MENTALHEALTH FI

What are the Civil Liberties for a pt committed to the psych ward?

• Pt has the right to refuse meds (unless it is an emergency condition or pt is lacking capacity to make an informed decision after a court hearing)

  • If the pt is found unable to lack the capacity to consent to meds, the pt may appeal the decision

• Pt has the right to refuse tx

• Pt has the right to send and receive mail

• Pt has the right to refuse visitors

What are some items that are taken away from the pt when committed to the psych ward?

• Strings

• Belts

• Glass

• Mirrors

What is one right a pt does not retain?

• Pt is not allowed to leave the hospital if deemed DTS, DTO, or GD

What does seclusion do for the pt?

• Seclusion is the involuntary confinement of a person in a specially constructed locked room

• This protects the pt by decreasing stimulation

• It provides privacy for the pt

• The GOAL: is to provide the pt with the opportunity to regain physical and emotional self control

What do the restraints do?

• Restraints are used to protect the pt and others

• Indicated for violent pts

What should the nurse monitor for when a pt is in seclusion/restraints?

• It is important for the nurse to monitor/document the pt’s skin condition

  • Check for circulation

  • Pt’s emotional well being

  • Observe for readiness to discontinue seclusions/restraints

• The nurse should also offer foods or fluids and bathroom use

• Must document ALL

What is a key component for when a pt is on a legal hold due to suicide precautions?

• Pt should always be in a safe enclosed observation setting

  • Usually on a 1 to 1

  • Don’t have access to items that can harm themselves

What is the purpose of the DSM-5?

• Provides standardized nomenclature and language

• Presents defining characteristics or symptoms that differentiate diagnoses

• Assists in identifying the underlying causes of disorders

When were mental institutions created?

• 1790s

What is an asylum?

• Safe refuge or haven for pts with mental illness to be treated and reside in

Who founded asylums?

• Dorothea Dix

  • Reformed tx of mental illness

What does serotonin do?

• Plays a role in sleep

• Hunger

• Mood (Feeling Happy)

• Pain perception

• Hormonal activity

• Aggression

• Sexual Behavior

• Decreased: Depression

• Increased: Anxiety

What does dopamine do?

• Works on complex movement (Fine motor skills)

• Motivation (Rewards)

• Cognition

• Emotions

• Thoughts

• Decreased: Parkinsons, Depression

• Increased: Mania, Schizophrenia

What does norepinephrine do?

• Effects specific lvls in the brain that affect mood

• Attention

• Arousal

• Stimulates sympathetic response

• Decreased: Depression

• Increased: Mania, Anxiety, Schizophrenia

What does Acetylcholine do?

• Plays a role in learning

• Memory

• Regulates mood

• mania

• sexual aggression

• Affects parasympathetic nervous system

• Decrease: Alzheimer, Huntington, Parkinson’s

• Increase: Depression

When Psychopharmacology begin?

• Before 1950s

  • Only amphetamines and barbiturates

When were antipsychotics first used and what did they do?

• After the 1950s

• Would only effect positive symptoms of psychosis

  • Were only able to block dopamine

• Typical antipsychotics (First Gen) like Thorazine and Haldol

What do atypical antipsychotics do?

• Not only block dopamine but serotonin too

• Are able to effect both positive and negative symptoms

• Atypical antipsychotics (Second Gen) like Risperdal, Zyprexa, Clozaril

What did Sigmund Freud’s psychoanalytic theories describe?

• All human behavior is caused and can be explained

• Repressed sexual impulses and desire motivated much human behavior

• Personality components: ID, EGO, SUPEREGO

What is ID?

• Represents uncoordinated, instinctual needs and desires

  • Ex: “I want that cookie so I’ll steal it”

What is SUPEREGO?

• Incorporates social values and morals, controlling the ID’s impluses?

  • Ex: “I want that cookie, but its wrong to steal, so I’ll buy it”

What is EGO?

• The mediator between ID and SUPEREGO, balancing needs vs what’s realistic

  • Ex: “I want that cookie but its wrong to steal”

What is appropriate ego development?

• A person that shows no anger or aggressive behaviors when something is not in their favor or liking

What is inappropriate ego development?

• A person becoming agitated and mad when something is not in their favor

What are the Freudian Defense mechanisms for Ego?

• Denial

  • Refusal to accept reality, blocking external events from awareness

  • Person may refuse to perceive it or deny that it exists

  • Husband may refuse to acknowledge his wife’s obvious signs of infidelity

• Dissociation

  • The mind “cuts off” a thought, a feeling, a memory to protect the greater whole

  • When you’re getting yelled at and your mind shuts off and your emotions shut down

• Suppression

  • Pushing unwanted thoughts, emotions, memories, fantasies, out of conscious so you aren’t thinking about it anymore

  • Blocking out uncomfortable memories of a traumatic event

• Projection:

  • Individual attributes UNWANTED thoughts, feelings, motives, to another person

  • If you hate someone but can’t accept it so you think they hate you instead

  • Hating on traits in someone else that are really traits you possess

• Sublimation

  • Displacing our unacceptable emotions into behaviors that are constructive and socially acceptable

  • Musicians who have had unhappy lives use music to express themselves 

• Isolation

  • The separation of ideas or feelings from the rest of one’s thoughts

  • Separating their feelings from the idea or thought associated with those feelings

  • A person who works in a demanding environment may be experiencing a stressful situation at home. To avoid affecting their productivity at work due to the stressing situation at home, they may use the isolation mechanism

• Undoing

  • Individual AVOIDS conscious awareness of disturbing impulses by thinking or acting in a way intended to revert those impulses

  • An absent father periodically returning to spoil and smother his children

• Intellectualization:

  • Using reason to block confrontation with unconscious conflict and its associated emotional stress

  • Rationalizing anxiety by analyzing its potential causes without acknowledging the distress it causes

What are signs of appropriate psychosexual development stages according to Freud?

• Ex: An 18 month old using a pacifier

• Ex: A 36 month old being able to control when/ where there pee

What are the 4 stages of nurse-pt relationship based on Peplau Nursing Theory?

• Orientation

  • First introduction between nurse and pt

  • Expectations, parameters, needs and preoccupations are shared

• Working

  • Problem identification

• Exploitation

  • Nurse guides pt to develop better coping skills by teaching

• Resolution

  • Termination phase between nurse and pt

  • Pt has the knowledge to care for self

What is the role of the nurse in a therapeutic relationship?

• Stranger

• Resource person

• Teacher:

  • Presents info to pt and family to understand disease

  • holds groups such as medication groups

• Leader

• Surrogate

• Counselor

What is Malsow’s hierarchy of needs?

• Starting at the bottom

• Physiological —> Food, water air, sleep, and excretion

• Safety —> Security, Shelter, Job, Resoruces

• Love/belonging —> Friendship, family, sexual intimacy

• Esteem —> Confidence, achievements, self-esteem

• Self actualization —> Desire to reach one’s full potential

What was Harry Sullivan’s greatest contribution to mental health?

• Establishment of satisfying interpersonal relationships through Milieu Therapy

• Milieu Therapy - clients interact with one another, giving feedback, working cooperatively, as a group

What happens during cognitive therapy?

• Focuses on immediate thought processing

• How a person perceives or interprets their experiences and determine their behaviors

What did Dr. Aaron Beck find?

• Founder of CBT

• CBT: works on thought distortions and how to change the thought and the behaviors associated with those thoughts

What is maturational crises/developmental crises?

• Predictable event

  • Ex: Entering High school or having a kid

What is situational crises?

• Unanticipated or sudden events

  • Ex: Job loss, death of a loved one

What is adventitious crises/social crises?

• Natural disasters

  • Ex: Earthquake or tsunami

How do crises affect an individual?

• Pt can go from well to dysfunctional which can be caused by a crisis

How long can crisis symptoms last?

• 4-6 weeks

How long do PTSD symptoms last?

• Over 4 weeks

How long do Acute Stress disorder symptoms last?

• 3 days to 4 weeks

How long does Adjustment disorder last?

• From 3 months to 6 months

What consists of Crisis Interventions?

• Directive interventions

• Figuring out the trigger

  • Assess person’s health status

  • Promote problem health solving

• Supportive interventions aim at dealing with the person’s needs for empathetic understanding (IE: encouraging the person to identify and discuss feelings)

What are the benefits of community mental health tx?

• Cost effective

• Staying connected with family, friends and support systems while in therapy

Why is culturally competent nursing care important?

• Health-illness beliefs might affect a person’s ability to engage in tx

  • They might want herbal meds or reject certain meds

• Don’t assume anything

• Include beliefs in assessment to develop individualized plan of care for pt

What is utilitarianism?

• A theory that bases decision on the greatest good for the greatest number

  • Who do we give this vaccine to?

What are the four main principles of ethics?

• Autonomy

  • Nurse’s ability to act according to their knowledge and judgement while providing care within their scope of practice

• Beneficence

  • Kindness and charity demonstrated by nursing action that benefit others

• Justice

  • Act of being fair or impartial, no bias regardless of pt’s circumstance

• Non-maleficence

  • To do no harm to others

What Neuroleptic Malignant Syndrome (NMS)?

• When a person has an adverse reaction to certain medications or rapidly withdraws from them

  • Fever

  • V/S instability

  • Elevated WBC

  • Extreme rigidity of muscles

  • Medical Emergency

What are the extrapyramidal symptoms (EPS)?

• A group of movement disorders that can occur as a side effect of taking antipsychotics

  • Acute dystonia: painful involuntary contraction after a few hrs of administration

    • Given Benadryl or Cogentin

  • Akathisia: Restlessness

  • Parkinsonism: tremor rigidity, shuffling gait

  • Tardive dyskinesia: Occurs with long term use of typical antipsychotics (Haldol, Thorazine)

What are Tricyclic antidepressants?

• Used to tx depression, anxiety, insomnia, OCD

• Major SE: Similar to Anticholingeric se and Sedation

  • Dry mouth, constipation, decreased urination, bowel obx, pupil dilation/blurred vision, orthostatic hypotension, high HR, less sweating

• Interventions:

  • Ice chips/hard candy for dry mouth, increase fluids+dietary fiber OR stool softener, assess for dizziness or lightheadedness

• Important, TCA will affect electrical circuit of the heart not prescribed much bc of fatal OD

What are Selective Serotonin Reuptake Inhibitors (SSRIs)?

• generally FIRST LINE also for anxiety

• Sexual side effects, gastrointestinal SE, weight GAIN

• Fluoxetine (prozac), paroxetine (paxil), sertraline (zoloft), citalopram (celexa)

 

• All antidepressants watch for Serotonin Syndrome where too many seratogenic drugs interact 

  • SE: diarrhea, hyperreflexia, shivering, increased temperature, VS instability, encephalopathy, restlessness, sweating

  • Also when STARTING these meds, can be an INCREASE in energy → can increase likelihood of suicidality 

  • BLACK BOX WARNING → INCREASED suicide risk in children and adolescent present 

What is lithium (eskalith)?

• FIRST agent for acute mania and Bipolar maintenance

• shown to REDUCE rates of suicide

• efficacy correlates to serum levels, watch for serum level toxicity → if level is >1.5 mEq/L NOTIFY PHYSICIAN & HOLD THE DOSE

What are benzodiazepines?

• Anxiolytics - tx acute and chronic anxiety

• Alprazolam (xanax), lorazepam (ativan), clonazepam (klonopin) work on gaba receptors which can make a person relax

What is busprione (Buspar)?

• Used for GAD

• does NOT cause dependency, does NOT cause sedation, takes a few weeks to kick in

What is Propanolol?

• Beta blocker → no FDA for stage anxiety, social anxiety; reduces PHYSICAL symptoms of anxiety (high HR, sweating)

What is clonidine (Catapres)?

• alpha 2 agonist non FDA → inhibit hyperactivity and impulsivity

  • Also used for ADHD

• USED FOR ANXIETY but NOT FDA APPROVED FOR ANXIETY

What is Attention Deficit Hyperactivity Disorder (ADHD)?

• inattention and distractibility

  • Stimulants have ACTIVATING effect on the CNS

    • amphetamines (Adderall) and methylphenidates (Ritalin) BOOST dopamine and norepinephrine 

    • Attention is function of dopamine and norepinephrine = increases focus

    • SE: Appetite suppression, Cardiovascular effects (transient increase in HR and BP), insomnia, growth restriction

What are examples of non stimulants?

• Atomoxetine (Strattera) (norepinephrine reuptake inhibitor) NO drug abuse potential

• Clonidine (Catapres) & guanfacine (tenex) = alfa receptors → inhibit hyperactivity and impulsivity 

• Bupropion (wellbutrin) → inhibits reuptake of norepinephrine and dopamine

When do withdrawal symptoms begin?

• Sx BEGIN 4 to 12 hrs AFTER stopping or reduction of alcohol intake

• coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea/vomiting.

• Severe or untreated withdrawal leads to short hallucinations, seizures, or delirium called Delirium Tremens (DT) 

  • DT is LIFE THREATENING → leads to seizures, arrhythmias, severe electrolyte imbalances

What drug helps decrease acute alcohol withdrawals and prevents seizures?

• Benzos, usually Lorazepam (Ativan)

What drug helps decrease intensity of withdrawals?

• Chlordiazepoxide (Librium)

What are the long term physiological effects of alcohol use?

• Cardiomyopathy, Wernicke encephalopathy, Korsakoff psychosis, Pancreatitis, Esophagitis, Hepatitis, Cirrhosis, Leukopenia, Thrombocytopenia, Ascites

What vitamin do alcohol users lack?

• a pt needs to receive is B1/thiamine, vitamin B12, folic acid

• Wernicke encephalopathy and korsakoff psychosis are related to low B1 from alcohol consumption

What is illegal amount of Blood Alcohol Concentration a person can have while driving?

• It is illegal for you to drive if you have a BAC of: 0.08% or higher if you are over 21 years old

  • 0.01% or higher if you are under 21 years old.

What would a pt with delirium present with?

•  Pts with delirium: are unable to answer and are confused, frightened, and angry

What are the causes of delirium?

• medications such as steroids are primary offenders and at times pts exhibit psychotic behaviors

• Post operative 2-5 days onset

• Using sedative drugs barbiturates opiates and/or steroids

• Continuous noise, dehydration, UTI, fever, pneumonia

What are the interventions for delirium?

• Protection/safety needs= 1:1, protect from poor judgement and memory impairment

• Keep room moderately lit, minimal stimulation

• Clearly visible calendar/clocks/staff/ function

• Communicate in calm, reassuring manner, frequent reorientation, simple concise statements

What are the risk factors for complicated grief?

• Risk factors for complicated (long lasting and severe) grief

  • Unexpected loss of child

  • Death of loved one r/t car accident, murder, suicide

  • Close or dependent relationship to deceased one

  • Social isolation or loss of support system

  • Preexisting mental illness or poor physical health

What are the Kubler-Ross five stages of grief?

• Denial, anger, bargaining, depression, & acceptance 

What is the priority nursing interventions when caring for a Rape Victim?

•  SAFETY 

  • Remember therapeutic communication, provide emotional support, have a safety plan, refer to support services

What is PTSD?

• REMEMBER the symptoms need to start within 3 months of the trauma

  • War, terrorism, natural disasters, MVAs, unexpected death of a loved one, a life-threatening medical diagnosis, and assault) and must last at least 1 month

• PTSD is usually chronic in nature, sxs can fluctuate in intensity and severity becoming worse during stressful periods

• It can happen at any age

• The severity and duration of the trauma and the proximity of the person to the event are the most important factors r/t likelihood of developing PTSD

• Safety is priority intervention →Make sure a support system is in place

  • Pt is at great risk for suicide, do assessment

What are the characteristics of anxiety disorders?

• group of conditions ensuing behavioral, emotional, cognitive, and physiological responses

  • clients demonstrate unusual behaviors

  • **significantly impairs daily routine, social lives, and occupational functioning

  • Physical sx of panic attacks  → sweating, palpitations, hyperventilation, chest pain → PRIORITIZE SAFETY

What is Obsessive Compulsive disorder?

• Obsessions 

  • cause marked anxiety

  • interfere with interpersonal, social, or occupational function

  • the person believes he/she has no control over them

• Compulsions → ritualistic or repetitive behaviors or mental acts that a person carries out to neutralize anxiety

  • usually (ex: handwashing = contamination), counting to a certain number multiple times

What is major depressive disorder (MDD)?

• Studies show major depression in first degree relatives are at twice the risk for developing depression = depression can be GENETIC

• Deficiencies of norepinephrine, serotonin and dopamine 

• Anhedonia (inability to feel pleasure), change in body weight, agitation

• Major depressive episode = depressed mood and 5 OUT OF THE 9 symptoms AKA SIGECAPS

  • Sleep disturbance

  • Interest or enjoyment (decreased)

  • Guilt or Hopelessness

  • Energy (decreased)

  • Concentration (decreased)

  • Appetite (decreased)

  • Psychomotor retardation 

  • Suicide thoughts

What is the nursing priority for a pt with MDD?

• OVERALL GOAL: keep pt safe, later to develop coping skills that DO NOT INVOLVE SELF HARM 

• Interventions: for SA and SI → SAFETY IS KEY

• NO access to contraband that could endanger pt → NO shoelaces, NO strings

• No suicide no self harm contract have been used when pt is admitted but never feel that a pt will not harm self with a contract

• Assess for support system → parents, therapist, friends, etc

What is a manic episode?

• increase in psychomotor energy and activity

  • Elevated or irritable mood, pacing

  • Rapid, pressured speech & poor personal boundaries, promiscuous behavior

  • DIG FAST

    • Distractibility

    • Impulsivity (buying random stuff, acting irrationally)

    • Grandiosity (inflated perception of one’s importance)

    • Flight of ideas (fast speech with frequent subject changes)

    • Activity (increased)

    • NO Sleep

What is Borderline Personality Disorder (BPD)?

• clients may cling and ask for help 1 minute and then become angry

• clients may attempt to manipulate staff to gain immediate gratification and split

• labile (unpredictable) mood, unpredictability, dysphoric (unhappy, unsatisfied, frustrated)

  • Impaired judgement & lack of care for safety

  • Extreme fear of abandonment, isolate