Exam 1

Question 1

Describe the Left and Right hemispheres

Answer 1

The cerebrum can be divided into two halves, or hemispheres. For most people one hemisphere is dominant. Each hemisphere controls functioning on the opposite side of the body. The left hemisphere, dominant in about 95% of people, control functions mainly on the right side of the body. The right hemisphere provides input into receptive nonverbal communication, spatial orientation and recognition, intonation of speech, and aspects of music, facial recognition and facial expression of emotion, and nonverbal learning and memory. The left hemisphere is more involved with verbal language function, including areas for both receptive and expressive speech control. The left hemisphere provides strong contributions to temporal order and sequencing, numeric symbols, verbal learning and memory. The two hemispheres are connected by the corpus callosum.

Question 2

True or False

An intact corpus callosum is required for the right and left hemispheres to function smoothly

Answer 2

True

Question 3

True or false

In general, the left hemisphere is more involved with verbal language function

Answer 3

True

Question 4

Describe the function of the Frontal Lobes

Answer 4

The frontal lobe contains the Brocas area, which controls the motor function of speech. Damage to the Brocas area produces expressive aphasia, or difficulty with the motor functions of speech.The frontal lobes are thought to make up most of our personality. Its functions ask include working memory, judgment, reasoning, problem solving, abstraction. These skills are often referred to as executive functions.

Question 5

True or False

When normal frontal lobe functioning is altered, it can lead to changes in mood and personality.

Answer 5

True

Question 6

What is the function if the hypothalamus

Answer 6

The hypothalamus controls basic human activities such as sleep/rest patterns, body temperatures, and physical drives such as hunger and sex. Dysfunction of this structure, whether from disorders or as a consequence of the adverse effects of drugs used to treat mental illness can produce appetite and sleep problems.

Question 7

Define Broca’s area

Answer 7

It controls the motor function of speech, located in the frontal lobes

Question 8

Define akathisia

Answer 8

Drug related body movements, uncontrollable limb and body movements

Question 9

Florence nightingales holistic view

Answer 9

Patient who lives within a family and community. She was especially sensitive to human emotions and recommended interactions that today would be classified as therapeutic communication

Question 10

DSM-IV Axes-

Answer 10

The diagnosis of mental disorders is based on criteria in the Diagnostic and statistical manual of Mental Disorders IV-TR, which was introduced in 2000. As a result of new research, mental disorders are now understood to be a group of brain disorders that primarily affect emotion, cognition, and executive functioning. A revision of the 2000 diagnostic criteria is expected to reflect this perspective, resulting in significant changes in the taxonomy. Publication of the revised diagnostic criteria in DSM-5 is expected in 2012. Even though nurses treat the “responses to mental disorders” not mental disorders themselves, they have to be knowledgeable about the characteristics of their patient’s diagnoses.
The current DSM-IV-TR system contains subtypes and other specifiers to describe further the characteristics of the diagnosis as exhibited in a given individual. Although the DSM-IV-TR provides criteria for diagnosing mental disorders, there are no absolute boundaries separating one disorders from another, and similar disorders may have different manifestations at different points in time.
Some disorders are influenced by cultural factors and others are culture-bound syndromes that are present only in a particular setting. A culture-bound syndrome is a recurrent, locality-specific pattern of aberrant behavior and troubling experience that is limited to specific societies or culture areas. These syndromes do not fit the DSM-IV-TR classification of mental disorders, which is dominated by Western thought.

Question 11

GAF-Global Functioning Scale

Answer 11

Scores Description
91-100 Superior functioning, no symptoms
81-90 Absent or minimal symptoms, good functioning in all areas
71-80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational or school functioning
61-70 Some mild symptoms or some difficulty in social, occupational or school functioning but generally functioning well; has some meaningful interpersonal relationships
51-60 Moderate symptoms or moderate difficulty in social, occupational or school functioning
41-50 Serious symptoms or any serious impairment in social, occupational or school functioning
31-40 Some impairment in reality testing or communication or major impair in several areas such as work or school, family relations, judgment, thinking or mood
21-30 Behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas
11-20 Some danger of hurting self or others or occasionally fails to maintain minimal personal hygiene or gross impairment in communication
1-10 Persistent danger of severely hurting self or others or persistent inability to maintain minimal personal hygiene or serious suicidal ac with clear expectation of death

Question 12

silence and listening

Answer 12

One of the most difficult but often most effective communication technique is the use of silence during verbal interactions. By maintaining silence, the nurse allows the patient to gather thoughts and to proceed at his or her own pace. It is important that the nurse not interrupt silences because of his or her own anxiety or concern of “not doing anything” if sitting quietly with a patient.
Listening is another valuable tool. Silence and listening differ in that silence consists of deliberate pauses to encourage the patient to reflect and eventually respond. Listening is an ongoing activity by which the nurse attends to the patient’s verbal and nonverbal communication. The art of listening is developed through careful attention to the content and meaning of the patient’s speech. There are two types of listening: passive and active. Passive listening involves sitting quietly and letting the patient talk. A passive listener allows the patient to ramble and does not focus or quite the thought process. Passive listening does not foster a therapeutic relationship. Body language during passive listening usually communicates boredom, indifference, or hostility.
Through active listening, the nurse focuses on what the patient is saying to interpret and respond to the message objectively. While listening, the nurse concentrates only on what the patient says the underlying meaning. The nurse’s verbal and nonverbal behaviors indicate active listening. The nurse usually responds indirectly using techniques such as open-ended statements, reflection, and questions that elicit additional responses from the patient. In active listening, the nurse should avoid changing the subject and instead follow the patient’s lead, although at times it is necessary to respond directly to help a patient focus on a specific topic or to clarify thought and beliefs.

Question 13

9) Study Side effects, adverse reactions and toxicity

Answer 13

The most commonly reported side effects of benzodiazepines result from the sedative and CNS depression effects of these medications. Drowsiness, intellectual impairment, memory impairment, ataxia, and reduced motor coordination are common adverse reactions. If used to sleep, many of these medications, especially the long-acting benzodiazepines, produces significant “hangover” effects experienced on awakening. Older patients receiving repeated doses of medications such as flurazepam (Dalmane) at bedtime may experience paradoxical confusion, agitation, and delirium, sometimes after the first dose. In addition, daytime fatigue, drowsiness, and cognitive impairments may continue while the person is awake. For most patients, the effects subside as tolerance develops; however, alcohol increases all of these symptoms and potentiates the CNS depression. Individuals using these medications should be warned to be cautious when driving or performing other tasks that require mental alertness. If these tasks are part of the person’s work requirements, another medication may be chosen. Administered intravenously, benzodiazepines often cause phlebitis and thrombosis at the IV sites, which should be monitored closely and changed if redness or swelling develops.
- Because tolerance develops to most of the CNS depressant effects, individuals who wish to experience the feeling of “intoxication” from these medications may be tempted to increase their own dosage. Psychological dependence is more likely to occur when using these medications for a longer period. Abrupt discontinuation of the use of benzodiazepines may result in a recurrence of the target symptoms, such as rebound insomnia or anxiety. Other withdrawal symptoms appear rapidly, including tremors, increased perspiration, palpitations, increased sensitivity to light, abdominal discomfort or pain, and elevations in systolic blood pressure. These symptoms may be more pronounced with the short-acting benzodiazepines, such as lorazepam. Gradual tapering is recommended for discontinuing use of benzodiazepines after long-term treatment. When tapering short-acting medications, the prescriber may switch the patient to a long-acting benzodiazepine before discontinuing use of the short-acting drug.
Ind reactions to the benzodiazepines appear to be associated with sensitivity to their effects. Some patients feel apathy, fatigue, tearfulness, emotional liability, irritability and nervousness. Symptoms of depression may worsen. The psych-MH nurse should closely monitor these symptoms when ind are receiving benzodiazepines as adjunctive treatment for anxiety that coexists with depression. GI disturbances, including N&V, anorexia, dry mouth, and constipation, may develop. These medications may be taken with food to ease the GI distress.
Older patients are particularly susceptible to incontinence, memory disturbances, dizziness, and increased risk for falls when using benzodiazepines. Pregnant patients should be aware that these medications cross the placenta and are associated with increased risk for birth defects, such as cleft palate, mental retardation and pyloric stenosis. Infants born addicted to benzodiazepines often exhibit flaccid muscle tone, lethargy, and difficulties sucking. All of the benzodiazepines are excreted in breast milk, and breastfeeding women should avoid using these medications. Infants and children metabolize these medications more slowly; therefore, more drug accumulates in their bodies.
Toxicity develops in overdose or accumulation of the drug in the body from liver dysfunction or disease. Symptoms include worsening of the CNS depression, ataxia, confusion, delirium, agitation, hypotension, diminished reflexes and lethargy. Rarely do the benzodiazepines cause respiratory depression or death. In overdose, these medications have a high therapeutic index and rarely result in death unless combined with another CNS depressant drug, such as alcohol.

Question 14

Study Serotonin Syndrome

Answer 14

Serotonin Syndrome
Cause: excessive intrasynaptic serotonin
How it happens: combining medications that increase CNS serotonin levels, such as SSRIs + MAOIs; SSRIs+ St Johns Wort; or SSRIs + diet pills; dextromethorphan or alcohol, especially red wine; or SSRI + street drugs such as LSD, MMDA or ecstasy.
Symptoms: mental status changes, agitation, ataxia, myoclonus, hyperreflexia, fever, shivering, diaphoresis, diarrhea
Treatment
• Assess all medication, supplements, foods and recreational drugs ingested to determine the offending substances
• Discontinue any substances that may be causative factors. If symptoms are mild, treat supportively on an outpatient basis with propranolol and lorazepam and follow up with the prescriber.
• If symptoms are moderate to severe, hospitalization may be needed with monitoring of vital signs and treatment with IV fluids, antipyretics and cooling blankets.

Question 15

nursing diagnosis for Stress/Psychological Domain

Answer 15

The nurse should consider a nursing diagnosis of ineffective coping for patients experiencing stress who do not have the psychological resources to effectively manage the situation. Other useful nursing diagnoses include disturbed though processes, disturbed sensory perception, low self-esteem, ear, hopelessness and powerlessness.

Question 16

Culture of poverty

Answer 16

Culture of poverty is a term that describes the norms and behaviors of people living in poverty. Poverty affects all cultural groups and other groups, such as older adults, people with physical disabilities, individuals with psychiatric impairments and single-parents families. In the US, 1/3 of people living below the poverty line are single mothers and their children; 24% of African Americans live below poverty level, 21% Hispanic Americans, and 10% white Americans. Currently in the US the poverty guidelines for a family of four is a yearly income of $22,050 or less in the 48 states, $27,570 or less in Alaska, and $25,360 in Hawaii.
Families living in poverty are under tremendous financial and emotional stress, which may trigger or exacerbate mental problems. Along with the daily stressors of trying to provide food and shelter for themselves and their families, their lack of time, energy and money prevents them from attending to their psychological needs. Often, these families become trapped in a downward economic spiral as tension and stress mount. The inability to gain employment and the lack of financial independence only add to the feelings of powerlessness and low self-esteem. Being self-supporting gives one a feeling of control over life and bolsters self-esteem. Dependence on others or the government causes frustration, anger, apathy, and feelings of depression and meaninglessness. Alcoholism, depression and child and partner abuse may become a means of coping with such hopelessness and despair. The homeless population is the group most at risk for being unable to escape this spiral of poverty.

Question 17

Study interventions for the biological domain-medications

Answer 17

An in-depth medication history is important in evaluating response to past medications and predicting response to the present regiment. The nurse should investigate adherence to past treatment to determine the probability of compliance. The nurse should develop a plan to increase compliance based on previous problems with adherence. For example, the nurse can use medication boxes and calendars and obtain help from others in managing the medication. Recognizing medication side effects quickly and intervening promptly to alleviate them will promote patient compliance. Understanding the need for medications is essential to the patient.
Mood and psychotic symptoms are of equal importance and are evaluated throughout treatment. Atypical antipsychotic agents are generally prescribed because of their efficacy and safe side effect profile. Clozapine, reported effected for SAD by several authorities, can reduce hospitalizations and risk for suicide. Atypical antipsychotic agents may have thymoleptic (mood stabilizing), as well as antipsychotic effects. Aripiprazole’s antidepressant response in SAD may replace polypharmacy, thus reducing drug costs, risk of drug interactions and potential adverse drug effects. Dosages are the same as those used for treating schizophrenia.

Question 18

Study the clinical course for Schizoaffective Disorder on pg 380-381: Review SAD, clinical course, Diagnostic Criteria, and Epidemiology and Risk Factors.

Answer 18

SAD is a complex and persistent psychiatric illness. This disorder was recognized in 1933 by Kasanin, who described varying degrees of symptoms of both schizophrenia and mood disorders beginning in youth. All of his patients were well adjusted before the sudden onset of symptoms that erupted after the occurrence of a specific environmental stressor. Since Kasanin’s time, debate and controversy about the status of this disorder have been extensive, resulting in many different definitions and classifications. More than 50 years after SAD was first described, the diagnosis was finally officially confirmed by the psychiatric community and included in the APA Diagnostic and statistical manual of mental disorders, 3rd edition. Even since, however, it has been argued that this disorder should be named either schizophrenia with mood symptoms or mood disorder with schizophrenic symptoms.
Clinical course: SAD is characterized by periods of intense symptoms exacerbation alternating with quiescent periods, during which psychosocial functioning is adequate. This disorder is at times marked by symptoms of schizophrenia; at other times, it appears to be a mood disorder. In other cases, both psychosis and pervasive mood changes occur concurrently.
Patients with SAD are more likely to exhibit persistent psychosis than are patients with a mood disorder. They feel they are on a “chronic roller coaster ride” of symptoms that are often more difficult to cope with than the ind problem of either schizophrenia or mood disorder. The diagnosis of this disorder is made only after these course-related characteristics are considered.
The long term outcome of SAD is generally better than that of schizophrenia but worse than that of mood disorder. These patients resemble the mood disorder group in work function and the schizophrenia group in social function. In one study, patients with SAD were less likely to recover and more likely to have persistent psychosis, with or without mood symptoms than those with bipolar disorder. Persons with SAD usually have higher functioning than those with schizophrenia with severe negative symptoms and early onset of illness.
(Patients with schizoaffective disorder have many similar responses to their disorder as people with schizophrenia, which one exception. These patients have many more “mood” responses and are very susceptible to suicide)
Diagnostic criteria: Mental health providers find SAD difficult to conceptualize, diagnose and treat because of the variable clinical course. Patients are often misdiagnosed as schizophrenic. The difficulty in conceptualizing SAD is reflected in the controversy regarding the diagnostic criteria discussed earlier.
To be diagnosed with SAD, a patient must have an uninterrupted period of illness when there is a major depressive, manic or mixed episode along with two of the following symptoms of schizophrenia: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior or negative symptoms (e.g. affective flattening, alogia, avolition). In addition, the positive symptoms (delusions or hallucinations) must be present without the mood symptoms at some time during this period (for at least 2 weeks). Two related subtypes of SAD have been identified: bipolar and depressive. In the bipolar type, the patient exhibits manic symptoms alone or a mix of manic and depressive symptoms. Patients with the depressive type display only symptoms of a major depressive episode. The most common disorders from which SAD must be differentiated include mood disorders (manic, depressive, or mixed type) and schizophrenia.
Epidemiology and risk factors: the lifetime prevalence of SAD is estimated to be less than 1%, but there are no current studies. This disorder occurs less commonly than doess schizophrenia. The incidence of SAD is relatedly constant across populations in varied geographic, climatic, industrial and social environments. Environmental contributions are minimal.
Patients with SAD are at risk for suicide. The risk for suicide in patients with psychosis is increased by the presence of depression. Risk factors for suicide increase with the use of alcohol or substances, cigarettes, previous suicide attempts and hospitalizations.
Lack of regular social contact may be a factor that confers a long-term risk for suicidal behavior, which may be reduced by treatments designed to enhance social networks and contact and help patients to protect themselves against environmental stressors.

Question 19

Tardive Dyskinesia

Answer 19

Tardive dyskinesia is late appearing abnormal involuntary movements (dyskinesia). It can be viewed as the opposite of Parkinsonism both in observable movements and in etiology. Whereas muscle rigidity and absence of movement characterize Parkinsonism, constant movement characterizes tardive dyskinesia. Typical movements involve the mouth, tongue, and jaw and include lip smacking, sucking, puckering, tongue protrusion, the bonbon sign (where the tongue rolls around in the mouth and protrudes into the cheek as if the patient were sucking on a piece of hard candy), athetoid (work-like) movements in the tongue and chewing. Other facial movements, such as grimacing and eye blinking, also may be present.
Movements in the trunk and limbs are frequently observable. These include rocking from the hips, athetoid movements of the fingers and toes, jerking movements of the fingers and toes, guitar strumming movements of the fingers and foot tapping. The long-term health problems for people with tardive dyskinesia are choking associated with loss of control of muscles used for swallowing and compromised respiratory alkalosis.
Because the movements resemble the dyskinetic movements of some patients who have idiopathic Parkinson’s disease and who have received long-term treatment with l-DOPA (a direct acting dopamine agonist that crosses the blood brain barrier), the suggested hypothesis for tardive dyskinesia includes the supersensitivity of the dopamine receptors in the basal ganglia.
There is no consistently effective treatment; however, antipsychotic drugs mask the movements of tardive dyskinesia and have periodically been suggested as a treatment. This is counterintuitive because these are the drugs that case the disorder. Second-generation antipsychotic drugs, such as clozapine, may be less likely to cause the disorder. The best management remains prevention through using the lowest possible dose of antipsychotic drug over time that minimizes the symptoms of schizophrenia.
- Tardive dyskinesia, the most well-known of the chronic syndromes, involves irregular, repetitive involuntary movements of the mouth, face, and tongue, including chewing, tongue protrusion, lip smacking, puckering of the lips, and rapid eye blinking. Abnormal finger movements are common as well. In some individuals, the trunk and extremities are also involved, and in rare cases, irregular breathing and swallowing lead to belching and grunting noises. These symptoms usually begin no earlier than after 6 months of treatment or when the medication is reduced or withdrawn. Once through to be irreversible, considerable controversy now exists as to whether that is true.
Part of the difficulty in determining the irreversibility of tardive dyskinesia is that any movement disorder that persists after discontinuation of antipsychotic medication has been described as tardive dyskinesia. Atypical forms are now receiving more attention because some researchers believe that may have different underlying mechanisms of causation. Some of these forms of the disorder appear to remit spontaneously. Symptoms of what is now called withdrawal tardive dyskinesia appear when use of an antipsychotic medication is reduced or discontinued and remit spontaneously in 1-3 months. Tardive dystonia and tardive akathisia have also been described. Both appear in a manner similar to the acute syndromes but continue after the antipsychotic medication has been withdrawn. More research is needed to determine whether these syndromes are distinctly different in origin and outcome.
The risk for experiencing tardive dyskinesia increases with age. Although the prevalence of tardive dyskinesia averages 15%-20%, the rate rises to 50% to 70% in older patients receiving antipsychotic medications; in addition, cumulative incidence of tardive dyskinesia appears to increase 5% per year of continued exposure to antipsychotic medications. Women are at higher risk than men. Anyone receiving antipsychotic medication can develop tardive dyskinesia. Risk factors are summarized in the box. The cause of tardive dyskinesia remain unclear. No one medication relieves the symptoms. Dopamine agonists, such as bromocriptine, and many other drugs have been tried with little success. Dietary precursors of acetylcholine, such as lecithin and vitamin E supplements, may prove to be beneficial.
Risk factors for tardive dyskinesia
• Age older than 50 years
• Female
• Affective disorders, particularly depression
• Brain damage or dysfunction
• Increased duration of treatment
• Standard antipsychotic medication
• Possible-higher doses of antipsychotic medication

The best approach to treatment remains avoiding the development of the chronic syndromes. Preventative measures include use of atypical antipsychotics, using the lowest possible dose of typical medication, minimizing use of PRN medication, and closely monitoring ind in high risk groups for development of the symptoms of tardive dyskinesia. All members of the mental health treatment team who have contact with ind taking antipsychotics for longer than 3 months must be alert to the risk factors and earliest possible signs of chronic medication-related movement disorders. 
Monitoring tools, such as the Abnormal Involuntary Movement Scale (AIMS) should be routinely used to standardize assessment and provide the earliest possible recognition of the symptoms. Standardized assessments should be performed at a minimum of 3-6 month intervals. The earlier the symptoms are recognized, the more likely they will resolve if the medication can be changed or its use discontinued. Newer atypical antipsychotic medications have a much lower risk of causing tardive dyskinesia and are increasingly being considered first line medications for treating patients with schizophrenia. Other medications are under development to provide alternatives that limit the risk for tardive dyskinesia.

Question 20

Study transference and countertransference

Answer 20

Transference is the displacement of thoughts, feelings, and behaviors originally associated with significant others from childhood onto a person in a current therapeutic relationship. For example, a woman’s feelings toward her parents as a child may be directed toward the therapist. If a woman were unconsciously angry with her parents, she may feel unexplainable anger and hostility toward her therapist. In psychoanalysis, the therapist uses transference as a therapeutic tool to help the patient understand emotional problems and their origin.
Countertransference, on the other hand, is defined as the direction of all of the therapist’s feelings and attitudes toward the patient. Countertransference becomes a problem when these feelings and perceptions are based on other interpersonal experiences. For example, a patient may remind a nurse of a beloved grandmother. Instead of therapeutically interacting with the patient from an objective perspective, the nurse feels an unexplained attachment to her and treat the patient as if she were the nurse’s grandmother. The nurse misses important assessment and intervention data.

Question 21

18) Study examples of confused speech and thinking patterns

Answer 21

• The following are examples of confused speech and thinking patterns:
  Echolalia: repetition of another’s words that is parrot-like and inappropriate
  Circumstantiality: extremely detailed and lengthy discourse about a topic
  Loose associations: absence of the normal connectedness of thoughts, ideas and topics: sudden shifts without apparent relationship to preceding topics
  Tangentiality: the topic of conversation is changed to an entirely different topic that is a logical progression but causes a permanent detour from the original focus
  Flight of ideas: the topic of conversation changes repeatedly and rapidly, generally after just one sentence of phrase
  Word salad: string of words that are not connected in any way
  Neologisms: words that are made up that have no common meaning and are not recognized
  Paranoia: suspiciousness and guardedness that are unrealistic and often accompanied by grandiosity
  Referential thinking: belief that neutral stimuli have special meaning to the ind such as the tv commentator speaking directly to the ind
  Autistic thinking: restricts thinking to the literal and immediate so that the ind has private rules of logic and reasoning that make no sense to anyone else
  Concrete thinking: lack of abstraction in thinking; inability to understand punch lines, metaphors, and analogies
  Verbigeration: purposeless repetition of words or phrases
  Metonymic speech: use of words interchangeably with similar meanings
  Clang association: repetition of words or phrases that are similar in sound bit in no other way, for example, right, light, sight, might
  Stilted language: overly and inappropriately artificial formal language
  Pressured speech: speaking as if the words are being forced out

Question 22

19) Review Evidence-Based Practice and Current Psychiatric Nursing

Answer 22

As research advanced health care, scientific findings provided a basis for mental health care. EBP became the standard of care in psych nursing and MH care. In MH, the most relevant evidence is ideally from research or EBP theories but other evidence such as expert opinion, patient data and clinical experiences are also used.
In most EBP approach, clinical questions are defined, evidence is discovered and analyzed, the research findings are applied in a practical manner and in collaboration with the patient and outcomes are evaluated. This approach requires using competent literature search skills followed by careful reading and critiquing of the studies. The MH care team collaborates with the patient in deciding the best treatment which is based on patient preferences and values.
Application of new research findings and updating clinical practice can be difficult for seasoned clinicians who may be reluctant to try a new approach. Changing behavior is difficult even for psychiatric clinicians. Education, time and support are needed as new approaches are introduced.
Over the past century, psychiatric nursing practice expanded from the hosp to the community and is now viewed as a core MH discipline. Today in the US, many master degree programs offer specializations in psych/MH as a NP and a clinical nurse specialist. Psychiatric nurses sit on corporate boards; serve in the armed forces; lead major health care initiatives; teach in major universities and care for young and old people, families and disadvantaged and homeless ind. Psych nursing is truly a versatile and rewarding field of nursing practice.

Question 23

Study Disordered Water Balance

Answer 23

Patients with schizophrenia, particularly of early onset, may experience disordered water balance. The prevalence rate of disordered water balance reportedly ranges around 5%-20%. Often a benign condition, disordered water balance may go undetected for months to years; however ingesting large amounts of water over a prolonged period may lead to complications, such as renal dysfunction, urinary incontinence, cardiac failure, malnutrition, or permanent brain damage.
Disordered water balance can progress to water intoxication for a few, but notable number, of ind. This is a life threatening complication of unknown cause when a patient ingests an unusually large volume of water, the kidneys’ capacity to excrete water is overwhelmed, serum sodium levels rapidly fall below the normal range of 135-145 mEq/L to a level of 120 or less, and the rapid decrease in sodium produces neurologic signs such as muscle twitching and irritability putting the patient at risk for seizures or coma or possibly death.
Physiologic signs and symptoms of disordered water balance
Mild disordered water balance
• Increased diurnal weight gain
• Specific urine gravity (1.011-1.025)
• Normal serum sodium (135-145)
Moderate disordered water balance
• Increased diurnal weight gain
• Specific urine gravity (1.010-1.003)
• Possible facial puffiness
• Periodic nocturia
Severe disordered water balance
• Possible evidence of stomach or bladder dilation
• Specific urine gravity (1.003-1.000)
• Frequent signs of N&V
• Possible history of major motor seizure
• Possible change in blood pressure or pulse
• polyuria
• polydipsia
• urinary incontinence during the night
Behaviorally, these patients seem to be “driven to drink” (polydipsia) and may consume between 4-10 liters of fluid a day. They carry soda cans and water bottles with them, hoard cups or other water containers and drink frequently from fountains and showers and sometimes from toilets. They make frequent trips to the bathroom because of the excessive need to urinate (polyuria). Generally, the amount of urine excrete reflects the amount of fluid ingested. The patient’s urine becomes very dilute with a very low specific gravity (1.008 or less). Because of increased urgency and incontinence, especially at night time, the patient’s clothing and room may smell like urine. Some patients may become highly agitated when efforts are made to limit access to water and other fluids. Other emotional or behavioral responses, such as increased psychotic symptoms, irritability, and lability, are caused by changes in sodium levels and the rapidity with which they occur.

Question 24

Study Extrapyramidal Side Effects

Answer 24

Parkinsonism that is caused by antipsychotic drugs is identical in appearance to Parkinson’s disease and tends to occur in older patients. The symptoms are believe to be caused by the blockade of D2 receptors in the basal ganglia, which throws off the normal balance between acetylcholine and dopamine in this area of the brain and effectively increases acetylcholine transmission.
The symptoms are managed by reestablishing the balance between acetylcholine and dopamine by either reducing the dosage of the antipsychotic (thereby increasing the dopamine activity) or adding an anticholinergic drug (decreasing acetylcholine activity) such as benztropine (Cogentin) or trihexphenidyl.
Abrupt discontinuation of anticholinergic drugs can cause a cholinergic rebound and result in withdrawal symptoms such as vomiting excessive sweating and altered dreams and nightmares. This, the anticholinergic drug dosage should be reduced gradually (tapered) over several days. If a patient experience akathisia (physical restlessness), an anticholinergic medication may not be particularly helpful. Table lists anticholinergic side effects of antiparkinson drugs and several antipsychotic meds and interventions to manage them.
Nurs interventions for Anticholinergic side effects
Dry mouth Provide sips of water, hard candies, and chew gum- preferably sugar free
Blurred vision Avoid dangerous tasks; teach pt that this side effect with diminish in a few weeks
Decreased lacrimation Use artificial tears if necessary
Mydriasis May aggravate glaucoma; teach pt to report eye pain
Photophobia Wear sunglasses
Constipation High-fiber diet, increased fluid intake, laxatives as prescribed
Urinary hesitancy Privacy, run water in sink, warm water over perineum
Urinary retention Regular voiding (at least Q2-3 hrs), and whenever urge is present; catheterize for residual; record I&O; evaluate for benign prostatic hypertrophy
tachycardia Evaluate for preexisting CV disease; sudden death has occurred with thioridazine (Mellaril)
Dystonic reactions are also believed to result from the imbalance of dopamine and acetylcholine, with the latter dominant. Young men seem to be more vulnerable to this particular extrapyramidal side effect. This side effect, which develops rapidly and dramatically, can be very frightening for patients as their muscles tense and their body contorts. The experience often starts with oculogyric crisis, in which the muscles that control eye movements tense and pull the eyeball so that the patient is looking forward the ceiling. This may be followed rapidly by torticollis, in which the head is pulled back or orolaryngeal-pharyngeal hypertonus, in which the patient has extreme difficulty swallowing. The patient may also experience contorted extremities. These symptoms occur early in antipsychotic drug treatment, when the patient may still be experiencing psychotic symptoms. This compounds the patient’s fear and anxiety and requires a quick response. The immediate treatment is to administer benztropine (Cogentin) 1-2 mg, or diphenhydramine (Benadryl), 25-50 mg IM or IV. This is followed by daily admin anticholinergic drugs and possibly by a decrease in antipsychotic meds. Read about Cogentin on pg 357.
Akathisia effects appears to be caused by the same biologic mechanism as other extrapyramidal side effects. Patients are restless and report they feel driven to keep moving. They are very uncomfortable. Freq, this response is misinterpreted as anxiety or increased psychotic symptoms and the patient may be inappropriately given increased dosage of antipsychotic drug, which only perpetuate side effect. If possible, the dose of antipsychotic drug should be reduced. A beta-adrenergic blocker such as propranolol (Inderal) 20-120 mg may be required. Failure to manage this side effect is a leading cause of patients ceasing to take antipsychotic medications. Tardive dyskinesia….

Question 25

Voluntary and Involuntary Commitment

Answer 25

Accessing the mental health delivery system is similar to seeking another type of health care. Whether in a public or private system, the treatment setting is usually outpatient. Treatment strategies (i.g. meds, psychotherapy) are recommended and agreed on by both the provider and the ind. Arrangements for treatment follow up are then made. The patient leaves the outpatient setting and is responsible for following the plan.
Inpatient treatment is generally reserve for patients who are acutely ill or have a forensic commitment. If hosp is required, the person enters the treatment facility, participates in the treatment planning process and follow through with the treatment. The ind maintains all civil rights and is free to leave at any time even if it is against medical advice. In most settings, this type of admission is called a voluntary admission. If an ind is admitted to a public facility, the state statute may refer to the process as voluntary commitment rather than admission; however, in both instances, full legal rights are retained.
Involuntary commitment is the confined hosp of a person without the person’s consent but with a court order. There are also legal provisions for people to involuntarily committed to outpatient mental health facilities through state civil laws. Because involuntary commitment is a prerogative of the state agency, each state and DC have separate commitment statutes; however three common elements are found in most of these statues. The ind must be (1) mentally disordered, (2) dangerous to self or others or (3) unable to provide for basic needs.
Patients who are involuntarily committed have the right to receive treatment but they also may have the right to refuse it. Arguments over the rights of civilly committed patients to refuse treatment first surfaced in 1975 when a federal district court judge issued a temporary restraining order prohibiting the use of psychotropic medication against the patient’s wo;; at a state hosp in Boston. Today, laws about commitment and refusal of medication vary from state to state. Many states recognize the rights of involuntarily committed patients to refuse meds. The state trend is to grant patients the right to refuse treatment whether they are competent or incompetent.
Commitment procedures vary considerably among the states. Most have provisions for an emergency short term hosp of 38-92 hours authorized by a certified mental health provider without court approval. At the end of that period, the ind either agrees to voluntary treatment or extended commitment procedures are begun. The judge must order the commitment, and the ind is afforded several legal rights, including notice of the proceedings, a full hearing (jury trial if requested) in which the government must prove the grounds for commitment and the right to legal counsel at state expense.

Question 26

medication Lithium

Answer 26

Lithium, a naturally occurring element, is effective in only about 40% of patients with bipolar disorder. Although lithium is not a perfect drug, a great deal is known regarding its use- its inexpensive, it has restored stability to the lives of thousands of people and it remains the gold standard of bipolar pharmacologic treatment.
Indications and Mech of Action: Lithium is indicated for symptoms of mania characterized by rapid speech, flight of ideas (jumping from topic to topic), irritability, grandiose thinking, impulsiveness and agitation. Because it has mild antidepressant effects, lithium is used in treating depressive episodes of bipolar illness. It is also used as augmentation in patients experiencing major depression that has only partially responded to antidepressants alone. Lithium also has been shown to be helpful in reducing impulsivity and aggression in certain psychiatric patients.
The exact action by which lithium improves the symptoms of mania is unknown, but it is thought to exert multiple neurotransmitter effects, including enhancing serotonergic transmission, increasing synthesis of norepinephrine, and blocking postsynaptic dopamine. Lithium is actively transported across cell membranes, altering sodium transport in both nerve and muscle cells. It replaces sodium in the sodium-potassium pump and is retained more readily than sodium inside the cells. Conditions that alter sodium content in the body, such as vomiting, diuresis and diaphoresis, also alter lithium retention. The results of lithium influx into the nerve cell lead to increased storage of catecholamines within the cell, reduced dopamine neurotransmission, increased norepinephrine reuptake, increased GABA activity, and increased serotonin receptor sensitivity. Lithium also alters the distribution of calcium and magnesium ions and inhibits second messenger systems within the neuron. Most likely, the mechanism by which lithium improves the symptoms of mania are complex, involving the sum of all or part of these actions and more. Molecular research in the next decade may provide the answers.
Pharmacokinetics: Lithium carbonate is available orally in capsule, tablet and liquid forms. Slow-release preparations are also available. Lithium is readily absorbed in the gastric system and may be taken with food, which does not impair absorption. Peak blood levels are reached in 1-4 ours, and the med is usually completely absorbed in 8 hours. Slow-release preparations are absorbed at a slower, more variable rate.
Lithium is not protein bound and its distribution into the CNS across the blood-brain barrier is slow. The onset of action is usually 5-7 days and may take as long as 2 weeks. The elimination half-life is 8-12 hours and is 18-36 hours in ind whose blood levels have reached steady state and whose symptoms are stable. Lithium is almost entirely excrete by the kidneys but is present in all body fluids. Conditions of renal impairment or decreased renal function in older patients decrease lithium clearance and may lead to toxicity. Several medications affect renal function and therefore change lithium clearance, About 80% of lithium is reabsorbed in the proximal tubule of the kidney along with water and sodium. In conditions that cause sodium depletion, such as dehydration caused by fever, strenuous exercise, hot weather, increased perspiration and vomiting, the kidneys attempts to conserve sodium. Because lithium is a salt, the kidneys retain lithium as well, leading to increased blood levels and potential toxicity. Significantly increasing sodium intake causes lithium levels to fall.
Lithium is usually administered in doses of 300 mg two to three times daily. Because it is a drug with a narrow therapeutic range or index, blood levels are monitored freq during acute mania and the dosage is increased every 3-5 days. These increases may be slower in older adult patients or patients who experience uncomfortable side effects. Blood levels should be monitored 12 hours after the last dose of medication. In the hosp setting, nurses should withhold the morning dose of lithium until the serum sample is drawn to avoid falsely elevated levels. Ind who are at home should be instructed to have their blood drawn in the morning about 12 hours after their last dose and before they take their first dose of medication. During the acute phases of mania, blood levels of 0.8 to 1.4 mEq/L are usually attained and maintained until symptoms are under control. The therapeutic range for lithium is narrow and patients in the higher end of that range usually experience more uncomfortable side effects. During maintenance, the dosage is reduced and dosages are adjusted to maintain blood levels of 0.4-1 mEq/L.
Lithium clears the body relatively quickly after discontinuation of its use. Withdrawal symptoms are rare, but occasional anxiety and emotional lability have been reported. It is important o remember that almost half the ind who discontinue lithium treatment abruptly experience a relapse of symptoms within a few weeks. Some research suggests that discontinuation of the use of lithium for ind who symptoms have stable may lead to lithium’s losing its effectiveness when use of the medication is restarted. Patients should e warned of the risks in abruptly discontinuing their medications and should be advised to consider the options carefully in consultation with their prescriber.
Side effects, adverse reactions and toxicity: At lower therapeutic levels, side effects from lithium are relatively mild. These reactions correspond with peaks in plasma concentrations of the medication after admin and most subside during the first few weeks of therapy. Freq, ind taking lithium complain of excessive thirst and an unpleasant metallic-like taste. Sugarless throat lozenges may be useful in minimizing this side effect. Other common side effects include increased freq of urination, fine head tremor, drowsiness and mild diarrhea. Weight gain occurs in about 20% of ind taking lithium. Nausea may be minimized by taking the med with food or by use of a slow-release preparation. However, slow-release forms of lithium increase diarrhea. Muscle weakness, restlessness, headache, acne, rashes, and exacerbation of psoriasis have also been reported. Patients most freq discontinued their own medication use because of concerns with mental slowness, poor concentration and memory problems.
As blood levels of lithium increase, the side effects of lithium become more numerous and severe. Early signs of lithium toxicity include severe diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination. Lithium should be withheld and the prescriber consulted if these symptoms develop. Lithium toxicity can easily be resolved in 24-48 hours b discontinuing the med but hemodialysis may be required in severe situations.
Monitoring of creatinine concentration, thyroid hormones and CBC every 6 months during maintenance therapy helps to assess the occurrence of other potential adverse reactions. Kidney damage is considered an uncommon but potentially serious risk of long term lithium treatment. This damage is usually reversible after discontinuation of the lithium use. A gradual rise in serum creatinine and decline in creatinine clearance indicate the development of renal dysfunction. Ind with preexisting kidney dysfunction are susceptible to lithium toxicity.
Lithium may alter thyroid function, usually after 6-18 months of treatment. About 30% of ind taking lithium exhibit elevations in thyroid stimulating hormone (TSH) but most do not show suppression of circulating thyroid hormone. Thyroid dysfunction from lithium treatment is more common in women and some ind require the addition of thyroxine to their care. During maintenance, TSH levels may be monitored. Nurses should observe for dry skin, constipation bradycardia hair loss cold intolerance and other symptoms of hypothyroidism. Other endocrine system effects result from hyperparathyroidism, which increased parathyroid hormone levels and calcium. Clinically this change is not significant but elevated calcium levels may cause mood changes anxiety lethargy and sleep disturbance. These symptoms may erroneously be attributed to depression if hypercalcemia is not investigated.
Lithium use must be avoided during pregnancy because it has been associated with birth defects, especially when administered during the first trimester. If lithium is given during the third trimester, toxicity may develop in a newborn producing signs of hypotonia, cyanosis, bradykinesia, cardiac changes, GI bleeding and shock. Diabetes insipidus may persist for months. Lithium is also present in breast milk and women should not breastfeed while taking lithium. Women expecting to become pregnant should be advised to consult with a MD before discontinuing use of birth control methods.

Question 27

Review variation in drug effects related to age

Answer 27

Pharmacokinetics are significantly altered at the extremes of the life cycle. Gastric absorption changes as ind age. Gastric pH increases and gastric emptying decreases. Gastric motility slows and splanchnic circulation is reduced. Normally, these changes do not significantly impair oral absorption of a medication, but addition of common conditions, such as diarrhea, may significantly alter and reduce absorption. Malnutrition, cancer and liver disease decrease the production of the primary protein albumin. More free drug is acting in the system, producing higher blood levels of the med and potentially toxic effects. The activity of hepatic enzymes also slows with age. As a result, the ability of the liver to metabolize meds may slow as much as a fourfold decrease between the ages of 20-70 years. Production of albumin by the liver generally declines with age. Changes in the parasympathetic nervous system produce a greater sensitivity in older adults to anticholinergic side effects, which are more severe with this age group.
Renal function also declines with age. Creatinine clearance in a young adult is normally 100-120 mL/min. but after age 40, this rate declines by about 10% per decade. Medical illnesses such as diabetes and hypertension may further the loss of renal function. When creatinine clearance falls below 30 mL/min the excretion of drugs by the kidneys is significantly impaired and potentially toxic levels may accumulate.

Question 28

Dopamine Dysregulation

Answer 28

Positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be caused by dopamine hyperactivity in the mesolimbic tract at the D2 receptor site in the striatal area where memory and emotion are regulated. Dopamine dysfunction is thought to be involved not only in schizophrenia, but also in psychosis in other disorders. If there is no psychosis, it is unlikely that there is an overactivity of dopamine in the striatal region.
On the other hand, chronic low levels of dopamine in the prefrontal cortex are thought to underlie cognitive dysfunction in schizophrenia. Cognitive and negative symptoms of schizophrenia, once thought to be related to dopamine dysfunction on a single pathway, are now thought to be associated with transmitter or neural systems. In many cases, these dysfunctions precede the onset of psychosis.

Question 29

Schizophreniform Disorder

Answer 29

The essential features of schizophreniform disorder are identical to those of criteria A for schizophrenia, with the exception of the duration of the illness, which can be less than 6 months. Symptoms must be present for at least 1 month to be classified as a schizophreniform disorder. Some research has suggested that this illness may be an early manifestation of schizophrenia.
Altered social or occupational functioning may occur bit it’s not necessary. Most patients experience interruption in one or more areas of daily functioning.

Question 30

27) Review Acetylcholine

Answer 30

Acetylcholine (ACh) is the primary cholinergic neurotransmitter. Found in the greatest concentration in the PNS, Ach provides the basic synaptic communication for the parasympathetic neurons and part of the sympathetic neurons, which sends information to the CNS.
Ach is an excitatory neurotransmitter and is found throughout the cerebral cortex and limbic system, arising primarily from cell bodies in the basal forebrain constellation, which provides innervations to the cerebral cortex, amygdala, hippocampus, and thalamus and from the dorsolateral tegmentum of the pons that projects to the basal ganglia, thalamus, hypothalamus, medullary reticular formation and deep cerebellar nuclei. These connections suggest that Ach is involved in higher intellectual functioning and memory. Ind who have Alzheimer’s disease or down syndrome, often exhibit patterns of cholinergic neuron loss in regions innervated by these pathways (e.g hippocampus), which may contribute to their memory difficulties and other genitive deficits. Some cholinergic neurons are afferent to these areas bringing information from the limbic system, highlighting the role that Ach plays in communicating ones emotional state to the cerebral cortex.

Question 31

28) Understand the Autonomic Nervous System-Fight or Flight Response

Answer 31

The concept of homeostasis, which is the body’s tendency to resist physiological change and hold bodily functions relatively consistent, well-coordinated and usually stable, was introduced by Walter Cannon in the 1930s. The body’s internal equilibrium is regulated by physiological processes such as blood glucose, pH and oxygen. Set points (normal reference ranges of physiological parameters) are maintained.
When the brain (amygdala and hippocampus) interprets an even as a threat, the hypothalamus and autonomic nervous system are signaled to secrete adrenaline, cortisol and epinephrine. These hormones activate the sympathetic nervous system, physiological stability is challenged and a “fight or flight” response occurs. Hear rate, blood pressure and blood sugar increase. Energy is mobilized for survival. As the sympathetic system is activated the parasympathetic is muted. After there is no longer a need for more energy and the threat is over, the body returns to a state of homeostasis.

Question 32

29) Study cultural and Linguistic competency

Answer 32

Psych-MH nurses have an obligation to be culturally and linguistically competent to proide quality care. All persons and organizations function within a culture and racially and ethnically diverse groups are less likely to receive mental health services and more likely to receive poorer quality care. There are several definitions of cultural or linguistic competence, but there is a general consensus that cultural and linguistic competence involves an adjustment or recognition of one’s own culture in order to understand the culture of the patient. Linguistic competence, the capacity to communicate effectively and convey information that is easily understood by diverse audiences, is an important part of cultural competence.
Cultural competence is demonstrated in several way. Valuing patient’s culture beliefs and recognizing the need to bridge language barriers are essential behaviors. There are linguistic variations within a cultural group. Speaking the same language does not guarantee shared meaning and understanding. Communication may be adversely affected when patients are unable to fully express themselves in English. Understanding the impact of literacy levels is integral to providing culturally competent care. Demonstrating an understanding the literacy levels contribute to the interpretation of personal, psychological experiences is critical.

Question 33

Review principles of therapeutic communication

Answer 33

Principles of therapeutic communication
• The patient should be the primary focus of the interaction
• A professional attitude sets the tone of the therapeutic relationship
• Use self-disclosure cautiously and only when the disclosure has a therapeutic purpose
• Avoid social relationships with patients
• Maintain patients confidentiality
• Assess the patients intellectual competence to determine the level of understanding
• Implement interventions from a theoretic base
• Maintain a nonjudgmental attitude. Avoid making judgments about the patients behavior
• Avoid giving advice. By the time the patient sees the nurse, he or she has had plenty of advice.
• Guide the patient to reinterpret his or her experiences rationally
• Track the patients verbal interaction through the use of clarifying statements
• Avoid changing the subject unless the content change is in the patient’s best interest

Question 34

31) Study Clozaril

Answer 34

Clozapine (Clozaril)
Drug class: atypical antipsychotic

Receptor affinity: D1 and D2 blockade, antagonist for 5-HT2, histamine (H1) alpha-adrenergic, and acetylcholine. These additional antagonist effects may contribute to some of its therapeutic effects. Produces fewer extrapyramidal effects than standard antipsychotics with lower risk for tardive dyskinesia.

Indications: severely ill ind who have schizophrenia and have no responded to standard antipsychotic treatment; reduction in risk of recurrent suicidal behavior in schizophrenia or schizoaffective disorders

Routes and dosage: available only in tablet form 25-100 mg doses
Adult dosage: initial dose 25 mg PO bid or qid, may gradually increase in 25-50 mg/d increments, if tolerated, to a dose of 300-450 mg/d by the end of the second week. Additional increases should occur no more than once or twice weekly. Do not exceed 900 mg/d. For maintenance, reduce dosage to lowest effective level.
Children: safety and efficacy with children younger than age 16 years have not been established

Half-life (peak effect): 12 h (1-6 h)

Select adverse reactions: drowsiness, dizziness, headache, hypersalivation, tachycardia, hypo or hyper tension, constipation, dry mouth, heartburn, nausea or vomiting, blurred vision, diaphoresis, fever, weight gain, hematologic changes, seizures, tremor, akathisia

Boxed warning: agranulocytosis, defined as a granulocyte count of <500 mm3 occurs at about a cumulative 1 year incidence of 1.3%, most often within 4-10 weeks of exposure but may occur at any time. WBC count before initiation and weekly WBC counts while taking the drug and for 4 weeks after discontinuation. Seizures, myocarditis and other adverse CV and respiratory effects (orthostatic hypotension)

WARNING: increased mortality in elderly patients with dementia related psychosis: rare development of NMS; hyperglycemia and diabetes, tardive dyskinesia, cases of sudden unexplained death have been reported: avoid use during pregnancy and while breastfeeding.

Precautions: fever, pulmonary embolism, hepatitis, anticholinergic toxicity and interference with cognitive and motor functions

Specific patient/family education
• Need informed consent regarding risk for agranulocytosis. Weekly or biweekly blood draws are required. Notify your MD immediately if lethargy, weakness, sore throat, malaise or other flu-like symptoms develop.
• You should not take Clozaril if you are taking other medicines that cause the same serious bone marrow side effects
• Inform the patient of risk of seizures, hyperglycemia and diabetes, and orthostatic hypotension. It may potentiate the hypotensive effects of antihypertensive drugs and anticholinergic effects of atropine-type drugs.
• Administration of epinephrine should be avoided in the treatment of drug-induced hypotension.
• Notify your MD if pregnancy is possible or planning to become pregnant. Do not breastfeed while taking this med.
• May cause drowsiness and seizures; avoid driving or other hazardous tasks
• During titration, the ind may experience orthostatic hypotension and should change positions slowly
• Do not abruptly discontinue.

Question 35

Review Agranulocytosis

Answer 35

Agranulocytosis is a reduction in the number of circulating granulocytes and decreased production of granulocytes in the bone marrow that limits one’s ability to fight infection. Agranulocytosis can develop with the use of all antipsychotic drugs, but it is most likely to develop with clozapine use. Although lab values below 500 cells/mm3 are indicative of agranulocytosis, often granulocyte counts drop to below 200 with this syndrome.
Patients taking clozapine should have regular blood tests. WBC and granulocyte counts should be measured before treatment is initiated and at least weekly or twice weekly after treatment begins. Initial WBC counts should be above 3,500 before treatment initiation; in patients with counts of 3,500-5,000, cell counts should be monitored three times a week if clozapine is prescribed. Any time the WBC count drops below 3,500 or granulocytes drop below 1,500, use of clozapine should be stopped and the patient should be monitored for infection.
However, a faithfully implemented program of blood monitoring should not replace careful observation of the patient. It is not unusual for blood cell counts to drop precipitously in a period of 2-3 days. This may not be discovered when the patient is on a strict weekly blood monitoring schedule. Any reported symptoms that are suggestive of a bacterial infection (fever, pharyngitis and weakness) should be cause for concern and immediate eval of blood count status should be undertaken. Because patients are freq discharged before the critical period of risk for agranulocytosis, patient education about these symptoms is also essential so that they will report these symptoms and obtain blood monitoring. In general, granulocytes return to normal within 2 weeks to 4 weeks after discontinuation of use of the medication.

Question 36

Review Psychosocial Theories

Answer 36

There are no accepted psychosocial theories that explain the cause of schizophrenia. However, social stressors cannot be ignored because they can contribute to the changes in brain function that result in schizophrenia and add to the day-to-day challenges of living with a mental illness. They can also create barriers to obtaining necessary treatment and recovery.
One of the major social stressors is the social stigma that surrounds mental illnesses. The clinical vignette describes the impact of living with a stigmatizing illness. Another is the absence of good, affordable, and supportive housing in many communities. With 2010’s enactment of insurance parity for mental illness, it is hoped that quality and continuity of care will be enhanced. Finally, the mental health service delivery system is fragmented and the quality and types of services vary from community to community.

Question 37

Review Delusional Disorder: Clinical Course and Diagnostic Criteria

Answer 37

-Delusional disorder is a psychotic disorder characterized by nonbizarre, logical, stable and well-systematized delusions that occur in the absence of other psychiatric disorders. Delusions are false, fixed beliefs unchanged by reasonable arguments. Nonbizarre delusions are characterized by adherence to possible situations that could occur in real life and are plausible in the context of the person’s ethic and cultural background.
Examples of real life situations include being followed, poisoned, infected, loved at a distance or deceived by a spouse or lover. A diagnosis of delusional disorder is based on the presence of one or more nonbizarre delusion for at least 1 month. Delusions are the primary symptom of this disorder.
Clinical Course: the course of delusional disorder is variable. The onset can be acute, or the disorder can occur gradually and become chronic. Patients usually live with delusions for years, rarely receiving psychiatric treatment unless their delusion relates to their health (somatic delusion) or they act on the basis of their delusion and violate legal or social rules. Full remissions can be followed by relapses.
Apart from the direct impact of the delusion, psycho-social functioning is not markedly impaired. Behavior is remarkably normal expect when the patient focuses on the delusion. At that time, thinking, attitudes and mood may change abruptly. Personality does not usually change, but the patient is gradually, progressively involved with the delusional concern.
Diagnostic criteria: Delusional disorder is characterized by the presence of nonbizarre delusions and includes several subtypes: erotomanic, grandiose, jealous, somatic, mixed, and unspecified. The subtype represents the prominent theme of the delusion. A patient who has met criteria A for schizophrenia does not receive a diagnosis of delusional disorder. Although hallucinations may be present, they are not prominent.
If mood episodes occur with this disorder, the duration of the mood episode is relatively brief compared with the duration of the delusional period. Delusions are not caused by the direct physiologic effects of substance (i.e. cocaine, marijuana, meth) or a general medical condition (i.e. Alzheimer’s, systemic lupus erythematosus). Delusional disorder is a diagnosis of exclusion requiring careful evaluation. Distinguishing this disorder from schizophrenia and mood disorders with psychotic features is difficult.
The prevalence of delusional disorder is about three per 10,000 in the general population. Research data are limited because numbers of recorded case studies and participants are small and the studies lack systematic description, assessment and diagnosis. Delusional disorder may be associated with dysfunction in the frontal-subcortical systems and with temporal dysfunction, particularly the left side.

Question 38

Review the positive symptoms of Schizophrenia

Answer 38

Delusions are erroneous fixed, false beliefs that cannot be changed by reasonable argument. They usually involve a misinterpretation of experience. For example, the patient believes someone is reading his or her thoughts or plotting against him or her. Various types of delusions include the following:
Grandiose: the belief that one has exceptional powers, wealth, skill, influence or destiny
Nihilistic: the belief that one is dead or a calamity is impending
Persecutory: the belief that one is being watched, ridiculed, harmed or plotted against
Somatic: beliefs about abnormalities in bodily functions or structures

Hallucinations are perceptual experiences that occur without actual external sensory stimuli. They can involve any of the five sense, but they are usually visual or auditory. Auditory hallucinations are more common than visual. For example, the patient hears voices carrying on a discussion about his or her own thoughts or behaviors.

Question 39

Review nursing documentation

Answer 39

Careful documentation is important both to help ensure protection of patient rights and for nurse accountability. Documentation can be handwritten or electronic. It is very common in psychiatric facilities that all disciplines record one progress note. Nursing documentation is based on nursing standards and the policies of the particular facility. Many documentation styles are problem focused. That is, documentation is structured to address specific problems that are identified on the nursing care plan or interdisciplinary treatment plan. No matter the setting or structure of the documentation, nurses are responsible for documenting the following
• Observations of the patients subjective and objective physical, psychological, and social responses to mental disorders and emotional problems
• Interventions implemented and the patient’s response
• Observations of therapeutic and side effects of medications
• Evaluation of outcomes of interventions
Particular attention should be paid to the reason the patient is admitted for care. IF the person’s initial problem was suicide or homicidal ideation, the patient should routinely be assessed for suicidal and homicidal thoughts even if the treatment plan does not specifically identify suicide and homicide as potential problems. Careful documentation is always needed for patients who are suicidal, homicidal, and aggressive or restrained in any way. Medications prescribed on a PRN basis also require a separate entry, including reason for admin, dosage, route and response to med.
A patient record is the primary documentation of a patient’s problems, verified the behavior of the patient at the point of care and describes the care provided. The patient record is considered a legal document. Courts consider acts not recorded as acts not done. Patients also have legal access to their records. For handwritten documentation, the entries should always be written in pen with no erasures. If an entry is corrected, it should be initialed by the person making the correction. All entries should be clear, well written and avoid use of jargon. Judgmental statements, such as “patient is manipulating staff” have no place in patient’s records. Only meaningful, accurate, objective descriptions of behavior should be used. General, stereotypic statements, such as “had a good night” or “no complaints” are meaningless and should be avoided.
With the universal use of electronic records, meaningful documentation is sometimes more difficult. Many institutions require health care workers to enter observations, assessment data and interventions into a template that requires a “click” in a box on the monitor screen. Additional narrative entries are usually required to provide quality individualized care. Nurses are held to the same standards of practice and documentation when entering electronic data as when entering data a non-electronic record.