NRSE 345: Final Exam Review

Mental Health National Emergency Number

988

Mandated reporting

Nurse must report suspected abuse, neglect, or mistreatment to appropriate authority base on policy

Duty to Warn

• Tarasoff case

• Legal obligation to breach confidentiality for safety

• If client has or is about to hurt someone*

• Says something specific like name

MSE parts (4)

1. Appearance

2. Behavior

3. Cognition

4. Thoughts

Assessing Cognition

• Orientation/LOC

• Attention/concentration

• Abstract reasoning & comprehension

• Memory

• Insight

• Judgement

Acute Stress Disorder

• within one month of traumatic event

• resolves in 4 weeks

• 3 following dissociative symptoms

  • numbing

  • detachment

  • absence of emotional responsiveness

  • reduction in awareness of surroundings

  • depersonalization

  • dissociative amnesia

PTSD

• 1-3 mo after a tramatic event

• delayed = 6 mo

• Symptoms and signs

  • Re-experiencing of event

  • Flashback/dissociative episode

  • Increased arousal

  • hypervigilance

  • Avoidance of triggers

  • Numbness from detachment

  • feeling of emptiness

  • Trust issues

4 areas of PTSD symptoms

1. Intrusion

2. Dissociative

3. Mood and cognition

4. Hyperarousal

Intrusion PTSD

flashback to traumatic experience

dissociative PTSD

• Derealization the environment is strange/unreal

• Depersonalization oneself is strange/unreal

• Spacing out

• Emotional numbing

• Amnesia

mood/ cognition PTSD

• Signs and symptoms

  • Irritable w anger

  • fear

  • guilt

  • shame episodes

  • Trouble feeling positive emotions

  • Trust issues

    exaggerated negative beliefs about self, others, world

Hyperarousal PTSD

irritable always seem like on guard, poor sleep, too wired

Adjustment Disorder

• Occurs 0-3 months after exposure to stressful event

• After the situation is resolved, the symptoms subside

Adjustment Disorder: Signs & symptoms

• Depressed mood

• anxiety

• mixed, or conduct disturbance

• distress that seems out of proportion to the severity of the stressor and may be unable to function socially

DSM-5 Criteria: Generalized Anxiety Disorder

• Excessive worry and anxiety occurring for more days than not for at least 6 months.

• Related to a number of real-life activities or events

• Difficult to control over the worry

• Significant impairment in daily personal or social life

Generalized Anxiety Disorder: Signs & Symptoms

• Restlessness

• feeling keyed up

• being easily fatigued

• difficulty concentrating

• irritability

• muscle tension

• sleep disturbance

• Chronic and Persistent Fear and Anxiety

DSM: Panic Disorder

• Recurrent UNEXPECTED panic attacks

• At least one attack has been followed by ONE month or more of:

  • persistent concern or worry about additional panic attacks

  • significant maladaptive change in behavior regarding the attacks

Panic Disorder: Signs & Symptoms

• Similar to cardiac emergencies

  • Shaking

  • Dizziness

  • Chest discomfort

  • SOB

  • Nausea

  • Feeling of impending doom

Panic Attack

• Abrupt surge of intense fear/discomfort

• Signs & Symptoms

  • palpitations

  • sweating

  • tremors

  • SOB

  • Choking feeling

  • nausea

  • dizziness

  • chills/hot

  • numbness

  • fear of "going crazy" or dying

Emergency care panic attack

• Assess EKG if cardiac complaint never overlook physical w "psych" pts

• stay with patient, reassure, calm, clear directions, minimize stimulation

OCD: DDM 5

• Presence of obsessions or compulsion or both

• Obsessive

  • Unwanted, intrusive persistent thoughts

• Compulsive

  • Repeatedly performed behaviors

• obsession or compulsion are time consuming take 1 hOUR or more

  not better explained by any other disorder

Obsessions (OCD)

• Unwanted, excessive thoughts --> distress

  not in the patient’s control

• Common

  • contamination

  • symmetry

  • repetition

Compulsions (OCD)

• repetitive behaviors

• performed to relieve anxiety from obsessions

• Common: hand washing, arranging, counting

Major Depressive Disorder

• five or more symptons for a 2 weeks period

  • Depressed Mood (All or most of the day)

  • Marked Loss of interest or pleasure

  • Disruption in sleep

  • Significant weight

  • Fatigue

  • Psychomotor agitation or retardation

  • Excessive guilt or feelings of worthlessness

  • Diminished ability to think or concentrate

  • Suicidal ideation

DSM 5: Anorexia

• Restriction of intake leading to significantly low body weight

• Intense fear of gaining weight

• Disturbance in body image

• Undue influence of body weight or shape on self-evaluation

• Signs & Symptoms

  • Over excising

  • Fasting

  • Dieting

Anorexia course and comorbidity

• 10x female

• Onset usually 14-16 years old

• Depression, OCD, panic, phobias

• HIGH MORBIDITY 3-7%

Anorexia: Clinical Manifestation

• 75% of ideal body weight

• lanugo

  • soft, fine hair

• jaundiced

• hypotensive

• bradycardia

• amenorrhea

  • No period

• peripheral edema

DSM-5 Criteria: Bulimia Nervosa

• Recurrent episodes of binge eating AND

• Compensatory Purging:

  • vomiting or use of laxatives, diuretics, or emetics

• Nonpurging behaviors:

  • fasting or overexercising

• Episodes occurring at least once a week for at least 3 months

  **No severe weight loss as with anorexia nervosa

Comorbidity of bulimia

• electrolyte imbalance

• cardiac arrhythmia

• seizure

• death

• Hunters sign

• parotid gland swelling

• esophageal damage

• acid reflux

• dental lesions

DSM-5 Criteria: Binge Eating Disorder (BED)

• Ingestion of large amount of food in short period of time and sense of loss of control

• Distress regarding binge

• Eating until uncomfortably full

• Feelings of guilt or depression after binge

Binge Eating Disorder: Signs and Symptoms

• Individuals binge like bulimia nervosa, but do not purge or compensate for binges

• Obesity

Benzodiazepines: Medications

• alprazolam

• lorazepam

• clonazepam

• diazepam

Benzodiazepines: Use

• PTSD

• Generalized Anxiety Disorder

  • Acute/Shorter Term Medications

• Panic disorder

• Seizures

• Insomnia

• Alcohol withdrawal

Benzodiazepines: Side effects & Adverse effects

• Side effects

  • Sedation

  • Amnesia

  • Poor coordination

• Adverse effects

  • Respiratory depression

  • dependence

    • tolerance & withdrawal

Benzodiazepines: Antidote

Flumazenil

Non addictive/non Benzodiazepines:Use & Medication

• Buspirone

• Used for long term anxiety (GAD)

Buspirone: Side effects & Adverse effects

Side effects

• Dizziness

• Drowsiness

• Nausea

• Headache

Adverse effects

• increased digoxin

SSRI: Medications

• Fluoxetine: 20-80 mg

• Sertraline: 50-200 mg

• Citalopram: 20-40 mg

• Escitalopram: 10-20 mg

SSRI’s Use

• Depression

• Anxiety

• OCD

• PTSD

• Eating disorders

SSRI’s: Side effects and Adverse Effects

• Side effects

  • Nausea/Diarrhea

  • Weight loss/gain

  • Insomnia or Drowsiness

  • Sexual dysfunction

  • Dry mouth

• Adverse effects

  • Serotonin syndrome

  • Withdrawal (flu-like, irritability)

SNRIs: Medications

• Duloxetine

• Desvenlafaxine

• Venlafaxine

Duloxetine, Desvenlafaxine & Venlafaxine: Side effects and Adverse Effects

• Side Effects

  • Hypertension

  • Hyponatremia

  • Nausea

  • Dry mouth

  • Dizziness

  • Fatigue

  • Sexual dysfunction

  • Sweating

  • Insomnia

• Adverse effects

  • Serotonin Syndrome

  • Withdrawal (flu-like, irritability)

SNRIs: Use

• Major Depressive Disorder

• Generalized Anxiety Disorder

• Panic Disorder

• OCD

• PTSD

NDRI: Medications

Bupropion

Bupropion: Use

• Major Depressive Disorder

• Stop smoking

Bupropion: Side effects & Adverse effects

• Side effects

  • Insomnia

  • Dry mouth

  • Dizziness

  • Nausea

  • Weight loss

  • Sweating

• Adverse effects

  • Seizures

  • Worsening mood

MAO-I: Medications

• Phenelzine

• Selegiline

Phenelzine & Selegiline: Uses

• Depression

• Anxiety

Phenelzine & Selegiline: Side effects & Adverse effects

• Side Effects

  • Dizziness

  • Drowsiness

  • Dry mouth

  • Weight gain

  • Insomnia

  • Sexual disfunction

  • Orthostatic Hypotension

• Adverse effects

  • Hypertension crises with tyramine foods

  • Serotonin syndrome

Phenelzine & Selegiline: Tyramine Diet

• AVOID these foods With MAOIs: Hypertensive crisis

• Foods

  • Aged cheese

  • Processed meats

  • Bananas/avocados

  • Chocolate

  • Beer/wine

TCAs: Medications

• Amitriptyline

• Clomipramine

Amitriptyline & Clomipramine: Use

Depression

Amitriptyline & Clomipramine

: Side effects & Adverse effects

• Side effects

  • Drowsiness

  • Dry mouth

  • Constipation

  • Blurred vision

  • Weight gain

  • Orthostatic Hypotension

  • Urinary retention

  • Sedation

• Adverse effects

  • Serotonin syndrome

  • Arrhythmias (high doses)

Bipolar 1 DSM Criteria

• Must have a MANIC EPISODE (a distinct period of abnormally + persistently elevated, expansive, or irritable mood)

• Increase energy for at least one week most of each day

• 3 or more symptoms

  • Could follow a hypomanic or depressive episode

  • Has specifiers

  • Depression, anxiety w psychotic features

Bipolar 2 DSM Criteria

• Must have a hypomanic episode + a major depressive episode (mostly depression; not as easily recognized)

• Many times misdiagnosed as Major Depressive DIsorder

Mood stabilizers: Medications

• Lithium

• Anticonvulsants: Used for Bipolar 1 & 2

  • Valproic Acid

  • Carbamazepine

  • Gabapentin

Lithium: Normal levels & Toxic levels

• NORMAL:

  • 0.6-1.2

• TOXIC

  • 1.5-2.5

Lithium: Toxicity Effects

• Tinnitus

• Ataxia

  • loss of muscle coordination

• Seizures

• Hallucinations

Anticonvulsants: Education

• Can cause CNS depression

• Blood work every 6 months to screen for Agranulocytosis

• Hepatotoxic

Another Anticonvulsant

• Used for Bipolar 2 ONLY

• Lamotrigine

  • Mood stabilizer

• Side Effects

  • Steven Johnsons

  • CNS depression

  • has a slower onset so won’t work for Bipolar 1

Schizophrenia

• Positive symptoms

  • delusions

  • hallucinations

  • bizarre behavior/thoughts

• Negative symptoms

  • affect

    • flat

    • blunt

  • alogia

    • poverty of speech

  • anhedonia

    • reduced ability to experience pleasure

  • associability

    • lack of connection between ideas

  • anergia

    • Lack of energy

  • apathy

  • avolition

    • Lack of motivation

Schizoaffective Disorder

All the schizophrenia signs/symptoms + a mood disorder (depression or mania)

Typical Antipsychotics

• Medications

  • Haloperidol & Chlorpromazine

• Used for schizophrenia (only positive symptoms)

• ACUTE:

  • EPS

  • Anticholinergic

  • Agranulocytosis

  • NMS

• CHRONIC

  • Tardive dyskinesia

Atypical Antipsychotics

• Medications

  • Risperidone

  • Olanzapine

  • Aripiprazole

  • Ziprasidone

• Used for schizophrenia positive and negatives symptoms

• Side effects

  • metabolic syndrome

  • EPS

  • NMS

  • less EPS than typical

  • Agranulocytosis

Atypical Antipsychotics: 3rd Generation

• Medication

  • Clozapine

• Treats Schizophrenia (positive & negative symptoms)

• Signs & Symptoms

  • Drooling

  • Metabolic Syndrome

  • Agranulocytosis

• PATIENT NEEDS WEEKLY BLOOD WORK!!

NMS

• Neuroleptic malignant syndrome

• Resulting from antipsychotic toxicity

NMS is characterized by…

• Rigidity

• High fever

• Altered mental status

Tardive dyskinesia (TD)

A motor disorder that results from chronic use of certain antipsychotic drugs

Examples of Tardive dyskinesia (TD)

• Facial grimace

• Tongue protrusion

• Jerky limbs

EPS extrapyramidal

• Group of movement disorder as a side effect of certain medication

• Caused by Antipsychotic medications

• Signs & Symptoms

  • Acute Dystonia

    • involuntary muscle contractions

  • Akathisia

    • uncontrollable need to move

  • Pseudoparkinsonism

  • Tardive Dyskinesia

    • Persistent chronic EPS

Acute Dystonia

Sudden, sustained contractions of one or several muscle groups (head and neck)

Akathisia

Uncontrollable urge to move, making it difficult to sit or stand still

Metabolic Syndrome

A medical condition associated with Obesity, Diabetes, High Cholesterol, and Hypertension

EPS are treated by…

• A decreased dose of typical antipsychotic

• Switch to atypical antipsychotic or Benztropine (Cogentin)

Anticholinergic Medications & Use

• Medications

  • Benztropine Mesylate

    Trihexyphenidyl

• Use

  • Acute EPS treatment

Anticholinergic can’t what??

• Can’t see

• Can’t pee

• Can’t shit

• Can’t spit

Other Medications to treat EPS

• Antihistamine

  • Diphenhydramine

• Benzos

  • ("-lams" & "-pams")

• Beta blockers

  • ("-lols")

Black Box for Anticholinergics

Delirium in older adults

Parkinsonism

• T.R.A.P

  • Tremors

  • Rigidity

  • A bradykinesia

  • Postural instability/ shuffling gait

what is CIWA/ GAGE?

An assessment tool used to assess withdrawal symptoms of alcohol

Alcohol Use Disorder treatments

• CIWA

• Adequate nutrition and supplemental vitamins

Alcohol: Withdrawal Medications

• Benzos

• Chlordiazepoxide

• Disulfiram

• Antidepressants

Alcohol: Withdrawl

• within 12 hours of abrupt discontinuation

• Respiratory Depression

• Cardiac Arrest

• Delirium Tremens

• Grad Mal seizure

Alcohol: Prolonged Use

• Affects all systems of the body

• Can lead to other dependencies

• Malnutrition

Opioids: Medications

• Naloxone (Narcan)

  • for overdose

• Naltrexone + Methadone

  • for maintenance and to taper down

Opioid Use Disorder: signs/symptoms

• Change in attitude/personality

• Tendency to avoid contact w family + friends

• Changes in friends/hobbies/activities/sports

• Drop in grades or work performance

• Isolation + secretive behaviors

• Tendency to steal

• Moodiness

• Irritability

• Nervousness

• Giddiness

Opioids: Effects

• Euphoria

• Sedation

• Decreased libido

• Memory and concentration difficulties

• Analgesia

• Constipation

• Constricted pupils

Opioids: Overdose

• Respiratory depression

• Stupor

  • State of near unconsciousness

• Coma

Opioids: Withdrawal

• Abdominal cramps

• Rhinorrhea

• Watery eyes

• Dilated pupils

• Yawning

• Goose flesh

• Diaphoresis

• Nausea

• Diarrhea

• Anorexia

• Insomnia

• Fever

Opioids: Prolonged Use

• Can lead to criminal behavior to get money for drugs

• Increased infection risk related to needle use

Opioid: Treatments

• Detox

• Methadone therapy w CBT + counseling

Borderline Personality Disorder

• Characterized by…

  • Emotional Instability

  • Impulsivity

  • Identity Issues

  • Intense relationship

  • Self-Destructive Behavior

ADHD Medications: Stimulants

• Methylphenidate

• Amphetamine/Dextroamphetamine

• Lisdexamfetamine

ADHD Medications: Non-Stimulants

• Atomoxetine

• Guanfacine

ADHD: Attentive Type

• Fails to pay attention to details

• makes careless mistakes in schoolwork, at work, or during other activities

• has difficulty paying attention in tasks/play activities

• Doesn't seem to listen when spoken to directly

• Doesn't follow on instruction

• Fails to finish schoolwork, chores, or duties at work

ADHD: Impulsive Type

• Often fidgets w or taps hands/feet or squirms in seat

• Often leaves seat when not supposed to

• Runs/climbs when inappropriate

• Unable to play/engage in leisure activities quietly

• "on the go"

• "driven by a motor"

Autism Spectrum Disorder

• Persistent impairment in social communication + interaction w others

• Children may or may not have intellectual disability, commonly show uneven pattern of intellectual strengths + weaknesses

• Restricted repetitive patterns of behaviors

• Severe verbal/nonverbal communication impairment

• Stereotypic behavior

• Repetitive behavior

• Self-stimulating

• Self-injurious

• Severe + sustained impairment in social interactions

• Social deficits

Autism: Signs/symptoms

• Low or no eye contact

• Repetitive behaviors

• Delayed speech development + emotional regulation

• Echolalia

  • involuntary repetition of words or phrases spoken by someone else

• Very specific interests

• Not responding to name

Autism: Medications

• Typical antipsychotics

  • Haloperidol (Haldol)**

  • Chlorpromazine (Thorazine)**

• Atypical antipsychotics

  • Risperidal

  • Olanzapine

  • Aripiprazole

  • Quetiapine

Autism: Nursing Interventions

• Dim the lights

• Use a weighted blanket or vest

• Allow repetitive movement that doesn't hinder care

• Establish consistent routines

• Offer repetitive activities

• Maintain peaceful environment