PSYCH QUIZ 2 Flashcards
Application of the Nursing Process
Assessment
Data Analysis
Outcome Identification
Nursing Interventions
Evaluation
Assessment
History
General Appearance and Motor Behavior
Mood and Affect
Thought Process and Content
Sensorium and Intellectual Processes
Judgment and Insight
Self-Concept
Roles and Relationships
Physiologic and Self Care Consideration
Depression Rating Scales
data can be collected from the client and family or significant others
History
data collection should not be rushed
History
client will look sad, sometimes looks ill
General Appearance and Motor Behavior
posture often is slouched with head down and make minimal eye contact
General Appearance and Motor Behavior
latency of response is seen when clients take up to 30 seconds to respond to a question
General Appearance and Motor Behavior
clients with depression may describe themselves as hopeless, helpless, down, or anxious
Mood and Affect
presence of anhedonia and they are maybe apathetic
Mood and Affect
they are overwhelmed by noise, so they withdraw from the stimulation of interaction with others
Mood and Affect
depressed clients have a slow thinking process
Thought Process and Content
they are negative and pessimistic in their thinking
Thought Process and Content
most clients readily admit suicidal thinking
Thought Process and Content
Some clients are oriented to TPP others are having difficulty in orientation
Sensorium and Intellectual Processes
Memory impairment is common
Sensorium and Intellectual Processes
Clients have difficulty in concentration or paying attention
If psychotic there is presence of hallucination (voices)
Sensorium and Intellectual Processes
impaired judgment because they cannot use their cognitive abilities to solve problems or to make decision
Judgment and Insight
insight maybe intact especially if they have previous depression
Judgment and Insight
they feel guilty about not being able to function and often personalize events or to take responsibility for incidents over which they have no control
Self-Concept
sense of self concept is greatly reduced, good for nothing or just worthless to describe themselves
Self-Concept
a belief that others would be better without them, which can lead to suicidal thoughts
Self-Concept
there is difficulty fulfilling roles and
responsibilities
Roles and Relationships
the more severe the depression the greater the difficulty
Roles and Relationships
lose interest in sexual activities, men often experience impotence
Physiologic and Self Care Consideration
pronounced weight loss because of lack of appetite or disinterest in eating
Physiologic and Self Care Consideration
sleep disturbance
exhaustion and unrefreshed no matter how much time they stay in bed
Physiologic and Self Care Consideration
Self-rating scales of depressive symptoms
Depression Rating Scales
Self-rating scales of depressive symptoms
Zung-Self Rating Depression Scales
Beck depression Inventory
Hamilton Rating Scale
for depression is a clinician rated depression scale
Hamilton Rating Scale
nursing diagnoses commonly established for the client with depression
Data Analysis
nursing diagnoses commonly established for the client with depression
Risk for suicide
Imbalanced nutrition: less thanbody
requirements
Anxiety
Ineffective coping
Hopelessness
Ineffective role performance
Self-care deficit
Chronic low self esteem
Disturb sleep pattern
Impaired social interaction
Outcome Identification
- Client will not injure himself or others
- Client will independently carry out ADL
- Client will establish a balance of rest, sleep, and activity
- Client will establish a balance of adequate nutrition, hydration, and elimination
- Client will evaluate self attributes realistically
- Client will socialize with staff, peers, and family and friends
- Client will return to occupation or school activities
- Client will comply with antidepressant regimen
- Client will verbalize symptoms of a recurrence
Nursing Interventions
- providing for safety of client and others
- institute suicide precautions if indicated
- begin a therapeutic relationship by spending non-demanding time with the client
- promote completion of activities of daily living
by assisting the client only as necessary - establish adequate nutrition and hydration
- promote sleep and rest
- engage the client in activities
- encourage the client to verbalize and describe emotions
- work with the client to manage medications and side effects
- providing client and family teaching
based on achievement of individual client outcomes.
evaluation of care plan
involve extreme mood swings from episode of mania to episode of depression
Bipolar Disorder
during manic phases clients are
Euphoria
Grandiose
Energetic
Sleepless
Poor judgment
Rapid thoughts, actions, and speech
if a person presentation is like a major depression, it will be diagnosed as what?
Depression
if a client experiences a manic stage, it can only be diagnosed as what?
bipolar disorder
if a person 1st episode of bipolar illness is depressed stage it will be diagnosed as?
major depression
the lifetime risk for bipolar disorder is at least _ with a risk of completed
suicide for _?
1.2%, 15%
___ ____ are at high risk in the early course of the disease of suicide
Young men
bipolar disorders occur almost equally among men and women. T or F?
True
more common among highly
educated people. T or F?
True
a person with bipolar disorder cycles between ___,___,____.
depression, normal behavior,
or mania
alternates between major depressive and manic episode interspersed with period of normal behavior
bipolar mixed episodes
the mean age for 1st manic episode is?
early twenties
Treatment
Psychopharmacology
involve a lifetime regimen of medication
Psychopharmacology
Anti-manic agent called
lithium/anticonvulsants medications
used as mood stabilizers
lithium or anticonvulsants medications
protects against the effects of
bipolar depressive cycles
lithium and anticonvulsants
is a salt contained in the human body; it is similar to gold and other trace elements
Lithium
the response rate in acute mania to
lithium is
70 to 80%
Lithium action peaks in
30min to 4 hours for regular forms
4 to 6 hours for the slow-release form
Anticonvulsant Drug
Carbamazepine
Valproic acid
used for grand mal epilepsy
and temporal lobe epilepsy
Carbamazepine
was the 1st anticonvulsant
found to have mood stabilizing
properties, but the threat of
agranulocytosis was of great
concern
Carbamazepine
therapeutic level
4 to 12 𝜇g/ml
Provision of Safety for the client and those around the client
Set limits on client’s behavior when needed
Use short, simple sentences to communicate
Clarify the meaning of clients communication
Frequently provide finger foods that are high in calories and protein
Promote rest and sleep
Protect the clients dignity when inappropriate behavior occurs
Channel clients need for improvement into socially acceptable motor activities.
not metabolized rather it is reabsorbed by the proximal tubule and excreted into the urine.
Lithium
used to monitor therapeutic or maintenance level.
Periodic serum lithium levels
Maintenance level
(0.5 to 1 mEq/L
treatment level
0.8 to 1.5mEq/L)
Toxic levels
1.5mEq/L and above)
potentially fatal in overdose
Lithium
Clients should drink adequate water
(approximately 2L/day)
High salt
low lithium level
high H2O
low lithium level
low H2O
High lithium level= toxicity
ordered as baseline and every 6 mos. during treatment.
Thyroid Function Test
Lithium is contraindicated for client with
renal function, brain or cardiovascular damage
men commit approx.__ of suicide
72%
methods of suicide
shooting, hanging, jumping from a high building.
Clients with increased risk for suicide
Depression
Bipolar disorder
Schizophrenia
Substance abuse
Post traumatic stress disorder
Borderline personality disorder
Medical problems associated with suicide
HIV or AIDS
Diabetes
Cerebrovascular accidents
Head and spinal cord injury
Environmental Factors that increase risk for suicide
Unemployment
Critical life events
Family history of depression or suicide
Behavioral Factors that increase suicide risk
Impulsivity
Erratic
means thinking about killing oneself.
Suicidal Ideation
when a person thinks about and seek ways to commit suicide.
Active Suicidal Ideation
Considered more lethal.
Active Suicidal Ideation
a suicidal act that either failed or was incomplete.
Attempted suicide
when a person thinks about wanting to die or wishes he or she were dead but has no plans to cause his or her death.
Passive suicidal ideation
People with suicidal ideation send either direct or indirect signals to others about their intent to harm themselves
Warnings of Suicidal Intent
Where and when does the client intend to carry out the plan
Warnings of Suicidal Intent
Few people give no warning signs
Risky Behaviors
Overall Goal
To keep the client safe and later to help him or her to develop new coping skills that do not involve self harm.
INTERVENTION
Using an authoritative role
Providing a safe environment
Initiating a no suicide contract
Creating a support system list
ultimate rejection of family and friends
Suicide
effective in many situations, they work well with certain clients.
No self harm/No suicide contracts
In outpatient settings , the interval maybe ____; inpatient interval may range from every shift to ___
1 week; every 1 to 3 days
salt contained in the human body;
lithium
the response rate in acute mania to
lithium
70 to 80%
Lithium action peaks in
30min to 4
hours for regular forms and 4 to 6
hours for the slow-release form
used for grand mal epilepsy
and temporal lobe epilepsy
Carbamazepine
Anticonvulsant Drug
Carbamazepine, Valproic acid
