Mental Health Exam 2

Rights of patient admitted to a psychiatric hospital

1. right to treatment

2. right to refuse treatment

3. right to informed consent

4. right in restraints/seclusion

5. right to confidentiality

6. right to psychiatric advanced directives

Right to treatment

right to be free from excessive or unnecessary medication, right to privacy and dignity, least restrictive environment

• right to attorney, clergy, private care providers

• not to be subjective to lobotomies, electro compulsive treatments, treatments without full informed consent

Right to refuse treatment

patient can withhold or withdraw consent at any time even if involuntarily committed

Right to informed consent

patient has been provided information in that nature of the problem and purpose of treatment, risks and benefits, alternatives, probability of successful treatment, risks of not consenting

Rights in restraint and seclusion

strict guidelines must be followed as far as duration of restraint either physical - “therapeutic holding” or chemical

• seclusion is limited to patients who are demonstrating violent or self-destructive behavior that jeopardizes the safety of others, is still considered seclusion even with the door unlocked

Right to confidentiality

only patient can waive the legal privilege

Right to psychiatric advanced directives

designation of preferred physician and therapists, appointment of someone to make mental health treatment decisions, preferences regarding medications to take or not, consent (or lack of) ECT and admission to a psychiatric facility, preferred facilities and unacceptable facilities, individuals who should not visit

Hospitalization admission procedure guidelines

1. neither voluntary admission nor involuntary commitment determines patient’s ability to make informed decisions about personal healthcare

2. care providers establish that a well-defined psychiatric problem exists based on current illness classifications in the DSM-5

3. the illness and it symptoms shuuld result in an immediate crisis situation and other less-restrictive alternatives an inadequate or unavailable

4. there is a reasonable expectation that the hospitalization and treatment will improve the presenting problems

Voluntary Guidelines

patient should understand the needs for treatment and willing to be admitted; patients have the right to request and obtain release but must be reevaluated before release which can result in involuntary commitment

• if under 16 the legal guardian has the authority to apply under the persons behalf

• between 16 and 18 may seek admission independently or by an authorized individual

Involuntary guidelines

court-ordered admission to a facility without the patient’s approval

• Criteria:

  • 1) diagnosed with mental illness

  • 2) posing a danger to self or others

  • 3) gravely disabled – unable to provide for basic necessities

  • 4) in need of treatment and the mental illness itself prevents voluntary help-seeking

Emergency commitment guidelines

use for 1) people who are so confused they cannot make decisions on their own 2) for people who are so ill they need emergency admission

• psychiatrist employed by the facility confirms the need for hospitalization

• a court hearing then determines next decision for discharge, voluntary or involuntary commitment

• LOS: 24-96

• Purpose: observation, diagnosis of patients how have mental illness or pose a danger to themselves

3 primary reasons an individual is admitted to the psychiatric hospital

1. potential for danger to others

2. potential danger to self

3. a need for care

Informed consent

legal term that means the patient has been provided with basic information regarding risks and benefits, and alternatives to treatment

Implied consent

occurs when no verbal or written agreement takes place prior to a caregiver delivering treatment

• giving medications

Mental Status Exam (MSE)

purpose: to evaluate the patients current cognitive processes

• aids in collecting and organizing subjective data

  • appearance

  • behavior

  • speech

  • thought disorders

  • perceptual disturbances

  • cognition

  • ideas of self or other harming

Neurotransmitters associated with schizophrenia

Dopamine

• high: positive symptoms

• low: negative symptoms

GABA: decreased

Glutamate: decreased

Norepinephrine: increased

Positive Symptoms of Schizophrenia

• hallucinations

• delusions

• paranoia

• disorganized or bizarre thoughts

• behavior and speech.

Negative Symptoms of Schizophrenia

• inability to enjoy activities (anhedonia)

• social discomfort

• lack of goal directed behavior

Cognitive Symptoms of Schizophrenia

subtle or obvious impairment in memory, attention, thinking, impaired executive functioning

• lack of impulse control

• prioritization

• problem solving

Affective Symptoms of Schizophrenia

Persecutory delusions

believing that one is being singled out for harm or prevented from making progress by others

Referential delusions

A belief that events or circumstances that have no connection to you are somehow related to you

Grandiose delusions

Believing that oneself is a powerful or important person

Erotomania delusions

Believing that another desires you romantically

Nihilistic delusions

The conviction that a major catastrophe will occur

Somatic delusions

Believing the body is changing in unusual ways

Control delusions

Believing that another person, group or external force controls your thoughts, feelings, impulses, and behaviors

5 types of hallucinations

1. auditory

2. visual

3. olfactory

4. gustatory

5. tactile

Most dangerous type of hallucination

Command halluciations

• may be telling the patient to harm themselves or others

Illusions

Misinterpretations of a real experience

• depersonalization

• derealization

Depersonalization illusion

A feeling of being unreal or having lost one element of one’s person or identity.

• Ex. Body parts don’t belong, or body parts have changed when they have not

Derealization illusion

A feeling that the environment has changed

• Ex. Surroundings seem bigger or smaller, one is detached from everything else, familiar surroundings seem strange or unusual

Anosognosia

is the inability to realize one is ill.

• Ex. Patient resists or stops treatment, won’t request help.

Anosognosia nursing implications

-       Establish trust and rapport

-       Seek areas of commonality

-       Seek agreement that symptoms are a problem, however, don’t push that they indicate an illness.

-       If another patient is aware of another ill patient, suggest it may be the same thing as them.

-       Get the patient around peers that have since had their anosognosia treated, so they may help them.

nursing implications for a patient experiencing delusions

• Build trust with honesty, openness, and reliability

• Respond to suspicion in a matter of fact, empathetic, supportive and calm manner

• Ask the patient to describe beliefs

• Never debate delusions.

• If the patient starts improving their reality testing, supportively convey doubt.

• Validate if the delusion is partly true

  • ex: There is a man at the nurse’s station, but he isn’t talking about you

• Focus on feelings or themes, not delusion itself.

• Find underlying needs and use reality-based interventions to help meet those.

• Acknowledge that while it is very real to the patient, that the disease process is what is making it feel real. INDIRECTLY

• Do not dwell on delusions.

• Help patient identify triggers of delusions and avoid them.

• Promote reality by offering other explanations

nursing implications for a patient experiencing hallucination

• Monitor for hallucination indicators (eye tracking where nothing is, muttering or talking to self, appearing distracted, stopping conversation as if interrupted, or intently watching an empty place, sudden burst of anxiety)

• Ask about content of hallucinations and how patient feels about them

• Assess for command hallucinations

• Avoid referring to the hallucinations as being real

  • ex. Say what are you hearing

• Do not negate client’s experience but convey empathy

• Focus on reality here and now

• Address underlying emotions caused by hallucinations

• Promote and guide reality testing

• Teach patient to ask trusted peers

• Guide patient to interpret hallucinations as symptoms of illness

• Teach patient to question perceptions if they seem unusual

Common sides affects of first generation antipsychtotics (dopamine 2 antagonists)

• Acute dystonia: contraction of one or more muscle groups

• akathisia: motor restlessness that causes pacing or inability to stay still

• pseudo Parkinsonism: temporary group of symptoms that resemble parkinsons

• tardive dyskineasa: involuntary movements of the face, jaw, and tongue

• neuroleptic malignant syndrome: muscle rigidity, dysphasia, reduced or absent speech

haloperidol, chlorpromazine

treatment for NMS

1.     Hold all antipsychotics, contact provider

2.     Transfer to CCU or call 911

3.     Administer Bromocriptine (parlodel), dantrolene (Dantrium), can relieve muscle rigidity and reduce heat.

4.     Cool body with cooling blankets, ice bath

5.     Maintain hydration with iv fluids

6.     Treat dysrhythmia

7.     Small doses of heparin may be necessary to reduce risk of pulmonary emboli

treatment for TD

1.     Administer valbenazine (Ingrezza), or deutetrabenazine (Austedo)

2.     Discontinue causative medication, adjust medication plan.

3.     Provide emotional support.

Most common side effects associated with second generation antipsychotics

• Sedation

• sexual dysfunction

• seizures

• increased mortality in older adults with dementia

• suicidal ideation

• anticholinergic toxicity

• NMS

• prolonged QT interval

• metabolic syndrome

Mania

period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy

• Last at least a week, most of the day, everyday

• Individuals experiencing episodes are the happiest, most excited, and optimistic

• gives way to agitation and irritability and eventually exhaustion, finally into depression

• Can reach psychosis: hallucinations, delusions, dramatically disturbed thoughts

•    Bipolar I

Hypomania

refers to low-level and less dramatic mania

• Euphoric and increases functioning

• Excessive activity and energy for at least 4 days & involves at least 3 behaviors listed under ‘Criterion B in DSM-5'

• Psychosis never met

• Does not impact functioning that is noticeable to others

• Under-diagnosed and often mistake for MDD or personality disorders

• Bipolar II

How do bipolar disorder and MDD differ from each other?

• Bipolar disorder alternates between states of euphoria and states of depression and/or mixed state of anxiety and depression.

• MDD only has one phase, that being depression

Safety concerns for patients experiencing mania

• Bc they feel so important and powerful, they engage in horrific chances and hazardous activities- do not recognize as problematic and resists treatment

• Hallucinations and delusions: distractibility and decreased concentration

• State of depression & agitation: lead to extreme behaviors such as violence or attempted suicide

• NURSING DIAGNOSIS: Risk for injury, Sleep deprivation, Self-care deficit, Risk for violence, Impaired socialization

Therapeutic window for lithium

0.8-1.2 mEq

• toxic level: >1.5 mEq/L

• takes 7-14 days to reach TL

Max dosage for lithium

1800 mg/day

Symptoms of lithium toxicity

• Nausea

• vomiting

• diarrhea

• thirst

• polyuria

• lethargy

• sedation

• fine hand tremor

• long term use: Renal toxicity, goiter, and hypothyroidism

Medications used for BPD that increase the risk for stevens johnson’s syndrome for those of asian decent

Anticonvulsants: Carbamazepine (Tegretol, Equetro)

• Asians are at a 10x greater risk

Symptoms of BPD treated by ECT

• mania, depressive, and mixed states

• cognitive improvement

• decreases suicidal ideation

Patient and family teaching for lithium therapy

• Lithium is a mood stabilizer and helps prevent relapse; Important to take even when episode subsides

• Not addictive

• It is important to monitor lithium blood levels closely until therapeutic levels are reached, then continued to prevent toxicity

  • Frequent blood level monitoring at first, then every several months after

• Important to maintain a consistent fluid intake (1500-3000 mL/day, six 12oz glasses)

• Consistent sodium intake; sodium can lower the level of lithium and thus the therapeutic effect

• Stop taking if excessive diarrhea, vomiting, or sweating- can lead to dehydration and increase blood lithium to toxic levels. Inform provider

• Tell provider if you take diuretics

• Talk to provider about having thyroid, parathyroid, and renal function levels checked for hypo/hyperthyroidism, hyperparathyroidism, and decreased kidney function

• Talk to the provider before taking any OTC medications; NSAIDS also can influence lithium levels

• Take lithium with meals to avoid stomach irritation

• In the first week you may gain up to 5 lbs, additional weight gain may occur particularly with females

• Groups are available to provide support for people w BPD and their families

• Keep a list of side effects and toxic effects handy, along with name and number of a contact person

• Lithium must be gradually tapered, if discontinued 

Lithium

Class: mood stabilizer

• AE: N & V, diarrhea, thirst, polyuria, lethargy, sedation, and fine hand tremor

Carbamazepine

Class: anticonvulsant

• AE: Dizziness, somnolence, N & V, ataxia, constipation, pruritis, dry mouth, weakness, blurred vision, and speech problems

Lamotrigine

class: anticonvulsant

• Dizziness, headache, diplopia, ataxia, blurred vision, nausea, somnolence, rhinitis, and pharyngitis

Lurasidone

Class: 2nd gen antipsychotic

Cariprazine

Class: 2nd gen antipsychotic

Anxiety co-morbid with

• Bipolar I

• Bipolar II

Substance abuse co-morbid with

• cyclothymic disorder

• arise with Bipolar II

sleep disorders co-morbid with

cyclothymic disorder

Dysthymia (persistant depressive disorder)

Chronic low-level depression

• Symptoms present for 2 yrs adults, 1-year children

• Onset during adolescence, not easily distinguished from personals normal pattern of functioning

  • ex: “I've always been this way”

Dysthymia manifestations

• Decreased/ increased appetite

• insomnia/ hypersomnia

• low energy/ chronic fatigue

• decreased self-esteem

• poor concentration or difficulty making decisions

• feeling hopeless or despair

Major depressive disorder

one of the MOST common psychiatric disorders

• persistently depressed mood lasting for minimum of 2 weeks

• History of 1+ major depressive episodes

• NO history of manic or hypomanic episodes

• Subtypes: Depression and the seasons, depression of grieving, psychotic features, atypical features, catatonic features, and postpartum onset

DSM-5 criteria for MDD

% or more of the following symptoms nearly every day for most waking hrs. Over same 2-week period:

• Affect (depressed mood)

• anhedonia= loss of pleasure in living

• Anergia

• weight loss/gain

• sleep disturbances

• lack of motivation

• Feeling worthless or excessive guilt

• difficult thought process, concentration or making decisions

• suicidal thoughts

Vegetative signs of depression

refer to alterations in those activities necessary to support physical life and growth (e.g., eating, elimination, sleeping, and sex).

• Sleep disturbances (insomnia, wake frequently, and have a total reduction in sleep)

• Appetite disturbances

• Changes in bowel habits (constipation)

• Sexual interest declines (loss of libido)

Nursing interventions for vegetative depression - nutrition

• Offer high-protein and high-calorie fluids frequently throughout the day and evening.

• When possible, encourage family or friends to join the patient during meals.      

• Include the patient in choosing foods and drinks; Involve a dietitian if necessary.

• Weigh the patient weekly and observe the patient’s eating patterns.

Nursing interventions for vegetative depression - Insomnia

• Provide periods of rest after activities.

• Encourage the patient to get up and dress and to stay out of bed during the day.

• Encourage the use of relaxation measures in the evening (e.g., a warm bath, warm milk, soothing music or sounds)

• Provide decaffeinated coffee and soda

Nursing interventions for vegetative depression - constipation

• Monitor intake and output, especially bowel movements.

• Offer foods high in fiber and provide periods of exercise.

• encourage fluid intake

• evaluate need for laxatives, enemas

SSRI

Block reuptake of serotonin

• 1^ST LINE THERAPY for depression & anxiety (OCD, Panic disorders)

•  ex: Citalopram (celexa),  Escitalopram (lexapro), Fluoxetine (prozac), Paroxetine (paxil), Sertraline (zoloft)

MAOIs

Prevents breakdown of NTs = norepinephrine, serotonin, dopamine, & tyramine

• Inhibits the enzyme monoamine oxidase (breaks down excess tyramine)

• Increases amount of available:

  • Norepinephrine

  • Serotonin

  • Dopamine

  •   Tyramine

• Prescribed when other antidepressants fail (last line) - highly treatment resistant depression

• ex: Selegiline (Emsam), Phenelzine (Nardil)

Toxic effects of MAOIs

• Restrictions to tyramine foods (regulated BP)

• Very high BP when taken w/ foods containing tyramine or certain meds (serotonin): Increased risk for hypertensive crisis

• hypertensive crisis

Hypertensive crisis with MAOIS

Occurs 15-90 min of ingestion of offending substance (tyramine + MAOI):

•   Headache – **initial symptom

• Very high BP

• Increased body temperature (pyrexia)

• Stiff or sore neck

• Palpitations

• Sweating

• Increased or decreased HR (possibly with chest pain)

• N & V

Antidepressants that have potential to be lethal

TCA’s

Manifestations of serotonin syndrome

• Hyperactivity, restlessness

• Tachycardia

• Fever (hyperpyrexia)

• Increased BP

• Altered mental status (delirium)

• Muscle rigidity, muscle incoordination (myoclonus)

• Seizures

• Abdominal pain, diarrhea, bloating

• Apnea – death

Nursing interventions for serotonin syndrome

• Stop the drug!!

• Initiate Symptomatic tx:

  • Serotonin receptor blockage= Propranolol (inderal)

  • Cooling blankets

  • Diazepam (valium) for muscle rigidity

  • Anticonvulsants

  • Artificial ventilation

3 questions to be asked immediately when evaluating patient suicide plan

1) Is there a specific plan with details?

2) How lethal is the proposed method?

3) Is there access to the planned method?

High risk lethality methods (hard methods)

• firearm

• jumping off a high place

• poisoning with carbon monoxide

• hanging

Low risk lethality methods (soft methods)

• cutting wrists

• inhaling natural gas

• ingesting pills

Environmental safety methods for minimizing suicidal behavior on psych unit

• plastic eating utensils (no glass or metal), collected and counted after meals

• NO private rooms, doors remain open at all times

• unbreakable glass windows, tamper proof, are locked when not in room

• no electrical cords used on the unit

• utility rooms, kitchens, offices, stairwells are locked

• personal belongings searched at admission and at return from a pass off the unit

• remove belts, shoelaces, metal nail files, tweezers, razors, perfume/shampoo, matches

• visitors not allowed to bring personal items onto the unit

Anger

emotional response to frustration of desires

• a threat to ones needs (emotional or physical) or a challenge

Aggression

an action or behavior resulting in a verbal or physical attache

• is not always inappropriate

• necessary for self-protection

Violence

an objectionable act of involving intentional use of force resulting (or potential to) in injury to another person

Medications used for acute de-escalation

antipsyhotics and antianxiety

• Haloperidol (haldol)- first gen antipysch

• Loxapine (adasuve)- inhalation powder single use FGA, limit use due to SE fatal bronchospasm

• Olanzapine (zyprexa)- 2^nd gen

• Ziprasidone (geodon)-2^nd gen

• Orally disintegrating tablets- olanzapine and risperidone (risperdal)

• COMBOs- Haldol (or zyprexa) + Ativan + Benadryl (or Cogentin)

Nursing nterivetions to avoid patient escalation

acknowledge the distress, stress (validates feelings and indicates willingness to find solutions)

• develop a relationship of trust:

  • numerous brief, nonthreatening, nondirective interactions

  • “good morning!”, “hello!”, “how is your day?”

  • topic examples: weather, sports, something interesting to the patient

Factors that contribute to non-adherence of treatment plan

• Anosognosia

• Medication side effects

• Medication costs

• Lack of trust in providers

• Poor access to care

• Stigma of mental illness

Nursing interventions to imporve adherence to treatment

• Encourage careful selections of medications that are most likely to be effective, well tolerated, and acceptable to the patient

• Help manage side effects to minimize distress

• Simplify treatment regimens to make it more acceptable and understandable to pt

• Tie treatment adherence to achieving patient’s goal to increase motivation

• Assign consistently committed caregivers

• Educate patient and family about SMI and the role of treatment in recovery

• Minimize obstacles to treatment by aiding with treatment costs and access

• Involve pt and family in support groups

• Provide culturally sensitive care

• When other interventions not successful, use medication monitoring and long-acting forms

• Never reject, blame, or shame the patient when nonadherence occurs

What does PHQ-9 Assess

• Major Depressive Disorder

• Suicidal ideation

Generation of antipsychotics for positive symptoms

1st generation

• haloperidol (haldol)

• chlorpromazine (thorazine)

• fluphenazine (prolixin)

Generation of antipsychotics for negative symptoms

Second genration

• clozapine (clozaril)

• risperidone (risperdal)

Medications that address the side affects associated with antipsychotic medication

- trihexyphidyl (artane)

- benztropine (cogentin)

- benadryl

- lorazepam

what if a BPD patient is prescribed an antidepressant alone

increases the risk of bringing on mania

• decrease risk if given with a mood stabilizer

Post partum depression contributers

- hormonal changes

- history of mental illness

- stressful life events

- lack of sleep

- health issues

- relationship strain

Post partum depression medication

Brexanolone (zalresso)

Anhedonia

loss of pleasure in living

Neurotransmitters in depression

seritonin = decreased

norepinephrine = decreased