Mental Health Exam 2 Flashcards
6 Steps of Nursing Process
1-Assessment
2-Diagnosis
3-Outcome Identification
4-Planning
5-Implementation
6-Evaluation
HEADSSS Psychosocial Interview Technique
-H Home environment (e.g., relations with parents and siblings)
-E Education and employment (e.g., school performance)
-A Activities (e.g., sports participation, afterschool activities, peer relations)
-D Drug, alcohol, or tobacco use
-S Sexuality (e.g., whether the patient is sexually active, practices safe sex, uses contraception, or practices alternative sexual lifestyles)
-S Suicide risk or symptoms of depression or other mental disorder
-S “Savagery” (e.g., violence or abuse in home environment or in neighborhood)
Documentaion Formats
-Narrative Charting
-Charting by Exception (CBE)
-Problem Oriented Charting (SOAPIE)
-PIE- Problems, Interventions, Evaluations
-Focus (DAR)- Data, Action, Response.
SOAPIE
-S: Subjective data (patient statement)
-O: Objective data (nurse observations)
-A: Assessment (nurse interprets S and O and describes either a problem or a nursing diagnosis)
-P: Plan (proposed intervention)
-I: Interventions (nurse’s response to problem)
-E: Evaluation (patient outcome)
therapeutic communication/ Techniques
Therapeutic communication is the purposeful use of communication to build and maintain helping relationships with clients, families, and significant others.
(1) silence, (2) active listening, and (3) clarifying techniques.
Verbal communication
consists of all words a person speaks. We live in a society of symbols, and our supreme social symbols are words. Talking is our most common activity—our public link with one another, the primary instrument of instruction, a need, an art, and one of the most personal aspects of our private lives. 5% - 10% - of Communication
Nonverbal communication
Body gestures, such as facial expressions, body posture, and hand movements. The tone and pitch of a person’s voice and the way a person paces speech are also examples of nonverbal communication. It is important to keep in mind, however, that culture influences the pitch and the tone a person uses. 65% - 90% of Communication
Phases of the nurse- patient relationship
-Preorientation phase. thoughts and feelings going into first clinical session.
-Orientation phase - establishment of rapport
-Working Phase – When patient is able to experience anxiety and demonstrate dysfunctional behaviors in a safe setting while experimenting with new and more adaptive coping behaviors.
-Termination Phase - Summarize goals, discuss patient outcomes.
Empathy vs Sympathy
-In empathy, we understand the feelings of others.
-In sympathy, we feel the feelings of others.
When a helping person is feeling sympathy for another, objectivity is lost, and the ability to assist the patient in solving a personal problem ceases.
Symptoms of Mania – DIG FAST
- Distractibility
- Impulsivity
- Grandiosity
- Flight of ideas/racing thoughts
- Activity/energy increase
- Sleep needs diminish
- Talkative
Interventions for: hypomania, mania, delirious mania
- The overall goal during the acute manic phase is to prevent injury and maintain safety.
1. Decreasing excessive physical activity
2. Maintaining adequate food and fluid intake
3. Ensuring at least 4 to 6 hours of sleep per night
4. Alleviating any bowel or bladder problems
5. Intervening to ensure self-care needs are met
6. Providing careful medication management
Some patients may require close observation, seclusion, or ECT for severe symptoms.
Milieu Therapy
persons who are hyperactive and easily distracted need
-atmosphere with decreased stimulation. solitary or noncompetitive activities, such as writing, drawing, or pacing/walking. protect the patient from potentially embarrassing behaviors on the unit.
-A patient should be assigned a private room when possible and encouraged to return to the room when showing beginning signs of agitation.
Seclusion
defined as the involuntary, solitary confinement of an individual.
Restraint
any method, device, or equipment that immobilizes or reduces an individual’s ability to freely move the arms, legs, body, or head.
chemical restraint
sedating a person to control or overpower by giving medication that is not a standard treatment or dosage for the condition
Lithium indications
the first-line treatment used for bipolar disorder. Multiple studies have demonstrated effectiveness in the treatment of acute mania, acute bipolar depression, and the prevention of manic and depressive episodes.
Lithium Serum/Toxic Levels
- Therapeutic serum levels in treating acute mania are 0.5 to 1.2 mEq/L,
-Maintenance serum levels are 0.6 to1.0 mEq/L,
-Toxic concentrations are greater than 1.5 mEq/L.
-lithium toxicity with levels of 2 mEq/L or greater constitute a life-threatening emergency.
-Serum lithium levels are drawn at a trough level (10 to 12 hours after the last dose)
Lithium toxicity Symptoms
- Neurologic: coarse tremor, slurred speech, ataxia, seizures, stupor, coma
- Gastrointestinal (GI): severe nausea, vomiting, and diarrhea
- Cardiac: hypotension, bradycardia, electrocardiogram (ECG) abnormalities
- Renal: renal failure
Positive Schizophrenia Sympotoms
-Hallucinations
-Delusions
-Bizarre behavior
-Catatonia
-Formal thought disorder
Negative Schizophrenia Symptoms
-Apathy
-Lack of Motivation
-Anhedonia
-Flat or Blunt Affect
-Poverty of speech
-Social withdrawal
Cognitive Schizophrenia Symptoms
-Impaired Memory
-Disruption in Social Learning
-Inability to reason, solve problems, focus attention.
Mood Schizophrenia Symptoms
-Depression
-Anxiety
-Demoralization
-Suicidality
-Excitability
-Agitation
Alterations in thinking
-Delusions are defined as false fixed beliefs that cannot be correct by reasoning, even with evidence to the contrary.
-Concrete thinking is another alteration in thinking and refers to an overemphasis on specific details and literal interpretation of ideas. It is contrasted with abstract thinking. The answer is literal; the ability to use abstract reasoning is lessened or absent.
-Disorganized speech
Typically arise from alterations in thought processes or how thoughts are connected. Associations are the threads that tie one thought to another and one concept to another.
Alterations in perceptions
-Illusion -
Misperceptions or misinterpretations of a real object or experience
-A man sees his coat hanging on a coat rack and believes it to be a bear about to attack him.
Alterations in perceptions
-Depersonalization -
Feeling disconnected or detached from one’s body and thoughts
-“I feel like I am observing myself from outside my body” or “I am not connected to my arm.”
Alterations in perceptions
-Derealization -
Alteration in the perception or experience of the external world so that it seems unreal. -Sights and sounds may be described as muted, strange, or unreal.
Alterations in behavior
When patients with schizophrenia are acutely ill, impulse control may be impaired.
-Grabbing another’s cigarette
-Throwing food on the floor
-Regressed behaviors like soiling oneself.
Schizophrenia outcomes Phase I
During the acute phase of the illness, the overall goal is patient safety and medical stabilization. * Patient consistently refrains from inflicting injury to self (self-harm or suicide) or others.
* Patient consistently refrains from acting on delusions or hallucinations.
Schizophrenia outcomes Phase II/III
Improvement in functioning through participation in social, vocational, or self-care skills training and involvement in social groups.
* Anxiety control and relapse prevention to reduce the patient’s vulnerability to psychosis
first-generation antipsychotics (FGAs)
Conventional or typical antipsychotics. These drugs are also called neuroleptics.
-dopamine antagonists (D2 receptor antagonists).
second-generation antipsychotics (SGAs)
Atypical antipsychotics. These are sometimes called serotonin–dopamine antagonists (5-HT2A and 5-HT2C receptor antagonists).
Common FGAs
Haloperidol (Haldol)
Trifluoperazine (Stelazine)
Fluphenazine
Loxapine (Loxitane)
Perphenazine
Chlorpromazine (Thorazine)
Thioridazine (Mellaril)
Common SGAs
Clozapine (Clozaril)
Amisulpride (Solian)
Aripiprazole (Abilify)
Asenapine (Saphris)
Iloperidone (Fanapt)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Paliperidone (Invega)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Sertindole (Serdolect)
Ziprasidone (Geodon)
Brexpiprazole (Rexulti)
Cariprazine (Vraylar)
FGA side effects
—Anticholinergic
* Urinary retention, constipation
* Dry mouth, blurry vision, tachycardia
—Cardiovascular events
* QTc interval prolongation and sudden death
* Myocarditis and cardiomyopathy
* Orthostatic hypotension
—Extrapyramidal side effects (EPSs)
* Dystonias
* Akathisia
* Parkinsonian symptoms
* Tardive dyskinesia (TD)
Metabolic syndrome
* Central or abdominal obesity
* ↑ Triglycerides
* ↑ High-density lipoprotein (HDL) cholesterol
* ↑ Blood pressure
* ↑ Fasting blood glucose
Seizures
Sedation/somnolence
Blood dyscrasias such as agranulocytosis
↑ Prolactin elevation
* Gynecomastia, galactorrhea, menstrual problems
Sexual problems
Nausea and vomiting
↑ Suicide risk
Contraindicated use in elderly with dementia
* Cardiovascular or infection complications
Neuroleptic malignant syndrome (NMS)
SGA Side Effects
Very similar with less movement associated side effects, like muscle stiffness
Lithium Side Effects
Gastrointestinal distress - Nausea, diarrhea, abdominal pain
Fine hand tremors
Polyuria – Excessive urination
Weight gain
Renal toxicity
Goiter and hypothyroidism
Bradydysrhythmias, hypotension, and electrolyte imbalances
Lithium use instructions
–Monitor plasma lithium levels while undergoing treatment. At initiation of treatment, monitor levels every 2 to 3 days until stable and then every 1 to 3 months. Closely monitor levels after any dosage change.
-Advise the client that effects begin within 5 to 7 days.
-Maximum benefits might not be seen for 2 to 3 weeks.
Identifying mania
Altman Self Rating Mania Scale (ASRM): A standardized tool that assesses the client’s placement on the continuum from depression to mania.
Major depressive disorder (MDD)
A single episode or recurrent episodes of unipolar depression, resulting in a significant change in a client’s normal functioning (social, occupational, self-care) accompanied by at least five of the following specific clinical findings, which must occur almost every day for a minimum of 2 weeks, and last most of the day.
-Depressed mood
-Difficulty sleeping or excessive sleeping
Indecisiveness
-Decreased ability to concentrate
-Suicidal ideation
-Increase or decrease in motor activity
-Inability to feel pleasure
-Increase or decrease in weight of more than 5% of total body weight over 1 month
Valproate
Antiepileptic Mood Stabilizer
-These medications are used to treat and prevent relapse of manic and depressive episodes.
-Work by - Slowing the entrance of sodium and calcium back into the neuron, thus extending the time it takes for the nerve to return to its active state
Valproate Side Effects
-GI effects (nausea, vomiting, indigestion)
-Hepatotoxicity
-Pancreatitis
-Thrombocytopenia
-Teratogenesis
-Weight gain
What to monitor for Valproate
AST/ALT and LDH
-the nurse should inform the client that routine monitoring of LIVER FUNCTION TESTS is necessary due to the risk for hepatotoxicity.
-therapeutic blood level
- 50 to 120 mcg/mL.
Common and serious side effects of Antipsychotics
-Anticholinergic Effects: -Dry mouth/Blurred vision/ Photophobia/ Urinary hesitancy or retention/ Constipation/ Tachycardia
-Acute Dystonia -Severe spasm of the tongue, neck, face, and back
-Pseudoparkinsonism -Bradykinesia/ Positive symptoms of schizophrenia/ Rigidity/Shuffling gait/ Drooling/ Tremors
-Akathisia - Inability to sit or stand still
-Tardive Dyskinesia (TD)
with months to years of medication- Involuntary movements
-Neuroendocrine Effects - weight Gain
-Orthostatic Hypotension
-Sedation
-Seizures
-Severe Dysrhythmias
-Sexual Dysfunction
-Skin Effects
-Liver Impairment
-Prolonged QT interval
Alterations in thought (delusions)
Alterations in thought are false fixed beliefs that cannot be corrected by reasoning and are usually bizarre. These include the following.
Ideas of reference
Misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about them
Persecution
Feels singled out for harm by others, such as being hunted down by the FBI
Grandeur
Believes that they are all powerful and important, like a god
Somatic delusions
Believes that their body is changing in an unusual way, such as growing a third arm
Jealousy
Believes that their partner is sexually involved with another individual even though there is not any factual basis for this belief
Being controlled
Believes that a force outside their body is controlling them
Thought broadcasting
Believes that their thoughts are heard by others
Thought insertion
Believes that others’ thoughts are being inserted into their mind
Thought withdrawal
Believes that their thoughts have been removed from their mind by an outside agency
Religiosity
Is obsessed with religious beliefs
Magical thinking
Believes their actions or thoughts are able to control a situation or affect others, such as wearing a certain hat makes them invisible to others
Clozapine
The first atypical antipsychotic developed; it is no longer considered a first-line medication for schizophrenia spectrum disorders due to its adverse effects.
-High risk of weight gain, diabetes, and dyslipidemia
- monitor of WBC
-Avoid alcohol and driving
Olanzapine
-Atypical antipsychotic
-observe for at least 3 hrs to monitor for adverse effects.
-Side effects -Sedation /Orthostatic hypotension
/Anticholinergic effects
Low risk of EPS
-High risk of diabetes, weight gain, and dyslipidemia
Risperidone
-Atypical antipsychotics
-Not for patients with Dementia.
-can cause death from cerebrovascular accident or infection
-monitor for weight gain, Eat healthy diet
Haloperidol
FGA - High Potency Antipsychotic agent
-used to control aggressive and impulsive behavior.
-Monitor for -parkinsonian and anticholinergic adverse effects.
-Keep client hydrated, check vital signs, and test for muscle rigidity due to the risk of neuroleptic malignant syndrome.
Chlorpromazine
Prototype-FGA. High potency
Thioridazine
Low Potency FGA.
Caring for a client experiencing hallucinations
Provide a structured, safe environment (milieu) -decrease anxiety and distract.
-Ask about hallucinations. Don’t argue or agree but offer a comment, such as, “I don’t hear anything, but you seem to be feeling frightened.”
-For command hallucinations, provide for safety due to the increased risk for harm to self or others.
-Focus conversations on reality-based subjects.
-Identify triggers (loud noises can trigger auditory hallucinations).
Managing anxiety
Provide safety and comfort - clients in severe- to panic-level anxiety are unable to problem solve and focus.
- Need- a calm, quiet environment.
-Remain with the patient during the worst of the anxiety to provide reassurance.
-Perform a suicide risk assessment.
A therapeutic nurse-client relationship
-Purposeful and goal-directed.
-Well-defined with clear boundaries.
-Structured to meet the client’s needs.
-Culturally competent practice and care.
-Characterized by an interpersonal process that is safe, confidential, reliable, and consistent.
Recognizing improvement in clients
-Improvement and/or prevention of acute psychotic manifestations, absence of hallucinations, delusions, anxiety, hostility
-Improvement in ability to perform ADLs
-Improvement in ability to interact socially with peers
-Improvement of sleeping and eating habits
Managing a patient with delusions
Do not argue with delusions, -focus on feelings and possibly offer reasonable explanations, such as, “I can’t imagine that the President of the United States would have a reason to kill a citizen, but it must be frightening for you to believe that.”
-Monitor for paranoid delusions, -increase the risk for violence against others.
-Identify manifestation triggers
