Psych Test 2

mania

alteration in mood that may be expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, racing thoughts, and accelerated speech

manic epsiode

-mood is elevated, expansive, or irritable

-sufficiently severe to cause marked impairment in occupational functioning or in usual social activities

-may require hospitalization to prevent harm to self or others

-excessive and frenzied motor activity

-may present w/ psychosis

bipolar depression

-similar diagnostic features as MDD, but with at least one recorded episode of mania

bipolar disorder with mixed features

-symptoms of both mania and depression present concurrently

hypomanic episode

-noticeable increased energy, activity, and sometimes irritability

-not severe enough to cause marked impairment in social or occupation functioning or to require hospitalization

-no psychotic features

Bipolar I

-presence or Hx of a manic episode

-modified w/ single manic episode, current episode mania, hypomanic, mixed, or depressed if have both

-may include psychotic, catatonic features

rapid cycling bipolar disorder

-more than four manic and depressive episodes in a year

Bipolar II

-recurrent bouts of MDD w/ episode hypomania

-depression is generally more severe, comes w/ significant impairment in function, increased SI

-may specify most recent episode

Epidemiology of bipolar

-onset around 25, but current research is finding the actual age to be lower

-becomes recurrent following 1st manic episode

-increase mortality, particularly from suicide

-more common in upper class, active, creative individuals

Clinical presentation of hypomania

-mood = cheerful and expansive. Underlying irritability that surfaces rapidly when wishes, desires goes unfulfilled. Volatile, different than normal mood

-exalted perceptions of the self, rapid flight of ideas

-heightened perception, easily distracted

-psychomotor agitation and goal-direct activity

-extroverted and sociable, but create superficial relationships

-hyper talkative, loud, at times inappropriate

-increased libido, anorexia, weight loss

-inappropriate behaviors (credit card debt, calling important people)

clinical presentation of acute mania - mood

-may occur as progression/intensification of hypomania or initial manifestation

-continuous high, elevated mood w/ frequent variation changing to irritability and anger or sadness and crying

clinical presentation of acute mania - perception and cognition

-fragmented or psychotic cognition: flight of ideas, racing thoughts, over connection of ideas

-pressured speech, may be disorganized or incoherent

-pervasive distractibility

-hallucinations, grandiose or paranoid delusions common

clinical presentation of acute mania-activity and behavior

-excessive psychomotor activity, poor impulse control

-low frustration tolerance

-excessive spending

-socially or sexual uninhibited

-little insight

-diminished need for sleep

-neglect of hygiene, grooming

-disorganized, flamboyant, or bizarre dress w/ excessive makeup or jewelry

Delirious mania clinical presentation

-severe clouding of consciousness and intensification of mania

-less common d/t antipsychotics

-labile: despair, unrestrained merriment, ecstasy, irritability, indifferent, panic anxiety

-confusion, disorientation, stupor

-religiosity, delusions of grandeur or persecution, auditory, visual hallucinations

-frenzied, agitated, purposeless movements

-may lead to exhaustion, injury to self or others, death

Lithium

-first line medication for bipolar

-high sodium can increase toxicity

-can cause weight gain, GI Sx, tremor, ataxia, confusion, increased urination, tinnitus

-monitor thyroid, kidney function

antipsychotics for bipolar disorder

-common examples include olanzapine, aripiprazole

-should be aware of drowsiness, sun sensitivity, report neurological or physical changes, avoid alcohol

-can result in EPS, akathisia, and metabolic disorders

Antidepressants in bipolar disorder

-should not be used w/out a mood stabilizer, as it may trigger a manic episode

-worse if mood switching, rapid cycling, or mixed Sx

Medication adherence in bipolar disorder

-may be helped by motivational interviewing

-should be emphasized as essential to relapse prevention to both family and pt

-family focused care improves rates

-frequent check-ins w/ healthcare professional

Monitoring in bipolar disorder

-lithium levels, medication adherence, SI/HI, medication AE

Pt education in bipolar disorder

-family education on nature of illness

-signs, early recognition, etiology, Tx, and self-management

-cyclic nature, medication management

-Sx of medication AE

-coping mechanisms

Maintaining a theraeutic environment

-minimize stimuli

-remove all sharp objects, class or mirrored items, belts, ties, smoking materials

-avoid interpersonal conflict

Positive Sx of schizophrenia

-delusions: fixed, false beliefs

-hallucinations

-disorganized thinking a/e/b speech

-grossly disorganized or abnormal motor behavior

Examples of disorganized thinking in schizophrenia

-loose association

-tangentiality (never answers question)

-circumstantiality (reaches point)

-incoherence, word salad

-neologisms

-clang associations

-echolalia

abnormal motor behavior in schizophrenia

-catatonia

-hyperactivity

-hypervigilance

-hostility

-agitation

-childlike silliness

-catatonic excitement (excessive or purposeless motor activity)

-stereotypes, repetitive movements

-unusual mannerisms or postures

catatonia

-ranges from rigid to bizarre posture and decreased responsivity to complete lack of verbal or behavioral response to the environment

Negative Sx of schizophrenia

-blunted affect

-lack of expressive body language

-lack of intonation during speech

-neglect of ADLs

-avolition (decreased motivation)

-alogia (decreased verbal communication()

-asociality

-withdrawal, poor rapport

-concrete thinking

Grandiose delusions

-exaggerated feeling of importance, power, knowledge, or identity

-may believe they have a special relationship with a famous person or assume of a famous person

-can also include assumption of deity or religious leader

Delusions of reference

-environmental stimuli assumed to be referencing the individual

-ideas = weaker. Assume same thing but can be convinced otherwise

extrapyramidal Sx

-associated w/ first generation antipsychotics

-acute dystonia = muscle spasms. Can be deadly

-parkinsonian

-tardive dyskinesia = involuntary movements of the tongue, lips, and jaw, dysphagia

clozapine

-second generation antipsychotic associated w/ risk for agranulocytosis

-should monitor absolute neutrophil count : assess prior to initiation of therapy and weekly for first 6 months, then biweekly for another 6 months, then monthly

-should remain at 1500 or higher, although certain ethnicities might have slightly lower normal

akathisia

-continuous restlessness + fidgeting

-most frequently in women

-50-60 days into therapy

-EPS

dystonia

-involuntary muscle spasms in the face, arms, legs, and neck

-most often in men, younger than 25

-medical emergency: laryngospasm, treated w/ benztropine mesylate

oculogyric crisis

-uncontrolled rolling back of the eyes

-EPS

-Sx of acute dystonia

-can be mistaken as a seizure

pseudoparkinsonism

-tremor, shuffling gait, drooling, and rigidity

-starts 1-5 days after starting therapy

-most often in women, the elderly, and dehydrated pts

Nursing considerations for antipsychotic medications

-hyperglycemia, weight gain, DM

-hypotension (orthostatic or other)

-lower seizure threshold

-prolonged QT interval

-anticholinergic effects

-sedation

-photosensitivity

-NMS (rigidity, hyperthermia, etc.)

-hormonal AE (gynecomastia, amenorrhea, etc.)

Recovery-oriented care of schizophrenia

-patient-centered care focusing on full recovery potential

-emphasizes patient engagement

-treatment can include medications, housing or financial assistance, faith-based approach, peer or family support, self-care, case management

-continual growth in one's health and wellness

-resilience for setbacks

-connectedness, hope, optimism for the future, identity, meaning in life, and empowerment

Relapse prevention in schizophrenia

-helped by family involvement, medication adherence

Therapeutic communication and delusions

-reasonable doubt: I understand you believe this is true, but I personally find it hard to accept

-do not argue or deny the delusion

-accept patient's belief but indicate that you do not share it

-discourage long rumination on the irrational thinking. Refocus on real events and people

therapeutic communication with paranoid deluasions

-use same staff

-keep all promises, be as honest as possible

-avoid physical contact, ask before necessary contact

-avoid laughing, whispering, or talking when the patient can see but not hear

-don't give individually prepared food

-mouth checks to ensure medication consumption

-activities that foster one-on-one relationships w/ nurse or therapist

-assertive, matter of fact, but genuine approach

Alcohol withdrawal Sx

-coarse tremor of hands, tongue, or eyelids

-N/V

-malaise or weakness

-tachycardia, diaphoresis

-elevated BP

-anxiety, depressed mood or irritability

-transient hallucinations or illusions

-headache

-insomnia

-seizures

Delirium tremens (DT)

a psychotic condition caused by alcohol withdrawal that can result in death

-occurs on second or third day of withdrawal

Marijuana intoxication

-tachycardia + orthostatic hypotension

-bronchodilation, chronic use = obstructive disorders

-men: decrease in sperm count, motility, and structure

-women: suppression of ovulation, disruption of menstruation and hormone levels

-developmental disorders, hyperactivity = exposure in utero

-euphoria, relaxed inhibitions, disorientation, depersonalization, and relaxation

-sensory alterations, impaired judgement, learning, and memory

-tremors, muscle rigidity, conjunctival redness

-toxic levels = panic reactions, acute psychosis

Heavy, long-term cannabis use

-amotivational syndrome: lack of motivation to persist in or complete a task that requires attention

-apathetic, anergic, weight gain

-cognitive impairments in memory, attention,, and organization

Withdrawal Sx of cannabis

-restlessness, irritability, insomnia, loss of appetite, depressed mood, tremors, fever, chills, HA, stomach ache

Cannabis use disorder

-can cause psychological addiction, tolerance can occur

-now determined to have clinically significant physiological

-synthetic types more addictive, dangerous

Sx of opioid overdose

-shallow breathing

-slowed pulse

-clammy skin

-pulmonary edema

-respiratory arrest

-convulsions

-coma

-possible death

Nursing actions for opioid overdose

-administration of naloxone (narcan)

-monitor for respiratory depression

Cermak's 1st stage of recovery from codependency

-the survival stage

-let go of denial of problems or that their persona capabilities are unlimited

-abstinence from blanket denial

Cermak's 2nd stage of recovery from codependency

-reidentification

-when they are able to glimpse their true selves

-accept the label of codependent and take responsibility for dysfunctional behavior

-only able to do so when able convinced it is more painful to not do so

Cermak's 3rd stage of treating codependency

-core issues stage

-accept the relationships cannot be managed by force of will

-must be independent and autonomous

-detatch from the struggles of life that exist because of prideful and willful efforts to control things beyond the individuals power to control

Stage 4 of Cermak's recovery from codenpendency

-reintegration

-self-acceptance and willingness to change when codependents relinquish power over others and reclaim the personal power

-integrity is achieved out of awareness, honesty, and being in touch with one's consciousness

-control is acheived through self-discipline and self-confidence

Therapeutic communication in alcohol use disorder

-provide accurate information about the effects of the disorder

-matter of fact, nonjudgmental communication

-set firm boundaires

-set firm limits

Adjustment disorder

-maladaptive reaction to an identifiable stressor that results in the development of clinically significant emotional or behavioral Sx

-impairment in social and occupational functioning or Sx that are in excess of an expected response

-occurs within 3 months of onset of stressor but lasts no longer than 6 months

-diagnosis might be modified by w/ depressed mood, w/ anxiety, w/ mixed anxiety and depressed mood, or w/ disturbance of conduct, or w/ mixed disturbance of emotions and conduct

PTSD

-multisymptom response triggered by a extremely traumatic event

-not related to common experiences, but in response to an event that would be markedly distressing to almost others

-Sx include reexperiencing traumatic event, sustained high level of arousal, general numbing of responsiveness, intrusive recollections, sleep disturbances, or nightmares, amnesia

onset of PTSD

-may begin within 3 months after trauma, but may be delay of several months or years

-must present for more than 1 month and significantly interfere w/ social or occupational functioning

acute stress disorder

PTSD symptoms that appear for a month or less

learning theory in PTSD

-trauma-related disorders are related to aversive learning

-traumatic event is associated w/ fear, which becomes a conditioned response to stimuli associated w/ the event and more general over reactivity, failure to adapt, to intense, novel, or fear related stimuli

Eye movement desensitization and reprocessing therapy (EMDR)

-client focuses eye movements on therapists fingers as they move it back and forth while concentrating on a particular physical sensation or emotion surrounding traumatic event

-then asked to focus on positive belief to replace the negative, disturbing belief, again while tracking movement of finger

-2X/week for 6-12 sessions

-thought to decrease imagery vividness while increasing memory access

-thinks information processing system and memories cause pathology

-focuses on past memories, current distressing situations, and future skills

Trauma-informed care

-philosophical approach that values awareness and understanding of trauma when assessing, planning, and implementing care

-collaboration, empowerment, transparent, respectful communication, avoiding coercive interventions as possible, understanding behaviors as adaptive survival responses

4 R's of trauma informed care

-realizing widespread impact of trauma and various paths for recovery

-recognizes S and S of trauma in clients, families, staff, etc.

-Responds by integrating knowledge about trauma in policies, procedures, and practices

-active resistance to retraumatization (e.g. using restraints, seclusion)

Promotion of physical and emotional safety in trauma-informed care

-providing grounding strategies and stabilization

-validating emotional responses, exploring meaning of loss, strengthening support networks

-maintain consistent staffing and therapeutic presence

-facilitate paced, safe processing

-address survivors guilt, distorted blame, and self-criticism

Signs of physical child abuse

-unexplained burns, bites, bruises, broken bones, or black eyes

-fading bruises or other marks noticable after an absence from school

-seems frightened of the parents and protests or cries when it is time to go home

-shrinks at the approach of adults

-reports injury by parent or another adults caregiver

-abuses animals or pets

signs of abusive parent

-offers conflicting, unconvincing or no explanation for child's injury

-describes the child as "evil" or in some other negative way

-uses harsh, physical discipline w/ the child

-has a history of abuse as a child

-has a history of abusing animals or pets

signs of emotional child abuse

-extremes in behavior, such as overly compliant or demanding behavior, extreme passivity, or aggression

-inappropriately adult or infantile behavior

-delays in physical or emotional development

-shows signs of depression, SI, or has attempted suicide

-reports an inability to develop emotional bonds with others

emotional abuse signs in a caregiver

-constantly blames, belittles, or berates the child

-is unconcerned about the child and refuses to consider offers of help for the child's problems

-overly rejects the child

indicators of child neglect

-frequent absence from school

-begs or steals food or money

-lacks needed medical or dental care, immunizations, or glasses

-is consistently dirty and has severe body odor

-lacks sufficient clothing for the weather

-abuses alcohol or other drugs

-states that there is no one at home to provide care

signs of neglect by a caregiver

-appears to be indifferent to the child

-seems apathetic or depressed

-behaves irrationally or in a bizarre manner

-abuses alcohol or other drugs

indicators of child sexual abuse

-has difficulty walking or sitting

-suddenly refuses to change for gym or participate in physical activities

-reports nightmares and bedwetting

-sudden change in appetite

-demonstrate bizarre, sophisticated, or unusual sexual knowledge or behavior

-becomes pregnant or contracts a venereal disease, particularly if under age 14

-runs away

-reports sexual abuse

-attaches very quickly to strangers or new adults in their environment

indicators of sexual abuse from a parent

-unduly protective of child, limits child's contact w/ other child, particularly of the opposite sex

-secretive and isolated

-does not respect boundaries or listen to know

-engages in touching that a child or caregiver have indicated is unwanted

-does not seem to have age-appropriate relatioships

-tries to be a child's friend rather than filling an adult role in the child's life

-makes up excuses to be alone with the child

-expresses unusual interest in the child's sexual development, such as commenting on sexual characterstics or sexualizing normal behaviors

Phase 1 of Cycle of Battering: Tension-Building Phase

-Abuser's tolerance for frustration declines

-abused may become very nurturing and compliant

-minor incidents may, abused rationalizes, accepts guilt for them

-jealousy and possessiveness increase, abuser fears partner will leave

-withdrawal from the abused is interpreted as rejection

-increasingly intense incidents

-lasts months to years

Phase 2 of the cycle of battering: The Acute Battering Incident

-only lasts around 24 hrs

-begins w/ abuser justifying behavior, then losing control

-abused may intentionally provoke to reach honeymoon phase

-generally minimize the abuse

Phase 3 of cycle battering: honeymoon phase

-abuser becomes extremely kind, loving, and contrite

-plays on feelings of guilt

-abused relives original dream of ideal love

-may pass quickly, abused may participate in their own battering to get to this phase

Characteristics of an abuser

-low-self esteem, pathologically jealous

-present w/ dual personality

-high stress, poor coping

-possessive, isolates the partner

-may use children as a mechanism of control

profile of the abused

-low self-esteem

-adhere to feminine sex-role stereotypes

-feelings of guilt, anger, fear, and shame

-may have learned helplessness

-may have grown up in abusive home, married early to escape

Reasons abused partners stay

-fear of retaliation

-custody loss of children

-physical or financial dependence

-lack of support network

-fears of what others will think (cultural or religious convictions, dual personality of abuser)

-hopefulness

-lack of attention to danger, feeling like they are responsible for abuse, dissociation

Risks associated w/ leaving abusive relationship

-75% of DV related homicides occur upon separation

-75% increase in violence for 2 years after abused partner leaves

mandatory reporting

-reasonable suspicion

-exception to confidentiality

-warning signs, objectively document findings, report concerns to appropriate agency

-applies to both child and elder abuse (in some states)

Nursing intervention following sexual assault

-ensure safety, validate experience, explain options, obtain consent, promote autonomy, adddress medical needs, explain confidentiality, provide resources

Response to IPV disclosures

-ensure immediate safety and assist w. safety planning

-validate experiences and avoid victim-blaming

-provide crisis intervention when needed

-connect to social support, shelters, hotlines, or forensic services

-reinforce empowerment and autonomy

-offer trauma-focused psychotherapy referrals

Crisis intervention in an abuse context

-immediate stabilization after violence or assault

-supporting emotional expression and grounding

-involve patient in decision-making

-adresseing guilt, fear, and confusion

-connecting to long-term therapeutic supports

Responsibilities of ED care following SA

-evidence collection and accurate documentation

-collaboration w/ law enforcement

-testifying in legal proceedings

binge eating disorder

-recurrent episodes of eating significantly more than most people would eat in a similar period under similar circumstances

-occurs at least once a week for 3 months

Anorexia nervosa

-morbid fear of obesity

-gross distortion of body image, preoccupation w/ food, and refusal to eat

-weight loss is usually accomplished by reduced food intake and extensive exercising . Can be done through binging and purging episodes

-may present as an obsession w/ food

-strongly correlated w/ depression and anxiety, bipolar, OCD, and substance use disorder

bulimia nervosa

-episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time, followed by inappropriate compensatory behaviors to rid the body of the excess calories

-may present as self-induced vomiting, misuse of laxatives, diuretics, or enemas, fasting, or excessive exercise

-most are within a normal weight range

Clinical manifestations of anorexia

-emaciated or obviously underweight

-prevention of weight gain

-hypothermia, bradycardia, hypotension w/ orthostatic changes, peripheral edema, lanugo, bone fractures

-acrocyanosis (bluish color to hands and feet d/t poor circulation)

-variety of metabolic changes

-amenorrhea (may be before significant weight loss)

-cold intolerance, dizziness, chest pain, abdominal bloating, pain or discomfort, constipation, weakness, decreased concentration and poor memory

S and S of BN

-excessive vomiting and laxative or diuretic misuse

-dehydration and electrolyte imbalance

-erosion of tooth enamel

-tears in gastric or esophageal mucosa

-Russell's sign: calluses on the dorsal surface of their hands, typically on knuckes

-many are able to induce vomiting at will

Pharmacological Tx of BED

-lisdexamfetamine/vyvanse = short term treatment, binge reduction

-high dose SSRIs, Qsymia, contrave (naltrexone and bupropion) = used for weight loss

-historically amphetamines for weight loss, but caution d/t addiction, dependence

Maudsley approach

-Phase 1: weight restoration, encourages parental control of eating which is returned after the adolescent demonstrates readiness and ability to establish control in healthier ways. Frequent power struggles

-Phase 2: control of maintaining weight gain is returned to the adolescent. Ability to maintain greater than 95% of ideal weight

-Phase 3: assisting development of healthy self-identity. CBT and DVT incorporated

-intensive outpatient program

-modified program for adults and their significant others

primary prevention

-preventing onset through education and stress reduction

secondary prevention

early detection and prompt intervention

tertiary prevention

reducing residual disability, improving functioning

Public health model

-based on the levels of prevention

effects of deinsitutionalization

-expansion of community health resources

-increasing criminalization of people w/ mental illness, homelessness

Partial hospitalization programs

-either prevent institutionalization or ease transition from inpatient care to community

-individual, group, family therapy, psychoeducation, crisis intervention, OT, therapeutic recreation, medication admin/monitoring

community residential facilties

-may offer food, shelter, minimal supervision and assistance w/ ADLS

-others have therapies, transition from hospital to independent living: counseling, medical care, job training, etc.

Psychiatric home health care

-must validate homebound status for insurance

-often depression, anxiety, neurocognitive disorders, bipolar, or schizophrenia

-monitor for decompensation, medication monitoring

-crisis intervention, patient education, hands on care

Common mental health diagnoses in homeless populations

-schizophrenia, bipolar, substance use disorder, depression, personality disorders, and neurocognitive disorders

-psychotic symptoms

-may have isolated themselves to avoid being identified as mentally ill

Barriers to care of homeless mentally ill people

documentation issues, lack of insurance, stigma, and past trauma

community mental health centers

-hub out outpatient care, case management, medication management, crisis services, group and individual therapy

-nurse is the case manager and coordinates care

assertive community treatment (ACT)

-multidisciplinary, team-based model providing Tx, rehab, and support in community settings (a person's home, parks, stores, etc.)

-relatively comprehensive care: meds, therapy, social support, employment, housing