Mental Health Exam 2

mania

period of intense mood disturbance w/ persistant elevation, expansiveness, irritability, and extreme goal-directed activity or energy

- mania intensifies = may become psychotic ( sx are severe enough that this state is a psychiatric emergency)

hypomania

low-level and less dramatic mania ; DOES NOT impact functioning in a way that is noticeable to others

mood lability

rapid shifts in mood with little or no changes in external events

bipolar I disorder

at least one episode of mania alternating w/ major depression

bipolar II disorder

one or more hypomanic episodes alternating w/ major depression

cyclothymic disorder

chronic mood disturbances of at least 2 years w/ many periods of elevated mood and DO NOT meet criteria for hypomanic episode AND many periods of depressed mood that DO NOT meet criteria for major depression

manic episode

mania plus 3 or 4 other symptoms

major depressive disorder

depressed mood or loss of interest coupled w/ 4 other symptoms

hypomanic episode

hypomania (less severe and shorter duration than mania) plus 3 or 4 other symptoms

mixed episodes

meets criteria for both a manic and a major depressive episode

assessment manic phase: mood

unstable, may change quickly to irritation/anger

assessment manic phase: miscellaneous

- decreased need for sleep

- activities w/ painful consequences (spending, sexual, etc.)

- marked impairment in social or occupational functioning/hospitalization

assessment manic phase: speech patterns

- pressured speech

- circumstantial speech

- tangential speech

assessment manic phase: thought processes

- flight of ideas

- loose associations

assessment manic phase: thought content

- grandiose delusions

- persecutory delusions

assessment depressive phase (7)

- flat/blunted/labile affect

- tearfulness

- anergia, anhedonia

- difficulty concentrating or problem-solving

- suicidal ideation

- decreased in hygiene

- loss or increase in appetite and/or sleep

what are the nursing interventions aimed at (6)

- LEAST restrictive environments

- safety!! (injury, harm to self or others)

- promote rest and sleep! (avoid caffeine!!)

- restore nutritional and hydration status (high protein/foods/drinks)

- anger management (techniques to control anger responses)

- set limits on inappropriate behaviors

what are our ACTUAL nursing interventions

- monitor sleep, fluid intake

- offer hand-held, nutritious food

- administer mood stabilizing agents

- provide a structured environment

- de-escalation & anger management

- communication

how should we use communication? (mood disorders)

- calm, matter-of-fact

- give concise explanations

- consistent w/ expectations and limit-setting

- avoid power struggle

what are the treatment modalities for bipolar disorder

pharm (mood stabilizers): lithium, anticonvulsants, atypical antipsychotics

brain stimulation therapies

psychological therapies (cognitive behavioral therapy, family-focused therapy)

what are mood stabilizers

classes of drugs used to treat sx associated w/ bipolar disorder

- effective in treating mania; not all do well with depression

- antidepressants = little effectiveness in treating bipolar depression; taking w/ mood stabilizers risks triggering a switch from depression to mania

what is important to know about lithium

gold standard among mood stabilizers for bipolar

- REGULAR monitoring (therapeutic index 0.6-1.5 mEq/L)

- BAD FOR BABY

- NSAIDs & diuretics can increase lithium levels

- baseline assessment of renal and thyroid function

what are the adverse effects of lithium (derm, G.I, endocrine, fluid/electro, nervous/MSK)

derm: acne, alopecia, psoriasis

G.I: diarrhea, N/V

endocrine: hypothyroidism, weight gain

fluid/electro: edema, polydipsia, polyuria

nervous/msk: ataxia, sedation, fine tremor

lithium levels < 1.5 mEq/L sx

G.I distress, weight gain, fine hand tremors, renal toxicity, hypothyroidism, electrolyte imbalances, hypoTN

lithium level 1-5 - 2.0 mEq/L

G.I upset, coarse hand tremor, confusion, hyperirritability of muscles, sedation

- withhold medication & notify HCP

lithium level 2.0-2.5 mEq/L

ataxia, blurred vision, large output of dilute urine, seizures, stupor, severe hypoTN, coma

- hospitalization indicated

lithium level > 2.5 mEq/L

convulsions, oliguria (none or small amounts of urine)

- DEATH CAN OCCUR

what are anticonvulsants with proven efficacy in bipolar disorder

- valproic acid

- carbamazepine

- lamotrigine

what is the FDA warning for anticonvulsants

carry a warning label indicating an increased risk for suicidal thoughts

mood stabilzer: valproate (valproic acid)

effective for the acute manic phase of bipolar disorder; used for the long term to prevent recurrence of mania

- therapeutic range: 50-125

- bad for baby

- FDA black box for several adverse responses

- monitor LFTs, CBC

valproate side effects (common and severe)

common: sedation, weight gain, tremor

serious: thrombocytopenia, pancreatitis, hepatic failure, hyperammonemia

mood stabilizer: carbamazepine

Second-line agent for bipolar disorder, effective for the acute manic phase

- therapeutic level: 4-12mg/L

- BAD FOR BABY

- FDA black box warning for serious derm reactions (SJS,etc)

- monitor LFTs, CBC, ECG, Na levels

carbamazepine side effects

dizziness, somnolence, N/V, ataxia, blurred vision, hyponatremia, leukopenia

mood stabilizer: lamotrigine

approved for maintenance tx of bipolar disorder; prevent recurrence of mania and depression

- benign rashes caused can be minimized by slow titration up

- can RARELY cause SJS

lamotrigine side effects

benign skin rash, nausea, vision changes, HA sedation

second-gen antipsychotics

serotonin/dopamine blockers may reduce psychotic sx in mania

- sedative properties in early phase of tx

- may cause weight gain, insulin resistance, DM, dyslipidemia, cardiovascular impairment

- to prevent mania from reoccuring; lithium & valproate used together with serotonin/dopamine blockers

what are integrative therapies

- brain stimulation therapies (ECT, TMS may be appropriate)

- client & family teaching: adherence to medication, reducing risk of relapse

- psychological therapies: cognitive behavioral therapy (w/ pharm), family-focused therapy (improve communication among family members)

what is mood

pervasive and sustained emotion that may have a profound influence on a person's perception of the world

what is affect

outward representation of one's emotions

- an objective finding based on the nurse's assessment

- incongruent with mood

what is depression

alteration in mood that is expressed by feelings of sadness, despair, pessimism

what are the 5 types of depressive disorders

- major depressive disorder (MDD)

- persistent depressive disorder

- premenstrual dysphoric disorder (PMDD)

- substance/medication induced depressive disorder

- depressive disorder due to another medical condition

what are the risk factors for depressive disorders

biochemical

hormonal

neuroinflammation

psychosocial factors

cognitive factors

biochemical risk factors

deficiency in serotonin, NE, DA

- serotonin: sleep/appetite disorders, low sex drive, irritability

- NE: apathy, slowed psychomotor activity

- NE, serotonin, ACh = role in stress regulation

hormonal risk factors

increased cortisol, elevated corticotropin-releasing hormone

what are neuroinflammation risk factors

elevated inflammatory biomarkers; oxidative stress

what are psychosocial risk factors

stressors and trauma trigger neurochemical changes

what are cognitive risk factors

early life experiences contribute to a negative, illogical, and irrational thought process

what are BIG things to know about major depressive disorder

key sx: depressed mood and anhedonia (reduced ability to experience pleasure or interest in previously enjoyed activities)

- most experience recurrent episodes (50% within first year; >85% within a lifetime)

- sx of anxiety occur in 70% of cases

what are other big sx of MDD

weight loss or gain (increase or decrease in appetite)

insomnia or hypersomnia

psychomotor agitation or retardation

fatigue or loss of energy

feelings of worthlessness or inappropriate guilt

diminished ability to concentrate

recurrent thoughts of death, suicidal ideation

what are assessment findings in MDD with appearance

neglected grooming and hygiene, no eye contact

what are assessment findings in MDD with behavior

anergia, appetite/weight changes, sleep disturbances, loss of libido

what are assessment findings in MDD with mood

depressed; feelings of worthlessness, helplessness, hopelessness

what are assessment findings in MDD with affect

constricted (reduced in range/intensity), blunted (shallow), flat (no expression)

what are assessment findings in MDD with speech

monotone, lack of spontaneity

what are assessment findings in MDD with thought processes

poverty of thought, slowed responses

what are assessment findings in MDD with thought content/perceptions

psychotic features may be present

what are assessment findings in MDD with insight and judgement

poor decision-making and problem-solving

what are assessment findings in MDD with cognitive changes

impaired thinking, concentration, attention, memory

what are age considerations for MDD

children/adolescents: core sx of depression are the same w/ adults, just differences in how they are displayed

- young child: cry

- school-aged child: withdraw

- teenagers: irritable, preoccupied w/ death or suicide

older adults: more likely to complain of physical illness than emotional concerns

what is suicidal ideation

thinking about death, considering methods of accomplishing death, formulating plans to carry out act

What is non-suicidal self-injury?

direct attempts to inflict injury to body without intending to die

how do you evaluate a 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

what are suicide risk factors

mental health, physical health, chronic pain, hx of trauma, access to lethal means, prolonged stress, hx of family mental illness and suicid

what should a nurse be alert for with suicide risk factors

nonverbal behavioral clues

- brightening of mood

- giving away possessions

- writting letters

- organizing finacial affairs

what are suicide protective factors

overall resilience

problem-solving skills

awareness and access to HCP/Mental health provider

postive peer relationships

positive adult relationships

safe environment

how do we talk to a severely withdrawn person

- when a patient is silent use the technique of observations

- use simple, concrete words

- allow time for pt to respond

- listen for convert messages, ask about suicide plans

- avoid things like "things will look up" or "everyone gets down once in awhile"

what else should a nurse do for implementation

- evaluate risk of harm to self or others

nursing measures: improving physical well-being and promoting adequate self-care

what is the nursing role and Milieu therapy

- suicide assessment: risk factors and protective factors

- paradoxical calm: be alert to sudden lifts in mood

- communication: simple sentences, time to respond

- assess level of suicide precautions

- remove unsafe items

- 1 : 1 for short periods of time

- safety plans

- monitor medication side effects

- positive reinforcement for accomplishments

what are other tx options for depression

pharmacotherapy (antidepressant medications)

brain stimulation techniques

light therapy

psychological therapy (individual/group/family)

what is the monoamine hypothesis (for antidepressant actions)

depression is linked to a deficit in monoamine transmission (serotonin, NE, DA)

- low levels cause postsynaptic receptors to up-regulate

- antidepressants cause down-regulation, which may explain why it takes 4+ weeks for antidepressants to work

what is the receptor sensitivity hypothesis (for antidepressant actions)

antidepressants normalize receptor function over time

what is the neurotrophic factors hypothesis (for antidepressant actions)

antidepressants increase the production of neurotrophic factors regulating the survival of neurons

what are other important things to know about pharmacotherapy for depression

- antidepressants have SE related to specific receptors being blocked or activated

- delayed onset of therapeutic action; complete relief of sx takes several weeks

- antidepressants carry an FDA black box warning for increased risk of suicidality in children, adolescents, and adults up to 25

what are selective serotonin reuptake inhibitors (SSRIs)

action: block the reuptake of serotonin

- first line tx for depression/anxiety

SE: sexual dysfunction, HA, sleep disturbances, restlessness or jitteriness, nausea

what are the specific ways some SSRIs differ from the slide

fluoxetine: activating agent, causes insomnia, nervousness

paroxetine: most anti-cholinergic

citalopram: prolongs QT interval in dose-dependent fashion

examples of SSRIs

fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine

what are Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)?

action: increase both serotonin and NE by inhibiting reuptake

- similar SE to SSRIs , but SNRIs more likely to cause excessive sweating

- MONITOR BP (dose changes, baseline) ; can increase BP

what are examples of SNRIs

venlafaxine, duloxetine, desvenlafaxine, levomilnaciprm, milnacipran

what is our norepinephrine and dopamine reuptake inhibitor (NDRI)

bupropion (wellbutrin)

SE: insomnia, tremor, anorexia, weight loss

- less sexual dysfunction

DO NOT GIVE: seizure disorders, ED, or anyone abruptly discontinuing alcohol or sedatives

- FDA approved for smoking cessation

what are tricyclic antidepressants (TCAs)

action: inhibit reuptake of NE and serotonin

- no longer considered first-line agents due to SE and greater lethality in OD

what receptors do TCAs antagonize

H1-histamine: sedation, weight gain

a1-adrenergic: ortho hypoTN

M1-muscarinic cholinergic: dry mouth, blurred vision, urinary retention, constipation

blocks Na channels on the heart = overdose can be fatal

what are TCA examples

amitriptyline, clomipramine, doxepin, imipramine, notriptyline

what are monoamine oxidase inhibitors (MAOIs)?

action: inhibit MAO (enzyme that metabolizes serotonin, NE, DA, tyramine

- last line agents due to drug and dietary restrictions

- risk of HTN crisis if ingesting too much tyramine-rich foods

MOAIs medication examples

isocarboxazid, tranylcypromine, phenelzine, selegiline

what is serotonin syndrome

due to the overactivation of central serotonin receptors

- can be life-threatening: cardiovascular shock or death

- D/C serotonergic medications

what are sx of serotonin syndrome

abd pain, diarrhea, sweating, fever, tachycardia, elevated BP, altered mental status, myoclonus (involuntary twitch, jerk, or spasm), hyperpyrexia (core body temperature rises above 106°F to 106.7°F)

what are brain stimulation therapies

electroconvulsive therapy (ECT)

transcranial magnetic stimulation (TMS)

Vagal nerve stimulation

deep brain stimulation

what is light therapy

light suppresses the nocturnal secretion of melatonin and has a therapeutic effect on people with seasonal affective disorder

individual therapy

time-limited, focused psychotherapy

group therapy

An environment where clients can explore patterns of interaction and response to others

- offer opportunity to socialize and share concerns

psychosis

altered cognition, altered perception, and/or impaired ability to determine what is real or not real

serious mental illness (SMI)

psychiatric conditions that significantly affect functioning and quality of life

- include mood/personality/psychotic disorders AND different subtypes of schizophrenia

what are the schizophrenia spectrum disorders?

- delusional disorders

- brief psychotic disorders

-schizophreniform disorders

- schizoaffective disorders

- substance-induced psychotic disorders & psychotic disorder due to medical condition

delusional disorders

delusions (false thoughts/beliefs) lasting 1 month or longer

brief psychotic disorders

sudden psychotic sx lasting < 1 month

schizophreniform disorders

features exactly like those of schizophrenia except sx last < 6 months and absence of decline in functioning

schizoaffective disorders

major depressive/manic/mixed episode concurrent w/ sx meeting criteria for schizophrenia

what is schizophrenia

psychotic sx lasting 6 months or more ; significantly disrupting functioning

what are core features of schizophrenia

disturbances of thought process, perception, and affect

- lead to SEVERE social and occupational impairment

schizophrenia onset

sx develops gradually (beginning between 15-25 y.o)