BH exam 3

bipolar 1

most severe form, highest mortality rate, at least one manic episode

Diagnoses in the hospital, become psychotic in a manic state 

More common in males 

bipolar 2

at least 1 hypomanic episode and at least one major depressive episode

Typical to diagnoses, takes years to diagnose, never reach the point of mania, rarely hospitalized 

Will come to hospital when in a depressed state, if put on an SSRI they will end up in a manic state 

More common in females 

cyclothymia

alternate with symptoms of mild to moderate depression for at least 2 years, rapid cycling possible, normally hypomania and depression, cant only diagnose with DMS 5, usually develops in adolescence of early adulthood  

unipolar

only major depressive states

Persistent depression that does not involve a manic, hypomanic, or mixed episode 

manic

distinguishes BP1 from BP2

feeling very “up”, elated or jumpy with a ton of energy, have trouble sleeping, and feel irritable or prone to risky or reckless behavior

hypomania

euphoric and increased functioning

excessive activity and energy for at least 4 days and involves 3 behaviors listed in DSM (irritability)

psychosis is never present and hospitalization is rare

Usually **does not cause** severe impairment in social or occupational functioning 

Depressive symptoms place them at risk for suicide 

BIPOLAR 2 

lithium toxicity symptoms

confusion, hyperirritability of muscles, clonic movements, seizures, convulsions, oliguria

lithium risk factors

cardiovascular disease, brain damage, renal disease, thyroid disease, myasthenia gravis, pregnancy, children under 12

lithium therapeutic doseage

0.8 to 1.4 mEq/L

lithium side effects

nausea, diarrhea, thirst, polyuria, lethargy, sedation, fine hand tremor 

suicide risk and bipolar

\
Depression and the agitated state of mania is a dangerous combination and can lead to extreme behaviors like attempted suicide

Women with bipolar are more likely to commit suicide

Depressive symptoms place them at risk for suicide (bipolar 2 hypomania state) 

Early detection of bipolar disorder can help diminish suicide 

pt experiencing mania: assessment

mood, behavior, thought processes and speech patterns, cognitive functioning

strong genetic component

circumstantial speech

never come back to the topic

tangential speech

eventually will come back to topic

flight of ideas

nearly continuous flow of accelerated speech with abrupt changes from topic to topic which are usually based on understandable associations or play of words

ex: how are you doing kid, no kidding around, i’m going home, home sweet home, home is where the heart is

clang associations

stringing together words with rhyming sounds, despite meaning

ex: cinema one and two, last row, row row row your boat, get out and vote

grandiose delusions

inflated self-regard, may exaggerate accomplishments or importance (they know someone famous, God is speaking to them)

ex: domesticated breeded cats, seales big ass cats

persecutory delusions

someone is trying to hurt them

symptoms of hypomania

euphoria, quickly change to irritability or anger, Sociability and euphoria are replaced by hostility, irritability, and paranoia

symptoms of mania

manipulative, profane, fault finding, adept at exploiting others vulnerability, constantly pushing limits

goals for mania

monitor sleep, hygiene, nutrition, I/O, education

if paranoid: open meds in front of patient

individual experiencing mania

unit activities appropriate to recommend to an individual experiencing mania; take them for a walk (concrete garden)

\-room that is least stimulating, a room far away from nurses’ station

\-finger foods

\-rule out hyperthyroid

\-lower your voice, talk slowly, reduce stimuli, short frequent contact

\-inappropriately dressed: protect, don’t embarrass (patient spinning, no underwear), suggest putting different clothes on

\-never force bathing but can encourage one step at a time

demanding and mean patients

“I hear what you are saying, I am with another patient now, I will get back to you as soon as you can”

Establishing therapeutic alliance with the individual with bipolar is crucial to support continued treatment 

divalproex sodium (Depakote)

anticonvulsant used for BP

monitor **liver function** (AST) and PLT periodically

SE: nausea, weakness, somnolence, indigestion, diarrhea, dizziness, vomiting, sedation, weight gain, tremor

serious ADRs: thrombocytopenia, pancreatitis, hepatic failure, hyperammonemia

must have liver function tests before prescribing

lithium

toxic level: 1.5 and above

therapeutic level: 0.8-1.

maintenance level: 0.4-1.3

SE: acne, alopecia, psoriasis, diarrhea, nausea, vomiting, hypothyroidism, weight gain, edema, polydipsia, polyuria, ataxia, sedation, fine tremor

monitor for toxicity, TSH levels, lithium blood levels

teaching: maintain consistent fluid intake, consistent sodium intake

lithium client teaching

be consistent with fluid intake, exercise

sodium intake can affect lithium, be consistent (more sodium=less lithium, vis versa)

do not take OTC medicines (including NSAIDs) without checking with provider

contraindications: CVD, brain damage, renal disease, thyroid disease, myasthenia gravis, pregnant and breast feedings, children under 12

oxcarbazepine/trileptal

mood stabilizer anticonvulsant

used for children because does not require frequent labs

lamotrigine/lamictal

used for bipolar depression

ADR: STEVENS-JOHNSON syndrome

titrate slowly to avoid

atypical antipsychotics

olanzapine (think obesity), risperidone, aripiprazole, cariprazine, lurasidone (Latuda take with fooda), quetiapine, ziprasidone

benzodiazepines

while waiting for mood stabilizer to become effective, administer these for short-term when pt is experiencing mania

treat agitation

anticonvulsants used to treat bipolar

depakote, tegretol, lamictal

antidepressants AFTER mood stabilization

administering antidepressant before mood stabilization can increase the risk of a manic episode occurring

most guidelines suggest depression in BPD can be treated with just a mood stabilizer

bupropion/wellbutrin

only known antidepressant that currently will not cause manic switches/episodes in those diagnosed with Bipolar 1 Disorder

opioids: given once withdrawal is complete

therapeutic interventions for paranoia

address, offer medication

short, frequent contact

reduce excess stimulation

provide increased supervision is risk for aggressive behavior

take action to help the patient feel safe and secure

don’t pretend to understand

schizoaffective disorder

An uninterrupted duration of illness during which there is a major mood episode (manic or depressive) in addition to criterion A for schizophrenia

Major depressive episode must include depressed mood

Bipolar and schizophrenia

Treated with anticonvulsants/mood stabilizers (Valproate (Depakote))

haloperidol/Haldol

1. Typical antipsychotic, depot drug 


2. Intramuscular, long acting 


3. Give in 10-2-50 

olanzapine/zyprexa

atypical antipsychotic

causes obesity!!

SE: sedation, obesity

meds used to augment antipsychotics

Augment means to make more effective 

Anticonvulsants (mood stabilizers) augment antipsychotics 

Ex: valproate and schizoaffective disorders 

Benadryl and Cogentin

administered as anti-parkinsonian drugs (anticholinergics)

for pseudo parkinsonism and dystonias

may be added for the treatment of side effects

ex: given in 10-2-50 to treat side effects of Haldol

REDUCES EPS

clozapine/clozaril

atypical antipsychotic

very effective in treatment resistant schizo, but last line treatment

agranulocytosis, blood dyscrasia

requires WBC every 1-2 weeks

low compliance d/t inconvenience and cost of blood tests and the medication itself

improves negative symptoms (depression, flat affect, anhedonia)

agranulocytosis

Loss of the white blood cells that fight infection 

Caused by clozapine 

If pt comes in with a sore throat and is on clozapine, think agranulocytosis 

blueler’s 4 a’s

affect, ambivalence, autism, association

affect

inappropriate or flat, emotions incongruent to situation

ambivalence

amotivation, depersonalization

holding of conflicting attitudes and emotions towards others and self, lack of motivation

autism

social withdrawal, preferring to live in a fantasy world rather than interact with social world appropriately

association

loosening of thoughts associations→ word salad, flight of ideas, thought disorders

hallucinations

perceiving a sensory experience for which no external stimulus exists

auditory, visual, tactile, command

sometimes olfactory and gustatory (typically a medical illness not mental)

command hallucinations

telling them to do something, direct the person to take action, may instruct to harm themselves or others 

ASK if they are seeing/hearing things. What are they hearing/seeing? Are they telling them to hurt anyone or themselves? 

positive symptoms of schizophrenia

Presence of something not normally present

Adds to the life experience

Hallucinations, delusions

Paranoia, disorganized or bizarre thoughts, behavior, or speech

first, second, and third generation antipsychotics treat

negative symptoms of schizophrenia

Absence of something that should be there

Takes away from life experiences

Anhedonia (reduced ability to enjoy activities), depression, flat affect

Social discomfort, lack of goal-directed behavior

second and third generation treat

anosognosia

inability to realize one is ill—an inability caused by the illness itself

Common in severe mental illness

May lead the pt to resist or stop treatment, making care more challenging and frustrating to others

Can interfere with requesting or accepting help

extrapyramidal symptoms

pseudo parkinsonism, acute dystonic reactions, akathisia, tardive dyskinesia

occurs as a side effect of typical antipsychotics, some atypicals

pseudo parkinsonism

tremors, impaired gait, stiffening muscles 

Stooped posture, shuffling gait, rigidity, bradykinesia, tremors at rest, pill-rolling motion of the hand 

acute dystonic reactions

contraction of muscles (usually head and neck)

facial grimacing, involuntary upward eye movement, muscle spasms of the tongue/face/neck/back (back muscle spasms cause trunk to arch forward), laryngeal spasms

akathisia

uncontrolled inner restlessness

Can be difficult to distinguish from anxiety 

Patient will not be able to/have difficult describing. Feel restless, uncomfortable, anxious 

Restless, trouble standing still, paces the floor, feet in constant motion, rocking back and forth 

tardive dyskinesia

involuntary movements of face, mouth, body extremities

Protrusion and rolling of the tongue, sucking and smacking movements of the lips, chewing motion, facial dyskinesia, involuntary movements of the body and extremities

No true cure 

Treatment: benzodiazepines, lioresal/baclofen (muscle relaxant), valporate/depakote 

AIMS

abnormal involuntary movement scale

should be performed when a new antipsychotic is begun, any time the dose is changed, and every 6 months

facial and oral movements, extremity movements, trunk movements, global judgments, dental status

Rate on a scale from 0-4 (0=none, 1=minimal, may be extreme normal, 2=mild, 3=moderate, 4=severe)

key in identifying and treating TD, etc

neuroleptic malignant syndrome

MEDCIAL EMERGENCY!!

Caused by tupical and atypical antipsychotics

Occurs most often early in therapy

Due to excessive dopamine receptor blockage:

\-Reduced consciousness, muscular rigidity

\-Hypertension, tachycardia, tachypnea, diaphoresis, drooling

FEVER: fever, encephalopathy, vital sign instability, elevated CPK and WBC, rigidity

NMS treatment

discontinue the antipsychotic

__**cooling blankets for fever**__

bromocriptine/Parlodel

dopamine receptor agonist in mild cases

__**Dantrolene/dantrium IV**__

muscle relaxer in severe cases

ideas of reference

An individual experiencing events/mere coincidences and believing they have strong personal significance 

Ex: people thinking people are trying to communicate with them through the TV or radio 

catatonia

Pronounced increase or decrease in the rate and amount of movement; Stuporous (most common)= little to no movement 

Can be caused by extreme trauma 

Won't move, talk, eat 

Give Ativan 

waxy flexibility

extended maintenance of posture (catatonia)

freeze in position

delusions

False, fixed beliefs, cannot be corrected by reasoning 

Grandiose  (NASA cheerleader), Persecutory, Religious, hypochondriacal ideas 

clang associations

words used based upon their sounds (rhyme), not meaning

ex: on the track, to get a big mac

word salad

schizophasia

disorganized, meaningless jumble of words that are not related

ex: throat horse strength of policy dreadful

poverty speech

alogia

reductions in spontaneity or volume of speech

according to textbook, a positive symptom

loose associations

inability to associate thoughts logically to each other

ex: friends talk about french fries and how can you trust the french

do not pretend to understand

neologisms

made up words or meaningless use of existing words

Schizophrenia Plan of Care Phase I: acute

settings: level of care needed, ability to cooperate, treatment available, treatment for concurrent needs

interventions: psychiatric, medical, & neuro evaluation, psychopharm, supervision

hospitalization

discharge

phase II: stabilization

identification of needs

housing, employment, family relationships

resilience, coping skills

phase III: maintenance

building relapse prevention skills

patient and family education

effective long-term care depends upon med administration/adherence, relationships with trusted care providers, community-based therapeutic services, and __**family psychoeducation**__

therapeutic communication with delusions/hallucinations

Call patient by the name they wish to be called

Speak simply, but loud enough to be understood

Do not maintain eye contact when they are paranoid (may make them aggressive)

Redirect patient’s focus to your conversation; present reality when they start discussing hallucinations → “while those may be real to you, they are not real to me? Are they speaking to you?”

Never argue!

short frequent contact to build rapport

emergency department alcohol intoxication assessment

Ask when the last time they had a drink (need to see if they are going to go through (withdrawal) 

Are you taking any other medications, herbs, drugs? (comorbidities) 

The only way we can help you is if you answer the questions honestly 

dopamine

Activate dopamine and glutamate in the reward neural pathways of the brain’s limbic system 

The behaviors are reinforced through the dopamine-glutamate cycle and become dysfunctional

dual-diagnosis

substance disorder + mental illness

want to be treated for both

tolerance

takes a higher dose to achieve the initial level of response

physical dependence

needing the substance to avoid undesirable physiologic effects

psychological dependence

cravings for the drug or obsessing over substance effects

alcohol withdrawal s/s

seizure, falls, pulse greater than 100, blood pressure greater than 140/90, nausea, vomiting, hypersensitivity to light and sound

biggest indicator: high pulse and high systolic, shakes, photosensitivity, band tightening around head

anxiety, insomnia, nausea, abdominal pain→ high blood pressure, increased body temp → hallucinations, fever, seizures, and agitation

delirium tremens

alcohol withdrawal delirium, medical emergency, treated with ativan

medications for alcohol withdrawal

benzodiazepine taper (GABA stimulation), thiamine, folate, valium, barbituates 

acute withdrawal: Ativan (psychosis during withdrawal is medical emergency) 

long-term treatment: Librium (treats tremors and agitation) 

XANAX=SHOT OF TEQUILA 

ATIVAN=BIG GLASS OF WINE 

CLONAZEPAM=SLOW BEER DRIP 

alcohol detox medications

chlordiazepoxide/librium

may prevent danger during detox

alcohol intoxication assessment

AST usually higher than ALT

The goal is prevention of alcohol withdrawal delirium

CIWA=clinical institute withdrawal assessment for alcohol, SMIRT, AUDIT, CAGE

patient who is craving alcohol: CAMPRAL (if family history) OR NALTREXONE

aversion drug: ANTABUSE, DISULFIRAM (absolutely no alcohol or severe nausea occurs)

cocaine intoxication

dilated pupils

dizzy, tremor, hallucination, extreme fever, tachycardia, hypertension, chest pain

opioid intoxication

Meiosis (pinpoint pupils), decreased TPR, BP, confusion, slurred/slowed speech, severe constipation 

Bradycardia, hypotension, hypothermia, sedation, meiosis, slurred speech, euphoria, calmness 

opioid withdrawal

Dilated/large pupils, respiratory insufficiency/failure, clammy skin, seizures, coma, death 

Tachycardia, hypertension, hyperthermia, insomnia, mydriasis, diaphoresis, increased respiratory rate, anxiety, abdominal cramps, N/V, diarrhea 

relapse prevention

naltrexone is used in prevention of relapse following detox

opioid overdose recognition and narcan administration

Extreme sleepiness, inability to awaken verbally or upon stimuli, less that 8 breathes per minute, fingernails or lips turning blue, extremely small pinpoint pupils, slow erratic heartbeat or low bp

Administer Narcan if overdose suspected (it won’t harm them if its not from opioids)

harm reduction

Healthcare professionals should work with all individuals to be as healthy as possible whether they are using drugs or not using drugs 

Promote recovery and treatment, promote Narcan saturation, promote hygiene (hand hygiene, keep injection sites clean, proper disposal of syringes, wound care, syringe safety), overdose prevention 

North Texas Harm Reduction Alliance

started at TCU because of presence of fentanyl in college life and society

improve harm reduction methods in north Texas to decrease substance abuse related illness and death

meds that prevent alcohol withdrawal

Diazepam, librium, benzodiazepines, Tegretol, barbituates, antabuse, campral, revia 

meds that decrease cravings for alcohol

Campral, naltrexone 

medication assisted treatment (MAT)

Alleviate physical withdrawal, opioid blockade, alleviate drug craving, normalized deranged brain changes and physiology 

Naltrexone, methadone, buprenorphine 

buprenorphine (suboxone)

partial opioid agonist 

produces effects such as euphoria or respiratory depression, but these effects are weaker than those of drugs such as heroin and methadone 

Methadone

full opioid agonist

You can be on methadone for the rest of your life and not get high, can be fully functional 

Treatment of choice for pregnant opiate addicted women 

clonidine (catapres)

alpha agonist antihypertensive, often used to reduce the symptoms of opioid withdrawal by blocking neurotransmitters that trigger sympathetic nervous system activity 

naltrexone (revia)

opioid antagonist      

long acting injectable, used in prevention of relapse following detox, if client relapses, the euphoric effects are locked also used in alcohol treatment 

naloxone (narcan)

opioid antagonist which helps in the reversal of opioid overdoses

pushes most other opioids off the receptors, then sits on the receptor preventing it from being activated for 30-90 minutes

A patient is admitted to the ED experiencing respiratory distress due to opioid overdose. As soon as his respiration is stabilized, administer narcan

lorazepam (ativan)

benzodiazepine 

emergency department and active withdrawal of alcohol 

help avoid delirium tremens with alcohol withdrawal

chlordiazepoxide (librium) 

Used for mild to moderate withdrawal, treats tremors and mild to moderate agitation 

LONG-TERM treatment (meaning it is not used in the Emergency department) 

May keep patient out of danger during withdrawal 

Use CIWA to determine use