trauma, stressor and dissociative disorders

Question 1

PTSD (jack in virgin river has it!)

Answer 1

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

Question 2

PTSD Pharmacology and treatment

Answer 2

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

Question 3

PTSD implementation

Answer 3

1) education, stabilization, safety,
2) processing, remembering, mourning
3) reconnecting to themselves

Question 4

Acute stress disorder

Answer 4

PTSD but not as acute

Question 5

Dissociative Identity Disorder

Answer 5

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

Question 6

Bipolar and related disorders
Bipolar 1
risk factors for all
risks in all

Answer 6

most severe form
at least one manic episode

genetic, neurobiological, psychosocial risk factors

high suicide risk in this population

Question 7

bipolar 2

Answer 7

at least one hypomanic episode and at least one major depressive episode

Question 8

cyclothymic disorder

Answer 8

alternate with sx/sx of mild to moderate depression for at least two years (adults)
rapid cycling possible

Question 9

hypomania

Answer 9

a lower-level and less dramatic mania
euphoric, increased activity and energy

Question 10

dx: bipolar disorder

Answer 10

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.

Question 11

nursing assessment

Answer 11

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

Question 12

planning: acute phase

Answer 12

Medical stabilization
Maintaining safety
In-hospital nursing care
Seclusion, restraint, or ECT may be considered during the acute phase

Question 13

planning: maintenance phase

Answer 13

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

Question 14

implementation: depressive vs. manic episodes

Answer 14

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

Question 15

implementation: acute manic episodes (acute mania)

Answer 15

Provides safety for a person experiencing acute mania
Imposes external control on destructive behaviors
Provides medication for stabilization

Question 16

communication techniques

Answer 16

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

Question 17

focus of pharmacotherapy in bipolar disorder

Answer 17

mood stabilization and controlling agitation

Question 18

pharmacotherapy: lithium carbonate

Answer 18

gold standard, reduces suicide, unknown action, half life 18-30 hours, pill, capsule, or liquid, takes 1-3 weeks to start working

Question 19

lithium carbonate: adverse effects

Answer 19

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.

Question 20

Lithium therapeutic levels

Answer 20

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

Question 21

Lithium overdose management

Answer 21

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

Question 22

before starting lithium

Answer 22

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

Question 23

depakote

Answer 23

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

Question 24

depakote contraindications

Answer 24

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)

Question 25

stevens-johnson syndrome

Answer 25

Illnessbegins with nonspecific symptoms such as fever and malaise, upper respiratory tract symptoms such as a cough, rhinitis, sore eyes, and myalgia. Over the next three to four days,a blistering rash and erosionsappear on the face, trunk, limbs, and mucosal surfaces.
Erythematous, targetoid, annular, or purpuric macules
Flaccid bullae
Large painful erosions
Nikolsky-positive (lateral pressure on the skin results in shedding of the epidermis)

Question 26

Lamotrigine

Answer 26

no evidenced has determined it’s effect on neurotransmitters

Answer 27

Contraindications
Pregnancy
Monitoring
monitor for changes in suicidality, including suicidal thoughts and increased desire to commit suicide
Aseptic Meningitis
inflammation of the brain linings, called meninges, due to various etiologies with negative cerebrospinal fluid (CSF) bacterial cultures
S/S-headaches, nausea, vomiting, malaise, weakness, stiff neck, photophobia, or even altered mental status
Toxicity
seizures, coma, and conduction abnormalities
No known antidote

Question 28

(Carbamazipine) Tegratol

Answer 28

Action
Modulates voltage-gated sodium channels- thus inhibition of action potentials and decreased synaptic transmission
Available
Tablets, extended release, solutions, supsensions
Take with food
Common side effects
dizziness, drowsiness, ataxia, nausea, and vomiting
mild anticholinergic activity, carbamazepine can increase the risk of delirium in the elderly population. This effect can also lead to urinary retention, increased intraocular pressure, and constipation
Adverse reactions
Stevens Johnson Syndrome- may be more prevalent in Asian ancestry
agranulocytosis and aplastic anemia. Other serious side effects include central nervous system depression, hepatotoxicity, confusion, renal toxicity, suicidal ideation, and hyponatremia