Psych final

Attitudes and actions of the culturally competent nurse → cultural awareness

the nurse recognizes the enormous impact that culture has on patients’ health values and practices

Attitudes and actions of the culturally competent nurse → Cultural knowledge

help us to understand behaviors that might otherwise be misinterpreted. It helps nurses to establish rapport, ask appropriate questions, avoid misunderstandings, and identify the cultural variables that should be considered in the planning of nursing care

Attitudes and actions of the culturally competent nurse → Cultural encounters

directly engage in interactions with patients from culturally diverse backgrounds → multiple cultural encounters of diverse backgrounds will decrease the likelihood of stereotyping

Attitudes and actions of the culturally competent nurse

• Cultural skill is the ability to perform a cultural assessment in a sensitive way

• Exhibit cultural desire through patience, consideration, and empathy → giving the impression that you are willing to learn from the patient = hallmark of cultural desire

ADHD → symptoms

• Hyperactivity and impulsivity

• overlooks or misses details, work is inaccurate, difficulty remaining focused, mind seems elsewhere, starts task but quickly loses focus and is easily sidetracked, difficulty organizing tasks and activities, avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort, loses things necessary for tasks or activities, easily distracted by extraneous stimuli, often forgetful in daily activities

ADHD → pharmacological treatment

• Stimulant drugs 

• Methylphenidate (Ritalin and others) and the mixed amphetamine salts (Adderall) are the most widely used

Autism spectrum disorder → symptoms

• Deficits in social relatedness → disturbances in developing and maintaining relationships

• Stereotypical repetitive speech, obsessive focus on specific objects, over adherence to routines or rituals, hyperreactivity or hyporeactivity to sensory input, and resistance to change

Pharmacological Tx of alcohol abuse disorder → Aversive conditioning: Disulfiram

• Inhibits aldehyde dehydrogenase

• Pt feels terrible when the consume ETOH when on this med

Pharmacological Tx of alcohol abuse disorder → Opiate antagonist therapies: Naltrexone

• Blocks mu opioid receptors → contribute to the high and euphoria from drinking 

• Diminish positive reinforcement “reward” craving 

Pharmacological Tx of alcohol abuse disorder → Glutamate-based interventions: Acamprosate

When ETOH is chronically used then withdrawn, state of glutamate hyperactivity occurs – with GABA deficiency 

Pharmacological Tx of alcohol abuse disorder → GABAergic interventions: Topiramate, Gabapentin

Topiramate (anticonvulsant) inhibits glutamate release and enhances GABA (not FDA approved) 

Addiction treatment → etiology

Block the reward center in the brain

Addiction treatment → principles

Abstinence and support are the main principles of treatment

Application of therapeutic communication and caring principals

• Facilitate communication 

• Assist with problem solving

• Develop insight

• Promote independence and recovery

• Educate 

• Increase accuracy of diagnosis

• Yields collaborative decision making

• Improves identification of pt emoticons, perceptions, apprehension, and pt and provider satisfaction

• Reduces risk of malpractice and provider burnout 

Delirium → symptoms

Occurs quickly, may last days or months, short-term memory impaired, erratic sleep, may have day-night sleep reversal, fluctuating consciousness, thought content matches LOC, thought process depends on LOC, lociacal alternating with illogical, slurred speech, visual and tactile hallucinations, anxious, fearful, may startle easily

Delirium → etilogy

• Complications from acute medical conditions 

• Effects of drugs or meds

• In combination with predisposing, non-modifiable risk factors (Dementia or hepatic disease) or precipitating, modifiable (infections, surgery) 

• Associated with: reduced acetylcholine, melatonin; increased dopamine, glutamate, norepinephrine

Personality disorders → symptoms

• significant challenges in self-identity or self-direction

• Have problems with empathy or intimacy within their relationships

Personality disorders → therapeutic interventions

• Psychotherapy 

• Group therapy →  noninvasive and supportive group

Violence and abuse → risk

• Patients 

• Spouse

• Stranger 

• They can get attacked 

Violence and abuse → etiology

• Genetics: more biologically predisposed to respond to life events with irritability, easy frustration, and anger

• Neurobiological: associated with anger and aggression. Brain tumors, Alzheimer disease, temporal lobe epilepsy, and traumatic injury to certain parts of the brain result in changes to personality that could include increased violence

• Neurotransmitters: serotonin, dopamine, and gamma-aminobutyric acid (GABA), play a role in anger and aggression

Violence and abuse → symptoms

• Burns

• Fractures

• Lacerations

• Delay in seeking treatment

• Inconsistent stories

• Injury does not match age or development of child

• High incidence of UTIs

• Bruised and multiple bruises in various stages of healing 

• Red or swollen vulva

• Rectal or vaginal trauma

• Evidence of old, repeated injuries

Violence and abuse → communication technique with a child

• Open ended questions (how did this happen, who takes care of you, what do you do after school, who are your friends, what happens when you do something wrong)

• Avoid asking too many people asking the same questions

Violence and abuse → communication technique with parent or caregiver

• Open ended questions (what arrangements do you make when you need to leave your child alone, how do you punish your child, when your infant cries for a long time, how do you get him/her to stop)

• Do’s: conduct private interviews; be direct, honest, professional, attentive, and understanding; inform them you need to make a referral to CPS and explain process

• Don'ts: try to “prove” accusations or demands; display horror, anger, or disapproval of parents or situation; place blame on or make judgments about the parents or child

Dementia → goal of treatment

• Prevent further buildup of amyloid plaques

• Keep what level of functioning they currently have

Dementia → general pharmacological intervention

• Donepezil (enhances effects of available ACh by inhibiting acetylcholinesterase activity)

• Rivastigmine (inhibits both acetylcholinesterase and butyrylcholinesterase; possible resulting in greater preservation of ACh activity) 

• Galabatmine (inhibits only acetylcholinesterase; also an allosteric modulator of nicotinic cholinergic receptors)

• Memantine (NMDA receptor uncompetitive; antagonist; 5-HT3 receptor antagonist; does not alter ACh

Dementia → general non pharmacological interventions

• Address unmet needs

• Identify/modify environment and daily routine stressors 

• Caregiver support/training 

• Behavior modification 

• Group/individual therapy 

• Problem solving, distracting

• Provide outlets for pent-up energy 

• Avoid behavior triggers

• Increase social engagement

• Relaxation techniques

• Reminiscence, pet, and music therapy 

• Aromatherapy 

Suicide and self harm → assessment

• Be blunt

• “Do you want to kill yourself”

• Find out if they have a plan and if so, the means to carry out the plan

• Assess everyone 

Suicide and self harm → interventions

• establishing a therapeutic alliance

• written safety plan

• careful administration of medication

Suicide and self harm → precautions

One-to-ones

Suicide and self harm → need for hospitalization

If they are a danger to self or others

Significant side effects of 1st gen SDAs

• Sedation, anticholinergic effects, and dizziness upon standing

• Dizziness and orthostatic hypotension

Significant side effects of 2nd gen SDAs

• Increase metabolic syndrome risk. 

• They produce weight gain, hyperglycemia, and hyperlipidemia to varying degrees

Major actions of dopamine

• Involved in fine motor movement

• Involved in integration of emotions and thoughts

• Involved in decision making

• Stimulates hypothalamus to release hormones

Major actions of serotonin

• Plays a role in sleep regulation, hunger, mood states, and pain perception

• Hormonal activity

• Plays a role in aggression and sexual behavior

Major actions of GABA

• Plays a role in inhibition; reduces aggression, excitation, and anxiety

• May play a role in pain perception

• Has anticonvulsant and muscle-relaxing properties

• May impair cognition and psychomotor functioning

Major actions of acetylcholine

• Plays a role in learning and memory

• Stimulates parasympathetic branch of autonomic nervous system for "resting and digesting" actions

• Affects sexual and aggressive behavior

Major actions of glutamate

• Excitatory

• AMPA plays a role in learning and memory

Major actions of norepinephrine

• Level in brain affects mood

• Attention and arousal

• Stimulates sympathetic branch of autonomic nervous system for “fight or flight” in response to stress

Somatic disorders: symptoms

• Pain or fatigue, to the point of excessive concern

• Preoccupation

• Fear

• Common symptoms for primary care visits → chest pain, fatigue, dizziness, headache, swelling, back pain, shortness of breath, insomnia, abdominal pain, and numbness

Eating disorders → symptoms

• can wax and wane over the life span

• Anorexia nervosa: low weight, amniorrhea, muscle weakening, constipation

• Bulimia nervosa: normal to low body weight, tooth erosion, muscle weakening, gastric dilation, calluses, scars on hand (Russell sign)

• Binge-eating: Dysfunctional eating pattern, eating in response to internal cues, sedentary lifestyle, attempts to hide weight gain, eats as a coping method

Eating disorders → intervention

• Collaborate with other members of healthcare team to develop treatment plan.

• Involve patient and/or significant others in the treatment plan.

• Work with team to set a target weight.

• Consult with a dietitian to determine caloric intake necessary to attain and/or maintain target weight → encourage patient to discuss food preferences with dietitian.

Mania symptoms

• Happiest, most excited, and most optimistic people you could meet

• They feel euphoric and energized

• They eat and sleep little, if at all, and are in perpetual motion

• They feel so important and powerful → take horrific chances and engage in hazardous activities

• As the mania intensifies, individuals may become psychotic → hallucinations, delusions, and dramatically disturbed thoughts

Differences in mood disorders → fear

Threat is known, external, definites, conflictual

Differences in mood disorders → anxiety

• Threat is unknown, internal, vague, and conflictual 

• Mild: perceptual field → heightened, flexible focus, aware

• Moderate: perceptual field → narrowed, focused on source, less aware and attentive

• Sever: perceptual field → greatly reduced, focused on specific detail, scattered attention; no instruction 

• Panic: perceptual field → unable to attend to environment, lost focus; no instruction

Differences in mood disorders → OCD

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

• Compulsions: unwanted, ritualistic behavior the individual feels driven to perform to reduce anxiety

• Exist along continuum

Differences between perceptual/psychosis disorders

• Schizoaffective disorder → psychotic disorder with co-occurring mood disorder

• Schizophrenia disorder → psychosis symptoms are independent of any mood disorders

•  Bipolar disorder with psychosis → psychosis symptoms start with increased severity of maina, and get worse as maina worsens

• Depression with psychotic features → psychosis symptoms start with increased severity of depression, and get worse as depression worsens

Symptoms of schizophrenia → positive

• The presence of symptoms that should not be present. 

• Hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or speech

Symptoms of schizophrenia → negative

• The absence of qualities that should be present

• Inability to enjoy activities (anhedonia), social discomfort, or lack of goal-directed behavior

Alcohol intoxication → symptoms

Drowsiness, N/V, slowed reaction, blackouts

Opioid intoxication → symptoms

• psychomotor retardation, drowsiness, slurred speech, altered mood (withdrawn to elated), and impaired memory and attention

• Physical →  miosis (pinpoint pupils) and decreased bowel sounds. Respiratory rates and blood pressure are reduced and heart rates are normal to low

Alcohol and opioid intoxication → assessment priorities

• Assess VS 

  • BP, HR, RR

• Assess airway 

  • Pulse ox and RR

  • Maintain airway 

Alcohol intoxication → risks

• undergoing withdrawal to the point of psychosis → considered a medical emergency because of the risks of unconsciousness, seizures, and delirium

• Withdrawal seizures → may occur within 12 to 24 hours after alcohol cessation. These seizures are generalized and tonic-clonic

• Alcohol withdrawal delirium →  medical emergency that can result in the death in 20% of untreated patients → pneumonia, renal disease, hepatic insufficiency, or heart failure

Opioid intoxication → risks

• Death due to respiratory arrest due to respiratory depressant effect of the drug

• OD → S/S: unresponsiveness, slow respiration, coma, hypothermia, hypotension, and bradycardia. 

• Three symptoms—coma, pinpoint pupils, and respiratory depression—are strongly suggestive of overdose

PTSD → symptoms

• Illusions and delusions 

• Paranoia and auditory pseudohallucinations 

• Vivid flashbacks to trauma 

PTSD → etiology

• Prior trauma history or psychiatric history 

• Persistent stress response with amygdala hyperactivity, sympathetic NS, hypothalamic-pituitary-adrenal axis involvement

PTSD treatment → non pharmacological

• Eye movement desensitization and reprocessing (EMDR)

• Cognitive processing therapy (CPT)

• Prolonged exposure (PE)

• Specific cognitive behavioral therapy, narrative exposure therapy (written or oral) and brief electric therapy

PTSD treatment → pharmacological

• SSRI and SNRI 

  • Sertraline (Zoloft); Paroxetine (Paxil); Venlafaxine (Effexor); Fluoxetine (Prozac)

PTSD treatment → others

• Prozan for nightmares

• Clonidine, Propranolol (help alleviate hyperarousal or physical symptoms)