exam 1 (chapters 1,2,3,4,5,6,7,12) Flashcards
stress
an individual’s reaction to any change that requires an adjustment or response
- can be physical, mental or emotional
healthy adaptions
responses directed at stabilizing internal biological processes and psychological preservation of self-identity
adaptive
behavior that maintains the integrity of the individual (positive)
maladaptive
behavior disrupts the integrity of the individual (negative)
stressor
a biological, psychosocial, social, or chemical factor that causes emotional or physical tension
general adaptation syndrome
“fight or flight”, Hans Selye; 3 stages
1. alarm reaction- fight or flight
2. resistance- uses physiological responses of first stage as a defense in attempt to adapt to the stressor
3. exhaustion- body responds to prolonged exposure to a stressor, adaptive energy is depleted, diseases of adaption may occur
stress as a biological response: hypothalamus stimulates SNS which innervates
adrenal medulla- norepinephrine and epinephrine is released
eye- pupils dilate
respiratory- bronchioles dilate and rr increases
cardiac- increase force of cardiac contraction, cardiac output, heart rate, and BP
GI- decrease motility and secretions sphincters contract
liver- increased glycogenesis and gluconeogenesis, decreased glycogen synthesis
urinary- decreased ureter motility, bladder muscle contracts sphincter relaxes
sweat- increased secretions
fat cells- lipolysis
stress as an environmental event: hypothalamus stimulates pituitary gland which releases:
ACTH- stimulates adrenal cortex which releases glucocorticoids (increases glucogenesis, decreases immune response and inflammatory response) and mineralocorticoids (increases retention of Na and H2O)
vasopressin (ADH)- increases BP through constriction of blood vessels and increases fluid retention
growth hormone- direct effect on protein, carbs, and lipid metabolism, resulting in increase of serum glucose and free fatty acids
thyrotropic hormone (TSH)- stimulates thyroid gland which increases basal metabolic rate
- increased levels of thyroid hormones (decreased secretion of TSH) leads to insomnia, anxiety, emotional lability)
- decreased levels of thyroid hormones (increased secretion of TSH) leads to fatigue and depression
gonadotropins- initially increases sex hormones and later with sustained stress will decrease secretion of sex hormones which leads to decrease libido impotence
stress as an environmental event
defines stress as an EVENT (which creates change in the life pattern of the individual requires significant adjustment) that triggers adaptive physiological and psychological responses
stress measured with RLCQ
high score = greater susceptibility to physical/psychological illness
criticized bc doesn’t consider individual ability to cope
stress as a transaction
transaction between the individual and the environment, emphasizes relationship between internal and external variables
stress as a transaction
precipitating event leads to cognitive appraisal leads to primary response:
irrelevant- no response
benign positive- pleasurable response
stress appraisals: harm/loss, threat, or challenge (lead to secondary response)
consider availability of coping strategies, perceived effectiveness of coping strategies, and perceived ability to use coping strategies effectively
leads to quality of response, either adaptive or maladaptive
precipitating event
stimulus arising from internal or external environment perceived by the individual in a specific manner
cognitive appraisal
individuals evaluation of personal significance of the event
predisposing factors
genetic influences, past experiences, existing conditions
hobfoll’s conservation of resources theory
as existing conditions exceed the person’s perception of adaptive capabilities the individual not only experiences stress in the present but also becomes more vulnerable to the effects of stress in the future
primitive thoughts regarding mental disturbances
mental illness was believed to have been caused by loss of soul, evil spirits, or sin
1st hospital in america with mental patients
18th century Philadelphia
benjamin rush: father of american psychiatry
19th century established system of state asylums
dorothea dix, former new england school teacher
psychiatric nursing began in 1873
graduation of linda richards– nursing program at new england hospital for women and children
historical psychiatric treatments
lobotomy, insulin shock therapy, metrazol therapy, electroconvulsive therapy, tranq chair, hydrotherapy
national mental health act of 1946
provided funds for education of psychiatrists, psychologists, social workers, and psych nurses and grad-level education in psych nursing was established
maslow’s heirarchy of needs
bottom to top: physiological needs, safety and security, love and belonging, self esteem and respect of others, self actualization
6 indicators that are a reflection of mental health
- positive attitude towards self
- growth, development, and the ability to achieve self-actualization
- integration
- autonomy
- perception of reality
- environmental mastery
incomprehensibility
the inability of the general public to understand the motivation behind the behavior
cultural relativity
the “normality” of behavior is determined by culture
anxiety
a feeling of discomfort and apprehension related to fear of impending danger
peplau’s four levels of anxiety
- mild- seldom a problem
- moderate- perceptual field begins to diminish
- severe- perceptual field diminishes greatly
- panic- most intense state
grief
subjective feeling of sorrow and sadness accompanied by emotional, physical, and social responses to the loss of a loved person or thing
hubler-ross’s 5 stages of the grief response
- denial
- anger
- bargaining
- depression
- acceptance
anticipatory grief
experiencing the grief process before the actual loss occurs
bereavement overload
grief is cumulative
maladaptive grief responses
delayed, prolonged, distorted
CNS: the brain
interprets info from the sensory receptors (PNS), effects a response, structurally has 2 hemispheres and 3 divisions: forebrain, midbrain, and hindbrain
forebrain
cerebrum and diencephalon
cerebrum
outer layer = cerebral cortex
largest part of the brain, interprets info received from the midbrain and decides what happens next, each hemisphere contains frontal, parietal, temporal and occipital lobes
frontal lobes
controls voluntary body movement, executive functions such as THINKING, JUDGEMENT, AND EXPRESSION OF FEELINGS
parietal lobes
its primary function is associated with LANGUAGE RECOGNITION; interprets sensory info like touch, pain, and taste
temporal lobes
manages HEARING, SHORT TERM MEMORY, and sense of smell
schizo patients
occipital lobes
focal center for visual reception and interpretation
diencephalon
the relay center for most sensory input from the PNS, direct autonomic, endocrine and motor function control, effects homeostasis, hearing, vision, taste, and touch perception
thalamus, hypothalamus, and limbic system
thalamus
integrates all sensory input except smell prior to being sent to the cortex
hypothalamus
regulates anterior and posterior pituitary gland, CONTROLS AUTONOMIC NERVOUS SYSTEM (ANS is part of PNS), manages APPETITE and body temp, BP, thirst
limbic system
THE EMOTIONAL BRAIN
key components: AMYGDALA AND HIPPOCAMPUS
amygdala takes memories from hippocampus and sends to forebrain to induce emotion
midbrain
structures of major importance are nuclei and fiber tracts, extends from pons to hypothalamus, responsible for integration of VISUAL, AUDITORY, and righting (balance) reflexes
hindbrain
pons, medulla, cerebellum
pons
part of the brainstem, contains centers for respiration, associated with SLEEPING AND DREAMING
medulla
connects the spinal cord and pons, responsible for heart rate, respiration, and reflexes
cerebellum
connects to the brainstem through bundles of fiber tracts, concerned with INVOLUNTARY MOVEMENT, regulates muscle tone, and coordination, maintain posture and equilibrium
nerve tissue
neurons: cell body, axons, and dendrites
classes of neurons:
AFFERENT- periphery to brain
EFFERENT- brain to periphery
interneurons
peripheral nervous system
cranial and spinal nerves
AFFERENT SYSTEM
somatic sensory neurons and visceral sensory neurons
EFFERENT SYSTEM
somatic nervous system and autonomic nervous system
somatic nervous system
somatic motor-voluntary (function)
conducts impulses from CNS to skeletal muscle (structure)
autonomic nervous system
visceral motor- involuntary (function)
conducts impulses from CNS to cardiac muscles, smooth muscles and glands (structure)
sympathetic division- mobilizes body system during activity (fight or flight)
parasympathetic division- conserve energy, promotes “housekeeping” functions during rest, HYPOTHALAMUS (CNS) DIRECTLY REGULATES ANS ACTIONS
synapse
junction between 2 neurons
presynaptic neurons
neurons conducting impulses toward the synapse
postsynaptic neurons
neurons conducting impulses away
neurotransmitters
receptor sites
central to the therapeutic action of many psychotropic medications
cholinergics
at the neuromuscular junctions of the PNS to cause muscle contraction and in the ANS with ROLES IN MEMORY, AROUSAL, AND ATTENTION
ACEYLCHOLINE
- decreased levels can implicate alzheimers
monoamines
modulate wide range of moods (depression, mania, anxiety) as well as thought disorders such as schizophrenia
NOREPINEPHRINE, DOPAMINE, SERATONIN, AND HISTAMINE
dopamine: frontal cortex/limbic system, decreased levels can lead to depression, increased levels (prolactin) lead to mania and schizo
serotonin: decreased levels = depression
histamine: functions include wakefulness
amino acids
make neuron’s dendritic receptor sites either less likely to “fire” (inhibitory) or increase fire likelihood (excitatory)
GABA (inhibitory) and glutamate (excitatory)
GABA ENHANCED BY USE OF ANXIOLYTICS (BENZODIAZEPINES)
GABA- function is the slowdown of body activity, decreased levels can lead to epilepsy
neuropeptides
endorphins and enkephalin = opioid peptides
neuroendocrinology
the study of the interaction between the nervous system and the endocrine system, and the effects of various hormones on cognitive, emotional, and behavioral functioning
circadian rhythm
follow a 24-hour cycle and may influence a variety of regulatory functions, affected to a large degree by the cycles of lightness and darkness
role of circadian rhythm in psychopathology
ASSOCIATION OF DEPRESSION WITH INCREASED SECRETIONS OF MELATONIN DURING DARKNESS HOURS, and symptoms that occur in the premenstrual cycle
L-tryptophan
a serotonin precursor which functions as an effective sedative-hypnotic to induce sleep in clients who have sleep-onset issues
GABA
INHIBITS POSTSYNAPTIC EXCITATION WHICH DISRUPTS THE ELECTRICAL IMPULSE MOVEMENT CAUSING A DECREASE IN BODY ACTIVITY
psychiatric illness in which familial tendencies have been indicated include:
SCHIZOPHRENIA, BIPOLAR DISORDER, MAJOR DEPRESSIVE DISORDER, anorexia nervosa, panic disorder, somatic symptom disorder, antisocial personality disorder and ALCOHOLISM
antidepressants
block reuptake of serotonin and norepinephrine (keep more of these NTs in the synapse)
antipsychotics
work by blocking specific neurotransmitter receptors (dopamine)
benzodiazepines
facilitate the transmission of GABA
psychostimulants
increase the release of norepinephrine, serotonin, and dopamine
peplau’s sub-roles within the nursing role
stranger, resource person, teacher, leader, surrogate, technical expert, and counselor
therapeutic nurse-patient relationship
occur when each views the other as a unique human being, are goal-oriented and directed at learning and growth promotion, and the goals are often achieved through use of the problem-solving model
therapeutic use of self
the ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing intervention
rapport
the is the primary task in relationship development (small talk)
trust
must be earned
respect
believe in the dignity and worth of an individual regardless of their behavior
genuineness
ability to be open, honest, and “real” in interactions with the patient
empathy
understanding from the patient’s pov
transference (clients feelings to nurse)
occurs when the patient unconsciously displaces to the nurse feelings formed toward a person from the past
countertransference (nurse feelings towards client)
the nurse’s behavioral and emotional response to the patient
boundaries
material, social, personal, and professional
concerns regarding professional boundaries
self-disclosure: only if it benefits the client
gift giving
touch
friendship or romantic association
interpersonal communication
a transaction between the sender and the receiver, both persons participate simultaneously
transactional model of communication
both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship
territoriality
the innate tendency to own space
density
the number of people within a given environmental space
distance
the means by which various cultures use space to communicate
intimate space
the closest distance that individuals allow between themselves and others
personal distance
the distance for interactions that are personal in nature such as close conversation with friends
social distance
the distance for conversation with strangers or acquaintances
public distance
the distance for speaking in public or yelling at someone some distance away
active listening SOLER
sit squarely facing the patient
observe an open posture
lean forward toward the patient
establish eye contact
relax
ethhics
a branch of philosophy that deals with distinguishing right from wrong
bioethics
term applied to ethics when they refer to concepts within the scope of medicine, nursing, and allied health
moral behavior
conduct that results from serious critical thinking about how individuals ought to treat others
values
personal beliefs about what is important and desirable
right
a valid, legally recognized claim or entitlement encompassing both freedom from government interference or discriminatory treatment and entitlement to a benefit or service
right to privacy, right to refuse treatment
absolute right
when there is no restriction whatsoever on the individual’s entitlement
legal right
a right on which the society has agreed and formalized into law
utilitarianism
an ethical theory that promotes action based on the end result that produces the most good (happiness) for the most people
ex: a few ppl will have an allergic rxn to the vaccine but more will benefit
Kantianism
suggests that decisions and actions are bound by a sense of duty (not based on outcome)
ex: duty to tell the truth even if it makes someone upset
christian ethics
do unto others as you would have them do unto you
natural laws theory
do good and avoid evil. human knowledge of the difference between good and evil directs decision making
ethical egoism
decisions are based on what is best for the individual making the decision
me me me
autonomy
emphasizes the status of persons as autonomous moral agents whose rights to determine their destinies should always be respected
beneficence
refers to one’s duty to benefit or promote the good of others
nonmalficence
abstaining from negative acts toward another; includes acting carefully to avoid harm
veracity
principle that refers to one’s duty to always be truthful
model for making ethical decisions
assessment, plan, implement, evaluate
nurse practice act
defines the legal parameters of professional and practical nursing (stage legislatures)
civil law
protects the private and property rights of individuals and businesses
criminal law
provides protection from conduct deemed injurious to the public welfare
crisis
a sudden event in one’s life that disturbs homeostasis during which the usual coping mechanisms cannot resolve the problem
characteristics of a crisis
crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology
precipitated by specific, identifiable events, personal by nature, acute (usually resolving in 1-3 months) and not chronic
phases in development of a crisis
1: individual is exposed to a precipitating stressor
2: when previous problem-solving techniques do not relieve the stressor, anxiety increases further
3: all possible resources are called on to resolve the problem and relieve the discomfort
4: if resolution does not occur in previous phases, the tension mounts beyond a further threshold or its burden increases to a breaking point
3 balancing factors
the individual’s perception of the event
the availability of situational support
the availability of adequate coping mechanisms
ATI types of crisis
situational (loss/change experienced everyday: divorce, job change)
maturational (developmental stages: marriage, baby, empty nest, retirement)
adventitious (natural disasters, crimes, community trauma)
crisis intervention
the goal is to at minimum restore individual to previous functioning level and possibly to higher level by enhancing personal growth
phases of crisis intervention (role of the nurse)
- assessment
- planning of therapeutic intervention
- intervention
- evaluation of crisis resolution and anticipatory planning
disaster
a common feature of disasters is that they overwhelm local resources and threaten the function and safety of the community
leave victims with a damaged sense of safety and well-being and varying amounts of emotional trauma
psychotropic medications
“mind-altering”, they do not cure
medications work best with therapy and life style changes
neurotransmitter (pharm)
a chemical that is stored in the axon terminals of the presynaptic neuron
an electrical impulse through the neuron stimulates the release of the neurotransmitter into the synaptic cleft, which, in turn, determines whether another electrical impulse is generated
NTs most commonly affected by psych meds
acetylcholine, norepinephrine, dopamine, serotonin, GABA, glutamate
receptor
molecules situated on the cell membrane tat are binding sites for NTs
big 3 for side effects are “anti-HAM”
antiHistamine = sedation and weight gain
antiAdrenergic = hypotension and dizziness
antiMuscarinic = anticholinergic effects (dry–can’t see, pee, spit, poop)
antianxiety/anxiolytics
(minor tranquilizers) benzodiazepines and buspirone/buspar
benzodiazepines
(clonazepam, diazepam, alprazolam) most common, highly addictive (dont stop abruptly)
work by depressing the CNS and potentiate the effects of inhibitory NT GABA, for short term use only
busprione/buspar
non-benzo med for anxiety, doesn’t depress the CNS, works through multiple mechanisms and is categorized as a selective serotonin subtype 1 A partial agonist
must be taken daily for effectiveness, not prn
benzo safety
short term use only due to risk of tolerance and dependence, don’t stop taking abruptly, boxed warning against combining with opioids or other CNS depressants due to increased risk of death, drowsiness/confusion, orthostatic hypotension, congenital manifestations especially if used in 1st trimester, caution with elderly due to risk of falls, impaired cognition, and paradoxical excitement
antidepressants
also used to treat anxiety, OCD, PTSD, bulimia, migraines, neuropathic pain, etc
work by increasing the concentration of serotonin, dopamine, and/or norepinephrine
MAOI
first “antidepressant” drug, monoamine oxidase inhibitor. very effective but many potentially deadly food and drug interactions
patient must avoid a diet high in tyramines (pickled, smoked, fermented and aged foods) because it can lead to HTN crisis, death
tricyclic antidepressants (TCAs)
next drug developed for depression and were first line for many years. not as effective as MAOIs but less interactions.
increase norepinephrine but are also “anti-HAM) leading to many side effects. also block sodium channels which makes them very deadly in cases of overdose so some providers won’t prescribe more than a week at a time
SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitor)
became the preferred first-line treatment for depression
atypical antidepressants
(such as bupropion, vilazodone, and mirtazapine) have unique MOAs
atypical antipsychotics (for depression)
most recent addition (aripiprazole/Abilify) that increase the availability of serotonin and dopamine and are used as adjuncts to antidepressants
clinical pearls for antidepressants (important)
1) as antidepressant drugs take effect and mood begins to lift, individuals may have increased energy to implement a suicide plan. nurses should be alerted to sudden lifts in mood.
2) all antidepressants carry an FDA black-box warning for increased risk of suicidality in children, adolescents, and young adults up to the age of 25)
always teach patients that antidepressants take up to a month to reach full effect
antidepressant safety
drug/food interactions (especially MAOIs)
BBW increased risk of suicide
discontinuation syndrome
Anti-HAM side effects (especially TCAs)
serotonin syndrome, hyponatremia, increased risk for bleeding, sexual dysfunction, GI upset (SSRIs/SNRIs)
serotonin syndrome
can be deadly, need to immediately stop meds, signs/symptoms: diarrhea, shaking, elevated BP, unstable vitals, will be hospitalized until symptoms stop
mood stabilizing agents
for years, drug of choice for bipolar mania was lithium carbonate (doesn’t work for bipolar depression)
drugs in the class of anticonvulsants are now approved
antipsychotics (2nd gen atypical)
lithium
a salt found in mineral springs, takes 7-10 days to reach full effect; it competes with sodium for receptor sites so anything that depletes sodium will make more receptor sites available and increase the risk for lithium toxicity
if sodium and water increase, lithium levels go down and vice versa. patients must maintain regular dietary sodium and fluid intake
very narrow therapeutic window
acute mania: 1.0-1.5 mEq/L
maintenance: 0.6-1.2 mEq/L
lithium toxicity early signs
levels over 1.5 mEq vomiting/diarrhea, levels over 2 can cause tremors, sedation, and confusion
levels over 3.5 can cause seizures, cardiovascular collapse, coma, and death
mood stabilizer safety
many drugs can increase or decrease their effectiveness
anticonvulsants have warning for increased suicidal thoughts
stevens-johnson syndrome (especially lamotrigine and carbamazepine)- life threatening rash, starts with a flu-like feeling
blood dyscrasias (esp valproate and carbamazepine) monitor for signs of infection or bleeding
risk of birth defects
antipsychotics
(aka neuroleptics, aka major tranquilizers) primarily used to relieve the symptoms of psychosis (hallucinations and delusions). used to treat schizophrenia, but also used for bipolar d/o, autism irritability, tourette’s, as antiemetics and as adjuncts to antidepressants
primary MOA is blockade of the dopamine D2 receptors
first meds in this class - 1950s, known as first gen/typical/conventional antipsychotics and are associated with a high level of extrapyramidal symptoms (EPS)
atypical/2nd gen antipsychotics
developed due to high rate of EPS
atypicals (antipsychotics)
not only block the D2 receptor but also block the serotonin 5HT2A receptor leading to less EPS, but have high metabolic symptoms
patients need to be monitored for weight changes and cholesterol levels
3rd gen atypicals
such as aripiprazole/Abilify, have a unique profile
dopamine partial agonists
mnemonic for extrapyramidal symptoms
ADAPT
AD= acute dystonia (oculogyric crisis -eyes roll back, muscle spasms of the face, neck and throat) treat with IM/IV benztropine or diphenhydramine
A= akathisia (restlessness) and akinesia (absent/impaired movement)
P= pseudo parkinsonism (tremor, shuffling gait, drooling, rigidity) stop meds will stop symptoms
T= tardive dyskinesia (bizarre face and tongue movements; this is permanent so monitor with the AIMS- abnormal involuntary movement scale)
antipsychotic safety issues
BBW for increased risk of death in elderly dementia patients, many can cause long QT syndrome leading to arrhythmias/Torsade’s
clozapine- seizures; agranulocytosis (watch for s/s infection, flu-like symptoms) check neutropenic levels with blood draw
EPS, neuroleptic management syndrome (NMS) monitor for muscle rigidity and fever- leads to rhabdo, metabolic syndrome- atypicals, anti-HAM
antiparkinsonism/anticholinergic
used to counteract EPS
restore natural balance of acetylcholine and dopamine in the brain
most common side effects are anticholinergic in nature
may also cause sedation and orthostatic hypotension
most common used: benztropine/cogentin, diphenhydramine/benadryl, and at times artane
sedative/hypnotics
short term management of various anxiety states and treatment of insomnia (diazepam/valium, temazepam/restoril, phenobarbital)
also used for epilepsy and alc withdrawal
selected agents are used as anticonvulsants, as pre-op sedatives
MOA is CNS depression, potential for dependence
sedative/hypnotic safety
CNS depressants shouldn’t be combined due to additive effects that lead to respiratory depression and death
abnormal thinking and behavioral changes have occurred
aggressiveness. hallucinations, and suicidal ideation have been reported
ADHD agents
CNS stimulants increase levels of dopamine, norepinephrine, and serotonin, but MOA is unclear
two main classes of stimulants are amphetamines and methylphenidate
the non-stimulants include alpha-agonists (clonidine), NRI (atomoxetine) and NDRI (bupropion)
- monitor HTN and dizziness
ADHD med safety
CNS stimulants shouldn’t be used with CVD due to risk of sudden death - monitor BP and pulse
stimulants have potential for misuse, can cause insomnia, GI upset, weight loss, tics, agitation, and psychosis
teach patients not to take other meds including OTC unless chacked with provider
bupropion shouldn’t be used with history of seizures or eating disorders
alpha agonists can cause sedation and hypotension, don’t stop abruptly
