depression ppt and readings Flashcards
*
what is major depressive disorder?
what is nec for dx of major depressive disorder according to DSM V
it can occur as single episode but is gen recurrent and progressiv
Depressed mood or a loss of interest or pleasure in nearly all activities must be present for at least 2 weeks
Plus, 4 out of 7 additional symptoms Disruption in sleep, (this is v important assessment for depressed pt) appetite (or weight), loss of energy Loss of concentration, psychomotor agitation or retardation Excessive guilt, feelings of worthlessness, suicidal ideation
what is dysthymic disorder
- diagnostic criteria for dysthymic disorder
milder but more chronic form of major depressive disorder
Feeling sad or low most days for at least 2 weeks Plus, 2 or more of the following: Poor appetite or overeating Insomnia or oversleeping Low energy or fatigue Low self-esteem Difficulty concentrating or making decisions Feelings of hopelessness
*outcome!!
risk factors of depression
Prior episode of depression Family history of depressive disorder Lack of social support Stressful life event Current substance use Medical comorbidity Economic difficulties
*which med categories are used for tx of depression *
ppt says SSRIs, TCA, MAOI
- outcome!!
* which med categories are used for tx of depression and what is the drug name associated with it
imipramine-TCA
sertraline-SSRI
phenelzine-MAOI
venlafaxine-second gen
*what is the focus of physical care for depressed pt
Sleep hygiene, exercise
if a pt was very tired what would you investigate other than sleep (which is imp) *
endocrine fx
t or f depressed pts are often still, not moving*
• Fidgeting all the time can be sign of depression
how to help pt with nutrition*
o Nutrition-eating can be effort for v depressed pt. Give them easy foods to handle. Comforting nurturing foods. Dont expect too much fromt hem.
which pop often has nausea and GI symptoms of depression
o Nausea-children have very GI symptoms for depression. Tx with simple foods or antiemetic.
what should you tell pt to start with if they are incredibly depressed and you want them exercsing
Exercise and being in nature can be very difficult-start slow with 5min walk
what is the primary role of the nurse for the psych domain
Role for psych domain is more counsellor and support.-may be beneficial to have family counselling. Pills wont be enough
pt is regaining their energy from hospitalization, what is a risk
• Suicide is high risk when pt might have enough energy to fulfill suicidal plan-caution when people are giving away their things and getting their affairs in order
*outcome!!
diagnoses fr spiritaul domain
Distress of the spirit Disturbances in one’s belief system Loss of hope Loss of meaning of life and suffering Discouragement and despair
outcome!!
interventions for spiritual domain
Get appropriate help! Contact the chaplain.
Guided conversations, life storytelling, ritual experiences
Encourage prayer, reading of comforting texts, meditation, attendance at devotional services or ceremonies and so on.
Promote and nurture hope
• We aren’t spiritual counsellors. Assess them and then bring in someone who cna help them
outcome says identify physiology of depression….not sure where this comes up but the most likely answer is in etiology so here goes
etiology
what role do genes play
- More common in 1st degree biologic relatives, suggesting “gene-env’t”
- Findings demonstrating potential interactions between genetic, neurochemical, and cognitive influences in establishing a disposition to the experience of depression
maybe not nec?
what do neurobiologic theories guess is the cause of depression
depression is caused by a def or dysregulation in CNS concentration of norepinephrine, dopamine and serotonin
-there may be hyperactivity of the amygdala contributing to negative processing of stimuli
maybe not nec?
neuroendocrine and neuropeptide hypotheses
basically depression is assoc with the following endocrine systems being altered
(Hypothamic-pituitary-adrenal axis, the hypothalamic-pituitary-thyroid axis, the hypothamic-growth hormone axis and the hypothalamic-pituitary-gondal axis)
• Evidence suggests that the sec of these hypothalamic and growth hormones are controlled by the neurotransmitters
maybe not nec?
psychoneuroimmunology as etiology of depression
didnt include any other psych, soc, spir etiologies
basically, cell signalling via cytokines may be assoc
- Diverse group of proteins called chemical messengers between immune cells
- Cytokines signal to the brain and erve as mediators bween immune and nerve cells.
- The connection between brain-immune interactions and susceptibility to depression is complex
priority care for depressed pt
safety
suicide risk
who can be interviewed regarding depressed pt
-it may be helpful to interview a family member or close friend in addition to pt. They can give info about day to day fx and specific symptoms etc
what are you assessing/trying to rule out when assessing biologic domain
- Hx of medications with special attention to CNS function, endocrine function, anaemia, chronic pain, autoimmune, diabetes, or menopause
- Medical hospitalizations: head traumas, episodes of LOC, pregnancies, abortions, childbirth, miscarriage
which labs to assess
do full Px with VS
, Hgb CBC, thyroid fx tests, uirnalysis, ECG
other than full Px, labs, and comprehensive med profile what should be assessed for biologic domain
• Appetite and weight changes: inc or dec when not dieting. wt loss is more typical.
• Sleep disturbance: insomnia. Initial insomnia (difficulty falling asleep), middle insomnia (waking up during the night and difficulty falling back to sleep), terminal insomnia (waking up too early and not sleeping). Less freq there is hypersomnia (prolonged sleep episodes at night or inc daytime sleep)
• Decreased energy, tiredness, and fatigue: regardless of how much sleep. even sm tasks take lots of effort
• Loss of interest or pleasure (ANHEDONIA) : interests that brought pleasure in the past don’t
anymore.
alcohol use, mood alt substances, the lethality of the meds the pt has(ask them abt number of sleeping pills in the bottle at home)
outcome!!
*nursing dx for biologic domain
Disturbed sleep pattern Imbalanced nutrition Fatigue Self-care deficit Nausea Disturbed thought processes Sexual dysfunction
outcome!!
*nursing interventions for biologic domain
Medications Nurse must administer, monitor effect, interactions, teach side effects and cautions Physical Care ECT Light therapy
bio domain: teaching physical care what can you help with
• Activity and exercise- start with where they are at and go slowly.
good sleep hygiene
gradually they should be en to have healthy diet and reg exercise
t or f depressive disorders are time limited. how does this impact meds?
false. SOME are time limited. therefore meds should be reviewed periodically
what can abruptly stopping med cause
v serious side effects and recurrence of depressive symptoms
Tricyclic antidepressants and monoamine oxidase inhibitors when are they useful and not?
are they used much?
First generation drugs (TCAs ad MAOIs)
• Used less often than atypical antidepressants and SSRIs (both of which are second gen drugs)
• Distinct adv in treating a specific subtype of depression, so-called atypical depression (characterized in the DSM-5 by inc appetite, mood improvement in response to actual or potential positive events and hyperinsominia)
other than for treating atypical depression who are MAOIs used for
what is the drug example for this we have
used for people with panic symptoms or social phobia
usually theyre reserved for pts who arent responsive to other antidep or unable to tolerate the other meds
Phenelzine
monitoring meds. what are you concerned about/have to watch
Monitoring medications
• Can indice the emergence of “medication activation syndrome” (extreme anxiety, hostility, agitation) and exacerbate suicidal ideation.
• Monitor vitals, liver and thyroid function, CBC
-make sure pts dont pocket meds
what kind of med is imipramine
MoA
Imipramine=Antidepressants (Tricyclic)
Potentiates effect of serotonin and norE. Has significant anticholergic properties
most common side effects of TCAs (imipramine) and MAOI (Phenelzine
• Most common side effects are antihistamine (sedation and weight gain) and
anticholinergic side effects (potentiating NCS drugs, blurred vision, dry mouth, constipation, urinary retention, sinus tachycardia, and dec memory)
why are TCAs dangerous for pt who is suicidal
lethal doses are ony 3-5x the therapeutic dose
these symptoms present within 12hrs
what is a consideration with intake and MAOIs
lethality and MAOI
Phenelzine or other MAo• Coadministered with food (aged cheese, beer, wine) can cause sudden headache, N and V, sweating which can trigger hypertensive crisis that can be life threatening
MAOIs are more lethal in OD than newer antidep and are often given in divided doses to dec side effects
ways of descriibing affect
blunted=sig dec intensity of emotional expression
flat=absent or nearl absent affective expression
labile=varied, rapid and abrupt shifts in affective expression
inappropriate=discordant affective expression accompanying speech content or ideation
restricted or constricted=mildly dec in range and intesity of emotional expression
what is serotonin syndrome
- Serotonin syndrome is a serious side effect of excess intrasynaptic serotonin
- Can occur after hours of initiating higher dose
- Symp: altered mental status, autonomic dysfunction, neuromuscular abn
- 3 of the following symp must be present for diagnosis: mental status changes, agitation, myoclonus, hyperflexxia, fever, shiver, diaphoresis, ataxia, and diarrohea
- if PVD or atherosclerosis or htn this may occur in presence of elevated serotonin
which drug is an SSRI that we are studying and what is its MoA
Sertraline aka Zoloft
T: antidepressants
P: (SSRIs)
Inhibits neuronal uptake of serotonin in the CNS,
thus potentiating the activity of serotonin. Has little
effect on norepinephrine or dopamine.
teaching points for taking meds
- Response (feeling happier) is not the same thing as remission. Cannot abruptly stop medications
- Should be continued after 6 months to a year after symp relief before stopping
- Cant take with st johns wort (causes htn). watch OTC
ECT as treatment
Electroconvulsive therapy: if not responding to drugs. Don’t do if inc intracranial pressure. Role of the nurse is to provide education and emotional support, assess baseline, prepare the patient, monitor and evaluate reponse
light therapy as tx
helpful for seasonal affective disorder via circadian rhythm effects. also nonadjuvant for nonseasonal depression
outcome!!
*nursing dx for psych domain
Risk for suicide Hopelessness Low self-esteem Ineffective individual coping Decisional conflict Spiritual distress Dysfunctional grieving
outcome!!
nursing interventions for psych domain
therapeutic rel cog therapy behav therapy interpersonal therapy family and marital therapy group therapy teaching pts with families
assessment of psych domain
Mood and affect-low
Thought content-unrealistic and negative
Suicidal behaviour- should be done intiailly and throughout course of treatment.
• Passive suicidal ideation: feels would be better off dead
• Active suicidal ideation: plans to commit suicide
• Risk factors: availability and adequacy of social supports, past hx of suicidal ideation, presence of psychosis or substance abuse, and dec ability to control suicidal impulses
Cognition and memory–impaired ability to think, concentrate, or make decisions. in o adult memory issues may be chief complaint and confused with dementia
therapeutic rel as part of tx in psych domain
Therapeutic relationship
• Trusting relationship w health care provider.
• Alliance is built from a number of activities including:
o Establishment and maintenance of a supportive relationship
o Availability in times of crisis
o Vigilance regarding dangerousness to self and others
o Education about the illness and tx goals
o Encouragement and feedback concerning progress
o Guidance regarding the patients ineractions with personal and work envt
o Relatstic goal setting and monitoring
cognitive therapy as tx
Cognitive therapy
• Monitoring thoughts, emotions, and actions to identify irrational. Disrorted thinking and beliefs
–it is first line tx for mild-mod depressed out pts
behaviour therapy
Behaviour therapy
• Behavioral action techniques: a ctive schedulcing, self-control therapy, social skills training and problems olcing
interpersonal therapy
Interpersonal therapy
• Explore, recognize and resolve interpersonal losses, role confusion and transitions, social isiolation, and deficits in social skills
family and marital therapy
Family and marital therapy
• Common among patients with mood disorders
• Group interventions
• Monitor patient and family for indicators of stress
• Teaching stress management techniques
• Counseling members on coping skills
• Providing services
• Facilitating family routines
• Assisting family to resolve feeling of guilt
• Identify strengths and resources among family members
• Facilitate communication
• Vital to teach about the nature, prognosis, and treatment of depression
teaching pts and families
pts often think the depression is their own fault and they need to snap out of it. teach them about meds the nature of depression adherence to therapy nutrition sleep sef care goal setting and problem solving social interaction skills follow up appt community support services
social domain assessment
Assessment:
• Developmental history, family psych history, patterns of relationship, education and work history, quality of support system, impact of physical and sexual abuse on interpersonal functioning.
social domain diagnoses
Nursing diagnosis • Compromised family coping • Ineffective role performance • Interrupted family processes • caregiver role strain
nursing intervention for social domain
Therapy to assist with coping mechanisms, change…help with return to work, community events and so on.
Interventions for family coping…education and support (• What is in our community can she share with church)
Safety (watch for suicide risk as hospitalization, treatment and support may give the patient enough “energy” to fulfill a suicide plan
outcome!!
dx for spiritual domain
Distress of the spirit Disturbances in one’s belief system Loss of hope Loss of meaning of life and suffering Discouragement and despair
outcome!!
assessment for spiritual domain
• Involves thoughts and feelings that contribute meaning and purposes to ones existsnce
• May have despairing thoughts and express a lack of spiritual well-being
ask eg do you wish toidentify a particular religion with which you are assoc?
would you like to speak with a representative of that religion?
Spiritual screening/Spiritual History taking/ Spiritual assessment
• Determining basic needs r/t persons religious affiliation
• Identify themes of patients spiritual concerns, recognizing the impact of the concerns on their condition
• HOPE acronym ( H- sources of hope, meaning, comfort, strength, peace, love, and connetion; O- organized religion; P- personal spirituality and practice; E- effects on medical care and end of life issues)
• Assess patients understanding of spirituality and exploration of spiritual history
what are complications of major depressive episode
• Complications: alcohol abuse disorders and suicidality may occur
what are the categorie of mood disorders
o Depressive disorders: major depressive disorder, single or recurrent; and dysthymic disorder
o Bipolar disorder: bipolar I disorder, bipolar II, and cyclothymic disorder
o Mood disorder caused by a general medical condition
o Substance-induced mood disorder
• seasonal depression- light deprived
