Exam 2 Flashcards
Depressive disorders all share symptoms of
Sadness, loneliness, emptiness, irritability, somatic (body) concerns like back/neck pain, and impairment of thinking
All impact a person’s ability to function
Can get agitated or delusional
Disruptive mood dysregulation disorder
Children being diagnosed with bipolar, temper tantrums, violence, recognized this as a mood dysregulation. Predominantly seen in adolescents up to 18, less bipolar being diagnosed now
More of a childhood disorder
Persistent depressive disorder
Happens for years, symptoms are all the time
Can work, function, be social, have friends, but having a difficult time. Pure depression can’t do this
Dysthymic disorder
Premenstrual dysphoric disorder
More than physical changes like PMS
Uncomfortable in their own skin, feel better when menses starts (symptoms go)
Medication usually works for them
Substance-induced depressive disorder
Cocaine use makes you high, the opposite bottoms you out
Relaxants can make you depressed (alcohol)
Depressive disorders due to another medical condition
Open heart surgery makes you more likely to have depression (95%)
Parkinson’s, cancer, end-stage terminal illness like cardiac, respiratory, renal
Genetics and depression
37% incidence if a monozygotic twin is depressed, also genetic influences linked to earlier onset and recurrence
Biochemical etiology of depression
serotonin (affects mood, makes us feel good) and norepinephrine (behavior and attention, produced more when stressed, low in depression), dopamine, glutamate, acetylcholine
Hormones in depression
hypothalamic-pituitary-adrenocortical axis involvement
Inflammation in depression
c reactive protein and interleukin-6
Tests for depression (hormone)
Dexamethasone suppression test and high cortisol in urine tests for depression
Inflammation plays huge role in these illnesses, inflammatory biomarkers show this
Cognitive theory of depression
See a helpless situation, think helpless thoughts, world is hopeless, can’t get out of this circle (triad)
Changing negative thought and working it through to realize it’s not so bad (cognitive behavioral theory)
Learned helplessness
Happens when someone feels powerless over a situation, they learn to continue to function that way. If they’re stuck in traffic they don’t get over it
Patient health questionnaire
2 first questions ask about little interest in things. If yes, do you feel depressed and hopeless. If yes, automatically answer other 7 questions which are more serious like appetite or thoughts of hurting self, may be on constant observation. Med surg or other units ask the two questions. Psych unit uses Columbia screening tool
Assessment of depression
Questionnaire
Anergia
Anxiety
Psychomotor agitation or retardation
Vegetative signs
Chronic pain
Religious beliefs and spirituality
Mental status exam
Affect
Thought process (can’t problem solve, memory and concentration problems, maybe delusional)
Mood/feelings (hopeless and helpless!!)
Communication (can’t get point across, don’t belong, inattention)
Hygiene and dress
Sleep habits
Bowel habits
Decreased libido from low serotonin and norepi
Number one predictor of suicide
hopelessness
Recovery model with depression
Focus on patient’s strengths (have you ever experienced this before, gives idea of where they’re at)
Treatment goals mutually developed (patients need to be involved in meetings and treatment plan)
Based on patient’s personal needs and values
Planning
Phases of treatment and recovery
1.Acute– 6-12 weeks
2.Continuation–4-9 months
3.Maintenance–1 year and beyond
When do people w depression see improvement
Clinical benefits at least 1-3 weeks after initiation. Some people have response in 8-10 days but it’s usually 3 weeks which is a long time.
Trial of meds for depression
Adequate trial of meds is 6-9 months. Doctor says you need to stay on meds for 6-9 months even if you feel well after 3 weeks. Sometimes they get off the med or lower the dose after the 9 months, some eventually come off in 12 months. Some people stay on it
How are antidepressants chosen?
Family history, genetics, the Es of taking it (easy bc side effects, eat [watch what you eat])
Sometimes people are so used to being in depressive body state and the meds make you jittery and anxious and you stop taking them. Need to go through this to make you feel better. Not all meds do this though, but the ones that do are pretty severe
SSRIs
Selective serotonin reuptake inhibitors
First-line therapy
block uptake of serotonin so more is available at synapses, other indications such as OCD, and Panic Disorder
Came out third
SNRIs
Serotonin norepinephrine reuptake inhibitors
SSRIs may be tolerated better
Came out last
Tricyclic antidepressants
Anticholinergic adverse reactions
Came out in like ‘59
inhibit reuptake norepinephrine and serotonin (makes mood better)
Monoamine oxidase inhibitors
Came out in 50s, first to come out
Effective for unconventional depression
Breaks down neurotransmitters (dopamine, norepinephrine, and serotonin)
Monoamine oxidase breaks them down so they can’t attach and get synapse connection to make them feel better. MAOIs prevent the breaking down
Used to be first-line therapy but not anymore because of cardiac effects Now it’s a last resort. It’s good if you can commit to diet
Side effects of SSRIs
agitation, sleep disturbance, tremor, sexual dysfunction (causes med inherence), headache, autonomic effects
Toxic effect of SSRIs
serotonin syndrome!!
Abdominal pain, diarrhea, increased
BP, HR, temp; delirium, muscle spasm, irritable, may lead to shock/death
caution when use 2 antidepressants or herbal supplement (Esp. MAOI)
Washout period between two antidepressants (2 weeks)
Therapeutic dose reached after how long with tricyclics
Therapeutic dose reached 2-8 weeks (will have some effect sooner)
Side effects of tricyclics
anticholinergic, postural hypotension, tachycardia
Toxic effects of tricyclics
cardiac rhythm, heart block, MI (lots of elderly pts got this med, cardiac effects seen. Doesn’t happen with everyone but still serious
Drug interactions with tricyclics
MAOI, barbiturates, disulfiram, oral contraceptives and estrogen, alcohol, antihypertensives (clonidine, reserpine)
Contraindications of tricyclics
Cardiac issues but tiny amounts help with back pain (neuropathic response instead of antidepressant
MAOI diet
Adhere to a restrictive diet of foods and drugs (tyramine free)
Tyramine involved which can cause HTN crisis, can’t eat pickled foods, herrings, pickles, chocolate, aged cheeses/wines/beers
Indications of MAOIs
Those individuals with atypical depressions, all other meds and nothing worked for them (hypersomnia and overeating, anxiety disorders)
Side effects of MAOIs
orthostatic hypotension, weight gain, cardiac rhythm changes, insomnia, fatigue, anticholinergic
Toxic effects of MAOIs
hypertensive crisis (tyramine), need to monitor vital signs
Don’t use MAOIs if you have cardiac history and can’t adhere to diet
How to get esketamine and what r we watching
Have to go to an esketamine center where licensed practitioners administer the nasal spray. Pt comes in, kind of like OR setup, monitored for HTN every 30 mins. Someone has to drive them home. Used for people with acute suicide, helps very much with symptoms
no food 2 hrs before and no liquid 30 mins before treatment
Side effects of esketamine
high BP, dissociation, dizziness, vertigo, sedation, numbness, anxiety, and feeling drunk, out of body experience with ketamine so esketamine isnt as bad, they feel outward though
Dosing of esketamine
twice weekly for 4 weeks, tapering once a week for 4 weeks, week 9 and after once every week or two
Brexanolone
Zulresso
antidepressant
1st and only FDA approved med for ppd- schedule II drug
Neuroactive steroid 60 hour IV infusion. It is a one time infusion
Side effects of brexanolone
hypoxia, excessive sedation, and potential LOC. patients are continuously monitored
Antidepressants in pregnancy
inconclusive some preterm esp with bipolar manic phase
congenital malformations MAOI and TCA
SSRI in first trimester some risk
Antidepressants in children/adolescents
black box warning suicidal risk, despite less prescriptions suicide increased. What are the implications?
Ages 15-25, brain doesn’t stop growing until 25
Weren’t being given these because of black box and ended up suiciding even more, so they put it back
Antidepressants in older adults
Polypharmacy and metabolism issues
ECT
Electroconvulsive Therapy
Mini OR setup, bilateral (less confusion) or unilateral (more confusion but quicker recovery). Electrodes used
Indications of ECT
most common depression up to 90% remission, suicidal thoughts, psychotic disorders, failure to respond to meds
Informed consent (6-8 treatments from this consent), education for patient and family
How to do ECT (meds)
anesthetic (barbiturate (brevital) and muscle paralyzing agent (Succinylcholine), EEG and EKG monitoring, brief seizure induced via electrodes (uni- or bilateral)
Adverse reactions of ECT
confusion (will last some period of time or never goes away), headache, memory deficits (can get better or maybe wont)
If MAOI doesn’t work this is the last resort
PACU after ECT
PACU certified nurse needs to watch pt
When anesthesia lets pt go to next level of care, they go to PACU so they need PACU certified nurse, psych doesn’t have this
TMS
Transcranial Magnetic Stimulation For those unresponsive to other treatments, pregnancy, outpatient, electrode deliver magnetic pulses, noninvasive
Good if they don’t want ACT
Strong magnet but not as strong as MRI, literally just under it
Looking at cerebral cortex, results within 2 weeks
Vagus nerve stimulation
electrical stimulation boosts neurotransmitters, implanted in chest (surgical procedure) and attached to vagus nerve in neck, treatment-resistant depression
Deep brain stimulation
implanted electrodes in underactive brain areas, device (stabilizer) in chest wall, also works for parkinson’s
Light therapy
first line treatment for Seasonal Affective Disorder (SAD)
Very specific bulb, lux bulb
Useful for when we fall back, darker early, not out as much
Depressed for the 6 months until spring
Sometimes people just use this or they supplement with meds
St John’s Wort
increases serotonin, norepinephrine and dopamine
Careful with serotonin syndrome!!
Exercise for depression
increases serotonin, decrease HPA axis (thought to be overly active in depression)
30-45 minutes a day, 5 days a week. For mild to slightly mild-moderate depression
If you’re in the middle or severe-moderate depression, it won’t work for you
Healthy People 2030 goals for depression
improved screening, reduce depression incidence and increase treatment options and compliance (75% people with depression will receive treatment)
What do suicidal people need
Ideation, intent, and plan
Red flag law
Need to confiscate the gun and report it to the state. Local authorities come to you and take the gun so the hospital/whatever place doesn’t deal with it
2-2-2 rule
Highest risk 2 days before admission, 2 days after admission, and 2 days after discharge
2 days after discharge, they have some energy and the meds haven’t kicked in yet
Suicidal ideation
Thinking about killing oneself
Completed suicide
Suicide successfully resulting in death
Nonsuicidal self-injury
Self-injury directed to the surface of the body to induce relief from a negative feeling/cognitive state or to achieve a positive mood state
Suicide can happen by accident
SUICIDE IS NOT THEIR INTENT
Highest suicide rates in who
Active duty service members
THEY HAVE ACCESS TO A GUN! FEELING HOPELESS AND HELPLESS
Gender, age, race, religion, marriage, profession, physical health, and history r/t suicide
Males more often successfully suicide, females attempt more
Increase in 50-75. Most common in adolescents 10-34
White people
decreased in religious and ppl married with CHILDREN
Increased in professionals
Half have a physical illness
PRIOR ATTEMPTS AND LETHAL PLAN
Lethal plan
having access to the means such as a gun, jumping off a building, purposeful crash maybe, jumping out of a car and into a river could be, carbon monoxide poisoning yes, etc), loss
Pills and hanging may not be lethal (hanging is lethal if done correctly but usually it’s not)
Warning factors of suicide
immediate risk of suicide
Often talking or writing about death, dying, or suicide
Making comments about being hopeless, helpless, or worthless
Expressions of having no reason for living: no sense of purpose in life
Saying things like “it would be better if I wasn’t here” or “I want out”
Increased alcohol and/or drug misuse (drinking + reckless behavior)
Withdrawal from friends, family, and community!!
Reckless behavior or more risky activities, seemingly without thinking
Dramatic mood changes (pt came in depressed, showing a little lift/happiness only after like 4 days. Negative thinking is still a problem, be worried)
Talking about feeling trapped or being a burden to others
Risk factors of suicide
characteristics that make it more likely that an individual will consider, attempt, or die by suicide
Previous attempt(s) BIGGEST RISK FACTOR
A history of suicide in the family
Substance use (people come into ED, feel very suicidal, sober up, and say they would NEVER want to kill themself, then they are let home)
Mood disorders (depression, bipolar disorder)
Access to lethal means (ex. Keeping firearms in the home)
Losses and other events (ex. The breakup of a relationship or a death, academic failures, legal difficulties, financial difficulties, bullying)
History of trauma or abuse (I can go to the safehouse, but someone did that and died so I’d rather stay here)
Chronic physical illness including chronic pain
Exposure to the suicidal behavior of others
Exposing suicidal people to others and TV
Talking to friends or hearing of it on social media
Let two suicidal people talk but if they start talking about which means is better, etc., stop their communication
A little negativity is fine though because they can be rearranged to positive comments and helping them learn and move forward
They watch movies and TV and we may think “wow why are we letting them watch that?” We can’t stop what they do when they go home. If they love to watch these crazy shows, they will do that at home, too. Better to allow them to watch it here and see what they do with it.
Suicide protective factors
Effective mental healthcare; easy access to a variety of clinical interventions
Strong connections to individuals, family, community, and social constitutions
Marriage, having children
Problem-solving and conflict resolution skills
Specific questions to ask about suicide (from SAMHSA)
Have you ever felt that life was not worth living?
Have you been thinking about death recently?
Do you ever think about suicide?
Have you ever attempted suicide?
Do you have a plan for ending your life?
If so, what is your plan for suicide
Steps to safe-t
Ask about risk factors, ask about protective factors, conduct suicidal inquiry (how they’re feeling, their thoughts on suicide, behavior, plan), then we determine level of risk and document it
Suicide Behavior Disorder (DSM-5) Guidelines for a new disorder
Attempt within last 24 months
Attempt was not initiated in delirium or confusion
Attempt was not undertaken for a religious or political objective
Nonverbal suicidal behaviors
change in mood, caution increase energy after treat with antidepressants, give away possessions (to specific people or to the masses)
Safety plan with suicide
Came out from VA hospital
Brings lots of tools used in psychiatry
Questions are very specific, they all ask about living. One of the final questions is “what do you feel you would live for?/what do you live for?” (protective factor)
Thinking about death recently: What about death? Thoughts about where you want to die or actually killing yourself
Thinking about suicide/attempted suicide: Is there a definite plan?
High risk (hard) suicide methods
Using a gun
Jumping off a high place
Hanging
Poisoning with carbon monoxide
Staging a car crash
Low risk (soft) suicide methods
Cutting wrists
Inhaling natural gas
Ingesting pills
Condemnation in health professionals about suicide
“This is the worst thing someone can do”
It WILL come across
so this is the only option you feel like you have? Are you open to hearing anything else I might be able to say to you? Might be open but feel like this is the only option. Them being open leads to many things we can do
Question Persuade Refer Training
Question their intent
Persuade against it
Refer them
Ultimate safety plan for suicide
Very involved piece of paper that gets patients involved in their own plan. Tells them if they’re feeling suicidal, talk to somebody
They will approach the nurse and the nurse has to stop what they’re doing. If the nurse can pull them down, great! If not, find somebody else like the doctor
If they’re home, have three people to consult. If you’re the third person, you’re the call before 911. Go over this before they come in, in case they have suicidal ideation while they’re in the hospital
Copies of plan go to involved family members
Interventions for suicide
Psychosocial interventions-Safety Plan
Psychobiological interventions (meds like SSRIs)
Safety and teamwork
Health teaching and health promotion
Case management
Documentation of care
Postvention for survivors of completed suicide (Refer them to support groups which can exist in the facility, may have to research outside)
Environmental safety guidelines for suicide
Use (and count) plastic utensils.
No private room; keep the door open at all times.
Jump-proof and hang-proof bathrooms.
Lock doors to non-patient areas.
Monitor for and remove potentially harmful gifts.
In the patient’s presence, assess belongings and search patients for harmful objects.
Ensure that patients do not bring or leave harmful objects
Non-suicidal self injury (NSSI)
Deliberate non-suicidal bodily harm
Intent to feel relief, not to kill themselves. They want positive relief
Cut, carve, bite, burn, skin picking
Last more than a year and repeated alleviate psychic pain or numbness
Risk factors- family depression, non-heterosexual, personality disorder (BPD), anxiety, substance use
They feel euphoric after self-harming. Bad coping habits
6 step approach to recovery
Limit setting for safety
Developing self-esteem
Discovery of motive and its role
Discovering self-control
Replacement with coping skills
Entering maintenance phase
Bipolar 1 disorder
Most severe form
Highest mortality rate of the three
At least one manic episode that lasted a week or more
May alternate with depressed moods and agitation, periods of symptom-free
Delusions, hallucinations, depression, mania
Breakthrough symptoms without a manic episode. Have to figure out if it’s depression or bipolar
Mania and depression
Bipolar 2 disorder
Happens for around 4 days
At least 1 hypomanic episode
Not so irritable
Most times they present hypomania and then depression shows later
At least 1 major depressive episode
Hypomania alternating with severe depression (make sure it’s not major depressive)
Not as much sleep deprivation, famous ppl
Cyclothymic disorder
Alternate with symptoms of mild to moderate depression for at least 2 years (adults) 1-year children
Irritable hypomanic episodes
Rapid cycling, may even occur in one day, 4 mood episodes in 12 months (also seen in bipolar 1)
More severe
Hypomania is more irritable in this than bipolar II
Partial hospital or intensive outpatient may be recommended by doctor but not preferred bc they get transferred to hospital fast, need to be danger to self or others
Rapid cycling
4 mood episodes in 12 months
Other bipolar disorders
Substance/medication-induced bipolar and related disorder
Bipolar and related disorder due to another medical condition
(HYPERTHYROIDISM and renal function studies if they’re suspected bipolar bc lithium is bad for kidneys)
Epidemiology of bipolar
Occurs in 4% of population
2% in children and adolescents
Usual onset late teens - early 20s
Gender differences (equal rates, a little more men in bipolar I have legal and violent issues during mania, bipolar II with women and substance abuse/suicide attempts usually in manic phase because they have energy,careful with meds because it could give them the energy they need to suicide, 2-2-2 rule)
Children (make sure it isn’t ADHD)
Comorbidities of bipolar
At least 50% of individuals with bipolar disorder have a comorbid psychiatric disorder–biggest one right now is substance (peer pressure of feeling different, self medicating and now they don’t want proper meds bc it makes them feel blank and gets rid of mania)
Higher rates of some physical disorders with Bipolar I
Panic is common in bipolar I because of disorientation and realizing you’re different from others
Chronic fatigue common in manic phase, 90% heritable (from parents, grandparents, etc)
Risk factors of bipolar with comorbidities
Biopsychosocial approach
Biological: genetic, neurobiological, neuroendocrine
Prefrontal cortex (can’t operate the way they want or think clearly)
Cognitive replacing Psychological
Environmental
Brain structure/function in bipolar
See dysfunction in prefrontal cortex (executive decision making, personality expression, social behavior)
Dysfunction in the hippocampus
(memory)
Dysfunction in the Amygdala
(Memory of what happened, decision making based on memory, emotion with memory, amygdala in charge of remembering anger and emotions)
Assessment of mania (mood, behavior, thought process/speech, cognitive)
Early identification and tx. is key!
Mood (lability, euphoria, inappropriateness based on situation, irritable, angry, poor boundaries, wanting to call the President, grandiose situations)
Behavior (hypersexual, extreme spending, sleep probably not. If not sleeping but goal directed, probably also not eating)
Thought processes and speech patterns (similar to schizophrenia, hallucinations, grandiosity, delusions, alterations in perception)
Cognitive functioning (impaired concentration, rule out ADHD in young person)
Self-assessment (not best bc they can lie)
Speech patterns in bipolar
Pressured speech
Circumstantial speech
Tangential speech
Loose associations
Flight of ideas
Clang associations
Thought content in bipolar
Grandiose delusions
Persecutory delusions
Mental status exam in bipolar (appearance)
Unusual dress, hyperactive or “busy” behavior
Excessive engagement in pleasurable activities (like excessive buying, sexual acting out)
MSE in bipolar (speech)
Rapid and “pressured speech” (speech that is hard to interrupt)
MSE in bipolar (mood/affect)
Feeling “on top of the world” or be angry and irritable
Mood can be “labile” (changes rapidly)
Is it congruent?
MSE in bipolar (perception)
possible hallucinations
MSE in bipolar (cognition)
Orientation
Little insight (understanding) of having an illness
Judgment impaired and can lead to painful consequences
Impulsive; can act aggressively
Ability to concentrate is impaired
Easily distractible
MSE in bipolar (harm)
Suicidal or homicidal hx. & current thoughts
Intent and presence of a plan
DIG FAST in mania
Distractibility and easy frustration
Impulsivity, Irritability, Irresponsibility and erratic uninhibited behavior
Grandiosity
Flight of ideas
Activity increased with weight loss and increased libido
Sleep is decreased
Talkativeness-excessive
Assessment guidelines/nursing diagnoses for mania
Danger to self or others
Need for protection from uninhibited behaviors
Need for hospitalization–very vulnerable based on behavior
Medical status
Coexisting medical conditions
Family’s understanding
Risk for injury
Risk for violence (other or self)
Ineffective coping
Manic patient
Manipulative, charming, rizz, could be best friend before delusions, once everything is resolved they’re still you’re best friend, might think this is borderline personality disorder but it’s not
Demanding
Splitting, so charming you’ll think they have borderline personality disorder
Staff member actions for mania
Frequent staff meetings to deal with patient behavior and staff response
Set limits consistently
Acute phase priority for mania
Prevent injury because they’re all over the place
Continuation phase priority in mania
Relapse prevention, they don’t think they’re sick. Stop taking meds after about 3-4 weeks because they feel good and then bottom out.
Maintenance phase priority in mania
Limit severity and duration of future episodes
Stay on meds consistently
Breakthrough periods can happen even on meds, stressful situations happen in life
Nursing Care Acute/Implementation of Mania (Hospital)
Medical stabilization
Maintain safety
Nursing care
Nursing care in hospital for mania
Managing meds, decreasing physical activity, usually need to go to court and get mandated treatment. Medicate PRN against will, document, set limits to decrease activity, finger foods so they use less energy
Increasing food and fluid intake (protein drink)
Ensuring at least 4 to 6 hrs. of sleep per night
Intervening so that self-care needs are met.
Seclusion, restraint, or electroconvulsive therapy (ECT) may be considered during the acute phase
Care for depressive episodes in hospital
Hospitalization for suicidal, psychotic, or catatonic signs
Medication concerns about bringing on a manic phase
Could see a manic episode with certain antidepressants based on chemical composition of patients
Could have psychotic episodes
Care for manic episodes in hospital
Hospitalization for acute mania (bipolar I disorder)
Communicating challenges and strategies
Why do people with bipolar delay treatment
don’t know what’s wrong and they don’t want to lose elated feeling during mania, during depression they can’t even get out of bed
Short and direct verbiage, can’t take so much information in but can put it out
Lithium carbonate
Lithobid
Therapeutic: 0.8-1.2 mEq/L
Toxic: 1.5+
Maintenance: 0.6-0.8
MONITOR RENAL AND THYROID
Predominantly for bp1
Make sure they actually have bipolar and not depression
First line of defense, then next mood stabilizer, then add antipsychotic and/or depakote
Sometimes provider doesn’t even want their levels up to 1.2
Takes 3 days to 3 weeks to work
If while they’re on lithium they’re still moving too fast, we can add an antipsychotic or depakote
Anticonvulsants for bipolar
Mood Stabilizers
valproate (Depakote)
carbamazepine (Tegretol)
lamotrigine (Lamictal): bad rash, 5 weeks into therapy, d/c it
Valproic acid may also work, on aggressive piece quicker and antipsychotic
Levels of vap acid: 50-100, also known as depakote/depakene (2nd line of defense)
Benzo is next line of defense if they don’t want antipsychotic or anticonvulsant (not a good option bc drug abuse)
Tegretol: levels are 6-12
Antianxiety meds for bipolar
clonazepam and lorazepam
Antipsychotics for bipolar
Atypicals-second generation- olanzapine (zyprexa) and risperidone (risperdol)
Typicals-first generation- chlorpromazine and loxapine (inhaled)
Calms them down quickly, works quick for aggression, takes a while for psychosis
Other interventions for bipolar
Omega-3 fatty acids, works well especially if pt is tx resistant or a rapid cycler
ECT for rapid cycling (succ as muscle relaxant, atropine for secretions)
safety precautions with mania because of grandiosity (in everyone’s face) or suicidal
Health teaching and promotion
Advanced practice: CBT, interpersonal therapy
Lithium (lithobid)
Most prescribed
900-1800mg daily in 2-4 divided doses, max 2400 daily
Lithium class
mood stabilizer
Lithium moa
addresses neurotransmitters
Priorities in mania
Safety/Prevent exhaustion (trazodone or benzos, traz is an antidepressant but makes u sleepy, rest periods, decrease stimulation even tho they want stimulation)
Set expected outcomes (will sleep 4-6h a night)
Safety/hydration and food intake (monitor I/Os, finger foods)
Impulse control (sedatives, avoid stimulation, limits, 1-1 if violent, least restrictive, go to room if they’re not safe)
Preventing exhaustion
Give sedative meds to facilitate sleep
Promote rest periods even when patient can not sleep
Decrease environmental stimulation
Expected outcomes in mania
Patient will rest/sleep at least 4-6 hours per night
Interventions and expected outcomes with food/water intake in mania
Monitor intake and output
Offer finger foods and foods with good nutritional value
Patient is easily distractible so verify actual intake
Patient will eat and drink enough throughout the day
Patient will not show signs of dehydration
Interventions for impulse control in mania
Give sedative meds to lessen hyperactivity
Monitor interpersonal interactions for intrusiveness
Help patient to avoid stimulating milieu activities like group
Set firm and consistent limits on unsafe behaviors
“One on one supervision” if violence
Have patient go to room if acting in an unsafe manner
Use restraints if ALL other “least restrictive measures” have been tried
Recognize and intervene quickly with escalating behavior (de-escalation techniques should be utilized)
Education for family of bipolar
Symptoms of depressive, manic, and mixed episodes
Supports self-efficacy and treatment adherence
Medications, SE, ways to lessen SE, toxic effects, when to report, importance of compliance
Lithium toxicity
Relapse prevention
Self-help strategies for family (support groups like NAMI), talk about experience, not the patient
Symptoms of manic episode
Elevated or expansive and irritable mood accompanied by changes in activity and energy
Background of personality disorder
Emotional dysregulation
Enduring pattern of inner experience and behavior deviating from expectations of individual’s culture
Leads to distress and impaired functioning
Long duration, onset adolescence or early adulthood
Inflexible traits, pervasive
If diagnosed under age 18, must have symptoms for 1 year (except antisocial which is only adults)
Etiology of personality disorders
Biological: genetic, neurobiological
Psychological
Environmental
Diathesis-stress model
Cluster A personality disorders
(odd, eccentric): Paranoid, Schizoid, Schizotypal, 5.7% prevalence
Cluster B personality disorders
(dramatic, emotional, erratic): Antisocial, Borderline, Histrionic, Narcissistic, 1.5% prevalence
Cluster C personality disorders
(anxious, fearful) : Avoidant, Dependent, Obsessive-Compulsive, 6.0% prevalence
Paranoid Personality Disorder-Cluster A
Clinical presentation: distrust and suspicious of others
Easily experiences shame and humiliation
Struggles with personal relationships
Defense mechanism of projection
Interventions for Paranoid Personality Disorder-Cluster A
Distraction
Give them space (they want to be alone bc they dont trust others)
You often dont see them in groups
Let connection and trust develop
Schizoid Personality Disorder-Cluster A
Clinical presentation: detachment from social relationships, restricted emotional expression, lifelong pattern of social withdrawal
Aloof, introspective,
No desire for social or sexual relationships
Generally well functioning, untroubled by their oddness
Interventions for Schizoid Personality Disorder-Cluster A
Don’t force them to go to group therapy, they wouldn’t enjoy it
Schizotypal Personality disorder-Cluster A
Clinical presentation: discomfort in close relationships, cognitive and perceptual distortions, eccentric behavior
Odd beliefs, magical thinking,
Fear social interaction, do not blend in with crowds
Interventions for Schizotypal Personality Disorder-Cluster A
Individual psychotherapy
Histrionic Personality Disorder-Cluster B
Clinical presentation: excessive emotionality and attention seeking
Lack self worth so depend on others’ attention for well-being
Dramatic, Excitable, overly charming or seductive
React poorly to criticism or disapproval
Histrionic Personality Disorder-Cluster B Interventions
Limit setting
Don’t defend yourself, reinforces their behaviors
Narcissistic Personality Disorder-Cluster B
Clinical presentation: grandiosity, need for admiration, lack of empathy
Sense of entitlement
Controlling, intolerant
Narcissistic Personality Disorder-Cluster B Interventions
Usually only come into the hospital when in trouble with the law
Don’t want to be in the group, think there’s nothing wrong with them
They’re mean to people in the group cause they’re above the group
Limit setting, daily expectations
Antisocial Personality Disorder-Cluster B Background Information
Often referred to as sociopaths
Diagnosed in adults, symptoms in mid teens to early 20s
Antagonistic, manipulative, hostile, risky behaviors, impulsive, irresponsible, often legal issues, substance use, seek own gratification, disregard needs of others, lack intimacy, Profound lack of empathy, absence of remorse/guilt, disregard for rules and responsibilities
More common in men (3%)
Etiology of Antisocial Personality Disorder-Cluster B
Biological
Environmental
Cultural
Assessment of Etiology of Antisocial Personality Disorder-Cluster B
Psychiatric setting often court ordered, avoid legal system, often disruptive on unit, may be co-occurring depression, anxiety
Assessment-Patients do not tend to answer honestly
Medical setting for injuries
Self-assessment
Nursing diagnoses for Antisocial Personality Disorder-Cluster B
Risk for other-directed violence
Defensive coping
Impaired social interaction
Ineffective health maintenance
Interventions for Antisocial Personality Disorder-Cluster B
Safety– limit setting, observation, boundaries, consistency, consequences for actions, documentation, therapeutic listening and communication, empathy, communicate expectations, don’t argue or bargain, monitor for aggression, physical outlets, identify anger triggers, “stop and think”, positive reinforcement p. 461
Medications– based on symptoms not diagnosis, mood-stabilizing medications
Background information of borderline personality disorder
Instability in emotional regulation, emotional lability (extremes), impulsivity, lack identity or self image, unstable mood and relationships, overreact
Separation and abandonment
Self-destructive (self soothing with cutting, burning, numbing with substances)
Promiscuity
Suicidality
Antagonism
Splitting (primary defense)
Epidemiology of borderline personality disorder
1.6% population,
10% mortality
85% co-occurring mental illness,
50% substance abuse
–what are the implications of this?
Etiology of borderline personality disorder
Biological: familial risk factor, hyperactive amygdala, impaired prefrontal cortex
Cognitive: early abandonment, Mahler’s separation-individuation, rapprochement phase (18-24 months)
Assessment of borderline personality disorder
MMPI-Minnesota Multiphasic Personality Inventory
Assess for self-harm, impulsivity, intense feelings, abandonment, idealization of others, suicidality, extreme mood changes, risky behaviors
History of abuse
Self-assessment
Meds for borderline personality disorder
Medications–anticonvulsants mood stabilizers, antipsychotics (low doses), Naltrexone(Vivitrol) for self-injurious behaviors
Nursing diagnoses for borderline personality disorder
Self-mutilation
Risk for suicide
Risk for self- and/or other-directed violence
Impaired social interaction
Disturbed personal identity
Ineffective coping
Advance practice interventions for borderline personality disorder
CBT
DBT
schema-focused
Avoidant Personality Disorder-Cluster C
Clinical presentation: social inhibition, feeling inadequate, hypersensitive to negative comments
Avoid others unless feel liked
Often associated with anxiety disorders
Avoidant Personality Disorder-Cluster C Interventions
Do not force these people to go to group
Dependent Personality Disorder-Cluster C
Clinical presentation: submissive and clinging behavior, excessive need to be taken care of
Lack self confidence
Dependent Personality Disorder-Cluster C Interventions
Limit setting
Setting expectations
Obsessive-compulsive Personality Disorder-Cluster C
Clinical presentation: preoccupied with rules, details order, schedules
Perfectionism
Rigid, controlling, cautious
Obsessive-compulsive Personality Disorder-Cluster C Interventions
Would not do well in group therapy because nobody fits their schedules
Complex social relationships
Exposure therapy does not work here
