Mod. 6 (ATI Ch. 18, 26, 14, 23, 10, 13, 22) Flashcards
Mood disorders neurotransmitters
- serotonin
- dopamine
- epinephrine
- GABA
Depressive disorders
recognized by DSM-5
(5)
- Major depressive disorder (MDD)
- seasonal affective disorder (SAD)
- Persistent depressive disorder (previously) known as dysrhythmic disorder)
- Premenstrual dysphoric disorder (PMDD)
- substance-induced depressive disorder
SIGECAPS
pneumonic for questions to ask regarding:
sleep interest guilt energy concentration appetite psychomotor suicidality
MDD phases Care
acute phase: severe findings of depression
- Tx generally 6 to 12 weeks in duration
- potential need for hospitalization
- reduction of depressive manifestations is the goal Tx***
- assess suicide risk and implement precautions
continuation phase: ^ ability to function
- Tx generally 4 to 9 months in duration
- relapse prevention through education, medication, therapy, and psychotherapy is goal***
maintenance phase: remission of manifestations
- phase can last for years
- prevention of future depressive episodes is goal***
DIGFAST mnemonic to guide questioning for a bipolar patient
distractibility indiscretion grandiosity or inflated self esteem flight of ideas or racing thoughts activity increase sleep deficit talkativeness or pressured speech
Only for clients who have stopped drinking
meds.
naltrexone
acamprosate (Campral)
disulfiram (Antabuse)
Milieu therapy for depression
suicide risk self-care communication maintenance of a safe environment counseling
Socialcultural Theories in substance use
Alaska natives and Native American may have high percentage of members who have alcohol disorder
Peer presssure
Older adult clients
Expected Findings in substance use and addictive disorders
What to ask
nurse should use open-ended questions to obtain following;
~ type of substance of addictive behavior
~ pattern and frequency of substance use
~ amount of substance used
~ age at onset of substance use
~ changes in occupational/ school performance
~ changes in use patterns
~ periods of abstinence in history
~ previous withdrawal manifestations
~ date of last substance use or addictive behavior
Review of systems in substance use/ addictive disorders
- blackout or loss of consciousness
- changes in bowel movements
- weight loss or weight gain
- experience of stressful situation
- sleep problems
- chronic pain
- concern over substance use
- cutting down on consumption or behavior
Population- Specific Considerations
Substance use and addictions
- rate of substance use is higher in age 18- 25
- Older adults: prone to falls, injuries, memory loss, somatic reports (headaches), changes in sleep patterns
» indications show decrease in ability for self-care (functional status), urinary incontinence, manifestations of dementia
» happens at lower doses
» consider many drug interactions (polypharmacy)
Standardized Screening Tools
for substance use/ addictive disorders
- Michigan Alcohol Screening Test (MAST)
- Drug Abuse Screening Test (DAST) or DAST-A: adolescent version
- CAGE Questionnaire: asks questions of clients to determine how they perceive their current alcohol use
- Alcohol Use Disorders Identification Test (AUDIT)
- Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
- Clinical Opiate Withdrawal Scale
Commonly Used Substances
substance use and addictive disorders
- Opioid Agonists
- CNS depressants
- CNS stimulants
- Other
Opioid Agonists
generalized CNS depression, listed as Schedule 2
Heroin, morphine, hydromorphone can be injected, smoked, inhaled, or swallowed.
- effects: rush of euphoria, relief from pain
- effects of intoxication: slurred speech, impaired memory, pupillary changes.
Decreased respirations and LOC which can cause death.
Maladaptive behavioral or psychological changes (impaired judgement)
***Antidote- naloxone IV
CNS depressants
physiological and psychological dependence
Alcohol: blood alcohol concentration of 0.08% is considered legally intoxicated for drivers. Death could occur for levels > 0.4%
- Effects of excess (major): respiratory arrest, peripheral collapse (low bp causes collapse of vessels), death (large doses)
- Chronic use: CV damage, liver damage (fatty liver to cirrhosis), erosive gastritis and GI bleeding, acute pancreatitis, sexual dysfunction
- Withdrawal manifestations: inability to sleep, ^ HR, transient hallucinations or illusions, anxiety, ^ BP, ^RR, ^temp., tonic-clonic seizure
- — delirium can occur 2-3 days after cessation, MEDICAL EMERGENCY. Manifest as severe disorientation, psychotic manifestations (hallucinations), severe htn, dysrhythmias, delirium. Delirium can progress to death
CNS depressant: sedative/ hypnotics/ anxiolytics
ex. club drug
Benzodiazepines (diazepam), barbiturates (phenobarbital), club drugs (flunitrazepam “rape drug”) can be injected or taken orally
intended to decrease anxiety, sedation
Effects of intoxication
- ^drowsiness, sedation, agitation, slurred speech, uncoordinated motor activity, nystagmus, disorientation, n&v
- resp. depression and decreased LOV, can be fatal
***antidote- flumazenil IV for benzo. toxicity
no antidote for barbiturate toxicity
Withdrawal manifestations: anxiety, insomnia, deaphoresis, htn, psychotic reactions, hand tremors, n&v, hallucinations/ illusions, psychomotor agitation, possible seizures
CNS depressant:
Cannabis
marijuana or hashish (more potent) can be smoked or ingested
intended effects: euphoria, sedation, hallucinations, decrease of n&v (chemo), chronic pain management
effects of intoxication
- chronic use: ^risk for lung cancer, resp. effects, problems with ADL
- in high doses: occurrence of paranoia (delusions and hallucinations)
- ^appetite, dry mouth, tachycardia
- can impair motor skills up to 8-12 hrs.
- synthetic; K2 and spice, have been associated w/ toxic doses.
withdrawal manifestations: irritability, aggression, anxiety, insomnia, lack of appetite, restlessness, depressed mood, abd. pain, tremors, diaphoreses, fever, headache
CNS stimulants: Cocaine
injected, smoked, or inhaled
intended effects: rush of euphoria, pleasure, ^energy
effects of intoxication
- mild toxicity- dizziness, irritability, tremor, blurred vision
- severe effects- hallucinations, seizures, extreme fever, tachycardia, htn, chest pain, possible cv collapse and death
Withdrawal manifestations:
- depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation
- not life-threatening but possible suicidal ideation
CNS stimulants: Amphetamines
orally, injected IV, or smoked
intended effects: ^energy, euphoria similar to cocaine
effects of intoxication:
- impaired judgement, psychomotor agitation, hypervigilance, extreme irritability
- acute cv effects (tachycardia, ^BP) which could cause death
withdrawal manifestations:
- craving, depression, fatigue, sleeping
- not life-threatening
CNS stimulants: Inhalants
amyl nitrate, nitrous oxide, solvents are sniffed, huffed, or bagged often by children or adolescents
intended effects: euphoria
Effects of intoxication:
- depend on substance, but generally can cause behavioral/ psychological changes, dizziness, nystagmus, uncoordinated movements or gait, slurred speech, drowsiness, hyporeflexia, muscle weakness, diplopia, stupor or coma, resp. depression, possible death
- withdrawal manifestations: none
Medications for substance withdrawal
Alcohol withdrawal- diazepam, cabamazepine, clonidine, chlordiazepoxide, phenobarbital, naltrexone
Alcohol abstinence- disulfiram, naltrexone, acamprosate
Opioid withdrawal- methadone substitution, clonidine, buprenorphine, naltrexone, levo- alpha- acetylmethadol
Nicotine withdrawal from tobacco use- bupropion, nicotine replacement therapy (nicotine gum and nicotine patch), varenicline, bupropion
Nicotine abstinence- varenicline, rimonabant
Psychotherapies for substance disorders
- cognitive behavioral therapies (relaxation techniques or cognitive reframing)
- acceptance and commitment therapy (ACT)
- relapse prevention therapy assists clients in identifying the potential for relapse and promotes behavioral self-control
12 step program and family groups
Alcoholics Anonymous, Narcotics Anonymous, Gambler’s Anonymous
family groups: Al-Anon, Ala-Teen
These programs will teach;
- abstinence is necessary for recovery
- a higher power is needed to assist in recovery
- clients are not responsible for their disease but are responsible for their recovery
- other people cannot be blamed for the client’s addictions, and they must acknowledge their feelings and problems
Brain Stimulation Therapies
ECT- electroconvulsive therapy
TMS- transcranial magnetic stimulation
VNS- Vagus nerve stimulation
Electroconvulsive therapies
- induce brief seizure activity while client is anesthetized
- thought to enhance the effects of serotonin, dopamine, and norepinephrine
Indications:
- MDD
- Schizophrenia spectrum disorders
- Acute manic episodes
Contraindications:
~cardiovascular disorders
~ cerebrovascular disorders
ECT not useful for substance disorder, personality disorders, dysphoric disorders
electroconvulsive therapy considerations
- 2-3 times per week total of 6 to 12 treatments for depression
- provider obtains informed consent. If involuntary, court of next of kin
- Pre-ECT work up includes CXR, blood work, ECG. Benzos are d/c
- medication management:
- –30 min prior, IM inj. of atropine or glycopyrrolate to decrease secretions and counteract bradycardia
- – anesthesia provider gives short acting anesthetic (propofol/ atomidate)
- – muscle relaxant (succinylcholine) given to paralyze muscles during seizure activity, decreases injury risk. Paralyzes resp. muscles
- Severe htn should be controlled
- dysrhythmias or htn should be monitored and treated before procedure
- 100% oxygen is applied
- should become alert 15 min after ECT
Transcranial magnetic stimulation
noninvasive, uses magnetic pulsations (MRI strength) to stimulate the cerebral cortex of the brain
indications- approved by the FDA for the tx of MDD who do not respond to meds. Similar to ECT but no seizures
Considerations
- daily for 4 - 6 weeks
- outpatient
- lasts 30 - 40 min
- electromagnet placed placed on scalp
- client is alert
- may feel tapping, knocking sensation in the head, scalp skin contraction, and tightening of jaw muscles during procedure
Contraindicated - cochlear implants - brain stimulators - medication pumps can cause neuro. deficits
Vagus nerve stimulation
electrical stimulation through a device surgically implanted under skin on the chest
result in ^level of neurotransmitters and enhances the actions of antidepressant meds.
Indications:
- depression resistant to meds. and/or ECT
- being researched to be used to treat anxiety, obesity, pain
Bipolar Disorders
Mood disorders w/ recurrent episodes of depression and mania
Usually emerge in early adulthood. Could be confused with ADHD in children.
Exhibit psychotic, paranoid, and/or bizarre behavior in mania.
Care for the Phases in bipolar disorder
Acute Phase
Acute Phase: acute mania
- – hospitalization can be required
- – reduction of mania and client safety are the goals
- – risk of harm to self/others is determined
- – one-to-one supervision can be indicated
Care for the Phases of Bipolar Disorder:
Continuation phase
Continuation phase: remission of manifestations
- – Tx is usually 4 to 9 months in duration
- – relapse prevention through education, medication, adherence, and psychotherapy is the goal
Care for the Phases of Bipolar disorder:
maintenance phase
maintenance phase: ^ability to function
- – Tx generally continues throughout the client’s lifetime
- – prevention of future manic episodes is goal
Behaviors shown with Bipolar Disorder
Mania: abnormally ^mood, expansive/ irritable, usually lasts at least 1 week. Hospitalization usually required.
Hypomania: less severe episode of mania, lasts at least 4 days, followed by 3 or more manifestations of mania. hospitalization not required, but can progress to mania.
Rapid Cycling: 4 or more episodes of hypomania or acute mania within 1 year and associated with ^ recurrence rate and resistance to Tx.
Types of Bipolar Disorders
1, 2, cyclothymic
Bipolar 1: has at least 1 episode of mania alternating w/ major depression.
Bipolar 2: has one or more hypomanic episodes alternating w/ major depressive episodes.
Cyclothymic: has at least 2 years of repeated hypomanic manifestations that don’t meet the criteria for hypomanic episodes alternating w/ minor depressive episodes.
Risk factors for Bipolar Disorder
Genetics
Physiological
Environmental
Manic Characteristics in bipolar disorders
+ labile mood w/ euphoria
+ agitation and irritability
+ restlessness
+ dislike of interference and intolerance of criticism
+ ^ in talking and activity
+ flight of ideas: rapid, continuous speech w/ sudden and frequent topic change
+ grandiose view of self and abilities
+ impulsivity: spending money, giving away possessions
+ demanding and manipulative behavior
+ distractibility and decreased attention span
+ poor judgement
+ attention-seeking behavior: flashy dress and makeup, inappropriate behavior
+ impairment in social and occupational functioning
+ decreased sleep
+ neglect of ADLs, including nutrition and hydration
+ possible presence of delusions and hallucinations
+ denial of illness
Depressive Characteristics in bipolar disorder
- flat, blunted, labile affect
- tearfulness, crying
- lack of energy
- anhedonia: loss of pleasure and lack of interest
- physical reports of discomfort/ pain
- difficulty concentrating, focusing, problem-solving
- self-destructive behavior, including suicidal ideation
- decrease in personal hygiene
- loss or ^in appetite and/or sleep disturbed sleep
- psychomotor retardation or agitation
screening tool for bipolar disorder
Mood Disorders Questionnaire- a standardized tool that places mood progression on a continuum from hypomania (euphoria) to acute mania (extreme irritability and hyperactivity) to delirious mania (completely out of touch w/ reality)
Medications used in Bipolar Disorder
Mood Stabilizers
-lithium carbonate
- anticonvulsants acting as mood stabilizers: valporate and carbamazepine treat acute mania;
lamotrigine for maintenance of bipolar mania
First-generation antipsychotics
-chlorpromazine and -loxapine
Second-generation antipsychotics
- olanzapine -risperidone -others
- lurasidone and quetiapine for depression in bipolar disorders
Antidepressants
-SSRI fluoxetine for major depressive episode
MDD
a single episode/ recurrent episodes of unipolar depression not associated with another disorder, and accompanied by at least 5 of the following (which must occur almost every day for a minimum of 2 weeks and last almost all day.
- depressed mood
- difficulty sleeping or excessive sleeping
- indecisiveness
- decreased ability to concentrate
- suicidal ideation
- ^ or decrease in motor activity
- inability to feel pleasure
- ^ or decrease in weight of more than 5% of total body weight over 1 month.
MDD
DSM5 specifier
Psychotic features: auditory hallucinations or delusions
Postpartum onset: depressive episode that begins within 4 wks of childbirth. Can include delusions
Seasonal affective disorder (SAD)
occurs seasonally, usually during winter.
Light therapy is first-line Tx for SAD
Persistent Depressive Disorder (previously dysrhythmic disorder)
milder form of depression w/ an early onset usually in childhood or adolescence, and lasts at least 2 years for adults (1 yr for children).
Contains at least three clinical findings of depression and can later become MDD
Premenstrual dysphoric disorder (PMDD)
dealing with the luteal phase of menstrual cycle. Can be severe enough to interfere with work or social life.
Emotional manifestations;
- mood swings
- irritability
- depression
- anxiety
- feeling overwhelmed
- difficulty concentrating
Physical manifestations; ~ lack of energy ~ overeating ~ hyper- or insomnia ~ breast tenderness ~ aching ~ bloating ~ weight gain
Tx= exercise, diet, relaxation therapy
Premenstrual dysphoric disorder (PMDD)
dealing with the luteal phase of menstrual cycle. Can be severe enough to interfere with work or social life.
Emotional manifestations;
- mood swings
- irritability
- depression
- anxiety
- feeling overwhelmed
- difficulty concentrating
Physical manifestations; ~ lack of energy ~ overeating ~ hyper- or insomnia ~ breast tenderness ~ aching ~ bloating ~ weight gain
Tx= exercise, diet, relaxation therapy
substance-induced depressive disorder
associated with the use of, or withdrawal from, drugs and alcohol
Risk Factors for MDD
- family hx or hx of depression
- females
- clients over 65
- neurotransmitter deficiencies:
serotonin deficiency affects mood, sexual behavior, sleep cycles, hunger, pain perception.
norepinephrine deficiency affects attention and behavior.
Depression screening tools
- Hamilton Depression Scale
- Beck Depression Inventory
- Geriatric Depression Scale (short form)
- Zung Self-Rating Depression Scale
- Patient Health Questionnaire- 9 (PHQ-9)
Milieu Therapy for depression
Suicide risk Self-care Communication Maintenance of safe environment Counseling
Counseling in depression
assist with the following:
- problem-solving
- ^ coping abilities
- changing negative thinking to positive
- ^ self esteem
- assertiveness training
- using available community resources
Medications for depression
SSRI: citalopram, fluoxetine, sertraline
Tricyclic antidepressants: amitriptyline
Monamine oxidase inhibitors: phenelzine
Atypical antidepressants: bupropion
SNRIs: venlafaxine, duloxetine
Light Therapy for SAD
first line of treatment for SAD
inhibits nocturnal secretion of melatonin
exposure of the face to 10,000- lux light box 30 min/day once or in two divided doses.
Interprofessional Care in depression
CBT: identify and change negative thought patterns or behaviors
IPT: interpersonal therapy: focus on relationships that contribute to disorder
Lithium Toxicity
bipolar
- Early indications: levels of 1.5 to 2.0
mental confusion, sedation, poor coordination, coarse tremors, ongoing GI distress - Advanced indications: levels of 2.0 to 2.5
extreme polyuria of dilute urine, tinnitus, giddiness, jerking movements, blurred vision, ataxia, seizures, severe hypotension and stupor leading to coma, and possible death form resp. complications
—- give emetic or gastric lavage
— urea, mannitol, aminophylline to increase rate of excretion - Severe toxicity: greater than 2.5
rapid progression leading to coma and death
—- hemodialysis may be required
Other meds. used for bipolar disorders
antipsychotics
anxiolytics
antidepressants: bupropion, venlafaxine, SSRIs. usually in combo. with mood stabilizers
Lithium therapeutic serum levels
0.6 to 1.2
Definitions: dysthymia, anhedonia, euphoria, anergia, aphasia, apraxia, agnosia, dystonia
- dysthymia: persistent depressive disorder
- anhedonia: inability to feel pressure ***
- euphoria
- anergia: abnormal lack of energy
- aphasia: loss of ability to understand/ express speech.
- apraxia: difficulty w/ skilled movement
- agnosia: loss of ability to identify objects or people
- dystonia: involuntary muscle contractions
Antidepressant meds: 5 main groups
- tricyclic antidepressants (TCA)
- SSRIs
- SNRIs
- MAOIs
- atypical antidepressants
Serotonin Syndrome:
S&S
Nursing Actions
SS: mental confusion abd. pain diarrhea agitation fever ansiety hallucinations hyperreflexia, incoordination diaphoresis tremors
nursing actions: start symptomatic Tx. Meds. to block receptors and muscle rigidity, cooling blankets, anticonvulsants, artificial vent.
