Mental Health Test #1
A severely depressed patient is hospitalized on a psychiatric unit. Which of the following are priority nursing interventions? Have her: A. Develop a safety plan and administer antidepressant medications. B. Use systematic desensitization and relaxation training. C. Focus on her underlying needs for delusions and present reality. D. Get her involved in unit activities.
A. Develop a safety plan and administer antidepressant medications.
*Behavioral* Symptoms of depression.
Aggressiveness Immobility Agitation Decreased activity Intolerance/anger Irritability Lacks spontaneity Suicidal gestures & acts Underachievement Withdrawal Poor hygiene & lack of ADLs Dependent behavior Social isolation/withdrawn Tearful Alcoholism & drug use- Self-medication
*Affective* Symptoms of Depression.
Anger & anxiety Apathy & bitterness Dejection & guilt Denying feelings Sad and despondent Helpless & hopeless Loneliness Low self-esteem Worthlessness
*Physiological* Symptoms of Depression.
Anorexia, overeating - Weight Loss or Weight Gain approximately 5% of body weight Head, back, chest, abdominal pain Constipation Dizziness Fatigue - Insomnia (Difficulty falling asleep, Staying asleep or early am wakening) Impotence and libido changes Indigestion Nausea Menstrual changes
What are the side effects of TCA's?
Anticholinergic side effects! Sedation Dry mouth Urinary retention Orthostatic hypotension Constipation Blurred vision Dizziness Tachycardia Cardiac conduction abnormalities Withdrawal *Extremely lethal in overdoses - some people stock pile and then overdose.*
Antidepressants - venlafaxine
Brand name: Effexor, Effexor XR S/NE reuptake inhibitor (SNRI) Works like an SSRI at low doses (<225 mg) S/NE reuptake inhibition only occurs at higher doses (>225mg) ☺ NE effects can lead to effects *hypertension* and *increased heart rate* ☺ Immediate release form is poorly tolerated
Cognitive Restructuring Techniques 1. Questioning the evidence:
Have patients look at the information upon which they draw conclusions. Often, patients give equal weight to all the information they receive whether it is relevant or not. This process helps them sort through information and make better decisions about what to act upon.
What personal qualities of the nurse is beneficial for therapeutic communication?
Have self-awareness Clarification of values Exploration of feelings Acknowledge own feelings
Nursing Interventions for Conversion Disorder
Help label and deal with feelings Cognitive-behavioral strategies Learn new coping strategies Group therapy Intervene in unhealthy defense mechanisms Problem-solving Discuss precipitants to anxiety
How do we enter a patient's personal space? What nurses need to know about space and distance?
Interpersonal distance Emotional closeness
Personal space
Intimate space- up to 18" Personal space- 18" to 4 feet Social space- 9-12 feet Public space- 12' and over Territoriality
Describe the introductory/Orientation phase.
Introduce self and set contract (boundaries) Ask pts why they seek help & Why Now? Set goals with patient Establish trust in atmosphere of acceptance Explore thoughts and feelings Set the tone of the relationship Prepare for termination Patient tests the boundaries How do you handle requests for personal information?
What are some verbal & nonverbal ways to convey empathy?
Introduce yourself Use good listening techniques-posture, eye contact, open arms, "Go on, Then what..." Mirror body positions Have voice tone consistent with body language
Repression
Involuntarily excluding a painful or conflicted thought from awareness.
What are the rights of patients throughout involuntary admission?
Least restrictive treatment Representation by an attorney Treatment plan Allowed to sign in voluntary if is willing/capable Does not lose rights - contracts, wills, property Is given and signs a patient Bill of Rights Has right to refuse medication
What is the job of the nurse on a psych unit?
Maintain the milieu : -a safe and therapeutic environment role of the nurse: -noise -music -talking and laughter -activities -light -feel
What is mental illness?
Maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms, and that interfere with the individual's social, occupational, and/or physical functioning.
Symptom vs. Syndrome (Disorder)
Many people have symptoms-depression, anxiety, manipulation, suspiciousness, etc. Disorder/Syndrome: Interference with social and occupational functioning (school work & attendance in children) Impairment in Activities of Daily Living
Delirious Mania
Mood: labile (up and down), despair converts to unrestrained merriment and ecstasy and indifferent to environment Cognition and Perception: Clouding of consciousness, confusion, disorientation, delusions, hallucinations, distractible and incoherent.
Bipolar Disorder - Depression
More amendable for treatment Symptoms similar to Major Depression *Monitor for suicidality* Medication used to treat are different Use of *Mood Stabilizers* *Antidepressants used with caution since they can precipitate manic episodes*
What is Panic Anxiety?
Most intense state of anxiety Cannot focus on even one detail Misperception occurs May lose contact with reality Behavior may have wild and desperate actions or extreme withdrawal Feels terror May be convinced they have a life-threatening disorder with physical symptoms
Etiology of Depression
Multiple theories on what causes depression -Social -Developmental -Biologic Biologic theory hypothesizes a decrease in brain monoamine neurotransmitters -Norepinephrine (NE) -Serotonin (S) -Dopamine (DA) Goals of Treatment -Reduce the symptoms of depression -Facilitate the patient's return to baseline level of functioning
Which task would be most appropriate for the nurse to focus on during the introductory phase when working with a teenage patient with low self-esteem? Mutual formulation of a contract Nurse's analysis of his or her own strengths Promotion of patient use of constructive coping mechanisms Review of progress of therapy and goal attainment with patient
Mutual formulation of a contract
What are the nursing diagnosis's & goals for a Panic Attack
ND: Anxiety related to panic attacks Goal: Pt. will show an improvement in anxiety within 30 minutes (or will show less panic within 30 minutes)
Identification
Process by which people become like someone they admire by taking on characteristics of them.
Compensation
Process by which people make up for perceived weakness by emphasizing characteristics they deem more attractive.
6. Failure to probe.
Pt:"I'm afraid I won't make it through surgery." Nurse-"You'll be fine, don't worry." More appropriate response: You are concerned you won't make it through surgery?
8. Focusing
Questions or statements that help patients expand on a topic of importance. "I Wonder if we should spend some time talking about your feelings about your father."
What is a duty to worn?
if someone is threatening to kill someone else, the LP has a duty to warn the person who potentially might be harmed
Settings for mental health treatment may be?
inpatient, outpatient (clinics, EDs) LTC facilities often treat mentally ill Jails and prisons
What is the goal for generalized anxiety disorder, and how do you know when the Pt is getting better?
look at behavior look at coping mechanisms look at self esteem look at their social behavior
What are the environmental influences of mental health and illness?
money insurance drugs
What does it mean to be Passive-Aggressive?
mutters to self rather than address person/issue. Facial expressions do not match how person feels. Uses sarcasm. Denies there is a problem. Appears cooperative while purposely doing things to annoy, disrupt, sabotage. Gets even. Takes issues to other people who are not involved. "I'm not okay, you're not okay"
Are people guilty by reason of insanity?
no ordered treatment facility and released when sane (in colorado, CMHI at pueblo)Not guilty by reason of insanity
2. The nurse dominating the interaction on a topic selected by the________.
nurse
obsession
recurrent persistent thoughts, impulses or images experienced as intrusive or stressful. Recognized as being excessive and unreasonable even though they are a product of ones mind. The thought, impulse, or image cannot be expunged by logic or reasoning.
7. Informing
skillfully giving information or teaching. "I think you need more information on your medication's side effects. The side effect written here is lethargy. It means to move slowly."
What are the nursing interventions for generalized anxiety disorder?
Quiet atmosphere 1:1 Ventilation of feelings Cognitive restructuring Learn new coping strategies Intervene in unhealthy defense mechanisms Problem-solving Relaxation exercises Discuss precipitants to anxiety Physical outlets (running, walking, swimming) Administer medication Nurse remains calm
For the patient who is manic, which of the following behaviors would be assessed by the nurse ? Select all that apply. Rapid shifts in topics and agitation Demure affect and staring straight ahead Interrupting others and being the center of attention Stating she is "Talking to the spirits in the room."
Rapid shifts in topics and agitation Interrupting others and being the center of attention
What are the factors that influence depression?
Reactions: to a stressor Biology: Physical events & changes like insomnia Medical issues: Diabetes (interferes with synthesis of neurotransmitters) MS Low thyroid Anemia Hormonal: Estrogen, progesterone Testosterone Medication-induced substance abuse Complicates every aspect of a mood disorder
Describe the Termination phase.
Review progress & goal attainment Help patient set future goals Explore feelings of rejection, sadness, loss, anger Each discuss the meaning of the relationship unless schizophrenic Patient can get sicker or resist leaving Terminate completely
What does it mean to be Assertive
states own opinions and feelings, advocates for rights and needs w/o violating rights of others. Calm, clear tone of voice. Positive eye contact. Does not allow others to abuse or manipulate. "I'm okay, you're okay"
Conversion
translating anxiety into paralysis of the voluntary muscles or problems with the special senses.
Is insanity is a legal definition?
yes
Can patients be given meds against their will?
yes; with court ordered or emergency medications
Who can discharge you?
a licensed practitioner
4. Clarification
asking for more information to make the patient's message clear. "I'm not sure I am following you. Tell me about your last hospitalization again. You said your father left when you were a teenager. I'm unclear about what happened before he left."
Undoing
Act or communication that partially negates a previous one.
Nursing Interventions for Depression
Administer Medications - takes 2-6 weeks to become therapeutic. structure #1 SSRI's Tricyclics MAO inhibitors Others: antidepressants Monitor medication side effects Assess for suicidal thoughts and ideation 1:1 for short periods Assist with activities of daily living as needed Deal with anger and externalize as needed Avoid acting cheerful Mute-make observations of patient's response to environment & document Use simple, concrete words and sentences Work on problems to gain acceptance of self Acceptance by the nurse forms basis for self-acceptance Cognitive-behavioral strategies for distortions in thinking
Nursing Interventions - manic episodes
Administer medications & monitor side effects Lithium - only true mood stabilizer Tegretol Depakote Others Administer low doses of antipsychotics PRN Benzodiazepines Give finger foods Give fluids to drink Do not laugh at jokes Use firm, calm approach Use short, simple words & explanations Be consistent with approach Provide a structured environment Set limits on behavior Crude jokes boundary violations threats or violent behavior Send to room to calm down if escalates De-escalate Use time outs Use distraction Avoid power struggles Redirect energy constructively Protect from self harm Remain calm
Medications used for PTSD?
Administer medications: (SSRI, Tricyclics and MAOI) Propranolol (Inderal), Fluoxitine (Prozac) Buspirone (Buspar), Fluvoxamine (Luvox) Trazodone for sleep Address substance abuse
Mild Depression
Affective: Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency Behavioral: Tearful, regression, restlessness, agitation, withdrawal, energy higher in AM, lower in PM Cognitive: Preoccupation with loss, self-blame, ambivalence, blaming others Physiological: Anorexia or overeating, insomnia or hypersomnia, headache, backache, chest pain
Moderate Depression
Affective: More depressed mood, anxious, irritable, guilt , worthlessness, self-blame Behavioral: Slowed down physically (psychomotor retardation), slowed speech, rumination, fatigue and lethargy increase, more physical complaints Cognitive: Indecisive, poor concentration, poor stress tolerance, distorted thinking process, pessimism and negativity, suicidal ideation Physiological: Anorexia/overeating, insomnia: awakens during night, low energy, feels best in morning and worse as day progresses
Severe Depression
Affective: Total despair, flat affect, appears devoid of emotions, inability to feel pleasure, Behavioral: Physical movement may come to a standstill or is agitated, nonexistent communication, no personal hygiene, social isolation Cognitive: Prevalent delusional thinking, confusion, indecisive, hallucination reflecting misinterpretations, self-depreciation, thoughts of suicide Physiological: Slowing down of entire body, , feels worse in morning and better as day progresses, insomnia and early dawn awakening
What is Conversion Disorder?
Affects voluntary muscles and special senses Clinical findings are not compatible with recognized neurological or medical conditions Produces impairment in social, occupational, or other important functioning Not intentionally produced or feigned For example - loose use of legs, go blind, loose hearing, speech.
11. Avoiding therapeutic intimacy.
After the nurse has a therapeutic alliance with a pt. taking hypertension medication, the pt. says, "I'm not having as much desire for sex as I did." Nurse-"You need to talk to the doctor about that." More appropriate: It sounds like you're concerned about your lessened desire for sex.
What are the characteristics of Panic Disorder?
Age of onset is late 20's but sometimes seen in adolescents/children Period of intense fear or discomfort
Transference
patient to clinician good or bad.
3. Being judgmental.
"And you'll keep getting sick as long as you don't take your meds like you are supposed to." More appropriate: It looks like this is your third acute admission this year; let's talk about why you keep getting sick.
8. Making stereotyped comments.
"Different stroke for different folks. Get a life. Whatever."
A patient tells the nurse, "I don't want to go on." The patient has reported feeling depressed for 3 weeks and has no hope of the current situation getting better. The appropriate response of the nurse is to say: "Things always get worse before they get better." "Tell me more about how you are feeling." "Have you had thoughts about killing yourself?" "Can't you stop thinking about such morbid things."
"Have you had thoughts about killing yourself?"
A bipolar manic patient cracks jokes before group starts. Appropriate action for the nurse is to: Laugh with the patients. Say, "That's really funny." Say, "That's enough funny stories for right now." Leave the room to withdraw support for the patient's behavior. Say, "I need you to calm down, right now"
"I need you to calm down, right now"
17. Disapproving of the patient.
"I thought you could handle that better." More appropriate: I'm concerned with the way you handled the situation.
7. Assumed understanding.
"I'm dreading my family visiting me today. It's the first time they have seen me since I got sick." Nurse: "You're going to do just fine. You look great." Nurse assumes he/she knows what the pt's concern is. More appropriate: Talk to me about that.
4. Falsely reassuring.
"Of course you're going to get better. You don't need to worry."
16. Challenging the patient.
"Tell me how you know the doctor is lying to you." More appropriate-"What leads you to think the doctor isn.t telling you the truth?"
A patient asks the nurse: "What should I do about the new medication?" The appropriate response of the nurse is to say: "What would you like to do?" "The doctor ordered it, didn't she?" "The medication can cause constipation." "Why don't you take it?"
"What would you like to do?"
5. Defending.
"You couldn't be in a better hospital, or have better doctors and nurses." More appropriate: Tell me about your concerns.
12. Giving advice.
"You should have the surgery." More appropriate: Tell me about your concerns regarding surgery.
10. Belittling the patient.
"You shouldn't feel that way." More appropriate: Tell me more about how you feel.
Four Assessment Factors
*Cognitive responses* - ability to stay on topic, perceive information accurately, thinks logically, making proper decisions *Affective responses* - states is feeling less anxious, states feels better *Behavioral responses* - appears calm, sits still, not restless or agitated, calm facial expression *Physiological*- heart rate back to resting, no numbness and tingling, normal breathing, no nausea, no dizziness, no shortness of breath, sweat free
Cyclothymic Disorder
*For at least 2 years* Numerous episodes that does not meet criteria for hypomanic episode or depressive symptoms Symptoms present half the time Not without symptoms for 2 months Not attributable to substances or another medical condition Cause significant distress or impairment in social, occupational or important area functioning
Antidepressants - MAOI'S
*Isocarboxazid (Marplan), Tranylcypromine (Parnate),* Phenelzine (Nardil), Selegiline (Emsam) Mechanism of action: Inhibits the reuptake of S and NE by destroying monoamine oxidase A and B, at the synapse. Nursing implications - Patient CAN NOT eat foods with *Tyramine* in them. (amino acid which is a natural byproduct of fermentation) May cause *hypertensive crisis.* Not used as often today because of the dietary restrictions
Types of Depressive Disorders
*Major Depressive Disorder (MDD)* - can be single episode or recurrent. Impaired functioning for at least 2 weeks *Persistent Depressive Disorder* - Dysthymia - chronically depressed mood over 2 years. *Premenstrual Dysphoric Disorder* - markedly depressed mood, anxiety, mood swings during the week prior to menses. *Substance/Medication Induced Depressive Disorder* - Depressed mood affecting function associated with intoxication or withdrawal from substances such as Etoh, Amphetamines, Cocaine, etc., medications or toxins. *Depressive Disorder due to Another Medical Condition* - Biochemical influences, Neuroendocrine Disturbances, Electrolyte Disturbances, etc.
What is Milieu Therapy?
-A safe and therapeutic environment -The goal is for patient to gain skills in that environment
What is the philosophical basis of psychiatric nursing?
-All individuals have worth and dignity -All deserve the opportunity to grow -Illness can produce growth -An interpersonal relationship can produce change & growth -People are responsible for their own growth -People continue to grow until they die -People are holistic beings who interact with and are influenced by their environment -People have basic needs (think Maslow) physiological, safety & security love and belonging, self-esteem self-actualization -People can participate in decisions concerning their physical & mental health -Behavior is meaningful & has a purpose -Behavior is composed of perceptions, thoughts, feelings, & actions -Disruptions can occur in any area Mental health is a critical component of comprehensive health services All people have the right to health care
Anticonvulsants Used as Mood Stabilizers
-Carbmazepine (Tegretol) Doses according to blood levels.- liver -Valporic acid/ Depakote Dose: According to blood levels - liver -Lamictal/lamotrigine - kidney -Topamax/topiramate - kidney -Oxcarbazepine (Trileptal) - kidney *Must stop taking if signs of *rash* Stephens-Johnson syndrome *May *decrease* the effectiveness of oral contraceptives *Avoid taking alcohol while on medication *Do not eat grapefruit or drink grapefruit juice *Must taper off of the medication - however if there is a sign of a rash stop immediately!!* *Monitor Liver function
When a patient is diagnosed with a DSM-V Mental Illness. What does that person has significant impairment in?
-Cognition, volition (free will) and/or emotional processes -Judgment -Capacity to recognize reality or control behavior -Ability to function effectively at work, home, or school
Treatment Resistant Major Depression (TRMD)
-Electroconvulsive Therapy (Townsend Ch 21) Thought to increase dopamine, serotonin, and norepinephrine by various mechanisms Safest and most effective treatment for major depression in the elderly *Memory loss side effect -Placement of internal device used for epilepsy- Vagus Nerve Stimulator -Functional EEG- matching of medication based on activity in different parts of brain -Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. TMS is typically used when other depression treatments haven't been effective
What are the side effect associated with - SSRI?
-Much better tolerated than any previous antidepressant medications -Less anticholinergic effects -Minimal cardiovascular effects SSRI's however have significant side effects: -Gastrointestinal side effects (nausea, vomiting, diarrhea) -Sexual dysfunction -Headache -Insomnia -Sedation -Tremor *Give with food so they don't have as bad GI effects*
Antidepressants - SSRI's
-Newer, safer medications that selectively block the reuptake of S at the 5-HT receptor -*Have no effect on NE or DA -Relatively low affinity for histamine, alpha, and muscarinic receptors in brain -Equally efficacious to the TCA's and to each other -Take 1 to 2 weeks to begin to see results -Take 4 to 6 weeks to reach full effect -Metabolized hepatically
Describe some psychosocial skills that help Pts. develop.
-Orientation-Time, place, person, & situation (X 4) -Support pts in expressing themselves -Recreation-Provides constructive outlets/ works around barriers -Industrious activity promotes a sense of accomplishment-OT, MT, ET
What are the goals and outcomes for suicidal ideation?
-Patient will not engage in self-harm each shift -Denies suicidal ideation -Makes a safety plan-will talk with someone before makes a suicidal gesture or attempt -Makes no suicidal gestures or attempts -Takes medication as ordered -Reports feeling safe on unit -Sleeps 6 hours a night -Eats most of meal tray -Verbalizes hope for future
Somatic Symptom Disorder
1 or more somatic symptoms that are distressing & disrupt life Excessive thoughts, feelings, or behaviors related to symptoms or health concerns manifested by at least 1 of the following: Persistent thoughts about the seriousness of symptoms High level of anxiety about health or symptoms Excessive time and energy devoted to symptoms or health concerns Lasts more than 6 months
Which Anxiety Level Is This? 1. A student nurse is taking the NCLEX and focuses only on answering the questions. 2. A student who attends class and pays attention. 3. A patient receives diabetic teaching from the nurse and sees the SQ needle and syringe. She can't think and has a fearful expression on her face. She says, "Can't do that." 4. A patient goes to the ER with chest pain that has been ruled out as a heart attack. He reports he thought he was dying and couldn't concentrate. 5. On the first day of clinical, a nursing student meets a suicidal patient for the first time. 6. Father comes to ER after a daughter has been in a serious MVA. Nurse is providing an update on condition. Father has difficulty understanding what the nurse is saying and the first question he asks is, "Has the insurance company been called?"
1. 2. 3. 4. 5. 6.
Anxiety medications
1. Benzodiazepines (diazepam/valium) 2. Antihistamines: (hydroxyzine/Vistaril, Atarax) & (diphenhydramine/Benadryl) 3. Non-Benzo anti anxiety agents: Buspirone/BuSpar and NDRIs 4. Beta Blockers: Propranolol/Inderal 5. SNRI 6. SSRI 7. Tricyclic antidepressants: Clomipramine/Anafranil
What are two essential components of therapeutic communication?
1. Self-respect of both individuals is preserved 2. Understanding is communicated before offering suggestions or information
What are the nursing Interventions with a Panic Attack?
1:1 Do not leave the pt alone (Emergency situation) Remain calm Decrease environmental stimulation Administer anti-anxiety medications as ordered (benzodiazepines) Provide structure Be direct with instructions Support Pt's intervention plan Non-verbal intervention
Lithium Toxicity *TEST*
2.0 level: Anorexia, Nausea/vomiting, Diarrhea, Coarse hand tremor, Twitching, Lethargy, Hyperactive deep tendon reflexes, Tinnitus, Vertigo, Weakness, Drowsiness Over 2.5: Fever, decrease urine output, decreased BP, irregular pulse, ECG changes, impaired consciousness, seizures, coma and death *Can lead to kidney failure
Suicide Statistics
2nd leading cause of death in teens 11th leading cause of death for adults Varies by ethnic group 2nd leading cause of death for Native Americans 15-34 yo 15% of depressed people complete suicide 90% of people who are suicidal will talk about it Guns are responsible for 50% of completed suicides
Common Obsessions
80%: contamination and safety 20%: hoarding, need for symmetry, and repeating series of numbers, song lyrics, etc. Hoarding is a very primitive response from the basal ganglia (reptilian brain) There are no good days with OCD: it is unrelenting
Anxiety-Textbook Review
8th Edition - Chapter 27 (pp. 578-579) Individual Psychotherapy Cognitive Therapy Behavior Therapy Implosion Therapy Eye Movement Desensitization and Reprocessing (EMDR) http://www.emdr.com/general-information/what-is-emdr.html Group Therapy Psychopharmacology
Phobia - Textbook Review
8th Edition - Chapter 27 (pp. 532-537) Review: Predisposing Factors: Psychoanalytic Theory Learning Theory Cognitive Theory Biological Aspects
Obsessive Compulsive Disorder: Textbook Review
8th Edition - Chapter 27 (pp. 539-540) Predisposing Factors Psychoanalytic Theory Learning Theory Biological Aspects
Trauma and Stressor - Related Disorders - Chapter review
8th Edition - Chapter 28 Post-Traumatic Stress Disorder Acute Stress Disorder Adjustment Disorder
Posttraumatic Stress Disorder (PTSD) - Textbook Review
8th Edition - Chapter 28 (pp. 561-564) Psychological Theory Learning Theory Cognitive Theory Biological Aspects
Psychiatric Nursing
A branch of nursing that deals with people who need assistance with coping (ADN & BSN) Clinical Specialists, NPs & private practice Masters- and DNP- prepared ANA has established Scope and Standards of Practice for this specialty of nursing - mental health nursing
Definition of Mental Disorder
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities
Indirect question
A question for which the patient decides whether to answer. "I wonder if there is a relationship between not taking your medications and how often you end up in the emergency room."
Closed-ended question
A question that is usually answered with one or two words. "How many children do you have?"
Open-ended question
A question that requires the patient to answer with more than one word and with an explanation. "What would you like to talk about today?"
Direct question
A question the patient feels compelled to answer. "What happened the last time you were admitted to the hospital?"
2. Examining alternatives:
Alternative options, solutions or behavior is examined, especially for patients who thinks they have lost all options. The goal is to help them see solutions to their problems. Call me when you have these feelings? Depression?
*Cognitive* Symptoms of Depression.
Ambivalence Confusion, uncertainty Unable to concentrate Indecisiveness/loss of motivation Loss of interest Pessimism & self- depreciation Self-destructive thoughts Suicidal ideation
Pharmacotherapy for depression?
Antidepressant therapy attempts to increase neurotransmitters in the brain (NE, S, DA) Classes of antidepressants Monoamine oxidase inhibitors (MAOI's) Tricyclic antidepressants (TCA's) Selective Serotonin Reuptake Inhibitors (SSRI's) Serotinin/Norepinephrine Reuptake Inhibitors (SNRI's) Miscellaneous mirtazapine bupropion - (Wellbutrin) nefazodone
What is Severe Anxiety?
Anxiety becomes overwhelming Greatly diminished perceptual field May focus on one detail or extraneous details Limited attention span Difficulty completing simple tasks Physical: headache, palpitations, insomnia Emotional: Dread and horror Behavior aimed at relieving anxiety Ability to solve problems compromised
What is Moderate Anxiety?
Anxiety increases Diminished perceptual field Less alert to events in environment Decreased attention span & concentration May need direction to attend to needs and with problem-solving Increased restlessness and muscle tension
What are the interventions for suicidal ideation?
Ask directly about suicidality Assess for plan & lethality Document patient safety and action taken Unit & patient searches for safe environment Remove harmful objects Each facility has specific protocols for suicide assessment, prevention, and monitoring. Suicide precautions 15 min, 30 min. and hourly checks 72 hour holds Monitor patient closely 1:1 or sitter for extreme suicidality Line of site Arms length Watch for elopement
What does Milieu management look like?
Ask people to lower voice Turn down radios & TVs Ask people to move to places to visit Ask patients to go to their rooms Turn off lights Offer productive activities Play relaxing music, video Select wall colors Select soft lights Offer prn medication as needed Use distraction 1:1's Use de-escalation Containment (quiet room, seclusion, restraint) as last choice
9. Sharing perceptions
Asking the patient verify the nurse's perception/understanding of that he/she is thinking and/ or feeling. "You seem sad all of a sudden." "While you are looking at me, I sense your mind is someplace else."
Assess Suicidal Ideation
Assess for suicidal thoughts "Are you thinking about killing yourself?" "Have you thought about hurting yourself?" "When people are as upset as you seem to be, they sometimes wish they were dead. I'm wondering if you are thinking about harming yourself?" Assess for presence of a plan & lethality Assess for safety plan- "Are you thinking about hurting yourself right now? If that changes, will you promise to talk with someone before you make an attempt?" Nurse's role in documentation Assess overt/covert cues
Projection
Attributing one's thoughts and emotions to another.
Defense Mechanisms Denial
Avoiding unpleasant realities by ignoring or refusing to recognize them. Driving
What does it mean to be Passive?
Avoids expressing feelings, opinions, protecting rights, meeting, needs. Soft-spoken or non-verbal. "I'm not okay, you're okay"
A patient diagnosed with severe depression exhibits psychomotor retardation and a sense of worthlessness manifested in poor personal hygiene with noticeable body odor and halitosis at the time of admission. The patient flatly refuses to shower, stating, "I can't." The nurse should: A. Not force the issue before a nurse-patient relationship has been established. B. Matter-of-factly help the patient shower and dress in clean clothes. C. State that the patient will be required to shower the following morning. D. Explain that other patients will respond negatively to someone with poor hygiene.
B. Matter-of-factly help the patient shower and dress in clean clothes.
A patient is extremely hyperactive and distractible. The patient rarely sleeps and eats little resulting in a loss of 6 pounds since admission 3 days ago. Which interventions should be considered a priority when developing a care plan for the patient's care? A. Require that the patient remain in the dining room for at least 15 minutes per meal. B. Offer high-calorie "portable" finger foods and nutritionally fortified fluids hourly. C. Record all food and fluid intake. D. Weigh the patient daily.
B. Offer high-calorie "portable" finger foods and nutritionally fortified fluids hourly.
A patient with depression has recently lost 8 pounds. In spite of regular encouragement by a nurse, after only a few bites the patient refuses to eat more, saying, "I'm full. All that food makes me sick just to look at it." The most effective way to increase the patient's dietary intake would be to: A. Provide a high-calorie liquid diet. B. Serve six small, calorie-dense meals daily. C. Take the patient to the hospital cafeteria for meals. D. Have the patient's family bring food from home.
B. Serve six small, calorie-dense meals daily. bring back to normalcy
10. Externalization of self-worth:
Basing one's value on other's approval. Ex. "If my patient does not like me I must not be a good nurse."
Empathetic Responses
Be aware of what patients express and do not express
Antidepressants - Buproprion
Brand Name: Wellbutrin, Wellbutrin SR, Wellbutrin XL Exact mechanism of action unknown NE DA *Only antidepressant with effects on DA* Also used for smoking cessation (Zyban) Activating, give last dose by 1600 Has a high occurrence of *seizures* at high doses (above recommended dosage range) Considered less potent than other antidepressants
Ineffective coping R/T depression
Behavioral responses- Suicide gestures & attempts Self-mutilation Decreased ADL's Not eating Not sleeping well Cognitive responses- Distorted negative thoughts Poor memory Slow thinking process Difficulty concentrating Affective responses- Guilt Worthless Helpless and Hopeless Unhappy Depressed
7. Mind Reading:
Believing one knows what another is thinking without checking it out. Ex. "The patient thinks I'm stupid because I didn't know what a Business Plan was."
______________ for panic attack
Benzodiazepine
What are the *medications* used for *anxiety*?
Benzodiazepines - Xanax, Ativan, Klonopin - usually short term or PRN basis Buspirone (BuSpar) - no grapefruit! SSRIs Velafaxine (Effexor) Duloxetine (Cymbalta) Escitalopram (Lexapro) Propranolol (Inderal) (beta blocker)
Anxiolytics or Anti-anxiety medication
Benzodiazepines - act throughout the CNS Brand Name: Xanax, Ativan, Klonopin, Valium Mechanism of action *GABA* - enhancement - blocks rapid release of stress hormones Some effects on the limbic system Muscle relaxation, sedative, anxiolytic, and anticonvulsant effects Nystagmus, ataxia, agitation are other side effects
Mood Disorders
Bipolar disorder Mania and Depression Cyclothymia
Antidepressants - fluoxetine
Brand name: Prozac *Advantages:* Longest half life (t1/2) of all the SSRI's, 4-6 days Allows for once weekly dosing Minimal fluctuation in blood levels from a missed dose Available in generic form Activating *Disadvantages:* Has significant amount of drug interactions due to it's ability to inhibit liver enzymes Long half life More side effects than newer SSRI's
Antidepressants - mirtazapine
Brand name: Remeron, Remeron Soltab Results in increased release of NE and S -Stimulates appetite Very sedating at lower doses (15mg or less) May be initiated at higher doses to avoid sedation (30 mg) Side effects: sedation, weight gain, lightheadedness, nausea, dry mouth
Which of the following is a nursing action that will help the nurse establish trust with patients? Confront inconsistent behavior exhibited by the patient. Turn off heavy metal music in the dayroom. Bring a sandwich to the patient in 30 minutes as promised. Insist the patient call the nurse by his/her last name.
Bring a sandwich to the patient in 30 minutes as promised.
Which of the following is a boundary violation of the nurse-patient relationship? The nurse: Offers the patient orange juice. Asks the patient what day it is. Brings the patient a picture of her/his family to keep. Wears a nametag to indentify himself/herself to the patient.
Brings the patient a picture of her/his family to keep.
A patient displaying symptoms of mania has been in constant motion for 1 hour, running in the halls, exercising vigorously, and pushing furniture around the dayroom. Finally, he approaches a frail man and orders him to do push-ups or be pushed down. The man looks fearful but gets down on the floor. The nurse should: A. Obtain an order for seclusion. B. Forbid the threatening of other patients. C. Gather several staff members to provide an escort to take the patient with mania to his room. D. Distract the patient with mania while allowing the older man to do a few push-ups.
C. Gather several staff members to provide an escort to take the patient with mania to his room.
Exam Q: The patient is having a panic attack. How will the nurse know that the patient is feeling better? A. Pts lower leg paralysis has resolved and headache has improved. B. Patient is cooperative and confrontational C. Patient has relaxed facial expression and states, "I'm not as scared." D. Patient is able to laugh at past mistakes.
C. Patient has relaxed facial expression and states, "I'm not as scared."
Techniques of Communication
Develop rapport Develop trust Use facilitators Use space effectively Use of listening skills Use open-ended questions Use of humor (careful) Use of silence - is it? Thoughtful? Resistive? Can they not hear?
Barriers to communication 1. Failure to listen.
Checking emails, texts, your watch, eyes wandering
A patient is taking a monoamine Oxidase inhibitor. Which of the following foods would the nurse remove from the lunch tray before serving to the patient? Grapefruit juice Cheese enchiladas Fish sandwich Vegetable soup
Cheese enchiladas
Exceptions where you CAN release information
Child abuse Elder abuse Medical emergency Subpoena from a court Duty to warn
Choosing a Psychiatric Medication
Choosing psychiatric medications is a patient specific decision Factors influencing medication selection Past medication history What have they tried in the past? What did they do well on in the past? What didn't they do well on in the past? Family history Has any related family member ever been treated successfully with psychiatric medications? Risk Factors Family history or personal history of diabetes Hyperlipidemia Cardiac risk factors Social history Is the patient compliant with taking medication and follow up visits? What can the patient afford? Patient specific factors Patient symptoms Negative symptoms Sedation Insomnia Other psychiatric illnesses
Nurses must accurately interpret patient's responses by?
Clarification Restatement Convey interest & concern
Countertransference
Clinician to patient transfer of relationship. Nurses feelings on patient. Good or bad.
Risk for self-directed violence R/T depression AEB:
Cognitive Reports suicidal ideation Presence of a plan and lethal method Affective Hopelessness, helplessness, worthlessness, guilt Behavior History of suicidal gestures and attempts Diagnosis of depression
What are the desired Outcomes for anxiety? How do we know the patient is getting better?
Cognitive responses- ability to stay on topic, perceive information accurately, thinks logically, making proper decisions Affective responses- states is feeling less anxious, states feels better Behavioral responses- appears calm, sits still, not restless or agitated, calm facial expression Physiological- heart rate back to resting, no numbness and tingling, normal breathing, no nausea, no dizziness, no shortness of breath, sweat free
Ineffective coping R/T manic episode
Cognitive responses-poor concentration, distracted easily, flight of ideas, thoughts racing, delusions Affective responses-expanded mood, inflated self- esteem, feels good Behavioral responses-decreased sleep, distractibility, pressured speech, decreased nutrition, agitation, sexual indiscretions, buying sprees
Nursing Interventions for Hoarding
Cognitive-behavioral strategies Help make decisions about what to let go of and what to keep Start small, an item at a time and work up Establish some guidelines, "If you haven't worn it or used it in 1 year, give it away." May need a professional house unclutter team Self-Help Groups Group Therapy
Nursing Interventions for Body Dysmorphic Disorder
Cognitive-behavioral strategies for distorted thinking Work on healthy body image Work on self-esteem issues Group Therapy
Which of the following behavior exhibited by patients might indicate suicidal ideation? The patient: Works on a model of a car during OT Writes a poem for a grandchild about life Completes a will and sends the dog to a kennel Contemplates the meaning of life in a journal
Completes a will and sends the dog to a kennel
What are the nursing diagnoses for generalized anxiety disorder & other anxiety disorders?
Coping, Ineffective Fear related to Self-esteem, Situational Low Social Interaction, Impaired Impaired adjustment Tissue Perfusion, Ineffective
Nursing Diagnosis & Goal with Obsessive Compulsive Disorder
Coping, Ineffective related to obsessive and compulsive behavior or rituals Goal: Pt. will show improvement in coping with obsessions and demonstrate less compulsive behavior by discharge.
Nursing Diagnosis & Goal - Posttraumatic Stress Disorder (PTSD)
Coping, Ineffective related to survival of traumatic event Goal: Pt. will show improvement in coping & adjustment with traumatic event by discharge
Protective Factors
Counseling & treatment (psychiatric & physical disorders and substance abuse) Support groups Access to help: 1-800-SUICIDE Restricted access to certain methods Problem-solving, conflict resolution and nonviolent dispute resolution Cultural and religious beliefs Sense of hope when trouble comes
A nurse gets angry with a patient who has diabetes & will not eat properly which is similar behavior to his/her father. What best explains the nurse's reaction? A. Incongruence B. Trust issues C. Countertransference D. Boundary violation
Countertransference
Nursing Interventions Acute Stress Disorder?
Critical incident debriefing Cognitive-behavioral strategies Discuss risk taking behavior Anger management Stress management Sleep interventions Teach coping skills Counseling & therapy Cognitive-behavioral strategies
What is the criteria for Involuntary admission?
Danger to self Danger others Grave disability - the way you feel or think indicated that you are not able to take care of yourself
What are *effective* coping strategies for anxiety?
Defense mechanisms Relaxation Meditation Exercise Nutrition Sleep Hobbies Pets Medication Others
Describe a *maladaptive* grief reaction.
Delayed grief Absence of emotions Can last for years Distorted grief/ complicated grief Illness Anger or hostility Self-destructive behavior
SSRI's are used to treat?
Depression Anxiety disorders Obsessive-compulsive disorder Eating disorders
Confrontation DESC Script
Describe the situation Express feelings Specify what want Consequences
What is Hoarding Disorder?
Difficulty parting with possessions Need to save Distress when discarding Accumulation that congests and clutters active living areas Compromises intended use for living areas If uncluttered, a third party has intervened Impairment in social, occupational, or other functioning
5. Reflection
Directing back to the patient, expressed ideas feelings, questions or content, usually using the patient's own words. "You're feeling tense and anxious and it is related to a conversation you had last night with your spouse."
6. Humor
Discharging energy through comic enjoyment of the imperfect. "That gives a whole new meaning to the word "nervous.."
Dissociative Identity Disorder
Disruption of identity by existence of two or more personalities in a single individual. (Multiple personalities) Alterations in affect, behavior, consciousness, memory, perceptions, cognition, and/or sensory-motor function Gaps in recall of everyday events, personal info, and/or traumatic events to great to be ordinary forgetting
Dissociative Disorders
Dissociation - Splitting off clusters of mental contents from conscious awareness Dissociative amnesia - Inability to recall information. Dissociative Identity Disorder - Presence of 2 or more distinct personalities. *Think of "the house"*
What are Appropriate Boundaries?
Don't go into patient rooms Clothing- dress appropriately Language- address patient with what he/she wishes to be called & age appropriate, tone, choice of words Appropriate self-disclosure Appropriate physical contact Honor appointments, time limitations Maintain professional role and standards of care Maintain confidentiality Don't engage in social relationships outside clinical Don't take over the problem from the patient. Don't do anything for a patient can do for self. Discussion Question: What does the nurse do about patients who make bad choices?
Examples of Cognitive Distortions 1. Overgeneralization
Draws conclusions about things based on a single event. Ex. "She turned me down for a date. I will never get a date; no one will ever love me."
Which of the following would a nurse include in a teaching plan for a patient who is taking lithium? Monitor blood glucose Eat potassium rich foods Drink a lot of fluid Get up slowly from sitting to standing
Drink a lot of fluid
Mania
Elevated mood Decreased sleep Pressured speech - can't get words out fast enough Flight of ideas Thoughts racing Agitation, excessive involvement in pleasurable activity -sexual indiscretions -Foolish business deals -Spending sprees
Describe a Manic Episode
Elevated, expansive or irritable mood Increased goal-directed activity/energy *Lasts at least 1 week* Impairment in social or occupational functioning Or necessitate hospitalization to prevent harm to self or others Or there are psychotic features 3 or more of: Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas Distractibility Increase in goal-directed activity (socially, at work, sexually) or psychomotor agitation Excessive involvement in activities with painful consequences - (buying sprees, sexual indiscretions, or foolish business investments)
4. Reframing:
Encourages patients to look at other aspects of situations from a different perspective. The goal is to change a person's perception of a situation or behavior. Example: Pt. "I'm so stupid when I do things like that." Nurse: "What you did was not the best you could do. It doesn't make you stupid." Other examples: The loss of a job can be a catastrophe or reframed as an opportunity for career development. A chronically ill patient feels good one day and not the next and concludes he/she will never get well or can be reframe: there are good days and bad days.
2. Broad openings
Encouraging patients to select the topic for discussion. "What are you thinking about? What would you like to talk about today?"
8. Magnification/Minimization:
Exaggerating or minimizing an event's importance. Ex. "I've given the medicine 10 minutes late. I'm going to get in a lot of trouble."
What are the characteristics of a generalized anxiety disorder (GAD)?
Excessive anxiety & worry about many events like work/school At least 6 months Difficult to control worry Impairment in social, occupational functioning or other important areas of functioning
What is Social Anxiety Disorder?
Excessive fear or situation where a person might do something embarrassing or evaluated negatively by others. "Can be related to underlying substance abuse."
Specific phobia
Excessive or unreasonable fear when in the presence of or anticipation of a specific object or situation.
What is Acute Stress Disorder?
Exposure to actual or threatened death, serious injury or sexual violation Direct experience, witnessing, learning event occurred to family or friend; the event must have been violent or accidental Presence of 9 or more symptoms from any of 5 categories Intrusion symptoms Intrusive thoughts; in children through repetitive play Distressing dreams Dissociative reactions (flashbacks) Distress in response to cues/ reminders about traumatic event Negative mood- inability to experience positive emotions Dissociative symptoms-altered sense of reality of surroundings or self (being in a daze, time slowing) Avoidance symptoms- Efforts to avoid memories or reminders of traumatic event Arousal symptoms- Sleep disturbances Irritable behavior or angry outbursts with little provocation Hypervigilance Problems with concentration Exaggerated startle reflex
6. Labeling/Mislabeling:
Extreme form of overgeneralization. Instead of describing the error, one attaches a negative label to self. Ex. "I missed that basketball shot. I'm a total loser."
Factitious Disorder Imposed on Another *TEST*
Falsification of physical or psychological signs/symptoms or inducing injury or disease in another Individual presents another individual (victim) to others as ill, impaired, or injured Deceptive behavior is present Children are often removed from parents who are diagnosed with this. The perpetrator gets the diagnosis.
Factitious Disorder Imposed on Self *TEST*
Falsification of physical or psychological signs/symptoms or induction of injury or disease Presents self to others as ill, impaired or injured Deceptive behavior present new name for munchausen
How is anxiety different from fear?
Fear is a cognitive process and anxiety is *emotional* process
Agoraphobia
Fear of being in places or situations from which escape might be difficult or help might not be available.
What are the characteristics of a Specific Phobia?
Fear or anxiety about a specific object or situation In children: manifests as crying, tantrums, freezing, or clinging Phobic object provokes immediate fear/anxiety Active avoidance of phobic object Fear/anxiety out of proportion to danger posed Lasts for 6 months Produces impairment in functioning
Social Anxiety Disorder
Fear/anxiety about situations when exposed to possible scrutiny by others In children may manifest as: Crying, tantrums, freezing, clinging, shrinking, or failing to speak; must occur in peer situations as well as with adults Actions will be negatively evaluated such as be humiliating or embarrassing and will lead to rejection or offend others Social situations are endured or avoided Fear/anxiety is out of proportion to situation
Key terms for anxiety disorders
Generalized Anxiety Disorder Social Anxiety Disorder Panic Disorder Specific Phobias Body Dysmorphic Disorder Post Traumatic Stress Disorder
What neurotransmitters are involved in the regulation of anxiety?
GABA Serotonin Norepinephrine
Anxiety disorders
GAD - Generalized anxiety disorder Panic Phobias OCD PTSD Somatoform Dissociative
What are *effective* responses of the nurse with therapeutic communication?
Genuineness and respect Empathy -feeling with the patient Unconditional positive regard Ethical conduct Confidentiality In control of own life and emotions Practice based on evidence and standards
5. Selective Abstraction:
Getting caught up in details and not considering all the relevant information. Ex. "The student gets a "B" on an exam and ignores the compliments of the patient, family and teacher that he/she has done a great job."
What is a therapeutic relationship?
Goal directed Present oriented Disclosure to help pt Knowledge & skill Client-directed
Greif
Grief reaction- Normal reaction to loss Related to significant loss Focus on present feelings & needs Adjustment to the loss is the outcome Grief reaction can become maladaptive if unresolved: Depression can become a distorted grief reaction. Grief can become pathological grief reaction
What are some Obsessive Compulsive Disorder symptoms?
Has obsessions: persistent thoughts, unwanted & intrusive Produces distress Has compulsions: repetitive behaviors Hand washing, ordering, checking, praying, counting, repeating words silently Aimed at reducing stress Time consuming- more than 1 hour per day Obsessions and compulsions are not linked in realistic way Specify if: With good or fair insight Recognizes O/C probably not true With poor insight Thinks O/C probably true With absent insight-convinced is true
What are behavioral disorders?
Has to do with how you act in situations -personality disorders -substance abuse
What are mood disorders?
Has to do with how you feel in situations or in life -depression -anxiety
What is Somatic Symptom Disorder?
Have high levels of worry about having an illness. Experience somatic symptoms that generally does not signify serious disease. (75% of these folks were previously dx with hypochondriasis)
What are *ineffective* responses of the nurse?
Inappropriate self-disclosure Dominating the conversation Judging the patient Asking, Why? Telling the patient what to do Changing the subject Countertransference Social rather than therapeutic relationship
Suppression
Intentional exclusion of a painful or conflicted thought from awareness.
What are some student nurse concerns?
Is self-conscious Is afraid of rejection Is afraid of patients Doubts own skill Fearful of physical danger Feels insecure Has prior bad experience Afraid of newness of experience Psychiatric patients stereotyped as different What if patient does not want to talk? Cannot make a difference Worry about hurting patients more What will I do without beds to make?
What are the Nursing Intervention for Severe Anxiety & panic?
Isolate patient Remain calm and stay with patient Keep patient safe Decrease environmental stimulation Administer medication- Benzodiazepine for panic attack Provide structure Be directive in instructions Nonverbal intervention
What are the Nursing Interventions for Anxiety?
Keep patient safe Provide a quiet environment Remain calm Encourage verbalization, 1:1 Use distraction Provide information Use of cognitive strategies Discuss potential causes-precipitants Ask what they usually do to cope Assist with problem-solving Administer PRN medication, if needed - *Benzodiazepines*
How can you increase self awareness of the nurse?
Known to us and not others Others know and we do not Blind spots Listening to self & own reactions What pushes my buttons? Deal with conflict Assess own strengths Work on limitations Seek feedback from others Address internal feelings toward patients Analyze own verbal & nonverbal communication
11. Silence
Lack of verbal communication for a therapeutic reason. Ex: Sitting silently with a patient communicating interest and involvement.
What are some Non-Beneficial Responses of Some Nurses?
Lacks empathy Feels depressed after talking with patients Careless with contract Late, runs over Drowsy during 1:1 Anger at patient's lack of change/progress Argues with patients Encourages dependency Helps patients in matters not related to goals Guilt related to patients Defends nursing interventions to others Inappropriate self-disclosure
Mood stabilizers
Lithium Anticonvulsants: Carbamazepine (Tegretal & Equetro) - dosed according to blood levels Valporic acid/Depakote- dosed according to blood levels Lamictal/Lamotrigine - no blood work needed Topamax/topiramate - no blood work needed Oscarbazepine (Trileptal) - no blood work needed Gabapentin (Neurontin) - no blood work needed Antipsychotics: Abilify/aripiprazole Lurasidone (Latuda)
Bipolar Medications - Mood Stabilizers - Lithium *TEST*
Lithium (Eskalith, Lithobid and Lithium citrate) Active phase daily dosage is 300-600 mg., 2 or 3 times a day. Therapeutic level considered *0.8-1.4 µ* (mEq/L) (loading dose). Toxic level is considered above *1.5 µ* (mEq/L). Note: small window between therapeutic and toxic blood levels. Maintenance dose depends on symptom control for the client. *Need periodic monitoring of renal and thyroid functioning.* *Does come in a liquid!* Patient Education Is Vital - Teach-closeness of therapeutic and toxic blood level. If have symptoms of toxicity, stop the medication and see the doctor immediately. -Adequate fluid intake daily. Fluid intake of 1500-3000 cc/day -Diet should include adequate salt -*Diuretics are contraindicated.
What is a Conversion Disorder?
Loss or change in body functioning resulting from psychological conflict. Affects the voluntary motor or sensory function. Is a mental condition in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation
What are common Medications used for Obsessive Compulsive Disorder?
Luvox (Fluvoxamine) SSRI Anafranil (Clomipramine) Tricyclic Zoloft (Serraline) SSRI Prozac (Floxetine) SSRI Paxil (Paroxetine) SSRI
What is a *mental health hold* called?
M-1 We have *72 hours* to make a decision about your treatment
What are the Levels of Anxiety?
MILD Moderate Anxiety Severe Anxiety Panic Anxiety
What are common medications for social anxiety?
Medications SSRIs Medications may or may not be as effective Social Phobia SSRIs Propranolol/Inderal (beta blocker) Some Benzodiazepines
What is the role of the nurse in the milieu?
Monitor the environment for: Noise/excessive stimulation Music Talking and laughing Activities Light Feel (tension, hostility, safe, comfortable, calm)
Cyclothymia
Mood disturbances of hypomania and depression not as severe as bipolar disorder (over 2 years)
Bipolar Disorder
Mood swings from profound depression to extreme euphoria with periods of normalcy between.
Hypomania
Mood swings mania/depression Not severe enough to cause hospitalization
4. Catastrophizing:
Negative thinking. Thinking the worst things will happen or the situation is worse than it is. Ex. "What if that happens to me? What if tragedy strikes?"
What is a social relationship?
No goals set Past & future Mutual disclosure No skill required Mutual sharing
Other medication used for anxiety
Non-benzodiazepine - *Buspirone (BUSPAR)* Used for GAD - especially with patient with COPD Stimulates release of serotonin May take 2-3 weeks for therapeutic effects *CAN NOT Eat Grapefruit or Grapefruit juice when taking Buspar* Dosage: 45mg-60mg/day Antihistamines - useful in children because of the sedation properties Hydroxyzine (Vistaril, Atarax) Diphenhydramine (Benadryl)
Principles of Communication
Nonverbal Congruence - everything matches Incongruence - things don't match up How often do we not communicate? How can we improve communication? Clarification Restatement Listening
What is Mild Anxiety?
Not usually a problem Results from day-to-day living Sharpens the senses Motivates people to action Increases the perceptual field Results in heightened awareness Enhances learning Promotes functioning at optimum level
Nurse's Expectations and Patient Behaviors
Nurses: Expect to form therapeutic relationships Expect patients to show improvement May feel helpless May pick up patient's feelings Patients: Do not respond Tell nurses to leave alone Acts aloof & cold May not improve May shows contempt for the nurse May be irritable and angry & push nurse away
Obsessive Compulsive Disorder (OCD)
OCD - Reoccurring obsessions or compulsions that are severe enough and time consuming enough to cause marked distress or significant impairment. Compulsions: Washing, cleaning, counting, checking, requesting or demanding assurances, repeating actions, and ordering All surrounding *anxiety* and how they try and make themselves feel better. *Look at rituals
What are different types of Obsessive Compulsive Disorders?
Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair-pulling disorder) Excoriation (Skin-picking) Substance/medication-induced obsessive-compulsive Body focused repetitive behaviors *Talk about what leads to the impaired functioning
Antidepressants - TCA's
Older class of medications that work on both S (5-HT) and NE reuptake receptors Blocking these reuptake receptors in the brain leads to increased levels of S and NE All are equally efficacious in treating depression Block many other receptors in the brain causing numerous side effects The "INE" drugs.
Who are Psychiatric Patients?
Ordinary people with problems People: with thought disorders who have experienced some sort of trauma who come from dysfunctional families who abuse or are addicted to substances who have no support/resources in crisis: depression, anxiety, OCD, phobic
Posttraumatic Stress Disorder (PTSD)
PTSD- results from exposure to an extreme traumatic event involving threat to physical integrity. May result from learning about unexpected or violent death, serious harm, or threat of death or injury. Intrusion symptoms (1 or more) (DSM-5) Intrusive thoughts; in children have repetitive play Dreams, nightmares; in children frightening dream Dissociative reactions (flashbacks); Kids reenact in play Distress at exposure to cues about trauma Physiological reactions to cues about trauma Avoidance of stimuli associated with traumatic event Memories, thoughts, feelings External reminders, (people, places, conversations) Negative alterations in cognition and mood Inability to recall aspects of traumatic event due to dissociative amnesia - self blame Negative beliefs or expectations of oneself, others or world, "I am bad." "No one can be trusted." Distorted thoughts about the cause or consequences of the traumatic event; leads to blaming self Negative emotional states (fear, horror, anger, guilt, shame) Decreased interest in participating in significant activities Feeling detached/estranged from others Inability to experience positive emotions (Happiness, satisfaction, or loving feelings) Alterations in arousal and reactivity associated with traumatic event Irritable behavior and angry outbursts with little provocation Reckless or self-destructive behavior Hypervigilance Exaggerated startle reflex Problems with concentration Sleep disturbances Duration of 1 month Impairment in social, occupational or other important functioning
With a panic disorder, 4 or more of the following: (Develop abruptly & peak within 10 minutes).
Palpitations Pounding heart or rapid heart rate Sweating Trembling or shaking Shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy Unsteady, lightheaded or faint Derealization (feelings of unreality) Depersonalization (being detached from oneself) Fear of dying Numbness or tingling sensations
Goal for Depression
Patient will show improvement in depression by shift/discharge: Outcomes would include Verbalizes improved mood Increases activity, especially self-care activities (ADLs) Reports sleeping 7-8 hours per night Reports feels safe on the unit Denies suicidal ideation, no gestures or attempts Reports eating normally, weight loss returns Engages in spontaneous interaction with others Decreased self-depreciating statements
18. Asking "Why" questions.
Patients can describe circumstances and the situation and often cannot tell you why. Often elicits a defensive response.
Describe a Hypomanic Episode
Persistently elevated, expansive or irritable mood Increased activity or energy Lasts at least 4 days Change in functioning uncharacteristic of individual observed by others Not severe enough to cause impaired social or occupational functioning Does not necessitate hospitalization Not attributed to substances or medical disorder 3 or more of: Inflated self-esteem or grandiosity Decreased sleep More talkative than usual or pressure to keep talking Flight of ideas Distractibility Increase in goal-directed activities (socially, at work, or sexually) Excessive involvement in activities with painful consequences (buying sprees, sexual indiscretions, or foolish business investments
Mental Status Exam (MSE)
Review MSE Chapter 9 in Townsend Review documented mental status exam for a patient in clinical
What are the phases of the Nurse-patient Relationship?
Pre-orientation phase Introductory/Orientation phase Working phase Termination phase
Where you might see Depressive Disorders
Premenstrual Dysphoric Disorder Seen in Women's Health Clinics Substance/Medication-Induced Depressive Disorder Seen in Chemical Dependency Treatment Centers Depressive Disorder Due To Another Medical Condition Seen in health care settings
What is Illness Anxiety Disorder?
Preoccupation with having or acquiring a serious, undiagnosed medical illness.
What is and Illness Anxiety Disorder?
Preoccupation with having or getting a serious illness Somatic symptoms not present or if present are mild If another medical condition is present, and high risk for developing a medical condition (strong family history), preoccupation is excessive High level of anxiety about health; alarmed about health status Performs excessive health-related behaviors (checks for signs of illness); or exhibits maladaptive avoidance (avoids doctor appointments/hospitals) Illness preoccupation for at least 6 months Concerns about undiagnosed disease do not respond to appropriate medical reassurance or negative diagnostic tests Illness becomes a central feature of their identity and self-image Illness is a frequent topic of conversation Repeated check themselves (looks at throat in mirror) Seeks constant reassurance from others that can lead to interpersonal conflicts
What is Body Dysmorphic Disorder
Preoccupation with perceived defect or flaw in appearance not observed by others or that appear slight At some point, person has performed repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance seeking, or mental acts (compare appearance with that of others) Preoccupation causes impairment in social/occupational functioning and other functioning Appearance preoccupation with body fat or weight meet diagnostic criteria for eating disorder
Art of Nursing
Presence Caring Compassion Advocacy
12. Suggesting
Presenting alternatives for patients to consider. "Have you considered approaching your son in a different way? For example, you're assuming he is angry with you. Perhaps you could ask him if he is angry with you or with something else."
Describe the Pre-orientation phase.
Prior to working with patient Explore past experiences and own feelings Explore fears Assess personal strengths & limitations Assess communication knowledge & skills Explore own values Determine how to handle requests for personal information boundary issues
What to do when you know what the problem is?
Problem-solving -Define problem When and how? -Propose solutions or alternatives -Pros and cons -Select solution -Evaluate application of solution -Make changes
13. Making generalizations.
Pt "I'm going home today nurse." Nurse-"That's good!" More appropriate response: How do you feel about going home?
19. Failure to break a non-therapeutic silence.
Pt. is using a resistant silence and nurse allows it. More appropriate: It seems you are not ready to talk right now. I can sit here with you for a few minutes if you would like.
14. Changing the subject.
Pt: "I'm concerned about my husband's lack of attention to me when I come home from work." Nurse -"What's your husband like?" More appropriate: Tell me about that. Or You're telling me your husband isn't paying attention to you when you come home from work?
3. Restating
Repeating the main thought expressed by the patient. Purpose: To make sure the nurse accurately hears the patient. "You said your father left you when you were 16." "What I hear you saying is you're angry your family hasn't visited today?"
What are common Roadblocks to Communication (Patient)?
Resistances in Patients Keeping pertinent information to self Symptoms get worse Devaluating self Forced hospitalization with a short lived recovery Nothing on the mind Late for sessions, cancels Acting out /irrational behavior Superficial talk Verbalizes understanding but continues destructive behavior Contempt for normality Transference - patient transfers feelings to nurse (relationship or experience)
Anxiety associated with 3 of following.
Restlessness/keyed up Easily fatigued Irritability Muscle tension Sleep disturbances Impairment in social and/or occupational functioning or impairment in ADL's
Regression
Returning to a former level of development.
Displacement
Shift of emotion from a person or place to another person or object.
Mental Illness and Mental Health is on a continuum
Role of Biology and Genetics Balance between: -stressors -coping strategies -defense mechanisms Supportive people, communities
Describe an *adaptive* grief reaction.
Runs a consistent course Related to significance of loss Abruptness. Preparedness Culturally based Adjustment is the outcome
Nursing Interventions - Posttraumatic Stress Disorder (PTSD)
Safe environment 1:1 trusting relationship Cognitive restructuring Critical incident debriefing Discuss risk taking behavior Anger management Counseling & therapy EMDR (therapist) Eye Moverment Desensitization and reprocessing , EFT (em. freedom technique: tapping), Cognitive-behavioral strategies Stress management Sleep hygiene Teach coping skills
Assertiveness Skills
Sandwich technique Good, bad, good Be assertive Fogging- Agree with what can
Dissociation
Separation of mental or behavioral processes from the rest of consciousness.
Nursing *Interventions* with Obsessive Compulsive Disorder
Set limits on compulsive acts (rituals) Do not take away rituals (until something has replaced them) Cognitive behavioral strategies involving exposure & ritual prevention Systematic Desensitization Administer medications
What are Nursing Interventions for Somatic Symptom Disorder?
Set limits on somatic complaints Cognitive-behavioral strategies to reshape distorted thinking about illness Reward interaction that is not focused on symptoms Withdrawal attention when making physical complaints Cognitive behavioral strategies Help them get a life.
Nursing Interventions for Illness Anxiety Disorder?
Set limits on somatic complaints Cognitive-behavioral strategies to reshape thinking Reward interaction that is not focused on symptoms Withdrawal attention when talking about health status Cognitive behavioral strategies Help them get a life.
9. Inappropriate timing.
Sharing information or observations before the client is ready to hear it.
Mental Health Law 27-65
Short Term Certification-90 days (3 months) Long Term Certification- Not to exceed 6 months Emergency Medication- up to 10 days Court-Ordered Medications Voluntary Admissions
A *syndrome* causes interference in?
Social functioning Occupational functioning (schoolwork for kids) Activities of daily living
Somatic Symptom & Related Disorders
Somatic Symptom Disorder Conversion Disorder Illness Anxiety Disorder
Isolation
Splitting off emotional components of a thought. Separating thoughts and feelings.
How is anxiety different from stress?
Stress is an *external* pressure
Depression
Symptom vs. disorder Mild to moderate to severe Earliest illness- 1500 B.C. Depression and anxiety disorders cost the global economy US$1 trillion each year; Every US$ 1 invested in scaling up treatment for depression and anxiety leads to a return of US $4 in better health and ability to work
Outcomes for the bipolar patient
Takes medication and monitors side effects Behavior less agitated & expansive Talk is slowed down Stays on one topic Sleeps 5-6 hours per night Eat while seated at a table Stops excessive behavior like spending or foolish business decisions Stops inappropriate sexual behavior
2. Personalization:
Takes things personally when it is unjustified. Ex. "My kid got a poor grade in math this semester. I am a terrible parent. I have failed utterly."
Nursing Interventions for Dissociative Identity Disorder
Talk to them through the main alter Body work for body memories Count backwards into a safe place Cognitive behavioral strategies and restructuring Takes extensive work with a therapist
How do we manage behavior in milieu?
Teach skills while managing behavior by: Setting limits Offering activities Structuring environment Establishing therapeutic alliance Identify behavior Analyze effects Take action 1:1 de-escalate; how? Seclusion Restraints
Nursing Interventions and Anxiety management includes?
Teach social skills Exposure-based procedures *Systematic desensitization* Cognitive behavioral strategies to change thinking process
Therapeutic Roles of Nurses in Communication
Teacher Socializer Clinician Advocate Role model Counselor Therapist Confidant
Bipolar Disorder - textbook review
Textbook Review, Chapter 26, Townsend Diagnostic criteria (pp. 500-501) Mania Bipolar I (predominately manic) Bipolar II (predominately depressive) Cyclothymia Predisposing Factors Genetics and biochemical factors Psychosocial Theories
The Science of Nursing
The nurse as the therapeutic tool
What to do for paradoxical calm?
The patient may have made the decision to follow through with suicide. Watch for this. It may occur 3-6 weeks after the start of medications. Look at change in energy. *cognitive part hasn't changed but energy part has.*
What is mental health?
The successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms.
3. Dichotomous thinking:
Thinking in extremes-always good or bad, sometimes referred to as "black and white" thinking. Ex. "I made a medication error, I might as well leave nursing."
9. Perfectionism:
To feel good about themselves, they must do things perfectly. Ex. "My instructor wrote all over my nursing care plan. To be a good nursing student, I need to develop a care plan with no mistakes."
Textbook Review-Chapter 30
Townsend, Chapter 29, 587-588 (Chapter 30, pp. 671-676) Predisposing Factors Associated with Somatic Symptom Disorder
Textbook Review - depression
Townsend: Chapter 17; (Chapter 18) Predisposing Factors: Theories of Suicide Ch- 17, pp. 277-278; (Ch- 18, pp. 309-310) Application of the Nursing Process Ch 17, pp. 278-286; (Ch-18, pp. 310-318)
Depressive Disorders - review
Townsend: Chapter 25 (Chapter 27) Predisposing Factors Chapter 25, pp. 464-467 (Ch-27, pp. 561-568) Application of the Nursing Process Ch 25, pp. 472-480; (Ch-27, pp. 569-580) Treatment Modalities for Depression Ch 25, pp. 482-485; (Ch-27, pp. 580-582) Review: Psychopharmacology Ch 25, pp. 485-491; (Ch- 27, pp. 582-589)
Textbook Review - For Dissociative Identity Disorder
Townsend: Chapter 29, pp. 591-592 (Chapter 30, pp. 676-693) Review: Predisposing Factors Genetics Neurobiological Psychodynamic Psychological Trauma
10. Theme identification
Underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse/patient relationship. "I've noticed that in all of your serious relationships with men/women, something has happened and you get angry and leave the relationship impulsively. I wonder if you fear closeness?"
What are *ineffective* Coping strategies for anxiety?
Use of alcohol and drugs Withdrawal and isolation Argumentativeness Blaming Victim behavior Getting stuck and can't let go
3. Decatastrophizing:
Uses the "What if?" technique for "all or nothing thinking." This helps patients evaluate what is happening and examine if they are overestimating the catastrophe that might happen. "What is the worst thing that could happen? Would it be so terrible? How would others cope with an event like this one?"
What communication tools can you use for therapeutic communication?
Verbal and nonverbal behavior Use of therapeutic techniques Analysis of patient problems
5. Thought stopping:
When patients want to change a negative thinking pattern and have a negative thought, they can picture a stop sign in their mind, imagine a brick wall or a bell going off or sometimes they use a rubber band around their wrist and flick it. If the negative thought happens during a 1:1 session with the nurse, the nurse says,"STOP."
Who is at risk for depression?
Women People with chronic, debilitating illness History of depression Concurrent psychiatric illnesses: - Substance Abuse/Dependence - Panic disorder - Bipolar disorder - Obsessive-compulsive disorder Prior suicide attempts Hopelessness a factor Decreased 5HT (serotonin) and/or NE (norepinephrine) Stressful life events Lack of social support History of sexual abuse Sexual orientation issues People with unresolved grief Humiliating life event Negativity and pessimistic - Negative assessment of self/others/world - Cognitive distortions and faulty thinking
Describe the Working phase.
Work on the identified problems & goals Promote developing insight & coping Overcome resistances Explore stress and stressors The real work is accomplished here
Confidentiality in Mental Health
Written permission necessary - Only discuss what pt. gives permission to discuss Federal Privacy Anonymous treatment
What does it mean to be Aggressive?
expresses feelings, opinions, and advocates for own needs while violating rights of others. Uses criticism, humiliation, blaming. Loud, demanding. "I'm okay, you're not okay"
FACILITATORS OF COMMUNICATION 1. Listening
eye contact, body posture, gestures and facial expressions that shows the patient the nurse is active in receiving information.
What are thought disorders?
has to do with how you process information -dementia -schizophrenia
How do you know if it is a phobia or healthy fear?
healthy is protective, when its a phobia it immobilizes.
Rationalization
offering socially acceptable explanations to justify unacceptable impulses, motives or behavior.
Who can place a patient on a hold?
physicians police park rangers nurse practitioners
