Mental Health Exam 1
About this set
Created by:
jdonah on May 22, 2012
Subjects:
Description:
lectures 1-8
1. Professional Aspects of Mental Health Nursing
2. Therapeutic Modalities
3. Milieu Management, Anger, and Aggression
4. Psychobiology and Psychological Needs of the Medically ill
5. Understanding Stress and Defense Mechanisms
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109 terms
Terms | Definitions |
|---|---|
 self concept | the sum of perceptions, feelings, and beliefs about one's self; includes self-esteem and identity |
| self awareness through self assessment | - nurses need to constantly monitor personal feelings and thoughts with a person in crisis --> always focus on the pt - supervision promotes professional growth of the nurse, and safeguards the integrity of the nurse-client relationship |
| therapeutic relationship nurse activities | - facilitating communication of distressing thoughts and feelings - assisting clients with problem solving - |
| professional roles of the psych nurse | 1. basic level - counseling, milieu tx, promotion of self-care, psychobiological interventions, health teaching, case mgmt, health promotion+maintenance 2. advanced practitioner - individual and group tx, counseling, rx mgmt 3. therapeutic encounters - interaction w/healthcare team |
| paplau | what nurses do WITH pts not TO pts - nurse as a therapeutic tool - therapeutic use of self - care for the person as well as the illness - think exclusively of patients as persons, not as a dx phases: 1. orientation 2. working 3. termination roles of the nurse - stranger - resource person - teacher - leader - surrogate - conselor |
| approaches | we use - milieu tx - goal: behavioral modification - group - psychopharm - crisis intervention - started before they got to the hospital |
| therapeutic milieu | goals: - re-socialization: behaviors you have to exhibit to live in normal society -- give pt opportunities to do this - ego development: better understanding of self. ex: how medications work, - prevent regression: via services, coping skills - safety, structure, support: impulse control etc is the #1 priority. ex: no scissors rules vs autonomy - every unit has rules/a schedule but pt isnt forced to do it, only encouraged. by following rules, pt shows s/he can live in the hospital community safely = possible to be safe at home |
| group therapy | - individuals share a common purpose/goal come together and benefit by giving and receiving feedback w/in the dynamic and unique context of group life - uniqueness depends on specifics: size, purpise, degree of similarity open group (ex: AA mtg) vs closed group goals: - correct behaviors - develops adaptive coping - develop stress-management skills - improve interpersonal skills pros - multiple clients treated at smae time cons - time constraints - privacy issues - disruptive behavior |
| roles in group | member roles: may be determined by observing communication and behavior patterns 1. task roles - focus on main purpose 2. maintenance roles - keeps group together/on track 3. individual roles - may interfere w group fxn More details on handout |
| process vs content | content = whats said in group process = what's done in group group sociogram: representation of interpersonal relationships w/in a group phases of group: 1. initial: create atmosphere of trust 2. working - issues of conflict, power+control, doesn't have to be attacking 3. mature - group identity, acceptance of differences 4. termination - acknowledge contribution |
| look up Irvin Yalom terms for group therapeutic factors | behaviors in the group relationship that helps them to move forward: imparting information instillation of hope universality altruism corrective recapitulation of primary fam group development of social interaction techniques imitative behaviors interpersonal learning existential factor caatharsis group cohesion |
| group leaders styles | 1. autocratic 2. democratic 3. laissez-faire |
| challenging group behaviors | monopolizing the yes but anger demoralizer silence |
| violence | violence - intention and propensity to cause harm aggression - action that results in a verbal or physical attack. tends to be used with violence anger - 1st intervention = DEESCALATE, acknowledge the person's feelings that they may not be able to control SEE handout - past history is greatest predictor - communicate what to expect and under what conditions |
| milieu assessment | - ongoing assessment of unit climate - always expect the unexpected - consistency with staff GOAL: safety - physically and psychologically of individual and milieu |
| anger/aggression assessment | assessment: pmh, MSE, risk, coping skills self assessment: personal triggers, competency intervention/mgmt: calm approach, relaxed posture, respect, eye contact, low + calm tone of voice, quiet environment but not isolated |
| cycle/phases of violence/aggression | - tension building - acute action - honeymoon/deescalation - gradual re-escalation |
| reaction to violence | 1. impact - shock, disbelief, denial 2. terror - victims regress: "traumatic psychological infantilism" - use childhood coping skills - do anything to save their lives - confused by their own behavior - start to self blame 3. depression - self-blame and sadness provider response: "pt, today when you hit other patient, describe for me what what going on." ....."if that situation presents itself again, what would you do differently" |
| assessing for violence | - identify victims = screen for ALL abuse - communicate in a direct, honest, empathetic manner - suspect abuse when -- injury is inconsistent with history -- client is evasive, ashamed, avoids eye contact, defers answering to partner |
| safety assessment strategies | - identify predictors of violence/aggression: hyperactivity, increased anxiety or tension, verbal abuse, intense eye contact - alcohol or drug intoxication - recent acts of violence, property destruction - possession of a weapon - new onset of isolation behavior - milieu conducive to violence/aggression: overcrowding, inexperienced staff, provocative or controlling staff, inconsistent limits setting - clear rules - identified protocols for handing aggressive behavior |
| safety intervention strategies | - avoid dangling earrings/necklances - adequate backup staff - knowledge od area layout - feedback for behavior, share observations with pt - avoid confrontation - maintain client dignity, calmness, debrief after |
| a nurse respinse to a loud angery voice from the day room. pt is there cursing and angry. which is likely to deescalate the pt? | a. act calm, quiet and in control |
| history of stress anxiety theory | Freud (1972) - saw stress and anxiety as an emotional conflict between the id & superego ; identified defense mechanisms Cannon (1963) - was the first to describe the "fight or flight" response Selye (1993) - defined stress as the non-specific (common) result of any demand on the body Jacobson (1974) - identified "relaxation response" the opposite of the "Fight or Flight" response; developed progressive relaxation |
| local adaptation response | A localized response of the body to stress, two common responses: Reflex Pain Response The rapid, automatic response to prevent injury Occurs without cognitive input (i.e. pulling hand away from flame) Inflammatory Response The body's local response to injury to infection A three phase response (i.e. injury such as a cut) |
| general adaptation syndrome | Finite amount adaptive energy - "Wear & tear" of daily life - Continual adaptation - Body's biochemical response to stress 3 stages of GAS 1. Alarm - fight or flight 2. Resistance - increase blood glucose - conservation of h2o, na; loss of k and h 3. Exhaustion (dis-ease) ---> SELYE - collapse of vital systems - electrolyte imbalance - inability to produce glucocorticoids = may result in compulsive behavior, neurotic response (anxiety disorder), psychotic response (a single response or schizophrenia) PNI = psycho-neuro immunology |
| neurosis vs psychosis | Psychosis is a generic psychiatric term for a mental state involving the loss of contact with reality, causing the detioration of normal social functioning Neurosis is a general term referring to mental distress that, unlike psychosis, does not prevent rational thought or daily functioning. |
| anxiety (peplau) | - easily transferred form client to RN and vice-versa - rn self-awareness - remain calm - a calm rn helps client to gain control, anxiety decreases/security increases Continuum 1. mild - occurs in everyday life - s/s discomfort, reslessness, irritability AEB fidgeting, nail biting, foot/finger tapping - mild anxiety = optimal time for teaching 2. moderate - selective inattention - s/s headache, gastric, urinary urgency - ask pt to verbalize, use relaxation techniques 3. severe - physical and emotional discomfort - focus on one details - s/s hyperventilating, tachycardia, n/v - help lower anxiety, give structure, give simple+concrete tasks, meds prn |
| interventions for panic | 1. major goals - safety and physical needs 2. stay w/pt, be calm 3. short simple sentences; firm vocie 4. decrease enviro stimuli 5. focus pt energy on repetitive/tiring tasks 6. anti-anxiolytic meds |
| coping mechanisms | 1. seeking comfort 2. holding it in 3. intesne expression of feeling 4. avoidance and withdrawl 5. talking it out 6. privately think through it 7. work it off 8. engaging in self-healing 9. spirituality 10. using symbolic substitutes (undoing) - ocd 11. somatizing |
| stress hardiness | dr. suzanne kobasa - commitment to job makes ppl stress hardy - control - challenge |
| healthy coping mechanisms | Altruism - Emotional conflicts and stressors are dealt with by meeting the needs of others Humor - Emphasizing the amusing or ironic aspects of conflict of stress through humor |
| mental defense mechanisms | = Unconscious adaptive reactions - everyone uses them Protect self from anxiety = Primary Gain Become maladaptive when? (1) blocks your ability to function (2) Distort reality and create problems with relationships "Secondary" |
| repression | Primary mech: basis of all other DMs Unconscious exclusion of distressing emotions, thoughts, or experiences The dynamic behind much "forgetting" Provides protection from a sudden trauma until person can deal with the shock ↓ effective in febrile or toxic states Supportive Protect client's defenses After initial shock has ↓ & anxiety is lower, help client examine traumatic event |
| undoing | Act or communication that partially negates a previous one Primitive defense mechanism Dynamic in OCD |
| sublimation | Acceptance of a socially approved substitute goal for a drive whose normal channel of expression is blocked. Nursing approach: Provide outlets for anxiety ? Examples of socially acceptable outlets |
| splitting | Viewing people & situations as either all good or all bad. Failure to integrate the positive & negative qualities of oneself Nursing approach: Promote independence & self-care Involve in decision-making Communication with staff |
| regression | Retreat in face of stress to behavior characteristic of earlier developmental level. Nursing focus: Promote independence & self-care Involve in decision-making |
| reaction behavior | Develop conscious attitudes & behaviors that are opposite of underlying feelings Wish to be sexually promiscuous: moralistic demeanor RN: Remember pt is not "lying" (unaware of true feeling) |
| cog behavior | think - feel - act |
| rationalization | "Good" reason for questionable behavior "rational lies" Avoid social disapproval; ↑SE |
| projection | Unconscious way of dealing w/ unacceptable urges by attributing them to others Blame others for out shortcomings or see them as harboring our own unacceptable feelings/thoughts Basis for paranoia RN: avoid personalizing client behavior |
| intellectualization | Excessive reasoning or logic is used to avoid experiencing painful feelings Blunts emotional impact of problems Expresses thoughts not feelings |
| identification | The wish to be like another person & assuming that person's characteristics |
| introjection | Accepting another's values & opinions as one's own if they contradict the values previously held |
| dissociation | Temporary alteration of consciousness or identity Refuses awareness of (dissociates) personal qualities disapproved by SOs These feelings come to exist separately from person's self-concept |
| displacement | Discharge of pent-up feelings on less dangerous object "Kick the dog" mech RN may be safe target for discharged feelings Do not personalize Remain calm & accepting Help pt determine why & at whom they are angry |
| suppression | Intentional act that ↓ anxiety Conscious form of repression "I don't want to talk about it." "I'll think about it later." |
| compensation | Making up for perceived deficiencies Emphasizing assets to cover up shortcomings Often manifested as: "Napoleon complex" Self-medicating |
| denial | Blocks awareness of painful feelings Ignoring existence of painful events Provides temporary protection diagnosis of illness early adjustment to death of SO RN Support the denial when helpful Not all clients need to face reality When dysfunctional: Assess motivation Do not reinforce |
| ANTs & Thought Stopping | automatic negative thoughts Listen Identify Act Replace |
| biological rhythm | Rhythm pattern disturbances are well documented in Bipolar Disorder and Depression |
| kindling | sub-clinical seizure activity (shows on EEG) shown in depression, biopolar, chemical dependency, schizophrenia ---> use of anticonvulsant for treatment |
| Most common medical diseases associated with clients diagnosed with Anxiety Disorders are | Cerebrovascular Disease Irritable Bowel Syndrome (IBS) |
| Long-tern abuse of various substances lead to a variety of medical complications | Alcohol - Hepatic/Liver conditions Marijuana - Memory, reasoning, lung disease Cocaine - Cardiac toxicity Ecstasy - Neurotoxicity, memory, reasoning, impulse control |
| interventions for anxiety | Conduct a thorough physical assessment Conduct a pain assessment Pain is a warning of tissue damage and must take priority Educate the client regarding specific medical treatment Identify an anxious client and refer the client to community support groups Evaluate the client's coping and teach alternative coping strategies Teach more effective coping skills Desired outcomes: More accurate diagnosis Increased remission rate Major areas of Focus: Obtaining remission Improving care of the family Decreasing suicidal behavior Desired outcomes: More accurate diagnosis Increased remission rate Major areas of Focus: Obtaining remission Improving care of the family Decreasing suicidal behavior |
| mental health | Successful performance of mental functions, resulting in the ability to engage in productive activities, enjoy fulfilling relationships, and change or cope with adversity. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self esteem |
| mental illness | A clinically significant behavioral or psychological syndrome experienced by a person and marked distress, disability, or risk of suffering disability or loss of freedom |
| mental health laws | Each State regulates the care and treatment of the mentally ill The Community Mental Health Center Act of 1963 - Created a shift in emphasis from large state institutional care to community-based care of the mentally ill Widespread use of psychotrophic drugs for the treatment of the mentally ill Need to provide the mentally ill with humane care that respects their civil rights |
| FVA - Formal Voluntary Admission | The Client Voluntarily agrees to an evaluation and psychiatric treatment The client is also agreeing to stay at least 72 hours even if they should become dissatisfied with treatment If clients become dissatisfied with treatment they have the right to sign a "72 Hour Release Form" The voluntary client may leave treatment 72 hours after signing the 72 Hour Release From |
| OPC - Order of Protective Custody | Usually originates in the community Police usually pick up the client Client is delivered to an emergency room for a psychiatric assessment |
| PEC - Physician's Emergency Commitment | Legal for 72 hours IN order to meet the criteria for involuntarily (PEC) committed to a psychiatric facility one must be: A danger to self A danger to others, or Gravely disabled (mentally) |
| CEC - Coroner's Emergency Commitment | The coroner (a physician in Louisiana) must agree with the physician that the client requires psychiatric treatment The CEC must be written within 72 hours |
| PEC+CEC= | 15 days |
| Exceptions to the Right to Confidentiality | When duty to warn (Tarasoff) and protect are mandated (when client threatens to harm self/others) Child abuse - The nurse is a mandated to report Elder abuse - The nurse is a mandated to report Communicable disease - State laws require reporting of certain communicable diseases LA State laws and Federal laws require reporting of gunshot wounds Nurses may also report knowledge of or reasonable suspicion of, mental abuse or suffering. |
| Statutes for Reporting Child and Elder Abuse | All 50 States and the District of Columbia have enacted child abuse reporting statutes Most states specifically require nurses to report cases of suspected abuse A growing number of states are enacting elder abuse reporting statutes Some states are enacting spousal abuse reporting statutes Because state laws vary, nurses must become familiar with the requirements of the state in which they practice |
| Failure to Report and Failure to Protect | If a suicidal client is left alone with the means of self-harm, the nurse who has a duty to protect the client will be held responsible for the resultant injuries Medication errors are a failure to protect Misconduct during the therapist-client relationship (sexual most common - ex: Prince of Tides) Precautions to prevent harm must be taken when a client is restrained Misdiagnosis is frequently charged in lawsuits |
| Malpractice and Negligence | Malpractice is an act or omission to act that breaches the duty of due care and results in or is responsible for a person's injuries Negligence is a general tort for which anyone may be found guilty, when health care professionals fail to act in accordance with professional standards Duty of care Breach of duty Cause in fact Proximate cause Damages |
| signs of schizophrenia | Affect: Flat , blunted, inappropriate, and bizarre Associative Looseness: Jumbled and illogical speech, impaired reasoning (looseness of associations) Delusions, hallucinations, neologisms Simultaneously holding two opposing emotions, attitudes, ideas, or wishes toward the same person |
| etiology of schizophrenia | What we call "Schizophrenia" is a complicated disorder and in fact may be a group of disorders with common, yet, varying features and multiple overlapping etiologies What is known is that brain chemistry, brain structure, and brain activity is very different in persons with Schizophrenia Everyone has a 0.7% chance of developing Schizophrenia Manifests in early adulthood Schizophrenia becomes chronic in 80% Genetic Research indicates multiple genes and different chromosomes interact with each other in complex ways to create vulnerability for Schizophrenia Neurobiological Dopamine, Serotonin, Glutamate theories Brain structure/abnormalities Enlarged lateral cerebral ventricles Lower brain volume and more cerebrospinal fluid Reduced volume of grey matter especially in the temporal and frontal lobes Prenatal Stressors Exposure to viral infection, poor nutrition, hypoxia and exposure to toxins Psychological trauma to mother (death in the family) Father older that thirty five (35) years Psychological Stressors Symptoms often manifests at times of developmental and family crisis and exposure to psychological trauma or social defeat Cannabis, drug and alcohol use seems to worsen symptoms Environmental Stressors Living in chronic poverty Migration to or growing up in a foreign culture Living in high crime environments |
| course of schizophrenia | Prodromal (forewarning) Symptoms Prodromal Symptoms ay occur a month to a year before the first psychotic break or full blown manifestations of the illness Their symptoms represent a clear deterioration in previous function Social History Socially awkward, lonely, depressed Express themselves in vague , odd, unrealistic dissociative ways Complains of anxiety, phobias, obsessions and compulsions may be noted Misinterpretation of Events May have the feeling that something is 'strange' or 'wrong' is happening Thinking ordinary events have mystical or symbolic meaning Difficulty discerning others emotions Preoccupation with religion/God/Spirits Receiving messages from God, believing that they are God or a saint, constant praying Preoccupation with sex and/or sexuality Doubts regarding sexual identity or preoccupation with homosexual themes Exaggerated sexual needs or altered sexual performance |
| phases of schizophrenia | Phase I - Acute (Onset or Relapse/Exacerbation) Hallucinations, delusions, apathy, and withdrawal, loss of functional ability Increased care is essential and hospitalization may be required for safety, medication management, and stabilization Phase II - Stabilization Acute symptoms diminish and stabilization is achieved May require day hospitalization, treatment in residential crisis center or supervised group home Phase III - Maintenance Person is at or near their 'baseline' functioning, symptoms are absent or greatly diminished Level of functioning allows the person to live in the community |
| DSM-IV-TR Criteria for Types of Schizophrenia | Paranoid Schizophrenia - Paranoid delusions, Hallucinations Disorganized Schizophrenia - Disorganized speech and behavior Catatonic Schizophrenia - Motor immobility, waxy flexibility, stupor Residual Schizophrenia - Social isolation, eccentric behavior, blunted affect, odd beliefs Undifferentiated Schizophrenia - Hallucinations, delusions bizarre behavior, No one symptom {paranoia, catatonia} dominates |
| positive symptoms | Alteration in thinking Impaired reality testing, Delusions, Concrete thinking. Alteration in Speech Neologisms, Echolalia, Echopraxia, Clang Association, Word Salad Alteration in perception Depersonalization, Derealization, Hallucinations, Illusions, Command Hallucinations (most dangerous) Alteration in behavior Catatonia, Motor Retardation or Agitation, Automatic obedience, Waxy flexibility, Negativism, Impaired impulse control |
| Negative Symptoms | Negative symptoms develop slowly and interfere most directly with the persons adjustment and ability to cope Negative symptoms impede the person's ability to : Initiate and maintain conversations and relationships Obtain and maintain a job Make decisions and follow through with plans Maintain adequate hygiene and grooming Affect Blunting - immobile or blank facial expression Anergia - passivity, lack of energy Anhedonia - Inability to experience pleasure, profound emotional barrenness Avolition - Reduced motivation, inability to initiate tasks (such as grooming) Poverty of content of speech Speech conveys little information because of vagueness or superficiality Poverty of speech Reduced amount of speech, gives brief one-word answers Thought blocking Sudden interruption of thought process, usually due to internal stimuli |
| cognitive symptoms | Cognitive symptoms are present in most people with schizophrenia and involve difficulty with: Attention Memory Information processing Cognitive flexibility - the ability to switch behavioral response according to the context of the situation Executive function - decision making, judgment, planning and problem solving These impairments leave the patient unable to manage personal health care, hold a job, initiate or maintain a support system or live independently |
| Affective Symptoms | Affect is the observable behavior that indicates a person's emotional state In schizophrenia, affect may not coincide or agree with inner emotions Affect in schizophrenia is categorized in one of four ways: Flat -Immobile, blank face Blunted - Reduced or minimal emotional response Inappropriate - Emotional response incongruent with the tone of the circumstances Bizarre - Odd, illogical, emotional state that is grossly inappropriate or unfounded (ex: uncontrolled giggling) |
| nursing assessment guidelines for schizophrenia | Assess for: Risk to self or others Hallucinations especially command hallucinations and delusions Determine if the patient has had a medical work-up Substance use and abuse Prescribed medication and adherence to medication regime Family's knowledge of schizophrenia and family's response to patient's illness |
| Interventions for Paranoia | Communication Guidelines Persons with paranoia have difficulty trusting those around them and often adopt an aloof, superior, or sarcastic attitude They may personalize unrelated events (ideas of reference) Self-Care Needs Grooming, dress and self-care may not be a problem for the person that is paranoid, in fact, many are meticulous Sleep and Rest May fear going to sleep, thinking others will harm them while they are sleeping Nutrition May have delusions that food is poisoned - provide food in sealed packaging Milieu Needs Provide activities that distract the patient from ruminating on paranoid themes May become aggressive in response to their hallucinations or delusions and project hostile drives on to others - provide safety |
| Interventions for Catatonia: Withdrawal Phase | Communication Guidelines Although these patients may appear to pay no attention to their surroundings, they are acutely aware of the environment and are likely to accurately remember events at a later date Remember to communicate with them as you do with all other patients even though they are not responding to you Self-Care Needs Total assistance may be required for feeding, bathing, dressing, even range of motion Milieu Needs Safety - the patient may suddenly with out provocation show brief outbursts of gross motor activity in response to inner hallucinations and delusions |
| Interventions for Catatonia: Excited Phase | Communication Guidelines Be clear, direct, and reflect concern for safety of the patient and others Self-Care Needs Reduce stimuli in the environment Provide additional calories, fluid, and rest IM administration of sedating antipsychotic medication may be required Milieu Needs Safety - A person who is constantly and intensely hyperactive can become completely exhausted and even die |
| Interventions for Disorganized Schizophrenia | Communication Guidelines Concise, clear and concrete Break tasks down to simple, one at a time actions Continuous redirection and refocusing Self-Care Needs These patients are too disorganized to carry out simple activities of daily living and will need significant direct assistance with ADLs Encourage optimal levels of functioning to prevent further regression Offer alternatives for inappropriate/bizarre behaviors Milieu Needs Assist to conform their behavior to social expectations Provide for the patient's privacy needs Conduct peer education to reduce peer frustration |
| Conventional or typical Antipsychotics | Thorazine (Chlorpromazine) Prolixin (Fluphenazine) Haldol (Haloperidol) |
| Atypical Antipsychotics | Abilify (Aripiprazole), Clozaril (Clozapine) Seroquel (Quetiapine) Respirdal (Risperidone) Geodon (Ziprasidone) |
| Long-Acting Injectable Antipsychotics | Some antipsychotics are produced in long-acting injectable forms depot or deconoate Taking injections that last two weeks or a month eliminates the need to take oral medication daily or several times daily Some medications that come in these long-acting form are: Haldol (Haloperidol) Prolixin (Fluphenazine) Respirdal (Risperidone) |
| Extrapyramidal Side Effects (EPS) | Akinesia -Absence or diminished voluntary motion Akathisia - Regular rhythmic movements Dyskinesia - Involuntary muscular activity Dystonia - Abnormal muscle tonicity, impaired voluntary movement = treat w/ Psudoparkinsonism - Medication induced Parkinson like tremor, movement, gait == see text for treatments |
| Tardive Dyskinesia (TD) | a persistent EPS that usually appears after prolonged treatment with antipsychotics, however TD can occur with short term treatment TD consists of a series of irreversible side effects of involuntary tonic muscle spasms typically involving the: Tongue Fingers, Toes Neck, Trunk, Pelvis cogentin, benadryl can lessen symptoms but it is irreversible |
| AIMS Scale | The National Institute of Mental Health (NIMH) developed the Abnormal Involuntary Movement Scale (AIMS) The AIMS is a brief test for the detection of Tardive Dyskinesia and other involuntary movements The AIMS Examines facial, oral extremity, and trunk movement |
| Medication for EPS and TD | Cogentin (Benztropine Mesylate) Akineton (Biperden) Artane (Trihexyphenidyl) Benadryl (Diphenhydramine Hydrochloride) Symmetrel (Amantadine Hydrochloride) |
| Neuroleptic Malignant Syndrome | Neuroleptic Malignant Syndrome (NMS) occurs in about 0.2% to 1 % of patients who have taken antipsychotics NMS is a life-threatening medical emergency (requiring treatment in the ICU) and is fatal in about 10% of the patients An acute reduction in brain dopamine activity is thought to play a role in the development of NMS S/S: Reduced consciousness Increased muscle tone (muscular rigidity) Autonomic dysfunction including: Hyperpyrexia Labile hypertension Tachycardia Tachypnea Diaphoresis Drooling Early detection STOP antipsychotic drugs Management of fluid balance Correct electrolyte imbalance Temperature reduction COOL THE BODY TO REDUCE FEVER Cooling blanket Bathe with alcohol and cool water Ice bath |
| Agranulocytosis | Agranulocytosis is a serious side effect of antipsychotics and can be fatal = CLOZARIL most commonly causes it Sudden onset occurs during the first 12 weeks of therapy Symptoms of Agranulocytosis include: Sore throat Fever Flu-like symptoms Malaise Mouth sores |
| Other Psychotic Disorders | Scizophreniform - Duration of psychosis is at least 1month and less than 6 months Brief Psychotic Disorder - Sudden onset of psychosis, duration at least one day and less than a month Schizoaffective Disorder - Psychosis resulting from untreated depression or bipolar disorder The symptoms are not due to drug, alcohol or medication Delusional Disorder - Non-Bizarre delusions such as Having a disease, being followed, for at least one month (not otherwise impaired) Shared Psychotic Disorder (Folie a` Deux) - "Madness between two" - another individual (usually a spouse) comes to share the delusional belief of the patient Induced Secondary Psychosis (Substance Induced Psychosis) |
| bipolar disorder | a chronic, recurrent illness that must be carefully managed throughout a person's life |
| cyclothymia | is a chronic mood disturbance of at least 2 year duration. There is no severe impairment in their social or occupational functioning, nor do they experience psychotic systems. [delusions, etc.] It is a milder form of the bipolar disorders. Hypomanic episodes alternating with minor depressive episodes. [at least 2 years in duration] = less manic (w/irritability) Cyclothymic clients are never without hypomanic or depressive symptoms for more than 2 months. |
| bipolar type 1 | at least one episode of mania alternates with major depression. psychosis my accompany manic episode - more common in males - onset ~ 18 years |
| bipolar type ii | hypomanic episodes alternate w/major depression. psychosis is not present hypomani tends to be euphoric and often increases functioning and depression tends to put pt at suicide risk - more common in femailes - onset age 20 |
| assessment | - determine if mania is a primary mood disorder or secondary to another condition - panic attacks are most common to co-occur mental status assessment - mood - behavior - cognitive impairment (more in BP I) |
| planning for bipolar | in acute phase - safety!!! continuation phase (lasts 3-9 mo) maintenance phase - prevent relapse |
| biopolar interventions | attributes - manipulative - splitting - aggressively demanding staff actions - set limits consistently - frequent staff meetings communication - remain neutral, avoid power struggle - use short and concise explanations - use firm, calm approach - reality orientation: tell them where they are, waht time, what's going on - distraction nutrition - monitor I+O for dehydration or cardiac injury - offer high cal, protein meals+finger foods - remind client to eat - no caffeine pace/lead - let client set the pace but the nurse decides the speed of the conversation |
| medication for bipolar | Lithium is the first choice of treatment for Bipolar I Acute and recurrent Manic and Depressive episodes. Inhibits about 80% of acute manic and hypo manic episodes within 10-21 days. Must reach therapeutic levels in patient's blood to be effective. Takes 7 to 14 days or longer to reach therapeutic levels in some patients. Therapeutic blood level 0.8 to 1.4 mEq/L Maintenance blood level 0.4 to 1.3 mEq/L |
| sub-tx level for LI | < 0/4-1.0 mEq/L s/s - fine hand tremor - polyuria - mild thirts - mild nausea - general discomfort - weight gain |
| toxic li level | blood level >1.5 mEq/L - n/v - diarrhea - thirst - polyuria - slurred speech - muscle weakness |
| advanced Li toxicity | blood level 1.5-2.0 mRq/L - coarse hand tremor - persistent GI upset - mental confusion - muscle hyperirrability - incoordination |
| severe Li toxicity | blood level 2.0-2.5 mRq/L - ataxia - blurred vision - clonic movements - large output if dilute urine - seizures - stupor - severe hypotension - coma - death |
| contraindications for Li | - cv disease - brain damage - renal disease - thyroid disease - MG - pregnancy - breastfeeding mothers - children <12 years |
| Li SE and interventions | confusions, reslessness, sleeplessness = withold Li nausea = give w meals thirst = drink 10-12 oz per day diarrhea = onserve closely for electrolye depletion weight gain = place on structured diet plan |
| other meds for bipolar | depakote - useful in treating pts not responsive to Li who are acute manic phases or haven't responded to tegretol tegretol - best for pts who cycle rapidly or are paranoid/angry lamictal - well toderated but has serious rare SE of rash |
| interventions for acute mania | use phenothiozines and seclusion to minimize physical harm seclusion or restrains used for ER basis when there is a clear risk of harm to pt or others milieu mgmt - maintain low level of stimuli in client's environment, give rest periods |
| two major long term risks of Li tx | - hypothyroidism - impairment of the kidneys ability to concentrate urine |
| anticonvulsant rx for bipolar | all - monitor liver valproate carbamazepine/tegretol lamotrigine/lamictal - SE rash |
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