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TAKE 2 Flashcards

1
Q

What is primary depression?

A

Depression not caused by any other illness

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2
Q

What is secondary depression?

A

Depression that occurs as a result of physical illness, or a medication or other non-mood mental illness
- i.e. cancer

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3
Q

What is major depressive disorder?

A

Clinical depression
Hospitalized

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4
Q

What are the symptoms of major depressive disorder?
How long do they last?

A

2 weeks

Depressed mood: hopeless, empty
Anhedonia: no joy
Appetite changes
Weight loss/gain
Insomnia
Fatigue
Constipation
Feelings of worthlessness/ guilt
Difficulty concentrating
SI (suicidal ideation)
Unable to function
May have psychosis; hallucinations/ delusions
Anorexia (poor appetite)

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5
Q

What is persistent depressive disorder?

A

Dysthymia
- Usually not hospitalized

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6
Q

What are the signs and symptoms of persistent depressive disorder?
How long do they last?

A

2 years
Think: Eeyore from Winnie the Pooh:
s/s becomes almost like their personality; it’s “the way they are”
s/s less severe
Overeating/ overweight

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7
Q

What are the phases of depression?

A

Acute
Continuation
Maintenance

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8
Q

Describe the acute phase of depression

A

Severe clinical signs in 6-8 weeks; high suicide risk

Goal: remission of symptoms
- Use of medication, therapy, psychotherapy, etc. to restore function

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9
Q

Describe the continuation phase of depression

A

Increased ability to function

Goal: prevent relapse
- Medication compliance

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10
Q

Describe the maintenance phase of depression

A

6-12 months

Goal: prevent reoccurrence of depression/maintenance of function
- Continue medication compliance for additional 12 months after showing signs of improvement

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11
Q

Assessment Guidelines for depression

A

risk of suicide or harm to others
Is depression primary or secondary
Hx of depression
Triggering events; what led to hospitalization
Support systems
Psychosocial/ Spiritual assessment

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12
Q

How do you assess for depression?
What is the Highest priority assessment?

A

Highest priority: risk of SI/HI

SIGECAPS: s/s of depression
S: Sleeping disturbances/ Sad mood: sleep too much/ too little
I: Interest diminished: apathy
G: Guilt in feeling: feelings of worthlessness
E: Energy decrease/ Esteem loss: anergia
C: Concentration diminished/ indecisiveness
A: Appetite changes: eat too much/ too little
P: Psychomotor retardation: slowing of movements/ agitation
S: SI

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13
Q

The highest likelihood of suicide occurs when

A

6-9 months after initial episode of depression

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14
Q

Depression assessment:
mood and affect

A

Anxiety
worthlessness
guilt
hopelessness/helplessness
anger
irritability

May not make eye contact
flat affect

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15
Q

Depression assessment:
Speech

A

poverty of speech; alogia;
volume low
Monotone speech
more time required to respond

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16
Q

Depression assessment:
thought Content and processes

A

Slow thinking/ delayed responses
rumination (thinking a thought over and over) on faults
indecisiveness
delusional thinking
negative automatic thoughts

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17
Q

Depression assessment:
Physical S/S

A

Anergia (lack of energy)
psychomotor retardation
psychomotor agitation
Decreased sexual desire
Constipation
Apathy
Appetite changes
sleep pattern changes

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18
Q

Depression s/s
Children and adolescents

A

Social withdraw
- Decreased interaction with peers; avoidance of play and recreational activities
Anxiety
Somatic symptoms
- headache & Stomachache
Irritable/ agitated rather than sad mood (especially adolescents)

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19
Q

Depression s/s
Older adults

A

Commonly associated with chronic illness;
- symptoms possibly confused with those of dementia or stroke

Depression is often missed in elderly due to ageism. Which leads to the elderly being under diagnosed and under treated. Thus you see a spike in suicides at age 75

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20
Q

Risk factors for depression

A

Female
LGBTQ community
Age: 40 years or younger
Postpartum period
Chronic medical illness
Absence of social support
Active alcohol or substance use disorder
Hx
- suicide attempts
- prior episodes of depression
- ACES
- Family Hx of suicide/ depression; first-degree relatives

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21
Q

Cognitive distortion
Filtering

A

Taking negative details and magnifying them while filtering out all positive aspects of a situation.

Only looking at the negative; not even allowing the positive thoughts to come in
- Ex. Get mad at your significant other for one small thing and forget all the positive things they’ve done

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22
Q

Cognitive distortion
Polaroid thinking (or black and white thinking)

A

Things are either “black or white.” We have to be perfect or we’re a failure—there is no middle ground or shades of gray.
- All or nothing thinking: “4.7 GPA isn’t good enough, I need a 5.0. No middle ground)

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23
Q

Cognitive distortion
Overgeneralization

A

Coming to a general conclusion based on a single incident or a single piece of evidence. If something bad happens only once, we expect it to happen over and over again.
- Ex. I failed the interview, this means I will never get a job.

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24
Q

Cognitive distortion
Jumping to conclusions

A

Without individuals saying so, we think we know what they are feeling and why they act the way they do.
- Ex. I know what you’re about to say

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25
Q

Cognitive distortion
Catastrophizing

A

We expect disaster to strike, no matter what. We exaggerate the importance of insignificant events.
- Ex. I’m going to die if I gain weight

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26
Q

Cognitive distortion
Personalization

A

A distorted belief that everything others do or say is somehow about us.
- Ex. A family moves and a child is having trouble making friends. The parents blame themselves

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27
Q

Cognitive distortion
Control fallacies

A

We see ourselves as helpless, a victim of fate, having no control, or we assume total responsibility for the pain and happiness of everyone around us (overcontrol).
- Ex. I’m sorry my stuttering makes you uncomfortable

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28
Q

Cognitive distortion
Fallacy of fairness

A

We feel resentful because we think we know what is fair, but other people won’t agree with us.
- Ex. Coworker gets promoted but we think the boss is being unfair because I should have been promoted

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29
Q

Cognitive distortion
Blaming

A

We hold other people responsible for our feelings and behaviors.
Nobody can “make” us feel any particular way—only we have control over our own emotions and emotional reactions.

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30
Q

Cognitive distortion
Shoulds

A

We have a list of ironclad rules about how we and others should and must behave.
- Ex. I should have arrived to the meeting earlier

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31
Q

Cognitive distortion
Emotional reasoning

A

We believe that what we feel must be true automatically. “I feel it; therefore it must be true.”
- Ex. I feel anxious so I know something dangerous will happen

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32
Q

Cognitive distortion
Global labeling

A

We generalize one or two qualities into a negative global judgment. For example, “I’m a loser” versus “In one situation, I failed.”
- Ex. Because she is always late to work she is irresponsible. I failed my test so i’m a failure

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33
Q

Cognitive distortion
Always being right

A

I have to prove my opinions and actions are correct. Being wrong is unthinkable.

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34
Q

Interventions for cognitive distortions

A

Health teaching and health promotion
Milieu therapy
Mindfulness-Based Cognitive Therapy
Group therapy
First-line psychotherapy interventions
- Cognitive Behavioral Therapy (CBT)
- Interpersonal psychotherapy (IPT)
- Problem-solving therapy (PST)- make lists?
- Cognitive Behavior Therapy for Insomnia (CBT-I)

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35
Q

interventions for depression:
Communication

A
  • question underlying assumptions, and consider alternative explanations to problems
  • identify cognitive distortions
  • activities that raise self-esteem
  • physical activities the patient enjoys
  • supportive relationships/ support groups, therapy, and peer support
  • referrals for spiritual/religious information
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36
Q

Interventions for depression:
Communication - Severely withdrawn

A
  • mute: make observations
  • Use simple, concrete words
  • Allow time for the patient to respond
  • Listen for covert messages and ask about suicide
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37
Q

Interventions for depression
Nutrition: anorexia

A
  • small, high calorie/protein food and fluids frequently
  • encourage family/ friend to remain with the patient during meals
  • Offer patient preferred foods/ drinks choices. Involve the dietitian
  • Weigh the patient weekly
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38
Q

Intervention for depression
Sleep: insomnia

A
  • Encourage patient to get up and dress and to stay out of bed during the day
  • periods of rest after activities
  • Encourage the use of relaxation measures in the evening (warm bath, warm milk, progressive muscle relaxation techniques)
  • Reduce environmental and physical stimulants in the evening-provide decaffeinated coffee, soft lights, quiet activities
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39
Q

Interventions for depression
Self-care deficit

A
  • Encourage the use of toothbrush, wash cloth, soap, make up, shaving equipment, and so forth
  • When appropriate, gift, step by step reminders, such as, “ wash the right side of your face, now the left”
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40
Q

Interventions for depression
Elimination: constipation

A
  • Specifically monitor bowel movements
  • Offer foods high in fiber, and provide periods of exercise
  • Encourage the intake of fluids
  • Evaluate the need for laxatives and enemas
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41
Q

Medication: First line treatment in depression

A

SSRIs

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42
Q

Offlable use of SSRIs

A
  • panic disorder
  • generalized anxiety disorder (GAD)
  • OCD
  • PTSD
  • bulimia
  • PMDD
  • panic disorder
  • social phobia
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43
Q

SSRIs MOA

A
  • Increase serotonin
  • inhibits serotonin transporter proteins (SERT)
    therefore inhibiting reuptake of serotonin from the synaptic cleft
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44
Q

SSRI s/s
Common

A

Increased SI
Headaches
Dizziness
Sweating
Blurred vision
Dry mouth
Insomnia/drowsiness

Indigestion
Diarrhea/constipation
Loss of appetite/weight loss

Sexual dysfunction:
- Reduced libido/ Erectile dysfunction/ Difficulty achieving orgasm in men

Anxiety : first few weeks

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45
Q

SSRI s/s
Serious

A
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46
Q

Serotonin syndrome s/s

A

Agitation
Increased HR
Increased BP
Increased Temp
Sweating
Mydriasis: dilated pupils
Seizures
Hypertonia

Mild: restlessness, shivering, and diarrhea
Severe: “cog-wheel” rigidity: incremental movement/ not fluid movement, fever, and seizures.

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47
Q

Serotonin syndrome treatment

A
  • muscle relaxants
  • serotonin antagonists
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48
Q

SSRI interactions

A
  • St. John’s wort
  • OTC: dextromethorphan (cough and cold medications)
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49
Q

Caution when using SSRIs

A

Teratogenic: Pregnant/ Breastfeeding
Diabetic
Epileptic
Diagnosed with Kidney, Liver, or Heart Disease
Diagnosed with Bipolar I
Diagnosed with bleeding disorders

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50
Q

SSRI contraindications

A

Other SSRIs /antidepressants
NSAIDs/ Antiplatelet Medication
Clozapine and Pimozide
St. John’s Wort
Alcohol /Caffeinated drinks
Bipolar 1: can cause mania
Do not discontinue abruptly

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51
Q

Black box warning
SSRIs

A

higher risk of suicide
Teratogenic

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52
Q

SSRI drugs

A

F-SPEC
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Escitalopram (Lexapro)
Citalopram: (Celexa)

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53
Q

Medication: Second line treatment for depression

A

SNRIs
SNDIs

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54
Q

How are SNDIs and SNRIs used in depression

A

may be added to SSRI (to augment)
counteract SSRI s/s: nausea, anxiety, or insomnia.

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55
Q

SNDI drugs

A

mirtazapine (Remeron)

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56
Q

SNRI/ SNDI MOA

A
  • blocks presynaptic α2-noradrenergic receptors
  • Increases norepinephrine
  • Increases serotonin
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57
Q

SNRI DRUGS

A
  • duloxetine (Cymbalta)
  • venlafaxine (Effexor)
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58
Q

SNRI s/s

A
  • Weight gain
  • fatigue
  • sexual dysfunction
  • hypotension
  • muscle cramps
  • urinary retention
  • constipation
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59
Q

duloxetine (Cymbalta) treats what

A

depression
chronic pain (neuropathy; improves sleep in pts with fibromyalgia)

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60
Q

duloxetine (Cymbalta) drug teaching

A

educate pt on why medication is given. Pt may refuse to take antidepressant meds for pain.

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61
Q

TCA drugs

A

CIAN
Clomipramine (anafranil)
Imipramine (Tofranil)
Amitriptyline (Elavil)
Nortriptyline (pamelor, Aventyl)

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62
Q

TCA treats what

A
  • depression and chronic pain
  • OCD/ anxiety
  • Neuropathic pain
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63
Q

TCA MOA

A
  • Blocks reuptake of norepinephrine and serotonin
  • Increase NE/ SR
  • Block: ACh, H1, A1
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64
Q

TCA s/s

A

dysrhythmias (cardiotoxic)
heart block (cardiotoxic)

Increased HR
Decreased BP; OTH (fall risk)
dizziness
weight gain
sedation/Drowsiness (give at night)
Sweating
anticholinergic effects:
- dry mouth
- blurred vision
- constipation- need immediate medical attention
- urinary retention- need immediate medical attention

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65
Q

MAOI drugs

A

phenelzine (Nardil)
tranylcypromine (Parnate)

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66
Q

MAOIS treat what

A

depression
panic disorder
social phobia/ anxiety
OCD
PTSD
bulimia

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67
Q

MAOI MOA

A

prevent monoamine oxidase from breaking down monoamines: norepinephrine, serotonin, and dopamine
Increases:
- norepinephrine
- serotonin
- Dopamine

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68
Q

MAOI S/S

A

Weight gain
Fatigue
Sexual dysfunction
Muscle cramps
Urinary retention
Constipation
HTN Crisis

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69
Q

Hypertensive crisis s/s

A

Increased BP
Increased HR
Increased Temp
Headache
AMS
Confusion
Nausea/ Vomiting
Chest pain
Arrhythmias
Palpitations

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70
Q

MAOI contraindications

A

Pseudoephedrine (Sudafed)
foods containing Tyramine
Other antidepressants

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71
Q

Foods containing tyramine

A

Chocolate
Wine
Cheese
Cured meats
Dried fruits
Avocado
Dry, pickled cured fish
Caffeine
Alcohol

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72
Q

ECT indications

A
  • drug therapy failure
  • acutely suicidal patient
  • depressed patient with psychotic symptoms
  • Severe manic behavior/ treatment resistant mania and pts with rapid cycling
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73
Q

ECT contraindications

A

Anticonvulsants

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74
Q

ECT caution

A

head trauma
seizure disorders
brain tumors

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75
Q

ECT teaching

A
  • short term memory loss
  • Don’t make any life changes/ decisions while undergoing ECT
  • Sedation; anesthesia
  • Do not drive; Fall risk
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76
Q

Most effective therapy for Depressed pts

A

Talk therapy
- CBT

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77
Q

What therapy revolves around reframing

A

CBT: reframes cognitive distortions

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78
Q

What therapy revolves around being mindful/ present in the moment

A

DBT: dialectical behavioral therapy

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79
Q

Which therapy involves action and is non-ruminative, goal, oriented, and positively reinforcing

A

Exercise
- At times as effective as talk therapy

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80
Q

Risk factors for bipolar

A

Genetics

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81
Q

Bipolar:
Which gender has a higher rate of depression and rapid cycling

A

Females

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82
Q

Bipolar:
Which gender has a higher rate of manic episodes

A

Males

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83
Q

High: dopamine, serotonin, norepinephrine= what?

A

Mania

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84
Q

Low: dopamine, serotonin, norepinephrine= what?

A

Depression

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85
Q

Bipolar comorbidity

A

Substance use
Anxiety disorders
- Panic disorder
- Social phobia

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86
Q

Unipolar

A

Only depression

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87
Q

Bipolar 1

A

Depression and mania
- Episodes last one week or need hospitalization

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88
Q

Most severe bipolar disorder?

A

Bipolar 1

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89
Q

Mania s/s
MOOD

A

Euphoric/elated/ energized (high)
irritable/hostile
labile: mood swings

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90
Q

Mania s/s:
Thoughts

A
  • Grandiose delusions; hallucinations; disorganized
  • Have many plans, but unable to organize thoughts to complete them;
  • poor attention- easily distracted: hallmark symptom of mania
  • Sexual thoughts; volger
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91
Q

Mania s/s
Communication

A
  • Pressured; loud, rapid
  • Circumstantial: adding unnecessary details
  • Taginatial: when people think taginitially they lose the point they were trying to make and never find it again.
  • LOA: mid sentence derailment
  • flight of ideas; nonstop talking; disorganized
  • clang associations: rhyming
  • inappropriately demanding, sarcastic, crude
  • Sexual inappropriate language
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92
Q

Mania s/s
Behavior

A
  • agitation
  • restless and disorganized;
  • impulsive; may have angry outbursts;
  • extreme goal oriented: too busy for eat, sleep (insomnia), sex;
  • manipulative and pushes limits;
  • wild & uncontrolled spending;
  • dress extreme (colorful/bizarre); may disrobe; push limits
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93
Q

Interventions: acute Mania
Non-pharmaceutical

A
  • reduce stimulation
  • No group contact
  • Physical exercise
  • Set structure and limits on aggression
  • finger foods/ water/ sleep/ self care
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94
Q

What is bipolar 2

A

Depression; Hypomania:
- 2 episodes

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95
Q

S/S hypomania
MOOD

A
  • Good humor
  • very sociable, boundless self-confidence
  • Partake in get rich quick schemes
  • inappropriately familiar with strangers (poor boundaries)
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96
Q

S/S Hypomania
Thoughts

A

Psychosis never present

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97
Q

S/S Hypomania
Communication

A
  • Flight of Pressured speech but makes sense;
  • sexual/crude themes; treats everyone as a friend
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98
Q

S/S Hypomania

A
  • Overactive
  • distractible
  • increased sexual activity
  • voracious appetite
  • decreased sleep
  • buying sprees & gives away money and gifts;
  • flamboyant dress and excessive make-up
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99
Q

Cyclothymia

A

milder lows and milder highs
cycle over a period of 2 years

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100
Q

Rapid cycling

A

4-5 cycles (high & lows) within 1 year

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101
Q

Treating bipolar depression, with a common antidepressant alone, increases the risk for what

A

Bringing on a manic episode

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102
Q

Meds: bipolar depression

A

Quetiapine monotherapy
Olanzapine and fluoxetine combo
Acute bipolar depression: Lurasidone

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103
Q

Bipolar s/s children and adolescents

A

Depression: Intense rage
Reflective of developmental level of child
Hard to dx

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104
Q

Bipolar older adult

A

Greater neurologic abnormalities/ cognitive disturbances
- Incidence of mania decreased with age

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105
Q

Number one assessment for bipolar

A

DTO/DTS

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106
Q

Bipolar interventions
Communication :

A
  • Use firm and calm approach: (“John come with me. Eat this sandwich” finger foods)
  • Use short and concise explanations or statements
  • Remain neutral; avoid power struggles and value judgments
    • Set limits in a firm, non threatening, and neutral manner to prevent further escalation/ provide safe boundaries
  • Be consistent in approach and expectations: limits manipulation
  • Have frequent staff meetings
  • Identify expectation in simple concrete terms with consequences
  • Firmly redirect energy into more appropriate and constructive channels
  • Use distraction techniques as a tool to de-escalate
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107
Q

Bipolar Key to treatment

A

Medication compliance

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108
Q

Bipolar: #1 one reason for relapse/hospitalization

A

Non-adherence to medication

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109
Q

Is nonadherence to medication egosyntonic or egodystonic

A

Egosyntonic
- They miss the highs of hypomania that make them to feel invincible, so they don’t believe they need the meds any longer

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110
Q

Drug of choice to treat bipolar

A

Lithium

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111
Q

When is lithium used as an augmentation?

A

Major depression
- Prevent manic episodes/anti-suicidal properties

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112
Q

Lithium MOA

A

its a salt; works on sodium channels.
Decreases dopamine & glutamate
Increases GABA

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113
Q

When should you D/C lithium

A
  • excessive diarrhea
  • vomiting
  • sweating
  • Drug serum: 1.5+ mEq/ L
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114
Q

Lithium onset

A

5-7 days

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115
Q

Lithium labs

A

Cr
BUN
GFR
TSH
Drug serum

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116
Q

Lithium contraindications

A

NSAIDS
- increase effects of lithium

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117
Q

Lithium therapeutic range

A

0.6 - 1.2

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118
Q

Normal Lithium s/s
Drug serum range?

A

< 1.5 mEq/L

fine hand tremor
polyuria
mild thirst
mild nausea (give with food)
mild weight gain

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119
Q

Mild Lithium intoxication s/s
Drug serum range

A

1.5 - 2.5 mEq/L

nausea
vomiting
lethargy
coarse hand tremor
fatigue

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120
Q

Moderate Lithium intoxication s/s
Drug serum range?

A

2.5 - 3.5 mEq/L

confusion
agitation
delirium
tachycardia
hypertonia

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121
Q

Severe Lithium intoxication s/s
Drug serum range?

A

> 3.5 mEq/L

Coma
seizures
hyperthermia
hypotension

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122
Q

Lithium Antidote

A

No antidote
- flush drug from system

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123
Q

Lithium levels:
Dehydration

A

High lithium levels

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124
Q

Lithium levels
Over hydrated

A

Low lithium levels

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125
Q

High Na intake
Lithium levels

A

Low lithium levels

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126
Q

Low Na intake
Lithium levels

A

High Lithium Levels

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127
Q

Lithium pt teaching

A

Maintain normal/ consistent fluid and Na intake

128
Q

Anticonvulsant drugs

A

carbamazepine (Tegretol)
valproic acid (Depakene/Depakote)
lamotrigine (Lamictal)

129
Q

Which anticonvulsant drugs treat rapid cycling bipolar

A

carbamazepine (Tegretol)
valproic acid (Depakene/Depakote)

130
Q

carbamazepine (Tegretol) treats what

A
  • rapid-cycling bipolar disorder; acute manic/ mixed episodes
  • neuropathic pain; migraines
  • Seizures
  • makes neurons less excitable in acute mania by stabilizing the inactive state of sodium channels in neurons
131
Q

carbamazepine (Tegretol) MOA

A

Decreases synaptic transmission in CNS by affecting the sodium channels.
- Inhibits Na channels
- increases dopamine
- increases GABA

132
Q

carbamazepine (Tegretol) s/s

A

bone marrow depression; D/C
Leukopenia
Agranulocytosis
Stevens-Johnson syndrome: Toxic Epidermal Necrolysis
Accidental pregnancy- birth control ineffective

133
Q

carbamazepine (Tegretol) Labs

A

CBC
ALT
AST
Bilirubin
Amylase
Lipase
Blood glucose
Platelets
Drug serum: (6-8 mg/L)

134
Q

carbamazepine (Tegretol)
Drug serum level

A

6-8 mg/L

135
Q

carbamazepine (Tegretol) interaction

A

Grapefruit
- Increases serum levels

136
Q

valproic acid (Depakene/Depakote)
Treats what

A
  • seizures
  • Bipolar with mania
  • Unresponsive to lithium
  • Rapid cycling
  • Severe agitation
137
Q

valproic acid (Depakene/Depakote) MOA

A

Increases GABA

138
Q

valproic acid (Depakene/Depakote) s/s

A
  • CNS depression
  • Vomiting
  • Anorexia
  • edema
  • Weight gain
  • tremors (postural)
  • Increase risk for bleeding with warfarin.
  • thrombocytopenia: PLT count
139
Q

valproic acid (Depakene/Depakote) Labs

A

ALT
AST
Bilirubin
Amylase
Lipase
Blood glucose
Platelets
Drug serum: 50-100 mcg/mL

140
Q

valproic acid (Depakene/Depakote)
Drug serum level

A

50-100 mcg/mL

141
Q

valproic acid (Depakene/Depakote)
Caution

A

CNS depression
- antihistamines
- antidepressants
- opioids
- MAOIs
- sedatives/hypnotics.
- increases the concentrations of lamotrigine (Lamictal)
Dont D/C abruptly

142
Q

valproic acid (Depakene/Depakote)
Black box warning

A

Hepatotoxicity
pancreatitis
Teratogenicity: Birth defects

143
Q

lamotrigine (Lamictal) treats what

A

bipolar depression/ antiepileptic

144
Q

lamotrigine (Lamictal) MOA

A

Inhibits sodium channels.
Inhibits glutamate
Inhibits aspartate
Increases GABA

145
Q

lamotrigine (Lamictal) s/s

A

Blurred vision
Double vision
Stevens–Johnson syndrome (SJS)
Photosensitive skin
arrhythmias
heart block
cardiac arrest

146
Q

Antipsychotics:
First line treatment of acute mania

A

AZ-O-QRAP
- aripiprazole
- ziprasidone
- Olanzapine (ZyPREXA)
- quetiapine
- risperidone
- asenapine
- paliperidone

147
Q

Antipsychotics:
Prevent relapse in bipolar

A

Olanzapine and quetiapine:
- monotherapy
- as adjunctive medications to lithium or valproate

148
Q

How many staff are needed to place restraints

A

4-5

149
Q

Restraint purpose

A
  • Reduces overwhelming stimuli
  • Protects the pt from self & others
  • Prevents destruction of property
  • Not used as punishment
  • Used when other less restrictive measures have been tried and failed.
  • Maintain usual procedures
  • Reassure pt that this measure is temporary.
  • Use brief, concrete, kind statements.
150
Q

When are restraints ordered

A

renewed every 24 hours
Emergency: obtain order within 1 hour

151
Q

Restraint levels

A

ask a patient to return to room
1–1
PRN meds
Seclusion
Emergency meds – chemical restraint
Physical restraints

152
Q

Restraint removal times

A

circulation: q15 MINS for 1st hour; then q30 min
ROM: q2h
Toileting: q2h
Refreshments: q2h

153
Q

Bipolar teaching

A
  • recurrent nature of disease
  • Long term medication therapy
  • Signs and symptoms of relapse
    • heightened mood
    • decreased sleep
    • increased activity
  • Help putting lives back together; support groups
    • Intensive therapy
    • Medications
    • Partial Hospitalization Programs
    • home visits
154
Q

Staff splitting

A

done to divide staff
- Must stay united/ staff meetings/ set limits
- consistency among the staff is the key to success.

155
Q

avoiding or over identifying with pt is known as what?

A

Counter transference

156
Q

What do you do if you find yourself avoiding or over identifying with a pt

A

Stop.
discuss these feelings with your supervisor.

157
Q

the primary stress hormone

A

Cortisol

158
Q

Good stress, motivates people

A

Eustress

159
Q

Bad stress; drains energy

A

Distress

160
Q

Short term (acute) stress s/s
“stressed-out”

A
  • Loss of interest in activities
  • Trouble sleeping
  • Trouble eating
  • physical aches/ pains
  • tense
  • irritable
  • powerless
161
Q

Long term (chronic) stress s/s

A

physiological harm and chronic emotional difficulties.
- Colds and influenza
- Asthma
- Stomach ulcers
- Eczema and other skin disorders
- Heart disease
- Cancer
- Depression
- PTSD

162
Q

Strategies to regulate stress

A
  • quality sleep
  • Balanced nutrition
  • Physical activity
  • Mindfulness practices:
  • Experiencing nature
  • Mental healthcare
  • Supportive relationships
163
Q

Stress process

A

Stress
Anxiety
Relief behavior : defense mechanisms
Effective or ineffective mediation

164
Q

The capacity to withstand stress and catastrophe; develops over time

A

Resilience

165
Q

Stress disorders

A

PTSD
ASD

166
Q

PTSD is caused from what

A

Exposure/witness to a severe trauma/ unbearable event. (Often ACEs)

167
Q

PTSD lasts how long

A

more than 4 weeks

168
Q

PTSD S/S

A

extraordinary helplessness or powerlessness
flashbacks
nightmares
Avoidance of stimuli associated with the event
numb
feeling empty
Detachment
Distorted negative cognitions
Relationship issues
Negative mood/ thoughts

169
Q

PTSD S/S
Increased arousal

A

irritability
Aggression
Self-destructive behavior
Hyper-vigilance
Exaggerated startle response
lack of trust
Dissociative symptoms

170
Q

PTSD Psychotherapy

A

Cognitive processing therapy (CPT)
Cognitive behavioral therapy (CBT)
especially when combined with exposure
Prolonged exposure (PE) therapy
Eye movement desensitization and reprocessing (EMDR)
Family therapy
Relaxation/stress relieving techniques

171
Q

PTSD MEDS

A

SSRI’s
- Sertraline
- Paroxetine
Psilocybin mushrooms AKA: Shrooms

172
Q

ASD s/s
How long does it last?

A

Same as PTSD
But lasts less than 4 weeks

173
Q

Dissociative Disorders

A

Depersonalization disorder
Dissociative Amnesia
Dissociative Amnesia: Fugue
Dissociative identity disorder

174
Q

Depersonalization disorder

A

Feeling detached from and outside one’s body or mental processes – “dreamy or mechanical.”
3rd person perspective
Not delusion

175
Q

Dissociative Amnesia

A

Unconscious/ involuntary
- Inability to recall important information about oneself.
- May be selective for the traumatic event or for a particular time period or can be one’s whole life

176
Q

Dissociative Amnesia: Fugue

A

Sudden unexpected travel away from home; assumes a new identity
Inability to remember the past

177
Q

Dissociative identity disorder

A

Existence of two or more distinct alternate-personalities “alters” that recurrently take control over the patient’s behavior
Each alter has its own characteristics
Alters are aware of other personalities
Primary personality notices gaps in memory; strange clothing; strangers call person by another name;
not aware of other personalities
Primary cause: ACEs

178
Q

Interventions: Dissociative disorder

A

Safe simple milieu
Reassure patient of their safety
Orientation pt to surroundings
Offer self
Allow expression of feeling
Let memories return on their own
Help pt recognize increased anxiety causes increase in symptoms
Help patient identify triggers
Assess current methods of coping
Journaling: helps pt see patterns
Grounding techniques:
- Ice in hands
- Counting
- Being in safe place
- Blanket wrapping

179
Q

Dissociative disorder psychotherapy

A

CBT
DBT
EMDR
Individual / group therapy

180
Q

Are anxiety disorders egosyntonic or egodystonic

A

Egodystonic

181
Q

sense of dread relating to an unspecified danger or loss

A

Anxiety

182
Q

CO-MORBIDITY: ANXIETY
MENTAL

A

Depressive disorders
alcohol/drug use disorders
eating disorders
bipolar disorders
Major depressive disorder (MDD)

183
Q

CO-MORBIDITY: ANXIETY
Medical

A

cancer
irritable bowel syndrome
kidney and liver dysfunction
reduced immunity
Cardiovascular: Chronic anxiety

184
Q

Anxiety is a direct result of which medical conditions

A

Respiratory
Cardiovascular
Endocrine
Neurologic
Metabolic

185
Q

Primary gains of anxiety

A

Relief of anxiety symptoms

186
Q

Secondary Gains of anxiety

A

Benefits as a result of the disorder
- Increased attention
- Decreased work Responsibilities

  • Preventing secondary gains is important during treatment, because they cause a person to be reluctant to change their behavior
187
Q

Normal anxiety

A

healthy life response that provides the energy to handle life
- Alex has a chemistry test this morning. She “crammed” for the test the previous night but did not study before that. She has an upset stomach and headache

188
Q

Acute anxiety

A

temporary response to loss of security. Example: anxiety before an exam
- Charlie is 19 years old with an ileostomy caused by rectal surgery for cancer, which has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name

189
Q

Chronic anxiety

A

persistent anxiety not related to any actual problem
- Mr. Jones has not left his house for 3 months. He tells his family, “I know this is not normal, but I just can’t go outside.” His wife died 3 years earlier

190
Q

Mild anxiety s/s:

A

Perceptual field:
- Heightened perceptual field, grasps all aspects of environment, able to identify anxiety producing issues
Ability to learn:
- Works effectively, problem solves
Other characteristics:
- restless, impatient, mild tension-relieving behaviors (tapping foot, nail biting)

191
Q

Moderate anxiety s/s

A

Perceptual field:
- narrowed perceptual field, focuses better if helped, selective inattention
Ability to learn:
- problem solves but not optimally, benefits from guidance from others
Other characteristics:
- shakiness, urinary frequency & urgency, increased pulse, more extreme tension-relieving behaviors (pacing)

192
Q

Severe anxiety s/s

A

Perceptual field:
- tunnel vision, not able to attend to events in environment even when pointed out
Ability to learn:
- compromised; unable to see connections, distorted perceptions
Other characteristics:
- feelings of dread, confusion, intense somatic symptoms (nausea, dizziness, headache), tachycardia, loud and rapid speech, demanding attitude

193
Q

Panic level anxiety s/s

A

Perceptual field:
- unable to focus, may have hallucinations or delusions.
Ability to learn:
- disorganized; irrational thinking
Other characteristics:
- sense of terror, agitation or immobility, mute or unable to speak in an understandable way, severe shakiness

194
Q

General anxiety disorder (GAD) physical s/s
How long do they last

A

last 6 months or more

  • Furrowed brow
  • Twitching eyelid
  • Wrenching of hands
195
Q

GAD dual dx

A

Depression

196
Q

GAD Meds

A

SSRI’s &/or Buspirone

197
Q

Social Anxiety Disorder

A

Excessive fear that: (provokes panic attack)
- a person might do something embarrassing
- be evaluated negatively by others

198
Q

Social Anxiety Disorder s/s

A

intense shyness
sensitive to criticism
Poor self-esteem
Distorted view of strengths and weaknesses
Avoidance of:
- situations where they have to talk to others
- feared situations:
— public speaking
— writing in public
— meeting strangers
— eating in public
— public restrooms

199
Q

Interventions: Anxiety

A
  • Reassure patient safety
  • Discuss perception of threat
  • Discuss the reality of the situation
  • Include patient in selection of alternative coping skills
  • Group activities; w/ patient if too scared
  • No touching
  • Space to exit
  • Positive feedback for interactions with others
200
Q

Treatment/ therapy: anxiety

A
  • Behavior therapy
  • Systematic desensitization
  • Exposure Therapy
  • Flooding
  • Aversion therapy
  • Relaxation techniques:
    — Breathing
    — progressive muscle relaxation
  • Decrease stimulants
    — Caffeine
    — pseudoephedrine
    — amphetamines
    — cocaine
    — assess for use of self medicating with alcohol (CNS depressant)
  • Sleep hygiene
  • Increase Physical Activity
201
Q

Interventions: Mild- moderate anxiety

A
  • Calm voice
  • Help patient focus on the problem
  • Exploring (Therapeutic coms)
  • Clarification (Therapeutic coms)
  • Explore previous successful coping strategies
  • Burn off excess energy
202
Q

Interventions: Severe to panic Anxiety

A

Remain calm
Stay with the person
Minimize environmental stimuli
Simple/ Clear statements
Set limits/ pt safety
Medication

203
Q

Anxiety medication

A

SSRIs
- Fluoxetine/Prozac
- Sertraline/Zoloft
- Paroxetine/Paxil
SNRIs
- Venlafaxine
Benzodiazepines: short term use
- Lorazepam
- Clonazepam/Klonopin
- Alprazolam/Xanax

204
Q

Defense mechanisms are used to help people how

A

Cope with anxiety
Make reality less threatening
Preserve self-esteem

205
Q

Healthy defense mechanisms

A

Altruism
Sublimation
Humor
Suppression

206
Q

Intermediate defense mechanisms

A

Displacement
Undoing
Repression
Reaction formation
Rationalization
Somatization /conversion

207
Q

Immature defense mechanisms

A

Denial
Regression
Passive aggression
Projection
Splitting

208
Q

Altruism

A

stressors met by meeting the needs of others

209
Q

Sublimation

A
  • substituting constructive activity for unacceptable impulses
  • Similar to displacement, but takes place when we manage to displace our unacceptable emotions into behaviors, which are constructive and socially acceptable, rather than destructive activities.
  • Satisfying an impulse (e.g. aggression) with a substitute object. In a socially acceptable way
    Example:
  • Sport is an example of putting our emotions (e.g. aggression) into something constructive.
  • Anger issues= pt takes up boxing
210
Q

Humor

A

deal with stressors by finding the humor in them

211
Q

Suppression

A

Consciously deciding to ignore stressor temporarily

212
Q

Repression

A
  • Unconsciously bury memories of stress unconsciously
  • not being able to recall a threatening situation, person, or event. Thoughts that are often repressed are those that would result in feelings of guilt from the superego.
    Example:
  • In the oedipus complex, aggressive thoughts about the same sex parents are repressed and pushed down into the unconscious.
  • War vet: forgetting trauma
213
Q

Displacement

A
  • transferring emotions to something non- threatening
  • The redirection of an impulse (usually aggression) onto a powerless substitute target. The target can be a person or an object that can serve as a symbolic substitute.
    Example:
  • Someone who is frustrated at his or her boss at work, may go home and kick the dog/ yell at wife
214
Q

Reaction formation

A
  • overcompensation, behavior opposite
  • “ believing the opposite”
  • A person goes beyond denial and behaves in the opposite way to which he or she thinks or feels
    Example:
  • Men who are prejudice against homosexuals, are making a defense against their own homosexual feelings by adopting a harsh, anti-homosexual attitude, which helps convince them of their heterosexuality
  • The dutiful daughter, who loves her mother, is reacting to her Oepipus hatred of her mother
  • Bad mom- you become good mom
215
Q

Undoing

A
  • making up for an unacceptable act or communication
  • Feeling bad for doing wrong and making up for it
216
Q

Rationalization

A
  • justifying unreasonable ideas, actions, or feelings through “acceptable” explanations; (blaming)
  • A cognitive distortion of “the facts” to make an event, or an impulse less threatening.
  • When a person finds a situation difficult to accept, they will make up a logical reason why it has happened.
    Example:
  • A person me explain a natural disaster as ‘Gods will’
  • Joe is broke and sells car, uses bike says i like the bike anyway
217
Q

Somatization/ conversion

A
  • physical s/s without medical explanation.
  • Unconsciously,
  • Ex: unexplained pain; Laryngitis with no medical explanation before a presentation.
218
Q

Passive aggression

A

indirect aggression against others often through procrastination or inefficiency

219
Q

Regression

A
  • behaving at a less mature level
  • A defense mechanism, whereby the ego reverts to an earlier stage of development, usually in response to stressful situations
  • a movement back in psychological time when one is faced with stress
  • When we are troubled or frightened, our behaviors often become more childish or primitive
  • Kids deal with anxiety with this one: using mommy daddy again; or bed wetting; transitional item
  • Educate parents that this behavior is normal and expected
    Example:
  • A child may begin to suck their thumb again or wet the bed when they need to spend some time in the hospital
  • Teenagers may giggle uncontrollably when introduced into a social situation involving the opposite sex.
220
Q

Splitting

A

inability to combine the (+) and (-) aspects of people; Manipulative

221
Q

Projection

A
  • rejecting unacceptable personal traits and attributes them to another (blaming)
  • This involves individuals attributing their own unacceptable thoughts, feeling and motives to another person
    Example:
  • Thoughts most commonly projected onto another are the ones that would cause guilt such as aggressive and sexual fantasies or thoughts.
  • You might hate someone, but your superego tells you that such hatred is unacceptable. You can ‘solve’ the problem by believing that they hate you.
  • Calling someone ugly because you have insecurities and feel you are ugly
  • Cheat on spouse- think spouse is cheating on you
222
Q

Denial

A
  • escaping unpleasant realities by ignoring them
  • Denial involves blocking external events from awareness. If some situation is just too much to handle, the person just refuses to experience it.
  • a refusal to accept reality, thus blocking external events from awareness.
    Example:
  • Smokers may refuse to admit to themselves that smoking is bad for their health
  • a husband may refuse to recognise obvious signs of his wife’s infidelity.
  • A student may refuse to recognise their obvious lack of preparedness for an exam
223
Q

Other defense mech:
Introjection

A
  • Sometimes called identification
  • Involves taking into your own personality characteristics of someone else, because doing so solves the emotional difficulty.
    Example:
  • A child, who is left alone frequently, may in someway try to become “mom” in order to lessen his or her fears
    —You can sometimes catch them telling their dolls or animals not to be afraid
  • Older children or teenager, imitating his or her favorite star, musician, or sports hero in an effort to establish an identity
224
Q

Other defense mechs:
Identification with the aggressor

A
  • A version of introjection that focuses on the adoption, not of general or positive traits, but of negative or fear treats.
  • Involves the victim adopting the behavior of a person who is more powerful and hostile towards them
  • If you are afraid of someone, you can partially conquer that fear by becoming more like them
    Example:
  • Stockholm syndrome, where hostages establish an emotional bond with their captors and take on their behaviors
225
Q

Other defense mechs:
Compensation

A
  • A way to cover up one’s perceived shortcomings
  • Take acting or display traits to come across as the thing they are insecure about
  • Pretending that they’re what they’re insecure about
    Example:
  • An employee may flaunt all of their awards and recognitions because they feel they are not good enough
226
Q

Panic attack physical s/s

A

Increased heart rate
palpitations
Sweating
Chest pain may think they are having a heart attack
Walls closing in on them

227
Q

Panic episode assessment:
Identify

A

characteristics of the panic attack
Pts strengths and problems.

228
Q

Panic attack questions

A
  • What were you doing when the panic attack occurred?
  • What did you experience before and during the episode,including physical symptoms, feelings and thoughts?
  • When did you begin to feel that way? How long did it last?
  • Do you have an explanation for what caused you to feel that way?
  • Have you experienced these symptoms in the past?
    —If so, under what circumstances?
  • Has anyone in your family had similar experiences
  • What do you do when you have these experiences to help you to feel safe?
  • Have the feelings and sensations ever gone away on their own?
229
Q

Irrationally afraid of objects or specific situations; focused anxiety

A

Phobias

230
Q

Phobia factors

A

history of traumatic event
repeated exposure to information warning of danger

231
Q

Types of phobias

A

Acrophobia: Fear of heights
Arachnophobia: Fear of spiders
Claustrophobia: Fear of closed places
Cynophobia: Fear of dogs
Hematophobia: Fear of blood
Microphobia: Fear of germs
Nyctophobia: Fear of the dark, Night
Ophidiophobia: Fear of snakes
Pyrophobia: Fear of Fire

232
Q

Agoraphobia

A
  • afraid to be placed in situation in which you don’t have control;
  • afraid to go outside
  • fear of being in places and situations from which escape is impossible.
    — Feared places are avoided to control anxiety.
    — Avoidance behaviors can be debilitating and life constricting
233
Q

INTERVENTION: PHOBIA

A

People cope by avoiding the stimuli that cause the fear
No Medication treatment
CBT: Exposure Therapy

234
Q

Obsessive Compulsive Disorder

A

Characterized by unwanted repetitive:
- intrusive thoughts (obsessions)
- causes distress and anxiety
ritualistic actions (compulsions)
- that relieve the distress.
- But only for a short time so on a loop

235
Q

Common Obsessions (Thoughts) in OCD

A

Dirt/Toxins/germs
Intense fear something terrible is going to happen
Need for symmetry
individuals feel uncomfortable unless the things around them are ordered.

236
Q

Common compulsions (actions) in OCD

A

Washing Constant need to check doors/appliances
Movement ritual
Enter and leave the room
Tap on the desk
Sit or stand

237
Q

OCD treatment

A

cognitive restructuring (CBT)
exposure and response prevention
SSRI’s (second line therapy because sx return when stop the meds)
Therapeutic Communication
Health Teaching focusing on Diet/Sleep/Exercise
Milieu
Cognitive Restructuring
Behavioral Techniques

238
Q

Adverse Childhood Experiences (ACEs)

A

trauma experienced by 18 years of age

239
Q

ACEs: 3 domains/10 categories

A

ABUSE:
- Physical
- Emotional
- Sexual
NEGLECT:
- Physical
- Emotional
HOUSEHOLD CHALLENGES:
- Mental Illness
- Intimate partner violence
- Parental separation or divorce
- Incarceration
- Substance misuse or dependence

240
Q

ACEs prevention

A

Mentorship
Career Workshops
Parent training classes
Summer camp
Child care; affordable/ high-quality
After school activities
Baseball, soccer, volleyball
Strategies to prevent ACEs and their side effects
Strengthening economic supports for families
Changing social norms to support positive parenting
Quality child care and education early in life
Enhancing parenting skills to promote healthy child development
Intervening to lessen harms and prevent future risk

241
Q

Experiencing trauma can do what to the pt

A

change the way they perceive the world

242
Q

Principles: trauma informed care

A
  • Safety
  • Trust/ transparency
  • Recognizing S/S of trauma
  • Peer support
  • Self-help
  • Collaboration; pt centered care/ EBP
  • Empowerment/voice/choice
  • Cultural/historical/gender sensitivity
243
Q

How do you avoid Re-traumatization

A
  • Maintain emotional safety
  • Supportive, compassionate responses to trauma histories of ACEs
  • Don’t elicit specific details.
  • Empower patients
  • Refer patients to mental health providers.
  • Practice compassionate resilience
  • Learn as much as you can
  • Grow your skill of being attuned with your patient and fellow staff
  • Look for causes of behaviors
  • Use Person-Centered, Strength based thinking and language
  • Provide consistency, predictability, and choice making opportunities
  • Always weigh the physiological, psychological and social risks of physical interventions
  • Debrief
244
Q

Risk Factors for Vicarious Trauma/ Compassion Fatigue

A
  • Being new to the field
  • Having a history of personal trauma or burnout
  • Working long hours and/or having large caseloads: COVID
  • Having inadequate support systems
245
Q

Second Traumatic stress s/s: (vicarious trauma/compassion fatigue) s/s

A
  • Withdraw socially; isolation
  • Emotionally disconnected
  • Demoralized
  • Questioning one’s professional competence and effectiveness
  • Easily frustrated
  • Insomnia
  • Lowered self-esteem
  • Loss of hope
  • Feeling overwhelmed; physically/mentally
  • Inability to function
  • Intrusive thoughts/images of another’s critical experience
  • Difficulty separating work from personal life
  • Pessimistic
  • Jaded
  • Critical
  • Irritable
  • Prone to anger
  • Dread of working with certain individuals
  • Depression; self-medication
  • Ineffective and/or destructive
  • Reduced sense of efficacy at work.
  • Concentration and focus problems
  • Apathy and emotional numbness.
  • Exhaustion
  • Secretive addictions
246
Q

Prevention of Second Traumatic stress

A

Self care

247
Q

Social Determinants of health

A
  • safe housing
  • Transportation
  • Neighborhoods
  • Racism
  • Discrimination
  • Violence
  • Education
  • Job opportunities
  • Income
  • Nutritious foods
  • Clean water
  • Clean air
  • Physical activity
  • Language/literacy skills
248
Q

COC conceptual framework:
Inquiry & caring

A
  • Professionalism
  • Leadership
  • Communication
  • Safety
  • Critical thinking
  • Patient centered care
249
Q

COC conceptual framework
Centerpiece:

A
  • Person
  • Nursing
  • Health
  • Environment
250
Q

Suicide hotline

A

988

251
Q

SAD PERSONS Scale

A

S: Male sex: 1
A: Age If less than19 or more than 45 years: 1
D: Depression or hopelessness: 2
P: Previous suicidal attempts or psychiatric care: 1
E: Excessive ethanol or drug use: 1
R: Rational thinking loss (psychotic or organic illness): 2
S: Separated, widowed, or divorced: 1
O: Organized plan or serious attempt: 2
N: No social support: 1
S: Stated future intent (determined to repeat or ambivalent): 1

252
Q

SAD PERSONS scale scoring

A

0-5: D/C
6-8: PSYCH CONSULT
8+: HOSPITAL ADMIT

253
Q

C-SSRS
Questions in order

A
  • Have you wished you were dead or wished you could go to sleep and not wake up?
  • Have you actually had any thoughts about killing yourself?
  • Have you thought about how you might do this?
  • Have you had any intention of acting on these thoughts of killing yourself, as opposed to you having the thoughts but you definitely would not act on them?
  • Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?
  • Have you done anything, started to do anything, or prepared to do anything to end your life?
254
Q

IS PATH WARM

A
  • ideation
  • Substance abuse
  • Purposelessness
  • Anger
  • Trapped
  • Hopelessness
  • Withdraw
  • Anxiety
  • Recklessness
  • Mood
255
Q

MYTHS about suicide

A
  • asking a depressed person about suicide, and they put the idea and their heads
  • There is no point in asking about suicidal thoughts… if someone is going to do it, they won’t tell you
  • Some of that make suicidal threats won’t really do it, they are just looking for attention
256
Q

Goal of suicidal pt

A

Establish sense of resiliency

257
Q

Suicide:
Verbal cues

A
  • “I cant take it anymore”
  • “Life isn’t worth living anymore”
  • “I wish I were dead”
  • “Everyone would be better if I died”
  • “I won’t be a problem much longer”
  • “I just want to go to sleep and not wake up”
  • “Things will never work out”
258
Q

Suicide:
BEHAVIORAL CUES

A

Giving away prized possessions
Writing farewell notes
Making out a will
Putting personal affairs in order
Having global insomnia
Exhibiting a sudden and unexpected improvement in mood after being
depressed or withdrawn
Neglecting personal hygiene

259
Q

Suicide strategies for open communication

A
  • Normalizing
  • Asking about behavioral events rather than the client’s opinions.
  • Gentle assumptions encourage further discussion by assuming there is more to tell.
  • Denial of the specific is helpful when a pt generally denies suicidal ideation.
260
Q

Suicide strategies for open communication
Normalizing

A

communicates that the pt is not the only one who experiences suicidal ideation.
- Example: “Sometimes when people are in a lot of emotional pain, they have thoughts of killing/hurting themselves. Have you had any thoughts like that?”

261
Q

Suicide strategies for open communication

Asking about behavioral events rather than the client’s opinions.

A

Example:
- “What did you do when you had those thoughts?”
- “How many pills did you take?”
- What happened next?”

262
Q

Suicide strategies for open communication

Gentle assumptions encourage further discussion by assuming there is more to tell.

A

Example: “What other times have you tried to attempt suicide?”

263
Q

Suicide strategies for open communication

Denial of the specific is helpful when a pt generally denies suicidal ideation.

A

This strategy encourages more in-depth thought and response by asking questions that might trigger memories of specific events.
- Example: After the pt denies suicidal ideation in response to a general question, the nurse asks more specifically:
- “Have you ever thought of overdosing?”
- “Have you ever had thoughts about shooting yourself?”

264
Q

Active Listening

A

Conveys to the sender that the receiver is interested in what is being communicated through:
- Open relaxed body language
- Listening for false notes or inconsistencies/ providing feedback
- Ask questions that permit the sender to expound on the message

265
Q

Using silence

A

Gives the person time to collect thoughts or think through a point.
- Increases self awareness
- Gives participants a break to reflect

266
Q

Accepting

A
  • Indicates that the person has been understood. The statement does not necessarily indicate agreement but is nonjudgmental. However, nurses should not imply that they understand when they do not understand.
  • indicates the person has been understood, non-judgemental and interested, attitude of regard
  • “Yes”… “I follow what you say”
267
Q

Broad openings

A
  • Clarifies that the lead is to be taken by the patient. However, the nurse discourages pleasantries and small talk
268
Q

Offering observations

A
  • Calls attention to the person’s behavior (e.g., trembling, nail biting, restless mannerisms). Encourages the person to notice the behavior to describe thoughts and feelings for mutual understanding. Helpful with mute and withdrawn people.
  • Stating to client what the nurse is observing, Enable patient to recognize behaviors
  • “You are pacing a lot”
  • “You seem angry when he said….”
269
Q

Restating

A
  • Repeats the main idea expressed. Gives the patient an idea of what has been communicated. If the message has been misunderstood, the patient can clarify it.
270
Q

Reflecting

A
  • Directs questions, feelings, and ideas back to the patient. Encourages the patient to accept his or her own ideas and feelings. Acknowledges the patient’s right to have opinions and make decisions and encourages the patient to think of self as a capable person.
  • Questions and feeling are referred back to the patient to allow recognition and acceptance, lets patient know that his or her view is valued
  • Example: Pt: “What should I do about my husband’s affair?” RN: “What do you think you should do?”
  • Example: Pt: “My brother spends all of my money and then has the nerve to ask for more” RN: “You feel angry when this happens”
271
Q

Focusing

A
  • Concentrates attention on a single point. It is especially useful when the patient jumps from topic to topic. If a person is experiencing a severe or panic level of anxiety, the nurse should not persist until the anxiety lessens.
  • Taking note of a single idea or even a word: effective with FOI
  • “You’ve mentioned many things. Let’s go back to talking about…”
  • “That is a good point you make. Perhaps we can discuss that a little bit more”
272
Q

Exploring

A
  • Examines certain ideas, experiences, or relationships more fully. If the patient chooses not to elaborate by answering no, the nurse does not probe or pry. In such a case, the nurse respects the patient’s wishes.
  • Going further into a subject, idea, experience
  • “Can you tell me a little more about that?”
  • “How did you feel when you heard that voice?’
273
Q

Seeking clarification

A
  • Clarifying the nurse’s understanding of the situation. Addresses a vague or incomprehensible concept
  • Helps patients clarify their own thoughts and maximize mutual understanding between nurse and patient.
274
Q

Voicing doubt

A
  • Undermines the patient’s beliefs by not reinforcing the exaggerated or false perceptions.
  • Expressing or voicing doubt when a client relates a situation. Often used with clts experiencing delusional thinking
  • “I find that hard to believe”
275
Q

Encouraging formulation of a plan of action

A
  • Allows the patient to identify alternative actions for interpersonal situations the patient finds disturbing (e.g., when anger or anxiety is provoked).
  • Allows the patient to identify alternative actions for situations (ie when anger, anxiety provoked)
  • “What could you do to let anger out harmlessly?”
  • “The next time this comes up what might you do to handle it?”
276
Q

Offering self

A

Offers presence, interest, and a desire to understand. Is not offered to get the person to talk or behave in a specific way.

277
Q

Non theraputic coms:
Asking “Why” questions

A

Implies criticism; often has the effect of making the patient feel defensive

278
Q

Non theraputic coms:
Asking excessive questions

A

Results in the patients not knowing which questions to answer and possibly being confused about what is being asked

279
Q

Non theraputic coms:
Giving approval; agreeing

A

Implies that the pt is doing the right thing- and that not doing it is wrong. May lead the patient to focus on pleasing the nurse or clinician; denies the pt the opportunity to change his or her mind or decision

280
Q

Non theraputic coms:
Falsely reassuring

A

Underrates the pt’s feelings and belittles the pt’s concerns.

281
Q

Non theraputic coms:
Changing the subject

A

May indicate the patient’s feelings and needs. Can leave the pt feeling alienated and isolated and increase feelings of hopelessness.

282
Q

Non theraputic coms:
Giving advice

A

Assumes the nurse knows best and the pt cannot think for self. Inhibits problem solving and fosters dependency

283
Q

Motivational interviewing (MI)

A
  • Promotes behavior change by guiding the patient to explore their own motivation for change and the advantages and disadvantages of their decisions.
  • may decrease defensive patient responses.
  • incorporates active listening and verbal therapeutic communication techniques, but is focused on what the patient wants rather than what the nurse thinks should be the next steps in behavior change.
  • NURSES GOAL: Understand the reasons why a patient exhibits difficult behaviors and then using therapeutic communication techniques to diffuse the behaviors.
284
Q

Spirit of MI

A

Empathy- feeling alongside of someone else

285
Q

BATHE OARS

A
  • background
  • Affect
  • Trouble
  • Handle
  • Empathy
  • Open ended
  • affirmation
  • Reflection
  • Summarizing
286
Q

ICRA

A
  • important
  • Confidence level
  • Readiness
  • Availability
287
Q

ANGER:
ENVIRONMENT THEORY

A

History of childhood violence, abuse, addictions

288
Q

ANGER:
COGNITIVE THEORY

A

Cognitions drive anger

289
Q

ANGER
NEURO-BIOLOGICAL THEORY

A

Some people may be biologically predisposed to anger & aggression; some disorders result in agitation

290
Q

Anger

A
  • normal human emotion/ emotional state
  • Need not be a negative expression
  • Responses to perceived threat or loss of control
  • instills feelings of power
  • generates preparedness
291
Q

Anger varies from ____ to _____

A

mild irritation - intense fury and rage

292
Q

Anger & aggression are Identified across cultures via what?

A

Facial expressions

293
Q

What happens when Anger is handled appropriately / expressed assertively

A

pts solve problems
make decisions concerning life situations

294
Q

When does anger become a problem?

A

When not expressed
When expressed aggressively

295
Q

physiological and biological changes caused by anger

A

increased HR, BP, levels of the energy hormones adrenaline and noradrenaline

296
Q

Violence

A

not always related to anger; always intends harm
- occurs when individuals lose control of their anger.

297
Q

The expression of Anger is _____?

A

Learned
- can come under personal control

298
Q

Anger experienced as an almost automatic inner response to:

A

hurt
frustration
fear.

299
Q

Risk factors of Anger

A

History of violence
Paranoid ideation
Poor coping skills/impulsivity

300
Q

Pt underlying feelings assoc. with aggression & violence

A

Frightened
Humiliated
Ignored
Insecure
Not heard
Vulnerable

301
Q

How do you ensure pt safety:
ANGER

A

Avoid emotional reactions, especially personal dislikes
Eliminate contraband
Give patient/staff enough space
Sufficient staff for show of force
Set limits appropriately:
- Realistic and enforceable
- Supported by entire staff

302
Q

Environment CONDUCIVE TO VIOLENCE

A

Overcrowding
Staff inexperience
Staff controlling
Poor limit setting
Not enough activities

303
Q

Environment that REDUCES VIOLENCE

A

Solutions with options
Empathy without options
Empathy with options (best)

304
Q

Signs of escalation

A

Hyperactivity (pacing)
Verbal abuse
Increased tension
Loud voice
Intense eye contact
Carrying a weapon

305
Q

De-escalation Techniques

A

Respond early
Maintain patient’s self-esteem/support their ego
Remain calm and emphasize you on on pts side
Do not speak when the aggressive person is yelling
Establish pt’s concern
Maintain large personal space off to the side
Give options and acknowledge needs
Non-aggressive posture
Pg 381 & 383

306
Q

PRE ASSAULTIVE STAGE
De-escalation approaches

A

Listen to the patient
Use de-escalation techniques (see next slide)
Maintain your safety
Offer PRN medications

307
Q

ASSAULTIVE PHASE
De-escalation approaches

A

Seclusion and/or restraint initiated: “Take down”
In emergencies nursing staff initiates procedure and obtains M.D. order within 1 hour
Medication

308
Q

POSTASSAULTIVE PHASE:
De-escalation approaches

A

Talk to pt about incident
Talk about stressors (trigger)
Explore alternative behaviors
Talk with staff and patients about incident

309
Q

DOCUMENTATION:
Assault

A

Behaviors during pre-assaultive phase
- Interventions & evaluation
Behaviors during assaultive phase
- Interventions & patient responses
Interventions during restraint
Reintegration into milieu

310
Q

Patients who are overwhelmed by circumstances/
Pt with Effective Coping:
Implications?
Anger

A
  • Collaborate to problem solve
  • Validation of patient’s feelings

Implications:
- Help patient name feelings underlying feelings of anger
- Anxiety reduction techniques

311
Q

Pt with Marginal Coping
How do you interact with patients who lack coping skills

A
  • Provide interactions when pt not abusive
  • Schedule regular contact which is separate from pt’s behavior

Verbal abuse:
- leave room & return at specified time
— If cannot leave, stop talking, finish procedure, leave

312
Q

Which pts are a risk for aggression

A

Patients with cognitive deficits

313
Q

Interventions: Pt with Cognitive Deficits

A

Orientation aids
Regular routine
Decrease sensory stimulation
- If agitated: Stay calm, make eye contact, meet needs, short simple sentences.

314
Q

Therapy for Chronic Aggression

A
  • Behavioral: reinforce appropriate behavior (token economy=positive reinforcement; Operant conditioning)
  • Cognitive-behavioral (CBT) is an anger management technique
  • Pharmacological interventions
315
Q

Medication Therapy: Acute Aggression

A
  • Haldol, Zyprexa, Risperdal
  • Ativan
  • Cogentin or Benadryl if Haldol used
    —Given IM
    —50 mg Benadryl
    —5 mg Haldol
    —2 mg Ativan=>must be administered in a syringe alone, otherwise crystalizes
316
Q

Medications therapy: Chronic Aggression

A

Antipsychotics
Beta-blockers:
- Propranolol
Buspar
Clonidine
Lithium
Anticonvulsants
SSRIs

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