Exam 1 Flashcards
Mental illness
Significant dysfunction in mental functioning, definable diagnosis
Resilience
Adaptation
Ability to access resources to promote well-being
Optimism
Mastery
Competence
3 As
Anxious
Anger
Aggressive
If you don’t deal with the previous one you might have the next
Protective factors for mental health and well being
Things that keep us going such as a family member or pet
Risk factors for mental health and well being
Things that make you at risk of killing yourself (engaging in dangerous activity like drinking for a while)
Warning signs for mental health and well being
Leads to risk factors, like saying you’re thinking of going back to drinking or saying you started again
Diathesis-stress model
Diathesis— biological predisposition like neurotransmitters or viruses during birth can increase risk for schizophrenia
Stress—environmental stress or trauma (outside environment)
Most accepted explanation for mental illness
NAMI and SAMHSA
NAMI: Support for patients and families
SAMHSA: people seek to live their full potential (substance abuse mental health society)
2 important components on mental health
Mental health is part of overall health
There exists effective mental health treatments
Human genome project
Identify genes and sequences, store information and analytic tools, address ethical, legal, and social issues
Most psych disorders result from mutated or defective genes
President’s new freedom commission on mental health
Goals for transforming US mental health system
Understanding that mental health is essential to overall health
Mental health care is consumer and family driven
Used to be patient driven and so slow
Early screenings and technology are important
Institute of medicine (IOM)
Now called national academy of medicine (NAM)
Improving quality of healthcare for mental and substance use conditions quality chasm series
If you had substance abuse history and mental illness, they wouldnt treat the substance abuse. This report allowed both to happen
Identified treatments and gaps
Highly educated nurses care for diverse populations with chronic conditions
Mental health parity act
Parity for mental health just like medicine
Wellstone-domenici party act
Based on volume of employees (50), we don’t have to cover mental health costs for substance abuse as well as mental
Patient protection and affordable care act
Coverage for everyone
Most common mental illnesses
Depression
Generalized anxiety
Panic disorder
3 studies we do for people with mental disorders
Natural history of illness (diathesis stress model, environment, did they meet all their milestones)
Diagnostic screening tests
Intervention
Results of mental disorder studies are used to describe the frequency of
Mental disorders
Symptoms appearing together (depression with cardiac disease and breast cancer)
Most patients who undergo bypass surgery develop depression
DSM-V
Diagnostic manual, categorized. By disorders occurring from youngest to oldest, and disorders related to one another
ICD-10-CM
International classification of disorders
Basic vs advanced nursing care
Basic: nursing graduate, can seek certification as part of professional development
Advanced: CNS and NP, certification or licensure—therapy, may have prescription privileges
CNS vs NP
CNS focuses more on education whereas NP focuses more on medical aspect and prescribing
Psych care in the 1860s
Has roots in the asylums before the civil war era
Psych care in the 1950s
Private psych/mental hospital—first antipsychotic med (thorazine, chlorpromazine)
Psych care in the 1960s
Medicare and medicaid with no funding of psych care, started to fund it
Psych care in 1999
Olmstead decision
Deinstutionalization. People would buy homes and turn them into residential treatment places. Not every neighborhood allowed this which lead to homelessness. Shelters were bad so people preferred being on the street
Psych care in 2016
Drop in psych hospitals
1st psych asylum and 1st psych hospital
500-1500AD (also when mentally ill were sick not posessed)
18th century by dr benjamin rush
Enlightenment in the late 18th to early 19th century
Dignity of psych patients upheld
Asylum movement
Study of mind and mental illness in the late 19th century
Studies and treatment approaches flourished
Development of CMHC
Least restrictive alternative evolved
CMHC’s act
Patients treated in familiar surroundings
Homelessness was linked to deinstitutionalization
Least to most restrictive care (11)
PCP
Specialty psych providers
Patient centered medical homes
Community mental health centers
Psych home care/personal recovery programs
Assertive community treatment
Intensive outpatient programs/partial hospitalization
Emergency care
Crisis stabilization units
General and private hospitals
State hospitals
Patient centered medical homes
Not actually in the home
Building with entire healthcare team
Psych home care/personal recovery programs
PROS for consistent outpatient treatment but patients not as high functioning
Do very well in recovery program
5 days a week, 6-7 hours
Nurses go in and out of homes and do assessments to see if patients can stay out of the hospital
ACT
Case manager program for patients once they are discharged
Nurse becomes case manager and consult with doctor/NP about how patient is doing
Someone goes into patient’s environment 2-3 times a week
More intensive
Usually not admitted to hospital but this method isn’t very common because of low funding
Intensive outpatient programs
2-3 days a week
5-6 hours a day
Partial hospitalization
5 days a week, 5-6 hours a day for patients who aren’t a danger but aren’t completely well
Go from this to intensive outpatient to community clinic to see doc/therapist. Most intensive care after hospital
Hospital based consultant model
Consultants (NP or psychiatrist) are called to see whether they should be admitted to inpatient or outpatient psych
What to ask with manic bipolar patients
How did you sleep?
Psych and medical emergencies
First on scene! DON’T LEAVE THE ROOM!! Seamless transition between you and mental health worker
Team comes in and may ask you to step aside but don’t leave
CPI needed to deescalation
Take valuables away IN FRONT OF PATIENT
Code gray
Somatic therapy
Patient has pain and we treat them because they are discomforts
What does a therapeutic milieu do
Should be purposeful and planned to provide safety
Provide interaction and communication among patients and personnel
Provide testing ground for new behavior while patients take responsibility for their behavior
Provide consistent limit setting
Patients stay in the dayroom a lot
Tries to mimic the outside world!
NPR only + weak milieu - meds
Decompensation when patients don’t receive meds
Possibility of decompensation to pre treatment state with bad milieu
Meds only
Custodial care only
Milieu only
Patient is de-emphasized
Meds + NPR - milieu
patient fends for themselves
Occurs with lack of leadership (weak head nurse)
Many staff avoid patient contact
Unit activities have irregular schedule and don’t contribute to overall unit philosophy
Meds + milieu - NPR
Ineffective nursing care
Other disciplines must make up for ineffective nursing care so pt can improve
Anger vs aggression vs violence
Anger is an emotion
Aggression is an action in response to anger
Violence is full action, came from the person who made them feel that way
One leads to the next
Limbic system and amygdala
Limbic system is emotions
Amygdala mediates anger
Helps remember emotions
Prefrontal cortex
Executive function, usually altered in psych patients
This and the temporal lobe light up when a patient is angry
Chemical imbalance in people who imitate others (social learning theory)
Excess dopamine
Risk factors of violence
HISTORY OF VIOLENCE
Substance use
Increasing hyperactivity
Verbal abuse, loud voice, silence
Possession of weapon
Intense eye contact
Increased simulation, poor boundaries and structures
Cognitive deficits
If someone cowers down and tries to look invisible
Possible abuse history
Inpatient factors in angry/aggressive patient interventions
Nurses who are respectful and empathetic for patients are more likely to succeed in diffusing situation
Confusion/anger r/t behavior of other patients (disputes over food or cigs)
Aversive stimulation
Over/under stimulation
Outpatient factors in angry/aggressive patient interventions
Usually s/s are stabilized so these incidents aren’t common
Important for a nurse to stress the need for treatment compliance (meds, program attendance, etc) to avoid relapses and situations
Timeline of restraints
Can put them on without order in emergency situation but need order within 30 mins (by 3rd year NP)
Skin integrity q15 mins
ROM needs to be done in opposites (LA, RL, RA, LL)
After 2 hours debrief with patient and renew order
Q24 hours debrief for 72 hours (3 chances)
Take their word for it, share what you saw if they ask
Check nutrition and hydration
Circulation in extremities
VS
Elimination and hygiene
Physical and psychological status and comfort
Contraindications of restraints
Pregnancy
Sleep apnea
Fracture
Seizure disorder
Head injury
Nursing responsibilities for seclusion
Must break seclusion q2h
Must observe and document q15m
Physical needs must be met
Monitor BP
What to do after incident
OMH incident report
Huddle with staff (review incident, what did we do good and bad, plan moving forward)
How to confront patient about discrepancies
Perception check:
Describe inconsistent or confusing behavior
Offer at least 2 possible interpretations
Ask for feedback
Ethics
The study of philosophical beliefs about what is considered right or wrong in a society
Bioethics
Used in relation to ethical dilemmas surrounding healthcare
Ethical dilemma
Conflict between two or more courses of action, each with favorable and unfavorable consequences
Beneficence
Being kind, merciful, and moral
Fidelity
Loyalty
Veracity
Honesty
Pharmacogenetic testing
Testing is done and we find out a drug may be good for someone but it ends up being contraindicated for them
Predictive psych
More for adults, have an ability to make a determination, checking genes, seeing which meds would be good, and then they don’t end up being good
Assisted outpatient treatment (Kendra’s law)
Mandates AOT to those having a hard time in rehab and pose a risk to themselves or those in their community
Parity law (timothy’s law)
Requires insurance to cover psych and physical health benefits equally
Voluntary inpatient admission
Doctor has 3 days to decide whether or not to admit the patient
Forms of involuntary inpatient admission
Emergency
Community designee
2 physicians certificate (usually seen when going from hospital to state hospital)
CPEP
Emergency admission
Danger to self or others
Person confused or demented
Used for observation, diagnosis, and treatment
Generally from 24-96 hours
Court hearing before discharge or next admission
AOT
Similar to ACT
Court ordered
Been in hospital and was not showing improvement or functioning
Due process in involuntary commitment
Writ of habeas corpus (patient can tell nursing staff they want to go to court hearing, nurse tells doctor. Sometimes onsite, sometimes offsite [if offsite, 2 mental health associates go out with them, not nurse])
Least restrictive alternative doctrine
Patient rights
Right to treatment
Right to refuse UNLESS emergency or court ordered
Right to informed consent
Rights related to restraint and seclusion
Right to confidentiality
Implied consent (testing), procedure in the OR is different kind of consent
Capacity–ability to make a decision
Competency–being able to act on things
Psychiatric advance directives (Can’t fill this out while in hospital, has to be before)
Types of discharge
Conditional release: Patient leaves with a plan (go to outpatient therapy [doctor, psychiatrist, etc.])
Unconditional release: Someone came in with psychosis due to cannabis, don’t need therapy or meds
Release against medical advice (AMA): Possible but rare in psych
restraint and seclusion
Least restrictive environment
Orders of documentation
Safety and assessment
In NY if pt is a danger, you can put a patient in restraint and then get order after 30 mins. In any other state you need an order first
Department of health, office of mental health, and joint commission
If no order, you need to remove the restraints and document it
Exceptions to confidentiality
duty to warn potential victim (tarasoff case [I’m gonna kill my neighbor])
Report safety concerns and threats to treatment team and instructor
Report elder and child abuse
Duty to protect patient (Don’t leave suicidal patient alone)
Therapist-patient abuse –sexual, misdiagnosis, restraint use (safety)
Tort law
Tort is a civil wrong that is done to someone
Intentional tort—willful or intentional acts that violate another person’s rights or property
Unintentional tort—unintended acts against another that produce injury or harm (very complicated to prove negligence)
Standards of nursing care
State Boards of Nursing (only people who can take your license away)
Professional Organizations
Institutional Policies and Procedures
Custom as a Standard of Care (if you do research, you give one group a different standard of care and compare them)
Forensic nursing issues at stake
Patient competency
Individual’s fitness to stand trial
Involuntary commitment
Responsibility for a crime
Support of victims or perpetrators of crime and violence
Collection of evidence!!
Provision of health care in prison settings
Schizophrenia
Can’t function
Brain disorder
Rare in children
Prodromal symptoms in adolescents (starts negative, not being social, sad affect, withdrawal, not doing well in school)
In all people there is at least 1 psychotic symptom and difficulty functioning
Symptoms HAVE to be present for 6 months and forward
Delusional disorder
Can last 1 month or less, altered thinking process, fixed false belief, still able to function though
Brief psychotic disorder
Lasts 1 day to less than 1 month
Psychotic thinking and presentation (bizarre affect)
substance induced psychotic disorders
Cannabis may be good for people with cancer bc pain and nausea but it can cause psychosis
Schizpreniform disorder
less than 6 months, all symptoms of schizophrenia. Less occupational, social, and situational dysfunction. No meds or short term med
Schizoaffective disorders
2 arms
Schizo=schizophrenia
Affective: r/t affective domain, usually depression
Why are prodromal symptoms seen in schizophrenia in teens
Breaking from support system in late teens to early 20s. Huge transitions, environment plays a role
Onset and prognosis of schizophrenia
Late onset usually has better outcomes and less brain abnormality
Good prognosis- acute onset, high baseline functioning
Less positive prognosis–younger age onset, longer duration between symptoms and treatment, more negative symptoms-
DSM-V Criteria for schizophrenia
Two or more of the following for a significant portion of time in 1 month straight:
Delusions
Hallucinations
Disorganized speech–makes no sense to anyone except patient
Gross disorganization or catatonia (loss of muscle movement [catalepsy or waxy flexibility])
Negative symptoms (diminished emotional expression or avolition)
Continuous disturbance for at least 6 months
physical illness in people with schizophrenia
remature death 3.5x higher (very sedentary lifestyle, smoking, unhealthy diet. 2nd generation psychotic meds cause metabolic syndrome so they tend to be overweight, exercise programs available)
Polydipsia–excessive thirst, sometimes to get medicine out, electrolyte imbalance!)
genetics and schizophrenia
first degree relative with disorder increases risk to 10%, identical twins to 50% and fraternal twins to 15%
Virus from mom when born, birth trauma,
Genetics thought to account for up to 80%
Multiple genes involved
Diathesis-stress model
dopamine theory
when D2 receptors are blocked reduces symptoms of schizophrenia (1st generation antipsychotics) (blocks dopamine receptors, too much dopamine)
biological factors of schizophrenia
Dopamine theory
Too little serotonin (depression)
Other neurochemicals– serotonin and dopamine blocked by 2nd generation antipsychotics
NMDA receptors and glutamate–glutaminergic synthesis depleted in schizophrenia
Acetylcholine–low in patients with schizophrenia
brain structure in schizophrenia
Enlarged ventricles or asymmetry
Reduced volumes in brain areas
Increased fissure sizes
Reduced connectivity
Decreased blood flow and glucose metabolism frontal lobe
Reduced gray matter
prenatal factors in schizophrenia
Poor nutrition
Hypoxia
Viruses-herpes 2, retrovirus
Psychological trauma
Father older than age 35
Birth in late winter/early spring–seasonal depression
stress as a factor in schizophrenia
Increase cortisol interferes with hypothalamic development
Often onset during time of stress (what can you identify?)
Stressors affect severity and course of disorder
Sexual abuse
Poverty
Migration
Toxins
Course of schizophrenia
Prodromal symptoms–forewarning one month to more than one year before first psychotic symptoms or manifestation, deterioration, withdrawal and antisocial
Recurrent exacerbations with periods of reduced symptoms, usually chronic
Focus on management not cure
Can somewhat control most symptoms, majority do not respond fully and require ongoing care (in- or outpatient)
phases of schizophrenic episode
- Prodromal-Before acute symptoms
- Acute–onset or exacerbation of symptoms with loss of function (good prognosis if high function before episode, early intervention!)
- Stabilization–decreasing symptoms
- Maintenance–near baseline. Symptoms absent or decreased
What settings will individuals be treated in for each of these phases?
Assessment of schizophrenia
Are they compliant/cooperative? Do they have judgment?
Anosognosia
Decreased sensation and confusion (summer clothes in winter)
Lab work for THYROID PANEL
Imaging if necessary like head trauma r/t episode
Speech pattern
Monitor those at risk
Adherance to treatment is a problem
Positive and negative symptoms
Cognitive and affective symptoms
Positive symptoms
presence of something that shouldn’t be there (hallucinations, delusions, depersonalization, derealization, paranoia, thinking disorder, abnormal movements, bizarre behavior, disorganized speech [associative looseness])
Negative symptoms
absence of something that should be there, anhedonia (reduced pleasure), apathy, blunted affect, poverty of thought [alogia], loss of motivation [avolition]
Cognitive symptoms
changes/impaired memory, attention issues, illogical thinking, poor problem solving & decision making skills, impaired judgment
Affective symptoms
emotions and emotional expression, suicidality, hopelessness, dysphoria
Perception vs delusion
Perceptions are hallucinations, delusions are fixed beliefs
Depersonalization vs derealization
Depersonalization–feeling of things being unreal or different, not part of self, sense self differently
Derealization–feeling that the environment has changed
Hallucinations
Sensory perception with no external stimuli, may involve any of the 5 senses, most common is auditory (approx 60% of individuals experience)
Illusion
Misinterpretation of a real experience
Positive speech symptoms
Looseness of association
Clang associations
Word salad
Neologisms
Echolalia
Religiosity
Magical thinking
Paranoia
Circumstantiality
Tangentiality
Alogia
Rapid or pressured speech
flight of ideas
Thought insertion
Thought deletion
Illogical or bizarre thinking
Inattentiveness
Clang association
Using words that rhyma or sound similar rather than meaning
Circumstantiality vs tangentiality
Circumstantiality is overuse of details but getting to the point
Tangentiality is going off topic and never getting to the point
Alogia
Poverty of speech
reduced volume or spontaneity in speech
Rapid or pressured speech
urgent/intense speech, reluctant to allow others to speak
Flight of ideas
move rapidly one thought to next, difficult to follow the conversation (looseness of association is not rapid, this is, also there’s no connection)
Thought blocking
reduced or abrupt stoppage of thoughts (sorry were you talking to me? Couldn’t hear you over the man in the corner, mind isn’t there)
Positive behavioral symptoms
Impaired boundaries
Catatonia
Motor retardation or agitation
Stereotype behaviors (motor behavior with no purpose)
Waxy flexibility
Echopraxia (mimicking MOVEMENTS)
Negativism (does opposite or fails what is asked of them)
Impaired impulse control
Posturing (unusual positions or expressions)
Negative symptoms
Develop over time and most interfere with functioning
The seven A’s:
Anhedonia–loss of pleasure
Avolition–reduce in motivation and goal directed behavior
Asociality–not being social?
Affective Blunting–reduced affect
Apathy
Alogia–poverty of speech
Affect
Thought blocking
Types of affect
Blunted–reduced
Flat–nothing
Constricted–lack of range in affect
Inappropriate/incongruent–laughing when someone dies
Bizarre–strange faces while talking
cognitive symptoms of schizophrenia
Concrete thinking
Impaired memory
Impaired information processing
Impaired executive functioning
Anosognosia
Why assess affective symptoms in schizophrenia
May herald impending relapse
Increases substance use D/O
Increases suicide risk
Further impair functioning
Mental status exam
Affect/mood/how they present themself
Cognition
SPeech
Kinesis
Judgment/reality test
What mimics schizophrenia
Hypo/hyperthyroid
Traumatic brain injury
Brain cancer
HSV
Hep C
Command hallucinations
VERY dangerous, can tell patients to hurt themselves or others
Nursing diagnoses for positive symptoms
Disturbed sensory perception
Risk for self-directed or other-directed violence
Impaired verbal communication
Phase 1 of schizo
Acute
Inpatient
Pt safety and medical stabilization
Phase 2 of schizo
Stabilization
Help patient understand illness and treatment
Near end of treatment
Being transferred
Helping understand their illness and treatment (and how it’s changed)
Stabilize meds
Control or cope w symptoms
May still have delusions but they’re not affecting ADLs
Phase 3 of schizo
Maintenance
Out of hospital
Maintain achievement
Prevent relapse
Achieve independence, satisfactory quality of life
Acute phase interventions for therapeutic milieu
Safety and structure
Practicing social skills, stress reduction (very anxious), symptom management
Group activities
Acute phase interventions for aggressive client
Potential for violence (more to themselves bc depression in schizophrenia)
Often response to altered reality tesing
Decrease stimulation (move others if needed)
Increase observation (DASA is used to assess)
Distraction
De-escalation
Implementation in acute phase
psych, medical, and neuro evaluation
Psychopharm treatment
Support
Supervision and limit setting in milieu
Monitor fluid intake (aggressive pts dont eat or drink well)
Assess for risk and safety
Interventions for hallucinations
Listen and attempt to understand “I don’t hear the voice but I understand you do”
Provide reality and convey patient’s reality
Safety esp with command hallucinations
Focus on here and now
Distraction
“What is the voice saying to you”
Interventions with delusions
Trust them
Dont argue or try to talk them out of it
Acknowledge their experience
Label feelings
Empathy
Gentle reality orientation—validate what is real
Focus on here and now
Interventions with health teaching
Involve patient and family as much as possible
Symptom management
Relapse prevention (who do you call in crisis)
Stress management
Support groups
Substance use avoidance bc of med interaction
Sleep!
Implementation in stabilization and maintenance phases
Med admin and adherence
Relationships w hcp
Community based services (how will they get there)
Activities and groups
First gen antipsychotics
D2 dopamine receptor agonists block altered reality
Positive symptoms only
First gen adverse effects
Atkinisia, dystonia
Looks like a medical emergency, head rolled back and to side, eyes rolled back. Can speak but not swallow
Give anti EPS meds (IM not oral)
Second gen antipsychotics
Serotonin dopamine antagonists
5hT receptor agonists
Positive and negative symptoms
Metabolic syndrome and diabetes!!
3rd gen antipsychotics
Pretty much same as 2nd but a little different
Positive and negative symptoms
Short acting injectable antipsychotic
For anger and aggression
Works quicker than pill
Predominantly for positive symptoms
Long acting injectable antipsychotics
See if they tolerate 2nd and 3rd gen well
Given for patients so they dont need to take pills every day
Compliance is key because they’ll feel well and stop
Quick relapse with PO so this is a good choice
Positive and negative symptoms
Advantages of 1st gen
Treats pos symptoms
Less costly
Less risk for metabolic syndrome
Disadvantages of 1st gen
Anticholinergic side effects: dry mouth, urinary retention, blurred vision, photosensitivity, dry eyes, sexual dysfunction
Weight gain, endocrine disturbances, hypotension and postural
Tardive dyskinesia
Irreversible, real issue
Lip smacking
Pill rolling
Shuffling gait
Tongue stuff
Seen in 1st gen
EPS
From blockage of D2 receptors in motor centers
Extrapyramidal symptoms
Acute dystonia
Akathisia
Pseudoparkinsonism
Akathisia
Increased restlessness, looks very anxious
Interventions for EPS in 1st gen antipsychotics
Lower the dose
Add antiparkinsonian drug
Benzos for akathisia
Will develop tolerance over time
Low potency antipsychotics vs high
Low potency drugs cause increased sedation and high anticholinergic effects, so low EPS
High potency drugs cause decreased sedation and anticholinergic effects, so high EPS
Tardive dyskinesia interventions for 1st gen antipsychotics
QT prolongation, very sleepy, not given to patients with QT issues already
Can treat with valbenazine (ingrezza) and deutetrabenazine (austedo)
Reduces severity of symptoms
AIMS test
Clozaril-serotonin (5-ht2a receptor) and dopamine (d2 receptor)
Second gen antipsychotic
Monitoring for second gen antipsychotics
Metabolic syndrome—diabetes so regular fingersticks
Agranulocytosis—WBC monitoring very often, patient needs to be VERY compliant
Increased risk for cardiovascular disease
Which gen of antipsychotics is first line of treatment and why
2nd gen
Less EPS/tardive dyskinesia
Which 2nd gen antipsychotic does not cause weight gain
Geodon
3rd gen antipsychotics
Dopamine system stabilizers
May improve positive and negative symptoms and cognitive function
Little risk of EPS or tardive dyskinesia
Anticholinergic toxicity
potentially life-threatening medical emergency
Symptoms-ANS instability, hyperpyrexia without diaphoresis, delirium, and hallucinations
neuroleptic malignant syndrome
Acute, life threatening emergency- can be fatal, altered consciousness, muscle rigidity, hyperpyrexia with diaphoresis, hypertension, tachycardia, tachypnea, drooling. Starts as muscle rigidity, very agitated (you think you need meds but the meds are what’s causing it).
Cogwheeling to demonstrate what they have. Bend elbow so hand is at shoulder, patient who’s cogwheeling has rigid elbow muscle. ICU or CCU, get them out of psych, too intense for stepdown unit
Cooling blanket and bramaline
agranulocytosis
monitor for decreased WBC or neutropenia, signs infection
Take them off meds
Liver impairment is in what antipsychotic
1st generation more-monitor liver function (check this and thyroid before starting anything because those issues could mimic psych stuff)
