Mental Health Lecture Exam 1

milieu therapy

environment of safety for pt who have impaired cognition

sets limits, provides safety, and containment

remove dangerous items from pt

community meetings

individualized programs - meaningful activities

governance

progressive levels of responsibility

linked to community and family

how to interact with a silent pt

introduce a neutral topic → broad openings and general leads

appropriate communication techniques

active listening

nonverbal communication

reason for using defense mechanisms 

intellectualization: analyzing disappointing situation

denial: refusing to acknowledge painful reality

displacement: transferring feelings onto a different object

isolation: separating ideas from feelings associated with them 

rationalization: using incorrect explanation to conceal own thoughts/feelings

projection: falsely putting ones own feelings onto another 

reaction formation: substituting feelings that are opposed to true ones

repression: cannot remember thoughts or experiences

suppression: intentionally avoiding thinking about experiences

sublimation: channeling maladaptive behaviors into socially acceptable behaviors

 introjection: take on attributes of others as your own

undoing: rituals to make amends for wrongdoing

compensation: overachievement in one area to offset perceived deficiencies 

regression: doing things already outgrown

defense mechanisms from examples (4)

instead of showing emotion jim analyzes a disappointing situation = intellectualization

tina thinks her brother is rude but tells everyone what a great guy he is = reaction formation 

a former gang member becomes a star football player = sublimation

nursing student sets high study standards within her class and many follow her lead = introjection

reasons for involuntary and voluntary admissions w psychiatric clients

voluntary = maintains all legal rights, with consent, must be examined by physician if wanting to be discharged

involuntary = Dr. examination to determine if danger to self or others → if not = released; if yes then petition to mental health court → yes = hospitalization; no = release

• danger to self

• danger to others

• unable to provide the basic needs → gravely disabled 

state reason for removing dangerous items from pt

to prevent harm to pt self or others

common nursing diagnoses for pts that are psychotic

disturbed personal identity, impaired verbal communication, social isolation, self-care deficit, caregiver role strain, ineffective coping, risk for violence (self-directed)

align assessment w nursing diagnosis (ex: hearing voices → appropriate nursing diagnosis)

panic attack/disorder → severe anxiety related to real or perceived threat as evidenced by physical/psychological symptoms (SOB, palpitations, sweating, trembling)

phobias → anxiety related to exposure to phobic stimulus as evidenced by dizziness, dyspnea, palpitations, and feelings of dread)

GAD → worry, ineffective individual coping mechanisms related to conflict about essential life values as evidenced by excessive worry about being a. failure in every endeavor

OCD → ineffective role performance related to obsessive thoughts and ritualistic behaviors as evidenced by frequently recocurring____

PTSD → as evidenced by recurring nightmares, palaptions, irritability, withdrawal

S/S of anxiety and diff levels of anxiety

dread w/o knowing why

normal - avoidable and serves purposes

abnormal - disruptive, disproportional 

mild: increased awareness, increased cognition, alert confident

moderate: decreased sensory awareness, decreased cognition, increased speech restless

severe: distorted sensory awareness, impossible cognition, tremors verbally

panic: impossible sensory awareness, impossible cognition, helpless verbal

long term goals for pts w anxiety

panic → recognize signs of anxiety when stressful situations occur and accepts life situations one cannot control 

phobia → gradually become desensitized to phobic stimulus 

GAD → alternative problem solving, reframing thoughts

appropriate assess questions w pt has anxiety

ask about comorbidities - depression or substance abuse

when / where it happens

what is happening when onset 

priorities when pt has anxiety and depression

ask about risk for suicide

how to measure growth from anxiety treatment

vital signs

assess level of anxiety 

details of benzos and buspar

GABA inhibit neurotransmitter to help regulate anxiety - anxiety pt have impaired GABA system = anxiety is not inhibited

Benzos enhance effects of GABA by helping to inhibit neurotransmission even more = calming the person w anxiety 

Buspar = non-benzo & effective in controlling anxiety

data for OCD, interventions, definitions

obsessions: recurring unwanted ideas, thoughts, and impulses

compulsions: unwanted repetitive acts that are intrusive

body dysmorphic→ low self esteem and disturbed body image (individual psychotherapy, avoid challenging perceptions, treat anxiety/depression)

hoarding → difficulty discarding items causes emotional distress in pt and family

trichotillomania → pulling out hair, feeling shame or loss of control (increased tension)

data regarding panic attacks

develops in late adolescence or early adulthood

coexist with depression and substance abuse

app. diagnosis and treatment are important to access.

S/S: palpitations, rapid pulse, nausea, SOB, diaphoresis - panic attacks

best time to intervene w anxiety disorder pt

exploring possible reasons for anxiety ONLY when anxiety has lessened

positive and negative symptoms

positive: (exaggerated) delusions, hallucinations, thought disorder, disorganized speech, bizarre behavior, inappropriate affect

negative: (diminished) flat affect, brief verbal responses, apathy, anhedonia (inability to experience pleasure), difficulty paying attention 

names for typical and atypical meds

typical = (older)

atypicals = (newer) Clozaril, Risperidone, Zyprexa, Geodon, Abilify, Invega, Saphris

tardive dyskinesia and AIMS scale

TD = supersensitivity of dopamine receptor

irregular, repetitive, involuntary movements of mouth, face, and tongue, rapid eye blinking, and abnormal finger movement

risk factors = >50 y/o, female, affective disorders (depression), brain damage, long duration of treatment, typical antipsychotics, high doses

AIMS scale is used for periodic testing q 90 days

ask pt to open mouth twice (looking at tongue at rest), ask them to protrude tongue twice (looking for abnormal movements), ask to tap thumb with each finger as fast as possible for 10-15 sec (observe facial and leg movements)

clozaril may have lower risk for TD

how to appropriately response to pt hearing voices

stay with the person

reorient to reality

music through headphones 

tell the voices to stop

how do antipsychotic meds work

typicals = work as dopamine antagonists and higher EPS → POSITIVE SYMPTOMS

atypicals = dopamine and serotonin antagonists less EPS  → BOTH POSITIVE AND NEGATIVE SYMPTOMS  

diff types of EPS

extrapyramidal symptoms = blockade of dopamine receptors in basal ganglia which is involved in motor control 

dystonia/acute dystonic reaction - jaw spasms, impaired swallowing, abnormal posture, tongue protrusion, slurred speech

akathisia - restlessness, rocking, pacing

parkinsonism - tremor, muscle rigidity, akinesia (loss of muscle movement)

effects of typical and atypical meds

typical = higher EPS

atypical = less EPS

drugs that help control EPS

using minimum dosage

anticholinergics 

antihistamines   

dystonia = benadryl IM or IV & benztropine (Cogentin)

akathisia = propranolol

polydipsia and schizophrenics

can have water toxicity because they keep drinking water and become fluid overloaded

metabolic syndrome

new onset diabetes

abd obesity

dyslipidemia

hyperglycemia

hypertension

actions taken when NMS happens / signs

severe muscle rigidity, elevated temp, LOC changes, difficult breathing, diaphoresis, tachycardia

reduce body temp, safety measures, supportive measures

1. obtain order to stop admin of offending med

2. obtain order to rasner to ICU

3. obtain order for a brain scan to r/o other

admin for LAI -

Fluphenazine decanoate you will need a large bore needle, changing the needle after drawing up the medication to ensure the needle is dry, and administer the drug using a Z-track method.

etiology of diagnoses from lecture

anxiety: genetic theories (familial predisposition), neurological abnormalities (abnormal activity in fear network of brain - amygdala, hippocampus, periaqueductal gray area), biochemical theories (deficient of GABA)

schizophrenia: genetic, greater paternal age, hypoxia (birth and pregnancy), stress, infection, maternal diabetes; urban settings; neurobiology ( prefrontal cortex and limbic cortex may never fully develop)

substance abuse combined with schizophrenia

many pts have co occurring substance related disorder

have tobacco use disorder → easy to get on street

clozaril problems and positives

may cause agranulocytosis, sedation, metabolic disturbances 

works very well for those who have been struggling on other med

how to communicate with a schizophrenia pt

establish trust

reorient to reality

dont challenge

encourage pt to verbalize feelings

describe and explain ideas of reference

delusions = firmly held belief that involves misinterpretation or perception or experience (fixed false belief) → identify content and type, assess intensity, freq. duration, identify what triggered, identify major stressors (ONLY intervene with pt begins to question the delusion)

hallucinations = errors in the way the brain is processing stimuli, manifested in erroneous messaging in sensory parts of brain (command hallucinations, auditory, visual)