Mental Health Exam 3

False Imprisonment

Unlawful restraint or restriction of a person's freedom of movement

- ex: Restraining a patient without proper justification or a provider's order

- Keeping a patient locked in a room against their wil

- Failing to discontinue restraints once they are no longer necessary

*Not false imprisonment if...

- A patient is an immediate danger to themselves or others.

if on restraints → skin checks/integrity per policy, more frequent checks if child (q15)

What to do if your patient is deemed incompetent in medical decision making?

The nurse must IDENTIFY and REVIEW the legally authorized person responsible for making decisions on the patient's behalf

* A mental health diagnosis alone does NOT mean a patient is incompetent

The only time confidentiality should be breached is when...

A patient states that they want to harm themselves or other people! Must report!!

CIWA Score, what is this?

used to assess alcohol withdrawal, NOT alcohol intoxication

- Nausea/ Vomiting

- Tremors

- Sweating

- Anxiety

- Agitation

- Tactile Disturbances

- Auditory Disturbances

- Visual Disturbances

- Headache

- Orientation/ Confusion

Defense Mechanisms: Repression

keeping distressing thoughts and feelings buried in the unconscious

ex: a person w a terrible childhood has no recollection of it

Defense Mechanisms: Sublimation

Transforming negative inpulses into valuable achievements

- an angry person channels their energy into working out

The agression cycle

1. Sensation

2. Impulse

3. Initiative

4. + Destruction

4. - Annihilation

5. Satisfaction

6. Withdrawal

*patient may go backward before getting better

Wernicke's encephalopathy

an acute, potentially life-threatening neurological condition caused by a severe deficiency of vitamin B1(thiamine).

- commonly due to chronic heavy alcohol use

*can lead to Korsakoff Syndrome if not treated EARLY

Wernicke's Triad (S/S)

1. Ataxia

2. Confusion

3. Ophthalmoplegia

Korsakoff Syndrome

Chronic, often irrevesible !

- chronic neurological disorder caused by a severe deficiency of thiamine (vitamin B1)

Korsakoff Syndrome: S/S

Hallucinations!

Confabulation (making up stories)!

Personality Changes!

Memory Loss!

Wernicke's encephalopathy/ Korsakoff: Treatment!!

If suspected Wernicke...

= IMMEDIATE HIGH DOSE IV THIAMINE

- BEFORE GLUCOSE!!

- Thiamine Supplementaion and alcohol cessation!

Delirium Tremens

a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol

- develop about 48-96 hrs after last drink, not 6-8 hrs

When do withdrawal symptoms start to occur?

6-12 hours!

S/S of Alcohol withdrawal

Tremors

Paroxysmal sweats

Insomnia/ Anxiety

Nausea/ Vomiting

Headaches

When to expect minor withdrawal symptoms

6-36 hours

When to expect withdrawal seizures?

6 - 48 hours

When to expect alcoholic hallucinosis?

12 - 48 hours

When to expect delirium tremens?

48 - 96 hrs

Disulfram (Antabuse)

a prescription medication used to support the treatment of chronic alcohol use disorder

- makes you violently ill if you consume alcohol!!

- do not even consume alcohol based products like toothpaste, foods, mouthwash

Disulfiram (Antabuse): Side effects

Intense facial flushing and sweating

Throbbing headache and dizziness

Nausea and violent vomiting

Chest pain, palpitations, and rapid heart rate (tachycardia)

Electroconvulsive Therapy: What to know

- Used for resistant depression, BPD, mania

- Afterwards Pt may be very sleepy and confused, headache, short term memory loss

Talk to patient and let them know the effects before

Performed under general anesthesia done in 10-15 min

Done in phases/ sessions

CANNOT drive themselves home

Bipolar 1 vs Bipolar 2

bipolar 1: severe mania with bouts of intense depression and may be psychotic

bipolar 2: hypomania with intense depression, still able to function at work/social

Narcan (naloxone): Adverse effects

- tachycardia

- hypertension

- nausea/ vomiting

- agression after waking up

Depakote: Uses

fatty acid derivative anticonvulsant and mood stabilizer

- used to treat seizures BUT also used for manic/ BPD pts

Lithium: Uses

Primary use: Treatment of bipolar disorder

- Treats acute manic episodes

- Helps stabilize mood and reduce mood swings.

-Decreases risk of suicide in patients with bipolar disorder.

Lithium: Therapeutic Levels

0.6 - 1.2 !!!

- must closely monitor levels

*Lithium toxicity should be suspected when levels reach or exceed 1.5 mEq/L, especially when symptoms are present.

Lithium Toxicity: From common to severe!

- Nausea/ Vomiting

- Coarse hand tremors

- Confusion

- Ataxia

- Hyperreflexia

- Seizures

- Coma

- Death

Lithium: Key Information

- Maintain hydration 2-3L

- maintain consistent sodium intake (don't cut or add)

- Avoid NSAIDS, ACE, ARBS, Diuretics

*Dehydration and sodium depletion cause the kidneys to retain more lithium, increasing the risk of toxicity

When to check lithium levels

Every 6 months once stable

Draw blood for check 12 hours post dose

Why do patients have problems adhering to antipsychotic medication?

-Sometimes too expensive

-Adverse effects are too harsh

-Trouble getting to appointments/ pharmacy

-Takes some time to work

Methadone Use

Detoxification and temporary maintenance treatment of narcotic addiction, relief of severe pain and withdrawal symptoms

What is mania?

Abnormal period of elevated, expansive, or irritable mood paired with a significant increase in energy, activity, and racing thoughts.

- a defining feature of bipolar I disorder.

Treatment for mania

Lithium

- (↓environmental stimuli)

- Promote appropriate clothing for the environment and monitor sleep, nutrition, impulsivity, and aggression risk.

- risk for impaired nutrition -> high calorie and protein finger foods

Schizophrenia: Positive Symptoms

Hallucinations, Delusions, Disorganized Thinking&Speech

Schizophrenia: Negative Symptoms

- Social withdrawal

- Anhedonia (inability of pleasure)

- Alogia / reduced speech

- Flat affect: no signs of emotional expression

- Avolition: decreased engagement in purposeful, goal-directed actions

Persecutory Delusions

Beliefs of being targeted or followed by others

Grandiose Delusions

Beliefs that one holds special power, unique knowledge, or is extremely important

Delusions of Reference ( referential)

Believes that TV, social media, or music has secret messages for them

Somatic delusions

belief that something highly abnormal is happening to one's body

ex. bugs crawling on them

Erotomanic delusions

beliefs that a celebrity or someone unavailable to them is secretly in love with them

Thought Broadcasting Delusions

Beliefs that another person can hear or know ones thoughts

Thought insertion delusion

belief that another person or object is inserting thoughts into one's head

Thought Withdrawal

a delusional belief that others are taking the client's thoughts away and the client is powerless to stop it

How to treat delusional patient?

Do not agree or argue with the patient

- Acknowledge and validate the underlying feelings

ex. If a patient says, "The nurses are trying to poison my food," respond with: "I can see that you are feeling very worried and unsafe right now. Would you feel more comfortable if I sat with you while you eat?"

Neuroleptic Malignant Syndrome

Emergent adverse reaction to antipsychotics/ dopamine blocking medications (Haloperidol, Olanzapine)

Triggered by antipsychotics

S/S:

- Severe "lead pipe" rigidty

-FEVER

-Mental status changes

- Autonomic instability

Neuroleptic Malignant Syndrome can cause what?

RHABDOMYALYSIS

- monitor increasing CK levels

Neuroleptic Malignant Syndrome: Treatment

- STOP antipsychotic

- Initiate Fluid Resuscitation

- Dantrolene or Bromocriptine!!

Clozapine, what is it?

Atypical (second-generation) antipsychotic.

-used primarily for treatment-resistant schizophrenia

-also reduces recurrent suicidal behavior

*Exam tip: If a patient has tried multiple antipsychotics without improvement, the provider may prescribe clozapine

Clozapine: Adverse Effect (s)

AGRANULOCYTOSIS

- monitor ANC levels and ...

Fever

Sore throat.

Weakness.

Chills.

Mouth ulcers.

Signs of infection.

Tardive Dyskinesia, what is it?

Neurological movement disorder characterized by involuntary, repetitive movements, especially of the mouth, tongue, and face.

S/S:

- Lip smacking

- Protruding tongue

- Repetitive chewing movements

- Unusual face making

- Other unusual repetitive body movements

USE AIMS SCALE

Tardive Dyskinesia: Causes

Antipsychotic medications (usually 3+ months of medication administration)

- especially first-generation (typical) antipsychotics.

Blood Alcohol Content : 0.0 - 0.05%

Mild Impairment

- (relaxed, mild speech / memory / attention / coordination / balance impairment)

Blood Alcohol Content: 0.06 - 0.15%

Increased impairment

- (speech, memory, attention, balance further impaired, moderate memory impairment, driving impairment, increased risk of injury / aggression)

Blood Alcohol Content: 0.16 - 0.30%

Severe impairment

- (speech, memory, attention, etc significantly impaired, driving extremely dangerous, judgement extremely impaired, loss of consciousness

Blood Alcohol Content: 0.31 - 0.45%

Life threatening impairment

- (loss of consciousness, alcohol poisoning, risk of death)

Reversal agent for anti- psychotic medications

Benztropine

Benztropine treats what?

Used for acute extrapyramidal symptoms that are potentially caused by antipsychotics

(dystonia, drug induced parkinsonism)

Antipyschotics can cause what effects?

Heavy duty anti-psychotic medications cause agranulocytosis (death of your white blood cells)

- this leads to increase risk of infection

Also can cause phtosensitivity and increased risk of being burned when in the sun (wear sunscreen)

Schizoaffective disorder

Psychotic disorder featuring symptoms of both schizophrenia and major mood disorder such as depression.