happening and plans for the future

Developing Awareness (Engel)

The client becomes aware of the reality of the loss resulting in intense feelings of grief. This begins within hours of the loss

Restitution (Engel)

The client carries out cultural/religious rituals, such as a funeral, following the loss

Assaultive

The client commits an act of violence. Seclusion and physical restraints can be required

Shock and Disbelief (Engel)

The client experiences a sense of numbness and denial over the loss

Disorganization and Despair (Bowlby)

The client feels hopelessness which impacts the client's ability to carry out tasks of daily living

Numbness or Protest (Bowlby)

The client is in denial over the reality of the loss and experiences feelings of shock

Resolution of The Loss (Engel)

The client is preoccupied with the loss. Over about a 12 month time period this preoccupation gradually decrease

Depression (Kubler-Ross)

The client mourns and directly confronts feelings related to the loss

Recovery (Engel)

The client moves past the preoccupation and forward with life

Bargaining (Kubler-Ross)

The client negotiates for more time or a cure

Reorganization

The client reaches acceptance of the loss

Grief

The inner emotional response to loss

Adventitious crisis

The occurrence of natural disasters, crimes, or national disasters

antipyschotics

These can be useful in early treatment to promote sleep and to decrease anxiety and agitation. These medications also demonstrate mood stabilizing properties

Aripiprazole (Abilify)

Third Generation Atypical Antipsychotic Tables, oral solution, long/short acting injectable Class: SDAM (serotonin-dopamine activity modulator) 10-30 mg/day Nursing Considerations: LOW RISK or no at all EPS Diabetes Weigh Gain Dyslipidemia Orthostatic Hypotension Anticholinergic effects Adverse Effects: Sedation Headache Anxiety Insomnia GI UPSET

Phases of a crisis: Phase 3

Trial-and-error methods of resolution fail Client's anxiety escalates to severe or panic levels leading to flight or withdrawal behaviors

Haloperidol (Haldol)

Typical Antipsychotic/High Potency Class: - Butyrophenones (because also used as antiemetic) - Dibenzapine 1-15 mg /day severe symptoms may require up to 100 mg/day

Fluphenazine (Prolixin)

Typical Antipsychotic/High Potency Class: Phenothiazine Max dose is 40 mg/day

Trifluoperazine (Stelazine)

Typical Antipsychotic/High Potency Class: Phenothiazines 2-40 mg/day

Thiothixene (Navane)

Typical Antipsychotic/High Potency Class: Thioxanthenes 20-60 (not to exceed 60) mg/day

Thioridazine (Mellaril)

Typical Antipsychotic/Low Potency Class: Phenothiazine 150-800 mg/day

Chlorpromazine (Thorazine)

Typical Antipsychotic/Low Potency Class: Phenothiazine 200-1600 mg/day

Loxapine (Loxitane)

Typical Antipsychotic/Medium Potency Class: Dibenzoxazepine 20-100 mg/day

Perphenazine (Trilafon)

Typical Antipsychotic/Medium Potency Class: Phenothiazine 8-64 mg/day

Situational Loss

Unanticipated loss caused by an external event

Agression

Unlike Anger Typically goal-directed with the intent of harming a specific person or object. Inappropriately expressed anger can become hostility or aggression. This includes physical or verbal responses that indicate rage and potential harm to self, others, or property. Client who is often angry and aggressive can have underlying feelings of inadequacy, sincerity, guilt, fear, and rejection.

Assessment for violence - preschoolers to adolescents

Unusual bruising Mechanism of injury - bruising in multiple stages of healing Burns Fractures with unusual features or multiple fractures Human bitemarks Head injuries - LOC, PERRLA

Characteristics of a perpetrator

Use of threats and intimidation to control Extreme disciplinarian - believes in physical punishment Possible history of substance use disorder Possible history of family violence as a child Difficult assuming adult roles

benzodiazepines nursing interventions/client education

administer around-the-clock or PRN obtain the clients baseline vital signs monitor the clients vital signs and neurological status on an ongoing basis provide for seizure precautions

Periods of escalation and deescalation

Usually becomes shorter and shorter periods of time in between Emotions for abuser and vulnerable person (fear, anger) increase in intensity Repeated violence leads to feelings of powerlessness

Nursing Administraion

Utilize AIMS to screen early EPS Administer anticholinergics, beta blockers, benzodiazepines to control early EPS Consider depot preparations administer IM every 3-4 weeks

Physical violence

When physical pain or harm is directed towards an infant or child, intimate partner, vulnerable adult

Sexual violence

When sexual ontact takes place without consent, whether the vulnerable person is able or unable to give consent

Teaching with Clonidine (Catapres)

advise the client to avoid activities that require mental alertness until drowsiness subsides, encourage chewing sugarless gum or suck hard candy to treat dry mouth

teaching with bupropion Zyban

advise the client to avoid caffeine and other CNS stimulants to control insomnia take measures to prevent dry mouth

depressive disorders

__________ are a leading cause of disability

combination

___________ of antidepressant meds can be required to alleviate all symptoms

opioid withdrawal manifestations

agitation insomnia rhinorrhea yawning sweating and diarrhea. Withdrawal manifestations are not life-threatening although suicidal ideation may occur

selective norepinephrine reuptake inhibitor (SNRI)

atomoxetine

Bupropion, venlafaxine, duloxetine, desvenlafaxine, levomilnacipran, mirtazapine, trazodone

atypical antidepressant examples

Paliperidone (Invega)

atypical antipsychotic Class: Benzisoxazoles 3-12 mg/day Extend release tablet or injection Nursing Consideration: HIGH RISK Diabetes weight gain dyslipidemia Adverse Effects Sedation Orthostaic hypotension MILD EPS!!! PROLONGED QT INTERVAL!!!!! Anticholinergic effects

Lurasidone (Latuda)

atypical antipsychotic Class: Benzoisothiazole 40-160 mg/day Nursing Consideration LOW RISK diabetes weight gain dyslipidemia DOES NOT CAUSE anticholinergic effects Adverse Efects Sedation Agitation & Anxiety Nausea AKATHISIA!! PARKINSONISM!!

Quetiapine (Seroquel)

atypical antipsychotic Class: N/A 50-800 mg/day Nursing Considerations: LOW RISK EPS Moderate Risk diabetes, weight gain, dyslipidemia Adverse Effects CATARACTS Sedation Othrostatic hypotension Anticholinergic effects

Ziprasidone (Geodon)

atypical antipsychotic Class: Piperazine Derivatives 40-80 mg/day Affects both dopamine and serotonin so it can be used for Pts who have concurrent depression. Capsules or short acting injectable Nursing Considerations: LOW RISK EPS Diabetes weight gain dyslipidemia Adverse Effects: Sedation Othrosatic Hypotension Anticholinergic effects ECG CHANGES AND QT PROLONGED ---> CAN lead to torsades de pointes

Olanzapine (Zyprexa)

atypical antipsychotic Class: Thienobenzodiazepines 5-20 mg/day tablet, short acting injectable, extended realease injection ****AFTER extended release injection, must observe client for 3 hrs or more for adverse effects***** Nursing considerations: LOW RISK EPS HIGH RISK Diabetes weight gain dyslipidemia Adverse Effects Sedation Orthostatic Hypotension Anticholinergic effects

Atypical anxiolytic purpose

binds to serotonin and dopamine receptors less potential for dependency does not result in sedation anti anxiety effects develop SLOWLY. initial response takes 1 week, and at least 2 to 6 weeks for it to reach its full effects Therapeutic uses: panic disorder obsessive compulsive social anxiety generalized anxiety

purpose of tricyclic antidepressants

block reuptake of norepinephrine and serotonin in the synaptic space, intensifying the effects of these neurotransmitters

purpose of SNRIs

block reuptake of norepinephrine at synapses in the CNS; atomoxetine is not a stimulant medication

purpose of atypical antipsychotics

block serotonin and dopamine receptors; also block receptors for norepinephrine, histamine, and acetylcholine

purpose of SSRIs

block the synaptic reuptake of serotonin, allowing more serotonin to stay at the junction of the neurons

Atypical anxiolytic

buspirone

contraindications for Atypical anxiolytic

buspirone not used in pregnancy or breastfeeding use cautiously in older adults and liver and renal dysfunction DONT USE WITH MAOIs or 14 days after MAOIs are discontinued --> hypertensive crisis can result.

serotonin syndrome

can begin 2-72 hours after start of treatment and can be lethal mental confusion, difficulty concentrating, abdominal pain, diarrhea, agitation, fever, anxiety, hallucinations, hyperreflexia, incoordination, diaphoresis, tremors

post traumatic stress disorder

can occur beyond 1 month after the attack

Abstinence syndrome

client abruptly withdraws from the drug on which he is physically dependent - can cause distressing manifestations that can also be life-threatening

Worden: Four Tasks of Mourning

completion of all 4 tasks generally takes about a year

headache, dry mouth, GI distress, constipation, increased heart rate, nausea, restlessness, insomnia, suppression of appetite, weight loss, seizures

complications with Bupropion (atypical)

sleepiness, increased appetite, weight gain, elevated cholesterol

complications with mirtazapine

CNS stimulation (insomnia, agitation, anxiety), orthostatic hypotension, hypertensive crisis, local rash associated with transdermal patch

complications with monoamine oxidase inhibitors

sexual dysfunction, CNS stimulation (insomnia, agitation, anxiety), weight changes, serotonin syndrome, withdrawal syndrome, hyponatremia, rash, sleepiness, faintness, lightheadedness, GI bleeding, bruxism

complications with selective serotonin reuptake inhibitors

sedation, priapism

complications with trazadone

orthostatic hypotension, anticholinergic effects (dry), sedation, toxicity, decreased seizure threshold, excessive sweating, increased appetite

complications with tricyclic antidepressants

headache, nausea, agitation, anxiety, dry mouth, sleep disturbances

complications with venlafaxine, duloxetine, desvenlafaxine, and levomilnacipran (SNRIs)

interactions of SSRIs

concurrent use of MAOIs or St. John's wort can cause serotonin syndrome

pregnancy, seizure disorder, anorexia nervosa, bulimia nervosa

contraindications for Bupropion (atypical)

pregnancy, pheochromocytoma, heart failure, cardiovascular and cerebral vascular disease, severe renal insufficiency, diabetes, seizure disorders

contraindications for monoamine oxidase inhibitors

pregnancy, liver or renal dysfunction, cardiac disease, seizure disorders, diabetes, ulcers, history of GI bleeding

contraindications for selective serotonin reuptake inhibitors

pregnancy, seizure disorders, coronary artery disease, diabetes, liver/kidney/respiratory disorder, urinary retention and obstruction, angle closure glaucoma, BPH, hyperthyroidism, suicidal thoughts

contraindications for tricyclic antidepressants

Intended effects of adjunct medications

decrease in seizures carbamazepine depression of autonomic response, decrease in blood pressure, heart rate abstinence maintenance disulfiram Antabuse intended effects aversion therapy - use with alcohol cause nausea vomiting weakness sweating palpitations and hypotension. Can progress to respiratory depression cardiovascular suppression seizures and death

bupropion Zyban intended effects

decreases nicotine craving and manifestations of withdrawal

tricyclic antidepressants

desipramine, imipramine, clomipramine

naltrexone (Vivitrol) teaching

determine if client is also dependent on opioids because concurrent use increases risk for overdose encouraged to take with meals to decrease G.I. distress suggest monthly IM injections for clients to have difficulty adhering to the medication regimen

teaching for Acapmprostate Campral

diarrhea may result maintain adequate fluid to prevent dehydration and avoid used during pregnancy

lithium level of less than 1.5

diarrhea nausea vomiting first polyuria muscle weakness find hand tremors speech

medications/food interactions with lithium

diuretics can lead to toxicity NSAIDs will increase renal reabsorption of lithium lead to toxicity anticholinergics can result in urinary retention and polyuria

adverse effects of Lamotrigine Lamictal

double or blurred vision dizziness headache nausea vomiting Stevens-Johnson syndrome

Teaching for methadone

encourage client to participate in a 12 step program and medication must be administered from an approved treatment center

verbalizing improvement in mood, ability to perform ADLs, improved sleeping and eating habits, increased interaction with peers

evaluation of antidepressant effectiveness

lithium level greater than 2.0 - 2.5

extreme polyuria of daily urine tinnitus were deficient ataxia seizures severe hypotension meeting to, and possible death from respiratory complications

selective serotonin reuptake inhibitors (SSRIs)

fluoxetine

tertiary intervention

focus on providing support and assistance to survivors of pt who committed suicide

primary intervention

focus on suicide prevention through the use of community education and screenings to identify ppl at risk

tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), atypical antidepressants

four main groups of antidepressant medications

alpha2-adrenergic agonists

guanfacine, clonidine

Teaching with nicotine replacement therapy

gum is not recommended for longer than six months chew gum slowly over 30 minutes avoid eating or drinking 15 minutes prior to and while chewing gum apply patch to an area of clean dry skin each day avoid using any nicotine while wearing the patch notify provider of local skin reaction occurs avoid using any nicotine products while pregnant or breast-feeding

Sertraline

indicated for panic disorder, OCD, social anxiety, PTSD

Purpose of SSRIs

inhibit serotonin reuptake more serotonin at the junction of neurons do not block uptake of dopamine, norepinephrine causes CNS stimulation which can cause insomnia, long effective half life up to 4weeks are necessary to produce therapeutic levels

Purpose of SNRI

inhibit the uptake of serotonin and norepinephrine ; used for major depression, panic disorders, GAD

MAOIs, SSRIs

interactions with Bupropion (atypical)

indirect acting sympathomimetic medications, TCAs, SSRIs, antihypertensives, meperidine, dietary tyramine, vasopressors

interactions with monoamine oxidase inhibitors

MAOIs, TCAs, St John's wort, warfarin, lithium, NSAIDs, anticoagulants

interactions with selective serotonin reuptake inhibitors

MAOIs, antihistamines, anticholinergic agents, direct and indirect sympathomimetics, alcohol, benzodiazepines, opioids

interactions with tricyclic antidepressants

therapeutic use of SSRIs

intermittent explosive disorder

tobacco withdrawal manifestations

irritability nervousness restlessness insomnia and difficulty concentrating

date rape

is a form of acquaintance rape in which the parties agreed upon a social engagement

purpose of alpha2-adrenergic agonists

known to activate presynaptic alpha2-adrenergic receptors within the brain

physical assessment Findings

lacerations, scratches, and scars that could indicate previous attempt at self- harm

mood stabilizer prototype medication

lithium carbonate

benzodiazepines intended effects

maintenance of clients vital signs within normal limits decrease in the risk of seizures decrease in the intensity of withdrawal manifestations

physical disorder: compound rape reaction

manifestations of a prior physical illness

alcohol withdrawal delirium

may occur 2 to 3 days after cessation and may last 2 to 3 days. Considered a medical emergency and include severe disorientation, psychotic effects, severe hypertension, cardiac dysrhythmias and delirium may progress to death

lithium level of 1.5 to 2.0

mental confusion poor coordination course tremors ongoing G.I. distress including nausea vomiting and diarrhea

CNS stimulants

methylphenidate, amphetamine mixture, dextroamphetamine

phenelzine, isocarboxazid, tranylcypromine, selegiline (transdermal patch)

monoamine oxidase inhibitor examples

Bipolar disorder is managed with

mood stabilizing medication antiepileptic medication atypical antipsychotics anxiolytic antidepressants

SSRI adverse effects

nausea, headache, CNS stimulation ( agitation, insomnia, anxiety)

Varenicline (Chantix) 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 severity or withdrawal manifestations. Reduces the incidence of relapse by blocking the desired effects of nicotine

provide list of tyramine foods to avoid (hypertensive crisis), avoid taking other medications

nursing administration of MAOIs

take in morning (sleep disturbances), take with food (GI disturbances), obtain baseline sodium level for older clients taking diuretics

nursing administration of SSRIs

monitor for cardiac dysrhythmias (toxicity), administer at bedtime (sedation and orthostatic hypotension)

nursing administration of TCAs

take daily and continue therapy even after improvement, therapy usually continues 6 months to 1 year or longer

nursing administration of antidepressants

begin taking in autumn each year and gradually taper dose and discontinue by spring for seasonal pattern depression, avoid use with MAIOs

nursing administration of atypical antidepressants

therapeutic effects can occur sooner and with less sexual dysfunction than SSRIs, generally well tolerated

nursing considerations for mirtazapine

usually used with another antidepressant, take at bedtime, use with caution with cardiac disease

nursing considerations for trazadone

monitor for hyponatremia, weight loss, and increased blood pressure; discuss ways to manage sexual dysfunction, not for patients with hepatic disease or who consume large amounts of alcohol

nursing considerations for venlafaxine, duloxetine, desvenlafaxine, and levomilnacipran (SNRIs)

adverse effects of carbamazepine

nystagmus double vision vertigo staggering gait headache blood dyscrasias(leukopenia, anemia, and thrombocytopenia) Teratogenesis (pregnancy) risk for fluid overload Stevens-Johnson syndrome( rash) can't take with birth control or warfarin

Naltrexone (Vivitrol) intended effects

opioid antagonists that suppresses the craving and pleasurable effects of alcohol also used for opioid withdrawal

carbamazepine medication/food interactions

oral contraceptives, warfarin Coumadin causes a decrease in the effects of these medications grapefruit juice inhibits metabolism increasing blood levels of the medication Phenytoin, phenobarbital decreases effects of carbamazepine

Fluoxetine

panic disorder OCD PTSD

inhibits dopamine uptake

pharmacological action of Bupropion (atypical)

increases release of serotonin and norepinephrine

pharmacological action of mirtazapine

Disulfiram Antabuse teaching

potential dangers of drinking alcohol encouraged to wear a medical alert bracelet encourage participation in a 12 step program acetylaldehyde syndrome persists for two weeks following discontinuation of disulfiram monitor liver function tests to detect hepatotoxicity

Expected pharmacological action of the stabilizing antiepileptic drugs

potentiates the inhibitory effects of GABA slows the entrance of sodium and calcium back into the neuron inhibits glutamic acid (glutamate) which suppresses CMS excitation

Contraindications/precautions for SNRI

pregnancy category risk C DONT TAKE MAOI don't abruptly stop this med avoid alcohol Duloxetine should not be used in clients who have hepatic disease or those who consumer Lrg amounts of alcohol.

Contraindications for use of Benzos

pregnancy category risk D; don't use don't give to clients with sleep apnea, resp depression, glaucoma. cautiously in clients with liver disease, or history of substance use disorder Used short term.

contraindications/precautions of lithium

pregnancy risk category D medication especially in the first trimester of pregnancy discourage from breast-feeding use cautiously in clients who have renal dysfunction heart disease sodium depletion or dehydration

Expected pharmacological action of lithium carbonate

produces neurochemical changes in the brain including serotonin receptor blockade controls episodes of acute mania helps to prevent the return of mania or depression and decreases the incidence of suicide

purpose of CNS stimulants

raise levels of norepinephrine, serotonin, and dopamine

lithium level greater than 2.5

rapid progression of manifestations leading to, and death

Acamprostate Campral intended effects

reduce the craving for alcohol taken orally three times a day

methadone Dolophine substitution intended effects

replaces opioid to which the client is addicted prevent abstinence syndrome from occurring and removes the need for the client to obtain illegal opioids used for withdrawal and long-term maintenance dependences transferred from the illegal opioid to methadone

atypical antipsychotics

risperidone, olanzapine

fluoxetine, paroxetine, sertraline, citalopram, escitalopram, vilazodone

selective serotonin reuptake inhibitor examples

acquaintance rape & marital rape

specify the relationship between the perpetrator and vulnerable person

client education

ssist the client to develop a support-system list with speci c names, agencies, and telephone numbers that the client can call in case of an emergency.

nicotine replacement therapy gum, patch, nasal spray intended effects

substitutes for nicotine in cigarettes or chewing tobacco. Rate of use cessation has nearly doubled with the use of replacements.

secondary intervention

suicide prevention for pt who is having an acute suicidal crisis suicide precaution are included

rape trauma syndrome

sustained & maladaptive response to a forced, violent sexual penetration against the individuals will and consent

Teaching for Varenicline (Chantix)

take med after meal, monitor blood pressure, monitored diabetic patients blood sugar, follow instructions for titration, notify provider if nausea vomiting insomnia new onset depression or suicidal thoughts occur contraindicated for clients of chronic depression serious mental illness or suicidal ideation

Nursing administration of Atypical anxiolytic

take with meals same time every day

silent rape reaction

the survivor does not report or tell anyone of the sexual assault, including family, friends, or the authorities

depression, alternative SSRI with no sexual dysfunction side effects, smoking cessation aid, prevention of seasonal pattern depression

therapeutic uses for Bupropion (atypical)

depression, bulimia nervosa, first-line treatment for atypical depression

therapeutic uses for monoamine oxidase inhibitors

major depression, OCD, bulimia nervosa, premenstrual dysphoric disorders, panic disorders, PTSD, bipolar disorders

therapeutic uses for selective serotonin reuptake inhibitors

depressive disorders, neuropathic pain, fibromyalgia, anxiety disorders, insomnia, bipolar disorder

therapeutic uses for tricyclic antidepressants

amitriptyline, nortriptyline, imipramine, trimipramine, amoxapine, doxepin

tricyclic antidepressant examples

risk for older adult pt

untreated depression loss of employment and fiances feelings of isolation, powerlessness prior attempts at suicide change in functional ability alcohol or other substance use disorder loss of loved ones

Interactions with SSRI's

use of MAOIs, TCAs, St. John's Wort can cause serotonin syndrome. (discontinue MAOI 14 days before, discontinue fluoxetine 5 weeks before use of an MAOI.) use with warfarin increases warfarin levels use with TCAs and lithium can result in increased levels of these meds. Use with NSAIDs and anticoagulants can increase risk for bleeding

Fluvoxamine

used for OCD and social anxiety disorder

therapeutic uses for mood stabilizing antiepileptic drugs

used to treat manic and depressive episodes as well as to prevent relapse of mania and depressive episodes. Useful for clients who Mania and rapid cycling bipolar disorders

Nursing evaluation of medication effectiveness

verbalized feeling of less anxiety description of improved mood improved memory retrieval maintenance of normal sleep pattern Greater ability to participate in social and occupational interactions Improved ability to cope with manifestations and identified stressors ability to perform ADLs report of increased well being

rape trauma syndrom

which is similar to post traumatic stress disorder, can occur after rape