302 unit 2 - mood, pain/comfort

crisis

A sudden event in one’s life, during which usual coping mechanisms cannot resolve the problem

3 factors influencing a patient’s crisis response

1. The individual’s perception of the event.

2. The availability of situational supports.

3. The availability of adequate coping mechanisms

types of crises

Dispositional crisis

An acute response to an external situational stressor

Example: extreme stress response from someone struggling with the decision of divorce

Crisis of anticipated life transitions

Normal life-cycle transition that may be anticipated but over which the individual may feel a lack of control

Example: moving to college and being separated from normal support system leading to anxiety

Crisis resulting from traumatic stress

Precipitated by an external stressor over which the individual has little or no control, and from which he or she feels emotionally overwhelmed and defeated

Example: a rape victim developing PTSD

Maturational/developmental crisis

Occurs in response to a situation that triggers emotions related to unresolved conflicts in one’s life

Example: starting a new job, leaving home for college, etc leading to anxiety/depression

Crisis reflecting psychopathology

A crisis that is triggered by a preexisting mental illness

Example: someone with a personality disorder might have trouble coping with a stressful life event

Psychiatric emergency

A crisis situation in which general functioning has been severely impaired and the individual is rendered incompetent or unable to assume personal responsibility

Example: severe emotional situation leading to a suicide attempt

milieu

a person’s social environment

SOLER acronym for active listening

SOLER = sit square, open posture, lean forward, eye contact, relax

Major Depressive Disorder (MDD)

depressed mood or loss of interest/pleasure in usual activities; impaired social & occupational functioning for >2 weeks; no hx of manic behavior

Persistent Depressive Disorder (Dysthymia)

milder sx than MDD, chronically depressed/irritable mood most days for >2 yrs; describe mood as sad or “down in the dumps”

Premenstrual Dysphoric Disorder

markedly depressed mood, anxiety, mood swings, decreased interest during week before menstruation

Depression - implications in childhood and adolescence

Adolescence:

• Behavioral change that lasts for several weeks

• Psychosocial intervention & medications

• SSRIs: fluoxetine, escitalopram (age 12-17)

→ Black-box warning

Depression - implications for elderly

Nursing process - planning/implementation of depression care

Types of talk therapy for depression

ECT - electroconvulsive seizure for depression

*Most common AE’s = memory loss and confusion

*Mortality risk = cardio complications

Pre-treatment meds for ECT

Atropine or glycopyrrolate

-30m before IM

-given to decrease secretions (prevent aspiration) and to reduce vagal stimulation from ECT which would lead to bradycardia

In-treatment meds for ECT

Short-acting anesthetic (propofol or etomidate)

Muscle relaxant = succinylcholine chloride

-Given to prevent severe muscle contractions during seizure

**Paralyzes resp muscles → must be on O2

Repetitive Transcranial Magnetic Stimulation (rTMS)

Stimulates nerve cells in brain by use of short magnetic pulses

• Waves passed through coil placed on scalp

• 40min sessions 3-5X/wk

• SE: tinnitus, headache, facial twitching

• Rarely seizures can occur

• Remission rate of 30%

Mood vs Affect

Mood = a pervasive and sustained emotion that may have major influence on someone’s perception of the world

Affect = an observable emotional rxn that is associated with an experience

Mania vs hypomania vs delirious mania

Mania = feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Lasts at least 1 week

Hypomania = manic symptoms that do not meet criteria for mania (not as severe). Lasts at least 4 days

Delirious mania = extreme exacerbation of acute mania. Rare.

Bipolar I vs Bipolar II

BP I = Pt has at least 1 full manic episode during life, may also have experience depressive episodes

BP II = Pt has major depressive episodes, with episodic occurrence of hypomania. Has never met criteria for full manic episode

Cyclothymic disorder

-Pt cycles between depression and hypomania, but neither episodes are ‘severe’ enough to meet criteria for BPI or BPII

-Experienced for at least 2 years

Bipolar & ADHD

-ADHD is the most common comorbid condition for people w/ bipolar

-ADHD meds may exacerbate mania → only give after bipolar symptoms have been controlled

Lithium therapeutic range

*Narrow therapeutic index, must check serum levels 1-2 months

Acute Mania: 0.5-1.5 mEq/L

Maintenance: 0.6-1.2mEq/L

Lithium and hydration

Hyponatremia can cause lithium toxicity → must drink 2-3L water per day and have lots of salt in diet

Anticonvulsants for Bipolar

Verapamil for Bipolar

Antipsychotics for bipolar

Cluster A personality disorders

Behaviors described as odd or eccentric.

• Paranoid personality disorder

• Schizoid personality disorder

• Schizotypal personality disorder

Cluster B personality disorders

Behaviors described as dramatic, emotional, or erratic.

• Antisocial personality disorder

• Borderline personality disorder

• Histrionic personality disorder

• Narcissistic personality disorder

Cluster C personality disorders

Behaviors described as anxious or fearful.

• Avoidant personality disorder

• Dependent personality disorder

• Obsessive-compulsive

personality disorder

Paranoid PD

• Constantly on guard

• Hypervigilant

• Appear tense and irritable

• Become immune or insensitive to the feelings of others

• Always feel that others are there to take advantage of them

Paranoid PD - predisposing factors

• Possible hereditary link

• Subject to early parental antagonism and harassment

Schizoid & Schizotypal PD

Schizoid = Characterized by a profound defect in the ability to form personal relationships → failure to respond to others in a meaningful way

-Diagnosis occurs more frequently in men than in women

Schizotypal = Less severe version → Aloof and isolated, behaves in a bland and apathetic manner

Antisocial PD

A pattern that is exploitative, socially irresponsive, and w/o remorse - “psychpath”

-more common in men and poverty, very common in prison centers

-Predisposing factors: childhood physical abuse, poverty, inconsistent parental discipline

Borderline PD

Common behaviors: depression, manipulation, inability to be alone, splitting, impulsivity, self-destructive behaviors

-More common in women

-Predisposing factors: Childhood trauma/abuse, especially if they fail to find autonomy btwn 16-24months

Histrionic PD

Behavior is excitable, emotional, colorful, dramatic, extroverted

Narcissistic PD

Exaggerated sense of self-worth, lack empathy

-More common in men

Avoidant PD

Dependent PD

Obsessive-compulsive PD

• especially concerned with organization + efficiency

• rank-conscious, integrate with authority figures

• rigid and unbending

Oppositional Defiant Disorder (ODD)

In children

Characterized by a persistent pattern of angry mood and defiant behavior that interferes with life activities. Can have low self esteem and low social interaction

-begins no later than adolescence

-May be a precursor to BPD in adulthood

Conduct disoder

In children and adolescents

Persistent physical aggression in the violation of the rights of others

-more common in males

-May be a precursor to APD in adulthood

Palliative care

Comfort and supportive care that is non-curable, NOT specific to end-of-life

-symptom management; an approach that improves quality of life

Palliative vs end-of-life (hospice) care

primary goal of EOL care

comfort

SPIKES communication model

SPIKES - S and P

SPIKES - I and K

SPIKES - E and S

Most common EOL medications

-Morphine

-Lorazepam (ativan)

-other opioids/pain meds, nausea meds, GI meds

How is death determined?

-Absence of apical pulse for at least 1 minute

-Brain death (apnea test, reflexes test, no brain activity)