drowsy but able to open eyes and respond
need vigorous or painful stimuli to get a brief response - may not be able to respond verbally
2 stimuli used to get a response from pt with decreased LOC?
pinching a tendon or rubbing the sternum
Purpose of the mini-mental status exam?
4 things it assesses?
- assess pt cognitive status
- 1. orientation to time & place
- 2. att span & ability to calculate(count backward by 7's)
- 3. registration & recalling of objects
- 4. language, including naming of objects, following commands, & ability to write
A score of ____ or less GCS indicates pt is in coma.
5 components of a healthy child/adolescent?
- 1. trust
- 2. view world as safe
- 3. accurately interpret env
- 4. master dev tasks
- 5. use appro coping
Psychosocial evaluation tool for adolescents?
3 extra assessments that may be done for an older adult?
- 1. functional ability
- 2. economic and social status
- 3. env factors: safety (stairs in home)
3 standardized assessment tools that are appro for the older adult?
4 pain assessment scales that may be used?
- 1. Geriatric Depression Scale (short form)
- 2. Mini-Mental Status Exam
- 3. Michigan Alcoholism Screeening Test (geriatric version)
- pain assessments: visual analogue scales, Wong-Baker FACES, McGill Pain Questionnaire (MPQ), & Pain Assessment in Advance Dementia (PAINAD)
8 things to do during mental assessment? (includes elderly)
- 1. private, quiet space with adequate lighting to accommodate impaired vision and hearing
- 2. intro self & det pt name preference
- 3. stand or sit at pt level
- 4. use touch to comm caring as appro
- 5. ask about difficulty sleeping, incontinence, falls/injuries, depression, dizziness, & loss of energy
- 6. include family etc as appro
- 7. obtain detailed med Hx
- 8. Summarize & ask for feedback from pt
4 aspects of counseling?
- 1. using therapeutic comm
- 2. assisting with prob solving
- 3. crisis intervention
- 4. stress mgmt
4 aspects of milieu therapy?
- 1. orienting pt to phys setting
- 2. ID rules & boundaries of setting
- 3. ensuring safe env
- 3. assisting to participate in activities
3 ways to promote self-care?
- 1. offer assistance
- 2. allow time
- 3. give incentives
3 Psychobiological interventions?
- 1. meds
- 2. teaching pt/family about meds
- 3. monitoring for AE & effectiveness
3 cognitive & behavioral therapies?
- 1. modeling
- 2. operant conditioning
- 3. systematic desensitization
Mental health teaching includes _____ & _____ skills.
social & coping skills
Role of case mgmt?
coordination holistic care (medical. psych, social)
3 rights guaranteed to ALL citizens?
- 1. humane Tx & care
- 2. right to vote
- 3. right to due process of law, including right to press legal charges against another person
8 rights guaranteed to ALL pt including mental health pt?
- 1. informed consent 7 right to refuse Tx
- 2. confidentiality
- 3. written plan of care/Tx including: d/c follow-up & participation in care plan & its review
- 4. Comm with ppl outside mental health facility: family, lawyer, health car
- 5. adequate interpretive services
- 6. care provided with respect, dignity & without discrimination
- 7. freedom from harm r/t phys or pharm restraint, seclusion, & phys or mental abuse
- 8. least restrictive interventions necessary
wrongful act/injury committed by an entity or person against another person or another person's property: decide liability issues & crimes
5 ethical issues that must be used to decide ethical issues?
- 1. beneficence
- 2. autonomy
- 3. justice
- 4. fidelity
- 5. veracity
quality of doing good (charity)
EX: nurse helps newly admitted pt feel safe in env
right to make own decisions & accept consequences of those decisions
pt must also respect rights of others
EX: RAther than giving advice to a pt, nurse helps the pt explore alternatives & arrive at a choice
fair & equal Tx for all
loyalty & faithfulness to pt & one's duty
being honest with pt
Pt info can be shared with what ppl?
only with ppl who will carry out pt care plan or with ppl pt has given consent for
Duto to warn & protect 3rd parties?
have duty to warn 3rd parties if pt is going to harm them & to report child & elder abuse
pt or pt guardian chooses commitment
may apply for release at any time & may refuse and med or Tx
Involuntary (civil) commitment?
Committment is based on?
How many MD's are usually required?
against will for an indefinite period of time
based on psych Tx need, risk of harm to self or others. or inability to provide self-care
judge, court, or other agency
usually requires 2 MD's
Emergency involuntary committment purpose?
Lenght of committment?
Who usually imposes this committment?
to prevent harm to self or others - usually temporary (may be up to 10 days)
PCP, mental health provider, or police officer
Observational or temporary involuntary commitment?
4 ppl who can impose?
pt is in need of observation, Dx, and Tx plan
time varies by state
- 1. family member
- 2. legal guardian
- 3. PCP
- 4. mental health provider
Long-term or formal involuntary commitment?
- similar to temporary commitment ut must be imposed by courts
- time varies - usually 60 to 180 days - may not have a release date
Pt admitted under involuntary commitment have the right to refuse Tx? Why?
still considered compentent & have right to refuse Tx
When are pt who are involuntarily committed not allowed to refuse TX?
How will decisions be made regarding this pt?
if they have been found incompentent at a competency hearing
temporary or permenant guardian will be appointed & will make decisions based on what they believe pt would want & can sign consent forms
Can a pt request temporary seclusion?
pt may request if env is disturbing or too stimulating
5 things that must be done in order to use phys/chem restraints?
- 1. Tx must be ordered by MD IN WRITING
- 2. order must specify duration of Tx
- 3. MD must rewrite order, specifying type of restraint q 24h or the frequency of time specified by facility policy
- 4. nursing responsibilities must be ID'd in protocol
- 5. complete documentation
4 nursing responsibilites to the restrained/chem restrained pt?
- 1. pt assessment & behavior documented
- 2. offered food & fluid
- 3. toileted
- 4. monitored for VS
Complete documentation of restraints includes what 5 things?
- 1. precipitating events & prior behavior
- 2. alternative actionstaken
- 3. time Tx began
- 4. pt current behavior, foods/fluids offered, needs provided for, & VS
- 5. meds admin
Can a nurse admin seclusion or restraints without MD order?
charge nurse can admin if in emergency situation, but must obtain order within specified time period (usually 15 to 30 min)
touching pt in a harmful or offensive way
2 things to document regarding violent or unusual episodes?
- 1. pt behavior - in clear/objective way
- 2. staff response
"self-talk" - not verbal
b/t 2 or more ppl in a small group
w/in lg groups of ppl
addresses individual's spiritual needs & provides interventions to meet those needs
4 characteristics of therapeutic communication?
- 1. pt centered
- 2. purposeful
- 3. planned
- 4. goal-directed
4 alterations in therapeutic communication when talking to a child?
- 1. simple language
- 2. be aware of own nonverbal messages
- 3. be at child's eye level
- 4. incorporate play
4 alterations in therapeutic communication for elderly?
- 1. may require you to speak louder
- 2. minimize distractions & face pt when speaking
- 3. allow time for pt to respond
- 4. if pt has impaired comm: ask for input from family/CG to det extent of deficits & how best to comm
When are defense mechanisms maladaptive?
when they interfere with functioning or when same defense mechanism is always used - should use a variety of mechanisms
2 defense mechanisms that are always healthy?
altruism & sublimation
dealing with anxiety by reaching out to others
dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression
voluntarily denying unpleasant thoughts & feelings
putting unacceptable stuff out of conscious awareness
shifting feelings r/t one thing/person onto another less threatening thing/person
overcompensatring or demonstrating opposite behavior of what is felt
performing an act to make up for prior behavior
creating explanations for unacceptable behavior
temp blocking memories & perceptions for comsciousness
inability to reconcile neg & pos attributes of self or others
blaming others for unacceptable thoughts & feelings
motivates ppl to take action
precipitated by imminent loss or change that threatens one's sense of security
3 char of chronic anxiety?
2 phys s/s that may occur?
dev over time
may start in childhood
may have phys s/s with anxiety: fatigue, HA
When may mild anxiety occur?
normal experience of everyday life
Advantage of mild anxiety?
increases ability to perceive reality
6 char of mild anxiety?
- 1. has identifiable cause
- 2. vague feeling of disomfort
- 3. restlessness
- 4. irritability
- 5. impatience
- 6. apprehension
3 physical behaviors that may occur with mild anxiety?
- 1. finger or foot tapping
- 2. fidgeting
- 3. lip-chewing
How does moderate anxiety affect perception, ability to think, & problem solving?
slightly reduced perception & selective inattention
decreased ability to think clearly but learning & problem solving may still occur
7 s/s of moderate anxiety?
- 1. concentration probs
- 2. tiredness
- 3. pacing
- 4. change in voice ptich
- 5. voice tremors
- 6. shakiness
- 7. increased HR & RR
4 somatic complaints that may occur with moderate anxiety?
HA, backache, urinary urgency & frequency, & insomnia
How can others help a person with moderate anxiety?
Functioning deficits that occur with severe anxiety?
functioning is ineffective: perceptual field is greatly reduced, disotroted perceptions,
learning & prob solving do not occur
6 char of severe anxiety?
- feelings of impending doom
- loud and rapid speech
- aimless activity
char of panic-level anxiety?
- 1. markedly disturbed behavior
- 2. not able to process what is occurring
- 3. extreme fright
- 4. severe hyperactivity or flight
- 5. immobility can occur
- 6. dysfunction in speech
- 7. dilated pupils
- 8. severe shakiness
- 9. severe withdrawal
- 10. inability to sleep
- 11. delusions
- 12. hallucinations
5 nursing interventions for mild-moderate anxiety?
- 1. active listening & comm techniques
- 2. be calm & recognize pt distress
- 3. eval past coping mechanisms
- 4. explore alternatives to probs
- 5. encourage participation in activites that may temp relieve feelings of inner tension (exercise)
6 nursing interventions for severe to panic-level anxiety?
- 1. env that meets phys & safety needs & remain with pt
- 2. quiet with low stimulation
- 3. meds & restraint only after less restricitive
- 4. encourage gross motor activites: walking/exercise
- 5. set limits by using firm, short, & simple statements. Repetition may be needed
- 6. direct pt to acknowledge reality & focus on what is present in env
Milieu goals & how are they accomplished?
learn tools needed to cope adaptively and use them in life
have community meetings regularly
5 things that occur during the orientation phase of the therapeutic relationship?
- 1. intro
- 2. make contract
- 3. build trust by est expectations
- 4. set goals & discuss pt concerns/needs
- 5. Explore pt thoughts & feelings & meaning of behaviors
4 things that occur during the working phase of the therapeutic relationship?
- 1. ongoing assessment to plan/eval care
- 2. work: increase SE, autonomy, coping, etc
- 3. reassess probs, goals, & revise plan prn
- 4. remind pt about date of termination
3 things that occur during the termination phase of the therapeutic relationship?
- 1. discuss loss & previous losses
- 2. summarize what has occurred & goal achievement
- 3. discuss how to incorporate what has been learning into life
pt sees healthcare team as being like someone from his/her personal life
When is transference more likely to occur?
with a person in authority
health care team member displaces char of ppl in her past onto a pt
When is countertransference likely to occur?
in pt who elicit strong personal feelings in the nurse
3 considerations for room assignments on a 24h care unit?
- 1. personalities of roomates
- 2. likelihood of nighttime disruptions for a roommate if 1 pt has difficulty sleeping
- 3. mental health & medical Dx
4 criteria to justify admission to an acute care facility?
- 1. clear risk of pt danger to self or others
- 2. failure of comm-based Tx
- 3. dangerous deline in mental health
- 4. having a medical need in addition to a mental illness
3 goals of acute mental health Tx?
- 1. prevention of harm
- 2. stabilizing mental crisis
- 3. return to some type of community care
When do discharge plans begin at acute care?
from time of admission
promotes health & prevents mental health probs from occurring
focuses on early detection of mental illness
focus on rehab & prevention of further probs in pt previously Dx
Partial hospitaliztion programs?
intense short-term Tx for pt who may go home q night & have a person responsible for them at home
Assertive community treatment (ACT)?
for pt with severe mental illness & noncompliant with traditional Tx
Community mental health centers?
provide educational groups, med dispensing, & individual counseling
Psychosocial rehabilitation programs?
provide structured range of programs: residential services, day programs for older adults, etc
How long does it last?
therapeutic process of assessing unconscious thoughts & feelings & resolving conflict by talking
months to years
Common focus of psychoanalysis therapy?
4 therapeutic tools used in psychoanalysis?
- 1. free association
- 2. dream analysis
- 3. transference
- 4. defense mechanisms
uncensored verabalization of what come to pt mind
pt & therapist dev trusting relationship to explore pt probs
Difference b/t psychoanalysis & psychotherapy?
psychotherapy uses same tools but focuses more on present relationships instead of past
assists pt in addressing specific probs to improve relationships, comm, roles, & bereavement
focus on individual thoughts & behaviors to solve current probs
Cognitive therapy may be used to Tx what condiitions?
anxiety, eating disorders, & others that may be changed by changing pt attitude toward life
What may behavioral therapy be used to Tx?
phobias, substance use, or addictive disorders
Dialectical behavior therapy?
Focus & goal?
cognitive-behavioral therapy for pt with personality disorder & exhibit self-injurious behavior
focus on gradual behavior changes and provides acceptance and validation for pt
assists pt to ID negative thougths that produce anxiety
decrease anxiety by changing cognitive distortions
Purpose of monitoring thoughts?
helps pt to be aware of negative thinking
pt imitates role model (therapist etc) to improve behavior
preventing pt from performing compulsive behavior with the intent that anxiety will diminish
shout stop when negtive thoughts/compulsions occur
eventually use the command silently
5 goals of group therapy?
- 1. sharing common feelings/concerns
- 2. sharing stories & experiences
- 3. diminishing feelings of isolation
- 4. creating a community of healing & restoration
- 5. less cost than individual therapy
Group therapy for children?
Why is group therapy good for adolescents?
they like their peers a lot
Why is group therapy good for older adults?
helps with socialization and sharing of memories
3 phases of group relationship?
Primary focus of the initial phase?
What 3 things occur?
doefining purpose & goals of the group
- 1. group leader sets tone of respect/trust
- 2. members get to know each other
- 3. discussion about termination
Working phase primary focus?
What issues may occur in this phase?
What 2 things occur?
promote prob-solving skills to facilitate behavioral changes
power & control issues may occur
- 1. work toward goals
- 2. members take informal roles w/in the group (some roles interfere & others help the group)
help maintain purpose & process of the group
prevent teamwork & help ind agenda
member of family with little power is blamed for probs w/in family
3rd party is drawn into relationship with 2 members whose relationship is unstable
emot issues or themes w/in a family that cont for at least 3 generations
Focus of family therapy?
focus on family system and not individuals
General Adaptation Syndrome (GAS)?
body's response to an increased demand
8 factors that increase person's resilience against stress?
- 1. phys health
- 2. strong sense of self
- 3. religious or spiritual beliefs
- 4. optimism
- 5. hobbies
- 6. satisfying interpersonal relationships
- 7. strong social support
- 8. humor
6 s/s of acute stress (fight or flight)?
- 1. apprehension
- 2. unhappiness or sorrow
- 3. decreased appetite
- 4. increased RR, HR, cardiac output, & BP
- 5. increased met & glucose use
- 6. depressed immune system
6 s/s of prolonged stress (maladaptive response)?
- 1. chronic anxiety or panic attacks
- 2. depression, chronic pain, sleep disturbances
- 3. weight gain or loss
- 4. increased risk for MI or stroke
- 5. poor DM control, HTN, fagiue, irritability, decreased ability to concentrate
- 6. increased risk for infection
What is involved in most nursing care r/t anxiety?
teaching stress-reduction strategies to pt
3 brain stimulation therapies?
- electroconvulsive therapy (ECT)
- transcranial magnetic stimulation TMS
- vagus nerve stimulation VNS
3 indications for ECT?
major depressive disorder
schizophrenia spectrum disorders that are less responsive to neuroleptic meds: schizoaffective disorder
acute manic episodes
4 types of pt with major depressive disorder that may have ECT?
- 1. s/s not responsive to pharm
- 2. risks of other Tx are greater
- 3. actively suicidal or homicidal & need rapid response
- 4. exp psychotic s/s
What type of manic episodes may be Tx with ECT?
How is their therapy performed?
used for rapid cycling (more than 4 manic per year) & for manic with destructive behavior
both have poor response to lithium
have ECT then get lithium
5 conditions that place pt at risk with ECT therapy?
- 1. recent MI
- 2. Hx of CVA
- 3. cerebrovascular malformation
- 4. intracranial mass
- 5. increased ICP
3 mental health conditions that ECT has not been found useful for?
- 1. substance use
- 2. personality disorders
- 3. dysthymic disorder
Typical course of ECT Tx?
3 X per week X 6 to 12 Tx total
Is informed consent needed for ECT?
If ECT is involuntary who signs informed consent?
next of kin or court order
Medication mgmt r/t ECT?
any meds that affect seizure threshold should be decreased or d/c several days before ECT & MAOIs & lithium should be d/c 2 wks before ECT
2 conditions that need monitored/Tx before ECT?
- 1. HTN b/c short period of HTN occurs after ECT
- 2. cardiac conditions
Nursing assessments before & during ECT?
VS & mental status before & after
assess pt & family understanding of procedure & provide teaching
Nursing care during ECT procedure?
- 1. give IM injection of atropine sulfate or robinul to decrease secretions & counteract vagal stimulation
- 2. insert IV line & maintain until full recovery
- 3. bite guard is used to prevent trauma to oral cavity
- 4. apply scalp electrodes for EEG
Monitoring that occurs during ECT?
- 1. EEG
- 2. cardiac monitoring
O2 during ECT?
mechanically ventilated & receive 100% O2
Anesthesia during ECT?
EX of muscle relaxant that may be used?
short-acting anesthetic (brevital etc) IV bolus & muscle relaxant are admin
muscle relaxant - succinylcholine
What is a cuff place on pt during ECT? Where is it placed?
placed on one leg or arm to black muscle relaxant so seizure activity can be monitored in limb distal to the cuff
How long is electrical stimulus typically applied during ECT?
What is monitored?
How long does seizure usually last?
0.2 to 0.8 seconds
monitor seizure activity
25 to 60 seconds
What is done after seizure activity ceases during ECT?
anesthetic is d/c & pt is extubated & assisted to breathe voluntarily
4 aspects of postprocedure care for ECT?
- 1. transfer to recovery area to monitor LOC, cardiac status, VS, & O2 sat
- 2. positioned on side to facilitate drainage & prevent aspiration
- 3. monitored for ability to swallow & return of gag reflex
- 4. usually awake & ready for transfer back w/in 30 to 60 min of procedure
5 complications of ECT?
- 1. memory loss & confusion
- 2. reactions to anesthesia
- 3. ECG changes
- 4. HA, muscle soreness, & N
- 5. relapse of depression
What type of memory loss occurs with ECT?
short-term memory loss
3 nursing interventions for short-term memory loss r/t ECT?
- 1. reorient
- 2. safe env to prevent injury
- 3. assist with hygiene prn
What should nurse be monitoring for throughout ECT?
reaction to anesthesia
What will happen to pt HR during ECT & early recovery?
increase by 25%
What will happen to BP during ECT?
What happens after?
BP may initially fall then rise
should go back to baseline shortly after procedure
2 interventions for relapse depression r/t ECT?
- 1. teach that ECT is temp solution
- 2. weekly ore monthly maintenance ECT can decrease relapse
Transcranial magnetic stimulation? (TMS)
noninvasive - uses magnetic pusations to stimulate specific areas of the brain
Indication for TMS?
major depressive disorder in pt not responsive to pharm
Nursing action for TMS?
Common schedule of Tx with TMS?
daily for 4 to 6 wks
TMS outpatient or inpatient?
How long does TMS last?
30 to 40 minutes
Procedure for TMS?
noninvasive electromagnet placed on scalp & pass pulsations through
pt is alert during procedure
3 complications of TMS?
What complications are not associated with TMS?
- 1. mild discomfort or tingling sensation at site of electromagnet
- 2. lightheadedness after
- 3. seizures (rare)
not asso with systemic AE or neuro deficits
Vagus nerve stimulation (VNS)?
electrical stimulation through the vagus nerve to the brain through a device that is surgically implanted under the skin on pt chest
Indications for VNS?
depression resistant to pharm and/or ECT
2 nursing actions for VNS?
- 1. educate about procedure
- 2. assist MD to obtain informed consent
Is VNS outpatient or inpatient?
When does the VNS deliver pulsations?
How is it turned off?
delivers around-the-clock pulsations
may be turned off at any time by placing special external magnet over the site of implant
3 complications of VNS?
- 1. voice changes r/t proximity of implanted lead on vagus nerve to larynx & pharynx
- 2. hoarseness, throat or neck pain, dysphagia (improve with time)
- 3. dyspnea, especially with physical exertion
Anesthetic for TMS?
pt is alert during procedure
Intervention for dyspnea r/t VNS?
may turn off device when exercising
4 anxiety disorders recognized & defined by DSM-5?
Other disorders with similar s/s?
- 1. separation anxiety disorder
- 2. panic disorder
- 3. phobias
- 4. generalized anxiety disorder GAD
- 1. OCD & hoarding disorder
- 2. trauma & stressor-related disorders
Generalized anxiety disorder (GAD)?
uncontrollable, excessive worry for more than 3 mo
Why do OCD pt do compulsions?
to relieve obsessive thoughts
Acute stress disorder?
exposure to traumatic event causes numbing, detachment, & amnesia about event for at least 3 days but no more than 1 mo following the event
Posttraumatic stress disorder (PTSD)?
exposure to traumatic event causes extreme fear, flashbacks, feelings of detachment & foreboding, restricted affect, & impairment for longer than 2 mo after event - may last for years
Anxiety disorder more likely in ____.
Why do s/s of anxiety need to be assessed well?
to rule out a physical cause such as hyperthyroidism or pulmonary embolism
Some causes of anxiety?
- traumatic event
- genetics & biology
- acute medical condition
- some meds & substances
How long do panic attacks typically last?
15 to 30 min
Dx of a panic attack?
4 or more of following s/s are present:
- choking or smothering sensation
- chest pain
- feelings of depersonalization
- fear of dying or insanity
- chills or hot flashes
What may cause anxiety in a pt with panic disorder b/t panic attacks?
worrying about another panic attack occurring
avoids being outside & has impaired ability to work or perform duties
6 s/s of GAD?
- 1. restlessness
- 2. muscle tension
- 3. avoidance of stressful activities or events
- 4. increased time & effort required to prepare for stressful sit.
- 5. seeks repeated reassurance
Results of OCD on pt life?
compulsions are time-consuming & cause impaired social & occupational functioning
Priority consideration in hoarding disorder?
can lead to unsafe living environment
Manifestations of acute stress disorder & PTSD?
ASD: s/s begin immediately & persist for 3d up to 1mo
PTSD: s/s any time after & last more than 1 mo
How do ASD pt re-experience traumatic event?
- 1. distress when reminded of event
- 2. dreams/images
- 3. flashbacks
- 1. recurrent intrusive recollection of event
- 2. dreams/images
- 3. flashbacks, illusions, hallucinations
Manifestations of ASD?
dissociative s/s: amnesia of the trauma event, absent emot response, decreased awareness of surroudings, depersonalization
indications of severe anxiety: irritability, sleep disturbance
S/S of PTSD?
indications of increased arousal: irritability, difficulty with concentration, sleep disturbance
avoidance of stimuli associated with trauma: avoiding ppl, inability to show feelings
4 nursing interventions for anxiety disorders during initial assessment/interview?
- 1. structured interview to keep pt focused on present
- 2. assess for substance use
- 3. perform suicide risk assessment
- 4. instill hope for positive outcomes
4 interventions for a pt in acute anxiety crisis?
- 1. provide safety & comfort
- 2. remain with pt & provide reassurance
- 3. provide safe env for other pt & staff
- 4. postpone health teaching until after subsides
Why should teaching be postponed during acute anxiety crisis?
pt is unable to concentrate, problem solve, or learn
4 interventions for ongoing assessment & Tx of anxiety?
- 1. provide milieu therapy
- 2. use relaxation techniques for pin, muscle tension, & anxiety
- 3. enhance SE by encouraging positive statements & discussing past achievements
- 4. assist pt to ID defense mech that interfere with recovery
Env requirements for anxiety disorders?
structured, predictable, & safe
monitor for self-harm
daily activities that promote sharing & cooperation
Cognitive behavioral therapy for anxiety disorders?
use cognitive reframing to ID negative thoughts that cause anxiety, find cause, & dev new ways
Behavioral therapies for anxiety?
teach ways to decrease anxiety or avoidant behavior with diff behavioral therapies
Eye movement desensitization & reprocessing (EMDR)?
therapy for pt with PTSD - pt focus on separate stimuli with eyes while thinking of or talking about the tramatic event
Meds for anxiety disorders? (4)
- 1. SSRI & other antidepressants
- 2. sedative hypnotic anxiolytics
- 3. nonbarbiturate anxiolytics
- 4. others: beta blockers, antihistamines, & anticonvulsants may be used
First line of Tx for trauma & stressor-related disorders?
How long are they used in anxiety disorders?
short-term use only
EX of nonbarbiturate anxiolytic?
What may anticonvulsants be used for in anxiety disorders?
Depression may be comorbid with what 5 conditions?
- 1. substance abuse
- 2. anxiety
- 3. psychotic disorders (schizo)
- 4 eating disorders
- 5. personality disorders
Depression = increased risk for suicide especially if have what 6 risk factors?
- 1. family or personal Hx of attempts
- 2. comorbid anxiety disorder
- 3. cormorbid substance use or psychosis
- 4. poor SE
- 5. lack of social support
- 6. chronic medical condition
Major depressive disorder (MDD)?
8 s/s of MDD?
single or recurrent episodes of depression (with no mania) that causes change in pt normal functioning accompanied by at least 5 other associated s/s
- 1 depressed mood
- 2. difficulty or excessive sleeping
- 3. indecisiveness
- 4. decreased ability to concentrate
- 5. suicidal ideation
- 6. increase or decrease in motor activity
- 7. inability to feel pleasure
- 8. increase or decrease in weight or more than 5% of body weight over 1 month
3 more specific classifications of MDD?
- 1. MDD with psychotic features
- 2. MDD postpartum onset
- 3. MDD - SAD
Char of MDD with psychotic features?
MDD with auditory hallucinations or delusions
Char of MDD postpartum onset?
Risk for ____?
begins w/in 4 wks of childbirth & may include delusions
harming newborn r/t delusions
Char of MMD - SAD?
occurs during winter & may be Tx with light therapy
milder depression that usually has early onset & lasts at least 2 years for adults or 1 year for children
has at least 3 s/s of depression and may dev into MDD
Premenstrual dysphoric disorder PMDD is asso with the ____ phase of the menstrual cycle.
Primary s/s (3)?
3 other s/s?
asso with luteal phase of the menstrual cycle
primary: mood lability, persistent/severe anger, & irritability
other: lack of energy, overeating, & difficulty concentrating
Char of acute phase of depression?
How long does Tx usually last?
Potential need for _____.
Goal of Tx?
6 to 12 wks
reduction of depressive manifestations
Interventions for acute phase of depression?
- assess suicide risk
- implement safety precautions or one-to-one observation prn
Continuation phase of depression char?
How long does Tx usually last?
Goal of Tx?
increased ability to function
4 to 9 months
relapse prevention through education, meds, & psychtherapy
Maintenance phase of depression char?
How long may this phase last?
Goal of Tx?
remission of manifestations
may last years
prevention of future episodes
Risk factors for depression?
Most important risk factor?
- 1. family Hx & previous personal Hx is most imp risk factor
- 2. females age 15 to 40
- 3. pt over age 65
- 4. pt with NT deficiencies
- 5. stressful life events
- 6. presence of med illness
- 7. postpartum period
- 8. poor social support
- 9. comorbid substance use
- 10. being unmarried
Why is depression harder to recognize in elderly? Imp intervention?
may mimic s/s of aging or dementia
S/S of depression that may look like dementia?
- memory loss
- behavioral probs (social isolation, agitation)
Pt with depression may seek health care for ____ probs that are s/s of untreated depression.
2 NT deficiencies that may cause depression?
What do each affect?
serotonin - mood, sexual behavior, sleep cycles, hunger, & pain perception
NE - attention & behavior
6 subjective s/s of depression?
- 1. anergia - lack of energy
- 2. anhedonia - lack of pleasure
- 3. anxiety
- 4. sluggishness (most common) or unable to relax or sit still
- 5. vegetative findings: cahnge in eating patterns, bowel habits, and sleep & decreased interest in sex
- 6. somatic reports
What eating disturbance usually occurs with MDD?
What eating prob usually occurs with dysthymic disorder and PMDD?
What somatic s/s may occur with depression?
fatigue, GI probs, pain
5 objective s/s of depression?
- 1. affect- sad & blunted
- 2. poor grooming/hygiene
- 3. psychomotor retardation or agitation
- 4. socially isolated
- 5. speech: slowed, decreased, delayed response: may seem too tired to speak
2 important assessments for depressed pt?
- 1. suicide risk
- 2. self care abilities
3 interventions for comm with depressed pt?
- 1. be with pt even if he does not speak
- 2. make observations rather than asking direct questions
- give pt sufficient time to respond - may have delayed response time
Councel depressed pt to assist with what 6 things?
- 1. prob solving
- 2. increasing coping
- 3. changing negative thinking
- 4. increasing SE
- 5. assertiveness
- 6. using avail comm resources
5 things to teach pt on ANY antidepressant?
- 1. do not d/c med suddenly
- 2. ther effects are not immediate - may take several weeks
- 3. avoid hazardous activities r/t sedation possibility
- 4. notify provider of any thoughts of suicide
- 5. avoid alcohol
celexa, lexapro, paxil, zoloft, paxil, luvox
5 AE of SSRIs?
- 1. N
- 2. HA
- 3. CNS stimulation - agitation, insomnia, anxiety
- 4. sexual dysfunction
- 5. weight gain with long-term
Important AE to look for r/t SSRIs?
usually occurs w/in hours of taking new Rx or increasing dose: s/s of stimulation CNS
- 1. increased HR & BP
- 2. pupil dilation
- 3. confusion, agitation, restlessness
- 4. shivering & goose bumps
- 5. heavy sweating
- 6. diarrhea
- 7. HA
What OTC med should be avoided while taking an SSRI?
St John's Wart
can increase chance of serotonin syndrome
Diet with SSRI?
need healthy diet r/t possible weight gain with long-term therapy
Tricyclic antidepressants? 6
all ines or ins (some of these are MAOIs too)
amitriptyline, imiprimine, clomiprimine, desipramine, doxepin, nortriptyline,
AE of tricyclic antidepressants?
- 1. orthostatic hypotension
- 2. tachycardia and dysrrhythmias
- anticholinergic s/s:
- 3. dry mouth & nose
- 4. blurred vision (pupil constriction)
- 5. slowed GI motility
- 6. cognitive &/or memory impairment
- 7. urinary retention
- 8. increased body temp
Interventions for AE of tricyclic antidepressants?
- 1. ortho hypotension - change positions slowly
- 2. dry mouth - chew sugarless gum
- 3. constipation - fiber & 2 - 3 L fluid/day
- 1. nardil
- 2. marplan
- 3. emsam
- 4. parnate
What will occur if pt on MAOI eats tyramine?
Foods that contain tyramine?
hypertensive crisis may occur
avocados, figs, fermented or smoked meats, liver, dried or cured fish, most cheeses, some beer & wine, & protein dietary supplements
OTC meds that may be taken with MAOIs?
no new meds should be taken without discussing with MD r/t high risk for interactions
Atypical antidepressant list? 4
- bupropion - Wellbutrin
8 AE of atypical antidepressants to educate pt about?
When should pt call MD?
HA, restlessnes, insomnia, dry mouth, GI distress, constipation, increased HR, N
if AE become unbearable
What needs to monitored if pt is taking atypical antidepressant?
weight & food intake - can cause decreased appetite
Atypical antidepressants are CI in what pt?
Serotonin Norepinephrine Reuptake Inhibitors list? (SNRI) 3
cymbalta, effexor, & pristiq
AE of SNRI?
N, weight gain, sexual dysfunction
Interpersonal therapy for depression (IPT) focuses on what?
focus on personaly relationships that contribute to the depressive disorder
2 alternative therapies for depression?
- 1. st johns wart
- 2. light therapy
A of St john's wort? (5)
- 1. photosensitivity
- 2. skin rash
- 3. rapid heart rate
- 4. GI distress
- 5. abd pain
Medication interactions with St John's wart?
may increase or decrease levels of some drugs
can increase serotonin syndrome with SSRI
may interact with tyramine
First-line therapy for SAD?
inhibits nocturnal secretion of melatonin
Who must monitor a pt that undergoes ECT before & after?
specially trained nurse
Exercise and depression?
30 min 3-5 X per week can decrease depression
When does bipolar disorder usually get Dx?
may be Dx in children but hard to Dx because similar to ADHD
Acute phase of bipolar?
____ and/or ____ supervision may be indicated.
Goals of Tx?
What is risk that needs assessed?
hospitalization and/or one to one supervision
reduction of mania & pt safety
risk of harm to self or others must be det
Continuation phase of bipolar char?
Goal of Tx?
remission of s/s
4 to 9 mo
Maintenance Tx for bipolar length?
Goal of Tx?
prevent mania episodes
less severe mania episode that lasts at least 4 days accompanied bvy 3 to 4 findings of mania
Char & Tx of mixed episode of bipolar?
marked impairment in functioning and may require admission to facility
Rapid cycling in bipolar?
4 or more episodes of acute mania w/in 1 year
at least one episode of mania alternating with major depression
one or more hypomanic episodes alternating with major depressive episodes
at least 2 years of repeated hypomanic manifestations that do not meet criteria for hypomanic episodes alternating with minor depressive episodes
4 comorbidities asso with bipolar?
- 1. substance use
- 2. anxiety
- 3. eating disorder
- 4. ADHD
4 risk factors for bipolar?
- 1. genetics: family
- 2 psychological: stressful events/life changes
- 3. physiological: bio or endocrine disorders
- 4. substance use: alcohol & cocaine
3 factors that may trigger an episode of mania?
- 1. substance use: alcohol, cocaine, caffeine
- 2. sleep disturbances: may come before, asso with, or brought on by mania
- 3. psychological stressors
17 S/S of mania?
- 1. labile mood with euphoria
- 2. agitation & irritability
- 3. restlessness
- 4. dislike of interference & intolerance of criticism
- 5. increase in talking & activity
- 6. flight of ideas
- 7. grandiose view of self & abilities
- 8. impulsivity
- 9. demanding & manipulative
- 10. distractibility & decreased att. span
- 11. poor judgment
- 12. att.-seeking behavior: flashy dress & makeup, inappro behavior
- 13. impairment in functioning
- 14. decreased sleep
- 15. neglect of ADLs: nutrition & hydration
- 16. possible presence of delusions & hallucinations
- 17. denial of illness
Focus of Tx during acute manic episode?
safety & maintaining physical health
- 1. safe env
- 2. assess for suicidal thoughts
- 3. decrease stimulation without isolating pt if poss
- 4. frequent rest periods
- 5. physical activity
- 6. protect from poor judgment & impulsive behavior
- 7. ADLs
Why may a bipolar pt have to be secluded?
stimulation around them may cause exacerbation of mania
What types of physical activity are good for a bipolar pt?
activities that don't last a long time or require high level of concentration or detailed instructions
4 interventions for bipolar acute mania pt self-care needs?
- 1. monitor sleep, fluid, & nutrtion
- 2. provide portable, nutritious food
- 3. supervising choice of clothes
- 4. give step-by-step reminders for hygiene & dress
6 interventions for comm with acute mania pt?
- 1. calm, matter-of-fact speech
- 2. concise explanations
- 3. consistency with expectations & limit-setting
- 4. avoid power struggles & don't react personally
- 5. listen & act on legitimate pt grievances
- 6. reinforce nonmanipulative behaviors
3 types of meds used for bipolar?
- 1. mood stabilizers
- 2. benzos
- 3. antidepressants
2 types of mood stabilizers for bipolar?
lithium & anticonvulsants
Anticonvulsants used as mood stabilizers in bipolar? 5
Why are benzos used for mania?
used for sleep impairment temporarily
When may ECT be used in bipolar?
subdue extreme manic behavior esp if pharm hasn't worked OR in pt who are suicidal or have rapid cycling
Teaching for bipolar pt?
importance of maintaining healthy sleep, eating, & drinking habits
Complication of bipolar?
physical exhaustion & possible death - mania can become a medical emergency
- . prevent self-harm
- 2. decrease pt physical activity
- 3. ensure adequate fluid & food
- 4. promote adequate sleep
- 5. assist with self-care needs
- 6. manage meds
A Dx of schizophrenia should not be made in children until after age ____. Why?
rule out ADHD wit violent tendencies
psychotic thinking or behavior present for at least 6 mo with areas of functioning impaired
Schizotypal personality disorder?
impairments of personality functioning
not as severe as schizophrenia
delusional thinking for at least 1 mo
self or interpersonal functioning not markedly impaired
Brief psychotic disorder?
psychotic s/s tht last b/t 1 day to 1 mo
s/s similar to schizo but furation is from 1 to 6 mo & social/occupational dysfunction may or may not be present
disorder meets both criteria for schizophrenia & depressive or bipolar disorder
Substance-induced psychotic disorder?
psyhosis w/in 1 mo of substance intox or withdrawal
could be a med meant for ther use
Positive s/s of schizo?
s/s of things that are not normally present: hallucinations, delusions, alterations in speech, bizarre behavior (EX; walking backward constantly)
absence of things that are normally present
- 1. affect: bluted or flat
- 2. alogia: poverty of thought/speech
- 3. anergia
- 4. anhedonia
- 5. avolition: lack of motivation
narrow range of normal expression
facial expression never changes
5 cognitive s/s of schizo?
- 1. disordered thinking
- 2. inability to make decisions
- 3. poor problem-solving ability
- 4. difficulty concentrating to perform tasks
- 5. memory deficits
Memory deficits that occur in schizo?
working memory - inability to follow directions
2 affective s/s of schizo?
- 1. hopelessness
- 2. suicidal ideation
believe their thoughts can be heard by others
believe others' thoughts are being inserted into their mind
believe thoughts have been removed from their mind by an outside agency
5 alterations in speech that occur in schizo?
- 1. flight of ideas
- 2. neologisms
- 3. echolalia
- 4. clang association
- 5. word salad
Depersonalization & derealization that occur in schizo?
depersonalization - feeling that person has lost ID & self is different or unreal
derealization: perception that environment has changed
7 alterations in behavior that occur in schizo?
- 1. extreme agitation: pacing rocking
- 2. stereotyped behaviors: motor patterns that had meaning to pt but now are mechanical & lack purpose (sweeping floor)
- 3. automatic obedience: respond like robot
- 4. waxy flexibility: excesssive maintenance of position
- 5. stupor: motionless for long periods of time
- 6. negativism: doing opposite of what is requested
- 7. echopraxia: purposeful imitation of movements made by others
Nursing interventions for schizo pt?
- 1. dev trusting relationship
- 2. encourage group work & psychoeducation
- 3. encourage dev of social relationships
- 4. use appro comm to address hallucinations & delusions
- 5. assess discharge needs: ability to perform ADLs
- 6. promote self-care by modeling & teaching self-care activites w/in facility
- 7. use s/s mgmt techniques to cope with depressive s/s & anxiety: distraction, walking, talking to someone, telling hallucinations to go away
- 8. encourage med compliance & med teaching
- 9. incorporate family when possible
7 interventions for appro comm with psychotic pt?
- 1. ask pt directly about hallucinations but don't validate them
- 2. do not argue with a pt delusions: focus on pt feelings & offer empathy
- 3. assess for paranoid delusions: increase risk for violence
- 4. provide safety if pt is exp command hallucinations
- 5. focus conversations on reality
- 6. ID s/s triggers
- 7. be genuine & empathetic
Med of choice for psychotic disorders?
Tx positive or negative s/s?
6 atypical antipsychotic drugs?
- 1. risperdal
- 2. seroquel
- 3. zyprexa
- 4. geodon
- 5. abilify
- 6. clozaril
Conventional antipsychotics are used to Tx mainly _____ s/s of schizo.
4 meds used?
- 1. haldol
- 2. loxitane
- 3. chlorpromazine
- 4. prolixin
5 AE of atypical antipsychotics?
- 1. weight gain
- 2. agitation
- 3. dizziness
- 4. sedation
- 5. sleep disruption
AE of conventional antipsychotics?
anticholinergic AE & ortho hypotension
- 1. chew sugarless gum
- 2. eat fiber & get 2-3L of fluids
- 3. teach to change positions slowly
Use of antidepressants in schizo?
Monitoring? When is risk the greatest?
used to Tx depressive s/s of schizo
monitor for suicidal ideation - greatest risk is when first taking med
Purpose of anxiolytics/benzo use in schizo?
Tx anxiety & pos/neg s/s
Pt teaching if taking anxiolytics/benzos?
- 1. can cause sedation
- 2. need blood tests to monitor for agranulocytosis
Use anxiolytics/benzos with caution in _____.
2 important health teaching for schizo?
- 1. abstinence from drugs and alcohol
- 2. keeping journal or log of feelings & changes in behavior to help monitor med effectiveness