Myk's Psychiatric Nursing Notes 4

Myk's Psychiatric Nursing Notes 4

EATING DISORDERS ANOREXIA NERVOSA ---------------BULIMIA NERVOSA - Eat, eat, eat --------------------------- Eat, eat, vomit - Less 85% expected body weight ------- Normal weight - 3 months amenorrhea --------------- Irregular menstruation BULIMIA NERVOSA • Metabolic alkalosis (vomiting results to decrease hydrochloric acid) • Metabolic acidosis (diarrhea results to decrease bicarbonate) • Dental caries • Wound in knuckles MANAGEMENT • Fluid and electrolyte imbalance • Meal contract • Weight gain for client • After eating stay with client for 1 hour and accompany when going to the comfort room PHARMA NOTES: ANTI – PSYCHOTIC DRUG • Stelazine • Serentil • Thorazine • Trilafon • Clozaril • Mellaril • Haldol • Prolixin SCHIZOPHRENIA • Ego disintegration • Impaired reality perception • Genetic vulnerability • Stress – Diathesis Model • Biological theory – increase dopamine level • Exact cause unknown ASSESSMENT • Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete) • Ambivalence: pulled into 2 opposing forces Autism • Looseness, no idea, not related to one another ASSESSMENT NEGATIVE ------------------------POSITIVE Hypoactive ------------------------ Hyperactive Withdrawn ------------------------- Sociable Thought Blocking ------------------Flight of ideas Apathy

I. ASSESS • Content of thought NURSING DIAGNOSIS • Disturbed thought process PLANNING/IMPLEMENTATION • Present reality • Provide safety EVALUATION • Improved thought process II. ASSESS • Hallucinations/Illusions NURSING DIAGNOSIS • Disturbed sensory perception PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Improved sensory perception III. ASSESS • Suspicious NURSING DIAGNOSIS • Risk for other directed violence PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Eliminate/minimize risk for other directed violence IV. ASSESS • Suicidal NURSING DIAGNOSIS • Risk for self directed violence PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Eliminate/minimize risk for self directed violence LOOSENESS OF ASSOCIATION • Thinking that is overgeneralized, diffuse, and vague with only a tenuous connection between one thought and the next FLIGHT OF IDEAS • Jumping from on topic to another AMBIVALENCE • Pulled between 2 strong opposing forces MAGICAL THINKING • acting like magician

ECHOLALIA • Client repeats what you say ECHOPRAXIA • Client repeats what you do WORD SALAD • Just words no rhyme CLANG ASSOCIATION • Words that rhyme NEOLOGISM • Formation of new words (needs clarification) DELUSION: PERSECUTORY • “The NBI is out to get me” DELUSION: RELIGIOUS • “I am Jesus Christ the savior” DELUSION: GRANDEUR • “ I am the queen of the world” DELUSION: IDEAS OF REFERENCE • “The nurses are talking about me” CONCRETE ASSOCIATION • Also known as “pilosopo” THOUGHT BLOCKING • Unable to think -----------------------HALLUCINATIONS------ ILLUSIONS STIMULUS ------------ ABSENT------------ PRESENT VISUAL ----------------ABSENT------------ PRESENT AUDITORY ----------- ABSENT------------ PRESENT TACTILE ABSENT --- ABSENT------------ PRESENT • • • • • • •

Present reality to clients experiencing hallucinations Technique in handling clients with hallucinations Hallucinations Acknowledgement “I know the voices are real to you” Reality orientation “I know the voices are real but I don’t hear them” Diversion “Lets go to the garden” 10% of schizophrenic clients hear voices

PARKINSON’S DISEASE • If acethylcholine (on switch) is increased there is excessive movement resulting to decrease in dopamine (off switch) ANTI-PSYCHOTIC Decrease dopamine level Parkinson like effect Extra pyramidal side effect With akathesia Restless, inability to rest

AKINESIA • Muscle rigidity DYSTONIA • Torticollis (wryneck) OCULOGYRIC CRISIS • Fixed stare OPISTHOTONUS • Arched back • Lips – smacking • Tongue – protruding • Cheeks – puffing • The 3 are irreversible and called tardive dyskinesia • Neuroleptic malignant syndrome – hyperthermia ANTI – PARKINSON Anticholinergics Dopaminergics (Decrease Ach) (Increase Dopa) Artane, Akineton Parlodel Benadryl Larodopa Cogentin Eldepryl Symmetrel OTHER SIDE EFFECTS OF DECREASE DOPAMINE • Photosensitivity • Agranulocytosis – decrease WBC • Clients prone to infection due to decrease WBC • First sign for infection is sore throat

TYPES OF SCHIZOPHRENIA DISORGANIZED SCHIZOPHRENIA -

Sad but smiles (inappropriate affect) No reaction (flat affect) Flight of ideas (disorganized speech) Giggling (hebephrenic giggle) Combination of positive and negative signs and symptoms

CATATONIC SCHIZOPHRENIA - Ambivalence - Waxy flexibility - Favorite word is “No” - Negativism (client do not follow what you tell them to do) Nursing management: meet needs

PARANOID SCHIZOPHRENIA - Suspicious - Mistrust, scared, withdrawn Nursing management: - Gain trust by 1 to 1 short interaction but frequent - Foods should be in a sealed container - Medications should be in tamper resistant foil.

Violent: - Keep door open - Position near door - Don’t touch client - Call for reinforcement - One arms length away from the client.

PARANOID SCHIZOPHRENIA - No more positive symptoms just withdrawn

UNDIFFIRENTIATED SCHIZOPHRENIA - Mixed classification, cant be classified PHAMRA NOTES: BI-POLAR, MANIC • Lithium: undergo first kidney test and check for blood levels • Level: .6 – 1.2 meq/L • Increase urination • Tremors, fine hand • Hydration of 3L/day • Increase • Uu (diarrhea) • Mouth dry Signs of Lithium toxicity • Nausea, vomiting, diarrhea • Increase sodium

* Wait for 2 – 4 weeks before lithium therapy takes effects

BIPOLAR DISORDER/MANIC PROFILE • 20 years old • Female • Stress • Obese ASSESSMENT • Decrease appetite (give finger foods) • Decrease sleep (place in a private room) • Hyperactive • Increase sexual activity – only means of addressing anxiety so decrease level of anxiety • Risk for injury/other directed violence • Impaired social interaction (care giver role: strain and stay with client) • Self esteem decrease (to cover up their sadness there is compensation to cover defective doing) • Because there is decrease self esteem there will be increase compensation resulting to increase interference with ADL’s and harm to others • Compensation is the culprit • Management: increase self esteem to decrease compensation and decrease interference with ADL’s and harm to others

HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS T- no sports (basketball, volleyball), no fine motor skills only gross motor skills A lot energies toward more productive endeavors (sublimation)

S - escorted walk outdoors K – punching bag (displacement) PHARMA NOTES: ANTI – DEPRESSANTS • Asendin • Norpralamin • Tofranil • Sinequan • Anafranil • Aventyl • Vivactil • Elavil • Prozac • Paxil • Zoloft ALCOHOL LEADS TO: • Blackout: awake but unaware • Confabulation: inventing stories to increase self esteem • Denial: “I am not an alcoholic” • Dependence: cant leave with out leading to enabling where in the significant other tolerates the abuser co dependence is another term • Tolerance: gradual increase in amount of stimuli to experience the same euphoria MANAGEMENT • Detoxification: withdrawal with medical doctor supervision • Avoid alcohol therapy • Aversion therapy a more technical term for avoid alcohol therapy • Antabuse: Disulfiram makes the client never drink alcohol because it causes vomiting • Alcoholics anonymous • Interval of 12 hours after last dose of alcohol or experience nausea and vomiting and hypotension • Alcoholism may result to Vitamin B1 (Thiamine) deficiency WERNICKE’S ENCEPHALOPATHY • Problem with motor KORSAKOFF’S PSYCHOSIS • Problem with memory • 24 – 72 hours after last dose of alcohol expect: • Delirium Tremens: sympathetic nervous system • Prevent hallucinations/Illusions by placing client in a well lit room • Formication: feeling of bugs crawling under the skin ALZHEIMERS DISEASE • Axon (away) and Dendrites (toward) nerve • Neurofibrillary tangles • Neurotic plaques --------------------------ALCOHOL --- ALZHEIMERS ONSET -------------------- Abrupt -------- Gradual LEVEL OF CONSCIOUSNESS -- Fluctuating ----Unaffected

DURATION ----------- Hours to days --- Progressive MEMORY -------------- Short term ---Short and long term

5 A’s OF ALZHEIMERS 1. Amnesia – memory loss 2. Anomia – don’t know the name 3. Agnosia – sensory problems smell, taste, sight 4. Aphasia - expressive: cant say/express - frontal lobe is affected particularly broca’s area - receptive: cant hear - temporal lobe is affected particularly wernicke’s area 5. Apraxia – cant do simple things * Reminiscing Therapy – talk about past • Patients with alzheimer’s may experience hallucinations, illusions thus becomes restless and may wander • As sun goes down client becomes restless, agitated, disoriented called sundowning • Drug of choice is Cognex and Aricept a cholinesterase inhibitor that increases Ach causing delay in disease progression SEROTONIN • Responsible for happiness • Decrease serotonin clients becomes sad give anti-depressants SELECTIVE SEROTONIN REUPTAKE INHIBITOR Safest drug Side effects low R I to 4 weeks - Increases serotonin and affects only serotonin - Prozac, Paxil, Zoloft TRICYCLIC ANTI DEPRESSANT Two – four weeks C A - Has higher incidence of side effects - Also increases norepinephrine - Asendin, Norpralamin, Tofranil, Sinequan, Anafranil, Aventyl, Vivactil, Elavil

MONO AMINE OXIDASE INHIBITORS • MAO kills serotonin • Increased MAO results to decreased serotonin the more depressed the client becomes • MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine, norepinephrine, dopamine but client becomes prone to hypertensive crisis • Avoid tyramine rich foods • Avocado, Alcohol • Beer • Chocolates, Cheese (aged) • Fermented foods • Pickles • Preserved foods • Soy sauce

• There is increase incidence of side effects after 2 – 6 weeks • Marplan, Nardil, Parnate

PERSONALITY DISORDERS 1. Schizophrenia - They avoid people because there is no enjoyment 2. Avoidant - They avoid people because they are afraid of criticisms - They have talent but has no confidence 3. Anti-Social - Constantly breaks law - Project charm - They are witty and articulate - Manipulative 4. Borderline - They perceive life as an empty glass - They like splitting friends - Sudden change in mood “labile affect” - Prone to suicide 5. Dependent - “Cant live if living is without you” 6. Histrioinic - Constantly wants to be the center of attention - Excited, dramatic, manipulative 7. Narcissistic - “I love myself” - They get jealous even with achievement of family members 8. Obsessive – Compulsive - “I am so organized” 9. Paranoid - Suspicious - May lead to domestic violence

ANTI – DEPRESSANT SIDE EFFECTS: Male – erectile dysfunction, prone to impotence

GRIEF PROCESS 1. Denial – shock/disbelief 2. Anger – question “why me?” 3. Bargaining – if, then 4. Depression – 2 weeks or more sign and symptoms becomes major clinical depression 5. Acceptance – client acts according to situation

ASSESSMENT • Decrease self actualization • Decrease self esteem • Withdrawn: stay with client • Suicidal: risk for self directed violence • Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual urge • Be sensitive to clients needs

FOR SUICIDAL OBSERVE FOR Verbal • “I wont be a problem” • “This is my last day on earth” • “I’ll soon be gone” Non verbal • Giving away of valuables • Sudden change in mood

WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO Direct: “Do you plan to commit suicide?” Irregular/interval visits Endorsement period, early morning clients are most likely to commit suicide

DOWNERS Alcohol Barbiturate Opiates Narcotics Marijuana Morphine Codeine Heroine

Resulting to: • Bradycardia • Bradypnea • Moist mouth • Pupils constrict • Constipation • Urinary retention • Hypotension • Coma • Weight gain • Narcotics overdose: give narcotic antagonist (Narcan, Naloxone hydrochloride)

UPPERS Cocaine Hallucinogens Amphetamines Resulting to: • Tachycardia • Awake • Tachypnea • Dry mouth • Pupils dilate • Hypertension • Seizures • Weight loss