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Rights of patient admitted to a psychiatric hospital
right to treatment
right to refuse treatment
right to informed consent
right in restraints/seclusion
right to confidentiality
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
neither voluntary admission nor involuntary commitment determines patient’s ability to make informed decisions about personal healthcare
care providers establish that a well-defined psychiatric problem exists based on current illness classifications in the DSM-5
the illness and it symptoms shuuld result in an immediate crisis situation and other less-restrictive alternatives an inadequate or unavailable
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
potential for danger to others
potential danger to self
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
auditory
visual
olfactory
gustatory
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
1ST 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)- 2nd gen
Ziprasidone (geodon)-2nd 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