mental health module 2

anorexia risk factors

genetics, living in a developed country, past child abuse, adolescence, athletes, high family expectations, goal-oriented family/personality

clinical manifestations of anorexia

preoccupation with foods, eating rituals, weighing multiple times a day, compensating for food intake

behavioral clues for anorexia

reheats food repeatedly, eats alone, cuts food into smaller pieces, self-induced vomiting, wears baggy clothing, feels cold

anorexia effects on the integumentary system

brittle hair/nails, dry and yellow skin, lanugo

anorexia effects on the brain

changes in loc, decreased concentration, agitation

anorexia effects on the kidneys

fluid and electrolyte imbalances due to compensation

anorexia effects on the heart

decreased HR and BP, risk for arrhythmias

anorexia effects on bones

brittle

anorexia effects on the GI system

delayed gastric motility, abdominal pain/distention

anorexia effects on the endocrine system

hypothyroid state, cold extremities

anorexia effects on the circulatory system

peripheral edema with advanced starvation due to impaired circulation and decreased albumin

anorexia appearence

emaciated and sunken eyes

anorexia treatment

cognitive behavioral therapy, stress management, maudsley approach

maudsley approach

a family-based treatment where parents take responsibility for feeding the child, one parent must be present for every meal and snack

refeeding syndrome

a potentially fatal condition with either enteral or parenteral feedings when fluids, electrolytes, and carbohydrates are reintroduced to a severely malnourished patient, which causes abnormalities and an insulin surge. hallmark: HYPOPHOSPHATEMIA

bulimia patent weight

within normal limits of slightly above

bulimia pattern

binge on food then purge to prevent weight gain, usually restricts calories between episodes

common purging methods with bulimia

self-induced vomiting, laxative abuse, enemas, diuretics, extreme exercise

bulimia diagnostic criteria

binge eating + unhealthy compensatory behaviors + occurring at least once a week over a 3 month period

bulimia patient history

secretive behaviors, hoarding/sneaking foods

bulimia patient’s perspective

can perceive they have a problem (unlike anorexia patients)

bulimia treatment

fluoxetine (SSRI) is the only approved drug, cognitive behavioral therapy

binge eating disorder assessment

recurrent consumption of large amounts of food without compensatory behaviors seen in bulimia. may feel a sense of relief during/after eating which gives way to shame and depression

binge eating disorder diagnostic criteria

at least once per week for 3 months

binge eating associated weight gain

increases the risk for type 2 diabetes, hypertension, and cancer

binge eating disorder treatment

psychotherapy and cognitive behavioral therapy

psychotherapy

exploring significant childhood events/adverse childhood experiences (ACEs)

cognitive behavioral therapy

focuses on present problems and practical solutions

medications for binge eating disorder

antidepressants

personality disorder cluster A characteristics

odd and eccentric

personality disorders in cluster A

paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder

personality disorder cluster A behaviors

social withdrawal, peculiar/paranoid beliefs, and difficulty forming close relationships

personality disorder cluster B characteristics

dramatic, emotional, and erratic

personality disorders in cluster B

antisocial, borderline, histrionic, and narcissistic

personality disorder cluster B behaviors

impulsivity, emotional instability, and challenges in maintaining stable relationships

personality disorder cluster C characteristics

anxious and fearful

personality disorders in cluster C

avoidant, dependent, and obsessive-compulsive

personality disorder cluster C behaviors

anxiety, fear of abandonment, and an excessive need for control or perfectionism

risk factors for personality disorder

comorbid substance use disorders, history of crime, childhood abuse/trauma, parenting style, and genetics

expected findings in personality disorders

inflexible responses to stress, compulsiveness, lack of social restraint, inability to emotionally connect, tendency to provoke conflict

defense mechanisms for personality disorders

repression, suppression, regression, undoing, and splitting

splitting

the inability to incorporate positive and negative aspects into a whole, more frequent in the acute mental health setting, characterizes people/things as ALL good or ALL bad at any given moment

personality disorder child considerations

difficulty in developing relationships and with schoolwork

personality disorder adolescent considerations

may report being bullied for odd behaviors

personality disorder adult considerations

trouble forming intimate relationships, difficulty establishing/maintaining careers, and difficulty fulfilling opportunities to mentor future generations

personality disorder milieu management

focuses on appropriate social interaction within a group context

personality disorder safety

borderline PD = danger to self, antisocial = danger to others

plan of care for cluster A

emphasize skill and resource development in finding and maintaining interpersonal relationships

plan of care for cluster B

develop skills to limit dramatic/inappropriate behaviors

plan of care for cluster C

provide education/therapies to manage anxiety

essentials for manipulative patients (borderline and antisocial)

limit-setting and consistency

communication with dependent/histrionic PD

patients benefit from assertive training, modeling, and psychotherapy

communication with schizoid/schizotypal PD

respect isolation, psychotherapy can improve response to social cues

communication with histrionic PD

patient can be flirtatious so the nurse must maintain professionalism

communication with dependent behaviors

the nurse should self-assess frequently for countertransference reactions

medications for personality disorder

psychotropic agents; antidepressants, anxiolytics, antipsychotics, or mood stabilizers

patient education for all antidepressants

taper, full benefits can take more than several weeks, possible sedation, notify thoughts of suicide, and avoid alcohol

selective serotonin reuptake inhibitors (SSRIs)

first line treatment for depression

ssri adverse effects

nausea, headache, CNS stimulation (agitation, insomnia, and anxiety), gi bleeding, hyponatremia, bruxism, withdrawal syndrome, sexual dysfunction, weight gain

ssri onset

long, effective half-life, takes up to 4 weeks to reach therapeutic levels

ssri interactions

avoid st. john’s wort because it increases the risk of serotonin syndrome

amitriptyline (tricyclic antidepressant) adverse effects

orthostatic hypotension, anticholinergic effects, prolonged QT intervals, arrhythmias, and torsades des pointes

phenelzine (MAOI) patient education

restrict tyramine due to risk of a hypertensive emergency (avocados, figs, fermented/smoked meats, dried/cured fish, cheese, beer, wine, protein supplements) and avoid taking all medications without talking to the provider

bupropion (atypical antidepressant) adverse effects

headache, dry mouth, GI distress, constipation, increased HR, nausea, restlessness, insomnia, appetite suppression (monitor intake and weight)

bupropion (atypical antidepressant) patient education

hold medication if the patient is at risk for seizures

serotonin norepinephrine reuptake inhibitors (SNRIs)

inhibits the reuptake of serotonin and norepinephrine with minimal effects on dopamine

SNRI complications

headache, nausea, agitation, anxiety, dry mouth, sleep disturbances, hyponatremia (esp in older adults), anorexia (weight loss, hypertension, sexual dysfunction), CNS depression (with alcohol, opioids, antihistamines, and sedatives)

SNRI education

concurrent use with NSAIDs and anticoagulants increase bleeding risk, use caution with history of hypertension

phases of depression treatment

acute, continuation, and maintenance

acute phase of depression treatment

6-12 wks. with potential hospitalization, goal: reduce manifestations, assess suicide risk, implement safety precautions

continuation phase of depression treatment

4-9 mo., goal: relapse prevention through education, medication, and psychotherapy

maintenance phase of depression treatment

can last for years, goal: prevention of future depressive episodes

risk factors of depression

family/personal history, stressful life events, illness, postpartum, trauma early in life, female, serotonin and norepinephrine deficiency, older adults

patients 65+ and depression

it is more difficult to recognize due to the difficulty in differentiating between dementia and depression

serotonin deficiency in depression

affects mood, sexual behavior, sleep cycles, hunger, and pain perception

norepinephrine deficiencies in depression

affects attention and behavior

expected findings in depression

anergia, anhedonia, anxiety, sluggishness (common), inability to stay still, vegetative findings, somatic reports, blunt effect, lack of hygiene, psychomotor retardation (common) and agitation, social isolation, slowed speech, and delayed response

vegetative findings in depression

change in eating patterns (anorexia), change in bowel habits (constipation), sleep disturbances, decreased interest in sexual activity

somatic reports in depression

fatigue, gastrointestinal changes, pain

depression screening

Hamilton depression scale, Beck depression inventory, gastric depression scale, Zung self-rating depression scale, patient health questionnaire (PHQ-9)

milieu therapy

fosters a therapeutic community environment that promotes safety and social interaction, allowing the patient to practice interpersonal skills and adaptive behaviors in a structured setting.

it reinforces positive behavior, provides consistent boundaries, offers opportunities for the patient to engage in group activities that enhance personal growth and recovery.

bipolar risk factors

genetics, neurobiological and neuroendocrine disorders, environment

environment that increases risk of bipolar disorder

increased environmental stress can trigger mania/depression and raise the risk of severe manifestations in genetically susceptible children

relapse triggers for bipolar disorder

use of substances, sleep disturbances, and psychological stressors

depressive characteristics of bipolar disorder

flat blunted labile affect, crying, anhedonia, pain, difficulty concentrating and problem solving, self-destructing behavior, suicidal ideation, decreased hygiene, loss of appetite/sleep, psychomotor retardation/agitation

manic characteristics of bipolar disorder

labile mood with euphoria, agitation, intolerance of criticism, increase in talking/activity, grandiosity (inflated view of self), demanding, manipulating, distracted, attention-seeking, impaired social functioning, neglect ADLs (nutrition and hydration)

screening for bipolar disorder

Altman self-rating mania scale (ASRM): a standardized tool that assesses the patient’s position from depression to mania, useful for guiding and management and treatment

nursing care for bipolar disorder

decrease stimulation without isolation, implement frequent rest periods, provide physical outlets (avoid lengthy or high concentration activities), and protect the patient from poor judgement and poor behavior

maintaining self-care needs for bipolar disorder

provide portable food because the patient may not sit down and eat, supervise clothing choices, give step-by-step reminders for hygiene and stress

therapeutic communication for bipolar disorder

give concise explanations, be consistent with expectations and limit-setting, avoid power struggles, reinforce nonmanipulative behaviors

interventions for bipolar disorder

brain stimulation therapy (electroconvulsive therapy), mood stabilizers, managing common side effects

electroconvulsive therapy (ECT)

can be used to moderate extreme manic behavior, especially when pharmacological therapy has not worked. patients that are suicidal or rapid cycling can also benefit

mood stabilizers for bipolar disorder

lithium carbonate: controls episodes of acute mania, helps prevent the return of mania and depression, and decreases the incidence of suicide

lithium carbonate education

administer medication with meals/milk, weight gain is common so diet and exercise

fine hand tremors with lithium carbonate

worsen with stress/caffeine, administer beta blocker (propanolol), keep dosage low, report increased tremors

polyuria and increased thirst with lithium carbonate

use a K+ sparing diuretic (spironolactone), maintain intake 1.5-3 L/day

renal toxicity with lithium carbonate

monitor I&O, assess baseline BUN/Creatinine, and monitor kidney function periodically

goiter and hypothyroidism with lithium carbonate

obtain a baseline T3, T4, and TSH, administer levothyroxine as prescribed, monitor for cold/dry skin, decreased HR, and weight gain

dysrhythmias, hypotension, and electrolyte imbalances with lithium carbonate

maintain adequate fluid and sodium intake

low level side effects of lithium carbonate < 1.5

diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremors, slurred speech, lethargy, these resolve over time!!