Mental Health Flashcards (Latest Update) Levels of Consciousness • Alert • Lethargic • Obtunded • Stuporous • • • • Patient is Responsive, Opens Eyes Spontaneously, and Answers Questions Appropriately • Patient Can Open Eyes & Respond to Questions, But Falls Asleep Quickly • Patient Responds to Light Shaking, But is Confused & Slow to Respond • Patient Barely Responds to Painful Stimuli (Like Sternal Rub) Comatose • Patient is Unresponsive & Abnormal Posturing May Be Present Decorticate • Arms Flexed & Inwardly Rotated, Legs Extended & Inwardly Rotated Decerebrate • Head Arched Back, Arms & Legs Extended Nursing Ethical Principles • Autonomy • • • • • • Patient has the right to make his/her own decisions, even if not in their best interest Beneficence • Do what is Best for the Patient (Do Good) Fidelity • Keep Your Promises Justice • Provide Fairness in Care & Allocation of Resources Nonmaleficence • Do No Harm Veracity • Tell the Truth Patient Rights • • Refusal of Treatment • Even Pts Who Are Involuntarily Admitted Have the Right to Refuse Treatment Confidentiality • HIPPA States Health Info Cannot be Released W/O the Pt’s Permission • If Someone Calls to Get an Update, Suggest They Reach Out to the Pt’s Family Regarding the Pt’s Condition • • If You Overhear a Convo in the Elevator, Take Immediate Action to Stop the Violation Mandatory Reporting • Nurses are Required to Report Suspicion of Abuse, and to Warn/Protect 3rd Parties Who are at Risk for Harm Informed Consent • • Provider Responsibilities • Communicate Purpose of Procedure, & Complete Description of Procedure in Pt’s Primary Language (Use Interpreter) • Explain Risk v. Benefits • Describe Other Options RN Responsibilities • Make sure Provider Gave the Pt the Above Information • Ensure Pt is Competent to Give Consent (Adult or Emancipated Minor, Not Impaired) • Have Pt Sign Consent • Notify Provider if Pt Has More Questions or Doesn’t Understand Any of the Info Restraints • • • Types • • Alternatives • • • Prescriptions • • • • • Physical (Vest, Belt, Mittens) Chemical (Sedative or Antipsychotic) Reorientation Supervision Diversions Prescriptions Must be in Writing If Need For Constraints Continues, Provider Must Rewrite Rx Every 24 Hours In an Emergency Situation, a Nurse can Use Restraints, But Must Obtain a Written Rx Per Facility Policy (Usually Within 15-30 Mins) Time Limits • Adults (18 & Up): 4 Hours • Ages 9-17: 2 Hours • Ages 8 & Under: 1 Hour Documentation • Complete Every 15-30 Minutes • Include: Precipitating Event, Alternative Interventions Attempted, Time Treatment Began, Medication Administration, Patient Assessment (Current Behavior, VS, Pain), Pt Care Provided (Food, Toileting) • Discontinuation • Restraints Can be Discontinued When Pt Can Follow the Nurse’s Directions Torts • Unintentional • Negligence (Forgetting to Set Bed Alarm for Pt At Risk For Falls) • Malpractice (Medication Error That Harms Pt) • Intentional • Assault (Nurse Threatens Pt) • Battery (Nurse Hits Pt, or Administers Medication Against Their Will) • False Imprisonment (Nurse Inappropriately Restrains a Patient or Administers a Chemical Restraint Such as a Sedative Communication • • • • • • • • • • • • Intrapersonal • Self-Talk, Thinking Thoughts, But Not Verbalizing Them Interpersonal • One-on-one Communication w/ Another Person Open-Ended • Promotes Interactive Discussions Ex. Tell me more…. Closed-Ended • Used to Obtain Specific Data, Use Sparingly as it Can Block Further Communication Restating • Repeat the Pt’s Exact Words Reflecting • Return Focus Back to Pt Paraphrasing • Restate Pt’s Feelings to Confirm Understanding of What Pt is Saying Exploring • Gathering More Info About Something Pt Has Mentioned General Leads • Allows Pt to Guide Discussion Presenting Reality • Communicate What is Actually Happening, Dispel Hallucinations, Delusions, False Beliefs Offering Self • Limited Self-Disclosure by Nurse. Return Focus to Pt as Soon as Possible Right Techniques • Asking Open Ended Questions “Tell Me More…You Seem Angry” to Facilitate Discussion • Maintaining Eye Contact to Convey Interest • Sitting/Standing at Eye Level • • Therapeutic Touch to Convey Caring & Provide Comfort Wrong Techniques • Asking “Why…?” • Offering Your Opinion • Giving False Assurance • Giving Advice • Changing the Subject & Minimizing Pt Feelings Therapeutic Communication With Older Adults • • • • • • Minimize Distractions, Discuss Health in Private Setting Face the Pt When Speaking Use a Lower Pitch of Voice Begin the Interview by Asking the Pt to Identify Their Feelings/Concerns Limit the Number of Items on a Questionnaire When Gathering Data Allow Plenty of Time for the Pt to Respond to Questions Defense Mechanisms • • • • • • • • • • • Altruism • Dealing w/ Stress/Anxiety by Helping Others Sublimation • Substitute Negative Impulses Into Acceptable Forms of Expression (Working Out Hard at the Gym) Suppression • Voluntary Denial of Unpleasant Thoughts or Feelings Repression • Unconscious Denial of Unpleasant Thoughts or Feelings Regression • Reverting Back to Childlike Behaviors That Are Inappropriate For the Pt’s Current Developmental Level Displacement • Redirecting Feelings About a Person or Situation Towards a Less Threatening Object/Person (Dad Loses His Job, Destroys His Child’s Toy) Reaction Formation • Demonstrating the Opposite Behavior vs. What is Actually Felt (I Love Nursing Exams) Undoing • Performing an Act to Make up For a Previous Behavior (Bringing Home Flowers After a Domestic Abuse) Rationalization • Creating an Acceptable Excuse For Unacceptable Behavior Dissociation • Temporary Compartmentalization of Feelings/Thoughts (Forgetting Who You Are During Sexual Assault) Denial • • • • • • • Pretending Truth is Not Reality Compensation • Emphasizing Strengths to Make up For Weakness (Physically Disabled Person Excels Academically Identification • Adopting the Characteristics of Another Individual or Group Intellectualization • Separation of Feelings/Emotions From Logical Facts to Facilitate Coping Conversion • Unconscious Development of Physical Symptoms as a Response to Stress Splitting • Inability to Recognize Positive AND Negative Attributes in Others or Self (All or Nothing Mentality) Projection • Attributing Your Own Thoughts/Feelings Onto Someone Else Who Does Not Have Those Thoughts/Feelings Anxiety • • • • • • Mild • • Enhances an Individual’s Perceptions. Normal Experience Symptoms: Restlessness, Irritability, Fidgeting, Foot-Tapping • • Slightly Reduced Perception & Ability to Think Symptoms: Pacing, Difficulty Concentrating, Increased RR/HR • • Perception Greatly Reduced, No Ability to Problem Solve Symptoms: Feeling of “Doom” Tachycardia, Hyperventilation, Rapid Speech Moderate Severe Panic-Level • Individual Loses Touch w/ Reality, Disturbed Behavior • Symptoms: Dilated Pupils, Hallucinations, Severe Withdrawal, Severe Shakiness Mild/Moderate Interventions • Active Listening, Evaluate Pt’s Past Coping Mechanisms, Assist Pt w/ Problem Solving, Teach Relaxation Techniques, Encourage Exercise to Reduce Anxiety Severe/Panic Interventions • Provide a Quiet Place with Minimal Stimulation, Remain w/ Pt, Set Limits w/ Short/Simple Statements, Help Pt to Focus on Reality. Problem Solving is NOT Realistic at the Level of Anxiety Therapeutic Relationship • • • Orientation • Introduce Self, Discuss Confidentiality • Establish Expectations & Boundaries/Parameters • Identify Pt Needs & Set Goals Working • Perform On-Going Assessments • Assist Pt w/ Problem Solving & Behavior Changes • Evaluate Coping Strategies Used by Pt in the Past • Introduce Pt to Others on Unit • Revise Goals & Plans as Needed • Support Pt’s Use of New Coping Skills Termination • Summarize Goals & Achievements • Allow Pt to Share Feelings About Termination of Relationship • Discuss Ways For Pt to Incorporate New Healthy Behaviors into Their Life Transference vs. Countertransference • Transference • Occurs When a Pt Views the Nurse as Being Similar to an Important Person in Their Life • Can Result in Pt Treating the Nurse Like This Individual • Countertransference • Occurs When the Pt Reminds the Nurse of Someone in Their Life Which Induces Strong Personal Feelings & May Cause the Nurse to Treat the Pt Differently Primary, Secondary, & Tertiary Prevention • • • Primary • Focus on Prevention of Mental Health Problems From Occurring (Community Education Program on Stress Reduction) • Focus on Early Detection & Screening For Mental Illness (Screening For Depression in Older Adults) • Focus on Rehab & Prevention of Complications in Pts Who Have Already Been Diagnosed w/ Mental Illness (Support Group For Those w/ Substance Abuse) Secondary Tertiary Psychoanalysis & Cognitive Reframing • • Psychoanalysis • Assesses Unconscious Thoughts & Feelings • Based on the Belief Which Internal Conflicts Stem From Early Childhood Experiences • Focuses on Past Relationships Cognitive Reframing • Identifies Negative Thoughts, Examines the Cause, & Replaces Negative Self-Talk w/ Healthier & More Constructive Thinking • Includes: Priority Restructuring, Journal Keeping, Assertiveness Training, Monitoring Thoughts Group Therapy • • • • Goals • Allow Members to Share Common Feelings & Experiences • Learn Alternative Ways to Solve Problems Silent Member • Divide Group Into Pairs to Discuss Topic, Then Summarize Discussion to Group Member Constantly Talking • Ask Group to Discuss Their Feelings Regarding the Member’s Monopolizing Behavior Angry/Agitated Member • Move Group Members Away From Member to Prevent Injury Behavioral Therapies • Modeling • • • • • Therapist Serves as a Role Model For Pt, Demonstrates Appropriate Behavior Operant Conditioning • Provides Positive Rewards For Desired Behavior Systemic Desensitization • Progressive Exposure to Anxiety Causing Stimuli While Using Relaxation Techniques Aversion Therapy • Punishment for Maladaptive Behavior (Bitter Taste, Mild Shock) to Promote Behavior Change Others • Guided Imagery, Biofeedback, Thought Stopping, Muscle Relaxation Transcranial Magnetic Stimulation (TMS) & Vagus Nerve Stimulation (VNS) • • TMS • • • • • Use of Magnetic Pulsations to Stimulate Cerebral Cortex of the Brain Performed as Outpatient Daily for 4-6 Weeks Electromagnet placed on Pt’s Scalp Pt May Feel Tingling, Tapping, Tightening of Jaw Muscles Used for Depression Resistant to Medical Therapy • Device is Surgically Implanted in Pt’s Chest & Provides Electrical Stimulation Through the Vagus Nerve to the Brain Has been Shown to Increase Levels of Serotonin, Norepi, & Dopamine in the Body Can be Turned Off by Placing External Magnet over Site of Implant Used for Depression Resistant to ECT & Medical Therapy VNS • • • Electroconvulsive Therapy (ECT) • ECT • • • • • • Indications • Use of Electrical Activity to Induce a Seizure, Which May Enhance the Effects of Neurotransmitters in the Brain Performed 2-3 Times a Week For a Total of 6-12 Months Major Depressive Disorder (Used in Conjunction w/ Antidepressants, Does Not Replace Medical Therapy), Schizophrenia, Acute Manic Episodes Medications • Anticholinergic (Atropine - To Decrease Secretions & Counteract any Vagal Stimulation Effects) • Short-Acting Anesthetic (Propofol) • Muscle Relaxant (Succinylcholine - To Paralyze Muscles During Seizure & Prevent Therapy) Nursing Care • Get Informed Consent Prior to Procedure • Treat HTN & Dysrhythmias Before Procedure • Monitor VS & Mental Status Before, During & After Procedure • Provide Ongoing Cardiac Monitoring as ECT puts Stress on the Heart During Seizures Complications • Short Term Memory Loss is Expected & May Last Several Weeks • Relapse of Depression. Not a Permanent Cure Obsessive Compulsive Disorder (OCD) • • OCD • Pt has Persistent Thoughts or Urges Which Cause Anxiety • The Pt Engages in Compulsive/Obsessive Behaviors to Alleviate Anxiety • Rituals are Time Consuming & Limit Time for Other Activities • Pt Adheres to a Rigid Set of Rules Treatment & Nursing Care • Help Pt Set Time Limits For Compulsive Behavior & Lengthen the Time Between Rituals • Cognitive Therapy to Help the Pt Identify the Source of Anxiety Which Leads to Compulsive Behavior • Thought of Stopping to Interrupt Compulsive Behavior Posttraumatic Stress Disorder (PTSD) • PTSD • • Exposure to a Traumatic Event, Which Can Cause the Following Manifestations: Flashbacks, Distressing Dreams, Difficulty Concentrating, Insomnia, Anxiety, Irritability, Detachment From Others, Hypervigilance, Exaggerated Startle Response, Feeling of Guilt, or Negative Self Image Treatment Options • Cognitive Behavioral Therapy • Prolonged Exposure Therapy (Combined w/ Relaxation Techniques) • Eye Movement Desensitization & Reprocessing • Hypnotherapy & Biofeedback Dissociative Disorders • Types • • • • Depersonalization/Derealization Disorder: Feeling of Detachment From One’s Own Body or Environment Dissociative Amnesia: Lack of Memory Regarding Personal Info Which is Triggered by a Traumatic Experience Nursing Care • Help Pt Make Decisions During Dissociative Periods • Encourage Use of Grounding Techniques (Clap Hands, Touch Object) Risk Factors • Family History • Females Between 15-40 Years Old • Pts Over 65 • Medical Illness • Negative Life Event • Substance Use Disorder • • Single Signs/Symptoms • Anergia, Anhedonia, Anorexia, Fatigue, Flat Facial Expression, Poor Grooming/Hygiene, Slowed Thinking & Speech, Indecisiveness, Psychomotor Changes Types of Depressive Disorders • • • • Major Depressive Disorder (MDD) • Occurs Every Day For Over 2 Weeks w/ 5 or More of the Following Symptoms: Depressed Mood, Insomnia or Excess Sleeping, Difficulty Concentrating, Indecisiveness, Suicide Ideation, Anhedonia, Weight Gain/Loss, of Greater Than 5% Over 1 Month, Psychomotor Increase/Decrease Seasonal Affective Disorder (SAD) • Typically Occurs in Winter • Light Therapy is First-Line Treatment Dysthymic Disorder • Milder From of Depression, Usually Childhood Onset • Contains at Least 3 Symptoms of Depression Premenstrual Dysphoric Disorder (PMDD) • Associated w/ Luteal Phase of Menstrual Cycle • Symptoms: Rapid Mood Swings, Anergia, Overeating, Difficulty Concentrating Major Depressive Disorder • • • Acute Phase • Severe Clinical Signs of Depression • 6-12 Weeks in Duration • Possible Need For Hospitalization • Greatest Risk for Suicide Phase (1:1 Observation Needed) • Goal is to Treat & Reduce Depressive Manifestations Continuation Phase • Increased Ability to Perform • 4-9 Months in Duration • Goal is to Relapse Prevention Through Education, Medical & Psychotherapies Maintenance Phase • Remission • Can Last 1 Year or More • Goal is to Prevent Future Depressive Episodes Depressive Disorders Nursing Care • • • • • • Priority: Assess Pt’s Suicide Risk & Implement 1:1 Observation if Needed No Private Room (Due to Risk of Self Harm) Communicate w/ Simple Sentences. Allow Extra Time For Responses (Due to Slowed Thinking & Indecisiveness) For Pts w/ Suicidal Ideation, There is Increased Energy to Carry Out Plan After 1 Week of Treatment Procedures: ECT, TMS, VNS Medical Therapy: SSRIs, SNRIs, TCAs, MAOIs, Atypical Antidepressants, St. John’s Wort Bipolar Disorders • • • • • • • Bipolar Disorder • Mood Disorder w/ Recurrent Episodes of Mania & Depression Behaviors • Mania: Excessively Elevated Mood, Lasts >1 Week, Usually Requires Hospitalization • Hypomania: Less Severe Form of Mania, Does Not Require Hospitalization • Rapid Cycling: > 4 Episodes of Mania or Hypomania Within a Year Types • Bipolar I: At Least 1 Episode of Mania Alternating w/ Major Depression • Bipolar II: One or More Hypomania Episodes Alternating w/ Major Depression • Cyclothymic Disorder: 2 Years of Repeated Hypomanic Episodes Alternating w/ Minor Depression Risk Factors • Genetics, Psychological Stressors, Neurological Disorders, Substance Use Disorder Mania S/S • Mood Swings, Restlessness, Flight of Ideas, Pressured Speech, Grandiosity, Impulsiveness, Poor Judgement, Decreased Attention Span, Insomnia (Risk of Physical Exhaustion), Neglect of ADLs (Including Eating/Drinking), Possible Hallucinations or Delusions Depressive S/S • Anergy, Flat Affect, Anhedonia, Crying, Difficulty Concentrating, Possible Risk For Suicide, Lack of Grooming/Hygiene, Changes in Sleep/ Appetite Nursing Care During Manic Episodes • Provide Safe Environment. Protect Pt From Poor Judgement (Giving Away Money, Sexual Indiscretions) • Decrease Stimulation • • 1:1 Observation, Seclusion, or Restraints May be Necessary if Pt Poses Risk to Self or Others Provide Frequent Rest Periods Monitor Sleep, Fluid & Food Intake. Provide High Calorie Finger Foods Set Limits, Give Concise Explanations, Use Calm Approach • • • Medications • Lithium, Anticonvulsants, Antipsychotic Meds, Anti Anxiety Meds, Antidepressants Psychotic Disorders • • • • • • • • Schizophrenia • Psychotic Thinking/Behavior for >6 Months • Functioning & Relationships Significantly Impaired Schizotypal Personality Disorder • Personality Impaired, but Not as Impaired as Schizophrenia Schizophreniform Disorder • Psychotic Thinking/Behavior for 1-6 Months • May Not Affect Social/Occupational Functioning Schizoaffective Disorder • Pt Meets Criteria For Schizophrenia AND Depressive or Bipolar Disorder Positive S/S • Presence of Things Not Normally Present: Hallucinations, Delusions (False/Fixed Beliefs), Strange Motor Movements, Speech Alterations, Agitation Negative S/S Absence of Things That Are Normally Present: 5 As: Affect (Flat), Alogia (Decreased Thoughts/Speech), Anergia (No Energy), Anhedonia (Lack of Pleasure), Avolition (Lack of Motivation for Activities) Other S/S • • • • • • Disordered Thinking, Poor Problem Solving, Difficulty Concentrating, Memory Issues, Hopelessness, Possible Suicide Ideation, Depersonalization (Loss of Identity), Derealization (Perception that Environment Has Changed) Flight of Ideas • Each Sentence Relates to a Different Topic • Listener Unable to Follow Pt’s Thoughts Neologisms • Made-up Words Which Only the Pt Understands Echolalia • Pt Repeats EXACTLY What is Said to Them Clang Association • Meaningless Rhyming of Words Word Salad • Words Are Jumbled Together in a Meaningless Way • • • • Hallucinations • Sensory Perceptions Which Do Not Have an External Stimulus Types: • Auditory: Pt Hears Voices/Sounds; Command Hallucinations: Voice Instructs Pt to Perform Action (At Risk to Hurt Self or Others) • Visual: Pt Sees Person or Things • Olfactory: Pt Smells Odors • Gustatory: Pt Experiences Tastes • Tactile: Pt Feels Body Sensations Nursing Care • Provide Safe, Structured Environment • Attempt to Identify & Reduce Symptom Triggers • Decrease Environmental Stimuli • Priority: Ask Pt Directly About Hallucinations, Including Command Hallucinations, Provide Safety For Pt & Others (1:1 Observation) • Do Not Argue or Agree w/ Hallucinations/Delusions Medications Conventional & Atypical Antipsychotics Personality Disorders • Paranoid • Schizoid • • • • • • • • • Distrust & Suspiciousness of Others • Emotional Detachment, Indifference Schizotypal • Magical Thinking, Odd Beliefs, Perceptual Distortions Antisocial • Exploitation, Manipulation, & Deceit of Others, Verbally Charming, Fails to Accept Personal Responsibility Borderline • Splitting Behavior (Characterize People or Things as All Good or All Bad), Emotional Lability, Impulsive Behavior, High Risk of Self-Injury or Suicide Histrionic • Attention Seeking, Seductive, Flirtatious Narcissistic • Arrogant, Need For Constant Admiration, Lack of Empathy Towards Others Avoidant • Avoids Social Situations & Interpersonal Contact Due to Extreme Fear of Rejection, Abandonment Dependent • Extreme Dependency in a Close Relationship, Needs Excessive Input From Others to Make Decisions Obsessive-Compulsive • • Focus on Perfection, Order, & Control Which May Prevent Pt From Completing Task Nursing Care • Provide Safety For Pts at Risk for Self-Injury or Violence (Borderline Personality Disorder at High Risk for Self Injury) • Provide Limits & Consistency (Especially For Borderline & Antisocial Personality Disorders) • Provide Assertiveness Training For Dependent & Histrionic Personality Disorders • Respect the Need for Pts w/ Schizoid & Schizotypal Personality Disorders to Isolate Themselves Alzheimer’s Disease • • • • • • • Alzheimer’s • Non-Reversible Neurocognitive Disorder (Dementia), Resulting in Memory Loss, Problems w/ Judgement & Changes in Personality Stage I (Mild) • Memory Lapses, Frequently Misplacing Items, Difficulty Concentrating, No Issues w/ ADLs Stage II (Moderate) • Difficulty Planning/Organizing, Wandering, Personality & Behavior Changes Stage III (Severe) • Assistance Needed w/ ADLs, Incontinent, Loss of Ability to Move, Death (Usually Due to Infection or Choking) Defense Mechanisms • Denial: Refusal to Believe Changes (Memory Loss), are Taking Place • Confabulation: Pt Makes up Stories to Prevent Admitting They Do Not Remember Things • Preservation: Pt Repeats Phrases or Behavior to Avoid Answering Questions Medication • Donepezil (Cholinesterase Inhibitor): Slows Cognitive Deterioration & Improves Ability to Perform ADLs; Side Effects: GI Upset & Bradycardia; Administer Once Daily at Bedtime Nursing Care • Provide Safe Environment (Protect From Falls, Wandering) • Use Monitors & Bed Alarms as Needed • Place Pt in Room Near Nurse’s Station • Provide Prominently Displayed Calendar/Clock • Reorient Pt as Needed • Maintain Consistently w/ Caregivers • Use Calm Voice & Short Sentences • Limit Choice • Home Safety • • • • • • • • • No Scatter Rugs Install Door Locks Lock Away Cleaning Supplies Provide Good Lighting (Especially Over Stairs) Mark Step Edges w/ Colored Tape Install Handrails in Bathroom Place Mattress on the Floor Secure Electrical Cords to Baseboards Remove Clutter Dementia & Delirium • • Dementia • • • • Gradual Onset Level of Consciousness, VS Unchanged Related to Neurological Disorder Progressive & Irreversible • • • • Rapid Onset Level of Consciousness Altered, VS May Become Unstable Extreme Distractibility Caused Secondary to a Medical Condition (Infection, Electrolyte Imbalance, Substance Use) Reversible if Underlying Cause Corrected Delirium • Alcohol • • • • Most Important Question: When Did You Have Your Last Drink? S/S of Intoxication • Slurred Speech, Decreased Motor Skills, Decreased LOC, Memory Impairment, BAC >0.08% is Considered Legally Intoxicated in Most States Withdrawal • Timing: Starts Within 4-12 Hours of Last Drink, Peaks at 24-48 Hours • S/S: Vomiting, Tremors, Restlessness, Tachycardia, Tachypnea, HTN, Seizures, Fever Alcohol Withdrawal Delirium • Timing: 2-3 Days After Cessation of Alcohol • S/S: Hallucinations, Severe HTN, Delirium, Cardiac Dysrhythmias Alcoholics Anonymous • Purpose • • • Key Points • • • • • • To Stay Sober & Help Other Alcoholics Achieve Sobriety AA Encourages Recovery Through Peer Support Total Abstinence is the Only Cure for Alcohol Use Disorder Individuals Should Take Responsibility For Recovery Rather Than the Addiction Individuals w/ an Addiction Cannot Place Blame on Other People or Issues For Their Addiction Individuals With an Addiction Must Face Their Problems & Feelings Program is Not Intended For Addiction to Other Substances Securing a Sponsor Improves Chance of Recovery Cocaine & Opioids • Cocaine • • • S/S of Intoxication: Tachycardia, HTN, Dilated Pupils, Chest Pain, Tremor/Seizures, Irritability/Agitation S/S of Withdrawal: Fatigue, Depression, Decreased Motor Skills, Disturbing Dreams, Agitation Opioids • • S/S of Intoxication: Slurred Speech, Decreased RR, LOC & Impaired Judgement & Memory S/S of Withdrawal: Sweating, Rhinorrhea, Pupil Dilation, Tremors, Irritability, Insomnia, GI Upset, Muscle Spasms Anorexia Nervosa • • • Anorexia Nervosa • Eating Disorder Characterized by a Distorted Body Image Which Causes an Individual to Restrict Calorie Intake S&S • Low Body Weight, Low BP, Decreased Pulse & Body Temp, Constipation, Lanugo, Mottled/Cool Extremities, Poor Skin Turgor, Amenorrhea Criteria for Hospitalization • Weight Loss >30% Over 6 Months, HR < 40 bpm, SBP <7mmHg, Body Temp ,36 Degrees C, EKG Abnormalities, Electrolyte Imbalances Bulimia Nervosa • • Bulimia • Eating Disorder Characterized by the Ingestion of an Abnormally Large Amount of Food in a Short Time Period, Followed by an Attempt to Avoid Gaining Weight by Purging What Was Consumed (Through Vomiting, Diuretics, and/or Enemas) • Normal (Or Slightly Higher) Body Weight, Calluses on Knuckles (Russell’s Sign) From Self-Induced Vomiting, Enlargement of Parotid Gland, Tooth Erosion, Hypokalemia, Metabolic Alkalosis (From Vomiting) or Metabolic Acidosis (From Laxative Use) S/S Eating Disorders Nursing Care • • • • • • • Offer Rewards for the Amount of Calories Consumed, Not the Amount of Weight Gained Monitor VS, I&Os, Weight (Weigh Each Morning Before Food/Fluids) Restrict Caffeine Due to its Stimulative & Diuretic Effects Provide a High-Fiber Diet to Control Constipation Monitor & Restrict the Client’s Exercise Provide Small, Frequent Meals at Scheduled Times Closely Monitor Pt During & After Meals Somatic Symptom Disorder • • • Somatic Symptom Disorder • Form of Mental Illness Where the Pt Experiences Physical Manifestations Which Are the Result of Physiological Factors (No Underlying Physical Pathology) R/T Conversion Disorder Risk Factors • Female Gender, Teen/Young Adult, Childhood Trauma, Mental Illness (Depression, Anxiety, Personality Disorder), Recent Stressful Event Nursing Care • Acknowledge Symptoms as Being Real to the Pt • Reattribution Treatment: Helps Pt Identify Link Between Psychological Factors & Physical Manifestations • Administer Meds as Prescribed: Antidepressants, Anxiolytics Factitious Disorder • • Factitious Disorder • Form of Mental Illness Which Drives an Individual to Report NonExistent Physical or Psychological Symptoms in an Effort to Fill an Emotional Need For Attention Factitious Disorder Imposed on Another • • • An Individual Deliberately Causes Injury/Illness to a Vulnerable Person in Order to Get Attention (Or Get Relief From Responsibility) Nursing Care • Avoid Confrontation, Build Rapport/Trust w/ Pt, Ensure Safety of Vulnerable Persons, Communicate Suspicion of Factitious Disorder to the Health Care Team Malingering • Not a Mental Illness, Exaggeration or Lying About Symptoms to Escape Duty/Work or Collect Disability Oppositional Defiant Disorder • • • Oppositional Defiant Disorder • Disorder in a Child or Adolescent Characterized by Defiant Behavior Against Authority Figures, Such as Parents or Teachers • Individuals View Their Behavior as a Response to Unreasonable Demands • Can Develop Into Conduct Disorder Manifestations • Disobedience, Hostility, Stubbornness, Argumentativeness, Limit Testing, Refusal to Compromise or Take Responsibility For Misbehavior Interventions • Use Calm, Firm Approach, Provide Short, Clear Expectations, Set Clear Limits For Behavior, Incorporate Physical Activities to Help Child Use Energy. Model & Reward Acceptable Behavior Conduct Disorder • • • • Conduct Disorder • Persistent Behavior in Children or Adolescents Which Violate the Rights of Others & Disregards Societal Norms Risk Factors • Neglect or Abuse by Parents, Large Family Size, Lack of Supervision, Difficult Temperament as Baby Manifestations • Bullying Behavior, Recklessness, Volatile Temper, Cruelty Towards Animals or Other People, Destroys Property, Lies & Steals, Low Self Esteem, Suicide Ideation Interventions • Reduce Environmental Stimuli, use Calm Firm Approach, Provide Short, Clear Expectations, Set Clear Limits for Behavior, Incorporate Physical Activities to Help Child Use Energy, Model & Reward Acceptable Behavior Attention Deficit Hyperactivity Disorder • • • ADHD • Condition Characterized by Inattention (Difficulty Paying Attention & Focusing, Hyperactivity (Inability to Sit Still), & Impulsively (Acting w/o Regard to Consequences) Increased Risk For Injury Interventions • Use Calm, Firm Approach, Set Clear Limits For Behavior & Consequences For Unacceptable Behavior • Incorporate Physical Activities to Help Child Use Energy • Provide Safe Environment (Remove Unnecessary Equipment From Child’s Environment) • Give Positive Feedback When Child Completes a Task • Decrease Distractions During Meal Time Meds • Methylphenidate (Ritalin, Methylin), • Amphetamine Mixture (Adderall) Autism • Autism • • • Genetic Neurodevelopmental Disorder Which Affects an Individual’s Ability to Communicate & Interact w/ Other People Abilities Range From Highly Functional to Poor Functioning S/S • • Lack of Eye Contact, Repetitive Actions, Strict Observance of Routines, Language Delay, Sleep Disorders, Digestive Problems, Epilepsy, Allergies Interventions • Provide Referral For Early Intervention, Provide Structured Environment, Use Short/Concise Communication, Give Plenty of Notice Before Changing Routines, Determine Emotional Triggers, Encourage Verbal Communication Anxiety Medications • • Benzodiazepines • Alprazolam (Xanax), Diazepam, Lorazepam, Chlordiazepoxide • Used For Anxiety, Seizures, Muscle Spasms, Alcohol Withdrawal, & to Induce & Maintain Anesthesia • Side Effects are Sedation, Amnesia, Dependency/Withdrawal, Respiratory Depression • Short-Term Use Only, Do not Discontinue Abruptly, Antidote is Flumazenil Atypical Anxiolytics • Buspirone (BuSpar) • Indicated For Anxiety, Panic Disorder, OCD, PTSD • • • Side Effects are Dizziness, Nausea, Headache No Sedation, Dependency not Likely, Long-Term use okay, Full Effects Not Felt for Several Weeks. Take With Meals to Decrease GI Upset • • • • • Fluoxetine (Paxil), Sertraline Indicated for Anxiety, Depression, OCD, PTSD Mode of Action is to Inhibit Serotonin Reuptake (Increases Serotonin) Side Effects Include Sexual Dysfunction, Weight Gain, Insomnia Key Points are to Watch for Serotonin Syndrome (Agitation, Hallucinations, Fever, Diaphoresis, Tremors), Do Not Take w/ St. John’s Wort, as This Increases the Risk for Serotonin Syndrome, Full Effects Not Felt For Up to a Month SSRIs Depression Medications • • • Tricyclic Antidepressants • Bupropion (Wellbutrin), Trazodone (Major Side Effect Sedation) • Indicated For Insomnia, Headache, GI Distress, Weight Loss, Agitation, Seizures MAOIs • Amitriptyline (Elavil), Imipramine • Indicated For Depression, Neuropathy, Fibromyalgia, Anxiety, Insomnia • Side Effects Include: Sedation, Orthostatic Hypotension, Anticholinergic Side Effects, Sweating & Seizures Atypical Antidepressants • Phenelzine (Nardil), Tranylcypromine • Indicated For Depression • Side Effects Include Agitation/Anxiety, Orthostatic Hypotension, HTN Crisis • Key Points Include: Interactions with MANY other Meds (Including OTC Cold Meds, Which can Result in Severe HTN), Do Not Eat Foods Rich in Tyramine Bipolar Medications • • Mood Stabilizer • Lithium • Side Effects: GI Upset, Fine Hand Tremors, Polyurea, Weight Gain, Kidney Toxicity, Electrolyte Imbalance • Key Points: Monitor Plasma Levels Tox Over 1.5 mEq/L, Symptoms of Tox: Coarse Hand Tremors, Confusion, Hypotension, Seizures, Tinnitus, Coma/Death, No Diuretics, Anticholinergics, or NSAIDs, Contraindicated For Pts w/ Renal Disease, Closely Monitor Na Levels. Need Adequate Fluid Intake (2-3 L) & Na Intake Antiepileptics • Carbamazepine (Tegretol), Valproic Acid (Depakote) • • • Indicated For Bipolar Disorder & Used as an Anticonvulsant/Antiepileptic Carbamazepine Side Effects: Blood Dyscrasias (Anemia, Leukopenia, Thrombocytopenia), Vision Issues, Hypo Osmolarity, Rash Valproic Acid Side Effects: GI Upset, Hepatotoxicity, Pancreatitis, Thrombocytopenia Antipsychotic Meds • • Conventional • Chlorpromazine (Thorazine), Haloperidol (Haldol) • Side Effects: EPS Effects, Dystonia, Parkinson’s Symptoms (Shuffling Gait, Rigidity), Tardive Dyskinesia (Lip Smaking, Tongue Rolling), Akathisia, NMS (Fever, Dysrhythmias, BP Fluctuations, Muscle Rigidity), Agranulocytosis, Anticholinergic Effects, Orthostatic Hypotension, Sedation, Seizures • Key Points: Monitor VS Every 1-2 HOurs, Anticholinergics (Benztropine, Atropine) Can be Used to Control EPS Effects. Muscle Relaxants (Dantrolene) Can Be Used For NMS Effects Atypical • Risperidone (Risperdal), Clozapine, Olanzapine • Indicated For Schizophrenia, to control Positive & Negative Symptoms (Anergia, Anhedonia, Social Withdrawal) • Side Effects: Diabetes, Weight Gain, Increased Cholesterol, Sedation, Orthostatic Hypotension, Anticholinergic Effects, Menorrhagia, Decreased Labido, Clozapine Risk for Agranulocytosis • Key Points: Risperidone Can Be Administered IM Injection Every 2 Weeks (For Non Compliant Pts). Avoid Alcohol ADHD Medications • • • • Medications • Indications • Side Effects • Key Points • • • Methylphenidate (Ritalin, Methylin), Amphetamine Mixture (Adderall) ADHD & Conduct Behaviors Insomnia, Dysrhythmias, Decreased Appetite, Weight Loss Do Not Administer at Night Give Medication Immediately Before/After Meals Monitor Child’s Weight During Therapy Alcohol Abuse • • Medications During Alcohol Withdrawal • Benzodiazepines: Used to Stabilize VS, Decrease Risk of Seizures, Decrease Withdrawal Symptoms • Carbamazepine: Decreases Risk of Seizures • Clonidine: Decreases Autonomic Response (Decreases BP & HR) • Beta Blockers: (Propranolol, Atenolol), Decreases Autonomic Response (Decreases BP & HR) & Craving Medications to Promote Abstinence • Disulfiram (Antabuse): If Pt Ingests Alcohol, They Will Get Many Unpleasant Side Effects Including: Nausea, Vomiting, Sweating, Palpitations & Hypotension • Naltrexone (Vivitrol): Suppresses Cravings for Alcohol (Also Available as Monthly IM Injections) • Acamprosate (Campral): Decreases Abstinence Symptoms (Anxiety, Restlessness) Medications of Opioid & Nicotine Withdrawal • • Opioid Withdrawal • Methadone: Used For Withdrawal & Long-Term Maintenance Nicotine Withdrawal • Bupropion (Wellbutrin): See Atypical Antidepressants For More Info • Nicotine Replacements: Gum, Patch, Nasal Spray • Varenicline (Chantix): Reduces Cravings & Withdrawal Symptoms; Monitor Pt Closely For Depressive/Suicidal Thoughts Types of Loss • • • • Actual • Loss of a Valued Person or Object Recognized by Others (Loss of Spouse) • Loss Felt by Pt, but Not Obvious to Others (Loss of Financial Independence) Perceived Maturational • Loss Experienced During Normal Life Transitions (Child Leaving for College) Situational • Unexpected Loss Caused by External Event (Tornado, Car Accident) Kubler-Ross 5 Stages of Grief • Denial • • • • • Individual Does Not Accept the Reality of the Situation Anger • • Bargaining • • Depression • Acceptance • • Individual Expresses Anger At Others Includes Dying or Deceased Loved Ones Individual Tries to Negotiate For More Time (Or Cure) Uses “Only If…” Statements Individual is Sad/Mournful Individual Acknowledges Loss & Moves Forward in Life Emotions More Stable Grief • • • • Normal Grief • Individual Has Some Acceptance by 6 Months Anticipatory Grief • Grieving Before an Actual Loss (Family Member w/ Terminal Illness) Maladaptive (Complicated) Grief • Grief is Prolonged, Severe, Interferes w/ Normal Functioning Months After Loss, No Acceptance After 6 Months Nursing Care • Use Therapeutic Communication (You Sound Angry. Anger is a Normal Feeling When You Lose Someone, Tell me More) • Encourage Individual to Share Memories About Loved One • Encourage Individual to Use Coping Mechanisms Successfully Used in the Past Crisis Management • • • • Situational • Crisis r/t Unanticipated Loss or Change (Physical Illness, Job Loss) Maturational • Crisis Associated w/ Developmental Stage • Naturally Occurring Event During the Lifespan (Retirement, Child Leaving for College) Adventitious • Crisis r/t Natural Disaster or Crime (Rape/Hurricane) Nursing Care • Provide for Pt Safety • Remain w/ Pt, Use Therapeutic Communication • Assess Past Ways of Coping • Help Pt Develop Action Plan Suicide • • • • Risk Factors • Untreated Depression or Other Mental Illness, Family Hx, Prior Suicide Attempt, Chronic Health Problem, Substance Abuse Disorder, Loss of Job or Loved One • Cultural Risk Factors: American Indian, Alaskan Native Ethnic Groups Protective Factors • Religious Beliefs, Social Support Network, Effective Coping Skills, Access to Health Care Priority Assessment • Assess Pt’s Risk of Suicide: Does Pt Have a Plan, How Lethal is It, Does the Pt Have Access to Intended Method • Is the Pt Thinking About Hurting Themselves? • Has the Pt Had a Sudden Change in Mood From Sad to Happy/Peaceful? This May Indication Intention to Commit Suicide Nursing Care • Provide 1:1 Constant Supervision • Document Pt Behavior Every 15 Mins • Search Belongings at Admission. Remove Dangerous Objects: Metal Silverware, Belts, Shoelaces, Tweezers, Razors, Plastic Objects, Glass, Shampoo & Perfume • Only Allow Pt to Use Plastic Silverware • Do NOT Place Pt in Private Room • Ask Pt ot Agree to a No Suicid Contract (Does Not Replace Other Suicide Prevention Interventions) • Make Sure Pt Swallows All Meds • Recognized Behaviors Which May Indicate Intention to Commit Suicide (Giving Away Possessions, Sudden Change in Mood to Happy/Peaceful, Suddenly Having More Energy, Showing Appreciation to Loved Ones, Verbalizing Getting Affairs in Order) Anger Management • Aggressive Behavior • Provide Safe Environment for Pt & Others (Move Others Away From Violent Pt) • Encourage Pt to Express Feelings Verbally • Provide For as Much Personal Space as Possible • Sit/Stand at Eye Level, Maintain Eye Contact • Set Limits, Present Options Clearly, & Inform Pt of Consequences of Behavior • Encourage Physical Activity to De Escalate Anger • Provide Meds if Limit Setting is Not Effective • • Have 4-6 Staff Members Visible as “Show of Force” & to Assist if Necessary Verbal Abuse • Leave Room Immediately & Return Later to Check on Pt • Refrain from Arguing w/ Pt Violence/Abuse Risk Factors • • • • • • • • • • Female Partner Pregnancy Hx of Violence in Family Substance Abuse Children Under 3 Physically/Mentally Disabled Children, Children From Unwanted Pregnancies Older Adults, Due to Poor Health & Dependence on Caregiver Individuals Trying to Leave Abusive Relationship Most Common Within Family Groups v. Strangers Occurs Across ALL Economic/Education Levels Family Violence • • • • Tension-Building Phase • Minor Episodes of Anger, Verbal Abuse, Vulnerable Person is Tense Acute Battering Phase • Serious Abuse Takes Place Honeymoon Phase • Abuser Becomes Loving & is Sorry For Behavior • Abuser Promises to Change After Honeymoon Phase, Cycle Begins Again w/ Periods of Escalation & De Escalation (Decreasing Time Between the 2 Over Time) Types of Violence • • • • Physical Violence • Physical Harm is Directed Towards Another (Child, Partner, Older Adult) Sexual Violence • Sexual Contact w/o Consent Neglect • Failure to Provide Physical Care (Food, Clean Clothes), Emotional Care (Interaction w/ Child), Education, and/or Health Care Economic Maltreatment • Failure to Provide For Needs of Vulnerable Person When Funds Are Available Signs of Abuse • Infants • • Signs of Shaken Baby Syndrome: Respiratory Distress, Bulging Fontanels, Increase in Head Circumference • Bruising on Infants Under 6 Months of Age Preschool & Older • Unusual Location of Bruising (Abdomen, back, Buttocks), Note: Bruising is Expected on Arms/Legs • Bruises in Different Stages of Healing • Forearm Spiral Fractures • Presence of Multiple Fractures • Small Round Burns (Possibly From Cigarettes) • Burns Covering Hands/Feet (Possibly From Immersion in Boiling Water) Sexual Assault • • • • • • • Sexual Assault • Forced Sexual Contact • It is a Crime of Violence, Aggression, & Power, Not a Crime of Passion • Majority of Perpetrators are Known to the Victim • Alcohol or Other Drugs are Often Associated w/ Acquaintance Rape Rape-Trauma Syndrome • Response to Sexual Assault Which Can Inlcude: • Expressed Reaction: Crying, Anger, Hysteria • Controlled Reaction: Confusion, Numb Feeling • Somatic Reaction: Physical Manifestations Such as Headache, Muscle Tension, & GI/GU Manifestations, PTSD • Reliving Assault, Flashbacks, Hyperarousal, Exaggerated Startle Response, Fears/Phobias, Difficulty w/ ADLs, Depression, Sexual Dysfunction Compound Rape Reaction • Mental Health Issues (Depression, Substance Disorder), Physical Illness Silent Rape Reaction • Nightmares, Changes in Sexual Behavior, Sudden Onset of Phobia, No Verbalization of Sexual Assault • Pt Showing Interest in Intimate Relationship is an Indication of Recovery From a Rape-Trauma Event Sexual Assault Nurse Examiner (SANE) • Trained Nurse Examines & Collects Forensic Evidence (Blood, Oral Samples, Hair & Nail Samples, Genital & Anal Swabs) • Requires Informed Consent Nursing Care • Provide for Pt Safety • • • • Administer Prophylactic Treatment For Sexually Transmitted Diseases Administer Emergency Contraception for Pregnancy Risk Provide 24 Hour Hotline for Rape Survivors Provide Referrals (Individual/Group Therapy)
