Psych Outline

Chapter 1

M
 Mental Health: the successful adaptation to stressors evidenced by thoughts, feelings and
behaviors appropriate for age and congruent with local and cultural norms
 Mental Illness: Maladaptive responses to stressors from the internal and external environment
evidenced by thoughts, feelings and behaviors incongruent with local and cultural norms and
interfere with individuals social, occupational and physical functioning
 Id: instinctual drive, pleasure principle, present at birth, satisfies needs of immediate gratification,
may be impulsive and irrational
 Ego: rational self, reality principle, starts to develop at 4-6 mths, brings external world in, adapts
and responds to it; replaces the pleasure principle and maintains harmony
 Superego: perfection principle, develops 3-6 yo, internalizes values and morals, right and wrong

Stress-Fight or Flight –Physical responses

 Alarm reaction: responses to fight or flight syndrome are initiated;↑ HR,↑ R, HA sweaty palms,
dizziness
 Stage of resistance: individual uses the physiological responses of the first stage as a defense
in attempt to adapt to the stressors.
 Stage of exhaustion: this occurs when there is a prolonged exposure to the stressor to which
the body has become adjusted. Energy is depleted. Diseases of adaptation may occur (ex:
headaches, mental disorders, CAD, ulcers)
 Immediate response: hypothalamus stimulates SNS with results in the following physical
effect: norepi and epi into bloodstream, pupils dilate, increased secretions of lacrimal glands,
increased RR, increased C/O-HR&BP, decreased GI motility, decreased glycogensythesis,
sphincter relaxes, sweat glands increase

 Sustained response: if person remains stressed for long period of time the hypothalamus
stimulates the pituitary gland to release hormones that produce—stimulates ACTH,
vasopressin, growth hormone, thyrotropic hormone, gonadotropins (pg 5 explains the MOA of
all of these) promotes susceptibility to disease

Stress- Fight or Flight-Psychological responses (anxiety and grief)

 Anxiety: feelings of uncertainty and helplessness; apprehension vague in nature. Can cause
neurosis, excessive anxiety expressed with defense mechanisms. Psychosis is gross
impairment of reality (delusions, hallucinations, crazy speech, and catatonic behavior
1. Mild: adaptive; seldom a problem. Sharpens the senses, increases motivation,
increases perceptual field, heightened awareness
2. Moderate: perceptual field diminishes, less alert, decreased attention span and
ability to concentrate. Increased muscular tension and restlessness are evident.
Assistance with problem solving may be needed.
3. Severe: perceptual field is so diminished that concentration centers on one detail
only or on many extraneous details. Physical symptoms include headache,
palpitations, insomnia and confusion, tachycardia, HTN, dread and horror may be
evident. In severe anxiety extended periods of repressed severe anxiety can lead to
psychoneurotic patterns of behaving
 a. Neuroses – psychiatric disturbances appear as symptoms, such as
obsessions, compulsions, phobias, and sexual dysfunction. Patient is aware
they are experiencing distress, and that it is maladaptive. They feel helpless
in situation and there is no loss of reality.

4. Panic anxiety: most intense state, unable to focus even on one detail within the
environment, may lose contact with reality. Hallucinations or delusions may be
evident. Wild and desperate actions and extreme withdrawal. May be convinced
they have a life threatening illness and are going crazy (late signs). Panic anxiety:
can lead to psychotic behavior including schizophrenia or delusional disorders
a. Psychosis - severe mental disorder, gross impairment in reality testing,
manifested by delusions, hallucinations, disorganized speech, or catatonic
behavior

Coping mechanisms that individuals use to relieve anxiety in stressful situations:

 Sleeping Eating Pacing
 Exercise Smoking Cursing
 Crying Yawning Fidgeting
 Drinking Daydreaming Finger tapping
 Nail biting Talking to someone who they feel comfortable

More psychological responses - Ego Defense Mechanisms – at the mild/moderate level, the ego calls
on the defense mechanisms for protections:

• Compensation: covering up a real or perceived weakness by emphasizing a trait one considers

more desirable
• Denial: refusing to acknowledge the existence of a real situation or the feelings associated with it
• Displacement: transfer feelings from one target to another that is considered less than
threatening or that is neutral
• Rationalization: attempting to make excuses or formulate logical reasons to justify unacceptable
feelings or behaviors
• Reaction Formation: preventing unacceptable or undesirable thoughts or behaviors from being
expressed by exaggerating opposite thoughts or types of behaviors
• Regression: responding to stress by retreating to an earlier level of development and the comfort
measures associated with that level of functioning
• Identification: attempt to increase self-worth by acquiring certain attributes and characteristics
of an individual one admires
• Intellectualization: attempt to avoid expressing actual emotions associated with the stressful
situation by using the intellectual processes of logic, reasoning and analysis
• Introjection: integrating the beliefs and values of another individual into one’s own ego structure
• Isolation: separating a thought or memory from the feeling tone or emotion associated with it
• Projection: attributing feelings and impulses unacceptable to one’s self to another person
• Repression: involuntarily blocking unpleasant feelings and experiences from ones awareness
• Sublimation: rechanneling of drives or impulses that are personally or socially unacceptable into
activities that are constructive
• Suppression: voluntary blocking of unpleasant feelings and experiences from ones awareness
• Undoing: Symbolically negating or canceling out an experience that one finds intolerable
Grief – subjective state of emotional, physical, and social responses to the loss of a valued entity. A loss is
anything perceived as such by an individual. A loss may be real or perceived.

Five Stages of Greif – Kubler Ross (DABDA)

1. Denial: response may be “no it can’t be true.” Reality of the loss is not acknowledged
2. Anger: “why me?” and “it’s not fair”
3. Bargaining: “if god will help me through this, I promise I will go to church every Sunday and
volunteer my time to help others”
4. Depression: full impact of loss is experienced. Time of quiet desperation and disengagement
5. Acceptance: brings a feeling of peace regarding the loss
 Anticipatory grief: experiencing the grief before the loss occurs
 Resolution: length of grief process is individual, it can last from weeks to years, influenced by
a number of factors
Maladaptive grief responses
 Prolonged response: intense preoccupation with memories of the lost entity for many years after
the loss occurred
 Delayed/inhibited response: individual becomes fixed in the denial stage of the grieving process.
Anxiety or sleep disorders may be evident
 Distorted response: fixed in the anger stage of grieving. Helplessness, hopelessness, guilt and
anger are all exaggerated

Chapter 4
 Ethics: systematic approaches to distinguish right from wrong
 Bioethics: concepts within the scope of medicine, nursing and allied health
 Moral behavior: “how you should treat people”
 Values: personal beliefs about what is important and desirable
 Values clarification: people identify and rank their own person values
 Right: valid, legally recognized claim or entitlement, encompassing both freedom from
government or discrimination and an entitlement to benefit or service
 Absolute right: no restriction whatsoever on the individuals entitlement
 Utilitarianism – the ethical theory in which decisions are based that ensure the greatest
happiness to the greatest number of people
 Kantianism – Ethical theory by which decisions are based on a sense of duty
 Christian ethics – The ethical theory that espouses the Golden Rule, “Do unto others”
 Natural Law – The theory in which decisions are based in which evil acts are never condoned,
even if they are intended to advance the noblest of ends
 Ethical egoism - An ethical theory that espouses making decisions based on what is most
advantageous for the person making the decision
 Legal right: right on which the society has agreed and formalized into law
 Ethical dilemma: choice between two equally unfavorable outcomes ** taking no action is
considered an action taken
Ethical Principles
 Autonomy: emphasizes the status of persons as autonomous moral agents whose rights to
determine their destinies should always be respected
 Beneficence: “do good” ones duty to benefit or promote good of others
 Nonmaleficence: “don’t do harm” abstaining from negative acts toward another
 Justice: “fair” duty to treat all individuals equally and fairly
 Veracity: always be truthful
A Model for Making Ethical Decisions – Nursing Process
1. Assessment: gather subjective and objective data, consider values of everyone involved in ethical
dilemma
2. Problem Identification: identify the conflict between two or more alternative actions
3. Plan: explore risks and benefits, consider principles, select alternative
4. Implementation: Act on the decision made and communicate to others
5. Evaluation: Evaluate outcomes

Ethical issues in Psychiatric nursing

 Right to refuse medications—must meet three criteria to administer meds without client consent
1. behavior that is dangerous to self or other
2. must have reasonable chance to providing help to the client
3. must be judged incompetent to evaluate the benefits of meds
 Right to the least restrictive treatment alternative – pt are protected by the Patient Self-
Determination Act of 1991 – see false imprisonment below for more on restraints

Legal Considerations
 Statutory Law: law that has been enacted by a legislative body such as county or city council,
state or us congress. Example: Nurse Practice Acts
 Common Law: developed by state to state basis, derived from decisions made in previous cases.
Example: how different states deal with a nurses refusal to provide care for a specific pt
 Torts – A violation of a civil law in which an individual has been wronged
 Malpractice – The failure of a professional to perform or refrain from performing in a manner in
which a reputable member within the profession would be expected to do so
 Civil Law: protects private and property rights
 Criminal Law: protection from conduct deemed injurious to the public welfare/ Example: theft

Confidentiality
 Exception: A DUTY TO WARN—threat of violence by a pt towards another, identification of
intended victim, ability to intervene in a feasible, meaningful way to protect the intended victim
 Involuntary commitments: emergencies, hurting self or other, involuntary outpatient, gravely
disabled (drinking, drugs, etc.)
 Libel: written info
 Slander: oral defamation
 Assault: threatening but not touching
 Battery: unconsented touching
 False imprisonment: confining pt against his or her wishes and outside an emergency situation
o “Talking down” verbal intervention
o Chemical restraints – tranquilizers; decrease agitation
o Restraints
 Seclusion or restraints disc at the earliest possible time
 1) q4h for >18 yo , 17-9 yrs q2h, and <9 yrs q1h, max 24h, 2)sitter with continuous
monitoring, must regularly check respiratory, circulatory, skin integrity, and vital
signs, 3)MD must see patient within 1 hr of admission
Avoid Liability
 Respond to client  Document carefully
 Educate client  Follow up as required
 Comply with standard of care  Maintain good interpersonal relationship
 Supervise care with client and family
 Adhere to nursing process
 Chapter 6

Communication – interpersonal communication techniques, verbal and non-verbal, are the tools for
psychosocial intervention
Therapeutic Nurse Client Relationship
 Relationships are goal-oriented and directed towards learning and growth promotion
 Problem solving is often how goals are achieved; goals should be mutually defined by patients and
nurses (mutually agreeable)
 Weigh risks and benefits of each alternative; encourage client; help client evaluate outcomes of the
change and make modifications as required
 Primary nursing goal when establishing a therapeutic relationship with the patient: promote
client growth

Conditions essential to Development of a therapeutic relationship

 Rapport – primary; Nurse and patient develop immediate mutual regard for each other
 Trust- confidence in each other, earned; Patient knows that the nurse will not tell anyone else
about what they have discussed
 Respect – dignity/self-worth of individual; Nurse does not approve of patient’s gay lifestyle but
accepts her unconditionally nonetheless
 Genuineness – be real; Patient knows that nurse is always honest with her and will tell her the
truth even if it is something painful
 Empathy – perceive/understand from another point of view; When patient talks about her
problems, Nurse listens objectively and encourages patient to reflect on her feelings about the
situation
Phases of Therapeutic Nurse-Client Relationship
1.Pre-interaction Phase- explore self-perception
 Begins before the nurse’s first contact with patient
 Obtain info about the patient
 Examine one’s own feelings, fears and anxieties about working with patient
 Explore personal thoughts and feelings that may adversely impact the provision of care

2.Orientation Phase – est. trust/formulate contract

 Create trust and rapport
 Expectations and time frame of the relationship are identified (Establish contract)
 Client centered goals are defined
 Gather assessment data
 Identify clients strengths and limitations
 Formulate nursing diagnosis
 Realistic plan of action
 Explore feelings of both client and nurse

3.Working Phase – promote client change

 Maintain trust and rapport
 Promote clients insight and perception of reality
 Problem solving skills
 Overcome resistant behaviors
 Continuously evaluate progress towards goal attainment
 Transference: pt tells nurse about feelings towards a person from the past
 Countertransference: nurses behavior and response to the patient
4.Termination Phase
 Reason: mutually agreed upon goals have been reached, client discharged from hospital, or
nursing student rotation has been completed. (goal of termination phase is to bring therapeutic
conclusion
 Progress has been made towards the goal
 Plan of action for more adaptive behaviors for coping for future situations
 Feelings about termination of the relationship are recognized and explored

Distance - intimate 0-18 in/personal 18-40 in/social 4-12 ft/public >12 ft

Nonverbal communication – 70-80% of all effective communication is all non-verbal.

 Physical appearance and dress – hair, tattoos, clothing, jewelry, clothing (formal, casual, unkept)
 Body movement and posture – the way an individual positions their body
 Touch – powerful tool, can be +/-,
o Functional/professional – impersonal/businesslike
o Social/polite – still impersonal but affirmation or acceptance of other person
o Friendship/warmth – strong liking
o Love/intimacy – emotional attachment
o Sexual arousal – expression of physical attraction only
 Facial expressions –primary source of communication, indicate emotions
 Eye behavior – “windows of the soul,” eye contact signifies communication open, eye behavior is
regulated by social rules, culture
 Vocal cues/paralanguage – gesture component of the spoken word; pitch, tone, loudness,
emphasis on certain words, influences interpretation of verbal message

Interpersonal Communication
 Transaction between sender and receiver; both participate
 Listen to each other and engage in process of creating meaning in a relationship
 Both sender and receiver bring certain preexisting conditions that influence the intended message
and the way which it is interpreted:
 Values, attitudes and beliefs
 Culture and religion
 Social status
 Gender
 Age or developmental level
 Technological ways of communicating (texting)
 Environment in which the transaction takes place

Therapeutic Communication Techniques

 Using Silence: allows patient to take control of discussion if they want to
 Accepting: conveys positive regard – “Yes, I understand what you said.” Nodding head
 Giving recognition: indicating awareness – “I notice you made your bed.”
 Offering self: making oneself available – “I’ll stay with you awhile.”
 Giving broad openings: allows client to select topic – “What would you like to talk about?”
 Offering general leads: encourages patient to continue – “Yes I see, go on…”
 Placing the event in time or sequence: clarifies events in time – “What seemed to lead up to..?”
 Making observations: verbalizing what is observed or perceived - “You seem tense.”
  Encouraging description of perceptions: asking patient to verbalize what is being perceived –
“Tell me what is happening now. “ “Are you hearing the voices again? What are they saying?”
 Encouraging comparison: asking patient to compare similarities and differences in ideas,
experiences and relationships – “Was this some like..?” “How does this compare with the time?”
 Restating: lets patient know whether or not the statement has or has not been understood – “You
have trouble concentrating?” “You’re afraid you will fail in this new position?”
 Reflecting: directs questions or feelings back to client so that they may be recognized and
accepted – “What do you think you should do?”
 Focusing: taking notice of a single idea or single word – “This point seems worth looking at closer.
Perhaps you and I can discuss it together.”
 Exploring: delving further into a subject, idea, experience or relationship – “Tell me more about…”
 Seeking clarification and validation: searching for mutual understanding – “Tell me if my
understanding agrees with yours.” “Do I understand correctly that you ….?”
 Presenting reality: clarifying misconceptions that patient may be expressing – “I understand the
voices seem real to you, but I do not hear the voices.”
 Voicing doubt: expressing uncertainty as to the patients perception – “I understand that you
believe that to be true, but I see the situation differently.” “I find that hard to believe (or accept).”
 Verbalizing the implied: putting into words what the patient has only implied – Client is silent. “It
must have been very difficult for you when your husband died in the fire.”
 Attempting to translate words into feelings: putting into words what the patient has stated
only indirectly – Client –“I am way out on the ocean.” Nurse – “You must be feeling very lonely right
now”
 Formulating a plan of action: striving to prevent anger or anxiety escalating to unmanageable
level when stressor recurs – “What could you do to let your anger out harmlessly?”

Nontherapeutic Communication
 Giving reassurance – “I wouldn’t worry about that right now”
 Rejecting – “I don’t want to hear about that.”
 Approving or disapproving – “That’s good.” “That’s bad.”
 Agreeing or disagreeing – “That’s right. I agree.” “That’s wrong. I disagree.”
 Giving advice – “I think you should…”
 Probing – “Tell me how your mother abused you when you were a child.”
 Defending – “No one hear would lie to you.”
 Requesting an explanation – “Why do you think that?” Why why why
 Indicating the existence of an external source of power – “What makes you say that?” “What
possessed you?”
 Belittling feelings – “Everyone gets down in the dumps at times.”
 Stereotyping comments – “Hang in there” “Keep your chin up”
 Using denial – “Of course you’re something. Everybody is somebody.”
 Interpreting – “What you really mean is…..”
 Introducing an unrelated topic – Flat out changing the subject

Active Listening
 S: sit squarely facing the client
 O: Observe an open posture
 L: lean forward and toward the client
 E: Establish eye contact
 R: relax
 Chapter 7

We already know this but I am going to put in terms and some key points we might be tested on

Nursing process – systemic framework, referred to as scientific methodology, goal directed with the
objective being the delivery of the quality of care. It is dynamic, not static; ongoing

Assessment - Core concept. A systemic, dynamic process in which the nurse interacts with pt, family,
groups, communities, population, and health care providers, collects and analyzes data. May include:
physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic,
and lifestyle.
 Assessment –nurse collects data pertinent to pt’s health/situation
 Diagnosis – analyzes data to determine diagnoses or problems, and level of risk;
Nursing diagnoses are clinical judgments to actual or potential health problems and life
processes. Interventions are made to achieve outcomes for which nurse has accountability.
 Outcome Identification – identifies expected outcomes for a plan individualized for the pt
or the situation. Outcomes are end result that are measurable, desirable, and observable.
 Planning – develops plan for strategies and alternatives to attain expected outcomes
 Implementation – includes: coordination of care, health teaching and health promotion,
Milieu therapy, pharmacological, biological, and integrative therapies, prescriptive
authority and treatment, psychotherapy, and consultation
 Evaluation – process of determining the progress toward attainment of expected
outcomes and effectiveness

Chapter 10

Crisis – A sudden event in one’s life that disturbs homeostasis, during which usual coping mechanisms
cannot resolve the problem

Crisis intervention – requires problem solving skills that are often diminished by the level of anxiety
accompanying disequilibrium. Assistance preserves self-esteem and promotes growth with resolution.

Characteristics of a Crisis
 Crisis occurs at one time or another in all individuals
 Crises are precipitated by a specific identifiable event
 Crisis personal by nature
 Crises are acute, not chronic and will resolve in one way or another within a brief period
 Crisis situation contains potential for psychological growth or deterioration

Crisis Phases:
1) Individual is exposed to precipitating stressor
2) Anxiety increases further when previous problem-solving techniques didn’t relieve stressor
3) All possible resources are called upon to resolve problems & relieve discomfort
4) Tension mounts to breaking point; anxiety at panic levels, emotions are liable, cognitive function is
distorted, and possible psychotic thoughts
The paradigm depends on three things with each individual:
 The individuals perception of the event
 The availability of situational support
 The availability of adequate coping mechanisms
Types of Crisis:
 Dispositional Crises – An acute response to an external stressor
 Crisis of Anticipated Life Transition – Normal life-cycle transition that may be anticipated but the
person may feel a lack of control
 Crisis resulting from traumatic stress – unexpected, external stressor that a person has little or no
control where a person may feel emotionally overwhelmed and defeated
 Maturational/Developmental Crisis – response to unresolved conflicts in one’s life
 Crisis Reflecting Psychopathology – Emotional crisis in which preexisting psychopathology has
been instrumental in precipitating the crisis or in which psychopathology significantly impairs or
complicates adaptive resolution (borderline personality disorder, severe neuroses, other
personality disorders, and schizophrenia
 Psychiatric Emergencies – Crisis situation in which general functioning has been severely
impaired and the individual rendered incompetent or unable to assume personal responsibility

Seven Stages of Crisis Intervention Model

I. Psychosocial and lethality assmt
II. Rapidly establish rapport
III. Identify the major problem
IV. Deal with feelings and emotions
V. Generate and explore alternatives
VI. Implement plan of action
VII. Follow up

Phases of Crisis Intervention: Role of the Nurse

I. Assessment – info gathered in which the stressor and resulting crisis that prompted the
individual to seek professional help; diagnoses are assigned after info evaluated
II. Planning of Therapeutic Intervention – nurse selects the nursing actions for the diagnoses,
taking into account type of crisis, pt’s strengths, resources, and support, and then goals are
established.
III. Intervention – actions identified are implemented; this is the working phase, guide the pt thru
problem solving process. Realize coping mechanisms are individual for each person, the nurse
can guide/offer suggestions but it is the pt that must resolve and overcome
IV. Evaluation of Crisis Resolution & Anticipatory Planning – reassessment is conducted to
determine stated objectives were achieved

Assessing for Anger – behaviors to look for (not limited to the following):
 Frowning facial expressions
 Clenched fist
 Low pitched verbalization forced thru clenched teeth
 Yelling and shouting
 Intense eye contact or avoidance of eye contact
 Easily offended
 Defensive response to criticism
 Passive-aggressive behavior
 Emotional overcontrol with flushing of the face
 Intense discomfort; continuous state of tension
Assessing for Aggression – can arise from a number of emotions. Can be classified as mild (sarcastic),
moderate (slamming doors), severe (threats of physical violence), or extreme (physical acts of violence
against others)
 Pacing; restlessness
 Tense facial expressions and body language
 Verbal or physical threats
 Loud voice, shouting, use of obscenities, argumentative
 Threats of homicide or suicide
 Increase in agitation with overreaction to environmental stimuli
 Panic anxiety, leading to misinterpretation of the environment
 Disturbed thought process, suspiciousness
 Angry mood, often disproportionate to the situation

Aggression is goal directed; intent to inflict harm or destruction. Aggression emerges from anger.

Crisis Risk factors – Three factors have been identified as considerations for potential violence
 Past history of violence
 Client diagnosis
 Current behavior

Broset Violence Checklist

 Behaviors – confusion, irritability, boisterousness, physical threats, verbal threats, attack on
objects are all rated
 De-escalation techniques – calm voice, helpful attitude, identify consequences, open hands and
non-threatening posture, allow phone call, offer food or drink, decrease waiting times and request
refusals, distract with more positive activity, walk outdoors or fresh air, reduction in demands,
group participation, relaxation techniques, express concern, reduce stimuli/noise, verbal
redirection, time out/quiet room, offer prn meds
 If de-escalation tech fails – offer prn meds, time out in open room which may lead to locked room

Prodromal Syndrome - characterized by anxiety, tension, verbal abuse or profanity, increasing

hyperactivity. Happen simultaneously. Predictive of impending violence and is an emergent situation that
needs immediate attention. Watch for: rigid posture, clenched fist/jaw, grim/defiant affect, rapid/raised
talking, arguing, demanding, threatening, cursing, agitation, pacing, pounding, slamming

Disaster – event that overwhelms local resources and threatens community safety and function. Also,
leaves victims with a damaged sense of safety and well-being; includes various amounts of emotional
trauma

Traumatic event - witnessed or confronted with an event or involved in actual or threatening death or
injury

 Grieving is a natural response. Common behaviors are anger, disbelief, sadness, anxiety,
fear, sleep disturbances, increased ETOH, caffeine, and tobacco use
 Children may experience separation anxiety, nightmares, and problems concentrating
 Intervention for the client is aimed at keeping anxiety manageable, encouraging free
expression and spiritual rituals, dealing with emotional reactions for the individual, and
promotion of activity to improve community functioning
 Ch 13: Neurocognitive Disorders (NCD)

Delirium: a disturbance in attention and awareness, a change in cognition that:

 Usually develops rapidly over a short period – due to head injury or seizure. Can be slow onset
(hrs to days, if due to systemic or metabolic illness), prodromal symptoms would be restlessness,
difficulty thinking clearly, insomnia, nightmares
 Attention disabilities, easily distracted
• Disorganized thinking and speech, disoriented to time and place, impaired recent memory
• Misperceptions of environment including delusions, hallucinations
• Disturbances in sleep/wake cycle
• Agitated or vegetative
• Short duration (1 wk) rarely more than 1 mth
• Tx: reversible; treat underlying cause (hypoglycemia, electrolyte imbalance, stroke, ICP, hypoxia)
Meds can be used but only after all underlying causes have been resolved. This would be aid tx for
cognitive impairment (cholinesterase inhibitors : donepezil, rivastigmine, galantamine,
memantine), agitation, aggression, hallucinations, thought disturbances, wandering (risperidone,
olanzapine, quetiapine, haloperidol)

Dementia: Major Neurocognitive disorder – cognitive functions closely linked to particular areas of the
brain that have to do with thinking, reasoning, memory, learning, and speaking
• Primary NCD is from organic brain disease (Alzheimer’s; enzymes to produce acetylcholine are
dramatically reduced. Other explanations: plaque and tangles, head trauma, genetic factors);
secondary NCD is from cerebral trauma (boxers) or HIV. Evident in abstract thinking, judgment,
and impulse control (uninhibited, inappropriate behavior, personal hygiene often neglected)
• Aphasia- can’t speak
• Apraxia- inability to perform motor functions
• Progressive/degenerative
Stages:
 No sx
 Forgetfulness: short term memory loss, makes lists, agitated
 Mild cognitive decline: interferes with life, noticeable
 Mild to moderate cognitive decline: forgets major events in life (kids b-days), confabulation
(making up things to fill in memory gaps)
 Moderate: difficulty with ADLs, disorientation to place and time, knows self but forgets phone
#/address
 Moderate to severe: ADL w/ assistance only, incontinence, wandering, sundowning (sx worse in
pm)
 Severe: bedfast (decubiti, contractures), aphasia, unable to recognize family
 Pseudodementia= depression. Mimics sx of dementia in elderly

Amnesia: most common sx post head trauma

Safety: nightlight, safe place to wander, low stimuli
 Chapter 14

Substance Use/Addiction - compulsive or chronic requirement; need so strong generates distress

 Physical dependence – need for increasing amount to produce desired effect

 Psychological dependence – cognitive need – Overwhelming desire to repeat the use of the drug
to produce pleasure and avoid discomfort from withdrawal.
 Tolerance - requiring increased amounts of a substance to achieve a desired affect
 Dependence – individual is addicted to drug and is high or drunk at least once a week.
 Intoxication – (too much of a substance at one time) physical and mental state of exhilaration and
emotional frenzy or lethargy and stupor. Shortly after ingestion direct effect on CNS, disruption in
physical/psychological functioning, judgment disturbed resulting in inappropriate maladaptive
behavior, social, occupational impairment.
 Withdrawal – physiological/mental readjustment from discontinuation of an addictive substance

Predisposing factors
 Biological – Genetics, Biochemical
 Psychological – Developmental influences, Personality factors
 Sociocultural – Social learning, conditioning, cultural and ethnic influences

Definite pattern to Alcohol Use Disorder

 Prealcoholic phase – relieves daily stress
 Early alcoholic phase - required; blackouts, amnesia
 Crucial phase – no control, ill, anger, aggression, inability to choose leads to job loss, relationship
issues, self-respect diminished
 Chronic phase – emotional/physical disintegration with profound self-pity and helplessness; can
lead to psychosis, depression, suicide

Effects of alcohol:
At low doses, produces relaxation (depresses CNS), loss of inhibitions, lack of concentration, drowsiness,
slurred speech, and sleep.

Chronic produces multisymptom physiological impairments:

 Peripheral Neuropathy – Peripheral nerve damage – pain, burning, tingling in the extremities
 Wernicke’s Encephalopathy- thiamine deficiency – paralysis of the ocular muscles, diplopia,
ataxia, somnolence, and stupor; if thiamine repl therapy not corrected can cause death
 Korsakoff’s Psychosis- confusion, short term memory loss, confabulation; usually seen in clients
recovering from Wernicke’s encephalopathy two disorders go together called Wernicke-
Korsakoff’s syndrome – tx is parenteral or oral thiamine repl
 Alcoholic Myopathy- Vitamin B deficiency – Acute - sudden onset of muscle pain (calves),
swelling, weakness, reddish tinge urine from breakdown of myoglobin, Labs ↑ enzymes CPK, LDH,
AST. Chronic – gradual wasting and weakness of skeletal muscle; tx is abstinence, nutrition, and
vitamin supplements
 Alcoholic Cardiomyopathy- accumulation of lipids in myocardial cells resulting in enlargement
and weakened condition; r/t Congestive HF or Arrhythmias. - ↓exercise tolerance, tachycardia,
dyspnea, edema, palpitations, nonproductive cough, labs show ↑ enzymes CPK, AST, ALT, LDH,
observed in ECG and xray. TX: total abstinence, for CHF – rest, O2, digitalization, sodium
restrictions, diuretics
 Esophagitis – inflammation/pain in esophagus, damage to mucosa, occurs from frequent vomiting
  Gastritis- inflammation of stomach lining, gastric distress, NV, distention; ETOH breaks down
stomachs protective mucosal barrier, hydrochloric acid erodes stomach wall, damage to blood
vessels possible hemorrhage
 Pancreatitis-
Acute: 1-2 days after binge. Constant/severe epigastric pain, NV, distention
Chronic: pancreatic insufficiency →steatorrhea, wt loss, DM, malnutrition
 Alcoholic Hepatitis- inflammation of liver →long term ETOH use ; enlarged, tender liver, NV,
lethargy, anorexia, ↑WBC & fever, jaundice. Severe= wt loss, ascites. TX: abstinence, nutrition, rest.
Severe cases lead to Cirrhosis or hepatic encephalopathy.
 Cirrhosis: it is end state ETOH liver disease, destruction of liver cells causing scar tissue;
symptoms include: NV, anorexia, wt loss, abdominal pain, jaundice, edema, anemia, blood coag
abnormalities. Complications include:
o Portal HTN – elevation of BP thru portal circulation re from defective blood flow thru sick
liver
o Ascites –serous fluid accumulates in abdominal cavity in response to Portal HTN
Esophageal Varices – excessive pressure causes distended veins which can rupture and
hemorrhage
o Hepatic Encephalopathy – diseased liver unable to function properly, ammonia builds up,
causing LOC Δ, apathy, euphoria or depression, sleep disturbances, ↑confusion, →to coma
or death. TX: abstinence, eliminate protein, ↓ ammonia using neomycin or lactulose.
 Leukopenia – seen in chronic ETOH; impaired production, function, movement of WBC places
individual at risk for infectious diseases, complicated recovery
 Thrombocytopenia – platelet production/lifespan impaired; risk for hemorrhage. Tx abstinence
 Sexual Dysfx- ETOH interferes with production of hormones; Women – changes in menstrual
cycles, ↓ ability to become pregnant. Men - ↓ libido, ↓ sexual performance, impaired fertility
o short term= ↑libido w/ no erection
o Long term= gynecomastia, sterility, impotence, ↓libido

Fetal Alcohol Syndrome (FAS): (African Americans and Native Americans) problems w/ learning,
speech/language delays, IQ, memory, attention, communication, vision, hearing
 Abn facial features
 Small head
 Short
 Low wt
 Hyperactive
 Poor coordination
 Poor reasoning
 Sleep and sucking probs (infant)
 Probs w/ heart, kidneys, bones
FAS Factors
 Variation of brain vulnerability
 Drinking pattern
 Difference in metabolism
 Genetics vs susceptibility
 Timing of consumption

Alcohol intoxication: Blood alcohol level between 100-200 mg/dL, death 400-700 mg/dL. Symptoms:
disinhibition of sexual or aggressive impulses, mood liability, impaired judgment, impaired social or
occupational functioning, slurred speech, incoordination, slow unsteady gait, nystagmus, and flushed
face, coma, death
Alcohol withdrawal: 4-12H post, tx: chlordiazepoxide(Librium) Benzo NUMBER ONE CHOICE

Withdrawal: starts as early as 4 hrs, after 12H, peak at 24-72H, subside 5-16D. Hyperactivity, tremors of
hands, tongue or eyelids, NV, malaise, weakness, tachycardia, sweating, ↑BP, anxiety, depressed mood or
irritability, hallucinations or illusions, HA and insomnia, can progress to seizures, ETOH withdrawal
delirium seen on second or third day

Inhalant: paint thinner, aerosols, adhesives, fuels

Effects:
 CNS: ataxia, dizzy, neuropathy, speech probs, tremor, ototox, encephalopathy, parkinsonism
 Resp: cough, wheeze, dyspnea, emphysema, pneumonia
 GI: abd pain, NV, rash around nose and mouth, bad breath, liver tox
 Renal: acute and chronic failure, acidosis, ↓K, ↓Ph, ↑Cl, azotemia, Hct, WBC, RBC and proteinuria
 Euphoria (excitation/inhibition), nystagmus (blurred/diplopia), slurred speech, DTR’s, lethargy &
psychomotor retardation, muscle weakness, stupor, coma

Intoxication: dizziness, ataxia, weakness, slurred speech, nystagmus, diplopia, hypoactive reflexes,
lethargy, psychomotor retardation, muscle weakness, stupor or coma

Nursing Process – must first look at own self

Assessment Tools –
CIWA, CAGE, MAST

Nausea and Vomiting: Ask, “Do you feel sick to
your stomach? Have you vomited?” Observation:
0 No nausea and no vomiting
1 Mild nausea and no vomiting
4 Intermittent nausea with dry heaves
7 Constant nausea, frequent dry heaves and
vomiting.
Tactile Disturbance: Ask, “Have you any itching,
pins and needles sensations, any burning, any
numbness, or do you feel bugs crawling under your
skin?” Observation:
0 None
1 Very mild itching, pins and needles, burning or
numbness
2 Mild itching, pins and needles, burning or
numbness
3 Moderate itching, pins and needles, burning or
numbness
4 Moderate severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Tremor: Arms extended and fingers spread apart.

Observation: Auditory Disturbances: Ask, “Are you more
0 No tremor aware of sounds around you? Are they harsh? Do
1 Not visible but can be felt fingertip to they frighten you? Are you hearing anything that is
fingertip disturbing to you? Are you hearing things you
4 Moderate, with patient’s arm extended know are not there?” Observation:
7 Severe, even with arms not extended 0 Not present
1 Very mild harshness or ability to frighten
2 Mild harshness or ability to frighten
3 Moderate harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations 7 Continuous hallucinations

Visual Disturbances: Ask, “Does the light appear

Paroxysmal Sweats: Observation: to be too bright? Is the color different? Does it hurt
0 No sweat visible your eyes? Are you seeing anything that is
4 Beads of sweat obvious on forehead disturbing to you? Are you seeing things you know
7 Drenching sweats are not there?” Observation:
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Anxiety: Ask, “Do you feel nervous?” different? Does it feel like there is a band around
Observation: your
0 No anxiety, at ease head?” Do not rate dizziness or lightheadedness.
1 Mildly anxious Otherwise, rate severity.
4 Moderately anxious, or guarded, so anxiety 0 Not present
is inferred 1 Very mild
7 Equivalent to acute panic states, as seen in severe 2 Mild
delirium or acute schizophrenic reactions 3 Moderate
4 Moderately severe
5 Severe
6 Very severe
7 Extremely severe
Headache, Fullness in Head: Ask, “Does your head
feel

Agitation: Observation Orientation and Clouding of Sensorium: Ask,

0 Normal activity
1 Somewhat more than normal activity
4 Moderately fidgety and restless
7 Paces back and forth during most of the interview,
or constantly thrashes about
“What
day is this? Where are you? Who am I?” Observation:
0 Oriented and can do serial additions
1 Cannot do serial additions or is uncertain about
date
2 Disoriented for date by no more than 2 calendar
days
3 Disoriented for date by more than 2 calendar
days
4 Disoriented for place and/or person

C: felt u should cut down

A: annoyed by people criticizing your drinking
G: guilty about drinking
E: eye-opener, drink first thing in the A.M. to steady nerves

Diagnosis – Outcome Identification

Planning/implementation
Detox – abstinence
Intermediate care
Rehab
 Substitution Therapy-may be used to reduce the life-threatening effects of intoxication or
withdrawal from some substances – see below
Client family education
Evaluation

Dual Diagnosis – drug dependency with psychological disorder; substance and mental illness

Codependency - that of a partner or the nurse; evident among members of a family of a chemically
addicted person; may harbor secrets of physical/emotional abuse, other cruelties, or pathological
conditions. Codependent person achieves self-control thru fulfilling needs of others. Personal identity
lost, boundaries blurred.
 Long hx focusing on other people
 People pleasers
 Appear competent but are very needy, helpless
 Have experienced abuse or emotional neglect as a child
 Outward focus towards others, unable to direct own life
Tx:
 Stage I. Survival stage: begins to let go, can be very painful
 Stage II. Reidentification stage: glimpse true self thru break in denial system. They accept label
as codependent and responsibility for their own dysfunctional behavior
 Stage III. Core Issue stage: face facts of relationship that relationships cannot be managed by
force of will
 Stage IV. Reintegration stage: self-acceptance, willingness to change, relinquish power

Pharmacotherapy for Withdrawal/Detox

Alcohol:
Detox: Benzodiazepines
chlordiazepoxide(Librium) oxazepam (Serax), lorazepam (Ativan), diazepam (Valium), naltrexone
(ReVia), nalmefene (Revex), acamprosate (Campral); start w/↑dose, ↓20-25% ea day till complete;addtl
dose for breakthroughs
contra:liver dysfunction

Abstinence: Disulfiram
Disulfiram (Antabuse)
Should only be used when ETOH out of clients system for 12 hrs; used as a deterrent to drinking. Within
5-10 minutes of ingestion of ETOH will see effects of disulfiram-alcohol reaction. At 5-10 mg/dL mild
reactions and symptoms fully developed at approx. 50 mg/dL; flushed skin, throbbing in head/neck, resp
difficulty, dizzy, NV, sweating, hyperventilation, tachycardia, hypotension, weakness, blurred vision,
confusion. As ETOH in blood reaches 125-150 mg/dL severe reaction can occur resp depression,
arrhythmias, MI, acute CHF, death. Drug has lasting effects in system –up to 2 wks after disc. Client must
read labels and avoid any ingestion of ETOH, topicals, and notify doctors, dentists, carry card. Consent
req. before program initiated
Anticonvulsants: carbamazepine, valporic acid, gabapentin for seizures
Multivitamin therapy - thiamine

Depressants: Inhalants
Withdrawal: phenobarbital (Luminal)↓ 30mg/day till complete
 Chapter 15
Schizophrenia Spectrum and other Psychotic Disorders
Psychosis
Delusions
Hallucinations
Positive symptoms
Negative symptoms
Epidemiology – distribution and determination of health-related states and events in populations
and the application of this study to the control of health problems
Nursing Assessment
Physical manifestations
Nursing interventions
Use of the nursing process, nursing diagnosis and outcomes for patient with schizophrenia
Medications –see drug sheet at end of outline

The disorder of schizophrenia falls under the core concept of psychosis; severe mental condition in which
there is disorganization of the personality, deterioration in social functioning, and loss of contact with, or
distortion of, reality. May be signs of hallucinations and delusional thinking. Psychosis can occur with or
without organic impairment.

Some of the disorders include: brief psychotic disorder, schizophreniform disorder, schizophrenia,
schizoaffective disorder, and substance-induced psychotic disorder. It may also be applied to
neurodevelopmental disorder, major depressive disorder, and bipolar disorders I and II.

Schizophrenia is considered the most crippling of the disorders. Disturbances in thought process,
perception, and affect result in severe deterioration of social and occupational functioning. Symptoms
generally appear in late adolescence or early adulthood but can become evident as early as age 13. In any
case, they are classified according to the onset of symptoms generally occurring earlier in men than
women. The pattern of development is also evident and labeled in phases: premorbid phase, prodromal
phase, active phase, and residual phase.
 Chapter 16
Depression

Predisposing factors in the development of depression:

No single theory or hypothesis can be confirmed as a definite explanation for the disease. Continuous
gathering of data supports multiple causations; genetic, biochemical, and psychosocial influences are
individual and unique to each person making them susceptible to depression.

Genetics: A genetic link has been suggested but a definitive mode of transmission has yet to be confirmed.
Twin studies show a strong correlation in monozygotic twins but then there is the interaction of the
environment that plays a factor in how each person adapts or responds. Family studies show that major
depression disorders are more common in first-degree biological relatives and external influences are
less of a factor. Adoption studies show that offspring of biological parents that have mood disorders are
more at increased risk for developing a mood disorder even though they are raised by their adoptive
parents.

Biochemical influences: Depressive illness may be related to a deficiency of neurotransmitters:

norepinephrine, serotonin, dopamine and acetylcholine. Norepinephrine has been identified as the main
component in the body’s ability to deal with stressful situations. Serotonin helps regulate mood, anxiety,
arousal, vigilance, irritability, thinking, cognition, appetite, aggression, and circadian rhythm. Dopamine
exerts a strong control over mood and behavior. A diminished supply of these –amines inhibits the
transmission of impulses resulting in failure of the cells to fire or become charged. Now acetylcholine is
said to have an influence on mood, sleep, and neuroendocrine function and may have a strong correlation
with mania and depression.

Neuroendocrine disturbances whether there is a lack of, or a hormone is being administered, could play a
role in the pathogenesis or persistence of depressive illness as it has been observed by mood disorders.

Physiological influences: Depressive symptoms that occur as a consequence of something else are
deemed secondary depression. This may be related to medication side effects, neurological disorders,
electrolyte disturbances, hormonal disturbances, nutritional deficiencies, and other physiological
conditions.

Types of depressive disorders

 Major depressive disorder: loss of interest or pleasure in activities, symptoms for atleast 2 weeks,
no attribution to another medical diagnosis or medication, impaired social and occupational
functioning
 Dysthymic disorder: “down in the dumps”, chronically depressed, for most days for atleast 2 years,
no psychotic symptoms
 Premenstrual dysphoric disorder: depressed mood, excessive anxiety, mood swings, decreased
interest in activities during the week prior to menses
 Substance-induced depressive disorder: direct effect of drugs/meds/alcohol
 Depressive disorder due to another medical condition: depressed bc of medical condition

Biochemical influences
 Decrease in norepinephrine, serotonin, and dopamine
  Excessive cholinergic transmission
 Possible failure within the hypothalamic-pituitary-adrenocortical axis **do ACTH test
 Adolescents: give Prozac for depression

Assessment
 Mild depression: normal grieving
Example: anger, anxiety, tearful, regression, preoccupied with loss, anorexia, insomnia
 Moderate depression: dysthymic disorder
Example: helpless, powerless, slow physical movements, slumped posture, limited verbalization,
anorexia or overeating, sleep disturbance
 Severe depression: major depression and bipolar depression
Example: feelings of total despair, flat affect, curled up position, absence of communication,
delusional thinking, somatic delusions, suicidal thoughts, general slow down of entire body

Suicidal Client – “Do you feel like hurting yourself?” **feeling better = warning sign**
 Put on 1:1
 Check contraband
 Establish rapport and trust
 Be direct and matter of fact about suicide
 Discuss current crisis in clients life

Chapter 17
Bipolar and other disorders

Various types of bipolar disorders

Bipolar disorder - characterized by mood swings from profound depression to extreme euphoria
(mania) with periods of normalcy. Delusions or hallucinations may or may not be present. May have a
seasonal pattern evident.

Manic episodes – mood is elevated, expansive (extreme), or irritable. May cause impairment of
occupational functioning, social activities, or personal relationships. May require hospitalization to
prevent harm from self or others. Motor activity erratic and psychotic features may be present.

Hypomania – is a milder degree of mania although severe enough to cause impairment as stated above
and may require hospitalization as well but does not include psychotic features.

Depression as already been defined above under chapter 16 but there is a major distinction with bipolar
disorder. The client must have a history of one or more manic episodes, alternating moods (sadness,
irritability, euphoria) accompanied by symptoms of depression and mania (considered mixed features).

 Mood: persuasive and sustained emotion that may have major influence on a person’s perception
of the world
 Affect: emotional reaction associated with an experience
 Mania: alteration in mood that is expressed by feelings of elation, inflation self-esteem,
grandiosity, hyperactivity, agitation and acceleration thinking and speaking
 Bipolar: mood swings from profound depression to extreme mania, with periods of normalcy
Types of Bipolar Disorders
 Bipolar l: a lot like MDD but client must have a history of one or more manic episodes; rapidly
alternating moods (sadness, irritability, euphoria); both depression and mania
  Bipolar ll: recurrent bouts of MDD with repeating episodes of hypomania; has never had a full
manic episode; may have psychotic or catatonic features
 Cyclothymic: chronic mood disturbance; atleast 2 years; hypomania and depressed mood

FIND-children and adolescents

 F: frequency; symptoms occur most days in a week
 I: intensity; symptoms severe enough to cause extreme disturbance
 N: number; symptoms 3-4 times a week
 D: duration; symptoms 4 or more hours a day
Symptoms characterized by degree of severity
 Stage l: hypomania-symptoms not sufficient to interfere with social or occupational functioning
(ex: cheerful mood, rapid flow of ideas, increased motor activites)
 Stage ll: acute mania—impairment in functioning (ex: flight of ideas, elation or euphoria,
hallucincations and delusions, social and sexual inhibition, little need for sleep)
 Stage lll: delirious mania—grave form of the disorder (ex: panic attack, clouding of consciousness,
frenzied psychomotor, exhaustion and possible death)
Family education of Lithium
 Take meds regularly
 Do not skimp on dietary sodium
 6-8 glasses of water a day
 tell PCP if N/V
 levels checked every 1-2 months

Chapter 18
Panic Disorder

Differentiate between normal anxiety and psychoneurotic anxiety

The term anxiety and stress are often used interchangeably however they are not the same. Anxiety is a
state of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary
threatening event or situation. Anxiety may have emotional, behavioral, cognitive, and/or physical
components.

Anxiety is considered a normal reaction to fear, danger, or a threat. It is what motivates us. If we did not
have it we would be poorly motivated to do anything challenging or difficult out of our comfort zone.
Normal anxiety diminishes when the threat is no longer present.

Abnormal anxiety is out of proportion to the situation that is creating it. The anxiety interferes with
social, occupational, or other important areas of functioning.

 Recurrent panic attacks; unpredictable onset; intense apprehension, fear and terror
 Feeling of impending doom
 Intense physical discomfort
 NOT triggered by situations in which the person is the center of attention (such as social anxiety)

 DSM-5: four of these symptoms must be present to identify a panic attack:

Increased HR, palpitations Sweating
Trembling/shaking SOB/feeling of smothering
Feeling of choking Chest pain/discomfort
Nausea/GI distress Dizzy/lightheaded
 Chills or heat sensations Numbness/tingling sensation
Feelings of unreality or unattached from self
Fear of losing control/going crazy Fear of dying
 Symptoms of depression are common, onset late 20’s, may or may not be assoc w/agoraphobia
GAD
 Persistent, unrealistic, and excessive anxiety and worry which have occurred more days than not
in the last 6 months
 Cannot be attributed to organic factors
 Clinically significant impairment in functioning, social and occupational
 Anxiety and worry are associated with muscle tension, restlessness, feeling of being on edge
 May avoid activities or spend a lot of time preparing for them
 Seeks reassurance from others
 Childhood/adolescent onset
 Depressive and somatic effects

Predisposing Factors to Panic and GAD

 Ego development is delayed
 Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to stress
 Genetic predisposition
 Biochemical: abnormal levels of blood lactate
 Increase in norepi
 Decrease in serotonin and GABA

Phobias
 Agoraphobia: fear of being outside the home; fear of being unable to escape places or situations
 DSM-5: fear or anxiety of atleast two of the five situations:
1. Using public transportation
2. Being in open spaces
3. Being in enclosed spaces
4. Standing in line or being in a crowd
5. Being outside of the home alone
 Social anxiety Disorder (social phobia)
 Excessive fear of situations in which a person might do something embarrassing or be
evaluated negatively by others
 Extreme fear of being embarrassed
 Sweating, tachycardia and dyspnea
 Specific Phobia
 Fear of specific objects or situations that could cause harm (snakes, lizards, heights)
 Reaction is excessive, unreasonable, and inappropriate
 Irrational fear restricts the individuals activities and interferes with his or her daily living
 Exposure to the phobia produces symptoms of palpitations, sweating, dizziness, and SOB

Predisposing Factors to Phobias

 Conditioned response
 Direct learning or imitation (ex: mother who exhibits a phobia)
 Negative self statements/ irrational beliefs
 Life experiences
OCD
 Presence of obsessions, compulsions or both
 Severity is significant enough to cause distress or impairment in social, occupational and other
areas
 Pt recognizes that behaviors are excessive and unreasonable but cannot stop due to the feeling of
relief of discomfort
 Common compulsions:
 Hand washing
 Ordering
 Checking
 Praying
 Counting
 Repeating words silently
 DSM-5: recurrent or persistant thoughts, urges or images that are experienced at some time
during disturbance, intrusive and unwanted, causes anxiety and distress
 Acts are aimed at preventing or reducing anxiety or distress
 Obsessions/compulsions are time consuming and may take more than 1 hour a day

Predisposing Factors to OCD and related disorders

 Psychoanalytic theory: underdeveloped ego for a variety of different reasons; regression to an
earlier developmental stage (anal-sadistic phase); with these two combined it produces symptoms
of obsessions and compulsions
 Learning theory: conditional response to a traumatic event
Treatment:
1. Individual psychotherapy: marked lessening of anxiety by having the patient talk about their
difficulties; psychologists give logical and rational explanations
2. Cognitive therapy: alters cognitive distortions
3. Behavior therapy: positive and negative reinforcements in an effort to modify hair pulling
behaviors
4. Systemic desensitization: gradually exposed to phobic stimuli; training in relaxation techniques;
only after they have mastered the relaxation techniques does the person get exposed to the stimuli
5. Implosion therapy: client must imagine situations that he/she finds extremely frightening for a
prolonged period of time; no relaxation taught; “floods” the client with information concerning
situations that trigger anxiety
6. Meds: antianxiety agents; anxiolytics, antihypertensives, antidepressants

Chapter 19
Post traumatic Stress Disorder
 Anxiety disorder that occurs after experiencing or witnessing overwhelming traumatic
events that resulted in intense fear, helplessness or horror
 Symptoms must be present for more than 1 month and cause significant interference with
social, occupational and other areas of functioning
 DSM-5: exposure in one or more ways:
1. Directly experience trauma
2. Witnessing the trauma
3. Learning about traumatic events
 4. Experiencing repeated or extreme exposure to details of traumatic events
 s/s: flashbacks, anxiety, detachment from people, nightmares, difficulty concentrating

Adjustment disorder
 maladaptive reaction to an identifiable stressor or stressors that results in development of
significant emotional or behavioral symptoms
 occurs within 3 months of onset of stressor
 symptoms do NOT represent normal bereavement
 can be seen in combination with anxiety, depressed mood, disturbance of conduct, or
unspecified
 Predisposing factors: neurocognitive developmental disorders; inability to deal with stress,
childhood trauma
Chapter 20
Somatic Symptom Disorder
 Multiple somatic (of the body) symptoms that are unable to be explained medically
 Associated with psychosocial distress and long term seeking of assistance from HCP
 Symptoms may be vague, dramatic or exaggerated
 Excessive amount of time and energy is devoted to worry and concern about the symptoms
 Seek relief by overmedicating
 Possible overlapping personality characteristics
Illness anxiety disorder
 Unrealistic/ inaccurate interpretation of physical symptoms or sensations
 Fear of having a serious illness becomes disabling and persists despite reassurance
 Profoundly preoccupied with their bodies
Conversion disorder
 Loss of or change in body function that cannot be explained by any known medical disorder
 Suggests the person has neurological disease
 Examples: aphonia, paralysis, seizures, urinary retention, deafness, loss of pain sensation, false
pregnancy
Factitious disorder
 Involves conscious, intentional feigning of physical and psychological symptoms
 Pretend to be ill in order to receive emotional care and support
 May inflict injury upon themselves
Predisposing factors for Somatic Symptom disorders
 Inherited genetically
 Decreased levels of serotonin and endorphins
 Brain dysfunction
 Ego defense mechanism
 Emotions associated with traumatic events may be converted to physical symptoms due to lack of
expressing emotions
 Possible learned theory
Dissociative Disorders
 Inability to recall important personal information, usually of a traumatic or stressful nature
 Type of amnesia
Dissociative Identity Disorder
 Formally multiple personality disorder
 Two or more personalities in a single person
 One of them is more dominant most of the time
  Transition from one personality to another can be sudden or gradual
 May or may not have amnesia episodes, meaning they may or may not recall episodes of diff
personalities
 Not an incapacitating disorder
Depersonalization-Derealization Disorder
 Temporary change in the quality of self awareness
 Feelings of unreality, changes in body language, feelings of detachment from the environment or
sense of observing oneself from outside the body
Treatments for Somatic Symptom disorders
 Individual psychotherapy
 Group therapy
 Behavioral therapy
 Psychopharmocology: TCA’s, Dilantin, Tetretol, Klonopin
Tx for DID
 Achievement of integration (bringing all the personalities into one)
 Long psychotherapy
Tx for DDD
 Combination of psychotherapy involving: antidepressants, mood stabilizers, anticonvulsants,
antipsychotics
 Cognitive Behavioral Therapy
**review nursing process in ch 20 for both

Chapter 21
Gender Dysphoria
 Incongruence between biological gender and ones expressed gender
 Characteristics: desiring to be the opposite sex in every aspect
 Etiology: usually in early childhood and more women then men
 Biological influence: congenital adrenal hyperplasia as a result of high levels of prenatal
androgens
 Signs and symptoms: insists on being the opposite sex, disgust with ones own genitals, belief that
they will be the opposite sex when they grow up, refusal to wear assigned gender clothing, desires
to have genitals of the opposite sex, refusal to play games and activities of assigned gender

Nursing process of patients with GD

 Assessment: look for those s/s listed above
 Diagnosis: disturbed personality identity, impaired social interaction, low self esteem
 Planning: client will demonstrate appropriate knowledge of assigned gender
 Interventions: spend time with client and show positive reguard
 Evaluation: reassess the clients behaviors
Tx for GD
 Some treatments say the children should be encouraged to be satisfied with assigned gender
 Other treatments suggest to encourage the child to want to become their opposite gender and
allow for acceptance

Chapter 22

 Bulimia and anorexia.

 Chapter 23

Paranoid Personality Disorder

 Persuasive, persistent, inappropriate mistrust of others
 Suspicious of others and assume others intend to exploit, harm or deceive them
 More in men than women
 Constantly on guard, hypervigilant and ready for any real or imagined threat
 Tense and irritable
 Avoid interactions with others
 Tend to misinterpret and distort situations
 Maintain self esteem by attributing short comings to others
 Do NOT accept responsibility for their actions
Schizoid Personality Disorder
 Profound defect in the ability to form personal relationships or to respond to others in a
meaningful way
 Display a lifelong pattern of social withdrawal and their discomfort with human interact is
apparent
 Appear cold, aloof and indifferent to others
 Prefer to work in isolation and are unsociable
 Usually unable to experience pleasure and commonly perceived as bland and constricted
Schizotypical Personality Disorder
 Odd and eccentric but does NOT decompensate to level of schizophrenia
 Unlike schizoid they have magical thinking, ideas of reference, illusions and depersonalization
 Speech may become bizzare
 Cannot orient their thoughts logically
 Under stress they may get hallucinations, delusional or bizzare but only for a brief time
 Affect is bland and inappropriate
 Usually seen in people with a first degree biological relative with schizophrenia
Antisocial Personality Disorder
 Pattern of socially irresponsible, exploitive and guiltless behavior that reflects general disregard
for the rights of others
 Manipulate others for personal gain and unconcerned with obeying the law
 Have problems with keeping a job and relationship

Borderline Personality Disorder

 Pattern of intense and chaotic relationships, with affective instability and fluctuating attitudes
toward other people
 impulse, self destructive and lack clear sense of identity

Histrionic Personality Disorder

 Colorful, dramatic and extroverted behavior in excitable and emotional people
 Difficult maintaining relationships although they require constant affirmation of approval and
acceptance from others
 Center of attention and manipulative
  Always seeking approval and attention from others and if they don’t feel like they have it then they
get bad anxiety
 Strongly dependent
 Lacks ability to provide others with affection
 May exhibit psychosis during major stress
Narcissistic Personality Disorder
 Exaggerated sense of self worth
 Lack of empathy and hypersensitive to the evaluation of others
 Idea that they deserve special consideration
 Overly self-conceited and exploit others to fulfill their own desires
 Mood is usually optimistic, relaxed and carefree but can change bc of fragile self esteem

Avoidant Personality Disorder

 Extremely sensitive to rejection
 Very withdrawn social life
 Creates needs for unusually strong assurances of acceptance
 Awkward and uncomfortable in social situations
 Lonely and feelings of being unwanted
 View others as critical, betraying and humiliating

Dependent Personality Disorder

 Relying excessively on other for emotional support
 Allow others to make decisions, feels helpless when alone, act submissively and tolerates being
mistreated
 Lack self confidence
 Passive to the desire of others

Obsessive Compulsive Personality Disorder

 Very serious and formal and have difficulty expressing emotions
 Overly disciplined, perfectionist, and preoccupied with rules
 Intense fear of making mistakes
 Inflexible and lack spontaneity
 Organized and efficient
 They see emotional behavior as immature and irresponsible

Chapter 24
Autism Spectrum Disorder
 Characterized by a withdrawal of the child into the self and into a fantasy world of his or her own
creation
 Markedly abnormal and impaired development in social interection and communication
 Comes from major alteration in brain function/structure
 Seen in early childhood
 Impairment in social interaction, impairment in communication
 Restricted activities and interests
 They are at risk for self-mutilation
ADHD
 Inattention/hyperactivity and impulsivity
 Highly distractible and unable to contain stimuli
 Difficult to diagnose under the age of 4
  Possible genetic predisposition
 Abnormal levels of neurotransmitters
 Difficulty in performing age appropriate tasks
 They are at risk for injury

Chapter 25
Intimate Partner Violence
 Battering is a pattern of behavior used to establish power and control over another person
 Abusive behavior is used to gain or maintain control over the other person
 Profile of the victim: some grew up in abusive homes, have low self-esteem, learned helplessness,
outcome in unpredictable and undesirable
 Profile of the victimizer: low self-esteem, jealous, dual personality, great deal of stress, limited
coping skills
 Cycle of battering:
1. Phase 1 (tension building phase): woman senses the man’s tolerance for frustration is
decreasing; minor battering incidents
2. Phase 2 (acute battering incident): most violent and shortest, batterer justifying himself,
woman may intentionally provoke
3. Phase 3 (calm, loving, honeymoon phase): batterer becomes extremely loving, kind and
contrite. Promises to never do it again and reassures his love for her
 Treatment: crisis intervention, safe house, family therapy, have an escape plan

Chapter 27
Deinstitutionalization –release of thousands of chronically mentally ill individuals from state hospitals
into the community setting due to state governments did not have the capability to match the federal
funds required for the establishment of the mental health centers
(DRG ) Diagnosis related groups – control of Medicare costs, have reduced the length of hospital stays
for psychiatric clients and increased the importance of aftercare
Primary prevention – Services aimed at reducing the incidence of mental disorders within the
population. Ex: teaching a class in prepared childbirth education
Secondary prevention – Interventions aimed at minimizing early symptoms of psychiatric illness and
directed towards reducing the prevalence and duration of the illness. Ex: caring for a widow who has
been hospitalized for major depression
Tertiary prevention – Services aimed at reducing the residual defects that are associated with severe
and persistent mental illness. Ex: Nurse visits patient who has chronic schizophrenia in his home to give
monthly injections of antipsychotic medication.
Community: a group with at least one common characteristic, such as location, occupation, ethnicity or
health concern that has some dependency on each other
Maturational crisis – crucial experiences that are associated with growth and development:
adolescence, marriage, parenthood, midlife, retirement
Situational crisis – acute responses that occur as a result of an external circumstantial stressor: poverty,
high rate of life changing event (death of a loved one, divorce), environmental conditions (tornado, flood),
trauma
Case management – effective method of providing care for clients in the community who require long-
term assistance
Community mental health centers – caring for individuals with severe and persistent mental health
illness; improve coping ability and prevent exacerbations
Mobile outreach units – volunteers and paid professionals form teams to drive or walk around and seek
out homeless persons who are in need of assistance
Day treatment programs – designed to east transition from hospitalization to community living
Groups, homeless shelters, crisis intervention
• Tertiary: reducing residual effects of severe and persistent mental illness
Rehab, daily living/encouraging independence, referrals for support services, aftercare

ECT – ATI pg 78 - Electroconvulsive Therapy – brainwave stimulation

Indications: Severe depression, acute mania, acutely suicidal, catatonic schizophrenia, schizoaffective
disoders

Course of tx: several times a week for 12 tx

Resynchronize rhythms
Anticonvulsant
Restore equilibrium between hemisphers
Prioritize function over depressive thoughs
Enhances effects of neurotransmitters

Complications:
Short term memory loss
Confusion
Anesthesia reactions
ECG changes
HA, muscle soreness, nausea

Client education:
Consent
NPO usually overnight
Assess VS, bite guard, electrodes on scalp
Meds: Atropine to decrease secretions and cardio protective, short acting anesthetic – brevital, and
muscle relaxant - anectine

Oxygen available
IV lines established
Have crash cart available
Intubation supplies (use face mask for procedure but need to have available)
Monitor VS, ECG, pulse ox

Patient artificially ventilated with oxygen

Electrical stimulus 0.2-0.8 seconds
Generalized seizure 25-60 seconds
Recovery on LATERAL recumbent position
Continue monitoring
Reorient frequently
 Neurotransmitters
Gamma
Acetylcholine Norepinephrine Aminobutyric
Dopamine Serotonin Histamine Glysine Glutamate
(Cholinergic) (Monoamine) Acid
(GABA)
-affects sleep, -regulation, -movement, -sleep, -allergic and GABA = Slow -inhibitory -relay of
arousal, pain, cognition, coordination, arousal, inflammatory Interrupts elec Amino acid sensory
coordination, perception, emotions, and libido, reactions impulses at the -motor neurons information
memory cardiovascular, voluntary appetite, -vasodilation, synaptic junct and spinal cord and the
retention functioning, decision mood, bronchoconstriction, everything regulation
sleep & arousal making aggression, ↑ gastric secretions slow of various
coordination, -Agonist: motor and
judgment, EPINEPHRINE spinal
pain reflexes
perception
Decreased: Decreased: Decreased: Decreased: Decreased: Decreased: Decreased: Decreased:
-PD, -Depression -PD, -Depression -Depression -Anxiety, -Spastic -Psychotic
Huntington’s, Depression schizophrenia, disorders
Alzheimers Increased: Increased: epilepsy, Increased:
-Mania, Anxiety, Increased: -Anxiety, Huntington’s Increased: -PD
Increased: Schizophrenia -Mania, Schizophrenia -Glysine
-Depression Schizophrenia encephalopathy

Meds for
Antipsychotic
Anxiety Depression BPD children and Substance Abuse
(Neuroleptic)
adolescents
Benzodiazepine, TCA: Atypical Conventional CNS Stimulants: Alcohol:
Anxiolytics: -Amitriptyline Antipsychotic: (typical) -Ritalin Detox: Benzodiazepines
-Alprazolam -Clomipramine -Risperidone Antipsychotic: -Focalin chlordiazepoxide(Librium) oxazepam
-Diazepam -Imipramine -Ariprazole -Chlorpromazine -Dexedrine (Serax), lorazepam (Ativan), diazepam
-Lorazepam -Doxepin -Clozapine -Haloperidol -Adderall (Valium), naltrexone (ReVia), nalmefene
-Chlordiazepoxide -Nortriptyline -Olanzapine -Fluphenazine (Revex), acamprosate (Campral); start
-Clonazepam -Quetiapine -Trifluoperazine Norepinephrine w/↑dose, ↓20-25% ea day till
SSRI: -Ziprasidone -Loxapine Selective complete;addtl dose for breakthroughs
Atypical, -Sertaline -Perphenazine Reuptake contra:liver dysfunction
Nonbarbiturate -Citalopram Anxiolytics: -Thioridazine Inhibitor: Abstinence: Disulfiram
Anxiolytic: -Escitalopram -Alprazolam -Amotexetine Anticonvulsants: carbamazepine, valporic
-Buspirone -Paroxetine -Lorazepam (non-stimulant) acid, gabapentin for seizures
-Fluoxetine Atypical Multivitamin therapy - thiamine
SSRI: -Duloxetine -Lithium Antipsychotic: TCA
-Sertaline -Fluvoxamine Carbonate -Risperidone -Amitriptyline Opioids:
-Citalopram -Vilazodone* -Ariprazole -Clomipramine Withdraw/Abstinence: methadone,
-Escitalopram Other: -Clozapine -Imipramine clonidine, buprenorphine
-Paroxetine MAOI: Antiepileptic -Olanzapine -Doxepin
-Fluoxetine - drugs (AED): -Quetiapine -Nortrptyline Nicotine:
-Duloxetine Tranylcypromine -Valporic Acid -Ziprasidone Withdraw/Abstinence: bupropion,
-Fluvoxamine -Selegiline TD -Carbamazepine SSRI Nicotine replacement
-Vilazodone* -Isocarboxazid -Lamotrigine -Sertaline
-Citalopram Depressants:
TCA Atypical -Escitalopram phenobarbital (Luminal)↓ 30mg/day till
-Amitriptyline Antidepressant: -Paroxetine complete
-Clomipramine -Bupropion -Fluoxetine
-Venlafaxine -Duloxetine Stimulants:
MAOI -Mirtazapine -Fluvoxamine chlordiazepoxide(Librium), haloperidol
-Tranylcypromine -Reboxetine -Vilazodone* (Haldol), desipramine (for cocaine)
-Selegiline TD -Trazodone
-Isocarboxazid Atypical Hallucinogens/Cannabinols:
Antipsychotic: ↓anxiety chlordiazepoxide(Librium),
BB -Risperidone diazepam(Valium). Psychotic reactions tx
-Propranolol -Olanzapine with antipsychotic meds

Anticonvulsant Atypical Gambling:

-Gabapentin Anxiolytic: clomipramine, lithium, carbamazepine,
-Buspirone naltrexone
Antihistamines
-Hydroxyzine
Pamoate
-Hydroxyzine
hydrochloride
Medications for Anxiety Disorders
 Anxiolytic Atypical Anxiolytic
Selective Serotonin Reuptake Inhibitors
Benzodiazepines Buspirone
(SSRI)
GABA Enhancer -Binds to serotonin and dopamine -Inhibits serotonin reuptake
receptors -Causes CNS stimulation
-Less dependency
MOA -Does not result in sedation MORNING DOSE
-Does not potentiate the effects of
other CNS depressants
GAD Panic GAD
Panic Disorder OCD OCD
ACUTE Social Anxiety Panic
Other uses: seizure disorder, PTSD Social Anxiety
Indicatio insomnia muscle spasms, ETOH wd, PTSD
n induced anesthesia, amnesia prior to Depression
sx Bulimia Nervosa
PMDD (pre-menstrual dysphoric disorder)
TOLERANCE CNS Effects: dizziness, nausea, -First days/weeks: nausea, diaphoresis, tremor,
-CNS Depression – sedation, H/A, agitation, lightheadedness fatigue
lightheaded, ataxia, ↓cognitive -After 6 weeks: Sexual dysfunction, weight gain,
function headache
-Anterograde Amnesia: difficulty -GI bleed
recalling events that occur after -Hyponatremia- older pt/diuretics
dosing -Bruxism: grinding and clenching of teeth usually
-Acute toxicity, oral toxicity: when sleeping
confusion, drowsiness, lethargy, -Withdrawal syndrome-nausea, sensory disturbances,
A/E respiratory depression, cardiac arrest anxiety, tremor, malaise TAPER
-Paradoxical response: insomnia, -Serotonin syndrome:
excitation, euphoria, anxiety, rage Agitation, confusion, disorientation, difficulty
-Withdrawal Effects: anxiety, concentrating, anxiety, hallucinations, abd pain
insomnia, diaphoresis, tremors, diarrhea, hyperreflexia, fever, diaphoresis,
light-headedness incoordination, and tremors *MAY BE LETHAL
*Begins 2-72 hours after initiation of treatment
Resolves when med discontinued
-Alprazolam- Xanax -Buspirone - Buspar -Sertaline- Zoloft
-Diazepam-Valium (IV) -Citalopram
-Lorazepam- Ativan (IV) -Escitalopram-Lexapro
-Chlordiazepoxide-Librium -Paroxetine-Paxil (GAD, panic, anxiety, OCD, social
Meds
-Clonazepam-Klonopin -Fluoxetine-Prozac trauma, depression)
-Duloxetine
-Flumazenil-Romazicon antidote -Fluvoxamine
Preg D Preg B – no breastfeeding MAOI’s Preg D
Class IV controlled substance Caution older adult –liver and renal TCAs
Contra: diazepam – pt w/sleep dysfunction St John’s Wort-natural form of serotonin
apnea, resp↓, glaucoma No grapefruit juice Coumadin
Interact Caution pts w/liver dysfunction Caution ↑ effect with Tricyclic Antidepressants
Avoid ETOH and other CNS↓ erythromycin,ketoconazole, and St Lithium
John’s Wart NSAID
Anticoagulants NO ETOH
Short term use only –addiction Non habit forming If effective: Take with food
Tolerance No MAOI’s 14 days Normal sleep pattern
Relief occurs rapidly Take with food Less anxious and more relaxed
Taper –do not stop suddenly Takes a week to show, 3-6 wks for Greater ability to participate in social and
Avoid hazardous activities till know full effect occupational interactions
reaction Take regularly NO PRN Caution GI bleed,ulcers,blood coag,-monitor dark
Notes:
Take with food stools, coffee ground emesis
Do not crush/break pill Watch liver,renal dysfunction, seizure disorders, Hx
of GI bleed
May take 4 wks full therapeutic effect
Mouthguard for bruxiam or may chg class of med or
give with buspirone

Medications for Depression

ALL ANTIDEPRESSANTS - Depression is a mood disorder (affective)
Clients starting medication need to be advised that symptom relief can take 1-3 weeks and 2-3 months for full therapeutic effect.
Elderly may need ½ dose.
 Monoamine Oxidase Inhibitors Selective Serotonin Reuptake Inhibitors
Tricyclic Antidepressants
(MAOI) (SSRI)
Block reuptake -Block MAO in the brain, -Inhibits serotonin reuptake ↑ effects
of norepinephrine and serotonin ↑ norepinephrine, dopamine and -Causes CNS stimulation
in the synaptic space ↑effect of NT serotonin ↑ NT
Atypical relieving depression
Antidepressants
MOA MORNING DOSE (↓ sleep disturbances)
Bupropion Venlafaxine Mirtazapine Reboxetine Trazodone
BEDTIME DOSE(for sedation,OH)
Wellbutrin Effexor Remeron Edronax Desyrel
Inhibits dopamine Inhibit serotonin and Increases release of Selectively inhibits the ↑ Serotonin,
Depression,
uptake, chronic pain,
will increase neuro pain reuptake,
norepinephrine Atypical ↑depression
serotonin and Major Depression
reuptake of moderate blockade
MOA enuresis, insomnia, anxiety Bulimia nervosa GAD
dopamine levels amount for impulse norepinephrine. norepinephrine
OCD
transmission. Minimal OCD
dopamine blockade Anxiety Panic
Indication
-Depression Well tolerated Social Anxiety
Similar results as SSRI’s Usually given with
-Alternative to SSRI PTSD
Well tolerated another
d/t sexual dysfunction Bulimia Nervosa antidepressant
SE PMDD (pre-menstrual dysphoric disorder)
Sedation may be an
Indicatio Preg
-Aid to Cquit smoking SSRI Fluoxetine is Preg C- can cause birth
issue, good for
n Pheochromocytoma defects, switch to SSRI
-Prevention of client with
Seizure disorders
seasonal affective HF Contra: MAOI/TCA insomnia
disorder (SAD) take Cardiovascular and cerebral vascular Caution: liver/renal dysfunction, cardiac,
Use cautiously
autumn to spring in client’s with: disease seizure disorders, DM, ulcers, hx of GI
Coronary
Headache Artery Disease, MI, Renal insufficiency
HA, nausea, agitation, Sleepiness and weight Dry mouth, low BP, Priapism –see HP
Drydiabetes,
mouth liver disorders,anxiety
kidney and sleepClients alreadygain
taking
withTegretol
elevatedor constipation, sexual
Contraindication
disorders,
GI distress respiratory disorders,
disturbances Trileptal cannot do patch
cholesterol dysfunction, urinary
urinary retention and obstruction,
Tachycardia Phenelizine –Preg C hesitancy or retention
angle closure glaucoma, BPH, and
Nausea Caution
A/E hyperthyroidism. Diabetics, HTN, hyperthyroidism,
Restless
Constipation seizure disorders, Parkinson’s,
Insomnia cardiac arrhythmias, and concurrent
Weight loss TCA
-Orthostatic hypotension,
Seizures -CNS stimulation- anxiety, agitation, First days/weeks: nausea, diaphoresis,
-Anticholinergic
Monitor weight effects:
Monitor: Weighthypomania,
dry mouth, loss, mania
Faster therapeutic results tremor,
Avoid fatigue
concurrent use Take at bedtime to
blurred
Teach vision, photophobia,
anticholinergic urinary increase
hyponatremia, -Orthostatic
in hypotension,
Less sexual dysfunction Uncommon
with MAOIs effects:sleepy,faint,
aid lightheaded
in sleeping
hesitancy or retention, constipation,
effects -HTN Crisis: a result of intense
diastolic BP, sexual After 6 weeks: Sexual dysfunction, weight
tachycardia
Lowers seizure vasoconstriction and stimulation of
function, and avoid gain, headache
-Sedation
threshold stopping abruptlythe heart; HA, nausea, ↑HR, ↑BP GI bleed
Notes: -Decreased seizure
Contra: any prior headthreshold from eating foods with tyramine Hyponatremia
-Excessive
trauma med willsweating
↑ risk Other meds: Antidote–for HTN Crisis Rash-give antihistamine or change med
MAOI –toxicity phentolamine-Regitine IV or
duloxetine-Cymbalta CNS stimulation: insomnia, agitation,
-Toxicity: resulting
Contra in anorexia in cholinergic nifedipine-Procardia
desvenlafaxine-Pristiq anxiety. Avoid caffeine, possibly reduce
blockade
nervosa and cardiac toxicity
& bulimia dose, relaxation techniques
evidenced by dysrhythmias, mental -Rash with transdermal, give topical Bruxism: grinding and clenching of teeth
confusion, agitation glucocorticoid usually when sleeping
Followed by seizures, coma and Withdrawal syndrome: nausea, sensory
A/E
death disturbances, anxiety, tremor, malaise
NI: Give 1 week supply to acutely ill TAPER
client, obtain baseline EKG, and Serotonin syndrome: agitation, confusion,
monitor vital signs. disorientation, difficulty concentrating,
anxiety, abd pain, diarrhea, hallucinations,
hyperreflexia, fever, diaphoresis,
incoordination, and tremors
*MAY BE LETHAL
*Begins 2-72 hours after initiation of
treatment
Resolves when med discontinued

-Amitriptyline-Elavil -Tranylcypromine-Parnate -Sertaline-Zoloft

-Clomipramine-Anafranil -Selegiline TD- Emsam -Citalopram-Celexa
-Imipramine-Tofranil -Isocarboxazid -Escitalopram-Lexapro
-Doxepin-Sinequan Phenelzine-Nardil -Paroxetine-Paxil
Meds
-Nortriptyline-Aventyl, Pamelor -Fluoxetine-Prozac
-Duloxetine
-Fluvoxamine
MAOIs Provide written material on meds to MAOI’s, TCA’s, & st johns wart combined
Antihistamines avoid OTC decongestants, TCA’s for ↑ risk of serotonin syndrome – must d/c
Sympathomimetics: HTN Crisis before starting SSRI. Fluoxetine d/c for 5
Direct sympathomimetics = SSRI’s for serotonin syndrome wks before taking MAOI
Salbutamol, Phenylephrine, antihypertensives, meperidine-
Isoproterenol. Demeral, & vasopressors can cause TCA, st johns wart with SSRI
Indirect= Amphetamines, Ephedrine, hyperpyrexia
Interact Cocaine Ephedrine, amphetamine) Concurrent use w/warfarin-Coumadin ↑
Alcohol, warfarin levels – monitor PT/INR
Benzodiazepines,
Opioids TCA’s & Lithium combined ↑ levels
Antihistamines
NSAID & Anticoags ↓ platelet aggregation
Medications for Bipolar Disorders
 Mood Stabilizer
Produces neurochemical
changes in the brain,
including serotonin receptor
MOA blockade
Want to ↓serotonin
Substancelevel
Abuse
Alcohol:
Controls acute mania, helps
Detox: Benzodiazepines
prevent
Abstinence: the returnNaltrexone,
Disulfiram, of mania orAcamprosate
depression, decreases the
Opioids:incidence of suicide,
alcoholism, bulimia,
Withdraw/Abstinence: and Clonidine,
Methadone,
Indication
schizophrenia
Buprenorphine
Take with food/milk
Nicotine:
Withdraw/Abstinence: Bupropion, Nicotine social skills
GI distress,
replacement, fine hand tremors, Carbamazepine: CNS effects: H/A.
Varenicline
polyuria, weight gain, renal
toxicity, bradydysrhythmias,
hypotension, electrolyte
imbalances, goiter and
hypothyroidism with long
term use
THIRSTY
A/E
Need baseline T3/T4/TSH &
monitor yrly
Can adjust dose, give BB
propranolol for hand tremors
Lithium Carbonate
Can give addtl antidepressant
during depressive phase
Meds
*Diuretics: Sodium is
excreted with diuretics
maintain adequate diet (give
K+sparing)
Drink at least 2,000 to 3,000
ml/day initially at (least 1500
ml)
*NSAID’s concurrent use will
Interact
increase renal reabsorption of
lithium=toxicity
Anticholenergics
(antihistamines, tricyclic
antidepressants) can cause
abdominal discomfort, avoid
use
Serum lithium levels 0.3 in
our bodies
Margin between therapeutic
and toxic is narrow
Maintenance: 0.6 to 1.2
Acute mania: 1.0 to 1.5
Effects seen 7-10 days
Early signs: less than 1.5
D/N/V, muscle weakness,
slurred speech
Notes: Advanced: 1.5 to 2.0 Blurred
vision, ataxia, tinnitus,
persistent n/v, tremors
Severe toxicity: 2.0 to 2.5
Extreme polyuria of dilute
urine, tinnitus, hypotension to
death
Greater than 2.5 Progression
Antiepileptic Drugs (AEDs) Anxiolytics Atypical Antipsychotics
Slows Na+/Cl back into neuron, ↓action GABA Enhancer Mainly blocks serotonin,
↑ GABA’s inhibitory effects dopamine (↓less)
↓ Glutamate (↓CNS excitatory) Also blocks norepinephrine,
histamine, and acetylcholine
BP Disorders and treatment of manic and Treat acute mania Negative and positive
depressive episodes, prevents relapse, Manage psychomotor symptoms of schizophrenia,
good for mixed mania & rapid cycling agitation, insomnia, psychosis induced by
BP anxiety Levodopa therapy, and
AED’s If effective: Relief of acute bipolar in mania and
manic symptoms, Verbalized improved psychosis
mood, Performs ADL’s, Improved
sleeping, Improved eating, and better
-TOLERANCE New onset diabetes, weight
dizziness, nystagmus, double vision, -CNS Depression gain, hypercholesterolemia,
vertigo, staggering gait. Blood dyscrasia: -Anterograde orthostatic hypotension,
leukopenia, anemia, thrombocytopenia, Amnesia: difficulty anticholinergic effects,
fluid overload. Skin disorders: rashes recalling events that agitation,
dermatitis, wear sun screen, rash, occur after dosing dizzy, sedation, sleep
Steven’s-Johnsons syndrome. Take at -Acute toxicity: disruption
Bedtime, start with lowest dose then ↑ drowsiness, lethargy, and mild EPS such as tremor
respiratory
Lamotrigine: Double or blurred vision, depression, cardiac CLOZAPINE used to treat
HA, N, V, rashes (SJS),long acting med arrest schizophrenia. This medicine
Paradoxical response: is only used when others have
Valporic acid: N/V, indigestion, insomnia, excitation, not worked. It has a risk of
hepatotoxicity (NV, anorexia, abd pain, euphoria anxiety, rage serious side effects
jaundice), pancreatitis (NV,abd pain), Withdrawal Effects: -WBC monitoring
thrombocytopenia, Take with food, anxiety, insomnia,
lowest dose possible diaphoresis, tremors,
light-headedness
Valporic acid -Alprazolam -Risperidone
Carbamazepine -Lorazepam -Ariprazole
Lamotrigine -Clonazepam -Clozapine
-Olanzapine
-Quetiapine
-Ziprasidone
Valporic Acid: Avoid alcohol. Preg D Immunosuppressive meds
Contraindicated in liver disorders. Class IV controlled (anticancer)
substance Alcohol
Carbamazepine - ↓ effect of OCP, Contra: diazepam – pt Opiods
Coumadin, AVOID grapefruit juice, ↓ w/sleep apnea, resp↓, Antihistamines
levels of phenobarbital/phenytoin glaucoma CNS depressants
Caution pts w/liver Levodopa
dysfunction TCAs
Avoid ETOH and Barbiturates and phenytoin
other CNS↓ Diflucan
Carbamazepine if effective: Short term use only Promotes sleep. ↓anxiety &
↓flight of ideas, ↓obsessive talking, addiction agitation, ↓EPS effects, and
↓agitation, ↓fatigue, ↑appetite, Tolerance mood stabilizing properties
Improved psychomotor retardation Relief occurs rapidly
**monitor liver fx every 2mths, and Taper –do not stop
amylase levels for pancreatitis suddenly
Avoid hazardous
activities till know
Valporic Acid: reaction
Need periodic blood level monitoring. Take with food
Therapeutic levels 50-100 Do not crush/break
Monitor bruising/bleeding pill
Educate pt when to hold med for serious
rash and notify HP
Educate pt caution w/driving due to
vision problems
 Medications for Schizophrenia: Antipsychotic (Neuroleptic)
Medication is used to treat symptoms!
Positive symptoms r/t behavior, thoughts and speech (shouldn’t be there)
Negative symptoms r/t social withdrawal, lack of emotion, flat affect
Clinical course of schizophrenia involves acute exacerbations with intervals of semi remission,
Goals
1. Suppression of acute episodes
2. Prevent recurrence
3. Maintain highest level of functioning

Conventional Antipsychotics –Typical-1st generation Atypical Antipsychotics – 2nd generation

Blocks Dopamine, acetylcholine, histamine, norepinephrine Mainly blocks serotonin, dopamine (less)
MOA Also blocks norepinephrine, histamine, and acetylcholine
Major Adverse effects More commonly used

Acute/chronic Psychosis, Schizophrenia, manic, bipolar, Negative and positive symptoms of schizophrenia, psychosis
Tourette’s syndrome, delusional and schizoaffective disorder, and induced by Levodopa therapy, and bipolar in mania and
dementia. psychosis
Indicatio Prevents NV by blocking CTZ receptors in medulla
n

-Agranulocytosis –monitor WBC/infection New onset diabetes, weight gain, hypercholesterolemia,

-Anticholingeric –educate on ways to releive orthostatic hypotension,
-EPS: anticholinergic effects, agitation,
1. Acute dystonia-severe spasms tongue, neck, face, back dizzy, sedation, sleep disruption
2. Parkinsonism-bradykinesia,rigidity,shuffling and mild EPS such as tremor
gait,drooling,tremors
3. Akathisia-inability to sit/stand still, pacing/agitation CLOZAPINE used to treat schizophrenia. This medicine is
4. TD-late EPS, inv mvmts of tongue/face, lip smacking, inv only used when others have not worked. It has a fatal risk of
mvmts of arms, legs, trunk Agranulocytosis -WBC monitoring
A/E
-Neuroendocrine-gynecomastia, galactorrhea, menstrual irr
-NMS (neuroleptic malignant syndrome): Sudden high fever,
muscle rigidity, change in LOC. TX: Stop med, treat temp,
Dantrolene and Bromcriptine
-OH - should diminish with tolerance
-Sedation-should diminish with tolerance
-Seizures – advise risks, may need to ↑seizure med
-Severe dysrhythmias – baselineECG/monitor with K+levels
Prototype: Chlorpromazine -Risperidone
High potency: Haloperidol, Fluphenazine Trifluoperazine -Ariprazole
Medium potency: Loxapine, Perphenazine -Clozapine
Low potency: Thioridazine -Olanzapine
Meds
-Quetiapine
-Ziprasidone
High levels can increase risk of seizures
Avoid OTC meds that contain anticholinergic agents, avoid Immunosuppressive meds (anticancer)
alcohol and CNS depressants, avoid use of Levodopa Alcohol –addtl risk w/opioids, antihist, and other CNS ↓
Opioids
Antihistamines
CNS depressants
Interact
Levodopa
TCAs
Barbiturates and phenytoin
Diflucan

Acute dystonia and parkinsonism tx: benztropine or Monitor blood tests

diphenhydramine
Akathisia tx: BB, benztropine, diphenhydramine, or amantadine
Notes: TD tx: lowest dose possible, monitor 12mth into then every 3 mths
Endocrine –notify HP
NMS-occurs w/in 2wks,stop med, VS, cooling blk, adm
antipyretics, ↑fluids, adm dantolene or bromocriptine, wait 2 wks
to resume or switch med
Medications for Children and Adolescents
 Norepinephrine
Selective
CNS Stimulants TCA SSRI Others:
Reuptake
Inhibitor
Raise levels of Non stimulant Block reuptake -Inhibits serotonin Reduce hyperactivity
norepinephrine, Block reuptake of of norepinephrine and reuptake ↑ effects Improve mood
serotonin, and norepinephrine serotonin -Causes CNS
dopamine in the synaptic space stimulation
MOA
↑effect of NT
Take with food MORNING DOSE (↓
Med before meals BEDTIME DOSE(for sleep disturbances)
sedation,OH)
ADHD children and ADHD Depression, depressive Major depression,
adults, conduct episodes of bipolar, bulimia, panic, school
disorder autistic disorder, ADHD phobia, separation
Indicatio in children and adult, anxiety disorder, PTSD,
n panic, school phobia, OCD, ADHD
separation anxiety, PTSD,
OCD

CNS stimulation, Appetite ↓, suicidal Orthostatic hypotension, CNS stimulation, weight

weight loss, insomnia, ideations, GI NV anticholinergic effects, loss (then gain),
dysrhythmias, chest and hepatotoxicity weight gain, sedation, serotonin syndrome,
pain, HTN, ↓ weight, ↓growth decreased seizure withdrawal syndrome,
development of threshold, excessive rash, sleepiness, fatigue,
A/E
psychotic symptoms, sweating, and GI bleeding, and
wd reaction, and bruxism
hypersensitive skin
with transdermal
-Ritalin -Amotoxetine Desipramine Sertaline-Zoloft Atypical antipsychotic:
-Focalin Imipramine -Citalopram-Celexa Risperidone
-Dexedrine Clomipramine -Escitalopram-Lexapro Olanzapine
-Adderall -Paroxetine-Paxil
Meds
-Fluoxetine-Prozac Atypical anxiolytic
nonbarb : buspirone

Contra in substance use Paroxetine and Caution seizure disorders, Used w/MAOI ↑ risk of HTN w/MAOI
disorder, CV disorders, MAOI’s DM, liver, kidney, resp, serotonin syndrome CNS stimulation w OTC
severe anxiety, and hyperTHism Fluoxetine ↑ effects of cold meds & caffeine
psychosis HTN with MAOI’s. Coumadin, TCA, and
**Interac
SSRI’s and lithium levels
t
Quinidine = ↑bleeding w/NSAID and
increase levels of anticoags
Amotoxetine

Decreases appetite Liver – monitor flu OH,Anticholinergic If effective: Better Risperidone-Risperdal

Stunts growth like symptoms abd effects: dry mouth, mood, improved Uses: Pervasive
MAOI-HTN crisis pain blurred vision, sleeping and eating, and development disorders
No caffeine, avoid Monitor for suicidal photophobia, urinary better interaction with (PDD), autistic disorders,
OTC cold meds depression hesitancy or retention, peers conduct disorders, PTSD,
Do not chew tablet Monitor weight constipation, tachycardia and relief of psychotic
Take regularly -Sedation symptoms
Advise parents ↑ -Decreased seizure SE: DM, weight gain,
potential for substance threshold hypercholesterolemia,
use disorder -Excessive sweating orthostatic hyptension,
Notes: -weight gain anticholinergic, agitation,
-Toxicity: resulting in dizziness, sedation, and
cholinergic blockade and EPS
cardiac toxicity evidenced
by dysrhythmias, mental
confusion, agitation
Followed by seizures,
coma and death
NI: Give 1 week supply to
acutely ill client, obtain
baseline EKG, and
monitor vital signs