Mental Health Nursing Exam 3

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Schizophrenia, Eating Disorders, Addictive Disorders, Cognitive Disorders, Disorders of Children and Adolescents, Psychosocial Needs of Older Adult, Serious Mental Illnesses

Schizophrenia DSM-IV Criteria

A. Characteristic Symptoms
Two or more in a month:
-Delusions
-Hallucinations
-Disorganized Speech
-Grossly Disorganized
-Negative Symptoms
B. Social/Occupational Dysfunction
C. Duration (At least 6 months with at least 1 month that meets criteria of A.)

Schizophrenia Epidemiology

Usually late teens-20s
More common in men
No racial/cultural difference

Schizophrenia Comorbidity

Polydipsia, Substance abuse (esp. nicotine), Anxiety, Depression, Suicide, Physical illness

Schizophrenia Genetics

Runs in families; Cluster A PD in family

Dopamine Theory

When dopamine is controlled, helps with positive symptoms of Schizophrenia

Positive Symptoms

-Alterations in Thinking
-Alterations in Speech
-Alterations in Perception
-Alterations in Behavior

Alterations in Thinking

-Delusions are false, fixed beliefs
-Concrete thinking (can't think abstractly)
-Ideas of reference (everything is related to them)
-Persecution
-Grandiosity
-Somatic Sensations
-Jealousy
-Though Broadcasting (TV, Radio)
-Thought Insertion/Withdrawal
-Delusions of being controlled

Alterations in Speech

-Neologisms (Made up words)
-Echolalia (Repeat what you say)
-Echopraxia (Repeat movements)
-Clang Associations
-Word Salad

Alterations in Perception

-Depersonalization
-Derealization (Outer environment doesn't feel right)
-Hallucinations
-Boundary Impairment

Alterations in Behavior

-Catatonia
-Motor Retardation/Agitation
-Stereotyped Behaviors
-Automatic Obedience
-Waxy Flexibility (Could have arm up in air for hrs)
-Negativism
-Impaired Impulse Control

Negative Symptoms

-Blunt, flat, bizarre affect
-Anergia (No energy)
-Anhedonia (No pleasure)
-Avolition (Reduced motivation)
-Poverty of speech/content
-Thought Blocking

Cognitive Symptoms

Difficulty with: Attention, memory, information processing, cognitive flexibility, executive functions

Affective Symptoms

Assess for depression is key!

Conventional Antipsychotics

First-Generation drug for Schizophrenia
-Treats pos. symptoms ONLY (dopamine receptors)
-Less expensive, more side effects
Disadvantages: Extrapyramidal side effects, Anticholinergic side effects, tardive dyskinesia, lower seizure threshold*

Atypical Antipsychotics

Second-Generation drug for Schizophrenia
-Treats both pos. and neg. symptoms
-Low extrapyramidal side effects or tardive dyskinesia
-Disadvantage: Wt. gain, metabolic syndrome/potential to develop diabetes (*Measure abdominal girth!)

Anticholinergic Symptoms

Seen in Atypical and Conventional Antipsychotics: -Dry Mouth
-Urinary Retention
-Constipation
-Blurred Vision
-Photosensitivity
-Dry Eyes
-Sexual Problems

Types of Atypical Antipsychotics

-Clozapine (Clozaril): Use declining (lowers WBCs)
-Risperidone (Risperdal)
-Olanzapine (Zyprexa)
-Quetiapine (Seroquel)*
-Ziprasidone (Geodon)
-Aripiprazole (Abilify)*

Extrapyramidal Side Effects

Seen in Conventional Antipsychotics:
-Acute Dystonia (head & neck muscles contract)
-Akathisia (Restless, pacing)
-Pseudoparkinsonism (give Benadryl or Cogentin)
-Tardive Dyskinesia (Abnormal involuntary movement scale- Persistant lip smacking)

Neuroleptic Malignant Syndrome

Response to antipsychotics
-Very high fever, muscle rigidity
-Treat Immediately!

Agranulocytosis

Low WBCs from antipsychotics

Residual Schizophrenia

Active-phase symptoms no longer present
Evidence of two or more residual symptoms:
-Reduced initiative, interests, or energy
-Social withdrawal
-Impaired role function
-Speech deficits
-Odd beliefs

Anorexia Nervosa

<85% Ideal Body Weight
-Terrified of wt. gain/Sees self as fat
-Amenorrhea (loss of menses)
-Preoccupied with food-related activities
-Uses vomiting/laxatives/diuretics

Medical Complications of Anorexia

-Bradycardia
-Changes in BP/HR
-Cardiac arrythmias
-Prolonged QT interval
-Leukopneia
-Lymphocytosis
-Elevated Carotene in blood
-Hypokalemic Alkalosis
-Elevated bicarbonate
-Electrolyte imbalances
-Osteoporosis
-Fatty degeneration of liver
-Elevated cholesterol
-Hematuria/Proteinuria

Bulimia Nervosa

-May not appear ill
-Often slightly above or below ideal body weight
-Purging and Non-purging types
-Binge eating
-Depression
-Relationship Problems

Medical Complications of Bulimia

-Sinus bradycardia
-Orthostatic changes
-Cardiac Murmur
-Abnormal Potassium, Sodium values
-Russell's Sign (Callused knuckles)
-Esophageal Tears
-Parotid Swelling
-Dental erosion

Binge Eating

-Frequently symptom of Affective Disorder/Mood Disorder
-2 days/wk for 6 months
-Lack of control over episode

Synergistic Effect

Drugs taken together to intensify/prolong effects
ex. alcohol & benaodiazepine/opiate

Antagonistic Effect

Drugs taken together to weaken/inhibit effects
ex. cocaine & heroine (speedball), caffiene & alcohol

Codependence

Family/friends enable addicts

Dual-Diagnosis

Addiction AND Mental Illness

Addiction Comorbidity

-Psychiatric: 6/10 have mental disorder (depression, anxiety, antisocial, paranoid, schizophrenic, histrionic)
-Medical: Alcohol medical problems are most common

Addiction Etiology

-Biological Factors: Substance abuse affects brain/neurotransmitters (Opoid, catecholamine, dopamine, GABA systems)

-Psychological Factors: Lack of tolerance for frustration/pain; Lack of success in life; Lack of affectionate and meaningful relationships; Low self-esteem; Risk-taking propensity

-Sociocultural factors: Socioeconomic stress, social/cultural norms

NO CLEAR genetic link, but highly likely

Red flag responses during assessment

-Rationalizations, automatic responses, slow/prolonged responses

Alcohol Poisoning

-Can result in death from choking on vomit or shutdown of body systems
Signs: inability to arouse pt, cool clammy skin, resp.<10/min, cyanosis under fingernails, emesis while semiconscious/unconscious, coma, shock, convulsions

Treatment: Induce vomiting, keep awake, give activated charcoal, check q 15 min
If in coma: Clear airway, insert endotracheal tube, give IV, pump stomach, check VS, initiate seizure precautions, administer flumazenil (romazicon) IV

Alcohol Withdrawal

Signs develop within few hrs of last drink, peaks at 24-48 hrs
-Let Dr. know if you see symptoms!

Symptoms: N&V, tachycardia, diaphoresis, anxiety, remors in hands/fingers/eyelids, marked insomnia, grand mal seizures, delerium, increase B/P

Alcohol Withdrawl Delirium

Seen after 5-15 yrs of heavy use
Medical emergency, can lead to death
-48-72 hrs after last drink, can last 2-3 days

Alcohol Intoxication

Slurred speech, incoordination, unsteady gait, drowsiness, decreased B/P, disinhibition of sexual or aggressive drives, impaired judgment, impaired social function, impaired attention/memory, irritability

CNS Stimulants

-Cocaine/Crack
-Caffeine
-Nicotine
-Amphetamines

CNS Stimulant Intoxication

Tachycardia, dilated pupils, elevated BP, N&V, insomnia, assaultiveness, grandiosity, impaired judgment, euphoria, increase energy
-Severe: State resembling paranoid schizophrenia, delusions, psychosis, hallucinations, panic levels of anxiety, violence

CNS Stimulant Overdose

Respiratory distress, ataxia, hyperpyrexia, convulsions, stroke, coma, myocardial infarction, death

Effects of CNS withdrawal

Fatigue, depression, agitation, apathy, anxiety, sleepiness, disorientation, lethargy, craving, sweating, chills, paranoia
Treatment: Antidepressants, dopamine agonist, bromocriptine

Cocaine and Crack

-Smoked: effect in 4-6 seconds, high for 5-7 min then deep depression
-Main effects on body: Anesthetic & Stimulant
-Produces imbalance in NTs

Opiates

-Morphine
-Heroin
-Codeine
-Fentanyl
-Methadone
-Meperidine

Opiate Intoxication

Constricted pupils, decreased respiration, drowsiness, decreased BP, slurred speech, psychomotor retardation, initial euphoria followed by dysphoria

Opiate Overdose

Possible dilation of pupils, respiratory depression/arrest, coma, shock, convulsions, death
Treatment: Narcotic antagonist

Effects of Opiate Withdrawal

Yawning, insomnia, irritability, runny nose, panic, N&V, cramps, muscle aches, chills, fever

-Less severe withdrawl

Marijuana

-Indian hemp plant
-THC is active ingredient
-Depressant and Hallucinogenic properties
Desired effects: euphoria, detachment, relaxation
Long-term effects: Lethargy, anhedonia, difficulty concentrating, loss of memory

Hallucinogens

-LSD/acid
-Mescaline
-Psilocybin (magic mushrooms)
-PCP

Hallucinogen Intoxication

Pupil dilation, tachycardia, diaphoresis, palpations, tremors, incoordination, elevated temp, pulse and respirations, hallucinations, bizzare behavior, paranoia, anxiety, depression, violent behaviors

-Can lead to permanent psychosis

Inhalants

-Spray paint, glue, lighter fluid, aerosols
-Alcohol-like symptoms, hallucinations, euphoria
-Toxic to heart, lungs, liver and kidneys
-May die from vagal stimulation, respiratory depression, profound systolic BP drop

Club Drugs

-Ecstasy, MDA, MDE
-Produce subjective effects resembling stimulants and hallucinogens (hyperactive, dilated pupils, tachycardia, central serotonin syndrome, severe sodium depletion, grinding teeth, increased BP and temp, tremors)

Date Rape Drugs

Flunitrazepam (Roofies), Gamma hydroxybutyric acid (GHB)
-Rapidly produce disinhibition, relaxation of voluntary muscles, anterograde amnesia

Naltrexone (ReVia)

Reduces/eliminates alcohol craving

Acamprosate (Campral)

Helps client abstain from alcohol

Topiramate (Topamax)

Works to decrease alcohol cravings

Disulfiram (Antabuse)

Alcohol-disulifram reaction causes unpleasant physical effects
-Must take daily!

Valium

Often used for alcohol withdrawal (decreases symptoms, stabilize V.S., prevent seizures)

Methadone (Dolophine)

Synthetic opiate blocks craving for and effects of heroin

LAAM

Alternative to methadone for heroin withdrawal

Naltrexone (ReVia)

Antagonist that blocks euphoric effects of opioids

Clonidine (Catapres)

Effective somatic treatment when combined with naltrexone

Buprenorphrine (Subutex)

Blocks signs and symptoms of opioid withdrawal

Assessment tool for pain in elderly

-Wong Baker FACES
-Present pain intensity rating
-Pain assessment in Advanced Dementia (PAINAD) scale (looks at 5 aspects)

Give morphine for pain (Safer in elderly)- regular dose, not PRN

Delirium

Change in cognition/consciousness, less clarity, sudden onset, fluctuating, common in hospitalized patients especially older adults (due to infection, high fever, pain, etc.)
-Low doses of Halidol can prevent

Cardinal Features of Delirium

-Acute onset and fluctuating course
-Inattention
-Disorganized thinking
-Disturbances of consciousness

Illusions

Misinterpresting something that is really there

Dementia

-Progressive, irreversible
-No change in consciousness
-Difficulty with memory, thinking, and comprehension

Alzheimer's Disease Etiology

-Cerebral Atrophy (especially in hippocampus)
-Neurofibrillary tangles
-Neuritic Plaques
-Ventricles enlarge
-Risk factors: Head injury, aging, down syndrome

Confabulation

Unconscious attempt to maintain self-esteem

Perseveration

Repetition of phrase or behaviors

Cardinal Symptoms of Alzheimer's Disease

-Amnesia/Memory impairment
-Aphasia
-Apraxia (loss of purposeful movement in absence of motor or sensory impairment)
-Agnosia (loss of sensory ability to recognize objects)
-Disturbances in executive functioning (can't make decisions)

Early AD

Plaques/tangles begin to form in areas of learning, memory, thinking and planning
-Forgetfulness

Mild AD

-Confusion

Moderate AD

-More plaques and tangles
-Problems with memory/thinking that is severe enough to affect work or social life
-Trouble identifying familiar objects or people

Severe AD

-Unable to identify familiar objects or people
-Most of cortex is seriously damaged
-Brain shrinks dramatically

Drugs for AD

-Tacrine (Cognex)
-Donepezil (Aricept) *Less liver toxicity
-Rivastigmine (Exelon)
-Galantamine (Razadyne)
-Memantine (Namenda)

-Anticonvulsants help with mood
-Benzodiapines help with anxiety

Tacrine (Cognex)

For mild-moderate symptoms of AD, improves functioning and slows progress of disease
-Side effects common: Nightmares, Elevated liver transaminase levels, GI effects, and liver toxicity

Aricept (Donepezil)

-BEST AD DRUG
-Most prescribed, slows deterioration w/o liver toxicity
-Improve/Maintain thinking
-Allow to perform ADLs
-Delay onset of negative behavioral symptoms
Side effects: Diarrhea, N&V

Nameda (Memantine)

-For moderate to severe stages of AD
-Low side effects and proven effective in helping treat symptoms of AD
-Improve/Maintain thinking
-Allow to perform ADLs
-Delay onset of negative behavioral symptoms

Pervasive Developmental Disorders

-Autistic Disorder: don't like touch/stimulus, pull away, poor eye contact, don't like to play with other kids, impairment in communication
-Asperger's Disorder: focus on one subject that they're very smart in, "high functioning autism"
-Rett's Disorder

ADHD

-Inattention
-Hyperactivity
-Impulsivity
Drugs: Ritalin (most prescribed, addictive, give before 4 PM); Strattera (less addictive)

Oppositional Defiant Disorder

Pattern of disobedience, but don't violate others
-More common in teens, boys

Conduct Disorder

-Worse that Oppositional; Hurt others, steal, etc.
-No remorse for actions
-Childhood & Adolescent onset
-History of ADHD common

Types of Conventional Antipsychotics

-Chlorpromazine (Throazine)
-Loxapine
-Molindone
-Perphenazine
-Trifluoperazine
-Thiothixene (Navane)
-Fluphenazine (Prolixin)
-Haloperidol (Haldol)** COMMON
-Pimozide (Orap)

-Give Cogentin if severe side effects!

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