NURS 105 final

primary prevention

services aimed at reducing the incidence of mental disorders within the population

secondary prevention

interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness

tertiary prevention

services aimed at reducing the residual defects that are associated with severe and persistent mental illness

-teaching parenting skills and child development to prospective new parents -teaching physical and psychosocial effects of drugs/alcohol to elementary students -teaching techniques of stress management to virtually anyone -teaching groups of individuals ways to cope with changes of life -teaching concepts of mental health to the community

examples of primary prevention

-ongoing assessments and screenings of individuals at high risk for illness exacerbation -provision of care for individuals in whom illness symptoms have been assessed -referrals the emergency services, psychiatrists or psychologists, day or partial hospitalization

examples of secondary prevention

-rehabilitation process -teaching client daily living skills and encourage independence to his or her maximum ability -referring clients for various aftercare services (support groups, home health, rehabilitation programs) -monitoring effectiveness of aftercare services

examples of tertiary prevention

-gather more information about crisis (what was the crisis and when did it happen) -stressor/trigger -coping skills -support system -safety (SI, HI) -stabilize patinet -medications and outpatient therapy

nursing interventions for crises

situational crisis (rape, physical attack, poverty, high rate of life changing events, environmental conditions, trauma)

acute responses that occur as a result of external circumstantial stressors (type of crisis)

adventitious crisis

occurrence of natural disaster, crimes, or national disaster (type of crisis)

maturational crisis

crisis associated with various stages of growth and development

-anyone in the hospital can refuse treatment -cannot refuse if treatment is required to prevent death or serious harm -in psychiatric care, clients who are involuntarily admitted and are at harm to themselves or others are not allowed to refuse treatment. Treatment will be administered without consent of the client in order to protect them and others.

who has the right to refuse treatment/medications

-physical (unable to move body) -chemical (medication outside of orders) -environmental (seclusion or isolation)

3 types of restraints

-last resort -never used to make care easier for staff -never used as punishment -alternatives are considered first -discontinue at earliest time possible -documentation (every 15-30 minutes) -should be able to slide 1-2 fingers under the restraint -check circulation -remove or release every 2 hours for 10 minutes (one arm and one leg at a time) -secure to moveable part of bedframe

restraint safety

-earliest time possible -client is exhibiting behavior that is safer and quitter -client is able to follow commands

when to discontinue restraints

-drugs (PRN benzo or antipsychotic for anxiety, aggression, agitation) (must be ordered) -distraction (take for walk, tv, play a game, take outside if possible) -de-escalation

alternatives to restraints

-danger to self (SI) -danger to others (HI) -unable to meet basic needs or care for self

criteria for involuntary admission

-client is danger to self/others or unable to meet needs -time limit is usually 72 hours but no more than 15 days -can be switched to voluntary -court documents are filed if client does not switch to voluntary -client may be discharged if the doctor no longer deems unsafe

emergency \temporary commitment

-continuation of emergency involuntary following court hearing (longer than emergency and court looks at evidence of danger and unable to meet needs) -know policy -in Illinois, may be up to 90 days -still have right to refuse treatment and meds (need a second court order to meds and treatment) (one for hospital stay and one for treatment) -involuntary clients have the right to informed consent -goal is to stabilize client with meds and therapy and to release into community prior to next court date if possible

mentally ill person in need of treatment/court ordered involuntary admission

generalized anxiety disorder

-persistent, unrealistic, and excessive anxiety and worry -often results in procrastination in activities and decision making

more days than not for at least 6 months

how long much you have symptoms of anxiety to have GAD

somatic symptoms disorder

a syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long term seeking of assistance from healthcare professionals

-pain -shortness of breath -fatigue -weakness -sleep disturbances -GI complaints -headaches

symptoms of somatic symptom disorder

-one or more somatic symptoms that are distressing to daily life -typically lasts for more than 6 months (not all symptoms have to be present at one time) (persistent thoughts of seriousness of illness, high level of anxiety about health, excessive time and energy devoted to symptoms)

criteria for somatic symptom disorder

conversion disorder

defined as a loss or change in body function that cannot be explained by any known medical disorder or pathophysiological mechanisms

-can occur without interventions -recurrence rate is 25% within 1 year of initial diagnosis -symptoms can last for days to weeks and suddenly go away

remission and recurrence of conversion disorder

illness anxiety disorder

defined as an unrealistic or inaccurate interpretation of physical symptoms or sensations -leads to preoccupation and fear of having a serious illness

somatic symptom actually has pain but illness anxiety does not have real pain or symptoms

difference between somatic symptom disorder and illness anxiety disorder

-benzodiazepines -antihistamines (atarax)

first choice drugs for acute anxiety

-buspar -SSRI -SNRI

first choice drugs for chronic anxiety

antihypertensives

what other medication can be taken for anxiety to help decrease symptoms

benzodiazepine

Clonazepam (Klonopin) drug class

-drowsiness/sedation -dizziness -decreased blood pressure, respirations, and heart rate -long term use can cause tachycardia -dependency (ideally PRN) -confusion, memory impairment, motor incoordination -paradoxical reaction (opposite of what should happen)

benzo side effects

-no alcohol -no driving until stable -don't stop suddenly taper off -not ideal for elderly -ideally PRN -dependency can occur with long term use -ideally 4 months or less of use -can start working in 15-30 minutes -toxic in overdose

benzo nursing interventions

-restlessness -agitation -nervousness (caffeine increases) -headache -nausea -dizziness -lightheadedness -insomnia

Buspirone (Buspar) side effects

-not addictive -works in 1-2 weeks -not PRN, take 2-3 times daily scheduled -take with food if GI upset -use cation with alcohol -no driving until stable -don't stop suddenly taper off -don't take with MAOI -don't take with St. John's wort

Buspirone (Buspar) nursing interventions

-Citalopram (Celexa) -Escitalopram (Lexapro) -Fluoxetine (Prozac) -Fluvoxamine (Luvox) -Paroxetine (Paxil) -Sertraline (Zoloft)

SSRI examples

-Anxiety -nervousness -Insomnia -fatigue -Sexual dysfunction -Nausea -Headache -weight gain -Serotonin syndrome -Hyponatremia

side effects of SSRI

-take in the morning daily -less dangerous in overdose -take 1-4 up to 6 weeks to work -don't stop suddenly - taper off -first choice drug in treating depression and chronic anxiety -minimal anticholinergic side effects -don't take with MAOI, St. John's Wort, and tricyclic antidepressants -take 4-9 months after depression episode

nursing interventions for SSRI

-Desvenlafaxine (Prisitq) -Duloxetine (Cymbalta) -Venlafaxine (Effexor)

examples of SNRI

-Nausea -vomiting -anorexia -Insomnia -Tremors -nervousness -agitation -Sexual dysfunction -Increased sweating -Headache -Hypertension -weight gain -Serotonin syndrome -Hyponatremia

side effects of SNRI

-take in the morning daily -less dangerous in overdose -takes 1-4 up to 6 weeks to work -don't stop suddenly - taper off -minimal anticholinergic side effects -don't take with MAOI, St. John's Wort, and tricyclic antidepressants -take 4-9 months after depression episode

nursing interventions for SNRI

-paranoid PD -Schizoid PD -Schizotypal PD

Cluster A personalities

-antisocial PD -borderline PD -histrionic PD -Narcissistic PD

Cluster B personalities

-avoidant PD -Dependent PD -obsessive-compulsive PD

Cluster C personalities

paranoid personality disorder

characterized by distrust and suspiciousness towards others bases on unfounded beliefs that others want to harm, exploit, or deceive the person

-constantly on guard -hypervigilant (keeping careful watch) -ready for any real or imagined threat -appear tense ad irritable -hard exterior -immune or insensitive to the feelings of others -avoid interactions with others -feel others are trying to take advantage of them -interanl they are extremely oversensitive -tend to misinterpret cues in the environment (magnify and distort into trickery and deception) -trust no one -constantly "testing" the honesty of others -can become easily angered and hostile -maintain self-esteem by attributing their short-comings to others -do no accept responsibility for own behavior and feelings -envious and hostile toward others who are highly successful (believe not successful because treated unfairly) -extremely vulnerable -constantly defensive -desire revenge -holds grudges

traits of paranoid personality disorder

-develop therapeutic relationship -develop trust -same staff as often as possible -establish boundaries -convey an accepting attitude -avoid being too nice or friendly (neutral tone) -clear and straight forward simple explanations -open medications in front of client -use caution with touch -tell them what to expect -warn about changes in tests/procedures -do not push into socialization (respect need for social isolation) -recognize reluctance to share information -offer the client realistic choices to enhance the client's sense of control

nursing interventions for paranoid PD or cluster A

schizoid PD

characterized by emotional detachment, disinterest in close relationships, and indifference to praise or criticism; often uncooperative

schizotypal PD

characterized by odd beliefs leading to interpersonal difficulties, and eccentric appearance, and magical thinking or perceptual distortions that are not clear delusions or hallucinations

antisocial personality disorder

characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, failure to accept personal responsibility; evidence of conduct disorder before age of 15, sense of entitlement, manipulative, impulsive, and seductive behaviors; nonadherecne to traditional and moral values; verbally charming and engaging

-at least 18 years old -may be admitted to healthcare system by court order -make up large population of people in prison and jail -"sociopath or psychopath" -general disregard for the rights of others -exploit and manipulate others for personal gain -unconcerned with obeying the law -difficulty sustaining employment and stable relationships -socially irresponsible -guiltless -appear cold and callous -argumentative -low tolerance for frustration -impulsive -restless and easily bored (thrill seeking and taking chances and substance abuse) -when things are going their way they can be cheerful and charming -when challenged can become furious and vindictive -easily provoked -seem themselves as victims (being a victim justifies their behavior to them) -lack satisfying interpersonal relationships

traits of antisocial PD

-develop a therapeutic relationship -develop trust -keep promises -convey an accepting attitude -watch for exploitative, manipulative and other behaviors (provide feedback, convey when behavior is unacceptable, watch for changes) -maintain low stimuli -remove all dangerous objects -observe client frequently -encourage client to verbalize feelings -explore alternative ways to handle feelings, frustrations and anger -sufficient staff present to show strength -be firm and matter of fact -make client aware of rules in writing and verbally -set limits and boundaries -watch for power struggles (all staff must be consistent and rotate staff) -be prepared to administer PRN meds

nursing interventions for antisocial PD

borderline PD

characterized by instability of affect, identify, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and a fear of abandonment; often self-injurious and potentially suicidal; ideas of reference are common; often accompanied by impulsivity

borderline injures self and antisocial does not

difference between borderline and antisocial PD

histrionic PD

characterized by emotional attention-seeking behavior, in which the person needs to be the center of attention; often seductive and flirtatious

narcissistic PD

characterized by arrogance, grandiose views of self-importance, the need for consistent admiration, and a lack of empathy for others that strains most relationships; often sensitive to criticism

avoidant PD

characterized by social inhibition and avoidance of all situations that require interpersonal contact, despite wanting close relationships, due to extreme fear of rejections; having feelings of inadequacy and are anxious in social situations

-develop therapeutic relationship -develop trust -establish boundaries -gently set limits -supportive approach -consistent care -maintain neutral, calm, respectful manner -encourage client to discuss feelings -do not push into socialization (respect need for social isolation) -assess client's self-perception (promote self-esteem and identify strengths and weaknesses) -relaxation training -assess for anxiety and or depression -structured daily schedule

nursing interventions for Cluster C

dependent PD

characterized by the individual having a lack of self-confidence and extreme reliance on to others to take responsibility for them

obsessive compulsive PD

characterized by indecisiveness and perfectionism with a focus on orderliness and control to the extent that the individual might not be able to accomplish a given task

-nausea and vomiting -shallow respirations -cold, clammy skin -weak or rapid pulse -coma -death -impaired judgment -impaired functioning -slurred speech -incoordination -unsteady gait -nystagmus -flushed face -blood shot eyes or dilated -blurry or double vision

signs of alcohol intoxication

-occurs in 4-12 hours -"detox" -anorexia -nausea/vomiting -fine tremors -diaphoresis -tachycardia -elevated BP -anxiety -irritability -headache -insomnia -hypoglycemia

early symptoms of alcohol withdrawal

-occurs in 48-72 hours -delirium tremens -course tremors -seizures -tachycardia -elevated BP -anxiety -irritability -hallucinations -illusions -paranoia -confusion -combativeness -fever may also occur in some cases

late symptoms of alcohol withdrawal

CIWA

assessment for alcohol withdrawal

benzodiazepines (Ativan and librium commonly used)

what medication treats acute manifestations of alcohol withdrawal

-thiamine; vitamin B1 (prevent neuropathy, confusion, Wernicke's ad Korsakoff's) -folic acid (reduce shaking and anxiety) -multivitamin

vitamin treatment for alcohol withdrawal

-deterrent to stop drinking -ingestion of alcohol while taking results in a syndrome of symptoms that can cause great discomfort or death) -stays in the body up to 2 weeks after last dose -not a cure for alcoholism

disulfiram (antabuse)

-naltrexone (Revia)-not for withdrawal but mainly to help with maintenance of abstinence from alcohol (suppress cravings) -acamprosate (campral)-maintenance of abstinence from alcohol (detox first)

other medications for alcohol withdrawal

-tremors -restlessness -anorexia -insomnia -agitation -increased motor activity -increased alertness -decrease in fatigue -elation and euphoria -subjective feelings of greater mental agility and muscle power -elevated BP -tachycardia -palpitations -cardiac arrhythmias -nasal rhinitis from cocaine -decrease GI motility so constipation -caffeine has diuretic effect -increased sexual urges -dilated pupils

signs of stimulant use

-can occur is 2-4 days or 24 hours -crashing -fatigue -cramps -depression -headache -nightmares -dysphoric mood -increased risk of suicide -drowsiness -irritability -frustration or anger -increased appetite or hunger -difficulty concentrating -flu like symptoms

stimulant withdrawal symptoms

-sedation -chronic constipation or fecal impaction -decreased respirations -constricted or pinpoint pupils -euphoria -mood changes -mental clouding -slurred speech -drowsiness -decreased sexual function

signs of opioid use

-occurs in 1-3 days or 6-8 hours -can subside within 5-10 up to 14-21 days -dysphoric mood -nausea and vomiting -muscle ache -lacrimation (flow of tears) -rhinorrhea (runny nose) -pupillary dilation -piloerection (goosebumps) -sweating -diarrhea -yawning -fever -chills -insomnia

signs of opioid withdrawal

COWS

assessment for opioid withdrawal

Methadone (Dolophine)

medication for heroin replacement

-Clonidine (Catapres)-treats increased HR and BP -Buprinorphine (Subutex) -Buprinorphine/Naloxone (Suboxone) -Benzodiazepines

other medications that can be used for to treat withdrawal symptoms of opioids

Naloxone (Narcan)

what medication is given for opioid overdose

-temporarily reverse effects of OD while waiting for emergency services -must be given quickly to prevent death -works in 2 minutes -give 2 or 4 mg (1 spray in one nostril). another spray may be given into the other nostril every 2 to 3 minutes until the patient responds or until emergency medical assistance becomes available -can be given IM, SQ, IV, or by nasal spray -call 911 -if patient is dependent on opioid, narcan may cause severe withdrawal effect

information about Narcan

flumazenil (romazicon)

medication for benzodiazepine overdose

major depressive disorder

characterized by a depressed mood or loss of interest or pleasure in usual activities (no mania, at least 2 weeks, can be single or recurrent)

-refers to mood, emotions or feelings displayed by the person -feelings of total despair -hopelessness and worthlessness -flat affect -feelings of emptiness -apathy -loneliness -sadness -anhedonia

affective symptoms of MDD

-psychomotor retardation or impairment -psychomotor agitation (pacing, wringing hands, taking off clothes, anxiety) -slumped posture -curled up position -walking slow or rigidity -lack of communication -lack or no hygiene, grooming (ADL's) -social isolation or withdrawn

behavioral symptoms of MDD

-confusion -indecisiveness -inability to concentrate and think -SI -Psychosis? (delusions, hallucinations, disconnect with reality)

cognitive symptoms of MDD

-Maslow's needs (basic needs) -slowdown of entire body -constipation -urinary retention -amenorrhea -anorexia -impotence (ED) -weight lose or gain -sleep disturbances -worse in morning and may improve as day goes on

psychological symptoms of MDD

-ask about suicidal thoughts -ask if they have a plan and if they have the means to carry out this plan

priority assessment of a depressed client

-Assess for SI -close observation every 15 minutes (regular and irregular intervals) -suicide precautions -remove anything potentially dangerous from room no harm contract

nursing interventions for MDD

-encourage client to express feelings -show empathy -develop trust -convey accepting attitude -offer self -use simple concrete words -use active listening -promote attendance in therapy groups -share observations; you may notice improvement before the client feels it -allow time to response -avoid cliches like "it will be okay" -be firm to get them to participate -choose activities that require decreased concentration and immediate gratification

communication with a depressed client

-offer high calorie and high protein snacks -offer fluids -sit with client during meals and encourage to eat with others -during meal time it is ok to socialize with client -weekly weight -ask about favorite foods and offer food choices

nutrition for depressed client

-short periods of rest -encourage client to get up, get dressed, and stay out of bed -reduce stimuli evening -reduce caffeine in evening -observe and record sleep patterns -medications: SSRI in morning and tricyclics at night

sleep for depressed client

-encourage basic hygiene -may need step by step instructions -simplify choices -don't do it for them unless they can't, encourage independence -assist with physical care as needed

self care for depressed client

-encourage exercise -encourage high fiber foods -encourage fluids -PRN laxative/stool softeners -monitor I and O

elimination for depressed client

suicide

the act of taking one's own life; it is a behavior

-age (45-54)(85 and older)(adolescents) -gender (women are more likely to attempt and men are more successful) -marital status (single, never married, divorced, widowed) -religion (protestant and jews increased risk)(being religious lowers risk) -socioeconomic status (highest and lowest classes at risk) -occupation (doctors, artists, dentists, law enforcement, lawyers, insurance agents, healthcare workers, business, unemployed) -ethnicity (whites are at highest risk)

what people are at higher risk for suicide

-previous attempt -access to plan -mental health disorder -chronic illness or pain -gay, lesbian, transgender -family history of suicide -bullying

other risk factors for suicide

-assessment about SI and plan -maintain close observation -documentation -meals (no metal and supervise) -remove all potentially harmful objects -search gifts or no gifts at all -can keep glasses, hearing aids, walker, and canes -see if a visitor gave anything to the client -medications (make sure patient swallowed) -develop trust and boundaries -supportive approach -encourage to express feelings

nursing interventions for suicide

-denial -anger -bargaining -depression -acceptance

5 stages of grief

grief

-inner emotional response to loss -can lead to depression

bereavement

described as the period of grief and sadness that is the normal process of reacting to a loss and may include mental, physical, social, and emotional reactions

normal grief

-grief that is considered uncomplicated -acceptance is achieved within 6 months after the loss

anticipatory grief

-when death is expected -opportunity for grieving before the actual loss -terminal illness

complicated grief

-remain in denial, anger, or depression stage of grief for extended period of time -unable to perform ADLS and tend to responsibilities -inability to progress through the stages of grief and events can trigger the grief response