NCLEX Mental Health

What is the number 1 thing you should think about with mental health nursing

Make sure you and the pt are safe at all times

Depression Medications

-SSRI’s → Fluoxetine, Sertraline, “pram.”

-SNRI’s → Duloxetine

-TCA’s → Amitriptyline, Nortriptyline

-MAOI’s → Isocarboxazid

Other → Busporine (no grapefruit)

Fluoxetine, Sertraline, “pram.” (SSRI’s) & Duloxetine (SNRI’s) Considerations

-Anticholinergic Effects

-Low libido (sexual dysfunction) & weight gain

-Take in the morning

-Serotonin Syndrome → Agitation, hallucinations tachycardia, hyperflexia

Amitriptyline, Nortiptyline (TCA’s)

-Anticholinergic Effects

-Must avoid alcohol

-Cardiac Dysrthmia’s

-High risk of seizures

Isocarboxazid (MAOI’s)

-Avoid Tyramine foods → Cheese, alcohol, avocados, organ meat

-DO NOT MIX WITH ANYOTHER ANTIDEPRESSENT = Hypertensive Crisis

Lithium

-Bipolar treatment

-Therapeutic range is 0.4-1.0

-Lithium Toxicity → Hyperirritability, blurred vision, seizures

-Low sodium = High lithium

-High sodium = Low lithium

Anxiety Medications

-Benzo’s → “pam+lam’s”

-Busporine

Benzos need to know

-Side Effects → CNS depression

-Adverse Effects → Paradoxical Response (insomnia, excitation, euphoria “opposite”)

-Antidote → Flumazenil

1st Gen Antipsychotic

Haloperidol

Haloperidol Nursing Need to knows

Side Effects are EPS

-Akathisia → “Inner Anxiety” like tapping foot, rocking back and forth, and pacing

-Tardive Dyskinesia → Lip smacking, pill rolling, tongue movements

-Acute Dystonia → Muscle spasms in the head, neck, and face

-Pseudoparkinsonism → Gait and rigid movements

Adverse Effects are Neuromalignant Syndrome → Severe fever, rhabdo, hyperflexia

2nd Gen Antipsychotics

-Respirodone

-”apines”

Respirodone + “apines”

-2nd Generation Antipsychotics

-Metabolic side effects

-Weight gain

-Diabetes

-High Cholesterol

ADHD Medications

-Stimulants→ Amphetamines (administer in morning)

-Nonstimulants → Atoxetine

Involuntary Admission

-Have to be harm to self or others

-Must stay for 72 hrs (holidays and weekends do not count)

-Have the same rights as everyone else just cant leave before 72 hrs.

Orientation Phase key points

-Trust & confidentiality are established

-Defines the purpose of the group

-Nurse’s role is clarified

-Client’s problems are brought up

Working Phase key points

-Maintain a trustworthy relationship

-Gather and share information

-Problem solve

Termination Phase key points

-Summarize the goals achieved

-Discuss new coping strategies

-Promote closure

Best way to communicate to pts

-Restate the pts statement

-Ask open ended questions

-Reflect → What do you think you should do?

-Exploring → Tell me more about?

Adaptive vs Maladaptive Defense Mechanisms

Adaptive → Positive defense mechanisms

Maladaptive → Negative mechansisms

Attempt to escape unpleasant realities

Adaptive

Unconscious rejection of emotionally unacceptable features and attributing them to others

Ex → Pt who is mad at the nurse yells the nurse hates me

Projection

Transferring the anger from the real source to a non-harmful source

Ex → pt hates their doctor so they start to yell and take it out on the nurse

Displacement

Reverting to an earlier developmental level

Regression

Directing unacceptable behavior into a socially acceptable area

Ex → A student who is angry at teacher writes a short super hero story instead of lashing out

Sublimation

Life stages crisis

Ex → Married, or Retired

Maturational

Sudden, unexpected changes in crisis

Ex → Death, divorce, job loss, severe illness

Situational

An uncommon large-scale disaster

Ex → Natural disaster, war, pandemic

Adventitious

Irrational fear of an object or situation that proceeds is called what

Phobia’s

Phobias Nursing Care

Offer Distraction’s

Recurrent episodes of panic attacks that can include palpitations, chest pain, breathing difficulties that last 15 to 30 minutes

Panic Disorder’s

Panic disorder’s nursing care

Take slow deep breath’s

Persistant intrusive thoughts and repetitive behavior’s that a client feels driven to perform

OCD

OCD nursing care

Schedule times for the pt to do rituals (still allow them to do it, just limit them)

Excessive anxiety/worry more days than not over 6 months

GAD

GAD nursing care

Reframe stressful situations

A complex brain disorder that affects thinking, language, emotions, social behavior, and the ability to perceive reality

Schizophrenia

Schizophrenia nursing assessment

-Positive Symptoms → Delusions, word salad, hallucinations, hearing voices

-Negative Symptoms → Flat & blunted affect

Schizophrenia Nursing Interventions

-Ask directly about the hallucinations (this is a safety concern and is a priority)

-Safe environment → Milieu

-Shift conversation to reality-based subjects

Tourette Disorder/Motor Disorder Interventions

-Maintain a safe environment → Wear a helmet

-Positive reinforcement

Both cognitive and physical function delays

Intellectual Development Disorder

Intellectual Development Disorder nursing care

-Early intervention with speech therapy, physical therapy, and occupational therapy

-Add visual cues

-Give one-step instructions

Children who show an inappropriate degree of impulsiveness and hyperactivity

ADHD

(Medication → Methylphenidate)

Deficits in social retardeness and nonverbal

Autism

Autism nursing interventions

-Early treatment

-Promote positive reinforcement

-Promote small success

-Decrease environmental stimuli

Pt has changes in appetite, insomnia, feeling of worthlessness, and thoughts of suicide

Depression

Depression Nursing Interventions

-Make sure they are not a suicide risk

-SSRI’s → Fluoxetine, Sertraline, “pram.”

-SNRI’s → Duloxetine

-TCA’s → Amitriptyline, Nortriptyline

-MAOI’s → Isocarboxazid

Other → Busporine & ECT (temporary short-term memory less may occour, informed consent needed)

Suicide Precautions

-No glass or silverware on meal trays

-Remove all of pts items

-One on one constant supervision

Bipolar I vs Bipolar II

Bipolar I → Manic episode

Bipolar II → Manic episode + depression

Manic Phase Manifestations

-Extreme energy

-Extreme self-esteem

-Hyper talkative

Manic Phase Nursing Care

-Administer Lithium

-Redirect

-Give finger food

Cluster A Personality Disorders (Odd)

-Paranoid → Distrust & suspicious

-Schizoid → Content with being an emotionally detached observer

-Schizotypical → Need for social isolation

Cluster B (Dramatic/Mean)

-Antisocial → Impulsive risk taking

-Borderline → Extreme emotional liability

-Narcissist → Lack empathy for others and inflammed self-esteem

Histronic → Attention seeking and is often seductive

Cluster C (Fearful)

-Dependent → Excessive clinging

-Avoidant → Hypersensitive to negative evaluation

-OCD

Over-responsibility for the behaviors of others, often ignoring own needs and desires.

Codependency

CNS Depressants

-Benzo’s

-Barbiturates

-Alcohol

CNS Depressants Intoxication manifestations

Drunk

CNS Depressants Withdrawal Manifestations

-N & V

-Tachycardia

-Resltessness

CNS Stimulants

-Cocaine

-Methamphetamine

CNS stimulant intoxication manifestations

-Dilated pupils

-Tachycardia

-Hypertension

CNS stimulant withdrawal

-Fatigue

-Drowsiness

-Increased appetite

Opiates

-Heroin

-Fentanyl

-Hydropmorphone

Opiates intoxication manifestations

-Constricted pupils

-Decreased respirations

Opiates Withdrawal Manifestations

Same as CNS depressants

Dementia Nursing Interventions

-Make sure pt is safe

-Speak to family to get full medical history

-Use short, simple, and word phrases

-Have clocks, calendars, and personal items in clear view

-Maintain a consistent routine

Meds → Donepezil

Delirium Nursing Interventions

Determine the physiological thing that is causing the delirium (environment, pain, drugs, emotional distress).

Predictor’s of Violence

-Loud voice

-Intense avoidant eye contact

-Pacing and restless

-Jaw clenched

Nursing Interventions for abuse

-Maintain calm

-Use short, simple sentences

-Use nonaggressive posture

-Maintain a large personal space gap

-Restraints

-Meds → Benzos

Restraints teaching

-Used least restrictive measures first

-Ordered by provider → Never PRN

-Assessed every 2 hrs

-Expires in 24 hrs

-Movable part of the bed → bed frame

What are the 5 stages of grief

-Anger

-Bargaining

-Denial

-Depression

-Acceptence

Anorexia

-Starvation

-Body image self-conscious

-Weigh daily

-Observe during and after meals

Binge Eating Disorder

-Eating big ass meals

-Go to support groups

-Positive self esteem

Bulimia Nervosa

-Big ass meal + compensation measures (Vomiting, laxative use, diuretic misuse)

-Eroded decaying teeth from throwing up

-Monitor potassium!!

-Monitor during and after meals

Clang association

“snip, snap, tap, take a nap”