NURS 3125 Test 2 Study Guide
All previously assigned readings and PowerPoint material is subject to be on Test 2. This is a general
guide and not all encompassing
Psychiatric Mental Health Assessment / Risk Assessment
 Components of the nursing assessment and patient/family history
Components of a Bio-Psycho-SocialAssessment
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Identifying Data
Chief Complaint
History of Present Illness
Psychiatric History
Medical History
Family Psychiatric History
Primary focus on immediate family
(grandparents, parents, sibling, children)
-Psych Diagnoses (When? By whom?)
-Treatment
-Hospitalizations (Why? When? Where? How
long?)
-Medications (Name, Dose, Indication,
Tolerated, Effective, Length of tx?)
-Individual therapy (When? How long?
Effective/skills learned?)
-Substance Use
-Suicide Ideation
-Suicide Attempt (lethality, medical
intervention?, did they go to someone or did
someone find them?)
-Self Injurious behavior (hx cutting, burning,
picking)
▪ Family Medical History
-Conditions (Thyroid, Cardiovascular, Cancer,
Metabolic syndrome, etc…)
-Treatments
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Social/Developmental History
Work History
Legal History (civilian and military)
Habits (substance use, ETOH, caffeine,
supplements, tobacco)
Mental Status Exam
Assessment (risk assessment, case
formulation, multi-axial dx)
Initial Treatment Plan
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Components of the MSE
▪ Appearance.
Is clothing clean, put on appropriately, are they
healthy, hair, color or texture, color of clothes.
Fidgety, depressed and not keeping eye contact,
posture, are they slumped? Bizarre look? Unusual
facial features? Do they look their age? Older or
young?
▪ Behavior.
Are they being cooperative? Rude, twitching?
Seductive, defensive, Guarded, Hostile, Agitated,
Combativeness, Rigid, Gait, Adlity
▪ Thought Content
What is the person actually thinking about?
Disturbances= Delusions, hallucinations, illusions,
ideas of reference, obsessions, homicidal
ideations, suicidal ideations
▪ Thought Process
Linear logical & goal directed, tangential (inability
to get to the point of the story), flight of ideas
(thoughts move abruptly from idea to idea; often
expressed through rapid, pressured speech),
circumstantiality (over inclusion of trivial or
▪ Speech
(Quality, Quantity, Rate) Speaking slow or fast,
Pressured (through teeth) Yellowing // Quantity:
Talkative, unspontaneous, Normally responsive
to cues? // Rate: Rapid, slow, hesitant, Stuttered
Quality: Monotone, Loud, Whispered, Slurred,
Mumbled
▪ Mood (subjective):
depressed, despairing, irritable, anxious, angry,
expensive, euphoric, empty, guilty, hopeless.
Labile or reactive (shifting between mood
extremes: depressed to angry?)
▪ Affect: Objective;
defined by pts facial expression, range of
expressive behavior
Described as: Normal, constricted (range and
intensity of expression is reduced; happy but not
able to smile often), blunted (emotional
expression is further reduced: emotion but not
visible: poker face), flat, expensive
Inappropriate//incongruent: killed pet and were
happy
▪ Perception: hallucinations and illusions
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irrelevant details that impede the sense of
getting to the point), clang associations (thoughts
associated by the sound of words rather than
meaning; right sight light might), looseness of
associations (breakdown in both the logical
connection between idea and the overall sense of
goal-directedness. Words make sense but not
together) perseveration (repeating the same
word or idea back to you), echolalia (parrot-like
repetition of the words spoken by another),
neologisms (new words that an individual invents
that are meaning less to others), word salad
(group of words that are put together in a
random fashion), blocking (abrupt interruption in
train of thought before a thought or idea is
finished)
▪ Sensorium and Cognition
Level of alertness/consciousness; orientation;
memory; capacity for abstract thought;
intelligence
▪ Impulsivity
Is pt capable of controlling sexual, aggressive and
other impulses? Is pt aware of socially
appropriate behavior
▪ Judgment and Insight
Capacity of pts ability to make decision of best
interest
▪ Reliability
Insight is a pts degree of awareness and
understanding about being ill
6 levels of insight …
Includes an estimate of pts truthfullness
Components of a risk assessment
Screening = low sensitivity levels compared to assessment tools
Suicide Risk Factors (acute = modifiable)
*intent; for secondary gain (attention-cry for help) vs. meant to die?
Active self-mutilation: have they practiced attempt?
Chronic (often static) middle age Caucasian men
Chronic medical problems (COPD)
Mitigating risk factors:
Married
Denies si, no previous history
Absence of alcohol
No weapon
Willingness to engage in treatment
Develop crisis response plan
 Risk factors vs protective factors
Suicidal desire and ideation (SDI)
Reasons for living
Wish to die
Frequency of ideation
Wish not to live
Passive attempt
Resolved plans and preparation (RPP)
…. “an attempt”
SAFE-T & CAMS = framework to determine overall SI level of risk
Risks: Mild= none
Moderate= any symptom or indicator
Severe= 2 or more
Extreme= severe symptoms
Nursing process:
Assessment
Diagnosis
Risk for SI
Outcomes identified
Implementation
Depression / Bipolar / Mood Disorders
 Types of mood disorders: depression, alterations in emotions-mania/depression or both.
Depressive Disorder
Bipolar Disorder (BP 1 more severe:
mania/depression/psychosis;hallucinations/illusions) 2: major depressive w hypomania
symptoms
Seasonal Affective Disorder
Post Partum Depression
If one episode 50% chance of another, 2 episodes 70% chance, 3 episodes 90% (about environment,
genetics)
 Sadness vs Depression
Sadness:
Depression:
Expected human emotion
Never normal
Response to life
Might happen suddenly
Intermittent
Continuous
Insight
Insight variable
Little or no functional impairment
Functional impairment
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CBT (Cognitive behavioral therapy)
Drugs
Counseling
Group Therapy
Phototherapy (seasonal affective disorder)
Electroconvulsive Therapy: used when medications aren’t working or side effects intolerable:
takes about 30 min inpatient setting, post recovery.. check ABC’s – maybe some amnesia as side
affect
Ketamine Therapy: formally an anesthesia, formally club drugs, date rape drug bc hallucinations:
infuse through IV for about 6 times. Works in in an hour or two.
Medications and group counseling is key treatment
CBT: Cognitive Behavioral Therapy: get patient to change thinking pattern
Focus on staying in the HERE & NOW: problem solving, coping mechanisms, role play
Effective w major depressive order, anxiety, bipolar
Once a day to wk but have to stick w it: highly effective
 Nursing interventions
 Antidepressants and Mood Stabilizers
Alleviate symptoms associate w moderate to severe depression
Ellevate/restore mood
Prevent recurrence of depression
Prevent the swing into mania for bipolar patients
Effective with Bipolar, anxiety, alcoholism, schizophrenia, chronic pain/migraine
 ECT: When is it used for treatment? Pre and Post Care
Used when pharm options don’t work:
Application of electrodes to head to deliver electrical impulse to brain- causes seizure.
Shock stimulates brain chemistry to correct imbalance of depression
6-15 treatments to be effective
Schizophrenia / Psychotic Disorders
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Positive vs negative symptoms
Hallucinations vs delusions
Types of hallucinations
Types of delusional thinking
Diagnostic screenings
Nursing interventions
Types of psychosocial treatment
Antipsychotic medications
Medications for Depression / Bipolar / Mood Disorders / Schizophrenia / Psychotic Disorders
(Do not need to know dosages)
 Class or type
SSRIs: serotonin 2nd Gen
***Increase concentration of norepinephrine,
serotonin, and/or dopamine in the body by
blocking the reuptake of these neurotransmitters
SNRIs: serotonin and norepinephrine 2nd Gen
Buproprion 2nd Gen
Tricyclic 1st Gen
MAOIs 1st Gen
Don’t eat tyramine containing foods
Prozac (fluoxetine)
Paxil (paroxetine)
Zoloft (sertraline)
Celexa (citalopram)
Luvox (fluvoxamine)
Lexapro (escitalopram)
Trintellix (vortioxetine)
Viibryd (vilazodone)
Desvenlafaxine (Pristiq, Khedezla)
Duloxetine (Cymbalta, Irenka)
Ievomilnacipran (Fetzima)
Milnacipran (Savella)
Venlafaxine (Effexor XR): fewer sexual side
effects but hypertension
Increase concentration of norepinephrine,
serotonin
Amitriptyline (pain management, fibromyalgia,
migraines)
Amoxapine
Desipramine (Norpramin)
Doxepin (Silinor) (used for insomnia)
Imipramine (Tofranil)
Maprotiline
Nortriptyline (Pamelor)
Protriptyline (Vivactil)
Trimipramine (Surmontil)
Inhibit monoamine oxidase enzymes that
inactivate norepinephrine, serotonin and/or
dopamine in the body
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline (Emsam)
Tranylcypromine (Parnate)
No alcohol because causes psychotic symptoms
Sexual dysfunction and weight gain
Serotonin syndrome
ANXIETY (speaking in front of ppl, or going into the store because too many people)
Not effective after taking for longer then 5 days because PRN
Really sedates pts, interacts with those listed above. Can aggravate symptoms in schizophrenia and
psychotic episodes in older patients. Potential for cardiac dysrhythmias! LETHAL IN OVERDOSE.
Huge drug interactions w SSRIs due to serotonin syndrome. Should not be taken with amphetamines
and cough meds, decongestants. Insomnia is most common side effect. Most dangerous is hypertensive
crisis. Have to take BP prior to administering.
Symptoms of Hypertensive Crisis: increased blood pressure, fever sweating, chin to chest = pain
Given to pts w no insurance bc cheaper but deadly when taken w street drugs
Avoid using MAOI within 2 weeks of adverse agent (SNRI,SSRI,TCA), and 5 weeks of Prozac therapy
(takes awhile to get out of symptom)
Can be lethal 6-10 times daily dose: use gastric lavage if w/in an hour or hemodialysis if longer
 Understand Mechanism of Action, which neurotransmitter they work on
Not fully understood how they work: start slow and go slow. Takes time to reregulate how the brain
works
o Why one class would be used before another
 Mental illnesses they treat
 Know off label use of some medications used in psychiatry
 Contraindications
 Responsibilities of the nurse in administering psychopharmaceuticals
 Important patient education ie: diet, labs, mixing meds, black box warnings
 Side effects
o Signs and symptoms
 Mild and Severe side effects – which drugs cause specific side effects
o Priority nursing actions
o Labs/tests
All have sedation and weight gain as a side effect, sexual dysfunction as a side effect.
If pt taking heparin or coumadin check Pt, PTT, Inr.
Antidepresants can cause hyponatremia in the elderly