LMR Flashcards
TSH Normal Range
-0.5 - 5 Mu/L
T4 Normal Range
0.8 - 2.8
Symptoms of hyperthyroidism can mimic symptoms of
Mania
TSH Down, T3 and T4 Up
Hyperthyroidism
Heat intolerance, agitation, anxiety, irritability, tachycardia, mood swings,
weight loss
Symptoms of hypothyroidism can mimic symptoms of
depression
TSH UP, T3 and T4 Down
Hypothyroidism
Cold intolerance, lethargy, weight gain, decreased libido
What drug - Can cause Spina Bifida (neural tube defect)
- Hepatotoxicity
Depakote - Divalproex Sodium
Patient taking depakote presents with signs of hepatotoxicity. List signs and symptoms
Abdominal pain in
the upper right portion of the abdomen, reddish brown urine, yellowing of the
skin and whites of the eye,fatigue
*Do a liver function test
AST normal range
5-40 U/l
ALT
5-35 U/l
The therapeutic range for valporic acid (total) is
50-125ug/mL.
The toxic level of valporic acid is
greater than 150 ug/uL
Signs of valporic acid toxicity
Disorientation, lethargy, respiratory depression,
nausea/vomiting
Intervention would you do for valporic acid toxicity?
DC med and check valporic acid levels, LFT and ammonia levels
***High yield
Herbal supplement used for anxiety, stress, insomnia
Kava Kava
Kava Kava can cause
Side Effects:
Hepatotoxicity - Can cause liver damage
Use a liver function test
What class of medications to avoid when taking kava kava?
Sedatives because it can cause excessive drowsiness
xanax
clonzapam
lorazepam
phenobarbital
zolpidem
What medication is associated with SJS (stevens-johnson syndrome)?
Lamotrigine (Lamictal)
S/S of Steven-johnson syndrome? signs and symptoms?
Fever, body aches, red rash, peeling skin, facial and tongue
swelling
What Mood stabilizer that causes the least weight gain?
Lamotrigine (Lamictal)
What Antipsychotics that can cause least weight gain?
Z.A.L
Ziprasidone - Geodon
Aripiprazole -Abilify (Least sedating)
Lurasidone - Latuda
Least sedating Antipsychotic?
Aripiprazole (Abilify)
For patients taking antipsychotics that can cause weight gain check routine labs like?
BMI, hip-to-waist ratio, glucose, and lipid panel
Interventions for Management of antipsychotic-induced weight gain (AIWG)?
1.Non pharmacologic interventions include Nutritional counseling and exercise
2.- Pharmacologic interventions consist of switching to another antipsychotic which
has less potential to gain weight (Ziprasidone, aripriprazole, lurasidone -ZAL-)
you need to eat 360 cals, preferably of
carbohydrates for which medications?
Ziprasidone (Geodon) and Lurasidone (Latuda)
Carbamazepine (Tegretol) can cause
- Agranulocytosis (decrease WBC) and Aplastic Anemia
Presents with pallor, fatigue, headache, fever, nosebleeds, bleeding gums,
skin rash and shortness of breath
Can cause SJS for ASIANS
Carbamazepine (Tegretol)
What to screen for before starting Carbamazepine (Tegretol) in asians?
SCREEN for allel HLAB-1502 before initiating
The HLA-B * 1502 is highly associated with the outcome of
carbamazapine-induced SJS
Clozaril can cause
agranulocytosis
Monitor patients taking carbamazepine and Clozaril for signs of
infection
Sudden fever, chills, sore throat, weakness
DC Clozaril and Carbamazepine at absolute neutrophil count (ANC)
less than 1000mm^3
whether patient is showing signs of infection or not
What is the baseline absolute neutrophil count (ANC) before initiating treatment with clozapine?
The baseline ANC must be at least 1500/μL for the general population, and at least 1000/μL for patients with documented Benign Ethnic Neutropenia (BEN)
What is the therapeutic range for absolute neutrophil count (ANC)?
2,500 to 6,000 per microliter
Lithium normal range
- 0.6 - 1.2 mEq/L
Lithium Toxicity can occur when levels reach what ?
1.5 meq/L or higher
What medication is gold standard for treating manic episodes?
Lithium
This is the only known antipsychotic medication that has been shown to reduce the risk of suicide in patients diagnosed with schizophrenia :
Clozapine (Clozaril)
Lithium can cause what birth defect?
Ebstein anomaly ( congenital heart defect)
inverted tricuspid valve
What labs to monitor for someone who is on Lithium?
Thyroid panel (TSH)
Serum creatinine (0..6- 1.2 mg/dl)
BUN (10-20mg/dl)
Urine analysis (check for proteins in urine. May indicate kidney disease
HCG for females of childbearing age 12yrs -51yrs
Side effects of Lithium
H.I.I.M
Hypothyroidism
inversions T wave
increased WBc’s (Leukocytosis)
maculopapular rash
Lithium is to ____
as Clozaril is to _____
Bipolar
Schizophrenia
Signs/ symptoms for lithium toxicity:
Severe nausea, vomiting, and diarrhea, confusion,
drowsiness, muscle weakness, heart palpitations, coarse hand tremors, and
unsteadiness while standing or walking
Intervention for Lithium toxicity
DC Lithium and check serum Lithium Levels
What can increase the serum levels of lithium?
Kidney disease
drugs that reduce renal clearance such as NSAIDS (Ibuprofen, Indocin
Thiazides (HCTZ)
ACE inhibitors (Prils)
dehydration and hyponatremia
**If patients go hiking and take extra water, that means that is good understanding
of lithium use
Neuroleptic malignant syndrome (NMS) is caused by
antipsychotics
Neuroleptic malignant syndrome (NMS) sign and symptoms :
Extreme muscular rigidity
Mutism
Muscles so rigid that the patient cannot talk
Hyperthermia
Tachycardia
Diaphoresis
Altered level of consciousness
Labs noted with Neuroleptic malignant syndrome (NMS)
Elevated CPK (Creatine phosphokinase) - muscle contraction/muscle destruction
Myoglobinuria - Resulting from the breakdown of muscle cells (rhabdomyolysis)
Elevated WBCs - Leukocytosis
Elevated LFTs - Liver function tests
Treatment of Neuroleptic malignant syndrome (NMS) :
DC the offending agent
Give bromocroptine (Parlodel) - Dopamine (D2) agonist
Dantrolene - Muscle relaxant (muscle rigidity)
Serotonin Syndrome is caused by
Antidepressants
These s/s are noted in what condition?
Hyperreflexia
Myclonic Jerks
agitation, anxiety, restlessness, disorientation, diaphoresis, hyperthermia, tachycardia, nausea, vomiting, tremor, muscle rigidity,
serotonin syndrome:
Treatment of serotonin syndrome:
DC Offending agent
Cyproheptadine
What herbal medication can cause serotonin syndrome
St johns wort
- Herbal medications can also cause Serotonin Syndrome
Can you mix SSRI/SNRI/TCA/MAOI
Do not place on multiple SSRIs or a mixture of the two
When switching from SSRI to MAOI/TCA/MAOI how long ?
14 days
One class to another wait the 14 days
When switching from Fluoxetine (Prozac) to MAOI/TCA/SNRI/SSRI how long?
- 5-6 weeks
This is because Fluoxetine (Prozac) has a long half-life
When switching from MAOI to Prozac; how long?
2 weeks
Triptans are used for:
Migraines - Sumatriptan (Imitrex)
SSRI/SNRI/TCA/MAOI
Mixture of the two can increase what?
serotonin levels
List some Norepinephrine and dopamine reuptake inhibitors (NDRIs):
Amineptine (Survector, Maneon, Directim)
Bupropion (Wellbutrin, Zyban)
Desoxypipradrol (2-DPMP)
Dexmethylphenidate (Focalin)
Difemetorex (Cleofil)
Diphenylprolinol (D2PM)
Ethylphenidate.
Fencamfamine (Glucoenergan, Reactivan)
What class of medications are safer for people who may overdose
SSRI
If a patient overdoses on an SSRI it has a lesser chance to cause an injury
If patient is depressed and has cancer
You can give them SSRIs as well
If a patient presents with low energy and fatigue. What medication can you give? Class?
Give them an NDRI - (Bupropion) Wellbutrin (can increase energy levels)
What two meds have Less potential for drug interactions
Citalopram (Celexa)
Escitalopram (Lexapro)
If patient has history of seizures or eating disorders what medication of avoid?
Bupropion (Wellbutrin)
Lower seizure threshold - Increasing seizure risk
If depressed and neuropathic pain give :
-SNRI
desvenlafaxine (Pristiq, Khedezla)
duloxetine (Cymbalta, Irenka)
levomilnacipran (Fetzima)
milnacipran (Savella)
venlafaxine (Effexor XR)
- TCA
amitriptyline (Elavil),
clomipramine (Anafranil),
doxepin (Sinequan),
imipramine (Tofranil),
trimipramine (Surmontil),
amoxapine (Amoxapine Tablets),
desipramine (Norpramin),
nortriptyline (Pamelor, Aventyl)
But remember about Safety for overdoses
-Even alpha 2 delta ligand medications
Gabapentin
Pregabalin
ALL ANTIDEPRESSANTS COULD ______________ , in
CHILDREN, ADOLESCENTS AND YOUNG ADULTS.
INCREASE THOUGHTS OF SELF-HARM
Always assess self-harm
Frequency and severeity
If patient is depressed, assess alcohol intake (may use to self-medicate)
Fluoxetine (Prozac). Take this medication what time of day?
Can cause insomnia, so take in the morning as opposed to the evening
Numerous conditions presents likely with homicidal ideation. Name some of those conditions:
Antisocial personality disorder
Schizoaffective,
BPD,
paranoid personality,
schizophrenia,
OC personality
D
Schizophrenia
Age of onset -
-18-25 males
-25-35 Females
In Schizophrenia what will you see on MRI/PET scans:
MRI/PET scan -
Enlarged ventricles,
- everything else is decreased in size
Do not give schizophrenic patients ________medications
Stimulant
potentiate dopamine release
- It will increase positive symptoms
- Antipsychotics lower ____.
(Neurotransmitter)
dopamine
Negative symptoms will get worse, but want to deal with positive symptoms first.
Might need social skills training
- Falls under tertiary levels of prevention
How do you perform a Mental status exam of a preeschooler 3-5 years old
Listen and observe cues.
Heavily dependent on clinical observation
Components
Clock drawing test
Serial 7s -
Learning items -Registration
Move from thought to thought that may or may not relate in
some way but never get to the point
Tangentiality
Provide unnecessary detail but eventually get to the point
Circumstantial
Refers to the themes that occupy the patient’s thoughts and perceptual
disturbances
Example - Suicidal ideations, homicidal ideations (SI or HI), plan, visual
hallucinations, auditory hallucinations
Thought content
Assess organization of patient’s thoughts and ideas
Normal: logical, linear, coherent and goal oriented
Abnormal: Associations are not clear, organized or coherent
Thought process
MIni mental status examination - MMSE (Folstein scale)
components :
CONCENTRATION /attention/calculation
I would like you to count backwards from 100 by sevens or do serial 7s
ORIENTATION
what is the year? season? date? day? month? where are we?
RECALL
REGISTRATION
–ability to learn new material- name 3 objects: one second to say each. Then ask the patient all 3 after you have said them. then repeat them until he/she learns all three.
FUND OF KNOWLEGDE
–who is the president/governor
What makes an antipsychotic atypical
-Serotonin - Receptor antagonism
5HT2A - Antagonism
typical antipsychotics has dopamine antagonism
First psychotic episode
Give what class of medication? Name a Few:
atypical antipsychotics, less likely to cause EPS due to the
serotonin receptor antagonism
Some atypical antipsychotics:
Seroquel
Geodon
risperidone
zyprexa
clozaril
First psychotic episode and want to stabilize them faster.
Give what class of medications?
What route?
Name a few:
Give them IM medications
Paliperidone (Invega)
Ziprasidone (Geodon)
Aripripazole (not written)
Hyperactivity of dopamine in the _______ pathway mediates positive
psychotic symptoms
Hallucinations, delusions, disorganized behavior
Mesolimbic pathway
Decreased dopamine in the ___________ to the dorsolateral
prefrontal cortex is postulated to be responsible for negative and depressed
symptoms of schizophrenia
Mesocortical pathway
The _________ pathway mediates motor movements
Nigrostriatal pathway
Dopamine blockade in this pathway can lead to increased acetylcholine levels
Nigrostriatal pathway
Dopamine has a reciprocal relationship with ?
Acetylcholine (ACh)
Bloackde of Dopamine (D2) receptors in this pathway can lead to (EPS)
Nigrostriatal pathway
What are some Extrapyramidal Symptoms?
Akathisia: Feeling restless like you can’t sit still. …
Dystonia: When your muscles contract involuntarily. …
Parkinsonism: Symptoms are similar to Parkinson’s disease. …
Tardive dyskinesia: Facial movements happen involuntarily.
Long-standing D2 blockade in the _________ can lead to tardive
dyskenisa
nigrostrital pathway
REGLAN can cause serious side effects, including:
Tardive dyskinesia (abnormal muscle movements).
Increase acetylcholine and decrease dopamine levels=
EPS
Decreased levels of dopamine receptors in this pathway can lead to increase
prolactin levels leading to hyperprolactinemia which clinically manifests as
amenorrhea, galactorhea (milk production from the breast unrelated to pregnancy or lactation) (Risperidone), sexual dysfunction and gynecomastia
Long term hyperprolactemia can be associated with osteroprosis
Tuberoinfiundibular pathway
Prolactin levels
Men - Less than 20ng/ml
Women - Less than 25ng/ml
An atypical antipsychotic drug that is metabolized to a major
extent by the cytochrome P450 enzyme CYP1A2
Clozapine
Can decrease the serum level of other drugs that are
substrates of that enzyme, thus possibly causing subtherapeutic drug levels
Enzyme Inducers
Cigarette smoking - VERY HIGH YIELD
Oral contraceptives
Schizophrenia - high rate of cigarette smoking
Olanzapine (Zyprexa) and cigarette smoking (inducer). How will you adjust dose?
If patient started smoking, you will need to increase the dosage
of Zyprexa
A few months later, they stopped smoking or started a smoking
cessation program, you want to decrease the dosage of Zyprexa
Can increase the serum level of another drugs that are
substrates of that enzyme, thus possibly causing toxic levels
Enzyme inhibitors
IF they started an inhibitor, they will cause high serum levels of their
medication
Medications that cause mania:
S.A.I.D
Steroids
Antidepressants (in people with bipolar)
Isoniazid (INH)
Disulfram (Antabuse)
Medications that cause
depression:
S.A.B.B.I R.A.P
Steroids
Antineoplastic drugs
Beta blockers - lols
Benzodiazepines
Interferon
Retroviral drugs
Accutane (Isotretinoin)
Progesterone
Steroids can cause
psychosis
If you are treating a patient with psychosis, and they are on abilify, and on
flonase/prednisone, it is because of the steroid component of their medicaiton, and
it is exacerbating their psychotic symptoms. You want to increase the dosage of
their antipsychotics.
Neurotransmitters for ADDICTION
Dopamine and GABA
These meds Can also cause delayed gastric emptying
Ranitidine, famotidine, omeprazole
Antacids
PPI - Protonix, Omeprazole
- Can decrease absorptions of psychotropic medications.
How many hours apart to take medications?
Take medications two hours apart to avoid delayed absorption
When giving older adults SSRI’s monitor for:
Increased anxiety
Medications can cause paradoxical effect. What is the meaning of paradoxical effect?
if patient is very anxious and agitated,
and you gave a benzodiazepine to help with anxiety and agitated, it is causing them
to be more anxious and agitated
- It is the opposite of what it was meant to treat
- If insomnia and gave them trazodone, it is causing them to stay awake all night
- Avoid the medication in the future
Apoptosis
Neuronal loss / Cell death
Bipolar disorder
What does D.I.G.F.A.S.T acronym mean?
Distractability
impulsivity/Irresponsibility?Indescretion (Lack of good judgement)
grandiosity (- Patient has self-exaggerated esteem, heightened esteem)
flight of ideas
activities
sleep
talkativeness
Bipolar disorder is very inheritable
If they gave you different risk factors, the greatest risk factor is family
history, through generations
Age at which bipolar disorder is most likely due to a medical condition is
45
years and above
First time presenting with manic or hypomanic episode it is most likely
due to:
a medical condition such as stroke
Borderline Personality Disorder:
What are some behaviors?
Treatment? Who developed treatment?
Goals of this therapy?
Presents with self-harming behavior
Recurrent suicidal behaviors
Treatment?
Therapy is mainstay - Dialectical Behavioral Therapy (DBT)
Goal: Decrease thoughts of self-harm
Developed by: Marsha Linehan
Patient with Borderline personality disorder is presenting with depressed mood, emotional lability, you can give
them
DEPAKOTE
Is a mental condition in which a person has blindness,
mutism, paralysis, or paresthesia (glove stocking syndrome), other nervous
system (neurologic symptom symptoms that cannot be explained by medical
evaluation
Conversion Disorder
Glove stocking, means
wearing gloves because they are cold
Symptoms usually begin suddenly after a stressful evaluation
Is an emotional or behavioral reaction
to a stressful event or change in a person’s life. The reaction is considered an
unhealthy or excessive response to the event or change within 3 months of it
happening.
Adjustment disorder
Examples: Stressful events or changes in life of your child or adolescents may be a family
move, the parents’ divorce or separation, the loss of a pet, or birth of a sibling
A sudden illness or restriction to your child’s life due to the chronic illness may
also result in adjustment response
Adjustment disorder with depressed mood: Presents with
feelings of
sadness, decreased interest, sleep, disturbance, appetite changes.
IF you can identify the stressor it is Adjustment disorder
Adjustment disorder with anxiety: Presents with symptoms of
feeling restless,
nervousness, lack of concentration
Adjustment disorder with disturbance of conduct:
A child may violate other
people’s rights or violate social norms and rules. Examples include not going to
school, destroying property, driving recklessly, or fighting
Adjustment disorder with mixed disturbance of emotions and conduct:
For example, child may
present with truancy, peer confict, verbal altercations, insomnia, and frequent
crying
It is an enduring pattern of angry or irritable mood and argumentative, defiant, or
vindictive behavior lasting at least 6 months with at least 4 of the associated
symptoms
-Loses temper
-touchy or easily annoyed
-angry or resentful
-argues with authority
-actively defies or refuses to -comply with requests or rules -from authority
-figures
-blames others
-Delibrately annoys others
-spiteful or vindicful
Oppositional defiant disorder
Treatment of Oppositional defiant disorder
Non-pharmacological
-Therapy is mainstay
-Family Therapy, with emphasis on child management skills; teaching
parents about positive reinforcement and boundary settings
-Child and parent problem-solving skills training
A repetitive and persistent pattern of behavior in which the rights of others or societal norms or rules are violated.
AGGRESION toward people or animals-bullies, threatens, intimidates ,initiates physical fights, uses a weapon to cause physical harm to others, physical cruel to people or animals, stealing while confronting a victim, forced sexual activity on someone.
LACK OF REMORSE
DESTRUCTION OF PROPERTY
deceit or theft
what disorder does this describe?
Conduct disorder
Treatment for conduct disorder
target mood and aggression
aggression and agitation treated with antipsychotics, mood stablizers, SSRI, and alpha agonist (clonidine and Guanfacine)
If you feel like the child needs to go to Juvenile Prison, it is most likely to be:
conduct disorder
At least two motor tics and one vocal tic for at least a year, does not have be at the
same time
Tics are not caused using a substance or medical conditions
Note - Children’s motor tics are fairly common and can be temporary
Wax and Wane in frequency but have occurred for more than 1 year
Tics started to appear before the age of 18
Tourette Syndrome (TS)
Primary Neurotransmitter involved in Tourette Syndrome (TS)
DNS
- Dopamine, norepinephrine (Noradrenaline), Serotonin
Hyperactivity of dopmainergic systems in the brain can cause Tourettes
Pharmacological management of Tourette Syndrome (TS)
Atypical antipsychotic
FDA: Haldol, Pimozide, Aripripazole
Medications such as clonidine (catapres, Kapvay) and Guanfacine (Intuniv)
can help control behavioral symptoms such as impulse control problems
and rage attacks
Is a psychiatric dx that may occur in patients within 4
weeks (4 weeks or less) of a traumatic event. Features include anxiety,
insomnia, poor concentration, intense fear, or helplessness, reexperiencing the
event and avoidance behaviors.
Acute stress disorder
Ex. Inpatient, patient becomes aggressive towards you and you dont want
to go back to work (anxiety, nightmares) if these symptoms last less than
a month, use acute distress disorder
If more than 4 weeks look at PTSD
Hallmark Symptoms
Intrusive re-experiencing of an extremely traumatic event
Increased arousal (Hyperarousal)
Avoidance of stimuli associated with the trauma
PTSD
Treatment for PTSD
SSRI, TCA
Prazosin for nightmares
Nonpharmacological treatment for PTSD
Nonpharmacological
EMDR/CBT
Phases of EMDR
Phases of EMDR
Desensiitization phase
Installation phase
Body Scan
The client visualizes the trauma, verbalizes the negative thoughts or
maladaptive beliefs, and remains attentive to physical sensations. This process
occurs for a limited time while the client maintains rhythmic eye movements. He
or she is then instructed to block out negative thoughts; to breathe deeply; and
then to verbalize what he or she is thinking, feeling or imaging.
What phase of EMDR?
Desensiitization phase of EMDR
The client installs and increases the strength of the positive thought that he
or she has declared as a replacement of the original negative thought.
What phase of EMDR?
Installation phase of EMDR
The client visualizes the trauma along with the positive thought and then
scans his or her body mentally to identify any tension within
What phase of EMDR?
Body Scan of EMDR
What part of the brain is associated with ADHD?
Frontal cortex
Basal Ganglia
Abnormalities of reticular activating system
Can lead to ADHD Symptoms
Abnormalities in the prefrontal cortex - inattentive type
Assess ______ History before placing patient on stimulants
cardiac
For parents who don’t want to start their child on stimulants for ADHD. You can offer non-stimulant such as :
Clonidine and Guanfacine - both FDA approved for children that 6-17 years old
Atomoxetine - Straterra - 6 years old and above, that have ADHD
Encourage the parent to start the patient on non-stimulant medication
Doing multiple dosing or placing them on extended release
Neurotransmitters involved in ADHD
DNS-Dopamine, norepinephrine (Noradrenaline), Serotonin
Neurotransmitters involved in OCD
Serotonin and Norepinephrine
Presence of anxiety-provoking obsessions (Recurrent and persistent
thoughts, impulses or images) or compulsions (for example tics) that function
to reduce the person’s subjective anxiety level
OCD
Pediatric Autoimmune Neuropsychatric Disorders Associated with
Streptococcal Infections (PANDAS) should be considered in all children with
sudden onset of
OCD Symptoms
If a child has strep infection, monitor for
OCD
Difference between OCD and Tourettes
OCD: INTRUSIVE THOUGHTS AND TICS
Tourettes: TICS ONLY
Someone deceives others by appearing sick, by purposely getting sick or by self-injury.
Usually presents with physical or mental symptoms that
induced for example drinking contaminating urine samples, taking
hallucinogens, injecting fecal material to produces abscesses, and similar
behavior.
Factitious disorder
1) It is the product of a severely dysfunctional early relationship between the
principal care giver and the child.
2) When the caregivers consistently disregard
the child’s physical or emotional needs, the child fails to develop a secure and
stable attachment with them.
3)The failure causes a severe disturbance of the
child’s ability to relate to others, manifested in a variety of behavioral and
interpersonal problems. Some children are fearful, inhibited, withdrawn,
apathetic, shows no emotion towards caregivers, others are aggressive,
disruptive and disorganized.
Abuse or Foster Care
What disorder is described above?
Reactive attachment disorder
Excessive worry, apprehension, or anxiety about events or activities occurs
more days than not for a period of at least 6 months.
GAD
Is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, and during which time a variety of psychological and physical symptoms occur. These symptoms include rapid hear rate, sweating, shaking, shortness of breath, hot flashes an lightheadedness as well as a sense of IMPENDING DOOM, chills, nausea, abd pain chest pain, headache, numbness or tingling.
Panic Attack
Treatment of panic attacks
1) betablockers
2)Propranolol - Can cause bronchspasms, so you cannot give with albuterol
(bronchodilator)
3)Benzodiazepines - Habit forming, CNS depressant, if had to choose
between the two go with beta blockers
How do you treat Performance Anxiety
Acute condition. Give beta blocker & benzos
For Maintenance/long term give SSRI
Is a diagnosis given to people who experience recurrent
UNEXPECTED panic attacks - that is, the attack seems to appear out of nowhere.
The term recurrent refers to the fact that the individual has had more than one
unexpected panic attack
Panic Disorder
Childhood depressive disorder that is diagnosed in children older than age
6 but younger than age 18
Sad, always mad, etc
Frequent intense temper outburst (Hallmark sign)
Severe irritability
Anger
Dysruptive mood dysregulation Disorder (DMDD)
List Anorexia Nervosa 5 signs and symptoms:
Low BMI
Amenorrhea
Emaciation (Being abnormally thing)
Bradycardia Low Pulse
Hypotension
If patient has low BMI, low pulse, low BP, you might need to refer out to futher
medical evaluation, to their PCP or possible hospitalization
Refer patient out but parent does not want to do that
Get CPS involved, due to the patient’s safety
For adults - notify Adult protective services
One key difference between Anorexia And Bulimia Nervosa
BMI for bulimia - usually in normal range BMI
Neurotransmitters involved in Autism Spectrum Disorder
Gaba, Glutamate, Serotonin
Deficit in social communication and social interaction across multiple settings
no response when called by name
little or no eye contact
Often like to line up, stack or organize objects and toys in long tidy rows
What disorder is described above?
Autism Spectrum Disorder
Claims that a dysfunction of the mirror neuron system may be a cause of poor
social interaction and cognition in individuals with autism
Broken mirror theory of autism
If patient is presenting with Irritability, Depressed and labile mood. What questionnaire?
Mood Questionnaire
Sleep disorders for children can be due to:
Nightmares in children can be due to:
1)Genetic Factors
Are there other family members that have nightmares?
Assess family patterns of nightmares
Do not make assumptions
Psychological Factors
Acute disturbance of LOC, cognition and attention
Poor prognosis: 1 year mortality rate is up to 40%
Delirium
Treatment of Delirium
Agitation and psychotic symptoms can be treated with low dose of HALDOL
Can give benzodiazepines but can cause longer delirium
Progressive - Months to years (Insidious)
Take a 1- 10 years to diagnose
Leads to
Mental decline
Irritability
Personality Changes
they might lack an answer or they might
CONFABULATE (make up answers)
Dementia
Dementia treatment
Check for B12 and Folic Acid Levels
treat Psychotic symptoms and agitation
Start with nonpharmacological management
Pharmacological
Atypical antipsychotics
Seroquel
Abilify
Primary diagnosis is Depression
Look for depression symptoms
Usually has “I DONT KNOW” answers more generalized answers
Cause by depression - Memory problems - in older patients.
Can present as
irritability and agitation
Hallucinations
Delusions
Cognitive deficit
Pseudo-dementia
Screen for cognitive impairment
MMSE
SLUM
MoCa
Mini-Cog
Delirium vs Dementia
Acute onset of memory problems
( delirium) (occur within weeks or months)
1-5 months, that is considered acute onset
Dementia - years
Delirium - hours to days
What type of dementia will you notice:
Motor symptoms
lack of coordination, tremors, dystonia, depression and apathy, muscle rigidity
Dementia : Subcortical
What type of dementia will you notice:
Language (aphasia) and memory impairments (amnesia)
Dementia: cortical
What type of dementia will you notice:
Early signs: cognitive decline, motor abnormalities , and behavioral abnormalities
Late signs: mutism, global cognitive impairment, hallucinations, delusions, mania
classified as a subcortical dementia
Dementia due to HIV
What type of dementia will have:
recurrent visual hallucinations
Parkinson’s features
adversely react to antipsychotics
Lewy body disease
Also known as frontotemporal dementia/frontal lobe dementia
more common in men
personality, behavioral , and language changes (slurred) in early stage
Picks disease
Subcortial type of dementia where it is characterized mostly by motor abnormalities
psychomotor slowing and difficulty with complex tasks
HIGH INCIDENCE OF DEPRESSION AND PSYCHOSIS
Huntington’s disease
This part of the brain is responsible for
- Personality, speech expression, Broca’s(expressive speech), proverb interpretation, voluntary movement, executive functions.
Frontal lobe
This part of the brain is responsible for:
Memory, emotion, hearing, Wernicke’s( language comprehension, receptive speech)
Temporal lobe
This part of the brain is responsible for:
Taste, reading and writing, sensation
Parietal Lobe
This part of the brain is responsible for:
Vision, visual perception
Occipital
HypoThaLamuS is responsible for
Libido, temperature, hunger, fatigue, sleep
Amygdala is responsible for
Aggression, fear, anxiety, emotions, decision making
Hippocampus is responsible for
emotions, stress, learning, memory navigation, motivation
Anterior cingulate is responsible for
Cognitive functions: decision making, empathy, impulse control,
emotions
Cerebellum is responsible for
Maintenance of balance and posture
_______ is produced in the
locus coeruleus and medullary reticular formation.
General function:
alertness, focused attention, learning, and memory
Norepinephrine
_____is produced in the
General function:
reduces arousal, aggression, and anxiety
GaBA
Which type of group therapy allows members to search for meaning and to find understanding and resolution of past conflicts?
Correct answer: Reminiscence therapy
Often used with older adults, reminiscence therapy focuses on a progressive return of memories of past experiences.
______ is produced in the
raphe nuclei of the brainstem
General function:
regulates sleep, pain, mood states, and temperature
serotonin
_______ is produced in the
Substantia nigra and VTA, Nucleus Accumbens
General function:
thinking, fine muscle action, and reward-seeking behavior
Regulates motor movements
Dopamine
_______ is synthesized by the
basal nucleus of meynert
General function:
Acetylcholine
Abnormalities or changes/deficits in the prefrontal cortex, amygdala, basal ganglia, hippocampus and limbic regions of the brain can cause:
aggression, implusivity, and abstract thinking problem in schizophrenia
Developmental delay, learning difficulties, irritability, loss of appetite, weight loss,
sluggishness and fatigue, abdominal pain, vomiting, constipation, hearing loss,
seizures, eating things such as paint chips, that are food (PICA)
- Houses in rural areas that are built in the 1970s
Signs of lead poisoning
Infant who is about to die
- Give the infant to the parents and allow them to grieve for their loss.
Normalize grief and loss in what age group?
children
non pharmacological management
Psychoeducation
Supportive group therapy
Grief repsonses vary - You don’t tell them how to grieve, because everyone
grieves differently.
Having an intact family is the most important thing to have
Neurotransmitters in Mood
DNS + GG
Gaba - Gamma aminobutyric acid
Risk factors for Osteoporosis
Smoking
Drinking caffeine
Lack of weight bearing exercises
Lack of diet rich in calcium and vitamin D
Social skills - What lobe of the brain?
Frontal lobe
Patient that is not comfortable sharing their problems in a group
setting. At the same time you want to promote
- INTERPERSONAL LEARNING - learn from each other
- Encourage the patient to attend the group session, and you want to provide
adjunctive individual sessions - Meet 1:1 with the patient and add adjunctive individual session to help facilitate
group involvement
What kind of therapy:
Developed by Aaron Beck
Replace patients negative, distorted, irrational thoughts with positive thoughts what type of therapy?
Cognitive therapy
What kind of therapy:
Developed by Arnold Lazarus
focuses on on changing maladaptive behaviors by participating in active behavioral techniques such as exposure, relaxation, skills training, problem-solving, modeling and role playing?
Behavioral Therapy
What kind of therapy:
Aims to change our thought patterns, our conscious beliefs, our attitudes, and ultimately, our behavior, to help us face difficulties and achieve our goals.
combining both cognitive and behavioral thinking.
Uses:
Cognitive restructuring
Journaling - of negative thoughts
CBT
What kind of therapy:
Developed by Carl rogers
“Person-centered”
Self-actualization and self-directed growth
Each person has the potential to actualize and find meaning
Humanistic
What kind of therapy:
Developed by Gerald Klerman an Myrna weissman
Focus on interpersonal issues that are creating distress
time limited, active, focused on the present and on interpersonal distress
developed to treat aspects of depression
Interpersonal therapy
targets youths (12-17 yrs old) who present with serious antisocial, problematic behavior, and with serious criminal offense by empowering parents with resources and skills and reducing barriers to resources needed for effective management of their youth
_____typically uses a home-based model of service delivery to reduce barriers that keep families from accessing services.
Develop a natural support system from their family and neighbors.
Multisystemic family therapy (MST)
What kind of therapy:
Developed by Jay Haley
Treatment goal is to help family members behave in ways that will not perpetuate the problem behavior.
Interventions are:
-Problem focused
-Symptom Focused
Techniques:
PARADOXICAL DIRECTIVES/intervention
-Non compliant patients, do the opposite
-Tell patient to not take their medication
-Use with caution
STRAIGHT FORWARD DIRECTIVE
tasks that are designed in expectation of the family members compliance.
REFRAMING BELIEF SYSTEM
Problematic behaviors are relabeled to have more positive meaning
Example: Reframing belief, means if a child is jealous, you say no, you are not
jealous, you love him very much
Strategic therapy
What kind of therapy:
Developed by Steve deShazer, Bill O’hanlon, Insooberg
Focus is to rework for the present situation solutions that have worked
previously
Treatment goal is effective resolution of problems through cognitive problem solving and use of personal resources and strengths
Techniques:
1)MIRACLE QUESTION
If you wake up and the problem no longer existed, what would’ve
happened
2)Exception-finding questions
Directing clients to a time in their lives when the problem dis not exist.
“was there a time when the problem did not occur?’
3) Scaling questions
“ on a scale of 1-10 with 10 being very anxious and depressed. How would you rate how you are feeling now”
Solution-Focused Therapy
Triangles/triangulation/self-differentiation, Genograms
Family system therapy/systemic family therapy
What kind of therapy:
Developed by Salvador Minuchin
Who placed emphasis on how when and to who family member relate in order to understand and then chnge the family’s structure.
The main treatment goal is to preodc structural change in the family organization to more effectively manage problems — changing transactional patterns and family structure.
family structure, structural mapping(genogram) ,Hierarchies
Structural family therapy
Teaching a patient about medication
Teach them about muscle relaxation, is an important component of medicaiton
Benefits of physical activity in children
Help improve their body image
Help promote resilience
Improve relationships
Helps with social anxiety
When communicating with patients, you want to use ______ communication
open ended communication
“I lost my husband”, show empathy
How has this affected you
I’m sorry this happened to you
Try not to use yes or no or close ended question
Cannot construct a narrative,
Patient reluctant to speak
Then you can use yes or no questions
Interview a 10 year old child
Cannot construct a narrative, then you can use close ended
questions
Had an appointment with a couple, but only the wife showed up for the appointment
Then you should cancel the appointment and reschedule
Lady calls you over the phone and tells you that her 5 year old boy reported to her
that he was sodomized or raped by the 15 year old brother. What do you do?
Insist that the mom not leave boy with brother, report to CPS, arrange for crisis
therapy with the family
If patient has rheumatoid arthritis
- Check the patient’s erythrocyte sedementation rates levels (ESR)
Research in nursing
PICOT question
Problem, patient, population
Intervention
comparison
Outcome
Time
A shrill cry means?
- ICP - increased intracranial pressure
Normal for a 3-6 years old for masturbation.
It is about children playing with their
genitals
It is normal for young boys 9-16 years old, to develop swelling or tenderness or
breast enlargement under their nipples. When will it disappear?
it will disappear in about 6 months
Elderly female patient, presents with decreased sex drive. Caused by?
caused by decreased
testosterone and decreased blood flow to the pelvic region
Why are women more likely to get drunk?
Enzyme- alcohol dehydrogenase
metabolizes alcohol, lower in women.
- Decreased quantity, more likely to get drunk
- Develop liver problems caused by alcohol
why would Psychiatric services be added onto medical services?
If you find OB/PCP doctor in the same clinic as a psych provider. They want to :
increase mental health access to people who
need it the most
Palmar reflex - grasp reflex
Last 5-6 months.
Place finger in baby’s palm, strong grasp
if 18-19 months, then it is an abnormal reflex
Moro reflex - startle response
Normal up to 5-6 months
- If change position of baby, higher to lower position, put arms outwards, normal of
baby.
Babinski reflex/Plantar reflex
Scratch sole of babies feet, they put their toes outwards.
- Normal up to age of 2 years
Medication for sexual dysfunction
PDE5 Medication - Rapidly absorbed after oral administration
Normocytic Macrocytic Anemia. What labs to check?
You want to check folic acid levels, vitamin b12,
and iron levels.
adolescents that have ADHD it can increase their
risk of ________
Screen all of your patients for substance use
- Screen all adolescents that have risk of abuse of substances for ADHD
Acupuncture - can be used for
pain and depression
you can find them a reputable practitioner
- Sometimes they don’t want medication
Is a legal concept that protects patients with mental illness against
unlawful hospitalization.
Habeas Corpus
Disseminated encephalomyelitis s/s
Nervous system is affected
Parasthesia - numbness and tingling
Fatigue
asymetrical body movements/extremities
Complete a Neuro exam
Auto-immune disease can lead to
increase cytokines levels.
You Want to diagnose a patient, review a timeline of symptoms so that you can establish
a diagnosis, but the patient is unable to remember what happened during that time
frame. what do you do?
Ask the patient specific questions to anchor their memory
Review a timeframe of symptoms, but cannot remember
Ask them very specific questions to anchor memory, or questions that link
memorable events.
Teach a patient about a medication -
- Assess what they know about the medication and what they believe about the
medication. - Identify misconceptions about what they believe about the medication
Caused by a medication, or medical procedure
Iatrogenic signs and symptoms
Pt has schizophrenia and you give them antipsychotic
- now they have parkinsonian symptoms
What to do ?
- Assess medication history, especially with older adults
Create a policy that is going to affect NPs nation wide
What do you have to do?
for you to create this policy you need input from all of these NPs
How do you get their responses
Create or host an online forum/survey
Easier for them to give their response
Implement a policy at the job site, coworkers are against that policy
What do you do?
Discuss how that policy is going to improve quality of care.
To ensure continuous improvement of quality of care - out patient clinic-, develop an
instrument to monitor clinical outcomes
Desmopressin (DDVP) used for?
enuresis, night time bed wetting- Decrease urine
production/output
Cannot look up patients information on social media. why?
violating their trust
Assume that you as a PMHNP you notice that there is conflict of interest of
pharmaceutical companies and NPs, and if you use my medication I will pay off your
student loan.
What should you do?
Might use even though not effective
Create a policy to address that conflict of interest between pharm companies
and NPs
Before creating a policy, assess the relationship between industry
provided samples and industry sponsered education
Started a patient on a medication, and has been taking it for a while. Contacting you
that the FDA recently released a black box warning about that medication. What
would you do?
Don’t stop medication, even if there is a Black box warning
Research the benefits and risk of continued use.
When using medication for off-label use, it should include
full disclosure ( discuss benefits
and risk)
Trazodone is used for insomnia, but it can also cause priapism
Include evidence that support off-label use
Some risk factors for sleep apnea
excess weight
obesity
diabetes
smoking
Tolerance
take meds, but need more of it to achieve the same effect
example : 2 pills of klonopin, for 4 years, now need 4 pills for same effect
- Decreased/diminished effect of continuous use of same dose of medication over a
long period of time
Uses a model or framework to systematically “make sense of experience”
Process to tell a story about self and others to gain insight into practice
Enhances critical thinking to problem-solve and enhance clinical reasoning and decision-making
link theory to practice
goal is to improve practice
Debriefing strategies
Reflective practice
A Mini-Mental State Examination (MMSE) scale
Moderate range:
10-20**
30-25
24-21
20-10
9-0
A score of 25 or higher is classed as normal. If the score is below 24, the result is usually considered to be abnormal, indicating possible cognitive impairment.
Becks Depression Inventory scale
Moderate range:
20-28**
0
10
19
30
0–9: indicates minimal depression 10–18: indicates mild depression 19–29: indicates moderate depression 30–63: indicates severe depression
Hamilton Anxiety Rating Scale (Ham A)
Moderate range
18-24
17
18-24
25+
<17 indicates mild severity, 18–24 mild to moderate severity and 25–30 moderate to severe.
HAMILTON DEPRESSION RATING SCALE
Ham-D
Moderate range:
14-18
0
8
14
19
23
In general the higher the total score the more severe the depression. HAM-D score level of depression: 10 - 13 mild; 14-17 mild to moderate; >17 moderate to severe. Assessment is recommended at two weekly intervals.
Patient Health Questionnaire (PHQ-9)
Moderate range:
10-14
0
5
11
15
20+
0 – 4 None-minimal
5 – 9 Mild
10 – 14 Moderate
15 – 19 Moderately Severe
20 – 27 Severe
GAD 7
Moderate range:
10-14
0
5
10
15
Score 0-4: Minimal Anxiety
Score 5-9: Mild Anxiety
Score 10-14: Moderate Anxiety
Score greater than 15: Severe Anxiety
Moderate severe - anxiety/depression
treatment?
medication and or therapy
Scoring on the depression scale on the severe range. Monitor for :
Suicidal Ideations
Clinical Opiate Withdrawal Scale (COWS)
moderate scale range and treatment:
13-24 Moderate - Buprenorphine or Suboxone (Sublingual medication)
Methadone - can cause cardiac arrhythmias
COWS score 5-12.
What treatment?
5-12 - Clonidine
COWS score 13-24.
What treatment?
13-24 Moderate - Buprenorphine or Suboxone (Sublingual medication)
Methadone - can cause cardiac arrhythmias
Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-R)
Refer the patient to a residential treatment center, cannot be done
outpatient
If they come to you outpatient
Start on Buspar or Vistaril
If they go rehab they will start them on benzos
*Don’t give on outpatient setting
If pregnant, priority action is not to report to CPS
Opiate/Alcohol withdrawal
Send them inpatient to residential treatment center
Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-R)
Score of 8 give:
8+ give them symptom triggered PRN
-Ativan
- Nausea
- Diarrhea
Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-R)
Score of 15 give:
15+ start on scheduled medication
Give them
diazepam- longer half life, use this
Librium
Ativan - if bad liver
Opioid withdrawal symptoms:
Yawning
Irritability/anxiety
Pupillary DILATION
piloerection (goosebumps)
runny nose
tearing
Alcohol withdrawal symptoms
N/V
Tremors
paroxysmal sweats
tactile disturbances
auditory disturbances
visual disturbances
headaches
anxiety
agitation
Treatment for ETOH use disorder (Dependence)
A.N.D
Acamprosate
(not metabolized by the liver)
disulfiram
Naltrexone
Irvin Yalom characteristics of group therapy
Installation of hope, universality, group cohesiveness, altruism
approach to organization change which focuses on strengths
rather than on weakness
- Appreciate strengths
- Employees, focus on strengths
Appreciate inquiry
Scope of practice is determined by who?
Determined by state legislative status (State board of nursing)
ECT or TMS - want to contact your state board of nursing
Verifying information with state board of nursing is usually the correct
answer
Do not report - usually wrong answer
who defines NP roles and actions
Varies broadly from state to state
Standard of Practice determined by?
ANA
Provide a way to judge nature of care provided
Client’s right to assume that info given to provider will not be disclosed
requires provider obtain signed medical authorization and consent forms to
release medical records and info when requested by clients family or another
healthcare provider
Confidentiality
Exceptions to confidentiality
if client reveals an intent to harm self or others
answering court orders, subpoenas, or summonses (perjury)
when appropriate persons or organizations determine that the need for information outweighs the principle of confidentiality
information given to attorneys involved in litigation
releasing records to insurance companies
meeting state requirements for mandatory reporting of diseases or conditions
Communication process between provider and client that results in client’s acceptance
informed consent
Dementia - Repeat the benefits and risk, and why they are choosing one option over
the other options
To Send a patient request to pharmacy, you have to get informed consent from them
why?
Before sending script, you have to get clearance. You’ve violated their right if you do
not get informed consent before hand
If patient is very sick, and they don’t have the energy to sign that authorization - Too sick to grab informed consent
What do you do?
you cannot give that patient the medication
- Assess patient the patient for involuntary treatment
Doing what is fair; fairness in all aspects of care
free samples from pharmaceuticals
Want to give it to everyone not just the ones that are too poor/social,
cannot provide someone with less care
Justice
Doing no harm
Action as a provider should not cause harm to your patient
nonmaleficence
Chronic history of abusing benzos
- Requesting benzos, do not give them benzos
being true and loyal
fidelity
romise keeping, just like keeping an appointment
- come back in 4 weeks and reasses, keep your word and assess them
- being professional is fidelity, competent care and effective care
Promoting well-being and doing good
beneficence
telling the truth
patient needs to know the truth about their medical conditions and treatment options
veracity
patients right to self determination
Autonomy
Remember have the right to refuse treatment
least restrictive environment
least restrictive environment
The PMHNP is asked to consult with a local inpatient psychiatric facility to provide nursing staff development. After meeting with the administrator to identify the nature of the problem requiring the consultations, the PMHNP’s next step is to:
A. Create an interdisciplinary teaching team
B. Develop outcome measures
C. market the education plan
D. Utilize a survey to assess the educational needs of the staff.
D. Utilize a survey to assess the educational needs of the staff.
Nurse advocators support the ______________ while respecting the
family’s important role.
patient’s best interests
Reduce the stigma of mental illness
Stigma can present as shame
Teaching university, and students are stigmatizing mental illness
Presenting on the radio - wider audience
Help clients receive available resources
Individuals are continually learning, designing safe systems, and managing
behavioral choices
Assess the patient, to make the patient is safe, then look at what cause
the problem.
Just Culture
A treatment approach which does not focus on full symptom resolution but emphasizes resilience and control over problems and life
self direction
individualized and person centered
non-linear. Recovery is not a step-by-step process, but one based on continual growth, occasional setbacks, and learning from experiences
Recovery Model
In counseling a 23yr old married Hispanic mother who brought her 4 yr old son to clinic for “mal de ojo” with symptoms of fitful sleep, diarrhea, vomiting’s and fever, the PMHNP:
A. Identifies what steps the mother has already tried in caring for the Childs symptoms
B. Explains that the symptoms are most likely caused by viral infection
C. Educates about importance of maintaining fluid and electrolyte imbalance
D. Respects the mother’s understanding of the child illness
D. Respects the mother’s understanding of the child illness
Projects designed to improve systems, decrease cost, and improve productivity
A retrospective chart review is an example of this
plan-do-study-act is a strategy used for quality improvement, this is the process.
Quality improvement
four components of health policy
process: formulation, implementation and evaluation (FIE)
policy reform: changes in programs and practices
Policy environment arena the process takes place in (government, media, public
**policy makers: key player and stake holders
Assess/address organizational barriers and facilitators
Brainstorm with stake holders
To assess barriers and facilitators to evidence-based practice, PMHNP should assess baseline knowledge, beliefs and practices among healthcare providers using a survey. **
Implement policy
- Assess and address organizational barriers
- Not always easy to meet with stakeholder
- Assess baseline knowledge, beliefs and practices among health-care providers
using a survey
Answer options - apply for funding -wrong.
Before implementing evidence-based practice changes, an adult psychiatric and mental health nurse practitioner’s initial action is to:
A. brainstorm with stakeholders and draft a detailed problem list
B. compare data with internal and external benchmarks and coordinate ongoing education
C. facilitate a collaborative multidisciplinary group to synthesize evidence and compare key themes
D. Identify potential barriers and facilitators that reflect patients values and expectations.
Answer D- Initial action - prioritization techniques - always see barriers, then meet
with stakeholders
Screening Brief Intervention Referral for Treatment (SBIRT)
screen for substance use disorders
As a PMHNP we treat patients with mental health disorders and co-occurring substance use disorders.
Duty to warn potential victim of imminent danger of homicidal clients.
Tarasoff Principle
Tarasoff vs. Regents at the University of california 1976
An involuntary committed patient who has not been found incompetent, absent an emergency, has a qualified right to refuse psychotropic medication
Rennie vs Klein court case:
confinement. It is unconstitutional to commit a person involuntarily ( for the longest time) who is not (imminently) dangerous to self or others.
Donaldson vs O’connor:
SBIRT
FRAMES- Meaning?
Feedback
Responsibility
Advice
Menu
Empathy
Self-esteem
Tarasoff principle does not apply in every state
you have to check with the boards
to see what you need to do.
Piaget Sensorimotor stage
What age?
Key points?
Sensorimotor - 0-2 months
- Object permanence
-object constancy
-experience the world through their senses.
Piaget Preoperational stage
What age?
Key points?
Preoperational - 2-7 years old
- Magical thinking is normal
- Their thoughts can influence the things around them
-use language and symbols
-egocentric thinking
Piaget concrete stage
What age?
Key points?
Concrete operational 7- 12 years
- Conservation
-reversibility
Piaget formal operational stage
What age?
Key points?
Formal operational - 12 years to adulthood
Abstract logic
- Patient is able to do a science project
- Test a hypothesis
Erikson’s
Trust vs Mistrust (HOPE)
Age?
Key points?
unfavorable outcome?
Infancy-1 year old
-form meaningful relationships
-trust in others
Unfavorable outcome?
suspicion, fear of the future
Addiction, depression, psychosis
Erikson’s
Autonomy vs Shame and Doubt (WILL)
Age?
Key points?
Unfavorable outcome?
Early childhood 1-3 years old
-self control, self esteem, willpower
unfavorable outcome? feeling of shame and self doubt
Erikson’s
Initiative vs. Guilt (PURPOSE)
Age?
Key points?
unfavorable outcome?
Late childhood 3-6 years old
-ability to be a “self starter”, to initiate one’s own activities
-self directed behavior
unfavorable outcome: sense of guilt
Erikson’s
Industry vs. Inferiority (COMPETENCE)
Age?
Key points?
unfavorable outcome?
School Age 6-12 years old
sense of competency and achievement
-ability to learn how things work, to understand and organize
Industry vs. Inferiority is the stage in which children enter into the greater society beyond the family for the first time. If they succeed in navigating this stage, then they are able to develop a meaningful social role to give back to society
Erikson’s
Integrity vs despair (WISDOM)
Age?
Key points?
unfavorable outcomes?
Late adulthood >65
-fullfillment and comfort with life
-willingness to face death
-insight
-balance and life events
sense of integrity
unfavorable outcome:
dissatisfaction with life, despair over prospect of death
According to Erikson, the last psychosocial stage is Integrity vs. Despair. This stage includes, “a retrospective accounting of one’s life to date; how much one embraces life as having been well lived, as opposed to regretting missed opportunities”
Erikson’s
Identity vs. Role confusion (FIDELITY)
Age?
Key points?
unfavorable outcome?
Adolescence 12-20 years old
personal sense of identity
seeing oneself as unique
unfavorable outcome: confusion over who and what really one is .
Failure to successfully resolve the psychosocial stage Identity vs. Role Confusion is linked to delinquent behavior, borderline psychotic episodes, and gender-related identity disorders.
Erikson’s
Generativity vs stagnation (CARE)
Age?
Key points?
Unfavorable outcome?
Middle adulthood 35-65
-Ability to care for others
-concern for family and society in general
unfavorable: concern for only self
Erikson’s
Intimacy vs. Isolation (LOVE)
Age?
Key Points?
unfavorable outcome?
Early Adulthood 20-35 years old
-commited relationships, capacity to love
unfavorable outcome: inability to form affectionate relationships– leads to isolation
Which of the following patient is at a higher risk of suicide?
A. a 30 yr old married African American female with previous suicide attempt
B. a 35 yrs old single Asian male with previous suicide attempt
C. A 38 yr old single African male who is a manager of a bank
D. A 68 yr old single Caucasian male with depression
D
A 48 yr old Caucasian male patient presents for his therapy session. He is sad about losing his wife recently to COVID19. He reports feeling thoughts of hurting himself. He has a past history of overdosing on propranolol several years ago. Which of the following places him at higher risk for suicide?
A. Previous suicide attempt
B. Age
C. Gender
D. Marital status
A. Previous suicide attempt
A 72 yr old female is brought in by her husband with increasing forgetfulness, decreased activity and decreased appetite for 2 months. She has a history of HTN and is being treated wit lisinopril. The exam is normal. and the mini mental status exam provides a score of 24 but she declines to answer some questions and needs to be urged to participate in the assessment. What is the most likely diagnosis ?
A. Alzheimer disease
B. Vascular dementia
C. Depression
D. Medication toxicity
C. Depression
2 month acute onset - Depressive symptoms, refuses to answer
- Depression
Vascular Dementia
Carotid bruits, fundoscopic abnormalities, and enlarged cardiac chambers
HAM-D is on a 22 - on antidepressant X - for four weeks, they are now scoring a 16.
Do not make any adjustments to your antidepressant.
Patient is on zoloft 20mg for three months, now you are screening the patient.
Scoring a 2 on the GAD 7 scale
Do not change zoloft
Mnemonic for Alcohol Dependence Treatment (DAN):
D=Disulfiram, A=Acamprosate, N=Naltrexone
Opioid Toxicity/Overdose treatment?
Naloxone
What does CAGE stand for/ask?
Cut down, annoyed, guilty, eye opener.
Mydriasis?
D for D = Dilated pupils (withdrawal sign, give Clonidine)
COWS Score/treatment?
Start PRN meds (Clonidine) at 7, give suboxone or buprenorphine at
13.
What do you do as pmhnp if 21 yr old female comes in for eval/assessment for meds and you
see she’s taking Accutane?
Check hcg for pregnancy.
Pregnant female patient presents and she is taking Accutane and 4 other medications. What is
primary intervention? D/C Accutane and check hcg
Pregnant female patient presents and she is taking Accutane and 4 other medications. What is
primary intervention?
D/C Accutane and check hcg.
A pregnant woman on antidepressants presents for follow up and you see she’s now taking
Accutane. What does PMHNP do
D/C Accutane and do hcg to confirm pregnancy
What s/e can happen with Accutane & antidepressants?
Worsen depression.
What are the teratogenic risks for carbamazepine?
=neural tube defects
What can benzos cause if taking while pregnant?
Floppy baby syndrome, cleft palate.
Suicide Risk Factors (purple book pg 163):
Previous suicide attempt
* Male 45 yrs & older
* Female 55 yrs old & older
* White/Caucasian
* Divorced, single, separated
* Living alone
* Psychiatric disorder
* Physical illness
* Substance abuse
* Family history of suicide
* Recent loss
* Male gende
Someone overdosed on MAOI and 10 days later saw an outpatient pmhnp for follow-up and
was started on venlafaxine, what s/s can you expect to see (and what is it called)?
Serotonin
syndrome because pmhnp started venlafaxine too soon (10 days instead of 14 days).
Signs/symptoms of serotonin syndrome include
increased HR, sweats, myoclonic jerks,
confusion, fever, agitation.
What do you treat serotonin syndrome with?
Cyproheptadine
What is the 1st line of treatment for a first psychotic episode?
A. Haldol
B. Clozaril
C. Thorazine
D. Invega
D. Invega
What is the primary neurotransmitter involved in the development of Alzheimer’s disease?
A. Acetylcholine depletion
B. Dopamine depletion
C. Excess GABA
A. Acetylcholine depletion
Which pathway is most implicated in Parkinson’s disease?
Nigrostriatal
What does elevated Creatine Phosphokinase (aka Creatine Kinase) indicate in a patient with
NMS?
Muscle contraction damage. Rationale: the more muscle rigidity there is the higher the
CPK will be).
How do you treat NMS?
Bromocriptine & if with muscle rigidity give Dantrolene.
What happens when you take MAOI with Meperidine (opioid)?
Hypertensive crisis (life
threatening, increased BP, explosive headache, facial flushing, sweating, fever.
How do you treat hypertensive crisis?
D/C offending drug and administer phentolamine.
What other drug combinations cause hypertensive crisis?
MAOIs taken with decongestants dextromethorphan (cough suppressant), tramadol, fermented foods/drinks, TCAs, St. John’s
Wart, stimulants, or asthma medications.
Who created DBT?
Marsha Linehan.
Who created Structural therapy?
Salvador Minuchin.
What part of the brain modulates stress?
Hippocampus (Hypothalamus wasn’t an option
provided)
What would you see in a schizophrenic patient who had a brain scan?
A. Decreased frontal lobal area
B. Reduced volume in the Hippocampus & amygdala
C. Decreased bilateral ventricles
D. Decreased cerebral blood flow
B. Reduced volume in the Hippocampus & amygdala
Pt is on an antipsychotic and developed EPS. Which neurotransmitter is the primary cause of
EPS?
A. Dopamine depletion > nigrostriatal pathway
B. Acetylcholine profuse
A. Dopamine depletion > nigrostriatal pathway
Bradykinesia
slowness
Hyperkinesia
excessive movement
Dystonia
uncontrolled muscle contraction
Which of the following questions is related to assessing the patient’s thought process?
A. Ask if he is having suspicious thoughts
B. Ask if he’s been having racing thoughts
C. Ask him if he’s been having any unusual thoughts or ideas
D. Ask the patient to describe his psychiatric history
D. Ask the patient to describe his psychiatric history
A new patient is a 33yr old man who recently overdosed on fentanyl and had to be resuscitated with naloxone. Activation of which opioid receptor triggers respiratory depression?
MU
goal of existential therapy
to live authentically
encourages reflection on life and emphasizes accepting feedom while making responsible choices
directs clients to find meaning and purpose in life
who developed existential therapy
Viktor Frankl
The area of the brain that is responsible for speech, cognition, judgment, perception, and motor function is
cerebral cortex
The area of the brain that is responsible for coordinating voluntary movements such as posture, balance, coordination, speech, resulting in smooth and balanced muscular activity.
this part of the brain regulates cardiovascular and respiratory systems
medulla oblongata
Edinburgh postnatal depression scale (EPDS)
Less than 8 Depression not likely
9–11 Depression possible
12–13 Fairly high possibility
of depression
14 and higher
(positive screen)
Probable depression
Positive score
(1, 2 or 3) on
question 10
(suicidality risk)
Which medications is FDA-Approved for PTSD
A. Fluoxetine (Prozac)
B. Sertraline (Zoloft)
C. Mirtazapine (Remeron)
D. Lamotrigine (Lamictal)
B. Sertraline
What two drugs to watch for prolonged QT interval?
celexa and geodon
characterized by repeat strokes leading cause ischemic damage in the brain
hallmark: stepwise decreases in cognition with each drop in functional ability representing another ischemic event.
vascular dementia
Treatment with Cholinesterase inhibitors and mementine
OH DEAR
Obliviousness
Hyperorality (putting things in mouth
Disinhibition
Executive dysfunction
Apathy
Repetitive behavior
Frontotemporal dementia
A test is a simple tool that is used to screen people for signs of neurological problem, such as Alzheimer’s and other dementias.
impairments on this test can be associated with damage to the right parietal lobe (right hemisphere)
Clock drawing test (CDT)
Feeling restless like you can’t sit still. …
Akathisia:
When your muscles contract involuntarily. …
Dystonia:
Symptoms are similar to Parkinson’s disease. …
Parkinsonism:
Tardive dyskinesia: Facial movements happen involuntarily
Tardive dyskinesia:
Patient has anorexia, is complaining of pain, bloating feeling, or stomach fullness
after eating
-Delayed gastric emptying
symptoms are faked,
but the motive is some secondary gain, such as getting out of jail
Malingering
Facitious disorder imposed on another:
When someone falsely claims that another person has physical or
psychological signs of symptoms or illness or causes injury or disease in
another person with the intention of deceiving others.
Munchausen syndrome
This is a form of abuse, and you have to report to CPS
Propranolol Can cause what when used with albuterol
(bronchodilator)?
Can cause bronchspasms
UTIs can cause ______ in older female patients
delirium
Do urinalysis with culture and sensitivity
First line treatment for psychosis and agitation in dementia?
1)nonpharmacological therapies first
2) ATYPICAL ANTIPSYCHOTICS
use lowest effective dose
Benzos should be avoided due to risk for falls, delirium and sedation
Thalamus is responsible for:
sleep, consciousness, alertness
Basal ganglia is responsible for:
movements, learning, habit, cognition and emotion
What therapy is described below:
Developed by Murray Bowen
A person’s problematic behavior may serve a function or purpose for the family or be a symptoms of dysfunctional patterns
Treatment goals are to increase the family’s awarness of each member’s function within the family and to increase levels of self-differentiation.
Triangles
Nuclear family system
Multigenerational transmission process
Family Projection process
Emotional cutoffs
Sibling position
Family systems therapy
What therapy is described below:
Developed by Virginia Satir
Behavior is determined by personal experience and not by external reality
Treatment goals are to develop authentic, nurturing communication and increased self-worth of each family member, overall goal is growth rather than symptom reduction alone.
Experiential Therapy
What 1981 case determined that patients have an absolute right to refuse treatment but a guardian may authorize their treatment?
Roger vs. Oken
A patient’s right to refuse treatment is a legal doctrine that applies to all persons except during emergencies. An emergency is defined as a condition in clinical practice that requires immediate intervention in order to prevent death or serious harm to either the patient or another person. In 1981, the case or roger vs oken determined that patients have an absolute right to refuse treatment, but a guardian may authorize their treatment.
What 1976 case ruled that harmless mentally ill patients cannot be confined against their will if they can survive outside. This case determined that the presence of a mental illness alone cannot justify involuntary hospitalizatio?.
O’conner vs Donaldson
in 1979 what case determined that patients have the right to refuse any treatment and use an appeal process?
Rennie vs. Klein
What case determined that an individual is not criminally responsible if the unlawful act was the product of mental illness? This case is known for originating the insanity defense.
Durham vs United states
What part of the brain in responsible for?
Stabilizing somatic motor activity
initiating complex motor function
maintaining muscle tone, posture, and common reflexes
Basal ganglia
What are cluster A personality disorder?
withdrawn, cold, suspicious, irrational
paranoid, schizoid, schizotypal
Drug class
Haloperidol
ThioridAZINE
Molindone
Thiothixene
FluphenAZINE
MesoridAZINE
TrifluoperAZINE
ChlorpromAZINE
Perphenazin
typical antipsychotics
These techniques are used in what therapy?
-paradoxical directives
A negative task that is assigned when family members are resistant to change
-straightforward directives
Tasks that are designed in expectation of the family members’ compliance
-reframing beliefs
Problematic behaviors are relabeled to have a more positive meaning
strategic therapy
A 27-year-old patient arrives at your office complaining about his case manager. He believes that his case manager is conspiring against him, and he says, “I plan to stop her.” Upon further questioning, the patient becomes angry and storms out of the room shouting, “I am going to shoot her in the head so she leaves me alone!”
What is the first thing you should do?
A nurse practitioner has the duty to protect identified victims from imminent danger. When a patient threatens to harm someone, your course of action should follow these steps:
Contact the party at risk
Notify the police
Take appropriate action to protect the party at risk
Competence to be executed was established in what Supreme Court case?
Ford vs. Wainwright
Competency to be executed was established in the Supreme Court case of Ford vs. Wainwright. The requirements to establish the competence to be executed are as follows:
The person must be aware of the retributive element of punishment.
The person must be in the best position to make whatever peace is appropriate with his or her religion.
What 1960 legal precedent approved a test of competence that determines if a criminal defendant is competent to stand trial?
Dusky vs. United States
The 1960 case of Dusky vs. United States approved a test of competence that seeks to ascertain whether a criminal defendant has the ability to consult with a lawyer and to rationally understand the proceedings against him or her. This case established competence to stand trial.
The evidence hierarchy ranks sources of knowledge according to the strength of information they provide. Which series correctly ranks items from the strongest to the weakest evidence?
Evidence-based practice demands the use of the best knowledge. The evidence hierarchy ranks sources of knowledge according to the strength of information they provide. The best evidence comes from Level 1 of the evidence hierarchy, which includes meta-analyses. All levels are listed below.
Level 1 (strongest): Systematic review of randomized controlled trials or systematic review of nonrandomized trials
Level 2: Single randomized controlled trial or single nonrandomized trial
Level 3: Systematic review of correlational or observational studies
Level 4: Single correlational or observational study
Level 5: Systematic review of descriptive, qualitative, or physiologic studies
Level 6: Single descriptive, qualitative, or physiologic study
Level 7 (weakest): Opinions of authorities and expert committees
Irvin Yalom was the first person to put a theoretical perspective on group work. He believed that all groups go through specific phases:
Pre-group
Forming
Storming
Norming
Performing
Adjourning
During the storming phase:
Members appear resistant and begin to use testing behaviors
Issues related to inclusion, control, and affection begin to surface
Leaders allow expression of both positive and negative feelings
Leaders assist the group in understanding the underlying conflict
Leaders examine unproductive behaviors
