Midterm Flashcards
ethical considerations
- 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
antipsychotic drug side effects
- agranulocytosis
- neuroleptic malignant syndrome
- extra-pyramidal syndrome
- tardive dyskinesia
- weight gain
- hyperprolactinemia
- metabolic syndrome & diabetes
- ketoacidosis risk
staff reactions to aggression
- 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
lithium
- gold standard for bipolar
- blood draws
- kidney risks
- mania, suicidality
opioid intoxication
- 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
anhydonia
lack of pleasure - negative sympton of schizophrenia
brain in compulsive substance use
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
DSM criteria: phobia
- 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
activity and the brain
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)
right to treatment in least restrictive setting
- 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
testimonial privilege
- 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
addiction: use despite harm
- persistently intoxicated
- persistently over-sedated
- declining fxning due to use of substance
- work
- relationships
- recreation
- health
- some genetic predisposition
common attitude/behavior-related triggers of schizophrenia
- 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
manifestations of corticostriatal thalamic cortical loop
- worry
- apprehension
- obsessions
hoarding Dx
- 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
incompetence
- 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
ethical decision-making
- 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
SSRIs: OCD, anxiety, MDD
Dose: OCD (80 mg) >>> anxiety (40) >>> MDD (20)
caffeine and nicotine in schizophrenia
- 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
manifestations of fear via amygdala-centered circuit
- fear
- anxiety
- phobia
depression
- 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
medical certification
commitment made on decision of physician
depression among medical patients
- 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
documentation of AMA requests
- 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
level 3 anxiety
- 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
behavioral changes of depressive episode
- tired, slowed down
- problems concentrating, remembering, making decisions
- restless or irritable
- change in eating, sleeping, other habits
- thinking of death/suicide, attempting suicide
nursing assessments: schizophrenia
- dysthymia
- hopelessness
- depressed mood
- mood elevations
- expansions
- sleep cycle
- appetite
- energy
- supports
- physical complaints
- behavioral changes
characteristics of secure attachment as adults
- having trusting, lasting relationsihps
- tend to have good self-esteem
- comfortable sharing feelings with friends and partners
- seek out social support
addiction: disordered function
- loss of control of something you do
- preoccupation with something you want to do
- doing something depsite adverse consequences
separation anxiety disorder prevalence
- 4% prevalence
- decreases over time (adolescenes into adulthood)
- most prevalent disorder in children under 12 yo
- equally common males:females
DMDD age consideration
not made 18 yo
age of onset by Hx or observation is usually ~ 10yo
SMAST-G
Short Michigan Alcoholism Screening Test - Geriatric version
treatment for suicide
- therapy
- talk
- cognitive behavior
- psychodynamic
- psychoanlysis
- medication
principles of informing
- 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
release of information
- 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
mood changes of mania
- overly long period of feeling “high” or an overly happy or outgoing mood
- extreme irritability
depression in children
- parental and family Hx of depression
- vague physical symptoms
- behavior issues, misdiagnosed
- school phobia, excessive clinging to parents, poor academic performance and attendance
AUDIT
Alcohol Use Disorders Tdentification Test
- how often do you drink alcohol?
- how many drinks on a typical day?
- how often do you have 6+?
- how often have you started and couldn’t stop drinking?
- how often have you failed to do what was normally expected from you b/c of drinking?
- how often have you been unable to remember the night before?
- how often have you needed alcohol first thing in the morning after a night of heavy drinking?
- how often do you feel guilt/remorse after drinking?
- how often have you/others been injured from your drinking?
- has a relative/health professional expressed concern?
why patient’s may be aggressive
- misunderstanding/dispute about medical issues
- not being taken seriously
- dissatisfaction with Tx
- pain
- enforced care or Tx
- disputes over hospital policy
Types of SSRIs for anxiety
- escitalopram/lexapro
- citalopram/celexa
- fluoxetine/prozac
- paroxetine/praxil
- sertraline/zoloft
- luvox
- fluvoxamine
course/outcome with treatment of psychosis
- complete, prolonged recovery w/ minimal/no negative S/Sx
- partial recovery or recurrent psychotic episodes
- no significant recovery of psychosis
cyclothymic disorder
- persistent and insidious onset
- parallel to bipolar disorder
- at least 2 yrs
forcing medicatons
- 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
emergency hospitalization
- 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
characteristics of avoidant attachment as adults
- may have problems with intimacy
- invest little emotion in social and romantic relationships
- unable/unwilling to share thoughts and feelings with others
motivation and change process
- 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
dissociative disorders
- dissociative identity dx
- dissociative amnesia
- depersonalization/derealization dx
circle of confidentiality
- 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
emotion in psychosis
- affect - (flat blunted, incongruent) - may vary by culture
- depressed mood common
psychotherapy in depression
- supportive
- insight-oriented
- interpersonal
- cognitive-behavioral
- psychodynamic
- individual, gorup or family
body dysmorphic Dx
- tends to be one body part
- muscle dysmorphia: body builders (tends to be male)
outpatient commitment
- 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
common environment-related triggers of schizophrenia
- 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
diabetes & metabolic monitoring in schizophrenia
- 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
confidentiality
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)
anxiety
sustained response that influences behaviors - no stimulus needed
hospitalized patients and AUD
- 15-20% hospitalized patients have AUD
- 43% trauma patients have AUD
- 31% trauma patients have withdrawal
clinical algorithm for involuntary commitment process
coping and patient insight with anxiety
- 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
cognition in psychosis
- memory, attention, speech, decision-making, thought content, thought process
- concrete thinking, difficulty with commands
- executive function alteration
beecoming that “solid object”
- calm
- centered/balanced
- empathetic/udnerstanding
- present and able to listen
- verbally reassuring
- firm but non-intimidating
- fair
- non-threatening, but not “wishy washy”
nurse as provider
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
pathogenesis of AWS
- 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
tardive dyskinesia
- lip smacking
- chewing
- tongue protrusion
- grimacing
- blinking
- choreiform movements, foot tapping
excoriation Dx
- scratching, skin picking
- most commonly begins in adolescence
- females 75%
predictors of dangerousness
- 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
dopamine in the brain
- substantia nigra
- midbrain
- hypothalamic-pituitary connection
involuntary admission
- 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
warning signs of suicide
- 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
nigrostriatal pathway
- 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)
other symptoms of schizophrenia
- depression
- mania
- anxiety
- obsessive-compulsive
- substance abuse
body systems involved in anxiety
- limbic (CNS)
- endocrine
- autonomic
cognitive and behavioral respones can exacerbate or mediate symptoms
long-term hospitalization or formal commitment
- 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
level 4 anxiety
- pathologic
- panic state = all of level 3 + following:
- decreased hand-eye coordination
- lowered BP - higher HR
- possible illogical thoughts, psychosis, hallucinations
characteristics of avoidant attachment as children
- may avoid parents
- does not seek much comfort or contact from parents
- shows little or no preference between parent and stranger
medical comorbidities/risks with anxiety
- pulmonary - asthma, CV disorders
- endocrine disturbances
- obesity
- inflammatory disorders
- Tx-related or Tx-caused or both?
- neurologic conditions
- migraines
- MS
de-escalating aggressive situations
- 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
voluntary admission
- 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
behavioral changes of mania
- 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
CRAFFT part A
- drink any alcohol?
- smoke marijuana?
- anything else to get high?
habeas corpus
- 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
AWS stages
- tremulousness: 6-36 hrs after last drink
- hallucinations: 12-48 hrs
- seizures: 6-48 hrs
- delirium tremens: 3-7 days
normal response to anxiety
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
protecting a third party
- 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
tangential thought
off-topic but with logical progression
can’t get back to the original topic/question
common health-related triggers of schizophrenia
- poor nutrition
- lack of sleep
- circadian rhythms
- fatigue
- infection
- CNS drugs
- lack of exercise
- barriers to accessing health care
family implications in schizophrenia
- 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
genetics and schizophrenia
significant hereditary component
still depends on some sort of external “trigger”
neurotransmitters involved in worry
- serotonin
- GABA
- DOPAMINE
- NE
- glutamate
- voltage-sensitive ion channels
prevalence of anxiety disorders
- 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
metabolic syndrome risk criteria
- 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
risk factors for delirium tremens
- 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)
Trazodone/deseryl
- weak 5-HT uptake block, a-block, 5-HT2 antagonist
- no anticholinergic actions
- risks: priapsim (sustained erection), postural hypotension
- better as sleep agent PRN
fear based disorders: overview
- 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
schizophreniform disorder
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
brain circuit of fear
amygdala-centered
other risks/causes of anxiety
- 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
nurse assessment of delusions
- determine error in reality
- test strength of conviction or belief
- encourage discussion about belief and details surrounding belief
- calmly present alternative explanations
benzodiazepines (BZ) in anxiety
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
MDD symptoms
<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
viral and infection theories of schizophrenia
- “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
recurrent anxiety
- pathologic response
- prolonged activation of autonomic system
- increased endocrine HPA reactivity
- cognitive perception affected
issues related to restrictiveness
- 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
biological stressors of schizophrenia
- 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
interventions in health promotion phase of schizophrenia
- 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
physical and cognitive signs of depression
- 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
cognitive symptoms of schizophrenia
- working memory
- declarative memory
- verbal memory
dopaminergic pathways
- mesolimbic
- mesocortical
- nigrostriatal
- tuberinfundibular
- incertohypothalamic
- medullary
- retinal
endocrine system/HPA axis: normal response
- amygdala perceives danger
- hypothalamus releases CRH
- pituitary releases ACTH
- adrenal glands release cortisol
- cortisol shuts off alarm, “fight/flight” stops and homeostasis returns
neuroleptic malignant syndrome
- dazed mutism
- fever
- tachycardia
- sweating
- muscle rigidity
- tremor
- stupor
- renal failure
- leukocytosis