Exam 2 Mod 3&4 (Psych) Flashcards
Complex neurobiological and developmental disability that typically appears during the first 3 years of life.
Autism Spectrum Disorder (ASD)
S/sx of Autism Spectrum Disorder (ASD)
Deficits in social relatedness, including communication, nonverbal behaviors, and interactions.
Can you SPOT the early signs of ASD?
Social: avoid eye contact; no interest in other kids, no pretend play, and unusual play patterns
Persistent Sensory Differences: getting upset over everyday sounds, over or underactive to light, smells, tastes, textures
Obsessive/repetitive behavior: flapping hands; rocking back and forth; having obsessive interests in a particular object or activity
Talking/Comm delays: little or no babbling by 12 months, no word by 16 months. May appear deaf; loss of previous verbal skills or language.
ASD Interventions
-Begin early 2nd or 3rd year
-Assist with behavior modification program
-Structure opportunity for small successes
-Set clear rules
-Decrease environmental stimulation
-Introduce child to new situations slowly
Children with ADHD show an inappropriate degree of
inattention and impulsiveness with hyperactivity
Absence of hyperactivity classified as
ADHD primarily inattentive type (previously known as ADD)
Sx of children with ADHD
Hyperactive: jumps in conversations
Inattentive: difficulty listening/paying attention
Impulsivity: difficulty waiting for them to turn in conversations
Medications for ADHD
Stimulants increase dopamine
Methylphenidate
Amphetamine and dextroamphetamine (Adderall)
Non-Stimulants
Guanfacine
Alpha 2 adrenergic agonist
Things to remember for stimulants
-Insomnia and weight loss are common side effects of stimulants
-Administer in AM to allow nighttime sleep
-Monitor weight and height
-Monitor VS
-Taper dose when discontinuing
S/E of non-stimulants
somnolence, lethargy, fatigue, insomnia, nausea, dizziness, hypotension
Group of psychiatric conditions, most of which are primarily biological in origin, that can significantly affect functioning and one’s quality of life, especially if they go untreated. Examples: mood disorders, Schizophrenia, personality disorders
Serious Mental Illness (SMI)
Inability to recognize one’s own illness due to the illness itself
Anosognosia
Treatment issues seen in those with serious mental illness
-Anosognosia: Inability to recognize one’s own illness due to the illness itself
-Nonadherence: Due to lack of trust in providers, anosognosia, med costs, and mental health stigma
-Medication Side effects
-Treatment inadequacy: lack of funded services, inadequate housing
Assessment strategies for SMI
Intentional & unintentional risk:
-Intentional: suicidality or homicidality
-Unintentional: Inadequate nutrition, inadequate clothing for weather, smoking, carelessness while driving.
Depression, hopelessness, anxiety
Signs of impending relapse
-Decreased sleep, increased impulsivity or paranoia, diminished reality testing, increased delusional thinking, or command hallucinations.
Physical health problems
-Brain tumor or drug toxicity can appear like a SMI
Comorbid illnesses
Tx nonadherence
-Signs such as worsening sx, unused meds, missed appointments, or reluctance to talk about the issues
Intervention strategies for SMI
-Involve pt in goal setting and tx planning
-Emphasize quality of life instead of focusing on sx
-Focus on the now
-Promote social skills and provide opportunities for socialization
-Involve in support groups to expose them to people who have been there
-Educate about illness and recovery
How to establish a relationship with SMI patient
-Do not stand too close as it may cause discomfort
-Breakdown complex skills such as resolving conflict, into more manageable subcomponents
-Calm and firm voice
What disease?
Low Acetylcholine (learning memory and mood), high Glutamate (involved in cell signaling, learning and memory)
Alzheimer’s disease
Alzheimer’s disease
Meds used for cognitive sx
MOA and examples
-Cholinesterase inhibitors –> increasing available acetylcholine
Ex: Donepezil (used for all stages including severe), Galantamine
-NMDA antagonists –> regulates glutamate
Ex: Memantine
Do the meds used to treat cognitive sx of Alzheimer’s stop the progression of the disease?
No. Only preserves function.
Are there any drugs approved to treat the behavioral sx of Alzheimer’s?
None approved; high risk!
Antipsychotics used off-label and with extreme caution, as last resort. FDA does not approve because of detrimental outcomes.
Alzheimer’s disease
Integrative therapy
Omega-3 fatty acids
Stage of Alzheimer’s disease & associated priority intervention, and family education
-Memory lapses: losing or misplacing items, difficulty concentrating and organizing. Short-term memory loss noticeable to close relations.
-Can still perform ADLs.
Stage 1/Mild
Stage of Alzheimer’s disease & associated priority intervention, and family education
-Forgetting events of one’s own hx: difficulty performing tasks that require planning and organizing, (Such as paying bills, managing money), difficulty with complex mental math.
-Personality and behavioral changes: appears withdrawn, compulsive, repetitive actions.
-Changes in sleep patterns, can wander and get lost, can be incontinent.
-Priority Intervention: Risk for Injury; identify threats to their safety.
Stage 2/Moderate
Stage of Alzheimer’s disease & associated priority intervention, and family education
-Losing ability to talk with others: need assist with ADLs, incontinence, losing awareness of one’s environment, progressing difficulty with physical abilities
-Eventually loses ability to move, can develop stupor and coma
-Death frequently related to choking or infection.
Stage 3/Severe
Points of education for family of Alzheimer’s pt
Safe environment
-Gradually restrict use of motor vehicles
-Minimize sensory stimulation
-Label rooms, drawers, and frequently used objects
Wandering
-Put mattress on the floor
-Wear medical alert bracelet that cant be removed
-Alert police and neighbors about wandering
-Put complex locks on doors
-Place locks at top of the door
-Encourage physical activity during the day
Useful activities
-Provide picture magazine and children books if reading ability declines
-Simple activities
-Group activities that are familiar and simple
A progressive deterioration of cognitive functioning and global impairment of intellect with no change in consciousness.
Onset is slow, over months to years. Not reversible.
Dementia
Contributing factors of dementia
Contributing factors: Alzheimer’s disease, neurological disease, vascular disease, alcohol use disorder, head trauma.
Describe the nursing care for pt with dementia:
Calm voice, short directions, remember their dignity, safe environment, reminders and cues in their environment.
Loss of language ability
Aphasia
Loss of purposeful movement
Apraxia
Loss of sensory ability to recognize objects & people
Agnosia
Creation of stories in place of missing memories to maintain self-esteem; lying to protect dignity
Confabulation
Repetition of phases or gestures long after stimulus is gone
Perseveration
Diminishing ability to read or write
Agraphia
Tendency to put everything in the mouth
Hyperorality
Tendency for mood to drop and agitation to rise as light of day diminishes
Sundowning
A disturbance of consciousness and a change in cognition that develops over a short period of time, abrupt onset with periods of lucidity.
MEDICAL EMERGENCY
Delirium
Sx of delirium
-Impaired memory, judgment, and attention span that can fluctuate, disorientation (often to time and place, but rarely to person), disorganized thinking, delusions and hallucinations (usually visual).
-Speech is rapid, inappropriate, and incoherent.
What do delirious pts look like?
Cardinal signs include inability to focus, an abrupt onset with features that fluctuate with periods of lucidity, disorganized thinking and poor executive functioning.
Contributing factors of delirium
Delirium is ALWAYS due to underlying physiological causes. Often due to sepsis and they are at risk for seizures.
fever, hypotension, infection, hypoglycemia, adverse drug reaction, head injury, emotional stress, seizures, dehydration, sleep deprivation, vision or hearing impairment.
Is delirium reversible?
Yes, w/ treatment
Interventions for delirium
-Assess for acute onset and fluctuating levels of consciousness
-Prevent physical harm due to confusion, aggression, or fluid and electrolyte imbalances
-Minimize use of restraints (increases confusion)
-Assist w/identification and treatment of cause
-Use supportive measures to relieve distress
Priorities for delirium
-Medical emergency - hemodynamically unstable!
-Risk for injury
-Assess vitals, LOC, and neurological signs
Errors in perception of sensory stimuli
Illusion
False sensory stimuli
Hallucinations
Most severe form of bipolar disorder w/ psychosis and at least 1 manic episode
Bipolar I
Less dramatic form of bipolar disorder w/ no psychosis and at least 1 major depressive episode and 1 hypomanic episode
Bipolar II
Sx seen in patient with bipolar disorders
Manic (lots of norepi & dopamine)
-Inflated sense of self-importance
-Extreme Energy-decreased need for sleep
-Excessive talking with pressured speech
-Racing thoughts, distractibility, poor impulse control
-Indiscriminate spending, reckless sexual encounters, risky behaviors
Vulnerable, big concern is safety
Sx seen in patient with bipolar disorders
Depressive (low levels of norepi & dopamine)
-Feelings of worthlessness
-Extreme sadness
-Suicidal thoughts
-Appetite changes
Different types of speech for bipolar
-Pressure speech: more talkative, urgent, intense, incoherent speech
-Circumstantial speech: add unnecessary details
-Tangential: never get to the point
-Loose associations: thoughts not connected
-Flight of ideas: racing, accelerated moving thoughts, changing topics
-Clang associations: rhyming words
Nursing care for patient with bipolar disorders
-Be proactive to estimate what the pt may do next
-Look out for signs of escalating behavior
-Set limits such as lights out at 11pm (main theme in treating a manic person)
-Firm and calm approach, short concise explanations
-Identify expectations in simple concrete terms
Nursing care of a manic patient
(Acute phase interventions)
-sx reduction
-prevent injury, maintain stable cardiac status, maintain hydration/tissue integrity, low stimuli
-if using seclusion or restraints, document why it was done!
Nursing care of a manic patient
(Maintenance phase interventions)
-Focus on preventing relapse
-Medication adherence is essential
-Health promotion and education, community support, use of outpatient resources
What medications are used for bipolarism?
mood stabilizers (lithium), anticonvulsants (valproic acid), atypical antipsychotics (aripiprazole), and anti-anxiety (clonazepam)
Gold standard med for bipolarism is mood stabilizer: lithium.
What are the side effects of this drug?
N/V, diarrhea, thirst, polyuria, lethargy, sedation, hand tremors
Sx of lithium toxicity
Therapeutic range: 0.8-1.4.
Lithium Toxicity: >1.5 mEq/L.
Early: Gastrointestinal upset, Coarse hand tremor, confusion, hyperirritability of muscles
Advanced: ataxia, blurry vision, clonic movements, large output of diluted urine, seizures, severe HYPOTENSION, coma
Severe: convulsions, oliguria, and death can occur
Pt education for lithium
-give with food
-take even after symptoms subsides
-may need frequent blood level monitoring at first then every few months
-lots of fluid intake 1500-300mL
-SODIUM intake affects Li. Low sodium leads to higher Li levels > toxicity!!
-stop if you have excessive diarrhea, vomiting, or sweating; leads to dehydration increasing Li levels
-dosage tapered gradually to avoid relapse
How to care for pts that are disruptive:
Use firm and calm approach; short and concise explanations or statements. Be consistent in approach and expectations; hear and act on legitimate complaints; structure in a safe Milieu; Low stimuli; provide structured solitary activities; frequent high-calorie foods; monitor I&Os; Frequently remind pt to eat.
Nursing intervention: least to most restrictive.
Identify the cause.
Type of Depressive Disorder
-Diagnosed in children 6-18 YO.
-Sx: constant and severe irritability and anger, temper tantrums out of proportion to the situation at least 3x/week in at least 2 settings.
Disruptive Mood Regulation Disorder
Type of Depressive Disorder
-Chronic, low level depressive feelings through most of the day, at least 2 yrs in adults and 1 in kids.
-Sx: 2 or more of: decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness.
Persistent Depressive Disorder AKA Dysthymia
Type of Depressive Disorder
-Persistent depressed mood lasting for a minimum of 2 wks
Chronic lasting more than 2 yrs.
-5 or more sx: weight & appetite changes, sleep disturbances, fatigue, worthlessness or guilt, loss of ability to concentrate, recurrent thought of death, psychomotor agitation.
-AND 1 sx is either depressed mood or anhedonia
Major Depressive Disorder (MDD)
Loss of interest or pleasure
Anhedonia
What are risk factors for Major Depressive Disorder (MDD)?
female, low socioeconomic status, post-partum, ACEs, unmarried, family hx, neuroticism
Suicidal ideations with a plan is an
EMERGENCY
Suicide assessment is priority for MDD. Biggest risk for pt with MDD is
suicide attempt
MDD Interventions
Acute, continuation, & maintenance
-Acute: focus is to reduce depressive sx and last 6-12 wks (start med therapy)
-Continuation: focus is to prevent relapse through meds, education, and psychotherapy 4-9 mos
-Maintenance: preventing further episodes and lasts 1 yr+
Antidepressant - First line of therapy
Med class, MOA, and examples
SSRI
Block reuptake of serotonin
Ex: fluoxetine, citalopram, escitalopram
Side effects of SSRI
SE: agitation, anxiety, tremors, sexual dysfunction, tension headache
Rare risk of serotonin syndrome
Pt education for SSRI
-provide info on possible SE
-May interact with other meds
-SSRIS should not be taken within 14 days of the last dose of MAOIs
-Do not drive or operate heavy machinery until side effects are ruled out
-No ETOH
-Liver and renal tests should be checked periodically
-Do not stop abruptly.
Antidepressant - Second line of therapy
Med class, MOA, and examples
TCAs (Tricyclics)
Inhibit serotonin and norepinephrine reuptake
Ex: amitriptyline, imipramine
Side effects of TCAs
Anticholinergic adverse effects
Drowsiness, dizziness and hypotension subside after a few wks.
Serious cardiovascular AE; dysrhythmias, tachycardia, MI, heart block.
Pt education for TCAs
Mood elevation may take 7-28 days. Up to 6 to 8 weeks may be required for full effect.
Alcohol blocks the effects.
How is an antidepressant chosen?
Sx profile, side-effect profile, ease of administration, hx of past response.
Diagnostic Criteria, symptoms, and risk factors for depressive disorders for each condition
Why are MAOIs the last line of tx for MDD?
risk of hypertensive crisis
A psychiatric treatment that involves the use of electrical currents to stimulate the brain. Induced seizure activity found to be helpful in treating clients who have MDD. Reserved for patients resistant to treatment.
Electroconvulsive therapy (ECT)
Side effects of ECT
Side effects of ECT: nausea, headache, jaw pain, muscle spasms. Clients may have temporary memory loss.
Muscle relaxer and general anesthesia may be given before ECT.
Which level of anxiety?
Occurs in normal experience of everyday life and promotes a sharp focus of reality.
Presentation: slight discomfort, attention seeking, restlessness, easily startled, irritability or impatience.
Intervention: use active listening & therapeutic comm; calm presence; check past coping mechanisms; alternatives for problem solving?; encourage participation in activities.
Mild anxiety
Which level of anxiety?
Narrows the perceptual field, and some details become excluded.
Presentation: Voice tremors, change in voice pitch, poor concentration, shakiness, somatic complaints, ^HR & RR, muscle tension
Intervention: use active listening & therapeutic comm; calm presence; check past coping mechanisms; alternatives for problem solving?; encourage participation in activities.
Moderate anxiety
Which level of anxiety?
Severely narrows the perceptual field, and right amount of focus on detail is lost.
Presentation: feeling of dread, confusion, purposeless activity, sense of impending doom, more intense somatic complaints (chest discomfort), diaphoresis, loud rapid speech.
Severe anxiety
Which level of anxiety?
The extreme level of anxiety; leaves a person unable to process the environment.
Presentation: experience of terror, immobility or severe fight or flight, unintelligible communication, somatic complaints increase (numbness, tingling, SOB, dizziness, chest pain), severe withdrawal, hallucinations or delusions, out of touch with reality.
Interventions: remain with pt and be calm, quiet environment, low stimuli, set limits using firm short and simple statements, speak slowly and in a low-pitched voice, may need repetition, use meds. do not restrain pt.
Panic!
Defense mechanisms can be used to manage conflict in response to anxiety.
Altruism and sublimation are defense mechanisms that are always __________.
healthy
Common defense mechanism
Voluntarily denying unpleasant thoughts and feelings.
Ex: not going to pay rent
suppression
Common defense mechanism
Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness
Ex: keep “forgetting” to go to dentist; has fear of dental offices
Repression
Common defense mechanism
Sudden use of childlike behaviors that do not correlate with person’s current developmental level
Ex: adult throwing objects at a coworker out of anger
Regression
Common defense mechanism
Shifting feelings to a less threatening object, person, or situation
Ex: adult loses job and destroys their child’s favorite toy
Displacement
Common defense mechanism
Putting one’s unacceptable thoughts and feelings onto another who does not have them
Ex: husband cheating on wife, but accuses wife of cheating
Projection
Common defense mechanism
Creating reasonable explanations for unacceptable behavior
Rationalization
What types of meds are used for anxiety?
Anxiolytic: benzodiazepines & non-benzodiazepines
Antidepressants: SSRIs, SNRIs
Buspirone is an alternative med that does not cause dependence but requires 2-4 weeks to reach full effect.
Side effects include:
SE: dizziness, nausea, HA, nervousness, light headed, and excitement
Contraindicated for pts w/ impaired hepatic
Client attempts to suppress persistent thoughts or urges that cause anxiety through compulsive or obsessive behaviors. Time consuming and cause impaired social & occupational functioning.
Obsessive Compulsive Disorder (OCD)
Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind
Obsessions
Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety
Compulsions
Why does OCD develop?
Sexual and physical abuse in childhood or trauma increases risks of this disorder. Genetics. May occur along with anxiety.
Why do they engage in compulsion what is the purpose?
temporarily reduce anxiety
What is the DSM5 Criteria for OCD
-obsessions, compulsions, or both
-not due to a substance or condition
-not explained by another psychiatric disorder
-time consuming (in excess of 1 hr per day)
Exposure to traumatic event cause anxiety, detachment, & other symptoms for at least 3 days and not more than 1 month after event.
Acute stress disorder (ASD)
Exposure to traumatic event causes anxiety, detachments, & other symptoms for longer than 1 month after event can last for years
Post traumatic stress disorder (PTSD)
What are pts w/ PTSD experiencing?
memories, flashbacks (feels like they are reliving the trauma in the present), dreams about traumatic event
How are pts w/ PTSD behaving?
aggression, irritability, & angry responses toward others, hypervigilance w/ startle response, unable to focus/concentrate, sleep disturbances (insomnia), destructive behavior (suicidal or hormonal thoughts). Will avoid people, places, events, or situations that bring back reminders of traumatic event.
Three stages of care for PTSD
1/acute- safety and stabilization
2- regulating emotions and reducing sx
3- coping skills
How is PTSD treated (meds)?
SSRI antidepressants- paroxetine, and sertraline
SNRI antidepressants- venlafaxine
TCA antidepressants- amitriptyline
Can antipsychotics be used to treat PTSD?
No!
What type of psychotherapy is used for PTSD pts?
-Cognitive behavior therapy
-Group or family therapy
-Crisis intervention
-Prolonged exposure therapy
-Eye movement desensitization and reprocessing (EMDR)
Stressor triggers a reactions causing changes in mood and/or dysfunction in performing usual activities; less severe than ASD or PTSD Ex: retiring, child moving and starting at new school
Adjustment disorder
Intentional act of killing oneself
suicide
Thoughts of killing oneself
suicidal ideations
Engaging in self harm with the intention of death
suicide attempt
Intentional damage to one’s on body tissue, without conscious suicidal intent, and for purposes not socially orculturally
Non-suicidal self-injury
Name some myths about suicide
-People who talk about suicide never commit it
-People who are suicidal only want to hurt themselves, not others
-Asking a client about suicide will cause the suicidal person to actually commit suicide
-Ignoring verbal threats of suicide or challenging a person to carry our suicide plans will reduce the person’s use of these behaviors
What is the purpose of a no suicide contract?
A verbal or written agreement made not to harm themselves, but instead to seek help. Not legally binding and should only be used according to facility policy.
Identify suicide precautions, when to be implemented.
-Initiate 1:1 constant supervision, always having the client in sight and close.
-Suiicde precautions include milieu therapy within the facility
-Document the client’s location, mood statements, and behavior every 15 minutes or per facility policy.
-Do not assign to a private room and keep the door open at all times.
-Ensure the client’s hands are always visible, even when sleeping.
-Search client’s belongings with client present. Remove all glass, metal silverware, electrical cords, vases, belts, shoelaces, metal nail fails, tweezers, matches, razors, perfume, shampoo, plastic bags, and other potentially harmful items from the client’s room and vicinity.
-When administering meds ensure the client swallows all medications. Clients can try to hoard meds until there is enough for suicide attempt. Check for cheeking.
-Provide a safe environment. Check the environment for potential hazards. Restrict visitors from bringing in possibly harmful items to the client. Allow the client to only use plastic eating utensils and count when finished. Lock doors to non-patient areas.
Direct/open messages
Ex: “There is just no reason for me to go on living”
Overt
Indirect/concealed messages
Ex: “Everything is looking pretty grim for me”
Covert
