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ANCC - Fitzgerald Notecards > Psychiatric-Mental Health > Flashcards

Psychiatric-Mental Health Flashcards

1
Q

Suicide Risk Factors

A
  • Older person who had recently lost a spouse (due to death or divorce)
  • Plan involving gun or other lethal weapon
  • Hx of attempted suicide and/or family hx of suicide
  • Mental illness (depression, bipolar ds)
  • Hx of sexual, emotional, and/or physical abuse
  • Terminal illness, chronic illness, chronic pain
  • Alcohol abuse, substance abuse
  • Age 15-24 yrs or >60
  • Significant loss (divorce, breakup w/ boyfriend/girlfriend, job loss, death of a loved one)
  • Elderly males who recently lost a partner are at highest risk of suicide

Demographic subgroups
- American Indian and Alaska Native youth and middle-age persons have the highest rate of suicide
- African Americans have the lowest suicide rate

  • Females make more attempts
  • Males more likely to die by suicide
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2
Q

Acute Serotonin Syndrome (Serotonin Toxicity): Overview

A
  • Occurs from high levels of serotonin accumulating in body d/t introduction of a new drug (drug interaction) and an ↑ in dose
  • acute onset with rapid progression
  • Hunter Toxicity Criteria Decision Rules/Criteria

Look for:
- dilated pupils (mydriasis)
- higher risk if combining 2 drugs that lboth both serotonin (e.g., SSRIs, MAOIs, TCAs, triptans, tryptophan)

If switching to another drug affecting serotonin, wait a minimum of 2 weeks

** Acute serotonin syndrome is a potentially life-threatening reaction → Refer to ED!

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3
Q

Acute Serotonin Syndrome (Serotonin Toxicity): Hunter Toxicity Criteria Decision Rules/Criteria

A

Pt must have taken a serotonergic agent and meet one of the following conditions:
- spontaneous clonus
- inducible clonus + agitation and diaphoresis
- ocular clonus + agitation or diaphoresis
- termor + hyperreflexcia
OR
- hypertonia + temperature >100.4º (38ºC) + ocular clonus or inducible clonus

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4
Q

Malignant Neuroleptic Syndrome: Overview

A
  • Rare life-threatening idiopathic reaction from typical and atypical antipsychotics
  • often seen w/ high-potency, first-gen antipsychotics (e.g., chlorpromazine, haloperidol)
  • Mortality rate 10-20%
  • can be seen in Parkinson’s disease (parkinsonism hyperpyrexia syndrome) d/t withdrawal of L-dopa or dopamine agonist therapy, dose reduction, or switching medications
  • usually develops following initiation or a rapid ↑ in dose

S/Sx
- sudden onset of high fever
- muscular rigidity
- mental status changes
- dysautonomia (fluctuating BP)
- urinary incontinence

Look for hx of mental illness and prescription of antipsychotics

** Potentially life-threatening reaction → Refer to ED!

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5
Q

Psychiatric-Mental Health Evaluation
At-Risk Patients: The Baker Act

A

Allows 72 (3 days) of involuntary detention for evaluation and treatment of persons who are considered at very high risk for suicide and/or hurting others

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6
Q

Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires

A
  • Beck Depression Inventory-II
  • Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)
  • Folstein Mini-Mental State Exam (MMSE)
  • Geriatric Depression Scale (GDS)
  • Generalized Anxiety Disorder 7-Item (GAD 7) Scale
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7
Q

Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - Best Depression Inventory-II

A

A multiple-choice self-report inventory for evaluating depression; based on the theory that negative cognitions about the self and world in general can cause depression

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8
Q

Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - DSM-5

A

The diagnostic manual for mental and emotional disorders created and used by the APA

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9
Q

Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - Folstein Mini-Mental State Exam (MMSE)

A

A questionnaire used to evaluate an individual for confusion and dementia (e.g., Alzheimer’s, stroke)

Testing tip: A question on the MMSE or MME will describe an action (such as asking a patient to spell world backward) and ask you to indicate the name of the tool that is being used

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10
Q

Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - GDS

A

A 30-item (yes/no response) questionnaire. Shorter version contains 15 items; used to assess depression in the elderly; self-assessment format

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11
Q

Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - GAD-7

A

A 7-item screening tool for helping to identify patients w/ anxiety
- valid and efficient tool (89% sensitivity and 82% specificity)
- The higher the score, the higher the anxiety level

Points for Levels of Anxiety:
Mild anxiety (5)
Moderate anxiety (10)
Severe anxiety (≥15)

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12
Q

Folstein Mini-Mental State Exam Components

A

Cognitive Skill → Action Required
* Orientation → What ist he date today? (current day, month, year); Location? (name of the city, county, state)

  • Immediate Recall (Recall 3 objects) → Instruct patient that that you will be testing their memory; say 3 unrelated words (pencil, apple, ball); ask pt to repeat words
  • Attention and Calculation (Counting backward, Backward spelling) → Say “starting at 100, count backward and keep subtracting 7”; say “spell the word world backward”
  • Writing and Copying (Writing a Sentence; copying a figure) → Give person one black piece of paper and ask them to write a sentence; draw intersecting pentagons; as pt to copy the pentagons
  • Scoring → Max score is 30 correctly done
    Score of <19 indicates impairment
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13
Q

Psychotropic Drugs: Atypical Antipsychotics
1. Examples
2. Adverse Effects
3. Monitor what?

A
    • Olanzapine (Zyprexa)
      - Risperidone (Risperdal)
      - Quetiapine (Seroquel)
    • Obesity
      - DM2
    • All can cause weight gain
      - Check BMI
      - Check weight Q3 months
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14
Q

Psychotropic Drugs: Typical Antipsychotics!
1. Examples
2. Adverse Effects
3. Monitor what?

A
    • Haloperidol (Haldol
      - Chlorpromazine
    • Elevates lipids/triglycerides
      - Extrapyramidal effects
      - Tardive dyskinesia
      - QT prolongation
      - Sudden death
      - Malignant neuroleptic syndrome (rare)
    • Labs → Fasting blood glucose and lipids

BBW!! → Frail elderly are at higher risk of death from antipsychotics

  • Look for signs of extrapyramidal sx: dystonia, parkinsonism, akathisia (inability to stay still) tardive dyskinesia
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15
Q

Psychotropic Drugs: Anticonvulsants
1. Examples
2. Adverse Effects
3. Monitor what?

A
    • Lamotrigine (Lamictal)
      - Carbamazepine (Tegretol)
      - Valproate (Depakote)
    • Stevens-Johnson syndrome (Lamictal)
    • Advise pt to report rashes (Stevens-Johnson)
      - some anticonvulsants are also used as a mood stabilizers for bipolar ds
      - Monitor serum carbamazepine concentration
      - check serum valproic acid concentration
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16
Q

Psychotropic Drugs: SSRIs! →
1. Examples
2. Adverse Effects
3. Monitor what?

  1. First-line treatment for?
  2. Common SSRIs
A
    • Sertraline (Zoloft)
      - Paroxetine (Paxil)
      - Citalopram (Celexa)
      - Escitalopram (Lexapro)
      * SSRIs are also indicated for chronic anxiety disorders (social anxiety disorder, panic disorder)
    • All SSRIs can cause sexual dysfunction
      - Highest risk of erectile dysfunction (ED)
      - elderly on multiple drugs, less risk of drug interactions
    • BBW!! → All SSRIs may cause suicidal ideation/plans (<24 yo)
      - Do NOT discontinue Paxil abruptly; wean gradually
      * Has a short half-life (compared w/ other SSRIs), and needs to be weaned; do NOT discontinue abruptly, will cause withdrawal sx
    • Major depressoin, OCD
      - GAD, panic ds, social anxiety ds
      - Premenstrual dysphoric ds
      - PTSD
    • Fluoxetine (Prozac) → Longest half-life and first SSRI (useful for noncompliance)
      - Paroxetine (Paxil) → shortest half-life
      * Common SE: erectile dysfunction → * Bupropion is used off-label for antidepressant-induced sexual dysfunction caused by SSRIs
  • Citalopram (Celexa) → Has fewer drug interactions compared w/ other SSRIs
  • Other SSRIs: Sertraline (Zoloft), fluvoxamine (Luvox)
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17
Q

SSRIs
6. Side Effects
7. Contraindications

A
    • Loss of libido, ED, anorexia, insomnia
      - avoid w/ anorexic pts and undernourished elderly (depresses appetite more)
      - Taper SSRIs over 2-4 weeks prior to discontinuation

Paroxetine (Paxil): common SE: ED
- most likely to cause sx and may need to be discontinued for a period of 3-4 weeks or longer (slower wean)

Fluoxetine is least likely to cause discontinuation syndrome because of its long elimination half-life; can be tapered over 1-2 weeks

  • Abrupt discontinuation may precipitate dysphoria, fatigue, chills, myalgias, headache, dizziness, gastrointestinal distress
  • discontinuation syndrome occurs in 20-30%
    • Avoid within 14 days of taking an MAOI (serotonin syndrome)
      - Can induce mania w/ bipolar pts
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18
Q

Psychotropic Drugs: Atypical Antidepressants
1. Examples
2. Adverse Effects
3. Monitor what?

A
    • Bupropion (Wellbutrin)
      - Bupropion (Zyban)
  • Bupropion is used off-label for antidepressant-induced sexual dysfunction caused by SSRIs
  • also used to treat major depression, seasonal affective disorder, and smoking cessation
  • increases risk of seizures; avoid if pt at higher risk of seizures (during abrupt discontinuation of ethanol, benzodiazepines)
    • Seizures
    • Contraindicated w/ seizures ds, anorexia, or bulimia
      - For smoking cessation
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19
Q

Psychotropic Drugs: SNRIs
1. Examples
2. Adverse Effects
3. Monitor what?
4. Mechanism of Action
5. Indications

A
    • Venlafaxine (Effexor)
      - Duloxetine (Cymbalta)
      - Desvenlafaxine (Pristiq)
    • Can precipitate acute narrow-angle glaucoma
      - Bioavailability ↓ in 33% in smokers
    • Avoid w/ uncontrolled narrow-angle glaucoma
      - Do not take 5 days before or 14 days after MAOI, linezolid, selegiline, IV methylene blue
  4. ↑ available serotonin and norepinephrine in brain

Duloxetine (Cymbalta) → can tx GAD, fibromyalgia, depression, and diabetic peripheral neuropathy; smoking ↓ bioavailability by 33%
* An SNRI used to for depression, chronic anxiety, and management of diabetic peripheral neuropathy

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20
Q

Psychotropic Drugs: TCAs
1. Examples
2. Adverse Effects
3. Monitor what?
4. Indications
5. Avoid in what?

A
    • Amitriptyline (Elavil)
      - Nortriptyline (Pamelor)
      - Doxepin (Sinequan)
      - imipramine (Tofranil)
    • Anticholinergic effects
      - Category X
    • Do not combine w/ SSRIs, or MAOIs, as they will ↑ risk of serotonin syndrome
    • NOT considered first-line tx for depression
      - Other uses: Postherpetic neuralgia (chronic pain), urinary incontinence
  5. Avoid if pt at high risk for suicide because they may hoard pills and overdose (suicide attempt)
    - Overdose causes fatal cardiac (ventricular arrhythmia) and neuro effects (seizures)

** TCAs used for herpetic neuralgia, migraine headache prophylaxis (NOT acute treatment)

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21
Q

Psychotropic Drugs: Lithium
1. Examples
2. Adverse Effects
3. Monitor what?

A
  1. Lithium carbonate (Eskalith)
    • Contrainidcated of sodium depletion, dehydration, significant renal or cardiovascular ds
    • Used for bipolar ds
      - “Ebstein’s anomaly” is a congenital heart defect caused by lithium
      - Check serum trough level (12 hrs after last dose)
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22
Q

Monoamine Oxidase Inhibitors (MAOIs)
1. Examples
2. Indications
3. Contraindications
4. What foods should you avoid?

A
    • Phenelzine (Nardil)
      - Tranylcypromine (Parnate)
    • RArely used d/t serious food (high tyramine content) and drug interactions
      - Do NOT combine w/ SSRIs, TCAs, monoamine oxidase B (MAO-B → selegiline [Eldepryl]), serotonin receptor agonists (e.g., sumatriptan [Imitrex], zolmitriptan [Zomig])
    • Do NOT combine MAOI w/ SSRI or TCA
      - Wait at least 2 weeks before initiating SSRI or TCA (high risk of serotonin syndrome)
  4. High-Tyramine Foods and MAOIs
    - The combination can cause tyramine pressor response (elevates BP, risk of stroke)
    - AVOID combining w/ fermented foods such as beer, Chianti wine, some aged cheeses, fava beans
    - High-tyramine foods can also cause migraine headache in susceptible persons
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23
Q

Benzodiazepines (Tranquilizers)
1. Indications & Considerations
2. Examples
- ultra-short acting
- medium-acting
- long-acting

A
    • anxiety ds, panic =ds, and insomnia
      - Diazepam (Valium) is also used for severe alcohol withdrawal and seizures
      - Do NOT abruptly discontinue d/t ↑ risk of seizures; wean slowly
    • Ultra-short acting: Midazolam IV only (Versed); triazolam (Halcion)
      - Medium-acting: Alprazolam (Xanax), lorazepam (Ativan)
      - Long-acting: Diazepam (Valium), chlordiazepoxide (Librium), temazepam (Restoril), and clonazepam (Klonopin)
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24
Q

Major and Minor Depression
1. Definition/Etiology
2. Symptoms

A
  1. Aka unipolar depression (vs. bipolar depression)
    - minor depression → milder form
    - criteria of s/sx are same as major depression except there are fewer sx (at least 2 but <5).
    - attributed to dysfunction of neurotransmitters serotonin and norepinephrine
    - strong genetic component
    • Mood: depressed most of the time; may become tearful
      - Anhedonia: diminished interest or pleasure in all or most activities
      - Energy: fatigues or loss of energy
      - Sleep: Insomnia or hypersomnia
      - Guilt: feelings of worthlessness and inappropriate guilt
      - Concentration: diminished concentration and difficulty making decisions
      - Suicide: recurrent/obsessive thoughts of death and suicidal ideation
      - Weight: weight loss (>5% of body weight) or weight gain
      - Agitation: psychomotor agitation or retardation
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25
Q

Major and Minor Depression
3. Immediate Goals
4. Differential Diagnoses
5. Screening Tools

A
  1. Assess for suicidal and/or homicidal Ideation or Plan
    - If pt is considered to be a real and present threat of harm to self or others
    - Refer to psychiatric hospital; pt must be driven by a family or friend
    - If non available, call 911 for police; the police can “Baker Act” the patient
    • Rule our organic causes
      - hypothyroidism
      - anemia
      - autoimmune ds
      - vitamin B12 deficiency
    • Beck Depression Inventory: Contains 21 Items
      - Beck Depression Inventory for Primary Care (99% specificity): contains 7 items
      - 2-Item Question → Ask the following 2 questions; if yes to either question (or both), positive finding:
      * During the past month, have you felt down, depressed, or hopeless?
      * During the past month, have you felt little interest or pleasure doing things?
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26
Q

Major and Minor Depression
6. Labs
7. Treatment Plan

A
    • CBC
      - chemistry profile
      - TSH
      - folate
      - vit B12
      - UA
      ** Rule out organic causes; toxicology screen to r/o illicit drug use if a risk
    • R/O ds such as anemia, diabetes, hypothyroid (TSH/thyroid panel), chemistry panel (low K for ADdison’s disease) and vit B12 anemia
      - Refer for psychotherapy; CBT can reduce sx (comparable to an antidepressant med) and is usually effective → if necessary, refer to psychiatrist or PMHNP; if psychotic → Refer to ED!
      - Psychotherapy + antidepressants work better together than alone
  • Pt starting to recover from depression may commit suicide (from ↑ in psychic energy); monitor closely!
  • If potentially suicidal, be careful when refilling or prescribing certain meds that may be fatal if pt overdose (e.g., benzos, hypnotics, narcotics, amphetamines, TCAs); give smallest amount and lowest dose possible with close follow-up!
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27
Q

Major and Minor Depression
8. First-line Meds
9. Other antidepressants
10. FDA BBW!

A
    • SSRIs
      - Tell pts that antidepressants effect may take 4-8 weeks (up to 12 wks) to manifest
      - also first line therapy for elderly pts because of fewer side effects
      * Initiation of meds for elderly and pts diagnosed w/ renal or hepatic ds should begin at low dose and increased slowly and gradually as tolerate
      * After initiation, follow up in 2 weeks to check for compliance and SE
      * Continue SSRI therapy for at least 4-9 months after sx have resolved (usually on first episode); frequent relapse means pt may need lifetime treatment
    • TCAs (amitriptyline [Elavil], nortriptyline [Pamelor])
      - Prefer bedtime dose d/t sedation
      - other sues: postherpetic neuralgia, chronic pain, stress urinary incontinence
      - Avoid w/ suicidal pts because they may hoard pills and take an overdose (causes fatal arrhythmias)
  3. ↑ risk of death in elderly (with dementia) on antipsychotic drugs such as haloperidol (Haldol) and chlorpromazine (Thorazine)
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28
Q

SSRIs: Special Considerations
1. FDA BBW in children, adolescents, & young adults
2. Elderly pts
3. Pts w/ sexual dysfunction caused by SSRI
4. Depressed pts who want to quit smoking
5. Depressed pt w/ peripheral neuropathy
6. Depressed pt w/ postherpetic neuralgia & chronic pain
7. Depressed pt w/ stress urinary incontinence

A
  1. ↑ risk of suicidal thinking and behavior in children, adolescents, sand young adults
    - risk of suicidality is ↑ in young adults 18-24 yrs during initial treatment (first 1-2 months)
    • Consider using citalopram (Celexa) and escitalopram (Lexapro)
      - fewer drug interactions than other SSRIs
      - may prolong QT interval
    • Consider adding bupropion (Wellbutrin)
      - another option is switch to an ANRI or atypical antidepressant
    • Consider bupropion (Zyban)
      - Can be combined w/ nicotine-avoidance products (e.g., patches, gum)
  5. Consider duloxetine (Cymbalta)
    - also indicated for neuropathic pain
  6. Consider TCAs
  7. Consider TCAs
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29
Q

Antipsychotics: Adverse Effects

A
  • pill rolling
  • shuffling gait
  • bradykinesia
    ► caused by chronic use of antipsychotics
  • Extrapyramidal symptoms (EPS):
  • Akinesia
  • Akathisia
  • Bradykinesia
  • Tardive dyskinesia
  • can lead to ↑ risk of obesity, DM2, HLD, metabolic syndrome, and hypothyroidism
  • Both classic and new generation have strong anticholinergic effects
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30
Q

Akinesia

A

inability to initiate movement

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31
Q

Akathisia

A

A strong inner feeling to move, unable to stay still

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32
Q

Bradykinesia

A

slowness in movement when initiating activities or actions that require successive steps such as buttoning a shirt

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33
Q

Tardive dyskinesia

A

Involuntary movements of the lips (smacking), tongue, face, trunk, and extremities (more common in schizophrenics)

34
Q

Anticholinergics: Side Effects

A

Many drug classes have strong anticholinergic effects, including:
- antipsychotics
- TCAs
- decongestants
- antihistamines (e.g., pseudoephedrine)

  • Use caution with BPS; urinary retention, narrow-angle glaucoma, and preexisting heart ds
35
Q

Anticholinergics: Side Effects - SAD CUB (mnemonic to help remember anticholinergics side effects)

A

Sedation
Anorexia
Dry mouth

Confusion and constipation
Urinary retention
BPH

36
Q

Minor and Major Depression: Complementary/Alternative Treatments

A

Include various herbs and supplements, guided imagery, and lifestyle measures such as exercise and yoga
*Be aware of herb-drug interactions

37
Q

Minor and Major Depression: CAM - St. John’s Wort
1. Drug interaction
2. Adverse Effects/Notes

A

St. John’s wort (Hypericum perforatum)

    • SSRIs (e.g., citalopram/Celexa, paroxetine/Paxil)
      - Tricyclics (e.g., amitriptyline/Elavil, imipramine/Tofranil)
      - MAOIs
      - alprazolam (Xanax)
      - protease inhibitors (indinavir), etc
      - cyclosporine
      - OC
      - TCAs
    • ↓ digoxin effectiveness
      - causes breakthrough bleeding that ↓ effectiveness of birth control pills
      - serotonin syndrome
  • used for depression, menopausal sx, and other conditions
38
Q

Minor and Major Depression: CAM - Amino acid supplements such as 5-HTP, L-tryptophan
1. Drug interaction
2. Adverse Effects/Notes

A
    • SSRIs and MAOIs
      - Dextromethorphan
      - Triptans (e.g., Imitrex, Zomig)
    • Serotonin Syndrome
39
Q

Minor and Major Depression: CAM - Omega-3 fatty acids (cold-water fish oil such as from salmon) + Folate and vitamin B6 (pyridoxine)
1. Drug interaction
2. Adverse Effects/Notes

A
  1. No major interactions
    • high doses of omega-3 fish oil may ↑ risk of bleeding
      - supplements are usually stopped ~1 week before surgery
40
Q

Minor and Major Depression: CAM - Exercise, yoga, massage, guided imagery, acupuncture, light therapy
1. Drug interaction
2. Adverse Effects/Notes

A
  2. Exercise is just as effective in treatment depression as some drugs
41
Q

Minor and Major Depression: SIG-E-CAPS (mnemonic for remembering s/sx of depression)

A

Sleep
Interest
Guild
Energy
Concentration
Appetite
Psychomotor
Suicide

42
Q

Minor and Major Depression: CAM - Kava-kava and/or valerian root
1. Drug interaction
2. Adverse Effects/Notes

A

used to tx anxiety and depression

  1. Do NOT mix w/
    - benzos
    - hypnotics
    - CNS depressants
43
Q

Alcoholism
1. Definition/Etiology
2. Legal Definition
3. Dietary Guidelines for Americans (Ethyl Alcohol or Ethanol)

A
  1. compulsive desire to drink alcohol despite personal, financial, and social consequences
    - strong craving for alcohol
    - unable to limit drinking
    - with alcohol dependence, pt experiences cognitive, behavioral, and physiologic sx generated from persistent and chronic use
    - Abrupt cessation causes withdrawal sx
    - alcohol abuse occurs when maladaptive behavior pattern appears from repeated alcohol use

Exam Tips:
- Questions may ask about who is most likely (or least likely to become an alcoholic)

    • ↑ BAL >0.08% is illegal for driving (blood alcohol or breathalyzer) in all US states
      - Standard drink sizes, considered “one drink”
      * Beer: 12 oz (~5% alcohol)
      * Malt liquor: 8-9oz (~7% alcohol)
      * Wine: 5 oz (~12% alcohol)
      * Liquor/spirits: 1.5 oz or a “shot” of 80-proof gin, vodka, rum, whiskey, or tequila (~40% alcohol)
    • Women: 1 drink per day
      - Men: 2 drinks per day
      - Binge drinking:
      * pattern of alcohol consumption that brings BAL to ≥0.08% on one occasion (generally within 2 hours)
      * Males ≥ 5 drinks in a single occasion
      * Females ≥ 4 drinks in a single occasion
  • Women metabolize alcohol (50%) more slowly than men; also more susceptible to alcohol-related liver damage
  • Excessive alcohol consumption is the 3rd leading preventable cause of death in US
  • The DSM-5 diagnosis of alcoholism is called “alcohol use disorder”
44
Q

Alcoholism
5. People who should abstain from Alcohol

A
  • pregnant women (or suspect pregnancy or breastfeeding)
  • recovering alcoholics or people who cannot control amount they drink
  • People w/ jobs requiring alertness and coordination (e.g., pilots, truck drivers)
  • People taking meds that interacts w/ alcohol
45
Q

Drugs that Interact w/ Alcohol (Ethanol) + Side/Adverse Effects

A

Benzodiazepines → Lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), diazepam (Valium)
- Drowsiness, impaired motor control, dizziness, respiratory depression, overdose risk

Hypnotics → Zolpidem (Ambien, eszopiclone (Lunesta), temazepam (Restoril), doxylamine (Unisom)
- Drowsiness, dizziness, impaired motor control, memory issues

Opioids → Meperidine (Demerol), oxycodone (Percocet), hydrocodone (Vicodin)
- Drowsiness, impaired motor control, respiratory depression

Antidiabetics → Glipizide (Glucotrol), glyburide (DiaBeta), Glucophage (Metformin)
- Hypoglycemia, flushing, headache, vomiting, palpitations

Statins → Atorvastatin (Lipitor), simvastatin (Zocor)
- Liver damage

Herbs → Kava-kava, kratom
- ↑ sedation, liver damage

Antiseizures → Phenytoin (Dilantin), topiramate (Topamax), gabapentin (Neurontin)
- ↑ risk of seizures, drowsiness, unusual behavior

Muscle relaxants → Cyclobenzaprine (Flexeril), carosprodol (Soma)
- Drowsiness, ↑ risk of overdose, impaired motor control

Antipsychotics → Haloperidol (Haldol), olanzapine (Zyprexa), risperidone (Risperdal)
- Drowsiness, respiratory depression, impaired motor control, hypotension, seizures

Antihistamines → Diphenhydramine (Benadryl), loratadine (Claritin), cetirizine (Zyrtec)
- Drowsiness, dizziness, ↑ risk of overdose

Hypertensives → Verapamil (Calan), benazepril (Lotensin), losartan (Cozaar), hydrochlorothiazide, clonidine (Catapres), terazonsin (Hytrin), doxazosin (Cardura)
- Dizziness, drowsiness, fainting, hypotension, arrhythmia

46
Q

Alcoholism
6. Lab Results
a. Gamma-Glutamul Transferase
b. AST/ALT Ratio (liver Transaminases)
c. MCV
d. Carbohydrate-Deficient Transferrin

A

a. - Lone elevation (w/ or w/out ALT and AST) is a possible sign of occult alcohol abuse

b. - Both AST and ALT are usually elevated (w/ or w/out elevated gamma-glutamyl transaminase [GGT])
- Ratio of 2:11 with AST/ALT (AST level is double the level of ALT) is associated w/ alcohol abuse (alcoholic hepatitis)
- ALT is more specific for the liver than AST; AST also found in liver, cardiac/skeletal muscle, kidneys, and lungs

c. RBCs may be larger size (MCV >100 fL) d/t folate deficiency resembling mild macrocytic anemia
- Platelets → chronic alcohol use affects production and function of platelets in body; alcoholism can cause thrombocytopenia; ↑ risk of bleeding (stroke)
- Triglycerides: alcohol affects synthesis of lipids in liver; effect is attributed to inhibition of lipoprotein lipase activity; very high levels of triglycerides can ↑ risk of acute pancreatitis

d. -Biomarker test for chronic alcohol abuse (2-3 weeks or longer); elevated level is highly suggestive of recent high alcohol consumption, esp if abnormal ALT and/or ST; can detect binge drinking or daily heavy drinking (≥4 drinks/day); can also detect relapse
- proved to be superior to GGT or MCV as indicator of chronic alcohol (ethanol) abuse and hepatitis caused by alcohol abuse (w/ ↑ AST and ALT)

** Lone GGT elevation can be a sign of occult alcohol abuse
** AST/ALT ratio of 2.0 or higher is more likely in alcoholism
** A male who drinks one glass of wine or one beer daily is NOT considered an alcoholic

47
Q

Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism: CAGE test

A

Positive finding of at leats 2/4 → highly suggestive of alcohol abuse:
C - Do you feel the need to CUT DOWN?
A - Are you ANNOYED when your spouse/friend comments about your drinking?
G - Do you feel GUILTY about your drinking?
E - Do you need to drink EARLY in the morning (an EYE-OPENER)?

Examples of some quote using CAGE:
C - “I would like to drink less on the weekends.” “I only drink a lot on weekends.”
A - “My wife nags me about my drinking.” “My best friend thinks I drink too much.”
G - “I feel bad that I don’t spend enough time with the kids because of my drinking.”
E - “I need a drink to feel better when I wake up in the morning.”

48
Q

Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism: T-ACE Test

A

Similar to CAGE test, except for the first question; last 3 questions are from the CAGE test

Positive finding of at least 2/4 is highly suggestive of alcohol abuse
T - Does it TAKE MORE THAN 3 DRINKS to make you feel high?
A - Have you ever been ANNOYED by people’s criticism of your drinking?
C - Are you trying to CUT DOWN on drinking?
E - How you ever used alcohol as an EYE-OPENER in the morning (having a drink when you wake up to treat a hangover)?

49
Q

Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism: Short Michigan Alcoholism Screening Test Questionnaire

A

13-item questionnaire that is a shorter version of the original Michigan Alcoholism Screening Test (MAST) Questionnaire (contains 24 items)
- Can be used in adults and adolescents
- a disadvantage is time required to take and score it.

50
Q

Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism: Alcohol Use Disorders Identification Test

A
  • 10-question tool used in women, minorities, and adolescents
  • Unlike other screening tests, AUDIT has proved to be accurate across all ethnic and gender groups
  • one of the most accurate alcohol screen tests (92%)
51
Q

Alcoholism
7. Treatment Plan (Meds vs Nonpharm)

A
  • Benzodiazepines (Librium, Valium), antipsychotics if needed (e.g., Haldol)
  • Vitamins:
  • Thiamine 100 mg IV
  • Folate 1 mg PO/IV daily
  • Multivitamins w/ high-caloric diet
  • Refer to AA (12-step program), a therapist, and/or recovery program
  • Avoid prescribing a recovering alcoholic/addict drugs w/ abuse potential such as narcotics or any meds that contains alcohol (cough syrup)

Meds:
- Disulfiram (Antabuse) → Causes severe N/V, headache, other unpleasant effects
- Naltrexone (Vivitrol) → ↓ alcohol cravings

52
Q

Alcoholism: AA

A

Alcoholic Anonymous
- one of the most successful methods for recovering alcoholics (founded by BIll Wilson and Dr. Robert Smith)
- Pt is paired w/ mentor (a recovered alcoholic); believes in a “higher power”
- Must follow a 12-step program and attend AA meetings (uses “chip” reward)
- Support group for family members and friends is called Al-Anon (Al-Anon Family Groups)
- Support group for teen children of alcoholics is all Alateen

53
Q

Acute Delirium Tremens

A

Characterized by a sudden onset of confusion, delusions, transient auditory/tactile/visual hallucinations, tachycardia, hypertension, hand tremors, disturbed psychomotor behavior (picking at clothes), and grand mal seizures
- Considered a medical emergency → Refer to ED!

54
Q

Korsakoff’s Syndrome

A

(Wernicke-Korsakoff Syndrome)
- Complications from chronic alcohol abuse
- neurologica ds w/ sx that include: hypotension, visual impairment, and coma

S/S
- mental confusion
- ataxia
- stupor
- coma
- hypotension

Tx: high-dose parenteral vitamins, esp thiamine (Vitamin B1)

55
Q

Korsakoff’s Amnesic Syndrome

A
  • type of amnesia caused by chronic thiamine deficiency d/t chronic alcohol abuse
  • problems w/ acquiring/learning new information (antegrade amnesia) and retrieving older information (retrograde amnesia)

s/Sx
- confabulation
- disorientation
- attention deficits
- visual impairment

  • chronic deficiency damages the brai permanently
56
Q

Smoking Cessation: Options - Nicotine Gum

A

Tobacco use → most common cause of preventable death
- Discuss at every visit w/ smoker patients

Nicotine gum use
- follow “chew and park” pattern → chew gum slowly until nicotine taste appears, then “park” next to cheeks (buccal mucosa) until taste disappears
- repeat pattern several times and discard nicotine gum after 30 mins of use

57
Q

Smoking Cessation: Options - Nicotine patches

A
  • cannot smoke while on nicotine patches
  • do not use w/ other nicotine products (e.g., gum, inhaler)
  • pt can overdose on nicotine
  • nicotine overdose can cause acute MI, HTN, and agitation in susceptible pts
  • nicotine products can be used w/ bupropion (Zyban)

** Do NOT mix nicotine patches w/ nicotine gum. Do NOT smoke while on patches

58
Q

Smoking Cessation: Options - Bupropion (Zyban)

A
  • decreases cravings to smoke
  • pt can still smoke while on bupropion
  • can be combined w/ nicotine products
  • individual eventually loses desire to smoke and finally quits

Contraindications:
- seizure disorders
- hx of anorexia/bulimia
- abrupt cessation of ethanol
- benzodiazepines
- antiseizure drugs
- severe stroke
- brain tumor

  • Be careful w/ depressed pts → may increase risk of suicidal thoughts and behavior
59
Q

Smoking Cessation: Options - Bupropion (Zyban)

A
  • decreases cravings to smoke
  • pt can still smoke while on bupropion
  • can be combined w/ nicotine products
  • individual eventually loses desire to smoke and finally quits

Contraindications:
- seizure disorders
- hx of anorexia/bulimia
- abrupt cessation of ethanol
- benzodiazepines
- antiseizure drugs
- severe stroke
- brain tumor

  • Be careful w/ depressed pts → may increase risk of suicidal thoughts and behavior
60
Q

Smoking Cessation: Options - Varenicline (Chantix)

A
  • prescribe for ≥12 weeks
  • even if not ready to quit, initiating drug will reduce cravings for tobacco use and facilitate quitting
  • may be combined w/ nicotine patch (↑ risk of adverse effects)
  • take a careful psychiatric hx and avoid prescribing to mentally unstable pts or those w/ hx of recent suicidal ideation

Adverse Effects:
- neuropsychiatric sx
- may impair the ability to drive or operate heavy machinery
- FAA prohibits pilots and air traffic controllers from taking the drug (FAA= Federal Aviation Administration)

61
Q

Electronic Cigarettes (Vaping)
1. Definition/Etiology/Contents
2. Sx of possible lung damage (EVALI)

A
  1. AKA: E-cigarettes, e-cigs, vapes, vaping, vape pens, e-hookahs
    - devices that heat a liquid into aerosol (vapor), which is inhaled by user
    - liquid contains nicotine, flavoring, and other additives
    - vitamin E acetate, used as a diluent, can cause serious lung damage → diagnosis is called e-cigarette, or vaping, product use-associated lung injury (EVALI)
    - Tetrhydrocannabiol (THC) vapes are also associated w/ EVALI
    - >2,800 causes of EVALI have been reported to CDC w/ 60 deaths
    - Favored vapes (e.g., cotton candy, mint, grape) are very popular w/ teens
    - newer vapes are smaller, easier to hide, and resemble USB flash drives
    - in 2018, 1/5 high school students reported using e-cigarettes in the past month
    - according to the CDC and FDA, e-cigarettes are not safe for youth, young adults, and pregnant women
    • difficulty breathing
      - SOB
      - chest pain
      - mild-to-mod GI sx (vomiting, diarrhea)
      - fevers
      - fatigue
    • EVALI should be suspected in younger pts w/ hx of vaping (or other e-cigarettes products) w/ pneumonia-like sx, progressive dyspnea, and/or worsening hypoxemia
      - some have a hx of asthma, which can become exacerbated w/ vaping
62
Q

Insomnia (Sleep Disorder)
1. Definition
2. Risk Factors
3. Etiology

A
    • ideal amount of sleeP: 7-8 hours
      - about 40-709 million Americans suffer from either transient (<1 week), short-term (1-3 months), or chronic (>3 months) insomnia
      - can manifest as either difficulty falling asleep (sleep-onset insomnia) or falling asleep but waking up during the night or too early and being unable to go back to sleep
      - can cause daytime drowsiness, fatigue, tension headache, irritability, and difficulty concentrating/focusing on tasks
      *Clinical diagnosis
      - self-medicating using alcohol to facilitate sleep may indicate a coexistent alcohol/drug-dependence problem
      - abrupt cessation of these agents may cause increased insomnia and/or anxiety
    • depression
      - severe anxiety
      - GERD
      - female gender
      - illicit drug use
      - musculoskeletal illness
      - pain
      - chronic health problems
      - shift work
      - alcohol
      - caffeine
      - nicotine
      - certain meds (e.g., SSRIs, cardiac, BP, and allergy meds, steroids, ACEi, ARBs)
    • Circadian rhythm disorders
      - psychic issues
      - mental illness
      - environmental factors
      - certain meds
      - jet lag
      - noise
      - idiopathic causes

Medical conditions that can cause insomnia
- OSA
- RLS
- chronic fatigue syndrome
- bipolar disorder
- GERD
- Alzheimer’s disease
- Parkinson’s disease
- arthritis pain
- stroke

63
Q

Insomnia Classification
1. Primary
2. Secondary
3. Tertiary
4. Short-term
5. Chronic

A
  1. 25%; not caused by disease, mental illness, or environmental factors
  2. caused by disease (physical, emotional, mental) or environmental factors
  3. duration of up to 3 nights
  4. AKA acute insomnia; duration of <3 months; caused by pain, stress, grief, or other factors; expected to resolve when stressor is gone or when pt has adjusted
  5. Presence of sx for at least 3 months, occurs at least 3 nights/week; can be primary or secondary insomnia
64
Q

Insomnia
4. Treatment Plan (Nonpharm)

A
    • FIRST LINE: sleep hygiene
      - improve sleep hygiene (maintain regular sleeping time, nighttime ritual, avoid caffeine/tobacco/heavy meals before bedtime, get out of bed in 30 mins if not asleep, use bed only for sleep and sex)
      - avoid using media w/ screens (smartphones, TV, computers) when in bed; the blue light can disrupt melatonin secretion by the pineal gland
      - CBT for insomnia (CBT-I) is recommended for chronic insomnia in most pts; alone or in combination w/ meds
      - Refer to sleep lab (polysomnography) ← GOLD STANDARD for sleep apnea
      - after diagnosis → Refer to otolaryngologist
65
Q

Insomnia
5. Meds
6. Benzodiazepines/Hypnotics (short-acting, intermediate, long-acting)
7. Nonbenzodiazepine Hypnotics

A
    • Diphenhydramine (Benadryl), OTC antihistamine; can cause exc ess sedation and confusion in the elderly
      - most sedating antihistamine
      - avoid w/ the elderly
  2. See Psychotropic Drugs
    - Some benzodiazepines are more sedating and are used a hypnotics, including triazolam (Halcion) and temazepam (Restoril)

Hypnotics and “sleeping pills” are ideally used for a short duration, but many insomniacs continue using sleeping pills daily to help w/ sleep. Physical dependence may develop w/ long-term use. If patient has been on benzodiazepine for a long time, do not discontinue abruptly (will ↑ risk of seizures); wean off slowly and gradually
- Short-acting (half-life <5 hrs): Alprazolam (Xanax), triazolam (Halcion), midazolam (Versed)
- Intermediate-acting (half life 5-24 hrs): Lorazepam (Ativan), temazepam (Restoril), clonazepam (Klonopin)
- Long-acting (half-life >24 hrs): Diazepam (Valium), chlordiazepoxide (Librium)

  1. These drugs have quick onset (0-15 mins). Do not take if unable to get 7-8 hours of sleep.

Adverse effects:
- agitation
- hallucinations
- nightmares
- suicidal ideation
- There has been cases in which person wakes up and does their normal routine (sleep-driving, eating, working) but is unable to recall incident

Ex:
- Zolpidem (Ambien) & eszopiclone (Lunesta) for sleep onset or inability to stay asleep
- Ramelteon (Rozerem)_ for sleep-onset insomnia (melatonin agonist)
- Temazepam (Restoril), lorazepam (Ativan) for sleep-onset insomnia and sleep maintenance insomnia

** Do not mix kava-kava and valerian root w/ benzodiazepines, hypnotics, or CNS depressants!

** Buspirone (BuSpar), a nonbenzodiazepine drug for chronic anxiety, is taken BID, NOT as an PRN like benzodizepines

66
Q

Insomnia
8. Complementary/Alternative Treatments

A
    • Avoid kava-kava or kava-containing supplements
      * FDA Consumer Advisory issues; they are associated w/ liver injury (hepatitis, cirrhosis, fulminant liver failure)
      - Valerian root (sedating, also used for anxiety)
      - Melatonin (also for circadian rhythm ds such as shift work, jet lag)
      - Chamomile tea
      - Meditation, yoga, tai chi, acupuncture, regular exercise (avoid 4 hours before bedtime)

** Kava-kava and valerian root are natural supplements used for insomnia/anxiety. Do not mix kava-kava and valerian root w/ benzodiazepines, hypnotics, or CNS depressants!

67
Q

Bipolar Disorder
1. Definition/Etiology
2. Clinical Presentation
3. Treatment/Meds

A
    • characterized by mood instability, alternating cycles of mania and depression
      - Peak incidence of onset is 20s (ranges from age 14-30 years)

TWO types:
- Bipolar type 1
Bipolar type 2 (hypomania instead of mania)

  • Bipolar pts are at higher risk of suicide (10-15% die by suicide)
  1. Manic sx:
    - increased energy/activity’
    - gradiosity
    - less need for sleep
    - disinhibition
    - talkativeness
    - euphoric mood

Depressive sx: similar to major depression
* at higher risk of suicide during the depressive phase of illness

*** LOOK FOR S/SX OF DEPRESSION AND SUICIDE WARNINGS!
- May have psychotic episodes (delusions, hallucinations)
- bipolar pts have higher rates of substance abuse (40-60%), and other comorbidities (ADHD, anxiety, OCD, eating disorders)

  1. Refer to psychiatrist or PMHNP for management

Meds:
- Lithium salts → Adversely affect kidney and thyroid gland
- anticonvulsants (divalproex [Depakote], lamotrigine [Lamictal])
- 2nd gen antipsychotics (risperidone [Risperdal], quetiapine [Seroquel], olanzapine [Zyprexa])

68
Q

Schizophrenia
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan

A
  1. Psychotic sx including delusions and paranoia (disorganized speech and behavior)
    - Onset usually around the second decade; peak incidence is between 16-30 years
    • hallucinations are common (usually auditory) with loss of ego boundaries
      - flat and restricted affect
      - poor social skills
      - executive function is very poor (ability to plan and organize day-to-day activities)
    • Refer to psychiatrist or PMHNP for management
69
Q

Schizophrenia
4. Medications + Safety Issues/Monitoring

A
    • Use of typical antipsychotics ↑ risk of sudden death among elderly who are in long-term care
      - Antipsychotics can prolong QT intervals and cause a fatal arrhythmia called torsade de pointes, including clozapine (Clozaril), thioridazine (Mellaril), ziprasidone (Geodon), haloperidol (Haldol), quetiapine (Seroquel)
  • Pregnancy testing (ALL medications)
  • Lithium → serum creatinine, eGFR, TSH, chemistry profile, EKG; if cardiac RF
  • Antipsyhoctics → A1C, lipid profile, EKG if cardiac RF
  • Divalproex (Depakote) → CBC, CMP
70
Q

Anorexia Nervosa
1. Definition/Etiology
2. Clinical Presentation
3. Treatment
4. Complications

A
  1. Onset is usually during adolescence
    - Morality rate is 5%; death rate is 5-10x greater than gen population
    - Definition: irrational preoccupation w/ an intense fear of gaining weight along w/ distorted perception of body shape and weight
    - pt tend to secretive, perfectionistic, and self-absorbed

2.- severe restriction of food intake
- marked weight loss (BMI <18.5)
- lanugo (face, back, and shoulders)
- amenorrhea for ≥ 3 months
- if purging, loss of dental enamel may be present
- engages in severe food restriction or cycles of binge eating and purging (ex. laxatives, vomiting)
- excessive daily exercise is common

  1. Refer to eating disorders therapist or inpatient hospitalization in eating disorder unit
    ** Bupropion (Wellbutrin) is contraindicated for anorexic/bulimic pts; increases seizure threshold
    • osteopenia/osteoporosis d/t prolonged estrogen depletion (from amenorrhea) and low calcium intake; higher risk of stress fractures
      - female athlete triad is seen in physically active slender females w/ amenorrhea, premature osteopenia/osteoporosis, and disordered eating
      - Peripheral edema may occur (low albumin from low protein intake)
      - Cardiac complications are the most common cause of death (e.g., arrhythmias, cardiomyo8pathy, atrophy of heart muscles, bradycardia); hypotension is common w/ BP <90/50 mmHg
71
Q

Posttraumatic Stress Disorder (PTSD)
1. Definition/Etiology
2. Clinical Presentation
3. Treatment

A
  1. & 2. Characterized by flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, sleep disturbance, and hypervigilance
    - causes: combat/war, sexual assault (12%), MI, stroke, ICU stay (20%)
    - comorbidity (e.g., depression, anxiety, antisocial disorder, and substance abuse) is higher in PTSD

Assessment tools: PTSD check list (PCL-5) → a 20-item self-report measure (for screening and for monitoring sx over time)

    • FIRST LINE: trauma-focused psychotherapy (exposure therapy, CBT, or eye movement desensitization and rep9rocessing [EMDR])
      - Meds can be used alone or w/ psychotherapy; SSRIs are the preferred drug class to treat PTSD
72
Q

Munchausen Syndrome

A
    • AKA “factitious disorder imposed on self”
      - pt falsifies sx of factitious ds (e.g., abdominal pain, chest pain, seizures) and/or injured self and seeks medical treatment, including multiple surgeries
  • Munchausen by proxy → a related ds, refers to a parent using a child (and making the child sick) to obtain medical care
  • Rare conditions (1%); difficult to diagnose
73
Q

Female athlete traid

A
  • amenorrhea
  • low bone mass
  • low BMI
74
Q

Recognize how anorexic patients present

A
  • lanugo
  • peripheral edema
  • amenorrhea
  • BMI <18.5
75
Q

Abuse: All Types
1. Definition/Etiology
2. Types

A
    • abusive behaviors are multifactorial
      - may include physical, emotional, and sexual abuse, and/or neglect, + economic abuse or material exploitation
      - can happen at any age and during pregnancy (higher risk)
      * State of pregnancy is also associated w/ higher incidence of abuse d/t jealousy over the pregnancy
  • Upon ED presentation, pattern of injuries is inconsistent w/ hx given
  • elderly most likely to be abused are those >80 years and/or frail
  • children w/ mental, physical, or other disabilities, and stepchildren are more likely to be abused
    • Physical
      - Sexual
      - Emotional/psychological
      - Neglect

Exam Tip: There will always be a few questions on physical abuse; the questions may address physical abuse, child abuse, sexual abuse, and/or elder abuse

Abuser: a person who does not want the abused person out of sight or interviewed alone; typically answers all the questions for the pt and will exhibit “controlling” behaviors toward abused pt

  • Common finding: delay in seeking medical tx for injury
  • intimate partner violence (IPV) → intentional control or victimization performed by a person to another w/ whom the person has an intimate or spousal relationship
  • MOST significant reason for missing diagnosis of IPV or other abuse is failure to ask
76
Q

Abuse: All Types
3. Risk Factors that increase Likelihood of Abuse

A
  • ↑ stress (partner/parent/caregiver)
  • alcohol/drug abuse
  • personal hx of abuse, positive family hx of abuse
  • major loss (e..g, financial, job loss)
  • social isolation
  • pregnancy (domestic abuse)
  • elderly abuse: frail elderly and those w/ dementia are more likely to be abused; about 2/3 of all elder abuse is perpetrated by family members (usually an adult child or a spouse); most abused elderly also suffer economic abuse
  • only certain states have mandatory reporting of partner abuse; be mindful of institutional abuse of elderly, children, and the disabled
77
Q

Abuse: All Types
4. Physical Exam

A
  • another health provider (witness) should be in the same room during the exam
  • interview victim without abuser in the same room
  • collect visual evidence of trauma via Polaroid or digital camera to document all injuries; keep all evidence in a safe place; use a ruler to identify and document the size of the injuries; document direct “quotes” in pt’s hx
  • use abuse assessment screening tool w/ a body map to document assessment findings
  • look for spiral fractures (greenstick fracture) multiple healing fractures (esp in rib area), burn marks w/ pattern, welts, etc
  • look for signs of neglect (e..g, dirty clothes, inappropriately dressed for weather)
  • for partner abuse, focus on developing a plan for safety w/ pt when appropriate; give pt the phone number of a crisis center and/or safe place
  • STD testing:
  • Chlamydial and gonorrheal cultures ( must use cultures + Geen-Probe)
  • HIV, hep B, syphilis, herpes type 2
  • Genital, throat, and anal area culture and testing MUST be done
  • Abuse pt is very fearful and quiet when with the “abuser”
78
Q

Abuse: All Types
5. Treatment Plan

A
    • Provide prophylactic treatment against several STDs (e/ parental consent for minors)
      - teach pt lthe cycle of abuse; education pt regarding safety issues and having an escape plan ready for use
      - healthcare professionals must report actual or suspected child abuse
      - be aware of individual state guidelines on reporting suspicion of elderly abuse
      - abuse of a disabled person MUST be reported to the Disabled Person Protective Commission; contact adult protective services or law enforcement agencies w/ concerns regarding self-neglect
  • Abuse Cases: Interview together and then separately
79
Q

Good Communication Concepts

A
  • State things objectively; do NOT be judgmental → “You have bright-red stripes on your back” instead of “it looks as if you have been whipped on your back”
  • Open-ended questions are preferred → “How can I help you?” instead of “what type of object was used to hurt your back?”
  • Do NOT reassure patients (this stops the pt from talking more about their problems) → “We will make sure you get help” instead of “Don’t worry, everything will be fine.”
  • Let the pt vent their feelings. Do NOT discourage pt from talking → “Please tell me why you feel so sad.”
  • Validate feelings → “Yes, I understand your anger when someone hits you”

Exam Tip: * Any answer choice that reassures patients is usually WRONG
* Delaying an action (e.g., waiting until the pt feels better) is ALWAYS wrong

80
Q

Motivational Interviewing

A

A counseling method used to help an individual resolve a state of indecision (ambivalence) into finding the internal motivation (motivational enhancement) to make positive and healthier behaviors
- Recent meta-analyses have shown that motivational interviewing is effective in ↓ drug and alcohol use in adolescents and adults
- method is used for substance abuse, smoking cessation, alcohol abuse, losing weight, reducing sexual risk behaviors, and other types of unhealth behaviors

81
Q

Five Principles of Motivational Interviewing

A
  1. Express and listen w/ empathy about pt’s issues (through reflective listening)
  2. Understand the pt’s own motivations
  3. Avoid argument (or direct confrontation)
  4. Adjust to pt (rather than opposing the pt)
  5. Support self-efficacy (empower the pt)
    * Alfred Bandura, a psychologist, defined self-efficacy as one’s belief in one’s ability to succeed in accomplishing a task

ANCC - Fitzgerald Notecards (27 decks)

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