Mental Health Nursing

Mental Health Nursing Psychiatric Nursing SUPPLEMENTAL

BULLETS

TYPICAL PROFILE OF PATIENT WITH ANOREXIA NERVOSA –

FEMALE , ADOLESCENT,UPPER CLASS ,PERFECTIONIST A PaTIENT WITH AN EATING DISORDER UNCONSCIOUSLY ASSOCIATES FOOD WITH LOVE AND AFFECTION LITHIUM LEVEL TOXIC AT 2.0 mEq / L NEUROLOGIC SIGNS AND SYMPTOMS INCLUDE NAVDA, TREMOR, HYPERREFLEXIA,FASCICULATIONS, BRADYCARDIA , ARRYTHMIAS ,SEIZURES AND COMA Korsakoff’s Psychosis : inability to process new information ( to

form new memories). This is a reversible condition resulting from brain damage induced by a thiamine deficiency which is generally secondary to chronic alcoholism. Werniche’s Encepalopathy : This disease is also due to an alcoholic-induced thiamine deficiency. It is an irreversible disease in which the brain tissues break down, become inflammed, and bleed

Pharmacological treatment of alcohol withdrawal – benzodiazepines or barbiturates First symptom of Alzheimer’s Disease – progressive memory loss Effective long term treatment for alcoholics – AA Methadone causes analgesia without euphoria,withdrawal symptoms

less

severe than heroin Medical/ health professionals prone to have anxiety and depression treated by generalist rather than physicians

Delirium – reversible organic mental syndrome reflecting deficits in attention, organized thinking, orientation , speech, memory and perception. Patients are frequently confused, anxious , excited and have hallucinations. A change in consciousness can be observed(clouding of consciousness) Dementia –irreversible impaired functioning secondary to changes / deficits in memory, spatial concepts, personality , cognition , language , motor and sensory skills, judgement or behavior. No change in consciousness

Substances that mimic generalized anxiety – amphetamines , cocaine , anticholinergics, alcohol and sedative withdrawal Geriatric drug induced hallucinations commonly due to propanolol Major risk or TCA’s – orthostatic hypotension leading to falls Symptoms of alcohol withdrawal and their temporal relations Hallucinations – after 24 hours Autonomic hyperactivity – after 6-8 hours Global confusion 1-3 days after

Side effects of Ritalin – insomnia abdl. Pain, depression, anorexia, HA and HPN First episode of Bipolar disease – mania before depression Lithium used for mania and – bulimia , anorexia nervosa, alcoholism

with mood d/o, headaches Borderline personality d/o – Chronic Boredom Parotid gland swelling and erosion of teeth enamel, elevated serum amylase and hypokalemia – Bulimia Conversion d/o – internal psychological conflict that manifests as somatic symptoms.

Dysthymia – chronic d/o more than 2 years Symptoms of depression I Nterest down Sleep Appetite Depressed mood Concentration diff. Activity Guilt Energy low Suicide

Dystonic rxn – side effect of neuroleptics-muscle spasm of tongue, face and neck and back,laryngospasm and extraocular muscle spasm Dystonic rxn – treated with Benadryl or Cogentin Hallucinogens affect – serotonin Munchausen syndrome – harm oneself – factitious d/o –

manchausen by proxy – seeks medical care for another (e.g. child)

Haloperidol – prefrred neuroleptic – few side effects , can be used IM during emergencies( but high

frequency of extrapyramidal effects) Clozapine

– no tardive dyskinesia but can develop agranulocytosis , seizures,hypotension, over sedation. Benzodiazepine contrindications – pregnancy ( 1st trim)acute narrow angle glaucoma, and hypersensitivity Extrapyramidal Rxns- involuntary spontaneous motor movements – dystonis, akathisia and parkinson like syndrome

Obsessive – Compulsive d/o –begins before 25 y.o. – SSRI and exposure therapy beneficial Positive operant conditioning – reinforce positive behavior PTSD possible even though there is no actual witnessing of event Flashbacks , nightmares,intense fear,avoidance and diminished

memory of event with an exagerrated startle response onset occurs at least 6 months - PTSD

Post partum psychosis – first few weeks post-partum(710 d/6-8wk,) primiparous,poor social support and

previous depression Schizophrenia – Association

looseness

Ambivalence Autism Affect

inappropriate Hallucinations + A’s + Regression + Delusions + Stimuli comprehension low (HARDS)

Somatization d/o – multiple , unexplained medical symptoms(four unexplained pain Sx) Suicide – bipolar d/o, depression, substance abuse and schiz. Reliable predictors of potentially violent patient – male gender , Hx

of violence , history of substance abuse Organic brain syndrome most frequent mood – irritability Labile affect – rapid shifts of mood

Medication used to relieve extrapyramidal effects of psychotropic medications: Benadryl Artane Cogentin

School age w/ terminal illness – honestly explain in understandable

terms. Provide reassurance that he will not be alone.

Prodromes of violent behavior – anxiety,defensiveness,volatility and physical aggression Akathisia-internal restlessness-Tx – propanolol Echolalia – meaningless automatic repition of someone else’s

words Catalepsy – maintains same posture for a long period of time Waxy flexibility –offers resistance to change in position but gradually allows to be moved to anew posture

Institutionalization only if patient poses a danger to self or others 10

most stressful events(Holmes and Rahe)

Death

of a spouse or child

Divorce Separation Institutional

detention of a close family member Major personal illness/injury Marriage Job loss Marital reconciliation retirement Death

Standard care for domestic violence Establish confidential system of identification Document Collect evidence Evaluate safety issues Formulate safety plan Give insight to options and resources Refer for counseling nad legal asst. Coordinate w/ law enforcement Transport to shelter prn Follow up w/ DV advocate

Common anti cholinergic meds- AtSO4, TCA’s,antihistamines, phenothiazines and antiparkinsonian drugs

Lithium toxicity –sign: tremor, symptoms:weakness and ECG

findings: flattening of T-waves.

Tx for Wernicke’s Encephalopathy – thiamine IV Organic Brain Syndrome – manifestations Hallucinations Perception aberration Mental status change Focal neurologic sign

Imipramine HCl – TCA – dry mouth – X drink excessively – leads to electrolyte imbalance – just ice chips/ gum Least therapeutic around depressed clients – Cheerfulness or gaiety Theory behind interpersonal model of behavior therapy: Behavioral Changes

result from stress on the individual and his body systems Systems model theory – behavior results from interaction between individual and environment Haldol’s CNS adverse reaction – Extrapyramidal side effects

Significant features of each AXIS in the Diagnosis Statistical Manual for mental disorders IV Axis 1 – organic brain syndromes,psychosis,affective d/o and

substance abuse Axis 2 – personality disorders Axis 3 – medical problems Axis 4 - Life events leading to problems Psychosocial

and environmental

Axis 5 – patient adaptation to problems

Schiz. patient – priority safety then self care needs , then health needs then behavior goals Major goals of psychosocial rehabilitation program – teaching

independent living skills OC d/o – substitution and undoing Adolescent behavior influence - peers Organic mental d/o : Agnosia,insomnia,amnesia,confusion

delirium and depression

Attributes negative traits to others - projection Showing emotion opposite to what is Alcohol aversion therapy – antabuse

truly felt – reaction formation

Alcoholism

– rationalization – substituting a more acceptable reason for one’s

behavior Heroin overdose – ABC’s Cocaine – red excoriated nostrils, tachycardia , nervousness and pupillary dilation AA – independent responsible arrangements(personally done)

Barbiturate overdose -respiratory failure Drug given at a non- intoxicating dose for barbiturate withdrawal –

Pentobarbital Na ( Nembutal) Long term amphetamine abuse – emotional lability, depression,dependency , hallucinations and delusions

Severe anxiety and withdrawn – diversion activities and increased social contact Anorexia nervosa when exercising – interrupt and redirect activity Antisocial – egocentrc and unconcerned Ultimate nursing goal for severe anxiety disorder – development of

adaptive coping behaviors and problem solving skills Inderal use to relieve physical symptoms of anxiety

Disclosure of a plan to kill someone – report to the staff and AP asap Obtained

sense of self – awareness, attributes , defense mechanisms and behaviors – gained INSIGHT Priority for suicidal depressed patients – safety and security ( not cause personal harm) Suicide an individual decision cannot be influenced by nurses questions Sudden increase in energy level or mood- warning sign

Client under influence of cocaine – agitated, aggressive and paranoid – priority safety / protect pnt. Tardive dyskinesia – involuntary twitching or muscle movements Dystonia – uncoordinated spastic movements of the body Discharge – preparation for termination of NPR Delusional withdrawn – encourage participation – reinforces reality

and brief one on one contacts in his own room

Fluphenazine decanoate ( prolixin ) drug of choice for Schiz. – given only once every 2-4 weeks Prolixin

– edema , blood dyscrasias and BP fluctuations – check weight , WBC count and BP.

Schiz – Client’s

complaints of hallucinations – assess for compliance discharge from involuntary admission – determined by legal or medical

approval Confused client – promote safety, prevent injury and maintain quality of life

Alcohol intoxication – allow pnt. Sleep it off Support gropu for spouses and significant others of alcoholics – Al-

non Breaking defenses of denial may lead to mental disorganization and depression Thorazine reduces seizure threshold Heroin addiction symptoms of late withdrawal – navda recovery principle to ease anxiety – “ one day at a time”

Barbiturates + alcohol – depressant effect 2-3 days barbiturate withdrawal – generalized convulsions-Given

nembutal to decrease seizure possibility Anorexia nervosa goal of Tx – stabilize weight and facilitate entry into outpatient care Xanax – short term Tx – tolerance can occur Do not respond to a client who tries to evoke feelings of anger / negative response

Endogenous depression – biochemical in nature amitriptyline HCl – urinary retention Elderly – reminiscing – reduce depression,

lessen feelings of isolation and loneliness Alcohol detoxification – inquire alcohol consumption past 24-48 hours to determine withdrawal severity ( auditory hallucinations – common) Delirium Tremens quiet , well lighted room with companion , last resort – restrain if violent only Heroin injection – tested for HIV and Hepa B

Methadone – liquid form under direct supervision Best measures to recovery success – number of chemically free days Drug tolerance – requires increasingly larger doses to achieve the same

desired effect Severe Sx of barbiturate with drawal – postural hypotension,psychosis, hyperthermia and seizures Anorexia nervosa – focus – nutritional status Patient on librium avoid alcohol Disciplining unacceptable behavior – person still accepted

Alcohol disulfiram Rxn – vomiting , dyspnea, hypotension,vertigo,syncope,confusion,respiratory depression,convulsions,coma,death Alcoholism defense – rationalization , repression /suppression,

denial

Heroin overdose – antidoteNarcan(naloxone)increased HR,BP and LOC ( but short acting ) Barbiturate ,Opiate or Benzodiazepine – sluggish, irritable, slurred

speech , impaired judgement and walking diff.Buspar – not prn – therapeutic effect 7 – 10 days…full effect 3 -4 weeks Epinephrine – decrease peristalsis Restraints discontinued when subj. and obj. assessments indicate an absence of aggression

Abusive family characteristics : History of family violence Unbalanced power ratio Stereotypical role playing Dysfunctional expression of feelings Strict boundaries Lack of empathy Substance abuse Low self esteem – common trait of abuse victims

Medication can only be forced to a patient if he poses a threat to himself and others Anti social personality – limit setting on behaviors Psychophysiological anxiety d/o – activities that promote rest, involve relaxation Self awareness towards mortality needed to be effective in caring for the

terminally ill Organic mental d/o – safe simple envt. To help his orientation Anorexia nervosa – perfectionists ,self starvation and rigorous exercise – high cal and high CHON diet.subconcious conflicts – parental , autonomy, identity

Isolation , medication and warning others –short term anger mngt. Does not place responsibility on the patient

for his own behavior, ineffective in behavior modification Positive reinforcement for good behaviors For manipulative clients – limit setting and positive reinforcement

Personality traits for ulcerative colitis – OC, perfectionist, inflexible, difficulty in showing emotions and obstinate Four point retraints – monitor circulation and skin, provide sensory

stimulation,means of elimination and nutrition and change in position MAO therapeutic effects – 4 weeks Turning unacceptable feelings into physical Sx that has no identifiable cause – conversion rxn

Sarcasm – expression of anger Confabulation – unconscious behavior used to hide memory loss by

replacing it with fabrication Unconscious forgetting of traumatic events– repression Projecting feelings or thought to someone – transference MAO – headache and neck stiffness – hypertensive crisis

Communication for someone who refuses to speak – open ended questions focussing on expression of feelings Anti-psychotics abrupt discontinuation- nausea and seizures Manipulative behavior – lack of trust Verbally and physically abusive patients – try setting limits verbally

before physical and chemical restraints

Abused child little showing of emotion and little response to pain Depressed clients readiness evaluated by responsibility for own

well being , ADL’s and continuing Treatment. Abused child – same primary nurse everyday – promote trust and provide continuity of care Anti –social – continue to enforce rules and set limits on behavior( provide appropriate explanation)

Demerol C/I for clients taking MAOI’s,can cause death Alzheimers memory and emotion difficulties – stage 1 Memory loss, confusion , wanderin aphasia, inability to do self Lithium therapy – monitor sodium Tyramine rich foods- smoked , aged , pickled or fermented Stage 1 alzheimers – recent memory loss only Hallucination episodes – redirect to reality ( activities)

care – stage 3

Lithium carbonate therapeutic level in 2 weeks Dementia –wandering – constant supervision A client exhibiting mania placed on lithium carbonate

and Thorazine simultaneously…Thorazine controls manic behavior until lithium reaches its therapeutic levella belle indifference – lack of concern for profound disability Highest treatment priority for anorexia nervosa-correction of nutritional and electrolyte imbalance Seclusion for – promotion of therapeutic limit setting, reduces overwhelming environmental stimulation, protects patient from self injury or injury to others- if patient does not respond to less restricted interventions – until pnt. Can assume self control Compulsion – irresistable urge to perform an irrational act Self esteem needs- self – worth ,self respect ,self –reliance , dignity

and independence Love and belongingness – affiliation , affection and intimacy

Minnesota Multiphasic Personality Inventory MMPI- 550 question test assess personality and detects d/o such as schizophrenia and depression ECT … 6-12 treatments of 2-3 per week Circumstaniality –disturbance in associate thought and speech

patterns Lithium levels checked every 6 – 8 weeks

Primary purpose of psychotropic medications to decrease symptoms to allow participation in therapy First

step in drug overdose or toxicity management- establish and maintain

airway Korsakoff’s syndrome – hallucinations,confabulation,amnesia and disorientation TCA ‘s A/R:

orthostatic hypotension,tremors seizures HPN shock arrythmias

overdosage:

Most common psychiatric disorder

depression