Pysch2

1. 19.3% of general pop has mood disorder

2. Depression in 21.3% women, 12.7% men

3. Depression onset: Mid 30's, often co-occuring with other psych and SA disorders. Variety of chronic medical conditions ex: endocrine, cardiovascular disease, neurological can lead to depression.

4. Check Thyroid, hypothyroidism can present as mood disorder.

1. Children/Adolescents: more likely to have anxiety symptoms. Risk of suicide inc, peaks during mid-adolescent years.

2. Older adults: Often undetected or inadequately treated. 8-20% older adults have depression. Suicide rates peak during middle age, 2nd peak occurs at 75 years >.

1. Mood: pervasive and sustained emotion, that colors one's perception of the world and how one functions in it.

2. Depression affects mood by: blunted, bright, flat, inappropriate, labile, restricted/constricted.

3. Pervasive = constant doesn't 100% go away

1. Genetics: hereditary factor implicated in both. Genetic influence stronger than the external factors in developing BP. Depression's inheritable influence is more tied to external factors of stress (loss), than it is for bipolar. Bipolar/schizophrenia seem to have similar genetic paths.

2. Biochemical influences- Deficiency in depression/oversupply in mania or proportional distortion of NTs: norepinephrine, serotonin (dopamine, acetylcholine, GABA and glutamate)

3. Neuroendocrine theories: Depression studies are being done on hormonal impact on mood.

1. sad, irritable, empty mood, with somatic and cognitive changes that interfere with functioning.

2. Disruptive mood dysregulation

3. Major Depressive Disorder

4. Persistent depressive (dysthymia)

5. Premenstural dysphoric

6. Substance/medication induced depression

1. Stressful events can precipitate triggering of disease for those biologically vulnerable.

2. In BP, stress may trigger/set off disease process. In depression, stress/perception of life events changes neurochemistry and impacts multiple areas of brain.

3. Cognitive theory- negative processing of thoughts. Cognitive distortions serve as the basis for depression. Negative view of self, expectations of the environment(world) and future.

4. Learned Helplessness - depression is related to perceived lack of control over events.

5. Psychoanalytic theory: Depression related to loss; Mania is defense against depression.

1. Physiological influences

2. Medication side effects

3. Neurological disorders: stroke/tbi

4. Hormonal Disorders: postpartum, thyroid, menopause

5. Nutritional deficiencies

6. Electrolyte disturbances

7. Other physiological conditions: loss of limb, chronic pain, cancer

1. Clinical course: progressive and recurrent

2. One or more moods, either a depressed mood or a loss of interest or pleasure in nearly all activities for at least 2 weeks

3. 4/7 Additional symptoms:

Disruption of sleep, appetite, concentration, energy.

Psychomotor agitation/retardation.

Excessive guilt or feelings of worthless.

Suicidal ideation.

4. Concerns when disruption in ability to fulfil life role in school/work/ADLs.

1. Patient specific symptoms

2. RN assesses, discusses with clien.t Which can they relate to? ex: increase/decrease in sleeping, loss of interests in activities, increase in calling in sick.

3. They can serve as marker for improvement.

4. Suicidal ideation, discuss features of this symptom, discuss desirable ,realistic outcomes for this symptom. figure out plan, intent, access

1. Over 2 years

2. Key element: Chronicity of depressed mood. Less severe than MDD.

3. Symptoms: nutritional variance, sleep variance, low energy/fatigue, poor concentration/decision making, feelings of hopelessness.

1. Peripartum depression

2. Catatonic features (stupor, negativism, mutism, posture)

3. Premenstrual dysphoric disorder: reoccurring mood swings, feelings of sadness, or sensitivity to rejection in the final week prior to menses.

4. Disruptive mood dysregulation disorder: severe irritability and outbursts of temper, begins before age of 10, similar to pediatric bipolar disorder.

1. Peripartum occurs up to 4 weeks prior to delivery. (approx 50%)

2. Baby Blues is period after delivery (Postpartum depression rates 50-80%)

3. Moderate PP symptoms: fatigue, irritability, loss of appetite, sleep disturbances, loss of libido, concerns about ability to care for infant.

4. PP Depression w/psychotic features symptoms: depressed mood, agitation, indecisive and abnormal attitude toward bodily functions.

5. Those with psychotic features have an increased risk for subsequent recurrence.

6. Etiology is not clear but mainly related to hormonal changes, tryptophan metabolism or cell alterations. Prior hx of depression increases risk for depression during pregnancy before/after delivery.

7. Monitor and teach patient along with family on symptoms to be concerned with.

1. Activity alterations: psychomotor agitation/retardation, decreased ADLs, eating/sleeping altered.

2. Social interactions altered: withdrawn/isolative, thought generation and conversation limited.

1. Affect: sadness and apathy, doom and gloom, guilt, self destruction

2. Cognition: ambivalence, indecision, pessimism, self-blame, decreased concentration/memory

3. Physical: headache, fatigue, constipation, chest pain

4. Perceptual: delusions and hallucinations congruent with depressed mood; tend to focus personally, less complex.

1. Characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy.

2. Delusions or hallucinations may or may not be part of clinical picture.

3. Onset of symptoms may reflect seasonal pattern.

1. Lifetime prevalence: 1% to 4%.

2. Symptoms onset: ages 14-21; fewer cases after 40.

3. No gender differences in incidence.

4. Females greater risk for depression/rapid cycling than males.

5. Male patients greater risk for manic episodes.

6. Ethnicity and cultural links require additional study.

1. Chronobiologic theory- sleep disturbances, hypothalamus, sleep wake cycle.

2. Genetic factors: twin study 40-70%

3. Chronic stress (allostatic load): inflammation, and kindling.

4. Psychological/Social Theories: focus on reducing environmental stress and trauma in genetically vulnerable individuals.

1. Stage 1 Hypomania: not severe enough to require hospitalization. Mood: superficially cheerful but easily irritated and volatile. Cognition: exalted idea of self, rapid idea flow, distractible with difficulty following through.

2. Stage 2 Acute mania: marked impairment often requiring hospitalization; Mood: Liability, euphoric to anger to crying. Cognition: racing and disconnected (flight of ideas; nonstop talking; usually unable to follow through, delusions.

3. Stage 3 Delirium Mania. Mood: very liable, from uncontrollable laughter to weeping or shutdown. Cognition: distractible, incoherent, disoriented, stupor but resistant.

1. One episode of mania or mixed (occurence of mania and depression.

2. Depression must also be present.

3. Catatonic or even psychotic episodes.

4. Hospitalization related to marked impairment in social or occupational function.

1. Major depressive episodes.

2. Occurrences of hypomania.

3. Never presented with full manic episode.

4. Marked impairment where hospitalization has been necessitated.

5. More difficult to diagnosis.

1. Chronic mood disturbance (Bipolar disorder)

2. At least 2 year duration

3. Numerous episodes of hypomania and depressed mood of insufficient severity to meet criteria for either bipolar disorder.

1. Safety

2. Suicide

3. Physiologic instability: appetite/nutrition, sleep disturbances, bowel habits

4. Thought process content: thought blocking/ difficulty concentrating, negative self-thoughts, hopelessness, guilt, psychotic features?

5. Judgement/insight: poor judgement reactions, anergia, slowed, poor insight limited ability to assess objectively.

1. Physiologic instability: appetite/nutrition/hydration, hyperactivity, sleep disturbance.

2. Risk of harm: to self due to, severe agitation/impulsivity, poor boundaries reaction poor judgement, hypersexuality/promiscuity. To others due to acting out on hallucinations/delusions.

3. Thought process/content: disturbed flight of ideas/tangential/loose association, superiority/competition

4. Judgement/insight: poor ability to assess danger and harm, limited to no insight.

1. Risk for injury/self: falls/exhaustion/impulsivity.

2. Risk for violence: suicide/hopelessness, manic excitement, agression to others, delusional thinking/hallucinations (responding to psychosis.

3. Impaired social interaction: depressed (isolation, passivity) vs. Manic (poor boundaries, manipulation, aggression)

4. Disturbed thought process- identify specific content for themes (worthlessness, guilt (D), grandiosity, entitlement, religiosity (M), and evidence or progression towards psychosis.

5. Imbalanced nutrition less than body requirements.

6. Insomnia

7. Self-care deficit.

8. Low self-esteem related to

1. Client will remain safe.

2. is free from injury (VS stable, ambulation at safe pace, navigate environment)

3. Maintains adequate physical boundaries keeping distance from staff and peers, respect physical property.

4. Interact with others using appropriate communication ( words, volume of speech)

5. Is oriented to reality, realistic goals

6. Verbalizes understanding of safe behavior/intent to comply with safety plan (insight)

1. Take in adequate nutrition/hydration (maintains weight)

2. Verbalizes plan for proper nutrition and intent to comply

3. Verbalizes adequate sleep (6-8 hrs) and plan to comply with adequate rest.

4. Complies with psychiatric medication and understanding of med purpose/SEs/schedule.

5. Performs ADLs independently.

6. Sets realistic goals for self

7. Is able to identify aspects of self control over life situation

8. Verbalizes positive statements about self and future with specific plan to work though issues (grief, self esteem)

9. Express personal satisfaction and support from spiritual practices.

10. Is able to concentrate, reason and solve problems (opposed to cognitive deficits in acute stage).

1. Safety issues: suicide prevention, injury /falls

2. Medical/Pharm managements: meds: antidepressants, mood stabilizers, antipsychotics, antianxiety, ECT (bipolar), trans magnetic stimulation (Depression), and light therapy (depression).

3. Therapeutic communication to medical Treatment: interested involvement w/ client (offering self); acceptance (both), appropriate limits on current behaviors (manic), and invitation to healthy/balancing behaviors (both), focusing (manic); exploring (depression).

4. Psychotherapy: individual, family, group

5. Behavioral: effective only when cognitively able

1. Assess safety issues: suicidality, behavioral dyscontrol, hyperactivity, boundaries, nutrition/hydration needs, hallucination/delusions. Observation, 1-1 at onset shift to intentionally clarify needs and plan.

2. Safety contract/ level of observation: 1-1 at onset shift, PRN: variable rounds (suicides); milieu management i.e. decrease stimuli (mania) provide socialization (depression); monitor appropriateness of interactions, limit setting as needed.

3. Monitor physical needs: I/Os, offer frequently. High protein/calorie finger foods/ drinks. Assess level of independence for adls/eating. Increase patient independence as able. Assess pt's understanding of proper diet. ADL as needed then teach principals.

4. Balance rest and activity.

1. Maintain clienty safety (behavioral and physical)

2. Medication management

3. Education: illness, treatment

4. Discussion of illness acceptance/compliance with treatment.

5. Assisting client through grief process (depression)

6. Promoting increase in self-esteem (clearly for depressed but also manic once stabilized)

7. Encouraging client self-control and control over life situation (both)

8. Helping client to reach out for social/spiritual support of choice and appropriate.

1. Has suicidal ideation subsided?

2. Does client know where to seek assistance outside the hospital when SI thoughts occur?

3. Can client name symptoms of mood disorder?

4. Is client compliant and knowledgeable of medication?

5. Are they able to verbalize positive aspects about self, past accomplishments, and future prospects?

6. Can client identify areas of life situation which he or she has control?

1. Mood stabilizers: relieve symptoms during manic and depressive episodes. Prevent recurrence of manic and depressive episodes. Do not worsen symptoms of mania or depression, or accelerate the rate of cycling.

2. Antipsychotics: given during severe manic episodes.

3. Antidepressants: Given during depressive episodes.

4. Drug selection: Acute therapy-manic episodes, acute therapy-depressive episodes, long term preventative treatment

5. Promoting compliance: short-term hospitalization, long-term hospitalization, educate both patient and family.

1. Education and psychotherapy

2. Electroconvulsive therapy (ECT)

1. Lithium (Salt)

2. Antiepileptic/Anticonvulsants

3. Antipsychotic

1. Simple inorganic ion, found naturally in animal tissues

2. TE: bipolar disorder, alcoholism, bulimia, schizophrenia, glucocorticoid-induced psychosis.

3. MoA: alter distribution of ions. alter synth and release of norepinephrine, serotonin and dopamine. Mediate intracellular responses between neurotransmitters. facilitates regen of damaged optic nerves. can inc total gray matter known to atrophy in bpd.

4. Onset: 5-7 days, up to 2 weeks.

5. Excretion: short half-life, excreted by kidneys, Sodium levels-lithium excretion reduced when sodium levels low.

6. Plasma levels: 0.8 - 1.4 mEq/L

1. TE levels: 0.8-1.4 mEq/L in mania, maintenace = 0.4-1.3 mEq/L

2. Normal SE: n/v/d (take w/ meals, transient), bloating and abd pain. Metallic taste, increases thirst, weight gain, tremors (fine), polyuria (antagonizes ADH), Monitor for renal toxicity. Goiter and hypothyroidism, reversible can treat.

3. Category D; avoid in pregnancy.

1. Excessive lithium levels > 1.5 mEq/L (early toxic): GI sx progress to severe n/v/d, tremors progress to course, neuro sx: slurred speech, start blurred vision, muscle weakness, decreased coordination, ECG changes.

2. Severe toxicity: > 2.0 mEq (if over 2.5 may die, need dialysis) severe hypotension, severe polyuria, dilute urine (progresses to oliguria), ataxia, giddy, tinnitus, blurriness, clonic movement.

3. Stupor->seizure->coma->death

4. drug interactions: diuretics, NSAIDs, anticholinergics

5. Preparations,dosage, and admin: lithium carbonate, lithium citrate, dosage is highly individualized.

1. Monitoring

2. Blood levels for toxicity (severe diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination); drug held if symptoms occur.

3. Creatinine concentrations, thyroid hormones, and CBC every 6 months.

4. Renal functions (kidney damage is possible)

5. Thyroid function (possible alteration after 6 to 18 months; observe for dry skin, constipation, bradycardia, hair loss, and cold interolerance)

1. When Lithium has failed.

2. Valproic Acid

3. Se: gi n/v, take with food

4. Hepatotoxic (anorexia, jaundice, abdominal pain) monitor baseline LFT.

5. pancreatitis

6. thrombocytopenia- reduces platelets.

7. hyperandrogenisms, polycystic ovary

8. fetal toxicity

1. Antiepileptic

2. Monitor liver function (inc enzymes) and platelets

3. Possible bone marrow suppression/ rare aplastic anemia, cardiac (rare), agranulocytosis (rare).

4. protects against recurrence of mania and depression.

5. fetal toxicity

6. s/e: dizziness, drowsiness, tremor, visual disturbances, nausea, vomiting (take with food)

1. indicated for acute and long-term maintenance

2. Monitor for skin rash, high risk in children and occurs 2-8 weeks after starting drug.

3. Dizziness n/v other GI SEs

1. use to control symptoms during manic episodes

2. use for long-term to help stabilize mood

3. benefit patients with or without psychotic symptoms.

4. Anti psychotics can be combined with mood stabilizer

1. Allow patient to express knowledge and experience with the medication.

2. Monitor the patients attitude towards consistent compliance:

3. Do they express false information about the medication? knowledge deficit or?

4. Is there a specific reason they struggle to comply? noncompliance

5. Let the pt. fully explore their choices and the potential impact of their choice on their life.

1. Most people who die by suicide have a mental disorder or emotional problem with depression as the most common underlying disorder.

2. Presence of mental illness

3. Gender

4. Age

5. Race

6. Religion

7. Marital status

8. biological theories: depression, severe childhood trauma, genetic factors.

9. Physical health: chronic pain, cancer

10. Previous attempt

11. Family history of suicide: same sex family member higher chance.

12. Occupation

13. Homelessness

14. Method

1. Suicide: voluntary act of killing oneself, a fatal, self-inflicted destructive act with explicit or inferred intent to die.

2. Suicidality: all suicide related behaviors and thoughts of completing or attempting suicide and suicidal ideation.

3. Suicidal ideation: thinking about and planning one's own death.

4. Suicide attempt: nonfatal, self-inflicted destructive act with explicit or implicit intent to die.

5. Parasuicide: voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death.

6. Lethality: the probability that a person will successfully complete suicide.

1. devastating effects on families

2. increased risk for suicide death in another family member if suicide death in a family occurs.

3. Survivors with increased grief, anxiety, depression, guilt, shame, self-blame, and family dysfunction

4. protective factors

1. Focused suicide assessment should occur for all acute psychiatric pts. (this may take form of coping assessment in generals/history for the psych pt who does not seem to be acutely depressed or at risk)

2. Other patients who express helplessness/hopelessness should be assessed (covert/overt statements)

3. It is within the nursing practice to assess suicidality. RN be aware of risk factors- age, medical conditions, medication side effects, psychosocial situation, current affect.

1. Assessing risk: identification of SI, elicitation of plan, determine the severity of intent, evaluation of available means.

2. Questions:

3. Do you have thoughts of harming yourself?

4. Do you have a plan for how you would kill yourself?

5. Do you have a means?

6. Can you stay safe and not harm your self

7. I am going to ask if you wuold contract with me.

1. Body search/belongings check

2. Safe physical environment: remove sharps, stranlging items, random checks, monitoring visits, locking of doors, give a roomate, constant 1-1 (full visual field and physical proxmiity), q10 to q 15 checks, no suicide contract

1. For more in depth, insight orientated assessment

2. You have mentioned that although you will not harm yourself now, you have in the past? Can you tell me about that? Most recently, how what happened?

3. What is different for you now? how do you think differently about killing yourself?

1. history, assessment, interventions

2. presence of absence of si, intent, plan , and means

3. use of drugs, alcohol, or prescription meds

4. level of pts judgement

5. prescribed meds, dosage, and number of pills dispensed

6. plan for ongoing treatment

1. Short-term: maintain pts safety, avert suicide, mobilizing the pts resources

2. Long-term: continuum of care, maintain the pt in psychiatric treatment, enabling the pt and family to identify and manage suicidal crises effectively, widening the patient's support network.

1. highly stressful

2. possible Secondary trauma for nurse

3. need for regular sharing experiences and feelings

4. role-modeling for patients by demonstrating how to effectively manage stressors in own lives.

1. SMS 988 (new access)

2. Suicide hotlines

3. ED

4. Family / survivor support after suicide.

5. If suicided in hospital, contact supervisor re: communication to family (legal issues)

6. Healthcare workers should ask survivors where they are at in dealing with their loss (if issue is raised)

7. give referrals for support.

1. Tricyclics

2. Monoamine Oxidase inhibitors (MAOIs)

3. Selective Serotonin Reuptake inhibitors (ssris)

4. serotonin/norepinephrine reuptake inhibitors (snris)

5. atypicals: mirtazapine (Remeron) and bupropion (Wellbutrin)

6. New ADs: Vilazodone (viibryd), Levomilnaciprin (Fetzima) and Vortioxetine (Trinetellix)

7. Tricyclics and MAOIs rarely used anymore

1. Structurally similar to phenothiazines (class of antipsychotics); has 3 rings, There are some similar side effects: sedation (due to histamine rec. block), orthostatic hypotension (due to alpha blockade), anticholinergic effect (due to muscarinic block).

2. Blocks reuptake of 2 Monoamine NTs: norepinephrine and serotonin

3. Ex: Clomipramine (Anaframil).

4. TE: depression, BP depression, neuropathic pain, chornic insomnia, panic disorder, adhd, ocd.

5.S/e: Most common is Orthostatic hypotension, Anticholingeric effects(dry, urine ret.,) and sedation. diaphoresis (paradoxical in some pts), seizures (rare), hypomania, yawngasm (anafranil), cardiac toxicity)

6. Make sure no hx of cardiac issues or HTN. can lead to HTN since fluid not being removed.

1. Cardiotoxic action(ekg baseline): dysrhythmias, tachycardia, intraventricular blocks, complete A/V blocks, ventricular tachycardia, v fib.

2. Muscarinic blockade causes: hyperthermia, flushing, dry mouth, and dilation of pupils

3. Treatment: propanolol, lidocaine, physostigmine (holinesterase inhibitor)

4. Lethal on OD

1. 3rd choice due to dangers/restrictions- used for atypical depression.

2. The MAO enzyme action

3. Hypertensive Crisis- Severe HTN, HA, tachycardia, n/v

4. MoA is dietary tyramine, stimulates release of NE systematically, serotonin and dopamine.

5. Tx: IV phentolamine, sublingual nifedipine

1. High tyramine foods are unsafe: ripe, fermented, smoked cured meats, fish, lunch meats, soy sauces.

2. Avocados, ripe bananas, broad beans, raisins

3. Most cheeses, especially aged

4. Beers, chianti, red wines

5. Caffeine

6. Low or No Tyramine (Safe) Foods: milk, cream cheese, nonfermented sausage, most vegetables and fruits, fresh chicken and unprocessed fresh meats.

1. 1987 introed

2. OD very rare in SSRIs

3. No cardiotoxicity

4. Ex: Celexa (citalopram), Lexapro (escitalopram), prozac (fluxetine), luvox (fluvoxamine), paxil (paroxetine), sertaline (zoloft).

1. GI: n/v/dry mouth/HA (INITIALLY), diarrhea or constipation

2. Insomnia or "activation"

3. Weight gain

4. Sexual dysfunction

5. Increased risk of GI bleed (warfarin inx)

6. Neonatal withdrawl

7. Bruxism (grind teeth)

8. Liver function test abnormality

9. Hyponatremia (esp in elderly) <135, esp pts taking thiazide diuretic

10. Serotonin syndrome- too much serotonin, interacts with MAOIs (need 14 days between class switch)

11. Increased suicidal ideation (esp children/adolescence)

12. Notes:

NO ABRUPT WITHDRAWL DIZZY, HA, NAUSEA, TREMOR, ANXIETY DAYS- 3WKS OF LAST DOSE​

TAPER!!!​

4% SEVERE RASH​

Take during day if having symptoms of insomnia. ​

Not as much weight gain as antipsychiotics​

SSRIs interact with warfarin​

Zoloft, clitopram ok for pregnant​

Hyponatermia if on antihypertensive esp​

Really teach 14 days between class switch​

Lexapro approved for children. Others not. Peds meds often off label and not FDA approved.​

1. Venlafaxine Effexor: nausea (40%), HA, anorexia, sweating, sleeping disturbance, sexual s.ie. diastolic HTN, no abrupt withdrawl

2. Desvenlafaxine Pristque

3. Duloxetine Cymbalta: mydriasis (no glaucoma), small inc in BP, nausea 20%, liver damage rare. (ensure good bp)

1. Too much serotonin

2. Agitation, jittery, tremulous, fever, sweat

3. Tachycardia, HTN -> Cardiovascular collapse

4. Abd pain, diarrhea

5. Confusion.

6. Spasms -> muscular rigidity -> rhabdo

7. Do not give SSRIs concurrently with MAOIs (need break of 2-5 weeks)

1. Buproprion (Wellbutrin),

a.Se: increase sexual desire

b.no weight gain

c. off label for adhd symptoms

d. HA, agitation, constipation, weight loss

e. Contraindicated with seizure history

2. Mirtazapine (Remeron)

a. Sedation (54%), and weight gain common s.e.

b. MoA: NaSSA, antagonizes the adrenergic alpha2-autoreceptors, blocks 5-ht2 and 5-ht3 receptors.

c. restless leg syndrome and military likes it

1. vilazodone (Viibryd, 2011 FDA): depression (use for anxiety and IBS non-FDA)

2. Levomilnaicprin( Fetzima) 2013 FDA

3. Multimodal agent vortioxetine (Trintellix) FDA 2016, old name = Brintellix (FDA 2013): possible cognitive enhancement, most common se causing discontinuation is nausea, sexual SEs are dose dependent.

1. All with similar efficacy. The choice of which drug depends on target side effects. Pts past treatments.

2. Slow variable onset (1-3, or 4 weeks) with full effect up to 2 months. Adequate trial for drug even longer ( 3-6 months. before trying others.

3. Medication dose does not actually change the specific thought content but may relieve target symptoms associated, fatigue, appetite, poor concentration.

4. Exeffor used more in males

5. ECT needs 1-2 years of med trail before escalating to ect.

6. SSRIs and SRNIs should be used in conjunction with therapy.

1. A maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use of substances.

2. Substance related problem must have occurred repeatedly during 12 month period.

3. Repeated failure to fulfill role obligations.

4. Social, interpersonal problems.

1. Depressants- ETOH, sedative hypnotics(barbiturates, benzos, non-barbs)

2. Stimulants- Amphetamines, cocaine, crack, nicotine, caffeine

3. Psychedelics/Hallucinogens (LSD, mescaline) Dissociative drugs- PCP (phencyclidine)/MDMA(ecstasy)

4. Narcotics/Analgesics-Opiates: (street-heroin) pain meds.

1. 3 or more criteria over 12 month period:

2. May or may not have Physiological dependence, depends on whether tolerance or withdrawal is present. Tolerance=need for greatly increased amounts to achieve intoxication or desired effect, or less effect with continued use of same amount. Withdrawal=physiological and mental (mal)adaptation that occurs when addictive substance is discontinued.

3. Pattern of Compulsive use: takes larger amounts over longer period of time, expressed desire and/or failure to cut down or control use. May spend increased time obtaining, using or recovering from effects of substance. Important activites given up. Despite recognized problem the person continues to use.

1. Reversible substance specific syndrome to due to recent ingestion.

2. Maladaptive behavioral or psychological changes due to the substance acting on the CNS: perceptual, wakefulness, thinking, judgement, psychomotor, interpersonal.

3. Intoxication != substance dependence/abuse

1. Cross tolerance - tolerance developed with one substance transfers so that one would have tolerance in a similar substance even if never used before. Ex: alcoholic require higher dose of anesthetics and barbituates.

2. Synergistic effects- when 2 drugs used together there may be intensification and/or prolongation of intoxication (ie. alcohol and benzos)

1. In lower doses there is more selective depressant action in brain, (affecting arousal), nerves, muscles.

2. Sleep, barbiturates decrease dream time.

3. Respiratory depression by inhibition of RAS; additive effects with other CNS depressants.

4. Cardiovascular, - hypotension with large doses.

5. Renal- in high anesthetic doses, barbs may suppress urine function.

6. Hepatic- stimulates production of liver enzymes; jaundice.

7. Sexual- biphasic, initially increases, disinhibition (inability to withhold an inappropriate behavior), then decreases ability to maintain erection.

1. CNS stimulants can excite entire nervous system; responses vary with dose and potency.

2. CNS, elation, subjective feelings of greater power, increased alertness, tremor, restlessness, anorexia, insomnia, agitation, may lead to paranoia.

3. Cardio/Pulm - Amphetamines have sympathomimetic effects: vasoconstriction, ^BP, ^HR, angina, hyperthermia, possibly leading to hypertensive crisis, MI stroke, and ventricular dysrhythmias.

4. Nasal Rhinitis, pulmonary hemorrhage; chronic bronch/pneumonia w/ inhaled form.

5. Sexual- aphrodisiacs (increases sexual arousal); men occasional dysfunction.

1. A distortion of perception is produced that can cause depersonalization or hallucinations; heightened response to color, texture, sounds, distorted vision, magnified feelings (intense) "dream like" state.

2. For PCP toxicity/OD - n/v, chills, pupil dilation, ^temp, decreased respirations, loss of appetite, insomnia, sweating, elevated bgl, rare intoxication that can cause seizures or coma.

3. Behaviorally, PCP users may experience severe psychosis and be combative or suicidal. Very dangerous behavior requires restraints.

1. ETOH (barbs and benzos similar)

2. thought process/mood changes, decreased inhibition, increased confidence/sociability, decreased attention, altered perception.

3. physical- slurred speech, decreased coordination, unsteady gait, vasodilation, nystagmus (moving eye), anesthesia, respiratory depression.

1. Initial "rush" = orgasmic like feeling, flushing, voice deepen followed by euphoria then lethargy or "nod" when eyes roll back, decreased response and finally, with awakening, arousal to drug seeking.

1. Breath Analysis for ETOH- immediate results at a low cost, narrow window of assessment.

2. Urine toxicology- depending on the metabolites and how long the last, usually in urine for 1-3 days; false positives from poppy seeds for opiates; marijuana in system for 3-4 weeks.

3. Serum testing - shortest window of detection as most drugs clear in less than 12 hours. BAL = 0.08%mg intoxicated in Colorado.

4. Hair sample- long term use from 90 days prior.

5. Sweat patch test/saliva testing.

1. BAL corresponds to alcohol level in brain and predicts CNS effects. (CNS effects are dose dependent)

2. Chronic heavy drinkers exhibit tolerance to lower dose effects but they remain vulnerable to the respiratory depressive effect once medulla effected at BAL between 0.40-0.52

1. Have you every tried to cut down use?

2. Has anyone annoyed you by criticizing your drinking?

3. Felt bad or guilty about drinking?

4. Have you every drank first thing in the morning as eye opener?

5. Cutdown, Annoyance, Guilt, Eyeopener.

1. Nurse assess many components of addiction: is an addiction present?, symptoms of intoxication and/or withdrawal (specific stages around use), physical sequela from substance use and psychological defense of addict and family.

2. Interview: be mindfully nonjudgemental, what (substance) and how do you use (route), when (last dose) and frequency of use, how much (circumstance), have others commented, defenses.

3. Physical: VS, Neuro: pupils, nystagmus, alertness, speech, coordination, tremors, speech, mood, impulsivity, psychosis. Respiratory and Cardiac System. Integumentary - needles, skin picking, cellulitis, nasal/oral, GI pancreatitis, hepatitis.

1. Children of alcoholics - parents offer decreased nurturing and children respond to dysfunction by learning to play a role rather than individuate at their developmental level: Hero or martyr; trouble maker or scape goat; lost child and mascot.

2. Spouse behaviors to enable addict arise from guilt, denial, fear of losing loved one and fear of future, identify with caretaking role, feeling they have no choice.

1. Risk for Injury - etoh intox, detox, stimulants, and hallucinogen intox

2. Risk for suicide (cocaine withdraw)

3. Ineffective denial

4. Ineffective coping (chemical use itself but other behaviors- risk taking, lying, poor work)

5. Chronic low self-esteem (prior to addiction and comes out in treatment)

6. Imbalanced nutrition (potential w/ all substances during addiction; ETOH, opioid during withdrawal)

1. cellulitis from infected needles (cardiac valvular infections)

2. HIV, hepC

3. Nasal septum erosion

4. Ischemic brain lesions

5. Dental erosion

6. Lung cancer, emphysema (MJ 50% more than tar and tobacco)

7. seizures

1. priority outcome depends on intox or detox and what pts symptoms are.

2. Ex: pt will remain safe/without injury as demonstarted by stable gait, VS WNL, neuro status intact (ex. no tremors, aox3, speech clear) verbalization of safety precautions and symptoms indicating need for assist. (syncope, increased temors, chest pain, vomiting)

1. Pt will verbally commit to and demonstrate safe behavior with staff (remain in bed, not pull lines, hydrate and eat when offered, accept assist with bladder/bowel, turning/positioining, wound care). Pt will respond positively to staff directions/redirections as needed. q1 (verbal) and ongoing (behavioral)

1. Pt will verbalize insight into own addiction by discussing their progression into substance use, identifying their specific triggers and naming specific ways they maintain sobriety and cope to prevent using.

1. RN will perform substance specific assessment to include: neuro assessment (responsiveness, PERLA, grips, gait, coordination, speech, judgement, perception); V.S.; respiratory assess (airway, oxygentation, pallor); cardiac (basic VS, chest pain/syncope and prn telemetry/EKG); Mood/cognition; GI(n/v/d, oral cavity integrity); integumentary (wounds/infections) upon onset of shift and q2h or prn distress.

2. RN will, after assessment, enact pt specific safety precautions (fall precautions, seizure prec) and communicate to MD need for specific orders to maintain pt safety including medications (prns narcan, antinausea, anti HTN, antianxiety) for pt symptoms (CIWA, prn restraint, IV hydration)

3. RN will discuss/teach plan for safe detox. with pt at onset of shift and prn pt need for reorientation.

1. Neurological- thiamine deficit

2. Wernicke's Encephalopathy - ataxia, mental status changes, paralysis of extraocular eye movement; possibly reversible with THIAMIN (vitamin B1)

3. Korsakoff's Syndrome- chronic amnesia, dementia, psychosis, confabulation(False memories), polyneuropathy (malfunction of nerves)

4. Pancreatitis

5. Cancer (GI tract, liver) higher in men.

6. Cardiomyopathy; myopathy; HTN

7. Esophagitis; Gastritis

8. Liver: fatty > hepatitis (90%) > cirrhosis of liver portal hypertension; ascites; esophageal varices; encephalopathy > increase ammonia levels

9. Fetal alcohol spectrum disorder (FASD) range form mild neurobehavioral symptoms to facial malformations, microcephaly.

1. Hallucinogens/PCP: keep environment stimuli down, monitor safety related to impulsivity, impaired judgement. Benzo's rarely effective for the labile or violent behavior. Gastric lavage(stomach pump) possibly related to OD.

2. Alcohol- consider safety specifically tailored to pts presentation: sleeping vs erratic

3. Cocaine- behavioral and physiological/medical

4. Opioids- NalxoneNarcan blocks the receptors fully for OD.

1. Effects the ventricles

1. Withdrawal symptoms: tremulousness, the shakes, anorexia, insomnia, tachycardia, HTN, fever, diaphoresis, agitation, n/v, loss of appetite

2. Acute hallucinations - may occur after tremors (usually visual), agitation

3. Delirium Tremens - (Alcohol withdrawal delirium) onset 24-72 hours after last drink; disorientation visual or tactile hallucinations.

4. Severe agitation, fever, perspiration, tachycardia, seizures (usually with liver disease)

1. Sedatives/Hypnotic: anxiety, intolerance to extreme brightness or loudness, muscle twitch, possible seizure; high doses of barbiturates can cause delirium, hallucinations, repeated seizures.

2. Opioid- (not dangerous but very uncomfortable) severe muscle cramps/spasms, yawning, bone pain, rhinorrhea, diarrhea, piloerection, temperature fluctuation, craving, pupil dilation, dysphoria.

3. Amphetamine/Cocaine- "crash" fatigue, severe depression, vivid bad dreams, psychomotor and sleep disturbances, increased appetite.

1. Alcohol- to prevent severe withdrawal, administer CNS depressant over 3-5 days, decreasing the dose 20% each day or prn. Benzos are 1st line for detox (Librium, valium, ativan) *CIWA protocols.

2. Sedative/Hypnotic- gradual reduction of dose, may require weeks; may use Tegretol or phenobarbital (longer acting) to prevent seizures.

3. Cocaine/Amphetamine- no physiological intervention; depression.

4. Hallucinogens/PCP- withdrawal not usually the issue but treatment to aid safe detox. Keep environmental stimuli down; Monitor Safety. Benzos rarely effective for liable or violent behavior. (Neuroleptics not implicated), acidify urine; gastric lavage.

5. Opioids- methadone, synthetic opioid; Buprenorphine (Suboxone) partial opioid agonist, these are for both detox and maintenance therapy for opiate addicts); Clonidine- nonaddictive suppresses withdrawal symptoms.

6. Naloxone (Narcan) blocks receptors fully, for overdose on opioids.

1. After detox

2. To MAINTAIN abstinence, decreases craving of ETOH. (used for maintaining the sobriety phase specifically, separate from shorter withdrawal period)

1. After detox.

2. Initially only for opiate users, but now for ETOH as well. Antagonist that blocks the receptor and prevents euphoria associated with opiates/ETOH. (IM only L.A.- vivitrol extended release) MAINTAINS abstinence, decrease craving

3. Used for maintain the sobriety phase specifically, separate from shorter withdrawal period.

1. Uses classical conditioning to deter drinking.

2. Watch for hidden ETOH

3. Used for maintaining the sobriety phase specifically, separate from shorter withdrawal period.

1. blocks cravings of opioids

2. Addictive

3. used to lessen/prevent withdrawal symptoms'

3. used to maintain sobriety phase as well

1. partial opioid agonist, decreases cravings

2. Used to prevent withdrawal symptoms

3. Used to maintain sobriety phase as well

1. Support Groups

2. Pharmacotherapy

3. Short term inpatient

4. MICA (mentally ill chemical abusing)

5. Psychotherapy

6. Family Therapy (ALANON, support group)