Exam 1

mental status and anxiety

I am a star

I - introduce

A - appearance & behavior

M - movement & gait

A - affect & mood

S - speech

T - thought pattern

A - attention & concentration or insight & judgement

R - respond & record abnormal results

appearance

body build

clothing appropriate to location and situation

hygiene, grooming, odor

behavior

increased or decreased activity

eye contact, mannerisms, posturing

• posturing → move away immediately

movement

foot tapping, tics, lip movements, nail biting

difficulty rising from chair, balance, clumsy, falling easily

can show how medication can be changedg

gait

manner of walking - shuffling, slow, etc

can show if patient is under the influence

affect

what you see as patient’s expression

full/appropriate - wide range of emotions, mood switch appropriately

constricted/restricted - little emotion

flat/blunted - no emotion

labile - unstable, rapid mood changes

inappropriate - wrong emotion for the situation

mood

how patient is feeling

can be measured by a scale

euthymic/normal

dysphoric/depressed

angry

irritable

anxious

speech

measure how well patient is speaking

accent, clarity, stutter or lisp

rate - fast or slow

latency - normal or increased/decreased pauses

volume - normal or soft or loud

intonations - normal of decreased

thought pattern

form: rate of thoughts, flow, and if they are connected

• circumstantial: going in circles but will answer the question

• tangential: going in many directions and will NOT answer questions

content: what occupies patient’s thoughts

• future-oriented? suicidal/homicidal ideation?

• hallucinations: what patient senses

• delusions: what patient believes

ex: word salad, clanging, flight of ideas

attention and concentration

distraction, concentration, memory

orientation to time, place and person

insight: awareness to own situation or illness

judgment: ability to anticipate consequences to behavior and make decisions to protect self and others

why temporary anxiety can be good

causes motivation; a function to protect an individual from danger

why excessive anxiety is bad

interferes with function and becomes a disorder

• happens at inappropriate times

• increases in frequency

• affect’s ability to function

• duration is increasingly prolonged

#1 cause of anxiety and depression

low serotonin

generalized anxiety disorder

excessive anxiety and worry in response to a lot of things

WATCHERS

• Worry and Anxiety

• Time: at least 6 months

• difficult to control

• Handicapped (restricted) life

• Exclude other mental disorders

• Rule out causes from substances or medical conditions

phobias

fear of specific object upon exposure

PHOBIA

• Persistent (at least 6 months)

• Handicapped (restricted) life

• Out of proportion fear

• Beginning immediately and always

• Intense fear about specific object leading to avoidance

social anxiety disorder

fear to social situations; feat or embarrassment, rejection, or offending others

FEAREeDd

• Fear of social situation, scrutiny, or negative evaluation from others

• Exposure to social situation causes fear

• Avoids or endures social situation

• Recognizes fear is out of proportion

• Exclude fear induced by substances or medical conditions

  • excessive fear of another medical condition

• Distress

  • duration lasts at least 6 months

panic disorder

fear that is unexpected and occurs for no reason (without triggering event)

STUDENTS Fear 3 C’s

• Sweating

• Trembling

• Unsteadiness

• Derealization

• Excessive heart rate/palpitations

• Nausea

• Tingling

• SOB

• Fear of losing control

• Chills, chest pain, choking

agoraphobia

fear of travel or location

COOPE

• crowded places

• open spaces

• outside of home

• public transport

• enclosed spaces

obsessive compulsive disorder

an obsession to do something; obsession to finish a compulsion; person will freak out if interrupted

REORIENT PATIENT

• recurrent thoughts and urges

• experienced as unwanted and intrusive

• often causes anxiety

• resist by suppressing thoughts with another thought or compulsion

• impaired social, occupation, and functioning

• exclude due to substance or other medical condition

• not related to other mental disorder

• time consuming (at least 1 hr)

• perform due to obsession

• acts repetitively

• to prevent anxiety

• impaired social, occupation, and functioning

• exclude due to substance or other medical condition

• not related to other mental disorder

• time consuming (at least 1 hr)

body dysmorphic order

preoccupations with defects of one’s appearance

hoarding

inability to part with possessions

trichotillomania

intentionally pulling out hair; maybe due to boredom and anxiety

excoriation disorder

picking at skin resulting in lesions

ptsd

exposure to traumatic event and can be re-experienced; avoids trauma-associated stimuli

TRAUMA

• traumatic event

• recurrent recollections

• avoidance

• unable to function

• month long symptoms

• arousal increased - can’t sleep, irritable

re-experiencing symptoms (ptsd)

flashbacks, nightmares, frightening thoughts

event relived over and over causing elevated vital signs

avoidance (ptsd)

effort to stay away from anything that triggers the trauma

negative changes in mood (ptsd)

can’t remember what happened

negative feelings about self and the world

blame, guilt, anger, shame

decreased interest, detachment

can’t express positive emotions

hyper-arousal (ptsd)

easily startled, tense, difficulty sleeping, angry outbursts, unable to turn off fight-or-flight

treatments for anxiety disorders

SSRIs

SNRIs

buspirone

antihistamines

anticonvulsant

benzos

antihypertensives

nonpharmacologic treatments for anxiety

• cognitive behavioral therapy - most popular

• cognitive therapy - eliminate negative thoughts that add to anxiety

• exposure therapy

• psychotherapy

• support groups

• lifestyle management

SSRI meds

• effective - escitalopram

• for - fluoxetine, fluovoxamine

• sadness - sertraline

• panic - paroxetine

• compulsion - citalopram

takes 4-6 weeks

SSRI side effects

• sexual dysfunction

• stomach upset

• serotonin syndrome

• suicidal thoughts

serotonin syndrome

too much serotonin syndrome

increases risk due to starting medications, increasing dose, and combining with other medications

• shivers

• hyperreflexia and myoclonus - exagerrated movements

• increased temp

• vital signs increased (HR, RR, BP)

• encephalopathy - lose consciousness, seizure, confusion, memory loss

• restlessness

• sweating

SNRI meds

venlafaxine, desvenlafaxine, duloxetine

takes 4-6 weeks

buspirone

anxiety med

no risk for withdrawals or dependence

no grapefruit

takes 1-2 weeks

works for 50% of the population

antihistamine meds

diphenhydramine, hydroxyzine

takes 30 min

antihistamine side effects

dry mouth, drowsiness, dizziness, blurred vision

anticonvulsant meds

gabapentin (at lower doses for anxiety)

takes 30 min

benzo meds

diazepam, alprazolam, chlordiazepoxide, lorazepam, clonazepam

not recommended due to risk for dependence, anterograde amnesia (unable to make memories), and paradoxical response (results shows opposite of what is intended)

immediate action

antihypertensive meds

propranolol, clonidine (used if can’t tolerate SSRI or SNRI)

not addictive or major cognitive impairment

takes 20-30 min

side effects: dizziness, hypotension, dry mouth

goal for anxiety disorders

eliminate anxiety through the use of therapy and medications

nurse role when caring for patients with anxiety disorders

understand implicit bias and habit-breaking strategies (self awareness)

understand trauma-informed care, therapeutic relationship, and client’s perspective (client-centered care)

understand changing lifestyle and learning coping strategies can help (prevention)

teach patient about resources, when to see physician, about disorder, manifestations, management, treatments, therapies (teaching)

priority for patient’s experiencing mood disorders

safety

SIGECAPS

• sleep ⇅

• interest ↓

• guilt

• energy ↓

• concentration/cognition ↓

• appetite ⇅

• psychomotor ⇅

• suicidality

cognitive behavioral therapy

change behavior by changing thinking

electroconvulsive therapy

anesthesia + induce brief seizures

invasive, voluntary after other options exhausted, done 3x per week

temporary memory loss so nurse has to ask “how will you get home”

jaw pain relieved by Tylenol

Benzos to be discontinued prior

transcranial magnetic stimulation

pulses stimulate brain

not invasive and done everyday

patient also on maintenance medication

light therapy

patient needs to sit in front of all-spectrum light to treat seasonal affective disorder

behavioral contract

patient able to not act on something and find nurse or respond to the nurse

sad persons scale for suicidal patients

0-2: home w/ follow up

3-6: admit or discharge w/ follow up

7-10: admitted to hospital

SADPERSONS

• sex male

• ages <19 and >45

• depressed

• previous attempt

• ethanol use

• rational thinking is lost

• social supports lacking

• organized plan created

• no partner

• sickness

other risk factors for suicide

legal problems, financial programs, risky behavior, job loss, substance use

experience abuse/neglect/bullying/sexual violence, hx of suicide, relationship problems

barriers to health care, beliefs, community, stigma, access to weapons or meds, portrayals of suicide

warning signs of suicide

stating they want to die

feeling hopeless w/ no reason to live

have no solutions to problems

unbearable physical and emotional pain

feel like a burden

socially withdrawing

giving away possession

arranging affairs and saying goodbye

engaging in risky behavior

thinking or talking about death

ISPATHWARM (for suicide)

• ideation

• substance abuse

• purposelessness

• anxiety

• trapped

• hopelessness

• withdrawal

• anger

• recklessness

• mood changes

bipolar disorder

mania + depression

overactivity, overeating, overspending, not enough sleep, talkative

DIGFAST (for mania)

• distracted

• indiscretions

• grandiose

• flight of ideas

• activity ↑

• sleep ↓

• talkative

medications for depression

SSRI, SNRI, TCA, MAOI, antipsychotics

what to ask when someone is suicidal

are you suicidal? do you have a plan?

taking action with depressed patients

inpatient

• create a structured plan

• consider fiber in diet

• monitored in psych unit

outpatient

• coordinate medication and psychotherapy

taking action with manic patients

inpatient

• high calorie/quality food

• structured plan

• quiet night, quiet designated periods

outpatient

• high calorie'/quality food

• good sleep and hygiene

taking action with general mood disorders

therapeutic milieu, positive communication, assess suicide risk, use suicide precautions

inpatient safety

assess suicidality, remove harmful objects, one-to-one

outpatient safety

ask about ideations, plans, or if help is needed

• encourage reporting as they occur

ask about lethality of plan

• report to provider and law enforcement if patient is DTS/DTO

short term outcomes for mood disorder

• absence of SI

• ability to self care

• thought process

• can function and heal in outpatient setting

• stable mood

  • knowledge about own disorder

long term outcomes for mood disorder

• adhere to meds

  • lack of suicidality

• functional in life

TCA meds

deadly (cardiac toxicity) to OD on due to narrow window of safety

for depression, not for suicidal patients

amitriptyline, imipramine, doxepin

MAOI meds

phenelzine, selegiline

inhibits breakdown of dopamine, norepinephrine, and serotonin

used for compliant patients suffering from depression

increased risk or HTN crisis caused by extra tyramine (severe headache, sweating, lightheaded, vomiting, increased HR)

not to be combined with SSRIs

trazadone for depression

antipsychotic for depression

causes sleepiness

antipsychotic NDRI for depression

bupropion

arouses people too much and might cause seizures

FINISH

withdrawal symptoms occur in all classes of antidepressants

taper off!

• flu-like s

• insomnia

• nausea

• imbalance

• sensory disturbances

• hyperarousal/anxiety

Q to ask when patient experiences symptoms: when did you stop taking your meds?

meds for bipolar disorder

mood stabilizers

anticonvulsants

antipsychotics

lithium

mood stabilizer for bipolar disorder

narrow therapeutic range - bloodwork necessary (0.5-1.2)

can be used for mania, bipolar disorder

processed in kidneys - BUN and creatine check required

decreased suicidality

lithium side effects

urine issues (pu/pd)

nausea

hand tremor

weight gain

lithium toxic effects

v/d both ways

sedation

severe tremor

muscle weakness

seizures

drowsiness

discontinue

must be taken with balance Na intake

anticonvulsant for bipolar disorder

valproic acid (50-100), carbamazepine (4-12)

blood levels required - decrease can mean meds are not being taken

lamotrigine

mood stabilizer for bipolar disorder

slowly increase

side effects: horrible rash → discontinue

2-20

quetiapine

antipsychotic medication causes drowsiness and weight gain

antipsychotic used as mood stabilizer or adjunct for antidepressant

lurasidone

antipsychotic medication that needs to be taken with food (at least 350 calories)

personality disorder

long term patterns of behavior and experience that different from what is expected

5 factor model of personality

extraversion

agreeableness

conscientiousness

neuroticism

openness to experiences

extraversion

reserved & thoughtful

vs

social & fun-loving

agreeableness

suspicious & uncooperative

vs

trusting & helpful

conscientiousness

impulsive & disorganized

vs

disciplined and careful

neuroticism

calm & confident

vs

anxious & pessimistic

openness to experiences

routine & practical

vs

imaginative & spontaneous

cluster a personality disorder

odd, eccentric (weird) but not considered DTS/DTO

paranoid, schizoid, and schizotypal

empathetic nurse can help patients process feelings/emotions

goal: focus on finding and maintaining relationships

paranoid personality disorder

suspicious and accusatory

• suspected spousal infidelity

• unforgiving

• suspicious

• perceives attacks and reacts quickly

• enemy or friend

• confiding in others

• threats in benign events

schizoid personality disorder

does not enjoy or want relationships; loner; aloof

• detached/flattened affect

• indifferent to criticism/praise

• sexual experiences are not interesting

• tasks done solitarily

• absence of friends

• neither desires/enjoys relationships

• takes little pleasure in activities

schizotypal personality disorder

metaphoric speech, magical thinking, can lead to schizophrenia

• magical thinking

• experience unusual perceptions

• paranoid ideation

• eccentric behavior/appearance

• constricted/inappropriate affect

• unusual thinking/speech

• lacks friends

• ideas of reference

• anxiety in socal situation

• rule out psychotic/pervasive development disorders

cluster b personality disorder

erratic, emotional, dramatic (wild)

antisocial, borderline, histrionic, narcissistic

empathetic nurse can help patient process needs while setting up boundaries

goal: focus on teaching patients to set boundaries on behavior

antisocial personality disorder

breaks laws; no remorse or guilt; superficial friendly; sociopathic; manipulative

• cannot conform to law

• obligations ignored

• reckless disregard for safewty

• remorselessness

• underhanded/deceitful

• planning insufficient or impulsive

• temper(irritated, aggressive)

borderline personality disorder

unstable; fear of abandonment; self destructive; mutilation;

• impulsive

• moody

• paranoia

• unstable self-image

• labeled intense relationships

• suicidal gestures

• inappropriate anger

• vulnerability

• emptiness

histrionic personality disorder

attention-seeking, excessive emotions, flamboyant; inappropriate sexual behavior, center of attention

• provocative behavior

• relationships considered more intimate than they are

• attention seeking

• influenced easily

• style of speech lacks detail

• emotions shift rapidly

• make up draws attention to self

• exaggerated emotions