Exam 2 power points Flashcards
Peplau’s Classic 4 Levels of Anxiety
1) Mild - slight discomfort. a persons sees, hears, and grasps more information, and problem-solving becomes more effective. (low tension EX: nail biting, foot or finger tapping) – best for taking tests.
2) Moderate - perceptual field narrows, and some details are excluded. Thinking clearly is hampered. Selective attention. Physical symptoms occur = (tension, pounding HR, increased pulse & RR, perspiration, gastric upset, HA)
3) Severe - perceptual field is greatly reduced. Scattered thoughts. Behavior is automatic and the aim is to stop or reduce the stress. Learning and problem-solving are not possible at this level. Dazed and Confused. (increased HR, trembling, hyperventilation, a sense of impending doom)
4) Panic - results in disturbing behavior. are no longer able to process information and lose touch with reality. (Symptoms: Confusion, shouting, screaming or withdrawal, erratic, uncoordinated, and impulsive, hallucinations, lack of ability to learn) – Exhaustion.
Positive Symptoms vs Negative Symptoms(Clinical Manifestations)
-Positive and Negative symptoms
- Positive Symptoms
+ Hallucinations (type)
+ Delusions
+ Bizarre Behaviors – includes movements like waxy flexibility
+ Loosening Associations–disorganized speech - Negative Symptoms
- -Affective flattening
- -Alogia (poverty of thought)
- -Avolition (loss of motivation)
- -Apathy
- -Autism
- -Anhedonia (loss of interest in activities)
- -ADL decline, social isolation and withdrawal (Asociality)
What part of the brain maintains homeostasis?
Hypothalamus
What structure in the brain is referred to as “the emotional brain?”
Limbic system
What does an extrapyramidal symptom (EPS) mean?
Abnormal involuntary movements
Name the 4 monoamine neurotransmitters in the brain:
Serotonin, Norepinephrine, Histamine, and Dopamine
Explain how (brain chemistry) benzodiazepines work on anxiety:
GABA is the major inhibitory (calming) neurotransmitter in the CNS. Benzodiazepines promote activity by binding to specific receptor sites in GABA
What is eustress?
Good stress
What is distress?
Negative energy that causes problems
Describe the stress response:
It is the “fight or flight response. It is a survival mechanism by which our body and mind become immediately ready to meet a threat or stress
What is posttraumatic stress disorder (PTSD)?
Occurs in people
who have experienced a highly traumatic event which often involves a threat of death or serious injury to self or others, including feelings of intense fear, helplessness, or horror that can often disrupt a person’s ability to carry out ADLs
How is acute stress disorder different from PTSD?
Resolution of the symptoms resolves within 1 month
Describe the levels of anxiety:
1) Mild- normal everyday living.
2) Moderate- selective attentions were an individual sees, hears, and grasps less information than someone not in that state.
3) Severe- perceptual field is greatly reduced and hyperventilation is classic symptom.
4) Panic- most extreme level resulting in markedly disturbed behavior.
Describe the most important properties of defense mechanisms:
Defenses are a major means of managing conflict and affect. They are relatively unconscious, discrete from one another, and adaptive as well as pathological. Although defenses are often the hallmark of major psychiatric syndromes, they are reversible
Defense mechanisms are automatic coping styles to protect individuals from anxiety and save face by blocking feelings, conflicts, and memories. Which defense mechanism is used in a healthy way?
Sublimation and Altruism
What are the 3 functions of the limbic system?
Appraisal of emotional stimuli, initiation of emotional responses (Fight or Flight) with sympathetic nervous system activated and cessation of reactivity after external stressors subside and restores the nervous system to a state of homeostasis via parasympathetic system
What is agoraphobia?
Intense, excessive anxiety about or fear of being in places or situations where help might not be available and escape might be challenging.
In this chapter which disorder is new in the DSM-V?
Hoarding
Which drugs are used to treat the somatic and psychological symptoms of anxiety?
Anxiolytics/antianxiety
Name other classes of medications used to treat anxiety disorders?
Beta-blockers, antihistamines, and anticonvulsants
- Transient –
- Mild –
- Moderate –
- Severe –
- Other depressive disorders
- Transient – Life’s everyday disappointments (your perception of stressors)
- Mild – Normal grief response
- Moderate – Dysthymic disorder
- Severe – Major Depressive disorder (with or without psychotic features)
- Other depressive disorders
• Seasonal affective disorder (SAD)
• Premenstrual dysphoric disorder
• Post-partum depression • Cyclothymia
Major depressive disorder (MDD)—
- Major depressive disorder (MDD)—Single Episode or Recurrent Episodes
• Substantial pain and suffering: psychologic, social, and occupational disability (a change in previous function that can cause significant distress)
• History: one or more major depressive episodes
• No history of manic or hypomanic episodes
• Possible psychotic features
Criteria MDD
• The following occur nearly everyday for most waking hours over the same 2 week period - Must have at least 5 of these symptoms:
- Depressed mood everyday all day
- Anhedonia
- Significant weight loss or gain (5% of body wt.)
- Insomnia or hypersomnia
- Increased or decreased motor activity
- Anergia
- Feeling of worthlessness/inappropriate guilt
- Decreased concentration/indecisiveness
- Recurrent thoughts of death/suicidal ideation (SI)
Dysthymic disorder (DD)
• Early and insidious onset that is less severe than MDD
• Occurs over a 2 year period and present most of the
day
• Chronic depressive syndrome (chronic sadness)
- Decreased or increased appetite
- Insomnia or hypersomnia
- Low energy or fatigue
- Decreased self-esteem
- Poor concentration or difficulty making decisions
- Feeling hopelessness or despair
Secondary Depression caused by
• Accompanying Illnesses - Neuroendocrine - Hormonal Disturbances - Electrolyte Imbalances - Nutritional deficiencies - Other • Complicated Grieving • Senescence – most common psychiatric disorder in elderly
- Older adults are grouped by age:
- Risk factors include?
- Most older adults who commit suicide have visited their primary care physician when?
- Recognition and treatment of depression in the medical setting helps prevent?
- Older adults are grouped by age: 65 to 74 years of age, and 75 years and older
- Risk factors include social isolation, solitary living arrangements, widowhood, lack of financial resources, poor health, and hopelessness
- Most older adults who commit suicide have visited their primary care physician the month before the suicide, sometimes that very day
- Recognition and treatment of depression in the medical setting helps prevent suicide in older adults
Adolescents and Younger Adults • Strongest risk factors, • Other factors: • Frequent episodes of? • Frequent expressions of? • Family loss, • Perception of failure: • Expression of suicidal thoughts when? • Difficulty dealing with? • Unplanned?
• Strongest risk factors, 14 to 24 years of age: Substance abuse, aggression, disruptive behaviors,
depression, and social isolation
• Otherfactors:
• Frequent episodes of running away
• Frequent expressions of rage and problems with parents
• Family loss, instability, and withdrawal
• Perception of failure: school, work, social
• Expression of suicidal thoughts when sad or bored
• Difficulty dealing with sexual orientation
• Unplanned pregnancy
Meds that increase depression
- Steroids
- Hormones
- CNS Depressants- Tranquilizers, Sedative/hypnotics
- Antihypertensive
- Antibacterial/Antifungal
- Antineoplastic
- Analgesics/Anti-inflammatory
- Antiulcer
Biological Theories
• Genetic factors –
• Biochemical factors –
-Primary major neurotransmitters:
Biological Theories
• Genetic factors – suicide clusters in families
• Biochemical factors – medications developed from research to target neurotransmitters
- Primary major neurotransmitters
* Serotonin (5HT)
* norepinephrine (NE)
- Note: Dopamine - to a lesser extent is also related to depression
Psychosocial Theories
- The Stress–Diathesis Model of Depression
- Learned helplessness
- Cultural considerations
Cognitive Theory - Beck’s cognitive triad:
- Negative, self-deprecating view of self
- Pessimistic view of the world
- Belief that negative reinforcement will continue
Areas of Assessment
- Affect
- Thought process
- Mood
- Feelings
- Physical behavior
- Communication
- Religious Beliefs and Spirituality
- Age
- Risk for Harm to Self & Others
Suicide Risk Factors
• Presence of a plan
• Previous suicide attempt
• History of mental disorder, in particular, depression, alcohol, and drug abuse
• Impulsive and aggressive
• Adverse life events, recent
or expected loss
• Hopelessness and isolation
• Family history of mental and substance abuse disorder, suicide, and/or violence
• Incarceration
• Exposure to suicide from family, peers, and others, as well as in the news and fiction
• Chronic physical illness and pain
Suicide
- Intentional act of killing oneself
- They are usually ambivalent about death
- The end to problems
- Suicidal ideation = thoughts about committing suicide
Assessment of suicide plan
- How lethal is the plan?
- Can the client describe the plan exactly?
- Does the client have access to the attended method?
- Has the client’s mood changed?
Sad Persons Scale
S Sex A Age and older D Depression P Previous attempts E Etho (alcohol) or drug use R Rational thinking loss S Social supports lacking O Organized plan N No spouse S Sickness
Sad persons scale guidelines for action
Points Clinical Action
0-2 Send home with follow-up
3-4 Closely follow-up: consider hospitalization
5-6 Strongly consider hospitalization
7-10 Hospitalize or commit
Other Assessment Tools
- Beck Depression Inventory
- Hamilton Depression Scale
- Zung Depression Scale
- Geriatric Depression Scale
- Patient Health Questionaire-9 (PHQ-9)
Diagnostic tools
- MRI
- CT – scan
- PET
- SPECT
Nursing supervision for suicide
- Depressed patients are always at risk for self harm or harm to others and hopelessness is one key indicator
- Nurses must watch for signs: changes in eating, sleeping, concentration, activity level, social interactions, care of personal appearance
- Nurses must always watch/assess for suicide if Antidepressants have been started (black box warning)
Therapeutic Communication •When asking a client about suicide, always use? •Establish a? •Encourage the client to? •Limit the amount of time? •Involve significant others in? •Explore cultural and? •Recommend cognitive?
- When asking a client about suicide, always use a follow-up question if the answer is negative
- Establish a trusting relationship
- Encourage the client to talk about feelings
- Limit the amount of time client spends alone
- Involve significant others in the treatment plan
- Explore cultural and religious beliefs that discourage suicide
- Recommend cognitive behavioral therapy and encourage group attendance
For persons with depression but without psychotic features, a combination of specific psychotherapies may be superior to either psychotherapy or psychopharmacologic treatment alone so combinations of these for example are recommended:
- Cognitive-behavioral therapy (CBT)
- Interpersonal therapy (IPT)
- Antidepressant therapy
Antidepressants
• most prescribed drugs in the U.S. (CDC, 2007)
• serious interactions with food, alcohol and other drugs
• Takes a couple weeks to start working
• Can put patients at increased risk suicide in early
treatment period
• Also used to treat pain, insomnia, anxiety, panic disorder, OCD & eating disorders
Antidepressants: SSRIs
- Prozac (fluoxetine)
- Zoloft (sertraline)
- Celexa (citalopram)
- Lexapro (escitalopram)
Antidepressants: SNRIs
- Effexor (venlafaxine)
* Cymbalta (duloxetine)
Antidepressants: SDNIs
- Wellbutrin (bupropion)
- Trazodone (oleptro)
- Remeron (mirtzapine)
Antidepressants: MAOIs
- Parnate (tranylcypromine)
* Nardil(phenelzine)
Antidepressants: TCAs
- Pamelor (noritriptylline)
- Norpramin (desipramine)
- Anafranil (clomipramine)

Side Effects for SSRIs/SNRIs
• Common S/E: agitation, anxiety, sleep disturbances, tremors, and sexual dysfunction/decreased libido; dry mouth, sweating, wt. changes, nausea, diarrhea
• Adverse S/E: serotonin syndrome,*discontinuation syndrome; Hypertensive crisis if interacts w/MAOI
*Must be titrated on and off of these medications – do not discontinue abruptly
Side Effects for TCAs
• TCA’s cause more sedation and weight gain; more anticholinergic effects: dry mouth, blurred vision, tachycardia, constipation, urinary retention, & esophageal reflux
• Adverse Toxic effects: tachycardia, dysrhythmias, MI, heart block
- Must take for 2-4 weeks before therapeutic blood levels occur – can be lethal with overdose.
Side Effects for SDNIs (Atypical)
• Bupropion (Wellbutrin) – takes 2-3 weeks for treatment; Zyban same medication used for smoking cessation
• CommonS/E:Drymouth,anxiety,headache,tinnitus, dizziness, insomnia, nausea & anorexia (Benefit: is energizing & less weight gain, less sexual side effects)
• Rare adverse side effect: Seizures (doses over 400mg)
• Trazodone (Oleptro) – sedating/prescribed at night; possible
priapism adverse reaction
• Mirtazapine (Remeron) – sedating/prescribed at night; increased confusion and use caution in elderly
MAOI’s Adverse Side Effects
Hypertensive Crisis when tyramine ingested in diet (avoid certain foods) TOXIC effect: increase in BP which can cause intracranial hemorrhage, hyperpyrexia, and convulsions. Foods to avoid:
- Aged, smoked meat, lunchmeat
- Pickled, fermented or spoiled food
- Most cheeses, especially aged cheese
- Alcoholic beverages, wine ( esp. Chianti)
- Some beans, avocados, eggplant, bananas
- Soy sauce, meat tenderizers (MSG)
- Chocolate, figs, raisins
Patient Teaching
- Teach on increased risk suicide 1st weeks
- Avoid CNS depressants (alcohol & drugs)
- Teach managing orthostatic symptoms
- Teach anticholinergic side effects
- Teach diet/weight control
- Teach about sexual dysfunction potential
- Teach about foods to avoid on MAOI’s and contraindication of SSRI’s/other meds (10-14 day between stopping/starting)
- Teach importance of med adherence/report S/E and investigate other forms of treatment
Alternative Treatments
- Rapid Transcranial Magnetic Stimulation (rTMS)
- Vagus Nerve Stimulation (VNS)
- Deep Brain Stimulation (DBS)
- Electroconvulsive Therapy (ECT)
- Light Therapy
- St. John’s Wort
- S-adenosylmethionine (SAMe)
- Peer Support
- Exercise
Bipolar Spectrum Disorders
- Bipolar I disorder
- Bipolar II disorder
- Cyclothymia
- Rapid-cycling bipolar disorder
Bipolar Disorder
• Neurotransmitters involved with mood • High-tech imaging, shows changes in the brain structure • Etiology unclear - Genetic link - Hormone balance involved - Environmental influences - Drugs/Alcohol - TBI
Bipolar I Symptoms
• Manic phases can be cyclic/rapid depression
• Mixed episode – manic and depressed
• Stages
- StageI: Hypomania
- Cheerful, extroverted and hyperactive
- Stage II: Acute Mania
- Euphoric, risky behavior, flight of ideas, grandiose
and may be hallucinating - Stage III: Delirious mania (grave illness)
- Disoriented, labile, frenzied, agitated
Bipolar Assessment
- Mood
- Behavior
- Thought processes & Speech patterns
- Cognitive Function
Nursing Interventions for communication
- Display a firm, calm approach
- Express short, concise explanations or statements
- Remain neutral
- Maintain consistency
- Conduct frequent staff meetings to agree on approach and limit setting
- Hear and act upon legitimate complaints
- Firmly redirect energy
Mood Stabilizers (Anti Manic) • Mood stabilizers (antiseizure meds) most commonly prescribed for anti-manic effects
- Eskalith, Eskalith CR, Lithobid (Lithium)
- Depakene (valproic acid)
- Tegretol (carbamazepine)
- Lamictal (lamotrigine)
- Neurontin (gabapentin)
(Topamax and Trileptal not as frequently used)
• Antipsychotics and antidepressants may be used in combination with mood stabilizers and are commonly prescribed together to treat bipolar disorder
Mood Stabilizer Lithium Facts
- History of discovery beginning 2 A.D.
- Used since the 1950’s/approved in U.S. 1970
- Inexpensive but dangerous if not monitored Works best managing acute mania/hypomania
- Aborts 60 – 80% of acute manic and hypomanic episodes within 10-21 days
- Effects begin within 1 week
- Full effects as early as 14 days
Common Lithium Side Effects
- Tremor, muscle twitches
- Nausea, diarrhea, gas
- Fatigue/cognitive dulling
- Dizziness
- Increased thirst, dry mouth
- Swelling BLE
- Decreased libido
- Increased appetite, weight gain
- Hair loss
- Acne
- Itching/rash
Blood Levels- Lithium • Therapeutic blood level: • Toxic blood level: - Adverse S/E [Hold Lithium]: - Lab draws –
• Therapeutic blood level: 0.8 to 1.4 mEq/L • Maintenance blood level: 0.4 to 1.3 mEq/L
• Toxic blood level: 1.5 to 2.0 mEq/L
- Adverse S/E [Hold Lithium]: Levels > 1.5 mEq/L
- Lab draws – schedule 12 hrs after last dose for trough
Lithium Blood levels(mEq/L) include:
- < 1.5
- 1.5 - 2. 0
- 2.0 - 2.5
- > 2.5
- < 1.5 normal side effects include tremor, vomiting,
diarrhea, polyuria, thirst, fatigue - 1.5 - 2. 0 confusion, twitching muscles, ECG changes, significant GI upset, and polyuria
- 2.0 - 2.5 stupor, seizures, hypotension, ataxia, impaired kidney function, coma, death
- > 2.5 symptoms progress to cardiovascular collapse and death. Long term therapy can lead to kidney damage (renal failure), diabetes insipidus, and hypothyroidism
Lithium Nursing Implications
• Long term therapy can lead to kidney damage, diabetes insipidus, nephritis, and hypothyroidism
• Monitor blood urea nitrogen, creatinine, thyroid, electrolyte levels and drug levels
• Check for drug interactions – 3 major classes identified precipitants of lithium toxicity
- Diuretics (thiazides and spironolactone)
- Angiotensin-converting enzyme (ACE) inhibitors
- Nonsteroidial anti-inflammatory drugs (NSAIDs)
Lithium Patient Teaching
- Tremor is a common side effect of lithium use
- Polyuria is common with lithium use
- Avoid dehydration: Drink 8-12 glasses fluid daily, normal salt intake & diet, normal exercise
- Avoid over the counter drugs
- Teach pt/family potential side effects/toxicity
- Divided dosing schedule/take with meals
- Do not split, crush or chew extended release tabs
- Do not abruptly discontinue; tapered slowly if D/C
- Labs for lithium levels and thyroid/kidney function needed: BUN, creatinine and electrolytes
- Anger is an?
- Aggression is an?
- Violence is?
- A history of violence is single best predictor of?
- Anger is an emotional response to frustration of desire’s, a threat to one’s needs or a challenge
- Aggression is an action or behavior that results in a verbal or physical attack
- Violence is always an objectionable act that involves intentional use of force that can result in injury to another person
- A history of violence is single best predictor of future violence (See Box 24-1, p. 466 for all predictors of high-risk)
- Bullying-
- Horizontal bullying happens between?
- Lateral bullying happens between?
- Bullying- an offensive, intimidating, malicious, condescending behavior designed to humiliate
- Horizontal bullying happens between people with different levels of authority (manager to nurse)
- Lateral bullying happens between those of equal status (nurse to nurse)
Stages of violence
•Preassaultive Stage: Client becomes increasingly agitated
- Intervention: verbal
•Assaultive Stage: Client losses control of behavior
-Intervention: medication, seclusion, and or restraints •Post assaultive Stage
- Debrief/review with the client & help w/coping skills •Critical Incident Debriefing
De-escalation Techniques • Assess: • Use therapeutic communication skills: •Set Limits: • Stay Calm: • Rule of thumb:
- Assess: Does the client have any coping skills? Do they have a tendency to use anger as a defense? So they know their triggers/stressors? Do they have cognitive deficits?
- Use therapeutic communication skills: Teach new skills to manage anger, ask what has helped in past, reflect on client demeanor, mood and affect – “You seem upset”
- Set Limits: Verbalize consequences
- Stay Calm: Use mirroring to de-escalate lowering and slowing down vocal tone, giving client space and maintaining composure, may turn down lights, decrease noise levels (find quiet space or remove other clients from area)
- Rule of thumb: Stay an arm’s length away, closest to door and call other staff (trust your instincts)
