trauma, stressor and dissociative disorders Flashcards
PTSD (jack in virgin river has it!)
inducing events: military combat, hostage situations, crime related events, natural disasters, accidents, people who have been abused
risks: long deployment, more severe combat exposure, severe physical injury, TBI, lower rank, low social support in unit, single, national guard, prior trauma, female gender, Hispanic ethnic group
sx/sx:
flashbacks
avoidance
persistent symptoms of increased arousal —> hypervigilance (amygdala is overactive)
mood alterations
PTSD Pharmacology and treatment
pharmacology: SSRIs and SNRIs
sertraline (zoloft), paroxetine (paxil) are first line.
Clonidine (catapress) and prazosin (minipress)*** can cause 1st dose hypotension, dizziness, fatigue, headache. CAUTION in patients with hepatic function impairment
CBT
exposure therapy– slowly work towards trigger
cognitive restructuring– helps people make sense of bad memories and deals with guilt and shame
PTSD implementation
1) education, stabilization, safety,
2) processing, remembering, mourning
3) reconnecting to themselves
Acute stress disorder
PTSD but not as acute
Dissociative Identity Disorder
two or more distinct personality states (my own reference: psych episode where Shawn is in the mental facility and Gus falls in love with the girl who turns into a plumber named frank)
each alter has own pattern of perceiving, relating too, and thinking about the environment
Assessment
memories, hx (self harm?), mood, suicide risk, family, self assessment
tx: talk therapy, pharmacotherapy to treat symptoms
Bipolar and related disorders
Bipolar 1
risk factors for all
risks in all
most severe form
at least one manic episode
genetic, neurobiological, psychosocial risk factors
high suicide risk in this population
bipolar 2
at least one hypomanic episode and at least one major depressive episode
cyclothymic disorder
alternate with sx/sx of mild to moderate depression for at least two years (adults)
rapid cycling possible
hypomania
a lower-level and less dramatic mania
euphoric, increased activity and energy
dx: bipolar disorder
Rapid cycling–at least four distinct mood episodeswithin the same twelve-month period.
With psychotic features–the presence of delusions, phobias or paranoid thoughts, auditory, visual or other hallucinations.
With mixed features–see above.
With atypical features–when a depressive episode has increased appetite, increased sleep, sensitivity to personal rejection.
With anxious distress–when the patient is uptight, tense, restless, and has feelings of loss of control and anxiety.
Has peripartum onset–which can be during pregnancy or within four weeks of delivery. A patient with a history of manic episodes postpartum has a high risk of relapse with future pregnancies.
The seasonal pattern–when a relationship can be observed with mania and a particular time of the year.
nursing assessment
Altman’s Self-Rating Mania Scale
Behavior
Can be manipulative and demanding
Splitting: a need for staff unity
Thought processes and speech patterns (pressured speech, tangential speech, circumstantial speech, loose associations, flight of ideas, clang associations)
Thought content (grandiose delusions, persecutory delusions)
Cognitive function
planning: acute phase
Medical stabilization
Maintaining safety
In-hospital nursing care
Seclusion, restraint, or ECT may be considered during the acute phase
planning: maintenance phase
Preventing relapse
Limiting severity and duration of future episodes
Patients with bipolar disorders require medications over long periods of time/over entire lifetime
Support patients in repairing their lives from the hardships that came out of the acute phase of illness
implementation: depressive vs. manic episodes
Depressive episodes
Hospitalization for suicidal, psychotic, or catatonic signs
Medication concerns about bringing on a manic phase
Manic episodes
Hospitalization for acute mania (bipolar I disorder)
Communicating challenges and strategies
implementation: acute manic episodes (acute mania)
Provides safety for a person experiencing acute mania
Imposes external control on destructive behaviors
Provides medication for stabilization
communication techniques
Use firm and calm approach
Provides structure & control
Use short, concise explanations
Minimizes potential for manipulative behaviors
Identify expectations in simple, concrete terms
Offers safety as patient experiences outside controls while understanding reasons for treatment choices
Hear and act on legitimate complaints
Reduces helpless feelings; minimizes acting out
Firmly redirect energy into more appropriate channels
Distractibility is the most effective tool for a patient experiencing mania
focus of pharmacotherapy in bipolar disorder
mood stabilization and controlling agitation
pharmacotherapy: lithium carbonate
gold standard, reduces suicide, unknown action, half life 18-30 hours, pill, capsule, or liquid, takes 1-3 weeks to start working
lithium carbonate: adverse effects
Cardiac: Bradycardia, flattened or inverted T waves, heart block, and sick sinus syndrome.
CNS: Confusion, memory problems, new or worsening tremor, hyperreflexia, clonus, slurred speech, ataxia, stupor, delirium, coma, and seizures (rarely). These effects are theoretically due to excess action on the same sites that mediate therapeuticaction.
Renal: Nephrogenic diabetes insipidus with polyuria and polydipsia. These side effects are due to lithium’s action on ion transport.
Hematologic: Leukocytosis and aplastic anemia
Gastroenterologic: Diarrhea and nausea
Endocrinal: Euthyroid goiter or hypothyroid goiter
Other: Acne, rash, and weight gain. Lithium-induced weight gain is more common in women than in men.
Lithium therapeutic levels
therapeutic range is 1.0to1.5mEq/Lfor acute treatment and 0.6to 1.2 mEq/L for chronic therapy
Monitoring should be done every 1 to 2 weeks until reaching the desired therapeutic levels. Then, check lithium levels every 2 to 3 months for six months
monitor patients for dehydration and lower the dose when there are signs of infection, excessive sweating, or diarrhea
Lithium overdose management
Toxic levels
when the drug level is more than 2 mEq/L
diuretics (especially thiazides), non-steroidal anti-inflammatory drugs like ibuprofen and COX-2 inhibitors, and angiotensin-converting enzyme inhibitors. Metronidazole raises lithium levels by decreasing its renal clearance. Carbamazepine, phenytoin, and methyldopa may increase the toxicity of lithium. See Table 13.4
Symptoms
interstitial nephritis, arrhythmia, sick sinus syndrome, hypotension, T wave abnormalities, and bradycardia
No antidote
Treatment for lithium toxicity is primarily hydration and to stop the drug. Give hydration with normal saline, which will also enhance lithium excretion
20 to 30 mg of propranolol given 2 to 3 times per day may help reduce tremors
before starting lithium
Before starting
Kidney and thyroid function and EKG, if over 50
Weigh, can lead to weight gain
Diabetes
Patient and Family Teaching
Long term use can lead to hypothyroidism, kidney impairment
Contraindications
Renal impairment, cardiac problems, children under 12, pregnancy, breastfeeding
depakote
Valproate (Depakote)
efficient in managing acute depressive episodes of bipolar mood disorder and severe manic or mixed episodes
patients treated with lithium had a lower risk of suicide attempt and suicide death than when treated with divalproex sodium
Acts on GABA- inhibits it breakdown
Available tablets, sprinkles, capsules
Takes 2 weeks to begin to work
many side effects
depakote contraindications
hepatic disorders, significant hepatic impairment, hypersensitivity to components of the drug and class of drug, urea cycle disorders, mitochondrial disorders, or suspected disorders in patients <2-year-old, and pregnancy
toxic levels: >175 mcg/ml (before morning dose)
