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What is mental illness? (p. 2 Varcarolis 9th ed.)
All psychiatric disorders that have a definable diagnosis; the disorders are manifested I dysfunctions that may be related to developmental, biological, or psychological disturbances in mental function
What is mental health? (p. 2 Varcarolis 9th ed.)
State of wellbeing in which individuals reach their own potential, cope with the normal stress of life, work productively and contribute to the community
What is the purpose of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and what does it classify? (p. 11 Varcarolis 9th ed
DSM 5 purpose is to diagnose psychiatric disorders; it classifies disorders based on specific criteria that will match the specific disorder
Who developed the first psychiatric nursing theory? (pp. 21-22 Varcarolis 9th ed.)
Interpersonal relationships theory (1952) by Hildegard Peplau
In the interpersonal relations theory what is the role of the nurse? (pp. 21-22 Varcarolis 9th ed.)
The role of the nurse is to be the observer and participate in therapeutic sessions
o describes the nurse-patient relationship as the foundation of nursing
o shifted the idea from “what nurses do to patients” to “what they do with their patients”
What neurotransmitters (NTs) are associated with mental illness? (Table 3.1 pp. 40-41 Varcarolis 9th ed
Dopamine: involved with fine motor movement, integration of emotions and thoughts, decision-making
Increase: schizophrenia mania
Decreased: Parkinson’s, depression
Norepinephrine: level in the brain affects mood, attention an arousal; stimulates sympathetic branch of the ANS flight or flight response
Increase: mania, anxiety, schizophrenia
Decrease: depression
Serotonin: plays a role in sleep regulation, hunger, mood states, pain perception, aggression and sexual behavior; hormonal activity
Decreased: depression
Histamine: involved in the level of alertness and inflammatory response; stimulates gastric secretion
Decrease: sedation, weight gain
GABA: plays a role in inhibition, reduces aggression, excitation, and anxiety; may play a role in pain perception, anticonvulsant properties and muscle relaxant properties
Increased: reduces anxiety
Decreased: anxiety, schizophrenia, mania, Huntington’s disease
Glutamate: excitatory AMPA plays a role in learning
Increased NMDA: Alzheimer’s
Increased AMPA: improves behaviors in performance tasks
Decreased: psychosis, schizophrenia
- Acetylcholine: plays a role in learning and memory; stimulates the PNS for resting and digesting actions
Increase: depression
Decrease: Alzheimer’s, Huntington’s, Parkinson’s
What is the target site of psychotropic medications? (p. 40 Varcarolis 9th ed.)
Postsynaptic cell: postsynaptic membrane receptors
How does the nurse establish a safe environment in the inpatient setting? (pp. 73-74 and Table 4.3 Varcarolis 9thed).
Check all personal property and clothing to protect them from any harmful items
Identify patients correctly: use at least two patient identifiers when provider care, treatment or services
Used medications safely: maintain and communicate accurate medication information for the individual served
Prevent infection: use hand-cleaning guidelines from either the CDC or WHO
Identify patient safety risk: determine which patients are most likely to attempt suicide
Monitor visitation to make sure it is contributing to the patients healing
Discourage intimate relationships with other patents
Track patients whereabouts and activities
What is culturally competent care? (p. 86 Varcarolis 9th)
The process of demonstrating culturally congruent practice which applies evidenced based nursing care that corresponds with the patients cultural values, beliefs, practices and world view
What is cultural awareness? (p. 87 Varcarolis 9th ed.)
The nurse recognizes the enormous impact that culture has on patients’ health values and practices
The nurse is aware of their own bias
What are the guidelines for voluntary, involuntary, and emergency admission or commitment?
Voluntary: patient should understand the needs for treatment and are willing to be admitted; patients have the right to request and obtain release but must be reevaluated before release which can result in involuntary
Involuntary: court-ordered admission to a facility without the patient’s approval
o Criteria
§ Diagnosed with mental illness
§ Posing a danger to self or other
§ Gravel disabled – unable to provide for basic necessities
§ In need of treatment and the mental illness itself prevents voluntary help-seeking
What are the 3 primary reasons an individual is admitted to the psychiatric hospital? (See Chapter 6 PP)
danger to self
danger to others
need for care
What is talk therapy (psychotherapy)? (p. 125 Varcarolis 9th ed)
Aims to help a person identify and change troubling emotions, thoughts and behaviors
o s/s improve with change in emotions, perceptions and interpretation of life experience
o aims to change patient behaviors
What is the most effective treatment for psychiatric disorders? (p. 125 Varcarolis 9th ed)
Combination of medication and psychotherapy
What is active listening? (pp. 140-141 Varcarolis 9th ed)
When nurses focus, response and remember what the patient is saying verbally and non verbally
Observes non-verbal behaviors, understanding and reflecting on verbal message, detect inconsistencies and provide feedback
What role does the autonomic nervous system (ANS) play in the response to and effects of stress on the body? (p. 155-156 Varcarolis 9th ed.)
ANS triggers fight or flight response: acute stress response; acts as the body’s way of preparing for a situation an individual perceives as a threat
Body’s response: increase BP, HR, RR, CO
What are potential causes of stress and stressors? (pp. 157-159 Varcarolis 9th ed.)
- Potential causes of stress and stressors: emotional arousal, fatigue, fear, humiliation, loss of blood, extreme happiness or unexpected success
Physiological: trauma, excessive cold or heat, infection, hemorrhage, hunger, pain
Psychological: divorce, loss of a job, unmanageable debt, death of a loved one, retirement, and fear of terrorist attack; can also include positive changes – marriage, arrival of a new baby, unexpected success
What should the nurse assess for in the patient’s ability to manage stress? (pp. 157-159, 161 Varcarolis 9th ed.).
Health sustaining habits: medical adherence, proper diet, relaxation, pacing ones energy
Life satisfaction: work, family, hobbies, humor, spiritual solace, arts, nature
Social support
Effective and healthy response to stress
Nursing assessment for a fight or flight response?
Increased: HR, RR, BP, CO
What are characteristics of the resilient child? (p. 169-170 V9th ed.)
1. Adaptability to changes in the environment
2. Ability to form nurturing relationships with other adults when the parent is not available
3. Ability to distance self from emotional chaos
4. Social intelligence
5. Good problem-solving skills
6. Ability to perceive a long-term future
How does temperament determine the development of future mental disorders? (p. 169 V9th ed.)
Temperament and behavioral traits can be powerful predictors of future problems.
Traits such as shyness, aggressiveness, and rebelliousness, for example, may increase the risk for substance use problems.
External risk factors for using illicit substances include peer or parental substance use and involvement in legal problems such as truancy or vandalism.
Protective factors that shield some children from drug use include self-control, parental monitoring, academic achievement, antidrug-use policies, and strong neighborhood attachment.
What are characteristics of the mentally healthy child or adolescent? (pp. 171-172 V9th ed.)
Trusts others and sees his or her world as being safe and supportive
• Correctly interprets reality and makes accurate perceptions of the environment and one’s ability to influence it through actions (e.g., self-determination)
• Behaves in a way that is developmentally appropriate and does not violate social norms
• Has a positive realistic self-concept and developing identity
• Adapts to and copes with anxiety and stress using age-appropriate behavior
• Can learn and master developmental tasks and new situations
• Expresses self in spontaneous and creative ways
• Develops and maintains satisfying relations
What deficits are present in intellectual disability disorders (IDD) formerly mental retardation? (p. 176 V9th ed.)
Intellectual functioning. Deficits in reasoning, problem solving, planning, judgment, abstract thinking, and academic ability.
Social functioning. Impaired communication and language, interpreting and acting on social cues, and regulating emotions.
Daily functioning. Practical aspects of daily life are impacted by a deficit in managing age-appropriate activities of daily living, functioning at school or work, and performing self-care.
Autism spectrum disorder (ASD) (pp. 177-178 V9th ed.)
is a complex neurobiological and developmental disability that typically appears during a child’s first 3 years of life.
Autism spectrum disorder affects the normal development of social interaction and communication skills
Autism spectrum disorder (ASD) (pp. 177-178 V9th ed.)
DSM 5 criteria (symptoms) for diagnosis (p. 178 V9th ed.)
Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive):
Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation to reduced sharing of interests, emotions, or affect to failure to initiate or respond to social interactions.
Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication to abnormalities in eye contact and body language or deficits in understanding and use of gestures to total lack of facial expressions or nonverbal communication.
Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts to difficulties in sharing imaginative play or in making friends to an absence of interest in peers.
Severity is based on social communication impairments and restricted repetitive patterns of behavior.
B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, excessive adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyperreactivity or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
Specify current severity:
Severity is based on social communication impairments and restricted repetitive patterns of behavior.
C. Symptoms must be present in the early developmental period (but may not fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms together limit and impair everyday functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; in comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
What is echolalia?
is the pathological repetition of another’s words, occurring perhaps because the patient’s thought processes are so impaired that she is unable to generate speech of her own.
What medications are used to target behavioral symptoms? (p. 179 V9th ed.)
1) Risperdal (Risperidone)
2) Abilify (Aripiprazole)
3) Lamictal (Lamotrigine)
The second-generation antipsychotics risperidone (Risperdal) and aripiprazole (Abilify) have FDA approval for treating children with autism-associated agitation.
Attention deficit hyperactivity disorder (ADHD) (pp. 180-181 V9th ed.)
Individual show an inappropriate degree of inattention, impulsiveness, and hyperactivity.
To diagnose a child with ADHD, symptoms must be present in at least two settings (e.g., at home and school) and occur before age 12.
Attention deficit hyperactivity disorder (ADHD), inattentive type (p. 180 V9th ed.)
Some children are inattentive but not hyperactive. In this case, the diagnosis is still ADHD and is then further classified as primarily inattentive type (previously known as ADD)
Be familiar with the stimulant medication used to treat ADHD and associated side effects (pp. 182-184; Table 11.2 p. 183 V9th ed.)
Methylphenidate (Ritalin), mixed amphetamine salts(Adderall)
S/E: insomnia, appetite suppression, headache, abdominal pain and lethargy.
Be familiar with the non-stimulant used to treat ADHD and associated side effects? (pp. 182-184; Table 11.2 p. 183 V9th ed.)
Atomoxetine (Strattera) approved for childhood and adult ADHD- takes up to 6 wks to work, preffered for client whose has cormobid anxiety, active substance abuse or tics
S/E: GI disturbance, urinary retention, dizziness, fatigue and dizziness
may cause liver injury and increase in bp and HR
What is the nurse’s priority assessments for the child taking methylphenidate (Ritalin)?
Administering medications no later than 4:00 in the afternoon or lowering the last dose of the day helps.
weight loss- monitor eating schedule
What are the 4 types of symptoms seen in schizophrenia? (pp. 194-198 Varcarolis 9th ed.). Be able to differentiate between the 4 symptom types.
Positive symptoms: hallucinations, delusions, paranoia, disorganized or bizarre thoughts, behavior and speech.
Negative symptoms: inability to enjoy activities (anhedonia), social discomfort, lack of goal directed behavior.
Cognitive symptoms: subtle or obvious impairment in memory, attention, thinking, impaired executive functioning (lack of impulse control, prioritization, problem solving)
Affective symptoms: symptoms involving emotions and their expression
What is considered the most dangerous type of hallucination (alteration in perception) that requires immediate attention from the nurse? (p. 196 Varcarolis 9th ed.)
Command hallucinations
1. What are the most common side effects associated with first generation antipsychotics? (p 208; Table 12.6 pp. 213-214 Varcarolis 9th ed.)
First generation antipsychotics are dopamine (D2) antagonists. These cause extrapyramidal side effects such as:
o Acute dystonia: Sudden, sustained, contraction of one or several muscle groups usually of the head or neck. Unless they involve the muscle of the airway, they are not dangerous.
o Akathisia: Motor restlessness that causes pacing and/or inability to stay still or in one place. Can be mistaken for anxiety or agitation and may lead to more of the drug being administered that caused the akathisia.
o Pseudoparkinsonism: A temporary group of symptoms that resemble parkinson disease. Ex. Tremor, reduced accessory movements, gait impairment, reduced facial expressiveness, and bradykinesia.
o Tardive dyskinesia: involuntary movements of face and jaw, tongue startsmoving involuntarily.
o Neuroleptic malignant syndrome: severe muscle rigidity, dysphasia, flexor extensor posturing, reduced or absent speech and movement, decreased responsiveness. Hyperpyrexia- temp over 103 F
o Haloperidol (Haldol)Chlorpromazine (Thorazine), fluphenazine (prolixin)
What are the most common side effects associated with second generation antipsychotics? (pp. 211-214 Varcarolis 9th ed.)
Sedation, sexual dysfunction, seizures and increased mortality in older adults with dementia, suicidal ideation, anticholinergic toxicity, NMS, prolonged QT interval.
Metabolic syndrome
Weight gain, dyslipidemia, increased blood glucose, and insulin resistance
Increases risk for diabetes, cancer, hypertension and cardiovascular disease
Clozapine ( Clozaril) risperidone (resperidal) olanzapine (Zyprexa)
Which is present in bipolar I Mania or Hypomania
Mania: period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy
o Last at least a week, most of the day, every day
o Individuals experiencing manic episodes are the happiest, most excited, and most optimistic
o Mania gives way to agitation and irritability and eventually exhaustion, finally into depression
o Can reach psychosis -- hallucinations, delusions, dramatically disturbed thoughts
o Bipolar I
Which is present in bipolar II Mania or Hypomania
Hypomania: refers to a low-level and less dramatic mania
o Euphoric and increases functioning
o Excessive activity and energy for at least 4 days & involves at least 3 behaviors listed under Criterion B in DSM-5
o Psychosis never met
o Does not impact functioning that is noticeable to others
o Underdiagnosed and often mistake for MDD or personality disorders
o Bipolar II
How is bipolar disorder different from major depressive disorder? (pp. 219-220, 242-243 Varcarolis 9th ed.)
Bipolar disorder alternates between states of euphoria and states of depression and/or mixed states of anxiety and depression.
MDD only has one phase, depression
Safety concerns for patients experiencing mania? (pp. 220, 223-226, Table 13.2 p. 227 Varcarolis 9th ed.)
Bc they feel so important and powerful, they engage in horrific chances and hazardous activities- do not recognize as problematic and resists treatment
Hallucinations and delusions -- distractibility and decreased concentration
State of depression & agitation -- lead to extreme behaviors such as violence or attempted suicide
Therapeutic communication for the patient experiencing mania? (pp. 228-229 Table 13.3 Varcarolis 9th ed.)
Use a firm and calm approach
Use short and concise explanations or statements
Be consistent in approach and expectations
Identify expectations in simple, concrete terms with consequence
Hear and act on legitimate complains
Firmly redirect energy into more appropriate constructive channels
Therapeutic window for Lithium. (pp. 232-233 Table 13.4 Varcarolis 9th ed.; Bipolar Disorder PP)
Therapeutic blood level: 0.8-1.2 mEq/L
Toxic level: >1.5
Takes 7-14 days to reach the effect level
What patient and family teaching are indicated for lithium therapy? (pp. 232, 234 Box 13.2 Varcarolis 9th ed.)
Lithium is a mood stabilizer and is important to take even when the episode subsusides; not addictive
Important to monitor lithium blood levels closely
Maintain a consistent fluid intake: 1500-3000 mL/day; six 12 oz glasses
Stop take if: excessive diarrhea, vomiting, sweating
Tell provider if they take diuretics
Take lithium with meals to avoid stomach irritation
Must be tapered off gradually if discontinued
What are the classifications of and the common and adverse side effects for: Lithobid (Lithium); Carbamazepine (Tegretol); Lamotrigine (Lamictal); Lurasidone (Latuda); and Cariprazine (Vraylar). (pp. 232-235 Varcarolis 9thed.)
LITHIUM: Mood stabilizer
o N & V, diarrhea, thirst, polyuria, lethargy, sedation, and fine hand tremor
CARBAMAZEPINE: Anticonvulsant
o Dizziness, somnolence, N & V, ataxia, constipation, pruritis, dry mouth, weakness, blurred vision, and speech problem
LAMOTRIGINE: Anticonvulsant
o Dizziness, headache, diplopia, ataxia, blurred vision, nausea, somnolence, rhinitis, and pharyngitis
LURASIDONE: Second-generation antipsychotic
CARIPRAZINE: Second-generation antipsychotic
1. What is the DSM 5 criteria for Major Depressive Disorder? (pp. 242-243 Varcarolis 9th ed)
DSM-5 criteria: % or more of the following symptoms nearly every day for most waking hrs. Over same 2-week period:
o Affect (depressed mood)
o anhedonia= loss of pleasure in living
o Anergia
o weight loss/gain
o sleep disturbances
o lack of motivation
o Feeling worthless or excessive guilt
o difficult thought process, concentration or making decisions
o suicidal thoughts
Which antidepressants are first line for treatment for depression? SSRI’s, SNRI’s, tricyclics, monoamine oxidase inhibitors (MAOI’s) (p. 256-261 Varcarolis 9th ed.)
SSRIs: citalopram (celexa); escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (paxil), sertraline (Zoloft)
Which of the antidepressants have the potential to be lethal? (p. 256-261 Varcarolis 9th ed.)
TCAs
What are the signs and symptoms of serotonin syndrome? (p. 257 and Box 14.3 p. 259 Varcarolis 9th ed.)
s/s: hyperactivity, restlessness, tachycardia, fever, increased BP, delirium, muscle rigidity, seizures, abdominal pain, diarrhea, bloating, apnea
What nursing interventions are indicated for the patient with serotonin syndrome
Stop the drug
Initiate symptomatic treatment: SSRI, cooling blankets, Diazepam (for muscle rigidity), anticonvulsants, artificial ventilation
Be able to differentiate between mild, moderate, severe, and panic level anxiety. (pp. 269-270 (Table 15.1) Varcarolis 9th ed.; pp 119-120 Varcarolis Care manual 7th ed.)
Mild: occurs in the normal everyday experience of living and allows the individual to perceive reality in sharp focus; a person experiences sees, hears and grasps more information and problem solving becomes more effective
o Physiological response: slight discomfort, restlessness, irritability or mild tension-relieving behaviors (nail biting, foot or finger tapping, fidgeting)
Moderate: As anxiety increases, the perceptual field narrows, and some details are excluded from observation; person sees, hears and grasps less information and may demonstrate selective inattention; ability to think clearly is hampered but learning and problem solving can still take place
o Physiological response: tension, pounding heart, increased HR and RR, perspiration and mild somatic symptoms (gastric discomfort, headache, urinary urgency), voice tremors
Severe: person may focus on one particular detail or on many scattered details and have difficulty noticing what is going on in the environment, even when another person points it out; learning and problem solving are not possible, person may be dazed and confused, behavior is aimed at reducing or relieving anxiety
o Physiological: headache, nausea, dizziness, insomnia; trembling, pounding heart, hyperventilation, sense of impending doom or dread
Panic: most extreme level of anxiety and results in marked dysregulated behavior; unable to process what is going on in the environment and may lose touch with reality
Review patient assessment, interventions, and rationale for client experiencing moderate level anxiety. (pp. 278, 280 (Table 15.9 Varcarolis 9th ed; pp. 131-132 Varcarolis Care Planning Manual 7th ed).
Help the patient identify anxiety: validate observations with the patients, name the anxiety, and start to work with the patient to lower anxiety
Anticipate anxiety-provoking situations: escalation of anxiety to a more disorganizing level is prevented
Use nonverbal language to demonstrate interest (lean forwards, maintain eye contact, nod head): verbal and nonverbal messages should be consistent
Encourage the patient to talk about feelings and concerns: when concerns are stated aloud, problems can be discussed and feelings of isolation decreased
Avoid closing off avenues of communication that are important to the patient; focus patient concerns: when staff anxiety increased, changing the topic or offering advice is common but isolates the patient
Ask questions to clarify what is being said: increased anxiety results in scattering of thoughts, clarification helps patients to identify their thoughts and feelings
Help the patient to identify thoughts and feelings before onset of anxiety: helps patient to identify thoughts and feelings facilitating problem solving
Encourage problem solving
Help patient to develop alternative solutions to a problem or through role-play or modeling behaviors
Explore behaviors that have worked to relieve anxiety in the past
Provide outlets for working off excess energy: walking, playing ping-pong, dancing, exercising
Be familiar with the defense mechanisms: regression, undoing, and splitting. (p. 271 Table 15.2 Varcarolis 9th ed
Splitting: inability to integrate the positive and negative qualities of oneself or others into a cohesive image
Regression: reverting to an earlier, more primitive and childlike patten of behavior that may or may not have been exhibited previously
Undoing: when a person makes up for a regrettable act or communication
Be familiar with the drugs: Lorazepam (Ativan), Chlordiazepoxide (Librium), Midazolam (Versed), Valproic acid (Depakote), Escitalopram (Lexapro)
Lorazepam- benzodiazepines; treatment of acute mania
Valproate- FDA-approved for manic episodes associated with bipolar disorder, recommended for mixed episodes and found to be useful for rapid cycling.
Chlordiazepoxide (Librium) is useful for tremulousness and mild to moderate agitation.
Which medication treats anxiety (chronic) long term and is first line?
SSRI
Which medications treat anxiety (acute) short term?
Benzodiazepines: alprazolam (Xanax)
What medication combinations might be used to treat severe anxiety?
Benzo and SSRI or TCA
Intervention for hyperventilation in response to anxiety?
if hyperventilation occurs ask pt to take slow deep breaths and breathing with pt can also help.
What are the signs and symptoms of PTSD in children, adolescents, and adults? (pp. 295-300 V9th ed.)
- Essential assessment data includes
in preschool children manisfestation of reduction in play
play that includes aspect of the traumatic event
social withdrawal
negative emotions such as fear, guilt, anger, horror, sadness, shame or confusion
Children may blame themselves for the traumatic event
children may feel detangled or estrange from others and diminished interest or participation in significant activities
irritability, aggression, or self-destructive behavior
sleep disturbance, problem concentrating, and hypervigilance.
Even if a child does not have sufficient symptoms for a diagnosis of PTSD, he can still suffer from overwhelming nightmares or difficulties with trust, phobias, somatic problems, impulse control, and identity issues
o Nightmares and night terrors
o Intrusive traumatic thoughts and memories
o Re-experiencing or flashbacks ‘numbing
o Avoidance of stimuli with the traumatic event
Presence of self-injurious behaviors due to anxiety and negative emotion states
Somatic symptoms: headaches, stomachaches, pain
Memory problems: amnesia, forgetfulness, difficulty concentrating, trance states
Children: may re-enact the trauma in play
Adult: flashbacks, avoidance of stimuli associated with the trauma, hyper vigilance, alterations in mood.
What role does resilience play in trauma? (p. 296 V9th ed.)
Resilience allows for a positive adaptation or ability to maintain or regain mental health despite adversity
presence of social support and protective factors that include collectivism help with resilience.
What are some of the basic level interventions for somatic symptom disorders? (p. 325 Table 17.4 V9th ed.)
Offer explanation and support during dx testing- reduce anxiety while ruling out organic illness.
After physical complaints have been investigated avoid further reinforcement, do not take vital signs each time they suspect they are off- directs focus away from physical symptoms.
Spend time with the patient at times other than when patient summons nurse to make a complaint. - reward non-illness-related behaviors and encourage repetition of desired behavior.
Observe and reinforce frequency and intensity of somatic symptoms-establish a baseline and later enable evaluation of effectiveness of interventions
Do not imply s/s are not real- Acknowledge that symptoms are real to pt.
Shift focus from somatic complaints to feelings or neutral topics-convey interest in pt as a person rather than pt with symptoms.
Assess secondary gains the physical illness provides – attention, increased dependency, distraction from another problem
Use a matter of fact approach to patient exhibiting resistance
Have patient direct all requests to case manager
Have patient look at effect of illness behaviors on others
Show concern for patient while avoiding fostering dependency needs
Reinforce patients strengths and problem solving abilities
Teach assertive communication
Anorexia nervosa (pp. 332-333 V9th ed.)
Intense fear of weight gain, Distorted body image, Restricted calories with significantly low BMI
difficult to treat
The two types of anorexia nervosa (p. 333 V9th ed.)
Bulimia Nervosa: Recurrent episodes of uncontrollable binging
o Inappropriate compensatory behaviors: vomiting, laxatives, diuretics, or exercise
o Self-image is largely influenced by body image
Binge eating: Recurrent episodes of uncontrollable binging without compensatory behaviors
o Binging episodes induce guilt, depression, embarrassment, or disgust
Refeeding syndrome? (p. 335 V9th ed.)
Refeeding syndrome: fatal condition caused by rapid refeeding after a period of undernutrition; result in abnormalities of fluid balance and glucose metabolism as well as hypophosphatemia, hypomagnesemia, and hypokalemia
thiamine deficiency may also occur
What is the effect of anorexia on tryptophan and serotonin? (p. 333 V9th ed.)
Tryptophan, an amino acid essential to serotonin synthesis, is available only through diet
Temporary declines in dietary tryptophan may actually relieve symptoms of anxiety and dysphoria and provide a reward for caloric restriction. However, continued malnutrition will result in a physiological dysphoria
This cycle of temporary relief, followed by more dysphoria, sets up a positive feedback loop that reinforces disordered eating behavior.
dietary need for tryptophan may also explain why antidepressants that boost serotonin do not improve mood symptoms until after a patient has been restored to 90% of optimal weight.
What drugs are FDA approved for insomnia (pp. 358-359 Table 19.3 Varcarolis 9th ed.)
Benzodiazepine: Estazolam (ProSom), Flurazepam (Dalmane), Quazepam (Doral), Temazepam (Restoril), Triazolam (Halcion)
Nonbenzodiazepine receptor agonists: Eszopiclone (Lunesta), Zolpidem, Zaleplon (Sonata), Immediate release (Ambien), Immediate release (Intermezzo
Melatonin receptor agonists: Ramelteon (Rozerem)
Orexin Receptor Antagonists: Lemborexant (Dayvigo), Suvorexant (Belsomra)
TCA: Doxepin (Silenor)
What psychiatric medications can cause sexual dysfunction? (Table 20.3 p. 378 V9th ed.)
Sedatives: alcohol
Antianxiety drugs: alprazolam, diazepam
Antipsychotics: first gerneation anti-psychotics, second generation antipsychotics
Antidepressants: SSRIs, SNRIS, TCAs, MAOIS
Antimanic: lithium
Priority nursing assessments for paraphilia.
Assess the potential for self-harm, because patients with paraphilic disorders may become despondent and be more likely to consider suicide.
The main focus of the assessment should be on the presenting problem (e.g., major depressive disorder with suicidal ideation).
Elicit the patient’s perception of the impact of the sexual disorder on the current illness.
Assess the potential for self-harm, because patients with paraphilic disorders may become despondent and be more likely to consider suicide.
The main focus of the assessment should be on the presenting problem (e.g., major depressive disorder with suicidal ideation).
Elicit the patient’s perception of the impact of the sexual disorder on the current illness.
Oppositional defiant disorder (ODD) (pp. 391-392 V9th ed.)
affects both emotions (e.g., anger and irritation) and behaviors (e.g., argumentativeness and defiance).
This disorder impairs the child’s life and makes school functioning, friendships, and family life extremely difficult.
The behaviors may be confined to only one setting or, in more severe cases, present in multiple settings such as both at home and in school.
Children and adults with oppositional defiant disorder show a preference for large rewards and pay little attention to increasing penalties.
most children outgrow the disorder
Adverse childhood experiences (ACEs) (p. 393 V9th ed.)
associated with oppositional defiant disorder and other impulse control disorders that continue into adulthood
ACEs include family distress, inadequate parenting, and problems with attachment.
Conflict in the marriage is more important than whether or not the parents separate.
Children from larger and impoverished families are also at risk
Conduct disorder (CD) (pp. 394-395 V9th ed.)
is a persistent pattern of behavior in which the rights of others are violated and societal norms or rules are disregarded.
The behavior is usually abnormally aggressive and can frequently lead to the destruction of property or physical injury.
Individuals with this disorder initiate physical fights and engage in bullying
They may steal or use a weapon to intimidate or hurt others.
Coercion into an activity against another’s will, including sexual activity,
Know DSM 5 criteria for CD (p. 394 V9th ed.)
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others
2. Often initiates physical fights
3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
7. Has forced someone into sexual activity
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing serious damage
9. Has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or Theft
10. Has broken into someone else’s house, building, or car
11. Often lies to obtain goods or favors to avoid obligations (i.e., “cons” others)
12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting but without breaking and entering; forgery)
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning before age 13 years
14. Has run away from home overnight at least twice while living in the parental or parental surrogate home or once without returning for a lengthy period
15. Is often truant from school beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.
What is callousness and what is it a predictor of? (p. 394 V9th ed.)
Callousness is characterized by lack of empathy and being unconcerned about the feelings of others.
they may be a predictor of future antisocial personality disorder in adults
Intermittent explosive disorder (IED) (p. 395 V9th ed.)
is a pattern of behavioral outbursts characterized by an inability to control one’s aggressive impulses.
can be verbal or physical and is targeted toward other people, animals, property, or even oneself.
Pyromania (p. 396 V9th ed.)
is described as repeated deliberate fire setting.
The person experiences tension or becomes excited before setting a fire and shows a fascination with or unusual interest in fire and its contexts, such as matches.
Kleptomania (p. 396 V9th ed.)
is a repeated failure to resist urges to steal objects not needed for personal use or monetary value.
For example, a person may take books even though he cannot read or take baby outfits considered cute even though she has no children and has enough money to buy them.
Is it possible for children to outgrow any of the impulse disorders?
How should expressed emotion be utilized in the treatment environment?
In the context of the treatment environment, strongly expressed emotion is a major cause of aggressive responses from patients with impulse control disorders.
What is the purpose of the Clinical Institute Withdrawal Assessment revised (CIWA-Ar)?
- Used to quantify the severity of alcohol withdraw syndrome
- Monitor and medicate pt going through withdrawal
- Measure withdrawal symptoms
Score of 8 or fewer: mild withdrawal
Score of 9-15: moderate withdraw
Score of greater than 15: severe withdraw
What is the purpose of the Clinical Opiate Withdrawal Scale (COWS)?
Assist in tailoring opioid treatment
Determines the severity of the opioid withdrawal
Inpatient and outpatient setting
Monitors how symptoms change overtime during treatment; uses 11 common symptoms of withdrawal and its severity
What medications are used for alcohol withdrawal? (p. 419 Varcarolis 9th ed)
Chlordiazepoxide (Librium): tremulousness, mild to moderate agitation
Diazepam (valium): given IV for withdrawal seizures
oral: symptomatic relief of acute agitation, tremor, impending or acute DTs, hallucinosis
IV lorazepam (Ativan): used for severe symptoms
Be familiar with delirium tremens (DTs), Wernicke’s (alcoholic) encephalopathy, Korsakoff’s syndrome, Wernicke-Korsakoff Syndrome. (pp. 419-420 Varcarolis 9th ed.)
delirium tremens (DTs): Alcohol withdrawal delirium, medical emergency that can result in the death of 20% of untreated patients; may happen anytime in the first 72 hours
o s/s: tachycardia, diaphoresis, fever, anxiety, insomnia, HTN, tactile and visual hallucinations, delusions
wernickes: acute; IV thiamine for two to three times daily for 1 to 2 weeks
Korsakoff: chronic: thiamine for 3 to 12 months
o s/s w + K: altered gait, vestibular dysfunction, confusion several ocular motility abnormalities (horizontal nystagmus, lateral orbital palsy, and gaze palsy), Sluggish reaction to light and anisocoria (unequal pupil size)
Which is reversible: Delirum or Dementia?
Are any reversible? – delirium is
What medication is used for opiate overdose? (p. 413 Varcarolis 9th ed)
Promote breathing: aspirating secretions, inserting an airway, mechanical ventilation
Naloxone (Narcan): can be given intranasally, IM, SubQ, IV
How is delirium different from dementia? (pp. 432-433, p. 440 Table 23.4 Varcarolis 9th ed)
Delirium: cute cognitive disturbance and often reversible condition that is common in hospitalized patients, especially older patients
s/s: inability to direct, focus, sustain, and shift attention; an abrupt onset with clinical features that fluctuate with periods of lucidity; and disorganized thinking
Dementia: Slowly, over months and years
s/s: Impaired memory, judgment, calculations, attention span, abstract thinking and agnosia; activity is not altered, agitation, slow, not reversible
What symptoms are associated with delirium? (pp. 432-433 Varcarolis 9th ed.).
Cognition: Impaired attention span, memory deficit, disorientation, disturbances in perception, not related to other cognitive disorders or reduced level of arousal
Activity level: Can be increased or reduced; restlessness, and behaviors may worsen in the evening (sundowning); sleep-wake cycle may be reversed
Emotional state: Rapid swings; can be fearful, anxious, suspicious, aggressive, have hallucinations and/or delusions
What is methadone (Dolophine, Methadose), clonidine (catapres), and buprenorphine used to treat? (pp. 413-414 Varcarolis 9th ed.)
Methadone (dolophine, methadose): synthetic narcotic, used to decreased the painful symptoms of opiate withdraw; blocks the euphoric effects of opiate drugs
Clonidine (catapres): antihypertensive, eases sweating, hot flashes, watery eyes and restlessness, can also reduce patient anxiety, and may shorten detox process
Buprenorphine: helps people reduce or quit opiates; produces euphoria and respiratory depression but the effects are weaker than other opioids such as heroin and methadone
Be able to distinguish between mild and moderate neurocognitive disorders, and the 3 stages of Alzheimer’s disease. (pp. 436-437 Varcarolis 9th ed.; p. 441 Table 23.5 Varcarolis 9th ed.)
early: Difficulty remembering recent conversations, names or events, apathy, and depression
Middle: Impaired communication, disorientation, confusion, poor judgment, and behavioral changes
Late: Difficulty speaking, swallowing, and walking
Mild: the impairments do not interfere with activities of daily living, although the person may have to make extra efforts
Moderate: interfere with daily functioning and independence
What are the priority nursing interventions for patients with severe Alzheimer’s disease? (pp. 440-442 Varcarolis 9th ed).
Supporting caregiver: Include family members in planning, providing, and evaluating care, to the extent desired.
Assessing safety and implementing safety regime: Identify and remove potential dangers in environment.
Assessing risk for falls, tendency to wander, discomfort, pain
Assessing cognition: Determine and monitor cognitive deficit(s), using standardized assessment tool.
Assessing self - care: Identify usual patterns of behavior for such activities as sleep, medication use, elimination, food intake, and self-care.
Providing emotional support: Ascertain what is important to these patients, their values and beliefs, as well as their life histories.
Assessing fatigue and facilitating rest: Provide rest periods to prevent fatigue and reduce stress.
Monitoring food and fluid intake: Monitor nutrition and weight. Provide finger foods to maintain nutrition for patient who will not sit and eat.
Implementing comfort care and managing anxiety:
introduce self and address patient by name when initiating interaction and speak slowly.
Give one simple direction at a time in a respectful tone of voice.
Avoid frustrating patient by quizzing with orientation questions that cannot be answered.
Use distraction, rather than confrontation, to manage behavior.
Provide consistent caregivers, physical environment, and daily routine.
Provide a low-stimulation environment with adequate lighting.
Provide cues—such as current events, seasons, location, and names—to assist orientation
Select television or radio programs based on cognitive processing abilities and interests.
Limit number of choices the patient has to make so as not to cause anxiety
Place patient’s name in large block letters in room and on clothing, as needed.
Use symbols, rather than written signs, to assist patient in locating room, bathroom, or other area.
What side effects are associated with donepezil (Aricept)? (pp. 443-446 Varcarolis 9th ed)
GI; Nausea, diarrhea, insomnia, muscle cramps, fatigue, anorexia
What patient education should be included for donepezil (Aricept)? (pp. 443-446 Varcarolis 9th ed)
- Take medications with food to reduce GI effects
- Side effects are usually short term
- GI are main side effects
- Used in caution with patient also taking NSAIDS
Be able to distinguish between the 10 personality disorders. (pp. 452-458, 464 Varcarolis 9th ed.).
Cluster A: Behaviors described as odd or eccentric
a. Paranoid personality disorder: characterized by a long-standing distrust and suspiciousness of others based on the belief, unsupported by evidence, that others want to exploit, harm, or deceive the person
s/s – appear in childhood or adolescence: hypervigilant, provide hostile responses, controlling behaviors, jealousy, unwillingness to forgive, projection
b. Schizoid personality disorder: exhibit a lifelong pattern of social withdrawal, somewhat expressionless and have a restricted range of emotional expression, others tend to view them as odd or eccentric because of their discomfort with social interaction
s/s – appear childhood or adolescence: childhood- loners, do poorly in school, objects of ridicule; emotional detachment; do not seek out or enjoy close relationships; they feel as an observer and describe feelings of depersonalization or detachment from self or the worlds
c. Schizotypal personality disorder: symptoms are strikingly strange and unusual; severe social and interpersonal deficits; can be made aware of their suspiciousness, magical thinking, and odd beliefs
s/s evident in young people - Magical thinking, odd beliefs, strange speech patterns, and inappropriate affect; extreme anxiety in social situations; ramble with lengthy, unclear, overly detailed, and abstract content; tend to misinterpret the motivations of others, suggesting that they are “out to get them,” and they blame others for their social isolation; possible hallucinations and delusions
Cluster B: Behaviors described as dramatic, emotional, or erratic
a. Borderline personality disorder: most dramatic disorder and is characterized by severe impairments in functioning; *emotional dysregulation – poorly modulated mood characterized by mood swings
s/s: patterns of marked instability, impulsivity, identify or self-image distortions, unstable mood and unstable interpersonal relationships; chronic SI, antagonism manifested in hostility anger and irritability, physically violent towards others
ii. Emotional liability: rapidly moving from one emotional extreme to another
iii. splitting
Narcissistic personality disorder: feelings of entitlement, an exaggerated belief in one’s own importance, and a lack of empathy; people with this disorder suffer from weak self-esteem and hypersensitivity to criticism, more common in males than females, sense of personal entitlement paired with a lack of social empathy can result in the exploitation of others
s/s: antagonism, arrogant with an inflated view of importance; has a need for constant admiration along with a lack of empathy for others, sensitive to rejection and criticism
Histrionic personality disorder: excitable and dramatic yet are often also high functioning, referred to as “drama queens” or “drama majors.” Classic characteristics of this population include extroversion, flamboyance, and colorful personalities, tend to have limited abilities to develop meaningful relationships, do not think that they need psychiatric help
s/s: emotional attention-seeking behaviors, including self-centeredness, low frustration tolerance, and excessive emotionality, often impulsive and may act flirtatiously or provocatively; does not have insight into a personal role in breaking up relationships
Antisocial personality disorder
Cluster C: behavior that are described as anxious or fearful
Aviodant:extremely sensitive to rejection, feel inadequate, and are socially inhibited, avoid interpersonal contact owing to fears of rejection or criticism; often avoid new interpersonal relationships or activities because of their fears of criticism or disapproval
s/s infants to children: shyness and avoidance, low self-esteem associated with poor functioning in social situations, feelings of inferiority compared with peers, and a reluctance to engage in unfamiliar activities involving new people
Dependent: characterized by a pattern of submissive and clinging behavior related to an overwhelming need to be cared for, may manipulate others to assume responsibility for such activities as dealing with finances or child rearing
s/s: submissiveness, feelings of insecurity about their self-agency and lack of self-confidence may interfere with attempts at becoming more independent
Obsessive- compulsive disorder: limited emotional expression, stubbornness, perseverance, and indecisiveness, more common in men and oldest sibling most affected; feel genuine affection for friends and family; leisure activities and friendships are dropped in favor of excessive devotion to work and productivity
s/s: preoccupation with orderliness, perfectionism, and control are the hallmarks of this disorder; obsessive thoughts and repetition or adherence to rituals; rigidity and inflexible standards for self and others, rehearse over and over how they will respond in social situations, goal-seeking behavior long after it is necessary
When evaluating the lethality of a suicide plan, what three questions should be asked of the patient immediately? (p. 476 Varcarolis 9th ed.)
Is there a specific plan with details?
How lethal is the proposed method?
Is there access to the planned method?
What are high and low-risk lethality methods? (p. 476 Varcarolis 9th ed.)
High risk
o Firearms
o Jumping of a high place
o Poisoning with carbon monoxide
o Hanging
o Staging a car crash
Low risk
o Cutting wrists
o Inhaling natural gas
o Ingesting pills
What environmental safety methods for minimizing suicidal behavior should be in place on the psychiatric unit? (p. 479 and Box 25.4 p. 481 Varcarolis 9th ed.)
plastic eating utensils (no glass or metal), collected and counted after meals
NO private rooms, doors remain open at all times
unbreakable glass windows, tamper proof, are locked when not in room
no electrical cords used on the unit
utility rooms, kitchens, offices, stairwells are locked
personal belongings searched at admission and at return from a pass off the unit
remove belts, shoelaces, metal nail files, tweezers, razors, perfume/shampoo, matches
visitors not allowed to bring personal items onto the unit
Anger (p. 502 V9th ed.):
emotional response to frustration of desires; a threat to ones needs (emotional or physical) or a challenge
positive if expressed in a healthy way
Aggression (p. 502 V9th ed.):
an action or behavior resulting in a verbal or physical attached; is not always inappropriate; necessary for self-protection
tends to be use synonymously with violence
Violence
an objectionable act of involving intentional use of force resulting (or potential to) in injury to another person
Bullying (p. 504 V9th ed.)
Less extreme form of violence that is far more prevalent and has significant consequences.
Bullying is any negative activity, including teasing, kicking, hitting, and spitting, intended to bother or harm someone
Note 
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