Mental Health

Part I:
Mental Health Pharmacology
Antianxiety Agents - Benzodiazepines
Short acting

● Midazolam | onset: rapid | duration 1-2 hours - quick on/ quick off

Intermediate acting

● Alprazolam | onset: intermediate | duration: 6-12 hours

● Clonazepam | onset: intermediate | duration: 18-50 hours
● Lorazepam | onset: rapid IV, intermediate PO| duration: 2-6 hours - medium on/long off

Long acting

● Diazepam| onset: rapid | duration: 20-50 hours - quick on/ long off

Lorazepam
Therapeutic class: antianxiety agent

Indication: anxiety, sedation, seizures

Action: general CNS depression

Nursing Considerations:

● Avoid alcohol
● Monitor for respiratory depression
● Antidote - flumazenil
Antidepressants
● SSRIs
○ Fluoxetine
○ Sertraline
○ Escitalopram
● TCAs
○ Amitriptyline
○ Nortriptyline
○ Protriptyline
● MAOIs
○ Isocarboxazid
○ Phenelzine

Selective Serotonin Reuptake Inhibitors - SSRIs

Examples: Fluoxetine, Sertraline, Escitalopram

Indication: Depression

Action: Prevent reuptake of serotonin increasing the availability of serotonin in

the body.

Nursing Considerations:

● Monitor for serotonin syndrome

○ Hypertension, confusion, anxiety, tremors, ataxia, sweating.
● Suicide precautions important for 2-3 weeks
○ When the client's mood starts to improve, they are are an inreased risk for suicide
○ Why? They now have the energy to follow through with a plan.
Tricyclic Antidepressants - TCA’s
Examples: Amitriptyline,
Nortriptyline, Protriptyline

Indication: Depression

Action: Prevents the reuptake of

norepinephrine and serotonin
increasing these
neurotransmitters in the body.

Monoamine Oxidase Inhibitors - MAOIs

Examples: isocarboxazid, phenelzine

Indication: Depression

Action: blocks monoamine oxidase enzymes to increase the levels of ALL

neurotransmitters ( dopamine, norepinephrine, epinephrine, serotonin)

Nursing Considerations:

● Avoid foods that are high in tyramine.

○ Aged cheeses
○ Wine
○ Pickled meats
● Side effect - hypertensive crisis
Mood Stabilizers
● Lithium

Lithium
Indication: Mania

Action: Inhibits excitatory neurotransmitters such as dopamine and glutamate,

and promotes GABA-mediated neurotransmission.

Nursing Considerations:

● Do not administer with NSAIDS

● Monitor drug levels:
○ Therapeutic level - 0.6-1.2 mEq/L
● Encourage adequate fluid intake
● Side effects:
○ Seizures, arrhythmias, fatigue, confusion, nausea, anorexia, hypothyroidism, tremors
Antipsychotics
● First generation
○ Haloperidol
● Second generation
○ Quetiapine
○ Olanzapine

Haloperidol
Therapeutic class: Antipsychotic

Indication: Schizophrenia, mania, aggressive behavior, agitation

Action: Inhibits the effects of dopamine

Nursing Considerations:

● Monitor for extrapyramidal side effects

● Tardive dyskinesia
● Neuroleptic malignant syndrome
● Can prolong the QT interval
○ Weekly EKG
● Contraindicated in pregnancy
Antihistamines
● Histamine-1 blocker → block H1 receptors in CNS - stopy allergies!
○ Diphenhydramine

● Histamine-2 blocker → block production of stomach acid!

○ Famotidine
○ Ranitidine

Diphenhydramine
Therapeutic class: Antihistamine

Indication: Allergy, anaphylaxis, sedation

Action: Antagonizes effects of histamine, CNS depression

Nursing Considerations:

● Monitor for drowsiness

● Anticholinergic effects
Electroconvulsive Therapy
● Treatment for severe depression/bipolar/schizophrenia.
● Induces a brief seizure during the treatment
● Typically 6 - 12 treatments
○ May need maintenance treatments
● Informed consent required
● Postprocedure:
○ Reorient client when they wake
○ Someone else must drive home
○ Normal to have some short term memory loss
 Part II:
Mental Health Diagnoses

Common Mental Health Diagnoses

● Anxiety
● Depression
● Bipolar Disorder
● Schizophrenia
● OCD
● PTSD
● Anorexia Nervosa
● Bulimia Nervosa
Anxiety
● The body’s natural response to stress
● A feeling of fear, worry, and nervousness about what’s to come.
● Can be normal!!
● Concerning if it is chronic and in response to normal life activities.
Therapeutic Management
● Address any physical symptoms
● Ensure they are in a safe environment
○ Reorient the client
○ Decrease stimuli
○ Calm environment
○ Monitor for self-harm
● Therapeutic communication
○ Establish trust/rapport
○ Rationalize their thoughts - be logical.
○ Encourage expression of thoughts and help problem solve
○ Help restructure their thoughts
○ Determine what triggers the anxiety

Depression
● “The feeling of severe despondency and dejection”
● A state of low mood
● Aversion to activity
● Affects their thoughts, behaviors, and feelings.
Therapeutic management
● Physiological needs
○ Nutrition/hydration
○ Sleep
● Safe environment - assess risk for self harm
○ One to one observation
○ Remove potentially harmful items
● Therapy
○ Express feelings
○ Validate their frustration and sadness
○ Get moving!
○ ADLs
Bipolar Disorder
● A mood disorder where there is difficulty regulating extreme emotions.
● There are periods of mania, periods of depression, and the inability to
self-regulate these emotions.
○ Mania: “A mood disorder marked by hyperactive wildly optimistic state”
○ Depression: “The feeling of severe despondency and dejection”
Therapeutic Management
● Physiological needs
○ Provide high-calorie, finger food they can eat on the go
● Safe environment
○ Calm, controlled, focused interactions
■ Don’t argue while in a manic state
■ Protect their privacy
○ Appropriate clothing
● Therapeutic Communication
○ Set boundaries
● Medications
○ Antipsychotics
○ Mood stabilizers
Post Traumatic Stress Disorder
● PTSD develops after exposure to a life-threatening or traumatic experience.
● Recurring thoughts
○ Flashbacks
○ Nightmares
● There are structural changes in the brain

Therapeutic Management
● Physiological needs
○ Sleeping?
● Safe environment
○ Avoid triggers
● Treatment of chronic PTSD

● Psychotherapy

● SSRIs
Schizophrenia
● A long-term mental disorder involving a breakdown in the relation between
thought, emotion, and behavior.
● There is faulty perception, inappropriate actions and feelings, withdrawal
from reality and personal relationships into fantasy and delusion, and a
sense of mental fragmentation

Diagnosis
● Strong genetic predisposition
● Brain imaging shows:
○ Enlargement of ventricles
○ Reduced volume of thalamus → disrupts communication and causes positive symptoms
○ Reduced volume of frontal lobe → causes negative symptoms
● Abnormalities in dopamine and glutamate neurochemicals
Assessment Findings
● Delusions
○ “False belief firmly held to be true despite rational argument”
■ Persecution
■ Jealousy
■ Grandeur
● Hallucinations
○ “a sensory experience of something that does not exist outside the mind”
■ Auditory
■ Olfactory
■ Tactile
■ Visual
■ Gustatory
Therapeutic Management
● Provide a safe environment
○ Decrease stimulation
○ Don’t touch them when experiencing a hallucination
○ Auditory hallucinations
■ Are they telling them to do something?
● Therapeutic Communication
○ Ask about the delusion to understand what they are experiencing
○ Do not argue about the delusion or hallucination
○ Stay focused on reality
○ Set limits
● PRN medications
○ Haloperidol

NCLEX Question
The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is
yelling and blocking the television. Other psychiatric clients around him are
getting angry. What is the most appropriate action of the nurse?

a. Restrain the client

b. Escort the other clients from the day room
c. Give Haloperidol IM
d. Approach the client calmly accompanied by two other staff
Answer: D
A is incorrect. Restraining the client should be the last approach for the nurse. The
first intervention should be to talk to the client to remove him from the day room.

B is incorrect. The nurse should not try to remove the other clients from the room. The
nurse should first remove the client from the place.

C is incorrect. An IM injection of Haldol will take 30 minutes to become active. The

nurse needs to remove the client from the day before the situation escalates.

D is correct. The first intervention is to approach the client calmly and attempt to
remove him from the day room. Staff members should not contact the agitated client
alone but should be accompanied by other personnel.

Obsessive Compulsive Disorder

● Irrational obsessions and ritualized acts
○ Obsessions
■ Preoccupation with doubting, religious or sexual themes
● “My children will become sick if I think blasphemous thoughts”
■ The belief that a negative outcome will occur if a specific act is not
performed
● “If I don’t walk in a perfectly straight line something horrible will happen to my children”
○ Ritualized acts
■ Handwashing
■ Repeatedly checking to make sure that doors and windows are locked
● Impairs normal functioning
○ Social relationships
○ Job performance
○ Academic success.
Therapeutic Management
● Physiological needs
○ Broken skin due to handwashing?
● Safety
○ Harmful compulsions?
● Therapeutic communication
○ Identify triggers
○ Psychotherapy
■ CBT
■ Exposure/Response
○ SSRIs

Personality Disorders
● Antisocial
○ Lacks empathy for others, manipulative, selfish
● Borderline
○ Risk for self harm, depression, poor self image, unstable relationships
● Histrionic
○ Attention seeking, inappropriate clothing
● Narcissistic
○ Lacks empathy, grandiose thoughts, needs to be admired
● Dependent
○ Struggles to make decisions, relies on others
● Avoidant
○ Socially isolated, lacks support systems
Assessment Findings
● Low body temperature
● Bradycardia
● Hypotension
● Cyanosis
● Electrolyte abnormalities
● Hormonal imbalances
● Sleep disturbances
● Bone degeneration→ Osteoporosis
● Amenorrhea
● Lanugo
● GI upset
Therapeutic Management
● Physiological needs
○ Body temperature
○ HR
○ Electrolyte imbalances
● Ensure safety
○ SI
○ Self harm
● Therapeutic Communication
○ Establish rapport
○ Validate their feelings
○ No judgement
○ Explore triggers
■ Help make a plan to avoid
■ What to do when triggered
Assessment Findings
● Labile mood
● Helplessness
● Purging via vomiting
○ Esophageal varices
○ Tooth enamel break down
○ Russell’s Sign

Therapeutic Management
● Physiological needs
○ Electrolyte imbalances
○ Esophageal varices
● Provide a safe environment
○ Monitor for self-harm and suicidal ideations
○ May not use the bathroom for 90 minutes after meals
○ Must be observed to prevent purging
● Therapeutic communication
○ Validate their feelings
○ Help identify triggers and avoid
NCLEX Question
A nurse is assigned to care for a client with bulimia nervosa. Which intervention
should the nurse apply following the client's meals?

a. Instruct the client to get some exercise or go for a walk after meals
b. Restrict client from going to the bathroom for 90 minutes
c. Ask the client to lie down for 2 hours after eating
d. Encourage client to start an intense exercise program

Answer: B
The nurse should observe the client while eating and prevent the client from
using the bathroom for 90 minutes after meals to break the purging cycle.
Exercise is not encouraged until the client has shown adequate weight gain. Until
then, training should be done in moderation. There is no need for the client to lie
down after meals. The correct answer is option B, while options A, C, and D are
incorrect.