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Mental Health Cheat Sheets
Medical Surgery 2 (Florida State College at Jacksonville)
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Mental Health
1. Therapeutic Communication
2. Non-Therapeutic Communication
3. Defense mechanisms
4. Legalities and Ethics
5. In Patient - Out Patient
6. Restraints and Seclusion
7. Anxiety
8. Panic Attacks
9. OCD
10. PTSD
11. Depression
12. Eating Disorder
13. Personality Disorders
14. Dissociative Identity Disorders
15. Schizophrenia
16. Schizoaffective
17. Bipolar Disorder / Manic
18. Substance Abuse
19. Alcohol Addiction & Abstinence medication
20. Dementia
21. Alzheimer
22. Delirium
23. Anti psychotics
24. Antidepressants
25. Anxiety medications
26. Mood stabilizers
27. ADHD medication
28. Mental heath - children
29. Communication with children
30. Erickson's Stages Of Development
31. Maslow's hierarchy of Needs
32. Test Prep and Guide
Table
of
Contents
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Therapeutic Communication
What is it?
The use of words and actions that promote a positive response in the client that will
allow the Nurse to obtain vital information and develop rapport that facilitates a
working relationship.
Uses
Gain clients attention
Gain Information on patients thoughts, feelings, needs, concerns
Information and feedback about the clients condition
promotes functional and effective behavior and relationship
Client centered, its purposeful, planned, and goal oriented
Parts
Time: Dont rush the client, mental health clients will often require more time
Active Listening:
Nonverbal actions that show the client you're paying attention
Eye contact if situation and culturally appropriate
Body language comfort and ease, (try not to tense up, or look guarded)
Techniques
What types
are there?
Silence: Allows time for the client to reflect and offer more information
Questions: Open-ended, Close-ended, What if, Presupposition - goals assessment
Clarifying: Restating, Reflecting, Paraphrasing, Exploring
Opening statements: Gives the client a starting point for communication
Acceptance and recognition: Nurse demonstrates interest and no judgement
Touch: If appropriate can show compassion and care for client
Focusing: Keeps the client on topic
Age are
group
What By
types
there?
Children: simple and straight to the point language, assess developmental level
be at eye level, use play during interactions, nonverbal is very important.
Adolescents: Assess how the client feels about the diagnosis, may refuse treatment
as a desire to feel normal, how with the diagnosis affect relationships with peers
Older adult: Minimize distractions, face the client, allow additional time for response,
interview family to determine best communication with impaired client
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Non-Therapeutic Communication
What is it?
The use of words and actions that inhibit communication and relationships
Types
False Reassurance: I'm sure everything
will be okay
Uses
Rejecting: refusing to discuss clients concerns
Agreeing / Disagreeing: instead try Lets discuss how you feel
Probing: Not appropriate when client becomes severely uncomfortable
Giving Advice: I think you should.. What do you think you should
Defending: The staff is the best, nobody lies here: I will answer your questions
Approval / Disapproval: That's good or that's bad: How did this behavior affect...
Belittling: Everybody feels this way at times: Keep the focus on client not everybody
Stereotype comments: hang in there, keep your head up.
Denial: Denying the problem exist: make sure to address the feelings
Interpreting: What you really mean is..
Unrelated topics: Stay on the topics that need to be addressed
Notes
These are all barriers to communication
Don't look guarded
Don't rush a mental health client
Mental health clients can be very hard to read sometimes and once they decide you
don't care about their feelings and concerns it can be a very hard barrier to
overcome
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Defense mechanisms
What is it?
Protective behaviors used to protect ones mental state or ego. Can have both
adaptive and maladaptive uses.
Defense mechanisms
Altruism: Reaching out for help
Compensation: Focusing on strength to make up for weaknesses
Conversion: Physiological symptoms present from mental thoughts
Denial: Refusing to accept the truth
Displacement: Shifting feelings towards something or someone less threatening
Dissociation: Compartmentalizing of information to ignore or block it out
Projection: Placing ones negative emotions/ actions onto another (cheating spouse
accuses the other of cheating)
Rationalization: Making excuses for bad behavior or actions
Reaction Formation: Displaying feelings or behavior other than what is felt
Regression: Revert to childlike behavior
Repression: Unknowingly removing unacceptable feelings from consciousness
Splitting: Lacks ability to reconcile difference between positive and negative
emotions
Sublimation: Substituting acceptable forms of expressions for unacceptable
feelings
Suppression: Denying unpleasant thoughts and feelings by choice.
Undoing: Performs actions to make up for wrong doings.
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Legallities and Ethics
What is it?
A nurse must know the laws and regulations dealing with clients, protecting their
rights, while abiding by local, state, federal laws and within the nurse practice act.
Legal Rights in Mental Health
Humane treatment
Informed Consent
Right to refuse treatment
Complete plan of care written out
Right to communication - with anybody to include Law, family, legal, medical
Ethical Considerations
Beneficence: The act of goodness
Autonomy: Allowing the patient to decide their fate, treatments, actions
Justice: Fair and equal treatment: nurses can tend to shy away from MH clients.
Fidelity: faithfulness to the client and the nurses duty.
Veracity: Honesty - Don't lie to the client: This often happens with diagnosis, simply
let the patient know the physician will be the one talking about the diagnosis.
Ethical Resources for decision making
Code of Ethics for nurses: Can be found on the ANA website
Nurse Practice Act: Specific to each State / Region
Senior Nursing Staff
Ethics Department
Torts
Intentional Tort: Acts that are done with conscious thought that damage or
violate the client or their rights.
False Imprisonment: Confining or Restraining a patient against will w/o orders
Assault: Making a threat
Battery: Causing Bodily harm
Unintentional Tort: Accidental action or inaction that damage or violate the client
or their rights.
Negligence: Simply failing to provide quality care that could have prevented injury
Malpractice: Professional negligence
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In Patient - Out patient
What is it?
In-Patient: When a client is admitted to the hospital for overnight stay or longer.
Out-Patient: The client is assessed, treated, and leaves upon completion.
Admission types in a Mental Health Facility
Informal: Least restrictive form: No threat from client to self or others and is free
to leave at any time.
Voluntary: Client or guardian chooses the admission to obtain treatment: The
client is considered competent and may refuse both treatment and medication.
Before leaving the client is assessed and a provider may initiate involuntary
admission for the client to keep them in the facility.
Emergency: The client is considered unable to make decision regarding care due
to Mental health. A Mental Health care provider will evaluate the admission to verify
the appropriateness. This type of admission usually is limited by law to 15 days.
Involuntary: A client is entered into a mental health care facility against their will
for an indefinate time frame.
Involuntary Admission
Criteria for admission:
Presence of a mental illness
Is danger to self or others
Severe disability or inability to meet basic
needs.
Needs Mental help but is unable to seek it out
voluntarily due to the illness
Typically at least 2 physicians must sign off on the Involuntary Admission
Client can request a legal review of the admission at any time.
Limited to 60 days before a review must be completed to extend the admission.
Clients still maintain the right to refuse treatment and medication.
Long Term Involuntary Admission
Must be imposed by the court, usually last from 60 - 180 days.
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Restraints and Seclusion
What is it?
Restraints: Use of Physical or Chemical means that limit the patients ability to
function.
Types
Physical:
Belts, Cloth Bands, Cloth Vest,
Use of physical restraints should be considered only when other methods fail.
Medication / Chemical:
Benzodiazepines and Anti psychotics (Typical meds, but not the only ones)
Less Restrictive means
Verbal Interventions:
encourage client to calm down
Diversion and/ or redirection
Creating calm / quite environment
Offer the clients PRN meds
Rules
WhatCommon
types are
there?
Restraints and seclusion are limited by age:
8 years and younger: 1hr
9-17 years: 2 hours
18 years and older: 4 hours
Provider must physically assess patient and re-write the prescription Q24 hours
Prescription must state the type of restraint to be used
and Do
WhatDO
types
areNot
there?
DO:
Use restraints as a last means
Only when there is an ORDER
Abide by state and local laws
Follow Time Limits
CHECK ON PATIENT Q15 -30Min and
complete documentation
DO NOT use Restraints for:
Staff Convenience
Intentional Punishment
Extreme physically / Mentally unstable
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ANXIETY
What is it?
Anxiety is the bodies natural response to stress
What levels are there and the assessment findings
Mild: Restless, increased motivation, and irritability
Moderate: Agitation, muscle tightness
Severe: Inability to function, ritualistic behavior, unresponsive
Panic: Loss of rational thoughts, distorted perceptions, unable to move
What types are there?
Separation: Occurs when not around a specific person
Phobias: Irrational fears of objects or situation. (Agoraphobia)
Social: Fear in social gatherings or when performing/ speaking
Panic: Recurrent attacks that immobilize the individual
Generalized (GAD): uncontrolled and excessive worry for over 6 months
Agoraphobia: Extreme fear of being in certain places. Heights, bridges
What Risk
types
Factors
are there?
Anxiety is more common in women than men
Family History of Mental disorders / Anxiety
What types
Medication
are there?
SSRI
Antidepressants
Benzodiazepines
Buspirone
TherapeuticWhat
Managementtypes are Behavioral
there?
Training
Relaxation: Focus on control and decreasing systemic response
Modeling: Attempt to imitate appropriate behaviors
Desensitization: Systemically introducing the anxiety inducing trigger
Flooding: Used for phobias: Large exposure to stimulus
Prevention: Attempt to stop anxiety inducing behaviors like OCD
Thought Stop: Client states "STOP" when negative behaviors arise
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Panic Attack
What is it?
Sudden onset of extreme and intense fear that triggers severe physical reactions
Assessment findings
Tachycardia / Chest pain
Tachypnea / Short of Breath / Choking
Increased Blood Pressure
Diaphoresis / Chills / hot flash
Feeling Depersonalized
Immobility
Loss of rational though
feeling of helplessness
Fear of dying / going insane
Behavior changes due to fear
of the next attack.
Diagnostics
DSM 5: Criteria for Panic attack / Panic Disorders
Episodes typically last 15-30 minutes
Must meet 4 or more of the criteria under assessment findings
Interventions/
nursing
Care
What types are
there?
Keep a calm environment / Free of extra stimuli
Remain with client during attacks and provide reassurance
Monitor for Self Harm / substance abuse / Suicide assessment
Encourage relaxation techniques /
Medication
What types
are there?
Benzodiazepines
Antidepressants
Both medications may be used together
depending on severity
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Relaxation: Focus on control and decreasing systemic response
Modeling: Attempt to imitate appropriate behaviors
Desensitization: Systemically introducing the anxiety inducing trigger
Flooding: Used for phobias: Large exposure to stimulus
Prevention: Attempt to stop anxiety inducing behaviors like OCD
Thought Stop: Client states "STOP" when negative behaviors arise
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OCD
What is it?
Obsessive-Compulsive disorder (OCD) is a recurrent, persistent, unwanted, and
actions of a client. Could also be thoughts, urges and images.The patient is driven to
do these actions and if they fail to do them could lead to a panic attack.
Assessment findings
Obsessions: are unwanted, intrusive thoughts, urges, or images, the presence of
which usually causes marked distress or anxiety.
Compulsions: More commonly refereed to as rituals.
Washing: can be showering or washing hands to kill germs
Checking: May be lights, Stoves, or if doors are locked
Counting: Doing a behavior for X times: Switching the lights on/off 3 times
Ordering: Everything must be in order / lined up / in its specific place
Hoarding and Body Dysphoric are types of OCD
Comorbidity: Other Mental health diagnosis often accompany OCD
Anxiety Disorders >70%
Depressive or Bipolar > 60% / Major depressive >40%
25-33% estimated have suicidal ideation
Diagnostics
A clinical diagnosis will be made based off of observation in accordance with DSM-V
Interventions/ nursing Care
Keep stress levels low
Create rigid rules
Keep the patient accountable
Medication
What types
are there?
SSRI - Fluoxetine, Paroxetine, sertraline, fluvoxamine
Tricyclic Antidepressant - Clomipramine
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Cognitive-Behavioral therapy: change negative distorted feelings
Exposure/ Flooding: Exposing large amounts of undesired trigger/ stimulus
Response prevention: preventing the client from performing the action
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PTSD
What is it?
Post Traumatic Stress Disorder is recurring, intrusive memories of an overwhelming
event that occured in the patients life. (Can be direct or indirect)
Assessment findings
Reoccurring memories - involuntary intrusive
Reoccurring dreams
Feeling as if the event is happening again
Intense psychological or physiologic distress
when the event is remembered
Avoidance of thoughts, feelings, memories
Avoiding places, things, people
Memory loss of the even
Persistent negative beliefs about
oneself-negative emotional state
Trouble sleeping, concentrating
Hyper-vigilance, reckless, irritable
Diagnostics
DSM 5: Criteria for PTSD
Screen for self harm / suicide risk
screen for Substance abuse
Assess for family and occupational
issues barrier
Assess for other Psychological conditions
Interventions/
nursing
Care
What types are
there?
Keep a calm environment / Free of extra stimuli
assess for memory gaps
Medication
What types
are there?
Antidepressants
Prazosin to reduce hyper vigilance and insomnia
SSRI
Beta blockers / control
physiological reactions
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Cognitive-Behavioral therapy: change negative distorted feelings
Prolonged exposure Therapy: Exposure therapy and relaxation techniques
Eye movement Desensitization: DO NOT USE IF SUICIDAL
Group/ Family therapy: Seek support from those close/ or same experiences
Hypnotherapy: used in dissociative disorders
Biofeedback: Increases awareness and gain control of triggers and reactions
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Depression
What is it?
Mood disorder that is expressed by feelings of sadness, despair, and pessimism.
Assessment findings
Sadness
Despair
pessimism
loss of interest
Changes in:
Sleep
Eating
Cognition level
Indecisiveness
lack of pleasure
suicidal ideation
>5% weight gain / loss
Types
Major Depressive: Single or recurrent episodes of uni polar depression
accompanied by 5 of the assessment findings above.
Seasonal Affective: occurs seasonally, most commonly winter/ short daylight
Persistent Depressive: Milder form of Depression that has a early onset in
adolescent or children, and last for at least 2 years for adults / 1 for kids.
Premenstrual Dysphoric: associated with the luteal phase of menstrual cycle
Substance Induced: Withdrawal from drugs / alcohol
Interventions/
nursing
Care
What types are
there?
Administer "Hamilton Depression Rating Scale" Questionnaire
Suicide / self harm assessment
Encourage Self care / Accomplish small goals to keep patient moving if possible
Medication
What types
are there?
SSRI
Tricyclic Antidepressants
MOI
Atypical Antidepressants
Serotonin Nor epinephrine Re uptake inhibitors
(St. Johns Wart may also be taken OTC)
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Electroconvulsive Therapy:
Transcranial magnetic Stimulation: MRI strength magnets to stimulate cerebral
cortex
Vagus Nerve Stimulation: Implanted device that provides small shocks
Light Therapy: First line treatment for Seasonal Affective Disorder (SAD)
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Eating disorder
What is it?
Serious and sometimes fatal that present as highly abnormal consumption
practices that lead to inadequate or excess caloric intake.
Types / diagnostics
Bulimia Nervosa
Binge eating the purging
(recurrent episodes)
Weight within normal BMI
Eat low calorie diets
between episodes
Anorexia Nervosa
Fear of gaining weight
Disturbed body image
refuse to eat
ritualistic eating habits
restrictive diet
Binge eating Disorder
Often eat large Meals
lack of control
once per week for 3 months
Both men and women
40s-50s most common age
Assessment
What types
are there?
Obsession of food / fat and calories
Fatigue with anemic signs
Eating in Seclusion
Muscle wasting
Brittle nails and hair from poor nutrition
excessive wight loss/ gain
abnormal dieting / restrictive eating
Distorted view of body
Interventions/
nursing
Care
What types are
there?
Assess for food hoarding
provide small snacks
Routine weights
Monitor labs / Vitals / I&Os
Establish goals
Encourage Therapy / groups
Dietician Consultation
Promote self care / education
Medication
What types
are there?
SSRI antidepressants
TPN nutrition
Anxiolytics
Therapeutic
ManagementTraining
What
types areBehavioral
there?
RE-FEEDING SYNDROME: fatal complications due to nutritional imbalances that
occur after initiating feedings for a severely malnourished client
Cognitive-Behavioral therapy: change negative distorted feelings
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Personality Disorders
What is it?
Impairments in Self-Identity, Self destruction, and interpersonal functioning
10 types in 3 clusters
Cluster A (Odd or Eccentric traits)
Paranoid: Distrustful, suspicious of others: People want to harm, exploit, or deceive
Schizoid: Emotional Detachment, no interest in relationships, indifferent to praise or
criticism
Schizotypal: Magical thinking or distorted perceptions, may not be clear delusions
Cluster B (Dramatic, Emotional, Erratic)
Antisocial: Disregard for others feelings / well being, outside of traditional morals
and values, will harm, steal, lie and accept no personal responsibility
Borderline: instability in identity, relationships, and affect. manipulative, impulsive
Histrionic: Attention Seeking, needs to be the center of attention Always.
Narcissistic: arrogant, believes self is most important, lack of empathy for others
Cluster C (Anxious, fearful, Insecure, and /or inadequate)
Avoidant: Actively avoids social events, gatherings, situations of contact / relations
Dependent: Always needs a close relationship, finds one immediately as one ends
Obsessive-Compulsive: indecisive, perfectionist, need for things to be a specific way
which can prevent accomplishing even basic task.
Assessment
- commonalities
What types
are there?
Inflexible/ maladaptive responses
Compulsive
Lack of Social restraint
Inability to emotionally connect
Interpersonal conflict provoking
Nursing Care
Be aware of personal reactions - Physical / Mental
Dont let your actions ruin building rapport / caring for patients
Milieu management - Orient the client to reality/ safety / appropriate activities
Communication: Use firm and supportive approach
offer realistic choices
consistency in actions and words
respect certain clients needs to self isolate when appropriate
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Dissociative Identity Disorders
What is it?
Formerly referred to as Multiple Personalities it is characterized by having 2 or
more personality states within one individual. (Often from trauma or stressful event
and is a coping mechanism to deal with these situations)
Assessment findings
Depression
Anxiety
Suicidal Ideation
Foggy state (mentally)
Detached feelings
distant or seclusive
limited coping abilities
Memory loss
Erratic Behavior
Diagnostics
Dissociative identity
2 or more identities (Distinct)
Abnormal Behaviors
Gaps in memory (Recurrent)
Denationalization Disorders
Describe out of body experience
Dreamlike or foggy state
aware of reality / real vs fake
Interventions/
nursing
Care
What types are
there?
Patient Safety
Calm, supportive environments
Promote coping skill
Keep patient oriented to reality
Assess clients ADL's / Assist if needed
Incorporate family where possible
Medication
What types
are there?
Medication is highly dependent on diagnosis and symptom presentation
Anti psychotics, Anxiolytics may be more commonly prescribed (typically PRN)
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Set limits and firm rules
Be assertive but compassionate
Therapeutic communication
Establish and maintain trust
Identify and avoid triggers
provide resources for coping
identify paranoid delusion (additional risk of
violent tendencies)
promote group activities and friendships
when applicable
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Schizophrenia
What is it?
Mental disorder that limits a persons ability to distinguish between reality and
imagination - disruption in how the person thinks, feels, and acts.
Assessment findings
Positive Findings:
Delusions
hallucinations
disorganized speech
Disorganized Behavior
Negative Findings:
Flat affect
Decreased emotion expression
Loss of interest / activities and relationships
Minimal communication
Symptoms by stage
Premorbid Phase: (1)
Signs occur prior to diagnosis
being very shy / antisocial
Prodromal Phase: (2)
Clearly manifested signs
Active Psychotic Phase: (3)
Psychotic symptoms are prominent
Residual Phase: (4)
remission period / follows active
phase
Diagnostic
Minimal one positive symptom and one additional symptom (positive or negative)
Present for 6 months or longer with one month of active symptoms
Not substance induced
Interventions/ nursing Care
Maintain safe environment and protect client from injury
Continuously monitor cognitive state
Maintain stable and controlled reactions
Dont let patient block the exit/ get inbetween nurse and exit.
Medication
What types
are there?
Atipical Antipsychotics
Therapeutic Management- Behavioral Training
Assess for Suicidal ideations
What types are there?
Keep patient oriented to reality
Educate on coping skills to recognize and manage delisional states
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Schizoaffective disorder
What is it?
Client meets clinical criteria for both Schizophrenia and depression or Bipolar
disorder
Assessment findings
Psychotic:
Delusions
hallucinations
Altered speech,
actions, thoughts
Manic:
Agitation, Distracted
Insomnia, Self-harm
Rapid speech, actions,
thoughts
Depressive:
Loss of interest
poor appetite
sleep changes
feeling worthless, guilty
suicidal ideation
Diagnostics
Made according to health history and current symptoms
Interventions/
nursing
Care
What types are
there?
Maintain a calm supportive environment
Assess for suicidal ideation
Keep client oriented to reality
Allow client to express thoughts, feelings
Stay with patient during hallucinations
identify triggers / avoid triggers
Encourage coping skills
Medication
What types
are there?
Antipsychotics
Antidepressants
Mood Stabilizers
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Cognitive-Behavioral therapy
Social Skills training
Support groups
Family counseling
Healthy consistent diet
Avoid stressors
Avoid Alcohol / illegal substances
Maintain calm environment
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Bipolar disorder / Manic
What is it?
Mood disorder that affect the emotional state of a prolonged period of time.
emotions and moods may fluctuate without any reason.
Types
Bipolar 1: At least one episode of mania and depression alternation
Bipolar 2: One or more hypomanic episodes that switch to depressive episodes
Cyclothymic: 2 years or more of hypomanic and minor depressive episodes
Assessment findings
Depressive:
Flat, affect
sad, tearful
low energy
loss of pleasure
Wont maintain ADL's
Manic:
Euphoria
agitation and irritable
restless
flight of ideas
impulsive
Attention seeking
poor judgment
decreased sleep
neglect ADL's
manipulative behavior
delusions/ hallucinations
Diagnostics
Mood Disorder questionaire
Clinical presentation
Intervention / Care Phases
Acute Phase: may require hospitalization, Self harm assessment / safety
Continuation: Remission of symptoms / focus on treatment adherence
Maintenance: Treatment may last for lifetime, goal is to prevent manic episodes
Medication
Mood Stabilizer - LITHIUM**
Antidepressants - SSRI, MAOI, TCA
Antipsychotics - Haloperidol
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Electoconvulsive Therapy (ECT)
Counseling/ Individual or group
Minimize Stimuli
Set limits and boundaries
Maintain patient Safety
Encourage expression/ communication
Promote self care needs/ education
Educate on identifying relaspe early
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Substance Abuse - Addiction
What is it?
Dependence and repeated use on chemical substances to alter mood/ gain a sense
of euphoria or escape from reality
Assessment Questions
Type used
Amount used
Frequency of use
Age started using
changes in performance
Precious withdrawal symptoms
Date last used
How it affects their
daily life and body
Diagnostics / Screening
Drug Abuse Screening Test
CAGE Questionnaire
Alcohol Use Disorder identification test
Clinical Opiate withdrawal scale
Types
/ side
effects
What
types
are
there?
Opioid: Heroin, Morphine - Slurred speech, respiratory depression, decreased LOC
Reversal: Naloxone
Alcohol: 0.08% blood alcohol level is intoxication: Death risk at 0.4% BAC
Sedatives: Benzodiazepines, barbiturates, Club drugs - drowsiness, sedation,
respiratory depression, decreased LOC Reversal: Flumazenil (Not for Barbituats)
Cannabis: Increased risk of lung cancer, relaxed, euphoric, paranoia w/ high dose
CNS stimulant: Cocaine, dizziness, tremors, blurred vision, tachycardia, seizures,
cardiovascular collapse, can lead to death
Amphetamines: Impaired judgment, hyper vigilant, irritability, tachycardia,
elevated blood pressure.
Inhalants: Depends on substance inhaled, nystagmus, phych changes, slurred
speech, dizziness, muscle weakness
Hallucinogens: anxiety, depression, hallucinations, pupil dilation, tremors, panic
attacks
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Maintain safe environment
use reversal agent if applicable
support patient to maintain vitals
Cognitive Behavioral Therapy
Therapy / support groups
Client education
Provide with resources for quitting
12 - step program encouragement
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Alcohol Addiction & Abstinence meds
Withdrawal Medications
Withdrawal symptoms by time frame:
Within 6 hours: Tremors, anxiety, N/V, Insomnia
Peak: 48-72 hours: Hypertension, diaphoresis, hallucinations, seizures
3-10 days after last drink: Withdrawal Delirium: Medical emergency DEADLY
Confusion, Disorientation, agitation, autonomic instability, seizures.
Withdrawal Medications
Diazepam, Chlordiazepoxide, lorazepam are used because they act on the
GABA receptors and mimic the effects of alcohol. It takes several days for the
neurotransmitters to readjust to normal function without alcohol.
Phenobarbital: Used for severe cases of Alcohol Withdrawal that are suspected to
go into Withdrawal Delirium long acting Barbiturate targeting GABA receptors:
Carbamazepine: Outpatient treatment to prevent relapse by decreasing cravings
and convulsions
Clonidine: used to control Neuroautonomic hyperactivity (decreases SNS side
effects of withdrawal)
Naltrexone: Suppresses the euphoric effect of alcohol (DOES NOT DECREASE
CRAVINGS)
Alcohol Abstinence
Disulfiram (Antabuse): Treat chronic alcoholism
Causes unpleasant symptoms / Nausea, Vomiting, chest pain, respiratory issue and
makes the client extremely uncomfortable. Medication last up to 2 weeks in system
Symptoms occur within 5-10 minutes
DON'T GIVE TO AN IMPAIRED CLIENT = Risk of death if enough ETOH is ingested
Acamprosate: Thought to stabilize chemical signaling in the brain that has been
disrupted by chronic alcohol use. (Does not reduce craving or cause reduced
euphoria if patient continues to drink)
Naltrexone: Same as above:
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Major Neurocognitive disorder (Dementia)
What is it?
Progressive decline in cognitive ability that mainly affects memory, has a slow onset
and is generally irreversable
Dementia Stages / Assessment
Early: Recent memory impaired, mood swings. Agnosia, Apraxia, Aphasia
Intermediate: Cannot learn new information, flat affect, depressed, wandering off
Late: cannot perform ADL's incontinent, almost in a comatose state - leads to coma
Diagnostics
Rule out delirium
Neurological assessment
Neuroimaging (CT, PET scans)
(X-ray of head / chest
ECG - Electroencephalography
EEG - Electrocardiography
ABG testing
Complete Metabolic Panel
- assess for imbalances
Perform screening
Functional dementia scale
Blessed Dementia scale (Family interview)
Interventions/
nursing
Care
What types are
there?
Client Safety
Room close to nursing station
Limit stimuli
Well lit environment
Bed / Chair alarms
Keep bed low
learn / avoid triggers
encourage ADL's
Medication
What types
are there?
Cholinesterase inhibitor: donepezil, rivastigmine, galantamine
*Caution w/ Asthma & COPD patients due to Bronchoconstriction*
Anxiolytics
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Educate caregiver on household dangers
Scatter rugs, clutter, electric cords
Install hand rails
Door locks / alert system on doors
Lower water temperatures in household
Provide caregiver with support
resources
Provide options for long term care
Encourage self care of Caregivers
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Alzheimer
What is it?
Sub type of a Neurocognitive Disorder progressive and irreversible neurological
disorder, the client suffers from memory loss and reduced cognitive function.
Symptoms have a slow onset that are commonly overlooked.
Assessment findings
Reduced short term memory
can't recognize faces
difficulty performing ADL's
Random pacing, wandering
Inappropriate behavior
Trouble remembering words
Trouble remember names
Forgetting details about the past
Loss of bladder and bowel
Personality changes
Diagnostics
No other explainable med/ condition
that causes the change
Slowed learning ability
Declining Memory
No brain injury or stroke
Inappropriate speech, loss for words
inappropriate judgement / Reasoning
Unable to interpret things around them
Visual-spatial
No Specific test to diagnose NC disorders
Interventions/
nursing
Care
What types are
there?
Patient safety
assisting ADL's
Assessing Cognition / noting deficits
Promote social engagement
enhance cognition, mood, behavior
Medication
What types
are there?
SSRI antidepressants
NMDA receptor antagonist
Cholinesterase Inhibitors
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Keep patient oriented
Implement consistent schedule
Provide structure
Guided activities
Educate on resources available
Caregiver support and therapy
Provide memory aids, games
assess risk for injury
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Delirium
What is it?
Change in awareness and attention with a change in cognitive function that
develops rapidly over a short period. Transient and usually reversible.
Common Risks
Drugs
Dehydration
High Fever
Sun downing
Systemic
infections
ABG imbalance
seizures
Migraines
Brain
neoplasms
heat stroke
stroke
head trauma
Assessment
unable to focus
disorganized thinking
scrambled speech
time and place disoriented
Hyper vigilance and stupor
-fluctuating between states
vivid dreams / nightmares
*attempts to flee*
Agitation
restlessness
fighting hallucinations
self destruction
Diagnostics
Mental status Examination / history
CT / MRI / CBC / Culture / Urine test
Confusion Assessment Method (CAM)
NEECHAM Scale
Interventions/
nursing
Care
What types are
there?
TREAT THE CAUSE
Bed / Chair alarms
Keep bed low
Nurses Safety/ dont let patient block exit
Client Safety
Room close to nursing station
Limit stimuli
Well lit environment
Medication
What types
are there?
Antipsychotics
Benzodiazepines
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Client safety measures
-bed alarm**
Nutrition consult
structured schedule
Redirect patient to reality
reassure the patient is safe
Community Resources education
maintain consistent staff during shift
use of TV / radio / photos to calm client
Assist client with ADL's
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Antipsychotics
Types
Typical - Conventional 1st generation
Positive manifestations
Hallucinations, Delusions, behavior
chlorpromazine, haloperidol
A-Typical-2nd / 3rd generations
Positive and Negative manifestations
1st line treatment Schizophrenia
risperidone, clozapine
How it works
Typical - Conventional 1st generation
A-Typical-2nd / 3rd generations
Blocks Dopamine, acetylcholine, histamine,
and norepinephrine receptors in the brain.
Blocks Serotonin, lesser effect dopamine,
acetylcholine, histamine, norepinephrine
Uses
What types
are there?
Bipolar (Manic phase)
Acute/Chronic psychotic disorders
Schizophrenia
Schizophrenia (positive and negative
levodopa induced psychosis
Bipolar disorder
Impulse control disorders
Complications
notify
provider
What types=are
there?
Extrapyramidal Side Effects**
Dystonia
Parkinsonism
Akathisia
Tardive Dyskinesia
Lip smacking/ puckering / pursing
Excessive Eye blinking
Abnormal tongue movements
Neuroleptic Malignant Syndrome
!!Life Threatening!!
**FEVER** stop med - give antipyretics
Use cooling blankets
monitor vitals
increase fluids
monitor Dysrhythmias
Diazepam - anxiety
Dantrolene, Bromocriptine (Muscle relaxant)
Wait 2 weeks to resume therapy
Contraindications
Cautions
What types are /there?
C/I - Dementia (Risk of CVA)
Alcohol use
Seizures
Diabetes Mellitus
Education
/ Considerations
What types
are there?
Dissolving pill - clients who hide /
pocket
Urine may turn pink / brown
1-6 weeks for therapeutic
Taper down medication
Case management if cost is an issue
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Anti depressants
Types
SSRI- Fluoxetine, sertraline,
Paroxetine, Fluvoxamine
Citalopram, escitalopram,
SNRI- Venlafaxin,
Duloxetine, Desvenlaxafine
Levomilnacipran
TCA - Imipramine,
Doxepin
Nortiptyline, Amoxapin,
Trimipramine,
Desipramine
Clomipramine.
MAOI:
Isocarboxazid
Tranylcpromine
Selegiline (Transdermal)
How it works
TCA
Increase serotonin
and Norepinephrine
SSRI:
Increase Serotonin
in blood /blocks uptake
MAOI
Seotonine, Melatonin, Epi,
NorEpi, Dopamine, Tyramine
What types
are there?
Uses
Bipolar (Manic phase)
psychotic disorders
Schizophrenia
Bipolar
Combined with SSRI
for resistant depression
Depression - Bulimia Nervosa
Social &Generalized anxiety
OCD
PTSD
WhatComplications
types are there?
SSRI *Sexual Dysfunction
Serotonin Syndrome:
Rapid onset
Tachycardia, hallucination,
coma and death
(*NO= St. Johns Wart)
TCA:
Arrhythmia
Anticholinergic effects
Seizure precaution
Cardiac arrest/ overdose
MAOI:
MOST Drug Interactions
**NO TYRAMINE (Cured
meats, Cheese, yogurt,
wine**)
(Wait 14 days between SNRI)
Contraindications
Cautions
What types/are
there?common
C/I - SSRI / SNRI do not mix with MAOI Seizures
NO - Alcohol use
Diabetes Mellitus
TAPER ALL MEDS SLOWLY
*One week supply for Suicide Risk
Educate on Sedative affects
Education
/ Considerations
What types
are there?
May take 2 weeks to start working
Can take up to 8 weeks for full effect
Dont mix with Grapefruit juice
Support / group Therapy / Give resources
Assess bowel and bladder function
(Anticholinergic effects from med)
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Anxiety medications
Types
Benzodiazepines
Diazepam
Lorazepam
Chlordiazepoxide
Clorazepate
Oxazepam, Clonazepam
SSRIParoxetine,
sertraline,
Fluvoxamine
Citalopram,
escitalopram
Others
Atypical - Buspiron
TCAs amitriptyline,
Imipramine,
clomipramine
How it works
SSRI
Increase Serotonin
in blood /blocks uptake
Benzodiazepines
Increases inhibitory
effects of GABA
Trauma - stress events
Hyper-arousal with
-dissociative disorders
Seizures & Muscle
Spasms
Insomnia
Buspiron
Exact action unknown
What types
are there?
Uses
Social & General Anxiety
Panic Disorder - OCD
Trauma / stress events
Depression
Adjustment Disorders
Dissociative Disorders
Long term anxiety
treatment
WhatComplications
types are there?
Benzodiazepines
Sedation / CNS depressant
Respiratory Depression
SSRI
Serotonin Syndrome
Sexual Dysfunction
Buspiron
Nothing major / very safe
drug
Contraindications
Cautions
What types/are
there?common
C/I - SSRI / SNRI
Do not mix with MAOI
NO - Alcohol use
TAPER ALL MEDS SLOWLY
*SSRI One week supply / Suicide Risk
Higher risk of side effects with anxiolytics
mixing
Educate on Sedative affects
Education
/ Considerations
What types
are there?
May take 2 weeks to start working
Buspiron / SSRI
Can take up to 8 weeks for full effect
Support / group Therapy / provide
resources
Dont mix with Grapefruit juice
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Mood Stabilizer - Lithium
How it works
Lithium exact actions are unknown
Lithium produces neurochemical changes in the brain and affects serotonin
receptor blocks
Uses
What types
are there?
Bipolar (Manic phase)
Controls manic episodes and prevents the return of mania and depression
Possibly decreases neuron atrophy
Side effects
What types
are there?
Fine Tremors (in hands)
weight gain
Hypotension
Hypothyroidism
Polyuria with mild thirst
Complications
notify
provider
What types=are
there?
Lithium Toxicity: > 1.5 mEq/L
Diarrhea, nausea, vomiting
muscle weakness, tremor
mental confusion, sedation
Lithium Toxicity: > 2 mEq/L
tinnitus,
extreme involuntary movements
ataxia, seizures
rapid progression - coma and death
Contraindications
Cautions
What types are /there?
Pregnancy
Renal , heart, liver issues
Use caution with Thyroid, seizure,
- diabetes disorders
Care
What Nursing
types are
there?
Therapeutic levels = 0.6 - 1.2 mEq/L
Measure levels 10-12 hours after last
dose in hospital / new prescription
Measure every 2 to 3 months after patient is stabilized on medication
Educate:
Dehydration increases toxicity risk
Nutrition counseling is key for safety
Effects may take 5-7 days
No OTC NSAIDS, Antihistamines
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ADHD medications
Types
Methylphenidate
Dexmethylphenidate
Dextroamphetamine
Amphetamine Mixture
Lisdexamfetamine dimesylate
How it works
Raises the levels of Dopamine and Norepinephirin withing the CNS
Uses
What types
are there?
ADHD
Conduct disorders
Narcolepsy
Obesity
Complications
notify
provider
What types=are
there?
Dysrhythmias, chest pain,
Decreased appetite
Increased Blood Pressure
Weight loss
Psychotic manifestations
Monitor height and weight
Can cause hallucinations and paranoia
Withdrawal
Reactions
What
types are
there?
Headache, nausea, vomiting,
depression and possible muscle
weakness
TAPER MEDICATION - Never stop
Abruptly
Contraindications
What
types are there?
Pregnancy
Substance abuse disorder
Severe anxiety
MAOI = Hypertensive crisis
Education
/ Considerations
What types
are there?
Do not chew
If patch/ alternate site daily (max 9
hours use from patch)
No alcohol
Resources for Family therapy
Cognitive behavioral Therapy
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Mental health - Children
What is it?
Mental health issues in children pose a special challenge as it can be hard to
communicate with them and the rate at which they develop, and activity levels very
greatly. (Healthcare treatment occurs when school, home life, peer interactions are
disrupted)
Assessment findings
ADHD
Autism
Intermittent explosive
Oppositional Defiant
Disruptive mood
Conduct disorders
Anxiety
PTSD
Diagnostics
Genetic testing for abnormalities
Family / child interview, assessment
Lifestyle / home life assessment
Traumatic exposure assessment
Interventions/
nursing
Care
What types are
there?
Use age appropriate words and speech
Identify desired behaviors
Encourage verbal communication
Determine triggers and avoid
Encourage family attachment / bonding
Assess risk for self harm
Assess drug / alcohol use
Encourage open communication and effective coping strategies
Medication
What types
are there?
ADHD: Psychostimulants, SNRI
Autism: SSRI, Anti psychotics
Explosive Disorder: fluoxetine, lithium,
clozapine
Conduct disorder: Varies depending on issue
Anxiety: SSRI may be given
Treatment for children try to
identify the issues and address
them with counseling if possible
before the start of medication
interventions
Therapeutic
ManagementTraining
What
types areBehavioral
there?
Cognitive-Behavioral therapy: change negative distorted feelings
Group/ Family therapy: Seek support from those close/ or same experiences
Grief and trauma Intervention for children
Music, play, and story telling to promote a calm and relaxing environment
Provide education and handouts on community resources
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Children - Communication
What to do
Try to be at eye level - standing over them can create a sense of anxiety
and a lower level of control that will reduce their willingness to
communicate.
Smile! seriously, smile let them know that not everything about being in
the hospital is terrifying!
Get the parents to help depending on age - young children who want to
cling to their parents can help by calming the child and interacting with
you to show the client that you are not a threat or "Bad person"
Reassure the client and give praise - Children love doing things right and
getting told they are doing so. Most of the time.
Use their clients"help" let them think they are helping "Can you hold my
penlight" "Do you want to help me with this equipment / test"
use toys and play time when appropriate - this can be helpful to calm
anxiety but must be used with caution as it could over stimulate the client
and reduce your ability to complete a task.
Ask the client what they are interested in / talking about their favorite
things or what makes them happy can help to ease their fears
Crayons and paper if available
DON'T LIE!
Keeping the client calm with help get more accurate information
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Eriksons Stages of Development
Stages
Infancy (birth to 18
months)
Trust
vs. Mistrust
Feeding
Hope
Early Childhood
(2 to 3 years)
Autonomy vs.
Shame and Doubt
Toilet Training
Will
Preschool
(3 to 5 years)
Initiative vs. Guilt
Exploration
Purpose
School Age
(6 to 11 years)
Industry vs.
Inferiority
School
Confidence
Adolescence
(12 to 18 years)
Identity vs.
Role Confusion
Social Relationships
Fidelity
Young Adulthood
(19 to 40 years)
Intimacy vs.
Isolation
Relationships
Love
Middle Adulthood
(40 to 65 years)
Generativity vs.
Stagnation
Work and
Parenthood
Care
Maturity
(65 to death)
Ego Integrity vs.
Medication
Despair
Reflection on Life
Diagnostics
Wisdom
Importance
These stages will not only help to determine where the individual should be at developmentally,
but can also help to identify if they have a regression or if an identity crisis is present.
Understanding this chart can help open communication flow, build a professional relationship,
and help identify possible sources of issues that you can use to better direct treatment,
education, while providing more accurate community resources to aid the client.
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SE
L
AN F-FU
D G LF
RO ILLM
WT
E
H NT
Maslows Hierarchy of needs
BA
SIC
NE
ED
S
PS
YC
H
OL
OG
ICA
LN
EE
DS
Self - Actualization
Morality/ Spontaneity/
problem solving
Esteem Confidence/ achievement/
respect
Love / Belonging
Friends / family/ sexual intamacy
Safety Security/ employment/ family/ health/ property
Psychological needs Breathing/ food/ sleep/ water/ sex/ homeostasis
How it applies
Mental health issues will often times lead to a person lacking multiple items from this
list that prevents their recovery.
It is also common that a person has developed a mental illness because they lacked an
essential part of feeling complete and maybe were simply not able to realize it, lacked
the knowledge what was missing, or had a barrier to seeking treatment.
As you are learning about mental health or treating patient try to identify what is
missing in their life and if there is a resource to help them in regaining stability beyond
simply giving them a pill.
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General Rules and Test Prep
Always think Patient Safety! Fall risk, sedatives, suicide, wandering
Always assess risk for suicide
Limited supply of meds
Meds will take time for full effect, may be at an increased risk of suicide
Dont forget about Maslow and ABCs, sometimes its the most basic answer
Mental Health patients still have their rights
MAOIs = no tyramine = cured meats, cheese, wine, yogurt
SSRI and MAOI can cause life threatening issue DO NOT MIX
Taper Medication / Do not stop abruptly
Use therapeutic techniques when possible, music, art, therapy
Alcohol and drug abuse: Last use, how much, how often
Lithium toxicity 2.5 or above think hemodialysis
Blurred vision, ataxia, TINNITUS, nausea, vomiting, diarrhea, coarse tremor
Consume enough Sodium/ kidneys conserve lithium with low salt diet
Diuretics and Nsaids increase lithium
Patients should NOT drive until they know how medication affects them
Abuse reporting
child, sexual, domestic, elderly
Somatoform Disorder - psychological disorder that show physical signs without
any apparent physical cause. (no medical explanation) May be called Conversion
Crisis Intervention: decrease emotional stress, protect victim, assist with
resources, return to per-crisis functioning level
Communication is a large part of testing questions (And they can be tricky)
Never ask why...
Coping and defense Mechanisms come up often (in my experience)
Drugs: Most severe side effects, Contraindications, diet
REMEMBER: NCLEX, ATI, and other test have a huge focus on Patient Safety!!
Practice questions can be your best friend, they help identify weak areas.
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