C7 NUR1212C Module 1

NUR1212C; Stress & Coping, Cognition, Alzheimer's, Dementia/Delirium, Mood & Affect, Depression, Bipolar, Schizophrenia

Mood

pervasive and sustained emotion that influences one’s perception of the world and how one functions

Patient's internal emotional state (Subjective)

Examples:

• Sad

• Happy

• Angry

• Hopeless

-what the pt reports

Affect

outward emotional expression; provides clues to a person’s mood

Observable emotional expression

Examples

• Flat

• Blunted

• Bright

• Labile

• Restricted

• Inappropriate

-what the nurse observes

Cognition

Mental process of acquiring, storing, processing, and using information.

Includes:

• Memory

• Attention

• Judgment

• Language

• Reasoning

• Executive functioning

• Decision making

Six Cognitive Domains

1. Complex Attention

2. Executive Functioning

3. Learning and Memory

4. Language

5. Social Cognition

6. Perceptual-motor function

Complex Attention

refers to a person's ability to maintain information in their mind for a short time and to manipulate that information

Example a drug calc problem with many steps

Executive functioning

refers to organization, self-control, flexibility.

Includes:

• Planning

• Organizing

• Problem solving

• Decision making

Example wanting chocolate cake but knowing the calorie count is to high

Learning and Memory

learning is acquiring new information; memory is the encoding (changing the info into a form so it can be stored in the brain)

Language

spoken or written communication with structure

Social cognition

in reference to people, social interactions, mostly at an unconscious level: perceptions and interpretation of behaviors

Perceptual-motor function

skills that are movement- related and essential to growth and development that work together with sensory-motor and cognitive development: how a person interacts with the environment

Psychosis

refers to a total inability to recognize reality (what’s real and what’s not)

-hallucinations, delusions

-not a diagnosis but a symptom

Depression

-Persistent depressed mood resulting in impaired functioning.

common mental state characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, poor concentration

Depression major symptoms

SIGECAPS

Sleep disturbances

Loss of Interest (Anhedonia)

Guilt

Low Energy

Poor Concentration

Appetite changes

Psychomotor changes

Suicidal thoughts

Depression Priority Assessment

Always assess: Suicide Risk FIRST

Ask directly: "Are you thinking about hurting yourself?"

Depression risk factors

Chronic illness (depression is often secondary to a medical condition)

Family history

Substance abuse

Social isolation

Older adults

Recent loss

Chronic pain

Depression in Older Adults

– Often undetected or inadequately treated

– Commonly associated with chronic illness

– Symptoms possibly confused with symptoms of bipolar, dementia, cerebrovascular accidents

– Differential diagnosis may be required

– Second suicide rate peak in those 75 years and older

– May present with:

Somatic complaints

Fatigue

Weight loss

Poor appetite

Depression in Children and Adolescents

– Anxiety and somatic symptoms more likely

– Decreased interaction with peers

– Avoidance of play and recreational activities

– Mood may be irritable rather than sad

– High risk of suicide

– Third leading cause of death among teens

– Chronic bullying increases risk

– Substance use intensifies suicide risk

Nursing Priorities for Depression

Suicide precautions

Safety

Nutrition

Hydration

Sleep

Medication adherence

Therapeutic communication (avoid false reassurance)

First-Line Medication for Depression

SSRIs (Selective Serotonin Reuptake Inhibitors)

Ex:

Fluoxetine (Prozac)

Sertraline (Zoloft)

Escitalopram (Lexapro)

Paroxetine (Paxil)

Nursing Considerations for SSRIs

-3-4 weeks to reach therapeutic effect

-Monitor suicidal ideation (adverse reaction)

-Watch for serotonin syndrome effects

-Avoid EtOH

-Avoid herbs (St. John’s wort)

-Do NOT stop abruptly

-BBW: increased risk of suicidal thoughts/behaviors in children, adolescents, & young adults (< 25 yrs. old)

Serotonin Syndrome

– Rare and life-threatening event from too much serotonin

– Early signs: flu-like symptoms-tachycardia-muscle stiffness-tremors, increase in temperature, BP can lead to unconsciousness-seizures-coma = HYPERMETABOLIC STATE

– Risk greatest when SSRI is administered in combination with monoamine oxidase inhibitor (MAOI)

Tricyclic Antidepressants (TCAs)

Amitriptyline

-corrects imbalance of serotonin and norepinephrine

-adverse effects: increased suicidal ideation in early therapy

-overdose is lethal: Cardiac dysrhythmias

-Contraindications:

-ETOH-blocks action of TCA

-can cause constipation/laxatives needed

-anticholinergic medications for COPD can cause intestinal paralysis

-antihypertensive medication- may induce hypertensive crisis

MAOIs Last line

Selegiline (Emsam)-(Eldepryl) & Tranylcypromine (Parnate)

-Tx for severe depression

-allows for more dopamine, serotonin, norepinephrine at neural receptor sites

-Avoid tyramine (no aged foods)

-Avoid OTC medications

-Avoid EtOH

-Contraindicated w/Carbamazepine, SSRI’s, SNRI’s, Narcotics = Hypertensive crisis

-Transcutaneous delivery of an MAOI with a patch called the Selegiline transdermal system (STS).

Electroconvulsive Therapy

Reserved for patients whose disorder are intolerant to drug treatments and who are so severely ill that rapid treatment is required

-A procedure done under general anesthesia, in which electrodes pass current through the brain, intentionally triggering a brief seizure

-Causes brain chemistry changes that can reverse certain mental conditions

Stress

the brain and body's natural, non-specific physiological and psychological response to any demand, challenge, or change (event)

Stressor

an event or stimulus that disrupts a person’s sense of equilibrium

Stress appraisal

the process by which a person interprets a stressor as a threat or a challenge

Coping

the dynamic cognitive and behavioral efforts to manage demands/stress (internal or external); (response to stress)

Distress

Negative stress

Produces:

• Anxiety

• Poor coping

• Illness

Eustress

Positive stress

Examples

• Graduation

• Wedding

• Promotion

Produces:

• Motivation

• Growth

• Improved performance

Homeostasis

body’s tendency to resist physiologic change and hold bodily functions relatively consistent, well coordinated, and usually stable

Allostasis

dynamic regulatory process that maintains homeostasis through a process of adaptation

Fight-or-Flight Response

Sympathetic Nervous System

↑ Heart rate

↑ Blood pressure

↑ Respiratory rate

↑ Blood glucose

↑ Cardiac output

Dilated pupils

Bronchodilation

Blood flow moves to skeletal muscles

-Hormones: Epinephrine, Norepinephrine, Cortisol

What is the body’s primary stress hormone?

Cortisol

Chronic Stress

When stress is prolonged, chemicals produced by the stress response (cortisol, adrenaline, and other catecholamines) can have damaging effects on the body

Long-term cortisol causes:

↓ Immune function

↑ Infection risk

Depression

Memory impairment

Hypertension

Metabolic disorders

GI disorders

Sleep disturbances

General adaption syndrome (GAS)

General adaption syndrome (GAS)

physical response to stress; a three-stage physiological response to stress:

-alarm (fight-or-flight) - SNS activated

-resistance (adaptation) -body attempts adaption; continued cortisol release

-exhaustion- resources depleted, illness develops, immune suppression

Adaptive Coping

-involves healthy cognitive and behavioral strategies used to manage stress, restore emotional balance, and build resilience

Exercise

Healthy sleep

Support system

Problem solving

Prayer

Relaxation

CBT

Maladaptive Coping

-unhealthy, dysfunctional methods patients use to temporarily relieve stress without addressing the root cause

Avoidance

Denial

Substance abuse

Poor problem solving

Isolation

Lack of support

What should nurse assess in regard to stress & coping

• Previous coping patterns

• Perception of stress

• Support system

• Mental status

Problem-focused Coping

Addressing the root cause of a stressor to resolve it

-Attempts to solve the problem.

Example: Making a study schedule.

Emotion-focused Coping

controlling the emotional response to the stressor

Ex: deep breathing, meditation, guided imagery

Meaning-focused Coping

using beliefs, faith, purpose, or values to change how you feel about the stressor

Mild Anxiety

Perceptual field may have heightened attention

-can learn, problem solve; alert

Moderate Anxiety

Perceptual field has narrowed

-able to solve problems and learn but difficulty concentrating

Severe Anxiety

Perceptual field has greatly reduced

-unable to learn and problem-solve; very limited focus

Panic (level of anxiety)

Unable to focus at all

-disorganization and irrational behavior; out of touch with reality

Nurse priorities for anxiety

Panic Level

Stay with patient

Simple instructions

Decrease stimulation

Ensure safety

Never leave patient alone

Panic Disorder

a diagnosable mental health condition characterized by recurrent, unexpected panic attacks and a persistent, chronic fear of future attacks

-pts may believe they’re losing their minds or are having a heart attack

-18% higher rate of suicide attempts

Panic attack

the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom

Physical symptoms:

• Chest pain

• Palpitations

• Hyperventilation

• Sweating

• Shaking

• Fear of dying

-increases rate of suicide attempts

-always rule out cardiac causes first

Generalized Anxiety Disorder (GAD)

Characterized by excessive, persistent, and uncontrollable worrying about everyday situations/circumstances

-”worry disease”

Duration: ≥6 months

Symptoms:

• Poor sleep

• Fatigue

• Restlessness

• Poor concentration

• Muscle tension

• Can affect disturbances in relationships and impair functioning at work

• No distinct symptomatic reaction pattern

Obsessive Compulsive Disorder (OCD)

Obsessions: unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause significant anxiety or distress

Compulsions: unwanted, repetitive behavior patterns or mental acts intended to reduce anxiety but not to provide pleasure or gratification

Post Traumatic Stress Disorder (PTSD)

develops after a person experiences a traumatic event outside of normal human experience

-must last more than 1 month

Symptoms:

• flashbacks

• avoidance

• hypervigilance

• nightmares

• negative mood

PTSD risk factors

military combat

abuse/violence

sexual assault

natural disasters

serious illness

Compassion Fatigue

a profound state of physical and mental exhaustion (“cost of caring”)

Those at risk: ER, ICU, Hospice, Psychiatric, Oncology nurses, Social workers

Symptoms:

• Burnout

• Depression

• Withdrawal

• Poor concentration

• Hopelessness

Compassion fatigue treatment

Self-care

Scheduled breaks

Exercise

Support system

Sleep

Avoid alcohol

Specific phobia

an irrational fear of a specific object, activity, or situation

Example: Spiders, Dogs, Needles

Social anxiety disorder (social phobia)

anxiety with exposure to a social situation or performance situation

-fear of public speaking is the most common

Agoraphobia

excessive fear about being in a place or situation from which help might not be available, and escape might be difficult

-avoids crowds & public places

Bipolar Disorder

a mental health condition causing extreme, unpredictable mood swings that range from emotional highs (mania or hypomania) to lows (depression)

-onset average is 14-20 years old, fewer after 40

-higher rates in females

Bipolar I Disorder

Mania & Depression

-more severe manic episodes; impairs daily functioning

Bipolar II Disorder

Hypomania & Depression

Mania

Primary symptom of Bipolar I Disorder

Elevated mood

Grandiosity

Pressured speech

Flight of ideas

Hyperactivity

Impulsivity

Poor judgment

Little need for sleep

Risk-taking behaviors

-Often hospitalized to prevent self-harm

Hypomania

Seen in Bipolar II Disorder

Same symptoms

Less severe

No psychosis

No hospitalization required

Nursing Priorities during Mania

Safety

Decrease stimulation

Hydration

Nutrition

Sleep

Medication compliance

Therapeutic Communication for Bipolar Disorder

Use firm limits

Remain calm

Short simple directions

Do not argue

Redirect behavior

Hear and act upon legitimate complaints

Phases of Mania and Nursing Interventions

-Acute Phase: medical stabilization, maintain safety, reduce stimuli, monitor exhaustion, finger foods

-Continuation Phase: maintain medication adherence, psychoeducational teaching, referrals

-Maintenance phase: prevent relapse

Cyclothymia (disorder)

a mental state/mood disorder characterized by mark mood swings between elation (mania) and depression

-essentially a milder, yet more persistent, form of bipolar disorder

Lithium carbonate

Antimanic agent- Mood stabilizer

First Line Tx for Bipolar Disorder manic episodes

Therapeutic levels: 0.5-1.2 mEq/L

Low Na+ and caffeine raise lithium levels (vice versa) so keep a consistent intake of both

Renal dysfunction increases lithium levels

Lithium can impair thyroid function (monitor TSH)

Report suicidal ideations

Drug interactions with: thiazides, ACE inhibitors, NSAIDs

Lithium toxicity level > 1.5

Lithium Toxicity

Levels > 1.5

GI upset

Vomiting

Diarrhea

Coarse tremors

Confusion

Slurred speech

Muscle weakness

Blurred vision

Seizures

Cardiac dysrhythmias

Lamotrigine (Lamictal)

Antiepileptic & Mood stabilizer; drug of choice instead of lithium

Tx for Bipolar manic episodes

No EtOH

Monitor liver and kidney function

Life-threatening rash, Steven-Johnson Syndrome, Toxic Epidermal Necrolysis (TEN)

Carbamazepine (Tegretol)

Antiepileptic and Mood Stabilizer; stabilizes electrical activity in the brain

Tx for Bipolar manic/depression episodes, epilepsy seizure disorder, neuropathic pain, sleep disorders, BPD

No EtOH; Avoid grapefruit juice

Causes bone marrow suppression & hyponatremia

Not for existing glaucoma, thyroid, liver disease, teratogenic (fetal abnormalities)

Drug interaction: Valproic acid, Cephalosporins, Antifungals, Diltiazem Verapamil, Anticoagulants

Depakote (Divalproex sodium)/ Valproic acid (Depakene)

Antiepileptic and Mood stabilizer; Tx for Bipolar disorder & epilepsy

increases GABA, calming neurotransmitter in the brain

Watch for Liver toxicity (BBW) & Pancreatitis (discontinue med if this occurs)

Monitor CBC & liver enzymes

Increase in birth defects

Olanzapine (Zyprexa)

Atypical antipsychotic; Tx for Bipolar mania, psychosis; restores balance of natural substances in the brain

-EPS symptoms are low

-take with food, drink extra fluids, beware of overheating

-can cause dehydration quickly, cholesterol, hyperglycemia, OH, PKU changes in newborns

-NO EtOH, monitor suicidal ideations

Risperidone (Risperdal)

Atypical antipsychotic; Tx for Bipolar mania, psychosis, schizophrenia; restores natural balance of neurotransmitters in the brain

-May be given an adjunct therapy with Lithium and Divalproex for mania

-Can cause EPS symptoms but less likely (parkinsonism, akathisia, dystonia)

-Do not discontinue med abruptly; NO EtOH; monitor for suicidal ideations

-WBC count risk for infection

-Dry mouth, weight gain, rash, nasal congestion, abdominal discomfort, fatigue, dizziness, OH

Schizophrenia

Chronic psychotic disorder affecting:
-Thinking, Emotion, Behavior, and Reality testing

Schizophrenia Phases

Prodromal Phase: pre-psychotic phase with early warning signs (social withdrawal, lack of motivation, difficulty concentrating

Acute phase: florid positive & negative symptoms; cognitive symptoms; psychosis symptoms (hallucinations, delusions, catatonic behavior)

Residual Phase: continual recovery, control/prevention of relapse; mild symptoms (remission)

-CT, MRI, PET-Scan: can provide substantial evidence that some people with schizophrenia have structural brain abnormalities

Schizophrenia Positive symptoms

• Hallucinations

• Delusions

• Catatonia

• Bizarre behavior

• Formal thought disorder (word salad; disorganized speech)

Schizophrenia Negative symptoms

• Flat or blunted affect

• Apathy

• Alogia (poverty of speech)

• Avolition (the severe lack of motivation or ability to start and complete goal-directed activities)

• Anhedonia (inability to feel joy or experience pleasure in activities that you normally enjoy)

• Social withdrawal

• Poor hygiene

Schizophrenia Cognitive symptoms

• Poor memory

• Poor attention

• Poor judgment/reasoning

• Difficulty solving problems

• Poor executive functioning

Schizophrenia Mood symptoms

• Depression

• Anxiety

• Demoralization

• Dysphoria

• Suicidality

Hallucinations vs. Delusions

Hallucinations: false sensory perceptions (hearing voices or seeing things that aren’t there) - think perceptual (senses)

Delusions: rigid, false fixed beliefs that persist despite objective evidence to the contrary (believing you’re being spied on) - think cognitive

Command Hallucinations

Auditory hallucinations where voices instruct a person to take specific actions

-Assess immediately; highest priority

-Determine: “what are voices telling you?”

-Risk of harm to self or others

Communication for Schizophrenia

DO:

-Present reality

-Short simple statements

-Acknowledge feelings

-Remain calm

-Maintain boundaries

DO NOT:

-Argue

-Validate delusions

-Whisper

-Touch unexpectedly

Therapeutic responses:

-"I understand you're hearing voices."

-"I do not hear the voices."

-"I will stay with you."

Planning/Interventions for Schizophrenia Phase I (Acute)

– Likely hospitalization for immediate stabilization & safety

– Psychopharmacologic treatment

– Supportive/directive communications

– Limit setting (milieu management and counseling)

– Psychiatric, medical, neurologic evaluation

Planning/Interventions for Schizophrenia Phase II (Stabilization)

– Symptom control and understanding the illness

– Family psychoeducation/community support

– Health teaching

– Disease, medication management

– Cognitive and social skills enhancement

– Stress and anxiety controls

Planning/Interventions for Schizophrenia Phase III (Maintenance)

– Relapse prevention, maximizing independence, and improving quality of life

– Health promotion and maintenance

– Improve functional deficits

– Encourage nonthreatening activities

– Encourage family and social interaction

Typical Antipsychotic Meds (older meds, first-generation)

-Target schizophrenic Positive symptoms

-EPS symptoms are mostly associated with these

-Block dopamine so they would increase risk for Neuroleptic Malignant Syndrome

Atypical Antipsychotic Meds (second-generation)

-Target Positive AND Negative symptoms

-Balance dopamine AND serotonin in the brain

-Atypical agents have fewer side effects

-Atypical agents treat anxiety, depression, and decrease suicidal behavior

• Disadvantages

-Metabolic syndrome:

-Weight gain, dyslipidemia, altered glucose

-Risk of diabetes, hypertension, atherosclerosis, and increase in heart disease

-Is more expensive than conventional antipsychotics

Haloperidol (Haldol)

First-generation Typical Antipsychotic; blocks dopamine D₂ receptors in brain

Tx for psychosis (schizophrenia)

-Known to cause EPS symptoms (high potency)

-WBC, BMP, Hem. A1C follow-up tests

-Regular dosing, do not stop abruptly; NO EtOH

-Monitor for NMS and QT interval prolongation

Chlorpromazine (Thorazine)

First-generation Typical Antipsychotic; blocks dopamine (D₁ and D₂) receptors in the brain

Tx for schizophrenia, bipolar acute mania, depression

-Less likely to cause EPS symptoms (low potency)

-WBC, BMP, Hem. A1C follow-up tests

-Regular dosing, do not stop abruptly; NO EtOH

-Monitor for NMS

Neuroleptic Malignant Syndrome (NMS)

a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction

-Symptoms think “FARM”: fever, autonomic instability, rigidity, mental status changes

-Elevate CPK or CK & WBC

Clozapine (Clozaril)

Atypical Antipsychotic; Tx for schizophrenia & suicidal ideations

-Use of this med has to be justified* - risk evaluation & mitigation strategy program

-regular dosing, do not stop med abruptly; NO EtOH

-regular follow-up visits with PCP; serum CBC

-can cause agranulocytosis

-dry mouth, weight gain, hyperglycemia, rash, OH

Extrapyramidal symptoms (EPS)

drug-induced movement disorders that primarily occur as side effects of antipsychotic medications, antiemetics, and antidepressants

-Akathisia (sense of inner restlessness resulting in an inability to sit or stand still)

-Acute dystonia (sudden, painful, and prolonged muscle spasms)

-Parkinsonism (resting tremors, muscle rigidity, slowed movement, and a shuffling gait)

-Tardive Dyskinesia (involuntary, repetitive facial movements such as lip-smacking, tongue-twisting, or grimacing) - late-onset symptom

-Valbenazine (Ingrezza) for Tardive dyskinesia

Treatment for EPS

– Lowering the dose

– Prescribing antiparkinsonian drugs:

• trihexyphenidyl (Artane)

• benztropine mesylate (Cogentin)

• diphenhydramine hydrochloride (Benadryl)

• biperiden (Akineton)

• amantadine hydrochloride (Symmetrel)

• Valbenazine (Ingrezza)

Mild Neuro-cognitive Impairment (MCI)

diagnosed if a modest cognitive decline from a previous level of function is found in one or more of the cognitive domains, but the cognitive deficits do not interfere with independence in daily activities

-Memory impairment main symptom

-Still independent

-Higher risk for dementia

Mild dementia

– More than one cognitive domain is affected

– Interferes with navigation of daily life

Major Neurocognitive Disorder

Significant cognitive decline

Unable to perform ADLs independently

Examples: Alzheimer’s disease & Vascular dementia

Delirium

Acute change in cognition and consciousness.

Always secondary to another medical condition.

Usually reversible

-Common causes: surgery, drug/alcohol withdrawal, infection, pneumonia, hypoglycemia, electrolyte imbalance

Delirium characteristics

-Cognitive disturbances- thinking, memory, disorientation, impairment, and perception

-Attention disturbances- loss of focus & attention; confusion

-Sundown syndrome- increased confusion in evening hours '

Acute onset

Hours to days

Fluctuating

Altered LOC

Poor attention

Disorganized thinking

Hallucinations- (visual and tactile): false sensory stimuli

Illusions- errors in perception and interpretation of real sensory stimuli

Hypervigilance; Labile mood swings

Delirium Assessment

✔Vital signs

✔ Neurologic assessment

✔ Family interview

✔ Medication review

✔ Laboratory findings

✔ CAM (Confusion Assessment Method