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Mental Health > Final > Flashcards

Final Flashcards

1
Q

Two most important mental health concepts

A

Clear boundaries and safety

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2
Q

4 elements of nurse-patient relationship

A
  1. Dignity and respect (clear boundaries)
  2. Information sharing
  3. Mutual participation (patient is full partner in care)
  4. Collaboration
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3
Q

What encompasses therapeutic use of self? (3)

A
  • using personality consciously and with full awareness to promote healing
  • attempting to establish relatedness
  • structured nursing interventions
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4
Q

6 goals of the nurse-patient relationship

A
  1. Establish nurse as safe, confidential, reliable, consistent
  2. Facilitate communication of distressing thoughts and feelings
  3. Assist with problem solving and development of coping skills
  4. Help patient examine self-defeating behaviors and test alternatives
  5. Promote self-care, recovery, and independence
  6. Provide education on condition and management
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5
Q

3 types of relationships and what they look like

A
  • Intimate (emotional commitment; not allowed in nurse-patient)
  • Personal (mutual needs met; purpose of friendship)
  • Therapeutic (nurse maximizes communication skills, understanding of human behavior, and personal strengths to enhance patient’s growth)
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6
Q

Five steps to establish therapeutic relationship

A
  1. Needs of patient identified and explored
  2. Clear boundaries established
  3. Problem-solving approaches taken
  4. New coping skills developed
  5. Behavioral change supported
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7
Q

4 Do’s of setting boundaries

A
  1. Ensure that the focus of the conversation remains on your patients
  2. Set firm limits and boundaries on negative or inappropriate behavior
  3. Disclose a small amount of personal information (if it will strengthen the therapeutic relationship)
  4. Show genuine concern for patients
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8
Q

7 Don’ts of setting boundaries

A
  1. Behave meanly towards your patient
  2. Become your patients’ friend
  3. Allow your needs to be met at the expense of your patient
  4. Accept cash or gifts for you personally (can blur boundaries)
  5. Excessively touch patients
  6. Try to influence patients’ beliefs
  7. Probe patient about sensitive topics
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9
Q

Transference and when it is intensified

A

The patient unconsciously and inappropriately displaces onto the nurse feelings and behaviors related to significant figures in patient’s past

Intensified in relationships of authority

Can be positive or negative

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10
Q

Countertransference

What is it?
When can it happen?
How to recognize it?

A
  • The nurse unconsciously displaces feelings related to people in his/her past onto patient
  • Patient’s transference to nurse often results in countertransference in the nurse
  • Common sign of countertransference in nurse is over-identification with the patient or strong emotions
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11
Q

Peplau’s Four phases of therapeutic nurse-patient relationship

A
  1. Preorientation phase
  2. Orientation Phase
  3. Working Phase
  4. Termination Phase
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12
Q

Pre-orientation Phase (3)

A
  • Obtain information about the client from chart, significant others, or other health-team members
  • Research client condition
  • Examine one’s own feelings, fears, and anxieties about working with a particular client
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13
Q

Orientation Phase (5)

A
  • Introductions (name, purpose)
  • Patient may discuss feelings, problems, goals
  • Establishing rapport (understanding, harmony, empathy)
  • Specifying a formal/informal contract (including terms of termination; this is with not for patient)
  • Establish confidentiality
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14
Q

Working Phase (6)

A
  • Maintain trust & rapport
  • Gather further data
  • Promote patient’s problem-solving skills & self-esteem
  • Promote symptom management
  • Provide education on diagnosis & medication
  • Evaluate progress
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15
Q

Termination Phase (5)

A
  • Summarize goals & objectives achieved
  • Review items taught
  • Discuss ways to incorporate new coping strategies
  • Review situations of nurse-patient relationship
  • Exchange memories to facilitate closure
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16
Q

What is the greatest trigger for the development of a patient’s nurse- focused transference?

a. The similarity between the nurse and someone the patient already dislikes
b. The nature of the patient’s diagnosed mental illness
c. The history the patient has with the patient’s parents
d. The degree of authority the nurse has over the patient

A

D

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17
Q

What should nurse do if patient interrupts during time with current patient?

A
  • Let the patient know you will meet with them later, the time contracted for one patient is their time
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18
Q

What should nurse do if the Patient threatens suicide? (3)

A
  • Figure out is patient has plan and lethality
  • Share with other staff
  • Discuss patient feelings and circumstances that lead to this decision
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19
Q

What should nurse do if the patient asks the nurse to keep a secret? (2)

A
  • Nurse cannot make such a promise; info may be important to health and safety of others
  • Nurse lets patient know then patient decides to share or not share
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20
Q

What should nurse do if the patient asks the nurse a personal question? (2)

A
  • Nurse can answer or not answer

- If nurse answers, be short then refocus on patient

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21
Q

What should nurse do if patient cries? (3)

A
  • Nurse stays with patient and reinforces that it is alright to cry
  • May inquire about reason for crying
  • Offer tissues when appropriate
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22
Q

What should nurse do if the patient makes sexual advances? (4)

A
  • Nurse sets clear boundaries
  • Nurse frequently states nurse role to maintain boundaries
  • Nurse leaves to give patient time to regain control
  • Reassignment if behavior continues
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23
Q

What should nurse do if patient leaves before session is over?

A
  • Check back in with patient later; they may have needed a break
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24
Q

What should nurse do if patient gives the nurse a present? (2)

A
  • “If the gift is expensive or money, the only policy is to graciously refuse.
  • If it is inexpensive, then (1) if it is given at the end of hospitalization when a relationship has developed, graciously accept; (2) if it is given at the beginning of the relationship, graciously refuse and explore the meaning behind the present
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25
Q

What should nurse do if patient does not want to talk? (3)

A
  • Spend short frequent periods with them
  • Let them know you do not half to talk, you will just spend time with them
  • Both of these establish nurse as reliable
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26
Q

What does verbal Communication communicate? (2)

A
  • Beliefs and values
  • Perceptions and meaning
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27
Q

What does verbal Communication convey? (4)

A
  • Interest and understanding
  • Insult and judgment
  • Clear or conflicting messages
  • Honest or distorted feelings
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28
Q

Examples of Nonverbal communication (8)

A
  • Tone of voice
  • Emphasis on certain words
  • Physical appearance
  • Facial expressions
  • Body posture and movement
  • Amount of eye contact
  • Touch
  • Hand gestures
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29
Q

Double-bind messages

A

Mutually contradictory messages, usually given by a person in power; no-win

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30
Q

How do verbal and nonverbal communication interact? (3)

A
  • Messages can be conflicting or congruent
  • Nonverbal messages and behaviors are less obvious.
  • Verbal message = content; nonverbal behavior = process
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31
Q

Autocratic leader

A
  • Exerts control over the group and does not encourage much interaction
  • Production ↑, morale ↓
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32
Q

Democratic leader

A
  • Supports extensive group interaction in the process of problem solving
  • Production somewhat ↓ than with autocratic leadership, morale much ↑
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33
Q

Laissez-faire Leader

A
  • Allows the group members to behave in any way they choose and does not attempt to control the direction
  • goals are undefined
  • Productivity and morale ↓
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34
Q

Milieu therapy (3)

A
  • a psychiatric philosophy involving a secure environment to support recovery
  • uses naturally occurring events as learning opportunity for patients
  • involves consistency and structure (Structured aspects of the milieu include activities, rules, reality orientation practices, and environment)
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35
Q

Peplau’s Therapeutic Milieu (2)

A
  • recognizes the people (patients and staff), the setting, the structure, and the emotional climate as important to healing
  • offers patients a sense of security and promotes healing.
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36
Q

4 steps of Milieu Therapy/Management

A
  1. Orienting patients to rights and responsibilities
  2. Providing culturally sensitive care
  3. Selecting activities (individual & group) meet patients’ physical and mental health needs
  4. Using the least restrictive environment (consistent and routine)
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37
Q

Paraphrasing (2)

A
  • when you restate the basic content of a patient’s message in different, usually fewer, words.
  • Using simple, precise, and culturally relevant terms, the nurse may confirm an interpretation of the patient’s message and patient confirms or denies
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38
Q

Restating (3)

A
  • Repeats the main idea expressed to give the patient an idea of what has been communicated.
  • If the message has been misunderstood, the patient can clarify it
  • avoid overuse
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39
Q

Reflecting (4)

A
  • Directs questions, feelings, and ideas back to the patient.
  • Encourages the patient to acknowledge and own personal ideas and inner feelings.
  • Encourages the patient to think of oneself as a capable person and acknowledges the patient’s right to have opinions and make decisions 
  • useful when patient asks for advice
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40
Q

Exploring (2)

A
  • Examines certain ideas, experiences, or relationships more fully by asking for more details
  • If the patient chooses not to elaborate by answering no, the nurse does not probe or pry.
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41
Q

Using Silence (4)

A
  • gives person time to collect thoughts or think through a point
  • some patients have slower thinking process
  • avoid with young people who may be uncomfortable with silence
  • allows patient to take control of the discussion if they desire
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42
Q

Active Listening

A

-nurses focus, respond, and remember what patient says verbally and nonverbally

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43
Q

Making Observations (4)

A
  • Calls attention to the person’s behavior (i.e. trembling, nail-biting, restless mannerisms)
  • Encourages patient to notice the behavior and describe thoughts and feelings for mutual understanding.
  • Posture change, facial expressions, behavioral change, etc. → what happened?
  • Helpful with mute and withdrawn people
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44
Q

Offering self

A
  • offers presence, interest, desire to understand
  • not offered to get person to talk or behave in a specific way
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45
Q

Offer General leads (2)

A
  • allow patient to choose direction
  • indicates nurse is interested in what comes next
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46
Q

Reflecting Examples (2)

A

Patient: “What should I do about my husband’s affair?”

Nurse: “What do you think you should do?”

OR

Patient: “My brother spends all of my money and then has the nerve to ask for more.”

Nurse: “You feel angry when this happens?”

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47
Q

Making Observations Examples(3)

A
  • “You appear tense.”
  • “I notice you’re biting your lips.”
  • “You seem nervous whenever John enters the room.”
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48
Q

Open-ended questions (3)

A
  • encourage patients to share information about experiences, perceptions, or responses to a situation.
  • not intrusive and do not put the patient on the defensive
  • useful in the beginning of an interview or when a patient is guarded or resistant to answering questions.
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49
Q

Closed-ending questions (2)

A
  • used sparingly, can give you specific and needed information.
  • most useful during an initial assessment, intake interview, or to determine specific results
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50
Q

Projective questions

A
  • usually start with a “what if” to help people articulate, explore, and identify thoughts and feelings.
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51
Q

Miracle question

A

A goal-setting question that helps patients to see what the future would look like if a particular problem were to vanish

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52
Q

Nontherapeutic communication (10)

A
  • excessive questioning
  • Approval/disapproval- value judgement
  • giving advice or interpretations
  • probing on sensitive topics
  • force treatments
  • asking why
  • minimizing
  • false reassurance
  • changing subjects
  • participate in negative behavior
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53
Q

4 Do’s in Client Interview (besides therapeutic communication)

A
  • keep focus on facts and patient perceptions
  • pay attention to nonverbal communication
  • encourage patient to look at pros and cons of treatment
  • if patient makes serious accusations, explore with senior staff and clarify perceptions
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54
Q

After introductions in the clinical interview, what should you do?

A

Turn conversation over to patient with an open-ended question

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55
Q

Methadone Side effects (5)

A
  • shallow or deep breathing
  • lightheadedness
  • chest pounding
  • hives and rashes
  • swelling of HEENT area
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56
Q

Methadone (3 notes)

A
  • synthetic slow acting agonist opioid (may have withdrawal symptoms), 1x a day
  • blocks euphoria, reduces cravings and prevents pure opioid withdrawal symptoms (lacrimation, rhinorrhea, pupillary dilation, yawning)
  • low dose = safest for pregnant women (neonatal withdrawal will be mild and managed w/ paregoric)
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57
Q

6 Symptoms of Wernicke-Korsakoff Syndrome

A
  • Altered gait
  • confusion
  • vestibular dysfunction
  • ocular motility abnormalities
  • sluggish reaction to light
  • anisocoria (unequal pupil size)
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58
Q

Wernicke-Korsakoff Syndrome

What is the cause?
What is the treatment?
What is the difference between the two?

A
  • Wernicke’s encephalopathy: acute and reversible condition (responds rapidly to Thiamine over 1-2 weeks)
  • Korsakoff’s syndrome is severe and chronic version of Wernicke’s encephalopathy (treated w/ Thiamine but no full recovery)
  • Both due to thiamine deficiency from malnourishment (drinking over eating) or poor nutrition
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59
Q

Normal anxiety

A

-Necessary for survival and provides energy to carry out tasks; constructive

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60
Q

Mild Anxiety (3)

A
  • Everyday problem-solving leverage to perceive reality in sharp focus
  • Grasps more information effectively
  • Coping mechanisms used
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61
Q

Mild Anxiety symptoms (6)

A
  • Slight discomfort
  • restlessness
  • attention-seeking behavior
  • easily startled
  • irritability/ impatience
  • mild tension-relieving behaviors (nail biting, fidgeting, finger taping)
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62
Q

Moderate Anxiety (6)

A
  • Selective inattention unless pointed out
  • Clear thinking hampered
  • Problem solving can happen, but not optimal
  • Defense mechanisms start here
  • can be constructive and indicate danger
  • SNS activation happens here
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63
Q

Moderate Anxiety symptoms (6)

A
  • muscle tension (and more tension relieving behaviors such as pacing, banging hands on table)
  • increase HR and RR
  • perspiration
  • mild somatic symptoms (gastric discomfort, headache, backache, urinary urgency, insomnia)
  • voice tremors and change in pitch
  • shakiness
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64
Q

Severe level of Anxiety (4 notes)

A
  • Perceptual field greatly reduced
  • Difficulty concentrating on environment even if pointed out
  • Dazed and Confused ; no problem solving or learning
  • all behavior is automatic and aimed at reducing anxiety
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65
Q

Severe anxiety Physical Symptoms (5)

A
  • more intense somatic (chest discomfort, nausea, dizziness, insomnia)
  • hyperventilation
  • trembling
  • pounding heart
  • diaphoretic
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66
Q

Severe anxiety Psychological Symptoms (5)

A
  • sense of impending doom and dread (purposelessness)
  • confusion
  • withdrawal
  • loud and rapid speech
  • threats and demands
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67
Q

Panic level of Anxiety (4)

A
  • Markedly dysregulated behavior and exhaustion
  • Unable to process reality and environment and may lose touch
  • life threatening
  • Automatic behaviors are used to reduce anxiety; may be ineffective*
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68
Q

Panic level of Anxiety Symptoms (8)

A
  • uncoordinated
  • erratic and impulsive ( including pacing, running, shouting, screaming)
  • severe withdrawal
  • hallucinations or delusions
  • terror
  • unintelligible communication (amplified or muffled speech)
  • somatic complaints increase (numbness, tingling, shortness of breath, dizziness, palpitations, overheating, chills, chest pain)
  • immobility or severe hyperactivity or flight
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69
Q

How does anxiety level affect perceptual field?

A

Mild: heightened
Moderate: narrowed, grasp less of what is going on
Severe: greatly reduced and distorted
Panic: unable to attend to environment

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70
Q

How does anxiety level affect focus?

A

Mild: focus is flexible; aware of anxiety
Moderate: focus on source of anxiety , less able to pay attention
Severe: focuses on details or one specific detail, scattered attention
Panic: focus is lost, may feel depersonalization or derealization

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71
Q

How does anxiety level affect problem-solving ability?

A

Mild: ability to work effectively and examine alternatives
Moderate: possible but not optimal
Severe: feels impossible; unable to connect events and details
Panic: completely unable to process what is happening; disorganized and irrational reasoning

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72
Q

2 General Interventions for mild to moderate anxiety

A
  • use therapeutic communication and calm presence techniques
  • closing off topics and bring up irrelevant details can increase anxiety
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73
Q

3 general Interventions for severe to panic anxiety

A
  • priority interventions are patient safety and meeting physical needs; seclusion and restraints may be necessary
  • they are unable to problem solve so therapeutic communication ineffective
  • focus on reinforcing environment and reality
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74
Q

Antidepressants used for Anxiety disorders (8)

A

-1st line of defense and treat comorbid depression

SSRIs

  • fluoxetine and sertraline are most activating
  • paroxetine is more calming
  • escitalopram
  • Fluvoxamine (for OCD)

SNRIs
Venlafaxine-for anxiety, depression, nerve pain
Duloxetine (GAD)

TCA (clomipramine for OCD)

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75
Q

Usage of Benzodiazepines for Anxiety (4 notes)

Ex: clonazepam, diazepam, lorazepam, chlordiazepoxide, Alprazolam (short term for PD and agoraphobia)

A
  • antianxiety (treat somatic and psychological symptoms)
  • quick onset
  • dependence and paradoxical reactions
  • not recommended in pregnancy, older adults, comorbid SUD
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76
Q

Usage of antihistamines for Anxiety

A

Hydroxyzine; safe non addictive alternative to benzodiazepines

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77
Q

Usage of Buspirone for anxiety (5)

A
  • antianxiety (treat somatic and psychological symptoms)
  • no dependence or CNS depressant
  • 2-4 weeks for full effect (effects start in 1-2 weeks)
  • not recommended for those with impaired hepatic, renal
  • safe for fetus
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78
Q

Usage of anticonvulsants for Anxiety

Ex. gabapentin, pregabalin

A
  • for GAD and social anxiety
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79
Q

Usage of antipsychotics for Anxiety

A

Only for more severe symptoms

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80
Q

Usage of noradrenergic drugs for Anxiety (3)

A
  • slow HR and BP
  • Propranolol-short-term relief social anxiety
  • Clonidine- PD and other anxiety
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81
Q

Intervention for mild to moderate anxiety:

Help the patient identify anxiety. “Are you comfortable right now?”

What is the rationale:

A

Rationale: It is important to validate observations with the patient, name the anxiety, and start to work with the patient to lower anxiety.

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82
Q

Intervention for mild to moderate anxiety:

Use nonverbal language to demonstrate interest (e.g., lean forward, maintain eye contact, nod your head)

What is the rationale:

A

Rationale: Verbal and nonverbal messages should be consistent. The presence of an interested person provides a stabilizing focus.

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83
Q

Intervention for mild to moderate anxiety:

Encourage the patient to talk about feelings and concerns.

What is the rationale:

A

Rationale: When concerns are stated aloud, problems can be discussed and feelings of isolation decreased.

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84
Q

Intervention for mild to moderate anxiety:

Avoid closing off avenues of communication that are important to the patient. Focus on the patient’s concerns.

What is the rationale:

A

Rationale: When staff anxiety increases, changing the topic or offering advice is common but leaves the person isolated.

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85
Q

Intervention for mild to moderate anxiety:

Help the patient to identify thoughts or feelings before the onset of anxiety. “What were you thinking right before you started to feel anxious?”

What is the rationale:

A

Rationale: The patient is helped to identify thoughts and feelings, and problem solving is facilitated.

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86
Q

Intervention for mild to moderate anxiety:

Help the patient to develop alternative solutions to a problem through role-play or modeling behaviors.

What is the rationale:

A

Rationale: Encouraging patients to explore alternatives increases their sense of control and decreases anxiety.

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87
Q

Intervention for mild to moderate anxiety:

Explore behaviors that have worked to relieve the patient’s anxiety in the past.

What is the rationale:

A

Rationale: The patient is encouraged to mobilize successful coping mechanisms and strengths

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88
Q

Intervention for mild to moderate anxiety:

Provide outlets for working off excess energy (e.g., walking, playing ping-pong, dancing, exercising).

What is the rationale:

A

Rationale: Physical activity can provide relief of built- up tension, increase muscle tone, and increase endorphin levels.

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89
Q

Intervention for mild to moderate anxiety:

Anticipate anxiety-provoking situations.

What is the rationale:

A

Rationale: “Escalation of anxiety to a more disorganizing level is prevented.”

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90
Q

Intervention for severe to panic anxiety:

Use a low-pitched voice; speak slowly.

What is the rationale:

A

Rationale: A high-pitched voice can convey anxiety. Low pitch can decrease anxiety.

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91
Q

Intervention for severe to panic anxiety:

Reinforce reality if distortions occur (e.g., seeing objects that are not there or hearing voices when no one is present).

What is the rationale:

A

Rationale: Anxiety can be reduced by focusing on and validating what is going on in the environment.

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92
Q

Intervention for severe to panic anxiety:

Listen for themes in communication.

What is the rationale:

A

Rationale: verbal communication themes may be the only indication of the patient’s thoughts or feelings.

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93
Q

Intervention for severe to panic anxiety:

Attend to physical and safety needs when necessary (e.g., need for warmth, fluids, elimination, pain relief, family contact)

What is the rationale:

A

Rationale: High levels of anxiety may obscure the patient’s awareness of physical needs

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94
Q

Intervention for severe to panic anxiety:

Physical limits may have to be set. Speak in a firm, authoritative voice

What is the rationale:

A

Rationale: A person who is out of control is often terrorized. Staff must offer the patient and others protection from destructive and self- destructive impulses.

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95
Q

Intervention for severe to panic anxiety:

Provide opportunities for exercise (e.g., walk with nurse, punching bag, ping- pong game).

What is the rationale:

A

Rationale: Physical activity helps channel and dissipate tension and may temporarily lower anxiety.

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96
Q

Intervention for severe to panic anxiety:

When a person is constantly moving or pacing, offer high-calorie fluids.

What is the rationale:

A

Rationale: Dehydration and exhaustion must be prevented.

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97
Q

Intervention for severe to panic anxiety:

Assess need for medication or seclusion after other interventions have been tried and have been unsuccessful.

What is the rationale:

A

Rationale: Exhaustion and physical harm to self and others must be prevented.

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98
Q

Obsessions

A

thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind

-seem senseless and cause distress and anxiety

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99
Q

Compulsions (3)

A
  • Ritualistic behaviors an individual feels driven to perform
  • temporaily reduce anxiety or prevent imagined calamity
  • time-consuming and interfere with function
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100
Q

Why should you not stop people doing compulsions? What should you do instead?

A

Do not stop people while doing obsessions and compulsions because they do it to relieve their anxiety. Stopping them will increase their anxiety. You should wait for them to finish

Nurse should relieve anxiety, not control behavior

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101
Q

Bipolar I disorder (3)

A
  • most severe bipolar; shifts in mood, energy, and ability to function
  • at least one Mania episode followed by hypomanic or major depressive episode
  • chronic interpersonal or occupational difficulties exist even during remission
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102
Q

Hypomania (3)

A
  • low-level and less dramatic mania; euphoric and increases functioning for at least 4 days
  • psychosis is never present; hospitalization is rare
  • usually does not impact social or occupational functioning in a way noticeable to others
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103
Q

How does mood look in bipolar disorder? (3)

A
  • Unstable euphoria that could quickly change to irritation and anger
  • Boundless enthusiasm, friendliness, self-confidence
  • More time depressed vs manic
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104
Q

How does behavior look in bipolar? (5)

A

o Big appetites for social, spending, activities, sex
o Makes grand plans and stays busy all hours of day and night
o Easily distracted
o May manipulate and exploit vulnerabilities of others
o May skip sleep for days -> worsens mania and physical exhaustion

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105
Q

Pressured speech

A

fast (rapid to frenetic) with inappropriate sense of urgency; often loud and incoherent; individual may dominate conversation

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106
Q

Circumstantial speech

A

addition of unnecessary details when communicating; person eventually gets to the point

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107
Q

Tangential speech

A

similar to circumstantial speech, but they forget the point but often a common word connects sentences to each other (awareness of losing the point and less tangential speech indicate less thought disturbance)

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108
Q

Name the Thought Process:

Ex. I had to do my laundry that day because it was Saturday. On Saturday, I always watch Ninja Turtles on television. Have you seen those 60-inch televisions? Giants. I used to think of giants as I fell asleep, and I thought that sleep activated them.

A

Tangenital speech

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109
Q

Loose associations

A

disordered way of processing information; thoughts are only loosely connected to each other in person’s conversation

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110
Q

Name the thought process

Ex. The sky’s the limit now that I have money. I took a flight, you know, from Kennedy. Drinking beer is a belly full of bags

A

Loose associations

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111
Q

Flight of ideas (2)

A

continuous flow of rapid, verbose, circumstantial speech with abrupt changes from topic to topic

Speech may be disorganized and incoherent; often uses associations, plays on words, jokes, teasing

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112
Q

Name the thought process:

How are you doing, kid, no kidding around, I’m going home … home sweet home … home is where the heart is, the heart of the matter is I want out and that ain’t hay … hey, Doc … get me out of this place.

A

Flight of ideas

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113
Q

Clang associations (and when it happens)

A

stringing together of words because of their rhyming sounds, w/o regard to meaning

may happen after flight of ideas as mania escalates

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114
Q

Name the thought process:

Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote.

A

Clang associations

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115
Q

Grandiose delusions

A

highly inflated self-regard; apparent in both ideas expressed and person’s behavior (religious, science fiction, supernatural themes are common)

ex. Brianna believes she is a famous playwriter

seen in schizophrenia and bipolar

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116
Q

Persecutory delusions

A

common in bipolar and Schizo; Believing that one is being singled out for harm or prevented from making progress by others

Ex. God or FBI is watching

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117
Q

5 barriers to bipolar treatment

A
  • individuals often ambivalent (avg. 10 yrs before getting treatment)
  • lack of adherence to mood stabilizers often leads to relapse.
  • self-medicating w/ alcohol complicates things and delays treatment
  • patients may minimize or deny consequences of their behavior
  • patient may be reluctant to give up the mania or hypomania
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118
Q

When is hospitalization indicated for bipolar depressive episodes?

A

when suicidal ideation, psychosis, catatonia

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119
Q

What is purpose of hospitalization in acute mania ? (3)

A

a. provide safety in BPD I mania via imposing external control and stabilizing with medication
b. limits set in firm, nonthreatening, and neutral manner to prevent escalation of behavior and safe boundaries
c. Ensure structure, clear expectations, needs are met (nutrition, sleep, hygiene, elimination)

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120
Q

What is the rationale for the following intervention in bipolar ?

Use firm and calm approach: “John, come with me. Eat this sandwich.”

A

Structure and control are provided for a patient who is out of control. Believing that someone is in control may improve feelings of security.

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121
Q

What is the rationale for the following intervention in bipolar?

Use short and concise explanations or statements.

A

Structure and control are provided for a patient who is out of control. Believing that someone is in control may improve feelings of security.

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122
Q

What is the rationale for the following intervention in bipolar?

Be consistent in approach and expectations.

A

Consistent limits and expectations minimize potential for patient’s manipulation of staff.

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123
Q

What is the rationale for the following intervention in bipolar?

Identify expectations in simple, concrete terms with consequences.

Example: “John, do not yell at or hit Peter. If you cannot control yourself, we will help you.” Or “The seclusion room will help you feel less out of control and prevent harm to yourself and others.”

A

Clear expectations help the patient experience outside controls as well as understand reasons for medication, seclusion, or restraints (if he or she is not able to control behaviors).

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124
Q

What is the rationale for the following intervention in bipolar?

Hear and act on legitimate complaints.

A

Underlying feelings of helplessness are reduced, and acting-out behaviors are minimized.

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125
Q

What is the rationale for the following intervention in bipolar ?

Firmly redirect energy into more appropriate and constructive channels.

A

Distractibility is the most effective tool with the patient experiencing mania.

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126
Q

What is the rationale for the following intervention in bipolar?

Maintain low level of stimuli in patient’s environment (e.g., away from bright lights, loud noises, and people).

A

Escalation of anxiety can be decreased.

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127
Q

What is the rationale for the following intervention in bipolar ?

Provide structured solitary activities with nurse or aide.

A

Structure provides security and focus.

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128
Q

What is the rationale for the following intervention in bipolar?

Provide frequent high-calorie fluids.

A

Serious nutritional deficiencies and dehydration are addressed.

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129
Q

What is the rationale for the following intervention in bipolar?

Redirect aggressive behavior.

A

Physical exercise can decrease tension and provide focus.

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130
Q

What is the rationale for the following intervention in bipolar?

In acute mania, use as needed medication, seclusion, and/or restraint to minimize physical harm.

A

Exhaustion can result from dehydration, lack of sleep, and constant physical activity.

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131
Q

What is the rationale for the following intervention in bipolar ?

Encourage frequent rest periods during the day.

A

Lack of sleep can lead to exhaustion and increase mania.

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132
Q

What is the rationale for the following intervention in Bipolar Disorder?

Keep patient in areas of low stimulation.

A

Relaxation is promoted, and manic behavior is minimized.

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133
Q

What to note about taking lithium? (4)

A
  • Not addictive but taper dose to reduce relapse of mania though
  • maintain sodium and fluid levels( 1500–3000 mL/day or six 12-oz glasses of fluid)
  • take with meals to reduce stomach irritation)
  • narrow therapeutic range so check levels regularly
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134
Q

Signs of <1.5 mEq/L Lithium toxicity (8)

A
  • N/V/D
  • thirst
  • polyuria (producing too much urine)
  • lethargy, sedation
  • fine hand tremor
  • Renal toxicity
  • goiter
  • hypothyroidism
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135
Q

Interventions of <1.5 mEq/L Lithium toxicity (2)

A

Doses should be kept low.

assess Kidney function and thyroid levels before treatment and then on an annual basis.

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136
Q

Interventions of 1.5-2.0 mEq/L early Lithium toxicity (3)

A

-hold medication
-measure blood lithium levels
-reevaluate dosage

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137
Q

Signs of 1.5-2.0 mEq/L early Lithium toxicity (7)

A
  • GI upset
  • coarse hand tremor
  • confusion
  • hyperirritability of muscles,
  • EEG changes
  • sedation
  • incoordination
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138
Q

Signs 2.0–2.5 mEq/L advanced Lithium toxicity (8)

A
  • Ataxia/ giddiness
  • serious EEG changes
  • blurred vision
  • clonic or seizure movements
  • large output of dilute urine
  • severe hypotension
  • coma/ stupor
  • Death is usually secondary to pulmonary complications.
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139
Q

Interventions of 2.0–2.5 mEq/L advanced Lithium toxicity (3)

A
  • hospitalization
  • hold drug and haste excretion
  • Whole bowel irrigation may be done to prevent further absorption
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140
Q

Signs of >2.5 mEq/L severe Lithium toxicity (3)

A

convulsions, oliguria (none or small amount of urine), death

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141
Q

Interventions of >2.5 mEq/L severe Lithium toxicity

A

-same as others plus hemodialysis

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142
Q

5 precautions for lithium

A

avoid diuretics, NSAIDS, if N/V/D present

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143
Q

When are anticonvulants used in bipolar? (5)

A

o continuously cycling patients

o no family history of bipolar

o to diminish impulsive and aggressive behavior in nonpsychotic pts

o useful when alcohol or benzodiazepine withdrawal

o useful to control mania (within 2 wks) and depression (within 3 wks)

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144
Q

Valporate usage

A
  • FDA approved anticonvulsant for acute mania and preventing future manic episodes; black box warning though for teratogenicity
    o Divalproex and valproic acid
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145
Q

Verbal and nonverbal cues of suicide (2)

A
  • Clues may be in overt/open or concealed/covert statements to someone patient trusts like nurse)
  • be wary of sudden bursts in energy, giving away possessions
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146
Q

5 Hard methods of suicide

A

gun, hanging, poison, car crash, jumping

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147
Q

3 soft methods of suicide

A

pills, gases, cutting wrists

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148
Q

6 specific questions to ask about suicide

A
  • 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?
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149
Q

What are four suicide precautions in the hospital?

A
  • One-to-one observation, 24hrs
  • Record mood, verbatim statements, behavior (esp hands)
  • Remove glass, silverware, “sharps”, strangulation risks
  • Observe patient swallowing medication
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150
Q

Persistent Depressive disorder (3)

A
  • chronic low-level depression most of the day for the majority of days AND at least two of the following: increased/decreased appetite, insomnia/hypersomnia, low energy, poor self-esteem, difficulty thinking, hopelessness
  • feelings last 2 yrs in adults, 1 yr in children and adolescents; often early onset
  • not severe enough for hospitalization
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151
Q

Major depressive disorder (3)

A
  • persistent depression lasting a minimum of 2 weeks (may last 5-6 months or even > 2 yrs)
  • Primary symptoms: depressed mood, loss of interest/pleasure
  • Secondary symptoms: significant weight changes, insomnia or hypersomnia, psychomotor retardation or agitation, fatigue, feeling worthless, thinking problems, thoughts on death (suicidal ideation, hx of suicide, suicide plan)
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152
Q

Appearance in depression (3)

A

neglected personal hygiene, grooming, dressing; lack of eye contact; slumped posture

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153
Q

Behavior in depression (5)

A
  • Anergia (abnormal lack of energy)
  • psychomotor retardation (fixed gaze, slow movements, lack of facial expressions, even incontinence)
  • some have psychomotor agitation (pacing, tension-relieving behaviors)
  • Vegetative signs of depression (alteration in physical life and growth activities) including appetite changes, bowel changes, sleep disturbance
  • low libido or impotence
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154
Q

Feelings and Emotions in depression (5)

A

specific and can change quickly

  • worthlessness (inadequate to unrealistic negative self-eval),
  • guilt (ruminate over failures),
  • helplessness (inability to problem solve)
  • hopelessness (^ suicidality),
  • anger and irritability (active byproducts)
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155
Q

Affect vs mood in depression

A

Mood is general emotional state (often depressed)

Affect is outward emotional state; may be congruent or incongruent with mood (often constricted, blunt, or flat)

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156
Q

Speech in depression

A

slow and softy; may also be monotone and lack spontaneity

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157
Q

Thought Processes in depression

A

poverty of thought (slow thinking), responses slow or absent, may even be mute in severe depression

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158
Q

Thought content and perceptions in depression

A

psychosis (delusions and hallucinations) may be present and ^ suicidality; psychosis may be mood congruent or incongruent

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159
Q

Cognitive Changes and judgement in depression

A

impaired concentration ( attention, short-term and working memory, verbal and nonverbal learning) which may linger after treatment

-poor judgment may lead to indecisiveness

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160
Q

What may be used if someone acutely suicidal since antidepressants have slow onset?

A

Electroconvulsive therapy

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161
Q

What do all antidepressants have in common? (5)

A
  • All have similar efficacy( in improving self-concept, social withdrawal, vegetative signs, activity level)
  • May induce psychotic or manic episode in those with schizophrenia or bipolar disorder
  • All have delayed response (3 month trials)–1-3 wks for improvement to be seen, maintain for 6-9 months after remission of symptoms
  • discontinuation syndrome
  • black box warning for suicidal thoughts and behaviors
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162
Q

4 things to note about SSRIs and depression

A
  • 1st line of treatment for major depression (w/ anxiety and psychomotor agitation as well)
  • Some SSRIs activate and others sedate; choice depends on patient symptoms
  • Risk of lethal overdose minimized with SSRIs
  • low side-effect profile and no anticholinergic effects
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163
Q

4 Patient teaching for MAOI

A
  • give wallet card with MAOI regimen
  • avoid asian restaurants
  • go to ED immediately if severe headache
  • maintain dietary and drug restrictions for 14 days after MAOI stopped
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164
Q

Symptoms of MAOI hypertensive crisis (5 early)

A

Early symptoms: irritability, anxiety, flushing, sweating, and a severe headache.

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165
Q

Symptoms of MAOI hypertensive crisis (4 late)

A

Late symptoms: severe fever, seizures, cerebrovascular accident, intracranial hemorrhage

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166
Q

4 Other foods with Tyramine

A

protein dietary supplements, soups with protein extract, shrimp paste, soy sauce

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167
Q

Food with yeast with Tyramine

A

yeast extract (marmite, bovril)

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168
Q

milk products with Tyramine

A

most cheeses except cottage cheese, cream cheese, yogurt, and milk

169
Q

Fish with Tyramine

A

Dried or cured fish; fermented, smoked, aged, or spoiled fish

170
Q

Sausages with tyramine

A

fermented (bologna, pepperoni, salami)

171
Q

Meats with Tyramine

A

fermented, smoked, aged, spoiled meats, and liver, unless very fresh

172
Q

Fruits with tyramine

A

figs, bananas in large amounts

173
Q

Vegetables with tyramine

A

avocados, fermented bean curd, soybean or soybean paste

174
Q

3 MAOIs used in depression

A

Isocarboxazid, Phenelzine, and Selegiline (patch w/o strict diet at lowest dose),

175
Q

What is the rationale for the following intervention with depression:

When a patient is silent, use the technique of making observations: “There are many new pictures on the wall.” “You are wearing your new shoes.”

A

When a patient is not ready to talk, direct questions can raise the patient’s anxiety level and frustrate the nurse. Pointing to commonalities in the environment draws the patient into and reinforces reality.

176
Q

What is the rationale for the following intervention with depression:

Avoid platitudes such as “Things will look up” or “Everyone gets down once in a while.”

A

Platitudes tend to minimize the patient’s feelings and can increase feelings of guilt and worthlessness because the patient cannot “look up” or “snap out of it.”

177
Q

What is the rationale for the following intervention with depression:

Use simple, concrete words.

A

Slowed thinking and difficulty concentrating impair comprehension.

178
Q

What is the rationale for the following intervention with depression:

Allow time for the patient to respond.

A

Slowed thinking necessitates time to formulate a response.

179
Q

What is the rationale for the following intervention with depression:

Listen for covert messages, and ask about suicide plans.

A

People often experience relief and decrease in feelings of isolation when they share thoughts of suicide.

180
Q

What is the rationale for the following intervention with depression:

Encourage formation of supportive relationships, such as individual therapy, support groups, and peer support.

A

Such relationships reduce social isolation and enable the patient to work on personal goals and relationship needs.

181
Q

What is the rationale for the following intervention with depression:

Provide information referrals, when needed, for religious or spiritual support

A

Spiritual and existential issues may ^ during episodes; people find strength, support, and comfort in spirituality or religion

182
Q

What should you know about furosemide?

A

It is a diuretic which can promote sodium loss and thereby increase the risk for lithium toxicity

Toxicity can occur because in the presence of low sodium, renal excretion of lithium is reduced, causing lithium levels to rise

183
Q

What is the rationale for the following intervention with depression:

Work with the patient to identify cognitive distortions that result in a negative self-perception. For example:

  1. Overgeneralizations
  2. Self-blame
  3. Mind reading
  4. Discounting of positive attributes
A

Cognitive distortions reinforce a negative inaccurate perception of self and world.

  1. Taking one fact or event and making a general rule out of it (“He always…”; “I never…”).
  2. Consistently blaming self.
  3. Despite a lack of evidence, assumes that others don’t like him or her.
  4. Focusing on the negative
184
Q

Delusions

A

false beliefs that are held despite a lack of evidence to support them

185
Q

Referential delusion and example

A

A belief that events or circumstances that have no connection to you are somehow related to you

Ex. Sarah believes that songs on the radio are chosen to send her a message.

186
Q

Somatic delusion and example

A

Believing that the body is changing in unusual ways

Ex. Chris says that her heart is dead and rotting away.

187
Q

Control delusion and example

A

Believing that another person, group, or external force controls your feelings, impulses, or behavior

Ex. Brian covered his apartment walls with aluminum foil to block aliens’ efforts to control his thoughts

188
Q

Nihilistic delusion and example

A

The conviction that a major catastrophe will occur

Ex. Deepesh is giving away all his belongings since they won’t be of any use when the comet hits.

189
Q

Word Salad and example

A

Extreme associative looseness; jumble of words which are meaningless to listener

Ex: agents want strength of policy on a boat reigning supreme

190
Q

Echolalia

A

pathological repetition of another’s words, may be due to patient’s thought processes being so impaired that they are unable to generate speech of their own.

191
Q

Neologism

A

Words that have meaning for patient but a different or nonexistent meaning of others

Ex. His mannerologies are poor

192
Q

Paranoia

A

An irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you)

193
Q

Why is paranoia dangerous in the schizophrenic?

A

may result in dangerous defensive actions such as harming another person before that person can harm the patient”

194
Q

Hallucinations

A

perception of sensory experience for which no external source exists

195
Q

4 ways to recognize person is experiencing an auditory hallucination

A
  1. tracking motions (turning one’s head in the direction of the perceived sound)
  2. lips moving silently
  3. talking as if to another when no one is present
  4. otherwise unexplained changes in affect (e.g., suddenly laughing with no apparent reason).
196
Q

Why are command hallucinations particularly concerning?

A

particularly concerning because person is directed to take action and may be warning of a psychiatric emergency

197
Q

Three things to assess in a patient whom you feel is experiencing command hallucinations?

A
  1. Assess what patient hears
  2. the source it is attributed to
  3. patient’s ability to recognize the hallucination as not real and resist commands
198
Q

Catatonia (definition, most common, persistent impact)

A

pronounced increase or decrease in the rate and amount of movement.

Most common form is when the person moves little or not at all

Persistent catatonia may contribute to rigidity/catalepsy, exhaustion, pneumonia, blood clotting, malnutrition, or dehydration

-in schizophrenia

199
Q

Motor retardation or agitation

A

Pronounced slowing of movement or excited behavior in response to internal or external stimuli.

-in schizophrenia

200
Q

Stereotyped behaviors

A

Repetitive behaviors that do not serve a logical purpose
-in schizophrenia

201
Q

Echopraxia

A

The mimicking of movements of another

-in schizophrenia

202
Q

Impaired impulse control

A

A reduced ability to resist one’s impulses.

Ex: interrupting others or throwing unwanted food on the floor; increases risk of assault.

-in schizophrenia, ADHD, borderline

203
Q

Boundary impairment

A

An impaired ability to sense where one’s body or influence ends and another’s begins

-in schizophrenia

204
Q

5 negative symptoms of schizophrenia

A

Anhedonia (lack of pleasure)
Avolition (lack of goal-directed behavior or motivation)
Asociality (decreased desire for social interaction)
Apathy (decreased interest in activities)
Alogia (reduction in speech)

205
Q

5 affects seen in schizophrenia

A

i. Flat: Immobile or blank facial expression

ii. Blunted: Reduced or minimal emotional response

iii. Constricted: Reduced in range or intensity (e.g., shows sadness or anger but no other moods)

iv. Inappropriate: Incongruent with the actual emotional state or situation (e.g., laughing in response to a tragedy)

v. Bizarre: Odd, illogical, inappropriate, or unfounded; includes grimacing

206
Q

Concrete thinking in Schizophrenia

A

impaired ability to think abstractly and respond or understand things like humor, love, sarcasm or recognize social cues

207
Q

4 Interventions for managing delusions

A
  1. Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner.
  2. Avoid questioning the delusion itself
  3. Focus on the feelings or themes within the delusion. (Ex. If a patient believes that he is a famous leader, comment: “It would feel good to be more powerful.” If the patient believes that others intend to hurt him, comment: “It must feel frightening to believe others want to hurt you.)
  4. Focus on helping patient feel safe and identify triggers
208
Q

Why should you not question delusions? What should you do instead?

A

Trying to prove the delusion is incorrect can intensify the delusion and cause patient to view staff as people who cannot be trusted

You can clarify misinterpretations of the environment and gently suggest more reality-based perspective

209
Q

Treatment for Tardive Dyskinesia

A

valbenazine and deutetrabenazine which reduce the severity of abnormal movements in tardive dyskinesia but tardive does not go away completely

Adverse effects: sleepiness and QT prolongation.

210
Q

What can you do if Tardive dyskinesia develops?

A

Switch to a SGA OR reduce or (paradoxically) increase FGA dosage can help too

211
Q

Tardive Dyskinesia

A

persistent EPS involving involuntary rhythmic movements usually after prolonged treatment and persists after the medication has been discontinued

212
Q

5 points on Tardive Dyskinesia

A
  • More common with FGAs
  • Increased risk with smoking, alcohol, stimulant use
  • Usually begins in oral and facial muscles and progresses to include the fingers, toes, neck, trunk, or pelvis.
  • More common in women
  • varies from mild to severe, and can be disfiguring or incapacitating
213
Q

Clozapine 5 problems

A

severe neutropenia
myocarditis
new onset diabetes
life-threatening bowel emergencies
ketoacidosis

214
Q

What is the impact of SUD on some psychiatric medications? (2 notes)

A
  • Substance use disorders affect the majority of people with schizophrenia and can intensify symptoms and cause relapse.
  • SUD can decrease effectiveness of some psychiatric meds
215
Q

Severe neutropenia Symptoms (3)

A

reduced neutrophil counts (<500), increased frequency and severity of infections, Any symptoms suggesting infection (e.g., sore throat, fever, malaise, body aches) should be carefully evaluated.

216
Q

3 things to note about severe neutropenia

A

-more common with Clozapine

-Left untreated, this life-threatening condition leads to death, most commonly through bacterial infection of the blood, or septicemia.

-some groups naturally have low ANC levels and this does not make them more susceptible

217
Q

4 notes on Somatic Symptom Disorder

A

-often have high level of help seeking but rarely eases concerns

-often multiple symptoms and one is severe (usually pain is primary symptom and subjective)

-suffering is real and patient often has high functional impairement

-often these individuals are hard on themselves and have limited self-compassion

218
Q

Somatic Symptom Disorder

A

focus on somatic/physical symptoms to point of excessive concern, preoccupation, and fear; used to be hypochondriasis

219
Q

4 treatments for Somatic Symptom Disorder

A

-hypnotherapy with strong, supportive approach useful

-avoid repetitive and unnecessary testing

-CBT and medication helpful

-TCA (amitriptyline) and SSRI (fluoxetine)

220
Q

5 common somatic symptoms

A

a. head pain
b. back pain
c. chest pain
d. paralysis
e. unexplained skin rashes

221
Q

5 notes on Illness Anxiety Disorder

A
  • frequent self-scanning for signs of illness (extreme fear and worry about possibility of having a disease)
  • chronic and relapsing esp w/ stress, depression, and loneliness
  • actual symptoms and complaints of symptoms are mild or absent
  • thoughts about illness are intrusive and hard to dismiss even when patient realizes their fears are unrealistic
  • may be reassurance seekers or care avoiders
222
Q

3 guidelines for Nursing Care with Illness Anxiety Disorder

A
  • allow time to discuss illness concerns, but limit amount of time in favor of other topics
  • emphasize and reassure patient that psychiatric care will supplement medical care; not replace it
  • encourage socialization due to loneliness relation
223
Q

3 treatments for Illness Anxiety Disorder

A
  • symptomatic pain relief with NSAIDs, laxatives, complementary medicine
  • SSRIs may treat anxiety
  • ECT and CBT useful as well
224
Q

Conversion Disorder (3)

A
  • functional neurological disorder; neurological symptoms in absence of a neurological diagnosis
  • deficits in voluntary motor or sensory functions (paralysis, blindness, movement, gait disorder, numbness, paresthesia)
  • emotional conflicts or stressors manifest in physical symptoms
225
Q

La belle Indifference

A

in Conversion disorder; aspect where patients show lack of emotional concern about often dramatic symptoms; despite this providers should assume organic cause of symptoms until ruled out

226
Q

2 Guidelines for Nursing Care of Conversion Disorder

A
  • avoid direct confrontation of the conversion symptom
  • provide reassurance and support for the patient’s feelings and beliefs
227
Q

4 Treatments for Conversion Disorder

A
  • hypnosis-> rapid resolution
  • Narcoanalysis with amobarbital -> immediate cessation of symptoms
  • body-oriented psychological therapy (use nonverbal expressive behavior to expression of emotions with change)
  • PT for motor symptoms
228
Q

6 general recommendations for Somatic Symptom Disorder

A
  1. Provide continuity of care.
  2. Avoid unnecessary tests and procedures.
  3. Provide frequent, brief, and regular office visits.
  4. Always conduct a physical examination.
  5. Avoid making disparaging comments such as “Your symptoms are all in your head.”
  6. Set reasonable therapeutic goals such as maintaining function despite ongoing pain.”
229
Q

Treatment of Factitious Disorder (2)

A
  • CBT
  • no benefit from various medical interventions such as antidepressants and antipsychotics
230
Q

Factitious Disorder

A

consciously controlled and compulsive; pretend to be ill (physical or psychiatric) to have their emotional needs met and achieve status of patient

231
Q

3 notes on Factitious disorder

A

-dramatic fabrication or self-infliction of violence with goal of assuming sick role; unusually proper medical terminology

-often conceals true nature of their alleged illness through deception

-may be imposed on self or on another

232
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Offer explanations and support during diagnostic testing.

A

Reduces anxiety while ruling out organic illness

233
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

After physical complaints have been investigated, avoid further reinforcement (e.g., do not take vital signs each time patient complains of palpitations).

A

Directs focus away from physical symptoms

234
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Observe and record frequency and intensity of somatic symptoms. (Patient or family can give information.)

A

Establishes a baseline and later enables evaluation of effectiveness of interventions

235
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Spend time with patient at times other than when patient summons nurse to voice physical complaint.

A

Rewards non-illness-related behaviors and encourages repetition of desired behavior

236
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Do not imply that symptoms are not real.

A

Acknowledges that symptoms are real to the patient

237
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Use matter-of-fact approach to patient exhibiting resistance or covert anger.

A

Avoids power struggles; demonstrates acceptance of anger and permits discussion of angry feelings

238
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Shift focus from somatic complaints to feelings or to neutral topics.

A

Conveys interest in patient as a person rather than in patient’s symptoms; reduces need to gain attention via symptoms

239
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Have patient direct all requests to case manager.

A

Reduces manipulation

240
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Help patient look at effect of illness behavior on others.

A

Encourages insight; can help improve intrafamily relationships

241
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Teach assertive communication.

A

Provides patient with a positive means of getting needs met; reduces feelings of helplessness and need for manipulation

242
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Show concern for patient while avoiding fostering dependency needs.

A

Shows respect for patient’s feelings while minimizing secondary gains from “illness”

243
Q

What is the rationale for the following Intervention in Somatic Symptom Disorder:

Reinforce patient’s strengths and problem-solving abilities.

A

Contributes to positive self-esteem; helps patient realize that needs can be met without resorting to somatic symptoms

244
Q
  1. Depression and anxiety are common comorbidities associated with somatic symptom disorders. Which of the following medications would the nurse anticipate the provider to prescribe for a patient diagnosed with a somatic symptom disorder and comorbid anxiety?

a. Paroxetine
b. Lithium
c. Risperidone
d. Buspirone
e. Phenelzine
f. Lorazepam

A

a. Paroxetine
d. Buspirone

245
Q

PTSD (definition and 3 notes)

A
  • persistent re-experiencing of a highly traumatic event (actual or threatened death or serious injury to self or others)
  • can occur after any traumatic event outside range of usual experiences (includes diagnosis with life-threatening illness or treatment for serious illness)
  • symptoms appear anywhere from 1 month to years after exposure
  • person often does not know where symptoms are coming from, so patient attributes them to present circumstances and past becomes present
246
Q

5 major features of PTSD

A
  1. Re-experiencing the trauma through recurrent intrusive recollections of the event (flashbacks) or dreams about the event.
  2. Avoidance of stimuli associated with the trauma (activities, people, or places) –avoidance is accompanied by feelings of detachment, emptiness, and numbing.
  3. Persistent symptoms of increased arousal, as evidenced by irritability, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated startle response.
  4. Alterations in mood, such as chronic depression, negative appraisals, and lack of interest in previously pleasurable activities
  5. Numbness
247
Q

General Treatment for PTSD

A

Primary is psychotherapy

-antidepressants used for depression, anxiety, sleep problems and concentration (SSRIs-sertraline, paroxetine)

248
Q

A client with a dementia diagnosis is throwing their dentures, screaming at staff, and trying to climb out the window. Which intervention is most appropriate for this patient?

A. Medicate the client with risperdal by mouth
B. Call the house supervisor for a sitter
C. Medicate the client with prn lorazepam by injection
D. Apply four-point restraints

A

C. Medicate the client with prn lorazepam by injection

249
Q

Symptoms of PTSD and ASD

A

Display 8 of 14 symptoms:
- A subjective sense of numbing
- Derealization (a sense of unreality related to the environment)
- Inability to remember at least one important aspect of the event
- Intrusive distressing memories
- Recurrent distressing dreams
- Feeling as if the event is recurring
- Intense prolonged distress
- Avoidance of thoughts about the event
- Sleep disturbances
- Hypervigilance
- Irritable, angry, or aggressive behavior
- Exaggerated startle response
- Agitation or restlessness

250
Q

Acute Stress Disorder (2)

A
  • after exposure to highly traumatic event
  • diagnosed 3 days to 1 month after the traumatic event (after 1 month resolves or becomes PTSD)
251
Q

3 treatments of Adjustment Disorder

A
  • psychotherapy to encourage verbalization of emotions
  • depressive symptoms treated with antidepressants
  • anxiety symptoms treated with benzodiazepines
252
Q

Adjustment Disorder (definition, time frame, symptoms)

A
  • milder, less specific version of ASD and PTSD precipitated by stressful event but not as severe i.e retirement, chronic illness, breakup
  • diagnosed immediately or within 3 months
  • Symptoms: all forms of distress and physical complaints; role performance deficits
253
Q

Dissociation

A

unconscious defense mechanism which protects individual against overwhelming anxiety through an emotional separation which results in memory, perception, and identity disturbances

-may serve protective function to decrease immediate distress of trauma (seen in children who cling to abusive caregivers

254
Q

Positive and negative symptoms of Dissociative Disorders

A

-Positive symptoms: unwanted additions of mental activity; flashbacks

-Negative symptoms: memory problems; inability to sense or control different parts of the body

255
Q

Treatments of Dissociative Disorders (2)

A
  • no specific but medications prescribed for hyperarousal and intrusive symptoms (includes antidepressants, anxiolytics, antipsychotics)
  • SUD and suicide risk are common so careful selection needed
256
Q

What is the rationale for the following Intervention for Dissociative Disorders:

Provide an undemanding, simple routine.

A

Reduces anxiety

257
Q

What is the rationale for the following Intervention for Dissociative Identity Disorders:

Ensure patient safety by providing safe, protected environment and frequent observation

A

Sense of bewilderment may lead to inattention to safety needs; some alters may be thrill-seeking, violent, or careless

258
Q

What is the rationale for the following Intervention for Dissociative Disorders:

Confirm the identity of patient and orientation to time and place.

A

Supports reality and promotes ego integrity

259
Q

What is the rationale for the following Intervention for Dissociative Disorders :

If patient does not remember significant others, work with involved parties to reestablish relationships.

A

Helps patient experience satisfaction and relieves sense of isolation

260
Q

Dissociative Identity Disorder (definition and 3 notes)

A

presence of two or more distinct personality states that recurrently take control of behavior which take shifts ranging from minutes to months (usually short)

  • Transitions may happen dramatically or be barely noticeable; often during times of stress
  • Often misdiagnosed as schizophrenic due to infrequency of episodes (minutes to months but shorter shifts common)
  • Extremely high suicide risk and difficult to assess due to presence of multiple personalities
261
Q

What is the rationale for the following Intervention for Dissociative Disorders:

Encourage patient to do things for self and make decisions about routine tasks.

A

Enhances self-esteem by reducing sense of powerlessness and reduces secondary gain associated with dependence

262
Q

What is the rationale for the following Intervention for Dissociative Disorders:

Assist with major decision making until memory returns.

A

Lowers stress and prevents patient from having to live with the consequences of unwise decisions

263
Q

What is the rationale for the following Intervention: for Dissociative Disorders

Accept patient’s expression of negative feelings.

A

Conveys permission to have negative or unacceptable feelings

264
Q

What is the rationale for the following Intervention for Dissociative Disorders:

Teach patient grounding techniques, such as taking a shower, deep breathing, touching fabric on chair, exercising, or stomping feet.

A

Helps to keep the person in the present and decrease dissociation

265
Q

What is the rationale for the following Intervention for Dissociative Disorders :

Support patient during the exploration of feelings surrounding the stressful event.

A

Helps lower the defense of dissociation used by patient to block awareness of the stressful event

266
Q

What is the rationale for the following Intervention for Dissociative Disorders:

Do not flood patient with data regarding past events.

A

Memory loss serves the purpose of preventing severe to panic levels of anxiety from overtaking and disorganizing the individual

267
Q

Alter vs primary personality in Dissociative Identity Disorder

A

o Alternate personality (alter) fixated on trauma but has its own pattern of perception, relations, and thinking of self and environment (may behave as different sex, race, religion, intelligence, EEG changes); often believe they are separate and unaffected by other’s actions (cognitive distortion)

o Primary is usually moralistic, pleasure seeking, nonconforming and not aware of alters so confused by lost time and unexplained events; blocks assess to traumatic memories

268
Q

What is the rationale for the following Intervention for Dissociative Disorders:

Provide support through empathetic listening during disclosure of painful experiences.

A

Can be healing, while minimizing feelings of isolation

269
Q

3 notes on Depersonalization/Derealization Disorder Treatment

A
  • usually go away without treatment
  • comorbidities treated with antianxiety, antidepressants
  • repetitive transcranial magnetic stimulation has been used to treat successfully
270
Q

Depersonalization/Derealization Disorder (definition and two notes

A

persistent or recurrent episodes of depersonalization and derealization

-mostly transient episodes; but may be constant
-severe stress and illegal drug use precipitate an episode

271
Q

Depersonalization vs derealization

A
  • Depersonalization: an extremely uncomfortable feeling of being an observer of one’s own body or mental processes.; feelings of unreality, detachment, or unfamiliarity
  • Derealization: recurring feeling that one’s surroundings are unreal or distant.
    o Visual ( blurriness, changes in the visual field, object sizes) and Auditory distortions(muting or heightening of sound)
272
Q

Autonomy

A

Respecting the rights of others to make their own decisions (e.g., acknowledging the patient’s right to refuse medication supports autonomy).

273
Q

Beneficence

A

The duty to act to benefit or promote the health and well-being of others (e.g., spending extra time to help calm an anxious patient).

274
Q

Justice

A

The duty to distribute resources or care equally, regardless of personal attributes (e.g., an intensive care unit [ICU] nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm).

275
Q

Fidelity

A

Maintaining loyalty and commitment to the patient and doing no wrong to the patient (e.g., maintaining expertise in nursing skill through continuing nurse education).

276
Q

Veracity

A

The duty to communicate truthfully (e.g., describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way)

277
Q

4 fundamental guidelines for MH Hospitalization

A

o Neither voluntary nor involuntary determines patient’s ability to make informed decisions about personal healthcare.
o Mental illness present
o The illness and its symptoms will result in an immediate crisis situation and other less-restrictive alternatives (i.e., outpatient care) are inadequate or unavailable.
o There is a reasonable expectation that the hospitalization and treatment will improve the presenting problems

278
Q

Nonmaleficence

A

Doing no harm to the patient (e.g., protecting confidential information about a patient)

279
Q

Voluntary Admissions

How to be admitted?
How to be released?

A

-apply in writing for admission
-individual can leave AMA (reevaluation can be done and make admission involuntary though)

280
Q

Involuntary Admissions 4 criteria

A
  • Diagnosed with mental illness
  • Danger to self or others
  • Gravely disabled (unable to provide for basic necessities)
  • In need of treatment and mental illness itself prevents voluntary help-seeking
281
Q

Two arguments patients can make to be released from involuntary commitment

A

i. Writ of habeas corpus: “formal written order” to “free the person; the procedural mechanism used to challenge unlawful detention by the government; hospital immediately submits to court and court decides

ii. Least restrictive alternative doctrine: mandates that care take the least drastic action to achieve a specific purpose i.e outpatient less restrictive than inpatient

282
Q

Emergency Commitment

Who is it used for? (2)
What is the primary purpose?
Length?

A

o Used for people who 1) are so confused they cannot make decisions on their own or (2) are so ill they need emergency admission

Primary purpose: observation, diagnosis, and treatment of patients who have mental illness or pose a danger to themselves or others

Length: 24 to 96 hours depending on the state. A court hearing is held and a decision is made for discharge, voluntary admission, or involuntary commitment.

283
Q

Unconditional release for Voluntary admission

What is it?
What if provider disagrees?

A

termination of legal patient-institution relationship by patient or provider

If provider disagrees, patient may be held 72 hours for involuntary admission or released AMA (against medical advice)

284
Q

Conditional release

What does it require?
What 3 things are evaluated during the time?
How does it differ for voluntary vs involuntary admitted?

A

requires outpatient for specified period of time

During time, individual evaluated for follow-through on medication regimen, ability to meet basic needs, and ability to reintegrate into community

o Voluntary admitted who are conditionally released cannot be readmitted without involuntary commitment process
o Involuntarily admitted who are conditionally released can be readmitted involuntarily based on original order

285
Q

Assisted outpatient treatment

What is it?
Who is it used for? (4)
How does it work?
Result of nonadherence?

A

court-ordered outpatient treatment; may occur post-discharge or straight from community to reduce or prevent relapse

  • Used for those with hx of repeated hospitalizations, arrested for treatment nonadherence, Unlikely to participate in outpatient treatment and need treatment to prevent relapse; threat to self or others if relapse happens
  • It is usually tied toward receipt of social welfare goods (disability benefits and housing) to improve adherence
  • Nonadherence may lead to inpatient admission
286
Q

6 patient rights in MH setting

A
  1. Right to treatment (most fundamental; right to quality care)
  2. Right to refuse treatment (even if involuntarily committed)
  3. Right to Informed Consent
  4. Rights of Psychiatric Advance Directives
  5. Rights on Restraints and Seclusion
  6. Right to Confidentiality
287
Q

AMA discharge

When done?
What must patient do?
Why is it an ethical dilemma?

A

AMA release is if treatment seems beneficial but there is no compelling reason to seek an involuntary continuance of stay

Patient must sign a form indicating that they are leaving AMA. This form becomes part of the patient’s permanent record.

AMA is ethical dilemma because patient autonomy and right to refuse treatment clash with beneficence to protect patient

288
Q

5 rights under right to treatment

A

i. The right to be free from excessive or unnecessary medication
ii. The right to privacy and dignity
iii. The right to the least restrictive environment
iv. The right to an attorney, clergy, and private care providers
v. The right to not be subjected to lobotomies, electroconvulsive treatments, and other treatments without fully informed consent

289
Q

Right to refuse Psychopharmacological drugs

How does it work in emergencies?
How does it work in nonemergencies? (5 criteria)

A

i. In an emergency where harm to self or others may occur, institution can medicate person without a court order

ii. In nonemergencies, after a court hearing, person can be medicated if all the following are met:
1.Patient has serious mental illness
2. The person’s functioning is deteriorating and if the person is suffering or exhibiting threatening behavior
3. The benefits of treatment outweigh the harm
4. The person lacks the capacity to make a reasoned decision about the treatment
5. Less-restrictive services have been found inadequate

290
Q

Informed Consent

What is it?
What does it require of the patient?
When is it needed?
What is nurse’s role?

A

it is when person has been provided basic info on problem, purpose of treatment, risks, benefits, alternatives to treatment; likelihood of success before accepting to do a procedure

  • Requires patient to have capacity and competence to voluntarily accept
  • Generally needed for surgery, ECT, and use of experimental drugs or procedures; may be required for all medications in some facilities (the more intrusive or risky the procedure; the greater need for informed consent)
  • Nurse role is to provide education and witness signature; provider gets consent
291
Q

Capacity

What is it?
When does it change?
Who decides if person has capacity?

A

Capacity: person’s ability to make an informed decision
- Fluid and can change rapidly
- Mental health providers may provide opinions about capacity.

292
Q

Competency

What is it?
When does it change?
Who decides if person has competency?
If someone is incompetent, who makes their decisions?

A

Competency: legal term related to the degree of mental soundness a person has to make decisions or to carry out specific acts

a. Competent until they have been declared incompetent

b. If found incompetent through formal legal proceeding, patient may be appointed a legal guardian or representative who is responsible for giving or refusing consent for the patient while always considering the patient’s wishes.
i. Order of selection usually (1) spouse or partner, (2) adult children or grandchildren, (3) parents, (4) adult siblings, and (5) adult nieces and nephews -> court-appointed person if no one available

293
Q

Restraints

Definition
What to assess before restraints?

A

any mechanical or physical device that reduces movement of patient including side rails and holding

-assess for physical origins of violence such as drug interactions and side effects; temp elevation, hypoglycemia, hypoxia, electrolyte imbalances which can all cause behavioral disturbances

294
Q

Seclusion

What is it?
What does it not include?
Who is it for?

A

confinement alone or in an area and preventing from leaving including if unlocked door but make threats about what happens if they leave

  1. Physical restraint in public room is not seclusion
  2. Reserved for violent, self-destructive
295
Q

Chemical Restraints (and how do they compare to mechanical restraints)

A

medications or doses of medication not used for patient’s condition

Less restrictive than physical or mechanical but can impact patient’s ability to relate to environment

296
Q

Restraints and least restrictive doctrine

5 less restrictive alternatives
What does CMS say about restraints in emergencies

A

i. In emergencies, CNS says less restrictive do not have to be used but need to be considered ineffective

ii. Least restrictive alternatives
1. Verbal intervention
2. Reducing stimulation
3. Actively listening
4. Providing diversion
5. Offering PRN medications

297
Q

Documentation for Restraints and Seclusion (3 things included)

A

a. specific behaviors and mental state leading to restraint or seclusion
b. time the patient is placed in and released from restraint
c. 15–30-minute assessments for physical needs, safety (including protection from harm), and comfort

298
Q

Orders for restraints and seclusion (4 notes)

A
  • no PRN or standing orders for restraints
  • renew every 4 hours (adults) for total of 24 hour (2 hours for children over 9-17; 1 hour for children under 9)
  • After 24 hours, provider personally assesses the patient
  • Restraint or seclusion is discontinued as soon as safer and calmer behavior begins and new order is required to reinstitute the intervention.
299
Q

Confidentiality and Nurse-patient (3 tidbits)

A
  • only patient can waive confidentiality (even in death)
  • avoid conversations about patients in public places
  • nurse does not have patient-nurse confidentiality like psychiatrists and attorneys (nurses must answer to the court)
300
Q

4 exceptions to patient confidentiality (and what does failure to report lead to ?)

A
  • Duty to warn (obligation to warn 3rd parties if they may be in danger from patient)
  • Duty to protect (required to call and warn intended victim, victim family, or police to take necessary steps under the circumstances)- must assess and predict patient’s level of danger and identify who they are threatening
  • Child Abuse (all nurses are mandatory reporters; some states allow anonymous reporting)
  • Older Adult and Dependent/Disabled Adult Abuse (required by most states to report)

Failure to report suspected abuse, neglect, or exploitation may result in misdemeanor

301
Q

7 interventions for seclusions and restraints

A

o Staff in constant attendance (do not leave patient alone)
o Monitor vital signs
o Assess range of movement
o Observe blood flow in hands/feet
o Observe that restraint is not rubbing
o Provide for nutrition, hydration, and elimination
o Continuously assess the need seclusion or restraint

302
Q

Negligence

A

most common unintentional tort involving failure to use ordinary care in any professional or personal situation when there is duty to do so

303
Q

5 elements to prove malpractice (and what each entails)

A
  • Duty of care established (nurse represents self as capable of caring for psychiatric patient and accepts employment)
  • Breach of duty (nursing performance below standard of care which exposes patient to unreasonable risk of harm; can be commission or omission)
  • Cause in Fact (Actual cause aka if nurse did not do what they did, would injury have occurred?)
  • Proximate cause (Legal cause aka determined by whether event was foreseeable; If average reasonable nurse could foresee injury that would result from action or inaction, injury was foreseeable)
  • Damages (Pain and suffering; Actual damages (loss of earning, medical expenses, property damage); Incidental damage (deprivation of benefits like normal relationships)
304
Q

Delirium

What is it?
6 cardinal symptoms

A

progressive and reversible acute cognitive disturbance with an underlying physiological cause that impairs lower-level cognition and can lead to permanent cognitive decline if not addressed

  • impaired attention (inability to direct, focus, sustain, or shift)
  • abrupt onset with fluctuating periods of lucidity and disorganized thinking
  • disorientation (to time and place; not usually person)
  • anxiety, agitation
  • poor memory
  • altered perceptions (visual hallucinations and illusions; delusions)
305
Q

Delirium

Onset
Causes/ Contributing Factors
Cognition (4)
Activity level (4)
Emotional state
Speech and language (4)
Prognosis

A

Onset: sudden and fluctuates throughout day

Causes/ Contributing Factors: underlying medical condition (UTI, substances, medications)

Cognition: impaired attention, memory deficit, disorientation, perceptual disturbances

Activity level: increased or decreased; restless; sundowning; reversed sleep-wake cycle

Emotional state: rapid swings (fearful, anxious, suspicious, aggressive; hallucinate or delusions)

Speech and language: rapid, inappropriate, incoherent, rambling

Prognosis: reversible with proper treatment

306
Q

Dementia

Onset
Causes/ Contributing Factors (5)
Cognition (6)

A

Onset: slowly over months and years

Causes/ Contributing Factors: Alzheimer’s; vascular disease; HIV, chronic alcoholism; head trauma

Cognition: impaired memory, judgment, calculations, attention, abstract thinking, agnosia (inability to recognize things)

307
Q

Dementia

Activity level (2)
Emotional state (2)
Speech and language (5)
Prognosis

A

Activity level: not altered; may have sundowning

Emotional state: flat (unresponsive in severe); agitation

Speech and language: incoherent, slow (difficulty finding the right word), inappropriate, rambling, repititious

Prognosis: not reversible; progressive

308
Q

Mild Alzheimer’s 8 hallmark symptoms

A
  • Difficulties retrieving correct words or names
  • Trouble remembering recent conversations, material just read (family may notice memory lapses)
  • Challenges in performing tasks in social or work settings (still able to work)
  • Losing or misplacing a valuable object
  • Increasing trouble with planning or organizing
  • Apathy
  • Depression
  • Personality is intact
309
Q

Moderate Alzheimer’s 8 hallmark symptoms

A
  • Forget events or their personal history i.e be unable to recall their own address or telephone number or the high school/college from which they graduated
  • Agnosia
  • Behavior changes i.e become moody or withdrawn, especially in socially or mentally challenging situations
  • Disorientation (confused about place and time)
  • Need for help choosing proper clothing for the season or the occasion
  • Wandering
  • Change sleep patterns (may sleep during the day and becoming restless at night
  • Paranoiac, agitated, and delusional or compulsive, for example, repetitive behavior like hand wringing
310
Q

Severe Alzheimer’s 6 hallmark symptoms

A
  • Require full-time, around-the-clock assistance with daily activities and personal care
  • Lose awareness of recent experiences and of their surrounding
  • Apraxia so they need repeated instructions and directions for simple tasks
  • Experience changes in physical abilities, including urinary incontinence ability to walk, sit, and eventually swallow,
  • Have increasing difficulty communicating and speaking (difficulty responding to environment)
  • Become vulnerable to infections, especially pneumonia
311
Q

Alzheimer’s and Symptoms

Confabulation (2)
Preservation
Agraphia

A

Confabulation: unconscious mechanism to protect ego involves creation of stories or answers in place of actual memories to maintain self-esteem; not lying b-c it is unconscious

Preservation: persistent repetition of word, phrase or gesture that continues after the original stimulus has stopped i.e repeatedly saying hello

Agraphia: early AD; diminished ability and eventual inability to read or write

312
Q

Alzheimer’s and Symptoms

Aphasia
Apraxia
Agnosia

A

Aphasia: the loss of language ability; from difficulty finding right word to few words to babbling or mutism

Apraxia: loss of purposeful movement in the absence of motor or sensory impairment which results in the inability to perform familiar and purposeful tasks.
-For example, in apraxia of dressing, the person is unable to put clothes on properly (e.g., putting arms in trousers).

Agnosia: loss of sensory ability to recognize familiar objects, sounds, sights (can be auditory, visual or tactile)

313
Q

Alzheimer’s and Symptoms

Hyperorality
Sundowning, or sundown syndrome
Memory impairment

A

Hyperorality: the tendency to put everything in the mouth and to taste and chew.

Sundowning, or sundown syndrome: tendency for an individual’s mood to deteriorate and agitation increase in the later part of the day, with the fading of light, or at night.

Memory impairment: initial difficulty remembering recent events -> deterioration of recent and remote memory.

314
Q

9 Interventions around comfort and anxiety for Delirium

A
  • Provide optimistic but realistic reassurance.
  • Provide patient with information about what is happening and what can be expected.
  • Accept patient’s perceptions or interpretation of reality and respond to the theme or feeling tone.
  • Approach patient slowly and from the front and address patient by name.
  • Always introduce self to patient when approaching.
  • Communicate with simple, direct, and descriptive statements.
  • Limit decision making if aggravates delirium
  • Encourage significant others to remain with patient.
  • Provide a consistent physical environment, daily routine, and caregivers.
315
Q

5 Interventions around safety for Delirium

A
  • Administer prn (as needed) medications for anxiety or agitation with caution.
  • Physical restraints may increase symptoms and should be avoided if possible.
  • Never leave a patient in acute delirium alone (family can watch)
  • Maintain a well-lit, hazard-free, low-stimulation environment
  • Encourage use of aids that increase sensory input (e.g., eyeglasses, hearing aids, and dentures).
316
Q

3 Interventions around Orientation for Delirium

A
  • Monitor neurological status on an ongoing basis
  • Avoid frustrating the patient by quizzing with orientation questions that cannot be answered.
  • Use environmental cues (e.g., signs, pictures, clocks, calendars, and color coding of environment) to stimulate memory, reorient, and promote appropriate behavior.
317
Q

4 basic Interventions for Alzheimer’s Disease

A
  • Provide emotional support to patient and family: Ascertain what is important to these patients, their values and beliefs, as well as their life histories. (unconditional positive regard is key)
  • support caregivers: Include family members in planning, providing, and evaluating care
  • assess and facilitate self - care: Identify usual patterns of behavior for such activities as sleep (provide rest periods), medication use, elimination, food intake, self-care
  • Provide finger foods to maintain nutrition for patient who will not sit and eat.
318
Q

7 interventions for comfort care and anxiety management in Alzheimer’s

A
  • Introduce self and address patient by name when initiating interaction and speak slowly.
  • Give one simple direction at a time in a respectful tone of voice.
  • Use distraction, rather than confrontation, to manage behavior.
  • Provide consistent caregivers, physical environment, and daily routine. (Limit number of choices patient must make so as not to cause anxiety.)
  • Select television or radio programs based on cognitive processing abilities and interests.
  • Place patient’s name in large block letters in room and on clothing, as needed.
  • Use symbols, rather than written signs, to assist patient in locating room, bathroom, or other area.
319
Q

What is the rationale for the following intervention for Dementia?

Gradually restrict use of motor vehicles

A

As judgment becomes impaired, the person may be dangerous to self and others.

320
Q

What is the rationale for the following intervention for Dementia?

Minimize sensory stimulation.

A

Decreases sensory overload, which can increase anxiety and confusion.

321
Q

What is the rationale for the following intervention for Dementia ?

If the person becomes verbally upset, listen and be supportive, allowing the person to be upset. Gradually try to redirect and change the topic.

A

Goal is to prevent escalation of anger. When attention span is short, the person can be distracted to more productive topics and activities.

322
Q

What is the rationale for the following intervention for Dementia?

Label all rooms and drawers. Label often-used objects (e.g., hairbrushes and toothbrushes)

A

May keep the person from wandering into other people’s rooms. Increases environmental clues to familiar objects.

323
Q

What is the rationale for the following intervention for Dementia?

Have the person wear medical alert bracelet that cannot be removed (with name, address, and telephone number). Provide police department with recent pictures.

A

The person can easily be identified by police, neighbors, or hospital personnel.

324
Q

What is the rationale for the following intervention for Dementia?

If the person wanders during the night, put mattress on the floor.

A

Prevents falls when the person is confused.

325
Q

What is the rationale for the following intervention for Dementia?

If the person is in the hospital, have the person wear brightly colored vest with name, unit, and phone number printed on back.

A

Makes the person easily identifiable.

326
Q

What is the rationale for the following intervention for Dementia?

Put complex locks on top of door and use sensor devices.

A

Reduces opportunity to wander.In moderate and late Alzheimer-type dementia, ability to look up and reach upward is lost. Sensor devices provide warning if person wanders

327
Q

What is the rationale for the following intervention for Dementia?

Encourage physical activity during the day.

A

Physical activity may decrease wandering at night

328
Q

What to know about use of psychotropic drugs and Alzheimer’s? (4)

A
  • they increase risk of mortality from cardiovascular and infectious causes
  • Antipsychotics, antidepressants, antianxiety, anticonvulsants are not FDA approved and are used off label
  • Try to avoid but If used, start low, go slow, use smallest dose for shortest duration and discontinue if not effective
  • Use as last resort to manage behavior
329
Q

Donepezil

Mechanism of action
Use
Therapeutic Effect
Drug interaction

A

Mechanism of action: Inhibit acetylcholinesterase from breaking down Ach

Use: all stages of AD including severe

Therapeutic Effect: small and short-lived improvements in cognitive function after 1 year but do not slow disease progression

Drug interactions: NSAIDs increase potential for GI bleeds and ulceration

330
Q

8 adverse effects of Donepezil

A

temporary GI disturbances (Nausea, vomiting, diarrhea)
Insomnia
muscle cramps
fatigue
anorexia
urinary incontinence
rare is bradycardia or syncope

331
Q
  1. Which statement made by the primary caregiver of a person with dementia demonstrates an accurate understanding of providing the person with a safe environment?

a. “The local police know that he has wandered off before.”
b. “I keep the noise level low in the house.”
c. “We’ve installed locks on all the outside doors.”
d. “Our telephone number is always attached to the inside of his shirt pocket.”

A

c. “We’ve installed locks on all the outside doors.”

332
Q
  1. Which statement made by a family member tends to support a diagnosis of delirium rather than dementia?

a. “She was fine last night but this morning she was confused.”
b. “Dad doesn’t seem to recognize us anymore.”
c. “She’s convinced that snakes come into her room at night.”
d. “He can’t remember when to take his pills or whether he’s bathed.”

A

a. “She was fine last night but this morning she was confused.”

333
Q
  1. In terms of the pathophysiology responsible for both delirium and dementia, which intervention would be appropriate for delirium specifically?

a. Assisting with needs related to nutrition, elimination, hydration, and personal hygiene
b. Monitoring neurological status on an ongoing basis
c. Placing an identification bracelet on patient
d. Giving one simple direction at a time in a respectful tone of voice

A

b. Monitoring neurological status on an ongoing basis

334
Q
  1. What side effects should the nurse monitor for while caring for a patient taking donepezil (Aricept)? Select all that apply.

a. Insomnia
b. Constipation
c. Bradycardia
d. Signs of dizziness
e. Reports of headache

A

a. Insomnia
c. Bradycardia
d. Signs of dizziness
e. Reports of headache

335
Q
  1. What is the rationale for providing a patient diagnosed with dementia easily accessible finger foods thorough the day?

a. It increases input throughout the day
b. The person may be anorexic
c. It helps with the monitoring of food intake
d. It helps to prevent constipation

A

a. It increases input throughout the day

336
Q
  1. Ophelia, a 69-year-old retired nurse, attends a reunion of her former coworkers. Ophelia is concerned because she usually knows everyone, and she cannot recognize faces today. A registered nurse colleague recognizes Ophelia’s distress and “introduces” Ophelia to those attending. The nurse practitioner understands that Ophelia seems to have a deficit in her

a. Lower-level cognitive domain
b. Delirium threshold
c. Executive function
d. Social cognition ability

A

d. Social cognition ability

337
Q
  1. After talking with her 85-year-old mother, Nancy became concerned enough to drive to her home and check on her. Her mother’s appearance was disheveled, her words were nonsensical, she smelled strongly of urine, and there was a stain on her dressing gown. Because she is a nurse, Nancy recognizes that her mother’s condition is likely due to

a. Early-onset dementia
b. A mild cognitive disorder
c. A urinary tract infection
d. Having skipped breakfast

A

c. A urinary tract infection

338
Q
  1. Lucia, 70 years old, recently underwent a major orthopedic surgical procedure. On postoperative day 3, she responds to the nurse who has been caring for her with affection. At other times, however, she tells the nurse to leave because she does not recognize her and asks to have another nurse care for her, specifically naming the nurse as the “nice one.” The most likely reason for Lucia’s behavior is that she is

a. Attention-seeking and manipulative
b. Showing signs of early dementia
c. Experiencing an acute delirium
d. Playing one staff member off against another

A

c. Experiencing an acute delirium

339
Q

What is the rationale for the following intervention for Dementia?

Provide picture magazines and children’s books when the person’s reading ability diminishes.

A

Allows continuation of usual activities that the person can still enjoy; provides focus.

340
Q

What is the rationale for the following intervention for Dementia?

Provide simple activities that allow exercise of large muscles.

A

Exercise groups, dance groups, and walking provide socialization, as well as increased circulation and maintenance of muscle tone.

341
Q

What is the rationale for the following intervention for Dementia?

Encourage group activities that are familiar and simple to perform.

A

Activities such as group singing, dancing, reminiscing, and working with clay and paint all help increase socialization

342
Q
  1. Since his wife’s death 2 months earlier, Aaron, 90 years of age and in good health, has begun to pay less attention to his hygiene and seems less alert to his surroundings. He complains of difficulty concentrating, disrupted sleep, and lacks energy. His family has to remind and encourage him to shower, take his medications, and eat, all of which he then does. Which of the following responses would be most appropriate?

a. Reorient Mr. Smith by pointing out the day and date each time you have occasion to interact with him.
b. Meet with the family and support them to accept, anticipate, and prepare for the progression of his stage 2 dementia.
c. Avoid touch and proximity. These are likely to be uncomfortable for Mr. Smith and may provoke aggression when he is disoriented.
d. Arrange for an appointment with a mental health professional for the evaluation and treatment of suspected major depressive disorder.

A

d. Arrange for an appointment with a mental health professional for the evaluation and treatment of suspected major depressive disorder.

343
Q
  1. Nurses caring for patients who have neurocognitive disorders are exposed to stress on many levels. Specialized skills training and continuing education are helpful to diffuse stress, as well as which of the following? Select all that apply.

a. Expressing emotions by journaling
b. Describing stressful events on Facebook
c. Engaging in exercise and relaxation activities
d. Having realistic patient expectations
e. Participating in a happy hour after work to blow off steam

A

a. Expressing emotions by journaling
c. Engaging in exercise and relaxation activities
d. Having realistic patient expectations

344
Q

Atttempted vs completed rape

A

Attempted rape: threats of rape or intention to rape that is unsuccessful

Completed rape: penetration, no matter how slight, of the vagina or anus with anybody part or object, or oral penetration by a sex organ of another person, without the consent of the victim

345
Q

Clinical Picture of survivors of abuse (6)

A
  • comorbid PTSD/ASD, MDD, anxiety, suicide
  • impaired daily functioning
  • low self-esteem
  • sexual dysfunction
  • somatic complaints
  • recurrent and intrusive memories, dreams, flashbacks, and distress from cues that remind them of the assault.
346
Q

Most effective counseling approach in ED for sexual assault (5)

A
  • Provide nonjudgmental care and optimal emotional support
  • Convey confidential nature of visit
  • Listen and let patient talk (a patient who feels listened to and understood no longer feels alone and can feel in control of situation)
  • Separate vulnerability from blame (survivor may try to rationalize or blame their behavior for the incidence)
  • Social support is key (Fewer somatic symptoms of stress if survivor is able to confide comfortably in at least one person, especially immediately after the assault)
347
Q

8 do’s of IPV interview

A
  • Conduct the interview in private.
  • Develop trust to make patient comfortable enough to self-disclose
  • Be direct, honest, and professional
  • Use language the patient understands. (ask about ways they solve disagreements or discipline methods rather than abuse or violence)
  • Ask the patient to clarify words not understood.
  • Be attentive but relaxed
  • Inform the patient if you must make a referral to Children’s or Adult Protective Services, and explain the process.
  • Use open-ended question that requiring descriptive response (also they are less threatening)
348
Q

7 Don’ts of IPV interview

A
  • Try to “prove” abuse by accusations or demands.
  • Display horror, anger, shock, or disapproval of the perpetrator or situation.
  • Place blame or make judgments.
  • Allow the patient to feel “at fault” or “in trouble.”
  • Probe or press for answers the patient is not willing to give.
  • Conduct the interview with a group of interviewers.
  • Interrupt the patient
349
Q

7 signs of physical abuse in child

A
  • minor complaints (headaches, back pain, dizziness, accidents)
  • overt signs (bruises, scars, burns, or wounds in various stages of healing in body parts that are usually covered or arms)–Any bruise on infant <6 months needs to be explored
  • Shaken baby syndrome: leading cause of death from physical abuse in children under 2; signs include respiratory problems, bulging fontanels, retinal hemorrhage, CNS damage (seizures, vomiting, coma).
  • In utero (Fetal alcohol spectrum disorders (brain damage and growth problems) & Neonatal abstinence syndrome (lasts days to weeks; includes irritability, difficulty soothing; long term hearing, vision, and learning difficulties)
  • inconsistent explanations for injuries
  • vague explanations
  • minimization of seriousness
350
Q

4 Signs of Sexual abuse

A
  • Sexualized behavior (acting out) in young children
  • Sexual promiscuity or knowledge in older children
  • PTSD symptoms (nightmares, somatic complaints, feelings of guilt)
  • Adults sexually abused as child mainly report depression (other symptoms also reported)
351
Q

5 Signs of emotional abuse

A

less obvious and more difficult to assess than other abuse

  • low self-esteem and feeling of inadequacy
  • anxiety
  • withdrawal
  • learning difficulties
  • poor impulse control
352
Q

3 signs of neglect

A
  • Undernourished
  • Dirty and poorly clothed
  • Inadequate medical care (lack of immunizations and untreated medical or dental conditions)
353
Q

What is economic abuse? 2 signs

A

Failure to provide for the needs of the victim when adequate funds are available

-leaving bills unpaid
-preventing spouse from seeking job or education to promote dependency

354
Q

Cycle of Violence: Tension building phase (3)

A
  • begins with minor incidents, such as pushing, shoving, and verbal abuse.
  • victim often ignores or accepts the behavior due to fear of escalation
  • As the tension builds, both participants may try to reduce it (abuser via substance use, victim through minimization of tension)
355
Q

Cycle of Violence: Acute battering phase (4)

A
  • when the tension peaks and becomes unbearable
  • It is usually triggered by an external event, abuser’s emotional state; or victim provokes it to move on
  • Victim may seek help or cover up abuse
  • Abuse may be worsened by pregnancy or move toward independence
356
Q

Cycle of Violence: Honeymoon phase (3)

A
  • period of calm after the abuse occurs
  • Abuser usually demonstrates kindness and loving behaviors and makes promises to change
  • The victim usually feels needed, loved, and hopes for change (often cancels plans to leave which were made during acute phase)
357
Q

Cycle of Violence

3 stages
How it changes over time?
Impact on victim

A

3 stages: tension building, acute battering, honeymoon
- Cycle repeats itself and honeymoon becomes briefer and other stages more intense
- cycle erodes victim’s self-esteem leading to depression, hopelessness, immobilization, and self-deprecation

358
Q

6 Interventions for PTSD or post-sexual assault

A
  1. reduce anxiety with use of relaxation techniques and sleep
  2. encourage help-seeking
  3. reduce arousal and regulate emotions
  4. encourage patient to develop narrative of event and the meaning of the event to them
  5. gently suggest that person was not responsible for what happened
  6. reassure that reactions to trauma do not indicate personal failure or weakness
359
Q

3 Signs of abuse or neglect

A

-hesitant to talk
-fearful in presence of perpetrator
-tearful

360
Q

4 guidelines for personality disorders

A
  • acknowledge the patient’s feelings but set limits on bad behavior
  • do not make empty threats. Set clear and realistic expectations
  • setting firm limits and boundaries is very important.
  • Know the facts before you act.
361
Q

How does intervention differ for “Sometimes, I just wish I could die” vs “I am going to kill myself.”

A

With the former, you would ask the patient to talk more about their feelings.

With the latter, you would immediately place them on 1:1 observation.

362
Q

Two treatment goals for personality disorders

A
  • decrease the behaviors associated with the various disorders that affect function and interpersonal relationships.
  • reduce the inflexibility that interferes with functioning and relationships
363
Q

Cluster A personality disorders

What are they?
Which personalities are included?

A

-odd or eccentric
- Paranoid, Schizotypal, Schizoid

364
Q

Cluster C personality Disorders

What are they?
Which personalities are included?

A
  • anxious or fearful
  • Avoidant, OCD personality disorder
365
Q

Cluster B personality Disorders

What are they?
Which personalities are included?

A
  • dramatic, emotional, or erratic
  • histrionic, narcissistic, borderline, antisocial
366
Q

Paranoid Personality Disorder: Characteristics (8)

A
  • Longstanding distrust and suspiciousness of others
  • believe that others want to exploit, harm, or deceive the person so anticipate hostility
  • Relationship difficulties due to jealousy, controlling behaviors, and envious behaviors
  • unwilling to forgive.
  • Hypervigilant, oversensitive, guarded
  • Provoke hostile responses by initiating a counterattack
  • Exhibits self-destructive behaviors
  • Projection is the dominant defense mechanism
367
Q

Paranoid Personality Disorder: Guidelines to Nursing Care (5)

A
  • Strictly adhere to promises, appointments, and schedules due considering the degree of mistrust
  • Being too nice or friendly may be met with suspicion.
  • Give clear and straightforward explanations of tests and procedures beforehand.
  • Use simple language and project a neutral but kind affect.
  • Limit setting is essential when threatening behaviors are present.
368
Q

Schizoid Personality Disorder: Characteristics (8)

A
  • Social withdrawal (Do not seek out or enjoy close relationships)
  • Expressionless with restricted range of emotional expression (cold and indifferent)
  • loners and poor academic performance
  • inappropriate seriousness
  • lack of spontaneity
  • Approval nor rejection by others has an effect
  • May have many imaginary friends or fantasies (aloof)
  • depersonalized and detached
369
Q

Schizoid Personality Disorder: Guidelines to Nursing Care (5)

A
  • avoid being too “nice” or “friendly.”
  • Do not try to increase socialization
  • Patients may be open to discussing topics such as coping and anxiety.
  • Conduct a thorough assessment to identify symptoms that the patient is reluctant to discuss.
  • Protect against ridicule from group members because of the patient’s distinctive interests or ideas.
370
Q

Schizotypal Personality Disorder: Characteristics (8)

A
  • Extreme anxiety in social settings
  • Do not blend with the crowd (lengthy, abstract, overly detailed contributions to conversations)
  • Magical thinking (belief they can do acts of god)
  • Odd beliefs (overly superstitious)
  • Strange speech patterns (rambling)
  • Inappropriate affect
  • Paranoia (overly suspicious and anxious of others; blame others for their social isolation)
  • Hallucinations and delusions (less than in schizophrenia and brief)
371
Q

Schizotypal Personality Disorder: Guidelines to Nursing Care (4)

A
  • Respect the patient’s need for social isolation.
  • Be aware of the patient’s suspiciousness and use appropriate interventions.
  • Help identify cognitive distortions
  • Be aware that strange beliefs and activities, such as strange religious practices or peculiar thoughts, may be part of the patient’s life.
372
Q

Histrionic Personality Disorder: Characteristics (6)

A
  • Excitable and dramatic yet high functioning
  • Drama queens (Extroversion, flamboyance, colorful personalities)
  • Limited ability to develop meaningful relationships due to partner smothering or insensitivity of histrionic
  • attention-seeking behavior (self-centeredness, low frustration, tolerance, excess emotionality)
  • Impulsive, flirtatious, provocative
  • Difficulty regulating their feelings
373
Q

Histrionic Personality Disorder: Guidelines for Nursing Care (5)

A
  • Know seductive behavior is a response to distress.
  • Communication and interactions should always be kept professional; ignore flirtations
  • Encourage and model the use of concrete and descriptive rather than vague and impressionistic language.
  • Help patients to clarify their own feelings, as they often have difficulty identifying them.
  • Teach and role model assertiveness.
374
Q

Histrionic Personality Disorder: Treatment (6 notes)

A
  • Often do not believe they need psychiatric help
  • Psychotherapy to help promote feelings clarification and expression (treatment of choice)
  • group therapy can be helpful but they may dominate the conversation
  • Antidepressants for somatic or depressive symptoms
  • Antianxiety for anxiety
  • Antipsychotics for derealization or delusions
375
Q

Narcissistic Personality Disorder:

Main trait
6 other Characteristics

A

Main trait: antagonism via grandiosity and attention-seeking behaviors (Blame others for issues)

  • Feelings of entitlement
  • Lacks empathy and exploits others
  • Exaggerated belief of one’s own importance(arrogance)
  • Suffer from weak self-esteem
  • hypersensitivity to criticism and rejection
  • Feel intense shame and fear of abandonment
376
Q

Narcissistic Personality Disorder: Guidelines for Nursing Care (5)

A
  • Nurses should remain neutral and recognize the source of narcissistic behavior—shame and fear of abandonment.
  • Help identify goals and to develop a stronger self-identity.
  • Role model empathy and practice how to engage in meaningful interaction.
  • Avoid engaging in power struggles or becoming defensive in response to the patient’s disparaging remarks.
  • Do not directly challenge grandiose statements.
377
Q

Narcissistic Personality Disorder: Treatment (4 notes)

A
  • Less impairment in functioning and quality of life than other personality-based disorders
  • Often difficult b/c pt must confront problem (often do not seek treatment)
  • CBT for deconstructing faulty thinking
  • Lithium for mood swings
378
Q

Borderline Personality Disorder

4 main features
Primary defense mechanism
3 other symptoms

A

Main features: emotional dysregulation, emotional lability, impulsivity, self-image distortions

Primary defense mechanism: splitting (inability to view both positive and negative aspects of others as part of a whole; people are either wonderful or horrible)

Others
- Self-destructive behaviors include ineffective self-soothing habits; chronic suicidal ideation
- Feelings of antagonism seen as hostility, anger, irritability-> physical violence or property damage
- May be psychotic during stress

379
Q

Borderline Personality Disorder Areas to Assess (8)

A
  • Feelings of emptiness
  • risky behaviors, such as reckless driving, unsafe sex, substance use, binge eating, gambling, or overspending
  • Intense feelings of abandonment that result in paranoia or feeling spaced out
  • Idealization of others and becoming close quickly
  • tendency toward anger, sarcasm, and bitterness
  • Self-mutilation and self-harm
  • Sudden shifts in self-evaluation that result in changing goals, values, and career focus
  • Intense, unstable romantic relationships
380
Q

Borderline Personality Disorder: Guidelines to Nursing Care (6)

A
  • Nurse understands complaints originate from feeling of being threatened
  • Be aware of manipulative behaviors such as flattery, seductiveness, instilling guilt
  • Provide clear and consistent boundaries and limits
  • Use straightforward and calm communication
  • Be neutral and respond matter-of-factly
  • Instruct patient to write down sequence of events leading to injuries and consequences before staff discusses the event
381
Q

Borderline Personality Disorder: Pharmacotherapy Treatment

Goals of pharmacotherapy (3)
5 categories of drugs and when are they used

A
  • Geared toward maintenance of cognitive function, symptom relief, improved quality of life
  • SSRIS, anticonvulsants, lithium for mood and emotional dysregulation
  • Naltrexone, opioid antagonist, can reduce self-injurious behaviors
  • SGAs control anger and brief episodes of psychosis
382
Q

CBT and Borderline Personality disorder (2)

A
  • helps individuals identify and change inaccurate core perceptions of themselves and relationship problems
  • reduces mood and anxiety symptoms including self-harm
383
Q

Dialectical Behavioral Therapy (DBT) and Borderline Personality disorder

What is it?
What is the goal?
What is its progression?

A
  • evidence-based to treat chronically suicidal which combines CBT with mindfulness

Goal to increase pt’s ability to manage distress and improve interpersonal effectiveness skills to emphasize awareness of one’s thoughts and actively shape them

Begins with identification and interventions for suicidal behavior and progress to disruption of destructive behaviors

384
Q

Schema-focused therapy and Borderline Personality disorder

A

combines CBT with other therapies to focus on ways individuals view themselves; reframing schemas to fix dysfunctional self-image

385
Q

Antisocial Personality Disorder:

Main trait
6 other Characteristics

A

Primary: antagonistic behaviors such as deceitfulness, manipulative, hostile (sociopaths) for personal gain

  • Callousness (profound lack of empathy) results in lack of concern about feelings of others, absence of remorse or guilt except in face of punishment ( Pattern of disregard for rights of others and their frequent violation)
  • Disinhibited behaviors (criminal misconduct and substance misuse are common; inability to delay gratification)
  • Little to no capacity for intimacy and exploit others (Adept at pretending to care or show concern if these behaviors help them manipulate and exploit others)
  • Shallow, unexpressive, superficial affect
  • intimidating and argumentative
  • restless and easily bored
386
Q

Antisocial Personality Disorder: Guidelines to Nursing Care (5)

A
  • Provide consistency, support, boundaries, limits and realistic choices
  • Prevent or reduce untoward effects of manipulation (flattery, seduction, instillation of guilt of others)
  • Assist patients in recognizing their feelings of anger, source, and identification of options to handle anger
  • Listening and showing empathy can defuse an aggressive situation
  • Help reduce anger and anxiety through physical outlets and therapeutic activities
387
Q

Antisocial Personality Disorder: Addressing Manipulation(2)

A
  • Direct discussion of your concerns is best ( For example, nurse can say: “People enjoy hearing positive comments made by others about themselves. However, in the context of a nurse-patient relationship, these comments are not acceptable.”)
  • For severe manipulation, address openly and include consequences in the form of rewards or penalties
388
Q

Antisocial Personality Disorder: Pharmacotherapy treatment (4 types and when used)

A

no FDA approved

  • Mood stabilizers i.e lithium or valproic acid for aggression, depression, impulsivity
  • SSRIs i.e fluoxetine and sertraline for irritability, anxiety, depression
  • Benzodiazepines for anxiety w/ caution due to addiction
  • Methylphenidate if comorbid ADHD
389
Q

Antisocial Personality Disorder: Psychological treatment (4 types and why helpful)

A
  • CBT helpful b-c bond with psychotherapists
  • Mentalization behavioral therapy: long-term treatment that supports individuals’ ability to recognize and understand their own and other people’s mental states
  • Dialectical behavior therapy (DBT): regulating emotions and being mindful
  • Group therapy helps to feel camaraderie
390
Q

Avoidant Personality Disorder:

Main trait
5 other characteristics

A

Main trait: low self-esteem related to poor functioning in social situations; feelings of inferiority compared with peers; Reluctance to engage in unfamiliar activities

  • Extremely sensitive to rejection
  • Feel inadequate
  • Socially inhibited
  • Failure of support system may lead to depression, anxiety, anger
  • preoccupation with rejection, failure, and humiliation
391
Q

Avoidant Personality Disorder: Guidelines to Nursing Care (4)

A
  • use a friendly, accepting, and reassuring approach.
  • Being pushed into social situations can cause severe anxiety for these patients. (accept patient fears)
  • Provide the patient with exercises to enhance new social skills but use these with caution because any failure can increase the patient’s feelings of poor self-worth.
  • assertiveness training
392
Q

Obsessive-Compulsive Personality Disorder:

Main trait
Defense mechanism
5 other Characteristics

A

Main: rigidity and inflexible standards for self and others

Defense mechanism: reaction formation

  • Limited emotional expression
  • Stubbornness, perseverance, and indecisiveness
  • Preoccupation with orderliness, perfectionism, and control
  • Constant goal-seeking behavior (self-defeating and goal-defeating because strict standards interfere with project completion)
  • Solicitous, ingratiating with superiors; pompous, self-righteous with subordinates
393
Q

Obsessive-Compulsive Personality Disorder: Guidelines to Nursing Care (3)

A
  • Guard against power struggles with these patients, as their need for control is very high.
  • It is helpful to provide structure yet allow patients extra time to complete habitual behavior (patients have difficulty dealing with unexpected change)
  • Help patients to identify ineffective coping and to develop better coping techniques.
394
Q

Difference between OCD and Obsessive-compulsive personality disorder

A

OCD has obsessive thoughts and repetition or adherence to rituals. People are aware that these thoughts and actions are unreasonable.

Obsessive-compulsive personality disorder has an unhealthy focus on perfectionism. Such people “know” that their actions are right and feel comfortable with their self-imposed systems of rules.

395
Q

Difference between Schizophrenia and Schizotypal Personality Disorder

A

People with schizotypal personality disorder can be made aware of their suspiciousness, magical thinking, and odd beliefs.

Schizophrenia is characterized by far stronger delusions.

396
Q

5 areas to assess for all personality disorders

A
  1. Assess for suicidal or homicidal thoughts
  2. Determine whether the patient has a medical disorder or another psychiatric disorder that may be responsible for the symptoms (especially a substance use disorder).
  3. Take into account the person’s ethnic, cultural, and social background.
  4. Ascertain whether the patient experienced a recent important loss. (Personality disorders are often exacerbated after the loss of significant supporting people or in a disruptive social situation.)
  5. Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized SUD
397
Q
  1. A man is being abused by his wife whom he loves very much. He initially decided to leave his wife but ultimately changed his mind after she agreed to go to marriage counseling. What is the best response by the nurse?

A. You are making the right decision. If you need help, our facility is here to assist you.

B. I hope you have made the right decision. If you need help, our facility is here to assist you.

C. You should be careful when you return. If you need help, our facility is here to assist you.

D. Why are you returning to this dangerous situation? If you need help, our facility is here to assist you.

A

B. I hope you have made the right decision. If you need help, our facility is here to assist you.

398
Q

Borderline personality disorder

What is emotional dysregulation?
What is emotional liability?
What is impulsivity?

A
  • Emotional dysregulation: poorly modulated mood; mood swings and difficulty managing painful emotions
  • Emotional lability: rapidly moving from one emotional extreme to another (Includes out of proportion emotional responses; fear of separation; intense sensitivity to personal rejection)
  • Impulsivity: act quick in response to emotions; may lead to damaged relationships or suicide
399
Q

4 Symptoms of Autism: Deficits in social relatedness

A
  • Abnormal social approach: failure of normal back-and-forth conversation; reduced sharing of interests, emotions, or affect
  • Disturbances in developing, maintaining, and understanding peer or parental relationships
  • Deficits or abnormal nonverbal communication (eye contact, body language, gestures, facial expressions)
  • Inability to engage in play or make believe
400
Q

Symptoms of Autism Spectrum Disorder: Repetitive or restrictive patterns of behavior (6)

A
  • Lack of spontaneous enjoyment
  • Stereotypical repetitive speech
  • Obsessive focus on specific objects or interests
  • Savant syndrome: low IQ but brilliant in specific areas i.e. music, visual-spatial, photographic memory recall; complex math calculations
  • Over adherence to routines or rituals; insistence on sameness and resistant to change
  • Hyperreactivity or hyporeactivity to sensory input (Sensitivity to loud noises)
401
Q

3 things that determine severity of Autism

A

o Degree of responsiveness or interest to others
o Presence of associated behavioral problems (head banging)
o Ability to bond with peers

402
Q

6 components of Autism Assessment

A
  1. Assess for developmental delays, uneven development, or loss of acquired abilities
    (Use baby books and diaries, photographs, videotapes, or anecdotal reports from nonfamily caregivers.)
  2. Assess the child’s communication skills (verbal and nonverbal), sensory, social, and behavioral skills (including presence of any aggressive or self-injurious behaviors).
  3. Assess the parent-child relationship for evidence of bonding, anxiety, tension, and fit of temperaments.
  4. Assess for physical and emotional signs of possible abuse.
  5. Ensure that screening for comorbid intellectual disability has been completed.
  6. Assess the need for community programs with support services for parents and children, including parent education, counseling, and after-school programs
403
Q

5 notes on interventions/treatment of Autism

A
  • Early intervention programs (usually around 2-3 years) is key to improve potential for full, productive life
  • Reward system
  • Teaching caregivers to provide structure, rewards, consistency, expectations to modify and foster developmentally appropriate skills
  • PT, SLP, OT, ABA, EIBI
  • Pharmacotherapy (to improve relatedness, decrease anxiety, compulsive behaviors, and agitation)
404
Q

What is Early intensive behavioral intervention?

A

combines operant conditioning (reinforcement and negative consequences) and ABA in long-term, intensive program to improve language and cognitive skills; most effective for Autism

405
Q

3 drugs used off-label for Autism

A
  • SSRIs: improve mood and reduce anxiety to improve tolerance of new situations and social interaction (Ex. Citalopram, Fluoxetine, Paroxetine, Sertraline)
  • Stimulants (methylphenidate, amphetamine compound, Lisdexamfetamine): for hyperactivity, impulsivity, or inattention
  • Naltrexone: reduce disability repetitive and self-injurious behaviors
406
Q

Usage of SGAs (risperidone and aripiprazole) in Autism (2 notes)

A
  • reduce irritability and agitation that is expressed in severe temper tantrums, aggression, and compulsive behavior
  • Improve relatedness by decreasing agitation, anxiety and compulsive behavior

Side effects: EPS, somnolence, weight gain, gynecomastia

407
Q

Attention-deficit/hyperactivity-Disorder

Definition
4 notes

A

inappropriate degree of inattention, impulsiveness, and hyperactivity that interferes with social, academic or occupational functioning

  • child can be inattentive yet not hyperactive
  • Symptoms must be present in at least two settings and occur before age 12 for at least 6 months (nowadays adults are diagnosed too)
  • Symptoms not due to schizophrenia or better explained by another disorder
  • ADHD is chronic and unremitting and often persists into adulthood
407
Q

Symptoms of ADHD: Inattentive (7)

A
  • Lacks close attention to detail and makes careless mistakes
  • Does not listen when spoke to
  • High distractibility
  • Disorganization
  • Unable to complete challenging or tedious tasks OR avoids or dislikes them
  • Easily bored (disruptive, noisy)
  • Require frequent prompts to complete tasks (lost or forgotten homework)
408
Q

Symptoms of ADHD: Hyperactivity and impulsivity (6)

A
  • Fidgeting, tapping, squirming
  • Unable to remain seated when expected
  • Runs or climbs in inappropriate situations (always on the go; inappropriate social norms for their age)
  • Unable to engage in leisure activities quietly
  • Talks excessively or when inappropriate
  • Difficulty waiting their turn and may interrupt others-
409
Q

5 components of ADHD assessment

A
  1. Gather data from parents, caregivers, teachers, or other adults involved with the child. (Ask about level of physical activity, span, talkativeness, frustration tolerance, impulse control, and the ability to follow directions and complete tasks)
  2. Monitor eating and sleeping patterns
  3. Assess through observations and note any developmental variance in these behaviors.
  4. Assess social skills, friendship history, problem-solving skills, and school performance.
  5. Assess for comorbidities such as anxiety and depression; learning disorders, autism spectrum disorder, or intellectual disabilities
410
Q

9 Interventions for ADHD

A
  • Focus on recognizing ineffective coping mechanisms and safety (may have difficulty assessing risks of danger)
  • Hospitalization if imminent danger due to aggressive or disruptive behaviors
  • Teach parents about behavior modifying techniques
  • provide consistent, structured, and nurturing home environment to promote achievement of normal developmental milestones
  • positive attention and additional affection
  • Effective instructions
  • Consistent rewards and consequences (limited)
  • Split tasks up
  • Use therapeutic and creative play
411
Q

Behavior therapy/CBT and ADHD (3 notes)

A
  • teaches parents skills and strategies to help child with conflict resolution, problem solving, empathy, and social skills
  • Younger than 6, first line of treatment is parent training in behavior therapy
  • Over 6, parent training in behavior therapy plus medication
412
Q

4 drug classes used for ADHD aggression

A
  • Stimulants- dose dependent; low doses stimulate aggression but moderate to high doses suppress aggression
  • Mood stabilizers (Lithium and anticonvulsants)- recommended for impulsivity, explosive temper, and mood lability
  • Alpha-adrenergic agonists (Clonidine and guanfacine)- reduce agitation, rage, and increase frustration tolerance due to side effects of fatigue and somnolence
  • Antipsychotics- reduce violent behavior, hyperactivity, and social unresponsiveness (only for severely aggressive behavior due to tardive dyskinesia and metabolic problems)
413
Q

Usage of SNRI (Atomexetine) in ADHD (3 notes)

A

o Slow responses (up to 6 weeks for full improvement)
o Preferred when individual’s anxiety is increased with stimulants OR comorbid anxiety, active SUD, or tics
o May cause suicidal ideation in those with comorbid depression

414
Q

Side effects of Atomexetine (6-ish)

A
  • GI disturbances
  • urinary retention
  • dizziness
  • fatigue
  • insomnia
    Rare: livery injury, small increase in BP and HR, serious allergic reactions
415
Q

Patient education for Stimulants and ADHD (3)

Ex. Methylphenidate, mixed amphetamine salts, lisdexamfetamine

A
  • Minimum dose and no later than 4pm or lower dose later in day
  • Extended-release formulation to improve dosing and scheduling and decrease insomnia
  • ALWAYS eat before stimulant use (and have finger foods available)
416
Q

Common side effects of stimulants (6)

Ex. Methylphenidate, mixed amphetamine salts, lisdexamfetamine

A
  • insomnia
  • appetite suppression (weight loss so take prior to meal)
  • headache
  • abdominal pain
  • lethargy
  • dry mouth
417
Q

Stimulants and ADHD (3 notes)

Ex. Methylphenidate, mixed amphetamine salts, lisdexamfetamine

A
  • paradoxical increase in attention and task-directed behavior while reducing impulsivity, restlessness, and distractibility
  • main drug/ drug of choice
  • Relatively safe and simple to use

Mental Health (4 decks)

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