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180 days is the longest time someone can be under involuntary hold
Seclusion and/or restraints should be ordered for the shortest duration necessary, and only if less
restrictive measures are not sufficient. They are for the physical protection of the client and/or the
protection of other clients and staff.
Restraints can be either physical or chemical.
Seclusion and/or restraint must never be used for:
o Convenience of the staff
o Punishment of the client
o Clients who are extremely physically or mentally unstable
o Clients who cannot tolerate the decreased stimulation of a seclusion room
RN can apply restraints without an order, however:
o A written order must be obtained within 15-30min!!!
o The treatment must be ordered by the PCP in writing
o The order must specify the duration of treatment
o The provider must rewrite the order, specifying the type of restraint, every 24hr or the
frequency of the time specified by the facility policy
Nursing responsibilities must be identified in the protocol, including how often the client shouldbe:
o Assessed (including for safety and physical needs), and the client’s behavior documented
■ Physical restraints require one-on-one observation
o Offered food and fluid
o Toileted
o Monitored for VS
o Complete documentation includes
■ Precipitating events and behavior of the client prior to seclusion or restraint
■ Alternative actions taken to avoid seclusion or restraint
■ The time treatment began
■ The clients current behavior, what foods or fluids were offered and taken, needs
provided for, and VS
■ Medication administration
o False imprisonment - confining a client to a specific area, sch as a seclusion room, is false
imprisonment if the reason for such confinement is for the convenience of the staff.
o Assault - making a THREAT to a client’s person, such as approaching the client in a
threatening manner with a syringe in hand, is considered assault.
o Battery - touching a client in a harmful or offensive way is considered battery. This would
occur if the nurse threatening the client with a syringe actually grabbed the clientand gave
an injection.
Basic Mental Health Nursing Concepts
• Therapeutic Strategies in the Mental Health Setting
■ Counseling
o Using therapeutic communication skills
o Assisting with problem solving
o Crisis intervention
o Stress management
Milieu therapy
o Orienting the client to the physical setting
o Identifying rules/boundaries of the setting
o Ensuring a safe environment for the patient
o Assisting the patient to participate in appropriate activities
Promotion of self-care activities
o Offering assistance with self-care tasks
o Allowing time for the patient to complete self-care tasks
o Setting incentives to promote client self-care
Psychobiological interventions
o Administering prescribed medications
o Providing teaching for the patient/family about medications
o Monitoring for adverse effects and effectiveness of pharmacological therapy
Cognitive and behavioral therapies
o Modeling
o Operant conditioning
o Systematic desensitization
Health teaching
o Teaching social/coping skills
Health promotion and health maintenance
o Assisting the patient with cessation of smoking
o Monitoring other health conditions
Case management
o Coordinating holistic care to include medical, mental health, and social services
Types of Admission to a Mental Health Facility:
Voluntary admission: client or client’s guardian chooses admission in order to obtain treatment—has
right to apply for release at any time. The pt is also considered competent, and has the right to refuse
Temporary emergency admission: pt is admitted for emergent mental health care due to the inability to
make decisions regarding care—healthcare provider may initiate the admission whichis then evaluated
by mental healthcare provider. Usually does not exceed 15 days.
Involuntary admission: against his/her will for an indefinite period of time. Pt may be risk of harmto self
or others or unable to provide self-care. Usually 2 physicians are required to certify that the pt’s
condition requires commitment varies from state to state. Limited to 60 days. Are still considered
competent and have right to refuse treatment.
Long-term involuntary admission: usually 60-180 days
Legal Rights of Clients in the Mental Health Setting:
◊ Guaranteed the same rights as any other civilian
o Right to humane treatment and care
o Right to vote
o Right to informed consent and right to refuse treatment
o Right to confidentiality
o Right to communication with people outside the mental health facility
Nonverbal communication
o Nurses should be aware of how they communicate nonverbally. The nurse should assessthe
client’s nonverbal communications for the meaning being conveyed, remembering that culture
impacts interpretation. Attention to the following behaviors is important, as itis compared to
the verbal message being conveyed
■ Appearance
■ Posture
■ Gait
■ Facial expressions
■ Eye contact
■ Gestures
■ Sounds
■ Personal space
■ Silence
Therapeutic communication is the PURPOSEFUL use of communication to build and maintain
helping relationships with clients, families, and significant others.
Characteristics of therapeutic communication include:
o Client centered – not social or reciprocal
o Purposeful, planned, and goal-directed
Barriers to effective communication (KNOW THESE; KNOW
o Asking irrelevant personal questions
o Offering personal opinions
o Giving advice
o Giving false reassurance
o Minimizing feelings
o Changing the topic
o Asking “why” questions
o Offering value judgments
o Excessive questioning
o Responding approvingly or disapprovingly
Effective Communication Skills:
◊ Silence: allows time for meaningful reflection
◊ Active listening
◊ Clarifying techniques
o Restating
o Reflecting
o Paraphrasing
o Exploring
◊ Offering self
◊ Touch (if appropriate)
■ Adaptive use of defense mechanism helps people to achieve their goals in acceptable ways.
■ Defense mechanisms become maladaptive when they interfere with functioning, relationships,
and orientation to reality
■ Defense mechanisms:
o Altruism - dealing with anxiety by reaching out to others; no maladaptive use
■ A nurse who lost a family member in a fire is a volunteer firefighter
o Sublimation - dealing with unacceptable feelings or impulses by unconsciously
substituting acceptable forms of expression
■ A person who has feelings of anger and hostility toward his work supervisor
sublimates those feelings by working out vigorously at the gym during his lunch
o Suppression - voluntarily denying unpleasant thoughts and feelings
■ A person who has lost his job states he will worry about paying his bills next week.
o Repression - putting unacceptable ideas, thoughts, and emotions out of conscious
■ A person who has a fear of the dentist’s drill continually “forgets” his dental
o Displacement - shifting feelings r/t an object, person, or situation to another less
threatening object, person, or situation
■ A person who is angry about losing his job destroys his child’s fave toy
o Reaction formation - overcompensating or demonstrating the opposite behavior of whatis felt
■ A person who dislikes her sister’s daughter offers to babysit so that her sister can go
out of town.
o Undoing - performing an act to make up for prior behavior
■ An adolescent completes his chores without being prompted after having an
argument with his parent.
o Rationalization - creating reasonable and acceptable explanations for unacceptable
■ A young adult explains he had to drive home from a party after drinking alcohol
because he had to feed his dog.
o Dissociation - temporarily blocking memories and perceptions from consciousness
■ An adolescent witnesses a shooting and is unable to recall any details of the event.
o Splitting - demonstrating an inability to reconcile negative and positive attributes of selfor
others; no adaptive use
■ A client tells a nurse that she is the only one who cares about her, yet the following
day, the same client refuses to talk to the nurse.
o Projection - blaming others for unacceptable thoughts and feelings
■ A young adult blames his substance use disorder on his parent’s refusal to buy hima
new car
o Denial - pretending the truth is not reality to manage the anxiety of acknowledging whatis
■ A parent who is informed that his son was killed in combat tells everyone he is
coming home fro the holidays.
o Regression - demonstrating behavior from an earlier developmental level; often exhibitedas
childlike or immature behavior
■ A school-age child begins wetting the bed and sucking his thumb after learning his
parents are separating.
o Levels of anxiety
■ Mild
• Occurs in the normal experience of everyday living
• It increases one’s ability to perceive reality
• There is an identifiable cause of the anxiety
• Other characteristics include:
o Vague feeling of discomfort
o Restlessness
o Irritability
o Impatience
o Apprehension
• The client may exhibit behaviors such as finger- or foot-tapping, fidgeting, or
lip-chewing as mild tension-relieving behaviors.
■ Moderate
• Occurs when mild anxiety escalates
• Slightly reduced perception and processing of information occurs, and
selective inattention may occur
• Ability to think clearly is hampered, but learning and problem solving may
still occur
• Other characteristics include:
o Concentration difficulties
o Tiredness
o Pacing
o Change in voice pitch
o Voice tremors
o Shakiness
o Increased HR and RR
• The client may report somatic complaints including headaches, backache,
urinary urgency and frequency, and insomnia
• The client with this type of anxiety usually benefits from the direction of
■ Severe
• Perceptual field is greatly reduced with distorted perceptions
• Learning and problem solving do not occur
• Functioning is ineffective
• Other characteristics include:
o Confusion
o Feelings of impending doom
o Hyperventilation
o Tachycardia
o Withdrawal
o Loud and rapid speech
o Aimless activity
• The client with severe anxiety usually is not able to take direction from
■ Panic-level
Characterized by markedly disturbed behavior
The client is not able to process what is occurring in the environment and
may lose touch with reality
The client experiences extreme fright and horror
The client experiences severe hyperactivity or flight
Immobility can occur
Other characteristics may include:
o Dysfunction in speech
o Dilated pupils
o Severe shakiness
o Severe withdrawal
o Inability to sleep
o Delusions
o Hallucinations
Nursing Interventions:
◊ Mild to moderate anxiety
■ Open-ended questions, giving broad openings, seeking clarification
■ Express feelings, develop trust, and identify the source of anxiety
Provide a calm presence, evaluate past coping mechanisms, encourage
participation in activities
Severe to panic-level anxiety
■ Remain with patient! Provide a quiet environment with minimal stimulation
■ Set limits by using short, firm, & simple statements
■ Direct patient to acknowledge reality and what is really happening!
Milieu Therapy
Creates an environment that is supportive, therapeutic, & safe
o Community meetings
o Individual therapy
o Recreational activities
o Unstructured, flexible time
o Psychoeducational groups
Therapeutic Nurse – Client Relationship
Roles of the nurse
o Consistently focus on the patient’s ideas, experiences, & feelings
o Discuss problem-solving alternatives
o Encourage positive behavior change
Phases & Tasks of the Nurse – Client Relationship (know these)
Orientation: client agrees to contract, understands limits of confidentiality, participates in settinggoals,
and explores the meanings of own behaviors
Working: nurse performs ongoing assessment, facilitates the patient’s expression of needs/issues,
promotes patient’s self-esteem, reassesses patient’s problems & goals, reminds patient about date of
Termination: nurse will provide patient the opportunity to discuss feelings about termination,
summarize goals/achievements, maintain limits of termination, rearview memories of work in
session; client will discuss thoughts and feelings, plans to continue new behaviors, plans for the
future, & accept termination as final
Boundaries of the Therapeutic Relationship:
■ Transference: occurs when the client views a member of the health car team as having
characteristics of another person who has been significant to the client’s personal life.
o Example: A client may see a nurse as being like his mother, and thus may demonstratesome
of the same behaviors with the nurse as he demonstrated with his mother.
o Nursing implication: A nurse should be aware that transference by a client is more likelyto
occur with a person in authority
■ Countertransference: occurs when a health care team member displaces characteristics of
people in her past onto a client.
o Example: A nurse may feel defensive and angry with a client for no apparent reason if theclient
reminds her of a friend who often elicited those feelings.
o Nursing implication: A nurse should be aware that clients who induce very strong
personal feelings may become objects of countertransference.
Psychoanalysis: a therapeutic process of assessing unconscious thoughts and feelings, and
resolving conflict by talking to a psychoanalyst.
o Past relationships are a common focus for therapy
Psychotherapy: involves more verbal therapist-to-client interaction than classic psychoanalysis
o Client and therapist develop a trusting relationship
o Psychodynamic psychotherapy employs the same tools as psychoanalysis; but focusesmore
on the client’s present state rather than his early life.
o Interpersonal psychotherapy (IPT) assists clients in addressing specific problems. It can
improve interpersonal relationships, communication, role-relationship, and bereavement.
o Cognitive therapy is based on the cognitive model, which focuses on individual thoughtsand
behaviors to solve current problems. It treats depression, anxiety, eating disorders, and other
issues that can improve by changing a client’s attitude toward life experiences.
o Behavioral therapy: is based on the theory that behavior is learned and has consequences.
Abnormal behavior results from an attempt to avoid painful feelings. Changing abnormal or
maladaptive behavior can occur without the need for insight into the underlying cause of the
■ Has been successful in treating clients who have phobias, substance use or
addictive disorders, and other issues.
Stress is the body’s nonspecific response to any demand made upon it.
Anxiety and anger are damaging stressors that cause distress
General Adaptation Syndrome (GAS) is the body’s response to an increased demand
o 1st stage - “fight or flight”
o if stress is prolonged maladaptive responses can occur
Acute Stress
o Apprehension
o Unhappiness or sorrow
o Decreased appetite
o Increased RR, HR, CO, and BP
o Increased metabolism and glucose use
o Depressed immune system
Prolonged stress (Maladaptive response)
o Chronic anxiety or panic attacks
o Depression, chronic pain, sleep disturbances
o Weight gain or loss
o Increased risk for MI, stroke
o Poor diabetes control, htn, fatigue, irritability, decreased ability to concentrate
o Increased risk for infection
o Uses electrical current to induce brief seizure activity while the client is anesthetized
o Indications:
• Clients whose manifestations are not responsive to
• Clients who are actively suicidal or homicidal and for whom there is a needfor
rapid therapeutic response
• Clients who are experiencing psychotic manifestations
■ Schizophrenia
• Spectrum disorders that are less responsive to neuroleptic medications, suchas
schizoaffective d/o
■ Acute Manic Episodes (Bipolar)
• ECT is used for clients who have bipolar d/o with rapid cycling (4 or more
episodes of acute mania within 1 yr) and very destructive behavior
• Both of these features tend to respond poorly to lithium therapy.
• These clients receive ECT and then a regimen of lithium therapy.
o Contraindications:
■ No absolute contraindications for this therapy if it is deemed necessary to save a
client’s life
■ Conditions that place client’s at a higher risk if ECT is used:
• Recent MI
• Hx of CVA
• Cerebrovascular malformation
• Intracranial mass lesion
• Increased intracranial pressure
o Mental health conditions for which ECT has not been found useful include:
■ Substance abuse
■ Personality d/o
■ Dysthymic d/o
■ Cyclothymia
■ Anxiety
o Nursing actions
■ Prepare the client
• Typical course of ECT is 3 x a week for a total of 6-12 tx
• Provider obtains informed consent
• Medication mgmt.
o Any medications that affect the client’s seizure threshold must be
decreased or discontinued several days prior to ECT procedure
o MAOIs and Lithium should be d/c 2 weeks prior to ECT
• Severe HTN should be controlled b/c a short period of HTN occurs
immediately after the ECT procedure
• Any cardiac conditions, such as dysrhythmias, should be monitored and
treated before the procedure
• The RN monitors VS and mental status before and after
• RN assesses the client’s and family’s understanding and knowledge of the
procedure and provides teaching as necessary
• 30 min prior to the beginning of the procedure, an IM injection of atropine
sulfate or glycopyrrolate (Robinul) is given to decrease secretions and
counteract any vagal stimulation
• An IV line is inserted and maintained until full recovery
■ Ongoing care
• ECT is administered early in the AM after the client has fasted for a
prescribed period of time
• A bite guard should be used to prevent trauma
• Electrodes are applied for EEG monitoring
• Client is mechanically ventilated and receives 100% O2
• Ongoing cardiac monitoring is provided, including BP, ECG, and oxygen
• An anesthesia provider administers a short-acting anesthetic, such as
methohexital (Brevital), via IV bolus
• A muscle relaxant is administered, succinylcholine (Anectine)
• A cuff is placed on one leg or arm to block the muscle relaxant so that
seizure activity can be monitored in the lib distal to the cuff
• An electrical stimulus is typically applied for 0.2-0.8 sec; enough to cause a2560 sec seizure
• After seizure activity has ceased, anesthetic is d/c and the client is extubatedand
assisted to breathe voluntarily
■ Postprocedure Care
• Client is transferred to recovery where LOC, cardiac status, VS, and
oxygenation continue to be monitored
• Client is positioned on his side to facilitate drainage and prevent aspiration
Client is monitored for ability to swallow and return of the gag reflex
The client is usually awake and ready for transfer back to the mental health
unit or other facility within 30-60 min after the procedure.
o Complications
■ Memory loss and confusion*
• Short-term memory loss, confusion, and disorientation may occur
immediately following the procedure.
Transcranial Magnetic Stimulation
o TMS is a noninvasive therapy that uses magnetic pulsations to stimulate specific areas ofthe
brain. “wakes the brain up”
o Indications:
■ MDD clients who are nonresponsive to pharmacologic tx
o Nursing Actions
■ Educate the client
• Daily for 4-6 wks
• can be performed as an outpatient
• lasts 30-40 min
• A noninvasive electromagnet is place on the client’s scalp, allowing the
magnetic pulsations to pass through
• Client is alert during the procedure
o Complications
■ Common adverse effects include mild discomfort or a tingling sensation at the siteof
the electromagnet
■ Seizures are a rare but potential complication
Vagus Nerve Stimulation
o VNS provides electrical stimulation through the vagus nerve to the brain through a devicethat
is surgically implanted under the skin on the client’s chest.
o VNS is believed to result in an increased level of NT
o Indications:
■ Depression that is resistant to pharmacological treatment and/or ECT
o Nursing Action:
■ Educate the client about VNS
• Performed as an outpatient surgical procedure
• Delivers around-the-clock programmed pulsations
• Client can turn off the VNS device at any time by placing a special external
magnet over the site of the implant
■ Assist provider in obtaining informed consent
o Complications
■ Voice changes due to the proximity of the implanted lead on the vagus nerve to the
larynx and pharynx
■ Other potential adverse effects include hoarseness, throat or neck pain, dysphagia;
usually improve with time
■ Dyspnea with exertion is possible; therefore, the client may want to turn off the
VNS during exercise.
Elevated or persistent anxiety can result in anxiety disorders causing behavior changes and
impairment in functioning.
Anxiety levels can be:
o Mild - restlessness, increased motivation, irritability
o Moderate - agitation, muscle tightness
o Severe - inability to fxn, ritualistic behavior, unresponsive
o Panic - distorted perception, loss of rational thought, immobility
Recognized anxiety d/o include:
o Separation anxiety d/o: the client experiences excessive fear or anxiety when separatedfrom
an individual to which the client is emotionally attached
o Panic d/o: the client experiences recurrent panic attacks
o Phobias: the client fears a specific object or situation to an unreasonable level
o Generalized anxiety d/o: the client exhibits uncontrollable, excessive worry for more than3
o Not recognized as anxiety d/o by DSM-5
■ Obsessive-compulsive and related d/o
• OCD: the client has intrusive thoughts of unrealistic obsessions and tries to
control these thoughts with compulsive behaviors
• Hoarding d/o: the client has difficulty parting with possessions, resulting in
extreme stress and functional impairments
■ Trauma- and stressor-related d/o
• Acute stress: exposure to a traumatic event causes numbing, detachment,and
amnesia about the event for at least 3 days but for not more than 1 month
following the event
• Posttraumatic stress disorder (PTSD): exposure to traumatic even causes
intense fear, horror, flashbacks, feelings of detachment and foreboding,
restricted affect, and impairment for longer than 1 month after the event.
Manifestations may last for years.
o Risk factors
■ Anxiety disorders are much more likely to occur in women; OCD has equal
■ Exposure to traumatic event or experience, such as military combat
o Panic disorders
■ Panic attacks typically last 15-30 min
■ For or more of the following manifestations are present during a panic attack:
• Palpitations
• Chocking or smothering sensation
• Chest pain
• Nausea
• Feelings of depersonalization
• Fear of dying or insanity
• Chills or hot flashes
o Phobias
Social phobia: the client has a fear of embarrassment, is unable to perform in frontof
others, has a dread of social situations, believes that others are judging him negatively,
and has impaired relationships
Agoraphobia: the client avoids being outside and has an impaired ability to work or
perform duties
Specific phobias
• The client has a fear of specific objects, such as spiders, snakes, strangers
• The client has a fear of specific experiences, such as flying, being in the
dark, riding in an elevator, being in an enclosed space.
■ The client exhibits uncontrollable, excessive worry for more than 3 months
■ Causes significant impairment in one or more areas of functioning
■ Manifestations include:
• Restlessness
• Muscle tension
• Avoidance of stressful activities or events
• Increased time and effort required to prepare for stressful activities or events
• Procrastination in decision-making
• Seeks repeated assurance
o Obsessive-compulsive and related d/o
■ OCD - persistent thoughts or urges that the client attempts to suppress through
compulsive or obsessive behaviors that can result in impaired social and
occupational functioning.
■ Hoarding - client has obsessive desire to save items regardless of value and can
often lead to an unsafe living environment.
o Specific therapies include:
■ CBT - anxiety response can decrease by changing cognitive distortions; helps theclient
identify negative thoughts that produce anxiety, examine the cause, and
develop supportive ideas that replace negative self-talk
■ Behavioral therapies - teach clients ways to decrease anxiety or avoidant behaviorand
allow an opportunity to practice techniques
• Relaxation training - used to control pain, tension, and anxiety
Modeling - allows a client to see a demonstration of appropriate behaviorin a
stressful situation; goal is for the client to imitate the behavior.
Systematic desensitization - begins with mastering of relaxation techniques.
Then the client is exposed to increasing levels of an anxiety producing
stimulus and uses relaxation to overcome the resulting anxiety;goal is to
build a tolerance until anxiety no longer interferes.
Flooding - involves exposing the client to great deal of an undesirable
stimulus in an attempt to turn off the anxiety response. (phobias)
Response prevention - focuses on preventing the client from performing a
compulsive behavior with the intent that anxiety will diminish.
Thought stopping - teaches the client to say “stop” when negative thoughtsor
compulsive behaviors arise and substitute a positive thought.
o Medications
■ SSRIs antidepressants such as sertraline (Zoloft) are the first line of treatment for
trauma- and stressor-related d/o
■ Benzos are indicated for short-term use
Buspirone (BuSpar) is used to manage anxiety
Nursing Care:
Provide safety & comfort
Remain with patient
Perform a suicide risk assessment
Safe environment
Open-ended questions
Identify defense mechanisms that interfere with recovery
Postpone health teaching until anxiety attack subsides
Depression may be comorbid with the following:
o Anxiety
o Psychotic
o Substance use
o Eating
o Personality
A client who has depression has a potential risk for suicide, especially if he has a family or
personal history of suicide attempts, or comorbid disorders
MDD is a single episode or recurrent episodes of unipolar depression (not associated with mood
swings from major depression to mania) resulting in a significant change in a client’s normal
functioning (social, occupational, self-care) accompanied by at least 5 of the following specific clinical
findings, which must occur almost every day for a minimum of 2 weeks, and last most ofthe day:
o Depressed mood
o Difficulty sleeping or excessive sleeping
o Indecisiveness
o Decreased ability to concentrate
o Suicidal ideation
o Increase or decrease in motor activity
o Inability to feel pleasure
o Increase or decrease in weight of more than 5% of total body weight over 1 month.
MDD may be further diagnosed:
o Psychotic features: the presence of AH or the presence of delusions
o Postpartum: a depressive episode that begins within 4 weeks of childbirth and may include
delusions, which may put the newborn infant at high risk of being harmed by themother
o Seasonal characteristics: seasonal affective disorder (SAD), which occurs during winterand
may be treated with light therapy.
Dysthymic disorder is a milder form of depression that usually has an early onset, such as in
childhood or adolescence, and lasts at least 2 years in length for adults (1 year in length for children)
dysthymic disorder contains at least 3 clinical findings of depression and may, later inlife, become
o Risk factors
■ Family history and a previous personal history of depression
Twice as common in females btwn 15-40 than in males
Neurotransmitter deficiencies
• Serotonin - affects mood, sexual behavior, sleep cycles, hunger, and pain
• NE - affects attention and behavior
■ Stressful life events
■ Presence of a medical illness
■ Being a female in the postpartum period
■ Poor social support network
■ Comorbid substance abuse disorder
■ Being unmarried
o Findings:
■ Subjective
• Anergia
• Anhedonia
• Anxiety
• Reports of sluggishness, or feeling unable to relax and sit still
• Vegetative findings, which include a change in eating patterns (usually
anorexia in MDD, increased intake in dysthymia, and PMDD), change in
bowel habits (usually constipation), sleep disturbances and decreased interest
in sexual activity
• Somatic reports, such as fatigue, GI changes, pain
■ Objective
• Affect – the client most often looks sad with blunted affect
• The client exhibits poor grooming and lack of hygiene
• Psychomotor retardation (slowed physical movement, slumped posture), but
psychomotor agitation (restlessness, pacing, finger tapping) can also occur
• Client becomes socially isolated, showing little or no effort to interact
• Slowed speech, decreased verbalization, delayed response – the client mayseem
too tired even to speak.
Nursing care:
Suicide risk – assess the client’s risk for suicide and implement appropriate safety precautions
Self-care – encourage independence
Thirty minutes of exercise daily for 3-5 days each week improves depression and helps preventrelapse
Tricyclic Antidepressants (TCAs)
o Prototype: amitriptyline (Elavil)
o Other medications
■ imipramine (Tofranil)
■ doxepin (Sinequan)
■ nortriptyline (Aventyl, Pamelor)
■ amoxapine (Asendin)
■ trimipramine (Surmontil)
o Action:
■ Block the reuptake of NE and SERO in the synaptic space
o Therapeutic uses:
■ Depressive disorders
o Other uses
■ Neuropathic pain
■ Fibromyalgia
■ Anxiety d/o
■ Insomnia
o Adverse Effects:
■ Orthostatic hypotension
■ Anticholinergic effects
• dry mouth, blurred vision, photophobia, urinary hesitancy or retention,
constipation, tachycardia
■ Sedation
■ Toxicity resulting in cholinergic blockade and cardiac toxicity evidenced by
dysrhythmias, mental confusion, and agitation, which are followed by seizures,
coma, and possible death
■ Decreased seizure threshold
■ Excessive sweating
o Contraindicated:
■ Pt’s with seizure d/o
o Medication/Food Interactions
■ Concurrent use with MAOIs may cause severe HTN
■ Concurrent use with antihistamines and other anticholinergic agents may result in
additive anticholinergic effects
■ Concurrent use with direct-acting sympathomimetics may result in increased effects
of these medications, because uptake is blocked by TCAs
■ Concurrent use with indirect-acting sympathomimetics may result in decreased effect
of these medications, due to the inhibition of their uptake and inability to getto the site
of action in the nerve terminal
■ Concurrent use with alcohol, benzos, opioids, and antihistamines may result in
additive CNS depression.
SSRIs (x’s and z’s)
o Prototype: fluoxetine (Prozac)
o Other medications:
■ citalopram (Celexa)
■ escitalopram (Lexapro)
■ paroxetine (Paxil)
■ sertraline (Zoloft)
■ vilazodone (Viibryd)
o Action:
■ Selectively block reuptake of serotonin in the synaptic space
o Therapeutic uses:
■ Major depression
■ Bulimia nervosa
■ Panic d/o
o Adverse effects:
■ Sexual dysfunction
■ CNS stimulation (insomnia, agitation, anxiety)
■ Occurrence of weight loss early in therapy that may be followed by weight gainwith
long-term treatment
■ Serotonin syndrome may begin 2-72 hrs after start of treatment
• Manifestations include:
o Mental confusion, difficulty concentrating
o Abdominal pain
o Diarrhea
o Agitation
o Fever
o Anxiety
o Hallucinations
o Hyperreflexia, incoordination
o Diaphoresis
o Tremors
■ Withdrawal syndrome (headache, nausea, visual disturbances, anxiety, dizziness,and
■ Rash
■ Sleepiness, faintness, lightheadedness
■ GI bleeding
■ Bruxisim
o Contraindications
■ Clients taking MAOIs or TCAs
o Medication/Food interactions
■ Concurrent use with MAOIs, TCAs, or St. John’s wort increases the risk of serotonin
syndrome (treated with peractin)
■ Concurrent use with warfarin (Coumadin) can displace warfarin from bound
protein and result in increased warfarin levels.
■ Concurrent use with TCAs and lithium may result in increased levels of these
■ Concurrent use with NSAIDs and anticoagulants can further suppress platelet
aggregation thereby increasing the risk of bleeding.
o Prototype: phenelzine (Nardil)
o Other medications:
■ isocarboxazid (Marplan)
■ tranylcypromine (Parnate)
■ selegiline (Emsam) – transdermal patch
o Action:
■ Block MAO in the brain, thereby increasing the amount of NE, dopa, and serotonin
available for transmission of impulses.
Therapeutic uses:
■ Depression
■ Bulimia nervosa
o Adverse Effects:
■ CNS stimulation (agitation, anxiety hypomania, mania)
■ Orthostatic hypotension
■ Hypertensive crisis resulting from intake of dietary tyramine – severe hypertensionas
a result of intensive vasoconstriction and stimulation of the heart.
• Manifestations include:
o HA
o Nausea
o Tachycardia
■ Local rash associated with transdermal preparation
o Contraindications/Precautions
■ Contraindicated in clients taking SSRIs, or clients who have pheochromocytoma,
heart failure, cardiovascular and cerebral vascular disease, and/or sevre renal
■ Transdermal selegiline (Emsam) is contraindicated for clients taking carbamazepine
(Tegretol) or oxcarbazepine (Trileptal). Concurrent use of these medications may
increase blood levels of the MAOI.
o Mediation/Food Interactions:
■ Concurrent use with indirect-acting sympathomimetic medications can promotethe
release of NE and lead to hypertensive crisis
■ Concurrent use with TCAs can lead to hypertensive crisis
■ Concurrent use with SSRIs can lead to serotonin syndrome
■ Concurrent use with antihypertensive may cause additive hypotensive effects
■ Concurrent use with meperidine (Demerol) can lead to hyperpyrexia
■ Hypertensive crisis can result from intake of dietary tyramine
• Tyramine-rich foods include aged cheese, pepperoni, salami, avocados, figs,
bananas, smoked fish, protein, some dietary supplements, some beers, and red
■ Concurrent use with vasopressors may result in hypertension
Atypical Antidepressants
o Prototype: bupropion (Wellbutrin)
o Action:
■ Inhibits dopamine uptake
o Therapeutic uses:
■ Treatment of depression
■ Alternative to SSRIs for clients unable to tolerate the sexual dysfunction side effects
■ Aid to quit smoking
■ Prevention of seasonal pattern depression
o Adverse effects:
■ HA, dry mouth, GI distress, constipation, increased HR, nausea, restlessness,
■ Suppression of appetite
■ Seizures
o Contraindications:
■ Contraindicated in clients who have a sz d/o
■ Contraindicated in clients who have anorexia nervosa or bulimia nervosa
■ Contraindicated in clients taking MAOIs
o Medication/Food Interactions:
■ Concurrent use with MAOIs, such as phenelzine (Nardil), may increase the risk for
o Other Medications:
■ venlafaxine (Effexor)
■ duloxetine (Cymbalta)
■ desvenlafaxine (Pristiq)
• Action:
o Inhibit Sero and NE reuptake
• Adverse effects:
o HA, nausea, agitation, anxiety, and sleep disturbances
■ mirtazapine (Remeron)
• Action: increases the release of serotonin and NE
• Therapeutic effects may occur sooner, and with less sexual dysfunction,
than with SSRIs
■ reboxetine (Edronax)
• Action:
o Inhibits the reuptake of NE
• Adverse effects:
o Dry mouth, decreased BP, constipation, sexual dysfunction, and
urinary retention.
■ trazodone (Desyrel)
• Action:
o Blocks serotonin receptors
• Adverse effects:
o This agent is usually used with another antidepressant agent. Sedation
may be an issue; therefore, it may be indicated for a clientwith
insomnia caused by an SSRI. Advise the client to take at bedtime.
o Priapism may be a serious adverse effect, and clients should be
instructed to seek medical attention immediately if this occurs.
Therapeutic effects may not be experience for 1-3 wks; full therapeutic effects may take 2-3
Mood disorders with recurrent episodes of depression and mania
Usually emerge in late adolescence/early adulthood but can be diagnosed in the school-age child
Psychotic, paranoid, and/or bizarre behavior may be seen during periods of mania
Behaviors shown with bipolar disorders
o Mania - an abnormally elevated mood, which may also be described as expansive or
irritable; usually requires hospitalization
o Hypomania - a less severe episode of mania that lasts at least 4 days accompanied by 34 findings of mania. Hospitalization, however, is not required, and the client who hashypomania
is less impaired.
o Mixed episode - a manic episode and an episode of major depression experienced by
the client simultaneously. The client has marked impairment in functioning and may
require admission to an acute care mental health facility to prevent self-harm or otherdirected violence.
o Rapid cycling - four or more episodes of acute mania with 1 year.
The various bipolar disorders:
o Bipolar I disorder: the client has at least 1 episode of mania alternating with major
o Bipolar II disorder: the client has 1 or more hypomanic episodes alternating with major
depressive episodes.
o Cyclothymia: the client has at least 2 years of repeated hypomanic manifestations that donot
meet the criteria for hypomanic episodes alternating with minor depressive episodes.
Risk factors:
o Genetics
o Psychological, such as stressful events or major life changes
o Physiological, such as neurobiological and neuroendocrine disorders
o Substance use disorder, such as alcohol or cocaine use disorder
o Use of substances can lead to an episode of mania
o Sleep disturbances may come before, be associated with, or be brought on by an episodeof
o Psychological stressors can trigger an episode of mania
Bipolar clinical manifestations:
o Manic characteristics:
■ Labial mood with euphoria
■ Agitation and irritability
■ Restlessness
■ Dislike of interference and intolerance of criticism
■ Increasing in talking and activity
■ Flight of ideas – rapid, continuous speech with sudden and frequent topic change
■ Grandiose view of self and abilities
■ Impulsivity – spending money, giving away money or possessions
■ Demanding and manipulative behavior
■ Distractibility and decreased attention span
■ Poor judgment
■ Attention-seeking behavior, flashy dress and makeup, inappropriate behavior
■ Impairment in social and occupational functioning
■ Decreased sleep
■ Neglect of ADLs
■ Possible presence of delusions and hallucinations
■ Denial of illness.
o Depressive characteristics:
■ Flat, blunted, labile affect
■ Tearfulness, crying
■ Lack of energy
■ Anhedonia
■ Physical reports of discomfort/pain
■ Difficulty concentrating, focusing, problem-solving self-destructive behavior,
including SI
■ Decrease in personal hygiene
■ Loss or increase in appetite and/or sleep, disturbed sleep
■ Psychomotor retardation or agitation.
o Nursing care
Acute manic episode
• Focus is on safety and maintaining physical health***
• Provide a safe environment; protect patient from poor judgment and
impulsive behaviors
• Maintenance of self-care needs
o Monitor sleep, fluid intake, and nutrition
o Give step-by-step reminders for hygiene/dress
o Medications:
■ Mood stabilizers
• lithium carbonate (Lithobid)
• Anticonvuslants that act as mood stablizers include:
o Valproic acid (Depakote)
o Clonazepam (Klonopin)
o Lamotrigine (Lamictal)
o Gabapentin (Neurontin)
o Topiramate (Topax)
• Benzos
o Lorazepam (Ativan)
o Used on a short-term basis for client experiencing sleep impairmentr/t
• Antidepressants
o SSRIs fluoxetine (Prozac), used to mange a major depressive episode.
o Therapeutic procedures
Bipolar is primarily managed with mood-stabilizing medications such as lithium carbonate
(Lithobid, Lithane)
Can also be treated with certain antiepileptic medicatons:
o valporic acid (Depakote)
o carbamazepine (Tegretol)
o lamotrigine (Lamictal)
Other medications used for bipolar disorder include:
o Atypical antipsychotics: these can be useful in early treatment to promote sleep and to
decrease anxiety and agitation.
o Anxiolytics: clonazepam (Klonopin) and lorazepam (Ativan) can be useful intreating acute
mania and managing the psychomotor agitation often seen in mania
o Antidepressants: mediations such as bupropion (Wellbutrin) and sertraline (Zoloft) are
useful during the depressive phase.
Mood Stabilizers
o Prototype: lithium carbonate (Lithobid)
o Action:
■ Produces neurochemical changes in the brain, including serotonin receptor
■ Decreases neuronal atrophy and/or increases neuronal growth
o Lithium is used in the treatment of bipolar disorders. Lithium controls episodes of acute
mania, helps to prevent the return of mania or depression, and decreases the incidence of
o Adverse effects:
■ GI distress (nausea, diarrhea, abdominal pain)
■ Fine hand tremors that can interfere with purposeful motor skills and can be
exacerbated by factors such as stress and caffeine
■ Polyuria, mild thirst
■ Weight gain
■ Renal toxicity
■ Goiter and hypothyroidism with long-term treatment
■ Brady dysrhythmias, hypotension, electrolyte imbalances.
o Lithium Toxicity
■ Early indications
• < 1.5 mEq/L
• diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand
tremors, slurred speech.
■ Advanced indications
• 1.5 – 2 mEq/L
• mental confusion, poor coordination, coarse tremors, and ongoing GI
distress, including nausea vomiting, and diarrhea
■ Severe toxicity:
• 2-2.5 mEq/L
o Extreme polyuria of dilute urine, tinnitus, blurred vision, ataxia,
seizures, severe hypotension leading to coma, and possible deathfrom
resp complications
• > 2.5 mEq/L
o rapid progression of manifestations leading to coma and death
o need HD
o Contraindications/Precautions
■ Discourage clients from breastfeeding
■ Use cautiously in clients who have renal dysfunction, heart disease, sodium
depletion, and dehydration.
o Medication/Food Interactions
■ Diuretics – sodium is excreted with the use of diuretics; with decreased serum
sodium, lithium excretions is decreased, which can lead to toxicity
■ NSAIDs – concurrent use will increase renal reabsorption of lithium, leading to
■ Anticholinergics – abdominal discomfort can result from anticholinergic-induced
urinary retention and polyuria.
o Nursing Actions:
■ Monitor lithium levels; initially q2-3 days until stable, and then every 1-3 months.
Lithium blood levels should be obtained in the morning, usually 12 hr after last
• During initial treatment of a manic episode levels should be between 0.81.4 mEq/L
• Maintenance level range is between 0.4-1 mEq/L
• Plasma levels > 1.5 mEq/L can result in toxicity
■ Should be administered in 2-3 doses daily due to short half-life
■ Taking lithium with food decreases GI distress
■ Stress importance of adequate fluid and sodium intake
Mood Stabilizers – Antiepileptic Drugs
o Prototype:
■ carbamazepine (Tegretol, Equetro)
■ valproic acid (Depakote)
■ lamotrigine (Lamictal)
o Action:
■ Slows the entrance of sodium and calcium ack intothe neuron, thus extending thetime
it takes for the nerve to return to its active state
■ Potentiates the inhibitory effects of GABA
■ Inhibits glutamic acid, which in turn suppresses CNS excitation.
o Therapeutic Uses:
■ Used to treat manic and depressive episodes, as well as to prevent relapse of maniaand
depressive episodes.
o Adverse Effects:
■ carbamazepine (Tegretol)
• Nystagmus
• Double vision
• Vertigo
• Staggering gait
• Headache
• Blood dyscrasias (leukopenia, anemia, thrombocytopenia)
• Teratogenesis
• Hypo-osmolarity – promotes secretion of ADH, which inhibits water excretion
by the kidneys, and places the client who has heart failure at riskfor fluid
• Skin disorders, including dermatitis, rash
■ lamotrigine (Lamictal)
• doubled or blurred vision, dizziness, headache, nausea, vomiting
• Serious skin rashes
■ Valproic acid (Depakote)
• GI effects including N&V, and indigestion
• Hepatotoxicity AEB anorexia, nausea, vomiting, fatigue, abdominal pain,
• Pancreatitis AEB N&V, abdominal pain
• Thrombocytopenia
• Teratogenesis
o Contraindications/Precautions
■ Carbamazepine (Tegretol) is contraindicated in clients who have bone marrow
suppression or bleeding disorders****
■ Valproic acid (Depakote) is contraindicated in clients who have liver disorders.
o Medication/Food Interaction:
■ Carbamazepine (Tegretol)
• Oral contraceptives, Coumadin; concurrent use causes a decrease in the
effects of these medications due to stimulation of hepatic and drugmetabolizing enzymes
Grapefruit juice – inhibits metabolism of Tegretol, thereby increasing blood
• Phenytoin, phenobarbital – concurrent use decreases the effects of Tegretolby
stimulating metabolism
Lamotrigine (Lamictal)
• Tegretol, phenytoin, phenobarbital – concurrent use decreases the effect of
• Valproic acid – concurrent use inhibits drug-metabolizing enzymes, thereby
increasing the half-life of Lamictal
• Oral contraceptives – concurrent use decreases the effectiveness of both
Valproic acid (Depakote)
• Phenytoin, phenobarbital – serum levels of these medications are increased
when used concurrently with valproic acid.
Schizophrenia spectrum and other psychotic disorders affect thinking, behavior, emotions, andthe
ability to perceive reality.
Typical age of onset is late teens and early 20s
The following various types of psychotic disorders are recognized:
o Schizophrenia: the client has psychotic thinking or behavior present for at least 6 months.
Areas of functioning, including school or work, self-care, and interpersonal relationships, are
significantly impaired.
o Schizotypal personality disorder: the client has impairments of personality (self and
interpersonal) functioning. However, impairment is not as severe as with schizophrenia
o Delusional disorder: the client experiences delusional thinking for at least 1 month. Selfor
interpersonal functioning is not markedly impaired
o Brief psychotic disorder: the client has psychotic manifestations that last between 1 day to1
month in duration
o Schizophreniform disorder: the client has manifestations similar to those of schizophrenia, but
the duration is from 1-6 months, and social/occupational dysfunction may or may not be
o Schizoaffective disorder: the client’s disorder meets both the criteria for schizophrenia and
depressive or bipolar disorder.
o Substance-induced psychotic disorder: the client experiences psychosis within 1 month of
substance intoxication or withdrawal. May be caused by medications intended for therapeutic
Characteristics of psychotic disorders
o Positive symptoms - the manifestations of things that are not normally present.
■ Hallucinations
■ Delusions
■ Alterations in speech
■ Bizarre behavior, such as walking backward constantly
o Negative symptoms - the absence of things that are normally present
■ Affect – usually blunted (narrow range of normal expression) or flat (facial
expression never changes)
■ Alogia – poverty of thought or speech; the client may sit with a visitor but may only
mumble or respond vaguely to questions
Avolition – lack of motivation in activities and hygiene; for example, the client
completes assigned tasks, such as making his bed, but is unable to start the next
common chore without prompting.
o Cognitive symptoms - problems with thinking make it very difficult for the client to live
■ Disordered thinking
■ Inability to make decision
■ Poor problem-solving ability
■ Difficulty concentrating to perform tasks
■ Memory deficits
• Long-term memory
• Working memory, such as inability to follow directions to find an address.
o Affective symptoms - manifestations involving emotions
■ Hopelessness
Alterations in thought (delusions) are false fixed beliefs that cannot be corrected by reasoning andare
usually bizarre. Include:
o Ideas of reference: misconstrues trivial events and attaches personal significance to them,such
as believing that others, who are discussing the next meal, are talking about him
o Persecution: feels singled out for harm by others (being hunted down by the FBI)
o Grandeur: believes that she is all powerful and important, like god
o Somatic delusions: believes that his body is changing in an unusual way, such as growinga
third arm
o Jealousy: may feel that her spouse is sexually involved with another individual
o Being controlled: believes that a force outside his body is controlling him
o Thought broadcasting: believes that her thoughts are heard by others
o Thought insertion: believes that others’ thoughts are being inserted into his mind
o Thought withdrawal: believes that her thoughts have been removed from her mind by an
outside agency
o Religiosity: is obsessed with religious beliefs
Alterations in speech
o Flight of ideas - associative looseness; the client may say sentence after sentence, but each
sentence may related to another topic, and the listener is unable to follow the client’sthoughts
o Neologisms - made-up words that have meaning only to the client, such as “I tranged
and flitteled”
o Echolalia - the client repeats the words spoken to him
o Clan association - meaningless rhyming of words, often forceful, such as “oh fox, box,and
o Word salad - words jumbled together with little meaning or significance to the listener,
such as, “hip hooray, the flip is cast and wide-sprinting in the forest.”
Medications are used to treat:
o Positive symptoms r/t behavior, though, and speech (agitation, delusions, hallucinations,
tangential speech patterns)
o Negative symptoms (social withdrawal, lack of emotion, lack of energy, flattened affect,
decreased motivation, decreased pleasure in activities)
o 1st generation (conventional) antipsychotic medications are used mainly to control positive
symptoms and re reserved for clients who are:
■ Using them successfully and con tolerate the adverse effects
■ Violent or particularly aggressive
o 2
generation (atypical) antipsychotic agents are the current medications of choice for
clients receiving initial treatment, and for treating breakthrough episodes in clients on
conventional medication therapy, because they are more effective with fewer adverse
■ Advantages of Atypical Antipsychotic Agents
• Relief both positive and negative symptoms
• Decrease in affective findings (depression, anxiety) and suicidal behaviors
• Improvement of neurocognitive defects, such as poor memory
• Fewer or no EPS, including tardive dyskinesia, due to less dopamine
• Fewer anticholinergic effects, with the exception of clozapine (Clozaril),
which has a high incidence of anticholinergic effects.
• Less relapse.
o 1st Generation Antipsychotics (Conventional)
■ Prototype: chlorpromazine (Thorazine), low potency
■ Other medications:
• haloperidol (Haldol), high potency
• fluphenazine, high potency
■ Action:
• Block dopamine (D2), acetylcholine, histamine, and NE receptors in the
brain and periphery
■ Therapeutic Uses:
• Treatment of acute and chronic psychotic d/o
• Schizophrenia spectrum d/o
• Bipolar disorder – primarily the manic phase
• Tourette’s disorder
• Prevention of nausea/vomiting through blocking of dopamine in the
chemoreceptor trigger zone of the medulla
■ Complications
• Agranulocytosis*
• Anticholinergic manifestations
o Dry mouth, blurred vision, photophobia, urinary retention,
constipation, tachycardia
o Acute dystonia
■ Severe spasm of the tongue, neck, face, and back
o Parkinsonism
■ Bradykinesia, rigidity, shuffling gait, drooling, tremors
o Akathisia
■ Inability to sit or stand still
■ Continual pacing and agitation
o Tardive dyskinesia
Late EPS; involuntary movements of the tongue and face, suchas
lip smacking and tongue fasciculations; involuntary movements
of the arms, legs, and trunk
• Neuroendocrine effects
o Gynecomastia, galactorrhea, menstrual irregularities
o Sudden high fever (>101)
o Blood pressure fluctuations
o Dysrhythmias
o Muscle rigidity
o Changes in LOC
o Coma
• Orthostatic Hypotension
• Sedation
• Seizures
• Severe dysrhythmias
• Sexual dysfunction
• Skin effects
o Photosensitivity that can result in severe sunburn; contact dermatitis
from handling medications.
■ Contraindications/Precautions
• Contraindicated in clients who are in a coma, or have severe depression,
Parkinson’s disease, prolactin-dependent cancer of the breast, or severe
• Contraindicated in older adults who have dementia
■ Medication/Food Interaction
• Anticholinergic agents
• CNS depressants – Additive CNS depressants with concurrent use of
alcohol, opioids, and antihistamines
• Levodopa – by activating dopamine receptors, levodopa counteracts effectsof
antipsychotic agents.
■ Nursing Care
• Use AIMS to screen for EPS
• EPS take a CAB
o Cogentin
o Artane
o Benadryl
10 Personality Disorders:
Cluster A (odd/eccentric traits)
Paranoid: distrust/suspiciousness of others based on unfounded beliefs
Schizotypal: odd beliefs leading to interpersonal difficulties, an eccentric appearance, magical
thinking/perceptual distortions that are not clear delusions/hallucinations
Cluster B (dramatic, emotional, or erratic traits)
Antisocial: disregard for others with exploitation, lack of empathy, repeated unlawful actions,deceit, and
failure to accept personal responsibility
Borderline: instability of affect, identity, and relationships, as well as splitting behaviors,
manipulation, impulsiveness, and fear of abandonment; often self-injurious and potentially
suicidal, impulsivity
Histrionic: emotional attention-seeking behavior
Narcissistic: arrogance, grandiose views of self-importance, lack of empathy for others that strains
relationships, sensitive to criticism
Cluster C (anxious/fearful, insecurity/inadequacy)
Avoidant: social inhibition/avoidance of all situations that require interpersonal contact
Obsessive-compulsive: perfectionism with a focus on orderliness/control to the extent thatindividual
might not be able to accomplish a given task
Nursing Care:
Self-assessment is vital for nurses and should be performed prior to care
Safety is always a priority concern because some pts who have a personality disorder are at a riskfor selfinjury/violence
Feelings of being threatened/having no control can cause a pt to act out toward the nurse
Neurocognitive Disorders
Types of Cognitive Disorders:
o Delirium
o Major neurocognitive disorder (dementia)
o Alzheimer’s disease: gradual impairment of cognitive function
Risk Factors:
o Delirium: physiological changes, metabolic/cardiovascular/respiratory disease, infections
(HIV/AIDS), surgery, substance use/withdrawal—timely recognition is essential
o NCD/AD: advanced age, prior head trauma, lifestyle factors, family hx
Stages of Alzheimer’s Disease:
Stage 1: mild
o Memory lapses, losing/misplacing items, difficulty concentrating/organizing, unable to remember
material just read, still able to perform ADLs, short-term memory loss noticeable to close relations
Stage 2: moderate
o Forgetting events of one’s own history, difficulty performing tasks that require
planning/organizing, personality/behavioral changes, changes in sleep patterns, can wander/get
lost, can be incontinent
Stage 3: severe
o Assistance required for ADLs, incontinence, progressing difficulty with physical abilities, death
frequently related to choking/infection
Screening/Assessment Tools:
o Confusion assessment method (CAM)
o Functional dementia scale: pt’s ability to perform self-care, extent of memory loss, mood
changes, and degree of danger to self/others
o Mini-mental status examination (MMSE)
o Functional assessment screening tool (FAST)
Nursing Care:
o Assess for potential injury (falls or wandering)
o Assign the patient to a room close to nurse’s station
o Identify disturbances in physiologic status which can contribute to cause of delirium
o Ensure adequate food/fluid intake (underlying causes of delirium can result in electrolyte
o Reinforce reality
o Reinforce orientation to time, place, and person
o Pt Education
Home Safety Measures –
o Remove scatter rugs
o Install door locks that cannot be easily opened
o Provide good lighting
o Install a handrail on stairs/bathroom
o Remove clutter
o Store cleaning supplies in locked cupboards
o Caregiver support: Encourage caregivers to ask for help form friends/other family for respite care;
Encourage them to take care of themselves and to take one day at a time
Substance Use and Addictive Disorders:
Risk Factors:
o Genetics
o Lowered self-esteem
o Few life successes
o Mental illness
o Male
o Lack of family involvement
o Alaska natives/Native Americans
o Peer pressure
o High stress
Standardized Screening Tools
Michigan Alcohol Screening Test (MAST)
Drug Abuse Screening Test (DAST) or DAST-A (adolescent version)
Cage: determine how they perceive their current alcohol use
Alcohol Use Disorders Identification Test (AUDIT)
Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA)
Clinical Opiate Withdrawal Scale
CNS Depressants
o Death can occur for levels greater than 0.4%
o BAC depends on many factors (body weight, gender, number of drinks, gastric absorption rate,and
individual’s tolerance)
o Effects of excess: slurred speech, nystagmus, memory impairment, altered judgment, decreased
motor skills/LOC, respiratory arrest, death
o Chronic use: cardiovascular damage, liver damage, sexual dysfunction, GI bleeding, pancreatitis
o Withdrawal: cramping, vomiting, tremors, restlessness, inability to sleep, increased
HR/BP/RR/temp., hallucinations/illusions, anxiety, tonic-clonic seizures
o Alcohol withdrawal delirium can occur 2-3 days after cessation of alcohol (MEDICAL
EMERGENCY)—psychotic manifestations, severe hypertension, dysrhythmias, delirium/death
o Benzodiazepines, barbiturates (pentobarbital), club drugs (flunitrazepam)
o Intoxication: increased drowsiness/sedation, agitation, slurred speech, nystagmus, N/V,
respiratory depression, decreased LOC
o Benzodiazepine antidote: flumazenil
o No antidote to revere barbiturate toxicity
o Withdrawal: anxiety, diaphoresis, HTN, hallucinations/illusions, possible seizure (opposite of
what drug does during intoxication)
CNS Stimulants
o Intoxication: hallucinations, seizures, fever, increased HR/BP, chest pain, death
o Withdrawal: depression, excess sleeping/insomnia, agitation; not life threatening, but possible
occurrence of suicidal ideation
o Intoxication: impaired judgment, hypervigilance, irritability, acute cardiovascular effects; death
o Withdrawal is not life threatening
Tobacco (Nicotine)
o Long-term effects: cardiovascular disease, respiratory disease, irritation to oral mucous
membranes with smokeless tobacco
o Withdrawal: irritability, craving, anxiety, insomnia, increased appetite, anger, depressed mood
Opioids (Heroin, morphine, hydromorphone)
o Intoxication: decreased respirations/LOC, impaired judgment, slurred speech, pupillary changes
o Antidote: naloxone
o Withdrawal: sweating/rhinorrhea, piloerection (gooseflesh), tremors, weakness, diarrhea, fever,
insomnia, pupil dilation, N/V, pain in muscles/bones
Nursing Care
Safety is primary focus during acute intoxication or withdrawal
Implement seizure precautions if necessary
Possibly one-on-one supervision
Provide emotional support/reassurance to pt and family