Mental Health Nursing

Psychiatric Nursing SUPPLEMENTAL BULLETS

TYPICAL PROFILE OF PATIENT WITH ANOREXIA NERVOSA FEMALE , ADOLESCENT,UPPER CLASS ,PERFECTIONIST A PaTIENT WITH AN EATING DISORDER UNCONSCIOUSLY ASSOCIATES FOOD WITH LOVE AND AFFECTION LITHIUM LEVEL TOXIC AT 2.0 mEq / L NEUROLOGIC SIGNS AND SYMPTOMS INCLUDE NAVDA, TREMOR, HYPERREFLEXIA,FASCICULATIONS, BRADYCARDIA , ARRYTHMIAS ,SEIZURES AND COMA Korsakoffs Psychosis : inability to process new information ( to form new memories). This is a reversible condition resulting from brain damage induced by a thiamine deficiency which is generally secondary to chronic alcoholism. Werniches Encepalopathy : This disease is also due to an alcoholicinduced thiamine deficiency. It is an irreversible disease in which the brain tissues break down, become inflammed, and bleed

Pharmacological treatment of alcohol withdrawal benzodiazepines or barbiturates

First symptom of Alzheimers Disease progressive memory loss Effective long term treatment for alcoholics AA Methadone causes analgesia without euphoria,withdrawal symptoms less severe than heroin Medical/ health professionals prone to have anxiety and depression treated by generalist rather than physicians

Delirium reversible organic mental syndrome reflecting deficits in attention, organized thinking, orientation , speech, memory and perception. Patients are frequently confused, anxious , excited and have hallucinations. A change in consciousness can be observed(clouding of consciousness) Dementia irreversible impaired functioning secondary to changes / deficits in memory, spatial concepts, personality , cognition , language , motor and sensory skills, judgement or behavior. No change in consciousness

Substances that mimic generalized anxiety amphetamines , cocaine , anticholinergics, alcohol and sedative withdrawal

Geriatric drug induced hallucinations commonly due to propanolol Major risk or TCAs orthostatic hypotension leading to falls Symptoms of alcohol withdrawal and their temporal relations
Hallucinations after 24 hours Autonomic hyperactivity after 6-8 hours Global confusion 1-3 days after

Side effects of Ritalin insomnia abdl. Pain, depression, anorexia, HA and HPN
First episode of Bipolar disease mania before depression Lithium used for mania and bulimia , anorexia nervosa, alcoholism with mood d/o, headaches Borderline personality d/o Chronic Boredom Parotid gland swelling and erosion of teeth enamel, elevated serum amylase and hypokalemia Bulimia Conversion d/o internal psychological conflict that manifests as somatic symptoms.

Dysthymia chronic d/o more than 2 years

Symptoms of depression I Nterest down Sleep Appetite Depressed mood Concentration diff. Activity Guilt Energy low Suicide

Dystonic rxn side effect of neuroleptics-muscle spasm of tongue, face and neck and back,laryngospasm and extraocular muscle spasm
Dystonic rxn treated with Benadryl or Cogentin Hallucinogens affect serotonin Munchausen syndrome harm oneself factitious d/o manchausen by proxy seeks medical care for another (e.g. child)

Haloperidol prefrred neuroleptic few side effects , can be used IM during emergencies( but high

frequency of extrapyramidal effects)

Clozapine no tardive dyskinesia but can develop agranulocytosis , seizures,hypotension, over sedation. Benzodiazepine contrindications pregnancy ( 1st trim)acute narrow angle glaucoma, and hypersensitivity Extrapyramidal Rxns- involuntary spontaneous motor movements dystonis, akathisia and parkinson like syndrome

Obsessive Compulsive d/o begins before 25 y.o. SSRI and exposure therapy beneficial
Positive operant conditioning reinforce positive behavior PTSD possible even though there is no actual witnessing of event Flashbacks , nightmares,intense fear,avoidance and diminished memory of event with an exagerrated startle response onset occurs at least 6 months - PTSD

Post partum psychosis first few weeks post-partum(710 d/6-8wk,) primiparous,poor social support and

previous depression
Schizophrenia
Association looseness Ambivalence Autism Affect inappropriate Hallucinations + As + Regression + Delusions + Stimuli comprehension low
(HARDS)

Somatization d/o multiple , unexplained medical symptoms(four unexplained pain Sx)

Suicide bipolar d/o, depression, substance abuse and schiz. Reliable predictors of potentially violent patient male gender , Hx of violence , history of substance abuse Organic brain syndrome most frequent mood irritability Labile affect rapid shifts of mood

Medication used to relieve extrapyramidal effects of psychotropic medications:

Benadryl Artane Cogentin

School age w/ terminal illness honestly explain in understandable terms. Provide reassurance that he will not be alone.

Prodromes of violent behavior anxiety,defensiveness,volatility and physical aggression

Akathisia-internal restlessness-Tx propanolol Echolalia meaningless automatic repition of someone elses words Catalepsy maintains same posture for a long period of time Waxy flexibility offers resistance to change in position but gradually allows to be moved to anew posture

Institutionalization only if patient poses a danger to self or others

10 most stressful events(Holmes and Rahe)
Death of a spouse or child Divorce Separation Institutional detention Death of a close family member Major personal illness/injury Marriage Job loss Marital reconciliation retirement

Standard care for domestic violence

Establish confidential system of identification Document Collect evidence Evaluate safety issues Formulate safety plan Give insight to options and resources Refer for counseling nad legal asst. Coordinate w/ law enforcement Transport to shelter prn Follow up w/ DV advocate

Common anti cholinergic meds- AtSO4, TCAs,antihistamines, phenothiazines and antiparkinsonian drugs

Lithium toxicity sign: tremor, symptoms:weakness and ECG findings: flattening of T-waves.

Tx for Wernickes Encephalopathy thiamine IV

Organic Brain Syndrome manifestations
Hallucinations Perception aberration Mental status change Focal neurologic sign

Imipramine HCl TCA dry mouth X drink excessively leads to electrolyte imbalance just ice chips/ gum
Least therapeutic around depressed clients Cheerfulness or gaiety Theory behind interpersonal model of behavior therapy: Behavioral Changes result from stress on the individual and his body systems Systems model theory behavior results from interaction between individual and environment Haldols CNS adverse reaction Extrapyramidal side effects

Significant features of each AXIS in the Diagnosis Statistical Manual for mental disorders IV
Axis 1 organic brain syndromes,psychosis,affective d/o and substance abuse Axis 2 personality disorders Axis 3 medical problems Axis 4 - Life events leading to problems
Psychosocial and environmental

Axis 5 patient adaptation to problems

Schiz. patient priority safety then self care needs , then health needs then behavior goals
Major goals of psychosocial rehabilitation program teaching independent living skills OC d/o substitution and undoing Adolescent behavior influence - peers Organic mental d/o :
Agnosia,insomnia,amnesia,confusion delirium and depression

Attributes negative traits to others - projection

Showing emotion opposite to what is truly felt reaction formation Alcohol aversion therapy antabuse

Alcoholism rationalization substituting a more acceptable reason for ones behavior Heroin overdose ABCs Cocaine red excoriated nostrils, tachycardia , nervousness and pupillary dilation AA independent responsible arrangements(personally done)

Barbiturate overdose -respiratory failure

Drug given at a non- intoxicating dose for barbiturate withdrawal Pentobarbital Na ( Nembutal) Long term amphetamine abuse emotional lability, depression,dependency , hallucinations and delusions

Severe anxiety and withdrawn diversion activities and increased social contact
Anorexia nervosa when exercising interrupt and redirect activity Antisocial egocentrc and unconcerned Ultimate nursing goal for severe anxiety disorder development of adaptive coping behaviors and problem solving skills Inderal use to relieve physical symptoms of anxiety

Disclosure of a plan to kill someone report to the staff and AP asap

Obtained sense of self awareness, attributes , defense mechanisms and behaviors gained INSIGHT Priority for suicidal depressed patients safety and security ( not cause personal harm) Suicide an individual decision cannot be influenced by nurses questions Sudden increase in energy level or mood- warning sign

Client under influence of cocaine agitated, aggressive and paranoid priority safety / protect pnt.
Tardive dyskinesia involuntary twitching or muscle movements Dystonia uncoordinated spastic movements of the body Discharge preparation for termination of NPR Delusional withdrawn encourage participation reinforces reality and brief one on one contacts in his own room

Fluphenazine decanoate ( prolixin ) drug of choice for Schiz. given only once every 2-4 weeks
Prolixin edema , blood dyscrasias and BP fluctuations check weight , WBC count and BP.

Schiz complaints of hallucinations assess for compliance Clients discharge from involuntary admission determined by legal or medical approval Confused client promote safety, prevent injury and maintain quality of life

Alcohol intoxication allow pnt. Sleep it off

Support gropu for spouses and significant others of alcoholics Alnon Breaking defenses of denial may lead to mental disorganization and depression Thorazine reduces seizure threshold Heroin addiction symptoms of late withdrawal navda recovery principle to ease anxiety one day at a time

Barbiturates + alcohol depressant effect

2-3 days barbiturate withdrawal generalized convulsions-Given nembutal to decrease seizure possibility Anorexia nervosa goal of Tx stabilize weight and facilitate entry into outpatient care Xanax short term Tx tolerance can occur Do not respond to a client who tries to evoke feelings of anger / negative response

Endogenous depression biochemical in nature

amitriptyline HCl urinary retention Elderly reminiscing reduce depression, lessen feelings of isolation and loneliness Alcohol detoxification inquire alcohol consumption past 24-48 hours to determine withdrawal severity ( auditory hallucinations common) Delirium Tremens quiet , well lighted room with companion , last resort restrain if violent only Heroin injection tested for HIV and Hepa B

Methadone liquid form under direct supervision

Best measures to recovery success number of chemically free days Drug tolerance requires increasingly larger doses to achieve the same desired effect Severe Sx of barbiturate with drawal postural hypotension,psychosis, hyperthermia and seizures Anorexia nervosa focus nutritional status Patient on librium avoid alcohol Disciplining unacceptable behavior person still accepted

Alcohol disulfiram Rxn vomiting , dyspnea, hypotension,vertigo,syncope,confusion,respiratory depression,convulsions,coma,death

Alcoholism defense rationalization , repression /suppression, denial

Heroin overdose antidoteNarcan(naloxone)increased HR,BP and LOC ( but short acting )

Barbiturate ,Opiate or Benzodiazepine sluggish, irritable, slurred speech , impaired judgement and walking diff.Buspar not prn therapeutic effect 7 10 daysfull effect 3 -4 weeks Epinephrine decrease peristalsis Restraints discontinued when subj. and obj. assessments indicate an absence of aggression

Abusive family characteristics :

History of family violence Unbalanced power ratio Stereotypical role playing Dysfunctional expression of feelings Strict boundaries Lack of empathy Substance abuse Low self esteem common trait of abuse victims

Medication can only be forced to a patient if he poses a threat to himself and others
Anti social personality limit setting on behaviors Psychophysiological anxiety d/o activities that promote rest, involve relaxation Self awareness towards mortality needed to be effective in caring for the terminally ill Organic mental d/o safe simple envt. To help his orientation Anorexia nervosa perfectionists ,self starvation and rigorous exercise high cal and high CHON diet.subconcious conflicts parental , autonomy, identity

Isolation , medication and warning others short term anger mngt. Does not place responsibility on the patient for his own behavior, ineffective in behavior modification

Positive reinforcement for good behaviors For manipulative clients limit setting and positive reinforcement

Personality traits for ulcerative colitis OC, perfectionist, inflexible, difficulty in showing emotions and obstinate
Four point retraints monitor circulation and skin, provide sensory stimulation,means of elimination and nutrition and change in position MAO therapeutic effects 4 weeks Turning unacceptable feelings into physical Sx that has no identifiable cause conversion rxn

Sarcasm expression of anger

Confabulation unconscious behavior used to hide memory loss by replacing it with fabrication Unconscious forgetting of traumatic events repression Projecting feelings or thought to someone transference MAO headache and neck stiffness hypertensive crisis

Communication for someone who refuses to speak open ended questions focussing on expression of feelings
Anti-psychotics abrupt discontinuation- nausea and seizures Manipulative behavior lack of trust Verbally and physically abusive patients try setting limits verbally before physical and chemical restraints

Abused child little showing of emotion and little response to pain

Depressed clients readiness evaluated by responsibility for own well being , ADLs and continuing Treatment. Abused child same primary nurse everyday promote trust and provide continuity of care Anti social continue to enforce rules and set limits on behavior( provide appropriate explanation)

Demerol C/I for clients taking MAOIs,can cause death

Alzheimers memory and emotion difficulties stage 1 Memory loss, confusion , wanderin aphasia, inability to do self care stage 3 Lithium therapy monitor sodium Tyramine rich foods- smoked , aged , pickled or fermented Stage 1 alzheimers recent memory loss only Hallucination episodes redirect to reality ( activities)

Lithium carbonate therapeutic level in 2 weeks

Dementia wandering constant supervision A client exhibiting mania placed on lithium carbonate and Thorazine simultaneouslyThorazine controls manic behavior until lithium reaches its therapeutic levella belle indifference lack of concern for profound disability Highest treatment priority for anorexia nervosa-correction of nutritional and electrolyte imbalance Seclusion for promotion of therapeutic limit setting, reduces overwhelming environmental stimulation, protects patient from self injury or injury to othersif patient does not respond to less restricted interventions until pnt. Can assume self control

Compulsion irresistable urge to perform an irrational act Self esteem needs- self worth ,self respect ,self reliance , dignity and independence Love and belongingness affiliation , affection and intimacy

Minnesota Multiphasic Personality Inventory MMPI- 550 question test assess personality and detects d/o such as schizophrenia and depression
ECT 6-12 treatments of 2-3 per week Circumstaniality disturbance in associate thought and speech patterns Lithium levels checked every 6 8 weeks

Primary purpose of psychotropic medications to decrease symptoms to allow participation in therapy

First step in drug overdose or toxicity management- establish and maintain airway Korsakoffs syndrome hallucinations,confabulation,amnesia and disorientation TCA s
A/R: orthostatic hypotension,tremors overdosage: seizures HPN shock arrythmias

Most common psychiatric disorder

depression