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Psychiatric Nursing > Midterm > Flashcards

Midterm Flashcards

1
Q

ethical considerations

A
  • factors in ensuring patients’ rights
    • attitude, knowledge, dedication of nurse
  • sensitivity to patients’ needs secures these human and legal rights
  • nurses have many roles
    • custodial “keeper of keys” to skilled therapist
  • nurses influence treatment
    • major source of information regarding patient’s behavior
  • paternalism
    • reduces adult patients to status of children and interferes with freedom of action
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2
Q

antipsychotic drug side effects

A
  • agranulocytosis
  • neuroleptic malignant syndrome
  • extra-pyramidal syndrome
  • tardive dyskinesia
  • weight gain
  • hyperprolactinemia
  • metabolic syndrome & diabetes
  • ketoacidosis risk
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3
Q

staff reactions to aggression

A
  • under-reaction
    • failure to set limits because of personal fear
  • over-reaction
    • non-professional response from caregiver which may physically or emotionally harm the patient
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4
Q

lithium

A
  • gold standard for bipolar
  • blood draws
  • kidney risks
  • mania, suicidality
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5
Q

opioid intoxication

A
  • recent use
  • clinically significant problematic behavioral or psychological changes that developed during or shortly after opioid use
  • pupillary constriction (dilation due to anoxia) + one or more:
    • drowsiness or coma
    • slurred speech
    • impairment in attention or memory
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6
Q

anhydonia

A

lack of pleasure - negative sympton of schizophrenia

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7
Q

brain in compulsive substance use

A

basal forebrain and part of the amygdala - compulsivity

first: euphoria; later: no euphoria - only want to not feel bad

r/t opioid and gaba receptors

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8
Q

DSM criteria: phobia

A
  • marked fear of object/situation that is out of proportion to actual danger
  • induces fear, avoidance, or when endured = intense fear
  • duration = 6 mo
  • distress occurs and functioning is compromised
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9
Q

activity and the brain

A

information about body’s activity is conveyed to SCN through indirect projections from brainstem arousal nuclei (BAN)

local feedback inhibition from other hypothalamc areas (dorsomedial nucleus -DSM)

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10
Q

right to treatment in least restrictive setting

A
  • goal: evaluate patient needs and maintain personal freedom, autonomy, dignity, and integrity
  • applies to hospital and community programs
  • requires patient’s progress to be carefully monitored
    • Tx plans changed based on current condition
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11
Q

testimonial privilege

A
  • legal term privilege applies only in court-related proceedings
  • includes communication between husband-wife, attorney-client, clergy-church member
  • right to reveal information belongs to person who spoke
    • listener cannot disclose info unless given permission
    • patient could sue listener for disclosing privileged information
  • only communications of professional nature are protected
  • third persons present during communication may be required to testify and are not privileged
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12
Q

addiction: use despite harm

A
  • persistently intoxicated
  • persistently over-sedated
  • declining fxning due to use of substance
    • work
    • relationships
    • recreation
    • health
  • some genetic predisposition
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13
Q

common attitude/behavior-related triggers of schizophrenia

A
  • low self-concept
  • lack of self-confidence
  • loss of motivation to use skills
  • demoralization
  • overpowered by symptoms
  • unable to meet spiritual needs
  • looks/acts different from others of same culture
  • poor social skills
  • aggressive behavior
  • violent behavior
  • poor medication management
  • poor symptom management
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14
Q

manifestations of corticostriatal thalamic cortical loop

A
  • worry
  • apprehension
  • obsessions
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15
Q

hoarding Dx

A
  • 2-6% prevalence
  • begins in adolescence, mild impact in 20s, impairs functioning in 30s
  • largely unsuccessful Rx response - no clear benefit of SSRIs
  • CBT and family involvement best option
  • chronic course, high genetic component
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16
Q

incompetence

A
  • legal term without precise medical meaning
  • to prove incompetence in court, must show:
    • person has mental disorder
    • disorder causes defect in judgment
  • defect makes person:
    • incapable of handling personal afairs
    • legal guardian appointed
    • can’t vote, marry, drive, make contracts
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17
Q

ethical decision-making

A
  • trying to distinguish right from wrong in situations w/o clear guidelines
  • a decision-making model can help identify factors/principles that affect decision
  • model for critical ethical analysis describes steps/factors that nurses should consider in resolving ethical dilemma
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18
Q

SSRIs: OCD, anxiety, MDD

A

Dose: OCD (80 mg) >>> anxiety (40) >>> MDD (20)

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19
Q

caffeine and nicotine in schizophrenia

A
  • increase metabolism of psychotropic medications
  • nicotine reduces negative symptoms severity
  • patients w/ schizophrenia smoke 2-3X the rate of gen. population
  • may help regulate mesolimbic dopamine system
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20
Q

manifestations of fear via amygdala-centered circuit

A
  • fear
  • anxiety
  • phobia
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21
Q

depression

A
  • often occurs with other psychiatric illnesses
  • has significant effect on quality of life
  • only 1/3 w/ depression seek help, are accurately diagnosed, obtain appropriate Tx
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22
Q

medical certification

A

commitment made on decision of physician

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23
Q

depression among medical patients

A
  • high incidence among pts hospitalized for medical illnesses
    • especially among severely ill patients
  • certain conditions often associated with depression
  • depression often unrecognized and untreated
    • often takes 2nd place to medical illness
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24
Q

documentation of AMA requests

A
  • mental status
  • reason to leave
  • content of dicussions in which possible risks of leaving were described
  • meds, follow-up care instructions
  • conversations with others present
  • destination and transportation of patient
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25
Q

level 3 anxiety

A
  • pathologic
  • autonomic CNS increase triggering
  • perceptual field further decreased
  • diaphoresis
  • increased urinary frequency
  • rigid muscle
  • decreased problem solving ability
  • distorted perception of time
  • decreased hearing
  • VS increased
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26
Q

behavioral changes of depressive episode

A
  • tired, slowed down
  • problems concentrating, remembering, making decisions
  • restless or irritable
  • change in eating, sleeping, other habits
  • thinking of death/suicide, attempting suicide
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27
Q

nursing assessments: schizophrenia

A
  • dysthymia
  • hopelessness
  • depressed mood
  • mood elevations
  • expansions
  • sleep cycle
  • appetite
  • energy
  • supports
  • physical complaints
  • behavioral changes
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28
Q

characteristics of secure attachment as adults

A
  • having trusting, lasting relationsihps
  • tend to have good self-esteem
  • comfortable sharing feelings with friends and partners
  • seek out social support
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29
Q

addiction: disordered function

A
  • loss of control of something you do
  • preoccupation with something you want to do
  • doing something depsite adverse consequences
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30
Q

separation anxiety disorder prevalence

A
  • 4% prevalence
  • decreases over time (adolescenes into adulthood)
  • most prevalent disorder in children under 12 yo
  • equally common males:females
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31
Q

DMDD age consideration

A

not made 18 yo

age of onset by Hx or observation is usually ~ 10yo

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32
Q

SMAST-G

A

Short Michigan Alcoholism Screening Test - Geriatric version

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33
Q

treatment for suicide

A
  • therapy
    • talk
    • cognitive behavior
    • psychodynamic
    • psychoanlysis
  • medication
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34
Q

principles of informing

A
  • assess ability to give informed consent
  • simplify language
  • offer opportunities to ask questions
  • test patient’s understanding after explanation
  • reeducate as often as needed
  • document what was disclosed, patient’s understanding, competency, voluntary agreement to treatment, actual consent
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35
Q

release of information

A
  • clinicians free from legal responsibility if they release information with patient’s written and signed request
  • writeen consent makes clear to both parties that consent has been given
    • if questions arise about onsent, documentary record of it exists
  • should be made part of patient’s permanent chart
  • patient’s place themselves in care of others and reveal vulnerable aspects of their personal life
  • in return they expect high-quality care and protection of interests
  • thus patient-clinician relationship is intimate:
    • demands trust, loyalty, privacy
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36
Q

mood changes of mania

A
  • overly long period of feeling “high” or an overly happy or outgoing mood
  • extreme irritability
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37
Q

depression in children

A
  • parental and family Hx of depression
  • vague physical symptoms
  • behavior issues, misdiagnosed
  • school phobia, excessive clinging to parents, poor academic performance and attendance
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38
Q

AUDIT

A

Alcohol Use Disorders Tdentification Test

  1. how often do you drink alcohol?
  2. how many drinks on a typical day?
  3. how often do you have 6+?
  4. how often have you started and couldn’t stop drinking?
  5. how often have you failed to do what was normally expected from you b/c of drinking?
  6. how often have you been unable to remember the night before?
  7. how often have you needed alcohol first thing in the morning after a night of heavy drinking?
  8. how often do you feel guilt/remorse after drinking?
  9. how often have you/others been injured from your drinking?
  10. has a relative/health professional expressed concern?
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39
Q

why patient’s may be aggressive

A
  • misunderstanding/dispute about medical issues
  • not being taken seriously
  • dissatisfaction with Tx
  • pain
  • enforced care or Tx
  • disputes over hospital policy
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40
Q

Types of SSRIs for anxiety

A
  • escitalopram/lexapro
  • citalopram/celexa
  • fluoxetine/prozac
  • paroxetine/praxil
  • sertraline/zoloft
  • luvox
  • fluvoxamine
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41
Q

course/outcome with treatment of psychosis

A
  • complete, prolonged recovery w/ minimal/no negative S/Sx
  • partial recovery or recurrent psychotic episodes
  • no significant recovery of psychosis
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42
Q

cyclothymic disorder

A
  • persistent and insidious onset
  • parallel to bipolar disorder
  • at least 2 yrs
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43
Q

forcing medicatons

A
  • criteria that may justify coerced treatment
    • patient judged to be dangerous to self or others
    • must have reasonable chance of benefiting patient
    • patient judged to be incompetent to evaluate necessity of treatment
  • even if these conditions are met, patient should be informed regarding what will be done, reasons for it, probable effects
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44
Q

emergency hospitalization

A
  • almost all states permit emergency commitment for acutely ill patients
  • to control immediate threat to self/others
  • in states w.o laws, police jail acutely ill person on disordely conduct charge (criminal charge)
  • emergency commitment 48-72 hrs long
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45
Q

characteristics of avoidant attachment as adults

A
  • may have problems with intimacy
  • invest little emotion in social and romantic relationships
  • unable/unwilling to share thoughts and feelings with others
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46
Q

motivation and change process

A
  • patients with SUD not unmotivated
    • motivated to engage in harmful behaviors b.c of need for reward OR
    • not ready to begin helpful behaviors
  • effective self management techniques not use after taught or voluntarily sought out
  • 44% SUD patients > 12 yo completed Tx course in 2010
    • high risk of relapse despite motivation
  • continuum
  • assessment
    • how serious is problem? 0-10
    • how much do you feel the need to stop forever? 0-10
  • increase motivation?
    • external factors - family, prison, legal factors
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47
Q

dissociative disorders

A
  • dissociative identity dx
  • dissociative amnesia
  • depersonalization/derealization dx
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48
Q

circle of confidentiality

A
  • many people outisde circle; nurse but consider relationships
  • family members not automatically entitled to clinical info about adult patient
  • nurses may wish to engage family in therapeutic alliance but info still belongs to patient
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49
Q

emotion in psychosis

A
  • affect - (flat blunted, incongruent) - may vary by culture
  • depressed mood common
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50
Q

psychotherapy in depression

A
  • supportive
  • insight-oriented
  • interpersonal
  • cognitive-behavioral
  • psychodynamic
  • individual, gorup or family
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51
Q

body dysmorphic Dx

A
  • tends to be one body part
  • muscle dysmorphia: body builders (tends to be male)
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52
Q

outpatient commitment

A
  • community initiatives to offer pts Tx in least restrictive setting
  • may include court-ordered community Tx or outpatient commitment
  • courts can order pts committed to a course of outpatient Tx specificed by clinicians
    • also called mandatory outpatient Tx
  • Tx resources must be effective
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53
Q

common environment-related triggers of schizophrenia

A
  • hostile/critical environment
  • housing difficulties
  • pressure to perform
  • changes in life events, daily patterns
  • interpersonal difficulties/disruptions
  • social isolation
  • lack of social support
  • job pressures
  • stigmatization
  • poverty
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54
Q

diabetes & metabolic monitoring in schizophrenia

A
  • heigh, weight, BMI
  • waist circumference
  • BP, HR
  • education about diet and exercise
  • evaluation of risks
    • lifestyle, genetic predisposition
  • labwork
    • fasting glucose, HGB 1AC, lipid panel, prolactin level
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55
Q

confidentiality

A

nondisclosure of specific information about a person to someone else, unless authorized by that person

every psychiatric professional responsible for protecting patient’s right to confidentiality (including knowledge that person is hospitalized or in Tx)

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56
Q

anxiety

A

sustained response that influences behaviors - no stimulus needed

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57
Q

hospitalized patients and AUD

A
  • 15-20% hospitalized patients have AUD
  • 43% trauma patients have AUD
  • 31% trauma patients have withdrawal
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58
Q

clinical algorithm for involuntary commitment process

A
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59
Q

coping and patient insight with anxiety

A
  • don’t interfere with repetitive acts initially
  • don’t force them to confront avoided situation/phobic object
  • coping mechanisms keep anxiety within tolerable limits
  • insight may often be intact
  • do not argue with patients or reason them out of coping mechanism
  • do not reinforce phobia, ritual
  • negotiate limits later
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60
Q

cognition in psychosis

A
  • memory, attention, speech, decision-making, thought content, thought process
  • concrete thinking, difficulty with commands
  • executive function alteration
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61
Q

beecoming that “solid object”

A
  • calm
  • centered/balanced
  • empathetic/udnerstanding
  • present and able to listen
  • verbally reassuring
  • firm but non-intimidating
  • fair
  • non-threatening, but not “wishy washy”
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62
Q

nurse as provider

A

malpractice: failure of pressionals to provide proper and competent care warranted by members of their profession; failure that results in harm to patient

all nurses held to standards of care

most claims filed ner law of negligent tort: civil wrong for which injured party is entitled to compensation

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63
Q

pathogenesis of AWS

A
  • alcohol = GABA agonist
    • decreased CNS excitability
    • sedation
    • cognitive dysfxn
    • poor muscle coordination
  • GABA increases neuronal inibition via chloride channel
  • downregulation of GABA receptors
  • need more alcohol for same effect
  • BAC 150 w. no S/Sx of intoxication = tolerance
    • BAC 300 = risk of death
    • patients awake and fxnal at very high BAC
  • EXTREMELY DANGEROUS
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64
Q

tardive dyskinesia

A
  • lip smacking
  • chewing
  • tongue protrusion
  • grimacing
  • blinking
  • choreiform movements, foot tapping
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65
Q

excoriation Dx

A
  • scratching, skin picking
  • most commonly begins in adolescence
  • females 75%
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66
Q

predictors of dangerousness

A
  • most mentally ill are not violent and are often victims of violence
  • possible predictors of violence
    • previous violent behavior
    • psychosis
    • noncompliance with meds
    • current substance abuse
    • antisocial personality disorder
    • lack of perceived need for Tx/Tx effectiveness
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67
Q

dopamine in the brain

A
  • substantia nigra
  • midbrain
  • hypothalamic-pituitary connection
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68
Q

involuntary admission

A
  • two legal theories
    • police power: state has authority to protect community from dangerous acts of mentally ill
    • parens patriae powers: state can provide care for citizens who cannot care for themselves
  • dangerousness used as standard for commitment
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69
Q

warning signs of suicide

A
  • wanting to die, ill oneself
  • looking for way to kill oneself
  • feeling hopeless, no reason to live
  • feeling trapped or in unbearable pain
  • being a burden to others
  • increasing use of alcohol/drugs
  • acting anxious/agitated; behaving recklessly
  • sleeping too little, too much
  • withdrawn, isolated
  • showing rage, talking about seeking revenge
  • displaying extreme mood swings
  • preoccupation with death
  • suddenly happier, calmer
  • loss of interest in things one cares about
  • visiting, calling people to say goodbye
  • setting affairs in order
  • giving things away
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70
Q

nigrostriatal pathway

A
  • originates in substantia nigra and terminates in caudace nucleus-putamen complex (neostratum)
  • function:
    • innervates motor and extrapyramidal systems
  • abnormal function:
    • some movement side effects of antipsychotic drugs (tardive dyskinesia, akathisia, dystonic rxns)
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71
Q

other symptoms of schizophrenia

A
  • depression
  • mania
  • anxiety
  • obsessive-compulsive
  • substance abuse
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72
Q

body systems involved in anxiety

A
  • limbic (CNS)
  • endocrine
  • autonomic

cognitive and behavioral respones can exacerbate or mediate symptoms

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73
Q

long-term hospitalization or formal commitment

A
  • hospitalization for indefinite time or until patient is ready for discharge
  • patient has right to consul lawyer at any time and requet court hearing to determine whether additional hospitalization is necessary
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74
Q

level 4 anxiety

A
  • pathologic
  • panic state = all of level 3 + following:
    • decreased hand-eye coordination
    • lowered BP - higher HR
    • possible illogical thoughts, psychosis, hallucinations
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75
Q

characteristics of avoidant attachment as children

A
  • may avoid parents
  • does not seek much comfort or contact from parents
  • shows little or no preference between parent and stranger
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76
Q

medical comorbidities/risks with anxiety

A
  • pulmonary - asthma, CV disorders
  • endocrine disturbances
  • obesity
  • inflammatory disorders
    • Tx-related or Tx-caused or both?
  • neurologic conditions
    • migraines
    • MS
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77
Q

de-escalating aggressive situations

A
  • decrease environmental timuli
  • do not focus on content of conversation
    • bring down the level of arousal to a safer place
  • respond selectively
    • do not answer abusive questions
  • explain limits and rules in authortiative but respectful tone
  • give choices where possible
  • empathaize with feelings not behavior
  • do not argue
  • give consequences of inappropriate behavior without threats/anger
  • represent external controls as institutional, not personal
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78
Q

voluntary admission

A
  • person agrees to treatment and hospital rules
  • people may seek help based on personal decision or advice of family or health professional
  • patient acknowledges problem in living, seeks help in coping, will probably actively participate in finding solutions
  • patient retains all civil rights
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79
Q

behavioral changes of mania

A
  • talking very fast, racing thoughts
  • unusually distracted
  • increasing activities, new projects
  • overly restless
  • sleeping little, not tired
  • unrealistic belief in abilities
  • impulsive and engaging in pleasurable, high-risk behaviors
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80
Q

CRAFFT part A

A
  1. drink any alcohol?
  2. smoke marijuana?
  3. anything else to get high?
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81
Q

habeas corpus

A
  • constitutional right
  • speedy release of person who claims to be detained illegally
  • committed patient may file writ anytime on grounds of being sane and eligible for release
  • court hearing takes place where those who restrain patient must defend their actions
  • patient discharged if judged to be sane
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82
Q

AWS stages

A
  1. tremulousness: 6-36 hrs after last drink
  2. hallucinations: 12-48 hrs
  3. seizures: 6-48 hrs
  4. delirium tremens: 3-7 days
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83
Q

normal response to anxiety

A

amygdala communicates with:

  • prefrontal cortex: emotional and cognitive experience of fear
  • locus ceruleus: NE released; HR and BP increase
    • NE also tones bladder: have to pee more
  • endocrine HPA: HPA activation
  • parabrachial nucleus: increased RR
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84
Q

protecting a third party

A
  • most states now recognize some variation of the duty to warn
  • clinicians must:
    • assess threat of violence to another
    • identify person being threatened
    • implement some alternative, preventative acts
  • courts extend scope of duty to protect property and persons
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85
Q

tangential thought

A

off-topic but with logical progression

can’t get back to the original topic/question

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86
Q

common health-related triggers of schizophrenia

A
  • poor nutrition
  • lack of sleep
  • circadian rhythms
  • fatigue
  • infection
  • CNS drugs
  • lack of exercise
  • barriers to accessing health care
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87
Q

family implications in schizophrenia

A
  • may not know how to talk to patient; perhaps even fear them
  • may need help to face problems encoutntered in additional roles of case manager, residential supervisor, legal guardian
  • can be emotionally painful, draining for families
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88
Q

genetics and schizophrenia

A

significant hereditary component

still depends on some sort of external “trigger”

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89
Q

neurotransmitters involved in worry

A
  • serotonin
  • GABA
  • DOPAMINE
  • NE
  • glutamate
  • voltage-sensitive ion channels
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90
Q

prevalence of anxiety disorders

A
  • 1/4 persons meet criteria for anxiety disorder in lifetime
  • common comorbidities:
    • substance use
    • 91% with panic disorder have other psychiatric disorder
    • 2/3 persons with panic d/o first experience S/Sx with onset of MDD episode
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91
Q

metabolic syndrome risk criteria

A
  • waist circumference (>40 in men, >35 in women)
  • triglycerides > 150 mg/dl
  • HDL cholesterol:
  • BP: > 130/85
  • fasting glucose: > 100 mg/dl

3 or more = metabolis syndrome

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92
Q

risk factors for delirium tremens

A
  • hx of sustained drinking
  • history of previous DT
  • age greater than 30 (some say 60)
  • presence of concurrent illness
  • presence of significant alcohol withdrawal in presence of elevated alcohol level (high level of tolerance)
  • longer period since last drink (more likely to enter DT after longer period of time)
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93
Q

Trazodone/deseryl

A
  • weak 5-HT uptake block, a-block, 5-HT2 antagonist
  • no anticholinergic actions
  • risks: priapsim (sustained erection), postural hypotension
  • better as sleep agent PRN
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94
Q

fear based disorders: overview

A
  • different from transient stress/fear
  • persistent (6 mo duration)
  • most develop in childhood and persist if not treated
  • can develop at any age
  • often result of traumatic event
  • are excessive
    • made by clinician
    • clients can over/underestimate danger
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95
Q

schizophreniform disorder

A

a serious mental disorder with symptoms similar to those of schizophrenia. the disorder including its prodromal, active, and residual phases, lasts longer than 1 mo but less than 6 mo.

unlike schizophrenia, in which prodromal symptoms may develop over several years, schizophreniform disorder has a rather rapid period from the onset of prodromal symptoms to the point at which all criteria for schizophrenia are met

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96
Q

brain circuit of fear

A

amygdala-centered

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97
Q

other risks/causes of anxiety

A
  • severity of trauma/nature of event
  • individual’s coping mechanisms
  • psychological defense
  • resources
  • person’s ego
    • adapts to internal and external stresses
  • delay or lack of treatment
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98
Q

nurse assessment of delusions

A
  • determine error in reality
  • test strength of conviction or belief
  • encourage discussion about belief and details surrounding belief
  • calmly present alternative explanations
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99
Q

benzodiazepines (BZ) in anxiety

A

binds to place on GABA receptor in limbic system to increase GABA in the brain

after time the channels get looser and looser so there is less binding - why long term BZs are not recommended and why there is a high level of addiction

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100
Q

MDD symptoms

A

<2wks depressed mood or marked loss of interest or pleasure in normal activities

+ 4 of:

  • significant weight change
  • significant sleep pattern change
  • agitation or retardation
  • fatigue/loss of energy
  • guilt/worthlessness (feel like burden)
  • can’t concentrate or make decisions (indecisiveness)
  • thoughts of death/suicide
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101
Q

viral and infection theories of schizophrenia

A
  • “schizophrenia virus”
  • prenatal exposure to influenza may be factor in etiology
  • more people with schizophrenia born in winter/early spring or urban settings
  • high levels of toxoplasma associated w/ increased risk
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102
Q

recurrent anxiety

A
  • pathologic response
  • prolonged activation of autonomic system
  • increased endocrine HPA reactivity
  • cognitive perception affected
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103
Q

issues related to restrictiveness

A
  • seclusion and restraints of particular concern
  • must be therapetucially justified with good rationale for use of these practices
  • document event that led to:
    • seclusion or restraint
    • alternatives attempted
    • patient’s behavior while secluded/restrained
    • nursing interventions
    • ongoing evaluation of patient
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104
Q

biological stressors of schizophrenia

A
  • information-processing overload related to faulty brain information feedback loop
  • dopamine = factor in overload of processing and feedback loop
  • abnormal gating mechanisms
  • decreased gating causes inability to selectively attend to stimuli
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105
Q

interventions in health promotion phase of schizophrenia

A
  • teaching focuses on prevention of relapse and symptom management through engaging patient in healthy lifestyle
  • patient teaching methods that involve simple, clear, concrete instructions including repetition and return demonstrations are most helpful
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106
Q

physical and cognitive signs of depression

A
  • sleep disturbances
  • sexual disturbances
    • assess sleep and sexual disturbances before medicine and not just as side effect of medicine
  • difficulty concentrating, making decisions
  • fatigue
    • assess before medicine
  • appetite changes including changes in body weight
  • social withdrawal/isolation
  • increased somatic complaints
    • including anxiety about illness, vague body complaints
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107
Q

cognitive symptoms of schizophrenia

A
  • working memory
  • declarative memory
  • verbal memory
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108
Q

dopaminergic pathways

A
  • mesolimbic
  • mesocortical
  • nigrostriatal
  • tuberinfundibular
  • incertohypothalamic
  • medullary
  • retinal
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109
Q

endocrine system/HPA axis: normal response

A
  1. amygdala perceives danger
  2. hypothalamus releases CRH
  3. pituitary releases ACTH
  4. adrenal glands release cortisol
  5. cortisol shuts off alarm, “fight/flight” stops and homeostasis returns
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110
Q

neuroleptic malignant syndrome

A
  • dazed mutism
  • fever
  • tachycardia
  • sweating
  • muscle rigidity
  • tremor
  • stupor
  • renal failure
  • leukocytosis
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111
Q

BPRS categories

A
  1. somatic conern
  2. anxiety
  3. emotional withdrawal
  4. conceptual disorganization
  5. guilt feelings
  6. tension
  7. mannerisms and posturing
  8. grandiosity
  9. depressive mood
  10. hostility
  11. suspiciousness
  12. hallucinatory behavior
  13. motor retardation
  14. uncooperativeness
  15. unusual thought content
  16. blunted affect
  17. excitement
  18. disorientation
112
Q

pharmacologic management of AWS

A
  • benzodiazepines: affect GABA receptors
    • most often used
  • long acting with active metabolites
    • librium (chlordiazepoxide)
    • valium (diazepam)
    • smoother course w/ less chance of withdrawal seizures
    • disadvantage: risk of accumulation in elderly and liver disease
  • fast to intermeidate
    • ativan (lorazepam)
    • serax (oxazepam)
    • appropriate frequency
    • intermediate half-life; no metabolites
113
Q

DMDD symptoms

A

across two or more settings (home & school/peers)

  • severe recurrent temper outbursts out of proportion in intensity and to situation/provocation
  • temper outbursts not consistent with deelopmental level
  • ~ 3+ times/week
  • mood between outbursts persistently irritable or angry and observable by others
  • differentiation with bipolar
    • when there is a behavior change, mood is not great change from usual mood
    • in bipolar, irritability is departure from usual mood
114
Q

opioid withdrawal criteria

A
  • presence of either:
    • cessation after heavy use
    • opioid antagonist after heavy use
    • >3 of:
      • dyspohoric mood
      • N/V
      • muscles aches
      • lacrimation or rhinorrhea
      • pupillary dilation, piloerection, sweating
      • diarrhea
      • dehydration
      • yawning
      • fever
      • insomnia
  • clinically significant distress/impairment
115
Q

neurtransmitters involves in fear

A
  • serotonin
  • GABA
  • glutamate
  • corticotropin releasing factor/HPA
  • NE
  • voltage sensitive ion channels
116
Q

antiepileptics

A
  • carbamazepine
  • lamotrigine
  • oxcarbazepine
  • valproate
117
Q

level 2 anxiety

A
  • normal
  • tension, worry
  • increased HR, muscle tone
  • narrowed perceptual field
  • increased motivation
118
Q

DMDD mood

A
  • mood, manic exclusion
  • no more than 1 day mania or hypomanic symptoms
  • behaviors do not occur exclusively during MDD
  • not better explained by ASD, PTSD, separation anxiety disorder, persistent depressive d/o (dysthymia)
119
Q

prognosticators for good outcome

A
  • later and abrupt onset
  • level of premorbid functioning
  • prominent affective symptoms or disorganized behavior
  • paucity of symptoms
120
Q

less commonly recognized factors leading to aggression

A
  • hunger
  • fatigue
  • lack of exercise
  • endocrine imbalance
  • medication rxn
  • poor oxygenation
  • constipation
  • pain
  • withdrawal (nicotine, ETOH, caffeine)
121
Q

bipolar II

A
  • hypomania does not reach level of acute manic symptoms
  • depressive episodes still significant
  • 0.3-4.8% lifetime prevalence
122
Q

medical status leading to aggression

A
  • recovering from unconsciousness
  • TBIs
  • dementia
  • delirium/confusion
  • alcohol/drug intoxication/withdrawal
  • mental illness/handicap, psychiatric Hx
123
Q

characteristics of ambivalent attachment as adults

A
  • reluctant to become close to others
  • worry that their partner does not love them
  • becomes very distraught when a relationship ends
124
Q

typical antipsychotic drugs

A
  • dopamine antagonist
  • improve positive symptoms (mesolimbic)
  • EPS and tardive dyskinesia
125
Q

avolition

A

feeling like you need a boost (tobacco, caffeine, etc.) - negative symptom of schizophrenia

126
Q

high risk areas for verbal abuse and threatening behavior

A

women and pediatric settings

127
Q

psychiatry and criminal responsibility

A
  • “insanity” defense based on humanitarian rationale that people should not be blamed for crimes if they did not know what they were doing or could not help themselves
  • movement from “not guilty by reason of insanity” (NGBI) to “guilty but mentally ill” (GBMI)
  • some states abolished insanity defense
128
Q

addiction: preoccupation

A
  • no interest in other interventions, recommendations
  • no interest in rehab
  • Rx from multiple sources
  • preference for specific meds
129
Q

CIWA-Ar S/Sx

A
  • N/V
  • tremors
  • sweats
  • anxiety
  • agitation
  • tactile dysfunction
  • auditory disturbance
  • visual disturbance
  • headaches
  • orientation
130
Q

staff-caused stressors leading to aggression

A
  • personality
  • staff unhappiness/frustration
  • spillover from outside lives
  • poor communication
  • lack of cohesion
  • inability to deal with aggression
  • fear of physical injury
131
Q

PTSD in preschool child

A
  • exposure to actual or threatened death/injury, sexual violence
  • intrusion symptoms
    • spontaneous, cued memories
    • dreams
    • dissociative reactions
  • alterations in arousal and reactivity associated with traumatic event
  • distress or impairment in relationships
  • duration of more than 1 mo
132
Q

epidemiology of schizophrenia

A
  • most common psychotic disorder
  • often results in chronic illness
    • nobody believes they have a medical illness
  • increased risk of suicide
  • biochemical factors
    • increase dopamine, NE
    • reward alterations
    • 5HT excess
    • GABA (inhibitory) and glutamate (excitatory) dysregulation
  • MRI, CT changes
    • large ventricles; atrophy of brain tissue
133
Q

specific phobia

A
  • median age of onset 7-11 yo
  • can be precipitated by traumatic event
  • can be connected to panic/anxiety occuring with media coverage of fearful situation
134
Q

nursing roles

A
  • develop therapeutic relationship
  • assess/provide safety
  • encourage grief of losses, expression of feelings
  • encourage expansion of positive coping skills
  • encourage adherence to treatment regimen
  • assess severity and readiness for change
  • listen, nonjudgmental, open
  • safety
  • education
  • promote help-seeking
  • treatment
    • medication
    • exercise
    • nutrition
    • sleep
    • comfort
    • relaxation
    • supportive relationships
135
Q

if physical aggression occurs

A
  • mobilize team resources/other staff
  • call security
  • remove patients, visitors, students, untrained staff from area
  • be aware of exit routes and potential weapons
  • important staff roles during psychiatric codes
    • know your role!
136
Q

high risk populations for suicide

A
  • white males 65+ yo: 3-4X
  • veterans/military: 2-4X
  • alaskan natives/american indians: 2-4X
  • serious mental illness: 6-12X
  • LBGTQ: 2-3X
137
Q

labs for AUD

A
  • GGT
    • most specific to alcohol use (liver enzymes)
    • elevated in 80% of alcohol dependent patients)
  • MCV: mean corpuscular volume
    • elevated in 60% of dependent patients)
  • AST:
    • liver enzymes (also w/ certain meds)
    • elevated in 40%
  • ALT:
    • liver enzymes (also w certain meds)
    • elevated in 20%
138
Q

delusional disorder

A

circumscribed symptoms of non-bizarre delusions, but without hallucinations, thought disorder, mood disorder, or significant flattening of affect

139
Q

strategies for working with patients who have delusions

A
  • place delusion in time frame and identify triggers
  • assess intensity, frequency, duration
  • identify emotional components
  • observe for evidence of concrete thinking
  • observe speech for symptoms of thought disorder
  • observe for ability to accurately use cause-and-effect reasoning
  • distinguish between description of experience and facts of situation
  • question facts as presented and their meaning
  • discuss consequences of delusion when person is ready
  • promote distraction to stop focusing on delusion
140
Q

social anxiety disorder

A
  • annual prevalence = 7%
  • similar prevalence in children and adults but rates decrease with age
  • females 2x greater in population (help seeking)
  • median age of onset = 13 yo
  • 75% between 8 and 15 yo
  • follows stressful/humiliating experience
141
Q

health insurance portability and accountability act

A
  • provides patients access to thei medical records
  • more control over personal health information is used and disclosed
  • first national, comprehensive privacy protection act
  • scope extensive
    • applies to almost any institution or individual in health care
142
Q

hospitalization

A

can be traumautic or supportive for patient, depending on insititution, attitue of family/friends, staff response, type of admission

types of admission:

  • voluntary
  • involuntary
143
Q

defense mechanisms

A
  • also called emotion- or ego-focused coping mechanisms
  • protect person from feelings of inadequacy and worthlessness and prevent awareness of anxiety
  • can be used to such extreme that they distort reality, interfere with relationships, and limit ability to work productively
144
Q

right to refuse treatment

A
  • voluntary patients have the right to refuse any treatment and should not be forcibly medicated except in situations when patient is actively violent to self or others and all less restrictive means have been unsuccessful
  • patient’s behavior should be clearly documented and all interventions recorded
145
Q

level 1 anxiety

A
  • normal
  • mild muscle tone increase
  • increased perceptual field
  • helps to motivate us
146
Q

suicide statistics

A
  • 2 million adolescents attempt suicid annually
  • 700,000 ER visits
  • 1,100 suicides/yr among college students
  • 50% colelge students report suicidal ideation at some time in life
  • of 1.1 mil adults who attempted suicide, 67.2% received medical attention and 51.1% stayed overnight or longer in hospital as a result of suicide attempt
147
Q

discharge of voluntarily admitted patients

A
  • patient voluntarily admitted can leave when ready
  • patients can be discharged by staff when max benefit received
  • voluntary patients may request discharge
  • most states require written notice of desire to leave
    • patients may ahve to sign form if leaving against medical advice (AMA)
148
Q

development of a therapeutic relationship

A
  • respect and dignity
  • situational alliance
    • working with the escalated individual so they understand they are not alone in this crisis and that you are there to help
  • objectivity
    • don’t allow personal agendas/values to impede ability to provide care
  • honesty
  • humor
    • only if you have the skill
149
Q

looseness of association

A

no connection between one thought and another

break in logic

150
Q

precipiated opioid withdrawal

A

patient who had been using mu opiod agonist is administered opioid antagonist

also possible for partial agonist to precipiate withdrawal

  • affinity
  • intrinsic activity
  • dissociation
151
Q

disruptive mood disregulation disorder (overview)

A
  • new diagnosis for children
  • irritability/reactivity out of range of what trigger would induce
  • created b/c of overdiagnosis of bipolar disorder in children
152
Q

CIWA-Ar scoring

A
  • 0-8 = mild withdrawal
  • 9-15 = moderate withdrawal
  • > 15 = severe withdrawal
  • not validated in ICU patients
    • altered by pain, meds, etc.
153
Q

antipsychotics

A
  • bipolar mania
  • need antidepressant in combo
  • aripiprazole, asenapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone
154
Q

cognitive perception in recurrent anxiety

A
  • from above
  • thoughts of helplessness
  • lack of control
155
Q

serotonin in anxiety

A

dysregulation of serotonin neurotransmission may play role in etiology of anxiety because patients experiencing these disorders may ahve hypersensitive 5HT receptors

SSRIs are best “long” term Tx for anxiety disorders: no risk of addiction, less risk of OD

156
Q

informed consent

A
  • informed, competent, voluntary
  • explain tx and possible complications, risks
  • goal: help pt make better decisions
  • pt must be able to consent and not be a minor and judged legally incompetent
157
Q

choice of professional

A
  • family doctor
  • psychiatrist
  • pschiatric nurse practitioner
  • psychotherapist can’t prescribe meds
  • most common source of lack of response in major depression is administration of inadequate doses, or use of psychotherapy alone
158
Q

grounds to commit mentally ill

A
  • dangerous to self or others
  • mentally ill and in need of tx
  • unable to provide for own basic needs
159
Q

SSRIs

A
  • first line treatment
  • fluoxetine/prozac, fluvoxamine/luvox, sertraline/zoloft, citalopram/celexa, escitalopram/lexapro, paroxetine/paxil
  • gradual benefit, takes time
  • relatively safe and better patient acceptability
    • less risk for OD fatality
  • absence of psychomotor and cognitive impairment
    • preferred in prophylaxis of recurrent depression
  • fatigue, sexual side effects, “poop-out” syndrome (lose efficacy)
160
Q

patients’ rights

A
  • document should be given to patients on admission and read/explained to them
  • evolution of patients’ rights uneven across United States
  • they have the right to:
    • communicate with people outside hospital
    • keep clothing/personal effects
    • religious freedom
    • be employed, if possible
    • manage/dispose of property
    • execute wills
    • enter contractual relationships
    • make purchases
    • education
    • habeas corpus
    • independent psychiatric exam
    • civil service status
    • retain licenes, priviliges, permits
    • sue or be sued
    • marry/divorce
    • not be subject to unnecessary mechanical restraints
    • periodic review of status
    • legal representation
    • privacy
    • informed consent
    • Tx
    • refuse Tx
    • Tx in least restrictive setting
161
Q

medications for opiate use, dependence

A
  • methadone: full agonist - acts like opiate to block receptor
  • buprenorphine: partial agonist, antagonist - dose response with ceiling effect; occupation without full actiation
  • naloxone: full antagonist - used for acute intoxication

opioid receptors:

Mu, Delta, Kappa

162
Q

mesocortical pathway

A
  • inntervates frontal lobes
  • function:
    • insight, judgment, social consciousness, inhibition, highest level of cognitive activities
  • abnormal function:
    • negative symptoms
    • affective flattening/blunting, poverty of speech, blocking, poor grooming, lack of motivation, anhedonia, social withdrawal, cognitive defects, attention deficits
163
Q

alogia

A

not talking - neg. symptom of schizophrenia

164
Q

major diagnostic categories (DSM) r/t substances

A
  • substance abuse dx
  • substance intoxication
  • substance withdrawal
  • substance induced mental dx
165
Q

behavior and movement in psychosis

A
  • avolition, aggression (only 10%)
    • perescutory delusions and command hallucinations are #1 risk factors for violence
  • deterioration in appearance
  • EPS, abnormal eye movements (medicine), unpredictable outbursts, paranoia
166
Q

depression in primary care settings

A
  • highly prevalent
  • 1/5 pts seeing primary care practitioner has significant symptoms of depression
  • providers fail to diagnose MDD up to 50% of the time
    • or undertreat it with low doses
167
Q

catatonia

A

characterized by muscular rigidity and mental stupor, posturing, mutism, sometimes alternating with great excitement and confusion

168
Q

BPRS overview

A

to assess positive, negative, and affective symptoms of individuals with psychotic disorders (especially schizophrenia)

169
Q

administrative commitment

A

determined by a special tribunal of hearing officers

170
Q

information to disclose

A
  • diagnosis
  • Tx: need informed consent
  • consequences:
    • risks/benefits of proposed Tx
  • alternatives
  • prognosis
    • w/ Tx
    • w/ alternative Tx
    • w/o Tx
171
Q

ethic

A
  • standard of behavior or belief valued by an individual or group
  • describes what ought to be, rahter than what is; goal to which individual aspires
  • standards are learned through socialization, growth, experience
  • ethical standards not legally enforceable unless incorporated into law
172
Q

commitment discharge

A
  • involuntarily committed pt lost right to leave hospital when desired
  • short-term/emergency commitments specify max length of detainment
  • long-term commitments do not have max length, but patient’s status should be reviewed often
  • if committed patient leaves before discharge, staff has legal obligation to notify police and committing courts
173
Q

assessing psychotic illness

A

understanding how brain processes information from senses and resulting behavioral responses

  • cognition
  • perception
  • emotion
  • behavior and movement
  • socialization
  • internal preoccupation - ok to ask/assess
174
Q

PHQ-9

A
  1. little interest in doing things
  2. down, depressed, hopeless
  3. trouble falling asleep, staying asleep, sleeping too much
  4. feeling tired, little energy
  5. poor appetite or overeating
  6. feeling bad about self
  7. trouble concentrating
  8. moving/speaking slowly or being ridgety/restless
  9. thoughts of self-harm/suicide
175
Q

separation anxiety disorder overview

A
  • strong risk factor for other anxiety disorders and affective disorders during childhood and into adulthood
  • under-researched
  • broad models exist but not focused ones
  • parental cognitions have impact on risk of SAD in children
    • parents of anxious children had significant dysfxnal beliefs related to self, child, environment
    • shows need for parental involvement in Tx
176
Q

ethical dilemma

A
  • a difficult p;roblem with no apparent satisfactory solution
  • a choice between equally unsatisfactory alternatives
  • when moral claims conflict
177
Q

trauma and stressor-related Dx

A
  • reactive attachment dx
  • disinhibited social engagement dx
  • PTSD
  • acute stress dx
  • adjustment dx
178
Q

preventing an aggressive crisis

A
  • identify critical times in schedule
  • identify individuals more likely to be a challenge
  • establish a proactive plan
179
Q

OFC

A

luanzethine-fluoxetine combo (anti-mania and antidepressant combined)

180
Q

paranoia

A

a type of schizophrenia characterized by systematized delusions or frequent auditory hallucinations and the projection of personal conflicts, which are ascribed to the supposed hostility of others.

it can progress to aggressive acts believed to be performed in self-defense or as a mission

181
Q

brain circuit of worry

A

corticostriatal thalamic cortical loop

182
Q

hallucinations

A

perception-like experiences without stimulus

183
Q

hypothalamic-pituitary connection

A

emotinal response and stress-coping patterns

184
Q

mesolimbic pathway

A
  • innerates limbic system
  • function:
    • memory, smell, automatic visceral effects, emotional behavior
  • abnormal function:
    • positive symptoms
    • hallucinations, delusions, disorganized speech, bizarre behavior
185
Q

bipolar maintenance

A
  • lithium (gold standard)
  • same as bipolar Tx
  • also psychotherapy and psychoeducation
    • with families too
186
Q

schizophrenia recovery program

A
  • structured recovery-oriented programs and “first episode psychosis” programs provide improvement in function, coping skills
  • promoting healthy lifestyle, encourage physical activity
  • help patients stop smoking; healthy diet
187
Q

dysthymic disorder

A
  • persistent depressive disorder
  • insidious onset and peristent course
  • patient may say “I’m always depressed”
  • less intense than MDD but parallel
  • at least 2 yrs, but usually more
188
Q

physical health of people with schizophrenia

A
  • shorter life span
  • high-risk lifestyle
    • sedentary
    • smoking
    • dietary habits
  • obesity, resulting in
    • diabetes
    • HTN
    • coronary artery disease
  • atypical antipsychotics may increase risk of certain medical conditions
189
Q

% of US population with schizophrenia

A
  • 1%
  • rates similar across cultures
  • equal prevalence between genders
    • men: 10-25 yo
    • women: 25-35 yo
190
Q

environmental stressors leading to aggression

A
  • noise/chaos
  • cramped space, no privacy
  • long wait times, boredom
  • other patients
  • visitors
  • inability to smoke
191
Q

perception in psychosis

A
  • hallucinations
  • delusions
  • misinterpretation of what is reality
192
Q

motor behaviors in psychotic disorders

A
  • silliness
  • agitation
  • difficulty in goal-directed behavior
    • stereotyped movements
    • blinking, staring
    • mutism, echoing of speech
    • catanonia, negativism
    • excessive motor activity
193
Q

court or judicial commitment

A

decision made by a judge or jury in formal hearing

194
Q

venlafaxine/desvenlafaxine/effexor/pristiq

duloxetine/cymbalta

A
  • SNRI
  • faster b/c of NE
  • no cholinergic, adrenergic and histaminic interference
  • raised BP at higher doses
195
Q

adjustment disorder

A

when someone has suffered a loss or event about 6 mo prior that has caused a mood/depressive issue and they are still adjusting to that problem

typically of shorter span and following event or loss that is specific and has triggered mood component

196
Q

delusions: is it really a psychotic illness

A
  • medication induced?
  • substance induces?
    • steroids
  • if confined to mood episodes, consider:
    • bipolar with psychosis
    • major depression with psychosis
197
Q

disorganized thinking

A

inferred from speech

198
Q

OCD

A
  • prevalence 1.2-2%
  • 30% of individuals have lifetime tic disorder
    • more common in males with OCD in childhood
    • ask about family hx of tourettes, anxiety
  • evaluate level of insight
    • most have good insight
    • poor insight = worse long-term prognosis
199
Q

addiction: loss of control

A
  • not able to take meds as prescribed
  • frequent requests for early med renewal
  • nursing: early request for PRN
  • reports frequent lost, stole, destroyed Rx
  • cannot produce meds when asked
  • abusing non-prescribed drugs or ETOH
  • withdrawal signs or symptoms in clinic
200
Q

schizophrenia symptom management techniques

A
  • distraction
  • fighting back
  • isolation
  • attempts to feel better
  • help seeking
201
Q

TCAs

A
  • tricylic antidepresants - last in line
  • anticholinergic - dry mouth, bad taste, constipation, urinary retention
  • dysphoric state, mania, fatigue
  • cardiovascular
    • postural hypotension
    • arrhythmia
    • QT changes
    • risk for fatality with overdose
  • weight gain
  • seizure in children
  • sedation, mental confusion/delirium - elderly and youth
  • sweating, fine tremor
202
Q

types of malpractice

A
  • negligence in preventing suicide or while assisting ECT
  • patient falls
  • failing to fllow physician orderes or established protocols
    • medication errors
  • improper use of equipment
  • inadequate discharge planning
  • failure to provide sufficient monitoring or failure to communicate
203
Q

increased endocrine HPA reactivity

A
  • increased cortisol
  • weakening of HPA
  • lack of ability to inhibit response and resume homeostasis
  • increased risk for diabetes
204
Q

time course of MDD

A
  • ~yr w/o treatment
  • changes icnrease by 50% for another episode after current episode
    • high relapse/recurrence rates
  • many go on to experience chronic depression
    • inadequate Tx
205
Q

interview questions about suicide

A

ask person directly if he/she is:

  • having suicidal thoughts/ideas
  • has a plan to do so
  • has access to lethal means
206
Q

schizoaffective disorder

A

mental condition that causes both a loss of contact with reality (psychosis) and mood problems

207
Q

substantia nigra

A

motor center, affecting movement and coordination

208
Q

anergia

A

lack of energy

week out if it’s a motivation anergia r/t depression or comorbid sleep problem

209
Q

prolonged activation of autonomic system

A
  • increase BP, HR
  • increase risk for MI, CVA
210
Q

DSM criteria: separation anxiety disorder

A
  • distress with separation
  • worry about danger to self, significant other
  • fear at night
  • impairs functioning
  • 4 wk duration
211
Q

spontaneous opioid withdrawal

A

patient who had been using mu opioid agonist stops OR decreases typical dose

  • heroin
    • onset 6-12 h
    • peak 36-72 hr
    • duration 5 days
  • oxy
    • similar to heroin
  • methadone
    • onset = 24-72 h
212
Q

trichotillomania

A
  • hair picking
  • 2% population
  • 10:1 female:male
  • pubertal onset most common
  • rule out tic side effect of meds
  • pull and eat = trichobezoars (dangerous)
  • pharmacotherapy
    • opioid antagonists
    • n-acetyl cysteine = glutamate agent
    • SRIs
    • antispychotics
213
Q

atypical antipsychotic drugs

A
  • antagonize both dopamine and serotonin
    • modulation of serotonin helps reduce adverse motor side effects
  • fewer cognitive, affective, motor side effects than typical
  • improve positive symptoms (mesolimbic)
  • improve negative symptoms (mesocorticol)
  • result in metabolic syndrome
214
Q

preventing stress and promoting stability of schizophrenia

A
  • stable conditions can regress when:
    • changes in sleep
    • acute stress
    • loss
    • trauma
    • altered self care
    • adherence to medicine
    • isolation
    • sensory deprivation or overload
215
Q

generalized anxiety disorder

A
  • median age of onset = 30 yo
  • females:males 2:1
  • nervousness, anxious all thier lives, anxious temperament
  • wax and wanes, same across ages
    • difference is content of worries
  • rates of full remissions = very low
  • difficult to treat
216
Q

managing aggression in healthcare

A

staff and patient safety equally important

217
Q

MDD

A
  • leading cause of disability in U.S. ages 15-44
  • affect ~12%
  • median age of onset = 40
  • highest risk is under 20 yo and over 70 yo
    • also for suicidality
  • more prevalent in women than men (2:1)
    • women may seek Tx more often and could skew ratio
218
Q

steps in ethical decision-making

A
  1. gather background information
  2. identify ethical components
  3. clarify responsibilities of ethical agents
  4. explore options
  5. apply nursing principles
  6. form a resolution
    1. social expectations
    2. action
    3. legal requirements
219
Q

circumstantial thought

A

circles back around to original topic eventually

220
Q

fear based disorders: examples

A
  • separation anxiety disorder
  • selective mutism
  • specific phobia
  • social anxiety disorder
  • panic disorder
  • agoraphobia
  • generalized anxiety disorder
221
Q

negligence

A
  • plaintiff must prove
    • legal duty of care existed
    • nurses performed duty negligently
    • damages suffered by plaintiff
    • damages were substantial
  • nurses should have malpractice insurance
222
Q

delirium tremens

A
  • acute reduction/abstinence from alcohol
  • <5% of withdrawal; mortality 2-10%
  • hallucinations, usually tactile
  • disorientation
  • tachy
  • HTN
  • fever
  • agitation
  • diaphoresis
  • can persist up to 7 days
223
Q

short-term or observational hospitalization

A
  • primarily for diagnosis and short-term therapy; emergency situation not required
  • for specified time that varies state-to-state
  • petition can be filed for long-term commitment of patient is not ready for discharge at end of period
224
Q

obsessive-compulsive and related disorders

A
  • OCD
  • body dysmorphic dx
  • hoarding dx
  • trichotillomania
  • excoriation dx
225
Q

professional nursing practice

A
  • interplay among patient’s rights, legal role of nurse, concern for quality care
  • three roles:
    • provider of services
    • employee/contractor of services
    • private citizen
226
Q

hormonal changes and depression

A
  • estrogen impacts monoamines, GABA (inhibitory - calming effect), and glutamate (excitatory - fight/flight)
    • also impacts serotonergic fxns (mood, anxiety, appetite, sex drive)
  • significant during puberty onset, menstrual cycles, postpartum period, during menopause
227
Q

DSM-5 AUD

A
  • 8.5% in adults
    • 12.4% men
    • 4.9% women
  • criteria
    • physical - tolerance, dependence
    • psychological - craving
  • alchol withdrawal syndrome
    • S/Sx occur w.in hrs to a week after cessation
228
Q

who is going to assault me?

A
  • 15-40 yo and 70-85 yo
  • during first 2-3 days of admission
  • physical assaults usually by patient
  • relatives more likely to assault ambulance personnel
229
Q

AWS diagnostic criteria

A
  • cessation or alcohol use that was heavy and prolonged
  • THEN: two + developing within hrs to weeks after (A)
    • autonomic hyperactivity (sweating, tachy)
    • increased hand tremor
    • insomnia
    • N/V
    • transient visual, tactile, auditory hallucinations/illusions
    • psychomotor agitation
    • anxiety
    • generalized tonic-clonic seizures
  • S/sx above cause clinically significant distress/impairment in social, occupational, or other important areas or functioning
  • S/Sx not attributable to another medical condition, mental dx, including intoxication or withdrawal from another substance
230
Q

socialization in psychosis

A
  • difficulty communicating
  • loss of drive, interests
  • stigma
231
Q

characteristics of ambivalent attachment as children

A
  • may be wary of strangers
  • become greatly distressed when parent leaves
  • do not appear to be comforted by return of parent
232
Q

GABA in stress

A
  • inhibitory neurotransmitter
  • controls activity/firing rates of neurons responsible for producing anxiety
  • makes postsynaptic receptor more sensitive
  • enhances neurotranmission and inhibits cell activity
233
Q

commitment

A

patient did not request hospitalization and may have opposed it

234
Q

managing hallucinations and delusions

A
  • increase awareness, facilitate communicaiton, assess for command hallucinations
  • maintain eye contact, speak simply
  • call patient by name, use touch (w/ permission)
  • isolation not recommended
  • do not reinforce hallucinations, identify triggers/risks
235
Q

antipsychotic side effect checklist

A
  1. loss of energy
  2. unmotivated
  3. daytime drowsiness
  4. sleeping too much
  5. muscles tense
  6. muscles tremble
  7. restless
  8. need to move around
  9. trouble going to/staying asleep
  10. blurry vision
  11. dry mouth
  12. drooling
  13. memory/concentration
  14. constipation
  15. weight changes
  16. change in sexual fxn
  17. menstrual/breast problems
236
Q

fear

A

emotional response to threat (perceived or real) that is short term

237
Q

DMDD duration

A

12 mo duration w/o 3 mo period w.o symptoms

238
Q

most at risk for AWS

A
  • chronic drinking over a period of years
  • males 5:1
  • middle-aged or older
  • previous hx of AWS seizures or DTs
  • CIWA-ar > 8-10
  • comorbid alcoholic liver dx, trauma, infections, sepsis
  • detectable blood alcohol on admission
  • use of eye opener
  • abnormal LFTs
239
Q

other medications for AWS

A
  • antabuse/disulfram
    • inhibits ETOH metabolism
    • increased acetaldehyde
    • sweating, N, flushing, tachy if ETOH is consumed
    • most stop taking prior to ETOH; can be life threatening if taken with ETOH
  • Naltrexone/ReVia:
    • blocks opioid receptors
    • reduces craving and reward
    • contraindicated with opiate use
240
Q

delusions

A

false belief based on incorrect inference about external reality that is firmly held despite proof or evidence of the contrary

241
Q

access to health records

A
  • most psychiatric records are separate; more sensitive than medical records
  • if patients request access:
    • expore reasons for request
    • prepare patient for review
    • be present to discuss questions
    • do not release material from other sources
  • do not alter/destroy record
  • physical record is facility/therapist’s property
  • information belongs to patient
  • only copy given to patient
  • record can be brought into cord and contents used in lawsuit
242
Q

PTSD

A
  • 80% likelihood of comorbid mental dx
    • substance abuse common
  • co-occurence of TBI and PTSD of US deployed in recent wars = 48%
  • highly associated with suicide risk
  • associated with mutism in children
  • comorbid bereavement S/Sx common
243
Q

depression in older individuals

A
  • more common than in general population (25-50%)
  • underrecognized and underdiagnosed
  • ageism
  • high suicide risk in older white males who are isolated/live alone
244
Q

bipolar I

A
  • manic or mixed episodes
  • acute mania + depressive episodes
  • depressed and not sleeping
  • mania and depression are intense
  • 0-2.4% lifetime prevalence
245
Q

general pharmacological Tx rules for depression

A
  • monitor adherence
  • 4-6 wks for response
  • monitor for response vs. remission
  • vegetative symptoms tend to improve first, cognitive symptoms take longer
  • SSRIs = first line Tx for MDD
  • address biopsychosocial needs and maintain meds 6-12 mo
246
Q

negative symptoms of schizophrenia

A
  • asociality
  • avolition
  • anhedonia
  • blunted affect
  • alogia
247
Q

bipolar disorder general

A
  • mood instability - depression vs. mania
  • depressive episodes very severe in bipolar patients
  • difficult diagnosis to differentiate
    • 31% patients misdiagnosed with unipolar depression
    • 35% waited 10+ yrs for accurate diagnosis
    • need thorough history
  • median age of onset = 30 yrs
248
Q

extrapyramidal syndrome (EPS)

A
  • acute dystonic reactions:
    • sudden muscle spasms in neck, back, eyes that may be painful or frightening
  • akathisisa:
    • pacing, inner restlessness, leg aches relieved by movement
  • Parkinson syndrome:
    • cogwheel rigidity, fine tremor, akinesia
249
Q

Tx for OCD

A
  • CBT
  • exposure therapy
  • 50% report response
  • 12-16 sessions
  • medications can be helpful prior to therapy to decrease anxious symtpoms
250
Q

genetic and environmental risks of anxiety

A
  • serotonin subtypes: decreased COMT reduced catecholemines = more anxiety
  • increased NMDA/receptors impact NE and glutamate
  • decreased GABA, increased glutamate
  • overprotective parent(s)
  • trauma
  • attachment problems
251
Q

barriers to successful intervention for delusions

A
  • becoming anxious, avoiding the person
  • reinforcing delusion
  • attempting to prove the person is wrong
  • setting unrealistic goals
  • becoming incorporated into delusional system
  • failing to clarify confusion surrounding delusion
  • being inconsistent in intervention
  • seeing delusion first and person second
252
Q

anxiety and pregnancy

A

1/10 women have anxiety during pregnancy which increases cortisol and increases risk of anxiety in the fetus (later in life)

253
Q

complements to psychopharmacology in schizophrenia

A
  • behavioral therapy such as cognitive behavioral therapy
  • interventions involving coping, family participation in maintenance phase
  • teaching for potential relapse
  • symptom management
  • patient engagement in decision making
254
Q

diagnosis of AUD

A
  • chronic heavy use
  • type
  • volume
  • frequency
  • drinking pattern
  • time of last drink
  • Hx of detox or withdrawal
  • social, financial, legal problems
  • Hx of alcohol-related seizures
  • family hx
255
Q

HPA

A

hypothalamus pituitary adrenal axis

responsible for endocrinologic changes when fear/stress occurs by releasing glucocorticoids and CRF

256
Q

release of information without consent

A
  • in emergency, act in patient’s best interests
  • court-ordered evaluations or reports
  • commitment proceedings
  • criminal proceedings
  • acting to protect third parties
  • child custody disputes
  • reports required by state law
  • child abuse proceedings
257
Q

agranulocytosis

A
  • fever, malaise
  • ulcerative sore throat
  • leukopenia
  • 1-2% of patients taking clozapine
258
Q

factors that may diminish a therapeutic relationship

A
  • public reprimands
  • sarcasm
  • favoritism
  • inconsistency
  • dishonesty
  • threats
  • disrespect
259
Q

SBQ-R

A

Suicide Behaviors Questionnaire-Revised

  1. lifetime suicide ideation and/or attempts
  2. frequency of suicidal ideation over past 12 mo
  3. threat of suicide attempt
  4. self-reported likelihood of suicidal behavior in future
260
Q

key features of psychotic disorders (DSM 5)

A
  • delusions
  • hallucinations
  • disorganized thinking
  • grossly disorganized or abnormal motor behavior (including catatonia)
  • negative symptoms
261
Q

evidence-based treatment of schizophrenia

A
  • typical and atypical antipsychotic drugs
    • improve psychotic symptoms in acute phase of illness
    • reduce risk of future relapse
  • psychosocial treatments
    • life skills training
    • supported employment
    • cognitive behavioral psychotherapy
    • behavior modification
    • social learning/token economy programs
    • assertive community treatment
262
Q

mood changes of depressive episode

A
  • overly long period of feeling sad, hopeless
  • loss of interest in activities once enjoyed, including sex
263
Q

emotional signs of depression

A
  • sadness
  • tearfulness
  • low self-esteem
  • obsessive self-critical thoughts
  • inability to experience pleasure
  • loss of ambition
  • loss of interest
  • inability to focus on tasks (ADHD in children)
  • irritability
  • anger
  • pessimism
  • guilt
  • helplessness
  • loss of hope
  • feelings of despair, including thoughts of suicide
  • anxiety (90%)
264
Q

buproprion/wellbutrin/forfivo

A
  • NDRI - inhibitor of DA and NE
  • non-sedative but excitant property
  • used in depression and cessation of smoking
  • seizure may be precipitated
265
Q

CAGE

A

C: cut down

A: annoyed (you or others)

G: guilty

E: eye-opener

266
Q

midbrain

A

emotion and memory

267
Q

characteristics of secure attachment as children

A
  • able to separate from parent
  • seek comfort from parents when frightened
  • return of parents met with positive emotions
  • prefers parents to strangers
268
Q

suicide

A
  • >1 million suicide deaths annually
  • 90% with diagnosed mood disorder
  • highest rates in white men over 85
  • 4x as many men than women die by suicide
    • but women attempt it 2-3X more often than men
269
Q

CRAFFT part B

A

C: car?

R: relax?

A: alone?

F: forget things?

F: family/friends say to cut down?

T: trouble?

270
Q

departments with high incidence of aggresive behavior

A
  • medical
  • surgical
  • ICU
271
Q

mirtazapine/remeron

A
  • NaSSA (noradrenergic and specific serotonergic antidepressant)
    • enhancement of NE release and specific 5-HT1 receptor action
  • lower doses = higher sedation
  • weight gain b/c it antihistaminic
  • avoids G1 5-HT - good for intractable nausea or anorexia
  • fewer sexual side effects
272
Q

Geriatric Depression scale

A
  1. basically satisifed with life?
  2. dropped activities/interests?
  3. life is empty?
  4. bored?
  5. good spirits?
  6. afraid something bad will happen to you?
  7. happy most of the time?
  8. helpless?
  9. prefer to stay at home?
  10. more problems with memory than most?
  11. wonderful to be alive?
  12. worthless?
  13. full of energy?
  14. situation is hopeless?
  15. most people better off?
273
Q

positive symptoms of schizophrenia

A
  • delusions
  • hallucinations
  • disorganization
  • catatonia
274
Q

shared psychotic disorder (folie a deux)

A

a rare condition in which an otherwise healthy person (secondary case) shares the delusions of a person with a spychotic disorder (primary case), such as schizophrenia, who has well-established delusions

275
Q

FDA approved Rx for OCD

A
  • clomipramine
    • SRI (blood levels)
    • if induced can have arrythmia
  • fluoexitine (prozac)
  • fluvoxamine
  • paroxetine
  • sertraline
276
Q

tuberinfundibular pathway

A
  • originates in hypothalamus and projects to pituitary
  • function:
    • endocrine, hunger, thirst, metabolism, temp control, digestion, sexual arousal, circadian rhythms
  • abnormal function:
    • implicated in endocrine abnormalities in schizophrenia and some side effects of antipsychotic drugs (hyperprolactinemia)

Psychiatric Nursing (2 decks)

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